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TMJ Pathologies
Facial Asymmetry	

Hemimandibular Hypoplasia with condylar-coronoid collapse	

Hemifacial Microsomia	

Hem...
Hemimandibular Hyperplasia
and Facial Asymmetry
!

College of Diplomates of the American Board of Orthodontists	

2013 Sum...
Facial Asymmetry
•
•
•
•
•

©Dr Sylvain Chamberland

Class III	

Mandibular deviation to the right	

Left posterior open b...
•
•
•
•

©Dr Sylvain Chamberland

Attrition of the left posterior teeth 	

3rd molars extracted :~ 2 years	

Jaw opening a...
Facial Asymmetry
• Right lateral open bite	

• Left TMJ click 	

• Pain on palpation: left pre-auricular area

NaRo.01-02-...
• ♀, 36 ans	

• Laterodeviation to the left	

• Chronic left TMJ pain since >10
years

©Dr Sylvain Chamberland
• ♀, 36 ans	

• Laterodeviation to the left	

• Chronic left TMJ pain since >10
years	


• It it because of her occlusion?...
Facial Asymmetry
1st & 2nd branchial arch syndromes

We will not discuss this topic today.

©Dr Sylvain Chamberland
Hemimandibular Hypoplasia with
condylar-coronoid collapse
• Usually not diagnose at birth	

• ∅ soft-tissue defects; norma...
Hemimandibular Hypoplasia with
condylar-coronoid collapse
• Condyle mandibular dysplasia "en
bosse de chameau" (camel hump...
Hemifacial Microsomia
Courtesy Dr Dany Morais

•
•

Diagnosed at birth. Prevalence 1 : 5600 	

Muscular, soft-tissue and n...
Hemifacial Microsomia
CCC

HF

Courtesy Dre A-C Valcourt

• Hypoplasia of 	

✦ Ascending ramus	

✦ Condyle 	

✦ Coronoid p...
Facial Asymmetry
Hyperplasia	

Hypoplasia

©Dr Sylvain Chamberland
Unilateral Condylar
Hyperplasia
• Most frequent postnatal anomaly of growth of the TMJ	

• Prevalence 2 F : 1 M	

• Symmet...
Diagnostic Test
• Scintigraphy Tc99	

✦ Allows to specify the presence or the absence of cellular

activity at the level o...
Dynamic Aspect
• Active	

✦ Growing patient	

✦ Adult	


• Inactive	

✦ Adult

©Dr Sylvain Chamberland
Nomenclature
•

According to Obwegeser	

✦ Hemimandibular Hyperplasia	

✦ Hemimandibular Elongation	

✦ Condylar Hyperplas...
Therapeutic options
• Wait and see if	

✦ Mild asymmetry 	

✦ Phasing out shown by serial Tc99 bone scan	

✓

Asymmetry co...
High Condylectomy

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


• In most ca...
Active
Growing patient

©Dr Sylvain Chamberland
Unilateral Condylar
Hyperplasia

• Vertical type	


✦ Vertical growth vector

(Prevalence 15:1)	


✦ Elongation + enlargem...
KaPaVa 02-03-10; 11 a

• Posterior open bite suddenly occurred during
treatment	


• Mandibular midline deviated to the le...
KaPaVa 02-03-10; 11 a

KaPaVa 29-03-11; 12 a

• Splitting of inferior border ➚	


✦ Flattening of the antegonial notch	


...
Decision
• Observation and reassessment in 6 months	

• Orthodontic extrusion of the lower right buccal
segment

KaPaVa 17...
Decision
KaPaVa 17-08-11

•

•

Posterior segment + vertical elastics







KaPaVa 15-12-11

Extrusion successful

KaPaVa...
Décision
KaPaVa 17-08-11

•

KaPaVa 02-02-12

Midlines are coincident and a fairly decent occlusion is achieved at
debondi...
Unilateral Condylar
Hyperplasia

•

Horizontal type (CH type 1a)	

