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-
tion characterized by excessive growth of the
condyle. The unilateral enlargement of the condyle
leads to facial asymmetry, mandibular deviation, maloc-
clusion, and articular dysfunction.1 The hyperplastic
condyle can be expanded to the condylar neck, the ramus,
and even the mandibular body.2 Since the anomaly oc-
curs during puberty and rarely begins after the age of
20,3,4 the maxilla usually follows mandibular downward
growth as a physiologic response to the affected side.5
As a result, the occlusal plane tilts toward the affected
side, whereas the teeth generally remain in occlusion.6,7
Treatment is primarily surgical and can entail high
condylectomy, orthognathic surgery, or both, according
a
Assistant professor, Department of Orthodontics, The Institute of Craniofacial
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.
c
Private practice, Seoul, South Korea.
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
Deformity, College of Dentistry, Yonsei University, Seoul, South Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Supported by a faculty research grant of Yonsei University College of Dentistry
for grant no. 2011-0033.
Address correspondence to: Young-Chel Park, Department of Orthodontics,
Institute of Craniofacial Deformity, College of Dentistry, Yonsei University, 134
Sinchon-dong, Seodaemun-gu, Seoul 120-749, Korea; e-mail, ypark@yuhs.ac.
Submitted, November 2013; revised and accepted, April 2014.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.04.025
to the severity and the status of condylar growth.2,8 A
high condylectomy is required to arrest active condylar
growth.7,9 When the mandible grows rapidly, a
posterior open bite can occur, indicating no need for
maxillary surgery. However, bimaxillary surgery is
generally necessary to correct both facial asymmetry
and occlusal cant. Several reports have described
orthognathic surgery or condylectomy as a treatment
option for condylar hyperplasia.1,8,10
Here, we report a case of combined surgical-
orthodontic treatment without orthognathic surgery for
a patient with facial asymmetry and condylar hyperplasia.
Facial asymmetry and tilting of the occlusal plane was
successfully treated orthodontically after a high condylec-
tomy. The condylectomy contributed to improve the
patient's facial asymmetry, and intrusion of the maxillary
tilted occlusal plane, resulting in a stable occlusal
relationship without additional orthognathic surgery.
DIAGNOSIS AND ETIOLOGY
A 26-year-old woman was referred from the Depart-
ment of Oral and Maxillofacial Surgery of Yonsei Univer-
sity, Seoul, South Korea, for orthodontic treatment
combined with future orthognathic surgery. Her chief
complaint was facial asymmetry, which she first noticed
at puberty. She reported that the condition had become
progressively more severe since then. She had a history of
surgery for gastric cancer at age 19 and reported that she
had a keloid.
S109
S110
Fig 1. Pretreatment facial and intraoral photographs.
Fig 2. Pretreatment panoramic radiograph.
At the initial clinical examination, deviation of
the chin to the left side was evident, and canting of
the lip and maxillary occlusal plane was also observed
(Figs 1-4). The initial radiographic evaluations showed
an asymmetric mandible with elongation of the right
condyle (Table I). A whole body bone scan using
Tc-99m hydroxydiphosphonate demonstrated an
intense focal uptake in the right condyle, indicating
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Choi et al
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
plane angle, 25.2 ) (Table II, Fig 4). She had Class I
canine and molar relationships on the left side, and Class
I canine and Class III molar relationships on the right
side, with a congenitally missing mandibular second
premolar. Consequently, a slight extrusion of the maxil-
lary right second molar, especially the palatal cusp, was
observed. The mandibular dental midline was deviated
2.0 mm to the left side; this was smaller than the amount
of skeletal discrepancy. Overjet and overbite were 1.3
and 1.0 mm, respectively.
Choi et al S111

Fig 3. Pretreatment study models.

Fig 4. Pretreatment cephalometric tracings.

On the basis of these findings, the patient was diag-
nosed as having facial asymmetry with condylar hyper-
plasia (possibly in an active state) and a skeletal Class
III malocclusion with a missing mandibular right second
premolar.
TREATMENT OBJECTIVES
The treatment objectives for this patient were to (1)
correct her facial asymmetry and simultaneously stop
any active condylar growth, (2) establish a functional
occlusion, and (3) improve her facial appearance.
TREATMENT ALTERNATIVES
Condylectomy was considered first because of the
hot spot on the scintigram at the right condyle.7 Simul-
taneous or consecutive orthognathic surgery was also
considered for correction of the dentofacial deformity
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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Choi et al S113

