u«. J.

Oral Surg, 1981: 10: 154-160

(Key words: con.dyle; hyperplasia, condylar: surgery; oral: delormitv, jaciall

Condylar hyperplasia
A case for early treatment

L.M.JONCK

Faculty of Dentistry, University of Pretoria, South Africa

ABSTRACT - Clinical experience indicates that the condylar growth

centre is an important factor in the dimensional changes of the face
up to the 10th year. Thereafter muscu lar and functional occlusion
determine the ultimate facial form. Condylar hyperplasia should be
recognised at a very early age. To achieve an acceptable result early
treatment of facial asymmetry related to condylar hyperplasia should
be considered in the most active growth phase of the mandible (6-8
years).

(Received for publication 13 May, accepted 26 September 1980)

Condylar hyperplasia with its resulting fa-
cial asymmetry can be most distressing for
the young child and parents. Often these
children are the target of mockery and pity
at school.
At a very early age, parents will seek
treatment and the oral surgeons are often
confronted with this problem. A certain
amount of doubt exists as to when is the
most opportune moment for surgical inter-
vention.
Facial growth is dependent on an active
centre related to the cartilaginous turnover
in the condyle. This could be correlated to
a similar process within the epiphysis of
long bones. The traditional concept of
mandibular growth views the condyle there-
fore as a primary growth centres. 3, 25, 27. The
alternative view is that the growth and
maintenance of the Skeleton depends al-
mos t exclusively upon functions , 20 - 22 , 29. In
other words, extrinsic factors regulate the
growth of the condyle. Moss & RANKOW 28
de-emphasize the role of the condylar car-
tilage in total mandibular growth, limiting
the influence of the cartilage to the con-
dylar process alone. This controversy has
led to a number af studies.
Post natal condylectomies performed on
rats and monkeys by a number of investi-
gatorss- 6,10 -12, 14,15 to determine whether or
not the condyle is a primary growth centre
were contradictory. The experimental mod-
el is a suspicious one.
Since the chondroblasts of the condylar
cartilage do not divide!,2 8, the only potential
source of cells able to maintain growth of
the mandible in this area is the cellular
layer of the covering perichondrium. There
is strong evidence that the articular and
proliferative zones of the condyle are de-
rived from the periosteum and that the chon-

0300·9785/Sl{030154-07$02.50/0 © 1981 Munksgaard, Copenhagen

 CONDYLAR HYPERPLASIA 155

drogenesis of the articular surface is a con- as well as the orthodontic contribution to

sequence of the altered functional require-
ments of the periosteum covering this par-
ticular part of the condyle.
Relevant experiments which support this
hypothesis are those of HAMS and Mtrn-
RAy24. HALO points out that the common
initiating factors in evoking either osteo-
genesis or chondrogenesis are the degree of
vascularity of the tissue and the presence
or absence of mechanical stress. HALL sug-
gests that mechanical stress may act by
producing ischaemia, thereby inducing os-
teogenic cells to chondrogenesis. Condylar
hyperplasia is self-limiting and usually
ceases with skeletal growth (RUSIITON2G,
WORTH30).
It is undeniably true that much of the
surgical therapy of dental facial anomalies
the overall treatment of oro-facial malfor-
mations is based upon an appreciation of
the growth process of this region.
The present paper attempts to utilize a
clinical case report of a therapeutic tech-
nique as a dramatic means of indicating
the relative importance of condylar growth
as a factor in facial asymmetry.
Treatment
The facial deformity in the young patient
can be divided into two clinical entitiesw.
In the first group, the vertical growth is ac-
centuated with a marked lengthening of the
condylar neck, the vertical dimension of
the ramus and a simultaneous enlargement
of the corpus. In the early stages the result-

