Hemimandibular hyperplasia and facial asymmetry

TMJ Pathologies
Facial Asymmetry

Hemimandibular Hypoplasia with condylar-coronoid collapse

Hemifacial Microsomia

Hemimandibular Hyperplasia
!

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Hemimandibular Hyperplasia
and Facial Asymmetry
!

College of Diplomates of the American Board of Orthodontists

2013 Summer Meeting

Bermuda 
©Sylvain Chamberland

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Facial Asymmetry
•
•
•
•
•


Class III

Mandibular deviation to the right

Left posterior open bite

Reciprocal click right TMJ, slight click on the left

Pain on palpation: external pterygoid: left > right

ErBé.12-12-00; 22 y

•
•
•
•


Attrition of the left posterior teeth

3rd molars extracted :~ 2 years

Jaw opening amplitude : 55mm

Right lat. excursion : 12mm; left : 7mm

Facial Asymmetry
• Right lateral open bite

• Left TMJ click

• Pain on palpation: left pre-auricular area

NaRo.01-02-06; 16 y


• ♀, 36 ans

• Laterodeviation to the left

• Chronic left TMJ pain since >10
years


• ♀, 36 ans

• Laterodeviation to the left

• Chronic left TMJ pain since >10
years

• It it because of her occlusion? 
her disc?


Facial Asymmetry
1st & 2nd branchial arch syndromes

We will not discuss this topic today.


Hemimandibular Hypoplasia with
condylar-coronoid collapse
• Usually not diagnose at birth

• ∅ soft-tissue defects; normal ears

• ∅ nerve deﬁcit, well-developed masseter

• Deviation of the chin on the affected side,

AJODO 2011;139:e435-e447

with fullness on the affected cheek

• Signiﬁcant deviation to the affected side
during opening


Courtesy Dr Dany Morais

Hemimandibular Hypoplasia with
condylar-coronoid collapse
• Condyle mandibular dysplasia "en
bosse de chameau" (camel hump look)

• Hypoplasia of the ascending ramus +
condyle + coronoid process

AJODO 2011;139:e435-e447

• Collapse of the condyle on the
coronoid process

• Temporal fossa is always present
Maezzini et al, True hemifacial microsomia and hemimandibular hypoplasia
with condylar-coronoid collapse: Diagnostic and prognostic differences,
AJODO2011;139:e435-e447


•
•

Diagnosed at birth. Prevalence 1 : 5600

Muscular, soft-tissue and nerve defects, (1st & 2nd
arch)

✦

Ear defects, pre-auricular tags, masseter muscle hypoplasia, Facial
nerve ( VII) asymmetries

•

Deviation of the chin on the affected side +
ﬂatness on the affected cheek

•

Deviation to the affected side during opening


Semin Orthod 2011;17:235-245

CCC

HF

Courtesy Dre A-C Valcourt

• Hypoplasia of

✦ Ascending ramus

✦ Condyle

✦ Coronoid process

✦ Absence of condyle and

temporal fossa


Maezzini et al, True hemifacial microsomia and
hemimandibular hypoplasia with condylarcoronoid collapse: Diagnostic and prognostic
differences, AJODO2011;139:e435-e447

Pedersen TK and Norholt SE, Early
Orthopedic Treatment and Mandibular
Growth of Children with
Temporomandibular Joint Abnormalities,
Semin Orthod 2011;17:235-245.)

Facial Asymmetry
Hyperplasia

Hypoplasia


Unilateral Condylar
Hyperplasia
• Most frequent postnatal anomaly of growth of the TMJ

• Prevalence 2 F : 1 M

• Symmetry observed at birth, develops during 2 decade

• Accelerated growth rate of condylar head & neck resulting
nd

in facial asymmetry

• Difference to do with hypoplasia of the opposite side or a

generalized asymmetrical growth (hemimandibular hyperplasia)


Diagnostic Test
• Scintigraphy Tc99

✦ Allows to specify the presence or the absence of cellular

activity at the level of the growth cartilage

✦ Positive if > 10-15 % of difference of uptake between left and

right


Dynamic Aspect
• Active

✦ Growing patient

✦ Adult

• Inactive

✦ Adult


Nomenclature
•

According to Obwegeser

✦ Hemimandibular Hyperplasia

✦ Hemimandibular Elongation

✦ Condylar Hyperplasia

•

According to Wolford

✦ CH Type 1

✓ 1a : unilateral

‣ Vertical or horizontal or

combo

✦ Hybrid form

✓ 1b : bilateral

!

