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CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 3  |  Page : 84-89

Bone scintigraphy as a diagnostic tool in condylar hyperplasia


Department of Dental Surgery, Government Royapettah Hospital, Chennai, Tamil Nadu, India

Date of Web Publication18-Dec-2017

Correspondence Address:
Dr. Deenadayalan Lingeshwar
Government Royapettah Hospital, Westcott Road, Opposite YMCA Ground, Chennai - 600 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jomr.jomr_26_17

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  Abstract 


Unilateral condylar hyperplasia (UCH) is a pathological condition characterized by unrestrained growth of condyle unilaterally and is of idiopathic in nature. It is often diagnosed clinically but more frequently if not always is augmented by planar and single photon emission computed tomography bone scans to confirm the finding. Hence, bone scintigraphy using technetium-99 m methylene diphosphonate is the diagnostic tool to identify these active growth centers. Detection and excision of active growth center are the line of management for condylar hyperplasia. This article highlights the importance of using these radioactive scans to diagnose as well as to monitor the prognosis of UCH in two such cases.

Keywords: Condylar hyperplasia, scintigraphy, technetium-99 m methylene diphosphonate, unilateral condylar hyperplasia


How to cite this article:
Appadurai R, Lingeshwar D, Shwetha V, Christina RD. Bone scintigraphy as a diagnostic tool in condylar hyperplasia. J Oral Maxillofac Radiol 2017;5:84-9

How to cite this URL:
Appadurai R, Lingeshwar D, Shwetha V, Christina RD. Bone scintigraphy as a diagnostic tool in condylar hyperplasia. J Oral Maxillofac Radiol [serial online] 2017 [cited 2018 Sep 21];5:84-9. Available from: http://www.joomr.org/text.asp?2017/5/3/84/221077




  Introduction Top


The history of unilateral condylar hyperplasia (UCH) dates back to 1830s.[1] It is featured as abnormal growth of the condylar cartilage even after the completion of growth spurts during puberty.[1],[2],[3] It usually presents unilaterally resulting in facial asymmetry and functional abnormality.[3],[4] The etiology of UCH is obscure and controversial although there is a slight female predilection.[5]

This article highlights the importance of bone scintigraphy by eliciting two cases of UCH which was clinically diagnosed and confirmed with subsequent bone scintigraphy with technetium-99 (Tc-99).


  Case Reports Top


Case report 1

A 23-year-old female patient presented to the dental department complaining of facial deformity. On examination, the patient revealed no history of trauma or any family history of UCH. On extraoral examination, the patient had a straight profile [Figure 1] but her facial form revealed an obvious deviation of mandible toward the right [Figure 2]. On intraoral examination, the midline was shifted to the right side [Figure 3], and Occlusal cant was noted to be 5° with respect to the interpupillary line [Figure 4]. A deviation in mouth opening toward the right side was also noticed; however, mouth opening was within normal limits and the patient did not experience any difficulty in speech or mastication. Posteroanterior (PA) view of skull in closed mouth position revealed an elongated condylar neck and ramus on the left side compared to the right [Figure 5]. The subsequent investigations of orthopantogram (OPG) revealed an elongated condylar neck on the left side and a short and flattened condylar neck on the right [Figure 6]. The Computed tomography (CT) scan revealed a left hemimandibular elongation with large left condyle showing degenerative changes and with prominent ostetophytosis [Figure 7] and [Figure 8]; in addition, there was evident cortical thickening and broadening of ramus buccally. The bone scan acquired in two phases, i.e., the blood pool phase and delayed bone uptake phase and single-photon emission computerized tomography (SPECT) of temporomandibular joint (TMJ) revealed a finding of asymmetrically increased tracer uptake in the left mandibular condyle suggestive of condylar hyperplasia and also a mild hyperemic response in left TMJ attributed to some degenerative changes [Figure 9]. The radiographic findings were then correlated with the clinical features to confirm the clinical diagnosis.
Figure 1: Extraoral examination revealing straight profile

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Figure 2: Facial form showing deviation of the mandible to the right side

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Figure 3: Intraoral examination revealing midline shift

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Figure 4: Occlusal cant with respect to the interpupillary line

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Figure 5: Posteroanterior view of skull in closed mouth, exhibiting elongated condylar neck and ramus on the left side

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Figure 6: Orthopantogram showing elongated condylar neck on the left side and flattened Condylar neck on the right side

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Figure 7: Computed tomography scans showing cortical bone thickening and broadening of ramus buccally on the left side

