hyperplasia of the mandibular condyle

161

d. max.-fac. Burg. 8 (1980) 161-175

Hyperplasia of the Mandibular Condyle* A historical review of important early cases with a presentation and analysis of twelve patients

John E. deBurgh NORMAN, D o r o t h y M. PAINTER

Department of Maxillo,Facial Surgery, (Head: Mr. J. E. deB. Norman, MB, ChB, MDS, FDSR CS, FRA CDS) Mater Misericordiae General Hospital, Sydney and St. George Hospital, Kogarah Department of Pathology (Head: Brian F. Quinn, MB, BS, DCP, FRCPA), Mater Misericordiae General Hospital, Sydney, Australia

Summary Thirteen patients with condylar hyperplasia have been examined and twelve operated upon in a nine year period ending December 1979. A further eight patients with facial asymmetry, considered to be the sequelae of condylar hyperplasia, had extra condylar osteotomies carried out. As no specimens are available for his- topathological examination, they have been excluded from the series. There appears to be a similarity between the histological findings of osteochondromata of the mandibular condyle and coronoid processes, active condylar hyperplasia and the changes noticed in the region of the costo-chondral junction of the acromegalic rib.

Key-Words: Mandibular condyle; Condylar hyperplasia; Condylar hypertrophy; Facial asymmetry; Osteochondroma of mandible.

Preface

displacement of the lower jaw, the left median incisor tooth being opposite to, or a little beyond, the lateral incisor of the upper jaw, and the whole lower alveolar arch, with its teeth being, in a propor t iona te degree, lateralised. Moreover , the jaw was placed obliquely; the right ramus and angle being on a plane lower than the left."

George Murray Humphry (1856)

"The lower jaw presented the following peculiarities: projecting from the thickened neck of the right condyle was a mass of bone about an inch in length, and having somewhat the form of an inverted pyramid ."

Frederic S. Eve (May 15 th, 1883)

"In some rare cases, as in that of Mary Keefe, there may be an hypert rophy and elongation of the neck of the condyle, as also of the ramus of the lower jaw on one side; and in such a case there must, of course, be a crooked or distorted state of the lower part of the face, and the chin will point to the opposi te side."

Robert Adams (1873)

"A healthy young woman aged 21 years, with dark hair and florid complexion, was admit ted as an out-patient in January 1854, on account of a peculiar distort ion of the face. The chin was thrust to the left side further than would, under natural circumstances, be practical. This was caused by

* Paper read at the 4 tl~ Congress of the E.A.M.F.S. Venice, September 1978

Introduction

Hyperplas ia or hyper t rophy of the mandibular condyle, although uncommon, produces a number of abnormalit ies of the lower jaw and occlusion. Eiselsberg (1906), Gruca and Meisels (1926), Ivy (1927), Dufourmentel (1927 a, b), Rushton (1944, 1946, 1951), Gottlieb (1951). Although mandibular condylar hyperplasia has been recognized as a cause of facial asymmetry since the early nineteenth century it was considered necessary to review the early l i terature and adequately acknowledge the impor tant contribu- tions of these pioneer colleagues. Critical histological examinat ion of the excised mandibular condyles shows two distinct groups and these are enum- erated (Table 2 - vide infra). We propose a classification of mandibular condylar hyperplasia into active and inactive on the assumption that it may

0301-0503 /80 1500-0161 $03.00 © 1980 Georg rh ieme Verlag, Stuttgart - New York

162 John E. de Burgh Norman, Dorothy M. Painter

Fig. 1 Dr. Robert Adams case of Mary Keefe (1836).

