J Oral Maxillofac Surg 70:1413-1425, 2012

Correction of Facial Asymmetry as a Result of Unilateral Condylar Hyperplasia

Robert Hillary Boucaut Jones, BDS, BSc(Dent), MDS, FRACDS, FRACDS(OMS),* and Graham A. Tier, BDS, FDSRCPS(Glas), FRACDS, FRACDS(OMS)
A mild degree of facial asymmetry is normal, and one only has to mirror the 2 separate sides of the face and compare the contours of the left side of the face with the right, to nd that the images will be completely different. However, if this mild disparity becomes markedly obvious, then individuals will seek treatment for the problem. The common causes of facial asymmetry include the following: 1. Craniosynostosis affecting the base of the skull, eg, Aperts syndrome (Fig 1A) 2. Craniofacial clefting (Fig 1B) 3. Hemifacial microsomia 4. Trauma to the mandibular condylar growth center 5. Condylar hyperplasia 6. Hemimandibular hyperplasia 7. Hemimandibular elongation 8. Tumors benign or malignant Obwegeser and Makek1 discussed the common causes of mandibular asymmetry, with particular emphasis on those relating to an increase in the activity of the condylar growth centers on 1 side or the other. These they referred to as hemimandibular elongation and hemimandibular hyperplasia. Wolford et al,2 in a more recent article, take this a step further and have simplied the classication. They consider condylar hyperplasia to be a pathological condition that induces overdevelopment of the condylar head, neck, or mandible generally and can be caused by several different pathological entities, each of which will have a different effect on the facial skeleton. The bilateral form will produce a symmetrical mandibular hyperplasia that progresses beyond the normal parameters of growth, and if there is a differential growth anomaly, with 1 side growing more than the other, an asymmetry will develop, which is usually progressive. This form of condylar hyperplasia is the same as Obwegesers hemifacial elongation, which may be symmetrical or asymmetrical. Wolford refers to the symmetrical form as CH 1A (bilateral symmetrical form) and CH 1B (asymmetrical form). He refers to the unilateral enlargement of the condylar head, neck, ramus, and body of the mandible as CH 2, which is the same as that described by Obwegeser as hemimandibular hyperplasia. Therefore,
CH 1A CH 1B CH 2 Bilateral, symmetrical, condylar hyperplasia Unilateral, asymmetrical, condylar hyperplasia Unilateral, asymmetrical, condylar hyperplasia (hemimandibular hyperplasia)

*Professor, Townsville Hospital, James Cook University, Institute of Surgery, Douglas, Townsville, Queensland, Australia. Consultant Oral and Maxillofacial Surgeon, Prince of Wales Hospital, Sydney, New South Wales, Australia; Senior Lecturer, University of New South Wales, Sydney, New South Wales, Australia. Address correspondence and reprint requests to Dr Boucaut Jones: Townsville Hospital, James Cook University, Institute of Surgery, 100 Douglas Smith Dr, Douglas, Townsville, Queensland 4813, Australia; e-mail: rhbjones@westnet.com.au
2012 American Association of Oral and Maxillofacial Surgeons

0278-2391/12/7006-0$36.00/0 doi:10.1016/j.joms.2011.03.047

Each of these conditions has its own particular facial appearance, and correction is aimed at the affected parts of the facial skeleton and the soft tissues involved. The common thread is an overactivity of the condylar growth center, and the nature of this will determine the method and timing of the surgery. Hemimandibular elongation, or CH 1B (Fig 2), will characteristically show an elongated condylar neck, thinning of the vertical ramus and body of the mandible, and signicant deviation of the chin away from the side of the overgrowth. The lower incisors will often be tilted toward the active condyle, with their apices lining up with the midpoint of the chin and the incisal edges close to the midsagittal plane. There is also canting of the occlusal plane away from the affected side, as the maxillary alveolus compensates for the abnormal mandibular growth. If there is an increase in activity of the condylar growth center beyond that of the compensatory growth of the maxillary alveolus, there will be a lateral open bite. There will also be a 3-dimensional alteration of normal chin anatomy, which will need to be addressed at the time of surgery.

