Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492

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Journal of Cranio-Maxillo-Facial Surgery

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Demographic features in Unilateral Condylar Hyperplasia: An

overview of 309 asymmetric cases and presentation of an algorithm*
J.W. Nolte a, *, R. Schreurs a, L.H.E. Karssemakers a, D.B. Tuinzing b, A.G. Becking a, c
a
Department of Oral and Maxillofacial Surgery, Academic Medical Centre/Emma Children's Hospital, University of Amsterdam, Amsterdam,
The Netherlands
b
Department of Oral and Maxillofacial Surgery/Oral Pathology, VU University Medical Centre and Academic Centre of Dentistry, Amsterdam,
The Netherlands
c
Department of Oral and Maxillofacial Surgery, Spaarne Gasthuis, Haarlem, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Unilateral Condylar Hyperplasia (UCH) is an acquired deformity of the mandible, which can
Paper received 16 March 2018 highly influence the symmetry of the face due to its progressive nature. It is caused by growth resembling
Accepted 5 June 2018 pathology in one of the mandibular condyles. Definition as well as classification is subject to discussion.
Available online 25 June 2018
The aim of this study is to evaluate a large cohort of alleged UCH patients, and to describe the clinical
characteristics, demographic features, classification and follow up. Secondly an algorithm is presented, in
Keywords:
order to achieve uniformity in diagnosis and treatment.
unilateral condylar hyperplasia
Patients and methods: From 1994 to 2014 a database of consecutive patients from 3 maxillofacial de-
Unilateral condylar hyperactivity
Mandibular asymmetry
partments (Academic Medical Center, Amsterdam; VU Medical Center, Amsterdam and Spaarne Gasthuis,
Hemimandibular hyperplasia Haarlem) with suspected UCH was set up. Patients were referred by orthodontists, dentists, general prac-
Hemimandibular elongation titioners or maxillofacial surgeons. Demographic features, bonescan outcomes, laterality, classification and
Demographic follow-up were noted. Secondarily, all patients were retrospectively diagnosed by one surgeon (JWN), using
available documentation. Missing data and follow-up were additionally retrieved from orthodontic offices.
Results: 394 asymmetric patients were evaluated. In 309 (78%) patients, the diagnosis UCH was justified and
SPECT data were available. The mean age at presentation was 20.3 years (SD ± 7.7, range 9.0e54.5 years). In
48% of the patients, the bonescan was positive. 80% of these patients received surgical treatment, of which
62% were treated with a condylectomy only, 33% were treated with condylectomy plus additive corrective
surgery, and 5% underwent corrective surgery only. Of the patient group without positive bonescan 42% of
the patients received surgical treatment: 34% condylectomy only, 15% condylectomy plus additive corrective
surgery, and 51% corrective surgery only. In total (N ¼ 309) 96 (31%) patients underwent condylectomy as
only surgical treatment and 124 (40%) patients received no surgical treatment at all. Treatment could be
finalized with orthodontic treatment without further surgery in 64% and 41% respectively. 96 patients were
subject to comparison of the classification as noted by the clinician and the author (JWN). In only 72% of the
cases, the secondary screening was in agreement with the initial classification.
Conclusion: Based on this study not all (active) UCH patients require corrective (orthognathic) surgery. A
(transoral) partial condylectomy for active patients is recommended, with a postoperative remodeling
period of 6 months with or without orthodontic treatment. Second stage correcting surgery may be
necessary upon evaluation, using general orthognathic diagnostic and planning procedures. It appears
difficult to classify patients reliably using the available clinical and radiological documentation. Objec-
tivity and quantification in the diagnostic process is necessary: uniformity in documentation and pa-
rameters. The attached documentation form and UCH treatment algorithm is recommended.
© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

*
Manuscript was presented at the following meetings ICOMS Hong Kong 2017.
* Corresponding author. Department of Oral and Maxillofacial Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. Fax: þ31 20
5669032.
E-mail address: j.w.nolte@amc.nl (J.W. Nolte).