be of greater significance in surgical management than a morphological and radiological description of the condyle. It is clear that in the group of young patients with active hyperplasia excision of the mandibular condyle is desirable if relapse is to be avoided. Follow-up studies confirm there has been no relapse to date in the operated patients. It is suggested that the first report of this condition in the English language was made in 1836 by Robert Adams (Adams 1873). The description and illustrations of his patient, Mary Keefe (Fig. 1), are a fine example of a meticulous clinical examination, although he (amongst others) considered the condition the result of chronic rheumatoid arthritis. The principal findings in the patient with condylar hyperplasia are a deviation of the chin to the contra-lateral side in association with prognathism, a bowing of the ramus and lower border of the jaw, angulation of the labial commissure, lateral tilting of the mandibular incisor teeth and a posterior open bite which is occasionally associated with a contra-lateral cross bite. The chin point and centre lines of the mandibular and maxillary incisors are not usually co-incidental. The symptoms of jaw joint dysfunction may be superimposed upon this clinical syndrome. Secon- dary deformity of the maxilla may occur in the extreme form with rotation or twisting in the coronal plane. The nasal septum and nasal tip reflect this as will the labial commissure, (Rowe 1972). The specimen of Mary Keefe, here illustrated

shows compensatory downgrowth of the right maxilla. Mary Keefe, a native of County Wicklow, suffered from chronic rheumatic arthritis and in addition complained of a constant aching pain in the right jaw, otalgia, stiffness and crepitus in the jaw joint. When she died (28 th July, 1840 with acute oedema of the larynx) five years later, Adams performed a post mortem examination. His findings at necropsy (1840) confirmed the diagnosis of condylar hyperplasia as we know it today: "When the thickened capsular ligament was cut into, the condyle of the lower jaw was found divested of all cartilaginous covering, it presented a rough, scabrous-looking surface; the neck of the condyle was more than an inch long, and was double the size of the neck of the opposite condyle; from its inner side a large bony spicula, about one quarter of an inch long, grew upwards and inwards, immediately in front of the internal lateral ligament (see Atlas, Plate 1., Fig. 1). The inter articular fibro-cartilage was altogether removed, as well as all cartilaginous covering, from the articular portion of the glenoid cavity, which was smooth, and expanded to nearly twice its normal size, at the expense of the maxillary eminence and root of the zygoma. The right ramus of the lower jaw, from its angle to the head of the bone inclusive, was not only an inch longer than natural, but was much thicker than the ramus of the left side, and was also bowed outwards, circumstances which accounted for the swollen appearance of the right side of the face and the projection of the chin to the left."

Historical Review

At least four surgeons and one physician during the nineteenth century recognized and described cases of condylar hyperplasia or hypertrophy. Although the specimens of Adams (1836), Hum- phry (1856) and Eckert (1899) do not appear to have been preserved, those of Heath (1883) and McCarthy (1883) remain extant, on display at the museums of The Royal College of Surgeons of England and University College Hospital, London (Table 1).

Heath's specimen (Fig. 2 a-d) Christopher Heath, surgeon to University College Hos- pital (1866-1900) operated upon a woman aged 36

Hyperplasia of the Mandibular Condyle 163

Fig. 2a

Fig. 2 b

Fig. 2c '-- ...... Fig. 2d

Fig. 2 (a) Illustrating the specimen from Mr. Christopher Heath's case of hypertrophy of the neck and condyle of the lower jaw, i, outer aspect; ii, inner aspect; iii, upper aspect. (From drawings by E. Gibson, Trans. Path• Soc. London•) (b) Heath's patient. (c and d) Contemporary photographs of Heath's specimen published by courtesy of the museum, University College Hospital Medical School. (Honorary curator, W. R. Merrington Esq., MS, FRCS), 1978•

Table 1 19 th Century Reports of Condylar Hyperplasia

Author Date Sex Age Side Description Figure

Adams, Robert 1836" F 30 yrs R author 1 Humphry, George M. 1856 F 21 yrs R author no illustration Heath, Christopher 1883 F 36 yrs L Victor Horsley 2 (a-d) McCarthy, Jerimiah 1883 M 40 yrs R Frederic S. Eve 3 (a-d) Eckert, Erich 1899** F 50 yrs R author 4 (a-c)

* First presented by Robert Adams to the Medical Section of the British Association, Bristol Meeting, September t836, collection in the Richmond Hospital (quoted by Adams 1873). * * Osteoma.


