Available online at www.sciencedirect.

com

British Journal of Oral and Maxillofacial Surgery 47 (2009) 502504

Abstracts

BAOMS Annual Scientic Meeting, Bournemouth,

35 June 2009
Symposium: The Management of Mandibular Asymmetry

Mandibular asymmetry secondary to TMJ active condylar hyperplasia (ACH)

Dorrit Nitzan
Professor of Oral and Maxillofacial Surgery, Hadassah
School of Dental Medicine, Jerusalem, Israel
Condylar hyperplasia (CH), a rare non-neoplastic pathology,
first described in 1836, is associated with overgrowth of the
mandibular condyle. This usually unilateral disorder results
in facial asymmetry, occlusal disorders and may be associated with pain and dysfunction. The clinical characteristics
of active condylar hyperplasia (ACH) are controversial since
issues such as the effect of gender, age of onset, types of
asymmetry and structure of the condylar head have not been
agreed upon. Historically, female predisposition was noted at
a ratio of 7:2, 3:1 and 7:3. Yet others claimed that CH afflicted
males and females at equal proportions. In one Iranian study
CH was described in 12 males and in only one female.
Most studies found that CH is encountered between the
age of 10 and 30. Obwegeser had suggested that, specifically,
hemimandibular hyperplasia occurs at a significantly younger
age.1 Others, however, presented a wider age range for CH:
1937 years with mean 25.8 years; 1040 years with mean
of 23.5 years or 1459 years as well as 1180 years.2 Age
at onset was unrelated to the type of CH or its severity and,
therefore, awareness to changes in facial symmetry due to
CH is indicated for any age.
Reports on preferential laterality are rather baffling, such
as those on right CH in 12 out of 13 patients, left CH in 8 out
of 12. In addition, the left side is significantly more frequent
in the male group (9:5) while the right side in the female
group (34:12). On the other hand, equal side distribution was
found by others. Further study of this finding, which remains
ambiguous to us, may shed some light on the pathogenesis
of this disorder.

0266-4356/$ see front matter

There was no correlation between the radiological and

the clinical findings in 51 patients with ACH.2 The condylar head was deformed in 27%, and enlarged in 58%. The
condylar neck was elongated in 69% and enlarged in 19%.
All these changes were uncorrelated with the type of asymmetry. Classification should therefore be simplified and based
upon clinical manifestation, in other wards, on the direction
of asymmetry.
Since this pathology is self-limiting, its activity should be
evaluated before treatment. This is effectively demonstrated
by bone scintigraphy, and is strongly correlated with the histological findings. Naturally it has become an efficient tool
in the differential diagnosis of facial asymmetry. However,
activity associated with other pathologies of the joints must
be differentiated.
Treatment plan should include both stop of the increasing
asymmetry and correction of the deformation that has already
been developed. This is usually performed by the elimination
of the actively growing site by high condylectomy followed
by correction of the created facial deformity by, usually, two
jaws orthognathic surgery. Commonly, these two procedures
are performed in one intervention.
A facial self-correction phenomenon was presented by
several authors following the removal of the growing site
(high condylectomy). Gradual changes in the facial asymmetry that took place in 39 patients, following the removal
of the pathological growth site, will be presented. Phenomena such as closure of open bites, leveling of the shifted
occlusal plane both meaning that the change in the mandible
is followed by the maxilla were observed. In addition,
changes in teeth position were experienced as well. These
changes suggest a different view of the need for orthognathic
surgery.
The last and the most intriguing issue is the search for the
factor that is associated with the over growth that is typical

Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) 502504

of the TMJ only. Uncovering of this factor may be useful in

cases of condyle undergrowth.