https://doi.org/10.1016/j.jcms.2018.06.007
1010-5182/© 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492
1. Introduction
Asymmetry of the face is present in many humans. This includes
structural or physiologic asymmetries as well as congenital or ac-
quired facial deformities.
Unilateral Condylar Hyperplasia (UCH) is an acquired deformity
of the mandible, which can highly influence the symmetry of the
face due to its progressive nature. It is caused by growth-
resembling pathology in one of the mandibular condyles, with
unknown etiology. It is recognized as a self-limiting condition, but
it can cause severe deformities of the mandible. The hyperactivity
may lead to dental and skeletal compensation of the maxilla and
sometimes complex asymmetries of the (mid) face. Hyperactivity
can occur gradually over years, with subtle changes in facial fea-
tures, or in a short period of time, creating clearly visible distortions
because of the lack of compensation of surrounding structures.
According to literature, the mean age at presentation is 21 years,
with a range from childhood to adulthood (Nitzan et al., 2008;
Raijmakers et al., 2012; Nolte et al., 2016). It may occur as unilat-
eral ongoing “growth” during the growth spurt in puberty, or as
renewed “growth” activity later in life. Orthodontic documentation
can be very helpful to reveal asymmetries in an early stage because
of precise documentation and follow up.
Definition as well as classification in UCH is subject to discus-
sion. There is no gold standard for measuring the hyperactivity in
UCH. Diagnosis is based on (hetero-) anamnesis, clinical charac-
teristics on examination and positive bone scintigraphy, with a left
to right quantitative difference of more than 10% (Saridin et al.,
2009). When results are non-conclusive, a wait-and-see policy is
conducted, with precise documentation using 2D/3D photogram-
metry and CBCT. No large populations of UCH have been described
in literature. Nitzan et al. gave an overview of 61 patients in which
they concluded it can occur at any age and it is more prevalent in
females (Nitzan et al., 2008), Mouallem and Raijmakers confirmed
this female predominance (Raijmakers et al., 2012; Mouallem et al.,
2017).
In 1986 Obwegeser and Makek made a classification in which
patients diagnosed with UCH could be divided in three categories:
hemimandibular hyperplasia, hemimandibular elongation and a
hybrid form (Obwegeser and Makek, 1986). Hemimandibular hy-
perplasia (HH) is defined by asymmetry of the vertical dimension
resulting in downward tilting of the occlusal plane on the ipsilateral
side. Open bite is only present on the affected side if joint growth
surpasses dento-alveolar compensation. Usually no cross bite or
chin deviation is present. Hemimandibular elongation (HE) is
characterized by deviation of the chin point and shifting of the
Table 1
Different strategies for correction in UCH.
Method 1 Method 2
Type of joint surgery NO joint surgery High partial condylectomy
Type of corrective Corrective surgery Corrective surgery
surgery
Stage END STAGE DELAYED STAGE
Considerations Severe asymmetry Surgery twice
Long-term stigmata Chance for observation
1485
dental midline of the mandible to the contralateral side. A cross-
bite on the unaffected side is common due to a lack of dento-
alveolar compensation (Obwegeser and Makek, 1986;
Karssemakers et al., 2012). The hybrid form (HY) consists of pa-
tients with both elongation and hyperplasia. Clinically, enlarge-
ment of the affected side and chin deviation to the contralateral
side are both seen. Tilting of the occlusal plane, a shifted midline,
cross bite and open bite may all occur in this group of patients. The
described classification is widely used.
Treatment may consist of high condylectomy in case of hy-
peractivity (positive anamnesis, clinical characteristics on ex-
amination and positive bonescan), after which a wait- and- see
policy is conducted for at least 6 months in order to let skeletal
and occlusal dimensions settle down. This can be observed with
or without orthodontic treatment, depending on age, dentofacial
deformity and wishes of the patient. After 6 months, treatment
can be followed up and finished with orthodontics only, or, in
cases with skeletal deformity, orthognathic surgery is planned
for.
Condylar surgery can be performed as a high condylectomy to
cessate growth only, or as a proportional condylectomy in order to
directly achieve compensation for the amount of asymmetry
(Rajkumar et al., 2012; Farin~ a et al., 2015, 2016; Mouallem et al.,
2017). Various different approaches are possible: one-stage com-
bined orthodontic-surgical treatment with condylectomy (Wolford
et al., 2002; Da Costa Araújo et al., 2012; Janakiraman et al., 2015),
or wait-and-see policy until hyperactivity ceases, followed by re-
establishment of symmetry with orthognathic surgery and/or
bony corrections. Combined surgery incorporates the risk of
overtreatment, while a wait-and-see policy may cause severe de-
formities over time. These deformities are very difficult and
sometimes impossible to correct, especially the vertical type with
lower mandibular border deformities. In fact, considering the
treatment options above, 4 different strategies for correction in
UCH can be defined (Table 1). Method 1 includes no joint surgery,
but corrective orthognathic surgery is performed (end-stage).
Method 2 includes a high partial condylectomy, followed by a
wait- and- see for 6 months after which corrective surgery is
performed (delayed stage). In method 3 a proportional con-
