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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 4  |  Page : 323-329

Three-dimensional correlation between condylar size and mandibular asymmetry with type 1B condylar hyperplasia: A quasi-experimental study from PERU


1 Surgical Medical Academic Department, Faculty of Dentistry, Universidad Nacional Mayor de San Marcos, Lima, Peru
2 Academc Department Faculty of Dentistry, Universidad Nacional Mayor de San Marcos, Lima, Peru
3 Surgical Medical Academic Department, Faculty of Dentistry, Universidad Nacional Mayor de San Marcos, Lima, Peru; Postgraduate Department in Dentistry, Faculty of Health Sciences, Universidad Científica del Sur, Lima, Peru

Date of Submission13-Dec-2019
Date of Decision26-Feb-2020
Date of Acceptance26-Feb-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Frank Mayta-Tovalino
Postgraduate Department in Dentistry, Universidad Cientifica del Sur, Av. Paseo de la República, Miraflores, Lima.
Peru
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_340_19

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  Abstract 

Aim: Condylar hyperplasia (CH) is an alteration of condylar development, which causes mandibular asymmetry and dentofacial deformity in different magnitudes. The aim of this investigation was to determine the relationship of the condylar size and mandibular asymmetry in patients with type 1B CH through analysis of cone beam computer tomographies (CBCT). Materials and Methods: The research was a quasi-experimental study. Thirty subjects were studied using a CBCT. Patients were recruited from the Dental Service of the Oral and Maxillofacial Surgery Unit of the Hospital Guillermo Almenara Irigoyen, Lima, Peru, between 2016 and 2018. Anteroposterior, upper–lower, and middle–lateral distance measurements of the condyle head were obtained and correlated with the difference of the measurements obtained. Spearman correlation coefficient was used and established a level of significance of P < 0.05. Results: The results showed a correlation between condylar size and mandibular asymmetry. In addition, it was found that the greater the difference in the upper–lower part of the hyperplastic (CH) and nonhyperplastic (NCH) condyles, the greater the magnitude of the mandibular asymmetry, finding a positive correlation r = 0.331 with significant value (P = 0.037). Conclusion: There was a positive correlation between upper–lower difference and mandibular asymmetry. Similarly, in the middle–lateral measurement, a negative correlation was found between the condylar difference and the mandibular symmetry in the anteroposterior measurement.

Keywords: Condyle, Cone Beam Computed Tomography, Condylar Hyperplasia


How to cite this article:
Sedano-Balbin G, Romero-Tapia P, Pérez-Vargas F, Alvitez-Temoche D, Mayta-Tovalino F. Three-dimensional correlation between condylar size and mandibular asymmetry with type 1B condylar hyperplasia: A quasi-experimental study from PERU. J Int Oral Health 2020;12:323-9

How to cite this URL:
Sedano-Balbin G, Romero-Tapia P, Pérez-Vargas F, Alvitez-Temoche D, Mayta-Tovalino F. Three-dimensional correlation between condylar size and mandibular asymmetry with type 1B condylar hyperplasia: A quasi-experimental study from PERU. J Int Oral Health [serial online] 2020 [cited 2020 Sep 23];12:323-9. Available from: http://www.jioh.org/text.asp?2020/12/4/323/292761




  Introduction Top


Condylar hyperplasia (CH) is an alteration of the development that is accentuated in puberty, which causes mandibular asymmetry and dentofacial deformity of different magnitudes. It is manifested by an exaggerated and accelerated growth of the condyle, which in turn can compromise the neck, branch, and body of the jaw. In general, it is unilateral, although there are bilateral conditions, accompanied by asymmetry, pain, masticatory dysfunction, and temporomandibular joint (TMJ) dysfunction. In its active form, it is frequently found in patients between the ages of 11 and 25 years. After this age range, it is usually detected in its passive form, as a clinical sequel to CH.[1]

Usually, the diagnostic presumption of CH is made by a mixture of clinical findings and later confirmed with imaging tests such as radiographs, scintigraphy, cone beam tomography, and multislice spiral scans. In some severe cases, it can be definitively concluded through anatomo-pathological studies.[1],[2]

