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ARTICLE IN PRESS

J Oral Maxillofac Surg


xx:xxx, 2010

Hyperplasia of the Mandibular Condyle:


Clinical, Histopathologic, and Treatment
Considerations in a Series of 36 Patients
Laura Villanueva-Alcojol, MD* Florencio Monje, MD, PhD† and
Raúl González-García, MD‡

Purpose: Mandibular condylar hyperplasia (CH) is a rare entity that causes overdevelopment of the
mandible, creating functional and esthetic problems. The aim of this article was to describe demographic
and clinical characteristics of CH, analyze histopathologic features and their association with scinti-
graphic and clinical findings, and evaluate esthetic and functional results after treatment by high
condylectomy during the active phase.
Materials and Methods: This retrospective study included 36 patients whose condyles were removed
because of excessive unilateral growth resulting in facial asymmetry and occlusal disturbance. Of the 36
patients, 13 had had symptoms related to the temporomandibular joint, such as pain or clicking. In all
the cases, high condylectomy was performed, and surgical specimens were sent for histologic exami-
nation and divided into 4 histologic types as described by Slootweg and Müller. Statistical analysis was
performed by use of R software (version 2.10.1; R Foundation for Statistical Computing, Vienna, Austria)
and SPSS software for Windows (version 15.0; SPSS, Chicago, IL) to evaluate our results. A ␹2 test was
carried out to assess the possible association between gender and involved side. The association of
histologic appearance with clinical symptoms was estimated by use of the Fisher exact test. An analysis
of variance test was performed to evaluate a possible association between patient age and histologic type
according to the Slootweg and Müller classification and between histologic type and uptake on bone
single photon emission computed tomography (SPECT).
Results: We could not find a relationship between histologic type and uptake of the affected condyle
on bone SPECT or between age and histologic type. However, our statistical analysis revealed an
association between histologic appearance and the presence of joint symptoms (P ⫽ .0049). Clinically,
occlusion and facial symmetry improved in all patients postoperatively, and no recurrence was noted in
any patient. Six patients required secondary surgery.
Conclusion: We could not find any significant association between age and histologic type or between
bone SPECT and histologic type. However, a significant association between histologic type and
temporomandibular joint symptoms was observed. High condylectomy combined with orthodontics
achieved optimal esthetic and functional results and constituted the unique and definitive treatment in
30 of 36 patients.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg xx:xxx, 2010

Mandibular condylar hyperplasia (CH) is a rare entity. then, there have been numerous reports in the liter-
It was first described by Robert Adams in 1836 as a ature referring to this clinical entity.2-4 The excessive
condition that causes overdevelopment of the mandi- unilateral growth of the mandibular condyle can lead
ble, creating functional and esthetic problems.1 Since to facial asymmetry, occlusal disturbance, and joint

Received from the Department of Oral and Maxillofacial-Head and Hospital Infanta Cristina, Badajoz, Juan de Badajoz, 14, 2G, 06003
Neck Surgery, University Hospital Infanta Cristina, Badajoz, Spain. Badajoz, Spain; e-mail: laurivillanueva@hotmail.com
*Resident Surgeon. © 2010 American Association of Oral and Maxillofacial Surgeons
†Department Head. 0278-2391/10/xx0x-0$36.00/0
‡Staff Surgeon. doi:10.1016/j.joms.2010.04.025
Address correspondence and reprint requests to Dr Villanueva-
Alcojol: Department of Oral and Maxillofacial Surgery, University

