Management of patients with condylar hyperplasia: A diverse experience with 18 patients

Clinical Practice Guideline: Condylar Hyperplasia of the Mandible—Diagnosis and Treatment

BACKGROUND

Condylar hyperplasia of the mandible is characterized by abnormal size and configuration of the condylar process. In Germany, the administrative prevalence of diagnosed and/or treated condylar hyperplasia is 2.4-9.6 cases per 100 000 persons. Misdiagnosis is common and can lead to severe esthetic and functional complications, including facial deformity that can progress into the patient's twenties, as well as dysfunctional speech and mastication.

METHODS

We conducted a systematic review of the literature and a structured consensus-finding process with the Delphi method.

RESULTS

The experts recommend timely diagnosis of condylar hyperplasia so that its progression can be prevented by appropriate treatment. The basic diagnostic evaluation consists of history taking, physical examination, and imaging with orthopantomography. If condylar hyperplasia is confirmed, three-dimensional imaging is performed, usually with SPECT. The treatment is mainly surgical: partial condylectomy techniques and orthognathic surgery are the most common methods. If left untreated, the disorder causes severe dysfunction of mastication as well as disfigurement. Most studies of treatments for condylar hyperplasia have been based on low case numbers and have yielded only level 4 or level 5 evidence.

CONCLUSION

Condylar hyperplasia is a common, but not widely known problem. Its early diagnosis and treatment can prevent severe jaw asymmetry and further complications such as craniomandibular dysfunction and arthrosis of the temporomandibular joints.

What Features on Routine Panoramic Radiographs Could Help Orthodontists to Estimate the Occurrence of Condylar Hyperplasia from Other Mandibular Asymmetries—Retrospective Analysis Study

Hemimandibular hyperplasia (HH) and elongation (HE) are the most common pathologies present in the mandible. Presented condylar hyperplasias have their own radiological and clinical features. In most cases, patients suffer from various forms of malocclusion. From a total of 150 asymmetrical jaw radiographs evaluated, 46 were evaluated and included in this study. A retrospective study on the data of 46 selected patients treated, diagnosed, and consulted from various forms of mandibular and skeletal asymmetry based on routine diagnostic panoramic radiographs evaluated typical and atypical radiological and anatomical symptoms of condylar hyperplasia. The presented evaluation focused on mandibular, maxillary, and other bones, in order to distinguish condylar hyperplasia from other forms of mandibular asymmetry. The degree of maxillary downward growth followed by the occurrence of an open bite on the affected side estimate the degree/presence or cessation of growth in the affected condyle. Mandibular asymmetry with incisor teeth inclination remains the most typical characteristic of condylar hyperplasia. Increased height of mandibular ramus differentiates between condylar hyperplasia and elongation, which also influences the position of the inferior alveolar nerve. Mentioned symptoms, described as the acronym “Go Moira!”, are useful in a quick and simple “glimpse of an eye” differential diagnostic approach. It is possible to quickly and accurately establish the first diagnosis simply by a careful evaluation of patients’ panoramic radiographs.

Panoramic Radiograph and CBCT in Unilateral Mandibular Condylar Hyperplasia—A Case Report

Condylar hyperplasia (CH) of the mandible is a rare developmental disorder that results in enlargement of the condyle. It is predominant in females, mostly unilateral and self-limiting. This report presents a case of a 35-year-old female patient with unilateral condylar hyperplasia with an increase in vertical height of mandibular ramus of the affected side. After initial radiographic evaluation, the asymmetry index using a panoramic radiograph was determined and also analyzed using cone-beam computed tomography (CBCT). Condylar dimensions in all the planes were measured for both sides using CBCT. This case report emphasizes the importance of CBCT and its role in the diagnosis and assessment of mandibular condylar hyperplasia.