Facial asymmetry, caused by a skeletal alteration of the lower facial third, is a pathological condition that can be common in different populations.[2] In some subjects it may be related to pathological processes of the mandibular condyle of the TMJ.[3] The clinical characteristics for the detection of this pathology have been analyzed, finding that approximately 30% of individuals with asymmetric facies also present phenomena of CH,[4] which is related to dysfunctions of mandibular dynamics, joint pain, facial pain, dental, and occlusal problems, among other abnormalities.[3]

Clinical and imaging evaluations of patients with asymmetric facies associated with CH have shown marked differences between the side that shows hyperplasia and the side that does not show it.[4] According to scientific literature, it is possible to quantitatively estimate the relationship between mandibular asymmetry that these patients present with CH, so that this pathology can be diagnosed early.[3],[4] Because it is reported that it is more common in women between 15 and 24 years old, although it can also occur at any age.[5],[6]

The aim of this study was to establish the correlation between condylar size and mandibular asymmetry in patients with type 1B CH of the Dentistry Service of the Oral and Maxillofacial Surgery Unit of the Hospital Nacional Guillermo Almenara Irigoyen in Lima, Peru.


  Materials and Methods Top


Study design

This research was a quasi-experimental, retrospective, and analytical study. The unit of analysis consisted of the maxillofacial tomographic structures of the TMJ and the mandible. Due to the low prevalence of patients presenting with this type of injury, it was decided to evaluate all subjects (N = 30) previously diagnosed with type 1B CH with facial asymmetry of the Odontology Service Unit of Oral and Maxillofacial Surgery of the Guillermo Almenara Irigoyen National Hospital (EsSalud) from 2016 to 2018.

For the development of this research, to avoid any type of bias in the preparation of this study, the guidelines for reporting nonrandomized studies were used, so there was no loss in the population evaluated; the patients were selected according mentioned sample criteria.

Sample criteria

Patients treated at the Dental Service of the Oral and Maxillofacial Surgery Unit of the Guillermo Almenara Irigoyen National Hospital between 2016 and 2018, with a diagnosis of type 1B CH were included. Another inclusion criterion was also the presence of having a permanent dentition, except the third molars, and that they are patients of both sexes between 15 and 30 years old.

Pregnant or lactating women, patients with different developmental disorders and with a history of previous facial surgeries, facial asymmetry not associated with CH, pathologies concomitant to a previously diagnosed syndrome, patients with diagnosed condylar resorption, bilateral CH, and patients under diagnosed psychiatric treatment were excluded from the study.

Study method

First phase: Before performing the data collection procedures, the operator was calibrated to avoid any kind of bias. The level of concordance obtained, between both measurements, was verified by calculating the intraclass correlation coefficient (ICC) index. Thirty cases that met the selection criteria were selected from the Dental Service of the Oral and Maxillofacial Surgery Unit of the Guillermo Almenara Irigoyen National Hospital during the period of 2015–2018, between the ages of 18 and 30 of both genders.

Second phase: In a second stage, we proceeded to the tomographic analysis (computerized tomography of cone beam [CTCB]), with the following steps: 30 tomographies (CTCB) were selected from the Dental Service of the Oral and Maxillofacial Surgery Unit of the Guillermo Almenara Irigoyen National Hospital, which fulfilled aspects of exclusion and inclusion. The tomographies (CTCB) were performed with Pax Zenith model equipment, Vatech Brand (2200 Fletcher Ave, Fort Lee, NJ 07024), using 90kV and 120 mA, voxel size 0.12 mm. Cuttings were made with 1 mm ± 0.25 interval sections evaluated by RealScan software. The measurements of bilateral mandibular lengths were obtained with the (RealScan) Phillipsburg, NJ 08865 USA program and each tomography (CTCB) was drawn by the principal investigator, after calibration.

Third phase: Training was received for a correct calibration in the measurement of chronometric points such as:

On the three-dimensional plane of Frankfurt: First, the right portion was located in the coronal section, then this same point is located on the left side; from there in the sagittal section, the infraorbital point is located on the right side and then on the left side. Once the four points have been squared, the next step is continued (if necessary, the plane is squared off the image until the para-linearity of the image with the floor or plane of the computer is achieved).

In the middle sagittal plane: The anterior nasal spine and the crista galli, which is the ethmoid bone, were located, then a perpendicular line was drawn joining these two points that served to locate the midline. The midpoint of the chin (central part of the symphysis) was zoomed 70% to have greater precision in the extent of the deviation of the chin.

