YIJOM-4231; No of Pages 10

Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx

https://doi.org/10.1016/j.ijom.2019.06.022, available online at https://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Condylectomy as the treatment J.-Y. Kim, T.-W. Ha,

J. H. Park, H.-D. Jung, Y.-S. Jung
Department of Oral and Maxillofacial Surgery,

for active unilateral condylar Oral Science Research Centre, Yonsei

University College of Dentistry, Seoul,
Republic of Korea

hyperplasia of the mandible and

severe facial asymmetry:
retrospective review over 18
years
J.-Y. Kim, T.-W. Ha, J.H. Park, H.-D. Jung, Y.-S. Jung: Condylectomy as the treatment
for active unilateral condylar hyperplasia of the mandible and severe facial
asymmetry: retrospective review over 18 years. Int. J. Oral Maxillofac. Surg. 2019;
xxx: xxx–xxx. ã 2019 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. Unilateral condylar hyperplasia (UCH) of the mandible is a disorder

affecting the condyle size, resulting in facial asymmetry. This study was a
retrospective review of 27 patients with UCH who underwent condylectomy
between 2000 and 2017 at Yonsei University Dental Hospital. Patient demographic
characteristics were summarized. UCH was divided into three subtypes:
hemimandibular elongation (HE, n = 15), hemimandibular hyperplasia (HH, n = 4),
and osteochondroma (OC, n = 8). Of the 27 patients, only one with the HE type and
five (18.5%) with the OC type complained of joint pain. Bone scans of all patients
showed higher uptake on the UCH side. Lip and maxillary canting was prominent in
the HH and HE types. Five patients (18.5%) underwent condylectomy alone, 13
(48.1%) underwent condylectomy with orthodontic treatment, and nine (33.3%)
underwent adjunctive jaw surgery with orthodontic treatment. The treatment
modalities varied according to the subtype. In all OC type patients, removal of the
hyperplastic condyle treated the facial asymmetry. Additional post-surgical
orthodontic treatment was necessary in only three cases (37.5%). All HH type
Key words: condylectomy; temporomandibular
patients required mandibuloplasty. All patients showed a stable occlusal outcome joint; unilateral condylar hyperplasia; facial
without relapse and an improvement in subjective symptoms, despite a decrease in asymmetry; orthognathic surgery.
mouth opening of 2.2 mm. These findings might be useful in treatment planning for
UCH patients. Accepted for publication 17 June 2019

0901-5027/000001+010 ã 2019 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

