CLINICAL ARTICLES

The Treatment of Hemimandibular Hyperplasia Preserving Enlarged Condylar Head

YASUSHI SUGAWARA, M.D. SHIN-ICHI HIRABAYASHI, M.D. TAKAFUMI SUSAMI, D.D.S., PH.D. SHIGETOSHI HIYAMA, D.D.S., PH.D.
Objective: To present a case of hemimandibular hyperplasia (HH) treated with orthognathic surgery that preserves the condyle without disturbing mandibular function. Methods: A 27-year-old woman with HH was treated with orthognathic surgery preserving the enlarged condylar head. Radiographic examination showed typical enlargement of the right condyle, elongation of the right ascending ramus and mandibular body, and tilted occlusal plane. A mandibular sagittal split osteotomy on the unaffected side and subcondylar ramus osteotomy on the affected side, Le Fort I wedge osteotomy to relevel the tilted occlusal plane, and contouring of the lower mandibular margin were performed. Results: Excellent results in the full-face appearance and occlusion were obtained. There was no change in the size of the reserved condylar head 4 years postoperatively. In a series of examinations of jaw function with electromyography, mandibular kinesiography, and computer-aided diagnostic axiography, more favorable ndings were obtained postoperatively. Conclusions: In a case of HH without abnormally high growth activity, orthognathic surgery preserving hypertrophic condyle produced functional improvement in addition to good occlusal and aesthetic outcomes.
KEY WORDS: computer-aided diagnostic axiograph, condylar hyperplasia, electromyography, hemimandibular elongation, hemimandibular hyperplasia, mandibular kinesiography

Hyperplasia of the mandibular condyle is an anomaly that usually occurs unilaterally and equally frequently in both men and women. Hyperplasia of the condyle is differentiated into hemimandibular hyperplasia (HH), hemimandibular elongation (HE), and condylar hyperplasia (CH). The term condylar hyperplasia refers to hyperplasia of the condyle alone and should not be confused with HH or HE (Obwegeser and Makek, 1986). The goals of treatment of HH are to obtain proper ocDr. Sugawara is Associate Professor, Department of Plastic and Reconstructive Surgery, Jichi Medical School, Tochigi, Japan. Dr. Hirabayashi is Professor, Department of Plastic and Reconstructive Surgery, Teikyo University, Teikyo, Japan. Dr. Susami is Associate Professor, Department of Oral Surgery, University of Tokyo, Tokyo, Japan. Dr. Hiyama is Consultant Orthodontist, Maxillofacial Orthognathics, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan. Presented at the 17th Meeting of the Japanese Society of Cranio-MaxilloFacial Surgery; November 2425, 1999; Osaka, Japan. Submitted May 2001; Accepted November 2001. Address correspondence to: Yasushi Sugawara, M.D., Department of Plastic and Reconstructive Surgery, Jichi Medical School, Minamikawachi-machi, Tochigi, 329-0498 Japan. E-mail sugawara@jichi.ac.jp. 646

clusion and good aesthetic appearance and prevent recurrence. A case of a patient with HH treated with orthognathic surgery preserving hyperplastic condyle and trying not to disturb mandibular function is presented here. Patient A 27-year-old woman was referred for treatment of mandibular asymmetry. Mandibular deviation and overgrowth were noticed at 15 years of age and progressed slowly until she reached age 21. The patient complained of discomfort in both temporomandibular joint (TMJ) and pain in the right masseter muscle. There was no history of trauma or inammation in the jaw. A deviation of the mandible to the left side and a protruded position of the chin, combined with an elongation of the right mandibular ramus, was evident in the patients appearance (Fig. 1). Occlusion showed displacement of the dental midline to the unaffected side with a resulting crossbite on the unaffected side (Fig. 2). Radiographic examination revealed enlargement of the right condyle, elongation of the right

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FIGURE 1 Preoperative facial appearances showing deviated chin midline, tilted lip ssure line, and marked downward displacement and bowing of the mandibular body.

FIGURE 2 Preoperative occlusion showing deviation of the mandibular midline to the left and lateral crossbite.

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FIGURE 3 Orthopantomogram showing hyperplasia of the right condyle and elongated mandibular ramus.

