Low Condylectomy and Orthognathic Surgery to Treat Mandibular Condylar Osteochondroma: A Retrospective Review of 37 Cases

A proposed protocol for correlation between bone density in hemimandibular hyperplasia radiography and histopathological findings - A retrospective study

The role of low-dose computed tomography (LDCT) in surgical planning can be assessed based on the correlation among bone density (BD/HU), radiographic values, and the histopathological appearance of hyperplastic overgrowth in mandibular condyles (hemimandibular hyperplasia/osteochondroma). The aim of this study was to evaluate the correlation between LDCT indices of bone-density measurements in surgical planning and histopathological specimens. The patients incuded in this study underwent detailed radiological evaluation as preparation for further clinical procedures. Excised condyles were evaluated in terms of bone density index using LDCT, and then histopathologically to investigate the accuracy of surgical procedures and set the basis for future surgical planning. An index value between both condyles' bone densities represented the relative difference between the healthy condyle and the side with hemimandibular hyperplasia (HH). Patients with unilateral condylar hyperplasia (UCH) showed a statistical correlation between condyle heads with increased bone density (BD) and scintigraphic (SCI) values (p < 0.001). On the other hand, correlation between BD and histopathological studies alone was significant (p < 0.001). With the increase in BD measured in HU in UCH condyles, the overall value of fibrous cartilage layer thickness decreased (p < 0.001). Furthermore, histopathological evaluation indicated that increased bone density on the UCH side resulted in increased total thickness (p > 0.001). The proposed index measurements in the mandibular condyles based on LDCT/BD can be used to estimate the degree of required surgical resection. Results from LDCT radiographic studies correlate with histopathological specimens more than scintigraphy.

'Adaptable condylectomy' for acquired facial asymmetry and malocclusion caused by temporomandibular joint condylar hyperplasia

This article describes the 'adaptable condylectomy' and highlights two innovative treatment protocols for the variety of acquired facial asymmetry and associated malocclusion caused by condylar hyperplasia, as illustrated by the cases of seven patients presenting different manifestations of condylar hyperplasia. Protocol I (three cases) is applied for condylar hyperplasia with a normal occlusion and involves a high condylectomy, with the goal of guiding the mandible back to the original occlusion. Protocol II (four cases) is applied for condylar hyperplasia with diverse acquired malocclusions and involves condylectomy at a level adapted to the malocclusion, allowing the mandible to be guided back to the occlusion that pre-existed the active change caused by the condylar hyperplasia, or to a position as close to the midline as possible. Both protocols are followed by gradual self-correction of the acquired facial asymmetry. These protocols often obviate the need for further surgical intervention and, if further correction is needed, it is much simpler.

Intraoral Condylectomy with 3D-Printed Cutting Guide versus with Surgical Navigation: An Accuracy and Effectiveness Comparison

This study compares the accuracy and effectiveness of our novel 3D-printed titanium cutting guides with intraoperative surgical navigation for performing intraoral condylectomy in patients with mandibular condylar osteochondroma (OC). A total of 21 patients with mandibular condylar OC underwent intraoral condylectomy with either 3D-printed cutting guides (cutting guide group) or with surgical navigation (navigation group). The condylectomy accuracy in the cutting guide group and navigation group was determined by analyzing the three-dimensional (3D) discrepancies between the postoperative computed tomography (CT) images and the preoperative virtual surgical plan (VSP). Moreover, the improvement of the mandibular symmetry in both groups was determined by evaluating the chin deviation, chin rotation and mandibular asymmetry index (AI). The superimposition of the condylar osteotomy area showed that the postoperative results were very close to the VSP in both groups. The mean 3D deviation and maximum 3D deviation between the planned condylectomy and the actual result were 1.20 ± 0.60 mm and 2.36 ± 0.51 mm in the cutting guide group, and 1.33 ± 0.76 mm and 4.27 ± 1.99 mm in the navigation group. Moreover, the facial symmetry was greatly improved in both groups, indicated by significantly decreased chin deviation, chin rotation and AI. In conclusion, our results show that both 3D-printed cutting-guide-assisted and surgical-navigation-assisted methods of intraoral condylectomy have high accuracy and efficiency, while using a cutting guide can generate a relatively higher surgical accuracy. Moreover, our cutting guides exhibit user-friendly features and simplicity, which represents a promising prospect in everyday clinical practice.

The learning curve of transoral condylectomy; a retrospective analysis of 100 consecutive cases of unilateral condylar hyperplasia

In this study, 100 consecutive scheduled transoral condylectomies for unilateral condylar hyperplasia were included. The safety and surgical performances were assessed, using the operating time, conversion rate and complication rate. The conversion rate learning curve was evaluated with a learning curve cumulative summation (LC-CUSUM). The total conversion rate was 8.0%. The LC-CUSUM for conversion signaled at the 53th procedure, indicating sufficient evidence had accumulated that the surgeon had achieved competence. For procedures 54-100, the conversion rate was 4.0%. The operating time for the transoral condylectomy was 41.5 ± 15.3 min; when a conversion was necessary, the operating time was 101.4 ± 28.3 min (p < 0.05). The estimated operating time in the post-learning phase was 37 min, this was reached after approximately 47 procedures. There was 1 major complication of a permanent inferior alveolar nerve hypoesthesia. The complication rate was not significantly decreased after the learning curve. Within the limitations of the study, it seems that transoral condylectomy for UCH is a safe procedure with several advantages over the traditional preauricular approach. Surgeons starting this procedure should be aware of the potential complications and of the learning curve of approximately 53 procedures.