✦

Horizontal growth vector	


✦

Usually begin at the ...
✦ Laterodeviation to the controlateral side	

✦ Ipsilateral class III	

✦ Posterior crossbite in the unaffected side or de...
PA Le 03-12-01; 6a 4m

©Dr Sylvain Chamberland

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	...
Display of 	

13 ≠ 23

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

Pearl: distal angulation /5s

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

• Frontal view	

✦ Sl...
Scintigraphy
•
•
•

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

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

Diminution of the activity	


• D...
Tx
• Goal : avoid the progression of the facial asymmetry	

• Orthosurgical tx	

✦ Dentoalveolar decompensation	

✦ Bimaxi...
At 10 weeks
• Dentoalveolar decompensation	

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

P-ALe 20-09-12

©Dr...
À 55 semaines
P-ALe 20-09-12

• Décompensation achevée
P-ALe 05-08-13

©Dr Sylvain Chamberland
• Laterodeviation to left	

• Hyperplasy of the right condylar neck

MéPo 16-08-06; 11a 5 m

©Dr Sylvain Chamberland
• Tx	

✦ RPE + facial mask	


• Slight improvement of
the deviation	


• Persistence of the right
class III relationship

...
• February 2007	

✦ Scintigraphy Tc99


= normal

MéPo 16-08-06; 11a 5 m

©Dr Sylvain Chamberland

MéPo 11-04-07; 12a 1 m
...
• Evolution of the
asymmetry	


• Slanting of inferior

MéPo 16-08-06; 11a 5 m

teeth (oblique)	


• Cant of the mouth
com...
Display of 

13 ≠ 23

MéPo 17-10-11; 16a 7 m

• Cant of the occlusal plane in frontal view	

• Splitting of the occlusal p...
Scinti Report
• Metabolism augmentation in the right condyle	

✦ Mean asymmetry index right / left = 1,49	

✦ Maximum asym...
Treatment
• Avoid asymmetry aggravation 	

• High condylectomy as soon as possible	

• Dentoalveolar decompensation	

• Co...
• Post condylectomy	

✦ Persistence of the facial asymmetry	

✦ &	

✦ Class III relationship	

✦ A more agressive cut of t...
•

©Dr Sylvain Chamberland

High condylectomy

• ~5 mm of the condylar head is shaved	

• The articular disk is preserved ...
• Condylar growth seem to
have stopped	


MéPo 21-05-13; 18a 2 m

Recall 13 months post
condylectomy
©Dr Sylvain Chamberla...
Differential Diagnosis

KaVe080801

• Facial asymmetry caused by a
functional shift

©Dr Sylvain Chamberland

KaHa080205
• Left class I molar, class II in the right	

• Slight asymmetry to the right	

• Right posterior Xbite
CrBo050901; 13a
©D...
•
•
•

©Dr Sylvain Chamberland

Symmetric condyle	

No splitting of md border	

Splitting of the occlusal plane
•
•

©Dr Sylvain Chamberland

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...
•
•
•

©Dr Sylvain Chamberland

Splitting of the occlusal plane	

Splitting of md border	

Elongation of the left condyle
• Scinti Tc 99	

✦ Positive

©Dr Sylvain Chamberland
• High condylectomy
CrBo091203; 15a 3m

©Dr Sylvain Chamberland
• After BSSO
CrBo300804; 16a

©Dr Sylvain Chamberland
CrBo300804; 16a

CrBo050901; 13a

©Dr Sylvain Chamberland

•
•

Normal growth of the left condyle	

Persistence of splitte...
Active
Adult patient

©Dr Sylvain Chamberland
Patient initial

Facial Asymmetry

✦ Rigth laterodeviation & Absence of shift	

✦ Reciprocal click of right TMJ, slight cl...
•
•
•
•

©Dr Sylvain Chamberland

Attrition of the left posterior teeth 	

3rd molars extracted :~ 2 years	

Jaw opening a...
Vue panoramique

• Hyperplasia of the right condyle : 	

