J Huazhong Univ Sci Technol [Med Sci] 35(2):265-270,2015

DOI 10.1007/s11596-015-1422-5
J Huazhong Univ Sci TechnolMed Sci 35(2):2015 265

Condylar and Occlusal Changes after High Condylectomy and

Orthodontic Treatment for Condylar Hyperplasia
Loaye A.El.mozen, Qing-gong MENG (), Ying-jie LI (), Xing LONG ( )#, Guo-xin CHEN ()#
Department of Oral and Maxillofacial Surgery, the State Key Laboratory of Breeding Base of Basic Science of Stomatology & Key
Laboratory of Oral Biomedicine of Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan 430079,
China

Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2015

Summary: Condylar hyperplasia (CH) of human temporomandibular joint (TMJ) often occurs unilater-
ally, and causes occlusal disturbance and facial asymmetry. The purpose of this study was to compare
the effects of high condylectomy with and without postsurgical orthodontic treatment. Forty patients
were diagnosed as having active CH and treated with high condylectomy. Patients in group A (n=24)
took the postsurgical orthodontic therapy immediately after surgery, and those in group B (n=16) did not
take orthodontic therapy. For both groups, the mandibular ramus height on the affected side was de-
creased significantly after surgery. Orthodontic treatment promoted maxillary alveolar remodeling sig-
nificantly by depressing alveolar bone of the affected side and increasing alveolar bone of the non-
affected side. Better improvement for facial midline deviations was observed in group A than in group
B. In both groups, the condylar remodeling was observed and manifested by the smoothening of condy-
lar surface and returning of condyle to normal position in glenoid fossa. It was concluded that high
condylectomy in the treatment of active CH of TMJ improved the functional occlusion and facial aes-
thetic. Postsurgical orthodontic therapy could more effectively enhance maxillary alveolar and condylar
remodeling, and more rapidly and meticulously establish the stable occlusal and normal position of
condyle than the spontaneous remodeling.
Key words: dentofacial asymmetry; condylar hyperplasia; condylectomy; orthodontic treatment

Condylar hyperplasia (CH) of human temporoman-
dibular joint (TMJ) is the unilateral excessive growth of 1 PATIENTS AND METHODS
the mandibular condyle, causing facial asymmetry and
occlusal disturbance. For unknown reason, one of the This retrospective study involved 40 patients (23
condylar growth areas becomes more active than others, females and 17 males) who were diagnosed with active
which may be associated with joint pains and dysfunc- CH from 2005 to 2012, and treated in the Department of
tions[13]. On clinical observation, hemimandibular elon- Oral and Maxillofacial Surgery, School & Hospital of
gation from CH presents the features of unilateral occur- Stomatology, Wuhan University. This study was con-
rence, severe deviation of chin, lower midline to the con- sented and approved by the Ethics Committee of the
tralateral side, and the lower incisors tilted to the affected School & Hospital of Stomatology, Wuhan University.
side. CH also causes the dentoalveolar compensations Before the surgery, all patients underwent the stan-
and related soft tissue changes in the maxilla[46]. dardized radiographic examinations, including pano-
Furthermore, these effects of unilateral condylar ramic tomography, cephalometry, and cone-beam com-
elongation are quite suitable for high condylectomy to puted tomography (CBCT). The bone scanning by single
correct this kind of mandibular asymmetry and to arrest photon emission computed tomography (SPECT) was
this condylar overgrowth. After high condylectomy, used to assess the active growth of condyle (fig. 1). Se-
open-bite usually occurs in the non-affected side and rial extra- and intra-oral photographs were taken before
premature contact occurs in the affected side[7, 8]. How- and after treatment. Clinical examinations were per-
ever, some patients are reluctant to take the postsurgical formed on all patients for facial symmetry, TMJ function
orthodontic treatment. The consequence without the and occlusion conditions. All the patients underwent the
postsurgical orthodontic treatment had not yet been in- standardized clinical and radiographic examinations at
vestigated. The purpose of this study was to compare the the following intervals: pre-surgery (P1), post-surgery
condylar and occlusal changes of high condylectomy (P2), and follow-up (P3).
with and without postsurgical orthodontic treatment. Then, all patients underwent high condylectomy to
arrest the overgrowth of the condyle and to prevent fu-
ture facial asymmetry after the same standardized clini-
Loaye A.El.mozen, E-mail: Dr_lo2y78@hotmail.com cal and radiographic investigation when the condylar
#
Corresponding authors, Xing LONG, E-mail: longxing_ch- growth was in the active phase. Under general anesthesia
ina@hotmail.com; Guo-xin CHEN, E-mail: chenguoxin91- with nasal cannula, this surgery was performed through
9@163.com the preauricular incision to reach TMJ region. Condylec-
266J Huazhong Univ Sci TechnolMed Sci 35(2):2015
tomy was achieved by removal of the excessive top of 19.833.26 years, 8 patients were affected in the left side,
the hyperactive condyle according to the measurement of and 16 patients affected in the right side. The average
ramus height. Then the articular disc was repositioned post-orthodontic follow-up period was 13.8 months. In
backward upon the shaved condylar head. Two titanium group B (n=16), there were 10 females and 6 males with
implants were planted in the affected side, between the the mean age of 19.934.13 years, 4 patients were af-
upper first premolar and canine tooth, and between lower fected in the left side, and 12 patients affected in the
lateral incisor and canine tooth, respectively. Intermaxil- right side. The average post-surgical follow-up period
lary traction was applied immediately after the surgery was 18.4 months. The treating procedures for representa-
for reposition of the shaved condylar head in glenoid tive patients in group A and group B are presented in fig.
fossa. One month after the surgery, the two implants 4 and fig. 5, respectively.
were taken out from patients. Based on the previous
shape of condyle, the remodeling changes after high
condylectomy were assessed during the follow-up period.
The remodeling changes of condyle include the profile of
condyle and new bone formation, and condylar position
in glenoid fossa was evaluated through CBCT.