Evaluation of treatment with unilateral mandibular sagittal split ramus osteotomy and maxillary osteotomy in patients with condylar osteochondroma and mandibular asymmetry: A retrospective case series

The aim of the study was to describe an approach where condylar resection with condylar neck preservation was combined with Le Fort I osteotomy and unilateral mandibular sagittal split ramus osteotomy (SSRO). Patients with a unilateral condylar osteochondroma combined with dentofacial deformity and facial asymmetry who underwent surgery between January 2020 and December 2020 were enrolled. The operation included condylar resection, Le Fort I osteotomy and contralateral mandibular sagittal split ramus osteotomy (SSRO). Simplant Pro 11.04 software was used to reconstruct and measure the preoperative and postoperative craniomaxillofacial CT images. The deviation and rotation of the mandible, change in the occlusal plane, position of the "new condyle" and facial symmetry were compared and evaluated during follow-up. Three patients were included in the present study. The patients were followed up for 9.6 months on average (range, 8-12). Immediate postoperative CT images showed that the mandible deviation and rotation and occlusion plane canting decreased significantly postoperatively; facial symmetry was improved but still compromised. During the follow-up, the mandible gradually rotated to the affected side, the position of the "new condyle" moved further inside toward the fossa, and both the mandible rotation and facial symmetry were more significantly improved. Within the limitations of the study it seems that for some patients a combination of condylectomy with condylar neck preservation and unilateral mandibular SSRO can be effective in achieving facial symmetry.

Clinical Application of Individualized 3D-Printed Templates in the Treatment of Condylar Osteochondroma

BACKGROUND

Osteochondroma (OC) is one of the most common benign tumors of the long bones, but it rarely occurs in the maxillofacial skeleton. However, mandibular condylar OC often leads to severe facial deformity in affected patients, including facial asymmetry, deviation of the chin, and malocclusion. This study aimed to explore the clinical application of individualized 3D-printed templates to accurately and effectively treat condylar OC.

METHODS

A total of 8 patients with mandibular condylar OC were treated from July 2015 to August 2021. The enrolled patients (5 women and 3 men) had a median age of 27 years (range: 21-32 years). All patients exhibited symptoms of facial asymmetry and occlusal disorders preoperatively. The digital software used to virtually design the process consisted of three-dimensional reconstruction, 3D-cephalometry analysis, virtual surgery, individualized templates, and postoperative facial soft-tissue prediction. A set of 3D-printed templates (DOS and DOT) were used in all cases to stabilize the occlusion and guide the osteotomy. Then, pre- and post-operative complications, mouth opening, clinical signs, and the accuracy of the CT imaging analysis were all evaluated. All the measurement data were presented as means ± SD; Bonferroni and Tamhane T2 multiple comparison tests were used to examine the differences between the groups.

RESULTS

All patients healed uneventfully. None of the patients exhibited facial nerve injury at follow-up. In comparing the condylar segments with T0p and T1, the average deviation of the condylar segments was 0.5796 mm, indicating that the post-operative reconstructed condyles showed a high degree of similarity to the reconstruction results of the virtual surgical plan.

CONCLUSIONS

Individualized 3D-printed templates simplified surgical procedures and improved surgical accuracy, proving to be an effective method for the treatment of patients with slight asymmetric deformities secondary to condylar OC.

"Proportional Condylectomy" for Vertical Condylar Hyperplasia Without Intermaxillary Elastics: Clinical Results and Patient Satisfaction

OBJECTIVES

First, to investigate the clinical outcome of 'proportional condylectomy' for patients with active unilateral condylar hyperplasia without complementary treatment by intermaxillary elastics and, second, to examine their level of satisfaction regarding function and esthetics.

STUDY DESIGN

A retrospective observational descriptive study was conducted. All patients included in the study suffered from active unilateral condylar hyperplasia with a vertical component. The length of the condylar-ramus unit was measured on both sides by an multidetector computed tomography scan. The difference was calculated and resected from the hyperplastic condyle during the operation. Facial, occlusal, and skeletal changes were evaluated using photographic and radiologic records, and a satisfaction questionnaire regarding function and esthetics was completed. P<0.05 was considered significant.

RESULTS

Fifteen patients were included in the study. The mean participants' age was 27.93±13.06 years, and the mean follow-up duration was 12.40±6.55 months. The mean chin deviation improved by 58.47% (P=0.001). Mean lip commissure plane tilt was improved by 61.31% (P=0.001). Six months postoperatively, all patients exhibited centered dental midlines (P=0.001). Occlusal plane tilt was significantly improved by 70.02% (P=0.001), and high patient satisfaction was recorded. Twenty-six percent (4/15) of patients did not require the complementary orthodontic treatment, and none of them required complementary orthognathic surgery.

CONCLUSIONS

'Proportional condylectomy' for patients with active unilateral vertical condylar hyperplasia without complementary treatment by intermaxillary elastics is a predictable procedure in terms of function and esthetics.

