Case Report

Unilateral condylar hyperplasia treated with simultaneous 2-jaw

orthognathic surgery and posterior segmental osteotomy
Seong-Sik Kima; Kyu-Sung Jungb; Yong-Il Kima; Soo-Byung Parka; Sung-Hun Kimc

ABSTRACT

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A 25-year-old woman presented with left condylar hyperplasia, canting-type facial asymmetry,
mandibular prognathism, and arch width discrepancy. Bone scintigraphy confirmed the inactive
status of the condyle, and the temporomandibular joint functioned within the normal range; thus,
orthognathic surgery without condylectomy was performed. To correct facial asymmetry
successfully through orthognathic surgery, sufficient dentoalveolar decompensation must be
achieved in the presurgical orthodontic phase. In cases of canting-type facial asymmetry, teeth on
the nondeviated side are extruded as dentoalveolar compensation. Therefore, vertical decompen-
sation is required for intrusion of the extruded teeth. A miniscrew and resin build-ups were used for
the intrusion of teeth, and posterior segmental osteotomy was simultaneously performed with
orthognathic surgery for further intrusion. The canting-type facial asymmetry was notably corrected
through successful vertical decompensation and close cooperation between orthodontists and
maxillofacial surgeons. After 2 years of retention, the treatment results remained stable. (Angle
Orthod. 2023;93:236–252.)
KEY WORDS: CBCT; Unilateral condylar hyperplasia; Posterior segmental osteotomy

INTRODUCTION very rare condition, is caused by excessive growth of

the mandibular condyle, leading to facial asymmetry,
The pursuit of beauty through symmetry has been
mandibular prognathism, and temporomandibular dis-
noted throughout human history.1 For example, the Taj
order (TMD).5 CH is more common in women than in
Mahal is an architectural monument that demonstrates
men,6 and its pathogenesis has not been completely
the beauty of symmetry. Humans prefer symmetric
elucidated.7
faces to asymmetric faces.2 Mild facial asymmetry is
The treatment options for CH depend on the age of
not obvious, owing to the soft tissue and dentoalveolar
the patient and the activity of the mandibular condyle.
compensation but facial asymmetry beyond a moder-
For adult patients, condylectomy is selected if the
ate level is easily noticeable.3
affected condyle has an active status, and orthognathic
Facial asymmetry has varying etiology, including
surgery is considered if the affected condyle has an
trauma, genetics, and tumors.4 One cause of severe
inactive status.8,9
facial asymmetry is condylar hyperplasia (CH). CH, a
CH can be broadly classified into three types:
hemimandibular hyperplasia, in which the vertical
a
Professor, Department of Orthodontics, Dental Research
Institute, and Dental and Life Science Institute, School of lengths of the mandibular condyle and ramus increase;
Dentistry, Pusan National University, Yangsan, South Korea. hemimandibular elongation, in which the horizontal
b
Private Practice, Seoul, South Korea. lengths of the mandibular condyle and ramus increase;
c
Assistant Professor, Department of Orthodontics, Dental or a hybrid form.9–11 In the hybrid form, there is a
Research Institute, and Dental and Life Science Institute, School
of Dentistry, Pusan National University, Yangsan, South Korea. combination of the 2 vectors, with a resultant severe
Corresponding Author: Dr Sung-Hun Kim, Department of expression of the pathology. If the unilateral mandib-
Orthodontics, Dental Research Institute, and Dental and Life ular condyle increases in length vertically, canting-type
Science Institute, School of Dentistry, Pusan National University, facial asymmetry occurs. On the other hand, if the
Yangsan, South Korea. 50612
(e-mail: kmule@hanmail.net)
unilateral mandibular condyle increases in length
horizontally, chin deviation occurs.10 Canting-type
Accepted: September 2022. Submitted: June 2022.
Published Online: November 9, 2022 facial asymmetry leads to dentoalveolar compensation,
Ó 2023 by The EH Angle Education and Research Foundation, with extrusion of teeth on the nondeviated side. To
Inc. correct canting-type facial asymmetry successfully

Angle Orthodontist, Vol 93, No 2, 2023 236 DOI: 10.2319/060122-401.1

CONDYLAR HYPERPLASIA TREATED WITH 2-JAW SURGERY 237

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Figure 1. Pretreatment facial and intraoral photographs.