✦ Bigger & larger condylar head	

✦ Elongation of the ascending r...
Vue panoramique
ErBé.12-12-00; 22 ans

• 1996	

✦ Normal

left
condyle

©Dr Sylvain Chamberland
Scinti Tc99

• Intense uptake of the left condyle

©Dr Sylvain Chamberland
ErBé.12-12-00; 22 ans

• Post high condylectomy

ErBé.07-06-01

©Dr Sylvain Chamberland
©Dr Sylvain Chamberland
• Comprehensive ortho tx + 24, 34, 44

©Dr Sylvain Chamberland
High Condylectomy
Description of a New Technique

• Radioguided high

condylectomy using a γ-probe	


• Injection of techn...
Malleable retracor (shield)

γ-probe

• Condylar neck elongated	

• No clear demarcation of
hyperplastic portion vs
normal...
• Patient is placed on soft

diet for 7 days	

• Postoperative period in
uneventful	

• No sign of relapse were
noticed 9 ...
Radio-guided surgery
• Sentinel lymph node surgery for breast cancer	

• Minimally invasive parathyroid surgery	

✦ Other ...
Radio-guided surgery
• γ-­‐emission are easily detected	

• Making bone resection easier and limited to the
affected area	...
Wisdom Thoughts

•"A patient with an elongated condylar process
is more likely to stop growing spontaneously
than one with...
Inactive
Adult patient or after normal growth has ceased

©Dr Sylvain Chamberland
Differential Diagnosis
• Absence of shift	

• Transverse asymmetry	

• Laterodeviated to left	

• Right elongation	

• Rig...
Follow up 2 years
• Stable occlusion	

• Persistence of chin asymmetry	

• Note hypodevelopment 


MP.Ro-Ja.0707

of left ...
Inactive
•Laterodeviation to right	

•Left condylar hyperplasia
(horizontal type)	


•Left posterior crossbite	

•Splittin...
Bike accident at ~ 10 years	

Severe impact on the right side
So, possible retarded growth
of the right TMJ & normal
growt...
Any Sceptics?

Bike accident

©Dr Sylvain Chamberland

In 5th grade

In Secondary I
Inactive

•Laterodeviation to left	

•Class III	

•Anterior openbite
©Dr Sylvain Chamberland

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

1st phase surgery: SARPE

•

2nd phase surgery 	


★ Le Fort 1 differential impaction	

★ BSSO	


• Implant positi...
Osteochondroma
35% of all benign bone tumors	

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

Ratio 1,8 ♀: 1♂	

No case...
Osteochondroma
• Rx findings	


Li.Ma.220312

★Tapering radiopaque mass extends from the anteromedial

aspect of the condyl...
Osteochondroma

•Possible etiology	

★ Peripheral displacement of undifferentiated cells from growth

cartilage or neoplas...
•Hyperplasy of right condyle +++	

•Laterodeviation to left	

•Indication of a condylectomy : osteochondrome or
osteome	

...
Osteochondroma
Li.Ma.220312-60y

Li.Ma.290508-56

• ♀ 56 y	

✦ Condylar hypertrophy noted	


©Dr Sylvain Chamberland

• At...
CBCT assessment

R

L

•

©Dr Sylvain Chamberland

Tapering radiopaque mass
extending from the anteromedial
aspect of the ...
Recurring osteochondroma
• High condylectomy perfomed >10y ago	

★ The lesion extended deep medially	

★ Access was limite...
Recurring osteochondroma

©Dr Sylvain Chamberland
Wisdom Thoughts

•"A patient with an elongated condylar process
is more likely to stop growing spontaneously
than one with...
Early fracture of the mandibular condyles: Frequently an
unsuspected cause of growth disturbance
Profit W.,Vig K., Turvey T...
Hypoplasia
Traumatism

©Dr Sylvain Chamberland
• Mandibular laterodeviation to right	

• Left class I, right class II	

• Vertical asymmetry : 	

✦ Gonial angle + inferi...
JuLe. 10 avril 2006

©Dr Sylvain Chamberland
JuLe. 10 avril 2006

• Bilateral condylar fracture (because of a fall)

©Dr Sylvain Chamberland

JuLe. 20 octobre 2006

5 ...
• Anterior open bite	

✦ ➜ posterior md autorotation	

✦ Fulcrum on the molars (55/85)

JuLe.201006; 5 ans 10 mois

©Dr Sy...
JuLe. 30 janvier 2008; 7 ans

• Healing of condylar stumps	

• Significant shortening of the right ascending
ramus	


• Ant...
• Normal development except the shortened right
condyle 	


• Midline deviation toward the normal growing side

©Dr Sylvai...
!

