CASE REPORT

The effect of treatment with functional appliance on a

pathologic growth pattern of the condyle
6. Melsen, J. Bjerregaard, and M. Bundgaard
Aarhus, Denmark

Hemifacial microsomia causes asymmetry of the face frequently known to progress throughout the
postnatal development if not submitted to any kind of treatment. According to the theoretic basis
for treatment of hemifacial microsomia as presented by Harvold and associates, generation of the
right muscle-bone interaction constitutes the necessary precondition for the bone apposition that
produces facial symmetry. This theory was the basis for the treatment of three patients with abnormal
condyles, one suffering from hemifacial microsomia, one patient with a unilateral condylar fracture
followed by displacement and secondary resorption of the condyle, and one patient with bilateral loss
of condylar cartilage as a result of trauma. The patients were treated with an activator a.m. Harvold,
and the treatment results analyzed radiographically and clinically. The results demonstrated clearly
that generation of an altered muscle balance is possible even though hemifacial microsomia patients
suffer from absence of normal muscles-that is, normal functional matrix as well as absence of
normal condyle-and that bone apposition required for establishment of symmetry can be achieved
if the right microenvironment is established. It was, however, also obvious that treatment should
be initiated as early as possible because the treatment result was dependent on both the timing and
the cooperation of the patient. (AM J ORTHOD DENTOFAC ORTHOP 90: 503-512, 1986.)

Key words: Condylar fracture, hemifacial microsomia, cephalometrics, stressformation

G rowth of the mandible and possibilities of

influencing it have been the topics of numerous inves-
tigations, clinical and experimental as reviewed by
McNamara.
Interest has focused on determinants of mandibular
form and size, tid factors controlling quantity and qual-
ity of condylar cartilaginous proliferation. Whereas a
number of authors24 have stressed the role played by
the condylar growth in forward growth of the mandible,
animal experiments and clinical observations- have
pointed at the possibility of influencing condylar growth
by external factors such as change in occlusal relation-
ship. A definite increase in terminal length, which can
be obtained in rats if a suitable stimulus is maintained
over a significant part of the postnatal development,
has not yet been shown in human subjects. Activators
seem to produce a temporal change in amount and di-
rection of condylar growth1,8,9 as does the Herbst ap-
pliance to an even greater degree,O but no convincing
permanent alterations have been demonstrated in stud-
ies of treatment effect on human subjects.
The clinical studies of stimulation of mandibular
growth in Class II patients do not permit any conclusion
From the Royal Dental College, Institute of Orthodontics
because the final length of the mandible without treat-
ment is unknown. It is therefore still an open question
whether the effect is of temporary character or whether
significant increase in the final size of the mandible has
been obtained. This can be studied through the analysis
of treatment results of patients with severe asymmetries
because the healthy side can serve as a control for
influencing growth on the affected side.
In a recent book, Harvold and associates presented
the theoretic basis for the treatment of hemifacial mi-
crosomia. The concept, which considers a change in
muscle bone interaction as a necessary precondition for
a successful treatment result, applies to both congenital
and acquired deformities.
The present report includes the analysis of three
patients-two with abnormal condyles (one hemifacial
microsomia and one unilateral condylar fracture with
displacement and secondary resorption of the condyle)
and one patient with a bilateral loss of condylar cartilage
following trauma. On this basis it was our purpose to
answer the following questions: How does the approach
proposed by Harvold concerning muscle-bone inter-
action significantly alter the development of patients
with lack of normal condylar growth? Is the response
to treatment dependent on the cause of the missing or
abnormal condylar growth?

503
504 Melsen, Bjerregaard, and Bundgaard
Flg. 1. a and b, Patient in Case 1, a 4-year-old girl, with hem-
ifacial microsomia. c and d, Posttreatment at age 12.
CASE REPORTS
CASE 1
The first patient studied was a Syear-old girl referred by
the pedodontist for further examination.