through orthognathic surgery, vertical decompensation On the pretreatment facial photograph, severe facial
is needed for the intrusion of these teeth.12,13 Methods asymmetry was observed with the chin deviated to the
using miniscrews or miniplates can be employed for right and the lip canted up on the right (Figure 1). On
the intrusion of teeth; however, for further intrusion, a the pretreatment intraoral photograph and digital
surgical approach, such as segmental osteotomy or model, the anterior teeth showed a crossbite, the right
contouring surgery, is needed.14
posterior teeth showed a buccal crossbite, and the left
In this report, a case of a patient with canting-type
facial asymmetry resulting from CH is described in posterior teeth showed an open bite (Figure 2). The
which simultaneous 2-jaw orthognathic surgery and pretreatment panoramic radiograph showed left con-
posterior segmental osteotomy were used. dylar hyperplasia and mandibular molar height dis-
crepancy. On posteroanterior cephalogram, severe
Diagnosis and Etiology mandibular canting was observed, and the frontal
The patient was a 25-year-old woman with a chief occlusal plane was not parallel to the Go-Go’ plane
complaint of facial asymmetry. She had no significant (Figure 3). The lateral cephalogram and tracing (Figure
medical, traumatic, or family history. A clicking sound 4) showed mandibular prognathism (Table 1) and a
was noted in the left temporomandibular joint (TMJ). severe height difference between the left and right
However, there were no specific TMDs. lower mandibular borders.

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Figure 2. Pretreatment digital models.

According to cone-beam computed tomography selected for optimal results instead of camouflage
(CBCT), the left mandibular ramal height was 24.1 treatment. Two surgical options were discussed: (1) 2-
mm longer than the right mandibular ramal height, and jaw orthognathic surgery with condylectomy, and (2) 2-
the left mandibular body length was 7.0 mm longer jaw orthognathic surgery without condylectomy. The
than the right mandibular body length. Menton was latter option was selected because the inactive status
tipped 22.9 mm to the right, and the mandibular dental of the condyle was confirmed through bone scintigra-
midline was deviated 8.1 mm to the right (Figure 5). An phy (condyle-to-clivus ratio: 1.11, relative percentage
arch width discrepancy (AWD) was noted, in which the uptake: 50.4%), and the TMJ functioned within the
maxillary width was 8.1 mm shorter than the mandib- normal range. In addition, because the intrusion of
ular width based on the furcation of the first molar. The mandibular molars using a miniscrew and resin build-
height of the left mandibular first molar was 6.8 mm up has limitations, a posterior segmental osteotomy
higher than that of the right mandibular first molar. The was planned simultaneously with the 2-jaw surgery for
right maxillary molars were buccally inclined (Figure 6). additional intrusion of the left mandibular molars.
Because the patient had canting-type facial asymmetry
and chin deviation, the patient was diagnosed with a Treatment Progress
hybrid form of condylar hyperplasia.
Presurgical orthodontic treatment. First, the maxilla
Treatment Objectives was expanded to improve the AWD. Considering the
patient’s age and the large amount of expansion
The treatment goals for this patient were: (1)
needed, a miniscrew-assisted rapid palatal expansion
correction of the AWD, (2) intrusion of the left
(MARPE) or surgically assisted rapid palatal expansion
mandibular molar region and decompensation of
(SARPE) could be used. Because SARPE was an
buccolingual inclination in the molar region, (3)
invasive surgical procedure with high risks and high
correction of facial asymmetry and mandibular prog-
costs,15 MARPE was used first (Figure 7). If MARPE
nathism, (4) development of normal overbite and
failed, it was planned to consider SARPE. After
overjet, and (5) development of a good occlusal
maxillary expansion, a fixed orthodontic appliance
relationship and improvement of esthetics.
was bonded to begin leveling and alignment. For
intrusion, a miniscrew was implanted between the left
Treatment Alternatives
mandibular first and second molars. Resin build-ups,16
Since there was severe facial asymmetry with which did not require patient cooperation and could be
mandibular prognathism, the surgical method was used even in the presence of brackets and wires, were

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Figure 3. Pretreatment radiographs.

applied to the occlusal surfaces of the left mandibular crisscross elastics were used for decompensation of
molars to attempt further intrusion (Figure 8). Study the buccolingual inclination and arch coordination. An
casts were frequently obtained to be analyzed for arch open coil spring was inserted between the left
coordination. The miniscrew of the MARPE and mandibular second premolar and first molar to create

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Table 1. Cephalometric Measurements

Measurements Norm Initial Final
SNA (8) 81.6 85.8 87.7
SNB (8) 79.1 89.3 85.3
ANB (8) 2.4 3.5 2.4
FMA (8) 25.0 23.6 26.7
U1-SN (8) 107.0 120.7 104.0
IMPA (8) 95.9 83.9 91.2
Overbite (mm) 2.3 v1.7 2.2
Overjet (mm) 3.2 2.0 2.9

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tomized posterior segment was fixed using a long
screw.