2 Kim et al.

Facial asymmetry can affect not only aes- reduced, and conventional orthognathic canting was determined using a 1:1 ratio
thetics but also the patient’s occlusion, surgery is preferred for treatment of the frontal photograph. The inter-pupillary line
temporomandibular joint (TMJ), mastica- facial asymmetry. was set as a reference line. Maxilla canting
tory function, and speech1. Unilateral con- The aim of this study was to evaluate was measured using a posteroanterior
dylar hyperplasia (UCH), one of the the clinical manifestations and treatment cephalogram (Fig. 1). The ramus height
causes of facial asymmetry, refers to a outcomes following condylectomy in was measured on a panoramic X-ray to
disorder in which the head and neck of patients diagnosed with UCH by bone evaluate the change in vertical dimension
the condyle on one side increase in size. scintigraphy. It appears that few previous- due to remodelling of the mandibular con-
Although UCH can have several causes, ly reported studies have compared the dyle. The distance from the tip of the con-
the aetiology remains unclear1,2. Osteo- three subtypes of UCH. Thus, it was also dylar head to the antegonial notch was
chondroma, which predominantly occurs sought to explore how the treatment pro- measured manually. To minimize the radio-
in patients between 30 and 50 years of age, tocol may be altered for the management logical distortion, the length of the first
is a non-self-limiting condition and may of the different UCH subtypes including molar was measured and the distortion ratio
also be regarded as a type of UCH3. hemimandibular elongation, hemimandib- was examined. The difference in measured
Obwegeser and Makek classified con- ular hyperplasia, and osteochondroma. A values between the immediate postopera-
dylar hyperplasia into three main catego- treatment algorithm to further help in de- tive and last follow-up was calculated.
ries4. Type 1 includes hemimandibular cision-making and treatment planning is All of the following data were recorded:
elongation, in which there is condylar proposed. age, sex, chief complaint, affected side,
neck elongation with a normal condylar diagnosis, bone scan, pre- and post-treat-
head, prominent horizontal growth, and ment TMJ evaluation, compensatory
displacement of the chin and midline to Materials and methods growth, extent of condylectomy, adjunc-
the contralateral side. Type 2 includes tive surgery, total treatment time, duration
Subjects and assessment
hemimandibular hyperplasia, in which of follow-up, relapse, and ramus height.
the asymmetry is more prominent and This retrospective study included 27
complicated due to the excessive growth patients (16 male, 11 female) with a diag-
of the condylar head, neck, and the as- nosis of facial asymmetry with UCH, who
Surgical procedure and postoperative
cending ramus. The vertical vector dom- underwent condylectomy between 2000
procedure
inates and affects the mandibular body and and 2017 in the Department of Oral and
angle. Due to increased growth at puberty, Maxillofacial Surgery, Yonsei University The treatment plan was established
type 2 cases of condylar hyperplasia pres- Dental Hospital. Patients diagnosed with according to the condylar growth activity
ent with a more prominent compensatory UCH who underwent orthognathic surgery and the degree of asymmetry. In the early
downward growth, as well as maxillary without condylectomy were excluded from 2000s, when there was no access to 3D
molar supra-eruption, compared to type 1 the study. These patients were diagnosed on simulation using a computer, virtual sur-
cases. Type 3 condylar hyperplasia cases the basis of clinical, radiographic, and facial gery was performed with a rapid prototype
present as a mixture of types 1 and 2. photographic evaluation. Computed to- model. Using this, it was possible to de-
In 2014, Wolford et al. classified condylar mography (CT) scans and cephalograms termine the amount of resection during
hyperplasia based on clinical features, im- were obtained, and bone scanning with condylectomy. Starting in 2010, 3D simu-
aging, and histology. Condylar hyperplasia technetium 99 m (99mTc) scintigraphy lation for surgical planning was performed
that was non-self-limiting with unilateral was performed to determine whether the using DICOM files from CT. For two
vertical elongation was regarded as type growth centre of the condyle head was patients, simultaneous orthognathic sur-
2, and histologically confirmed as an osteo- active. In the early 2000s, a planar whole- gery with condylectomy was performed.
chondroma5. Osteochondroma usually body bone scan was used. Starting in 2010, For all patients, the pre-auricular ap-
occurs in the mandibular condyle, which single photon emission computed tomogra- proach was used to expose the condylar
develops by endochondral ossification in phy (SPECT) was widely used, and three- head on the affected side, and the condy-
the facial bone. Although osteochondroma dimensional (3D) analysis was performed lectomy was performed based on the
rarely recurs, it is a neoplastic growth that using SPECT–CT. amount of resection required for each
requires surgical removal by condylectomy. The medical charts, facial photographs, patient. The resection performed was
The most important determinant in the and radiographs were reviewed and ana- more than 15 mm in all cases, and includ-
diagnosis of facial asymmetry with UCH lyzed retrospectively. A detailed diagnosis ed the cartilaginous cap. The ablation
is the assessment of condylar growth ac- was performed and the cases were divided volume was adjusted for each individual
tivity. In the case of active condylar into three subtypes based on clinical and and a proportional condylectomy was per-
growth, the treatment plan must aim to radiographic examinations, as follows: (1) formed. To prevent TMJ ankylosis, the
correct the asymmetry and avoid recur- hemimandibular elongation (HE) type; (2) discs were preserved and procedures such
rence. For growth analysis, bone scintig- hemimandibular hyperplasia (HH) type; as disc repositioning were not performed.
raphy is performed to determine whether (3) osteochondroma (OC) type. Active physiotherapy using intermaxillary
the isotope uptake is increased6,7. Osteochondroma was confirmed by his- elastic therapy was conducted, and re-
Condylectomy is considered the treat- tological examination of the resected con- evaluation was carried out periodically.
ment of choice in the case of active condylar dyle. Dental casts were used for occlusion Most of the patients were treated with
growth, based on the understanding that and dental evaluation. Preoperative and orthodontic treatment during this period9.
resection of the growth centre is necessary postoperative TMJ function, including max- The need for additional surgery was eval-
in order to prevent relapse after surgery8. imum mouth opening, joint sounds, and uated after about 6 months. In some
Conversely, when condylar growth has sta- pain, was also assessed. Transverse canting patients, secondary orthognathic surgery
bilized, the need for a condylectomy is of the lip and maxilla were measured. Lip was performed to correct the residual

