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Facial asymmetry and hemimandibular hyperplasia

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Here is the Keynote of a conference on temporomandibular disorders. The theme is facial asymmetries caused by unilateral condylar hyperplasia. The discussion also focuses on facial asymmetries caused by condylar hypoplasia.
This is the 1st part of an advanced course for orthodontists, oral surgeons and dentists.

This conference was presented to the Société dentaire de Québec, to resident students in orthodontics of the Université de Montréal and to residents in oral and maxillofacial surgeries of the Hôpital de l’Enfant-Jésus.

Objectives:

To differentiate non syndromic pathologies that cause facial asymmetry.

To understand the effects of unilateral condylar hyperplasia in a growing and non growing patient.

To understand the effects of condylar fracture or trauma (impact) to the joint that may affect mandibular growth.

To know the diagnostic tests and surgical treatments that are recommended.

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Questions and comments

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  1. caroline says:

    I have read Dr Chamberland’s report on facial asymmetry which was very helpful in the case of my daughter who is 23 and has increasing facial deformity, which is now very evident due to accelerated growth over the last 18 mths.
    She has significant mandibular asymmetry, mainly on the vertical dimension and significant cant of her maxilla, down on the right side.
    She has had a technetium scan and there is a very increased uptake in the right condylar area, growth is still active.
    OPT radiograph shows an element of hemimandibular hypertrophy with increased body height on the right side.
    We have been told that no treatment can be started until the growth has burned out.
    I would appreciate a second opinion as at the age of 23, my daughter is very aware and upset regarding her change of appearance of which no evidence was given to the length of time for growth to stop or other alternatives. She refuses any photographs to be taken front on, which is affecting her confidence.
    I am not a profession person in the medical world and would deeply appreciate a second opinion and whether prevention of further growth or exision of bone at the head of condyle, removing the condyle head, etc, can be done as well as a sagittal split osteotomy before growth stops.
    As examinations were done in November 2013, you may well advise a 2nd bone scan in April to assess growth and earlier trauma as Dr Chamberland highlighted and further advise would be gratefully accepted.

    1. Madame Caroline,

      Facial-asymmetry-_-Cant-of-the-occlusal-plane-Chamberland-Orthodontiste-QuebecYour 23 years old daughter has a facial asymmetry to the left with a vertical component, canting the occlusal plane to the right like this young girl on the left pict. The girl, in this exemple had a bone scan and the intake of the right side was the double of the left side (3,07 versus 1,56).

      We could have decide to wait and redo a bone scan in 6 months to see if the hypergrowth of the condyle is burning out, but since the asymmetry was evident, the question was: how much more facial asymmetry is she willing to tolerate before growth phaseout?

      Therefore, the decision was to do a high condylectomy as soon as possible. This case is shown in the keynote presentation above.

      One have to remember that significant facial asymmetry usually need bimaxillary surgery. This was the case of this girl, but she declined further treatment and the high condylectomy stopped asymmetric facial growth.

      In the situation of your daughter, i doubt it would be an undiagnose condylar fracture at an early age even if it is not impossible.

      If you could send me a similar photograph of your daughter and a panoramic radiograph, I could provide more specific information. You know my email. 

      Thank you Caroline for this excellent question. I value your concern about your daughter.

      Best regards

       

  2. Anna says:

    Dear dr Chamberland.
    My case is comparable and I have a similar question.
    I am a 40-year old women with slowly increasing facial asymmetry since my late twenties which is becoming more and more evident over the last 2 years. Other people are also telling me my appearance has changed and that my lower face looks canted /rotated.
    I have significant mandibular asymmetry, both on the vertical and horizontal dimension and a significant cant of my maxilla down on the right side.
    A technetium scan was performed in March 2014 which showed a slightly increased uptake in the right condylar area. Radiography showed hemimandibular hypertrophy with increased height (1,5 cm) on the right side.
    I was told that no treatment can be started until the growth has burned out, and in March 2015 a new technetium scan will be performed to check the condylar activity. However, I am worried the situation is becoming worse and worse, and the change of my appearance is really bothering me even though I am a mother of 4 who does not mind getting older in general.
    My asymmetric face and smile affect my self esteem. Therefore I would really like to ask your opinion.
    Would you advise prevention of further growth so that surgery can be performed? Or would you recommend waiting?
    Thank you in advance.

