Accepted Manuscript

An updated protocol for the treatment of condylar hyperplasia: computer-guided

proportional condylectomy

Salvatore Sembronio, MD, PhD, FEBOMFS, Alessandro Tel, MD, Fabio Costa, MD,
Massimo Robiony, MD, FEBOMFS

PII: S0278-2391(19)30192-2
DOI: https://doi.org/10.1016/j.joms.2019.02.008
Reference: YJOMS 58658

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 25 October 2018

Revised Date: 5 February 2019
Accepted Date: 5 February 2019

Please cite this article as: Sembronio S, Tel A, Costa F, Robiony M, An updated protocol for the
treatment of condylar hyperplasia: computer-guided proportional condylectomy, Journal of Oral and
Maxillofacial Surgery (2019), doi: https://doi.org/10.1016/j.joms.2019.02.008.

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DEPARTMENT OF MEDICINE

UNIVERSITY OF UDINE

Maxillofacial Surgery Unit - Academic Hospital of Udine

Chief : Prof. Massimo Robiony

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An updated protocol for the treatment of condylar hyperplasia: computer-
guided proportional condylectomy

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Salvatore Sembronio, MD, PhD, FEBOMFS 1 *

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Alessandro Tel, MD 2

Fabio Costa, MD 1

Massimo Robiony, MD, FEBOMFS 3

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1. Assistant Professor, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of
Medicine, University of Udine
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2. Resident, Maxillofacial Surgery Department, Academic Hospital of Udine, Department of

Medicine, University of Udine
3. Full Professor, Department Head, Maxillofacial Surgery Department, Academic Hospital of Udine,
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Department of Medicine, University of Udine

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corresponding author:

Dr. Salvatore Sembronio MD, PhD, FEBOMFS

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Assistant Professor

Maxillofacial Surgery Unit,

Academic Hospital of Udine
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Department of Medicine
University of Udine
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P.le S. Maria della Misericordia 1

33100 Udine
info@sembroniomaxillo.com

KEYWORDS:

condylar hyperplasia; condylectomy; virtual surgical planning; cutting guides; Facial Care Project
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DEPARTMENT OF MEDICINE

UNIVERSITY OF UDINE

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An updated protocol for the treatment of condylar hyperplasia:

computer-guided proportional condylectomy

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PURPOSE: To present an updated protocol for proportional condylectomy in which virtual sur-

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gical planning and 3D printing allow one to precisely define the osteotomy level.
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METHODS: 3D mirroring was performed to generate a virtual replica of the healthy hemi-
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mandible, which was subsequently aligned and overlapped with the actual mandible to esti-

mate the level for condylectomy. A custom-fitted 3D printed surgical guide was modeled for
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the condylar head allowing one to reproduce virtual planning in the surgical scenario. The up-

dated protocol for computer-guided condylectomy was applied to 7 patients.

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RESULTS
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For all patients, a follow-up period of twelve months was considered. Surface deviation color
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maps showed a high correspondence between the virtually calculated condylectomy and the

surgical outcome achieved with the aid of the surgical guide. No cases of condylar hyperplasia

recurrence were observed.

CONCLUSION
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An updated protocol based on accurate three-dimensional analysis was performed by means

of virtual surgical planning and 3D printing. Virtual surgical planning allows one to precisely

define the level of condylectomy, and custom-made 3D printed cutting guides are useful to

reproduce virtual measurements during surgical maneuvers.

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Introduction
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Unilateral condylar hyperplasia (UCH) is non-neoplastic and non-congenital pathology charac-

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terized by asymmetry of the lower third of the face due to an excessive growth of the condylar
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head and neck.

According to Obwegeser1 classification, this form of asymmetry is characterized by an abnor-

mal posterior vertical growth and it should be differentiated from other patterns of unilateral
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asymmetric mandibular growth, such as hemi-mandibular elongation, which involves the hori-

zontal plane, and the combined forms.

UCH typically begins at puberty and predominantly affects young women. Patients present

progressive facial asymmetry, with both occlusal and aesthetic impairment. Additional clinical

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appearances of UCH consist of contralateral chin deviation, unilateral posterior crossbite or/and

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ipsilateral open bite and variable canting of the maxilla with a dento-alveolar compensation

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that follows the overgrowth of the condyle.

The etiology of this condition is poorly understood: traumatic and mechanical causes have

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been proposed, as well as genetic and hormonal factors, but the ultimate cause remains un-

clear.
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Nowadays, cone beam computed tomography (CBCT) provides optimal anatomical visualization,
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allowing for the diagnosis of the form of the asymmetry pattern and can be used for three-

dimensional virtual planning of the surgery.

