Facial asymmetry condylar hyperplasia or condylar hypoplasia (v a dgkfo)

Facial Asymmetry
Condylar Hyperplasia
or
Condylar Hypoplasia
Kieferorthopädie auf den Punkt Gebracht
11. - 14. Oktober 2017
World Conference Center Bonn
www.slideshare.net/sylvainchamberland

©sylvainchamberland.com
Biography
Sylvain Chamberland
•D.M.D. (Docteur en Médecine Dentaire), University Laval, 1983
•Private practice, general dentistry 1983-1988
•Certiﬁcate in Orthodontics, University of Montreal, 1990
•M.Sc. in dental science, University Laval, 2008
•Private practice in orthodontics since 1990
•Publications
✦ Closer look at SARPE, JOMS 2008
✦ Short-term and long-term stability of SARPE revisited, AJODO 2011
✦ Long-term dental and skeletal changes following SARPE, letter to editor, OOOO 2013
✦ Functional genioplasty in growing patients, AO 2015,
•Lecturer in several graduate program and scientiﬁc meeting in USA, Canada, Europe

In Memoriam
Capt. Vanessa Chamberland
June 25,1989 - November 14, 2016
Vanessa lived 10 000 days.  
It seemed like a moment.
The next 10 000 days that I, Carole,
Pier-Eric and Richard will live will be an
eternity.

Conflict of Interest Declaration
•I declare that neither I nor any member of my family have a financial
arrangement or affiliation with any corporate organization offering
financial support or grant monies for this continuing education
presentation, nor do I have a financial interest in any commercial
product(s) or services I will discuss in this presentation

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

•2 years post ortho
•Md deviation to the right
•Right TMJ clicking
✦ Is it caused by the occlusion?
Final Follow up 2 y
14 y 3 m 16 y 2 m

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 left
•Chronic left TMJ pain since >10 years

•♀, 36 ans
•Chronic left TMJ pain since >10 years
•Is it because of her occlusion? 
Her disc?

©Dr Sylvain Chamberland
Facial Asymmetry
1st & 2nd branchial arch syndromes
We want to exclude congenital deformities from this discussion.

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,
with fullness on the affected cheek
• Signiﬁcant deviation to the affected side
during opening
AJODO 2011;139:e435-e447
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
• Collapse of the condyle on the
coronoid process
• Temporal fossa is always present
AJODO 2011;139:e435-e447
Maezzini et al,True hemifacial microsomia and hemimandibular hypoplasia with
condylar-coronoid collapse: Diagnostic and prognostic differences,
AJODO2011;139:e435-e447

Hemifacial Microsomia
• 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

Hemifacial Microsomia
• Hypoplasia of
✦ Ascending ramus
✦ Condyle
✦ Coronoid process
✦ Absence of condyle and
temporal fossa
Maezzini et al,True hemifacial microsomia and
hemimandibular hypoplasia with condylar-
coronoid 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.)
Courtesy Dre A-CValcourt
CCC HF

Facial Asymmetry
Condylar Hyperplasia
Condylar Hypoplasia

Classiﬁcation system
•CH Type 1
✦ 1A : Bilateral
✓ Bilateral symmetric or asymmetric growth; self-limiting; can grow into mid-20s; class III occlusion
✦ 1B : Unilateral
✓ unilateral accelerated asymmetric growth; self-limiting; can grow into mid-20s; deviated mandibular
prognathism; ipsilateral class III, anterior and contralateral Xbite
•CH Type 2
✦ Unilateral vertical elongation of face and jaws; not self-limiting; ipsilateral posterior open bite
✓ Type 2 A: Osteochondroma
✓ Type 2 B: Osteome (horizontal exophytic tumor growth)
Wolford, Larry M, Reza Movahed, and Daniel E Perez. "A Classiﬁcation System for Conditions Causing Condylar Hyperplasia.  
JOMS 72, no. 3 (2014): doi:10.1016/j.joms.2013.09.002

Rodrigues, DB, Castro V, Condylar hyperplasia of the temporomandibular joint. Types, treatment, and surgical implications, Oral Maxillofacial Surg Clin N Am
27. 155-167 (2015): dx.doi.org/10.1016/j.coms.2014.09.011

•CH Type 3
✦ Unilateral facial
✓ Benign tumors: osteoma, neurofibroma, giant cell tumor, fibrous dysplasia,
chondroma, chondroblastoma, arteriovenous malformation
•CH Type 4
✦ Unilateral vertical enlargement
✓ Malignant tumors: chondrosarcoma, multiple myeloma, osteosarcoma,
metastatic lesion, Ewing sarcoma
Wolford, Larry M, Reza Movahed, and Daniel E Perez. "A Classification System for Conditions Causing Condylar Hyperplasia.  
JOMS 72, no. 3 (2014): doi:10.1016/j.joms.2013.09.002