1
ARTICLE IN PRESS
2 HYPERPLASIA OF THE MANDIBULAR CONDYLE

dysfunction. Prominent features include an enlarged scintigraphy, and histopathologic assessment.5,12 TMJ
mandibular condyle, elongated condylar neck, out- radiographs may show abnormalities in the size and
ward bowing, and downward growth of the body and morphology of the condylar head and/or neck re-
ramus of the mandible on the affected side, causing gions. Bone single photon emission computed tomog-
fullness of the face on that side and flattening of the raphy (SPECT) scan is an essential diagnostic tool for
face on the contralateral side. Some patients also may visualizing hyperactivity in the condyle. Various stud-
present with symptoms from the temporomandibular ies have shown the clinical significance of this tech-
joint (TMJ) such as pain, joint sounds, and limitation nique in such patients because this method identifies
of mouth opening.5 those with persistent unilateral condylar activity.5,13,14
Obwegeser and Makek6 classified the asymmetry The radioactive isotope is technetium 99 methylene
associated with CH into 3 categories: hemimandibular bisphosphonate. Increased radionuclide uptake by
elongation, with a horizontal growth vector (type 1); the hyperplastic condyle can be an indication of con-
hemimandibular hyperplasia, with a vertical growth tinued abnormal growth. It has been reported that a
vector (type 2); and a combination of the 2 entities. difference in uptake of 55%:45% or more between the
Type 1 is associated with chin deviation toward the condyles can be indicative of CH, because the af-
contralateral side and mandibular midline deviated to fected condyles had a relative uptake of 55% or
the unaffected side. On the other hand, type 2 is more.15-17
characterized by an ipsilateral open bite or compen- Slootweg and Müller12 described 4 histologically
satory vertical overdevelopment of the maxilla on the different types of mandibular CH. They proposed a
involved side with canting of the occlusal plane. Most classification based on histologic criteria and divided
commonly, the mandibular midline is straight and the hyperplastic condyles into 4 types depending on the
chin is less deviated. The third type is a combination arrangement and morphology of the various layers of
of the other 2 types. the condyle (fibrous articular layer, undifferentiated
The etiology and pathogenesis of CH remain uncer- mesenchyme proliferative layer, transitional layer,
tain. It is not known what triggers a condyle to sud- and hypertrophic cartilage layer)18 (Table 1).
denly start growing and become hyperplastic. Sug- Although most reported cases are documented his-
gested theories include trauma followed by excessive tologically,5,12,19,20 in general, correlation of histo-
proliferation in repair, infection, hormonal influ- logic aspects with age, SPECT, and clinical symptoms
ences, arthrosis, hypervascularity, and a possible ge- remains unclear.
netic role.7-9 Obwegeser and Makek6 suggested that Treatment is primarily surgical, with or without
different growth factors individually controlling gen- orthodontics, and depends on the degree of severity
eralized hypertrophy and elongation might be respon- and the status of condylar growth. Different surgical
sible for the deformities. Another possible cause be- options have been proposed for treating this anomaly,
ing taken into consideration, but thus far not ranging from high condylectomy to orthognathic sur-
substantiated, is an increase in functional loading of gery or even a combination of both. There is also
the TMJ.10,11 controversy with respect to the time of surgery, with
The diagnosis of CH may be made by a combination some authors preferring to perform surgery as soon as
of clinical and radiologic findings. Various methods possible and others waiting for cessation of excessive
have been used, including radiographic studies, bone activity to perform any intervention.

Table 1. HISTOLOGIC CLASSIFICATION OF MANDIBULAR CONDYLAR HYPERPLASIA DESCRIBED BY SLOOTWEG


AND MÜLLER12

Histologic Classification Characteristics

Type I Broad proliferation zone


Underlying thick layer of hyaline growth cartilage
Bone containing numerous cartilage islands
Type II Patchy distribution (cell-rich areas alternating with nonproliferative, cell-poor zones)
Cartilage islands in cancellous bone are less frequent than in type I
Type III Great distortion
Irregularly shaped masses of hyaline cartilage extending into cancellous bone of condylar neck
or encroaching upward onto superficial articular layer
Type IV Continuous subchondral bone plate covered by cell-poor fibrocartilaginous layer
No proliferation layer of hyaline growth cartilage
Burned-out appearance of condyle
Villanueva-Alcojol, Monje, and González-García. Hyperplasia of the Mandibular Condyle. J Oral Maxillofac Surg 2010.
ARTICLE IN PRESS
VILLANUEVA-ALCOJOL, MONJE, AND GONZÁLEZ-GARCÍA 3

