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CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 67-71

Comprehensive management of unilateral condylar hyperplasia with prognathic mandible


1 Department of Oral and Maxillofacial Surgery, Mamata Dental College, Giriprasad Nagar, Khammam, Andhra Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopedics, Mamata Dental College, Giriprasad Nagar, Khammam, Andhra Pradesh, India

Date of Web Publication13-Mar-2013

Correspondence Address:
Rajasekhar Gaddipati
Department of Oral and Maxillofacial Surgery, Mamata Dental College, Giriprasad Nagar, Khammam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.108522

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  Abstract 

Facial asymmetry does exist in general population as an innate equity and contributes to the uniqueness of an individual. Absolute facial symmetry of two halves of the face is a rare occurrence, some degree of right and left variation is not an exception. Management of facial asymmetry varies with the age and clinical features of the patient. A case of unilateral condylar hyperplasia on right side, with prognathic mandible was reported to the department. Detailed history, clinical examination, and radiographic (cephalometric) evaluation was carried out and a comprehensive management was designed, which included presurgical orthodontics, surgical procedures (condylectomy, bilateral sagittal split osteotomy, and lefort I osteotomy) followed by postsurgical orthodontics. This case report highlights the interdisciplinary mode of management in treating facial asymmetries for better results.

Keywords: Asymmetry, condyle, condylar hyperplasia, hyperplasia, prognathism


How to cite this article:
Gaddipati R, Vura NG, Rayapudi N, Tirunagari H. Comprehensive management of unilateral condylar hyperplasia with prognathic mandible. J NTR Univ Health Sci 2013;2:67-71

How to cite this URL:
Gaddipati R, Vura NG, Rayapudi N, Tirunagari H. Comprehensive management of unilateral condylar hyperplasia with prognathic mandible. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Apr 4];2:67-71. Available from: http://www.jdrntruhs.org/text.asp?2013/2/1/67/108522


  Introduction Top


Rarely, human face is perfectly symmetrical in its structure. [1] Various etiological factors like genetic, congenital, trauma, and functional habitual deviation result in the development of facial asymmetry. [1] Mandibular asymmetry is divided into condylar hyperplasia (CH) and hemimandibular hyperplasia (HH). CH is excessive unilateral growth of mandibular condyle, [1] rarely occurs bilaterally in which growth of condyle is continued at later age. HH is enlargement of condyle, ramus, and body of the mandible. [2] Rationale behind our treatment plan is to correct the facial asymmetry and to restore the stable functional occlusion.


  Case Report Top


A 24-year-old male patient was reported to the department of oral and maxillofacial surgery with chief complaint of deviation of chin towards left side. On extra-oral examination, patient had an obvious facial asymmetry, concave profile, skeletal Class III with retrognathic maxilla, prognathic mandible, and chin deviated to the left side [Figure 1]. Intra-oral examination revealed that deviation of lower dental midline of 8 mm to left side, Angle's class III molar relation on both sides, reverse overjet of 4 mm [Figure 2], occlusal cant seen on right side [Figure 3] resulted from compensateory vertical over development of maxilla. Cephalometric analysis (cephalometrics for orthognathics (COGS) and frontal analysis Grammon's and Keppenye) revealed asymmetry in the lower third of face with mandibular prognathism and retrognathic maxilla. The case was diagnosed as unilateral CH with prognathic mandible and retrognathic maxilla. Patient underwent presurgical orthodontics for leveling, alignment, and decompensation with fixed appliances in both the arches. Planning of operation was based on both clinical and radiographic examination [Figure 4] and [Figure 5]. Presurgical procedures included face bow transfer, model surgery, and the surgical splint (intermediate and final) preparation.
Figure 1: Pre-operative frontal

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Figure 2: Pre-operative occlusion

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Figure 3: Pre-operative Cant

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Figure 4: Pre-operative orthopantomography

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Figure 5: Pre operative lateral cephalogram

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The surgical management includes gap arthroplasty [Figure 6] on right side temporomandibular joint to remove the growth center through Rowe's pre-auricular approach with the preservation of facial nerve branches. Bilateral sagittal split osteotomy [Figure 7] performed with the differential setback of 11 mm on right side and 6 mm on left side with the placement of temporary splint for the correction of prognathism. Lefort I osteotomy [Figure 8] for the correction of occlusal cant (6°) was performed based on model surgery with the final splint in place. Post-operative period was uneventful; however, patient developed mild weakness of temporal and zygomatic branches of facial nerve which was resolved in 3 weeks. After 8 weeks of post-operative period, patient underwent postsurgical orthodontic treatment for 6 months, patient was followed for an year and a half after postsurgical orthodontics. By performing the above-mentioned synergistic procedures, the patient attained a straight profile [Figure 9], [Figure 10] and [Figure 11] and good symmetry with no deviation of mandible.
Figure 6: Intra-operative condylectomy

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Figure 7: Intra-operative bilateral sagittal split osteotomy

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Figure 8: Intra-operative lefort I osteotmy

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Figure 9: Post-operative frontal

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Figure 10: Post operative occlusion

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Figure 11: Postoperative cant

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  Discussion Top


CH was first described by Adams [3] in 1836 as a condition which causes overgrowth of mandible resulting in facial asymmetry is a selflimiting, nonmalignant. Mostly unilateral not been described in any other joint. [4] It usually develops during puberty and rarely begins after 20 years. [5] Pubertal onset strongly suggests the hormonal influence in its etiology. Suggested theories behind CH are trauma followed by excessive proliferation and repair, infection, hormonal influence, arthrosis, and hyper vascularity. [6] According to Obwegessor and Mekek, [4] different growth factors controlling the generalized hypertrophy and elongation are responsible for deformity and increased functional loading on temporomandibular joint. [3] In the present case report, CH is present on right side contrary to Nitzen et al who has stated that is highly gender-dependent with right side being more common in females and left side in males.