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

Condylectomy for active UCH of the mandible 3

Fig. 1. Methods for the measurement of lip and maxilla canting. (A) Lip canting was evaluated as the difference in the vertical distance from the
inter-pupillary line to the lip commissures on the two sides. (B) Maxilla canting was evaluated as the difference in the vertical distance from the
reference line passing through the internal-most points of the two frontozygomatic sutures to the mesiobuccal cusp of each of the upper first
molars. Abbreviations: HRL, horizontal reference line; Z-line, line passing through the internal-most points of the two frontozygomatic sutures
(lateral orbitale); MBC, mesiobuccal cusp.

asymmetry or anteroposterior skeletal dis- growth, type of adjunctive surgery, TMJ severe. As shown in Tables 1–3, the lip and
crepancy. evaluation, maximum mouth opening, maxillary canting were more prominent in
treatment time, and follow-up period, the HH type compared to the other types. In
are shown in Tables 1–3. The average the OC type, canting was mild in most cases,
Follow-up
height and width of the condyle resection and no canting was observed in two of the
All patients underwent periodic follow-up were 21.3 mm (SD 3.19) and 16.4 mm patients.
for a duration ranging from at least 2 years (SD 3.14), respectively.
to 18 years. At Yonsei University College
Adjunctive surgery
of Dentistry, patients are followed up for
Chief complaint
at least 2 years after the treatment, and Nine (33.3%) of the 27 patients in this
then it is recommended that they attend the All patients with HE and HH complained study required orthognathic surgery; the
clinic once a year. Patients with at least 2 of facial asymmetry, with an additional remaining 18 patients (66.7%) did not
years of follow-up were included in this complaint of a prognathic mandible or require adjunctive surgery. Of these latter
study. For each patient, periodic radio- malocclusion. For both of these types, patients, condylectomy alone was per-
graphs and facial photographs were taken only one patient complained of joint pain. formed in five (18.5%) with the OC sub-
to examine the condyle and monitor for a In the OC type, five patients (62.5%) type; the other 13 patients (48.1%)
relapse of the condylar hyperplasia. In complained of joint pain. underwent orthodontic treatment to treat
addition, post-treatment TMJ evaluation the remaining malocclusion.
was performed after the completion of Second stage orthognathic surgery was
Bone scan
treatment. performed in four of the 15 HE patients
When the difference in activity level be- (26.7%), and surgically assisted rapid pal-
tween the two sides was more than 10%, it atal expansion (SARPE) was performed
Results
was judged that there was a significant for the relief of crowding and arch width
The mean age at the time of diagnosis was uptake. For all patients, the uptake was discrepancy correction in one patient
22.8 years (standard deviation (SD) 3.85) higher on the side with condylar hyperpla- (6.7%). All four HH type patients under-
for the HE subtype patients (13 male, 2 sia. went orthognathic surgery, of whom two
female), 21.5 years (SD 2.38) for HH (50%) had second stage orthognathic sur-
subtype patients (1 male, 3 female), and gery and two (50%) had simultaneous
Lip and maxillary canting
47.0 years (SD 8.22) for OC subtype orthognathic surgery with condylectomy
patients (2 male, 6 female). All patient A vertical difference of 2 mm was classi- (Fig. 2). Of particular note is that mandi-
demographic data, as well as details in- fied as mild canting, a difference of 2–4 mm buloplasty including border shaving
cluding the complaint, compensatory as moderate, and a difference of 4 mm as was performed in all HH-type patients.

