J Oral Maxillofac Surg

66:312-318, 2008

The Clinical Characteristics of Condylar

Hyperplasia: Experience With 61 Patients
Dorrit W. Nitzan, DMD,* Alex Katsnelson, DMD,†
Ido Bermanis, DMD,‡ Ilana Brin, DMD,§ and
Nardi Casap, DMD, MD储

Purpose: Much reported variation and discord exist regarding mandibular condylar hyperplasia (CH).
This study evaluated some of the characteristics of this disorder in a series of 61 patients with active CH.
Patients and Methods: A total of 61 patients with active temporomandibular CH who had been
evaluated in our departments were included. Demographic, clinical, radiologic, and bone scintiscan data
were collected and analyzed. Asymmetries were classified as transverse, vertical, or combined.
Results: CH was diagnosed during the growth period in 22 patients, and 39 patients were older than
20 years (range, 11 to 80 years). In 66% of the patients, the main complaint was progressive facial
asymmetry; and in the remainder, the main complaint was pain, dysfunction, or both. Transverse
asymmetry predominated (52%), and vertical or combined asymmetry occurred in 31% and 16% of
patients, respectively; asymmetry type was independent of age. The occlusal plane deviated in 48% of the
patients. Laterality was significantly gender-biased (females, 72% right; males, 64% left; P ⫽ .017). The
condylar head shape was normal in 15% of patients, deformed in 27%, and enlarged in 58%; the condylar
neck was elongated in 69% and enlarged in 19%. All of these changes were uncorrelated with the type
of asymmetry (vertical, transverse, or combined).
Conclusions: CH may occur at any age and is more prevalent in females. Clinicians should be aware
that only some patients complain primarily of facial asymmetry, and that symptoms of temporomandib-
ular disease also may be present. Because there is no correlation between the radiologic findings and the
clinical evaluation, classification should be simplified and based on clinical manifestation only—in other
words, the direction of asymmetry.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:312-318, 2008

Temporomandibular joint (TMJ) condylar hyperplasia
(CH) is a rare pathology that was first described in
1836 as overgrowth of the mandibular condyle; com-
parable pathology has not been described in any
other joint. CH is a distinct entity, a unilateral disorder
Received from the Hebrew University-Hadassah School of Dental
Medicine, Jerusalem, Israel.
*Professor, Department of Oral and Maxillofacial Surgery.
†Formerly, Resident, Department of Oral and Maxillofacial Sur-
gery; and Currently, Resident, Oral and Maxillofacial Surgery De-
partment, University of Illinois at Chicago, Chicago, IL.
‡General Practitioner, Department of Oral and Maxillofacial Sur-
gery.
§Associate Professor, Department of Orthodontics.
储Senior Lecturer, Department of Oral and Maxillofacial Surgery.
Address correspondence and reprint requests to Dr Nitzan: Depart-
ment of Oral and Maxillofacial Surgery, Faculty of Dental Medicine,
POB 12272, Jerusalem 91120, Israel; e-mail: Dorrit@cc.huji.ac.il
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6602-0018$34.00/0
doi:10.1016/j.joms.2007.08.046
in which the pathology occurs at the head of the
condyle consequently affecting facial symmetry and
occlusion and may be associated with pain and dys-
function.1-4 The disorder is self-limiting, but as long as
it remains active, the asymmetry progresses together
with the associated occlusal changes.
Obewegeser and Makek5 classified the asymmetry
associated with CH into 3 categories: hemimandibular
hyperplasia, causing asymmetry in the vertical plane;
hemimandibular elongation, resulting in asymmetry
in the transverse plane; and a combination of the 2
entities.5 The first type is caused by unilateral growth
in the vertical plane and is characterized by a sloping
rima oris with almost no deviation of the chin and,
intraorally, by increased height of the maxillary alve-
olar bone and downward deviation of the occlusal
plane in the ipsilateral side. If the maxillary plane fails
to follow the mandibular plane, then an open bite
may develop on the same side. Most commonly, the
mandibular midline is straight, but it may shift ipsilat-
erally. Radiologically, Obewegeser and Makek5 re-
ported that the condyle appears enlarged and that its

312
NITZAN ET AL
head is usually irregular and deformed and its neck
thickened and elongated, with coarse trabeculae fill-
ing the condyle. The mandibular angle is typically
round, with the canal in low position. Joint pain was
reported in 70% of the patients.6
Hemimandibular elongation, the second type of
CH,5 is associated with chin deviation toward the
contralateral side with no vertical asymmetry. In-
traorally, the mandibular midline deviates to the un-
affected side, while the contralateral mandibular molars
deviate lingually in attempt to remain in occlusion; how-
ever, cross-bite may develop in the contralateral side.
