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

Facial AsymmetryCondylar Hyperplasia

or Condylar Hypoplasia

Kieferorthopädie auf den Punkt Gebracht11. - 14. Oktober 2017

World Conference Center Bonn

www.slideshare.net/sylvainchamberland

http://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

http://sylvainchamberland.com

In MemoriamCapt. 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 Asymmetry1st & 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-C Valcourt

CCC HF

Facial AsymmetryCondylar 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.2013.09.002Rodrigues, 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


http://dx.doi.org/10.1016/j.coms.2014.09.011


Classification system• 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.2013.09.002Rodrigues, 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


http://dx.doi.org/10.1016/j.coms.2014.09.011


Classification system• 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):321–329Bouchard 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


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

DecisionKaPaVa 17-08-11

KaPaVa 02-02-12

KaPaVa 15-12-11



•Midline are coincident and a decent occlusion is achieved at debonding

DécisionKaPaVa 17-08-11

KaPaVa 02-02-12

KaPaVa 23-08-12



Condylar Hyperplasia Type 1B • 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



Condylar Hyperplasia Type 1B ✦ 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 3,2July 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• 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 ElongationClass III Subdivision Right

May 2011 April 2012 Jan 2015 Aug 2017



Aug 2017June 2012May 2011



•Laterodeviation to left

•Hyperplasy of the right condylar neck

MéPo 16-08-06; 11a 5 m



•Tx

✦ RPE + facial mask

•Slight improvement of the deviation

•Persistence of the right class III relationship

MéPo 16-08-06; 11a 5 mMéPo 11-04-07; 12a 1 m



• February 2007

✦ Scintigraphy Tc99= normal

MéPo 16-08-06; 11a 5 mMéPo 11-04-07; 12a 1 m

MéPo 16-04-08; 13a 1 mMéPo 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 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

• 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 sideWolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321–329

1. Increased length of the condylar head and neck, without a



Differential Diagnosis

•Facial asymmetry caused by a functional shift

KaHa080205 KaVe080801



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



ActiveAdult 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, 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

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


©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



InactiveAdult 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 sideMP.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


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.

http://www.ncbi.nlm.nih.gov/pubmed/21203710


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 normalR 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 ProffitPersonal communication. January 2012


HypoplasiaRhumatoid 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


HypoplasiaTraumatism


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 planeMaezzini 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 reductionBut 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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