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Adding Balance to A Child’s Life Bradford Edgren, DDS, MS

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Just a few days prior to Raida's* visit to my office for continuation of her orthodontic treatment, another child at school told her, "Your face is crooked." It was only during the exam that the parents first heard this comment from their almost 12-year-old daughter. As with any child, these parents were troubled to hear that their daughter was being subjected to hurtful remarks. Comments like these are never good for self-esteem or confidence, especially at a young age. Facial deformities are very embarrassing, and a significant facial asymmetry falls into this category. Asymmetries are often associated with head and neck syndromes. However, they can also occur, as in this case, with condylar hypoplasia.

Raida was a transfer patient from an orthodontist in another state. Clinical evaluation of the patient revealed a noticeable, superior cant to the occlusal plane on the right. Both maxillary first bicuspids were previously extracted. The maxillary and mandibular first molar relationship was Class I. Clinically the right canine relationship was Class III; the left canine relationship was Class I (Figs. 1a, 1b, 1c). Further evaluation of the patient demonstrated a significant mandibular asymmetry to the right and interlabial incompetence. She had discomfort and crepitus associated with the left temporomandibular joint and a significant opening deviation to the right.

Complete diagnostic records were taken including: mounted models, photographs, CBCT scan, carpal index with growth analysis, and lateral and frontal cephalometric analyses (Figs. 2 & 3). The CBCT scan and frontal analysis revealed a significant mandibular skeletal asymmetry to the right (Figs. 4 & 5). The midline of the mandible was displaced to the right 8mm and the lower incisors were subsequently inclined to the left. The frontal analysis also exposed a skeletal lingual crossbite pattern due to both the maxilla and mandible.


Evaluation of the right mandibular condyle from the CBCT scan demonstrated hypoplastic growth and poor condylar form. The right ramus was significantly foreshortened compared to the left (Fig. 6). Hypoplasia, defective formation, or under-development of the condyle may be congenital or acquired. Congenital hypoplasia might affect one or both condyles and is present at birth. Acquired hypoplasia is the result of an incident that affects the normal development of the condyle. Events that can negatively affect the normal development of the condyle include: external trauma, radiation for the treatment of skin lesions, infection, circulatory and endocrine disorders. Bilateral condylar hypoplasia is considerably less common than unilateral involvement. However, both unilateral and bilateral condylar hypoplasia can lead to a significant clinical facial deformity. The extent of the deformity with acquired condylar hypoplasia is dependent upon the severity of the injury that caused the disruption in condylar growth, the duration of that injury and the age that it occurred. As seen in this case, unilateral condylar hypoplasia can produce a severe facial deformity that can lead to difficulties in orthodontic treatment, especially in the young and growing patient.1



Unilateral hypoplasia leads to limitation of normal movement and exaggeration of the antegonial notch on the affected side. Though growth at the affected condyle(s) might be arrested, growth does continue to occur at the posterior border, near the angle of the mandible. This continued growth, at the posterior border, leads to widening or thickening of the ramus(es). Clearly, the younger the patient at the time of disruption of normal condylar growth, the greater the facial deformity. Based upon the carpal index for this patient, she has at least four more years of growth left, thus, increasing her already significant facial asymmetry.1

Lateral cephalometric analysis, using the 3D scan, revealed significant mandibular ret- rognathia and a high mandibular plane angle contribution of the severe right condylar hypoplasia. Evaluation of the lateral cephalogram demonstrates a significant difference in the right and left mandibular planes. Moreover, this patient, who had a previous thumb habit and is a mouth breather, has an upper airway obstruction from an enlarged adenoid pad (Figs. 7a & 7b).



So, as you can see, I have my hands full with this particular case of condylar hypopla- sia, a significantly retrognathic mandible with a steep mandibular plane, airway obstruction and missing teeth. Currently, the treatment plan for this patient includes a bonded RME, referral (along with the scan) to an otolaryngologist for T&A, upper and lower appliances, possible replacement of missing maxillary first bicuspids (if space closure becomes difficult) and orthognathic surgery of both jaws to correct her significant facial asymmetry.



*Name has been changed to protect patient privacy

References
  1. Shafer WG, Hine MK, Levy BM: A Textbook of Oral Pathology. 4th Ed. Philadelphia: WB Saunders Co., 1983, pp 702-703
  2. Linder-Aronson S, Woodside DG, and Lundstrom A: Mandibular growth direction following adenoidectomy. Am J Orthod 89:273 – 284, 1986
  3. Lundstrom A, Woodside DG: A comparison of various facial and occlusal characteristics in mature individuals with vertical and horizontal growth direction expressed at the chin. Eur J Orthod 3: 227-235, 1981.
  4. Lundstrom A, Woodside DG: Longitudinal changes in facial type in cases with vertical and horizontal mandibular growth directions. Eur J Orthod 5: 259-268, 1983.
  5. R.M. Ricketts: Respiratory obstruction syndrome. Am J Orthod 54:495 – 507, 1968
  6. Harvold EP: The role of function in the etiology and treatment of malocclusion. Am J Orthod 54" 883 -898, 1968.
  7. Harvold EP, Chierici G, Vargervik K: Experiments on the development of dental malocclusion. Am J Orthod 61: 38-44, 1972.
  8. Harvold EP, Tomer BS, Vargervik K, Chierici G: Primate experiments on oral respiration. Am J Orthod 79: 359-372, 1981.
  9. Vargervik K, Miller AJ, Chierici G, Harvold EP, Tower B: Morphologic response to changes in neuromuscular patterns experimentally induced by altered mode of respiration. Am J Orthod 85: 115-124, 1984.
  10. Linder-Aronson S: Adenoids – their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the dentition. Acta Otolaryng (Stockholm) (Suppl) 265:1, 1970
  11. Woodside DG, Linder-Aronson S: The channelization of upper and lower anterior face heights compared to population standards in males between 6 and 20 years. Eur J Orthod 1: 25-40, 1979.
  12. Woodside DG, Linder-Aronson S, Holmes A: Progressive increase in lower anterior face height in a large population of Canadian girls and the use of the posterior occlusal bite block in its management. Submitted for Publication 1985.
Author's Bio
Dr. Bradford Edgren earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from University of Iowa, College of Dentistry. He is a diplomate of the American Board of Orthodontics and an affiliate member of the SW Angle Society. Dr. Edgren has presented to numerous groups on the value of CBCT and cephalometrics. His articles have been published in both the AJODO and American Journal of Dentistry. Dr. Edgren currently has a private practice in Greeley, Colorado.
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