Non Growing
•
•

Motor bike accident	

Open reduction

But the condylar head moved
forward	

✦ Could be because

inadeq...
Automobile
Accident
PACl.160309; 14 ans 9 mois

• Bilateral condylar fracture	

✦ Fixation in the left (Reduced in the lef...
Followed for 4 Years
• Compensatory growth	


PACl.160309; 14 years 9 months

✦ Right condyle reshaped

normally	


✦ R : ...
Conclusion
•
•

Facial asymmetries are sometimes difficult to diagnose	


•

Articular clicking can be a confounding factor...
• Thank you
http://www.sylvainchamberland.com/en/blog/facial-asymmetry-and-hemimandibuar-hyperplasia/
http://www.sylvainch...
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Hemimandibular hyperplasia and facial asymmetry

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Objective: To differentiate non syndromic pathology that cause facial asymmetry. To understand the effect of unilateral condylar hyperplasy in a growing and non growing individual. Understand the effect of condylar fracture or trauma (impact) to the joint that may affect mandibular growth. To know the diagnostic test and surgical treatment that is recommended.

Published in: Health & Medicine

Transcript of "Hemimandibular hyperplasia and facial asymmetry"

  1. 1. TMJ Pathologies Facial Asymmetry Hemimandibular Hypoplasia with condylar-coronoid collapse Hemifacial Microsomia Hemimandibular Hyperplasia ! www.slideshare.net/sylvainchamberland www.sylvainchamberland.com ©Dr Sylvain Chamberland http://www.sylvainchamberland.com/en/blog/facial-asymmetry-and-hemimandibuar-hyperplasia/?submenu
  2. 2. Hemimandibular Hyperplasia and Facial Asymmetry ! College of Diplomates of the American Board of Orthodontists 2013 Summer Meeting Bermuda
 ©Sylvain Chamberland http://fr.slideshare.net/sylvainchamberland/hemimandibular-hyperplasia-and-facial-asymmetry https://www.facebook.com/drsylvainchamberland http://www.sylvainchamberland.com/en/blog/facial-asymmetry-and-hemimandibuar-hyperplasia/
  3. 3. Facial Asymmetry • • • • • ©Dr Sylvain Chamberland 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
  4. 4. • • • • ©Dr Sylvain Chamberland Attrition of the left posterior teeth 3rd molars extracted :~ 2 years Jaw opening amplitude : 55mm Right lat. excursion : 12mm; left : 7mm
  5. 5. Facial Asymmetry • Right lateral open bite • Left TMJ click • Pain on palpation: left pre-auricular area NaRo.01-02-06; 16 y ©Dr Sylvain Chamberland
  6. 6. • ♀, 36 ans • Laterodeviation to the left • Chronic left TMJ pain since >10 years ©Dr Sylvain Chamberland
  7. 7. • ♀, 36 ans • Laterodeviation to the left • Chronic left TMJ pain since >10 years • It it because of her occlusion?
 her disc? ©Dr Sylvain Chamberland
  8. 8. Facial Asymmetry 1st & 2nd branchial arch syndromes We will not discuss this topic today. ©Dr Sylvain Chamberland
  9. 9. 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 ©Dr Sylvain Chamberland Courtesy Dr Dany Morais
  10. 10. 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 Courtesy Dr Dany Morais ©Dr Sylvain Chamberland
  11. 11. Hemifacial Microsomia Courtesy Dr Dany Morais • • 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 ©Dr Sylvain Chamberland Semin Orthod 2011;17:235-245
  12. 12. Hemifacial Microsomia CCC HF Courtesy Dre A-C Valcourt • Hypoplasia of ✦ Ascending ramus ✦ Condyle ✦ Coronoid process ✦ Absence of condyle and temporal fossa ©Dr Sylvain Chamberland 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.)
  13. 13. Facial Asymmetry Hyperplasia Hypoplasia ©Dr Sylvain Chamberland
  14. 14. 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) ©Dr Sylvain Chamberland
  15. 15. 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 ©Dr Sylvain Chamberland
  16. 16. Dynamic Aspect • Active ✦ Growing patient ✦ Adult • Inactive ✦ Adult ©Dr Sylvain Chamberland
  17. 17. 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 ! ©Dr Sylvain Chamberland ✓ 2B : Osteome
  18. 18. 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?) ©Dr Sylvain Chamberland
  19. 19. 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; ©Dr Sylvain Chamberland
  20. 20. Active Growing patient ©Dr Sylvain Chamberland
  21. 21. 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 ©Dr Sylvain Chamberland Courtesy Dr Dany Morais
  22. 22. 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 ©Dr Sylvain Chamberland
  23. 23. 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 
 ©Dr Sylvain Chamberland right condyle compatible with a right hypercondyle (condylar hyperplasia) Difficult to evaluate ∆ at the condyle
  24. 24. Decision • Observation and reassessment in 6 months • Orthodontic extrusion of the lower right buccal segment KaPaVa 17-08-11 ©Dr Sylvain Chamberland
  25. 25. Decision KaPaVa 17-08-11 • • Posterior segment + vertical elastics
 