A B

c 0
Fig.1. Tracings of Panorex roentgenograms. A, Active growth phase with condylar hyperplasia
and bowing effect of left half of mandible. No deviation of chin; increase in vertical dimensions
and a resulting open bite on the side of growth disturbance (cf. Fig. 2A). B, Growth completed
with a resulting hemi-facial hypertrophy; increased vertical depth of maxilla to accommodate to
lower jaw form (cf. Fig. 2D). C, Type II growth disturbance limited to mandibular half; chin
swinging over to opposite side; crossbite; ramus and condylewithin normal limits. D, Post growth
condylar hyperplasia limited to the condyle resulting in an open bite on the affected side.
156
ing affect is an open bite in the molar-
premolar area with a bowing effect of the
lower border of the mandible on the af-
fected side. There is no deviation of the
chin, which is confirmed by the central
relationship of the central teeth (Fig. IA).
In the second group, the deviation of the
chin was the most outstanding feature. The
occlusion was disrupted and a crossbite was
evident (Fig. lC). The growth disturbance
appears to be more evenly distributed over
the whole of the affected mandibular half.
The most difficult decision is when to do
the corrective surgery aimed at the retard-
ing of growth at the condylar centre.
By postponing treatment until facial
growth is complete the problem becomes
more complex in the sense that it is not
only a case of a disturbing facial asymme-
try, but the permanent teeth, being fully
erupted, can further complicate the treat-
ment (Fig. IB).
Once the permanent teeth are in occlu-
sion on the affected side, the opportunity
for a relatively simple operative procedure
has slipped by. Several operative procedures
and sometimes extensive orthodontic treat-
ment may then be necessary to achieve a
good result. The best time to consider
surgery is in the active growth phase when
the general facial dimensions are actively
approaching that of the adult. A correla-
tion exists between skeletal maturation and
tooth eruption. LEE et al. 16 found signifi-
cant correlations between skeletal matura-
tion and eruption of the permanent teeth
in most age groups 6-14 years.
As far as the growth and length of the
dental arches are concerned the most ac-
tive growth period is during the time of
eruption of the permanent dentition. After
14 years there is little changet? -10. The final
period of growth is from the 10th year to
adult dimensions. By the 10th year the skull
has almost reached adult dimensionsst.
Notwithstanding the vast literature on the
JONCK
subject of facial growth and development,
no set rule exists whereby one can decide
when and when not to operate. The surgeon
has an interest in the normal growth pat-
tern, but it is the abnormal situation he is
confronted with. The ideal situation is to
see these patients when they are still very
young, 3-4 years of age. Mostly they pre-
sent with a slight deviation of the chin and
a crossbite with the jaw swinging to the
normal side. These patients should be fol-
lowed up at regular 6 monthly intervals.
The time to decide whether to operate or
not becomes critical with the eruption of
the central incisors and the first molars:
This is the stage when the dimensional
changes are most marked due to active
growth of the tooth bearing areas.
CASE REPORTS
In the case presented here, the operation was
performed with the first molar fully erupted
and at a stage where the jaw was in a very ac-
tive growth spurt. The patient was 7 years old.
A condylectomy operation was performed.
The condyle and proximal half of the neck was
removed. Care was exercised not to enter the
upper compartment of the joint. The attach-
ments of the external pterygoid muscle to the
capsule and neck of the mandible were identi-
fied and the attachment was carefully stripped
out of the condylar fossa. The attachment to
the capsule was left intact. This procedure en-
hances the reattachment of the external ptery-
goid initially by means of scar tissue to the
neck and new condylar process which is the
remodelled upper end of the neck of the
mandible. Where the bowing effect of the
lower border is marked or where an open bite
exists, an osteotomy operation is indicated in
the canine/premolar area. The affected segment
can then be moved bodily in an upward direc-
tion (Fig. 2).
Microscopically no abnormality could be
demonstrated in the condylar process. The
surface was covered with normal fibrous
cartilage. The deeper layer demonstrated active
cartilagenous growth and cartilagenous cells
could be traced deep down in the trabecular
bone. The general appearance was that of ac-
tive endochondral bone proliferation (Fig. 3).
 CONDYLAR HYPERPLASIA 157