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

4 Kim et al.

F, female; IVRO, intraoral vertical ramus osteotomy; M, male; MMO, maximum mouth opening; SARPE, surgical assisted rapid palatal expansion; SSRO, sagittal split ramus osteotomy; TMJ,
Follow-up
Adjunctive surgery was not required for
time (months) (years) the eight patients with the OC type, and
only condylectomy was performed.

10

13

10

18
5

2
4

2
3

8
7

6
3
4
Treatment

Orthodontic treatment and total

treatment time
Of the total 27 patients, 22 (81.5%) had
30

22

28

20

12
15

12
17
38
36
24

24
18
16
24
post-surgical orthodontic treatment. All
HE and HH patients required orthodontic
treatment with or without adjunctive sur-
MMO (mm)
After

gery, while five (18.5%) of the OC-type

53

55

50

50

50
43

55
65
52
46
49

42
56
48
42
patients showed a stable postoperative
occlusion without orthodontic treatment
Before

at the 6-month follow-up after condylect-

omy. All five patients treated with con-
55

58

51

53

51
49

52
65
51
55
48

49
56
50
40
dylectomy alone had the OC type, and a
stable occlusion was achieved in these
Clicking

Clicking
(Sound or pain)
TMJ evaluation

patients just with physiotherapy after con-

None

None

None

None

None
None

None
None
None
None

None

None
None
After

dylectomy. The three remaining patients

with the OC type (37.5%) required ortho-
dontic treatment. The total treatment
Clicking

Clicking

Clicking

Clicking

Clicking

Clicking
Clicking

Clicking
Clicking
Clicking
Clicking
Before

duration including the orthodontic treat-

None

None

None
None
Pain

ment period varied, and was an average of

22.4 months (SD 7.98) for patients with
(Le Fort I + SSRO + advancement

(Le Fort I + SSRO + advancement

(Le Fort I + SSRO + advancement

(Le Fort I + IVRO + advancement

the HE type, 27.5 months (SD 7.42) for

Secondary orthognathic surgery

Secondary orthognathic surgery

Secondary orthognathic surgery

Secondary orthognathic surgery

Secondary SARPE for relief of

those with the HH type, and 15.6 months

(SD 3.21) for those with the OC type.
Adjunctive surgery

and reduction genioplasty)

TMJ evaluation
The preoperative and post-treatment max-
genioplasty)

genioplasty)

genioplasty)

imum mouth opening values of the 27

Table 1. Clinical data and demographic features of patients with hemimandibular elongation.

crowding

patients were compared and analyzed by

paired t-test. The preoperative and post-
None
None

None
None
None
None

None
None
None
None

operative values were 49.8 mm (SD 1.16)

and 47.6 mm (SD 1.28), respectively
growth (maxilla
Compensatory

(P = 0.007). However, the degree of joint

and lip cant)

pain and joint sounds either remained

Moderate

Moderate

Moderate

Moderate

Moderate
Moderate

Moderate
Moderate
Moderate

stable or improved after the surgery in

Severe

Severe
Severe

all patients.
Mild

Mild

Mild

Relapse
Affected
side

After treatment, condylar regrowth was

Right

Right

Right

Right
Right
Left

Left

Left

Left

Left
Left

Left
Left
Left
Left

not observed in any of the patients, and

long-term stable occlusion was main-
prognathic mandible

prognathic mandible
except asymmetry

tained.
Other complaint

Clicking sound on

Malocclusion
Progressive

Progressive

Ramus height
Long face

Open bite
left side

The mean interval between the day after

None

None

None
None
None

None

None
None
None

the operation and the day of the last fol-

low-up panoramic X-ray was 4.17 years
(SD 3.14). The mean mandibular ramus
Sex

temporomandibular joint.
M

M
M
M
M
M

M
M
M

height measured at the last panoramic

F

X-ray was decreased by 0.74 mm (SD

(years)
Age

1.26, range –3.01 mm to +2.80 mm) com-

24

20

20

19

19
20

29
20
21
21
22

30
26
22
29

pared to the height on the day after the

operation, and this was statistically signif-
icant (P = 0.009). Although there was a
Patient

