EXCELLENT WORLDCLASS DESCRIPTION NEVER SEEN BEFORE

1. Condylar Hyperplasia(CH)
DR JAMEEL KIFAYATULLAH
ORAL AND MAXILLOFACIAL SURGEON
KCD PESHAWAR PAKISTAN

2. Condylar Hyperplasia
• Condylar hyperplasia is a generic term
describing conditions that cause excessive
growth and enlargement of the mandibular
condyle

3. What is Hyperplasia?
• Hyperplasia indicates the increased
production and growth of normal cells in a
tissue or organ without an increase in the size
of the cells, but the affected part becomes
larger yet retains its basic form.

4. Etiologies of condylar Hyperplasia
1) Neoplasia
2) Trauma
3) Infection
4) Abnormal condylar loading
5) Aberrant growth factors

5. Affect of Condylar Hyperplasias
1) Affect the size and morphology of the mandible
2) Alter the occlusion
3) Indirectly affect the maxilla with resultant
development or worsening of dentofacial
deformities such as mandibular
prognathism,unilateral enlargement of
condyle,neck,ramus and body,facial asymmetry,
malocclusion,pain,post orthognathic surgery
stability

6. Wolford et al Classifiction
Based on horizontal and vertical growth
vectors
• Condylar Hyperplasia Type 1
• Condylar Hyperplasia Type 2
The following types are tumors
• Condylar Hyperplasia Type 3
• Condylar Hyperplasia Type 4

7. Condylar Hyperplasia Type 1
• OCCURRENCE: Adolescence
• INITIATION: Pubertal growth phase (Hormonal
etiology)

8. Condylar Hyperplasia Type I
• It is an accelerated and excessive growth of
the ‘’normal” condylar growth mechanism
creating overgrowth of the mandible
predominantly in a Horizontal vector
( mandibular prognathism) with the growth
continuing into the patients early to middle
20’s
• CH type 1 is a self limiting growth aberration

9. Condylar Hyperplasia TYPE I
Divided into
• CH type 1 A
• CH type 1 B
Based on unilateral or bilateral condylar
involvement

10. Condylar Hyperplasia Type IA
• Patients with bilateral condylar hyperplasia
Type 1
• Age of onset: Pubertal growth

11. Clinical characteristics CH type IA
• Bilateral accelerated symmetric or asymmetric
growth
• Self limiting growth aberration
• Growth continuing into Mid 20’s
• Class III malocclusion
• Prognathic mandible

12. Imaging findings in CH Type IA
• Elongated condylar head ,neck,body
• Normal condylar head shape
• MRI shows thin discs; Assymetric cases (where
one side grows faster than the other side) may
involve contralateral disc displacement

13. Histology CH type IA
• Normal growing condyle but may show slight
widening of fibrocartilage on condyle or
increased vascularity in proliferative zone

14. Treatment options
• Patients in Middle 20’s or older no further jaw
growth:Just do orthognthic surgery only
Teenager or Early 20’s when growth process is
active there are two tx options :-
Tx option 1:
• Bilateral high condylectomy(5 mm
top of condylar head removed)
• Disc repositioning
• Orthognathic Surgery(BSSO AND maxillary
osteotomy)

15. Treatment options
• Teenager or early 20’s growth process active
Option 2:
• Wait until growth is completed
• Then perform orthognathic surgery

16. Condylar Hyperplasia Type 1A
1) bilateral high condylectomies and
articular disc repositioning with
Mitek anchors
2) bilateral mandibular ramus
osteotomies
3) Multiple maxillary osteotomies
4) removal of impacted third molars
5) bilateral partial inferior
turbinectomies
6) rhinoplasty.

17. Class III occlusal relation

18. 2 years Post operative

19. Class I occlusion post surgery

20. Skeletal Class III relation Lateral Ceph

21. Cephalometric STO
The surgical treatment
objectives included 1)
bilateral high
condylectomies; 2) disc
repositioning; 3) bilateral
mandib- ular ramus
osteotomies; 4) multiple
maxillary osteotomies;
and 5) rhinoplasty to
establish good facial
balance and occlusion.