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SPECT (single photon emission computed tomography), by measuring bone metabolism2, is

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helpful to differentiate between active and inactive forms of UCH. A 10% difference between
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the two condyles in SPECT analysis is associated with the active form of condylar hyperplasia3.

Condylectomy was established to be the preferred technique for the treatment of active con-

dylar hyperplasia4,5. In the literature, many papers report that the standard treatment for these
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patients consists of high condylectomy and, eventually, orthognathic surgery, which might be

performed at the same stage or a later time6.

High condylectomy involves the removal of the upper 5 mm of the mandibular condyle; it

aims to eliminate the most active part of condylar head which drives the overgrowing process.

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Delaire7 proposed a systematic protocol for proportional condylectomy, which is a low con-

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dylectomy resecting the growth centre and decreasing the posterior vertical excess, thus allow-

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ing for the correction of the mandibular deformities.

Modern CAD (computer-aided design) software allows for the accurate analysis of morphologi-

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cal differences between the healthy and hyperplastic condyle, and provides surgeons with the

possibility to virtually designing the level of the osteotomy, in order to restore the symmetry of
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the face.
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The combination of virtual surgical planning and 3D printing has been used to produce surgi-

cal guides, defined as patient specific intraoperative templates allowing one to trace surgical
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osteotomies according to the virtual project.

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The aim of this study is to develop a protocol for the treatment of unilateral condylar hyper-
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plasia by means of virtual surgical planning and a novel 3D printed custom surgical guide to

perform a precise proportional condylectomy.

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Material and methods

Seven patients were treated from 2016 to 2017 at Maxillofacial Surgery Department, Academic

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Hospital, University of Udine. Patients clinical and demographic characteristics are described in

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Table 1. The present study was approved by Regional Ethical Committee, with the registration

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number protocol 2056 CEUR . All patients recruited in this study had a diagnosis of active

condylar hyperplasia.

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Inclusion criteria were the following: 1) patients developing a progressive asymmetry of the

lower face; 2) computed tomography (CT) scan showing a unilateral enlargement; 3) single
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positron emission computed tomography (SPECT) assessing a difference of more than 10% in
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condylar uptake.
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The following patients were excluded: 1) condylar enlargement associated with neoplastic
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growths; 2) patients that previously underwent any other facial or condylar surgical procedures;
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3) patients with congenital abnormalities.

CT scanning provided raw data which could be reformatted into three-dimensional models for

the use in virtual surgical planning (Fig. 1a).

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Virtual planning

DICOM data obtained from CT scan were imported in ProPlan CMF (Materialise, Leuven, BE) for

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virtual surgical planning. First, skull models were aligned according to Frankfurt plane. In order

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to restore the correct occlusal plane, the supraorbital line, namely the line which joins the top

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of orbital roofs, was set as a reference. The mandible was realigned resulting in supraorbital

line being parallel to the tangent to the healthy condyle, and the vertical difference between

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hyperplasic condyle and healthy condyle was estimated. In order to perform a 3-D study, the

half mandible containing the healthy condyle was mirrored and overlapped with hyperplasic
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condyle, allowing to identify the osteotomy plane for proportional condylectomy (Fig. 1b, 1c).
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In order to translate virtual surgical planning coordinates on the actual patient, a custom-fitted

surgical guide (Fig. 1d) was modeled in 3-Matic software (Materialise, Leuven, BE) and printed
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using stereolithographic resin (Formlabs, Somerville, MA, USA). The cutting edge of condylar
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guide was designed in order to replicate the natural shape of healthy condyle and to fit the
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lateral part of the condyle that is the most easily accessible. Measurements of condylar head

diameters were performed in order to choose an appropriate length for the fixation screws.

3D printing (stereolithography) was used to manufacture the condylar cutting guide. The pro-

tocol implemented in the present study is summarized in figure 2.

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Surgical procedure

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Patients underwent surgery in general anesthesia by the same surgeons (S.S. and M.R.). A

preauricular incision extending to the temporal region, curving backwards and upwards poste-

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rior of the main branches of the temporal vessels was performed. The incision was carried

