Efficacy of proportional condylectomy in a treatment protocol for unilateral condylar hyperplasia: A review of 73 cases
Introduction
Unilateral condylar hyperplasia (UCH) is a non-neoplastic pathology resulting from the excessive growth of the condylar head and neck causing an increase in size and volume. Described for the first time in 1836 by Adams (Norman and Painter, 1980), UCH excludes congenital malformations such as Sturge–Weber syndrome and congenital facial hemihypertrophy. Unilateral condylar hyperplasia also excludes vascular and hormonal dysfunctions such as lymphomatosis, angiomatosis, and acromegalia.
The aetiology of UCH remains unclear. It is thought that temporo-mandibular joint (TMJ) infections and traumas are involved (Lineaweaver et al., 1980); additionally, other genetic (Persson, 1973), embryological (Rushton, 1946, Couly, 1980), microvascular, or hormonal causes could be implicated (Norman and Painter, 1980, Egyedi, 1969). Epidemiological data have suggested that there is a female predominance in UCH, which theories suggest is related to oestrogenic influences (Raijmakers et al., 2012, Chen et al., 2012, Talwar et al., 2006). Clinical, radiological, and scintigraphic arguments are usually part of the diagnosis of UCH.
This pathology can adversely affect mandibular morphology, dental occlusion, TMJ function, and indirectly maxillary growth (Bruce and Hayward, 1968). Typically beginning at puberty (Gottlieb, 1951), UCH presents with a progressive facial asymmetry caused by posterior vertical excess. This pathology includes two different but related entities. One is condylar hyperplasia caused by overgrowth of a mandibular condyle, and on the other hand facial asymmetric deformation caused by condylar hyperplasia (Olate et al., 2013). Both can be treated separately or at the same time (Villanueva-Alcojol et al., 2011).
Commonly, UCH is differentiated into active and inactive forms using scintigraphic features. Planar or SPECT (single photon emission computed tomography) methods are used for differentiation where technetium-99m methylene diphosphate (Tc99m-MDP) can measure the level of bone metabolism in relation with osteoblastic activity (Kanishi, 1993). A 10% difference between the two condyles in SPECT analysis associated with progressive facial asymmetry therefore suggests an active form of condylar hyperplasia (Pripatnanont et al., 2005, Pogrel et al., 1995, Saridin et al., 2011, Chan et al., 2000). Various protocols have been published to treat UCH due in part to the lack of classification consensus. The evidence of scintigraphic hyperactivity typically requires a precocious condylectomy. For some authors, this treatment, either a high condylectomy with sole resection of the growth cartilage (Wolford et al., 2002), or a low condylectomy which allows the adjustment of the posterior vertical excess at the same time (Fariña et al., 2015), is supposed to avoid the progression of homolateral occlusal plane tilting and dento-facial adaptive deformities (Bohuslavizki et al., 1996). In non-active cases (Marchetti et al., 2000, Obwegeser, 2001, Deleurant et al., 2008), or in cases where surgical treatment is delayed until the UCH has stopped growing (Saridin et al., 2011, Bohuslavizki et al., 1996), a more conventional orthognathic surgery is typically suggested to respect the TMJ.
Moreover, many clinicopathological classifications for condylar hyperplasia have been proposed. These are based on analysis of the spatial and dynamic features of the deformation. Obwegeser and Makek (1986) suggested three categories to classify forms of UCH: Hemimandibular hyperplasia (HH), hemimandibular elongation (HE), and a mixed form. Nitzan et al. (2008) suggested another classification based on the mandibular overgrowth vector. More recently, Wolford et al. (2014) presented a classification system based on clinical, radiological, and histological analysis, which grouped various types of condylar hyperplasia. Delaire described two dynamic growth directions induced by condylar unit: a vertical form and a transversal form (Gordeeff et al., 1988).
Regardless of disease activity or classification, Delaire (Delaire et al., 1983) has proposed a systematically ‘proportional condylectomy’ protocol solving the aetiology of UCH by resection of the growth centre, and correcting the mandibular deformities. The purpose of this study was to evaluate clinical and radiological characteristics in patients with UCH treated according to the Delaire protocol. Analyses were performed on the architectural, aesthetic, and functional results after treatment.