The aim of this retrospective study was to describe, In all the cases in our series, high condylectomy
in a group of 36 patients diagnosed with unilateral was performed through an intra-aural or preauricular
CH, demographic and clinical characteristics; analyze approach, incision on the superficial temporal fascia
histopathologic features of CH and their association and periosteum of the zygomatic arch, and dissection
with scintigraphic and clinical findings; and evaluate just above the TMJ capsule. Then, a T-incision was
our esthetic and functional results after treatment by performed for entry in the inferior joint space, and 4
high condylectomy during the active phase. to 5 mm of the condylar head was removed, without
smoothing of the cortical edges. Orthodontic treat-
Materials and Methods ment and mouth opening exercises were started
thereafter.
This retrospective study, which covered the period All surgical specimens were sent for histologic ex-
between 1998 and 2009, included 36 patients (25 amination. The condyles were first placed in 4% buff-
female and 11 male patients) whose condyles were ered formalin and then decalcified in hydrochloric
removed because of excessive unilateral growth re- acid (Surgipath Medical, Richmond, IL) and dehy-
sulting in facial asymmetry and occlusal disturbance. drated sequentially in 70%, 90%, and 100% alcohol.
The inclusion criteria for the study were 1) patients Samples were cleared with 50% and 100% methyl
with facial asymmetry and malocclusion, with or salicylate before infiltration with paraffin. Micrometer
without pain or clicking related to the TMJ; 2) pa- sections were prepared from blocks, deparaffinized in
tients who showed enlarged and/or elongated con- xylene, rehydrated in descending concentrations of
dyles on the orthopantograph; 3) patients whose alcohol, and stained with hematoxylin-eosin. The sam-
SPECT scan showed a difference in uptake of 55%: ples were subsequently divided into 4 histologic types
45% or more between condyles or a large difference as described by Slootweg and Müller.12
assessed subjectively by a specialist in nuclear medi- All the cases were confirmed histopathologically as
cine; and 4) patients in whom histopathologic exam- CH, but only 18 were divided according to the Slootweg
ination confirmed mandibular CH. and Müller classification. We compared the histology of
Exclusion criteria included patients in whom en-
the condylar specimen with preoperative bone scintig-
largement of the condyle was caused by neoplasia or
raphy to try to find functional-morphologic correlations.
dysplasia, as shown by radiologic and histologic ex-
amination. All patients were informed of the nature of
this investigation and all provided their informed con- STATISTICAL ANALYSIS
sent. Statistical analysis was performed by use of R soft-
Each patient had a complete clinical examination. ware (version 2.10.1; R Foundation for Statistical
The presenting clinical features in these patients in- Computing, Vienna, Austria) and SPSS software for
cluded facial asymmetry and malocclusion. Moreover, Windows (version 15.0; SPSS, Chicago, IL). The level
13 of the 36 patients had had symptoms related to the of statistical significance was set at .05. The descrip-
TMJ. In each case, these consisted of mild pain and tive statistical analysis was based on the mean and
clicking. Apart from the clinical examination, plain standard deviation for continuous variables, whereas
radiographs with orthopantographs and posteroante- the frequency and percentage were used for categor-
rior and lateral cephalograms were obtained. These ical variables. A ␹2 test was carried out to assess the
showed enlarged and/or elongated condyles in most possible association between gender and involved
cases. side. The association of histologic appearance with
In all 36 cases, bone SPECT scans were performed. clinical symptoms was estimated by use of the Fisher
Patients who had a ratio of 55%:45% or more and exact test. An analysis of variance (ANOVA) test was
clinical and radiographic findings in accordance with performed to evaluate a possible association between
CH were operated on. A 6-month to 1-year patient patient age and histologic type according to the clas-
evaluation period was sometimes required before sur- sification of Slootweg and Müller and between histo-
gery in cases in which condylar activity was uncer- logic type and uptake on bone SPECT.
tain. Exceptionally, 1 patient with an uptake of 54%: This study was approved by the Hospital Ethical
46% after several scintigraphic studies was treated Committee and by the Institutional Human Studies
surgically because of persistent and increasing symp- (IRB) Committee.
toms after various evaluations.
In relation to the scintigraphic study, we must
point out that only 24 of the SPECT scans were quan-
Results
tified. In the earlier cases, the planar and SPECT im-
ages were assessed only subjectively by a specialist in The mean age at surgical intervention was 22.7
nuclear medicine. years (SD, 6.7; range, 11 to 42 years). The female-male
ARTICLE IN PRESS
4 HYPERPLASIA OF THE MANDIBULAR CONDYLE

ratio was 25:11, and the right-left affected side ratio bination of the 2 types was seen in 4 patients (11.1%).
was 11:7 (22 right and 14 left) from SPECT, histolog- Additional symptoms, such as mild pain or clicking of
ically and clinically. the joint, were present in 13 cases (36.1%).
It has been suggested that there is an association Bone SPECT scan had been performed on all 36 sub-
between female gender and right side, with the right jects. On all the scans, there was appreciable asymmetry
side predominating in female patients and the left side in relative condylar uptake. The maximum difference
predominating in male patients.21 In our sample, we among quantified scans was 68% to 32%. The mean
could not find a statistically significant association percentage of the affected condyle was 59.04% (SD,
between gender and affected side. 3.56), whereas the unaffected condyle showed a lower
All patients had unilateral excessive growth of the percentage (40.96%; SD, 3.56) (Table 2).
mandibular condyle with concomitant occlusal distur- On examination of the histologic sections, all pa-
bance and/or chin deviation toward the opposite side. tients exhibited a persistent layer of undifferentiated
According to the clinical classification of Obwegeser mesenchyme cells and a layer of hypertrophic carti-
and Makek,6 24 patients were considered type 1 lage, and evidence of cartilage rests in the cancellous
(66.7%), 8 patients showed an asymmetry in the vertical bone. Classification into types according to Slootweg
plane and were classified as type 2 (22.2%), and a com- and Müller was only performed in 18 patients, as

