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

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To differentiate non syndromic pathology that cause facial asymmetry.
To understand the effect of unilateral condylar hyperplasy in a growing and non-growing individual.
To Understand the effect of condylar fracture or trauma (impact) to the joint that may affect mandibular growth.
To know the diagnostic test and surgical treatment that is recommended.

Publié dans : Santé & Médecine
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Facial asymmetry condylar hyperplasia or condylar hypoplasia (v a dgkfo)

  1. 1. Facial Asymmetry Condylar Hyperplasia or Condylar Hypoplasia Kieferorthopädie auf den Punkt Gebracht 11. - 14. Oktober 2017 World Conference Center Bonn www.slideshare.net/sylvainchamberland
  2. 2. ©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
  3. 3. ©sylvainchamberland.com
  4. 4. ©sylvainchamberland.com
  5. 5. In Memoriam Capt. Vanessa Chamberland June 25,1989 - November 14, 2016 Vanessa lived 10 000 days. 
 It seemed like a moment. The next 10 000 days that I, Carole, Pier-Eric and Richard will live will be an eternity.
  6. 6. ©sylvainchamberland.com 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
  7. 7. ©sylvainchamberland.com 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
  8. 8. ©sylvainchamberland.com •Attrition of the left posterior teeth •3rd molars extracted :~ 2 years •Jaw opening amplitude : 55mm •Right lat. excursion : 12mm; left : 7mm
  9. 9. ©sylvainchamberland.com •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
  10. 10. ©sylvainchamberland.com Facial Asymmetry •Right lateral open bite •Left TMJ click •Pain on palpation: left pre-auricular area NaRo.01-02-06; 16 y
  11. 11. ©sylvainchamberland.com •♀, 36 ans •Laterodeviation to left •Chronic left TMJ pain since >10 years
  12. 12. ©sylvainchamberland.com •♀, 36 ans •Laterodeviation to left •Chronic left TMJ pain since >10 years •Is it because of her occlusion?
 Her disc?
  13. 13. ©sylvainchamberland.com
  14. 14. ©Dr Sylvain Chamberland Facial Asymmetry 1st & 2nd branchial arch syndromes We want to exclude congenital deformities from this discussion.
  15. 15. ©Dr Sylvain Chamberland 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
  16. 16. ©Dr Sylvain Chamberland 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 Courtesy Dr Dany Morais Maezzini et al,True hemifacial microsomia and hemimandibular hypoplasia with condylar-coronoid collapse: Diagnostic and prognostic differences, AJODO2011;139:e435-e447
  17. 17. ©Dr Sylvain Chamberland 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 Courtesy Dr Dany Morais Semin Orthod 2011;17:235-245
  18. 18. ©Dr Sylvain Chamberland Hemifacial Microsomia • Hypoplasia of ✦ Ascending ramus ✦ Condyle ✦ Coronoid process ✦ Absence of condyle and temporal fossa Maezzini et al,True hemifacial microsomia and hemimandibular hypoplasia with condylar- coronoid collapse: Diagnostic and prognostic differences,AJODO2011;139:e435-e447 Pedersen TK and Norholt SE, Early Orthopedic Treatment and Mandibular Growth of Children with Temporomandibular Joint Abnormalities, Semin Orthod 2011;17:235-245.) Courtesy Dre A-CValcourt CCC HF
  19. 19. ©sylvainchamberland.com
  20. 20. Facial Asymmetry Condylar Hyperplasia Condylar Hypoplasia
  21. 21. ©sylvainchamberland.com Classification system •CH Type 1 ✦ 1A : Bilateral ✓ Bilateral symmetric or asymmetric growth; self-limiting; can grow into mid-20s; class III occlusion ✦ 1B : Unilateral ✓ unilateral accelerated asymmetric growth; self-limiting; can grow into mid-20s; deviated mandibular prognathism; ipsilateral class III, anterior and contralateral Xbite •CH Type 2 ✦ Unilateral vertical elongation of face and jaws; not self-limiting; ipsilateral posterior open bite ✓ Type 2 A: Osteochondroma ✓ Type 2 B: Osteome (horizontal exophytic tumor growth) Wolford, Larry M, Reza Movahed, and Daniel E Perez. "A Classification System for Conditions Causing Condylar Hyperplasia. 