418 DISEASES OF TI fE

Z/y2crh'~p/~y of d,: 3¥c/: a,d Condyle was observed by Dr. Adams in the case of rheumatoid arthritis of the temporo- maxillary jNnt already referred to, and is beautifully shown in Plate 1 of his ldmirable "Atlas." Though occurring in a woman of only fldrty, thet,e can, I think, be no doubt;, from the description and drawings of her hand and feet, that the patient, was the subject of rheumatoid arthritis. It is by no means certain, however, that the hypertrophy of tim neck and condyle must be considered to be the results of that disease, Nr, ~s I shatl show, tdhi~s same mrs deferral V has been fmmd in patients otherwise healthy.

]?ig. 194 shows a lower jaw no like that figured in Adams' "Atlas" in every respect, that the preparations are evNently

identical in their natm'e. It was presented to the College of Sugeons' Museum (2205)by Mr, Jeremiah McCarthy, and is thus described by Mr. Eve :--

"A lower jaw with a mass of bone, having somewhat the form of an inverted pyramid, attached to the thickened neck

T E ~ P O t l O - M A X I L L A R Y ARTICULATION. 4 1 (9

of the right sondyMd process. The upper surface of the mass, corresponding to the base of the pyramid, is fiat m~d smooth as i[ it had been covered with fibro-cartib,ge (t~g. 195). Upon its ironer side is a deep indentation, from which a fissure extends outwards al~d downwm'ds nearly to t/he cxte~T~at surface of the bone. The indentatlon and the fissure constitute the upper boundary of a portion of bone wlfich,

/,'1 ~. 195,

from its form and position, might be taken for an enlarged condyle. Tile right half of the jaw is larger in all its dbncn~ sions than the left half, the breadth of the horizontal ranms in front of the angle being doable that on the left side, which, from the slenderness of the coronoid and condyloid processes, appears atrophied. ]}'rom amiddle-agcd man, who died with apoplexy. There wo~ a remarkable deformity of the face from the deviation of the symphysis from the middle line; and the projecgon of the enlarged condyle was considerable. The base of the skull was not examined, and nothing was found in the pos~-mortem examination except aflteroma of the vessels. Nothing unusual had been noticed about his mouth in childhood, nor could any account of an

-~:E2

Fig. 3a Fig. 3 b

Fig. 3c Fig. 3d

Fig. 3 (a and b) A description of McCarthy's case prepared by Mr. Frederick S. Eve and quoted by Christopher Heath. Photographs of pages 418 and 419 of Heath's, Injuries and diseases of the jaws (1884). (c and d) Contemporary photographs of the enlarged mandibular condyle (McCarthy's case) published by kind permission of The President and Council of the Royal College of Surgeons of England (19"78).


years and excised a hypertrophic mandibular condyle. This unique specimen is still held in the Museum of University College Hospital, London (Fig. 2 a-d). Heath made the observation that his own cases and those of Mr. Jeremiah McCarthy and Dr. Robert Adams "belonged to the same category". The museum catalogue, (Beck and Shattock 1881), gives the following details: 1407. "A section of the condyle, neck, coronoid process, and part of the ramus of the left side of a lower jaw. The natural size and shape of the condyle and neck are entirely altered, so as to form a mass expanded superiorly and measuring 4 cm. in the antero-posterior diameter. The greatly enlarged articular surface is irregular and in parts apparently covered with fibro-cartilage: the borders of this surface are nodular and obliquely fissured. The section of the hypertrophied condyle and neck displays cancellous bone surrounded by a thin compact layer."

"From a woman aged 36, whose face had for 10 years become gradually more deformed by the increasing displacement of the chin to the right side and the projection outwards of the left condyloid process. The movements of the jaw were restricted, and the length of the left ascending ramus was 3 inches, of the right 1'/2inch. She had an attack of hemiplegia, implicating the left side of the face, when she was 25 years of age and from this affection her limbs had recovered perfectly and her face partially." The part of the jaw preserved in the specimen was removed by operation with a very satisfactory result, the face being brought straight and the patient having free movement of the jaw. A detailed account of the case was published by Heath (1883, 1884). "Heath's teaching was practical with a great fund of common sense. He specialized in jaw surgery and of many surgical books he published one classic on injuries and diseases of the jaws was based on a Jacksonian prize essay at the Royal College of Surgeons in 1867" (Mer- rington 1976).