Table 2. CLINICAL DATA OF 36 PATIENTS WITH MANDIBULAR CONDYLAR HYPERPLASIA

Patient Age (yr) Gender Side SPECT Clinical Type* TMJ Symptoms Secondary Surgery

1 27 F R — 1 No No
2 24 F R — 2 Yes Yes
3 24 M L — 2 No No
4 26 F L — 2 No No
5 26 F R — C Yes No
6 19 F R — 1 No No
7 24 F R — 2 Yes No
8 32 M R — 2 Yes No
9 11 M R — 1 No No
10 18 F L — 1 No No
11 24 M R — 1 No Yes
12 17 F L — 1 No No
13 17 M R 59%:41% 1 No No
14 29 M R 60%:40% 2 Yes No
15 22 M R 68%:32% 2 No Yes
16 25 M L 46%:54% 1 No No
17 16 F R 56%:44% 1 No Yes
18 22 F R 62%:38% 1 No No
19 20 F L 43%:57% C Yes Yes
20 18 F L 44%:56% 1 No No
21 28 F R 62%:38% 1 No No
22 19 F L 46%:54% 1 Yes No
23 14 F R 65%:35% 1 Yes No
24 35 M L 39%:61% 1 No No
25 24 F R 57%:43% 2 No No
26 14 F R 58%:42% 1 No No
27 42 F L 38%:62% 1 No No
28 21 F L 43%:57% 1 Yes No
29 26 F L 36%:64% 1 Yes Yes
30 36 F R 60%:40% C Yes No
31 22 F R 57%:43% C Yes No
32 16 M R 57%:43% 1 No No
33 24 M L 44%:56% 1 No No
34 13 F L 43%:57% 1 Yes No
35 17 F R 58%:42% 1 No No
36 25 F R 60%:40% 1 No No
Abbreviations: C, combination of 2 clinical types; SPECT, single photon emission computed tomography; TMJ, temporoman-
dibular joint.
*Clinical type according to classification of Obwegeser and Makek.6
Villanueva-Alcojol, Monje, and González-García. Hyperplasia of the Mandibular Condyle. J Oral Maxillofac Surg 2010.
ARTICLE IN PRESS
VILLANUEVA-ALCOJOL, MONJE, AND GONZÁLEZ-GARCÍA 5