 JOMS 72, no. 3 (2014): doi:10.1016/j.joms.2013.09.002 Rodrigues, DB, Castro V, Condylar hyperplasia of the temporomandibular joint. Types, treatment, and surgical implications, Oral Maxillofacial Surg Clin N Am 27. 155-167 (2015): dx.doi.org/10.1016/j.coms.2014.09.011
  22. 22. ©sylvainchamberland.com 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.2013.09.002 Rodrigues, DB, Castro V, Condylar hyperplasia of the temporomandibular joint. Types, treatment, and surgical implications, Oral Maxillofacial Surg Clin N Am 27. 155-167 (2015): dx.doi.org/10.1016/j.coms.2014.09.011
  23. 23. ©sylvainchamberland.com Classification system •Previous classification ✦ According to Obwegeser ✦ Hemimandibular Hyperplasia ✦ Hemimandibular Elongation ✦ Condylar Hyperplasia ✦ Hybrid form
  24. 24. ©sylvainchamberland.com Keep in mind What is important is which treatment must be done for the observed and diagnosed problem. David Precious
  25. 25. ©sylvainchamberland.com 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)
  26. 26. ©sylvainchamberland.com 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
  27. 27. ©sylvainchamberland.com Dynamic Aspect •Active ✦ Growing patient ✦ Adult •Inactive ✦ Adult
  28. 28. ©sylvainchamberland.com 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?)
  29. 29. ©sylvainchamberland.com High Condylectomy •Removal of the top 3-5 mm of the condylar head including the lateral and medial poles •In most cases, pathologic portion is difficult to identify making bone resection arbitrary Wolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321–329 Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2;
  30. 30. ©sylvainchamberland.com
  31. 31. Active Growing patient
  32. 32. ©sylvainchamberland.com 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 Courtesy Dr Dany Morais Condyle & neck: bigger & longer
  33. 33. ©sylvainchamberland.com •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
  34. 34. ©sylvainchamberland.com •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
  35. 35. ©sylvainchamberland.com Decision •Observation and reassessment in 6 months •Orthodontic extrusion of the lower right buccal segment KaPaVa 17-08-11
  36. 36. ©sylvainchamberland.com •Posterior segment + vertical elastics
 
 
 
 •Extrusion was successful Decision KaPaVa 17-08-11 KaPaVa 02-02-12 KaPaVa 15-12-11
  37. 37. ©sylvainchamberland.com •Midline are coincident and a decent occlusion is achieved at debonding Décision KaPaVa 17-08-11 KaPaVa 02-02-12 KaPaVa 23-08-12
  38. 38. ©sylvainchamberland.com 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
  39. 39. ©sylvainchamberland.com 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
  40. 40. ©Dr Sylvain Chamberland 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
  41. 41. ©sylvainchamberland.com •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
  42. 42. ©sylvainchamberland.com •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
  43. 43. ©sylvainchamberland.com Scintigraphy •In July ratio 3,2/1,93 = 1,66 •In January: ratio 2,13/1,97 = 1,08 •Diminution of the activity •Decision: ✦ No condylectomy ✦ Initiate comprehensive ortho treatment at appropriate timing (around 17 y) ✦ Scinti presurgery if midline ∆ P.-A. Le. Mean Maximum Right 1,98 3,2 July 2011 Left 1,65 1,93 Right 1,58 2,13 January 2012 Left 1,25 1,97
  44. 44. ©sylvainchamberland.com Tx •Goal : avoid the progression of the facial asymmetry •Orthosurgical tx ✦ Dentoalveolar decompensation ✦ Bimaxillary surgery ✦ High condylectomy could be possible if still actively overgrowing
  45. 45. ©sylvainchamberland.com At 10 weeks •Dentoalveolar decompensation •Early engagement of rectangular wire: 16x22/20x20 niti P-ALe 20-09-12
  46. 46. ©sylvainchamberland.com At 68 weeks •Pre surgery •Dental decompensation achieved ✦ .021 x.025 TMA for 43 weeks P-ALe 29-10-13
  47. 47. ©sylvainchamberland.com 3D Planification
  48. 48. ©sylvainchamberland.com Surgery •Mx Le Fort 1 •Md: BSSO
  49. 49. ©sylvainchamberland.com •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
  50. 50. ©sylvainchamberland.com
  51. 51. ©sylvainchamberland.com Follow up 20 Months in Retention P-ALe 02-08-14
