hemimandibular hyperplasia and facial asymmetry

Dr Sylvain Chamberland

TMJ PathologiesFacial 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

BermudaSylvain Chamberland

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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

Facial Asymmetry

ErB.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 Asymmetry1st & 2nd branchial arch syndromes

We will not discuss this topic today.



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



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



Diagnosed at birth. Prevalence1: 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



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-C Valcourt

CCC HF


Facial AsymmetryHyperplasia

Hypoplasia


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


Nomenclature According to Obwegeser

Hemimandibular Hyperplasia

Hemimandibular Elongation

Condylar Hyperplasia

Hybrid form

!

!

!

According to Wolford

CH Type 1

1a: unilateral

Vertical or horizontal or combo

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 3-5mm 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):321329!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;


ActiveGrowing patient



Vertical type

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


DecisionKaPaVa 17-08-11

Posterior segment + vertical elastics

Extrusion successful

KaPaVa 02-02-12

KaPaVa 15-12-11


DcisionKaPaVa 17-08-11

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

KaPaVa 02-02-12

KaPaVa 23-08-12



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 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 spring2011

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 3,2July 2011

Left 1,65 1,93

Right 1,58 2,13January 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


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

P-ALe 20-09-12


55 semaines

Dcompensation acheveP-ALe 20-09-12

P-ALe 05-08-13


Laterodeviation to left

Hyperplasy of the right condylar neck

MPo 16-08-06; 11a 5 m


Tx

RPE + facial mask

Slight improvement of the deviation

Persistence of the right class III relationship

MPo 16-08-06; 11a 5 mMPo 11-04-07; 12a 1 m


February 2007

Scintigraphy Tc99

= normal

MPo 16-08-06; 11a 5 mMPo 11-04-07; 12a 1 m MPo 16-04-08; 13a 1 m

MPo 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

MPo 16-08-06; 11a 5 m

MPo 11-04-07; 12a 1 m

MPo 16-04-08; 13a 1 m

MPo 11-04-07; 12a 1 m

MPo 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

MPo 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 uptakeM. Po.

Mean Maximum

Right 2,51 3,07January 2012

Left 1,68 1,56


Treatment

Avoid asymmetry aggravation

High condylectomy as soon as possible


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 openbiteMPo 17-10-11; 16a 7 m

MPo 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

MPo 21-05-13; 18a 2 m

Recall 13 months post condylectomy


Differential Diagnosis

Facial asymmetry caused by a functional shift

KaHa080205 KaVe080801


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


Normal growth of the left condyle

Persistence of splitted occlusal planeCrBo300804; 16a

CrBo050901; 13a


ActiveAdult patient


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

Facial Asymmetry

ErB.12-12-00; 22 ans

Patient initial


Attrition of the left posterior teeth

3rd molars extracted :~ 2 years

Jaw opening amplitude: 55mm

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


Vue panoramique

Hyperplasia of the right condyle:

Bigger & larger condylar head

Elongation of the ascending ramus


Vue panoramique

1996

Normal

left condyle

ErB.12-12-00; 22 ans


Scinti Tc99

Intense uptake of the left condyle


Post high condylectomy

ErB.12-12-00; 22 ans

ErB.07-06-01


Comprehensive ortho tx + 24, 34, 44

High Condylectomy Description of a New Technique

Radioguided high condylectomy using a -probe

Injection oftechnetium-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]

Sylvain Chamberland

Condylar neck elongated

No clear demarcation of

hyperplastic portion vs normal bone

-probe

Malleable retracor (shield)

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

Prevent reading of -emission of the cranial base

1st reading: right mandibular parasymphysis = 2965 CPS

2nd reading: right condyle = 4197 CPS

Marking the section to be resected

-probe was used until normal reading was obtain


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

-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 ProffitPersonal communication. January 2012


InactiveAdult 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

most likely explanation of the asymmetryMP.Ro-Ja.0404; 15a


Follow up 2 years

Stable occlusion

Persistence of chin asymmetry

Note hypodevelopment

of left md corpus

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


Osteochondroma35% 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


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 +++


Indication of a condylectomy: osteochondrome or

osteome

>20 years ago: Jigli osteotomy + genioplasty


Osteochondroma

56 y

Condylar hypertrophy noted

At 60 y

Osteochondroma

Li.Ma.220312-60yLi.Ma.290508-56


CBCT assessment

Tapering radiopaque mass extending from the anteromedial aspect of the condyle

Left condyle is normalR L


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 ProffitPersonal communication. January 2012


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


HypoplasiaTraumatism


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


!

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

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


Followed for 4 Years

Compensatory growth

Right condyle reshaped

normally

R: Overgrowth vertically?

L: Overgrowth horizontally?

PACl.160309; 14 years 9 months

PACl.160511; 16 ans 9 mois


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


Thank you

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hemimandibular hyperplasia and facial asymmetry

Health & Medicine

left pain

left chronic left tmj

yearsdr sylvain chamberland

left posterior teeth

left rightfacial asymmetryerb

affected cheek deviation

mandibular deviation

lateral open bite left