hemimandibular hyperplasia and facial asymmetry
DESCRIPTION
Objective: To differentiate non syndromic pathology that cause facial asymmetry. To understand the effect of unilateral condylar hyperplasy in a growing and non growing individual. Understand the effect of condylar fracture or trauma (impact) to the joint that may affect mandibular growth. To know the diagnostic test and surgical treatment that is recommended.TRANSCRIPT
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Dr Sylvain Chamberland
TMJ PathologiesFacial Asymmetry
Hemimandibular Hypoplasia with condylar-coronoid collapse
Hemifacial Microsomia
Hemimandibular Hyperplasia
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Hemimandibular Hyperplasia and Facial Asymmetry
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College of Diplomates of the American Board of Orthodontists
2013 Summer Meeting
BermudaSylvain Chamberland
http://fr.slideshare.net/sylvainchamberland/hemimandibular-hyperplasia-and-facial-asymmetry
https://www.facebook.com/drsylvainchamberland
http://www.sylvainchamberland.com/en/blog/facial-asymmetry-and-hemimandibuar-hyperplasia/
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Dr Sylvain Chamberland
Class III
Mandibular deviation to the right
Left posterior open bite
Reciprocal click right TMJ, slight click on the left
Pain on palpation: external pterygoid: left > right
Facial Asymmetry
ErB.12-12-00; 22 y
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Dr Sylvain Chamberland
Attrition of the left posterior teeth
3rd molars extracted :~ 2 years
Jaw opening amplitude: 55mm
Right lat. excursion: 12mm; left: 7mm
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Dr Sylvain Chamberland
Facial Asymmetry
Right lateral open bite
Left TMJ click
Pain on palpation: left pre-auricular area
NaRo.01-02-06; 16 y
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Dr Sylvain Chamberland
, 36 ans
Laterodeviation to the left
Chronic left TMJ pain since >10
years
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Dr Sylvain Chamberland
, 36 ans
Laterodeviation to the left
Chronic left TMJ pain since >10
years
It it because of her occlusion?her disc?
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Dr Sylvain Chamberland
Facial Asymmetry1st & 2nd branchial arch syndromes
We will not discuss this topic today.
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Dr Sylvain Chamberland
Hemimandibular Hypoplasia with condylar-coronoid collapse
Usually not diagnose at birth
soft-tissue defects; normal ears
nerve deficit, well-developed masseter
Deviation of the chin on the affected side,
with fullness on the affected cheek
Significant deviation to the affected side during opening
AJODO 2011;139:e435-e447
Courtesy Dr Dany Morais
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Dr Sylvain Chamberland
Hemimandibular Hypoplasia with condylar-coronoid collapse
Condyle mandibular dysplasia "en bosse de chameau" (camel hump look)
Hypoplasia of the ascending ramus + condyle + coronoid process
Collapse of the condyle on the coronoid process
Temporal fossa is always present
AJODO 2011;139:e435-e447
Courtesy Dr Dany Morais
Maezzini et al, True hemifacial microsomia and hemimandibular hypoplasia with condylar-coronoid collapse: Diagnostic and prognostic differences, AJODO2011;139:e435-e447
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Dr Sylvain Chamberland
Hemifacial Microsomia
Diagnosed at birth. Prevalence1: 5600
Muscular, soft-tissue and nerve defects, (1st & 2nd
arch)
Ear defects, pre-auricular tags, masseter muscle hypoplasia, Facial nerve ( VII) asymmetries
Deviation of the chin on the affected side + flatness on the affected cheek
Deviation to the affected side during opening
Courtesy Dr Dany Morais
Semin Orthod 2011;17:235-245
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Dr Sylvain Chamberland
Hemifacial Microsomia
Hypoplasia of
Ascending ramus
Condyle
Coronoid process
Absence of condyle and temporal fossa
Maezzini et al, True hemifacial microsomia and hemimandibular hypoplasia with condylar-coronoid collapse: Diagnostic and prognostic differences, AJODO2011;139:e435-e447
Pedersen TK and Norholt SE, Early Orthopedic Treatment and Mandibular Growth of Children with Temporomandibular Joint Abnormalities, Semin Orthod 2011;17:235-245.)