Prominent features of CH includes an enlarged condyle, elongated neck, outward bowing, and downward growth of body and ramus on affected side, if deformity occurs before the growth completion, occlusal plane usually becomes slanted for dental compensation. Posterior open bite with canting of occlusal plane is seen if deformity occurs after growth cessation. [7] In our case hyperplasia occurred before the completion of growth, and the presenting features were chin deviation, occlusal canting, cross bite, and outward bowing of mandible. In 1986 Obwegessor and Mekek [3] classified CH into type I hemimandibular elongation (horizontal growth vector type IIHH (vertical growth vector), and combination of both. In type I CH chin deviated to contralateral side, midline shift to contralateral side is seen, in type II CH ipsilateral open bite, compensatory vertical development of maxilla on affected side is seen. [4] The present case falls into the combination of type I and type II. According to clinical criteria, Nitzen et al. [4] classified asymmetry into three types as vertical, transverse, and combination. Case discussed here is categorized under combination criteria.

Management of CH depends on age at which it presents. [2] Traditionally, the surgical method includes orthognathic surgery for correction of asymmetry when further growth is not anticipated [4] because in our case the patient age is 24 years, we predict that further growth does not occur. According to Wolford et al. [3] simultaneous orthognathic surgery along with condylectomy is preferred as it supports the procedure we performed. If an occlusal cant exceeds 4° orthognathic surgery is indicated by Young et al., [8] as in our case occlusal cant was 6°, Lefort I osteotomy was performed where leveling of occlusal plane was done as stated by Fergusson. [9]


  Conclusion Top


Facial asymmetry is determined by careful and systematic examination of each facial area. Strategy of our treatment plan by combined orthodontic and maxillofacial protocol is to correct the dental asymmetry by pre and postsurgical orthodontics, skleletal asymmetry by gap arthroplasty to arrest the further growth at temporomandibular joint, lefort I osteotomy for leveling of occlusal and lip cant, and bilateral sagittal split osteotomy for the correction of prognathic mandible and deviation. All these surgical procedures [Figure 12] and [Figure 13], along with pre- and post-surgical orthodontics provided the patient with good functional and esthetic outcome. For a good prognosis, accurate diagnosis with well-planned orthodontic and surgical procedures is necessary.
Figure 12: Post operative orthopantomography

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Figure 13: Post operative lateral cephalogram

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  References Top

1.Thapliyal GK, Bandopadhyay TK, Kaushik. Non syndromal facial asymmetry. Medical Journal Armed Forces India 2005:61:297-9.  Back to cited text no. 1
    
2.Sandor GK, Habil, Taylor P, McGuire, Ylikontila LP. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am 2007:19:395-422.  Back to cited text no. 2
    
3.Villanueva-Alcojol L, Monje F, González-García R. Hyperplasia of the mandibular condyle: Clinical, histopathologic, and treatment considerations in a series of 36 patients. J Oral Maxillofac Surg 2011;69:447-55.  Back to cited text no. 3
    
4.Wolford LM, Mehra P, Reiche-Fischel O, Morales-Ryan CA, García-Morales P. Efficacy of high condylectomy for management of condylar hyperplasia. Am J Orthod Dentofacial Orthop 2002;121:136-50.136-151  Back to cited text no. 4
    
5.Kim YH, Jeon J, Rhee JT, Hong J. Change of lip cant after bimaxillary orthognathic surgery. J Oral Maxillofac Surg 2010;68:1106-11.  Back to cited text no. 5
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6.Lippold C, Kruse-Losler B, Danesh G, Joos U, Meyer U. Treatment of hemimandibular hyperplasia: The biological basis of condylectomy. Br J Oral Maxillofac Surg 2007;45:353-60.  Back to cited text no. 6
[PUBMED]    
7.Mehrotra D, Dhasmana S, Kamboj M, Gambhir G. Condylar hyperplasia and facial asymmetry: Report of five cases. J Maxillofac Oral Surg 2011;10:50-6.  Back to cited text no. 7
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8.Ferguson JW. Definitive surgical correction of the deformity resulting from hemimandibular hyperplasia. J Craniomaxillofac Surg 2005;33:150-7.  Back to cited text no. 8
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9.Nitzan DW, Katsnelson A, Bermanis I, Brin I, Casap N. The clinical characteristics of condylar hyperplasia: Experience with 61 patients. J Oral Maxillofac Surg 2008;66:312-8.  Back to cited text no. 9
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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