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along with the cant may be signicant, but if the activity of the condyle is high, an open bite will develop, as the compensatory changes in the alveolus of the maxilla will not be able to keep pace with the growth of the mandible. As in the previous example, there will also be a 3-dimensional alteration of the chin. If an osteochondroma is the cause of the asymmetry (Fig 4), a similar facial appearance will occur but the architecture and shape of the mandibular condyle will be different. The condyle will be abnormal in appearance and may be multilocular in size and shape. This article is a retrospective article that deals with the diagnosis, assessment, and treatment of facial asymmetry, arising from a consecutive series of patients with the various combinations of unilateral condylar hyperplasia (CH 1B or CH 2).

Materials and Methods

Seventeen consecutive patients in this retrospective series were treated for facial asymmetry arising from unilateral condylar hyperplasia (CH 1B or CH 2) and are presented in tabular form. All patients underwent the same investigations to determine a diagnosis, and all patients were investigated for overactivity of the affected growth center using Tc-99 bone scans (Tc-99 methylene diphosphonate [MDP] with singlephoton emission computed tomography [SPECT]), serial models, photographs, cepahalometric radiographs, and tracings. Ethics approval for this study was granted by the Townsville Health Services District Human Research Ethics Committee. Those patients who showed continuing activity within the affected joint over a period of 12 months were offered condylectomy as part of the operative procedure to shut down the growth center and prevent ongoing asymmetry of the face. Most of the cases included in this study fell into this category.
FIGURE 1. Facial asymmetry caused by Aperts syndrome (A), and a facial cleft (B). Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

ASSESSMENT

For hemimandibular hyperplasia or CH 2 (Fig 3), the mandibular condyle and neck are enlarged, along with the vertical ramus and body of the mandible on the affected side. There is often a distinctive bowing of the body of the mandible that stops at the midline. There is also compensatory growth of the maxillary alveolus on the affected side producing a cant of the occlusal plane. The activity of the condylar growth center will determine the nature of the cant. If the condyle is slowly growing, the compensatory changes

The assessment process aims to achieve a balance between the denition of the problem, as perceived by both the surgeon and the patient, and the need to address the discrepancy at the source of the problem without camouaging it. First, accurate photographs of the face and of the occlusion are taken, followed by radiographs, including lateral and posterior anterior (PA) cephalometric projections, and nally, study models, set up on an anatomical articulator. Combining the data thus obtained, the overall deformity can be diagnosed and an accurate treatment plan formulated, particularly with respect to the amount of bone removal required to correct the occlusal cant. It is

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FIGURE 2. Hemimandibular elongation. Note cant of the occlusal plane (A) (CH 1B), elongation of the condylar neck (B), and lengthening of the right side of the face, producing the asymmetry (C). Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

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CORRECTION OF FACIAL ASYMMETRY FOR UNILATERAL CONDYLAR HYPERPLASIA

FIGURE 3. Hemimandibular hyperplasia (A). Note the cant of the occlusal plane (B), and bowing of the mandibular body (C) (CH 2), and also the increase in activity of the mandibular condyle on Tc-99 bone scan (D). Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

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FIGURE 4. Asymmetry because of osteochondroma of the mandibular condyle (CH 2). Preoperative photographs (A) lateral and (B) full face, (C) CT scan of the active condyle, (D) preoperative occlusion, (E) postoperative occlusion. Postoperative photographs, (F) lateral face and (Figure 4 continued on next page.) Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

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FIGURE 4 (contd). (G) full face, (H) postoperative lateral CT with costochondral graft. Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

therefore necessary to remove the same amount of bone from the mandibular condyle, to stop the activity of the condylar growth center. In most cases, this will also align the angles of the mandible. This process will give a diagnosis at the time of the initial assessment, but condylar hyperplasia is a dynamic problem, and time will also need to be factored in. If ongoing growth in the affected mandibular condyle is suspected or conrmed, it will be necessary to repeat the process at a later date, and compare the 2 sets of records. A bone scan (Tc-99 MDP with SPECT) will also be required in both instances, to determine the activity of the condylar growth center. This scan compares the activity of the affected side with that of the normal side, and if necessary, with that of another growth center. Unfortunately, this may be subject to some inaccuracy, as the affected condyle may be subject to either an inammatory process or the normal physiological growth stimulus of early adolescence, yielding a false positive result. Furthermore, this scan is a static assessment and only indicative of the activity of the condylar growth center at the time it is taken, necessitating further future scans to determine if the joint was still active. However, if all the information, photographs, study models radiographs, and bone scans are correlated over time, some indication of the activity can be made.
TREATMENT