Courtesy Dre A-C Valcourt
CCC HF
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Dr Sylvain Chamberland
Facial AsymmetryHyperplasia
Hypoplasia
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Dr Sylvain Chamberland
Unilateral Condylar Hyperplasia
Most frequent postnatal anomaly of growth of the TMJ
Prevalence 2 F: 1 M
Symmetry observed at birth, develops during 2nd decade
Accelerated growth rate of condylar head & neck resulting
in facial asymmetry
Difference to do with hypoplasia of the opposite side or a generalized asymmetrical growth (hemimandibular hyperplasia)
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Dr Sylvain Chamberland
Diagnostic Test
Scintigraphy Tc99
Allows to specify the presence or the absence of cellular
activity at the level of the growth cartilage
Positive if > 10-15 % of difference of uptake between left and right
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Dr Sylvain Chamberland
Dynamic Aspect
Active
Growing patient
Adult
Inactive
Adult
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Dr Sylvain Chamberland
Nomenclature According to Obwegeser
Hemimandibular Hyperplasia
Hemimandibular Elongation
Condylar Hyperplasia
Hybrid form
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!
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According to Wolford
CH Type 1
1a: unilateral
Vertical or horizontal or combo
1b: bilateral
CH Type 2
2A: Osteochondroma
2B: Osteome
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Dr Sylvain Chamberland
Therapeutic options
Wait and see if
Mild asymmetry
Phasing out shown by serial Tc99 bone scan
Asymmetry corrected by standard orthognatic surgery
High condylectomy
Significant asymmetry
Active abnormal condyle
Prevent worsening (How much more asymmetry are you willing to tolerate?)
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Dr Sylvain Chamberland
High Condylectomy
Removal of the top 3-5mm of the condylar head including the lateral and medial poles
In most cases, pathologic portion is difficult to identify making bone resection arbitrary
Wolford LM et al, Surgical management of mandibular condylar hyperplasia type 1, Proc (Bayl Univ Med Cent) 2009;22(4):321329!Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2;
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Dr Sylvain Chamberland
ActiveGrowing patient
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Dr Sylvain Chamberland
Unilateral Condylar Hyperplasia
Vertical type
Vertical growth vector (Prevalence 15:1)
Elongation + enlargement :
Condylar head & neck + mandibular ramus and body
Ipsilateral posterior open bite
Progressive laterodeviation to the unaffected side
Mandibular midline inclined to the affected side
Courtesy Dr Dany Morais
Condyle & neck: bigger & longer
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Dr Sylvain Chamberland
Posterior open bite suddenly occurred during treatment
Mandibular midline deviated to the left
KaPaVa 02-03-10; 11 a
KaPaVa 29-03-11; 12 a
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Dr Sylvain Chamberland
Splitting of inferior border
Flattening of the antegonial notch
Scintigraphy Tc99
Discreet increase of the uptake of the
right condyle compatible with a right hypercondyle (condylar hyperplasia)
Difficult to evaluate at the condyle
KaPaVa 29-03-11; 12 aKaPaVa 02-03-10; 11 a
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Dr Sylvain Chamberland
Decision
Observation and reassessment in 6 months
Orthodontic extrusion of the lower right buccal
segment
KaPaVa 17-08-11
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Dr Sylvain Chamberland
DecisionKaPaVa 17-08-11
Posterior segment + vertical elastics
Extrusion successful
KaPaVa 02-02-12
KaPaVa 15-12-11
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Dr Sylvain Chamberland
DcisionKaPaVa 17-08-11
Midlines are coincident and a fairly decent occlusion is achieved at debonding