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
at the surgical-orthodontic conference.
The first option was to perform a condylectomy
with simultaneous orthognathic surgery followed by
orthodontic treatment. This option would require
only 1 surgical procedure to obtain balanced occlu-
sion, TMJs, and jaws in a short time.11 In addition,
the surgery-first approach would reduce the duration
of postoperative orthodontic treatment by acceler-
ating tooth movements.12 However, the postoperative
changes were difficult to predict accurately because
the extent of TMJ remodeling could not be estimated
precisely. Furthermore, the correction of facial
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
result in postoperative occlusal instability. Moreover,
early mobilization for rehabilitation of the TMJs
can be challenging for a patient undergoing the
concomitant orthognathic surgery with maxilloman-
dibular fixation, which might compromise the
surgical outcome.13
The second option was to perform the 2 surgical pro-
cedures at different times. After the condylectomy, the
occlusion as well as the facial asymmetry might be
changed significantly, creating a malocclusion with a
posterior open bite. The occlusal, muscular, and TMJ
changes would be expected to settle down to a quiescent
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
surgery during the postcondylectomy orthodontic treat-
ment. In addition, rehabilitation of the TMJ and the plan-
ning and execution of the orthognathic surgery would be
easier if the 2 surgical procedures were performed sepa-
rately.2 However, 2 procedures would burden the patient
physically and economically, and she could suffer from
significant occlusal discomfort between the surgeries.
The last option was a less invasive treatment approach
that included the condylectomy and orthodontic camou-
flage treatment. The tilted maxillary occlusal plane would
be corrected by molar intrusion using temporary
anchorage devices (TADs). We hoped that this plan would
eliminate the need for additional orthognathic surgery; if
not, then we could still perform the orthognathic sur-
gery.14 Minimizing the extent of surgery, early mobiliza-
tion after the condylectomy, and molar intrusion of the
affected side would enhance postoperative recovery in
terms of occlusion and TMJ rehabilitation. On the other
hand, ideal correction of the facial asymmetry would
not be possible with this treatment option. Because
clockwise rotation of the mandible would occur after

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Fig 12. Posttreatment facial and intraoral photographs.
Fig 13. Posttreatment panoramic radiograph.
the condylectomy, maxillary premolar extraction might
be necessary.
These treatment alternatives were discussed with the
patient. Because of her history of gastric cancer, she
strongly desired limiting the number and extent of the
surgeries. Condylectomy would arrest the active condylar
growth, correct the facial asymmetry significantly, pro-
vide long-term stability, and remove the necessity of
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Choi et al
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
bonded to the maxillary and mandibular arches. A trans-
palatal arch with an extension hook on the right side was
inserted to intrude the palatal cusp of the maxillary right
second molar. A rapid prototyped model was fabricated
from computerized tomography data. Then surgical
simulation of the condylectomy was made to estimate
the amount of bone resection. It was possible to predict
the postoperative mandibular shape and position as well
as the premature contacts in the molar area of the
involved side. Based on the simulation results, a rapid
Choi et al S117

Fig 14. Posttreatment dental casts.

Fig 15. Posttreatment cephalometric tracings.