    1. Hi Anna,

      Thank you for sending pictures to help me for the diagnosis of your case.. I made a composite picture of 3 views to help the reader to understand.

      Asymetrie-faciale-vers-la-gauche-Chamberland-Orthodontiste-a-Quebec

      The picture confirms that you have a mandibular deviation to the left. On the smile view, we note that occlusal plane of the front teeth is canted to the right. The upper right teeth have more display when smiling compare to the left teeth. We see gums on the upper right side but not on the left side. The maxillary midline is inclined to the left while the lower midline is inclined to the right. Your case is very comparable to the case depicted above. You chin is allso canted to the right. On the picture on the far right, we can see that right mandibular gonial angle is lower that the left mandibular gonial angle.

      You say that this asymmetry begun to be noticeable in your late twenties and your are 40 years old.

      You definitely have after-effect of a hypercondyle, slowly but continuuously growing condyle. The maxilla has adapted over the years to the overgrowing condyle and skeletal and dental compensation occurred. You said that the radiography show a 15 mm increase of height of the ramus on the right side.

      You had a bone scan in march 2014 that confirm an increase uptake of the right condyle. You are schedule for another bone scan next march 2015.

      I agree with the approach of 2 bone scan, but i would have made them 6 months apart, not 12 months. Since march is coming soon, there no reason to not do another bone scan and if you can have your rendez-vous earlier, it is nice.

      I understand that your asymmetric face affect your self esteem and despite this asymmetry you have a very good looking (vous êtes jolie). But because you are “jolie”, i understand that you would like to correct the asymmetry of you face.

      I ask you for a panorammic xray, which you will send me by next week i hope. I want to see if your condyle is elongated or enlarge. There is a slight difference. An enlarge condyle might indicate an osteochondroma (see slide 79 to 87 of the above keynotes). As Dr Bill Proffit said in a personnal communcation: “an elongated condylar process is more likely to stop growing than an enlarge condyle” (slide #87).

      You asked me if it possible to prevent further growth. The answer is yes. A surgeon can do a high condylectomy of the growing condyle by shaving the cartilage surface. This is also describe in the keynote. A high condylectomy would be indicated if the 2nd bone scan is positive. I would not recommend you to wait until the process of overgrowth is burned out because it might be active since the last 10 years and you are already affected with the asymmetry.

      So let’s assume that the bone scan is positive, i would consider a high condylectomy to stop the growth process and let you heal for 6 to 12 months. Meanwhile, i would start a comprehensive orthodontic treatment ot decompensate the dentition and plan for a bimaxillary surgery.

      3D-surgical-planning-NaRo-Chamberland-Orthodontiste-a-quebec

       

      If the bone scan is negative, you could plan a comprehensive orthodontic orthognathic treatment plan and  do the same type of surgery describe above.

      Of course, the pro and cons of surgical approach will need to be discuss with you, the surgeon and the orthodontist.

      WHat I wrote is an opinion that can not be consider a final diagnosis or a final treatment plan.

      I have recommend you Dr Martin Gaboury, a surgeon that graduated from the oral and maxillifacial surgery program at Hôpital Enfant-Jesus in Quebec. He is actually doing a fellowship in Bruges with Professor Gwen R.J. Swennen.

      You should get a rendez-vous with Professor Swennen and mention that you would like Dr Gaboury to assist during the consultation.

      Gwen R.J. Swennen, MD, DMD, PhD, FEBOMFS, MSc
      Professor, Division of Maxillo-Facial and Facial Plastic Surgery, Department of Surgery,
      Bruges Cleft and Craniofacial Centre,
      Three-Dimensional Facial Imaging Research Group (3-D FIRG),
      General Hospital St-Jan Bruges,
      Ruddershove 10, Bruges 8000, Belgium

      Telephone: +32 50 453018

       

      Best regards

      Keep me inform.