change in the ramus height due to

10
11

12
13
14
15

bone remodelling, its correlation with

1

5
6

7
8
9

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
 YIJOM-4231; No of Pages 10
Table 2. Clinical data and demographic features of patients with hemimandibular hyperplasia.
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the

Compensatory TMJ evaluation

Age Other complaint Affected growth (maxilla and (Sound or pain) MMO (mm) Treatment Follow-up
Patient (years) Sex except asymmetry side lip cant) Adjunctive surgery time (months) (years)
Before After Before After
16 19 M Prognathic mandible Right Severe Secondary orthognathic surgery Clicking None 50 46 36 6
(Le Fort I + IVRO + mandibuloplasty)
17 20 F None Left Moderate Secondary orthognathic surgery Clicking Clicking 56 53 27 5
(Le Fort I + SSRO + mandibuloplasty)
18 24 F None Right Moderate Simultaneous orthognathic surgery None None 50 43 18 3
(Le Fort I + contralateral
IVRO + mandibuloplasty)
19 23 F None Left Severe Simultaneous orthognathic surgery Crepitus Clicking 43 50 29 7
(Le Fort I + mandibuloplasty)
F, female; IVRO, intraoral vertical ramus osteotomy; M, male; MMO, maximum mouth opening; SSRO, sagittal split ramus osteotomy; TMJ, temporomandibular joint.

Table 3. Clinical data and demographic features of patients with osteochondroma.

Compensatory TMJ evaluation
Age Affected growth (maxilla and Adjunctive (Sound or pain) MMO (mm) Treatment Follow-up
Patient (years) Sex Other complaint except asymmetry side lip cant) surgery time (months) (years)
Before After Before After

Condylectomy for active UCH of the mandible

20 48 F Recent progressive asymmetry Left None None Clicking Clicking 52 50 17 5
21a 57 F Acute malocclusion Left None None Pain None 40 45 6 3
Left TMJ pain
22 38 F Posterior open bite Right Mild None Pain None 40 35 12 4
Right TMJ pain
23a 58 F Recent progressive asymmetry Left Mild None Crepitus None 40 34 6 2
Left TMJ pain Pain
24a 47 F Recent progressive asymmetry Right Mild None Clicking None 50 44 6 2
25a 34 M Left TMJ pain Left Mild None Clicking None 42 40 6 2
Pain
26a 48 F Posterior open bite Right Mild None Clicking Clicking 50 42 6 2
Right TMJ pain Pain
27 46 M Recent progressive asymmetry Right Moderate None None None 48 46 18 4
F, female; M, male; MMO, maximum mouth opening; TMJ, temporomandibular joint.
a
Stable postoperative occlusion without orthodontic treatment.

5
YIJOM-4231; No of Pages 10

6 Kim et al.

Fig. 2. Long-term follow-up of a hemimandibular hyperplasia case (patient 18). Images obtained preoperatively: (A) frontal photograph, (B)
posteroanterior radiograph, and (C) panoramic radiograph. Images obtained at 4 years after condylectomy with simultaneous orthognathic surgery
and mandibuloplasty: (D) frontal photograph, (E) posteroanterior radiograph, and (F) panoramic radiograph.