dylectomy is carried out, with the aim of no further corrective
orthognathic surgery (no stage), and method 4 encompasses
combined condylectomy and corrective orthognathic surgery (one
stage).
Literature about UCH mainly consists of case series. As the origin
of the condition remains unclear, it is of utmost importance that
large series are described.
Method 3 Method 4
Proportional condylectomy Combined
No need for corrective Same stage condylectomy
surgery? and orthognatic surgery
NO STAGE ONE STAGE
Unpredictable Overtreatment?
Pre-existing deformity?
1486 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492
The aim of this study was to evaluate a large cohort of alleged
UCH patients, and to describe the clinical characteristics, de-
mographic features, classification and follow up. An algorithm is
created in order to achieve uniformity in diagnosis, documentation
and treatment.
2. Materials and methods
From 1994 to 2014 a database of consecutive patients from 3
maxillofacial departments (Academic Medical Center, Amsterdam;
VU Medical Center, Amsterdam and Spaarne Gasthuis, Haarlem)
with suspected UCH was maintained. All patients were clinically
supervised by 3 surgeons (DBT, AGB, JWN). All patients were
referred with suspected progressive asymmetry of the mandible by
an orthodontist, dentist, general practitioner or maxillofacial
surgeon.
Patient charts were reviewed and the following parameters
were noted:
Gender, date of birth, date of first visit, date, number and
outcome of bone scintigraphies, the presence of orthodontic gear
during treatment, date and laterality of performed condylectomy
and date and specification of orthognathic or corrective surgery.
Patient charts were screened for laterality and classification (HE/
HH/HY/not noted). One surgeon (JN) separately diagnosed every
patient in laterality and classification (HE/HH/HY), using available
photographs, X-rays and/or CBCT, cast models. Missing data and
follow up were additionally retrieved from orthodontic offices.
When insufficient information was available, it was noted as “not
possible to diagnose”.
Descriptive statistics were used to evaluate the retrieved data.
This research was approved by the Ethical Committee (VUMC,
ref. nr 2012/156).
3. Results
3.1. Demographics, clinical characteristics and follow up
In the period of 20 years, 394 asymmetric patients were eval-
uated. In Figs. 1e4, the following outcomes are shown.
Fig. 1: 15 (4%) patients were excluded because of known facial
trauma, bilateral condylar hyperplasia and other diagnosis such
as hemifacial microsomia, cleft, etc. In 379 (94%) patients, the
clinical and radiological diagnosis of UCH was justified. For
further evaluation, another 70 (18%) patients were excluded
because of missing SPECT data. The remaining 309 (78%) patients
were analysed.
Fig. 1. Evaluation of suspected UCH patients.
Fig. 2: The mean age at presentation was 20.3 years (SD ± 7.7,
range 9.0e54.5 years), with a male to female ratio of 135: 174 (44%:
56%). The right side was predominantly affected (right: 168 left: 140
(55%: 45%). In 1 patient, the laterality was not noted in the patient
chart nor in the SPECT-application form, and thus scored as un-
known laterality: 1 (0%).
Fig. 3: 148 (48%) patients were diagnosed as “active” UCH, based
on the progressive clinical information in combination with a
positive bonescan. The remaining 161 (52%) patients showed no
significant left to right difference on the bonescan, or the results
were controversial to the clinical observation (eg. right side activity
on bonescan with left side clinically suspected). Of the 148 patients
with active UCH, 118 (80%) received surgical treatment; 30 patients
did not receive surgical treatment at all (20%). Of the surgically
treated patients, 73 (62%) underwent a growth-stopping con-
dylectomy as the only surgical treatment. 39 patients (33%) un-
derwent condylectomy plus additive corrective surgery. Corrective
surgery included orthognathic surgery and/or transpalatal
distraction osteogenesis (TPD), genioplasty and gonial angle
correction. 6 patients received corrective surgery only (5%).
94 of the 161 patients (58%) without a positive bonescan
received no surgical treatment. Surgical treatment in 67 patients
without a positive bonescan was subdivided as follows: 23 (34%)
condylectomy only, 10 (15%) condylectomy and corrective surgery,
34 (51%) corrective surgery only.
In summary, within the population of 309 patients, 124 (40%)
patients did not receive any surgical treatment. 96 (31%) received a
condylectomy only, 49 (16%) underwent a condylectomy and
additional corrective surgery and 40 (13%) patients underwent
corrective surgery only. In 3 (1%) patients, a revision of the con-
dylectomy was necessary due to ongoing asymmetric deviation of
the mandible.
A specification of the 89 corrective treatments is provided in
Table 2.
Fig. 4: In the condylectomy only patient group (N ¼ 96), treat-
ment could be finalized orthodontically in 61 (64%) patients; or-
thodontic treatment was started pre-condylectomy in 49 of these
61 patients (80%). In the group of UCH patients that received no
surgery at all (N ¼ 124), treatment was finalized with orthodontics
in 51 (41%) patients. In the corrective surgery group (N ¼ 89), 7 (8%)
early cases received surgery without orthodontics.
3.2. Classification
Table 3: The available documentation of 309 patients was
reviewed (JWN) to score again the classification in HE, HH or HY,
 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492 1487