      Dr Sylvain Chamberland

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      1. Anna says:

        Hi dr Chamberland,

        Thank you so much for your answer, it is of great help to me and hopefully also to your readers. I also thought that one year interval between the two bone scans was a little long, especially since the asymmetry becomes worse. I will ask my oral surgeon if I can have the second bone scan as soon as possible.
        Also thank you for understanding how this asymmetry affects my self esteem. Like I told you I don’t mind getting older nor having several wrinkles here and there, but this asymmetry really bothers me.

        I will send you the panogram next week, once I have received it from my oral surgeon (I have appointment next Monday the 12th of January).

        I am also very happy to inform you that I have a rendez-vous with Professor Swennen and dr Gaboury on Tuesday the 3rd of February. Thank you for arranging this for me.
        I am really excited, though also a little nervous, that treatment is coming closer now. That feels so much better than doing nothing and just waiting.

        I will keep you informed about my visit to my surgeon, about the second bone scan and of course the panogram. Hopefully my condyle is only elongated and not enlarged.

        Have a great day ahead dr. Chamberland. I really appreciate your intervenience.

        Best regards,

        Anna

        1. Anna says:

          Dear Dr. Chamberland,

          How are you? Please find attached the radiography that I promised to send you. The photos have been made in March 2014.
          I am really looking forward to hear your expert opinion! The oral surgeon told me that the increased height (or is it increased length?) of the right ramus is approximately 10 mm. I thought is was more (15 mm), I apologize for this wrong information.
          I also asked for the uptake values of the bone scan that was done in March 2014: right condyle 56% and left condyle 44%. Is that a big difference?
          The 27th of January I am scheduled for another bone scan (I asked the surgeon to do it earlier).
          I don’t think teh results of this new bone scan will be available before my rendez-vous with professor Swennen.

          Best regards,

          1. Thank you Anna for sending me your radiographs.

            Here is the panogram.

            AnMaWa-hypercondylie-droite-Chamberland-Orthodontiste-a-Quebec

            I traced 2 lines. The lower line is at the sigmoïde notch (échancrure sigmoïde), the other one is at the top of the left condyle. It is obvious the the right condyle is longer than the left condyle. I would also say that it is slightly enlarged.

            The difference in uptake between left and right side is 12% (56-44). Such difference is significant and demonstrate that the right condyle is actively growing, may be at a slow pace, but it is growing.

            AnMaWa-Ceph-Chamberland-Orthodontiste-a-QuebecHowever, I would have expect to see some asymmetry in the cephalogram. Normally, with such asymmetry seen in the panogram, the cephalogram would show a splitting of the mandibular plane and the occlusal plane because the right side of the mandible and the right side of the posterior teeth are not at the same level of the left side when projected on a flat plane. It does confuse me and the cephalogram do not correlate with the faical photo that you sent. Chances are that the positionning of your head in the cephalostat might have been wrong.

            It will be interesting to see the result of your bone scan next tuesday. If it is still positive, chances are that you will have the choice between a high condylectomy or a wait and see when it burn out. I don’t think you would tolerate anymore aggravation of you facial asymmetry.

            If you have a high condylectomy, a second surgical phase will be necessary to correct the facial asymmetry in the 3 plan of space. The surgeon might offer you to do the high condylecotmy and the bimaxillary surgery at the same time. I don’t know what he could recommend.

            If the bone scan is negative, then you might have a bimaxillary surgery as explained above.

            I can’t wait to see what Dr Gaboury and Professor Swennen will tell you. I feel very limited to give you more explanation without their opinion. I did as much I could in such circumstances.

            It would be so simple for me if you would live in Quebec.

            Best regards.