Fig. 2 The measurements on panoramic X-ray photograph

Ramus height (RH): distance between the most cranial
point of the high condyle (HC) and the most inferior
point of the gonial angle (AG); maxilla height (MH):
distance between the most inferior point of the orbit
(OR) and the tip of the mesiobuccal cusp of the maxil-
lary first molar (U6)

Fig. 1 Bone scanning showing the increased activity (indicated

by the arrow) of the left condyle of a typical patient

Then these patients were divided into two groups

based upon their desire to take postsurgical orthodontic
treatment. In group A, there were 24 patients who took Fig. 3 A: Pre-surgery CBCT showing the deviation of the facial
the orthodontic treatment one month after surgery in or- midline; B: Follow-up CBCT showing normalized facial
der to further correct the transverse and vertical dental midline
discrepancy and enhance the functional occlusion and
facial aesthetic. In group B, there were 16 patients who 2.2 Radiographic Data
did not receive the postsurgical orthodontic treatment. In group A, the mandibular RH on affected side
The multi-loop edgewise arch wire (MEAW) with the showed significant difference between P1 and P2
intermaxillary elastic traction[9] was used in the postsur- (P<0.01), P1 and P3 (P<0.01), but no significant differ-
gical orthodontic treatment. Improvements of facial aes- ence was found between P2 and P3 (P>0.05) (fig. 2 and
thetic in the treatment outcome were evaluated by pano- 6). In group B, RH on the affected side showed statisti-
ramic tomography and CBCT. Ramus height (RH)[10] and cally significant change between P1 and P2 (P<0.01), P1
maxilla height (MH)[11] were investigated (fig. 2). The and P3 (P<0.01), but no significant difference was found
mandibular ramus length and the maxillary height on between P2 and P3 (P>0.05) (fig. 6). Besides, no statisti-
both sides were measured. Meanwhile, the change of fa- cally significant difference was found between P1, P2,
cial midline was measured before and after surgery, post- and P3 of these two groups (P>0.05).
orthodontic treatment, and in follow-up stage in both In group A, MH on the affected side was decreased
groups (fig. 3). The results were analyzed by Digimizer significantly during the follow-up period (fig. 2 and 7A),
software 3.1.1.0. shown by statistically significant change between P1 and
P3 (P<0.01), or P2 and P3 (P<0.01). In group B of the
2 RESULTS affected side, there was no significant difference between
P1 and P2, P2 and P3, or P1 and P3 (P>0.05) (fig. 7A).
2.1 Clinical Data In the non-affected side, MH was increased significantly
Forty patients were involved in this study, with age in group A during the follow-up period (fig. 7B), shown
ranging from 14 to 33 years old. In group A (n=24), there by statistically significant change between P1 and P3
were 13 females and 11 males with the mean age of (P<0.01), or P2 and P3 (P<0.01). However, in group B
J Huazhong Univ Sci TechnolMed Sci 35(2):2015 267