✦ CH Type 2

!

✓ 2A : Osteochondroma

!

✓ 2B : Osteome

Therapeutic options
• Wait and see if

✦ Mild asymmetry

✦ Phasing out shown by serial Tc99 bone scan

✓

Asymmetry corrected by standard orthognatic surgery

• High condylectomy

✦ Signiﬁcant asymmetry

✦ Active abnormal condyle

✦ Prevent worsening (How much more asymmetry are you willing to tolerate?)

High Condylectomy

• Removal of the top 3-5 mm of the condylar head
including the lateral and medial poles

• In most cases, pathologic portion is difﬁcult to identify
making bone resection arbitrary

Wolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321–329!
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New
Technique. J Oral Maxillofac Surg. 2013, Feb 2;

Active
Growing patient


Unilateral Condylar
Hyperplasia

• Vertical type

✦ Vertical growth vector

(Prevalence 15:1)

✦ Elongation + enlargement :

➡ Condylar head & neck + mandibular ramus and body

Condyle & neck:
bigger & longer

✦ Ipsilateral posterior open bite

✦ Progressive laterodeviation to the

unaffected side

✦ Mandibular midline inclined to the affected

side



KaPaVa 02-03-10; 11 a

• Posterior open bite suddenly occurred during
treatment

• Mandibular midline deviated to the left

KaPaVa 29-03-11; 12 a


KaPaVa 02-03-10; 11 a

KaPaVa 29-03-11; 12 a

• Splitting of inferior border ➚

✦ Flattening of the antegonial notch

• Scintigraphy Tc99

✦ Discreet increase of the uptake of the  

right condyle compatible with a right
hypercondyle (condylar hyperplasia)

Difﬁcult to evaluate
∆ at the condyle

Decision
• Observation and reassessment in 6 months

• Orthodontic extrusion of the lower right buccal
segment

KaPaVa 17-08-11


Decision
KaPaVa 17-08-11

•

•

Posterior segment + vertical elastics 
 
 
 
KaPaVa 15-12-11

Extrusion successful

KaPaVa 02-02-12

Décision
KaPaVa 17-08-11

•

KaPaVa 02-02-12

Midlines are coincident and a fairly decent occlusion is achieved at
debonding

KaPaVa 23-08-12

Unilateral Condylar
Hyperplasia

•

Horizontal type (CH type 1a)

✦

Horizontal growth vector

✦

Usually begin at the adolescence and
stop at mid-20s

✦

Elongation of condylar head & neck

✦

Laterodeviation to the unaffected side &
midline deviation

✦

Loss of the antegonial notch


✦ Laterodeviation to the controlateral side

✦ Ipsilateral class III

✦ Posterior crossbite in the unaffected side or dentoalveolar

compensation

PA Le 19-05-11

PA Le 03-12-01; 6a 4m


PA Le 11-02-04; 8a 5m

PA Le 15-10-09; 14a 1m

PA Le 19-05-11; 15a 8m

Compare the height

of sigmoid notch

• Scintigraphie Tc99

• Scinti Tc99 = Positive (increased uptake) in spring 2011

• Left TMJ clicking at maximum jaw opening
PA Le 15-10-09; 14a 1m


PA Le 19-05-11; 15a 8m

PA Le 19-05-11; 15a 8m

PA Le 15-10-09; 14a 1m

Display of

13 ≠ 23

PA Le 15-10-09; 14a 1m

Pearl: distal angulation /5s

PA Le 19-05-11; 15a 8m

• Frontal view

✦ Slight vertical compensation causing a cant of the occlusal plane

• Lateral view

✦ Splitting of the occlusal plane and inferior mandibular border


Scintigraphy
•
•
•

In July ratio 3,2/1,93 = 1,66

In January: ratio 2,13/1,97 = 1,08

Diminution of the activity

• Decision:

✦ No condylectomy

✦ Initiate comprehensive ortho

treatment at appropriate timing
(around 17 y)


✦ Scinti presurgery if midline ∆

P.-A. Le.

