Int. J. Oral Maxillofac. Surg.

2016; 45: 1607–1613

http://dx.doi.org/10.1016/j.ijom.2016.07.002, available online at http://www.sciencedirect.com

Clinical Paper
Clinical Pathology

Evaluation of three analysis H. Rushinek1, R. Tabib1, Y.Fleissig1,

M. Klein2, S. Tshori2
1
Department of Oral and Maxillofacial
99m
methods for Tc MDP SPECT Surgery, Hadassah Medical Center, Kiryat
Hadassah, Jerusalem, Israel; 2Department of
Nuclear Medicine, Hadassah Medical Center,
Kiryat Hadassah, Jerusalem, Israel

scintigraphy in the diagnosis of

unilateral condylar hyperplasia
H. Rushinek, R. Tabib, Y. Fleissig, M. Klein, S. Tshori: Evaluation of three analysis
methods for 99mTc MDP SPECT scintigraphy in the diagnosis of unilateral condylar
hyperplasia. Int. J. Oral Maxillofac. Surg. 2016; 45: 1607–1613. # 2016
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The aims of the study were to evaluate the diagnostic accuracy and utility of
the mean region of interest (ROI) and mean and maximum volume of interest (VOI)
analysis methods for 99mTc MDP SPECT scintigraphy in the diagnosis of active
unilateral condylar hyperplasia (UCH). Inactive UCH (n = 43) and active UCH
(n = 8) patients, and patients without condylar hyperplasia (controls, n = 41) were
analyzed. Inter-observer agreement was good for all methods. Condylar uptake was
not normally distributed, with a longer right tail in UCH patients compared to
control patients. Receiver operating characteristic curve analysis indicated that the
ROI method was slightly superior to both VOI methods for the diagnosis of active
UCH (area under the curve = 0.866, 0.811, and 0.817, and J = 0.642, 0.596, and
0.573, respectively). The ‘traditional’ 55% cut-off value proved optimal for ROI
and mean VOI methods, but a cut-off of 56.125% was optimal for maximum VOI.
Sensitivity was 88% for all three methods using these cut-off values, while
Key words: TMJ hyperplasia; MDP SPECT;
specificity was 77%, 65%, and 70% for mean ROI, mean VOI, and maximum VOI, condylar uptake.
respectively. These results indicate that corrective surgery for negative scan patients
can be performed without delay, with an error rate of only 3%, but not in positive Accepted for publication 7 July 2016
scan patients. Available online 28 July 2016

Condylar hyperplasia is a pathology of the
temporomandibular joint (TMJ) resulting
in a progressive unilateral non-neoplastic
growth, involving both the size and con-
figuration of the neck and the mandibular
condyle. Condylar hyperplasia is a unilat-
eral condition characterized by generalized
enlargement of the condyle, the condylar
neck, the ramus and body of the mandible,
leading to facial asymmetry and occlusal
alterations.1 Unilateral condylar hyperpla-
sia (UCH) usually presents as an excessive
growth of one condyle. It is the most
common postnatal growth abnormality of
the TMJ. Women tend to be predisposed to
UCH, with a female to male ratio of ap-
proximately 2:1. However, large heteroge-
neity between populations has been
observed.2 Although it has previously been
suggested that there is also a sex difference
in the laterality of UCH,3 this was not