1. Orthodontics to align and decompensate the dentition 2. Surgery to correct the problem and restore the facial midlines 3. Orthodontics to complete and correct the occlusion 4. Attention to the soft tissues will often be required either to remove any excess tissues on the expanded side or to increase the bulk of tissues on the nonaffected side. This can be achieved by the placement of an implant on the lateral aspect of the mandible on the nonaffected side, which will both bulk out the soft tissues and augment the mandible. However, this will be patient dependent, determined by their esthetic desires and which side of the face they prefer after the skeletal correction. The surgical phase of treatment is dependent on the accurate assessment of the activity of the condylar growth center. If the growth center activity has ceased, the correction can be made without involvement of the previously affected condyle (Fig 5). However, if the condyle is continuing to grow and the asymmetry becoming worse, consideration to shut the growth center down should be made, and if not, the decision should be to wait until the growth has ceased. The problem with waiting until growth has ceased is its unpredictability, and how much further asymmetry will develop before it ceases. In such a case, the correction may require considerably more orthodon-

The treatment is carried out in the 4 following phases:

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FIGURE 5. Asymmetry where the condylar growth center was inactive (A), preoperative full face showing asymmetry (B), preoperative occlusion (C), preoperative occlusion after preliminary orthodontics (D), postoperative result. Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

tics and surgery (particularly of the soft tissues) if a satisfactory correction is to be achieved. In general, the correction of facial asymmetry involves the maxilla, the mandible, the chin, and the soft tissues. If there is an orbital component, it can also be addressed at the same time with an intraoral zygomatic osteotomy.3 However, this is uncommon. If the condyle is still active, a condylectomy will be required, either at the same time as the jaw correction or at another time, depending on the nature of the problem and the choice of the surgeon. It has been

found that at least 6 mm of the articular surface requires removal to shut the growth center down.2 Attention to disc position is important; therefore, any disc displacement should be corrected at operation and the incidence of displacement should be reduced after surgery. An anchor placed in the posterior aspect of the mandibular condyle and attachment of the disc to this anchor will address this problem and allow the disc to move more accurately with the condyle during mandibular movement.4 It is advisable to remove the same amount of bone from the condylar head as that removed from the

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CORRECTION OF FACIAL ASYMMETRY FOR UNILATERAL CONDYLAR HYPERPLASIA

maxilla on the affected side. This will correct the occlusal cant and bring the angle of the mandible close to that of the nonaffected side, thereby correcting the asymmetry of the mandibular angles. Bilateral sagittal split osteotomies are then performed to bring the teeth to the midline and close the lateral open bite on the affected side. This will correspond to the same amount of bone removed from the maxilla and the condylar head. In this instance, the splaying of the proximal segment of the sagittal split on the nonaffected side will provide some of the contour correction, but will need a graft between the halves of the sagittal split, to hold the segments in place, and reduce torque of the condylar head.5 After the mandible and maxilla have been xed, the chin can be corrected with a genioplasty. In most instances, this will be a complex 3-dimensional genioplasty, where bone will be removed from 1 side in the vertical direction, to move it across to the midline, and set it back or advance it, depending on the nature of the problem. Once the surgery has been completed and stabilized, the orthodontics can be completed. When the swelling has settled, an assessment of the soft tissues can be made. The soft tissue surgery will require either a facelift on the affected side to remove excess tissue or an augmentation of the opposite side, either with a medpore ramus/body implant or dermis fat, or fat graft to the soft tissues. However, this is age dependent, and the older patient in whom the asymmetry is signicant will require this type of surgery, while the younger patient is more resilient. If the asymmetry is diagnosed early, and it can be determined that the patient has an ongoing problem, early condylectomy and redirection of growth with functional appliance therapy and orthodontics can address the problem. The girl in Figure 6, diagnosed with hemimandibular hyperplasia (CH 1 B), as seen on the OPG and Tc-99 bone scan at age 11 years, underwent high condylectomy followed by functional appliance and orthodontics. Her postoperative result is seen at the age of 17 years in the last photograph. Table 1 presents the cohort of consecutive patients referred to in this article and represents the demographics and the diagnosis of the patients treated.

