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CASE REPORT

Consecutive condylectomy and molar intrusion


using temporary anchorage devices as an
alternative for correcting facial asymmetry
with condylar hyperplasia
Yoon Jeong Choi,a Sang-Hwy Lee,b Man-Suk Baek,c Jae-Young Kim,d and Young-Chel Parke
Seoul, South Korea

This case report demonstrates the successful treatment of facial asymmetry with condylar hyperplasia with
limited surgical and orthodontic treatment. A high condylectomy was performed to shorten the elongated condyle
and to remove its active growth site. The maxillary molars on the affected side were then orthodontically intruded
using temporary anchorage devices to improve the occlusal cant and posterior open bite of the unaffected side.
This combined surgical-orthodontic treatment provided a satisfactory outcome without additional orthognathic
surgery. (Am J Orthod Dentofacial Orthop 2015;147:S109-21)

C
ondylar hyperplasia is a developmental malforma- to the severity and the status of condylar growth.2,8 A
tion characterized by excessive growth of the high condylectomy is required to arrest active condylar
condyle. The unilateral enlargement of the condyle growth.7,9 When the mandible grows rapidly, a
leads to facial asymmetry, mandibular deviation, maloc- posterior open bite can occur, indicating no need for
clusion, and articular dysfunction.1 The hyperplastic maxillary surgery. However, bimaxillary surgery is
condyle can be expanded to the condylar neck, the ramus, generally necessary to correct both facial asymmetry
and even the mandibular body.2 Since the anomaly oc- and occlusal cant. Several reports have described
curs during puberty and rarely begins after the age of orthognathic surgery or condylectomy as a treatment
20,3,4 the maxilla usually follows mandibular downward option for condylar hyperplasia.1,8,10
growth as a physiologic response to the affected side.5 Here, we report a case of combined surgical-
As a result, the occlusal plane tilts toward the affected orthodontic treatment without orthognathic surgery for
side, whereas the teeth generally remain in occlusion.6,7 a patient with facial asymmetry and condylar hyperplasia.
Treatment is primarily surgical and can entail high Facial asymmetry and tilting of the occlusal plane was
condylectomy, orthognathic surgery, or both, according successfully treated orthodontically after a high condylec-
tomy. The condylectomy contributed to improve the
a
Assistant professor, Department of Orthodontics, The Institute of Craniofacial patient's facial asymmetry, and intrusion of the maxillary
Deformity, College of Dentistry, Yonsei University, Seoul, South Korea.
b molars on the affected side successfully corrected the
Professor, Department of Oral and Maxillofacial Surgery, College of Dentistry,
Yonsei University, Seoul, South Korea. tilted occlusal plane, resulting in a stable occlusal
c
Private practice, Seoul, South Korea. relationship without additional orthognathic surgery.
d
Clinical assistant professor, Department of Oral and Maxillofacial Surgery,
Gangnam Severance Hospital, College of Dentistry, Yonsei University, Seoul,
South Korea.
e
Professor emeritus, Department of Orthodontics, The Institute of Craniofacial
DIAGNOSIS AND ETIOLOGY
Deformity, College of Dentistry, Yonsei University, Seoul, South Korea. A 26-year-old woman was referred from the Depart-
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported. ment of Oral and Maxillofacial Surgery of Yonsei Univer-
Supported by a faculty research grant of Yonsei University College of Dentistry sity, Seoul, South Korea, for orthodontic treatment
for grant no. 2011-0033. combined with future orthognathic surgery. Her chief
Address correspondence to: Young-Chel Park, Department of Orthodontics,
Institute of Craniofacial Deformity, College of Dentistry, Yonsei University, 134 complaint was facial asymmetry, which she first noticed
Sinchon-dong, Seodaemun-gu, Seoul 120-749, Korea; e-mail, ypark@yuhs.ac. at puberty. She reported that the condition had become
Submitted, November 2013; revised and accepted, April 2014. progressively more severe since then. She had a history of
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists. surgery for gastric cancer at age 19 and reported that she
http://dx.doi.org/10.1016/j.ajodo.2014.04.025 had a keloid.
S109
S110 Choi et al