Fig. 2. Gender, mean age at presentation and laterality in UCH patients (N ¼ 309).

without insight in the primary diagnosis. In 63 (20%) of the
screened cases, there was insufficient documentation to be able to
classify the type of UCH. The classification of the remaining 246
patients by the author was as follows: HE 183 (74%), HH 47 (19%)
and HY 16 (7%).
On initial diagnosis by the clinician, a specification of the sub-
type was provided in 96 patients (31% of 309). The classification
was as follows: 54 HE (56%), 35 HH (37%), HY 7 (7%).
Thus, 96 patients were subject to comparison of the classifica-
tion as noted by the clinician and the author (JWN). In only 72%, the
secondary screening was in agreement with the initial classification
and laterality. In the HE group 9 (9%) patients were scored differ-
ently, in HH 13 (14%) patients, and in HY 5 (5%) patients.
4. Discussion
Diagnosis and treatment of UCH is subject to different ap-
proaches. It varies per surgeon or maxillofacial center and is
dependent on the patient's wishes and expectations. Different
parameters are responsible for decision-making in the man-
agement of this condition, such as type of UCH, interpretation of
the SPECT-scan and degree of hyperactivity, and surgical
possibilities.
4.1. Classification
According to these results it proves to be difficult to classify
patients reliably. Although the classification parameters of
Obwegeser are quite clearly described (Obwegeser and Makek,
1986), the subjective nature of interpreting the clinical obser-
vation and available documentation appears to be an important
factor. Only in 72% of the patient group the secondary screening
matched the initial classification. In many cases, it is difficult to
decide which side is the “affected” side. A one-sided hemi-
mandibular hyperplasia may resemble a hemimandibular elon-
gation on the other side (Fig. 5) and it is sometimes even
difficult to predict which side is expected to be more active on
bone scanning. Classifying a patient who has obvious canting of
the occlusal plane with a slight midline shift and chin deviation
but no signs of hyperplasia or open bite may be confusing. In
fact, it can be considered “HE with canting” but that does not fit
the classic types of Obwegeser. Nitzan observed that clinical
appearance may be different from the radiological observation

Fig. 3. Distribution of characteristics in UCH patients; C ¼ condylectomy only; C þ CS ¼ condylectomy þ corrective surgery; CS ¼ corrective surgery only.
1488 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492

Fig. 4. Orthodontic specifications in UCH patients.