Osteochondroma of the Scapula: A Case Report and Literature Review

Osteochondromas are bone lesions composed of medullary and cartilaginous bone covered by a cap of hyaline cartilage. The presence of medullary and cortical bone with the continuity of the tumor is pathognomonic for osteochondroma and aid in establishing the diagnosis. We report a case of a two-year-old girl who presented to our clinic following her mother noticing a palpable, growing, and painful mass on her left scapula. There was no limitation in the range of motion. A clear-cut mass was seen on the dorsal aspect and palpated measuring around 2.5x3 cm. Surgical excision of the mass followed by histologic examination confirmed osteochondroma. Upon follow-up, the patient had no pain and had a full range of left shoulder motion without discomfort or pain. In conclusion, scapular exostoses are very rare and more so when they present dorsally. Symptomatic lesions can be managed effectively with surgical excision of exostosis.

Can malocclusion provide clinicians with information for differential diagnosis of temporomandibular joint diseases?: A review

The aim of this literature review was to summarize the clinical characteristics and symptoms of temporomandibular joint diseases, and to discuss the associations between temporomandibular joint diseases and categorization of malocclusion. Electronic literature searches were performed using the PubMed database. The authors established a differential diagnostic method for temporomandibular joint diseases related to malocclusion. A literature search using PubMed yielded 213 texts, of which based on exclusion criteria, 28 were included in this study. Malocclusions were categorized into 5 types. The authors suggested a diagnostic tree of temporomandibular joint diseases based on the types of malocclusion and 4 variables in clinical characteristics and symptoms. Clinicians treating malocclusions must attempt to clarify the cause of the occlusal condition. If caused by temporomandibular joint disease, it is important to make a proper differential diagnosis at first, and not to overlook the causative disease. Further clinical knowledge of associations between temporomandibular joint diseases and malocclusions should be accumulated, and the diagnostic tree should be improved based on new information.

Can electrocautery of the mandibular condyle effectively treat condylar hyperplasia?

This study aims to introduce and evaluate a novel technique to treat unilateral condylar hyperplasia (UCH) by electrocauterization of the mandibular condyle via an intraoral approach. Patients suffering from unilateral condylar hyperplasia (UCH) were included in this study. All patients underwent electrocauterization of the affected condyle. An intraoral incision on the anterior border of the mandibular ramus was made to expose the external surface of the ramus and access the anterior border of the condylar head. A hole was then drilled into the condyle and cauterization was performed; six patients also received orthognathic surgery during the procedure. Patients underwent careful clinical assessment and radiological evaluation including panoramic view, lateral and posteroanterior cephalometry, cone-beam computed tomography (CBCT) and scintigraphy to assess condylar growth for a period of 12-24 months. Ten patients (5 male and 5 female) with active UCH type 1B or 2A were included in this study with a mean age of 20.7 years (range, 18-21.7 years). At the 12-month postoperative assessment, clinical evaluation showed stable dental occlusion with no midline shift; scintigraphy showed persistently reduced cellular activity, and computed tomography scans revealed no degeneration in either of the condyles with complete healing of the drilled holes. Within the limitations of this study it seems that the proposed treatment approach might be an alternative to previously established protocols.

Simultaneous Condylar Reconstruction by Free Ramus Osteotomy Graft After Complete Condylectomy for Osteochondroma

ABSTRACT

Mandibular condyle osteochondromas cause morphologic and functional disturbances. Multiple options exist for reconstructing the condylar segment following complete condylectomy. In this series, we describe 3 cases of mandibular condyle osteochondroma treated with complete condylectomy, orthognathic surgery, and a novel free ramus osteotomy graft. This is the first report to reconstruct the temporomandibular joint using a free ramus graft. Through this single-staged approach we were able to avoid recurrence, preserve function, and restore facial balance without a separate donor site or an alloplastic implant.

Unilateral Condylar Hyperplasia: Two Case Reports and a Literature Review

Condylar hyperplasia (CH) is a rare idiopathic condition affecting the mandibular condyle where the growth of the condylar head and/or neck continues beyond the normal growth period. The disorder presents clinically as facial asymmetry and occlusal discrepancy. Here, we present two cases of CH managed at our centers between 2012 and 2017 with a successful outcome. We highlight the clinical presentation, investigation, and surgical management and give a brief literature review.

Osteochondromas: An Updated Review of Epidemiology, Pathogenesis, Clinical Presentation, Radiological Features and Treatment Options

Osteochondroma, the most common benign bone tumor, is a projection on the external surface of the bone, which can be sessile or pedunculated. 85% of osteochondromas present as solitary lesions, while 15% occur in the context of hereditary multiple exostoses (HME), a genetic disorder that is inherited in an autosomal dominant manner. Although often asymptomatic, symptoms may eventuate from compression of adjacent vessels or nerves, fractures, osseous deformities, bursa formation, or malignant transformation. Cartilage cap thickness >2 cm in adults or >3 cm in children as well as new onset of pain or growth, or rapid growth of the lesion, especially after the closure of the growth plate, might reflect cancerous transformation. Surgical resection is indicated for symptomatic lesions, complications, cosmetic reasons or malignant transformation. Excision of the tumor with free margin is the treatment of choice. Local recurrence is less than 2% if complete resection is achieved.