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though subcutaneous areolar tissue and superficial temporalis fascia. Blunt dissection was car-
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ried out to the point where the deep temporals fascia subdivides into two layers enclosing fat
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tissue. The superficial layer of deep temporalis fascia and underlying fat tissue were incised,
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and inferior layer of deep temporalis fascia was reached. When dissection was complete, a
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composite flap extending from the skin to the deep layer of deep superficial fascia was
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achieved, allowing for additional protection of the facial nerve. Subsequently, the periosteum
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of the malar arch was incised and comfortable surgical approach to the articular capsule was
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performed. Surgical capsule was incised at the insertion of temporomandibular lateral liga-

ments in order to enter the inferior joint space, leaving the superior joint space and the disk

intact. After exposure of the condylar head and neck, Dunn-Dautrey temporomandibular joint

condyle retractors were used to protect and laterally distract the condyle, enabling the opera-
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tor to position the surgical cutting guide fitting the lateral condylar pole. The surgical guide

was secured to the condylar head with an 11 mm screw (Fig. 3). A condylectomy was per-

formed with the aid of condylar cutting guide, designing the osteotomy by means of piezosur-

gery according to virtual surgical planning.

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Postsurgical care

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After surgery, all patients underwent combined physiotherapy and orthodontic treatment.

Postoperative physiotherapy included mandibular opening exercises in order to achieve the

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normal range of motion in 10 days.

Patients received postoperative orthodontic treatment consisting of orthodontic appliances. It was

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important to warn patients that condylar reduction could result in malocclusion, with a precontact
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on the ipsilateral side.

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Intermaxillary elastic therapy consisted of nocturnal fixation and intermittent passive/active re-

habilitation8. Elastic propulsion on the affected side was directed to bring the occlusion into
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dental contact with consequential rotation of the mandible.

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Postoperative orthodontic treatment objective is to help the decompensation of dentoalveolar ex-

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trusion and move upwards the point of ipsilateral dental contact on the operated side, in order to

further enhance mandibular rotation. Additionally, orthodontics allows one to correct maxillary oc-

clusal plane canting, remove pre-contacts, and stabilize the occlusion. According to our protocol in

which a follow-up of 12 month is required, the average time of postoperative orthodontic treatment

was 1 year.
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Results

The condylectomy did not cause any major complications. No transient or permanent facial

palsy was observed. Condylectomy did not result in functional limitation of mouth opening and

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all patients showed normal postoperative mouth opening (> 35 mm), with a mean postopera-

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tive (1 year) maximal interincisal opening (MIO) of 41,3 mm. None of the patients at 1-year fol-

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low-up reported pain of the operated joint.

In all patients, the amount of resected bone was superior to 5 mm, with a mean value of 9

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mm.

Postoperative CBCT was performed 1 year after surgery and a postoperative 3D model was
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achieved and overlapped with the planned counterpart. Surface deviation color map showed
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high correspondence between the original virtual surgical plan and postoperative result (Fig. 4).

No case of condylar hyperplasia recurrence was observed.

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Immediately after surgery all patients presented with a precontact on the ipsilateral side, man-
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aged with orthodontic treatment and elastic traction.

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In the group of 7 patients who were treated by proportional condylectomy, at one-year follow-

up, six had clinically satisfactory results with aesthetic improvement of the facial asymmetry,

occlusal cant correction and a stable occlusion. One patient, because of residual asymmetry,

needed further treatment and underwent subsequent orthognathic surgery consisting of bi-
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maxillary surgery. Figure 5 (a-b) and figure 6 (a-b) show clinical preoperative and postoperative

photos with the correction of asymmetry and canting of occlusal plane.

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Discussion

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In literature, proportional condylectomy was demonstrated to be an effective method to re-

move the overgrowth of the condylar head and to establish adequate symmetry and occlusion.

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Farina et al.9 in 2015 showed that a low or proportional condylectomy is suitable for the treat-

ment of facial asymmetry caused by condylar hyperplasia and illustrated the efficacy of the
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procedure: the mandible is rotated on the side in which condylectomy has been performed
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and it is vertically lifted until dental contact is achieved. Facial symmetry improves due to

mandibular rotation. The rationale of such a treatment is to intervene early with a single pro-
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cedure to reduce the number of patients undergoing conventional orthognathic treatment. In

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fact, the same authors10 in 2016 compared high condylectomy with proportional condylectomy,
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concluding that proportional condylectomy reduced the need for secondary orthognathic sur-

gery, since it avoided the progression of homolateral occlusal plane tilting and dento-facial

adaptive deformities.
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Multidisciplinary care is necessary to provide patients with the best treatment options and co-

operation with the orthodontist is to be encouraged. In our experience the main advantage of

elastic therapy and orthodontic treatment was to guide the mandible until the new condylar

head reached the glenoid fossa. An additional advantage of orthodontic treatment was to de-

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termine the intrusion of ipsilateral molars to improve the orthopaedic effect of intermaxillary

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elastic fixation in maximal occlusion8. As a consequence of combined use of orthodontic and