McCarthy's specimen (Fig. 3 a-d) One of the finest specimens of condylar hyperplasia or hypertrophy remains preserved in the museum of The Royal College of Surgeons of England, (Fig. 3 c and d). The specimen was presented to The College by Mr. Jeremiah McCarthy and first described by Mr. Frederick S. Eve (1883). This mandible from a 40 year old man who died in The London Hospital exhibits most of the physical characteristics described by Adams (1873) and others. Although the catalogue of the pathological specimens, (Paget et al., 1884) gives an excellent account of the case further details are provided by Christopher Heath (1884) in the chapter on diseases of the temporo- maxillary articulation and pages 418 and 419 are here reproduced, (Fig. 3, a and b) by courtesy of the Royal Society of Medicine. It is necessary to revisit the important paper of Dr. Erich Eckert (1899) which contains not only an illustration of the surgical specimen but pre- and post-operative photographs of his patient (Fig. 4, a-c).

Materials and Methods (Surgical Correction)

The surgical correction of hyperplasia of the mandibular condyle produces excellent results with restoration of both the occlusion and appearance. In the gross case, mandibular condylectomy and arthroplasty (of the hyperplastic condyle) in com- bination with osteotomy of the contra-lateral mandibular ramus allows rotation of the frag- ments and produces an aesthetic result. The bowed lower border is exposed through a skin crease incision in the neck and resected. Care is taken to determine the exact position of the mandibular canal prior to operation and this is best estimated by a sagittal tomogram of the mandible. The canal can then be accurately marked out and the neurovascular bundle dissected prior to comple- tion of the horizontal osteotomy (Fig. 11). Less severe degrees of deformity in the active case are successfully treated by excision of the affected mandibular condyle and a proportion of its surgical neck to allow the chin to be centred. The jaws are then immobilized for several weeks by the surgeon's favourite technique. When the deformity is of long standing and associated with marked prognathism, it is best managed with a bilateral mandibular osteotomy of the Obwegeser type (1964). This manner of treatment assumes that the condylar hyperplasia is no longer active, an assumption only justified if deviation of the chin has not progressed.

Results (Table 2)

The six patients histologically classified as having "inactive" hyperplasia presented with gross (albeit static) deviation of the lower jaw. One patient had received psychiatric treatment for a period; con- vinced that her face was distorted and her jaw growing to one side! The average age of this group was 28.5 years, and the duration of the complaint was in excess of four years in each patient. A cephalometric analysis was carried out on every patient. The sella turcica was within normal radiographic limits with no clinical evidence of acromegaly in the series. The average age of the patients with "active" hyperplasia was 18.1 years; approximately ten years difference between the two groups. These patients presented with moderate to gross deviation and all considered their deformity progres-

John E. de Burgh Norman, Dorothy M. Painter 166

\

Fig. 4a Fig. 4b Fig. 4c

Fig. 4 (a, b and c) The important case of Dr. Erich Eckert (1899) showing (a) pre-operative condition and the aesthetic post-operative result (b), with an accompanying drawing of the tumour (c).

sive. Four stated their occlusion was undergoing alteration. They reported the deformity to have first been noticed between two and three years previously. Our impression after an examination of informal family and school photographs tends to suggest that several of our patients may have been conservative in their estimation of the length of time the condition was pre-existant. A tomographic examination was carried out in the sagittal plane in every case and in the coronal plane in six others. These radiographs showed considerable elongation of the surgical neck of the condyle on the affected when compared with the contra-lateral side. The most extreme case measured 5 cm. from the tip of the capitulum to the level of the sigmoid notch. The contra-lateral mea- surement in this case was 2 cm. A comparison of cases 1 and 11 is interesting. In the former (F/39) the mandibular condyle was large and bosselated and the surgical neck grossly elongated (5cm.). The chin point was severely deviated (Fig. 9 c). Microscopic examination of the condyle showed no cartilage despite the length of history (4 + years) and the degree of deformity and the alternate diagnosis of osteochondroma of the condyle might have to be considered. Case 11 (M/23) presented with a three year history of progressive deviation and a painful jaw joint. Radiographic examination confirmed the grossly