and points out that the direction of asymmetry (ie vertical or
horizontal) should be used instead of the Obwegeser classifica-
tion (Nitzan et al., 2008). With modern three-dimensional
quantitative measurements, Nolte et al. also could not objec-
tively confirm Obwegeser's classification (Nolte et al., 2015,
2016).
In 2014, Wolford proposed a new classification system for all
condylar hyperplasia related asymmetries in 4 categories based
on type of pathology and occurrence rates. Type 1A and 1B show
respectively bilateral and unilateral elongated accelerated
growth, mainly in pubertal patients. Type 2 includes unilateral
vertical condylar enlargement that is supposed not to be self-
limiting, and expresses either non-exophytic growth of the
condyle (2A) or enlargement of condyle with exophytic growth of
the head (2B), based on osteochondroma. Type 3 and type 4 can
cause unilateral facial enlargement at any age, including also
known causes such as osteoma and other benign tumours (type
3), or malignant tumors (type 4) (Wolford et al., 2014). Chen et al.
recommend using the term condylar hyperplasia in case of
asymmetries, and the term hemimandibular hyperplasia only
when actual deformity develops (Chen et al., 1996). Khorsandian
et al., and Xu et al., define subtypes of HH with a typical form
including enlarged condyle, and an atypical form with an increase
in volume of ramus and body but no enlargement of the condyle
(Khorsandian et al., 2001; Xu et al., 2014). All of these different
classification proposals point out that true classification is very
difficult and that there is large heterogeneity in mandibular
asymmetries. Misdiagnosis of UCH can also occur due to other
pitfalls or similar conditions. A small transverse maxillary
dimension, or the presence of sliding in a forced bite situation,
may mimic a progressive asymmetry. Although at first sight this
seems obvious or easy, a small transverse maxillary dimension
with (unilateral) collapse leading to crossbite, can paradoxically
appear as hemimandibular ‘elongation’ of the mandible. It can be
subtly asymmetric and may mislead the surgeon or orthodontist
to think there is a mandibular asymmetry. Mouallem et al.
describe that mandibular laterognathia in maxillary transverse
discrepancies results in contralateral cross-bite and may cause

Table 2
Specification of corrective surgeries.

N¼89 Condylectomy first Condylectomy simultaneous No condylectomy

TPD 1 3 4*
SS unilateral 1 1
SS bilateral 7 5
SS þ genioplasty 1 1
SS þ angle contouring 1
SS þ genioplasty þ angle contouring 1
Le Fort 3 1
Le Fort þ SS unilateral 7
Le Fort þ SS unilateral þ genioplasty 1
Le Fort þ zygoma þ genioplasty 1
Bimax 11 12
Bimax þ genioplasty 11 y 3
Bimax þ genioplasty þ angle contouring 1
Bimax þ zygoma 1
Bimax þ zygoma þ genioplasty 3 1
Genioplasty 3 1
Genioplasty þ angle contouring 1
Unspecified 1 1
TOTAL 42 7 40

*1 + TMD. y out of 11 bimax+genioplasty, 3 genioplasties were performed simultaneously with the first condylectomy.
 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492 1489