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elastic treatment for the correction of posterior vertical excess, rise and flattening of the occlu-

sal plane were observed, as well as rotation of the mandible and improvement of the asym-

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metry. The correction of symmetry was generally not complete, although in the majority of

cases patients significantly improved their aesthetic facial appearance (Fig. 5a-b; Fig. 6a-b).
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Once condylar hyperplasia is no longer active because of condylar surgery, there is residual
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asymmetry, as reported by Higginson et al.11; traditional orthognathic surgery allows for further

correction. In our protocol orthognathic surgery was considered in case of inactive disease
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(SPECT -) or if at 1-year follow-up patients were unsatisfied with the restoration of symmetry.
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Moreover, low condylectomy does not restrict mandibular range of motion and does not inter-
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fere with temporomandibular function12. In our patients we did not observe any temporoman-

dibular dysfunction or pain. Therefore, it s important to preliminarily differentiate active

(SPECT+) and inactive hyperplasia, in order to candidate patients to proportional condylecto-

my.
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In previous reports, the determination of the condylar resection size was based on two-

dimensional cephalometric analysis. Mouallem et al. proposed to measure vertical distance be-

tween mandibular angles and supraorbital line on the coronal plane8. Farina et al. obtained dif-

ferential measurements drawing a line from the uppermost point of the condyle to the man-

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dibular angle10.

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In condylar hyperplasia, although the growth center is localized into the condylar head, the en-

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tire anatomy of the mandibular body and ramus-condyle unit is distorted, resulting in difficult

determination of reference cephalometric points and lines. Therefore, measurements to define

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the entity of proportional condylectomy may not be reliable.

The advent of CBCT has allowed for comparable resolution, sensitivity, and specificity to con-
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ventional CT with lower doses of radiation. CBCT should be used for extensive comprehension
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of the surgical problem and three-dimensional virtual planning11. Digital techniques, such as

mirroring and superimposition, allow to create a virtual replica of the healthy hemi-mandible,
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which can be in turn used as a reference to orient the osteotomy performed on the condyle.
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As suggested in previous reports, this ultimately allows to remove the hyperplastic growth cen-
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ter and to perform simultaneous correction of the posterior vertical excess. 3D virtual surgical

planning has a very important role in our protocol, consisting of three steps: mirroring of the

contralateral healthy side, measurement of vertical amount excess, and positioning of the re-

section plane. Specifically, three-dimensional mirroring allows to recreate symmetry in the af-
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fected side, and enables to quantify the vertical excess, overcoming the imprecise traditional

two-dimensional cephalometric evaluation. In our series of patients, 3D-mirroring led to define

a precise level for condylectomy, in order to restore the symmetry of the mandible.

However, the process of transferring preoperative measurements to the operating room could

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be subject to procedural errors because intraoperative measurements to perform condylectomy

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were traditionally operator-dependent and not precise. Our updated protocol for computer

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guided proportional condylectomy provides a method to exactly reproduce the level of oste-

otomy, based on the creation of a 3D printed custom-made surgical guide, which fits the con-

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dylar head. The use of a surgical guide permitted to trace the precise level of osteotomy as

planned. Moreover, the surgical guide was designed to replicate the morphology of a new
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condyle, making it unnecessary to perform a reshaping of the condylar head after condylecto-
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my. The intraoperative positioning of this custom-designed surgical guide on the lateral condy-

lar pole was straightforward and fast, thus providing a feasible solution to connect results of
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computer guided condylectomy with surgical maneuvers. Modern 3D-printers are widespread
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and economically affordable, and rapid prototyping might become part of the daily surgical
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workflow for many centers.

Postoperative CBCT after 1 year was three-dimensionally reconstructed and allowed to assess

the intraoperative accuracy of proportional condylectomy compared with preoperative virtual

planning, demonstrating high concordance.

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CONCLUSIONS

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Proportional condylectomy has the advantage of reducing the need for secondary orthognathic

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surgery. The updated protocol for proportional condylectomy introduces two novel key steps:

1) the exact position of the resection plane based on three-dimensional virtual mirroring and

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the definition of the vertical discrepancies; 2) the use of an intraoperative custom designed

surgical cutting guide to transfer the virtual planning in the operating room. A computer-
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guided proportional condylectomy allows for precise reproduction of the virtual planning in
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the surgical field and provides advantages in terms of precision and predictability.
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References

1. Obwegeser HL, Makek MS: Hemimandibular hyperplasia--hemimandibular elongation. J

Maxillofac Surg 14: 183, 1986.

2. Kanishi D: 99mTc-{MDP} accumulation mechanisms in bone. Oral Surg Oral Med Oral

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Pathol 75: 239, 1993.