0901-5027/01201607 + 07 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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1608 Rushinek et al.
substantiated in a recent meta-analysis.2
Left-sided UCH seems to be slightly more
prevalent than right-sided UCH, regardless
of sex.
The main complaint of UCH patients is
progressive facial asymmetry,3,4 but al-
most one-third of the patients complain
of swelling on the contralateral side, pain,
and dysfunction. Therefore, attention must
be paid to facial asymmetry even when it
is not among the patient complaints.5
The treatment of mandibular asymme-
try is primarily surgical, with or without
orthodontics, and consists of two types of
intervention depending on the condylar
activity. A high condylectomy of the af-
fected side is indicated to limit progressive
asymmetry during the active phase of
UCH. Secondary correction by mandibu-
lar or maxillary osteotomies or both
(orthognathic surgery) is appropriate to
correct any residual occlusal and facial
asymmetry. However, if orthognathic sur-
gery is performed while condylar activity
persists, then further asymmetry may de-
velop. Consequently, accurate assessment
of the cessation of excess activity in the
condyle is warranted. Conversely, condy-
lectomy in a ‘burnt-out’ condyle causes
undue and unnecessary disruption of the
TMJ and can affect occlusion.
Cisneros and Kaban were the first to use
bone scintigraphy to study patients with
mandibular asymmetry in 1984.6 Bone
scintigraphy offers an instant method of
comparing the differential activity be-
tween normal and abnormal condyles,
and this reflects the relative growth rates
at the time of the investigation.7 Studies
published in the literature, most of them
using planar imaging, have demonstrated
a 5% to 12% difference in bone activity
between normal and abnormal con-
dyles.7,8
However, there is no standard method
for diagnosing a patient with UCH by
skeletal scintigraphy. No uniform method
for quantification of bone activity was used
in any of the planar or single photon emis-
sion computed tomography (SPECT)-
based studies included in a recent review
and meta-analysis.9 Although many stud-
ies have been published since 1984, only
seven of these were found to be sufficiently
detailed and large enough to be included in
the recent meta-analysis, and SPECT was
used in only three of these publications.9
Only one prospective study using
SPECT scintigraphy on a normal popula-
tion has been published. Kajan et al. stud-
ied 38 patients, ranging in age from 13 to
34 years, who were undergoing skeletal
scintigraphy for a variety of conditions.10
They concluded that the variation in
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growth activity in normal right and left
mandibular condyles was less than 6.2%,
which is lower than the 10% difference
that is widely employed.
The lack of a standardized and detailed
method for skeletal scintigraphy in these
patients and the lack of two-by-two con-
tingency tables limit the ability to assess
the diagnostic accuracy of the test and to
use it effectively in UCH patients.9
The objectives of this study were
to describe and evaluate three different
quantification methods, to describe and
compare a population without condylar
hyperplasia to a population of inactive
UCH patients, and to evaluate the useful-
ness of SPECT scintigraphy in the man-
agement of UCH patients.
Methods
Normal population and TMJ patients
Fifty-one patients (24 male, 27 female)
with a mean age of 21.5 years (range 8–
66 years) suspected of having mandibular
condylar hyperplasia were referred for
bone scintigraphy during the years 2008
to 2011. These patients underwent a com-
bined total of 60 scans (seven patients had
two scans and one patient underwent three
scans). The clinical records of all of these
patients were assessed by a maxillofacial
surgeon.
Forty-one patients (23 male, 18 female)
with a mean age of 33.3 years (range 18–
73 years) who were referred to the nuclear
medicine department for bone scintigra-
phy for reasons unrelated to a TMJ pathol-
ogy agreed to participate in the study
(control population). All of these patients
provided signed informed consent and
completed a questionnaire designed to
ensure that the patient had no TMJ pathol-
ogy. Six of these patients were also exam-
ined by a maxillofacial surgeon according
to surgeon availability. No TMJ abnor-
mality was found in any of the patients.
This study was approved by the institu-
tional review board and all normal parti-
cipants signed an informed consent
agreement.
Clinical work-up
The patient evaluation included the ad-
ministration of a questionnaire to collect
demographic information and obtain a
comprehensive history, including primary
complaints, initial symptoms, duration of
symptoms, presence of joint noise, limita-
tion in mouth opening, and prior treat-
ment. Each patient self-assessed his or
her level of pain and the extent of dys-
function using a visual analogue scale
(VAS) and indicated the location of the
pain on a facial diagram.
Deviation was evaluated in the trans-
verse, vertical, or both planes. The evalu-
ation was based on clinical signs,
including occlusion, occlusal plane, and
deviation of the mandibular midline. The
clinical examination included the determi-
nation of maximum mouth opening, range
of lateral and protrusive mandibular
movements, characteristics of the limita-
tion in jaw movement, determination of
joint noise on palpation, and the evalua-
tion of pain on palpation of the head and
neck muscles and both TMJs. The severity
of the occlusal plane inclination was eval-
uated by the angle between the occlusal
plane and the inter-pupil line. Deviation of
the dental midline, cross-bite, and open-
bite were also recorded.
The radiological evaluation included
preoperative transpharyngeal and tran-
scranial radiographs of the TMJ in
closed-mouth and open-mouth positions,
along with panoramic and cephalometric
X-rays in anterior–posterior and lateral
views. The condylar head was classified
as normal, enlarged, deformed, or en-
larged and deformed, and the condylar
neck was classified as normal, elongated,
or enlarged.
TMJ SPECT imaging
Skull bone SPECT scans were obtained
using either an Infinia Hawkeye 4 (GE
Healthcare, Tirat Carmel, Israel) or Var-
icam Hawkeye (GE Healthcare, Tirat Car-
mel, Israel) dual-head gamma camera
equipped with a lower-energy general-
purpose parallel hole collimator using
740 MBq of technetium 99m methylene
diphosphonate (99mTc MDP) for adults.
One hundred and twenty projection
images were acquired over 360 degrees
during 20 s per projection as a 128  128
matrix. Transaxial, coronal, and sagittal
tomograms were reconstructed using a
Butterworth filter (power 10, critical fre-
quency 0.48) and ordered-subset expecta-
tion maximization (OSEM) iterative
reconstruction (two iterations, 10 subsets).
Interpretation of SPECT images
All images were assessed in a blinded
manner; the interpretation was performed
by two independent nuclear medicine phy-
sicians (ST and MK). The volume of
interest (VOI) of 1.8 cm3, including the
TMJ, was measured on a Xeleris 3 work-
station (GE Healthcare, Tirat Carmel,
Israel), and both the mean and maximum
values were recorded. A fixed size region
 Three SPECT analysis methods for UCH 1609