Table 3 is the most important factor. Although the mean age of UCH is
Classification of UCH patients. around 21 years of age, there is a substantial number of patients
Classification Clinician Author Difference presenting in childhood or early adolescence (up to 18 years). In
(N¼96) (N¼246) (N¼96) the Netherlands, orthodontic therapy is easily available for chil-
HE 54 (56%) 183 (74%) 9 (9%) dren under 18 years of age; asymmetries, and in particular pro-
HH 35 (37%) 47 (19%) 13 (14%) gressive conditions such as UCH, may therefore be identified
HY 7 (7%) 16 (7%) 5 (5%) earlier and in milder cases. Early diagnosis of asymmetry should
TOTAL 27 (28%)
however not lead to overdiagnosis and (surgical) overtreatment
of UCH. In this study, 40% of the UCH patients received no surgery
at all, and 31% were treated with a condylectomy only. Treatment
could be finalized with orthodontics without further surgery in
adaptive condylar elongation without condylar increase in vol- 64% and 41% respectively. This reinforces the authors’ opinion
ume or occlusal plane tilting (Mouallem et al., 2017). Even uni- that a delayed stage (method 2) or non-stage (method 3) strategy
lateral masseteric hypertrophia can mimic hemimandibular can be recommended to prevent further invasive treatments. The
hyperplasia in clinical appearance. In general, asymmetric dental morbidity of a condylectomy is low (Saridin et al., 2010), and
and skeletal features may be subsequent to compensational di- currently the trans-oral approach for condylectomy becomes
common practice (Herna ndez-Alfaro et al., 2016). The absence of
mensions because of UCH, or just the result of structural asym-
metries in other parts of the face such as the maxilla or soft a visible scar, the relatively small intraoral incision and the
tissues. Proper standard documentation, preferably with ortho- minimal postoperative morbidity plead for this approach instead
dontic documentation, is advisable for accurate diagnosis, and as of a wait-and-see policy until ceasing of activity to try to avoid the
Olate et al. stated: “the study of TMJ and condylar hyperplasia condylectomy. Di Blasio et al. concluded in young patients up to
must be incorporated into all treatment protocols for facial 18 years, that after condylectomy, the healthy side continues to
asymmetry as a starting point for any treatment” (Olate et al., grow in a normal way, and the affected side first ceases growth
2013). after condylectomy, but then recovers to normal growth again (Di
Blasio et al., 2015). Xavier et al. described a two-stage (delayed
stage) treatment, but noticed that after the first stage (con-
4.2. Treatment options dylectomy) noticeable improvements in occlusion were already
visible (Xavier et al., 2014). Farina et al. studied the possibility of
As described in the introduction, there are roughly 4 methods condylectomy as a sole treatment (non-stage) and found satis-
for treatment management in UCH: end-stage, delayed stage, fying results, concluding that a proportional condylectomy re-
non-stage and one-stage surgery. Abuzinada et al. described a duces the need for secondary orthognathic procedures (Farin ~a
great diversity in presentation of condylar hyperplasia. They et al., 2015, 2016).
stated that assessment of condylar growth activity is the most A relevant question would be if we can predict which of the 4
important factor in treatment management and concluded that described methods would be the best treatment in an early stage.
after that, each case has its own diverse treatment plan to reach Objective determination of progression is an important key to
satisfactory facial symmetry (Abuzinada and Alyamani, 2012). The this problem and therefore, uniformity in SPECT-registration and
authors of this study also suppose that different approaches may SPECT-interpretation is highly relevant. At present, there is a
lead to the same satisfying results, but prevention of overtreatment variety of ways to present the SPECT-data from nuclear physician

Fig. 5. Controversy in classification of UCH patient.