            Next week, I will be lecturing in Bruxelles for SOBOR-BEVOR (Société Belge d’orthodontie) à l’Hôtel Métropole (thursday 29, 2015)

  3. Anna says:

    Dear dr Chamberland,

    I am very sorry for my late reply, I have been a little occupied these last days (work, rebuilding of our house and our 4 kids ;-))

    Thank you very much for your answer, it really is very helpful and makes things clear to me. In addition, it makes me feel understood and taken seriously, which is very pleasant. Unfortunately I have the impression that my own oral surgeon considers me overreacting and focusing to much on the facial asymmetry. He seems to prefer a wait and see policy. So I am very happy that I came into contact with you and that you give me a good, objective view and understanding of my situation as well as your expert opinion. Indeed, I do not tolerate an aggregation of the asymmetry. To be honest, I also don’t tolerate my current situation, but I also feel a little ashamed about me being so concerned about my appearance. However, I am a woman so this is quite normal I guess 😉

    It is a shame indeed that I don’t live in Quebec! I am also very happy that you brought me into contact with your former student dr. Gaboury and with professor Swennen. I will meet them next Tuesday the 3rd of February and I am very excited. Of course I will inform you immediately about my rendez-vous.

    You told me you are a little confused by the discrepancy between the cephalogram and my facial photos. Is there a chance that my facial asymmetry has aggravated this past year, which might explain this discrepancy? The panogram and cephalogram were done in March 2014 while the facial photos are very recent.

    Well, probably you already have arrived in Bruxelles. Bruxelles is about one hour drive from where I live, just like Bruges. I hope you had a good trip, and I wish you good luck with your lectures tomorrow!

    Thank you and talk to you soon,

    Anna

  4. Anna says:

    Dear dr Chamberland,

    I am writing you to let you know that I visited dr Gaboury and professor Swennen last Tuesday.
    It was a very useful rendez-vous. There has been taken a 3D CT-scan, which was in fact very informative and clarifying. The CT-scan showed that my right condyle is enlarged, and that the right mandibular ramus is elongated. According to dr Gaboury and professor Swennen there is no hyperplasia, only elongation. They also performed clinical examination of my jaws and teeth. My occlusal plane was found to be stable, and I have no crossbite. According to professor Swennen and dr Gaboury this makes it likely that my ‘problem’ is not from recent date and that it has been there for 10 years or maybe even longer. I had bracelets during 8 months in 2006, and since then probably not much has changed, based on the clinical finding of a stable occlusal plane.
    Professor Swennen and dr Gaboury told me that therefore I do not need pre-operative orthodontic treatment, and that surgery alone will be enough.
    I am still waiting for the results of the second nuclear scan that was done recently. Of course I will also inform you about these results, as well as dr Gaboury and professor Swennen.
    The next rendez-vous will be the 24th of February, and the exact treatment plan will be discussed with me then. Professor Swennen asked me to collect several photos (in frontal view) that have been performed in these last 20 years. He is pretty much convinced that the facial asymmetry was already there in my early twenties. The results of the second nuclear scan in combination with these photos from the past have to confirm this.
    So probably I have become more aware of the asymmetry in these last years, rather than the asymmetry really getting worse. Of course I am getting older and my skin looses elasticity which makes my jaw-line not that tight anymore ; this might emphasize the asymmetry and make it more obvious?
    Well, I am very excited and very happy that I went to Bruges. Thank you so much for your mediation dr Chamberland. Both dr. Gaboury and dr. Swennen said that they understood very well why I would like to have the asymmetry corrected; to them it’s also very obvious. So I am definitely having no doubts anymore about my own observation.
    I will keep you informed about the results of the nuclear scan.
    Thank you once again.

    Best regards,
    Anna

    1. Dear Anna,

      I am very please to be updated of your visit to Dr Swennen and Gaboury.

      It make sense that you problem was existing a while ago. A review of photos of the past 20 years of your face will be very informative. May be if you send me 1 or 2, I could publish it hiding your eyes to keep your anonymat and it would be helpfull for the reader.

      I like your comment about the elasticity of your skin. Being older than you, I had stop counting the wrinkles in my face. My wife share your worries about skin elasticity. I keep telling her she should not worry about aging because I am aging too.  Ah! les femmes…HiHiHi!

      I am please that I had help you in your quest for the truth about your facial asymmetry. This is a very good reward for all the time I spend on this website.

      Keep us informed. Your story is very interesting and will be helpful for many persons.

      Best regards

      Dr Sylvain Chamberland

  5. Anna says:

    Dear dr Chamberland,

    It has been a couple of months since our last email contact. I deeply apologize for that. Hope you are doing fine!