Rodrigues, DB, Castro V, Condylar hyperplasia of the temporomandibular joint. Types, treatment, and surgical implications, Oral Maxillofacial Surg Clin N Am
27. 155-167 (2015): dx.doi.org/10.1016/j.coms.2014.09.011

•Previous classiﬁcation
✦ According to Obwegeser
✦ Hemimandibular Hyperplasia
✦ Hemimandibular Elongation
✦ Condylar Hyperplasia
✦ Hybrid form

Keep in mind
What is important is which treatment must be done for the
observed and diagnosed problem.
David Precious

Unilateral Condylar Hyperplasia
•Most frequent postnatal anomaly of growth of the TMJ
•Prevalence 2 F : 1 M
•Symmetry observed at birth, develops during 2nd decade
•Accelerated growth rate of condylar head & neck resulting 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

Therapeutic options
•Wait and see if
✦ Mild asymmetry
✦ Phasing out shown by serial Tc99 bone scan
✓ Asymmetry corrected by standard orthognatic surgery
•High condylectomy if
✦ 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;

Condylar Hyperplasia Type 2B
•Unilateral vertical elongation of face and jaws
✦ Vertical growth vector (Prevalence 15:1)
✦ Elongation + enlargement : Condylar head & neck
+ mandibular ramus and body
✦ Ipsilateral posterior open bite
✦ Progressive laterodeviation to the unaffected side
✦ Mandibular midline inclined to the affected side
Condyle & neck:
bigger & longer

•Posterior open bite suddenly occurred during treatment
•Mandibular midline deviated to the left
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
KaPaVa 29-03-11; 12 aKaPaVa 02-03-10; 11 a

Decision
•Observation and reassessment in 6 months
•Orthodontic extrusion of the lower right buccal segment
KaPaVa 17-08-11

•Posterior segment + vertical elastics 
 
 
 
•Extrusion was successful
Decision
KaPaVa 17-08-11
KaPaVa 02-02-12
KaPaVa 15-12-11

•Midline are coincident and a decent occlusion is achieved at
debonding
Décision
KaPaVa 17-08-11
KaPaVa 02-02-12
KaPaVa 23-08-12

•Horizontal type (CH type 1B)
✦ Horizontal growth vector;
✦ Growth is self-limiting
✦ 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 15-10-09; 14a 1mPA Le 11-02-04; 8a 5mPA Le 03-12-01; 6a 4m PA Le 19-05-11; 15a 8m

•Scintigraphie Tc99
•Scinti Tc99 = Positive (increased uptake) in spring 2011
•Left TMJ clicking at maximum jaw opening
PA Le 19-05-11; 15a 8mPA Le 15-10-09; 14a 1m PA Le 19-05-11; 15a 8m PA Le 15-10-09; 14a 1m
Compare the height
of sigmoid notch

•Frontal view
✦ Slight vertical compensation causing a cant of the occlusal plane
•Lateral view
✦ Splitting of the occlusal plane and inferior mandibular border
PA Le 19-05-11; 15a 8mPA Le 15-10-09; 14a 1m
Display of
13 ≠ 23
Pearl: distal angulation /5s

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.
Mean Maximum
Right 1,98 3,2
July 2011
Left 1,65 1,93
Right 1,58 2,13
January
2012
Left 1,25 1,97

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

At 68 weeks
•Pre surgery
•Dental decompensation achieved
✦ .021 x.025 TMA for 43 weeks
P-ALe 29-10-13

3D Planiﬁcation

Surgery
•Mx Le Fort 1
•Md: BSSO

•Still some asymmetry
✦ Would have beneﬁt from
sliding the chin to the right
as it was planned…
P-ALe 02-08-14
Tx time: 98 weeks

Follow up 20 Months in Retention
P-ALe 02-08-14

Hemimandibular Elongation 
Class III Subdivision Right
May 2011 April 2012 Jan 2015 Aug 2017

Aug 2017June 2012May 2011

•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 16-04-08; 13a 1 m
MéPo 11-04-07; 12a 1 m

• Evolution of the
asymmetry
• Slanting of inferior teeth
(oblique)
• Cant of the mouth
commissure
• Vertical asymmetry of
inferior border of the
chin
MéPo 16-08-06; 11a 5 m
MéPo 11-04-07; 12a 1 m
MéPo 16-04-08; 13a 1 m
MéPo 11-04-07; 12a 1 m
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
Display of  
13 ≠ 23
MéPo 17-10-11; 16a 7 m

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
M. Po.
Mean Maximum
Right 2,51 3,07
January
2012
Left 1,68 1,56