 
 
 KaPaVa 15-12-11 Extrusion successful KaPaVa 02-02-12 ©Dr Sylvain Chamberland
  26. 26. 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 ©Dr Sylvain Chamberland
  27. 27. 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 ©Dr Sylvain Chamberland
  28. 28. ✦ Laterodeviation to the controlateral side ✦ Ipsilateral class III ✦ Posterior crossbite in the unaffected side or dentoalveolar compensation PA Le 19-05-11 ©Dr Sylvain Chamberland
  29. 29. PA Le 03-12-01; 6a 4m ©Dr Sylvain Chamberland PA Le 11-02-04; 8a 5m PA Le 15-10-09; 14a 1m PA Le 19-05-11; 15a 8m
  30. 30. 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 ©Dr Sylvain Chamberland PA Le 19-05-11; 15a 8m PA Le 19-05-11; 15a 8m PA Le 15-10-09; 14a 1m
  31. 31. 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 ©Dr Sylvain Chamberland
  32. 32. 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) ©Dr Sylvain Chamberland ✦ 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
  33. 33. Tx • Goal : avoid the progression of the facial asymmetry • Orthosurgical tx ✦ Dentoalveolar decompensation ✦ Bimaxillary surgery ✦ High condylectomy could be possible if still actively overgrowing ©Dr Sylvain Chamberland
  34. 34. At 10 weeks • Dentoalveolar decompensation • Early engagement of rectangular wire: 16x22/20x20 niti P-ALe 20-09-12 ©Dr Sylvain Chamberland
  35. 35. À 55 semaines P-ALe 20-09-12 • Décompensation achevée P-ALe 05-08-13 ©Dr Sylvain Chamberland
  36. 36. • Laterodeviation to left • Hyperplasy of the right condylar neck MéPo 16-08-06; 11a 5 m ©Dr Sylvain Chamberland
  37. 37. • Tx ✦ RPE + facial mask • Slight improvement of the deviation • Persistence of the right class III relationship MéPo 16-08-06; 11a 5 m ©Dr Sylvain Chamberland MéPo 11-04-07; 12a 1 m
  38. 38. • February 2007 ✦ Scintigraphy Tc99
 = normal MéPo 16-08-06; 11a 5 m ©Dr Sylvain Chamberland MéPo 11-04-07; 12a 1 m MéPo 11-04-07; 12a 1 m MéPo 16-04-08; 13a 1 m
  39. 39. • 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 ©Dr Sylvain Chamberland 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
  40. 40. 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 ©Dr Sylvain Chamberland
  41. 41. 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. ©Dr Sylvain Chamberland January 2012
  42. 42. Treatment • Avoid asymmetry aggravation • High condylectomy as soon as possible • Dentoalveolar decompensation • Comprehensive ortho treatment, bimaxillary surgery ©Dr Sylvain Chamberland
  43. 43. • 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 ©Dr Sylvain Chamberland
  44. 44. • ©Dr Sylvain Chamberland High condylectomy • ~5 mm of the condylar head is shaved • The articular disk is preserved (not touched or detached)
  45. 45. • Condylar growth seem to have stopped MéPo 21-05-13; 18a 2 m Recall 13 months post condylectomy ©Dr Sylvain Chamberland • Facial asymmetry persist • Patient declined any further treatment
  46. 46. Differential Diagnosis KaVe080801 • Facial asymmetry caused by a functional shift ©Dr Sylvain Chamberland KaHa080205
  47. 47. • Left class I molar, class II in the right • Slight asymmetry to the right • Right posterior Xbite CrBo050901; 13a ©Dr Sylvain Chamberland