elongated condyle with a boot shaped capitulum. The chin point was ahnost central (pre-operative photograph Fig. 12 c) although the bowing of the mandible was clearly marked. The distance from the crest of the capitulum to the level of the sigmoid notch was 4.5 cm. Microscopic examination of the condyle showed cartilage cells stream- ing past the osteocartilaginous transition zone (8.22 ram.).

Histopathology An histological examination of all mandibular condyles was carried out by a standard technique following slow decalcification and staining with haemotoxylin and eosin. A study of the section was made and the cartilage depth measured in millimetres from the surface of the fibro cartilage to the deepest cartilage island in each case. In the group of "active" hyperplasia the cartilage depth measured between 2.04 millimetres and 8.22 millimetres (average 4.59 millimetres), (Fig. 5, a-c). In the cases classified as "inactive" no islands of trapped cartilage were seen although scattered "ghost" cartilage cells were present in one specimen. Osteoarthritic changes were present in all the specimens examined. The most severe changes were noted in case I which shewed irregularity of the articular surface, loss of sub-articular bone and

Hyperplasia of the Mandibular Condyle

Table 2 Condylar Hyperplasia

167

No. Sex Age Microscopic Deformity Operation

"Inactive" hyperplasia 1 F 39 No cartilage 2 F 26 No cartilage 3 F 23 No cartilage 4 F 22 No cartilage 5 F 35 No cartilage 6 F 26 Scattered cartilage

"ghosts"

"Active" hyperplasia 7 F 17 2.04 mm. 8 F 18 2.53 mm. 9 F 13 3.44 mm.

10 M 21 5.00 mm. 11 M 23 8.22 mm.

12 F 17 6.34 mm.

Osteochondromata 13 F 71

14 M 2I

15

Gross deviation of chin Moderate deviation of chin Moderate deviation of chin Gross deviation of chin Moderate deviation of chin Moderate deviation of chin

(L) MC + SA (L) MC 4- SA + IMF (L) M C + S A + ( R ) VSSO + IMF (R) M C + S A + ( L ) OSSO + IMF (L) MC + SA 4- IMF (L) MC 4- SA 4- IMF

Moderate and progressing Moderate and progressing Gross and progressing Gross and progressing Moderate and progressing, bowing of lower border Gross and rapidly progressing

(L) M C + S A + ( R ) VSSO + IMF (R) M C + S A 4 - ( L ) VSSO + IMF (R) MC + SA + IMF (L) MC 4- SA 4- (R) VSSO 4- IMF (L) MC 4- SA + lower border reduction (L) MC 4- SA + IMF

distinctive cartilage cap

distinctive cartilage cap with "pseudo-condyle" showing changes of condylar hyperplasia

osteochondroma (L) mandibular condyle, swelling, trismus, deafness and pain. osteochondroma (L) mandibular coronoid process with history of progressive trismus.

Osteoarthrectomy 4- SA

Resection tumour/ coronoidectomy

The unoperated case F/19 with gross and progressive deviation to the (L) side is excluded from table.

MC + SA = Mandibular condylectomy and silastic arthroplasty. IMF = intermaxillary fixation. VSSO = vertical subsigmoid mandibular osteotomy. OSSO - oblique subsigmoid mandibular osteotomy.

extension of vascular f ibrous tissue f rom the

ar t icular surface into the m a r r o w spaces (which

were adipose). Where present sub-ar t icular bone

was sclerotic and relatively inact ive and seen t h roughou t the condyle.

The his tological f indings in the o s t e o c h o n d r o m a

of the co rono id process i l lustrated (Fig. 6) were

identical to those of condylar hyperplasia . The

"pseudo condy le" (Fig. 7) was found at opera t ion

to ar t iculate wi th the G R E A T E R wing of the

sphenoid and the pat ient unable to open his mou th for 6 years. O the r co rono id processes r emoved

(Fig. 8) showed no his tological s imilar i ty to this un ique specimen.