KaPaVa 02-02-12
KaPaVa 23-08-12
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Dr Sylvain Chamberland
Unilateral Condylar Hyperplasia
Horizontal type (CH type 1a)
Horizontal growth vector
Usually begin at the adolescence and stop at mid-20s
Elongation of condylar head & neck
Laterodeviation to the unaffected side & midline deviation
Loss of the antegonial notch
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Dr Sylvain Chamberland
Laterodeviation to the controlateral side
Ipsilateral class III
Posterior crossbite in the unaffected side or dentoalveolar compensation
PA Le 19-05-11
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Dr Sylvain Chamberland
PA Le 15-10-09; 14a 1mPA Le 11-02-04; 8a 5mPA Le 03-12-01; 6a 4m PA Le 19-05-11; 15a 8m
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Dr Sylvain Chamberland
Scintigraphie Tc99
Scinti Tc99 = Positive (increased uptake) in spring2011
Left TMJ clicking at maximum jaw opening
PA Le 19-05-11; 15a 8mPA Le 15-10-09; 14a 1m PA Le 19-05-11; 15a 8m PA Le 15-10-09; 14a 1m
Compare the height
of sigmoid notch
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Dr Sylvain Chamberland
Frontal view
Slight vertical compensation causing a cant of the occlusal plane
Lateral view
Splitting of the occlusal plane and inferior mandibular border
PA Le 19-05-11; 15a 8mPA Le 15-10-09; 14a 1m
Display of
13 23
Pearl: distal angulation /5s
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Dr Sylvain Chamberland
Scintigraphy In July ratio 3,2/1,93 = 1,66
In January: ratio 2,13/1,97 = 1,08
Diminution of the activity
Decision:
No condylectomy
Initiate comprehensive ortho treatment at appropriate timing (around 17 y)
Scinti presurgery if midline
P.-A. Le.Mean Maximum
Right 1,98 3,2July 2011
Left 1,65 1,93
Right 1,58 2,13January 2012
Left 1,25 1,97
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Dr Sylvain Chamberland
Tx
Goal: avoid the progression of the facial asymmetry
Orthosurgical tx
Dentoalveolar decompensation
Bimaxillary surgery
High condylectomy could be possible if still actively overgrowing
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Dr Sylvain Chamberland
At 10 weeks
Dentoalveolar decompensation
Early engagement of rectangular wire: 16x22/20x20 niti
P-ALe 20-09-12
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Dr Sylvain Chamberland
55 semaines
Dcompensation acheveP-ALe 20-09-12
P-ALe 05-08-13
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Dr Sylvain Chamberland
Laterodeviation to left
Hyperplasy of the right condylar neck
MPo 16-08-06; 11a 5 m
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Dr Sylvain Chamberland
Tx
RPE + facial mask
Slight improvement of the deviation
Persistence of the right class III relationship
MPo 16-08-06; 11a 5 mMPo 11-04-07; 12a 1 m
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Dr Sylvain Chamberland
February 2007
Scintigraphy Tc99
= normal
MPo 16-08-06; 11a 5 mMPo 11-04-07; 12a 1 m MPo 16-04-08; 13a 1 m
MPo 11-04-07; 12a 1 m
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Dr Sylvain Chamberland
Evolution of the asymmetry
Slanting of inferior teeth (oblique)
Cant of the mouth commissure
Vertical asymmetry of inferior border of the chin
MPo 16-08-06; 11a 5 m
MPo 11-04-07; 12a 1 m
MPo 16-04-08; 13a 1 m
MPo 11-04-07; 12a 1 m
MPo 17-10-11; 16a 7 m
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Dr Sylvain Chamberland
Cant of the occlusal plane in frontal view
Splitting of the occlusal plane in the lateral view
Elongation of the right condylar neck
Slanting of the lower midline to the affected side
Display of 13 23
MPo 17-10-11; 16a 7 m
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Dr Sylvain Chamberland
Scinti Report
Metabolism augmentation in the right condyle
Mean asymmetry index right / left = 1,49
Maximum asymmetry index right / left = 1,97
Right intense uptakeM. Po.