[Clinical and imagenological evaluation of the temporomandibular joint in patients undergoing condylectomy for the treatment of unilateral hyperplasia. Case series study]

Unilateral condylar hyperplasia is a non-neoplastic and self-limiting overgrowth of the mandibular condyle that usually begins during puberty, predominates in women and is considered an aberration of the normal growth mechanism of the condyle. This abnormal growth continues until the mid-20s and produces mandibular prognostism, facial and occlusal asymmetry with progressive displacement of the mandible to the contralateral side. The purpose of this report was to describe the cases of two female patients (23 and 25 years old) with unilateral condylar hyperplasia treated with high condylectomy and orthognathic surgery, with emphasis on clinical and imaging aspects and late post-surgical follow-up. Both patients presented satisfactory cosmetic results, without pain / noise related to the temporomandibular joint, mouth opening within the normal range, and class I canine and molar relationship. Computed tomography showed signs of remodeling in the affected condyle. High condylectomy combined with orthognathic surgery is an adequate treatment in cases of unilateral hyperplasia, restoring functionality and aesthetics to the patient. The bone remodeling observed in the intervened condyles seems to indicate that the condylar head maintains its adaptive capacity even in adult patients.

Unilateral Condylar Hyperplasia With Active Bony Overgrowth: A Case Report

Condylar hyperplasia (CH) is an overgrowth disorder of the temporomandibular joint bones caused by growth center overactivity of the mandibular condyle. Although the disorder is mostly idiopathic, several etiologies have been proposed. CH presents as progressive facial asymmetry with functional abnormalities. A combination of clinical, histopathological, and radiological findings is crucial to determine the diagnosis. Several diagnostic algorithms have been described in the literature. Management of CH is variable and depends on the growth of the bone. Here, we present the case of a 36-year-old female who presented with progressive facial asymmetry which was diagnosed as unilateral CH with active bony overgrowth.

The need for secondary orthognathic surgery after high condylectomy in patients with active unilateral condylar hyperplasia

The need for secondary orthognathic surgery (OS) after a high condylectomy (HC) in patients with active unilateral condylar hyperplasia was assessed in 25 patients, reviewing patient characteristics and treatment planning. At 6-12 months after HC, 13 patients (52%) required secondary OS. The amount of mandibular dental midline shift before the HC (P=0.037), and a dental crossbite that was present before the HC (P=0.017) were significantly associated with the need for secondary OS. Overall, the mandibular dental midline coincided with the facial midline in eight patients (32%) at 2 weeks after HC. In 16% of the patients, no additional OS was needed despite this being the initial treatment plan. Additionally, the initially planned type of secondary OS was modified in six other patients. Early HC in skeletally immature patients provided very good results, both aesthetic and functional, with only two of them needing supplementary OS at 6-12 months after HC. The HC remains a valuable treatment in patients with active unilateral condylar hyperplasia, as it can eliminate the need for secondary OS and is very well tolerated by most patients.

Concurrent High Condylectomy and Orthognathic Surgery for Treatment of Patients With Unilateral Condylar Hyperplasia

BACKGROUND

Facial asymmetry from unilateral condylar hyperplasia (UCH) may be definitively treated in the presence of active disease (with high condylectomy and concurrent orthognathic surgery) or after waiting for disease inactivity (orthognathic surgery alone). There is currently no consensus on the standard of care. In this study, we sought to compare functional and esthetic outcomes, as well as treatment duration, between these 2 management options.

METHODS

Patients who underwent treatment for UCH were identified through retrospective review. Pre- and postoperative 3-dimensional (3D) images were obtained. Short- and long-term operative outcomes of those treated during the active (group 1) were compared to those treated in the inactive phase (group 2). Total treatment time, operative time, and length of hospital stay were evaluated. Facial asymmetry was also assessed by laypersons using a Likert scale.

RESULTS

Fifteen patients (mean 25.6 years, range 14-56) were included: 6 in group 1 and 9 in group 2. All surgical outcomes were statistically independent of procedure type. Treatment time was significantly longer in the group 2 (P = 0.03). Both groups demonstrated significant improvement in facial asymmetry scores postoperatively with no significant difference in pre- or postoperative asymmetry between groups (P = 0.64).

CONCLUSIONS

In patients with active UCH, high condylectomy and orthognathic surgery is a procedure that restores facial symmetry and improves jaw function while halting mandibular growth. Good esthetic and functional outcomes, as well as reduced treatment time and disease burden, support the use of this treatment option for this population.

Case Report: unilateral condylar hyperplasia

Case: This report describes a clinical case of unilateral condylar hyperplasia (CH) with unique, atypical morphology. An important feature of this report is the documentation of a series of clinical photographs of the patient, showing a gradual increase in facial asymmetry associated with the CH. The main symptom reported in this case was facial asymmetry. The main intraoral clinical features observed in the patient were contralateral crossbite and ipsilateral open bite associated with CH. Surgical reshaping of the condyle was the treatment plan for this case. Conclusions: The main take away point from this case is the importance of obtaining previous photographs of the patient at different ages during case diagnosis, which helps the clinician to determine the approximate time of commencement of CH. This case also highlights the imaging features of rarely observed atypical shape of the hyperplastic condyle.

