Efficacy of proportional condylectomy in a treatment protocol for unilateral condylar hyperplasia: A review of 73 cases

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Abstract

Introduction

Unilateral condylar hyperplasia (UCH) is characterized by an excessive growth of a mandibular condyle, resulting in facial, and occlusal deformities. Scintigraphic hyperactivity usually triggers the need of condylectomy. Delaire has presented a protocol for the treatment of active or non-active UCH using systematically a proportional condylectomy, which could solve both aetiology and adaptive deformities. The aim of this study was to evaluate this protocol by clinical and radiographical analysis.

Materials and methods

Seventy-three patients with UCH were included in this retrospective study, and divided by clinical and cephalometric analysis in vertical, or transversal forms of UCH according to Delaire's classification. All patients were treated with ‘proportional condylectomy’, any indicated orthognathic procedures, along with maxilla-mandibular elastic therapy, and rehabilitation. Architectural, aesthetical, occlusal, and functional features were evaluated using clinical, cephalometric, and photographic measurements both preoperatively, and at the end of the follow-up.

Results

A female predominance was observed (65.8%). Vertical forms were more represented than transversal forms (61.6% versus 38.4%). There was a significant improvement of the occlusal plane, the posterior vertical excess, the chin deviation and the soft-tissue features (p < 0.0001), regardless of the preoperative scintigraphic activity status (p < 0.0001). The occlusion, and temporo-mandibular joint (TMJ) functions was considered as normal in respectively 72.7%, and 93% of the patients.

Conclusion

The results of this study have demonstrated that a protocol using a ‘proportional condylectomy’, any indicated orthognathic techniques, maxilla-mandibular elastic therapy, and rehabilitation, is a reliable option for treating UCH, regardless the activity status of the pathology.

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

Source of supports

None.

References (45)

  • H.L. Obwegeser et al.

    Hemimandibular hyperplasia–hemimandibular elongation

    J Maxillofac Surg

    (1986)
  • M. Persson

    Mandibular asymmetry of hereditary origin

    Am J Orthod

    (1973)
  • M.A. Pogrel et al.

    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

    (1995)
  • P. Pripatnanont et al.

    The use of SPECT to evaluate growth cessation of the mandible in unilateral condylar hyperplasia

    Int J Oral Maxillofac Surg

    (2005)
  • C.P. Saridin et al.

    Evaluation of temporomandibular function after high partial condylectomy because of unilateral condylar hyperactivity

    J Oral Maxillofac Surg

    (2010)
  • C.P. Saridin et al.

    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

    (2011)
  • R.M. Talwar et al.

    Effects of estrogen on chondrocyte proliferation and collagen synthesis in skeletally mature articular cartilage

    J Oral Maxillofac Surg

    (2006)
  • L. Villanueva-Alcojol et al.

    Hyperplasia of the mandibular condyle: clinical, histopathologic, and treatment considerations in a series of 36 patients

    J Oral Maxillofac Surg

    (2011)
  • L.M. Wolford et al.

    A classification system for conditions causing condylar hyperplasia

    J Oral Maxillofac Surg

    (2014)
  • K.H. Bohuslavizki et al.

    The value of bone scanning in pre-operative decision-making in patients with progressive facial asymmetry

    Nucl Med Commun

    (1996)
  • R.A. Bruce et al.

    Condylar hyperplasia and mandibular asymmetry: a review

    J Oral Surg

    (1968)
  • W.L. Chan et al.

    Planar versus SPET imaging in the assessment of condylar growth

    Nucl Med Commun

    (2000)
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