Right

Mean

Maximum

1,98

3,2
July 2011

Left

1,65

1,93

Right

1,58

2,13

Left

1,25

1,97

January
2012

Tx
• Goal : avoid the progression of the facial asymmetry

• Orthosurgical tx

✦ Dentoalveolar decompensation

✦ Bimaxillary surgery

✦ High condylectomy could be possible if still actively

overgrowing


At 10 weeks
• Dentoalveolar decompensation

• Early engagement of rectangular wire: 16x22/20x20 niti

P-ALe 20-09-12


À 55 semaines
P-ALe 20-09-12

• Décompensation achevée
P-ALe 05-08-13


• Laterodeviation to left

• Hyperplasy of the right condylar neck

MéPo 16-08-06; 11a 5 m


• Tx

✦ RPE + facial mask

• Slight improvement of
the deviation

• Persistence of the right
class III relationship

MéPo 16-08-06; 11a 5 m


MéPo 11-04-07; 12a 1 m

• February 2007

✦ Scintigraphy Tc99 

= normal

MéPo 16-08-06; 11a 5 m


MéPo 11-04-07; 12a 1 m
MéPo 11-04-07; 12a 1 m

MéPo 16-04-08; 13a 1 m

• Evolution of the
asymmetry

• Slanting of inferior

MéPo 16-08-06; 11a 5 m

teeth (oblique)

• Cant of the mouth
commissure

• Vertical asymmetry
MéPo 16-04-08; 13a 1 m

MéPo 11-04-07; 12a 1 m
MéPo 11-04-07; 12a 1 m

MéPo 17-10-11; 16a 7 m

of inferior border
of the chin

Display of  
13 ≠ 23

MéPo 17-10-11; 16a 7 m

• Cant of the occlusal plane in frontal view

• Splitting of the occlusal plane in the lateral view

• Elongation of the right condylar neck

• Slanting of the lower midline to the affected side

Scinti Report
• Metabolism augmentation in the right condyle

✦ Mean asymmetry index right / left = 1,49

✦ Maximum asymmetry index right / left = 1,97

• Right intense uptake

Mean

Maximum

Right

2,51

3,07

Left

1,68

1,56

M. Po.


January
2012

Treatment
• Avoid asymmetry aggravation

• High condylectomy as soon as possible

• Dentoalveolar decompensation

• Comprehensive ortho treatment, bimaxillary surgery

• Post condylectomy

✦ Persistence of the facial asymmetry

✦ &

✦ Class III relationship

✦ A more agressive cut of the condyle could  
MéPo 17-10-11; 16a 7 m

have caused an anterior openbite

MéPo 27-04-12; 17a 1 m


•


High condylectomy

• ~5 mm of the condylar head is shaved

• The articular disk is preserved (not touched or detached)

• Condylar growth seem to
have stopped

MéPo 21-05-13; 18a 2 m

Recall 13 months post
condylectomy

• Facial asymmetry persist

• Patient declined any further
treatment

Differential Diagnosis

KaVe080801

• Facial asymmetry caused by a
functional shift


KaHa080205

• Left class I molar, class II in the right

• Slight asymmetry to the right

• Right posterior Xbite
CrBo050901; 13a

•
•
•


Symmetric condyle

No splitting of md border

Splitting of the occlusal plane

•
•


Left side larger than the right side

Asymmetric arch form

• Progression of asymmetry to the right

• Left Cl III molar; right cl II molar

• Md midline deviated to right

• This is illogical!
CrBo041103; 15a 2m


•
•
•


Splitting of the occlusal plane

Splitting of md border

Elongation of the left condyle

• Scinti Tc 99

✦ Positive


• High condylectomy
CrBo091203; 15a 3m


• After BSSO
CrBo300804; 16a


CrBo300804; 16a

CrBo050901; 13a


•
•

Normal growth of the left condyle

Persistence of splitted occlusal plane

Active
Adult patient


Patient initial

Facial Asymmetry

✦ Rigth laterodeviation & Absence of shift

✦ Reciprocal click of right TMJ, slight click in the left

✦ Pain on palpation ext. pterygoid muscle

✦ Left posterior openbite > right

✦ Attrition of posterior teeth

•

The deformation would have gradually appeared


ErBé.12-12-00; 22 ans

Vue panoramique

• Hyperplasia of the right condyle :