    I would like to give you an update about my situation.
    In February and March I have visited professor Swennen and your former student dr Gaboury 2 times.
    Both of them are convinced that my ‘problem’ has been there for over 20 years. This is also based on several pictures from the past, which I will also send you in a separate email.
    On these pictures the deviation of chin to the left is already visible indeed, although it seems to me it is less obvious than at the present moment.
    But of course I rely on the expert opinion of dr Swennen and dr Gaboury. No condylectomy is necessary, and orthognathic surgery is planned on June the 3rd.
    In these coming weeks 2 more consultations are planned as a preoperative work-up.
    I am excited about the surgery, and also a little nervous of course.
    Hopefully everything will go right….

    1. Dear Anna,

      Thank you for the follow up.

      This is good news and i agree that you can rely on the expert opinion of Dr Sweenn and Dr Gaboury. They will likely do a 3D treatment planning of your surgery similar to the one showed in my reply of 7 January 2015 at 20 h 55 min .

      The picture of you taken some 20 years ago effectively confirm facial asymmetry.

      Please keep us informed of your progress. We will be glad to hear form after your surgery. I wish you will accept to show a photo of the ower part of your face after surgery.

      Best regards

      Dr Sylvain Chamberland

      1. Anna says:

        I have visited dr. Swennen on Tuesday the 30th of June, and Martin Gaboury was also there. They are both very good doctors.
        It has been 5 weeks since the surgery now, and these last 2 weeks I am finally starting to feel a little better. I have to admit the surgery has been more heavy than I had expected.
        The swelling and stiffness of my face with loss of my own facial expression, the scars in my mouth, the difficulty in talking, the lack of energy due to the inability to eat and the loss of weight: I know it is all temporary but it really came down on me.
        But….. I am already starting to see the results of the surgery and that makes me very happy 🙂
        It is too early yet to send you pictures (my face is still swollen especially on the right side), but of course I will do this later!!!

        1. Hi Anna, I am glad to receive good news. I am sure that the outcome is nice. When you feel you are ready to send update picture, I will make a composite of before and after.

          Yours truly.

  6. Jack Gilbert says:

    Hello Dr Chamberland,

    Is it known what causes condylar hyperplasia or hemimandibular hyperplasia?

    I suspect this to be the cause of my facial asymmetry.

    Thank you so much for your time.

    It speaks volumes that you are so willing to communicate with others on your website.

    1. Hi Mr Gilbert,

      That is a good question, but i don’t know if the cause of condylar hyperplasia is know. I don’t think i could answer this question. If if could make a comparison, i would ask: do we know the cause of scoliosis? May be not, i am not a physician or an orthopedist.

      But for TMJs and jaws deformity, chances are it is likely hereditary as often time i would note that the father of the mother or a relative has a facial asymmetry. Condylar hyperplasia is often time self limiting but the the question is, when significant overgrowth is noted and the bone scan reveals an increased uptake, how much more asymmetry are we willing to tolerate before it stop.

      I would guess that you are a non growing adult and your condyle is likely non growing. I would recommend that you visit an orthodontist for a better diagnosis of your condition.

      Best regards

      1. Jack Gilbert says:

        Thank you Dr Chamberland,

        No history of facial asymmetry in my family. I seem to be the only one affected.

        Perhaps you are right and it is unknown what causes overgrowth of one side. It seems to me that more is understood about stunted growth than overgrowth.

        I would definitely say my asymmetry is significant. I think it began to develop some time in my mid teens, I am now 24. I am almost certain it is the result of unilateral hyperplasia rather than hypoplasia.

        Along with the asymmetry I do also suffer from ‘TMD’ although perhaps they are not related?

        There is so much poor quality and outdated information regarding ‘TMD’ that it can be difficult to know where to look for answers. It seems many orthodontists and surgeons hold on to out of date beliefs.

        If you like I don’t mind showing a scan or photo.