of the non-affected side, there was no significant differ- (P>0.05) (fig. 7B).
ence between P1 and P2, P2 and P3, or P1 and P3

Fig. 4 A representative patient in group A

A: Pre-surgical intra-oral photograph; B: Intra-oral photograph of mid-orthodontic treatment; C: Follow-up photograph show-
ing normal occlusion; D: Pre-surgical panoramic radiograph; E: Follow-up panoramic radiograph

Fig. 5 A representative patient in group B

A: Pre-surgery intra-oral photograph showing the lower midline shifted to the left side. B: Post-surgery intra-oral photograph.
C: Two-years follow-up intra-oral photograph demonstrating coincident midlinet. D: Pre-surgical panoramic radiograph. E:
Two-year follow-up panoramic radiograph

Fig. 6 The mandibular RH on the affected side

In group A, RH changes were compared between P1 and P2, P1 and P3, or P2 and P3. In group B, RH changes were also com-
pared between P1 and P2, P1 and P3, or P2 and P3. No significant difference was observed between P1, P2, and P3 of these
two groups. **P<0.01
268J Huazhong Univ Sci TechnolMed Sci 35(2):2015

Fig. 7 A: The MH on affected side. MH on affected side of orthodontic group decreased significantly. B: MH on non-affected side.
MH on non-affected side of orthodontic group increased significantly. **P<0.01

The facial midline deviation in group A presented (P<0.01). However, no statistically significant difference
statistically significant change between P1 and P2 was found between P2 and P3 in group B. Besides, sig-
(P<0.01), P2 and P3 (P<0.01), or P1 and P3 (P<0.01) nificant difference was found in P3 between these two
(fig. 3 and 8). In group B, there was significant differ- groups.
ence between P1 and P2 (P<0.01), or P1 and P3

Fig. 8 Facial midline deviations of the both two groups

Significant improvements in midline deviations were observed in both two groups after the surgery. Orthodontic treatment
could further improve midline deviations. However, further improvement in non-orthodontic group was not observed.
**
P<0.01