Two-dimensional condylar measurements, the mid-sagittal plane, and the chin line were recorded in the tomographies performed with a repetition of these, in two noncontinuous days.

Measurement of the condyle

The measurements were determined through images selected with strokes in RealScan, at a scale of 0 mm ± 0.25. The following measurements were determined in the axial planes (antero–posterior and medial–lateral measurement) and coronal (superior–inferior):

  • Medial–lateral distance: Axial image taken from the widest point of the condyle. From a longitudinal line, the measurement was obtained, perpendicular to the axial axis of the condyle, which begins and culminates in the most medial and most lateral cortical point of the condyle obtaining a bidimensional measurement for the measured condyle.


  • Upper–lower distance: Coronal image obtained from the highest point of the condyle and lower from it. From a longitudinal line, the measurement was obtained perpendicular to the midlateral axis, which begins at the most superior cortical point and ends at the inferior point of the condylar head obtaining a two-dimensional measurement.


  • Posterior–anterior distance: Axial image obtained from the most posterior and anterior point of the condyle. The measurement was obtained from a longitudinal line, perpendicular to the axial axis of the condyle, which starts and ends at the most posterior and most anterior cortical point of the condyle [Figure 1].
  • Figure 1: Tomographic sections: (A) medial-lateral distance, (B) anterior–postero distance, (C) upper–lower distance, and (D) deviation of the chin

    Click here to view


    Measurement of the jaw

    The middle sagittal line is composed of the anterior nasal spine and the Galli Crista, and the midline of the chin is composed of the following:

  • Central point where the chin is located in right or left lateral relation to the average sagittal line obtained from the imaginary intersection of the Crista Galli and anterior nasal spine points.


  • Middle sagittal line: Established from the junction of the points Crista Galli and Espina Nasal Anterior.


  • Midline of the chin: From the mid-sagittal plane and central point where the mandibular symphysis is located.


  • Statistical analysis

    The processing and statistical analysis of the information was carried out through descriptive statistics of the continuous variables (mean, confidence interval, and standard deviation) and the Spearman correlation coefficient. The ICC index was accepted as the concordance index; the process and analysis of the data were performed using the Spearman correlation coefficient, for quantitative variables to determine the degree of correlation between the variables, applying a software statistical processor SPSS/PC version 20.0, SPSS, Chicago, Illinois, establishing a value of P < 0.05 to obtain statistically significant differences.


      Results Top


    Superior–lower/antero–posterior/middle–lateral measurements of the hyperplastic and nonhyperplastic condyle

    For the superior–lower measurement of CH and noncondylar hyperplasia (NCH), an average of 19.60 ± 1.50 was found for CH and 15.8 ± 1.35 for NCH. On the contrary, for the ante–posterior measurement, an average value of 9.10 ± 0.69 was found for the CH and 8.11 ± 0.65 for NCH. Finally, a measure of 19.04 ± 0.69 for the CH and 16.25 ± 0.58 for NCH was found in the middle–lateral measure [Table 1].
    Table 1: Superior–lower/antero–posterior/middle–lateral measurements of condylar hyperplasia (CH) and noncondylar hyperplasia (NCH)

    Click here to view


    Difference and relationship between condylar measurements

    The difference between the upper–lower measure is 3.71 with an NCH:CH ratio of 1:1.23 and the middle–lateral difference is 0.99 with a NCH:CH ratio of 1:1.12 and antero–posterior is of 2.79 with an NCH:CH ratio of 1:1.17, respectively, for each measurement [Table 2].
    Table 2: Condylar measures of the difference between condylar hyperplasia (CH) and noncondylar hyperplasia (NCH) in cone beam computed tomography (CBCT)

    Click here to view


    Correlation between condylar size and mandibular asymmetry

    The correlation of the difference of the superior–lower measure of the condyles with the magnitude of the mandible asymmetry gives us a unilateral significance, where a P value of 0.037 is established, so it follows that we have a positive correlation with an r = 0.331 [Table 3] and [Graph 1].
    Table 3: Correlation between the upper–lower difference of condylar size and mandibular asymmetry

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    Graph 1: Correlation between the upper–lower difference of the condylar size and the mandibular asymmetry

    Click here to view



      Discussion Top


    The data from this study show the correlation between condylar size and mandibular asymmetry, which agree with the work performed by some studies.[3],[4],[5] Also, according to Wolford et al.,[7] the data of the difference of 3.71 mm in the superior–inferior condylar distance between CH and NCH are close to the results obtained by this author (3.94 mm), a very significant value as a predictive method for decision-making of the condylectomy within the planning of a surgical orthodontic treatment. In addition, they suggest two options widely used in his orthodontic-surgical treatment protocol today: the first one of performing a unilateral high condylectomy with disc repositioning plus orthognathic surgery, and the second waiting until growth is complete of the condyle and then performing the orthognathic surgery. However, in the latter option, the facial asymmetry due to the excessive growth of the unilateral condyle would have to be corrected, which would also distort the upper jaw.