Hemimandibular hyperplasia treatment with condylectomy and orthodontic camouflage treatment using miniplate

A 13-year-old growing female patient presented with hemimandibular hyperplasia of the right side, Class III hypodivergent skeletal pattern, and severe facial asymmetry. Corrective surgery was deferred until her growth had been completed. When the patient was 16 years old, a low condylectomy was performed on the hyperplastic side of her mandible to prevent its progressive condylar hyperplasia, while simultaneous orthodontic camouflage treatment was performed with the intrusion of the maxillary right posterior teeth using temporary skeletal anchorage devices without additional orthognathic surgery. A low condylectomy caused anterior and lateral open bite after the downward and backward movement of the chin, which improved Class III appearance. The intrusion of the maxillary right posterior teeth followed by compensating extrusion of the mandibular posterior teeth contributed to improve the patient's facial asymmetry with correction of the transverse occlusal plane and lip canting. After 30 months of treatment, an acceptable esthetic outcome and functional occlusion were achieved. The treatment results were well maintained for 1-year retention.

Osteochondroma of the mandibular condyle: Indications for different surgical methods: A case series of 7 patients

The aim of this study was to evaluate and discuss the long-term outcomes of patients with condylar osteochondroma managed through 3 different surgical techniques. Seven patients with condylar osteochondroma treated in the author's department from May 2012 to January 2019 were included in this retrospective study. Clinical evaluations (visual analogue scale for TMJ pain, jaw function, symmetry, and quality of life), maximum interincisal opening (MIO) and radiological findings were collected pre- and postoperatively. Other parameters assessed included tumour size and location; complications and follow-up. Radical condylectomy with immediate total joint alloplastic reconstruction was performed in 4 patients, local excision in 2 patients and low condylectomy with concomitant orthognathic surgery in 1 patient. During an average follow-up period of 40,8 months no clinical or radiographic signs of recurrence were found. Average MIO increased from 25,5mm to 39,5mm at the longest follow up, and all clinical evaluations were greatly improved. In conclusion, the described surgical techniques appear valuable in the treatment of condylar osteochondroma. Local excision is indicated in tumor involving less than half the surface of the condylar head; radical condylectomy with immediate alloplastic total joint reconstruction is indicated in gigantic lesion compromising the anatomical components and function of the joint. Orthognathic surgery procedures should be combined with tumor resection when correction of associated dentofacial deformities is indicated.

[Tumors affecting the temporomandibular joint - a literature review]

Benign and malign tumors can affect the temporomandibular joint (TMJ) as any other articulation. Nevertheless, TMJ tumors are rare and mostly benign. Their clinical expression is varied including symptomatology similar to TMJ dysfunctional disorders, otologic or neurologic pathologies. In some cases, they remain totally asymptomatic. Hence, diagnosis is difficult since the symptomatology can be misleading with TMJ dysfunctional disorders or otologic disorders wrongly diagnosed. There is thus frequently a long delay between symptoms onset and diagnosis. The great variety of TMJ lesions explains the wide range of possible treatment modalities, mostly based on surgery. We provide here a review of the lesions originating from the TMJ. Tumoral or cystic mandibular lesion affecting the TMJ through local extension will not be discussed. Osteoma, osteoid osteoma, osteoblastoma, chondroma, osteochondroma, chondroblastoma, tenosynovial giant cell tumors, giant cell lesions, non-ossifying fibroma, hemangioma, lipoma or Langerhans cell histiocytosis are all possible diagnosis among the benign tumors found in the TMJ. Pseudotumors include synovial chondromatosis and aneurysmal bone cyst. Finally, malign tumors of the TMJ include mainly sarcomas (osteosarcoma, chondrosarcoma, synovial sarcoma, Ewing sarcoma, and fibrosarcoma), but also multiple myeloma and secondary metastases. We will review the clinical, radiological and histological aspects of each of these lesions. The treatment and the recurrence risk will also be discussed.

Effect of condylar osteochondroma resection through an intraoral approach on the masticatory functions: a preliminary evaluation based on occlusion and temporomandibular joint functions

With this research, we aimed to evaluate the effect of condylar osteochondroma (OC) resection through an intraoral approach on the masticatory functions. Resection of condylar OC was carried out via an intraoral approach with the help of three-dimensional (3D) design, endoscope, and navigation system. The T-Scan III computerised occlusal analysis system was used to evaluate the occlusal force distribution, recorded at pre-treatment (T1) and post-treatment (T2) intervals. Records of the clinical examination of the temporomandibular joint (TMJ), including maximal interincisal opening, mandibular lateral and forward movements, were also collected. Ten patients with condylar OC were enrolled in this study. The difference of force distribution between bilateral occlusion was reduced in T2 compared with T1 (11.92% ± 4.41% vs 48.52 % ± 28.37%, p<0.05), indicating better occlusal force distribution obtained after surgery. There was no significant difference in functions of the TMJ, such as maximal interincisal opening, and mandibular lateral and forward movements between T2 and T1 (p>0.05). Accordingly, condylar OC resection through an intraoral approach would obtain a satisfactory occlusal balance with no impairment of the temporomandibular joint functions.