FIGURE 4 Preoperative three-dimensional computed tomography revealed differences in size of both condylar head and elongation of the ascending ramus and the mandibular body on the right side.

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FIGURE 5 Four-year postoperative facial appearances.

ascending ramus and mandibular body, and tilted occlusal plane (Fig. 3). Three-dimensional computed tomography apparently showed differences in the size of both condylar heads as well as elongation of the ascending ramus and mandibular body on the right side (Fig. 4). Operative Procedure After 8 months of presurgical orthodontic treatment, the patient was operated on under general anesthesia. A mandibular sagittal split osteotomy on the left (unaffected) side, subcondylar ramus osteotomy on the right (affected) side, and Le Fort I wedge osteotomy to relevel the tilted occlusal plane were performed. An approximately 12-mm length of the condylar neck was resected and the proximal segment was stabilized via overlap. The procedure was completed using an intraoral approach. Intermaxillary xation was maintained for 6 weeks postoperatively. Postsurgical orthodontic treatment was started thereafter. Contouring of the lower mandibular margin without exploration of the inferior alveolar nerve was performed 12 months after surgery at the patients request. A 4-year follow-up examination revealed a dramatic improvement in the full-face appearance and occlusion (Figs. 5 and 6). The patient showed no relapse, recurrence, deviation, or TMJ disorders. There was

no change in the size of the preserved condylar head on an orthopantomogram 4 years postoperatively (Fig. 7). All complaints regarding mastication were fully resolved. Examinations of Mandibular Function To examine jaw function, electromyographic (EMG) activity of the masticatory muscles using bipolar surface electrodes and mandibular movements with mandibular kinesiography (MKG; K6-I, Myotronics, Tukwila, WA) (Jankelson et al., 1975) and computer-aided diagnostic axiography (CADIAX; Gamma, Klosterneuburg, Austria) (Slavicek, 1988) was recorded before and after surgery. Although the preoperative recording showed a low level of EMG activity of the temporalis muscles on the left side, more coordinated and a higher level of EMG activity was recorded postoperatively (Fig. 8). MKG further demonstrated improvement in mandibular movement. Although the frontal view of border mandibular movement was both asymmetrical and tilted preoperatively, postoperative tracing revealed almost symmetrical and balanced mandibular movement, despite a slight decrease in the amount of movement (Fig. 9). During tapping jaw movement, tapping end points, which were dispersed preoperatively, coincided at one point, indicating a more stable occlusion postoperatively (Fig. 10). Similarly, recordings of condylar movements during tapping

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FIGURE 6 Postoperative occlusion.

FIGURE 7 Postoperative orthopantomogram taken after surgical-orthodontic treatment.

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FIGURE 8 Electromyographic (EMG) activities of the anterior and posterior temporalis (Temp) and masseter (Mass) muscles during clenching (A) and tapping (B) jaw movement. EMG activities of masticatory muscles during clenching and tapping jaw movement were recorded in the intercuspal position.

jaw movement by CADIAX further demonstrated signicantly stabilized both condylar movements and terminal occlusal position (Fig. 11). DISCUSSION CH with mandibular asymmetry was rst described in 1836 as a complication of rheumatoid arthritis. There is considerable speculation and controversy with regard to the etiology of this ailment. Trauma, infection (particularly in the TMJ), heredity, and intrauterine inuences have been advanced as possible etiologic factors (Wang-Norderud and Ragab, 1977; Lineaweaver et al., 1989). Obwegeser and Makek (1986) differentiated hyperplasia of the condyle into the following categories: HH, enlargement of the condyle, condylar neck, ramus, and body with tilting of the occlusal plane; HE, condylar neck enlargement and variable displacement of the ramus and body without tilting of the occlusal plane; and CH, hyperplasia of the condyle alone. Chen et al. (1996) suggested that the term CH should not be used to refer to either HH or HE but should be used before mandibular deformity occurs because progression of CH to HH or HE, although difcult to prove, was possible.

FIGURE 9 The frontal view of border mandibular movement recorded with mandibular kinesiography. A: Before surgery. B: After surgery.

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FIGURE 10 Tapping end points during tapping jaw movement with mandibular kinesiography. A: Before surgery. B: After surgery.