of interest (ROI) of 1.7 cm2 was drawn on

the summed transaxial slices that included
the right TMJ and the mean value was
recorded (only by ST). The ROI was
mirrored and placed on the left side to
assure a fixed size.

Statistical analysis
The statistical analysis was performed
using IBM SPSS Statistics version 21.0
software (IBM Corp., Armonk, NY,
USA). The control population and the
inactive UCH population were compared
using a one-tailed Mann–Whitney U-test.
For all other analyses, appropriate two-
tailed tests were used. Pearson’s correla-
tion coefficient (r) and Cohen’s kappa
test with a cut-off value of 55% condylar
uptake were used to assess inter-observer
agreement for each measurement meth-
od. The area under the curve (AUC) of
the receiver operating characteristic
(ROC) curve, Youden’s index (J),
Cohen’s kappa, and the odds ratio (OR)
were calculated to compare scintigraphy
results against active or inactive UCH. A
P-value of less than 0.05 was considered
statistically significant.

Results
Inter-observer agreement in VOI
calculation methods
The summed ROI method, at least for a
fixed ROI size, has been reported previ-
ously as having very good inter-observer
agreement.11 However, only one article
describing the use of VOIs could be iden-
tified in the literature, and the interpreta-
tion was performed by a single observer.12
Therefore, inter-observer agreement was
evaluated by assessing Pearson’s correla-
tion coefficient (r) for both the mean VOI
method (r(48) = 0.913, P < 0.001) and
maximum VOI method (r(48) = 0.948,
P < 0.001) in inactive UCH patients.
These results were highly significant;
however, Pearson’s correlation coefficient
(r) only indicates that there is a linear
relationship between observers.
In order to further assess inter-observer
differences, the difference between the
two observers for each method was also
plotted against the mean of the measure-
ments of the two observers (Bland–Alt-
man plots; Fig. 1). The difference values
were largely clustered around the zero line
for both methods. However, for a minority
of the patients, large differences were
noted, and the impact of such differences
on the decision regarding whether a
condyle was active or not cannot be
ascertained from Bland–Altman plots.
Fig. 1. Bland–Altman plot of the difference in percentage uptake in the active condyle between
the two observers against the mean percentage uptake of the two measurements using the mean
VOI (A) and maximum VOI (B) methods (VOI, volume of interest).
Therefore, Cohen’s kappa was calculated (control population). The lack of condylar
using the generally accepted cut-off value hyperplasia was verified using question-
of 55% for the active condyle. The kappa naires; some patients also underwent a
score was 0.662 for mean VOI and 0.877 physical examination depending on the
for maximum VOI (Table 1). availability of a maxillofacial surgeon.
These results, together with those The condylar uptake values did not
reported in the previous literature,11 indi- seem to follow a normal distribution
cate that there is very good inter-observer (Fig. 2). The distribution was skewed with
agreement for all three of the methods a long right tail, which was even longer in
used in this study. the inactive UCH population. Both
the median and the interquartile range
were increased in the inactive UCH pop-
Comparison of the normal condyle
ulation compared to the control popula-
population and the UCH populations
tion (Table 2).
Forty-one patients without condylar hy- The statistical analysis was performed for
perplasia referred to the department for all three methods using the non-parametric
unrelated indications were analyzed Mann–Whitney U-test (Table 2). In patients
Table 1. Inter-observer agreement for mean and maximum VOI methods (n = 48).
Method Pearson’s r P-value Cohen’s kappa P-value
Mean VOI 0.913 <0.001 0.662 <0.001
Max VOI 0.948 <0.001 0.877 <0.001
VOI, volume of interest.

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1610 Rushinek et al.

calculating Cohen’s kappa and the OR

using a cut-off value of 55% for all meth-
ods.
Optimal cut-off values were also calcu-
lated from the ROC curve. The 55% cut-
off value was optimal for both the mean
ROI method (OR 23.1) and the mean VOI