✦ Bigger & larger condylar head

✦ Elongation of the ascending ramus


Vue panoramique
ErBé.12-12-00; 22 ans

• 1996

✦ Normal

left
condyle


Scinti Tc99

• Intense uptake of the left condyle


ErBé.12-12-00; 22 ans

• Post high condylectomy

ErBé.07-06-01


• Comprehensive ortho tx + 24, 34, 44


High Condylectomy
Description of a New Technique

• Radioguided high

condylectomy using a γ-probe

• Injection of technetium-99m
methylene diphosphate,  
25 mCi, 2 hours pre op

Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of
Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]

Malleable retracor (shield)

γ-probe

• Condylar neck elongated

• No clear demarcation of
hyperplastic portion vs
normal bone


• Malleable retractor inserted at
the medial aspect of the
condyle to provide
appropriate shielding

• Prevent reading of γ-‐emission
of the cranial base

• 1st reading: right mandibular
parasymphysis = 2965 CPS

• 2nd reading: right condyle =
4197 CPS

• Marking the section to be

resected

• γ-‐probe was used until normal
reading was obtain

Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of
a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]

• Patient is placed on soft

diet for 7 days

• Postoperative period in
uneventful

• No sign of relapse were
noticed 9 months post
surgery

• Intraoperative view of the

residual condylar head

• No adjunct procedure of the
articular disk were performed
because it appeared normal
and free of any pathologic
process


• 7 mm of bone removed

• 3 cuts were necessary

to obtain normal reading


Radio-guided surgery
• Sentinel lymph node surgery for breast cancer

• Minimally invasive parathyroid surgery

✦ Other described applications in cutaneous, gastrointestinal,

urologic, gynecologic, thoracic, neuroendocrine and head and
neck malignancies



Radio-guided surgery
• γ-‐emission are easily detected

• Making bone resection easier and limited to the
affected area

• Surgery is less invasive

• May decrease postoperative discomfort and

complications such as arthalgia and osteoarthrosis



Wisdom Thoughts

•"A patient with an elongated condylar process
is more likely to stop growing spontaneously
than one with an enlarged condyle — but I
don't have enough cases to prove it".

Dr William Profﬁt 

Personal communication. January 2012

Inactive
Adult patient or after normal growth has ceased


Differential Diagnosis
• Absence of shift

• Transverse asymmetry

• Laterodeviated to left

• Right elongation

• Right Hypercondyle

★ A left hypoplasia is not necessarily excluded. In fact, it could be the
MP.Ro-Ja.0404; 15a

most likely explanation of the asymmetry

Follow up 2 years
• Stable occlusion

• Persistence of chin asymmetry

• Note hypodevelopment  

MP.Ro-Ja.0707

of left md corpus

MP.Ro-Ja.0707

MP.Ro-Ja.0106

Inactive
•Laterodeviation to right

•Left condylar hyperplasia
(horizontal type)

•Left posterior crossbite

•Splitting occlusal plane &
gonial angle


Ja.Du.29-11-06; 40 a

Bike accident at ~ 10 years

Severe impact on the right side
So, possible retarded growth
of the right TMJ & normal
growth in the left TMJ

•
•BSSO

SARPE


Ja.Du.28-01-10; 43 a

Any Sceptics?

Bike accident


In 5th grade

In Secondary I

Inactive

•Laterodeviation to left

•Class III

•Anterior openbite

Do.Vo.20-04-09; 32 a

Note:  
1st phase surgery: SARPE

•

2nd phase surgery

★ Le Fort 1 differential impaction

★ BSSO

• Implant position 12

• A genio of vertical reduction  

& right deviation would have  
been beneﬁcial

DoVo 28-11-11

DoVo 05-4-12

Osteochondroma
35% of all benign bone tumors

Average age at presentation: 40 y (range 11-69)

Ratio 1,8 ♀: 1♂

No cases of malignant transformation of TMJ yet reported
•Chapter 82- Mandibular asymmetry: temporomandibular joint degeneration, Wolford L. In Current therapy in Oral and maxillofacial surgery, W.B.Saunders, 2012

•Osteochondroma of the temporomandibular joint: a case report. Utumi ER, Pedron IG, Perrella A, Zambon CE, Ceccheti MM, Cavalcanti MG. Braz Dent J. 2010;21(3):253-8. PMID: 21203710

• Shintaku WH,Venturin JS, Langlais RP, and Clark GT. Imaging modalities to access bony tumors and hyperplasic reactions of the temporomandibular joint. J Oral Maxillofac Surg. 2010, Aug
68(8):1911-21.