Case report A twenty-one-year-old male presented with a progressive history of difficulty in opening the mouth over a period of 6 years. Radiographs of the facial bones and mandible confirmed the left mandibular coronoid process to be grossly enlarged, angulated forward and sur-

mounted by a mushroom shaped mass. The patient was admitted to hospital for operation and blind nasal intu- bation was carried out with some difficulty as mouth opening was limited to 3 mm. A large osteochondroma of the left mandibular coronoid process was resected by the trans-oral route. Macroscopic examination confirmed the specimen to be 3.0 cm. in height and 2.0 cm. in the antero-posterior direction. The "pseudo-condyle" measured 1.5 cm. in greatest diameter and articulated with the posterior aspect of the GREATER wing of the sphenoid. The patient made uneventful post-operative progress and mouth opening has been maintained in excess of 3.0 cm. between the maxillary and mandibular incisor teeth over a five year period. Although histological examination of the specimen confirmed osteochondroma extensive areas showed changes identical to those of active condylar hyperplasia.

Case report A 71-year-old edentulous female patient presented with a progressive history of deafness, trismus and left preauricular pain in the absence of any significant aural disease. There was no relevant history of facial trauma. On examination there was a swelling immediately

] 6 8 John E. de Burgh Norman, Dorothy M. Painter

Fig. 5 (a) H 4- E, x30. Irregular columns of cartilage cells extending past the osteochondral junction into underlying bone. There is a preparation artifact separat- ing the fibrous and precartilage layers.

Fig. 5 (b) H + E, x 75. The layers are well defined. A -f ibrous layer B -thickened precartilaginous layer C -thickened cartilage layer D -normal bone with cartilage inclusions extending

past the osteochondral junction.

Fig. 5 Photomicrographs from a case of hyperplasia of the mandibular condyle.

Fig. 5 (c) H 4- E, x180. The fibro-cartilaginous transition zone containing plump normal cartilage cells.

Fig. 6 Photomicrograph from author's case of osteochondroma of the mandibular coronoid process showing similarity to Fig. 5 (b). H 4- E, x 75.


Fig. 7 True lateral photograph of osteochondroma of Fig. 8 Hypertrophy of the coronoid process in a case mandibular coronoid process with "pseudo-condyle". of long standing mandibular ankylosis.

anterior to the left tragus. The left AUDITORY meatus was reduced to a vertical slit by the bony hard mass. There was no deviation of the chin point. Radiographs of the left mandible and temporal bone confirmed a dense mushroom-shaped mass replacing the left mandibular condyle. This mass was apparently fused to the temporal bone with no evidence of a plane of cleavage or a joint space. The patient was admitted to hospital for operation and the left temporo mandibular joint was explored through a modified facelift incision. A large osteo-cartilaginous mass was demonstrated uniting temporal bone and ramus mandibularis. This mass extended medially for 3 cm. and was fused to the skull base. An osteoarthrectomy was carried out and a silastic arthroplasty achieved utilizing a Dow-Corning Swanson ulnar prosthesis. The wound was closed in layers and drained. The patient made excellent post-operative progress and was discharged home on day seven. Macroscopic examination of the bosselated mass confirmed it to be 2.5 cm. in height, 2.5 cm. in the antero-posterior direction and 3.0 cm. in a medio-lateral direction. Histological examination confirmed osteochondroma (Spjut et al. 1971).

Temporo-mandibular Meniscus

George M u r r a y Humphry (1856), surgeon to

Addenb rookes Hospi ta l , Cambr idge descr ibed the opera t ion of mand ibu la r condy lec tomy in a case of

condylar hyperplasia. His opera t ive findings are

identical to ou r o w n and his c o m m e n t s on the

appearance of the mand ibu la r condyle and its

meniscus are apposi te . In only one of the pat ients

(Case 1, F/39) ope ra ted upon in this depa r tmen t

was the t e m p o r o - m a n d i b u l a r meniscus part ial ly ossified. The condyle and meniscus are i l lustrated

(Fig. 9, a and b) and the p h o t o m i c r o g r a p h s show

the extent of this ossif icat ion, (Fig. 10). As a gen-

eral rule secondary changes in the meniscus are

u n c o m m o n .