1490 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492
to the clinician (Saridin et al., 2009). Especially in growing chil-
dren it is important to consider that the mandible can grow
intermittently on each side. Thus, the combination of patient
history (hetero-) anamnesis, clinical observations and documen-
tation are obligatory in addition to the SPECT-scan before
deciding on any surgical treatment. In fact, a SPECT-scan is not
justified if there is no circumstantial evidence for progression of
mandibular asymmetry with UCH characteristics. In this study
group, the majority (52%) of the patients turned out to have a
negative or controversial bone-scan outcome, but 33 (20%) of
these patients showed clinical progression leading to con-
dylectomy anyway.
Secondary procedures sometimes may be indicated to correct
the remaining asymmetry. An observation period after con-
dylectomy is advisable before indicating further therapy (delayed
stage, method 2). Elbaz et al. concluded that after early con-
dylectomy an interval of at least 6 months should be respected
before indicating second stage surgeries (Elbaz et al., 2014). The
one-stage approach (combining the condylectomy with orthog-
nathic surgery, method 4) may look like an efficient treatment.
But, after a partial condylectomy, remodeling may lead to
acceptable occlusion and facial features without further correc-
tions. The one-stage approach may be considered as over-
treatment in an unknown amount of cases. Naturally, this decision
is also related to the age of the patient and the amount of defor-
mity that might need surgical correction in the first place,
regardless of ongoing growth. In this study, corrective surgery was
performed in addition to the condylectomy in 49 (16%) patients,
and 40 (13%) patients received corrective surgery without pre-
ceding condylectomy. The condylectomy was combined with
simultaneous other surgery in 7 out of 49 cases (14%), this con-
cerned simultaneous transpalatal distraction or simultaneous
genioplasty.
4.3. Relation between classification and treatment options
Although classifying UCH patients proves to be difficult, an
interesting question would be whether the type of UCH (HE, HH,
HY) or vector of asymmetry matters in the treatment choice and
stage. One can imagine that the HE patient group can very well
benefit from a partial condylectomy in the early hyperactive
phase of the disease. The patients in the HH patient group usu-
ally demonstrate more complex asymmetry. This kind of asym-
metry can be more difficult to correct (ie lower mandibular
border correction). Further research should be directed to the
growth patterns after condylectomy, and ideally reveal if an early
partial condylectomy in HH causes “natural correction” of the
asymmetric deformity of the mandible in the same way as in HE.
Xu et al. proposed a surgical management algorithm on the basis
of the severity of the deformity in HH, distinguishing a typical
type and an atypical type (Xu et al., 2014). However, none of the
patients in their group had undergone a condylectomy, so it can
be considered more as an orthognathic asymmetry algorithm
than as a UCH algorithm. Elbaz et al. introduced a treatment
algorithm that distinguishes functional laterognathia and
condylar hyperplasia, in which the latter was diagnosed with
SPECT outcome and the degree of vertical deformity. It was
suggested to perform a condylectomy in cases with severe
vertical distortion, even without clear signs of hyperactivity
(Elbaz et al., 2014).
Based on the findings in this study, the authors propose the
attached diagnostic standard form for documentation (appendix
A). This will enable comparison of series of UCH patients, which
will lead to better understanding of this rare disorder. In
appendix B, the proposed treatment algorithm is presented. If
the patient presents with mandibular asymmetry and suspected
UCH on first visit, the standard documentation is performed,
paying special attention to the clinical and radiological charac-
teristics such as dental compensation, maxillary or occlusal
plane canting. The type of asymmetry is noted, and if there are
clear signs for progression of the asymmetry, a SPECT-CT is
made. According to the outcome of the bone-scan, a high con-
dylectomy is performed, or in case of a negative or controversial
outcome, a wait and see period is conducted with repeat of
documentation after 6 months. If progression becomes visible, a
high condylectomy is performed. After a remodeling period of 6
months, further corrective surgery can be done, dependent on
the level of remaining asymmetry and malocclusion. In this
phase, the normal orthognathic treatment schedules and con-
cepts are used.
5. Conclusion
Based on the findings of this study it becomes clear that not
all (active) UCH patients require corrective (orthognathic) surgery
for the correction of the asymmetry. A (transoral) partial con-
dylectomy is recommended, with a postoperative remodeling
period of 6 months with or without orthodontic treatment. After
this, second stage corrective surgery may be necessary upon
evaluation. The type of orthognathic surgery is dependent on
individual cases according to severity and nature of the remain-
ing asymmetry. The use of an algorithm may be helpful, but
general orthognathic diagnostic and planning procedures are
recommended.
An objective and standard diagnostic process is mandatory,
preferably with uniformity in parameters to compare series from
different centers. This includes standardized clinical assessment,
2D and 3D radiologic imaging, and dental casts with accurate
wax-bites. SPECT data should be interpreted in a standardized
protocol. The authors recommend the attached protocol and
algorithm.
Sources of support
None.
Financial interest in this study
None.
Conflicts of interest
None.
Acknowledgments
Sophie van de Vijfeijken for her contribution in collecting data.
 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492 1491

Appendix A

UCH STANDARD DOCUMENTATION FORM

CLINICAL DOCUMENTATION
FACIAL MEASUREMENTS
Orbital cant : yes no
Nose deviaon : median right le
Lip cant : median right lower le lower
Chin deviaon : median right le
Mandibular angles : equal right lower le lower
Maxillary cant to pupil line : parallel right lower le lower
Occlusal plane cant to pupil line : parallel right lower le lower

Open bite : front L/R posterior L/R

Crossbite : front L/R posterior L/R
Missing teeth : yes no specificaon

Midline upper teeth : median right .. mm le .. mm

Midline lower teeth to upper midline: median right .. mm le .. mm

Occlusal angle classificaon : right class I/II/III le class I/II/III

Dental compensaon : yes: front/posterior no

Progression clinically suspected : yes no

IMAGING / RADIOLOGIC DOCUMENTATION

2D photoseries : check
3D stereophotogrammetry : check
CBCT full skull in occlusion : check
3D cephalometry : check

ADDITIONAL DOCUMENTATION
Previous orthodoncs : yes no specificaon:
Orthodoncs on first visit : yes no specificaon:
Cast models + wax bite : check

CLASSIFICATION
Obwegeser : HE HH HY NA
Wolford : 1A 1B 2A 2B 3 4 NA
Nitzan : horizontal vercal NA

SPECT-CT
Outcome : mean L: R:
max L: R:
1492 J.W. Nolte et al. / Journal of Cranio-Maxillo-Facial Surgery 46 (2018) 1484e1492

Appendix B. UCH treatment algorithm.

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