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Figure 8: Computed tomography scan exhibiting hyperplastic left condyle

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Figure 9: Single-photon emission computerized tomography of temporomandibular joint showing mild hyperaemic response in left temporomandibular joint

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Case report 2

A 16-year-old female patient presented to our dental department with the chief complaint of facial deformity since childhood. On extraoral examination, she had concave profile [Figure 10]; and the facial form presented a deviation of lower jaw toward the right side [Figure 11]. Intraoral examination featured midline deviation towards the right side and posterior crossbite, on the right side. An evident Occlusal cant was noted to about 10° [Figure 12]. Clicking was palpable on the right side TMJ, however, it was asymptomatic. The patient did not find any difficulty in speech although she did experience difficulty in mastication and had accustomed to unilateral chewing habit. PA view of skull revealed an elongated and thickened mandibular rami and condylar neck on the left side [Figure 13]. The OPG revealed a long and thin condylar neck on the left and a short and stout condylar neck on the right and the mandibular rami also appeared longer on the left side compared to the right [Figure 14]. The transcranial radiograph of TMJ shows the condyle in both open and closed positions and its relation with the articular fossa; it also reveals the long and slender neck of the left condyle and a short neck on the right condyle [Figure 15]. The CT scan revealed a mediolaterally widened left condyle with conjurated articular surface [Figure 16]. The Tc-99 m methylene diphosphonate (Tc-99 m-MDP) whole body bone scan revealed an active metabolism at the site of the left condyle and a relatively elongated ramus on the left side of the mandible [Figure 17]. The clinical features of both the cases have been listed in [Table 1].
Figure 10: Extraoral examination revealing concave profile

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Figure 11: Facial form presenting deviation of lower jaw towards the right side

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Figure 12: Occlusal cant with respect to the interpupillary line

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Figure 13: Postero-anterior view skull in closed mouth showing elongated condyle and thickened mandibular rami on the left side

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Figure 14: Orthopantogram revealing thin elongated condylar neck on the left and short stout Condylar neck on the right side

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Figure 15: Transcranial radiograph of temporomandibular joint showing elongated and slender neck of the left condyle and a short neck on the right condyle and its position in relation to the articular fossa in both open and closed positions

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Figure 16: Computed tomography scan exibits medio-laterally widened left condyle with conjurated articular surface and enlarged left condylar head

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Figure 17: Planar bone scans of case 2 exhibiting increased uptake of isotope in the left condyle

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Table 1: Demographic data and clinical features

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  Discussion Top


Although the pathogenicity of UCH remains idiopathic, many theories have been put forth to understand UCH. Local circulatory theory suggests that UCH is due to increased number of capillaries.[6] Other factors associated with it are fractures, hormonal, genetics, infections (middle ear infections, osteomyelitis) intrauterine components.[7],[8]

CT scans are used to quantify left and right condylar discrepancies. The CT radiograph of Cases 1 and 2 reveals enlarged left Condylar head which emphasizes UCH. Orthopantogram of Cases 1 and 2 showed long and slender neck of the left condyle in both cases. According to Obwegeser and Makek [9] classification, Case 1 follows the criteria of type 1 UCH (hemimandibular elongation) with the clinical features involving chin deviation towards the contralateral side, midline shift toward the unaffected side and Case 2 follows type 2 UCH (hemimandibular hyperplasia).

For accurate and quantitative assessments CT scans are not sufficient, thus a bone scan is desirable. As scrutinizing a condition is pivotal in arriving at definitive treatment plan, diagnostic procedures play a vital role in investigating bone pathologies. Bone scintigraphy is one such nuclear medicine procedure which was brought into limelight by Subramanian and Mcafee in the year 1971.[10] T99 m-MDP are the radioactive tracers incorporated to highlight the areas of increased osteoblastic activity and growth center as they have greater affinity toward bone.[10] These radioisotopes emit gamma rays of 140keV photon energy which is recorded using gamma cameras and then converted to images.[11] The degree of radioactive tracer uptake depends on blood flow and rate of bone osteogenesis.[11] The major advantage of using T99 m-MDP includes 6.02 h of half-life, hence can be cleared from the body easily.[12]