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

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Fig 16. Superimposed tracings (POD 10D, postoperative
10 days; POD 6M, postoperative 6 months; the tracings
for debonding and 3-year retention were made with 1
line because little change was observed).
Morphologic changes in the condyle were observed
over the 6 months after the condylectomy (Fig 8). Even
though intrusion of the maxillary second molar during
the period contributed to a decrease in the open bite,
the canting of the maxillary occlusal plane, posterior
open bite, chin deviation, large overjet, and Class II rela-
tionship remained (Figs 9 and 10). We therefore decided
to intrude the maxillary right molars additionally using
TADs and to extract the maxillary first premolars.
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
teeth were retracted (Fig 11). The tilted occlusal plane
was improved after 6 months of molar intrusion, and
routine orthodontic treatment was continued. After
21 months of postoperative orthodontic treatment, the
brackets were removed, and fixed lingual retainers
were bonded to the lingual surfaces of both arches
(Fig 12). A maxillary clear retainer was delivered and
worn full time for the first year with instructions to
add an elastic (3/16-in, medium) with the TADs on the
buccal and palatal sides at night.
TREATMENT RESULTS
The sequential condylectomy and intrusion of the
maxillary molars on the affected side improved the facial
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Choi et al
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
remnant after the condylectomy, considering the shape
of the initial condylar head. The temporarily osteotom-
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
mouth opening except for intermittent myofascial pain
in the left occipital area throughout the follow-up period.
The treatment results were maintained after 3.5 years
of retention (Figs 16-18). No additional apical root
resorption was observed, and the right condylar head
showed a relatively intact cortical margin, suggesting
favorable remodeling and TMJ function as well as a
stable occlusion. The plate on the coronoid process
was removed.
DISCUSSION
Condylar hyperplasia is characterized by unilateral
condylar enlargement with overeruption of the dentition
on the affected side.1,2,5,6 Condylectomy is most often
proposed for the treatment of condylar hyperplasia
because leaving an active growth site may lead to
recurrence of the deformity.10,16 Even if the condyle is
inactive, treatment may also involve condylectomy or
condyloplasty when the hyperplastic condyle is grossly
enlarged and normal remodeling changes cannot be
predicted.17,18 In our patient, bone scintigraphy
demonstrated active bone growth on the right condyle,
indicating the necessity for the condylectomy.
In an experiment with a canine model, remodeling of
the condylar head was observed within 3 months of a
Choi et al
Fig 17. Retention facial and intraoral photographs 3.5 years after treatment.
unilateral condylectomy with disc preservation; regener-
ation was the most advanced in the medial plane and the
least advanced in the lateral plane.19 Remodeling of the
condylar head could be first observed radiographically in
our patient at 3 months postoperatively, and significant
morphologic changes occurred during the next 3 months
(Fig 8). At 18 months postoperatively, a cortical demar-
cation was observed on the condylar head. As seen in
Figure 18, the condylar head seemed to maintain this
shape and size until 5.5 years postoperatively. Not only
orthodontic force but also functional force seems to
lead to remodeling of the TMJ. Functional force applied
to the condyle, TMJ, and alveolus was continued from
the immediate postoperative period until 12 months
postoperatively, when the molar intrusion was finished.
The spontaneous decreases in the anterior and posterior
open bites during the first 6 months after the condylec-
tomy may represent functional adaptations of the
condyle and alveolus. In addition, the active exercise
of mandibular movement that started at postoperative
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day 7 and continued for 6 weeks also contributed to
the remodeling of the TMJ.
A high condylectomy can sometimes cause a lateral
limitation due to lost or decreased function of the lateral
pterygoid muscle.20 In addition, coronoidectomy, which
was required during the intraoral approach, carries the
risk of morbidity in terms of postoperative pain, swelling,
and even trismus.21 We preserved the disc during surgery
to allow for remodeling of the condylar head. The
patient had neither restricted jaw function nor TMJ-
related signs or symptoms throughout the postoperative
orthodontic treatment and follow-up periods.
Generally, condylar hyperplasia is accompanied by
compensatory vertical overgrowth of the maxillary and
mandibular alveoli on the affected side. To correct this
kind of deformity by orthodontic camouflage treatment,
intrusion of not only the maxillary molars but also the
mandibular molars may be ideal. However, the extent
of intrusion of the mandibular molars is practically
limited because the application of force is difficult on
S120
Fig 18. Lateral and frontal cephalograms and panoramic radiograph 3.5 years after treatment.
the lingual side. Therefore, we decided to intrude the
maxillary molars of the affected side, even though mild
facial asymmetry would be expected. Our treatment
result proved that molar intrusion by orthodontic force
could correct the occlusal cant and improve the facial
asymmetry as well.
The average relapse rate in the treatment of ante-
rior open bite when corrected by molar intrusion is
reportedly 10.3% to 30.3%,22-24 with more than
80% of the relapse occurring during the first year of
retention.24 Based on these reports, we did not remove
the buccal and palatal TADs between the maxillary
right first and second molars, even after debonding,
and used them to hang an elastic over the retainer
covering the maxillary occlusal surface. We believe
that this retention strategy also contributed to the
maintenance of the treatment result until 3.5 years
after treatment.
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Choi et al
CONCLUSIONS
Orthodontic camouflage treatment combined with a
high condylectomy for condylar hyperplasia can be a
challenging option for the correction of facial asymme-
try for both the orthodontist and the maxillofacial
surgeon. The final mandibular position and the degree
of asymmetry correction are not precisely predictable.
However, accurate diagnosis and precise treatment plan-
ning based on sound biologic concepts can minimize
extended surgical attempts while maintaining the
desired outcomes.
This case report illustrates the process of diagnosis
and treatment of facial asymmetry with condylar hyper-
plasia. The high condylectomy improved the facial
asymmetry significantly without causing functional dis-
turbances. Molar intrusion contributed to the correction
of the occlusal cant. This consecutive surgical and
Choi et al
orthodontic treatment could be used to avoid additional
orthognathic surgery, providing an alternative treatment
option for facial asymmetry with condylar hyperplasia.
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