Mean Maximum
Right 2,51 3,07January 2012
Left 1,68 1,56
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Dr Sylvain Chamberland
Treatment
Avoid asymmetry aggravation
High condylectomy as soon as possible
Dentoalveolar decompensation
Comprehensive ortho treatment, bimaxillary surgery
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Dr Sylvain Chamberland
Post condylectomy
Persistence of the facial asymmetry
&
Class III relationship
A more agressive cut of the condyle could have caused an anterior openbiteMPo 17-10-11; 16a 7 m
MPo 27-04-12; 17a 1 m
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Dr Sylvain Chamberland
High condylectomy ~5 mm of the condylar head is shaved
The articular disk is preserved (not touched or detached)
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Dr Sylvain Chamberland
Condylar growth seem to have stopped
Facial asymmetry persist
Patient declined any further
treatment
MPo 21-05-13; 18a 2 m
Recall 13 months post condylectomy
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Dr Sylvain Chamberland
Differential Diagnosis
Facial asymmetry caused by a functional shift
KaHa080205 KaVe080801
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Dr Sylvain Chamberland
Left class I molar, class II in the right
Slight asymmetry to the right
Right posterior Xbite
CrBo050901; 13a
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Dr Sylvain Chamberland
Symmetric condyle
No splitting of md border
Splitting of the occlusal plane
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Dr Sylvain Chamberland
Left side larger than the right side
Asymmetric arch form
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Dr Sylvain Chamberland
Progression of asymmetry to the right
Left Cl III molar; right cl II molar
Md midline deviated to right
This is illogical!
CrBo041103; 15a 2m
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Dr Sylvain Chamberland
Splitting of the occlusal plane
Splitting of md border
Elongation of the left condyle
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Dr Sylvain Chamberland
Scinti Tc 99
Positive
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Dr Sylvain Chamberland
High condylectomy
CrBo091203; 15a 3m
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Dr Sylvain Chamberland
After BSSO
CrBo300804; 16a
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Dr Sylvain Chamberland
Normal growth of the left condyle
Persistence of splitted occlusal planeCrBo300804; 16a
CrBo050901; 13a
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Dr Sylvain Chamberland
ActiveAdult patient
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Dr Sylvain Chamberland
Rigth laterodeviation & Absence of shift
Reciprocal click of right TMJ, slight click in the left
Pain on palpation ext. pterygoid muscle
Left posterior openbite > right
Attrition of posterior teeth
The deformation would have gradually appeared
Facial Asymmetry
ErB.12-12-00; 22 ans
Patient initial
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Dr Sylvain Chamberland
Attrition of the left posterior teeth
3rd molars extracted :~ 2 years
Jaw opening amplitude: 55mm
Right lat. excursion: 12mm; left: 7mm
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Dr Sylvain Chamberland
Vue panoramique
Hyperplasia of the right condyle:
Bigger & larger condylar head
Elongation of the ascending ramus
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Dr Sylvain Chamberland
Vue panoramique
1996
Normal
left condyle
ErB.12-12-00; 22 ans
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Dr Sylvain Chamberland
Scinti Tc99
Intense uptake of the left condyle
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Dr Sylvain Chamberland
Post high condylectomy
ErB.12-12-00; 22 ans
ErB.07-06-01
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Dr Sylvain Chamberland
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Dr Sylvain Chamberland
Comprehensive ortho tx + 24, 34, 44
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High Condylectomy Description of a New Technique
Radioguided high condylectomy using a -probe
Injection oftechnetium-99m methylene diphosphate, 25 mCi, 2 hours pre op
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
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Sylvain Chamberland
Condylar neck elongated
No clear demarcation of
hyperplastic portion vs normal bone
-probe
Malleable retracor (shield)
Malleable retractor inserted at the medial aspect of the condyle to provide appropriate shielding
Prevent reading of -emission of the cranial base
1st reading: right mandibular parasymphysis = 2965 CPS
2nd reading: right condyle = 4197 CPS
Marking the section to be resected
-probe was used until normal reading was obtain
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
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Sylvain Chamberland
Intraoperative view of the residual condylar head
No adjunct procedure of the articular disk were performed because it appeared normal and free of any pathologic process
7 mm of bone removed
3 cuts were necessary
to obtain normal reading
Patient is placed on soft diet for 7 days
Postoperative period in uneventful
No sign of relapse were noticed 9 months post surgery
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
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Dr Sylvain Chamberland
Radio-guided surgery
Sentinel lymph node surgery for breast cancer
Minimally invasive parathyroid surgery
Other described applications in cutaneous, gastrointestinal,
urologic, gynecologic, thoracic, neuroendocrine and head and neck malignancies
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
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Dr Sylvain Chamberland
Radio-guided surgery
-emission are easily detected
Making bone resection easier and limited to the
affected area
Surgery is less invasive
May decrease postoperative discomfort and
complications such as arthalgia and osteoarthrosis
Bouchard C, Paris M, and Villemaire JM. Intraoperative Use of a Gamma Probe for the Treatment of Condylar Hyperplasia: Description of a New Technique. J Oral Maxillofac Surg. 2013, Feb 2; [In press]
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Dr Sylvain Chamberland
Wisdom Thoughts
"A patient with an elongated condylar process is more likely to stop growing spontaneously than one with an enlarged condyle but I don't have enough cases to prove it".