Removal of the condyle is indicated in patients in whom joint function is disturbed, accurate pathological and anatomical diagnosis is required, or abnormally high growth activity can be demonstrated. In such cases, removal should be carried out as early as possible to avoid further facial asymmetry (Feldmann et al., 1991). However, whether the active pathological condyle should be resected is a clinically difcult problem. The speed of condylar overgrowth can be estimated by history and comparing serial orthopantomographs and cephalograms. Technetium-99m phosphate studies can detect condylar activity. The scintigram is highly sensitive but nonspecic, and should therefore not be used as the single determinant of the need for condylar resection because the activity level of the scintigram does not necessarily correlate with the histological signs of active growth (Slootweg and Muller, 1986). When an early diagnosis of unilateral CH is made, high condylectomy should be performed in concert with the related other mandibular surgery. Orthodontic treatment is essential afterward in patients treated by early condylar resection. How-

ever, if the surgery to remove the condylar head is excessively traumatic, with damage to the meniscus or failure to reestablish normal jaw function postoperatively, decient secondary growth and even TMJ ankylosis are possible (Epkar and Fish, 1986). In cases with nonactive enlargement and acceptable movement of the condyle, the condyle should be preserved and the joint capsule should not be violated. There have been a few reports of complications in the case of condylectomy: anterior open bite, lateral precontact treated by cup grinding, deviation to the operated side when opening the mouth (Hampf et al., 1985), and loss of lateral excursion on the operated side because of the failure or reinsertion of the lateral pterygoid muscle to the neocondyle (Chen et al., 1996). Motamedi (1996) reported that patients with unilateral CH of the mandible and deviation can be treated favorably by unilateral ramus osteotomy of the affected side and that bilateral ramus osteotomy did not have any advantage in such cases. However, bilateral ramus osteotomy was required in prognathic cases and in cases in which a unilateral procedure would cause excessive rotation of the contralateral condyle. In cases where mandibular osteotomy is combined with Le Fort I osteotomy, especially in cases with occlusal canting, it would be quite difcult to project how much the contralateral condyle would rotate postoperatively. Bilateral osteotomies should be performed to avoid postoperative TMJ pain and dysfunction. The operative procedure, preserving the affected condyle, was indicated for our patient for several reasons: (1) active growth of the unilateral mandible, including the enlarged condyle, had clinically ceased for more than 7 years; (2) no specic examination, except biopsies, was performed to detect the pathological activities; and (3) the function of the affected condyle was acceptable and the functioning of the reconstructed condyle might become worse postoperatively. In a series of examinations of jaw function, more favorable ndings were obtained postoperatively. The frontal view of border jaw movement recorded with MKG showed a rather symmetrical and balanced gure postoperatively. This may be derived from improvement in the tilted occlusal plane by Le Fort I wedge osteotomy and establishment of proper occlusal guidance during mandibular excursion resultant from orthognathic treatment. Nirasawa (1995) reported that the range of mandibular jaw movement increased after sagittal splitting osteotomy, which was speculated to be relevant to laxities of stylomandibular ligaments restricting border jaw movement. On the other hand, the mandibular mobility of our patient was slightly reduced postoperatively. Although the reason is unclear, it may be related to the subcondylar ramus osteotomy performed on the affected side in addition to the Le Fort I osteotomy. In the recording of tapping jaw movement, more stable jaw trajectories and tapping end points were observed postoperatively. The EMG recording showed more coordinated masticatory muscle activity during clenching and tapping jaw movement postoperatively. This nding is probably one of the most important changes observed in jaw function. These changes could have resulted from establishment of maximum interdigitation between upper and lower dentition in the phys-

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FIGURE 11 Pre- and postoperative condylar movements during tapping jaw movement by computer-aided diagnostic axiograph. A: Before surgery. B: After surgery.

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iological mandibular position after orthognathic treatment. It will be essential for this patient to maintain the obtained stable occlusion to retain an effective and favorable masticatory function in the long term.
Acknowledgments. The authors thank Professor Kuroda, Tokyo Medical and Dental University, and Professor Harii, University of Tokyo, for helpful criticisms.

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