Cllnlcal examination (Fig. 1, a and b)
In the frontal view a marked deviation of the mandible
to the left side was observed. This was exaggerated during
maximal opening. The lateral view gave the impression of a
relative mandibular retrognathism with a rather convex pro-
file. The patient exhibited a complete deciduousdentition with
neutral molar relationships on both sides and a midline dis-
crepancy of 4 mm.
Roentgen examination. The panoramic films (Fig. 2)
demonstrateda pronounced asymmetryof the mandible. Mea-
suring the maximal length from the muscle attachment (the
spina mentalis), the length of the right side was 26 mm longer
than the left. The condyle, including head and neck of the
left side, was missing and the ramus underdeveloped. Ac-
cording to the radiologic classificationsuggestedby Chierici,
the patient had a type II mandibular deformity with missing
condylar head and neck. A pronounced preangular notch was
present on both sides.
The profile radiographs (Fig. 3) showed an increased
sagittal jaw relationship caused by a mandibular retrognath-
Am. J. Orthod. Denrofac. Orthop.
December 1986
Fig. 2. Panoramic films of patient in Case 1 before (a), during
(b), and after treatment (c), oriented according to normal head
posture. The condyle of the left side is missing and the ramus
markedly shortened on the affected side. The midline is marked
with an arrow. The growth in height of the ramus with treatment
is obvious is the correction of the midline (b).
ism, possibly related to the short left side of the mandible.
Proclination of the lower and retroclination of the upper in-
cisorscompensatedfor the increasedsag&al jaw relationship
to a degree that no increased overjet (3 mm) was seen. The
asymmetry was confirmed by the fact that the posterior mar-
gins of the ramus deviated 13 mm as measured horizontally
at the level of the external cranial base.
The anteroposteriorcephalometric x-ray films confirmed
the marked asymmetry and showed a compensatory inclina-
tion of the incisors in the lower jaw to the right and in the
upper jaw slightly to the left. The spina mentalis of the man-
dible deviated 15 mm from a midline constructed as a per-
pendicular to the orbital roof through the crista galli. The
Volume 90
Number 6
Fig. 2 (Contd). d through f, Corresponding drawings oriented
according to the midline of the mandible as indicated with arrows
in Fig. 2, a through c.
enlargement of the x-ray film was 5.5% at the midsagittal
plane.
Measurements of the ramus height after the method of
Kaban, Mulliken, and Murray showed a significant dif-
ference.
When applying the multiplane analysisdescribedby Gray-
son and associates,14the asymmetry in various depths could
be compared. At each of the three selecteddepths in Fig. 4,
a frontal tracing was produced and the three tracings were
finally superimposedon the outer contour of the skull as seen
in Fig. 4. The tracing of the deepest plane c through sella
and the condyles illustrated the difference in the height of
ramusby the angle formed between the tangentsto the condyle
and a line passingthrough antegonion bilaterally. The medial
distortion of the affected side led to displacement of the mid-
point toward the abnormal side. The tracing on plane b
through the permanent molars and the coronoid process
Case report 505
Fig. 3 a, Profile radiograph at the start of treatment. The right
and left lower borders of the mandible are at different horizontal
levels and the posterior borders of the ramus are deviating
sagittally. b, Profile radiograph at the end of treatment. No de-
viation of lower border is noted, whereas the posterior borders
are still at different frontal planes.
showed that the asymmetry of the coronoid process corre-
sponded to that of the condyles, and that the occlusal plane
was tilted upward on the affected side aswas the plane through
the foramen mentalis. The anterior plane a through orbita and
the incisors revealed that the asymmetry was concentrated
almost entirely to the mandible, but that the inferior midline
deviated even more anteriorly than in the deeper planes. Bas-
ilar exposureconfirmed the resultsof the multiplane analysis
(Fig. 5).15
The patients parents had not previously been informed
that the child suffered from a congenital malformation in-
506 Melsen, Bjerregaard, and Bundgaard
cba
\a
cb
b c
Flg. 4. Tracing of the multiplanes analysis at start (a), during
(b), and following treatment(c). The same frontal plane is shown
in each figure with lines indicating measurement points from
different frontal planes. (For more detailed description, see text.)