    The inequality in the anterior–posterior distance of the CH and NCH in this study was 0.99 mm, a result that disagrees with those obtained by others studies. This could be due to the fact that some cases of our study sample probably had more displaced condyles in the anterior–posterior plane, a fact that could be corroborated with a larger study sample. The correlation of the difference of the upper–lower measure of the condyles with the magnitude of the mandible asymmetry gives us a unilateral significance, where a P value of 0.037 is established, so it follows that we have a positive correlation with an r = 0.331, as the greater difference in the upper condylar-inferior size of the hyperplastic condyles and the nonhyperplastic condyle, the greater the magnitude of the mandibular asymmetry.[8],[9],[10],[11]

    The correlation value between the difference of the anteroposterior measurement of the condyles with the magnitude mandibular asymmetry, had a negative correlation with r = –0.306. However, it was not statistically significant. Thus, it can be deduced that it is not strictly accepted that the greater the difference in the anterior–posterior condylar size of the hyperplastic condyles and the nonhyperplastic condyle, the greater the magnitude of the mandibular asymmetry. With respect to the correlation of the difference of the midlateral measure of the condyles with the magnitude of the mandibular asymmetry, they give a unilateral significance, where a value of P = 0.040 is established with a positive correlation of r = 0.324. According to the aforementioned, it follows that the greater the difference in the medial–lateral condylar size of the hyperplastic condyles and the nonhyperplastic condyle, the greater the magnitude of the mandibular asymmetry.[8],[9],[10],[11],[12],[13],[14]

    In addition, it was observed in this study that there are significant inequalities in some of the measurements made. It should be emphasized that it is important to assess the clinical implications observed in these measurements in relation to condylar size and mandibular asymmetry, through a positive correlation. On the contrary, Zulma et al.,[9] who conducted a search of 21 articles and 210 cases treated between 1991 and 2012, concluded that orthognathic surgery was the most commonly used option (42%) and was sometimes combined with open joint surgery (19% condylectomy). That stability was observed, respectively, in 57% and 100% of orthognathic surgery and cases of open joint surgery. Condylectomy and reconstruction with chondrocostal graft or total TMJ prosthesis were used in 19% and 10% of all cases of orthognathic surgery and open joint surgery with good results (95% and 100%, respectively). The osteogenic distraction was anecdotal (1%). On the contrary, although this evidence had limitations, the bone removed in the proportional condylectomy was superior when compared to the bone removed in the high condylectomy, restoring the occlusal plane, which resulted in fewer asymmetries and, therefore, reduced the need for additional surgery.[10] These results obtained by various studies show that the proposal of condylectomy in the hyperplastic condyles requires early detection in adolescence, a fact that would avoid greater deformity in the patient, greater difficulty in the treatment, elevation of costs, and comorbidities of the disease, such as internal TMJ disorders, muscle alterations, tooth skeletal, and soft-tissue facial alterations.[9]

    Similarly, Arora et al.[15] also mentioned that unilateral CH is characterized by a slow and constant development of the different parts of the jaw, with an uncertain etiology. It occurs mainly between 11 and 30 years of age, causing facial asymmetry. The treatment of CH generally involves performing the condylectomy that has continued to grow and a reduction of the maxillary bone to correct the occlusal angle. Also, it is suggested to perform sagittal osteotomies to correct the lateral bite of the affected side and center the sagittal midline of the affected patient.[16] This coincides with what was proposed by Wu et al.[17] and Usumi-Fujita et al.,[18] who found that facial asymmetry was corrected and the occlusal plane improved thanks to condylectomy as the only surgical treatment combined with orthodontic treatment and can provide an alternative method for the correction of facial asymmetry associated with active unilateral CH. Finally, although computed tomography is an excellent means of diagnosis, it is important to highlight that there are other digital tools free of X-rays such as magnetic resonance imaging and photogrammetry that have also showed great applicability in the evaluation and dynamics of the internal structures of the body.[19],[20],[21]