Differences in dental arch characteristics between genders in patients with suspected condylar hyperplasia in a North Sumatra subpopulation: a cross-sectional study

Background: Condylar Hyperplasia (CH) is a self-limiting mandibular condyle disorder that shows asymmetry progress in conjunction with associated occlusal changes as long as condylar growth is still active and leads to facial asymmetry. This study aimed to analysis the difference of dental arch characteristics  based on genders in orthodontic patients with suspected CH in a North Sumatra subpopulation.

Methods: This is a retrospective study of suspected CH patient’s clinical records who sought for the initial orthodontic treatment between January 2015 to March 2019. Patient with facial asymmetry (based on photography, posterior crossbite and midline deviation), the positive temporomandibular joint disorder in functional analysis, and no history of facial trauma were included in the study. Dental arch asymmetry was based on the measurement of dental midline deviation, canine tip in the dental arch, the distance of the upper canines from the palatal suture, and inter canine distance. The evaluation of dental arch was achieved by comparing arch width and length.

Results: There was a significant difference (p<0.05) of upper canine distance from the palatal suture in female patients when evaluating upper dental arch asymmetry. There was a moderate correlation (r=0.379) in midline deviation between upper and lower dental arch. The dimension and dental arch form were mid and flat, and there was moderate correlation (r=0.448) between the upper and lower dental arch form in these suspected CH patients.

Conclusion: Indeed skeletal asymmetry, the evaluation of the dental arch characteristic symmetry and arch form showed asymmetric occlusal characteristics in orthodontics patient with suspected  CH in the North Sumatera subpopulation. In treating these patients, we recommend the plaster cast evaluation as essential and routine procedure in order to understand the complexity of occlusal change due to active growth of condylar and limitation in radiography evaluation.

Review and Classification Update: Unilateral condylar hyperplasia

Unilateral condylar hyperplasia is characterised by slow progressive growth of the different parts of mandible, the aetiology of which is still unclear. It is a self-limiting condition mostly seen between the age of 11-30 years causing facial asymmetry and its progression ceases after a certain time. In literature until now very few cases have been reported and every case that is being reported adds to its features or the aetiology. Previously, it has been classified into two types that is, hemimandibular hyperplasia and hemimandibular elongation. Here, we report a similar case with a few features distinct from those reported earlier.

Condylectomy and "surgery first" approach: An expedited treatment for condylar hyperplasia in a patient with facial asymmetry

Condylar Hyperplasia (CH) is a self-limiting pathology condition that produces severe facial deformity at the expense of mandibular asymmetry. In this case report a 15-year-old female patient was diagnosed with Unilateral Condylar Hiperplasia (UCH) by mean of single-photon emission computed tomography (SPECT) and histological study. A high condylectomy in the right condyle was performed to stop the active status of the hyperplasia. A month after condylectomy, orthognathic jaw impaction and asymmetric mandibular setback surgery was performed with the Surgery First Approach (SFA). After 10 days, orthodontic appointments were made every two weeks during 4 months. The active phase of treatment lasted 14 months. Excellent facial and occlusal outcomes were obtained and after 24 months in retention the results remained stable.

Role of fluorine-18 fluoride PET-CT scan in the assessment of unilateral condylar hyperplasia in faciomandibular asymmetry patients: a preliminary study

OBJECTIVES

This prospective study was aimed to determine and quantify the change in mandibular condylar hyperactivity over a period of time by using a fluorine-18 (18F) fluoride PET-computed tomography (CT) scan.

MATERIALS AND METHODS

Sixteen patients (age 19.50 ± 2.58 years) with noticeable faciomandibular asymmetry caused by unilateral condylar hyperplasia (UCH) were included in the test group and underwent an 18F-fluoride PET-CT scan at the beginning of the study (T0); these patients were then followed up for a minimum of 12 months, after which the 18F-fluoride PET-CT scan was repeated at first follow-up (T1). An age-matched control group consisted of 10 patients with apparently symmetrical faces whose PET-CT scans were acquired for some other medical conditions. Statistical analysis of maximum standardized uptake values (SUV max) obtained through 18F-fluoride PET-CT was performed using the paired t-test.