the follow-up period was not statistically year in growing patients. This controver- type of 47.0 years (SD 8.22). These find-
significant (P = 0.167). sial step could help to predict bone growth ings are indicative of the difference in
and determine the optimal timing for a pathogenesis of the OC type, which is
surgical approach14. neoplastic, compared to the HE and HH
Discussion
Various surgical methods for the treat- types, which develop during growth at
This study was a retrospective review of ment of UCH have been introduced in puberty.
patients with facial asymmetry due to many studies, such as high condylectomy, Patients with the HE type were less
active UCH. These patients were divided low condylectomy, proportional condy- likely to require jaw surgery (26.7%) than
into three subtype groups (HH, HE, OC), lectomy, orthognathic surgery, and TMJ the patients with the HH type (100%).
and the characteristics of each subtype reconstruction surgery2,15. Condylectomy However, all patients required orthodon-
were analyzed. The subtypes were defined can be categorized as high condylectomy tic treatment. In the case of HE and HH,
based on a combination of Obwegeser’s when the resection is performed within maxillary canting and lip canting oc-
classification (based on morphology) and 5 mm from the upper side of the condylar curred gradually as a result of the com-
Wolford’s classification (based on histo- head, and low condylectomy when the pensatory growth of the dentoalveolar
pathological findings)4,5,10. condylar neck is preserved. High condy- portion of the maxilla during pubertal
Bone scintigraphy measures increased lectomy has been reported to be successful growth. With the gradual progression of
osteoblastic activity using methylene with removal of the condyle including the asymmetry, patients often do not recog-
diphosphonate labelled with 99mTc, a growth cartilage, which can prevent re- nize the facial asymmetry immediately,
bone-seeking material11. The use of planar lapse after surgery16. In low condylect- but only when it has progressed suffi-
scintigraphy for the evaluation of condylar omy, removal of the growth centre and ciently far.
growth was first reported by Kaban et al.6. simultaneous correction of the posterior On the other hand, due to the difference in
Recently, there has been an increase in the vertical excess are possible. In this study, growth rate of older patients, the degree of
use of SPECT for quantitative evaluation, an average length of 21.3 mm (SD 3.19) compensatory growth was at most mild in
and Pogrel et al. reported that SPECT is was resected. By removing all of the patients with the OC type. As indicated in
more valuable in obtaining reproducible growth cartilage and correcting the verti- the treatment algorithm (Fig. 3), occlusal
results compared to planar imaging12,13. cal excess, the asymmetry could be im- seating was performed during the 6-month
However, this test can provide false-posi- proved. follow-up period after primary condylect-
tive results in the presence of TMJ disease. The mean age at the time of diagnosis of omy, and the patients were re-evaluated to
Therefore, periodic 3D CT or cephalo- the patients with the HE and HH subtypes determine whether a secondary surgery or
grams are necessary to determine the pres- in this study was similar, at 22.8 years (SD additional orthodontic treatment was nec-
ence of residual growth. Several authors 3.85) and 21.5 years (SD 2.38), respec- essary. Patients with the OC type showed
have previously reported that bone scin- tively, and this differed significantly from less dental decompensation than those with
tigraphy must be measured at least once a the mean age of the patients with the OC the HE and HH types, which manifested as a

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

Condylectomy for active UCH of the mandible 7

Fig. 3. Proposed algorithm for the treatment of unilateral condylar hyperplasia of the mandible. (Abbreviations: SPECT-CT, single photon
emission computed tomography–computed tomography; SSRO, sagittal split ramus osteotomy; IVRO, intraoral vertical ramus osteotomy.)

mild malocclusion. In most OC type cases, factors including the anteroposterior rela- condylectomy alone, asymmetry may per-
orthodontic treatment was either omitted or tionship of the maxilla and mandible, the sist in the HH type due to hyperplasia of
minimal. These results suggest that favour- degree of compensatory growth, the shape the mandibular angle and body region, and
able treatment outcomes can be obtained of the jaw, and the presence of dental additional surgery for these regions
with condylectomy alone in the OC type. problems. In addition, genioplasty or man- was necessary in the HH-type patients
In some cases, asymmetry was treated dibuloplasty with border shaving were included in this study. However,
with condylectomy alone, while in other performed according to the genial profile since the mandibular canal was also dis-
cases a secondary orthognathic surgery or mandibular contour; these are almost a placed, it was important to consider this
was needed. This depended on various requirement for the HH type17. Following during surgery.