Histologic types Discussion


Rowe2 defined mandibular CH as an entity that
50%
produces an asymmetry of the mandible resulting
45%
from an enlargement of one side that is not due to
40%
neoplasia or dysplasia.
35%
Traditionally, it has been reported that CH afflicts
30%
male patients and female patients in equal propor-
25%
tions.23,24 Moreover, some authors have even indi-
20% cated that this condition is more common in male
15% patients.25 However, a female predisposition has been
10% noted in other studies,20 and, indeed, our group in-
5% cluded more female patients than male patients (ratio,
0% 25:11), in agreement with other reports of ratios of
CH I CH II CH III 7:27 and 3:1.5,21 In light of our results, we can state
FIGURE 1. Distribution of histologic types. that treatment was more commonly sought by female
Villanueva-Alcojol, Monje, and González-García. Hyperplasia of
patients than by male patients.
the Mandibular Condyle. J Oral Maxillofac Surg 2010. With regard to preferential laterality, an equal side
distribution has been found by some authors, whereas
others have found that the left side is more frequently
affected.26 In our study, the right side was more
depicted in Figure 1. None of the samples was classi-
affected, with a ratio of 11:7 (22 right and 14 left).
fied as type IV. We only found types I, II, and III in our
This result is consistent with other reports.21,27
series. Type I was the most frequently observed
Nitzan et al21 found that this preferential laterality was
(44.4%), followed by type III (38.9%). Only 16.7% of
highly gender dependent, with the right side predom-
the patients showed type II CH (Fig 2). inating in female patients and the left side predomi-
A possible association between patient age and nating in male patients. Nevertheless, we have not
histologic type, as suggested by Slootweg and Müller, found this association in our series.
was evaluated, without a statistically significant asso- With respect to clinical classification depending on
ciation. the growth vector, a prevalence ratio between types
When analyzing our results, we observed that all 1 and 2 of approximately 15:1 has been reported.28 In
the patients with type II CH presented with symp- our group of patients, this ratio was 3:1, and more-
toms, such as pain and clicking. In type III patients, over, we found 4 patients with a combination of both
some had symptoms and some did not. Conversely, vertical and horizontal asymmetry. Our results (type 1
none of the patients with type I CH had any problems in 66.7% of patients, type 2 in 22.2%, and a combina-
in relation to the TMJ. Our statistical analysis showed tion of transverse and vertical asymmetry in 11.1%)
an association between histologic type and the pres- are similar to those of Nitzan et al,21 who reported
ence of joint symptoms (P ⫽ .0049). frequencies of 53%, 31%, and 16% for type 1, type 2,
On the other hand, we could not find a relationship and a combination of the 2 entities, respectively.
between histologic type and uptake of the affected The scintigraphic results showed hyperactivity of
condyle on bone SPECT. one of the condyles consistent with clinical findings.
The mean follow-up was 4.3 years. Occlusion and It is important to emphasize that SPECT results should
facial symmetry improved in all patients postopera- be interpreted in light of a full clinical, radiographic,
tively, and no recurrence was noted in any patient and cephalometric evaluation. It should be borne in
(Figs 3, 4). Six patients required orthognathic surgery mind that this method of bone scanning, though
or esthetic surgery to correct residual deformity dur- highly sensitive, is nonspecific and does not necessar-
ing the follow-up period (4 bimaxillary surgeries, 2 ily correlate with active growth because it can also be
mentoplasties, and an angle prosthesis). Furthermore, the result of inflammatory conditions, infection, heal-
we observed, in accordance with other authors, that ing after traumatic injuries, and neoplastic lesions.
the function of the joint was unimpaired and pain Bone SPECT scintigraphy should not be used as the
free.22 The clinical examination showed a normal sole determinant of the need for condylar resection.
maximum interincisal opening and lateral excursions In describing the histologic characteristics of spec-
before and after surgery. High condylectomy left a imens of hyperplastic condyles that were surgically re-
normally functioning joint. No long-term joint mor- moved, similar to other authors,5,12 we have observed the
bidity in patients treated in this way has yet been presence of an interrupted layer of undifferentiated mes-
observed. enchymal cells and a hypertrophic cartilage layer. Another
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6 HYPERPLASIA OF THE MANDIBULAR CONDYLE

FIGURE 2. Histopathologic examination. A, Type I CH. The photomicrograph shows a broad proliferation area. Cartilage islands are
present within the bony trabeculae (hematoxylin-eosin stain, original magnification ⫻20). B, Cartilage island in deep layers of trabecular
bone (4.6 mm deep from surface) of a hyperplastic condyle. C, Type II CH. Cartilage rests are less frequent in the spongy bone than in type
I (hematoxylin-eosin stain, original magnification ⫻10). D, Type III CH, showing more distorted layered pattern (hematoxylin-eosin stain,
original magnification ⫻10).
Villanueva-Alcojol, Monje, and González-García. Hyperplasia of the Mandibular Condyle. J Oral Maxillofac Surg 2010.

structural feature observed consistently in hyperplastic Gray et al5 reported that the increase in uptake was
condyles is the distribution of cartilage rests in the sub- directly related to the frequency and penetration
chondral spongiosa, which is histologic proof of progres- depth of the cartilage islands. They also reported that
sive lengthening of the condyle. those patients who had marked uptake on the scinti-
Given the retrospective character of the study, al- scan also had a higher frequency of cartilage islands,
though all the cases were confirmed histopathologi- and the depth at which they were found was greater.
cally to have mandibular CH, only 18 were divided However, they did not correlate these findings with
according to the classification of Slootweg and Müller. histologic types.
In all the patients with increased radionuclide up- Slootweg and Müller12 found that the results of
take, we observed the histologic characteristics of scintigraphy did not correlate with histologic growth
CH. However, when analyzing a possible association evidence. On the other hand, they assumed that there
between the activity level of the affected condyle on was a correlation between histologic growth activity
scintigraphic examination and the histologic features and age, with type I being more frequently found in
of a determined type of CH according to the Slootweg patients younger than 20 years of age and type II
and Müller classification, we could not find consistent being more common in patients over 20 years of age.
results in our series. They indicated that type III would be more frequently
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VILLANUEVA-ALCOJOL, MONJE, AND GONZÁLEZ-GARCÍA 7