method (OR 13.1), but the optimal cut-off
value for the maximum VOI method was
56.125% (OR 16.2).
Sensitivity was 88% for all three meth-
ods using these optimal cut-off values,
while specificity was 77% for the mean
ROI method, 65% for the mean VOI
method, and 70% for the maximum VOI
method (Table 4).

The utility of SPECT uptake values in the

management of UCH patients
The maxillofacial surgeons in the facility
have adopted a modified version of the
algorithm suggested by Hodder et al.13
The main adaptation is a ‘wait and see’
step in the <55% uptake arm, in addition
to the ‘clinical follow-up’ step in the
>55% group that was suggested by Hod-
Fig. 2. Distribution of the percentage uptake in the active condyle in the population without der et al.
condylar hyperplasia (normal) (A) and in the inactive UCH population (B). The x-axis
demonstrates the percentage uptake, while the y-axis shows the frequency (UCH, unilateral
In the present research group, all
condylar hyperplasia). patients who underwent a high condylect-
omy were ‘true-positive’, as all patients
had a positive pathology. All patients who
Table 2. Condylar uptake in the normal condyle group (n = 41) and inactive UCH group underwent corrective surgery did not need
(n = 43).a a later surgery, either orthognathic or high
Method Normal Inactive UCH P-value condylectomy. The cost of this policy,
Mean ROI 51.1 (50.6–52.2) 52.2 (51.1–54.7) 0.003 however, is a prolonged ‘wait and see’
Mean VOI 52.0 (50.7–53.9) 53.0 (51.1–56.7) 0.041 period for all patients.
Max VOI 53.3 (51.5–54.6) 53.7 (50.9–57.2) 0.240 The results of this study show that if this
UCH, unilateral condylar hyperplasia; ROI, region of interest; VOI, volume of interest. ‘wait and see’ policy was skipped for all
a
Data are presented as the median (interquartile range); the one-tailed Mann–Whitney U-test negative scans, assuming that there is no
was used. growth, only one out of 34 patients (using
mean ROI) would have been erroneously
assigned to the ‘inactive UCH’ group
with inactive UCH, the percentage maxi- for all methods, as expected (P = 0.001, (Table 4).
mum activity of the abnormal condyle was 0.006, and 0.004 for the mean ROI, mean In contrast, approximately two-thirds of
significantly higher than the corresponding VOI, and maximum VOI methods, respec- the positive scans were from inactive UCH
condyle activity in the control group for tively). patients, and only one-third were from
both the mean ROI (P = 0.003) and active UCH patients (Table 4). Therefore,
the mean VOI (P = 0.041) methods, but interpreting a positive scan as ‘active
Comparison of the three methods in the
not for the maximum VOI method UCH’ would result in a high percentage
diagnosis of active UCH
(P = 0.240). This is in accordance with of incorrect assignment.
the results of AlSharif et al., who also found The sensitivity and specificity of the three
uptake in the inactive UCH population to be methods were calculated. The ROC curve
Discussion
significantly increased with almost all of the provides a useful tool to compare the dif-
methods utilized.12 ferent methods of analysis. The ROC Bone scintigraphy is used widely in the
It should be noted that if the traditional curves (Fig. 3) illustrated that all three evaluation of patients suspected for UCH,
55% cut-off value is used, the resulting methods can help in the diagnosis of active and the literature suggests that a >10%
false-positive rate for the mean ROI, mean vs. inactive UCH, although the mean ROI side difference can distinguish between
VOI, and maximum VOI methods is method (AUC = 0.866, J = 0.642) consis- normal and abnormal condylar activity.
23.3%, 34.9%, and 39.5%, respectively. tently provided slightly better results than However, this assumption raises several
The percentage activity of the active both the mean VOI (AUC = 0.811, issues. There is no uniform method for the
condyle was significantly higher in the J = 0.596) and maximum VOI (AUC = quantification of SPECT-based studies,
active UCH population (n = 8) than in 0.817, J = 0.573) methods (Table 3). and in many reported studies the methods
the inactive UCH population (n = 43) This interpretation is also supported by used are not sufficiently detailed. There is