One-Stage Computer-Guided Customized Management of Skeletal Asymmetry by Concomitant Proportional Condylectomy and Orthognathic Surgery in Patients With Unilateral Condylar Hyperplasia

PURPOSE

Facial asymmetry associated with unilateral condylar hyperplasia can benefit from condylectomy, which aims to arrest the pathologic condylar growth and restore an appropriate posterior height. However, there are several cases in which condylar hyperplasia is combined with various dentofacial deformities, for which joint surgery has to be accompanied by concomitant orthognathic surgery. The literature is relatively poor of examples in which virtual planning for orthognathic surgery includes the evaluation of condylectomy, which is often manually performed. The aim of this study was to present and discuss a workflow for 1-stage computer-guided customized management of skeletal asymmetry by simultaneous condylectomy and orthognathic surgery.

MATERIALS AND METHODS

Five patients were enrolled in this study from 2018 to 2019. All patients underwent combined virtual planning of orthognathic surgery and condylectomy. Virtual surgery was translated into real surgical coordinates using patient-specific surgical guides and custom-designed osteosynthesis plates.

RESULTS

All surgical procedures were uneventful, and in all patients, virtual planning was successfully brought into the operating room with high accuracy, as confirmed by superimposition analyses. Symmetrization of the face and achievement of correct occlusion were observed in all cases.

CONCLUSIONS

The presented protocol is a reliable solution for the combined planning of orthognathic surgery and condylectomy. Virtual planning, surgical guides, and custom-designed plates allow computerized simulations to be replicated in the real patient.

Stability of Orthognathic Surgery in the Treatment of Condylar Osteochondroma Combined With Jaw Deformity by CT Measurements

PURPOSE

We evaluated the stability of orthognathic surgery in the treatment of unilateral condylar osteochondroma combined with jaw deformity.

PATIENTS AND METHODS

Patients with unilateral condylar osteochondroma and jaw deviation deformity who had undergone surgery at the Ninth People's Hospital of Shanghai Jiaotong University School of Medicine from July 2014 to March 2017 were enrolled. The operation included a low condylectomy and both Le Fort I osteotomy and bilateral mandibular sagittal split osteotomies. ProPlan CMF, version 1.4, software (Materialise, Leuven, Belgium) was used to reconstruct and measure the preoperative, immediately postoperative, and follow-up (>6 months) maxillofacial computed tomography images. The position of the jaw and contralateral condyle and remodeling of the affected side were compared during follow-up.

RESULTS

Eight patients were included in the present study. The canting of the maxilla was significantly decreased postoperatively, and the contralateral condyle had rotated inward. The position of the maxillary and contralateral condyles was stable during follow-up, and the posterior aspect of the affected condyle demonstrated significant resorption.

CONCLUSIONS

The results of single-stage surgery combined with orthognathic surgery and condylar osteochondroma resection were stable, and the affected condyle stump had adaptively reconstructed.

Spontaneous Condyle-Like Development after Total Resection of Mandible Giant Osteochondroma: Case Report and a Follow-Up for Five Years

Osteochondroma manifests as a benign tumor that occurs as an abnormal bony development. This tumor is commonly asymptomatic and presents an exophytic outgrowth on bone surfaces, near synovial joints, a condition that invariably induces evident facial deformities. Treatment for this type of tumor usually involves a surgical approach promoting a total or partial resection of the affected anatomical area associated to prosthetic reconstruction of the bone area extracted. We present a case report about a giant mandibular condyle osteochondroma in a 37-year-old female patient. Her treatment involved a total condylectomy without immediate condylar reconstruction, which would be performed in a posterior surgical approach. During the patient's follow-up (every 6 months of post operation), a spontaneous and rudimentary condyle-like formation was observed. Because the stomatognathic function and facial harmony were satisfactory, we observed the condyle-like development for 5 years of follow-up. Also, because both the aesthetic aspect and functional evolution of the maxillary bone were considered satisfactory, no complementary reconstruction surgical treatment was required for the giant osteochondroma of the mandibular condyle.

Histopathological features of condylar hyperplasia and condylar Osteochondroma: a comparison study

Background

Both mandibular condylar hyperplasia and condylar osteochondroma can lead to maxillofacial skeletal asymmetry and malocclusion, although they exhibit different biological behavior. This study attempted to compare the histological features of mandibular condylar hyperplasia and condylar osteochondroma using hematoxylin-and-eosin (H&E) staining, and immunohistochemistry staining of PCNA and EXT1 with quantitative analysis method.

Results

The H&E staining showed that condylar hyperplasia and condylar osteochondroma could be divided into four histological types and exhibited features of different endochondral ossification stages. There was evidence of a thicker cartilage cap in condylar osteochondroma as compared condylar hyperplasia (P = 0.018). The percentage of bone formation in condylar osteochondroma was larger than was found in condylar hyperplasia (P = 0.04). Immunohistochemical staining showed that PCNA was mainly located in the undifferentiated mesenchymal layer and the hypertrophic cartilage layer, and there were more PCNA positive cells in the condylar osteochondroma (P = 0.007). EXT1 was mainly expressed in the cartilage layer, and there was also a higher positive rate of EXT1 in condylar osteochondroma (P = 0.0366). The thicker cartilage cap, higher bone formation rate and higher PCNA positive rate indicated a higher rate of proliferative activity in condylar osteochondroma. The more significant positive rate of EXT1 in condylar osteochondroma implied differential biological characteristic as compared to condylar hyperplasia.