" I t was much al tered in shape, widened and flat-

tened, having an uneven kno t ty surface, covered

by structure present ing the appearance of fibro-

cartilage. I found the in terar t icular cart i lage lying in the back par t of the glenoid cavity, misshapen,

thick, hard and knot ty . The surface of the glenoid

cavity was uneven; and, judging f rom the informa-

t ion conveyed by the finger, I conc luded it has undergone changes s imilar to those in the con-

dyle", (Humphry 1856).

Fo l low-up

There have been no relapses in either the " ac t i ve" or " i nac t i ve" g roup treated. All condyla r resec-

tions were carr ied ou t at the low level and wi th in 5 ram. of the s igmoid notch of the ramus man-

dibularis. Regular fo l low-up has been carr ied out

] 70 John E. de Burgh Norman, Dorothy M. Painter

C

. . . . Fig. 9a Fig. 9b

Fig. 9 (a) Specimen of condylar hyperplasia showing large bosselated mass surmounting the surgical neck of the condyle (C). The temporo mandibular meniscus (M) is pictured above and was found at operation lying detached within the glenoid fossa. (b) Tomogram of hyperplastic condyle and ossified meniscus; inset of contact radiograph of the specimen. (c) Pre-operative photographs (case 1) showing right mandibular deviation (cf case 11 ).

Fig. 9c

Fig. 10 Photomicrograph of the meniscus illustrated in Fig. 9 showing osteo-cartilaginous transition zone. (H 4- E, x 30).


Fig. 11

Fig. 11 H - hyperplastic condyle; RM - ramus mandibularis. EXC - the excised portion of the corpus mandibularis. The hatched line demonstrated the level of horizontal osteotomy immediately below the neurovascular canaL.

Fig. 12 Pre- and post-operative photographs of four patients in this series. a and b Case No. 3 c and d Case No. 11 e and f Case No. 8 g and h Case No. 12

Fig. 12a Fig. 12b

Fig. 12c Fig. 12d

1 7 2 John E. de Burgh Norman, Dorothy M. Painter

Fig. 12e Fig. 12f

Fig. 12g Fig. 12h

in all cases and the absence of relapse is confirmat- ory evidence that the cause of the deformity was within the mandibular condyle. In case number 11 (M/23) there was gross and progressive bowing of the lower border of the mandible. This bowing was considered to be secondary to the condylar hyperplasia. At post-operative follow-up (year five) there was no evidence of relapse.

Discussion

If the stimulus to bone growth is reflected by the entrappment of cartilage as it seems to be in

acromegaly, we postulate that those condylar specimens with no cartilage islands are quiescent and the deformity static. This has in fact been borne out by the clinical history in each case (Table2). Patients with condyles showing an increasing depth of entrapped cartilage have been aware of a recent and rapid change in facial sym- metry. The more recent and the more rapid, the deeper the cartilage islands. This bears no relationship to the age of the patient. The cartilage in all the histological sections appears normal as it does in the acromegalic ribs examined. We gain the clinical impression that a transitional group of


Fig. 13a Fig. 13b

Fig. 13c

Fig. 13 (a) Plain radiograph of bosselated osteochondroma of the left mandibular condyle. (b) Pre-operative photograph of osteochondroma illustrating osteo- cartilaginous union with temporal bone. The temporalis muscle has been split and retracted to provide surgical access. (c) Orthopantomograph of the osteochondroma (vide supra).