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 Three SPECT analysis methods for UCH 1611

imaging, and only five studies have

reported SPECT results for a normal pop-
ulation. These five studies together includ-
ed only 107 patients.10,12,14–16 Moreover,
four of the studies described the normal
population without comparison to UCH
patients, and only one study directly com-
pared the left to right uptake ratio between
a normal population and a population of
UCH patients, and it included only 16
normal cases.12 The current study, which
included 41 patients without condylar hy-
perplasia and 43 inactive UCH patients, is
thus the largest study so far. The study
results, together with those of AlSharif
et al.,12 indicate that the normal popula-
tion is different from the inactive UCH
patient population, and that there might be
little added value to be gained from further
studies of the normal population. It should
also be noted that the normal population
and, to an even greater extent, the UCH
population are not normally distributed for
the percentage uptake in the condyle, but
Fig. 3. Receiver operating characteristic (ROC) curves of the different analysis methods. True are rather skewed with a long right tail.
positives are plotted against (1 specificity) for the different cut-off points of the three analysis Thus, it is recommended that future stud-
methods used (ROImean, mean region of interest; VOImean, mean volume of interest; VOImax, ies use non-parametric testing for the sta-
maximum volume of interest). tistical analyses.
Traditionally, as well as in many stud-
Table 3. Comparison of the mean ROI, mean VOI, and max VOI methods. ies, unilateral uptake of more than 55% is
Method AUC P-value Cohen’s kappa P-value OR P-value considered ‘active UCH’; however, some
studies have suggested the use of a lower
Mean ROI 0.860 0.001 0.441 0.001 23.1 0.005
Mean VOI 0.811 0.006 0.307 0.008 13.1 0.021 threshold8,10 and others the use of a higher
Max VOI 0.817 0.005 0.264 0.019 10.7 0.033 threshold.17 ROC curve analysis of the
present study results suggests the use of
ROI, region of interest; VOI, volume of interest; AUC, area under the curve; OR, odds ratio.
this 55% threshold for two of the three
methods employed, but the use of a higher
Table 4. Sensitivity and specificity of the three methods in the diagnosis of active UCH with threshold for the maximum VOI method.
optimal cut-off values (n = 51). The threshold may be dependent on the
Positive scan Negative scan Total method of analysis, and it is suggested that
Mean ROIa the method used should be described in
Active 7 1 8 sufficient detail, together with its specific
Not active 10 33 43 optimized threshold.
Total 17 34 51 Currently there is no ‘gold standard’ for
Mean VOIb the diagnosis of active UCH and this limits
Active 7 1 8 both the clinical work-up and studies.
Not active 15 28 43 Instead, a combination of clinical fol-
Total 22 29 51 low-up, bone scintigraphy, and sometimes
Max VOIc
histopathological analysis are used, and
Active 7 1 8
Not active 13 30 43 algorithms including 6–12-month fol-
Total 20 31 51 low-up periods have previously been sug-
gested.13 The rate of both unnecessary
UCH, unilateral condylar hyperplasia; ROI, region of interest; VOI, volume of interest.
a high condylectomy and repeated surgery
Mean ROI method: sensitivity 88%, specificity 77%, cut-off 55%.
b
Mean VOI method: sensitivity 88%, specificity 65%, cut-off 55%. due to incorrect assessment of activity can
c
Maximum VOI method: sensitivity 88%, specificity 70%, cut-off 56.125%. be reduced by extending the follow-up
period. Since, unlike Hodder et al.,13 the
follow-up policy that was adopted (‘wait
also great variability between studies, and to present detailed methods for measuring and see’) also included the apparently ‘no
inter-observer variability might also influ- TMJ activity with good inter-observer growth’ group (Fig. 4), no unnecessary
ence the performance of quantitative stud- agreement, detailed statistical analyses, high condylectomies or orthognathic sur-
ies.9 Furthermore, the statistical analyses and two-by-two contingency tables. geries were performed in any of the 51
in many studies are limited, and contin- Despite the growing number of articles UCH study patients, but at the price of
gency tables are lacking in almost all on bone scintigraphy in UCH, most studies delayed treatment. The present results
reported studies.9 The present study aimed have used planar imaging and not SPECT show that this ‘wait and see’ policy for