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  
have caused an anterior openbite
MéPo 17-10-11; 16a 7 m
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
•Facial asymmetry persist
•Patient declined any further treatment
MéPo 21-05-2013; 18a 2 m
Recall 13 months post
condylectomy

Follow up 4 y 3 m
MéPo 21-05-2013; 18a 2 m
13 m post condylectomy

Follow up 4 y 3 m
•Some overgrowth may have
occurred
•Further exam requested
✦ CBCT

•2 years post ortho
•Md deviation to the right
•Right TMJ clicking
✦ What happened between the
removal of the appliances and
monitoring 2 years post
treatment?
Final Suivi 2 ans
14 a 3 m 16 a 2 m

Scintigraphy
•She had clicking in the right TMJ near the end of ortho
treatment (2012)
✦ Discrete increase uptake in the left joint
✓ Decision to observe
•New scinti July 2014
✦ Decrease of maximum ratio
✓ Follow up December 2014: no change
•Follow up September 2015
✦ No worsening of the deviation. Persistence of a right click.
Février 2012
Juillet 2014

Conclusion
•Do not confuse a joint clicking problem with a problem of condylar
hyperplasia
•Clicking is rather a consequence of the condylar hyperplasia
causing torsion of the contralateral condyle in the glenoid fossa

Common clinical and radiographic characteristics
observed in asymmetrically growing condylar hyperplasia
type 1 patients
•Characteristics in asymmetric cases:
✦ 1. TMJ articular disc displacement and arthritis on the contralateral side as a result
of increased loading of that joint caused by the condylar hyperplasia on the
opposite side
✦ 2. Worsening facial and occlusal asymmetry, with the mandible progressively
shifting toward the contralateral side
✦ 3. Unilateral posterior cross-bite on the contralateral side
✦ 4. Transverse bowing of the mandibular body on the ipsilateral side
✦ 5. Transverse ﬂattening of the mandibular body on the contralateral side
Wolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321–329

Differential Diagnosis
•Facial asymmetry caused by a
functional shift
KaHa080205KaVe080801

Class II subdivision right
•Slight asymmetry to the right
•Right posterior Xbite
•Lower midline deviated to the right
CrBo050901; 13a

Ceph & Panogram
•Symmetric condyle
•No splitting of md border
•Splitting of the occlusal plane

Occlusal view
•Left side larger than the right side
•Asymmetric arch form
•Mx intrarch dental asymmetry: 26 more
mesial

2 y into tx…!
•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

Ceph & Panogram
•Splitting of the occlusal plane
•Splitting of md border
•Elongation of the left condyle

Bone scan
•Scinti Tc 99
✦ Positive

•High condylectomy
CrBo091203; 15a 3m

Final outcome
•After BSSO
CrBo300804; 16a

•Normal growth of the left condyle
•Persistence of splitted occlusal planeCrBo300804; 16a
CrBo050901; 13a

Active
Adult patient

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
Patient initial

Vue panoramique
•Hyperplasia of the left condyle :
✦ Bigger & larger condylar head
✦ Elongation of the ascending ramus

Vue panoramique
•1996
✦ Normal left
condyle
ErBé.12-12-00; 22 ans
•2000
✦ Hyperplasia
of left
condyle

Scinti Tc99
•Intense uptake of the left condyle

•Post high condylectomy
ErBé.12-12-00; 22 ans
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, andVillemaire 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]

©Sylvain Chamberland
•Condylar neck elongated
•No clear demarcation of
hyperplastic portion vs
normal bone
γ-probe
Malleable retracor (shield)
•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, andVillemaire 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]

©Sylvain Chamberland
•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
•Patient is placed on
soft diet for 7 days
•Postoperative period in
uneventful
•No sign of relapse
were noticed 9 months
post surgery

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

Inactive
Adult patient or after normal growth has ceased

Differential diagnosis
•Could be hypercondyle that has stop growing
•Could be hypoplasia following trauma to the joint
•Could be sequella of rhumatoid arthritis

Differential Diagnosis
•Absence of shift
•Transverse asymmetry
•Laterodeviated to left
•Right condyle longer than left
•Most likely explanation could be
✦ Left condylar hypoplasia
✓ Lack of vertical alveolar development on the left side
MP.Ro-Ja.0404; 15a

Follow up 2 years
•Stable occlusion
•Persistence of chin asymmetry
•Note hypodevelopment  
of left md corpus
•Increased left antegonial notch
MP.Ro-Ja.0707
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

•SARPE
•BSSO
Ja.Du.28-01-10; 43 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

Any Sceptics?
In 5th grade In Secondary I
Bike accident

Inactive
•Class III
•Anterior openbite
Do.Vo.20-04-09; 32 a

•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
Note:  
1st phase surgery: SARPE

