Condylar osteoma: correcting asymmetry via simultaneous 3D surgery

Simultaneous management of a condylar osteoma and facial asymmetry

Condylar osteoma is a rare clinical entity, with an estimated frequency between 0.01% and 0.04%, which places the practitioner before a major surgical dilemma: the profound alteration of the temporomandibular joint architecture. For this 36-year-old patient, the pathology manifested as a sclerotic mass of 2.3 cm x 1.9 cm x 1.1 cm, resulting in pain during mastication, a right posterior open bite, and marked mandibular deviation. The challenge lies in correcting the aesthetic and functional deformities induced by the tumour.

The objective of this study is to report a combined treatment protocol associating osteoma resection and bimaxillary orthognathic surgery (Le Fort I, bilateral sagittal split osteotomy, and genioplasty) in a single procedure. The approach uses virtual surgical planning (VSP) and customized titanium cutting guides. This strategy tests the ability of a simultaneous intervention to restore skeletal symmetry and occlusal stability, while managing the benign but invasive tumor margins of the peripheral osteoma.

Design and surgical protocol

This case report documents the management of a 36-year-old Saudi female patient presenting with a condylar osteoma (CO) associated with facial asymmetry. The protocol is based on the integration of virtual surgical planning (VSP) and simultaneous orthognathic surgery. 3D modeling was performed via Materialise software, using CT scan data (DICOM) and optical impressions (Trios3 system).

The surgical procedure followed a precise three-step sequence:

• Tumor resection: Pre-auricular approach (Al-Kayat) for a conservative marginal resection of the right condyle. Excision control was validated intraoperatively using O-Arm imaging.
• Maxillary procedure (Le Fort I): Correction of the occlusal plane including a 2.5 mm descent on the left, a 1.6 mm impaction on the right, a 1.7 mm advancement and a 3.3 mm posterior impaction.
• Mandibular step (BSSO): Bilateral sagittal split osteotomy for a 1.3 mm mandibular advancement associated with a 1.3 mm clockwise rotation.
• Genioplasty: Chin advancement of 0.44 mm with a clockwise rotation of 3.12 mm.

The precision of the execution was ensured by the use of custom-made cutting guides and titanium plates (PSI), specifically designed according to the initial virtual planning to coordinate the resection and orthognathic movements.

Precision of virtual planning and surgical execution

Preoperative CT imaging revealed a sclerotic mass of the right condylar process measuring 2.3 cm x 1.9 cm x 1.1 cm, resulting in mandibular deviation and marked facial asymmetry. The therapeutic strategy, coordinated by virtual surgical planning (VSP), allowed for the integration of tumor resection and orthognathic correction in a single operative stage.

Planned skeletal movements, executed with precision through the use of customized cutting guides and titanium plates, are summarized in the following table:

Surgical Procedure	Planned and Executed Movements
Le Fort I (Maxillary)	Correction of the occlusal plane tilt: 2.5 mm descent (left) and 1.6 mm ascent (right). 1.7 mm advancement and 3.3 mm posterior impaction.
BSSO (Mandible)	1.3 mm advancement and 1.3 mm clockwise rotation.
Genioplasty	0.44 mm advancement and 3.12 mm clockwise rotation.

O-Arm intraoperative imaging was used to evaluate the resection in real time, confirming the complete excision of the osteoma and the restoration of an anatomical condylar contour. Immediately after the release of the maxillomandibular fixation (MMF), occlusal stability was verified, confirming perfect alignment with the virtual planning objectives. This combined approach allowed for the simultaneous treatment of the tumor pathology and the morphological (asymmetry) and functional (right posterior open bite) sequelae.

Resection and orthognathic surgery: the challenge of simultaneity

Treating a 2.3 cm × 1.9 cm condylar osteoma while correcting severe facial asymmetry in a single procedure: this is the clinical challenge addressed in this report. The use of Virtual Surgical Planning (VSP) proves decisive here. By integrating CT data and occlusal scans (Trios3), the team was able to coordinate a precise marginal resection with a complex orthognathic protocol: Le Fort I (3.3 mm posterior impaction and cant correction), bilateral sagittal split osteotomy of the mandible (1.3 mm advancement), and genioplasty.

The major interest of this approach lies in the immediacy of the functional and aesthetic correction. The osteoma, although benign, had caused a right posterior open bite and a chin deviation of 2 to 3 mm. Simultaneous intervention avoids multiple surgical sequences, thus reducing overall morbidity for the patient. The use of customized cutting guides and titanium plates (CAD/CAM) secured the resection margins while ensuring the stability of the new occlusion.

This study, however, presents inherent limitations due to its single-case format (n=1). Although intraoperative imaging (O-Arm) confirmed the complete resection of the sclerotic mass, the classic pre-auricular approach (Al-Kayat incision) involves significant iatrogenic risks. Surgical manipulation near the temporomandibular joint requires extreme vigilance to preserve the surrounding nerve structures.

Compared to conventional treatments that often favor a sequenced approach (resection followed by orthodontics/surgery), this case shows that the digital workflow allows for the simultaneous management of the tumor pathology and its morphological consequence. This is a paradigm shift where VSP technology transforms a complex pathology into a predictable procedure.

In concrete terms, for the practitioner:

• Privilégiez la planification virtuelle (VSP) pour synchroniser la résection tumorale et la chirurgie orthognathique : le gain de précision permet de corriger l'asymétrie dès le premier temps opératoire.
• Always use patient-specific cutting guides to secure the resection margins of the condylar osteoma while preserving the integrity of the joint.
• Consider the simultaneous approach to reduce the number of interventions and accelerate the functional rehabilitation of your patients presenting with condylar tumors with asymmetry.

This case report details the management of a 2.3 cm x 1.9 cm peripheral condylar osteoma in a 36-year-old female patient. Through virtual surgical planning (VSP) and the use of custom-made cutting guides, the team simultaneously performed tumor resection and complex orthognathic surgery (Le Fort I, BSSO, and genioplasty). The 14-month follow-up confirms restored skeletal symmetry, stable occlusion without post-surgical orthodontics, and complete nerve recovery despite initial transient frontal paresis.

Technical lexicon of the study

Peripheral osteoma: Exophytic benign tumor developing from the periosteum. In this clinical case, the 2.3 x 1.9 x 1.1 cm lesion was located on the right condyle, causing facial asymmetry and occlusal disturbance.

Virtual Surgical Planning (VSP): Engineering process using CT data (DICOM format) and intra-oral scans (STL format) to simulate osteotomies and design cutting guides as well as custom-made titanium plates.

Al-Kayat incision: A variant of the pre-auricular approach used to expose the temporomandibular joint. It requires meticulous dissection through the superficial temporal fascia down to the zygomatic arch.

Le Fort I Osteotomy: Maxillary orthognathic surgery technique applied here to correct occlusal canting through posterior impaction and a 1.7 mm advancement.

Bilateral Sagittal Split Osteotomy (BSSO): Bilateral sagittal split osteotomy of the mandibular rami, allowing in this case an advancement and clockwise rotation to restore mandibular symmetry.

O-Arm Imaging: Mobile intraoperative imaging system used to confirm in real time the complete excision of the tumor mass and the regularity of the bone margins after resection.

Intermaxillary fixation (IMF): Temporary immobilization of the arches in occlusion using screws and elastics, essential for stabilizing bone segments before their definitive osteosynthesis.

---

Information intended for healthcare professionals. This content may contain errors or truncated summaries. We recommend always verifying with the original source article. Delynov disclaims all responsibility regarding the use of this information. This document is not intended for patients or the general public.