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1612 Rushinek et al.

and it should be noted that SPECT results

should not be interpreted alone, but only in
conjunction with the clinical data.

Funding
None to disclose.

Competing interests
None to disclose.

Ethical approval
Ethical approval was obtained from the
institutional Helsinki committee (0195-
09-HMO).

Patient consent
Patient consent was obtained, as required
by the institutional Helsinki committee.

Acknowledgements. This work is dedicated

to the memory of Dr Martine Klein. We
would like to extend our deepest gratitude
to Prof. Norman Grover for his kind help.

Fig. 4. Algorithm for the work-up and treatment of unilateral condylar hyperplasia. In the
current work, all patients were followed up for 6–12 months before surgery, which was either a
high condylectomy or orthognathic surgery. Alternatively, follow-up can be skipped in patients
with a percentage uptake below 55%.
negative scans can be skipped, with an
error rate of only 3%. In contrast, a posi-
tive scan cannot be used to diagnose active
UCH due to a high error rate. The low
number of active UCH patients in this
study should be taken into consideration,
as it limits the robustness of this conclu-
sion. This low number of active UCH
patients may be due to the decision-mak-
ing protocol used by the clinicians, or to
the timing of the SPECT study. It should
be noted that the current study was not
designed to evaluate the reasons for the
low percentage of active UCH among the
References
UCH patients. However, a prevalence of
active UCH of only 15–30% in these
patients has been reported previously.4,18
A detailed analysis with a larger number
of active UCH patients may be of benefit.
SPECT bone scintigraphy is utilized
widely as an aid in the classification of
inactive vs. active UCH, but standardiza-
tion of the method used is necessary in
order for SPECT bone scintigraphy to
truly be an effective method in the assess-
ment of UCH activity. A larger clinical
database may be needed to further sub-
stantiate the present study conclusions,
1. Angiero F, Farronato G, Benedicenti S, Vinci
R, Farronato D, Magistro S, et al. Mandibu-
lar condylar hyperplasia: clinical, histopath-
ological, and treatment considerations.
Cranio 2009;27:24–32.
2. Raijmakers PG, Karssemakers LH, Tuinzing
DB. Female predominance and effect of
gender on unilateral condylar hyperplasia:
a review and meta-analysis. J Oral Maxillo-
fac Surg 2012;70:e72–6.
3. Nitzan DW, Katsnelson A, Bermanis I, Brin
I, Casap N. The clinical characteristics of
condylar hyperplasia: experience with 61
patients. J Oral Maxillofac Surg 2008;66:
312–8.
4. Alyamani A, Abuzinada S. Management of
patients with condylar hyperplasia: a diverse
experience with 18 patients. Ann Maxillofac
Surg 2012;2:17–23.
5. Eslami B, Behnia H, Javadi H, Khiabani KS,
Saffar AS. Histopathologic comparison of
normal and hyperplastic condyles. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod
2003;96:711–7.
6. Cisneros GJ, Kaban LB. Computerized skel-
etal scintigraphy for assessment of mandib-
ular asymmetry. J Oral Maxillofac Surg
1984;42:513–20.
7. Robinson PD, Harris K, Coghlan KC, Alt-
man K. Bone scans and the timing of treat-
ment for condylar hyperplasia. Int J Oral
Maxillofac Surg 1990;19:243–6.
8. Kaban LB, Cisneros GJ, Heyman S, Treves
S. Assessment of mandibular growth by

Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en febrero 06, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.

skeletal scintigraphy. J Oral Maxillofac Surg
1982;40:18–22.
9. Saridin CP, Raijmakers PG, Tuinzing DB,
Becking AG. Bone scintigraphy as a diag-
nostic method in unilateral hyperactivity of
the mandibular condyles: a review and meta-
analysis of the literature. Int J Oral Max-
illofac Surg 2011;40:11–7.
10. Kajan ZD, Motevasseli S, Nasab NK, Gha-
nepour H, Abbaspur F. Assessment of
growth activity in the mandibular condyles
by single-photon emission computed tomog-
raphy (SPECT). Aust Orthod J 2006;22:
127–30.
11. Karssemakers LH, Raijmakers PG, Nolte
JW, Tuinzing DB, Becking AG. Interobserv-
er variation of single-photon emission com-
puted tomography bone scans in patients
evaluated for unilateral condylar hyperactiv-
ity. Oral Surg Oral Med Oral Pathol Oral
Radiol 2013;115:399–405.
12. AlSharif AA, Tarawneh ES, AlKawaleet YI,
Abukaraky AE, AlAhmad HT, Malkawi ZA,
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en febrero 06, 2021.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
Three SPECT analysis methods for UCH
et al. Standardization of quantitative single
photon emission computed tomography in
control individuals and in patients with con-
dylar hyperplasia. Nucl Med Commun
2014;35:1268–76.
13. Hodder SC, Rees JI, Oliver TB, Facey PE,
Sugar AW. SPECT bone scintigraphy in the
diagnosis and management of mandibular
condylar hyperplasia. Br J Oral Maxillofac
Surg 2000;38:87–93.
14. Chan WL, Carolan MG, Fernandes VB,
Abbati DP. Planar versus SPET imaging in
the assessment of condylar growth. Nucl
Med Commun 2000;21:285–90.
15. Pripatnanont P, Vittayakittipong P, Markma-
nee U, Thongmak S, Yipintsoi T. The use of
SPECT to evaluate growth cessation of the
mandible in unilateral condylar hyperplasia.
Int J Oral Maxillofac Surg 2005;34:364–8.
16. Fahey FH, Abramson ZR, Padwa BL, Zim-
merman RE, Zurakowski D, Nissenbaum M,
et al. Use of (99m)Tc-MDP SPECT for
assessment of mandibular growth: develop-
1613
ment of normal values. Eur J Nucl Med Mol
Imaging 2010;37:1002–10.
17. Saridin CP, Raijmakers PG, Tuinzing DB,
Becking AG. Comparison of planar bone
scintigraphy and single photon emission
computed tomography in patients suspected
of having unilateral condylar hyperactivity.
Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2008;106:426–32.
18. Olate S, Almeida A, Alister JP, Navarro P,
Netto HD, de Moraes M. Facial asymmetry
and condylar hyperplasia: considerations for
diagnosis in 27 consecutives patients. Int J
Clin Exp Med 2013;6:937–41.
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