RESULTS

Mean SUV max of the affected condyle at T0 and T1 was 9.18 ± 4.07 and 9.18 ± 3.88, respectively. The mean SUV max of the contralateral condyle at T0 and T1 was 6.21 ± 2.30 and 6.66 ± 2.64, respectively. The mean right-left difference in tracer uptake between the test and control groups both at T0 and T1 was statistically significant. Right-left percentage difference of isotope uptake of the test group was 16.87 ± 15.75% at T0 and 14.97 ± 12.72% at T1. Right-left percentage difference of isotope uptake of the control group was 5.51 ± 5.72%. Although these differences were statistically significant, their clinical relevance was insignificant. SUV max of the higher uptake side and the lower uptake side of the control group was 5.63 ± 1.85 and 5.09 ± 1.83, respectively.

CONCLUSION

Great diversity exists in the clinical presentation of UCH. The growth trend of UCH is highly variable because of the age and sex of patients. The results of the present study show that the 18F-fluoride PET-CT scan may guide us in determining the right time and in making the right choice of surgico-orthodontic intervention in UCH patients. The clinical presentation and SUV max of PET-CT of UCH patients were in agreement with each other. The baseline values of the control group indicated that these could also be used to differentiate normal from abnormal condylar growth in potential class III skeletal pattern cases - that is, patients having sagittal skeletal dysplasia resulting from either maxillary deficiency or mandibular protrusion, or both in combination, thus resulting in a concave facial profile.

Condylar hyperplasia: An updated review of the literature

Condylar hyperplasia (CH) is a rare disorder characterized by excessive bone growth that almost always presents unilaterally, resulting in facial asymmetry. Classification of the different types of CH can differ depending on the authors. Correct diagnosis is critical in determining the proper treatments and timing. This paper is a review of the recent literature on the epidemiology, etiology, diagnosis, classification, and surgical treatments of CH.

Unilateral condylar hyperplasia: a treatment strategy

Condylar hyperplasia (CH) is a pathologic condition that causes overdevelopment of the condylar head and neck as well as the mandible. Slowly progressive unilateral enlargement of the head and the neck of the condyle causes crossbite malocclusion, facial asymmetry, and shifting of the midpoint of the chin to the unaffected side. The etiology and the pathogenesis of CH remain uncertain. The diagnosis is made by clinical and radiologic examinations and bone scintigraph. A difference in uptake of 10% or more between condyles is regarded as indicative of CH, and the affected condyles had a relative uptake of 55% or more. When the diagnosis of active CH is established, the treatment consists of removal of the growth center by a partial condylectomy. The authors present the case of a 46-year-old male patient with right active type II CH or hemimandibular hyperplasia who underwent a high condylectomy.

Clinical value of 99Tcm-MDP SPECT bone scintigraphy in the diagnosis of unilateral condylar hyperplasia

Purpose. To investigate the clinical value of ⁹⁹Tc^m-MDP SPECT for the diagnosis of unilateral condylar hyperplasia (UCH). Methods. One hundred forty-nine patients who underwent mandibular ⁹⁹Tc^m-MDP SPECT between January 2009 and December 2012 were studied, including 105 cases that were clinically suspected of UCH and 44 comparable cases without UCH as a control group. Results. Increased bone activity was observed in the affected condyles for all UCH patients. In the UCH group, the relative percentage uptake on the affected side was 59% (SD ± 4.3%), significantly higher than the 41% (SD ± 4.1%) uptake on the contralateral side (P<0.001). Similarly, the condyle/skull ratio was significantly higher for the affected side (1.66 ± 0.63) than for the contralateral side (1.34 ± 0.34, P < 0.01. No significant difference was found in the control group between the left and right condyles. Values for the sensitivity (95%), specificity (61%), positive (84.4%) and negative (84.6%) predictive values, and accuracy (84.5%) for ⁹⁹Tc^m-MDP SPECT in the diagnosis of UCH were calculated. However, for the hyperplastic condyle, no correlation was observed between the thickness of each cartilage layer and the relative uptake in the SPECT image. Conclusion. ⁹⁹Tc^m-MDP SPECT is accurate for diagnosing UCH and can provide a reference for treatment options.