All patients in group A were adjusted to normal oc- or inactive growth. SPECT using 99mTc-labeled methyl-
clusion during the follow-up period. However, 9 patients ene diphosphonate shows the activity in the affected
in group B achieved normal occlusion during the follow- condyle (fig. 1)[12]. And active growth of CH can usually
up period. Open bite still remained in the rest 7 patients be determined by worsening functions and aesthetic
in group B. changes with clinical serial assessments involving clini-
The condylar surface had new bone formation and cal evaluation, dental model analysis and radiographic
became smooth again gradually during the follow-up pe- evaluation by superimposition within 6 to 12 month in-
riod after high condylectomy. Condylar position in gle- tervals[4].
noid fossa was changed immediately after surgery. But Options and timing of treatment should be considered
condylar position gradually got normal during the fol- in active CH. The protocol of high condylectomy re-
low-up period in both groups (fig. 9). moves 58 mm upper surface of the condylar head in-
cluding the medial and lateral poles, and arrests the ex-
3 DISCUSSION cessive growth of the condyle by removing the growth
site of mandible[7, 8]. If the high condylectomy is deferred
There were different kinds of methods to diagnose until the accomplishment of active growth of condyle,
CH. For active CH, SPECT is the most effective method the patient might consequently suffer from dysfunctions
to distinguish whether condylar hyperactivity is in active in mastication and speech, worsening aesthetic configure,
J Huazhong Univ Sci TechnolMed Sci 35(2):2015 269
and psychosocial problems. Additionally, the deformity
of CH may result in severe deformation of the mandible.
The dentoalveolar compensations and associated soft tis-
Fig. 9 Sagittal plane of CBCT
A: Pre-surgery. B: Post-surgery. C: Two-year follow-up showing the remodeling condylar head
However, the types for treating CH are debatable on
asymmetrical severity and whether the growth is active
or inactive. Some authors recommended condylectomy
accompanied by orthognathic surgery for the adult active
condylar growth. However, orthognathic surgery is pref-
erable for inactive condyle[1416], rather than for CH of
the activity phase, because orthognathic surgery yet does
not stop the growth hyperactivity. Besides, orthognathic
surgery also requires the orthodontic treatment including
the pre-surgical and post-surgical treatments. In this
study, the serial therapy combining high condylectomy
and orthodontic treatment is recommended when the
condylar growth is active, because condylectomy cor-
rects the condylar elongation of the affected side (fig. 6)
and orthodontic treatment enhances the remodeling of
the dentoalveolar deformity in maxilla[14, 16].
The occlusal relationships are affected closely by
high condylectomy. Clinical observation after surgery
indicates that mandibular midline shifts to the normal
position, premature contact exists in the posterior denti-
tion of the non-affected side, and a posterior open-bite
appears with no intercuspal dental contact at the non-
affected side. It is noteworthy that maximum occlusion
can be achieved slowly by the spontaneous remodeling
for the dentoalveolar deformity in maxilla and unilateral
movement of the affected mandible to a normal position[8,
17]
. Spontaneous remodeling processes may bring about
improvement in symmetry or simplify treatment in the
future by modifying the unfavorable growth pattern.
Spontaneous correction on the vertical discrepancy is
mainly resulted from the force of masticatory muscles. In
this study, through the analysis of the inferior border of
the orbit to the tip of the upper first molar, the orthodon-
tic group presented significantly more maxillary alveolar
remodeling, manifested by that the alveolar bone was
depressed in affected side and increased in non-affected
side (fig. 7). Therefore, post-surgical orthodontic treat-
ment could enhance and accelerate the spontaneous re-
modeling, and facilitate patients to achieve maximum
occlusion and neutroclusion within shortened time.
The postsurgical orthodontic goals are to align and
level the teeth over the basal bone and to remove dental
compensations, regardless of the magnitude of skeletal
and dental malalignment[18]. MEAW technique is a pref-
erable method to correct the open-bite in the non-
sue changes would occur in the maxilla, which signifi-
cantly makes the therapy compromised[7, 13].
affecting side and the premature contacts in the affecting
side, a phenomenon which occurs when the condyle is
repositioned in the glenoid fossa after condylectomy.
This technique provides a proper vertical positioning of
the maxillary incisors, compatible cant of the maxillary
and mandibular occlusal planes, and upright of the incli-
nation of the posterior teeth[18]. In this study, through or-
thodontic treatment, the malocclusion and crowding were
solved. Also normal overbite, overjet, and aligned dental
midline were achieved under the natural function of mas-
ticatory muscles and intermaxillary elastic traction. Be-
sides, the orthodontic treatment improved the facial mid-
line deviation with better effect than non-orthodontic
groups. Therefore, the facial and dental esthetic could be
improved by the postsurgical orthodontic treatment.
In conclusion, high condylectomy in the treatment
of active CH of TMJ improved the functional occlusion
and facial aesthetic. Postsurgical orthodontic therapy
could more effectively enhance maxillary alveolar and
condylar remodeling, and more rapidly and meticulously
establish the stable occlusal and normal position of
condyle than the spontaneous remodeling.
Conflict of Interest Statement
The authors declare no conflicts in interest in the publica-
tion of this article.
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