Dr William ProffitPersonal communication. January 2012
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Dr Sylvain Chamberland
InactiveAdult patient or after normal growth has ceased
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Dr Sylvain Chamberland
Differential Diagnosis
Absence of shift
Transverse asymmetry
Laterodeviated to left
Right elongation
Right Hypercondyle
A left hypoplasia is not necessarily excluded. In fact, it could be the
most likely explanation of the asymmetryMP.Ro-Ja.0404; 15a
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Dr Sylvain Chamberland
Follow up 2 years
Stable occlusion
Persistence of chin asymmetry
Note hypodevelopment
of left md corpus
MP.Ro-Ja.0707
MP.Ro-Ja.0707
MP.Ro-Ja.0106
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Dr Sylvain Chamberland
Inactive
Laterodeviation to right
Left condylar hyperplasia
(horizontal type)
Left posterior crossbite
Splitting occlusal plane &
gonial angle
Ja.Du.29-11-06; 40 a
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Dr Sylvain Chamberland
SARPE
BSSO
Ja.Du.28-01-10; 43 a
Bike accident at ~ 10 years
Severe impact on the right side
So, possible retarded growth of the right TMJ & normal
growth in the left TMJ
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Dr Sylvain Chamberland
Any Sceptics?
In 5th grade In Secondary I
Bike accident
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Dr Sylvain Chamberland
Inactive
Laterodeviation to left
Class III
Anterior openbite
Do.Vo.20-04-09; 32 a
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Dr Sylvain Chamberland
2nd phase surgery
Le Fort 1 differential impaction
BSSO
Implant position 12
A genio of vertical reduction
& right deviation would have been beneficial DoVo 28-11-11
DoVo 05-4-12
Note: 1st phase surgery: SARPE
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Dr Sylvain Chamberland
Osteochondroma35% of all benign bone tumors
Average age at presentation: 40 y (range 11-69)
Ratio 1,8 : 1
No cases of malignant transformation of TMJ yet reported
Chapter 82- Mandibular asymmetry: temporomandibular joint degeneration, Wolford L. In Current therapy in Oral and maxillofacial surgery, W.B.Saunders, 2012
Osteochondroma of the temporomandibular joint: a case report. Utumi ER, Pedron IG, Perrella A, Zambon CE, Ceccheti MM, Cavalcanti MG. Braz Dent J. 2010;21(3):253-8. PMID: 21203710
Shintaku WH, Venturin JS, Langlais RP, and Clark GT. Imaging modalities to access bony tumors and hyperplasic reactions of the temporomandibular joint. J Oral Maxillofac Surg. 2010, Aug 68(8):1911-21.