  52. 52. ©sylvainchamberland.com
  53. 53. ©sylvainchamberland.com Hemimandibular Elongation
 Class III Subdivision Right May 2011 April 2012 Jan 2015 Aug 2017
  54. 54. ©sylvainchamberland.com Aug 2017June 2012May 2011
  55. 55. ©sylvainchamberland.com
  56. 56. ©sylvainchamberland.com
  57. 57. ©sylvainchamberland.com •Laterodeviation to left •Hyperplasy of the right condylar neck MéPo 16-08-06; 11a 5 m
  58. 58. ©sylvainchamberland.com •Tx ✦ RPE + facial mask •Slight improvement of the deviation •Persistence of the right class III relationship MéPo 16-08-06; 11a 5 m MéPo 11-04-07; 12a 1 m
  59. 59. ©sylvainchamberland.com • February 2007 ✦ Scintigraphy Tc99
 = normal MéPo 16-08-06; 11a 5 m MéPo 11-04-07; 12a 1 m MéPo 16-04-08; 13a 1 m MéPo 11-04-07; 12a 1 m
  60. 60. ©sylvainchamberland.com • 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
  61. 61. ©sylvainchamberland.com •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
  62. 62. ©sylvainchamberland.com Scinti Report •Metabolism augmentation in the right condyle ✦ Mean asymmetry index right / left = 1,49 ✦ Maximum asymmetry index right / left = 1,97 •Right intense uptake M. Po. Mean Maximum Right 2,51 3,07 January 2012 Left 1,68 1,56
  63. 63. ©sylvainchamberland.com Treatment •Avoid asymmetry aggravation •High condylectomy as soon as possible •Dentoalveolar decompensation •Comprehensive ortho treatment, bimaxillary surgery
  64. 64. ©sylvainchamberland.com •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
  65. 65. ©sylvainchamberland.com •High condylectomy •~5 mm of the condylar head is shaved •The articular disk is preserved (not touched or detached)
  66. 66. ©sylvainchamberland.com •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
  67. 67. ©sylvainchamberland.com Follow up 4 y 3 m MéPo 21-05-2013; 18a 2 m 13 m post condylectomy
  68. 68. ©sylvainchamberland.com Follow up 4 y 3 m •Some overgrowth may have occurred •Further exam requested ✦ CBCT
  69. 69. ©sylvainchamberland.com •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
  70. 70. ©sylvainchamberland.com 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
  71. 71. ©sylvainchamberland.com 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
  72. 72. ©sylvainchamberland.com Common clinical and radiographic characteristics observed in asymmetrically growing condylar hyperplasia type 1 patients •Characteristics in asymmetric cases: ✦ 1. TMJ articular disc displacement and arthritis on the contralateral side as a result of increased loading of that joint caused by the condylar hyperplasia on the opposite side ✦ 2. Worsening facial and occlusal asymmetry, with the mandible progressively shifting toward the contralateral side ✦ 3. Unilateral posterior cross-bite on the contralateral side ✦ 4. Transverse bowing of the mandibular body on the ipsilateral side ✦ 5. Transverse flattening of the mandibular body on the contralateral side Wolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321–329
  73. 73. ©sylvainchamberland.com
  74. 74. ©sylvainchamberland.com Differential Diagnosis •Facial asymmetry caused by a functional shift KaHa080205KaVe080801
  75. 75. ©sylvainchamberland.com Class II subdivision right •Slight asymmetry to the right •Right posterior Xbite •Lower midline deviated to the right CrBo050901; 13a
  76. 76. ©sylvainchamberland.com Ceph & Panogram •Symmetric condyle •No splitting of md border •Splitting of the occlusal plane
  77. 77. ©sylvainchamberland.com Occlusal view •Left side larger than the right side •Asymmetric arch form •Mx intrarch dental asymmetry: 26 more mesial
  78. 78. ©sylvainchamberland.com 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
  79. 79. ©sylvainchamberland.com Ceph & Panogram •Splitting of the occlusal plane •Splitting of md border •Elongation of the left condyle
  80. 80. ©sylvainchamberland.com Bone scan •Scinti Tc 99 ✦ Positive
  81. 81. ©sylvainchamberland.com •High condylectomy CrBo091203; 15a 3m
  82. 82. ©sylvainchamberland.com Final outcome •After BSSO CrBo300804; 16a
  83. 83. ©sylvainchamberland.com •Normal growth of the left condyle •Persistence of splitted occlusal planeCrBo300804; 16a CrBo050901; 13a