The occlusal plane is maintained with no deviation. The
condyle is of normal shape and size, but its neck can be
either slender or normal, with an elongated ascending
ramus. The third type of CH is a combination of the
first 2 types.5
Histopathologically, widening of the fibrocartilage
that covers the condyle, a wide richly vascularized
proliferation zone enriched with large cells near its
bony aspect, and osteoclasts in the lacunae between
new trabeculae formed by the surrounding osteo-
blasts can be observed.7 In active CH, the abnormal
presence of large masses of hyaline cartilage sur-
rounding large cells and new cartilage formation also
have been reported,8 along with the constant pres-
ence of mesenchymal germinal cells and cartilage
islands in the bone under the fibrocartilage.9 The
growth center, however, is localized in the center of
the condyle and not in the fibrocartilage.5 When ac-
tive growth ceases, the histological appearance is of a
normal condyle with an irregular shape.1 In the ver-
tical type of active CH, cartilage maturation layers and
increased growth are also noticeable, and inclusions
of cartilaginous tissue with glove fingers extending
into the underlying cancellous bone have been de-
scribed.10
Activity of CH is effectively demonstrated by bone
scintography, is strongly correlated with the histolog-
ical findings, and has become an efficient tool in the
differential diagnosis of facial asymmetry.7,9,11-16 Ac-
tivity associated with other pathologies of the joints
must be differentiated, however.17
Both types of CH have been reported to be equally
prevalent in males and females, with onset during or
after the period of growth.5 Others found hemiman-
dibular elongation mostly in younger patients and
hemimandibular hyperplasia in older patients.18 In
any case, early diagnosis in the active stage is impor-
tant because of the progressive nature of CH, partic-
ularly when the patient is under orthodontic treat-
ment or when orthognathic surgery is planned.8
The pathogenesis of CH that occurs only in the TMJ
remains obscure. It has been suggested that the stim-
ulus for the abnormal growth originates from the
fibrocartilaginous layer.5 One study, based on a series
313
of 22 patients, has suggested that CH may represent
reactive growth in response to provocation by certain
agents, and that genuine CH might be a process reac-
tive to joint arthrosis.18 The appearance of CH in 2
siblings raised the possibility of a genetic cause, pos-
sibly a Y-linked or autosomal dominant trait.19 In
addition, condylar and ramus overgrowth, malocclu-
sion, and complementary maxillary deformity devel-
oping after severe facial injury suggested that trauma
may be contributive.20 Increased formation of condy-
lar bone and cartilage was induced experimentally in
rats by removal of the tibial marrow.21
The present study reports a series of 61 patients
with facial asymmetry due to active CH. From this
relatively large series, we hoped to resolve these re-
ported disagreements and to gain further insight into
this evasive disorder.
Patients and Methods
This retrospective study included 61 patients with
active TMJ CH who were evaluated in the Depart-
ments of Oral and Maxillofacial Surgery and Orth-
odontics at the Hebrew University Hadassah School of
Dental Medicine between 1980 and 2004. Inclusion
criteria were vertical, transverse, or vertical and trans-
verse plane facial asymmetry with matching occlusal
changes, as demonstrated clinically and by panoramic
and cephalometric (posterior-anterior and lateral)
roentgenograms, and an active hyperplastic process
confirmed by bone scan performed at the initial diag-
nosis and repeated at least 6 months later.
Patient evaluation included a patient questionnaire
detailing demographic information and a comprehen-
sive history that included primary complaints, initial
symptoms, duration of symptoms, presence of joint
noise, limitation in mouth opening, and earlier treat-
ment. Each patient self-assessed his or her level of
pain and extent of dysfunction using a visual analog
scale (VAS) and indicated its location on a facial dia-
gram. Two surgeons independently evaluated the se-
verity of the facial asymmetry (VAS range, 0 to 5) and
recorded its direction as transverse, vertical, or both.