Conclusions

These features might be useful in histopathologically distinguishing condylar hyperplasia and osteochondroma.

Anatomical and Clinical Implications in Neocondyle Stability After a Condylectomy

: A condylectomy of the mandibular condyle is considered to be the treatment of choice in most cases of condylar head hyperactivity. The aim of the procedure is to remove the growth center of the mandible which is responsible for the mandibular enlargement and asymmetry. This surgical procedure has an impact on the condyle shape and position, but the restoration of mandibular movement and a stable joint position (namely, the proper alignment of the newly shaped condylar head within the condyle fossa) should also be considered important surgical outcomes. In this article, the authors present their own experience in performing condylectomies with an arthroplasty procedure and a special forced suturing technique (FST) in terms of achieving early, accurate mandibular movement and maintaining a stable condyle position in early and late outcomes.

MATERIALS AND METHODS

A modified high condylectomy with arthroplasty and FST results had been studied in anatomical, radiological, and clinical model.

RESULTS

Early findings after FST are promising. A slight improvement in lateral jaw movement was noted after condylectomy with arthroplasty (P < 0.05) both in early and late follow-up. Incisal opening, mandibular protrusion, and lateral movement were sustained. A stable condyle position within the fossa was achieved in each case of condylectomy with arthroplasty (P < 0.05).

CONCLUSIONS

The FST condylectomy and reattachment of the lateral pterygoid muscle in a new, wider position provided an improvement in lateral jaw movement as well as in incisal opening and mandibular protrusion in early follow-up examination compared to the presurgical values. It seems that the FST enabled a better new condylar head position in the glenoid fossa and improved early functional mandibular movement.

Comprehensive Post Orthognathic Surgery Orthodontics: Complications, Misconceptions, and Management

Post orthognathic surgery patient management is critical for high-quality and predictable outcomes. Surgeons and orthodontists must have the knowledge and ability to implement postsurgical management protocols and strategies to provide the best care and outcomes possible. This article presents basic concepts, philosophies, treatment protocols, risks, and potential complications associated with postsurgical patient management. Postsurgical orthodontic goals are to maximize the occlusal fit and provide predictable means to retain the occlusion. Aggressive orthodontic mechanics may be required to provide the best occlusal fit. Complications can occur, but early recognition of complications and implementation of corrective tactics should minimize adverse outcomes.

Osteochondroma of the coronoid process: A case report and review of the literature

Osteochondroma (OC) is considered the most common tumor of the axial skeleton, although it is relatively uncommon in the craniofacial region. The present study describes an atypical case of OC of the coronoid process. A 34-year-old woman presented with severely limited mouth opening (5 mm) and swelling of the right zygoma. Cone-beam computed tomography (CBCT) revealed a mushroom-shaped outgrowth from the coronoid process to the inner surface of the zygomatic arch, forming a pseudojoint. The patient was treated with coronoidectomy via an intraoral approach. Histopathological examination revealed features suggestive of OC. Subsequently, the patient was able to open their mouth, and there was no evidence of recurrence or post-operative complications in the 21-month follow-up. A review of the literature revealed only 38 histologically proven cases of coronoid OC in the past 30 years (1989-2018). The incidence of the disease was higher in men compared with that in women (male:female, 2.17:1), and the median age at onset was 28.7 years, with a range of 5-57 years. Gradual limitation of mouth opening and facial asymmetry are the most noticeable symptoms. Water's view and submentovertex projection of the zygomatic arch may be useful in identifying the tumor and its association with the zygoma, while CT and CBCT permit a detailed visualization of the location and density of the tumor. Coronoidectomy is the preferred treatment option, and the prognosis is excellent, with no evidence of recurrence or malignant transformation.

Three-dimensional skeletal changes after early proportional condylectomy for condylar hyperplasia

The purpose of this study was to evaluate volumetric and dentoskeletal changes in 21 patients with active unilateral condylar hyperplasia (AUCH) after proportional condylectomy. A split-mouth design was used: control group healthy joints (HS, healthy side) and test group affected joints (AS, affected side) (21 per group). Cone beam tomography scans were obtained at T0 (preoperative), T1 (10days after the intervention), and T2 (approximately 12 months post-surgery). The condylar unit volume (CUV), articular cavity volume (ACV), and dentoalveolar units (DAUs) were measured. CUV showed a difference of 1.12cm³ between T0 and T1, increasing 0.4cm³ between T1 and T2 on AS. There was no difference between T0 and T2 on HS. ACV increased 0.65cm³ between T0 and T1 on AS, after which it decreased by 0.36cm³ at T2 (0.30cm³ larger than the initial articular cavity at T0). ACV showed no post-surgery differences on HS. Midline DAU showed extrusion of 0.20mm for maxilla and 0.52mm for mandible, while in the lateral area, maxilla was extruded by 0.3mm on HS and was intruded 0.12mm on AS. For the mandible, both sides showed extrusion (0.4-0.6mm). In the distal to canine and molar areas, intrusion of 0.2mm and 0.9mm, respectively, was observed on AS; there was extrusion of 0.6mm distal to the canine on HS. At the mandibular level, AS distal to the canine showed extrusion of 1mm, while intrusion of 0.2mm was observed in the molars. For HS, only extrusion at the molar level (0.2mm) was observed. In conclusion, after proportional condylectomy, a neocondyle forms within 12 months to equal the healthy contralateral side. The articular cavity, which is reduced in the initial stage, increases in size after surgery and the volume gradually approaches that of the healthy side. Dentoalveolar changes occur at the anterior and posterior levels, causing intrusion and extrusion of the interdental crests. An early proportional condylectomy as the sole surgical treatment for patients with AUCH allows normalization of the maxillomandibular relationship.