- = Anterior symmetry line a. ---- = Midface sym-
metry line b. ----- = Posterior symmetry line c.
eluding deformities of the mandible; it was explained to them
that treatment could principally be carried out based on three
different concepts: (1) allow the deformity to fully develop
and then perform the combined orthodontic/surgical correc-
tion as previously described by Kaban, Mulliken, and Mur-
ray,13 and Converse and associates6; (2) treatment during the
growth-period development by means of combined functional
therapy and surgery as described by Vargervik, and Ous-
terhout and Owsley8; and (3) possible avoidance of surgical
treatment through generation of the right microenvironment,
thereby provoking sufficient additional growth in the man-
dible.
Treatment and treatment results in relation to the two first
treatment principles could be demonstrated,92 whereas the
final result with regard to the last suggestion could not be
predicted because we had not performed any such treatment
and to our knowledge no convincing example was to be found
in the literature at the start of treatment in 1976.
The parents did, however, insist that they wanted treat-
ment to begin as soon as possible and surgery to be avoided,
if possible, It was therefore decided to provide the patient
with an activator a.m. Harvold.22 The construction bite was
taken with a lowering of the condyle on the left side (the
affected side), thereby forcing the mandible into the correct
midline position by a rotational movement around the healthy
condyle. The acrylic was removed from all occlusal contact
Am. J. Orrhod. Denrofac. Orrhop.
December 1986
Flg. 5. Basilar radiograph at start (a) and following treatment
(b). Before treatment, the affected side of the mandible ap-
peared shortened and distorted. The midline discrepancy was
obvious. The posttreatment radiograph showed the correction
that had taken place during treatment.
with the maxillary teeth in the underdeveloped side to allow
eruption. In the unaffected side, acrylic was maintained (full
coverage of the occlusal surface). To give the maximum sen-
soric input through the periodontal ligament, the patient was
instructed to use the activator at night and 1 to 2 hours a day.
After 6 months, the bite of the activator was raised to create
further distraction of the underdeveloped side and improve
the midline. This was repeated every sixth month and after
2 years a new activator was constructed according to the same
principles. After 4 years, a new set of x-ray films was pro-
duced and treatment continued along the same line. Two years
later the development of the occlusion was terminated and
the last set of diagnostic material was produced at age 12.
The analysis of treatment results revealed the following:
Extraoral examination. The face appeared symmetric
and, when asked to open her mouth, the patient performed a
symmetric movement of her mandible (Fig. 1, c and d).
Occlusion. Normal molar relationship was seen on both
sides as was normal overbite. Dental midlines coincided.
Radiographic analysis demonstrated that the asymmetry was
v01lme 90
Number 6
Fig. 6. Tomograms at the end of treatment of the normal condyle (a and c) and the affected condyle
(b and c), in occlusion (a and b) and in maximal opening (c and d).
reduced basally and the difference in right and left mandible
lengths was relatively reduced. The panoramic film demon-
strated that the condylar process was still underdeveloped,
and exhibited the typical cone shape of a type II deformity,*
but that pronounced growth in ramus height had taken place,
reducing the difference in length between the two sides of
the mandible (Fig. 2, b and c). The preangular notch had
likewise been gradually reduced with increasing age. Up-
righting of the lower incisors was obvious. The analysis of
the anteroposteriorradiograph in the three different crosssec-
tions showed that changes had taken place in all three levels
of the analysisI (Fig. 4, b and c). Through the additional
height of the ramus, which had occurredduring the treatment,
the asymmetry of plane c had decreased.The modeling and
redirection of the mandibular growth had led to a complete
concordance of planes a and 6. These planes, on the other
hand, still deviated slightly from plane c-a finding that could
be explained by lack of a normal joint on the affected side.
Tomograms (Fig. 6) of the normal and the affected tempo-
romandibular joints showed that the affected side had devel-
oped into a condyle-like shape, although considerably more
clumsy than the condyle of the contralateral side (Fig. 6).
