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Available online at www.sciencedirect.com

Review ScienceDirect
Condylar hyperplasia: current thinking
British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx

J.A. Higginsona,∗, A.C. Bartramb, R.J. Banksb, D.J.W. Keithb

a Institute ofHead and Neck Studies and Education, University ofBirmingham, B15 2TT
b Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP

Abstract

Unilateral condylar hyperplasia is a rare disease that causes facial asymmetry as a result of excessive vertical or horizontal growth, or both,
of the mandibular condyle. Investigation should address the patient’s concerns, and establish whether the disease is active with the use of
single positron emission tomography (PET). Proportional reduction of the condyle arrests active disease and restores mandibular height,
and any residual asymmetry can be corrected according to conventional orthognathic principles. We recommend the use of 3-dimensional
virtual planning for such complex movements. The rarity of the disease means that, to our knowledge, high-quality evidence is lacking and
further research is needed.
© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Condylar Hyperplasia; Condylar Reduction; Orthognathic Surgery; Facial Asymmetry; Review

Introduction asymmetry.3,4 Most patients are female, but it is not clear

Unilateral condylar hyperplasia is a rare condition that leads
to considerable facial asymmetry. The biology is poorly
understood, medical options are limited, and treatment is
therefore surgical.
The condition initially presents as asymmetry of the lower
third of the face, but is not found in all patients who present
with this problem. Perceived facial asymmetry is common,
and is cited in over 35% of patients who present for orthog-
nathic evaluation.1 Deviation of the chin of 5 mm or less is not
discernible by clinicians or patients, but larger amounts have
exponential effects on perceptions of “acceptability” and the
need for surgical correction.2
Epidemiological data are scarce. As most patients present
in adolescence or young adulthood, other differential
diagnoses should be considered (particularly condylar osteo-
chondroma) when older patients present with mandibular
∗ Corresponding author.
E-mail addresses: james.higginson@cantab.net (J.A. Higginson),
andrew bartram8@hotmail.com (A.C. Bartram), rjbanks@mac.com
(R.J. Banks), d.keith541@btinternet.com (D.J.W. Keith).
https://doi.org/10.1016/j.bjoms.2018.07.017
0266-4356/© 2018 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
whether this is a true predilection, or whether women are
more likely to seek referral. An association that was postu-
lated between the sex of the patient and the side affected 5
has been disproved by meta-analysis.6
Clinical features
Unilateral condylar hyperplasia is characterised by ipsilat-eral
fullness of the lower third of the face with contralateral
flatness and deviation of the chin away from the affected side.
The precise changes in facial appearance and occlu-sion,
however, vary because abnormal growth can be vertical or
horizontal. Obwegeser and Makek reported that in many
cases, one of these vectors predominates, and they proposed
three subtypes, one for each vector and one combined form. 7
These have acquired many different names (Table 1),5,7,8 but
we recommend simple terminology that reflects the clinical
findings: vertical, horizontal, or combined.5
In vertical cases, there is down-growth of the ipsilateral
mandibular condyle with minimal deviation of the chin or

Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg (2017),
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Table 1
Summary of some of the different nomenclature used to classify clinical patterns of condylar hyperplasia. Wolford includes all subtypes as one
classification.8 We favour the simplicity and clinical focus of that by Nitzan et al.5
First author and reference Excess vertical growth Excess horizontal growth Excess growth in both vectors
Nitzan5 Vertical condylar hyperplasia Horizontal condylar hyperplasia Combined condylar hyperplasia
Obwegeser7 Hemimandibular hyperplasia Hemimandibular elongation Hybrid hemimandibular hyperplasia
Obwegeser7 Type I Type II Type III
Wolford8 Type 1b Type 1b Type 1b