Section snippets
Materials and methods
A group of 73 patients was retrospectively studied. Each patient presented with UCH, and was treated from 1980 to 2015 in the Maxillofacial and Stomatology Surgery Department of the Nantes University Hospital, Nantes, France. All patients underwent a condylectomy either alone or associated with another surgical or orthodontic technique. Patients with other causes of mandibular asymmetry were excluded, such as patients with functional mandibular laterognathia. In this retrospective study, no
Epidemiologic data
A statistically significant female predominance was observed where 65.8% of the 73 patients were female. According to Delaire's classification, vertical forms were more represented than transversal forms (61.6% versus 38.4%). A minority, 35.6%, of the patients presented symptoms of TMJ dysfunction and pain. The mean follow-up was 35.43 ± 33.7 months (range: 6–180). All of the data was collected in Table 1.
Treatment plan
The average condyle resection height was 11.2 ± 5.2 (range: 5–25) mm; however, vertical
Discussion
Seventy-three cases of unilateral condylar hyperplasia were studied retrospectively, and classified in vertical or transversal forms according to Delaire's classification (Gordeeff et al., 1988). Epidemiologic data revealed a female predominance for UCH (65.8 %. p = 0.0071) as reported in literature (Raijmakers et al., 2012, Nitzan et al., 2008), although, data from the 73 cases showed vertical forms were more represented (61.6 %), unlike other publications (Wolford et al., 2002, Fariña et al.,
Conclusion
An “all in one” treatment protocol as described by Delaire was examined herein of the 73 patients reviewed. Results indicated the treatment protocol using ‘proportional condylectomy’ allowed both aetiological treatment of condylar overgrowth and also facial architectural restoration. Maxilla-mandibular fixation therapy and functional rehabilitation allow its efficiency, and improve TMJ dysfunctions. The use of associated orthognathic techniques can improve occlusal and aesthetic features, when
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References (45)
- et al.
Progressive mandibular retrusion – idiopathic condylar resorption. Part I
Am Orthod Dentofacial Orthop
(1996) - et al.
Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity
Am J Orthod Dentofacial Orthop
(1999) - et al.
Functional results after condylectomy in active laterognathia
J Cranio-maxillo-fac Surg
(2010) - et al.
Insulin-like growth factor-1 boosts the developing process of condylar hyperplasia by stimulating chondrocytes proliferation
Osteoarthritis Cartilage
(2012) - et al.
An architectural and structural craniofacial analysis: a new lateral cephalometric analysis
Oral Surg Oral Med Oral Pathol
(1981) - et al.
Low condylectomy as the sole treatment for active condylar hyperplasia: facial, occlusal and skeletal changes. An observational study
Int J Oral Maxillofac Surg
(2015) - et al.
Correction of facial asymmetry as a result of unilateral condylar hyperplasia
J Oral Maxillofac Surg
(2012) 99mTc-MDP accumulation mechanisms in bone
Oral Surg Oral Med Oral Pathol
(1993)- et al.
Treatment of hemimandibular hyperplasia: the biological basis of condylectomy
Br J Oral Maxillofac Surg
(2007) - et al.
The clinical characteristics of condylar hyperplasia: experience with 61 patients
J Oral Maxillofac Surg
(2008)
Hemimandibular hyperplasia–hemimandibular elongation
J Maxillofac Surg
Mandibular asymmetry of hereditary origin
Am J Orthod
A comparison of single-photon emission computed tomography and planar imaging for quantitative skeletal scintigraphy of the mandibular condyle
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
The use of SPECT to evaluate growth cessation of the mandible in unilateral condylar hyperplasia
Int J Oral Maxillofac Surg
Evaluation of temporomandibular function after high partial condylectomy because of unilateral condylar hyperactivity
J Oral Maxillofac Surg
Bone scintigraphy as a diagnostic method in unilateral hyperactivity of the mandibular condyles: a review and meta-analysis of the literature
Int J Oral Maxillofac Surg
Effects of estrogen on chondrocyte proliferation and collagen synthesis in skeletally mature articular cartilage
J Oral Maxillofac Surg
Hyperplasia of the mandibular condyle: clinical, histopathologic, and treatment considerations in a series of 36 patients
J Oral Maxillofac Surg
A classification system for conditions causing condylar hyperplasia
J Oral Maxillofac Surg
The value of bone scanning in pre-operative decision-making in patients with progressive facial asymmetry
Nucl Med Commun
Condylar hyperplasia and mandibular asymmetry: a review
J Oral Surg
Planar versus SPET imaging in the assessment of condylar growth
Nucl Med Commun
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