Postsurgical Orthodontic Treatment

One month after orthognathic surgery, the left
vertical elastics on the miniscrews, which were
implanted for intermaxillary fixation, were used to
stabilize the occlusion. A lace-back was used to fix
the left mandibular molar region where the posterior
segmental osteotomy was performed. Three months
after surgery, a full archwire was inserted to the left
mandibular molar for tooth movement. After 14 months
of postsurgical orthodontic treatment, good occlusion
was achieved and facial asymmetry was improved.
After debonding the fixed orthodontic appliances, fixed
Figure 4. Pretreatment lateral cephalogram tracing.
retainers were bonded in the anterior region. Circum-
ferential retainers were then placed in the maxilla and
mandible.
a gap for the incision for segmental osteotomy. After 13
months, the AWD and buccolingual inclination of the
Treatment Results
molar region were corrected. Interocclusal clearance
was also accomplished since it was required for After 27 months of treatment, a Class I molar and
canting correction on the left (Figure 9). canine relationship was achieved (Figures 12–19). The
correction of the AWD improved the right posterior
Orthognathic Surgery buccal crossbite. ANB improved from 3.58 to 2.48,
improving the mandibular prognathism and anterior
At the immediate presurgical timepoint, re-evaluation crossbite. The midlines of the maxilla and mandible
was done and showed that Le Fort I osteotomy was were aligned, producing a normal overbite and overjet.
required for leveling though the initial plan had been to The canted occlusal plane was significantly improved,
avoid Le Fort I osteotomy. A 3-dimensional surgical leading to facial symmetry. The lateral cephalogram
simulation was used to plan the orthognathic surgery showed an improvement in the height difference
(Figure 10). Propelling Le Fort I osteotomy,17,18 which between the left and right lower mandibular borders.
involved shortening of the longer side and lengthening The patient did not show any specific discomfort in the
of the shorter side, was performed in the maxilla to TMJ. After 2 years of retention, the treatment results
improve maxilla canting. Considering the deviated remained stable (Figure 20).
chin, asymmetric setback sagittal split ramus osteoto-
my was performed in the mandible. To reduce the gap DISCUSSION
between the proximal and distal segments, an inten- In general, patients with CH have a normal mandib-
tional osteotomy of the posterior part of the distal ular shape but a vertically longer mandibular condyle.
segment was performed.19 To fill the remaining gap, a As a result, canting-type facial asymmetry occurs.20
bone graft using the residual bone was performed. In Camouflage orthodontic treatment is used in some
addition, for the intrusion of the left mandibular molar, cases of mild CH, but this is not an ideal solution.
posterior segmental osteotomy was performed simul- Condylectomy can be considered a priority for cases of
taneously with 2-jaw surgery (Figure 11). The osteo- CH beyond a moderate level, but there is a risk of

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Figure 5. Pretreatment cone-beam computed tomography images.

temporomandibular dysfunction after surgery. 21–23 CH must wait until growth ceases because facial
Therefore, if the patient’s condyle is confirmed to be asymmetry may get severe.8
inactive through bone scintigraphy, orthognathic sur- Patients with severe facial asymmetry require
gery is recommended.8,9 In addition, adolescents with orthognathic surgery with orthodontic treatment to

Figure 6. Pretreatment coronal cut of cone-beam computed tomography at the first molar site and dental arch width.

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Figure 7. Maxillary expansion using miniscrew-assisted rapid palatal expander.

improve function and esthetics. Orthognathic surgery teeth, mesiodistal and buccolingual inclination of the
for facial asymmetry first adjusts the maxilla to the posterior teeth, and extrusion of teeth because teeth
facial midline in the natural head position and then move to compensate for skeletal disharmony. There
adjusts the mandible to the maxillary midline. The aim are different methods for dentoalveolar decompensa-
of presurgical orthodontic treatment is dentoalveolar tion depending on the type of facial asymmetry
decompensation. In other words, it is important to (canting, yawing, or translation type).12,24 Horizontal
evaluate the labiolingual angulation of the anterior decompensation is needed in yawing-type facial

Figure 8. Left lower molar intrusion using a miniscrew and resin buildups.