bone scans, serial models, photographs, cephalometric radiographs, and tracings to determine the activity of the mandibular condyle and to formulate a treatment plan. Table 2 represents the results of the 17 patients treated in this study and outlines their diagnosis, treatment, and outcomes. Those patients who showed continuing activity within the affected joint over a period of 12 months were offered condylectomy as part of the operative procedure. This was performed to shut down the growth center and stop the continuing growth of the mandible, thereby preventing further asymmetry of the face. Most patients presented in this article were in this category. Some patients with hemimandibular hyperplasia (CH 2) underwent condylectomy with costochondral graft replacement (Fig 3). In these cases, there is bowing of the lower border of the mandible, which was corrected by removing the bowed segment. This bone could then be onlayed to the lateral aspect of the mandible to recontour it. Unfortunately, this bone behaves as any onlay, and the initial symmetry achieved is subject to change as the bone remodels. Most of the patients underwent the regimen of temporomandibular joint (TMJ) surgery and disc reposition at the same time as the corrective jaw surgery to the maxilla, mandible, and chin, with the same amount of bone removed from the maxilla as taken from the condyle to restore symmetry.

Discussion
A degree of facial asymmetry is common in the community, and those who require surgical correction for a signicant condition are few. This article presents 17 patients with facial asymmetry arising from unilateral condylar hyperplasia, either as hemimandibular elongation (CH 1B) or as hemimandibular hyperplasia (CH 2). In each category a similar facial appearance can be shown, but each group will require a different surgical procedure. Nonetheless, the principles of treatment are the same. The various phases of treatment are as follows: 1. Orthodontics to align and decompensate the teeth. 2. Surgery to the maxilla, mandible, and chin, and where indicated; condylectomy of the affected joint to shut down the mandibular condylar growth center. 3. Orthodontics to complete and rene the occlusion. 4. Attention to the soft tissues as required. Condylectomy at the same time as orthognathic surgery can make the operation technically dif-

Results
Seventeen consecutive patients were treated for the correction of facial asymmetry arising from unilateral condylar hyperplasia, and the results are presented in Table 2. All patients underwent the same investigations to determine the nature of the problem, and all patients were investigated with Tc-99

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FIGURE 6. Hemimandibular hyperplasia corrected early with condylectomy and functional therapy. A, Preoperative full face. B, OPG showing asymmetry. C, Posterior anterior cephalometric projection showing asymmetry. (Figure 6 continued on next page.) Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

cult, but approached in a systematic way, it is easily achievable. It has been reported that the removal of 6 mm6 from the condylar head is required to shut growth down; however, if one removes the same amount of bone from the condyle as that required to correct the occlusal cant, total symmetry of the facial skeleton is the result. The authors prefer a single operation, as previously outlined. Some peo-

ple advocate a 2-stage approach, rst to perform condylectomy to shut the growth of the mandible down, and once this has been determined, then to proceed to correct the asymmetry. A problem with 2-stage procedures is that many patients will not accept a second operation. In the combined single procedure, the maxillary osteotomy is carried out rst.

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CORRECTION OF FACIAL ASYMMETRY FOR UNILATERAL CONDYLAR HYPERPLASIA

FIGURE 6 (contd). D, Tc-99 bone scan showing active condyle. E, Functional appliance in position. F, Final result. Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

The initial records are taken with the jaws in centric relation with each condyle intact and centrally placed within the glenoid fossa. Therefore, the maxilla is set up on the articulator in the original position, using the original unoperated mandibular condyle (in some instances, this may be incorrect due to abnormal condylar or ear position). The maxilla is then repositioned, with correction of the occlusal cant and xed using the intermediate wafer. This then acts as a stable platform onto which to place the mandible after correction of the asymmetry.