  84. 84. ©sylvainchamberland.com
  85. 85. ©Dr Sylvain Chamberland Active Adult patient
  86. 86. ©sylvainchamberland.com 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
  87. 87. ©sylvainchamberland.com Vue panoramique •Hyperplasia of the left condyle : ✦ Bigger & larger condylar head ✦ Elongation of the ascending ramus
  88. 88. ©sylvainchamberland.com Vue panoramique •1996 ✦ Normal left condyle ErBé.12-12-00; 22 ans •2000 ✦ Hyperplasia of left condyle
  89. 89. ©sylvainchamberland.com Scinti Tc99 •Intense uptake of the left condyle
  90. 90. ©sylvainchamberland.com •Post high condylectomy ErBé.12-12-00; 22 ans ErBé.07-06-01
  91. 91. ©sylvainchamberland.com
  92. 92. ©sylvainchamberland.com •Comprehensive ortho tx + 24, 34, 44
  93. 93. ©sylvainchamberland.com High Condylectomy Description of a New Technique •Radioguided high condylectomy using a γ-probe •Injection of technetium-99m methylene diphosphate, 
 25 mCi, 2 hours pre op Bouchard C, Paris M, andVillemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
  94. 94. ©Sylvain Chamberland •Condylar neck elongated •No clear demarcation of hyperplastic portion vs normal bone γ-probe Malleable retracor (shield) •Malleable retractor inserted at the medial aspect of the condyle to provide appropriate shielding •Prevent reading of γ- emission of the cranial base •1st reading: right mandibular parasymphysis = 2965 CPS •2nd reading: right condyle = 4197 CPS •Marking the section to be resected •γ-probe was used until normal reading was obtain Bouchard C, Paris M, andVillemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
  95. 95. ©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 Bouchard C, Paris M, andVillemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
  96. 96. ©sylvainchamberland.com 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 Bouchard C, Paris M, andVillemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
  97. 97. ©sylvainchamberland.com 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 Bouchard C, Paris M, andVillemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
  98. 98. Inactive Adult patient or after normal growth has ceased
  99. 99. ©sylvainchamberland.com Differential diagnosis •Could be hypercondyle that has stop growing •Could be hypoplasia following trauma to the joint •Could be sequella of rhumatoid arthritis
  100. 100. ©sylvainchamberland.com Differential Diagnosis •Absence of shift •Transverse asymmetry •Laterodeviated to left •Right condyle longer than left •Most likely explanation could be ✦ Left condylar hypoplasia ✓ Lack of vertical alveolar development on the left side MP.Ro-Ja.0404; 15a
  101. 101. ©sylvainchamberland.com 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
  102. 102. ©sylvainchamberland.com Inactive •Laterodeviation to right •Left condylar hyperplasia (horizontal type) •Left posterior crossbite •Splitting occlusal plane & gonial angle Ja.Du.29-11-06; 40 a
  103. 103. ©sylvainchamberland.com •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
  104. 104. ©sylvainchamberland.com Any Sceptics? In 5th grade In Secondary I Bike accident
  105. 105. ©sylvainchamberland.com Inactive •Laterodeviation to left •Class III •Anterior openbite Do.Vo.20-04-09; 32 a
  106. 106. ©sylvainchamberland.com •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
  107. 107. ©sylvainchamberland.com
  108. 108. Osteochondroma 35% of all benign bone tumors Average age at presentation: 40 y (range 11-69) Ratio 1,8 ♀: 1♂ No cases of malignant transformation of TMJ yet reported •Chapter 82- Mandibular asymmetry: temporomandibular joint degeneration,Wolford L. In Current therapy in Oral and maxillofacial surgery,W.B.Saunders, 2012 •Osteochondroma of the temporomandibular joint: a case report. Utumi ER, Pedron IG, Perrella A, Zambon CE, Ceccheti MM, Cavalcanti MG. Braz Dent J. 2010;21(3):253-8. PMID: 21203710 • Shintaku WH,Venturin JS, Langlais RP, and Clark GT. Imaging modalities to access bony tumors and hyperplasic reactions of the temporomandibular joint. J Oral Maxillofac Surg. 2010,Aug 68(8): 1911-21.