Fig 1. Pretreatment facial and intraoral photographs.

active growth potential (Fig 5). The condylar enlarge-


ment appeared to have caused rotation of the maxillo-
mandibular complex to the left side, based on the
significant differences in ramus lengths and the frontal
ramal inclination, occlusal plane cant, and chin devia-
tion. She reported intermittent clicking with discomfort
on the left but not the right temporomandibular joint
(TMJ), with no limitation in mouth opening.
Cephalometric and model analysis showed that she
had a skeletal Class III malocclusion (ANB angle,
2.8 ) with a hypodivergent facial profile (mandibular
Fig 2. Pretreatment panoramic radiograph. plane angle, 25.2 ) (Table II, Fig 4). She had Class I
canine and molar relationships on the left side, and Class
At the initial clinical examination, deviation of I canine and Class III molar relationships on the right
the chin to the left side was evident, and canting of side, with a congenitally missing mandibular second
the lip and maxillary occlusal plane was also observed premolar. Consequently, a slight extrusion of the maxil-
(Figs 1-4). The initial radiographic evaluations showed lary right second molar, especially the palatal cusp, was
an asymmetric mandible with elongation of the right observed. The mandibular dental midline was deviated
condyle (Table I). A whole body bone scan using 2.0 mm to the left side; this was smaller than the amount
Tc-99m hydroxydiphosphonate demonstrated an of skeletal discrepancy. Overjet and overbite were 1.3
intense focal uptake in the right condyle, indicating and 1.0 mm, respectively.

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Fig 3. Pretreatment study models.

Fig 4. Pretreatment cephalometric tracings.

On the basis of these findings, the patient was diag- any active condylar growth, (2) establish a functional
nosed as having facial asymmetry with condylar hyper- occlusion, and (3) improve her facial appearance.
plasia (possibly in an active state) and a skeletal Class
III malocclusion with a missing mandibular right second TREATMENT ALTERNATIVES
premolar. Condylectomy was considered first because of the
hot spot on the scintigram at the right condyle.7 Simul-
TREATMENT OBJECTIVES taneous or consecutive orthognathic surgery was also
The treatment objectives for this patient were to (1) considered for correction of the dentofacial deformity
correct her facial asymmetry and simultaneously stop and the malocclusion. Based on these surgical

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Table I. Condylar length in functional unit measurements shows the progressive recovery after the right condylec-
tomy until 1.5 years postoperatively
Condyle (mm) Coronoid (mm) Con/Cor

Right Left Right Left Right Left


Preoperative 53.84 39.42 35.63 39.23 1.511 1.005
6 mo postop 35.29 39.35 38.19 37.21 0.924 1.058
1.5 y postop 37.76 39.78 37.54 37.23 1.006 1.068

Con/Cor, Ratio of the condyle to coronoid length; postop, postoperative.


The parameters were measured on the panoramic radiographs.

Fig 5. Pretreatment bone scintigraphy.

Table II. Cephalometric measurements


Variable Norm Pretreatment 6 months after condylectomy Posttreatment 3.5 years of retention
SNA ( ) 81.6 83.3 83.2 83.4 83.4
SNB ( ) 79.1 86.1 82.6 82.4 82.0
ANB ( ) 2.5 2.8 0.6 1.0 1.3
Wits appraisal (mm) 2.8 6.2 1.5 2.7 2.1
ork sum ( )
Bj€ 393.3 385.2 391.0 389.6 390.6
SN-MP ( ) 34.0 24.8 31.1 29.8 30.7
Facial height ratio 66.0 75.2 69.8 71.0 69.9
U1-SN ( ) 106.0 118.2 121.0 110.9 108.6
IMPA ( ) 94.0 94.4 94.1 90.1 89.2
Interincisal angle ( ) 126.0 126.0 114.5 130.2 131.5
Upper lip to E-line (mm) 1.0 1.4 1.7 1.1 0.7
Lower lip to E-line (mm) 1.0 1.6 4.2 0.4 0.7

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Fig 6. Progress intraoral photographs 10 days after the condylectomy.