The condylectomy is then performed, followed by sagittal osteotomy of the mandible, and the operated mandibular condyle can be seated under direct vision. However, the face bow transfer in patients with asymmetry can present a problem, because of the variable position of the ear or TMJ, and may be inaccurate. Wolford and Gatiano have presented an article on a simplied and more accurate method of transferring the maxillary model to the articulator, thereby eliminating an inaccurate face bow transfer.7

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1423 should be remembered that if this bone is onlayed to the lateral aspect of the mandible, it will most likely resorb over time, and further surgery may be required to correct the problem. A 3-dimensional genioplasty will also be required to correct the asymmetry.
HISTOPATHOLOGY

Once the mandible has been positioned and rigidly xed correctly, the genioplasty can be carried out. This may be complicated because of the need to correct the chin in 3 dimensions. Before closure of the TMJ, it is necessary to ensure the disc is in position, particularly if one is to avoid clicking and locking post surgery. This is best carried out using a 2-mm anchor and attaching the disc to mandibular condyle4 or disc plication depending on surgical preference. For hemimandibular hyperplasia (CH 2), or when the asymmetry has resulted from an osteochondroma, it is often necessary to perform a complete condylectomy and reconstruct the joint with either a costochondral rib graft (Fig 3) or a total joint replacement. Correction of the bowing of the lower border, in cases of hemimandibular hyperplasia (CH 2), can be achieved by an intraoral approach, using a long sagittal split and then decorticating the mandible to the mental foramen and releasing the inferior dental nerve from its canal. Then, the osteotomy of the lower border can be completed through the inferior dental (ID) canal to the lingual side of the mandible, and the lower border removed.8 The lower border may then be adjusted by grinding to shape with a large bone bur to achieve the symmetry required. If there is a deciency of mandibular width, the resected section of mandible can be xed to the side of the mandible, or rotated up onto the operated side, to correct contour if needed. However, it

In describing the normal histology of the mandibular condyle, Hansson et al9 have described 4 tissue layers and have referred to them as 1. A connective tissue lining (brous articular layer) 2. An undifferentiated mesenchyme (proliferating) layer 3. A transitional layer 4. A hypertrophying cartilage layer The total thickness of these layers is approximately 0.48 mm in normal condyles. In the original article by Obwegeser and Makek,1 discussion occurred about the histopathology associated with the overgrowth of the mandibular condyle. They indicated there was a thickened cartilage zone with a wide richly vascularized proliferative zone enriched with large cells near the bony aspect, with osteoblasts surrounded by newly formed trabeculae. This new growth and the changed architecture of the condylar head and neck force the mandible to grow inferomedially. The classic histopathological slides as described above have continued; however, other authors have divided the histopathological picture into several different subtypes10 and an article by Eslami et al11 has further subdivided some of the samples into further subtypes. However, the overall conclusion is that the hyperplastic cartilage layer undergoes a signicant increase in thickness in condylar hyperplasia, and that this increase in growth drives the asymmetry. Another article that looked at the histopathology of resected condylar heads from treated cases of condylar hyperplasia found the histopathological picture was different, and they found little correlation between the histopathological pictures seen and considerable variation.12 This correlates with a study carried out some years before by one of the authors and presented to the annual meeting of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons meeting in Christchurch, New Zealand, where it found that no specic histopathological picture of the active joint was found, once again with considerable variation, albeit in a small number of cases.