Osteochondroma
• Rx ﬁndings

Li.Ma.220312

★Tapering radiopaque mass extends from the anteromedial

aspect of the condyle

★Globular pattern

• Recurrence ~ 2% most likely because of incomplete
excision


Osteochondroma

•Possible etiology

★ Peripheral displacement of undifferentiated cells from growth

cartilage or neoplastic cells arising from the periosteum form
metaplastic cartilage

★ Residues from the cartilaginous cranium and Meckel cartilage

that have not been replaced by mandibular bone

★ Possible trauma, but there is inadequate data to support this

hypothesis

•Hyperplasy of right condyle +++

•Laterodeviation to left

•Indication of a condylectomy : osteochondrome or
osteome

• >20 years ago : Jigli osteotomy + genioplasty


Osteochondroma
Li.Ma.220312-60y

Li.Ma.290508-56

• ♀ 56 y

✦ Condylar hypertrophy noted


• At 60 y

✦ Osteochondroma

CBCT assessment

R

L

•


Tapering radiopaque mass
extending from the anteromedial
aspect of the condyle

•

Left condyle is normal

Recurring osteochondroma
• High condylectomy perfomed >10y ago

★ The lesion extended deep medially

★ Access was limited

★ Risks were high

• ♂ 40y: recurrence!

★ Comprehensive ortho tx plan is needed along with orthognathic

surgery


Recurring osteochondroma


Early fracture of the mandibular condyles: Frequently an
unsuspected cause of growth disturbance
Proﬁt W.,Vig K., Turvey T., AJODO 1980, 78, #1, 1-24

• If unilateral : deviation + openbite + xbite

+ distal
occlusion ipsilaterally

5 to 10% of
If bilateral : distoclusion + anterior openbite

asymmetries or
severe md
Recommandation post trauma

deﬁciencies

•
•

✦ Observation + exercices to maintain normal fonction & occlusion

• Compensatory growth occur but will not necessarily
compensate for the loss of condylar lenght

• Compensatory overgrowth is also possible

Hypoplasia
Traumatism


• Mandibular laterodeviation to right

• Left class I, right class II

• Vertical asymmetry :

✦ Gonial angle + inferior border of the chin

• Midline coincident (??)
JuLe.260811; 10 ans 7 mois

JuLe. 10 avril 2006


JuLe. 10 avril 2006

• Bilateral condylar fracture (because of a fall)


JuLe. 20 octobre 2006

5 y 10 m

• Anterior open bite

✦ ➜ posterior md autorotation

✦ Fulcrum on the molars (55/85)

JuLe.201006; 5 ans 10 mois


JuLe. 30 janvier 2008; 7 ans

• Healing of condylar stumps

• Signiﬁcant shortening of the right ascending
ramus

• Anterior posturing permits conterclockwise
md rotation to close the openbite


• Normal development except the shortened right
condyle

• Midline deviation toward the normal growing side


Ju.Le230412

!

Non Growing
•
•

Motor bike accident

Open reduction 
But the condylar head moved
forward

✦ Could be because

inadequate immobilization
or the fragment were not
realigned at surgery


Automobile
Accident
PACl.160309; 14 ans 9 mois

• Bilateral condylar fracture

✦ Fixation in the left (Reduced in the left)

• Parasymphyseal fracture in the right

• Le Fort 1 left segment

Followed for 4 Years
• Compensatory growth

PACl.160309; 14 years 9 months

✦ Right condyle reshaped

normally

✦ R : Overgrowth vertically?

✦ L : Overgrowth horizontally?

PACl.160511; 16 ans 9 mois


Conclusion
•
•

Facial asymmetries are sometimes difﬁcult to diagnose

•

Articular clicking can be a confounding factor in the diagnosis,
but should be considered as a clue.

•
•

The treatment often implies a surgical approach


An asymmetric growth can express itself in the adolescence
without having been present during childhood

5 to10 % of the facial asymmetries are due to an undiagnosed
early condylar fracture or a traumatic impact in period of growth

• Thank you
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http://www.sylvainchamberland.com/blogue/asymetrie-faciale-et-hyperplasie-hemimandibulaire/
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