Fig 7. Panoramic radiograph and frontal and lateral cephalograms 10 days after the condylectomy.

considerations, 3 treatment alternatives were discussed the surgery-first approach would reduce the duration
at the surgical-orthodontic conference. of postoperative orthodontic treatment by acceler-
The first option was to perform a condylectomy ating tooth movements.12 However, the postoperative
with simultaneous orthognathic surgery followed by changes were difficult to predict accurately because
orthodontic treatment. This option would require the extent of TMJ remodeling could not be estimated
only 1 surgical procedure to obtain balanced occlu- precisely. Furthermore, the correction of facial
sion, TMJs, and jaws in a short time.11 In addition, asymmetry inevitably called for changes to the

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Fig 8. Serial panoramic radiographs showing remodeling of the condylar head after the condylectomy.

Fig 9. Progress facial and intraoral photographs 6 months after the condylectomy.

preoperative functional occlusion, which could then The second option was to perform the 2 surgical pro-
result in postoperative occlusal instability. Moreover, cedures at different times. After the condylectomy, the
early mobilization for rehabilitation of the TMJs occlusion as well as the facial asymmetry might be
can be challenging for a patient undergoing the changed significantly, creating a malocclusion with a
concomitant orthognathic surgery with maxilloman- posterior open bite. The occlusal, muscular, and TMJ
dibular fixation, which might compromise the changes would be expected to settle down to a quiescent
surgical outcome.13 phase after the remodeling period. This option would

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Fig 10. Progress cephalometric tracings 6 months after the condylectomy.

Fig 11. Progress intraoral photographs 10 months after the condylectomy.

allow time to make a precise plan for the orthognathic be corrected by molar intrusion using temporary
surgery during the postcondylectomy orthodontic treat- anchorage devices (TADs). We hoped that this plan would
ment. In addition, rehabilitation of the TMJ and the plan- eliminate the need for additional orthognathic surgery; if
ning and execution of the orthognathic surgery would be not, then we could still perform the orthognathic sur-
easier if the 2 surgical procedures were performed sepa- gery.14 Minimizing the extent of surgery, early mobiliza-
rately.2 However, 2 procedures would burden the patient tion after the condylectomy, and molar intrusion of the
physically and economically, and she could suffer from affected side would enhance postoperative recovery in
significant occlusal discomfort between the surgeries. terms of occlusion and TMJ rehabilitation. On the other
The last option was a less invasive treatment approach hand, ideal correction of the facial asymmetry would
that included the condylectomy and orthodontic camou- not be possible with this treatment option. Because
flage treatment. The tilted maxillary occlusal plane would clockwise rotation of the mandible would occur after

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Fig 12. Posttreatment facial and intraoral photographs.

additional orthognathic surgery with postorthodontic


treatment.2,8,9,15 Even though the treatment could take
longer with this last option, it was more conservative
and would provide circumstances in which the alveolus,
which exhibits compensatory growth, could recover the
original positioning via functional forces after the
condylectomy. Therefore, we selected the last option
and started to prepare the patient for treatment.

TREATMENT PROGRESS
Before the surgery, 0.018-in edgewise brackets were
Fig 13. Posttreatment panoramic radiograph. bonded to the maxillary and mandibular arches. A trans-
palatal arch with an extension hook on the right side was
the condylectomy, maxillary premolar extraction might inserted to intrude the palatal cusp of the maxillary right
be necessary. second molar. A rapid prototyped model was fabricated
These treatment alternatives were discussed with the from computerized tomography data. Then surgical
patient. Because of her history of gastric cancer, she simulation of the condylectomy was made to estimate
strongly desired limiting the number and extent of the the amount of bone resection. It was possible to predict
surgeries. Condylectomy would arrest the active condylar the postoperative mandibular shape and position as well
growth, correct the facial asymmetry significantly, pro- as the premature contacts in the molar area of the
vide long-term stability, and remove the necessity of involved side. Based on the simulation results, a rapid

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Fig 14. Posttreatment dental casts.