  109. 109. ©sylvainchamberland.com 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
  110. 110. ©sylvainchamberland.com CBCT assessment •Tapering radiopaque mass extending from the anteromedial aspect of the condyle •Left condyle is normal R L
  111. 111. ©sylvainchamberland.com 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
  112. 112. ©sylvainchamberland.com •Hyperplasy of right condyle +++ •Laterodeviation to the left •Indication of a condylectomy : osteochondroma or osteoma • >20 years ago : Jigli osteotomy + genioplasty
  113. 113. ©sylvainchamberland.com Osteochondroma •♀ 56 y ✦ Condylar hypertrophy noted •At 60 y ✦ Osteochondroma Li.Ma.220312-60yLi.Ma.290508-56
  114. 114. ©sylvainchamberland.com 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
  115. 115. ©sylvainchamberland.com Recurring osteochondroma
  116. 116. ©sylvainchamberland.com Wisdom Thoughts •"A patient with an elongated condylar process is more likely to stop growing spontaneously than one with an enlarged condyle — but I don't have enough cases to prove it". Dr William Proffit
 Personal communication. January 2012
  117. 117. ©sylvainchamberland.com Chamonix
  118. 118. Hypoplasia Rhumatoid Arthritis
  119. 119. ©sylvainchamberland.com Juvenile Rhumatoid Arthritis •Class I •Xbite 22/32 •Deviation to the left •Followed by a rhumatologist ✦ Rx: methotrexate, Folic acid, Infliximab MeGa20072017 9y5m
  120. 120. ©sylvainchamberland.com •Hypoplasia left condyle •Deep left antegonial notch •Splitting of Md inferior border •No pain, no symptoms
  121. 121. Hypoplasia Traumatism
  122. 122. ©sylvainchamberland.com 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
  123. 123. ©sylvainchamberland.com •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
  124. 124. ©Dr Sylvain Chamberland JuLe. 10 avril 2006
  125. 125. ©sylvainchamberland.com •Bilateral condylar fracture (because of a fall) JuLe. 10 avril 2006 JuLe. 20 octobre 2006 5 y 10 m
  126. 126. ©sylvainchamberland.com •Anterior open bite ✦ ➜ posterior md autorotation ✦ Fulcrum on the molars (55/85) JuLe.201006; 5 ans 10 mois
  127. 127. ©sylvainchamberland.com •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
  128. 128. ©sylvainchamberland.com •Normal development except the shortened right condyle •Midline deviation toward the normal growing side Ju.Le230412
  129. 129. ©sylvainchamberland.com •Diagnostic record prior to initiating comprehensive ortho tx. Ju.Le280113
  130. 130. ©sylvainchamberland.com •Right short ramus : sequela of the fracture ✦ Explain deviation to the right on opening •Left condylar neck and left condyle relatively normal
  131. 131. ©sylvainchamberland.com •At debonding •Deviation to the right on opening Ju.Le270415
  132. 132. ©sylvainchamberland.com Follow up 1 y •Functional genioplasty ✦ Improved profileJu.Le270415 Ju.Le180516
  133. 133. ©sylvainchamberland.com •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
  134. 134. ©sylvainchamberland.com •Hypoplasia of left TMJ. (Condylar-coronoïd collapse??) •Increased left antegonial notch ✦ Compensatory growth at gonial angle •Splitting of mandibular border and occlusal plane Maezzini et al,True hemifacial microsomia and hemimandibular hypoplasia with condylar- coronoid collapse: Diagnostic and prognostic differences,AJODO2011;139:e435-e447 OlLa080914
  135. 135. ©sylvainchamberland.com Follow up 8 months •After RME + exo 53, 63 OlLa130415
  136. 136. ©sylvainchamberland.com Follow up +2 y •Right: normal condylar growth •Left: hypoplasia or normal growth followed the loss of the stump OlLa080217
  137. 137. ©sylvainchamberland.com Sequella of Trauma
  138. 138. ©sylvainchamberland.com At Baseline •Panogram can tells a look if you look at the condyles
  139. 139. ©sylvainchamberland.com 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
  140. 140. ©sylvainchamberland.com 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
  141. 141. ©sylvainchamberland.com 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
  142. 142. ©sylvainchamberland.com 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
  143. 143. ©sylvainchamberland.com 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
  144. 144. ©sylvainchamberland.com 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

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