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Dr Sylvain Chamberland
Osteochondroma
Rx findings
Tapering radiopaque mass extends from the anteromedial
aspect of the condyle
Globular pattern
Recurrence ~ 2% most likely because of incomplete excision
Li.Ma.220312
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Dr Sylvain Chamberland
Osteochondroma
Possible etiology
Peripheral displacement of undifferentiated cells from growth
cartilage or neoplastic cells arising from the periosteum form metaplastic cartilage
Residues from the cartilaginous cranium and Meckel cartilage that have not been replaced by mandibular bone
Possible trauma, but there is inadequate data to support this hypothesis
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Dr Sylvain Chamberland
Hyperplasy of right condyle +++
Laterodeviation to left
Indication of a condylectomy: osteochondrome or
osteome
>20 years ago: Jigli osteotomy + genioplasty
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Dr Sylvain Chamberland
Osteochondroma
56 y
Condylar hypertrophy noted
At 60 y
Osteochondroma
Li.Ma.220312-60yLi.Ma.290508-56
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Dr Sylvain Chamberland
CBCT assessment
Tapering radiopaque mass extending from the anteromedial aspect of the condyle
Left condyle is normalR L
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Dr Sylvain Chamberland
Recurring osteochondroma
High condylectomy perfomed >10y ago
The lesion extended deep medially
Access was limited
Risks were high
40y: recurrence!
Comprehensive ortho tx plan is needed along with orthognathic surgery
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Dr Sylvain Chamberland
Recurring osteochondroma
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Dr Sylvain Chamberland
Wisdom Thoughts
"A patient with an elongated condylar process is more likely to stop growing spontaneously than one with an enlarged condyle but I don't have enough cases to prove it".
Dr William ProffitPersonal communication. January 2012
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Dr Sylvain Chamberland
Early fracture of the mandibular condyles: Frequently an unsuspected cause of growth disturbance
Profit W., Vig K., Turvey T., AJODO 1980, 78, #1, 1-24
If unilateral: deviation + openbite + xbite + distal occlusion ipsilaterally
If bilateral: distoclusion + anterior openbite
Recommandation post trauma
Observation + exercices to maintain normal fonction & occlusion
Compensatory growth occur but will not necessarily compensate for the loss of condylar lenght
Compensatory overgrowth is also possible
5 to 10% of asymmetries or
severe md deficiencies
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Dr Sylvain Chamberland
HypoplasiaTraumatism
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Dr Sylvain Chamberland
Mandibular laterodeviation to right
Left class I, right class II
Vertical asymmetry:
Gonial angle + inferior border of the chin
Midline coincident (??)
JuLe.260811; 10 ans 7 mois
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Dr Sylvain Chamberland
JuLe. 10 avril 2006
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Dr Sylvain Chamberland
Bilateral condylar fracture (because of a fall)
JuLe. 10 avril 2006
JuLe. 20 octobre 2006 5 y 10 m
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Dr Sylvain Chamberland
Anterior open bite
posterior md autorotation
Fulcrum on the molars (55/85)
JuLe.201006; 5 ans 10 mois
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Dr Sylvain Chamberland
Healing of condylar stumps
Significant shortening of the right ascending
ramus
Anterior posturing permits conterclockwise md rotation to close the openbite
JuLe. 30 janvier 2008; 7 ans
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Dr Sylvain Chamberland
Normal development except the shortened right condyle
Midline deviation toward the normal growing side
Ju.Le230412
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Dr Sylvain Chamberland
!
Non Growing Motor bike accident
Open reduction
But the condylar head moved forward
Could be because inadequate immobilization or the fragment were not realigned at surgery
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Dr Sylvain Chamberland
Automobile Accident
Bilateral condylar fracture
Fixation in the left (Reduced in the left)
Parasymphyseal fracture in the right
Le Fort 1 left segment
PACl.160309; 14 ans 9 mois
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Dr Sylvain Chamberland
Followed for 4 Years
Compensatory growth
Right condyle reshaped
normally
R: Overgrowth vertically?
L: Overgrowth horizontally?
PACl.160309; 14 years 9 months
PACl.160511; 16 ans 9 mois
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Dr Sylvain Chamberland
Conclusion
Facial asymmetries are sometimes difficult to diagnose
An asymmetric growth can express itself in the adolescence
without having been present during childhood
Articular clicking can be a confounding factor in the diagnosis, but should be considered as a clue.
The treatment often implies a surgical approach
5 to10% of the facial asymmetries are due to an undiagnosed
early condylar fracture or a traumatic impact in period of growth
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Dr Sylvain Chamberland
Thank you
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