Condilectomia alta associada à discopexia, com mini-âncoras, no tratamento da hiperplasia condilar: relato de caso

Introdução: A hiperplasia condilar (HC) é uma patologia rara caracterizada por crescimento não neoplásico que afeta a morfologia do côndilo mandibular com deformação progressiva. Dentre os sinais mais comuns se encontram a assimetria facial e mandibular, além de possíveisalterações oclusais como mordida aberta ipsilateral e transversal contralateral. Objetivo: O objetivo do estudo foi demonstrar a eficácia terapêutica da condilectomia alta associada à discopexia, com mini-âncoras, no tratamento da hiperplasia condilar. Relato de caso: Paciente de 24 anos de idade, apresentando assimetria facial, déficit e incompetência funcional mastigatória, mordida aberta posterior ipsilateral e mordida cruzada posterior contralateral. A proposta terapêutica escolhida foi o tratamento cirúrgico com condilectomia alta e discopexia com âncora para estabilização do disco articular, através de acesso endaural para o côndilo afetado com tamponamento auricular. Foi realizado infiltração com ácido hialurônico intra-articular após sutura da cápsula articular e sutura por planos para sutura da pele. Conclusão: A condilectomia alta preveniu a progressão da deformidade facial, minimizando as sequelas funcionais e estéticas, o que visa a favorecer o tratamento das deformidades faciais através de correção ortognática em segundo momento cirúrgico.

Three-dimensional evaluation of craniofacial characteristics related to mandibular asymmetries in skeletal Class I patients

INTRODUCTION

Our objective was to analyze the characteristics that affect skeletal Class I adults with mandibular asymmetries using cone-beam computerized tomography.

METHODS

The sample included cone-beam computerized tomography images of 120 subjects. Asymmetry was determined by the deviation of gnathion from the midsagittal plane and classified as relative symmetry, moderate asymmetry, or severe asymmetry. Maxillary and mandibular measurements were made, and the differences between the contralateral side and the deviated side were evaluated, as well as the differences between the categories of asymmetry.

RESULTS

For patients with moderate asymmetry, there were significant differences between the contralateral and deviated sides for some measuments in the transverse and vertical planes. For those with severe asymmetry, statistically significant differences were found between the sides for all measurements, except for the measuments that evaluated the position of the mandibular condyle in the transverse and sagittal directions. Furthermore, a strong correlation was found in patients with severe asymmetry, between the deviation of the mandibular dental midline and the lateral displacement of gnathion.

CONCLUSIONS

Patients with relative symmetry had a bilateral balance, whereas those with moderate and severe asymmetries showed several skeletal imbalances. A great deviation of the mandibular dental midline may indicate severe skeletal asymmetry in Class I adults.

Guideline for the Treatment of Condylar Osteochondroma Combined With Secondary Dentofacial Deformities

OBJECTIVE

Surgical treatment of condylar osteochondroma combined with secondary dentofacial deformities is a significant clinical challenge. The authors present this review article to provide some guidelines for the surgical treatment for this severely complex condition.

MATERIALS AND METHODS

Diagnosis and treatment protocol of condylar osteochondroma patients combined with secondary dentofacial deformities are discussed at the basis of published literatures and the authors' own clinical experiences. Proper treatment protocol was designed according to features of tumor and dentofacial deformities. Follow-up and radiographic examination was performed to evaluate recurrence of tumor, occlusion, joint function, and facial appearance after surgery.

RESULTS

The patients received 1 or several methods of resection of tumor, condylar reconstruction, correction of skeletal deformities, and treatment of malocclusion. The condylar ostechondroma and secondary dentofacial deformities were treated satisfactorily. Temporomandibular joint function, occlusion, and facial appearance were improved obviously after operation evidenced by radiographic examination and follow-up.

CONCLUSION

Surgical management of condylar osteochondroma with secondary dentofacial deformities requires careful patient selection, treatment planning, and precise execution. This article has reviewed the current status of surgical treatment options and provided practical guidelines for oral and maxillofacial surgeons to consider their clinical practice.

Computer-assisted surgical planning and simulation for unilateral condylar benign lesions causing facial asymmetry

OBJECTIVE

The purpose of this study was to investigate the best surgical sequence for the treatment of unilateral condylar benign lesions causing facial asymmetry by applying computer-assisted surgical planning and simulation.

STUDY DESIGN

Computed tomography (CT) data from 12 patients whose maxillary cant was corrected by maintaining the vertical position of the central incisors and equally intruding the long side of the maxilla and extruding the short side were analyzed by ProPlan CMF 1.4 software (Materialise Medical, Leuven, Belgium). Condylectomy and double jaw orthognathic surgery with 2 different surgical sequences were simulated: 1) maxillary LeFort I osteotomy first (MaxF), then condylectomy, followed by bilateral sagittal split ramus osteotomy (BSSO); and 2) mandible first (ManF), beginning with condylectomy, then BSSO, and lastly LeFort I osteotomy. The greatest space between the maxillary and mandibular first molar in the interim positions was measured virtually to compare the 2 surgical sequences.