  48. 48. • • • ©Dr Sylvain Chamberland Symmetric condyle No splitting of md border Splitting of the occlusal plane
  49. 49. • • ©Dr Sylvain Chamberland Left side larger than the right side Asymmetric arch form
  50. 50. • 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 ©Dr Sylvain Chamberland
  51. 51. • • • ©Dr Sylvain Chamberland Splitting of the occlusal plane Splitting of md border Elongation of the left condyle
  52. 52. • Scinti Tc 99 ✦ Positive ©Dr Sylvain Chamberland
  53. 53. • High condylectomy CrBo091203; 15a 3m ©Dr Sylvain Chamberland
  54. 54. • After BSSO CrBo300804; 16a ©Dr Sylvain Chamberland
  55. 55. CrBo300804; 16a CrBo050901; 13a ©Dr Sylvain Chamberland • • Normal growth of the left condyle Persistence of splitted occlusal plane
  56. 56. Active Adult patient ©Dr Sylvain Chamberland
  57. 57. 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 ©Dr Sylvain Chamberland ErBé.12-12-00; 22 ans
  58. 58. • • • • ©Dr Sylvain Chamberland Attrition of the left posterior teeth 3rd molars extracted :~ 2 years Jaw opening amplitude : 55mm Right lat. excursion : 12mm; left : 7mm
  59. 59. Vue panoramique • Hyperplasia of the right condyle : ✦ Bigger & larger condylar head ✦ Elongation of the ascending ramus ©Dr Sylvain Chamberland
  60. 60. Vue panoramique ErBé.12-12-00; 22 ans • 1996 ✦ Normal left condyle ©Dr Sylvain Chamberland
  61. 61. Scinti Tc99 • Intense uptake of the left condyle ©Dr Sylvain Chamberland
  62. 62. ErBé.12-12-00; 22 ans • Post high condylectomy ErBé.07-06-01 ©Dr Sylvain Chamberland
  63. 63. ©Dr Sylvain Chamberland
  64. 64. • Comprehensive ortho tx + 24, 34, 44 ©Dr Sylvain Chamberland
  65. 65. 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]
  66. 66. Malleable retracor (shield) γ-probe • Condylar neck elongated • No clear demarcation of hyperplastic portion vs normal bone ©Sylvain Chamberland • 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]
  67. 67. • 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 ©Sylvain Chamberland • 7 mm of bone removed • 3 cuts were necessary to obtain normal reading 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]
  68. 68. 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 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] ©Dr Sylvain Chamberland
  69. 69. 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 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] ©Dr Sylvain Chamberland
  70. 70. 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
 ©Dr Sylvain Chamberland Personal communication. January 2012
  71. 71. Inactive Adult patient or after normal growth has ceased ©Dr Sylvain Chamberland
  72. 72. 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 ©Dr Sylvain Chamberland most likely explanation of the asymmetry
  73. 73. Follow up 2 years • Stable occlusion • Persistence of chin asymmetry • Note hypodevelopment 
 MP.Ro-Ja.0707 of left md corpus MP.Ro-Ja.0707 ©Dr Sylvain Chamberland MP.Ro-Ja.0106
  74. 74. Inactive •Laterodeviation to right •Left condylar hyperplasia (horizontal type) •Left posterior crossbite •Splitting occlusal plane & gonial angle ©Dr Sylvain Chamberland Ja.Du.29-11-06; 40 a