Tomograms of maximal opening demonstrated that the artic-
ular tuberculum was flattened on the affected side compared
to the unaffected. The profile radiograph showed that the
posterior margin of the ramus on the affected side was lo-
calized 6 mm anterior to that of the normal side, but that the
right and left lower borders of the mandible were at the same
Case report 507
level (Fig. 3, c). The basilar radiograph confirmed this find-
ing, indicating that the compensation had taken place in the
glenoid fossa and also through apposition of the ramus
(Fig. 5).
CASE 2
A lo-year-old girl was referred by the local hospital to
the dental school for treatment of an increasing asymmetry.
Five years earlier the patient experienced a fracture of the
right condyle. She was treated by repositioning and by in-
termaxillary fixation for 2 weeks. Radiographic analysis at
the time of fracture demonstrated a fracture of type I low
according to Lund and a dorsal dislocation of the condyle.
Six months later an asymmetry had been observed for tbe
first time and the child was given a program to increasemo-
bility of the right temporomandibular joint. Since exercises
did not stop the development of the increasing asymmetry,
the patient was referred to the dental school in Aarhus.
Clinical examination. The clinical examination showed
a slight deviation of the jaw to the right, a deviation that
increasedon opening.
Intraoral examination. The intraoral examination showed
the midline deviation to the fractured side of the mandible
correspondingto about one incisor width (Fig. 7). The molar
relationship was distal by one premolar width on the right
side and normal on the left.
Radiographic examination. Profile radiographs showed a
normal position of the condyle on the left side. The right
508 M&en, Bjerregaard, and Bundgaard
Fig. 7. a, intraoral photograph of the patient in Case 2 before
treatment. The lower midline is displaced to the right. b, Same
patient following treatment.
condyle could not be traced, but on the profile radiograph
taken at maximal opening, it appeared that the right condyle
was missing (Fig. 8). Tomograms of both temporomandibular
joints confirmed this diagnosis. Tomograms at opening further
demonstrated a good mobility of both joints (Fig. 9). The
panoramic film clearly demonstrated that the inclination of
the incisors compensated for the midline discrepancy between
the upper and lower jaws. A multiplane analysisI (Fig. 10)
of an anteroposterior radiograph demonstrated that the asym-
metry was most pronounced in the deep plane c, but that the
superior limitation height of the ramuc was 5 mm less and
situated more inferiorly in the fracturL:tl than in the normal
side. This resulted in a displacement If the midline of the
anterior planes b and a toward the hea ly side. When open-
ing, the midline was, however, displace{ toward the fractured
side.
Treatment
It was decided to provide the patient with a Harvold
activator similar to the one used in Case 1. After 1 year of
treatment, the asymmetry was corrected; however, since the
patient was still in the mixed dentition, she was advised to
wear the activator at night until full permanent dentition had
been reached, which in her case was 4 months later.
A control 2 years out of treatment demonstrated the sta-
Am. .I. Orthod. Dentofac. Orthop.
December 1986
Fig. 8. a, Profile radiograph. Right condyle fractured and miss-
ing. The neck of the condyle appears lower and more anteriorly
positioned than the healthy left condyle. b, Anteroposterior ra-
diograph at maximal opening. The right condyle appears to be
missing. The midline deviation is pronounced.
bility of the treatment results. The clinical examination at this
time revealed a complete symmetry of the face in occlusion,
but when opening, the mandible was still deviated as before-
approximately 15 mm to the former fractured side. This may
imply that although the mandible was apparently symmetri-
cally controlled by facial musculature, there was still a bony
deficiency on the fractured side, which at a later stage might
cause problems.
tntraorally a normal molar relationship was present on
both sides, but a midline discrepancy of 1 mm to the right
of the mandible was still present. A slight space discrepancy
resulted in a labially displaced canine on the right side.
Volume 90
Number 6
Fig. 9. Tomograms of the healthy side (a and b) and the fractured side (c and d) before treatment,
and of the fracture side following treatment (e and f). Tomograms a, c, and e were taken in occlusion;
b, d, and f were taken in maximal opening.