RESULTS

The vertical distance between the upper and lower teeth of ManF patients was significantly smaller than that of MaxF patients (mean 2.99 mm, P < .001).

CONCLUSION

When occlusal cants are corrected by equally intruding one side and extruding the other side of the maxillary dentition, the interim position is more conducive to sequencing corrective surgery by performing condylectomy, then BSSO, followed by Le Fort I osteotomy.

Osteochondroma of the condyle: case report with 15 years of follow-up

Osteochondromas (OC) in the craniofacial region are very rare. Following on from a literature review published in 2011, further single case reports and case series are reviewed herein. To date, approximately 235 studies on OC of the mandibular condyle have been published in the English language literature. There is debate regarding the surgical techniques for treatment. Whereas the use of condylectomy has shown no recurrences, follow-up of conservative excision of the tumour has shown recurrence in three cases. One of these relates to the case presented here, which was first reported in 2002. The patient has declined any further surgery since that date. The tumour has shown no further growth and there is no functional impairment. This underlines Cottrell's claim that excision of the entire cartilage cap appears to stop the growth of the tumour and represents the most important focus of surgical treatment.

Minimally invasive intraoral condylectomy: proof of concept report

A significant proportion of facial asymmetry cases are caused by abnormal growth of the mandibular condyles. Surgical management is generally based on a condylectomy performed through a pre-auricular transcutaneous access. However, this approach entails potential neurovascular, salivary, and aesthetic complications. In this study, a proof-of-concept evaluation was performed of a novel minimally invasive technique for condylectomy performed through an intraoral approach. Based on precise three-dimensional virtual planning to define intraoperative references, this technique provides an excellent access for total or partial condylectomy through a limited intraoral incision. Piezoelectric surgery with customized attachments enables the safe, accurate execution of the condylectomy. In addition, experience gained in seven consecutive cases suggests that the need for coronoidectomy can be obviated, surgical time is reduced to an average of 16.9min, and postoperative morbidity is minimal. This alternative intraoral approach could become the treatment of choice for most condylar hyperplastic conditions.

Conservative condylectomy alone for the correction of mandibular asymmetry caused by osteochondroma of the mandibular condyle: a report of five cases

We describe our experience with conservative condylectomy for the correction of facial asymmetry in five patients with osteochondroma of the mandibular condyle. All five patients presented with malocclusion and facial asymmetry, which are common clinical findings of osteochondroma involving the mandibular condyle. We performed conservative condylectomy without additional orthognathic surgery for all five patients, preserving the vertical height of the condylar process as much as possible. Following surgery, intermaxillary traction using a skeletal anchorage system with rubber elastics was performed on all patients to improve occlusion, and, when necessary, additional minimal orthodontic treatment was performed. The mean follow-up period was 42 months. At the last follow-up visit, all patients exhibited satisfactory facial symmetry and remodeling of the remaining condyle, with stable health and no signs of recurrence. In conclusion, conservative condylectomy alone, without subsequent orthognathic surgery, is adequate for the restoration of facial symmetry and the preservation of vertical condylar height in select patients with condylar osteochondroma.

Treatment of Dentofacial Deformities Secondary to Osteochondroma of the Mandibular Condyle Using Virtual Surgical Planning and 3-Dimensional Printed Surgical Templates

PURPOSE

One-stage treatment for condylar osteochondroma and secondary facial deformities by resection and reconstruction of the mandibular condyle, orthognathic surgery, and mandibular contouring has been reported recently. This study investigated the clinical feasibility of treating osteochondroma of the mandibular condyle and secondary dento-maxillofacial deformities by virtual surgical planning and 3-dimensional (3D) printed surgical templates.

MATERIALS AND METHODS

A composite skull model with accurate dentition was obtained with data from spiral computed tomography (CT) and surface scanning of the dental arch. Virtual surgical simulation was performed using Dolphin Imaging 11.7 Premium and Mimics software after a comprehensive 3D diagnosis and surgery planning. Surgical templates were fabricated by 3D printing using data from virtual surgical simulation for guidance of excision of the mandibular condyle with osteochondroma, reconstruction of the mandibular condyle, mandibular contouring, and reconstruction of a normal occlusion. Le Fort I osteotomy of the upper jaw and genioplasty were performed when indicated. The linear difference between virtually simulated and postoperative skull models was evaluated.

RESULTS

All surgeries were successfully simulated using virtual surgical planning, and the guiding templates were successfully applied for all patients. Successful reconstruction of condylar function, normal occlusion, and symmetry of the facial profile was achieved. Postoperative CT scans and quantitative analysis showed that virtual surgical plans provided acceptable accuracy in the operating room. The linear difference of the incisors and first molars was no more than 1.4 mm, and the greatest difference was found for the menton landmark, which was up to 2.4 mm.

CONCLUSIONS

Results from this study suggested that virtual surgical planning and guiding templates facilitated accurate diagnosis, treatment planning, accurate osteotomy, repositioning of bony segments, and contouring of the mandibular border in the treatment of condylar osteochondroma and secondary facial asymmetry.