Planar bone scans are nothing but the two-dimensional (anterior, posterior) viewing of radioactive tracer in the skeleton. Bone scans of Cases 1 and 2 suggest that there is focal intense uptake of the radioisotope (Tc-99 m-MDP) by 55% in the left condylar region which is comparatively higher than that of the right side condyle. SPECT provides precise and more sensitive values of bone activity. It gives the three-dimensional (axial, sagittal, and orthogonal) view of radioactive tracer uptake, which aids in localization and characterization of the growth.[13] In accordance to Hodder et al. if the uptake of isotope by the condyle is more than 55% it is considered abnormal.[14] A 10% difference between the left and right condylar isotope uptake is considered atypical in the proposition to Pogrel theory.[15] SPECT of Case 1 shows there is 33% uptake of isotope in right condyle and 55% in the left condyle. Thus, the difference between left and right condyle is more than 10% and the abnormality is confined to the left condyle of Case 1 is confirmed. The planar bone scans of Case 2 reveals that there is 55% uptake in the left condyle. In Case 2, based on the patient's clinical age (16 years), the condyle is still in the active phase of growth, serial bone scans with the interval of 6 months should be taken to attain treatment plan. The clinical feature along with the bone scintigraphy reports of Cases 1 and 2 confirms the abnormality is confined to the left condyle. The main advantages of using SPECT include that active and inactive growth patterns can be monitored, along with that it can differentiate whether the overgrowth is confined to the condyle region or it involves the whole mandible.[16]

Saridin et al.[17] in the year 2011 compared planar and SPECT bone scans, the sensitivity and specificity of SPECT bone scans are more than planar bone scans, thus, SPECT bone scans are considered superior to planar scans. Depending only in bone scintigraphy for the diagnosis can be misleading in identifying degenerative changes in TMJ, as bone scintigraphy is a sensitive indicator of metabolic activity in the bone, it shows similar changes in a remodeling bone or degenerated joint, hence, scintigraphy should be used along with the clinical findings and other imaging procedures to confirm the diagnosis.[18] SPECT in fusion with CT can be useful in these cases as it gives coronal imaging of the isotope in the bone.

Utilizing the same procedure of bone scintigraphy, gamma probes for executing high condylectomy has been introduced by Carl Bouchard in 2013.[19] Tc-99 m-MDP uptake can be read by the gamma probes. The gamma probe readings taken from the condyle and parasymphysis are compared. Bone resection is proceeded until the gamma probe readings of parasymphysis and condyle are equal. This technique is used to control excess bone removal and is less invasive compared to other surgeries.[19] Other investigations adjunct to SPECT includes positron emission tomography (PET) scans. [18F]-fluoride is used as the radioisotope in PET scans. It involves correlating histomorphometric parameters of bone formation by recognizing altered tissue metabolism which gives more precise details of abnormal bone growth than SPECT.[20],[21]

Condylar hyperplasia can be treated invasively by surgical procedures such as condylectomy and osteotomy. Hemimandibular elongation (type 1) which involves growth in the horizontal vector can be corrected by LeFort 1 osteotomy and bilateral sagittal split osteotomy (BSSO). Hemimandibular hyperplasia (type 2) which involves excessive growth in the vertical vector can be treated by high condylectomy followed by BSSO or LeFort 1 osteotomy and inferior alveolar nerve repositioning.[22] In severe cases to correct the increased chin deviation genioplasty is recommended, Occlusal cant correction can also be achieved by molar intrusion [23] method along while facial asymmetry correction can be attained by the above mentioned orthognathic procedures.


  Conclusion Top


Bone scans using Tc-99 m-MDP SPECT is an important diagnostic tool for the assessing the condylar growth activity. It is a precise method for identifying UCH patients with ongoing bone growth. With present advancements in technology, these bone scans not only act as a diagnostic tool but also can be used to choose the appropriate treatment modality for the patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adams R. The disease in the temporomandibular articulation or joint of the lower jaw. In: A Treatise on Rheumatic Gout or Chronic Rheumatic Arthritis of all the Joints. 2nd ed. London: Churchill; 1873. p. 271.  Back to cited text no. 1
    
2.
Rushton MA. Unilateral hyperplasia of the mandibular condyle. Proc R Soc Med 1946;39:431-8.  Back to cited text no. 2
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Mehrotra D, Dhasmana S, Kamboj M, Gambhir G. Condylar hyperplasia and facial asymmetry: Report of five cases. J Maxillofac Oral Surg 2011;10:50-6.  Back to cited text no. 3
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Butt FM, Guthua SW, Nganga P, Edalia M, Dimba EA. One-stage treatment of acquired facial deformity caused by severe unilateral condylar hyperplasia. J Craniofac Surg 2011;22:1966-8.  Back to cited text no. 4
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Raijmakers PG, Karssemakers LH, Tuinzing DB. Female predominance and effect of gender on unilateral condylar hyperplasia: A review and meta-analysis. J Oral Maxillofac Surg 2012;70:e72-6.  Back to cited text no. 5
    