Fig 15. Posttreatment cephalometric tracings.

prototyped-based surgical template was constructed Condylar hyperplasia was confirmed by histopatho-
with a pressure-molding system (Biostar and Duran; logic examination, which showed increased levels of
Scheu-Dental, Iserlohn, Germany) to mark the osteot- zones of proliferation and maturation at the condylar
omy line. One month after bracket bonding, a high con- head. After the condylectomy, the facial asymmetry
dylectomy was performed on the right side using an was immediately improved; the dental midline was devi-
intraoral approach because of the patient's history of a ated 1 mm to the right side. Clockwise rotation of the
keloid. The coronoid process was osteotomized and mandible resulted in anterior and posterior open bites
temporarily distracted to gain surgical access and an on the left side with a large overjet and a Class II canine
unobstructed view. relationship (Figs 6 and 7).

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asymmetry significantly. Even though neither additional


orthognathic surgery nor mandibular reshaping was per-
formed, the chin deviation and canting of the occlusal
plane were favorably corrected, and the facial appear-
ance was dramatically improved (Figs 12-14). The
lateral cephalogram demonstrated that the molar
intrusion resulted in counterclockwise rotation of the
mandible with a decrease in the vertical dimension
(Figs 15 and 16). Retraction of the maxillary anterior
teeth improved the facial esthetics, but mild apical
root resorption was observed in those teeth. The dental
midlines were aligned with the facial midline, and proper
overjet (2.5 mm) and overbite (2.0 mm) were established.
The posterior occlusion was improved as well to achieve
Class I canine relationships on both sides, a Class I molar
relationship on the right side, and a Class II molar rela-
tionship on the left side.
The panoramic radiograph (Fig 13) showed remodel-
ing of the condylar head, which was well fitted to the
glenoid fossa. A deep notch was observed on the superior
surface of the right condyle that looked like surface re-
modeling of either an irregular cutting line or a small
Fig 16. Superimposed tracings (POD 10D, postoperative remnant after the condylectomy, considering the shape
10 days; POD 6M, postoperative 6 months; the tracings
of the initial condylar head. The temporarily osteotom-
for debonding and 3-year retention were made with 1
line because little change was observed).
ized coronoid process showed a slight upward displace-
ment despite rigid fixation with a plate. However, the
patient experienced no clicking, pain, or limitations in
Morphologic changes in the condyle were observed mouth opening except for intermittent myofascial pain
over the 6 months after the condylectomy (Fig 8). Even in the left occipital area throughout the follow-up period.
though intrusion of the maxillary second molar during The treatment results were maintained after 3.5 years
the period contributed to a decrease in the open bite, of retention (Figs 16-18). No additional apical root
the canting of the maxillary occlusal plane, posterior resorption was observed, and the right condylar head
open bite, chin deviation, large overjet, and Class II rela- showed a relatively intact cortical margin, suggesting
tionship remained (Figs 9 and 10). We therefore decided favorable remodeling and TMJ function as well as a
to intrude the maxillary right molars additionally using stable occlusion. The plate on the coronoid process
TADs and to extract the maxillary first premolars. was removed.
Four TADs were implanted into the buccal and
palatal interproximal bones of the maxillary right molars.
While the molars were intruded with TADs, the anterior DISCUSSION
teeth were retracted (Fig 11). The tilted occlusal plane Condylar hyperplasia is characterized by unilateral
was improved after 6 months of molar intrusion, and condylar enlargement with overeruption of the dentition
routine orthodontic treatment was continued. After on the affected side.1,2,5,6 Condylectomy is most often
21 months of postoperative orthodontic treatment, the proposed for the treatment of condylar hyperplasia
brackets were removed, and fixed lingual retainers because leaving an active growth site may lead to
were bonded to the lingual surfaces of both arches recurrence of the deformity.10,16 Even if the condyle is
(Fig 12). A maxillary clear retainer was delivered and inactive, treatment may also involve condylectomy or
worn full time for the first year with instructions to condyloplasty when the hyperplastic condyle is grossly
add an elastic (3/16-in, medium) with the TADs on the enlarged and normal remodeling changes cannot be
buccal and palatal sides at night. predicted.17,18 In our patient, bone scintigraphy
demonstrated active bone growth on the right condyle,
TREATMENT RESULTS indicating the necessity for the condylectomy.
The sequential condylectomy and intrusion of the In an experiment with a canine model, remodeling of
maxillary molars on the affected side improved the facial the condylar head was observed within 3 months of a