occlusal midline, and substantial sloping of the ipsilateral Table 2

mandibular occlusal plane. The entire hemimandible looks Differential diagnoses of facial asymmetry.1,9,17–19
enlarged in three dimensions, from ipsilateral condyle to sym- Causes of facial asymmetry and differential diagnoses
physis. Initially, it causes an ipsilateral open bite, but gradual Abnormal positioning:
compensatory growth of the maxillary and mandibular den- Torticollis
Condylar dislocation
toalveolar complexes results in an occlusal cant. Ipsilaterally,
Dental interference
the mandibular body is bowed and the angle rounded; con- Mandibular posturing
tralaterally it looks flattened. The inferior alveolar bundle Macroglossia
remains in its position close to the lower border of the Contralateral ankylosis of the TMJ:
mandible because of overgrowth of the dentoalveolar seg- Delivery trauma
ment. The whole face appears rotated.5,7,9 Condylar fracture
Juvenile condylar arthritis
The horizontal form presents with deviation of the chin Childhood TMJ radiotherapy
and mandibular occlusal midline to the contralateral side, Abnormal facial development:
with a contralateral crossbite. The ipsilateral mandibular Unilateral coronal craniosynostosis
molars usually tip to maintain occlusion. 5,7 The combined Deformational plagiocephaly
Hemifacial microsomia (contralateral)
form presents with excess growth in both planes and
Mandibular hypoplasia (contralateral)
clinical features of the vertical and horizontal types. Parry-Romberg syndrome
The horizontal form seems to be more common than the Ipsilateral tumour:
vertical form, but estimates of relative incidence vary Osteochondroma
widely.4,5,10 In all cases, the increased functional load may Chondroma
Fibro-osteoma
cause contralateral temporomandibular dysfunction with
Giant cell tumour
associated pain and clicking.5 Fibrosarcoma
Neurofibromatosis
Fibrous dysplasia
Myxoma
Fibrosarcoma
Ameloblastoma
Aetiology Metastatic disease
Proteus syndrome
Unilateral condylar hyperplasia constitutes organised growth
that is both accelerated and prolonged in the area affected
(growth can continue until the patient’s mid-twenties), 11 but
the underlying biology is poorly understood. Traumatic,
genetic, hormonal, and mechanical causes have been pro-
posed, but conclusive evidence is lacking. Investigation
The histological appearances of the condition are char-
acteristic, with an undifferentiated mesenchymal layer, a History
hyperplastic cartilage layer, and pathognomonic cartilage
“islands” in the proximal bony trabeculae.12,13 These layers Clinical evaluation is crucial for diagnosis and the planning
vary in thickness, but the importance of this is uncertain.14 of treatment. The patient’s main complaint is paramount, and
Insulin-like growth factor 1 (IGF-1) has been implicated their concerns and expectations should be central to the plan.
in the development of condylar hyperplasia. High concen- Aesthetic and functional problems should be recorded.
trations are found in the proliferating zone of hyperplastic Progressive asymmetry of the lower face that presents dur-
condyles,15 and chondrocytes cultured from such condyles ing the pubertal growth spurt supports a diagnosis of condylar
express more than their normal counterparts. The addition hyperplasia. Asymmetry that has been present since birth
of IGF-1 to normal cultured chondrocytes increases their probably suggests another disease, and photographs may help.
proliferation.16 This, however, is inconclusive, and the A full medical and social history should be taken, as with any
factors underlying the process remain unclear. surgical patient.

Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
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Fig. 1. Clinical photographs and 3-dimensional virtual reconstructions of patient with left-sided condylar hyperplasia before treatment (left) and one year
after condylar reduction of 8 mm (right).

Examination guide or wooden tongue depressor with the interpupillary

Facial asymmetry may be the result of skeletal, dental, soft
tissue, or postural factors. Systematic examination aims to
identify the contribution of each one to the overall pre-
sentation, identify the underlying disease, and inform the
subsequent treatment plan. Conditions that distort the struc-
ture or position of the temporomandibular joint (TMJ) can
lead to abnormal mandibular growth or positioning that
should be distinguished from unilateral condylar hyperplasia
(Table 2).1,9,17–19
Examine the patient with the Frankfort plane parallel to the
floor. Record the relation of the point of the chin, mandibular
dental midline, and maxillary dental midline to the facial mid-
line and to each other. Inspect the lower mandibular borders for
bowing and check the occlusion for dental interferences during
closure (asymmetrical posturing of a normal mandible can be
the result of functional deflection). Inferior bowing of the
mandibular occlusal plane may be associated with an open bite
or an occlusal cant because of dentoalveolar compensa-tion,
which can be identified by comparing a Fox’s plane
plane.
After inspection, palpate the faceto differentiate between
bony and soft-tissue asymmetry, and palpate the TMJ at
both sides in function to identify clicks or crepitus. Support
the examination with clinical photographs and articulated
dental models to identify changes over time. More details
about the evaluation of facial asymmetry have been
discussed elsewhere.20
Differential diagnosis
A comprehensive list of the differential diagnoses is shown in
Table 2.1,9,17–19 Most can be distinguished by meticu-lous
investigation, but osteochondroma, a benign neoplasm of the
condyle that is easily mistaken for unilateral condylar
hyperplasia, presents a more difficult diagnostic challenge. It
presents after the pubertal growth spurt has been completed
(later than unilateral condylar hyperplasia) but the changing
occlusion, progressive asymmetry, and ipsilateral open bite,
are similar.17 While many authors consider osteochondroma

Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
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Fig. 2. Close-up virtual reconstruction of the left temporomandibularjoint
of the patient in Fig. 1, showing the appearance preoperatively (left) and
one year after condylar reduction of 8 mm (right).
as a separate clinicopathological entity, others include it as
a subtype of unilateral condylar hyperplasia along with
other benign and malignant tumours of the condyle.8
Radiological investigation
Plain radiography and panoramic tomography are impor-tant,
but decisions about management require more detailed
anatomical and functional imaging. Incorrect positioning can
lead to geometric discrepancies on plain imaging, and
intraobserver agreement about condylar asymmetry on
panoramic imaging is poor.21 Lateral cephalometry is of lim-
ited value, as bilateral structures are superimposed.
Computed tomography (CT) provides detailed anatomi-cal
information and can be reformatted into 3-dimensional
images for use in surgical planning. It can also distin-guish
between the smooth condylar enlargement of unilateral
condylar hyperplasia, and the bony growth arising from a
normal condyle that characterises osteochondroma.22,23 It is
the standard method of anatomical imaging, but may be
replaced by cone-beam CT as this becomes more widely
available. Cone-beam CT gives comparable resolution, sen-
sitivity, and specificity to conventional CT with lower doses
of radiation,23,24 and can be used for 3-dimensional virtual
planning.25–27 Magnetic resonance imaging (MRI) provides
detailed images with no ionising radiation, but is costly, and
visualises hard tissue less well than CT. It should be used
Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
Fig. 3. Occlusal views of the patient shown in Figs. 1 and 2, showing the
occlusion preoperatively (left), six months after condylar reduction of 8 mm
(centre), and one year after condylar reduction (right).
when clinical and CT findings suggest other diseases of the
TMJ.
Treatment depends on whether or not growth has stopped.
CT and cone-beam CT cannot evaluate this, and should be
supplemented by functional imaging techniques, usually single
positron emission computed tomography (SPECT). In SPECT
examinations, a compound that has been labelled with
radioactive technetium (99mTc) and has an affinity for
osteoblastic activity, is injected intravenously, and the
resulting radiation detected by a rotating gamma camera that
allows 3-dimensional views of areas of increased bony
turnover. SPECT was initially an adjunct to simple planar
scintigraphy,28 butis now used alone29,30 because of its superior
sensitivity and equivalent specificity.31
The correlation between the uptake of 99mTc and the his-
tological evidence of disease is inconsistent,10,11,32,33 but
clinical evidence has established (with a sensitivity of 88% -
100%) that a difference of 10% in bilateral condylar uptake
is diagnostic of active hyperplasia.29,34 SPECT how-ever,
cannot distinguish between condylar hyperplasia and
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Fig. 4. Three-dimensional virtual reconstructions of the patient shown in Figs. 1–3. Preoperative planning to correct the maxillary cant: initial position (top
row) and planned final position (second row, right). Also, planning for mandibular surgery alone (after left condylectomy one year earlier) with genioplasty
and reduction of the lower border, calculated as 2.8 mm by mirroring the right side (bottom row).

inflammatory, infective, neoplastic, or healing processes, 23 proceed with condylar surgery with or without delayed
so the results should be correlated with clinical findings orthognathic surgery.
and anatomical imaging.

Treatment
Treatment aims to restore normal function and a balanced
facial profile. To do this, it is necessary to establish whether
or not the disease is active and to use the appropriate oper-
ative technique. The contribution of an expert orthodontist is
crucial, and a multidisciplinary approach is necessary to
provide patients with the best care.
Active disease
If SPECT shows that the disease is active, there are three
options: defer surgery until it stops; proceed with orthog-
nathic surgery immediately or after condylar reduction; or
Deferred surgery
Waiting until growth has “burnt out” allows for stable results
after a single orthognathic procedure. Hyperplastic growth
can, however, continue well into the mid-twenties, so a patient
who presents in their mid-teens has to face a decade of wors-
ening facial asymmetry and occlusal function during a period
of great social and psychological importance, and for many,
this is unacceptable. Compensatory changes in the occlu-sion
and the maxilla can then make the final orthognathic
procedure more complicated.
It may be acceptable to defer surgery when patients report
no clinical change for over a year, when SPECT findings are
equivocal, or when minimal asymmetry can be corrected with
bimaxillary osteotomy or mandibular osteotomy alone. If
there is no further change after a year of observation,
orthodontics can begin, giving a total observation period of
two to three years before orthognathic surgery. When there is

Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
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Fig. 5. Flowchart for evaluation and treatment of patients with unilateral condylar hyperplasia (CT: computed tomography; CBCT: cone-beam CT; SPECT:
single positron emission CT).
no clinical evidence of continued growth, we do not
routinely repeat SPECT before the operation.
Orthognathic surgery: immediately or after condylar
reduction
In active cases, orthognathic surgery alone is not biolog-ically
sound because the final position will not be stable.
Anticipatory over-correction is unreliable as the magnitude of
subsequent growth cannot be predicted with certainty. In one
key study, further corrective surgery was needed in all
patients who had orthognathic surgery alone, whereas those
who had orthognathic surgery with simultaneous condylec-
tomy to remove the abnormal centre of growth, had a relapse
rate of only 4%, which clearly established the importance of
condylar surgery.4
Condylar surgery with or without orthognathic surgery
Condylar surgery is a biologically-driven approach that
aims to arrest progression by removing the affected tissue.
Its use is supported by a systematic review that showed that
the removal of 3 mm of condylar tissue was enough to
prevent relapse.8
Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
The term “condylar surgery”, however, can refer to several
procedures such as condylar shave, high condylectomy, low
condylectomy, condylar reduction, or complete condylec-
tomy. This is misleading and complicated, so we suggest that
“condylectomy” is used to describe the removal of the entire
condyle down to the mandibular notch, and “condylar reduc-
tion” should specify the amount of tissue removed (in mm) in
less radical techniques.
Condylar reduction that is proportional to the clinical dis-
crepancy simultaneously removes the pathological focus and
corrects the mandibular height. The rationale is to inter-vene
early with a single procedure that often prevents the need for
conventional orthognathic treatment. We favour this approach
in all patients with active disease or severe asymme-try (more
than 5 mm). We then observe them for 12 months to assess
for relapse and the need for further correction. In practice,
some are happy with the results and do not request or require
another operation, which was the case with the patient shown
in Figs. 1–4.
It is important to warn patients that condylar reduction
results in occlusal change with premature contact on the
ipsilateral side. This can resolve over the period of a year,
but further options such as orthodontics, correction of the
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maxillary cant, or recontouring of the mandibular asymme-try
can be explored with the help of 3-dimensional virtual
planning (Fig. 4). Concern that proportional condylar reduc-
tion could impair long-term function of the TMJ has led some
authors to suggest that this approach is inappropriate. 4 Func-
tion, however, can be satisfactory after condylectomy,35,36 and
proportional condylar reduction has the advantage of
considerably reducing the need for subsequent orthognathic
correction.37
Inactive disease
Once the hyperplasia is no longer active (because of condylar
surgery or the self-limiting course of the disease), residual
asymmetry can be corrected according to conventional
orthognathic principles. The aim is to restore a balanced and
symmetrical facial profile with normal temporomandibular
function.
Mandibular osteotomy can result in a good outcome when
there has been minimal compensatory growth of the maxil-
lary dentoalveolar complex. Unilateral ramus osteotomy has
been described for small rotational movements but is not rou-
tinely done as it places substantial torque on the contralateral
TMJ.38
Le Fort I osteotomy with differential impaction is
indicated in cases of maxillary compensation. We use 3-
dimensional surgical planning software in collaboration with
a commercial provider because of the complex movements
and unusual starting position. In the case already shown, the
maxillary cant was of little concern to the patient (Fig. 4).
Bowing of the mandibular body in patients with vertical,
unilateral condylar hyperplasia can leave an asymmetrical
jawline (even after repositioning of the occlusion) that may
need to be reshaped. We think that this is best done using 3-
dimensional virtual planning to fabricate a cutting guide for
the lower border, as it will produce a symmetrical result
without compromising the dental roots or the inferior alveolar
nerve (Fig. 4). We recommend that 12 months is allowed
between condylectomy and orthognathic surgery to assess for
relapse, and to ensure a stable, predictable outcome. Our
treatment guidelines are summarised in Fig. 5.
In conclusion, treatment relies on careful assessment,
including the patient’s concerns, and confirmation of the pres-
ence of active growth with SPECT. Active disease should be
treated by condylar reduction followed by monitoring. Inac-
tive disease or residual asymmetry can be corrected according
to conventional orthognathic principles. The rarity of the con-
dition means that there is little level I evidence, and further
research is needed.
Conflict of interest
We have no conflicts of interest.
Please cite this article in press as: Higginson JA, et al. Condylar hyperplasia: current thinking. Br J Oral Maxillofac Surg
(2017), https://doi.org/10.1016/j.bjoms.2018.07.017
7
Ethics statement/confirmation of patient’s permission
Ethics approval not required. The patient’s written consent
for publication has been obtained and is available on request.
Acknowledgements
We thank Mr Andrew Sidebottom for his comments that
greatly improved the manuscript, and staff from Materialise
NV with whom we work closely to virtually plan our orthog-
nathic cases, and who provided the three-dimensional virtual
operative plans.
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