The profile radiograph showed that the posterior margins
of the rami were still deviating. Tomograms clearly demon-
stratedthat modeling of the fractured condyle had taken place,
that the fractured condylar neck had been supplied with a
club-shapedcondyle, and further that a pronounced modeling
of the articular area of the cranial base was occurring. A
flattening and an anterior displacement of the fossa had oc-
curred, and the club-shaped condyle was situated centrally in
the fossa. The anteroposterior exposure confirmed correction
of the facial midline, but the ramus of the fractured side
was still shorter than on the contralateral side. This was,
however, partially compensatedfor through a modeling of the
glenoid fossa that had taken place. The deviation at opening
did, however, demonstrate that the compensation was not
complete.
CASE 3
The patient in Case 3 was a 13-year-old boy referred by
the family dentist for treatment of a dramatic overjet and
overbite. The malocclusion had developed over a few years
following an accident in which the child had experienced a
severetrauma on the chin. The x-ray films taken at the local
hospital did not show any pathologic findings and becauseno
immediate changes could be observed in the occlusion, no
Case report 509
therapy had been induced. The start of the development of
the overjet could not be reported in detail, but comparison of
profile radiographs taken at the community clinic 2 years
before referral to a radiograph taken at the time of referral
showed that no growth had occurred in the mandible, whereas
a normal forward-downward growth of the maxilla had oc-
curred.
Clinical examination at the time of referral. Extraorally,
the patients appearancewas dominated by an extreme ovejet
and a retrognathic mandible. The anterior lower face height
appeared very short; the lower lip was curled up behind the
upper incisorsresulting in a pronounced sulcusmentolabialis.
The mentalis muscle was hyperactive when the patient swal-
lowed and talked. The molar relationship was 195cusp width
distal, overjet was 18 mm, and overbite 14 mm (Fig. 11).
Opening movement appeared normal. Radiographic analysis
of the panoramic film revealeda short neck and a club-shaped
condyle bilaterally, which were judged from tomograms not
to be coveredby cartilage. On the profile radiograph, a sagittal
jaw relationship of 8 could be measured. Hand-wrist x-ray
films showed that the child had passed the capping stagez4
and was beyond the peak of the pubertal growth.
We attempted to provoke an additional condylar growth
by means of activator treatment, taking advantageof the pos-
510 Melsen, Bjerregaard, and Bundgaard
a$
b --s-m = Tracing at time of trauma. -
Fig. 10. Multiplane analysis before (a) and after (b) treatment.
Symmetry planes a, b, and c are defined as in Fig. 4.
sible remaining growth potential during the last period of
pubertal growth. An activator a.m. Harvold** was produced
with a construction bite 6 mm beyond freeway spaceand with
maximal protrusion. The patient was to wear the activator at
night and 1 to 2 hours in the evening. After 6 months, the
construction bite was revised and protrusion increased again
to the maximum. This was then repeated for 2 years at 6-
month intervals. After 2 years, height measurementsshowed
that the patient had reached final-height body stature and,
along with improved appearance, cooperation was declining
dramatically. It was therefore decided to terminate the acti-
vator treatment and refer the patient for othodontic surgical
correction.
Am. J. Orthod. Dentofac. Orthop.
December 1986
b
Fig. 11. a, Tracing of profile radiograph of the patient in
Case 3 at 2 years before treatment, at start of treatment, and
following 2 years of activator treatment superimposed on an-
terior cranial base. b, Tracing of mandible superimposed on
stable structures of symphysis and the mandibular canal.
= Tracing 2 years
following trauma. ---- = Tracing after 2 years of activator
treatment.
Comparison of the profile radiographs taken 2 years be-
fore the start of treatment and after 2 years of treatment
showed that no condylar growth was seen before treatment
and that a pronounced growth occurred during treatment,
leading to a decrease of the sagittal jaw relationship by 4.
DISCUSSION
Three patients have been described, two of which
had one missing condyle, and the third exhibiting a lack
of condylar cartilage on the existing condyles. In case
of hemifacial microsomia, the asymmetry is reported
to increase in severity with age25.3;the same is often
Volume 90
Number 6
true with asymmetry that develops as a result of
23 26-29 None of the patients possessed the normal
trauma.
condylar cartilage claimed to be crucial for normal
development.27 In spite of this doubtful prognosis, all
three patients responded well to treatment with func-
tional appliances.