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Fig 17. Retention facial and intraoral photographs 3.5 years after treatment.

unilateral condylectomy with disc preservation; regener- day 7 and continued for 6 weeks also contributed to
ation was the most advanced in the medial plane and the the remodeling of the TMJ.
least advanced in the lateral plane.19 Remodeling of the A high condylectomy can sometimes cause a lateral
condylar head could be first observed radiographically in limitation due to lost or decreased function of the lateral
our patient at 3 months postoperatively, and significant pterygoid muscle.20 In addition, coronoidectomy, which
morphologic changes occurred during the next 3 months was required during the intraoral approach, carries the
(Fig 8). At 18 months postoperatively, a cortical demar- risk of morbidity in terms of postoperative pain, swelling,
cation was observed on the condylar head. As seen in and even trismus.21 We preserved the disc during surgery
Figure 18, the condylar head seemed to maintain this to allow for remodeling of the condylar head. The
shape and size until 5.5 years postoperatively. Not only patient had neither restricted jaw function nor TMJ-
orthodontic force but also functional force seems to related signs or symptoms throughout the postoperative
lead to remodeling of the TMJ. Functional force applied orthodontic treatment and follow-up periods.
to the condyle, TMJ, and alveolus was continued from Generally, condylar hyperplasia is accompanied by
the immediate postoperative period until 12 months compensatory vertical overgrowth of the maxillary and
postoperatively, when the molar intrusion was finished. mandibular alveoli on the affected side. To correct this
The spontaneous decreases in the anterior and posterior kind of deformity by orthodontic camouflage treatment,
open bites during the first 6 months after the condylec- intrusion of not only the maxillary molars but also the
tomy may represent functional adaptations of the mandibular molars may be ideal. However, the extent
condyle and alveolus. In addition, the active exercise of intrusion of the mandibular molars is practically
of mandibular movement that started at postoperative limited because the application of force is difficult on

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S120 Choi et al

Fig 18. Lateral and frontal cephalograms and panoramic radiograph 3.5 years after treatment.

the lingual side. Therefore, we decided to intrude the CONCLUSIONS


maxillary molars of the affected side, even though mild Orthodontic camouflage treatment combined with a
facial asymmetry would be expected. Our treatment high condylectomy for condylar hyperplasia can be a
result proved that molar intrusion by orthodontic force challenging option for the correction of facial asymme-
could correct the occlusal cant and improve the facial try for both the orthodontist and the maxillofacial
asymmetry as well. surgeon. The final mandibular position and the degree
The average relapse rate in the treatment of ante- of asymmetry correction are not precisely predictable.
rior open bite when corrected by molar intrusion is However, accurate diagnosis and precise treatment plan-
reportedly 10.3% to 30.3%,22-24 with more than ning based on sound biologic concepts can minimize
80% of the relapse occurring during the first year of extended surgical attempts while maintaining the
retention.24 Based on these reports, we did not remove desired outcomes.
the buccal and palatal TADs between the maxillary This case report illustrates the process of diagnosis
right first and second molars, even after debonding, and treatment of facial asymmetry with condylar hyper-
and used them to hang an elastic over the retainer plasia. The high condylectomy improved the facial
covering the maxillary occlusal surface. We believe asymmetry significantly without causing functional dis-
that this retention strategy also contributed to the turbances. Molar intrusion contributed to the correction
maintenance of the treatment result until 3.5 years of the occlusal cant. This consecutive surgical and
after treatment.

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orthodontic treatment could be used to avoid additional orthodontic tooth movement. J Oral Maxillofac Surg 2011;69:
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13. Stavropoulos F, Dolwick MF. Simultaneous temporomandibular
option for facial asymmetry with condylar hyperplasia.
joint and orthognathic surgery: the case against. J Oral Maxillofac
Surg 2003;61:1205-6.
14. Suh HY, Lee SJ, Park HS. Use of mini-implants to avoid maxillary
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