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

8 Kim et al.

Nine of the 27 study patients (33.3%) condylectomy and orthognathic surgery but the degree was not severe (about
required secondary orthognathic surgery. have been performed simultaneously to 2.2 mm), and there was an improvement
Interestingly, in the OC type, facial asym- obtain good results18,19. in terms of joint pain and sounds. Previous
metry was resolved just with the removal There are various reports on the total studies have examined mandibular move-
of the hyperplastic condyle in all eight treatment duration including the period of ments after condylectomy. Villanueva-
patients, and additional post-surgical or- orthodontic treatment20,21. In the present Alcojol et al. reported no significant
thodontics for occlusal stabilization was study, the HE and HH types, which devel- changes in maximum mouth opening be-
needed in only three cases (37.5%). oped during adolescence, required a total fore and after condylectomy in 36
A Le Fort I osteotomy for the correction treatment period of about 22.4 months and patients15. Additionally, Lippold et al.
of maxillary canting was performed in 27.5 months, respectively. For patients reported no significant changes after con-
eight patients, and one additional patient who underwent orthognathic surgery after dylectomy in six patients21. Wolford et al.
underwent SARPE to treat a maxillary condylectomy, the treatment period – with reported an decrease of 2.3 mm in maxi-
transverse deficiency and crowding of preoperative and postoperative orthodon- mum mouth opening in 37 patients with
the maxillary teeth. Four patients under- tics – was longer. With regard to the OC condylar osteochondroma after low con-
went a sagittal split ramus osteotomy type, three patients (37.5%) required post- dylectomy, which is similar to the result
(SSRO) for mandibular advancement, operative orthodontic treatment, and the found in the present study23. However,
and an intraoral vertical ramus osteotomy average treatment duration for this group Brusati et al. studied articular function
(IVRO) was performed in two patients of eight patients was 15.6 months. The after high condylectomy and found that
with a skeletal class III tendency. In pa- patients showed various patterns of asym- 40% of the patients showed suboptimal
tient 18, an IVRO was performed on the metry and individual differences due to function, with deviation or decreased
unaffected side at the same time as the canting and dental problems. Thus, the movement2. Shen and Darendeliler de-
condylectomy on the affected side. This subtypes and various factors such as the scribed the concept of a neocondyle as
simultaneous surgery was a good way to degree of maxilla and lip canting, as well remodelling of the condylar stump to form
achieve optimal jaw function and facial as crowding of the teeth, should be taken a new condyle. In fact, long-term follow-
balance at the same time, without the into consideration when estimating the up in the present study showed that remo-
burden of a second surgery, which greatly duration of treatment. delling of the condylar head was achieved,
improved the patient’s quality of life. Miyamoto et al., in a study of beagle and the TMJ adapted to the situation with-
Genioplasty or mandibular border shaving dogs, reported that the pattern of condyle out functional problems24 (Fig. 4). Rou-
was performed depending on the pattern of regeneration at 3 months after surgery tine panoramic X-ray and cephalograms
asymmetry and genial profile of the pa- showed greater regeneration in the medial are considered good diagnostic methods to
tient. A mandibuloplasty was performed region compared to the lateral region22. examine remodelling of the condyle25.
in all patients with the HH type; the man- Displacement of the condyle increased the It is important for clinicians to consider
dibular border was shaved due to the load on the lateral part, resulting in in- potential complications that can occur after
difference in size of the mandibular body. creased damage to this region compared to condylectomy. In the absence of complete
Before the development of 3D surgical the medial part during surgery. In addition, resection, regrowth of the mandibular con-
simulation using a computer, a staged histologically it was observed that the dyle may occur. Conversely, the newly
approach was performed at the study in- bone around the glenoid fossa was main- adapted condyle can be resorbed or dislo-
stitution (condylectomy + secondary tained, while the cartilage regenerated in cated in the process of remodelling or load-
orthognathic surgery), as mentioned an irregular manner and was thickened in ing, which may lead to a loss of vertical
above. This traditional treatment method compensation. dimension. Wolford et al. reported that
is useful for obtaining good postoperative In the patients included in the present facial asymmetry could recur if the osteo-
results considering relapse, but requires a study, long-term follow-up of TMJ func- chondroma is not completely removed23. In
secondary operation and a longer treat- tion showed satisfactory results without addition, the articular space between the
ment period. In recent years, 3D simula- relapse. There was a decrease in the new condyle and the mandibular fossa
tion surgery has become possible and amount of the maximum mouth opening, may change with the passage of time.