  75. 75. 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 ©Dr Sylvain Chamberland Ja.Du.28-01-10; 43 a
  76. 76. Any Sceptics? Bike accident ©Dr Sylvain Chamberland In 5th grade In Secondary I
  77. 77. Inactive •Laterodeviation to left •Class III •Anterior openbite ©Dr Sylvain Chamberland Do.Vo.20-04-09; 32 a
  78. 78. Note: 
 1st phase surgery: SARPE • 2nd phase surgery ★ Le Fort 1 differential impaction ★ BSSO • Implant position 12 • A genio of vertical reduction 
 ©Dr Sylvain Chamberland & right deviation would have 
 been beneficial DoVo 28-11-11 DoVo 05-4-12
  79. 79. 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. ©Dr Sylvain Chamberland
  80. 80. 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 ©Dr Sylvain Chamberland
  81. 81. 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 ©Dr Sylvain Chamberland
  82. 82. •Hyperplasy of right condyle +++ •Laterodeviation to left •Indication of a condylectomy : osteochondrome or osteome • >20 years ago : Jigli osteotomy + genioplasty ©Dr Sylvain Chamberland
  83. 83. Osteochondroma Li.Ma.220312-60y Li.Ma.290508-56 • ♀ 56 y ✦ Condylar hypertrophy noted ©Dr Sylvain Chamberland • At 60 y ✦ Osteochondroma
  84. 84. CBCT assessment R L • ©Dr Sylvain Chamberland Tapering radiopaque mass extending from the anteromedial aspect of the condyle • Left condyle is normal
  85. 85. 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 ©Dr Sylvain Chamberland
  86. 86. Recurring osteochondroma ©Dr Sylvain Chamberland
  87. 87. 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
 ©Dr Sylvain Chamberland Personal communication. January 2012
  88. 88. 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 ©Dr Sylvain Chamberland
  89. 89. Hypoplasia Traumatism ©Dr Sylvain Chamberland
  90. 90. • 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 ©Dr Sylvain Chamberland
  91. 91. JuLe. 10 avril 2006 ©Dr Sylvain Chamberland
  92. 92. JuLe. 10 avril 2006 • Bilateral condylar fracture (because of a fall) ©Dr Sylvain Chamberland JuLe. 20 octobre 2006 5 y 10 m
  93. 93. • Anterior open bite ✦ ➜ posterior md autorotation ✦ Fulcrum on the molars (55/85) JuLe.201006; 5 ans 10 mois ©Dr Sylvain Chamberland
  94. 94. 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 ©Dr Sylvain Chamberland
  95. 95. • Normal development except the shortened right condyle • Midline deviation toward the normal growing side ©Dr Sylvain Chamberland Ju.Le230412
  96. 96. ! 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 ©Dr Sylvain Chamberland
  97. 97. 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 ©Dr Sylvain Chamberland
  98. 98. 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 ©Dr Sylvain Chamberland
  99. 99. 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 ©Dr Sylvain Chamberland 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
  100. 100. • Thank you http://www.sylvainchamberland.com/en/blog/facial-asymmetry-and-hemimandibuar-hyperplasia/ http://www.sylvainchamberland.com/blogue/asymetrie-faciale-et-hyperplasie-hemimandibulaire/ https://www.facebook.com/drsylvainchamberland ©Dr Sylvain Chamberland
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