Evaluation was based on clinical signs, including oc-
clusion, occlusal plane, deviation of mandibular mid-
line, and others. The clinical examination included
the determination of maximal mouth opening; range
of lateral and protrusive mandibular movements; char-
acteristics of the limitation in jaw movement, when
present; determination of joint noise on palpation;
and evaluation of pain on palpation of the head and
neck muscles and both TMJs. The severity of occlusal
plane inclination was evaluated from the angle be-
tween the occlusal plane and the interpupil line. In-
traorally, deviation of dental midline, cross-bite, and
open-bite were also recorded.
314
Table 1. PREOPERATIVE DEMOGRAPHIC AND CLINICAL CHARACTERISTICS IN 62 PATIENTS WITH DIAGNOSED
ACTIVE CH
Characteristics
Females/males, n (%)
Age (years), mean ⫾ standard deviation (SD) (range)
Duration, months, mean ⫾ SD (range)
Main complaint, n (%)
Asymmetry, n (%)
Pain and dysfunction, n (%)
Asymmetry, pain, and dysfunction
Affected joint (right/left bilateral), n (%)
Males (right/left), n (%)
Females (right/left/bilateral), n (%)
Maximal mouth opening (mm), mean ⫾ SD (range)
Asymmetry type: transverse/vertical/combined
Occlusal plane inclined, n (%)
Severity of asymmetry (VAS 0 to 5), mean ⫾ SD (range)
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia. J Oral Maxillofac Surg 2008.
Radiologic evaluation (n ⫽ 52) included preopera-
tive transpharyngeal and transcranial radiographs of
the TMJ in the closed-mouth and open-mouth posi-
tions, along with panoramic and cephalometric x-rays
in anterior-posterior and lateral views. The condylar
head was classified as normal, enlarged, deformed, or
enlarged and deformed, and the condylar neck was
classified as normal, elongated, or enlarged.
Bone scintography using 99Tc was performed in all
patients before the surgical intervention. The proce-
dure was repeated after at least 6 months, and was
performed in 3 phases to ascertain that the activity
originated from osteoblastic activity. In young pa-
tients, corrections were made for activity due to nor-
mal growth.
The Mann-Whitney test was used for comparing
continuous or ordinal variables, and the ␹2 test was
applied to determine association between the cate-
gorical variables. Pearson’s correlation examined the
relationship between the age and severity of CH.
Results
The demographic and clinical data of the study
group are detailed in Table 1. A total of 61 patients
(46 females [75%] and 15 males [25%]), with a mean
age of 27.8 ⫾ 14.7 years (range, 11 to 80 years) were
diagnosed as having active CH. As shown in Figure 1,
22 of the patients were diagnosed during the
growth period and 39 after age 20 years. The age
distribution was similar for both genders (mean age
of females, 28.51 ⫾ 15 years; of males, 25.87 ⫾
14.21 years).
In 40 patients (65.6%), the main complaint was
progressive facial asymmetry; 17 (27.9%) complained
of pain, dysfunction, or both. Among the latter, 1
patient had ankylosis, and 2 patients were diagnosed
CLINICAL CHARACTERISTICS OF CONDYLAR HYPERPLASIA
46 (75)/15 (25)
27.85 ⫾ 14.7 (11–80)
31; 18.03 ⫾ 12.81 (6–72)
40 (65.6)
17 (27.9)
4 (6.6)
39 (64)/21 (34)/1 (1.6)
5 (36)/9 (64)
34 (72)/12 (26)/1 (2)
44.31 ⫾ 7.48 (10–65)
32 (52)/19 (31)/10 (16.9)
29 (48%)
3.24 ⫾ 1.04 (1–5)
1 year after release of ankylosis, 1 in the affected joint
and the other in the contralateral joint. Four patients
(6.6%) complained of both pain and asymmetry.
In 32 patients (53%), the asymmetry was in the trans-
verse plane; in 19 patients (31%), it was vertical; and in
10 (16%), the asymmetry was both transverse and ver-
tical. The type of asymmetry was independent of age.