References
1. Obwegeser HL, Makek MS. Hemimandibular hyperplasiahemimandibular elongation. J Maxillofac Surg 1986;14:183208.
2. Nitzan DW, Katsnelson A, Baranis I, Brin I, Casap N. The clinical characteristics of condylar hyperplasia: experience with 61 patients. J Oral
Maxillofac Surg 2008;66:3128.

doi:10.1016/j.bjoms.2009.06.022
Post-traumatic mandibular asymmetry

503

This presentation will examine:

1. the incidence, aetiology, terminology and features of
HFM,
2. investigations required to establish the diagnosis and
appropriate treatment, especially multislice 3DCT,
3. the relevance and limits of classifications and some suggested modifications,
4. the planning of surgery and especially the use of 3D imaging in planning,
5. management in the growing child and in the adult,
6. the role of distraction osteogenesis (DO), of bone grafting
and of osteotomies,
7. augmentation procedures,
8. results,
9. long term outcome.

S.M. Balaji
Balaji Dental and Craniofacial Hospital, Chennai, India
Traumatic injury induces mandibular asymmetry by either
truncating normal growth or consequent to inappropriate
alignment and restitution of disrupted anatomy where remodelling and other compensatory mechanisms fail to establish
morphological harmony. Since the mandible is the only
mobile skeletal segment of the facial skeleton and possesses unique morphology, the functional and aesthetic
consequences following trauma can be very diverse in clinical presentation and difficult to manage. Therefore in this
presentation an attempt will be made to identify the mechanisms and aetiopathology of traumatic injury as it relates
to the mandible and an analysis of the mechanism and
nature of morphological alterations. The discussion will also
examine the role of compensatory mechanisms in restoring normal form and function as well as in inducing gross
facial asymmetry. In many cases pathological changes in
trauma are not restricted to the mandible but also encompass the skull base, other elements of the facial skeleton
and soft tissue units responsible for function. The presentation will demonstrate with a number of case studies the
steps in analysis and establishing effective management
strategies for the correction of post-traumatic mandibular
asymmetries.
doi:10.1016/j.bjoms.2009.06.023
The management of syndromic mandibular asymmetry,
especially hemifacial microsomia
Adrian W. Sugar

The importance of treating the patient in all features of

the syndrome will be emphasised despite the complexity
and inevitable multidisciplinary nature of care. These common features include vertebral anomalies, facial nerve palsy,
conduction and sometimes sensorineural hearing loss and
microtia. In its severe form, the spectrum must include the
Tessier no. 7 facial cleft and occasional bilateral (but asymmetric) forms.
With regard to the mandible, patients are separated into:
1. those who require/or wish for no intervention,
2. those who require/or wish for minimal intervention,
3. those whose mandible is hypoplastic but essentially intact
with a normal TM joint in an essentially normal position,
4. those as in (3) but with a TM joint in an abnormal position,
5. those with missing elements of the mandible especially
the condyle/ramus and sometimes body,
6. those with missing zygomatic arch/fossa.
The fundamental issue in reconstruction of the mandible
remains the production of functional joints and normal
mandibular contours and position as well as appropriate soft
tissue cover and animation. Where there is aplasia (Pruzansky 3), reconstruction with grafts remains the best option to
convert the patient to Pruzansky 2. Where there is hypoplasia
(Pruzansky 2), lengthening by DO or osteotomy and grafting in both antero-posterior and lateral dimensions, may be
indicated. The relative role in all these situations of grafts,
bone lengthening and reshaping by osteotomies, augmentation, onlay grafting, and distraction osteogenesis will be
described together with timings based on a series of over 100
cases.

Maxillofacial Unit and South Wales Cleft Service, Morriston Hospital and Swansea University Medical School, ABM
University NHS Trust, UK

References

Syndromic mandibular asymmetry occurs most commonly in

hemifacial microsomia (HFM) but is by no means its only or
even its predominant feature. HFM itself is the most common
craniofacial anomaly after cleft lip and/or palate.

1. Farrier J, Sugar AW. Mandibular distraction osteogenesis for lateral contour defects in craniofacial microsomia. BAOMS Abstracts. Br J Oral
Maxillofac Surg 2002;40:363.
2. Figueroa AA, Pruzansky S. The external ear, mandible and other components of hemifacial microsomia. J Maxillofac Surg 1982;10:20011.