22. MRI features condylar hyperplasias

23. MRI features
A to C: Normal condyle and
temporomandibular joint anatomy.
D to F, Condylar hyperplasia type 1 shows an
increased vertical length of the condylar
head and neck. In the coronal view, the
crown of the condyle may be more
rounded than a normal condyle
. G to I, Condylar hyperplasia type 2A shows
increased vertical height of the condylar
head and neck.
H, with greater deformity in the condyle
observed in the cor- onal view.
J to L, Condylar hyperplasia type 2A with a
larger condyle but with a predominantly
vertical growth vector.
M to O, Condylar hyper- plasia type 2B shows
the exophytic growth from the head of
the condyle. In the coronal view, the
abnormal growth may not be seen.
O, There is significant vertical growth and
enlargement of the right mandibular
condyle, neck, ramus, and body of the
mandible. CH, condylar hyperplasia

24. SURGICAL PROCEDURE
High condylectomy removing the top 4 to 5 mm for treatment of condylar
hyperplasia type 1. B, For condylar hyperplasia type 1 in active growth, a high
condylectomy will arrest any further anteroposterior mandibular growth. The
articular disc is repositioned and stabilized on the condyle with a Mitek anchor.

25. Condylar Hyperplasia Type IB
• Overgrowth of mandible in a horizontal vector
unilaterally
Age of onset: Pubertal growth

26. Clinical Characteristics CH type IB
• Unilateral accelerated asymmetric growth
• Self limiting growth aberration
• Growth continuing into mid 20’s
• Deviated mandibular prognathism(towards
contralateral side
• Ipsilateral Class III occlusion
• Anterior and contralateral cross bite

27. Imaging characteristics CH type IB
• Unilateral elongated condylar head
,neck,body(mandible)
• Deviated prognathism
• MRI shows Thin discs;may have
ipsilateral/contralateral disc displacement

28. Histology CH type IB
• Normal growing condyle but may show slight
widening of fibrocartilage on condyle or
increased vascularity in proliferative zone

29. Treatment Options
Confirmed non growing patients:
• Traditional orthognathic surgery
• Only address TMJ if disc displaced
Active condylar Hyperplasia Type IB
(patient a teenager or in their early 20’s)
Option 1:
• Unilateral high condylectomy
• Disc repositioning
• Orthognathic surgery

30. Treatment options
Active condylar Hyperplasia Type IB
Option 2
Wait until growth is complete and then
perform orthognathic surgery

31. Condylar Hyperplasia Type 1B
A 15-year-old female patient with
left-sided condylar hyperplasia
type 1B, bilateral displaced
articular discs, and significant
temporomandibular joint pain
and headaches. She was treated
in a single surgical stage with
1) unilateral left high condylectomy
2) bilateral disc repositioning;
3) bilateral ramus osteotomies;
4) multiple maxillary osteotomies;
5) nasal turbinectomies;
6) third molar re- moval

32. Malocclusion Unilateral Class III

33. At 3 years after surgery, the patient has good facial balance,
stable skeletal and occlusal relations, and is pain free.

34. OCCLUSION CLASS I ACHEIVED

35. Lateral Ceph CH type IB
Cephalometric analysis
does not reflect the
severity of this patient’s
left-sided condylar
hyperplasia type 1B
because the growth
vector is predominantly
horizontal, with the
mandible deviating off
to the right side.

36. Surgical treatment Ceph
Surgical treatment
consisted of 1) left high
condylectomy; 2) bilateral
articular disc
repositioning; 3) bilateral
mandib- ular ramus
sagittal split osteotomies;
and 4) maxillary
osteotomies to establish
good facial balance with
skeletal and occlusal
stability.

37. Condylar hyperplasia Type 2
• An abnormal unilateral excessive vertical growth
of mandible usually caused by a condylar
osteochondroma accompanied with unilateral
compensatory downward growth of maxilla
OR
• Unilateral mandibular condylar enlargement
caused by an osteochondroma that vertically
lengthens the ipsilateral mandible can shift it
towards the contralateral side and is not self
limiting relative to growth

38. CH type 2
• Progressive and deforming
• Age of onset: Two thirds of cases begin in
second decade

39. CH TYPE 2 Clinical Chracteristics
• Unilateral vertical elongation of Face and
Jaws(condyle ,neck,ramus,mand body and
dentoalveolus of ipsilteral mandible) increases
in height
• Not self limiting ;can grow indefinitely
• Ipsilateral posterior open bite

40. Imaging features CH type 2
• Unilateral vertical enlarged condylar
head,Neck, Ramus,Body
• MRI show ipsilateral disc commonly in place
• Contralateral TMJ arthritis and disc displaced
in 75% cases