Table 1. PATIENT COHORT WITH DIAGNOSIS

Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Gender F F F F F M F F F F F M F F F F F

Diagnosis HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) Osteochondroma (CH2) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH1B) HMH (CH 2) HMH (CH 2) HME (CH 1B) HMH (CH 2) HME (CH 1B) HME (CH 1B)

Abbreviations: HME, hemimandibular elongation (CH 1B); HMH, hemimandibular hyperplasia (CH 2); F, female patient; M, male patient.
Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

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Table 2. RESULTS OF THE 17 PATIENTS TREATED IN THIS STUDY AND THEIR DIAGNOSIS, TREATMENT, AND OUTCOMES

Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Diagnosis HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) Osteochondroma (CH 2) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) HME (CH 1B) HMH (CH 2) HMH (CH 2) HME (CH 1B) HMH (CH 2) HME (CH 1B) HME (CH 1B)

Treatment Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Costochondral graft and orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery removal lower border Condylectomy Costochondral graft Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Costochondral graft Orthognathic surgery Condylectomy Orthognathic surgery Condylectomy Orthognathic surgery

Outcome Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory

Jones and Tier. Correction of Facial Asymmetry for Unilateral Condylar Hyperplasia. J Oral Maxillofac Surg 2012.

BONE SCANS

Tc-99 bone scan uptake is specic for osteoblasts and the laying down of new bone, and as such, the Tc-99 bone scan was thought to be an accurate indication of activity within the condyle. The Tc-99 bone scan will show activity within the joint in condylar hyperplasia if new bone is being laid down, but the scan is very nonspecic. In an article by Saridin et al,13 quantitative analysis of planar scintigrams using Tc-99 hydroxymethylene diphosphonate (HDP) in unilateral condylar hyperplasia was not found to be superior to qualitative visual interpretation of the scans, and that quantied ratios between the active condyle and other growth centers did not seem to be helpful; therefore, clinical assessment was thought to be mandatory. The importance of time in this assessment has been stressed by Kaban,14 particularly in cases of hemifa-

cial microsomia. However, time is also important with condylar hyperplasia when determining activity of the affected condyle and the timing of surgery. Interestingly, in another article15 using SPECT, Tc-99 MDP, or MDP, SPECT was found to be more accurate in determining the activity of the condyle over planar scintigrams. In this article, isotope counts were found to be of value and were able to predict active growth from growth cessation. They concluded that condylar isotope deposits for each pair of condyles differing by less than 10% can be regarded as normal, and that an activity of greater than 10% suggested that bone growth was still active and that corrective surgery should be delayed or that interceptive surgery should be offered. There have been several articles discussing the use of Tc-99 bone scan with and without SPECT to deter-

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1425 tion (CH 1 and 1A) and another in hemimandibular hyperplasia (CH 2). While the surgery to correct the problem is relatively straightforward, there are many questions that need to be answered before we have a total understanding of this interesting clinical problem.

mine the activity of the affected condyle, but few articles have discussed and compared the histopathological ndings with the bone scan ndings. Gray et al16,17 have looked at this correlation and discussed the macro- and micromorphology, but little in relation to the correlation between this and the bone scans. Lippold et al18 have discussed this aspect in some detail and have reported that activity of the affected condyle on bone scan was associated with a typical histopathological nding, that those condyles with a high uptake of Tc-99 showed histopathological signs of destroyed cartilage, accompanied by a broadening of the subcondylar layer of bone, and that this broad proliferating zone of bone was associated with an overlying layer of degenerative cartilage. The high tissue turnover was characterized by resorption and replacement, which caused bony areas to contain islands of cartilage, and that by comparison, those condyles showing less activity showed fewer signs of arthrosis. This pattern of bone turnover would t in with an understanding of Tc-99 bone scan technology, with the Tc-99 uptake relating to active areas of bone turnover and uptake by the osteoclasts and osteoblasts. According to Kruse-Losler et al,19 this cartilage degeneration was also seen in distraction osteogenesis and that the active growth of the mandibular condyle with resultant pressures on the articulating surfaces may be the cause of the degeneration. Another interesting nding was the high number of females in this group of patients, with similar gures having been reported elsewhere. It has been suggested that there are increased numbers of estrogen receptors in the temporomandibular joint in females, which could account for this increased activity.20 The questions raised are as follows: 1) why the differentiation between condylar hyperplasia I and II, hemifacial elongation, and hemifacial hyperplasia; 2) what is the stimulus for the 2 different types of hyperplasia; 3) why does the hyperplasia stop at the midline of the mandible. There would appear to be some sort of mediator stimulating the activity of the condyle, condylar neck, and ramus of the mandible in the case of hemimandibular hyperplasia (CH 2), which is different from that stimulating hemimandibular elongation (CH 1A and B). We do know that performing a condylectomy, albeit high in hemimandibular elongation (CH 1 B) and total in hemimandibular hyperplasia, will stop the growth of the mandible, and therefore, it would appear that the effective stimulus is in the mandibular condyle near the articular surface. The only other possibility is that there are 2 separate mechanisms stimulating the process, 1 in hemimandibular elonga-