found in older patients. In our group, when we tried


to find an association between age and the various
histologic appearances of the condyle, a statistically
significant relationship was not encountered.
Nevertheless, we found a significant correlation
between histologic type and the presence or absence
of symptoms (P ⫽ .0049). Particularly, we observed
that all patients with type II CH had clinical manifes-
tations such as pain and joint sounds. Among the type
III patients, some were symptomatic and the rest did
not report any disturbance in relation to the TMJ.
Conversely, none of the patients with type I CH had
any joint symptoms. To our knowledge, this associa-
tion has not been reported in the literature until now,
and it could suggest that histologic types represent
different stages of the pathologic entity, with the
onset of symptoms as the illness becomes more evi-
dent and their disappearance as the fibrosis develops.
Type I CH could be considered as a first phase of
proliferation in which there are no symptoms yet.
These would start in a latter phase (type II CH) of
patchy activity, and patients would probably become
asymptomatic again as the fibrosis generalizes and
hyaline cartilage disappears (type III CH). However,
because this study was conducted in a relatively small
group of patients, the results cannot be generalized to
the whole population of CH patients. They first need
to be confirmed in further studies in larger series.
Traditionally, the surgical methods used have con-
sisted primarily of orthognathic surgery for correction of
the asymmetry when further growth is not anticipated.
Motamedi27 performs unilateral or bilateral ramus os-
teotomy when growth is complete. Macintosh29 leaves
the articulation surgically undisturbed, allows the hyper-
plasia to run its course, and then treats its sequelae with
appropriate osteotomies. In our opinion, this option
often means waiting a long time, and consequently, the
patient may have functional and esthetic disturbances,
associated with psychosocial problems derived from a
severe facial deformity. Moreover, the magnitude of the
deformity and its compensatory changes in the maxilla
and dentoalveolar structures could compromise clinical
treatment outcomes. Some authors perform a bimaxil-
lary operation including resection of the involved con-
dyle in the same procedure. Wolford et al28 and Sheffer
et al30 propose orthognathic surgery and simultaneous
high condylectomy to correct the asymmetry.
In our opinion, basic considerations in the manage-
ment of facial asymmetry caused by active CH must
include control of the growth process to allow more
FIGURE 3. A, B, and C, Unilateral mandibular type II CH in a 24-year-
old patient. The elongation of the left side of the face, chin deviation, and balanced facial development. If evidence of abnormal
canting of the occlusal plane should be noted. The mandibular midline is condylar growth is present, then condylar surgery
not deviated. D, E, and F, Patient at 2 years after high condylectomy, should be undertaken before a severe facial deformity
showing significantly improved facial harmony and good occlusal result.
develops.31 It is expected that the removal of the
Villanueva-Alcojol, Monje, and González-García. Hyperplasia of the condyle will arrest the excessive and disproportionate
Mandibular Condyle. J Oral Maxillofac Surg 2010.
growth of the mandible in the diseased region and
ARTICLE IN PRESS
8 HYPERPLASIA OF THE MANDIBULAR CONDYLE

ditional surgical interventions in most cases. If not,


secondary correction by mandibular or maxillary os-
teotomies or both can be appropriate to correct any
residual occlusal and facial asymmetry. In general
terms, if a high condylectomy has been performed
and posterior orthognathic surgery is necessary, this
second operation will be easier.
High condylectomy (removal of 4 to 5 mm of the
condyle) instead of condylar shaving (removal of 2 to
3 mm of the condyle) is our preferred method. The
presence of cartilage islands in the cancellous bone
shows that the pathology is not limited to the carti-
lage surface. Masses of hyaline cartilage extending
into the cancellous bone of the condylar neck have
been identified in our samples. Therefore, not only
the cartilage surface but also the subchondral bone
should be removed to eliminate the growth center.
In summary, we could not find any significant as-
sociation between age and histologic type or between
bone SPECT and histologic type. However, a signifi-
cant association between histologic type and TMJ
symptoms was observed. High condylectomy com-
bined with orthodontics achieved optimal esthetic
and functional results and constituted the unique and
definitive treatment in 30 of 36 patients.

Acknowledgments
The authors thank Dr Fernandez de Mera for the histologic
analysis.

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