The right TMJ was affected in 39 patients (64%), a
significantly higher rate than the left joint (P ⫽ .025);
1 female presented with bilateral CH. Females were
more affected in the right TMJ (72%); males, in the left
TMJ (64%) (P ⫽ .017). The mean maximal mouth
opening (not counting 1 patient with limited mouth
opening due to ankylosis) was 44.3 ⫾ 7.5 mm (range,
10 to 65 mm). Joint pain, dysfunction, or clicking was
found in 24 patients (38.7%).
FIGURE 1. Age distribution of active CH.
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia.
J Oral Maxillofac Surg 2008.
NITZAN ET AL
FIGURE 2. Severity of active CH and age (VAS scale 0 to 5).
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia.
J Oral Maxillofac Surg 2008.
The occlusal plane was tilted in 29 patients (48%).
The mean severity of asymmetry (on a scale of 1 to 5)
was 3.24 ⫾ 1.04. Twenty-three patients (38%) had a
severity score between 3 and 4, and 8 (16%) scored
between 4 and 5. Indeed, the asymmetry was less
severe in the transverse type than in the vertical type
(respective means of 3.1 and 3.6, and medians of 3
and 4). The severity of asymmetry increased with age
(r ⫽ 0.27; P ⫽ .034; Fig 2); gender had no effect on
the degree of severity.
The radiologic evaluations of the condylar head and
neck and the ramus are summarized in Table 2. In
most patients (73%), the shape of the condylar head
was normal; in 27%, it was deformed. Condylar head
deformity did not correlate with any type of hyper-
plasia. Among the patients with transverse CH, 5 had
deformed condyles (17.8%) and 23 had normal con-
dyles (82.2%), whereas in those with vertical CH, 7
patients had deformed condyles (39%) and 11 had
normal condyles (61%). The size of the affected con-
dyle was notably larger than the contralateral condyle
in 30 patients (58%). In the patients with transverse
CH, 13 had enlarged condyles (46%) and 15 had
normal condyles (54%), whereas in the patients with
vertical CH, 14 had large condyles (78%) and 4 had
normal condyles (22%). These differences in these
proportions were statistically significant. The condy-
lar neck was elongated in 36 patients (69%) and en-
larged in 6 patients (12%), and its proportion was
similar in all types of asymmetry.
Discussion
The clinical characteristics of CH are controversial,
because such issues as the effect of gender, age of
onset, type of asymmetry, and structure of the con-
315
dylar head have not been agreed on. Historically,
female predisposition has been noted, and indeed our
group of 61 patients had more females than males (at
a ratio of 3:1), in agreement with other reports of
ratios of 7:222 and 3:1 ratios.18 However, other stud-
ies found that CH afflicted males and females in equal
proportions.12,17,23 An Iranian study found CH in 12
males and only 1 female.24
Most studies have found that CH occurs between
ages 10 and 30 years,8,12,22,25 and it has been sug-
gested that the abnormal growth of the hyperplasia
ceases with that of general growth and that hemiman-
dibular hyperplasia occurs at a significantly younger
age.5 Active CH after the growth period was consid-
ered prolongation of growth. Other studies, however,
presented a wider age range for CH: 19 to 37 years
(mean, 25.8 years),24 10 to 40 years (mean, 23.5
years),26 and 14 to 59 years.18 In our group, age varied
widely, ranging from 11 to 80 years. About one third
of the patients were referred during the growth pe-
riod, with the rest diagnosed after age 20. We found
no association between age at onset and the type of or
severity of CH, and thus suggest that awareness of
changes in facial symmetry as a result of CH is indi-
cated for any patients of any age.
Reports on preferential laterality, such as those
on right CH in 12 of 13 patients24 and left CH in 8
of 12 patients,26 are rather baffling. On the other
hand, an equal side distribution has been found by
others.2 In the present study, 1 side was signifi-
cantly more affected. This affect was highly gender-
dependent, with the right side predominating in
females and the left side predominating in males.