6.
Angiero F, Farronato G, Benedicenti S, Vinci R, Farronato D, Magistro S, et al. Mandibular condylar hyperplasia: Clinical, histopathological, and treatment considerations. Cranio 2009;27:24-32.  Back to cited text no. 6
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7.
Pereira-Santos D, De Melo WM, Souza FA, de Moura WL, Cravinhos JC. High condylectomy procedure: A valuable resource for surgical management of the mandibular condylar hyperplasia. J Craniofac Surg 2013;24:1451-3.  Back to cited text no. 7
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Egyedi P. Aetiology of condylar hyperplasia. Aust Dent J 1969;14:12-7.  Back to cited text no. 8
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Obwegeser HL, Makek MS. Hemimandibular hyperplasia – Hemimandibular elongation. J Maxillofac Surg 1986;14:183-208.  Back to cited text no. 9
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Subramanian G, McAfee JG, Bell EG, Blair RJ, O'Mara RE, Ralston PH, et al. 99m tc-labeled polyphosphate as a skeletal imaging agent. Radiology 1972;102:701-4.  Back to cited text no. 10
    
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Genant HK, Bautovich GJ, Singh M, Lathrop KA, Harper PV. Bone-seeking radionuclides: An in vivo study of factors affecting skeletal uptake. Radiology 1974;113:373-82.  Back to cited text no. 11
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Carty H. Radionuclide bone scanning. Arch Dis Child 1993;69:160-5.  Back to cited text no. 12
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Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone imaging: An illustrative review. Radiographics 2003;23:341-58.  Back to cited text no. 13
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14.
Hodder SC, Rees JI, Oliver TB, Facey PE, Sugar AW. SPECT bone scintigraphy in the diagnosis and management of mandibular condylar hyperplasia. Br J Oral Maxillofac Surg 2000;38:87-93.  Back to cited text no. 14
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15.
Pogrel MA. Quantitative assessment of isotope activity in the temporomandibular joint regions as a means of assessing unilateral condylar hypertrophy. Oral Surg Oral Med Oral Pathol 1985;60:15-7.  Back to cited text no. 15
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Gray RJ, Sloan P, Quayle AA, Carter DH. Histopathological and scintigraphic features of condylar hyperplasia. Int J Oral Maxillofac Surg 1990;19:65-71.  Back to cited text no. 16
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17.
Saridin CP, Raijmakers PG, Tuinzing DB, Becking AG. Bone scintigraphy as a diagnostic method in unilateral hyperactivity of the mandibular condyles: A review and meta-analysis of the literature. Int J Oral Maxillofac Surg 2011;40:11-7.  Back to cited text no. 17
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18.
Kim JH, Kim YK, Kim SG, Yun PY, Kim JD, Min JH, et al. Effectiveness of bone scans in the diagnosis of osteoarthritis of the temporomandibular joint. Dentomaxillofac Radiol 2012;41:224-9.  Back to cited text no. 18
    
19.
Bouchard C, Paris M, Villemaire JM. Intraoperative use of a gamma probe for the treatment of condylar hyperplasia: Description of a new technique. J Oral Maxillofac Surg 2013;71:1099-106.  Back to cited text no. 19
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20.
Laverick S, Bounds G, Wong WL. [18F]-fluoride positron emission tomography for imaging condylar hyperplasia. Br J Oral Maxillofac Surg 2009;47:196-9.  Back to cited text no. 20
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21.
Piert M, Zittel TT, Becker GA, Jahn M, Stahlschmidt A, Maier G, et al. Assessment of porcine bone metabolism by dynamic [18F] fluoride ion PET: Correlation with bone histomorphometry. J Nucl Med 2001;42:1091-100.  Back to cited text no. 21
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22.
Ferguson JW. Definitive surgical correction of the deformity resulting from hemimandibular hyperplasia. J Craniomaxillofac Surg 2005;33:150-7.  Back to cited text no. 22
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23.
Choi YJ, Lee SH, Baek MS, Kim JY, Park YC. Consecutive condylectomy and molar intrusion using temporary anchorage devices as an alternative for correcting facial asymmetry with condylar hyperplasia. Am J Orthod Dentofacial Orthop 2015;147:S109-21.  Back to cited text no. 23
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
 
 
    Tables

  [Table 1]



 

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