The general principle followed in all three cases
was to establish a change in muscle activity with the
existing stress environment,* which in all patients de-
viated significantly from normal. The aim of the treat-
ment was to establish a new stress system that could
lead to bone apposition on the condyle or bone appo-
sition in case of a missing condyle in the condylar
region.
A ramus that was too short uni- or bilaterally to
support the mandible in a proper relation to the skull
was the problem in the cases presented. Two of the
patients suffered from a facial asymmetry and a pro-
nounced convexity of the face, whereas the third patient
suffered from a marked retrognathism. The means by
which the necessary stress system could be established
was an activator. Through the special construction of
the activators, we attempted to maximize the sensory
input from the periodontium of the mandibular teeth.
The applied method was only possible because mobility
of the mandible was normal in all three patients. In the
two asymmetry cases, treatment was started long before
the pubertal growth spurt, whereas treatment of the boy
with the bilateral trauma was not initiated until the lack
of condylar growth had led to a distortion of his facial
appearance. At that stage, the peak of the pubertal
growth spurt was reached.
In a report by Rune & associates3 on three patients
with hemifacial microsomia treated by FrHnkel appli-
ance, by activator, and by Herbst appliance, two
showed changes in the same direction as the cases pre-
sented here. However, none of these cases were fol-
lowed for more than 2 years and the final results could
not be predicted.
Apart from a report by Rune and associates in
198 1 ,33who showed a spontaneous improvement in the
horizontal plane of space in three patients, previous case
reports have frequently advised surgeryz.30~32 as part of
treatment. The present treatment of the asymmetry pa-
tients made further treatment such as surgery redundant;
only the patient in Case 3, who was treated after the
pubertal growth spurt and whose cooperation was un-
satisfactory, was referred for surgical completion of
treatment. The normal muscle balance acquired had
apparently produced and maintained facial symmetry
during the remaining development. The multiplane
analysis proposed by Grayerson and associates dem-
onstrated that the correction of the asymmetry was more
pronounced in the anteriorly situated planes than in the
Case report 511
more posteriorly situated planes. This could, however,
be confirmed by the tomographic analysis of the tem-
poromandibularjoints of the patients before and after
treatment, which clearly showed that treatment effect
was not limited to the mandible, but that the glenoid
fossa of the affected side was also greatly influenced
by the treatment. The modeling of the cranial base as
part of the treatment effect was found in the case of
congenital defects (Case 1) and in acquired defects.
The findings also corroborate our recent report on ac-
tivator treatment studied by means of the implant
method.
The presented case reports clearly demonstrated that
generation of a normal muscle balance is possible even
in absence of a condyle, and that bone apposition re-
quired to obtain symmetry can be achieved if the right
microenvironment is established.3
The patient who was treated during the last period
of growth did improve his facial skeleton, but did not
reach a normal sagittal relationship. This may indicate
that a successful treatment depends on the quantity of
growth during treatment as well as consistency in use
of the appliance (the last patient exhibited poor coop-
eration) .
The patients in the present report were all treated
by a Harvold activator. It is possible that other appli-
ances-that is, Frlnkel, Bionator, or Herbst appli-
ances-would generate the same effect. In conclusion,
it can be stated that treatment of patients with congenital
or acquired abnormal condyles should be initiated as
early as possible and that the right stimulus does induce
apposition to a degree that surgical intervention can
sometimes be avoided.
It is, however, imperative that the patients accept
the long treatment time because the stimuli attempted
with the activator treatment aim not only at a morpho-
logic change but also (and primarily) at generation of
a change in microenvironment by generation of muscle
activity necessary for maintenance of the results.
We would like to thank Prof. E. Harvold, who is the
former head of the Department of Orthodontics, Aarhus, Den-
mark, for the inspiration to start this type of treatment for the
asymmetry patient.
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Reprint requests to:
Dr. Birte Melsen
Department of Orthodontics
Royal Dental College
Vennelyst Blvd. DK-8000
Aarhus C, Denmark