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3. Saridin CP, Raijmakers PGHM, Shamma S Al, Tuinzing DB, Becking AG: Comparison of

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different analytical methods used for analyzing SPECT scans of patients with unilateral

condylar hyperactivity. Int J Oral Maxillofac Surg 38: 942, 2009.

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4. Brusati R, Pedrazzoli M, Colletti G: Functional results after condylectomy in active

laterognathia. J Craniomaxillofac Surg 38: 179, 2010.

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5. Farina R, Pintor F, Pérez J, Pantoja R, Berner D. Low condylectomy as the sole treatment
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for active condylar hyperplasia: facial, occlusal and skeletal changes. An observational

study. Int J Oral Maxillofac Surg 44: 217, 2015.

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6. Jones RH, Tier GA. Correction of facial asymmetry as a result of unilateral condylar hy-
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perplasia. J Oral Maxillofac Surg 70: 1413, 2012.

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7. Delaire J, Gaillard A, Tulasne JF: [{The} place of condylectomy in the treatment of hyper-

condylosis]. Rev Stomatol Chir Maxillofac 84: 11, 1983.

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8. Mouallem G, Vernex-Boukerma Z, Longis J, Perrin JP, Delaire J, Mercier JM, Corre P: Effi-

cacy of proportional condylectomy in a treatment protocol for unilateral condylar hy-

perplasia: A review of 73 cases. J Cranio-Maxillofacial Surg 45: 1083, 2017.

9. Fariña R, Pintor F, Pérez J, Pantoja R, Berner D: Low condylectomy as the sole treatment

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for active condylar hyperplasia: Facial, occlusal and skeletal changes. An observational

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study. Int J Oral Maxillofac Surg 44: 217, 2015.

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10. Fariña R, Olate S, Raposo A, Araya I, Alister JP, Uribe F: High condylectomy versus pro-

portional condylectomy: Is secondary orthognathic surgery necessary? Int J Oral Maxillo-

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fac Surg 45: 72, 2016.

11. Higginson JA, Bartram AC, Banks RJ, Keith DJW: Condylar hyperplasia: current thinking.
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Br J Oral Maxillofac Surg, 2018.

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12. Saridin CP, Gilijamse M, Kuik DJ, Veldhuis EC te, Tuinzing DB, Lobbezoo F, Becking AG:

Evaluation of temporomandibular function after high partial condylectomy because of

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unilateral condylar hyperactivity. J Oral Maxillofac Surg 68: 1094, 2010.

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FIGURE LEGENDS
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Figure 1: Virtual surgical planning in proportional condylectomy. a) 3D reconstruction allows to

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identify asymmetry of the lower third and occlusal plane tilting. b) Virtual mirroring of contrala-

teral healthy side is superimposed to the side of condylar hyperplasia. c) the amount of vertical

excess which is to be removed is defined and d) a custom-designed condylar cutting guide is

modeled on the condylar head, allowing to precisely trace osteotomy as planned.

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Figure 2: Flowchart for the updated protocol in condylectomy

Figure 3: Surgical phases. a) custom-designed condylar cutting guide is positioned over the

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condylar head. b) Detail. The surgical guide allows to create a curved osteotomy in order to

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replicate the preoperative shape of the condylar head. c) Condylar head after cutting guide is

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removed.

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Figure 4: Surface deviation analysis. Green color corresponds to neglectable discrepancies be-

tween preoperative and postoperative entities while red color accounts for differences. Range
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is set to 1 mm difference detection. After one year, there is high similarity between preopera-
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tive planning and achieved outcome.

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Figure 5: Frontal view: a) preoperative; b) postoperative at 12-month follow-up.

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Figure 6: Intraoral view: a) preoperative; b) postoperative at 12-month follow-up.

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TABLES

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Age Gender Side of hyperplasia Clinical results after condylectomy Further treatment

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23 female right Satisfactory Elastic therapy and

Orthodontics

22 female right

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Orthodontics
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29 male right Satisfactory Elastic therapy and

Orthodontics
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28 male left Non satisfactory Elastic therapy and

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Orthodontics + orthog-
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nathic surgery

19 female left Satisfactory Elastic therapy and

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Orthodontics
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27 female right Satisfactory Elastic therapy and

Orthodontics

25 female left Satisfactory Elastic therapy and

Orthodontics
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Table 1: Demographic and clinical data of patients included in the study.

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Dear Editor and Reviewers,

We are grateful Your valuable requests, which have been accomplished.

Changes have been highlighted in blue color.

Figures have been submitted as individual views.

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Best regards,

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The Authors

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