Fig. 4. Serial panoramic X-rays after condylectomy showing condyle remodelling to form a neocondyle, which has adapted to the condylar fossa
(patient 19): (A) preoperative; (B) immediately postoperative; (C) 2 years postoperative; (D) 4 years postoperative; (E) 6 years postoperative.

Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

Condylectomy for active UCH of the mandible 9

In the present study, there was no case Funding oral vertical ramus osteotomy. J Oral Max-
of condylar regrowth after condylect- illofac Surg 2012;70:e431–7.
This research did not receive any specific 10. Wolford LM, Morales-Ryan CA, Garcia-
omy. The ramus height was slightly de-
grant from funding agencies in the public, Morales P, Perez D. Surgical management
creased (within 1 mm on average) by
commercial, or not-for-profit sectors. of mandibular condylar hyperplasia type 1.
remodelling. Various factors such as
changes in the articular space and adap- Proc (Bayl Univ Med Cent) 2009;22:321–9.
tation of the surrounding muscles may 11. Kanishi D. 99mTc-MDP accumulation
Competing interests
affect the occlusal dimension in a com- mechanisms in bone. Oral Surg Oral Med
plex manner. Therefore, it is important None declared. Oral Pathol 1993;75:239–46.
12. Pogrel MA, Kopf J, Dodson TB, Hattner R,
for clinicians to monitor the occlusal
Kaban LB. A comparison of single-photon
state of the patient and the position of Ethical approval emission computed tomography and planar
the maxilla and mandible over long-term imaging for quantitative skeletal scintigra-
follow-up. Studies on the long-term sta- The study was conducted according to the
dictates of the Declaration of Helsinki and phy of the mandibular condyle. Oral Surg
bility after surgery may further justify Oral Med Oral Pathol Oral Radiol Endod
this approach as the treatment of choice was approved by the Ethics Review Board
1995;80:226–31.
for UCH. of Yonsei University Dental Hospital In-
13. Saridin CP, Raijmakers PG, Tuinzing DB,
This study involved a retrospective stitutional Review Board (IRB No. 2-
Becking AG. Bone scintigraphy as a diag-
analysis of patients who underwent con- 2018-0037). The need for informed con- nostic method in unilateral hyperactivity of
dylectomy for the treatment of active sent was waived due to the retrospective the mandibular condyles: a review and meta-
UCH, as confirmed by bone scans. The nature of the study. analysis of the literature. Int J Oral Max-
overall sample size and the sample sizes illofac Surg 2011;40:11–7.
for each subtype were limited. However, Patient consent 14. Wen B, Shen Y, Wang CY. Clinical value of
the clinical features, response to treat- 99Tcm-MDP SPECT bone scintigraphy in the
ment, and outcomes were described for Not required. diagnosis of unilateral condylar hyperplasia.
each subtype, which will be helpful for ScientificWorldJournal 2014;2014:256256.
the treatment of patients. Using this in- 15. Villanueva-Alcojol L, Monje F, Gonzalez-
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Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/
YIJOM-4231; No of Pages 10

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Please cite this article in press as: Kim JY, et al. Condylectomy as the treatment for active unilateral condylar hyperplasia of the
mandible and severe facial asymmetry: retrospective review over 18 years, Int J Oral Maxillofac Surg (2019), https://doi.org/10.1016/