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Figure 9. Intraoral photographs immediately before orthognathic surgery.

asymmetry to make the mesiodistally inclined teeth achieved by surgical methods, including lower border
upright. Transverse decompensation is needed in ostectomy and subapical segmental osteotomy. There
translation-type facial asymmetry to make the bucco- is a risk of damaging the inferior alveolar nerve during
lingually inclined teeth upright. Vertical decompensa- lower border ostectomy, which may require inferior
tion is needed in canting-type facial asymmetry for alveolar nerve repositioning.14,26 In this case, this
intrusion of the extruded teeth on the non-deviated approach was excluded because the lower mandibular
side. If presurgical orthodontic treatment fails to border and the mandibular canal of the patient were too
achieve sufficient dental decompensation, it is difficult close to each other. There are two methods of posterior
to improve skeletal disharmony. segmental osteotomy: one performed separately from
CH occurs at an early age and progresses over the 2-jaw surgery,22 and one performed simultaneously
long term, leading to the extrusion of the teeth on the with 2-jaw surgery. The disadvantage of the former
nondeviated side owing to vertical compensation method is that the patient has to undergo surgery
(Figure 21).25 Because of the extrusion of the teeth, under general anesthesia twice. Therefore, in the case
the frontal occlusal plane is not parallel to the Go-Go’ presented, the latter method was selected; however,
plane, which makes it difficult to completely correct because of its difficulty, this method requires close
canting-type facial asymmetry. If presurgical orthodon- cooperation between orthodontists and maxillofacial
tic treatment fails to achieve sufficient vertical decom- surgeons from the diagnosis phase.
pensation, it will lead to a lack of interocclusal Depending on the methods, the amount of molar
clearance on the nondeviated side and, consequently, intrusion was different. The average amount of molar
mandibular asymmetry will remain because the man- intrusion with resin buildups was 1 mm.16 The average
dible cannot roll enough during orthognathic surgery. amount of mandibular first and second molar intrusion
Contouring surgery or overcorrection of maxillary with miniscrews was 1.7 mm and 2.8 mm, respective-
canting can be alternatives, but they are not funda- ly.27 A case report showed that the amount of molar
mental treatments.25 Therefore, orthognathic surgery intrusion with maxillary posterior segmental osteotomy
after sufficient vertical decompensation is the best was approximately 7 mm.28
treatment option for improving canting-type facial The miniscrew, which was implanted only on the
asymmetry. buccal side of the mandible, caused intrusion as well
Orthodontic intrusion mechanisms, such as minis- as buccoversion of the teeth. The combination of
crews or resin buildups, can be applied for intrusion of miniscrews with light force and fixed orthodontic
extruded teeth. However, because such methods offer appliances with rigid rectangular archwires may pro-
only a limited amount of intrusion, further intrusion is vide a balanced force system for effective intrusion of

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Figure 10. 3D simulation for orthognathic surgery.

molars. In addition, the occlusal force of resin buildup CONCLUSIONS

helped control the buccolingual root axis.  To successfully correct facial asymmetry through
There were some limitations with the results of
orthognathic surgery, sufficient dentoalveolar decom-
treatment. First, the patient still showed a prognathic
pensation must be achieved in the presurgical
chin because a posterior impaction of the maxilla was
not sufficiently performed. Second, the patient still orthodontic phase.
showed a difference in the mouth commissure and the
 In the case presented of canting-type facial asym-
mandibular border. This would be enhanced by metry caused by CH, miniscrews and resin build-ups
additional surgery such as muscle attachment sur- were used for vertical decompensation.
gery29 and contouring surgery.22  For further vertical decompensation, posterior seg-
Canting-type facial asymmetry resulting from CH mental osteotomy was simultaneously performed
was successfully corrected through simultaneous 2- with 2-jaw orthognathic surgery.
jaw orthognathic surgery and posterior segmental  An improvement in canting-type facial asymmetry
osteotomy. After 2 years of retention, the patient had was achieved because of successful vertical decom-
no TMD and maintained a good facial appearance and pensation and close cooperation between orthodon-
occlusion. Long-term follow-up is needed in the future. tists and maxillofacial surgeons.

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Figure 11. Left lower molar segmental osteotomy for molar intrusion.

ACKNOWLEDGMENTS 9. Wolford LM, Movahed R, Perez DE. A classification system

for conditions causing condylar hyperplasia. J Oral Max-
This work was supported by a 2-year research grant of Pusan illofac Surg. 2014;72:567–595.
National University. 10. Obwegeser HL, Makek MS. Hemimandibular hyperplasia–
hemimandibular elongation. J Maxillofac Surg. 1986;14:
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Figure 12. Posttreatment facial and intraoral photographs.

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Figure 13. Posttreatment digital models.

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Figure 14. Posttreatment radiographs.
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Figure 16. Cephalometric superimpositions. Blue line: pretreatment,
black line: posttreatment.

Figure 15. Posttreatment lateral cephalogram tracing.

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Figure 17. 3D volume-rendering images.

Figure 18. Occlusal canting correction.

Figure 19. Changes in the height of the mandibular first molar

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Figure 20. Facial and intraoral photographs after 2 years of retention.

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Figure 21. Dentoalveolar compensation in case of canting-type facial asymmetry.

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