adult patients may exist whose chief complaint is of alteration in the occlusion and mandibular deviation of mature onset but in whom little or no cartilage is found on examination of the mandibular condyle. There are insufficient patients in this "transitional group" to draw any definite conclusions. The patients have been dentate adults who have presented within twelve to eighteen months of the onset of symptoms. Although histological examination of the mandibular condyle shows no significant changes is it possible that condylar growth has been reactivated after skeletal growth has ceased? This small group may represent the earliest stages of mature onset (active) condylar hyperplasia. It should be emphasized that this is a clinical impression gained over the last decade and

is made in the hope that it will be constructively criticized by colleagues. Miiller (1978, 1979) has reviewed the important theories of aetiology of condylar hyperplasia and reported a unilateral case associated with acromegaly. There was no significant history of aural disease or trauma in our group of patients. Although cartilaginous neoplasms of the jaws are uncommon (Lucas 1976) the more florid cases seen with large bosselated tumefactions of the condyle are indisputably tumours, either osteoma, (Nvaohu and Koch 1974), osteochondroma or chondroma, (Kanthak and Harkins 1938). Other condylar neoplasms have been described but are of singular rarity (Fig. 13, a-c). It is utilikely the remainder are enchondroma and


the terms "active" and "inactive" hyperplasia are applicable depending upon the presence or absence of a thickening of the pre-cartilage and cartilage layers. If, in addition to the clinical and radiographic findings, there is microscopic evidence of significant cartilage inclusions extending past the osteochondral junction a diagnosis of "active" condylar hyperplasia may be made, in the normal adult, with impunity.

Conclusions

1 .19 th century European and English surgeons and physicians recognized the relationship between the mandibular condyle and the resultant deformity of the lower jaw. It is fortuitous that specimens of great historical importance were available in a London medical school and the Royal College of Surgeons of England.

2. A clinical and histological classification of "active" and "inactive" hyperplasia of the mandibular condyle is proposed.

3. On a small series of thirteen patients we suggest that this may be predominantly a feminine deformity.

4. Surgical correction of the deformity has been carried out in twelve of the thirteen cases. The thirteenth patient developed an intra-osseous giant cell reparative granuloma of the ipsilateral corpus mandibularis. She was pregnant when last seen for review and has subsequently migrated to North America and been lost to follow-up.

5. The results of surgical correction of the deformity have been aesthetically and functionally pleasing with no evidence of relapse. The average period of hospitalisation was seven days; the surgical scars are inconspicuous and there have been no deaths in the series.

6. A case of osteochondroma of the mandibular coronoid process is included. A "pseudo-condyle" had formed with a nearthrosis between it and the GREATER wing of the sphenoid. Surgi- cal excision of the turnout and the entire coronoid process resulted in cure. A long standing case of osteochondroma of the mandibular condyle producing trismus and deafness is included for comparison.

Acknowledgements Appreciation and thanks are due Professor Hugo Obwegeser MD., DMD, FDSRCS, for his encourage- ment to publish this paper and Dr. Edmond Hirst MB, DCP, FRCPA, Director, Kanematsu Institute, Sydney Hospital for permitting access to the specimens of acromegalic ribs. Thanks are due Miss Elizabeth Allan, curator, Hunterian Museum for her invaluable assist- ance in tracing specimens and records. The historical section was prepared with the generous help of J. D. Maynard Esq., MS, FRCS, consultant surgeon and honorary curator of The Gordon Museum, Guy's Hospital Medical School; W. R. Merrington Esq., MS, FRCS, Honorary curator to The Museum, Univer- sity College Hospital Medical School and Dr. Martin Israel MRCP, FRC, Path., Royal College of Surgeons of England. Photographs of McCarthy's specimen are published by kind permission of The President and Council of The Royal College of Surgeons of England. Illustrations have been prepared by the photographic units of The Royal Society of Medicine, The Royal College of Surgeons of England, Guy's Hospital Medical School, University College Hospital Medical School and by Mr. Raymond de Berquelte, University of Sydney. Thanks are also due Professors M. Jolly and G. C. Stacy, L. P. Oliver Esq., DFC, T. E. C. Williamsz Esq., FRCS. The invaluable advice of Professor H. P. Freihofer MD., DMD, in establishing the final format of the paper is acknowledged with pleasure.

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Mr. J. E. deB. Norman, 9 West Street, Hurstville NSW 2220, Australia

hyperplasia of the mandibular condyle

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