    The main limitation of this investigation was the number of patients with diagnostic of this condition of the condyle; however, a considerable size was evaluated in relation to the published scientific literature. Therefore, it is always suggested to perform a tomographic evaluation for the early detection of CHs, and to include condylar measures as proposed in this study, to avoid complications later due to the pathological growth of the hyperplastic mandibular condyle. So, it is recommended to perform studies with larger samples at younger ages, it would help to highlight the importance of early detection of the hyperplastic condyle, because it is a pathology that is initially asymptomatic and is mostly detected when the asymmetry is present.

    Conclusion

    According to our results, there was a correlation between the difference of the upper–lower and middle–lateral measurement of the condyles with the magnitude of the mandibular asymmetry, this being positive and statistically significant, concluding that the greater the difference in the size of the middle–lateral condylar of the hyperplastic condyles and nonhyperplastic condyle, the greater the magnitude of the mandibular asymmetry.

    Acknowledgement

    We thank the Graduate Unit of the Faculty of Dentistry of the Universidad Nacional Mayor de San Marcos and to the Oral and Maxillofacial Surgery Unit of Hospital Guillermo Almenara Irigoyen (EsSalud), Lima, Peru, for its unconditional support in the execution of the present scientific investigation.

    Financial support and sponsorship

    None to declare.

    Conflicts of interest

    None.

    Authors contributions

    Study conception (GSB, PRT, FPV), data collection (GSB, PRT, FPV), data acquisition and analysis (FMT, DAT), data interpretation (FMT, PRT FPV), manuscript writing (FMT, PRT, DAT).

    Ethical policy and Institutional Review board statement

    The study respects the ethical aspects stipulated in the Declaration of Helsinki and the Belmont Report and was approved by the Steering Committee of the Postgraduate and Research Unit in Dentistry (FO-UNMSM 030919) of the Universidad Nacional Mayor de San Marcos for its execution.

    Patient declaration of consent

    Patients were assigned after written informed consents.

    Data availability statement

    The data that support the study results are available from the author (Dr. Frank Mayta-Tovalino, e-mail: fmaytat@ucientifica.edu.pe) on request.



     
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    Brignardello-Petersen R Very low-quality evidence suggests that proportional condylectomy results in a lower risk of undergoing additional surgeries than high condylectomy in patients with active condylar hyperplasia. J Am Dent Assoc 2019;150:e168.  Back to cited text no. 3
        
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    Sun R, Sun L, Sun Z, Li G, Zhao Y, Ma X, et al. A three-dimensional study of hemimandibular hyperplasia, hemimandibular elongation, solitary condylar hyperplasia, simple mandibular asymmetry and condylar osteoma or osteochondroma. J Craniomaxillofac Surg 2019;47:1665-75.  Back to cited text no. 4
        
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    Wolford L, Movabed R, Perez D A classification system for conditions causing condylar hyperplasia. J Oral Maxillofac Surg 2014;72:567-95.  Back to cited text no. 7
        
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    Zapata S, Medina H, Saravia D, Navarro P, Olate S. Analisis Morfométrico de la mandíbula de pacientes con asimetría facial asociada a hiperplasia condilar. Estudio en radiografía panorámica. Int J Morphol 2014;32:161-5.  Back to cited text no. 8
        
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    Niño-Sandoval TC, Maia FPA, Vasconcelos BCE Efficacy of proportional versus high condylectomy in active condylar hyperplasia––A systematic review. J Craniomaxillofac Surg 2019;47:1222-32.  Back to cited text no. 10
        
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    Depeyre A, Constant M, Bauer C, Barthélémy I Unilateral condylar hyperplasia: Is reactivation after a long latency period of inactivity plausible? J Craniofac Surg 2019;30:e707-10.  Back to cited text no. 13
        
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    López DF, Aristizábal JF, Martínez-Smit R Condylectomy and "surgery first" approach: An expedited treatment for condylar hyperplasia in a patient with facial asymmetry. Dental Press J Orthod 2017;22:86-96.  Back to cited text no. 14
        
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        Figures

      [Figure 1], [Graph 1]
     
     
        Tables

      [Table 1], [Table 2], [Table 3]



     

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