        1. Condylar hyperplasia

          Hi Jack
          You are in the age group that can be affected by condylar hyperplasia. You remember it might have developped in your mid teens and you are now a young adult. The hyperplasia might be burnout now (self-limited) but the asymmetry is there. You are like the young adult shown in the keynote on slide 57 to 64 who was 22 when i first saw him. The bone scan revealed increase uptake, so the condyle was actively growing. That is why we did a high condylectomy.

          However, at 24, your condyle may have stop growing. It need to be confirmed by a bone scan. In the section questions and answer, there is another case that may look like you. See “asymétrie des masseters” . You will find the translation if you click on the word english in the upper right corner, but there is much more comments in the french version of the page. I have treated this young man when he was 12-14 years old. I have final photos of his face and it was perfectly symmetric at that time. He came back at age 28, because he thought his bite has changed. It did, but there was some compensation so the bite is OK. However, he have a significant deviation to the left. I refered him to the surgeon for a bone scan, but there was no increased activity. The patient decided to not go into a surgery. He accept to live with his asymmetry. I have other patient who would not accept that.

          The condylar hyperplasia can be related to a contralateral clicking of the joint. The overgrowth on one side make the contrallateral condyle rotate in its narrow condylar fossa and the disk may displace.

          If you are still interested to send me photos and accept that they may be published, il will tell you my email.

          Best regards

          1. Jack Gilbert says:

            Hello Dr Chamberland,

            Please accept my apologies for the belated response!

            The person in your presentation is very similar to myself. I do feel that growth has stopped and probably has been for some time, but I worry that perhaps it could start up again?

            My mandibular asymmetry was present long before I developed any ‘TMD’ symptoms, I just lived with the asymmetry and assumed it was just the way I was.

            When I began experiencing ‘TMD’ symptoms I ended up in the care of a ‘TMD Expert’ and began an orthodontic treatment that lasted many years and cost over £10,000. At the beginning I totally bought into the reasoning, this was before I began asking questions and doing my own research on ‘TMD’.

            Unfortunately, it is only since the orthodontics finished that I became concerned with the mandibular asymmetry. I went to see a maxillofacial surgeon on the NHS who told me I would need potentially even more orthodontics if I wanted to have orthognathic surgery to correct the asymmetry. This is something I just can’t commit too, so he recommended genioplasty only as a compromise. This I feel is my only option now.

            1. If you note that the growth has stopped chances are that it won’t change anymore. A genioplasty will likely correct part of your asymmetry. I wish you good luck and hope that our communications did help.

              1. Jack Gilbert says:

                Thank you for all your answers Dr Chamberland, they have been most helpful.

                Over the years I have developed a real interest in TMD, Occlusion, Facial Growth etc.

                If you can point me towards any resources on these I would be most grateful!

                1. Hi Jack,

                  I think you are form UK. Dr Mercuri has provided me a list of oral surgeon he know personnaly and that you can consult:

                  They are THE TMJ surgeons in UK and are well versed in management of ICR cases.

                  In London – Mr. Robert Hensher
                  In Birmingham – Mr. Bernard Speculand
                  In Nottingham – Mr. Andrew Sidebottom
                  In Oxford – Mr. Nadim Saeed
                  In Bradford – Mr. Stephen Worrall

                  Chances are that if they know well about idiopathic condylar reseorption, they know well in hypercondyle and facial asymmetry.

              2. Verna says:

                Hello Dr Sylvain,

                A schwarz appliance I wore to correct a unilateral posterior crossbite created a maxillary cant and has caused asymmetry/lopsidedness in my face. Is it that the condyle has disengaged on one side? Can this be corrected by orthodontics alone?

                Please advise.

                Thanks.

                1. It is unlikely that a condyle would disengage whn doieng expansion. I don’t know if you are an adult, but be aware that a schwarz appliance do not do skeletal expansion. It does only do buccal tipping of the posterior teeth which will likely be very unstable.

  7. Isabelle says:

    Hello doctor I don’t know if this conversation is still active but I would like to know your opinion about my smile and bite
    I think my jaw is canting to the left but I would like your opinion about it please

    1. I can help you but I will need photo and xray. You can send it to my professional FB account. If you do so, that means you accept that I can publish it in my reply.

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