References
1. Obwegeser HL, Makek MS: Hemimandibular hyperplasia hemimandibular elongation. J Maxillofac Surg 14:183, 1986 2. Wolford LM, Morales-Ryan CA, Garcia-Morales P, et al: Surgical management of mandibular condylar hyperplasia type 1. Proc (Bayl University Med Cent) 22(4):321, 2009 3. Jones RH, Ching M: Intraoral zygomatic osteotomy for correction of malar deciency. J Oral Maxillofac Surg 53:483, 1995 4. Mehra P, Wolford LM: Use of the mitek anchor in temporomandibular joint disc reposition surgery. Proc (Bayl University Med Cent) 14(1):22, 2001 5. Temporomandibular joint ramications of orthognathic surgery, Vol. 1, chapt 20, in William HB (ed). Modern Practice in Orthognathic and Reconstructive Surgery. WB Saunders, Philadelphia, 1992, pp 523-593 6. Wolford LM, Mehra P, Reich-Fischell O, et al: Efcacy of high condylectomy for the management of condylar hyperplasia. Am Orthod Dentofacial Orthop 121:136, 2002 7. Wolford LM, Gatiano A: A Simple and accurate method of mounting models in orthognathic surgery. J Oral Maxillofac Surg 65:1406, 2007 8. Ferguson JW: Denitive correction of the deformity resulting from hemi mandibular hyperplasia. J Craniomaxillofac Surg 33:150, 2005 9. Hansson T, Carlsson GE, Kopp S: Thickness of the soft tissue layers and the articular disk in the TMJ. Acta Odontol Scand 35:77, 1977 10. Slootweg PJ, Muller H: Condylar hyperplasia: A clinicopathological analysis of 22 cases. J Maxillofac Surg 14:209, 1986 11. Eslami B, Behnia H, Javadi H, et al: Histopathologic comparison of normal and hyperplastic condyles. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 96:711, 2003 12. Nitzan DW, Karsneison A, Bermanis I, et al: The clinical characteristics of condylar hyperplasia: Experience with 61 patients. J Oral Maxillofac Surg 66:312, 2008 13. Saridin CP, Raijmakers P, Becking AG: Quantitative analysis of planar bone scintigraphy in patients with condylarhyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 104:259, 2007 14. Kaban L: Mandibular asymmetry and the 4th dimension. J Craniofac Surg 1:622, 2009 (suppl) 15. Pripatnanont P, Vittayakittipong P, Markmanee U, et al: The use of SPECT to evaluate growth cessation of the mandible in unilateral condylar hyperplasia. IJOMS 34:364, 2005 16. Gray RJ, Sloan P, Quale AA, et al: Histopathological and scintigraphic features of condylar hyperplasia. IJOMS 19:65, 1990 17. Gray RJ, Horner K, Testa HJ, et al: Condylar hyperplasia: Correlation of histological and scintigraphic features. Dentomaxillofac Radiol 23:103, 1994 18. Lippold C, Kruse-Losler B, Danesh G, et al: Treatment of hemimandibular hyperplasia: The biological basis of condylectomy. BJOMS 45:353, 2007 19. Kruse-Losler B, Meyer U, Floren C, et al: Inuence of distraction rates on the temporomandibular joint position and cartilage morphology in a rabbit model of mandibular lengthening. J Oral Maxillofac Surg 59:1452, 2001 20. Ribeiro-Dasilva MC, Peres Line SR, Leme Goday dos Santos MC, Estrogen receptora polymorphisms and predisposition to TMJ disorder. J Pain 10:527, 2009