A B

c o
Fig. 2. Panorex roentgenograms to demonstrate the results of correc tion of condylar hyperplasia
at an early age. A, Seven-year-old girl with marked left condylar hyperplasia; bowing effect of
left mandibular arch; open bite in active growth period. B, Post-operative panorex to demon-
strate the immediate results; Condylectomy and osteotomy of the mandibular body were performed
to correct the bowing effect of mandible. C, Follow-up Panorex, 6 years after operative treat-
ment demonstrating good jaw relations with scarcely noticeable facial assymetry. Redevelop-
ment of condylar process with normal range of movement. D, A roentgenogram of an untreated
case of condylar hyperplasia resulting in hemi-facial hypertrophy. Note the increased vertical
depth of the left half of the face.

Fig. 4 shows the girl at the time of opera-
tion and 6 years later.
Discussion
Facial asymmetry and the malocclusion re-
sulting from unilateral condylar hyperplasia
presents interesting growth characteristics
which challenge both diagnostic as well as
surgical skills. Most oral surgeons have had
experience with young individuals with con-
dylar fractures. A Greenstick fracture of
the condyle even in the very young, al-
though sometimes badly displaced, causes
no asymmetry of the face, whereas with a
complete break and displacement of the
condyle, or with destruction of the condyle
because of infection, the underdevelopment
of the mandibular half of the affected side
could be most disturbing with marked de-
formity in the young patient.
From the clinico-diagnostic point of view,
it is important for the oral surgeon to de-
velop a sound clinical judgement as to when
to intervene in cases of condylar hyperplasia
in young patients.
The facial deformity becomes most
marked in the active growth period of the
jaws which coincides with the eruption of
incisors and first molars. It is therefore im-
perative that the oral surgeon sees these
patients at regular intervals, preferably in
conjunction with an orthodontist who also
has a prime interest in dento-facial devel-
opment and growth. In the study of 40
children between the ages of 4-12 years,
four periods of change in growth velocity
were noted by HARRISo.
(a) Rapid deceleration of growth during
the early years of life.
158 JONCK

. .... ';
-,

.:...
.' , . ,.
I·

··T..f
, f • . . ' ~' Jl . .\. ,
Fig. 3. Active endochondral bone proliferation.

(b) Gradual acceleration of growth in early

childhood.
(c) A pre-adolescent period of deceleration
of growth.
(d) Beginning of an adolescent spurt.

The 3rd year to about the LOth year is the

critical growth period. By the 10th year the
skull has almost reached adult dimen-
sionsst.
In the skull as in other parts of the ske-
leton, there are two major determinants of
skeletal variabilities, a genetic and an en- Fig. 4. A, Clinical photograph of young patient
vironmental one. If we regard, for the sake 7 years old, demonstrating facial asymmetry of
the left side of the face. B, Follow-up photo-
of argument, the disturbance in the growth
graph of the same patient 6 years later.
pattern as a genetic anomaly and the fac-
tors such as the musculature and functional
occlusion as being responsible for the en- that these two processes are inter-related
vironmental variability, it becomes clear ancl inter-dependent. Together they are re-
 CONDYLAR HYPERPLAS IA
sp onsible for fa cial h armony. D isturbances
of the on e m u st sur e ly influence the other.
F rom a clinical p oint of view we cannot
hu t stress th e importance of the condylar
process as an important growth centre in
the 3rd to the 10th year. By the 10th year,
under the influence of environmental fac -
tors, the musculature and the functional
occlusion with its alveolar bone deve lop-
ment lead to a complex sequence of re-
modelling changes embodied in selective
periosteal additions and selective resorbt ion.
The final change in t he oro-facial com p lex
from childhood to the adult depends almost
exclusively upon function as determi ned by
environmental factors.
A ckno wledgements - Th is investigation was
support ed by a grant from the Medical Re-
searc h Council.
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Address :
Department of Oral Pathology
Oral and Dental Hospital
University of Pretoria
Pretoria 0002
South Africa