Further study of this finding, which remains ambig-
uous to us, may shed some light on the pathogen-
esis of this disorder. The underlying cause of CH
remains unclear; however, it is worth mentioning
Table 2. ASSESSMENT BY 2 SURGEONS OF THE
MANDIBULAR DEFORMATION IN PATIENTS WITH
THE TRANSVERSE, VERTICAL, AND COMBINED TYPES
OF ACTIVE CH (N ⴝ 52)
Asymmetry
Transverse Vertical Combined
Shape of condylar head
Deformed 5 (18%) 7 (39%) 2 (33%)
Normal 23 (82%) 11 (61%) 4 (67%)
Size of condylar head
Large 13 (46%) 14 (78%) 3 (50%)
Normal 15 (54%) 4 (22%) 3 (50%)
Neck
Long 19 (68%) 13 (72%) 4 (67%)
Large 2 (7%) 4 (22%) 0
Normal 7 (25%) 1 (6%) 2 (33%)
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia.
J Oral Maxillofac Surg 2008.
316 CLINICAL CHARACTERISTICS OF CONDYLAR HYPERPLASIA

that 3 of our patients had ankylosis, due to trauma,
associated with the disease.
Attention to the patient’s primary complaint is im-
portant for the early diagnosis of CH, because the
patient’s awareness of the exact nature of such a
slowly growing pathology may be low. Almost one
third of the patients complained not about asymme-
try, but rather about swelling on the contralateral
side, pain, and dysfunction; therefore, attention must
be paid to facial symmetry even when it is not among
the patient’s complaints. Pain, dysfunction, and click-
ing were common findings, indicating that the disease
may be associated with various degrees of pain and/or
dysfunction, as as been reported by others.6,18 This
persistent pain is most likely caused by changes in the
length, form, and size of the condyle and occasionally
unstable occlusion.
The classification of asymmetry in CH suggested by
Obwegeser and Makek5 was challenged by 3-dimen-
sional reconstructions from computed tomography
data showing that the mandibular morphology varied
from one case to another uncorrected with the clas-
sification.27 We have classified the asymmetries by 3
types according to the clinical criteria as vertical (akin
to hemimandibular hyperplasia), transverse (compa-
rable to hemimandibular elongation), or combined,
and found that about 52% of the patients had sole-
ly the transverse form of asymmetry, 31% had only
the vertical type, and the rest had the combined type.
The occlusal line, an indicator of the asymmetry in the
vertical direction or combined, was inclined in 48% of
the patients.
The 3 types of asymmetry demonstrate typical clin-
ical signs and symptoms, whereas the radiologic ap-
pearance varies and fails to follow the classification
system of Obwegeser and Makek.5 In our group of
patients, condylar deformity was present in all types
of asymmetry, with no correlation with the vertical
type of hyperplasia as proposed by Obwegeser and
Makek.5 Normal-shaped condyles also were observed
among all types of asymmetry and in most of the
patients with vertical asymmetry (Table 2) and not as
suggested. Enlarged condyles were found in almost
one half of the patients with transverse or combined
asymmetry and in approximately one quarter of the
patients with vertical asymmetry. This random radio-
logic appearance is demonstrated by the description
of 2 patients in Figures 3 and 4.

FIGURE 3. A, Facial asymmetry in the vertical aspect in an 11-year-old girl with a marked inclined occlusal line. B, Marked open bite in the affected
side with deviation of the midline contralaterally. C, In the panoramic view, the left condyle is slim and long.
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia. J Oral Maxillofac Surg 2008.
NITZAN ET AL
FIGURE 4. A, Facial asymmetry in the vertical aspect in a 56-year-old man. B, Marked deviation of the mandibular midline to the contralateral side,
with no inclination of an occlusal line or an ipsilateral open bite. C, In the panoramic view, the right condyle is large and deformed.
Nitzan et al. Clinical Characteristics of Condylar Hyperplasia. J Oral Maxillofac Surg 2008.
In conclusion, our findings indicate that CH may
occur at any age, it does not stop at the end of the
growth period, it is more prevalent in females, and its
laterality is gender-dependent. Clinicians should be
aware that the primary complaint is facial asymmetry
in only some patients, and that signs and symptoms of
TMJ disease can be present. Purely transverse asym-
metry, vertical asymmetry, and a combined type of
asymmetry were seen in 32, 19, and 10 patients,
respectively. The shape and size of the condyle varied
among the types of asymmetry, not correlated with
CH as had been suggested previously. Therefore, clas-
sification of CH should be based on the clinical signs
and symptoms, namely the direction of asymmetry:
transverse, vertical, or combined (Table 2).
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