41. Histology
• Osteochondroma:Layer of germinating
undifferentiated mesenchymal cells
,hypertrophic cartilage,islands of
chondrocytes in subchondral trabecular bone
;thickened and irregular bone trabeculae

42. Types of CH type 2
• Based on tumor morphology
• Two primary groups I) condylar hyperplasia
Type 2A
II) Condylar Hyperplasia Type 2B

43. Condylar Hyperplasia Type 2A:
• Enlargement of the condylar head and neck
with a predominant vertical growth vector of
osteochondroma without significant exophytic
tumor development
• Imaging features: Vertical growth vector no
horizontal exophytic groth of condyle

44. Condylar Hyperplasia TYPE 2B
• Indicates exophytic tumor extensions off the
condyle ,usually forward and medially with
the head becoming significantly enlarged and
deformed
• Imaging characteristics:enlargement of
condyle with exophytic growth of head

45. Treatment Options
• Ipsilateral Low Condylectomy to preserve
condylar neck
• Reshape the condylar neck to function as a new
condyle
• Disc repositioning on contralateral side when disc
displaced
• Orthognathic surgery to correct the associated
maxillary and mandibular deformities
• If TMJ disc NON SALVAGEABLE: Custom fitted
total joint prosthesis indicated

46. CH type 2A patient
• A -16year-old female patient
presented with condylar hyperplasia
type 2A.
• She first became aware of
developing facial asymmetry 4 to 5
years before the first appointment.
• She developed significant elongation
of the right side of the face, right-
side posterior open bite, pain, and
headache.
• Surgical treatment in a single stage
included 1) right low condylectomy;
2) bilateral temporomandibular joint
disc repositioning; 3) bilateral
mandibular ramus osteotomies; 4)
multiple maxillary osteotomies; and
5) right inferior border ostectomy
with preservation of the inferior
alveolar nerve.

47. OCCLUSION
• right-side posterior
open bite

48. POSTOPERATIVE PHOTOGRAPHS
• The patient 3.5 years
after surgery shows
good facial balance and
a stable skeletal and oc-
clusal result

49. Postoperative occlusion
• Shows improvement
and CLASS I relation

50. Preoperative Cephalometrics
• Cephalometric analysis
shows severe vertical
elongation of the right
side of the mandible at
the inferior border and
at the occlusal plane.

51. STO /PREDICTION TRACING
• Surgical treatment included
1) right low condylectomy;
2) bilateral
temporomandibular joint
articular disc reposition-
ing; 3) bilateral mandibular
ramus osteotomies; 4)
multiple maxillary
osteotomies; and 5)
resection of inferior border
of the mandible on the right
side with preservation of
the inferior alveolar nerve.

52. Surgical procedure
• Schematic for the treatment of
condylar hyperplasia type 2
includes a low condylectomy,
preserving the condylar neck as
outlined to remove the
osteochondroma. B, The condyle
is removed, the condylar neck is
recontoured, the articular disc is
repositioned with a Mitek anchor,
sagittal split osteotomies are
completed, and an inferior border
ostectomy is performed with
preservation of the inferior
alveolar nerve. Most of these
cases also had an indication for
maxillary osteotomies.

53. Type 3 CH
• Includes other rare benign tumors causing
condylar hyperplasia
• No specific age of onset
Clinical characteristics
• Unilateral facial enlargement
IMAGING
Varies from normal anatomy of condyle;usually
presenting as condylar enlargement

54. CH type 3
• Histology: benign tumor e.g
osteoma,neurofibroma,giant cell
tumor,fibrous
dysplasia,chondroma,chondroblstoma,Avm
• Treatment depends on pathology and size

55. CH type 4
• These are malignant tumors that originate in
the condyle causing enlargement
Age of Onset:no specific age
Clinical characteristics: unilateral facial
enlargement
• Imaging:varies from normal anatomy of
condyle presenting as condylar enlargement
with lytic lesions

56. CH type 4
• Histology: malignant tumors e.g
chondrosarcoma,multiple
myeloma,osteosarcoma,metastatic
lesions,Ewings Sarcoma
• Treatment: dependent on malignant
pathology

57. REFERENCES
• Wolford LM, Movahed R,Perez DE :A
Classification System for Conditions Causing
Condylar Hyperplasia. J Oral Maxillofac Surg
2014;72:567-95.
• LARRY WOLFORD