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
✦ Tapering radiopaque mass extends from the
anteromedial aspect of the condyle
✦ Globular pattern
•Recurrence ~ 2% most likely because of incomplete
excision
Li.Ma.220312

CBCT assessment
•Tapering radiopaque
mass extending from the
anteromedial aspect of
the condyle
•Left condyle is normal
R L

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 the left
•Indication of a condylectomy : osteochondroma or osteoma
• >20 years ago : Jigli osteotomy + genioplasty

Osteochondroma
•♀ 56 y
✦ Condylar hypertrophy
noted
•At 60 y
✦ Osteochondroma
Li.Ma.220312-60yLi.Ma.290508-56

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

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

Hypoplasia
Rhumatoid Arthritis

Juvenile Rhumatoid Arthritis
•Class I
•Xbite 22/32
•Deviation to the left
•Followed by a rhumatologist
✦ Rx: methotrexate, Folic acid,
Inﬂiximab
MeGa20072017 9y5m

•Hypoplasia left condyle
•Deep left antegonial notch
•Splitting of Md inferior border
•No pain, no symptoms

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
•If bilateral : distoclusion + anterior openbite
•Recommandation post trauma
✦ 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
5 to 10% of
asymmetries or
severe md
deﬁciencies

•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

•Bilateral condylar fracture (because of a fall)
JuLe. 10 avril 2006
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

•Healing of condylar stumps
•Signiﬁcant shortening of the right ascending ramus
•Anterior posturing permits conterclockwise md rotation to close
the openbite
JuLe. 30 janvier 2008; 7 ans

•Normal development except the shortened right condyle
•Midline deviation toward the normal growing side
Ju.Le230412

•Diagnostic record prior to initiating comprehensive ortho tx.
Ju.Le280113

•Right short ramus : sequela of the fracture
✦ Explain deviation to the right on opening
•Left condylar neck and left condyle relatively normal

•At debonding
•Deviation to the right on opening
Ju.Le270415

Follow up 1 y
•Functional genioplasty
✦ Improved proﬁleJu.Le270415
Ju.Le180516

•At 2 years:
✦ Fall & dentoalveolar trauma: intrusion of primary incisor (51)
•Laterodeviation to the left
•Constriction of left hemimaxilla
•Ipsilateral Class II (class II subdivision left)
OlLa080914

•Hypoplasia of left TMJ. (Condylar-coronoïd collapse??)
•Increased left antegonial notch
✦ Compensatory growth at gonial angle
•Splitting of mandibular border and occlusal plane
Maezzini et al,True hemifacial microsomia and hemimandibular hypoplasia with condylar-
coronoid collapse: Diagnostic and prognostic differences,AJODO2011;139:e435-e447
OlLa080914

Follow up 8 months
•After RME + exo 53, 63
OlLa130415

Follow up +2 y
•Right: normal condylar growth
•Left: hypoplasia or normal growth followed the
loss of the stump
OlLa080217

Sequella of Trauma

At Baseline
•Panogram can
tells a look if you
look at the
condyles

Follow up 1 y into Retention
•Left condylar hypoplasia, likely sequella of the fall at 5-6y
•Deepened antegonial notch, compensatory growth at the
gonial angle

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

Growing patient
•Car accident
✦ Bilateral condylar fracture
✓ Fixation in the left (Reduced in the left)
✦ Parasymphyseal fracture in the right
✦ Le Fort 1 left segment
PACl.160309; 14 ans 9 mois

Follow up 4 Years
•Compensatory growth
✦ Right condyle reshaped normally
✦ R : Overgrowth vertically?
✦ L : Overgrowth horizontally?
PACl.160309; 14 years 9 months
PACl.27022013; 18 y 11 m

Follow up 8
Years
•Overgrowth right
condyle
✦ Right post Xbite
✦ Cant of lower
occlusal plane
•CH type 2 vertical
PACl.160309; 14 years 9 months
PACl.27022013; 18 y 11 m
PACl09052017; 22 y 10 m
PACl09052017; 22 y 10 m
PACl16032009
PACl.27022013; 18 y 11 m
PACl30102007

Conclusion
•Facial asymmetries are sometimes difﬁcult to diagnose
•An asymmetric growth can express itself in the adolescence without having
been present during childhood
•Articular clicking can be a confounding factor in the diagnosis, but should
be considered as a clue.
•The treatment often implies a surgical approach
•5 to10 % of the facial asymmetries are due to an undiagnosed early
condylar fracture or a traumatic impact in period of growth

Facial asymmetry condylar hyperplasia or condylar hypoplasia (v a dgkfo)

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