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104
Hyperplasias non-syndromal
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U. Meyer and V. Kerkfeld
discussed in the literature, recent studies have suggested that no signicant catchup growth of the mandible in PRS occurs in the rst 22months of life. The differential growth shown in these studies does not improve the size of the pharyn­geal airway but does improve the relative size of the oropharynx, which can have a positive effect on breathing difculties. There is normally no eye or ear involvement. The most prominent fea­ture is the micrognathic state, often accompanied by a cleft palate of various extents.
Hyperplastic/Overgrowth Diseases
The term overgrowth generalizes abnormally tall stature and is used to describe three phenotypes: prenatal overgrowth, postnatal overgrowth, or segmental overgrowth. In the prenatal overgrowth group, Beckwith-Wiedemann syndrome (BWS) is included. Affected individuals may continue to show an accelerated growth postnatally (pre- and postnatal overgrowth) or may grow at a normal pace with length falling within 2 SDs of the mean. The postnatal overgrowth phenotype includes individuals who are noticed to have an accelerated growth pattern starting typically in childhood or adolescence. Marfan syndrome, homocystinuria, Klinefelter syndrome, and
47-XYY syndrome are typical syndromes in this group.
A phenotype of excessive growth that is con­ned to one or a few regions of the body is called segmental overgrowth, e.g., one side of the face, or the entire head can be affected. It can be expressed as symmetrical or asymmetrical growth of musculoskeletal, adipose, and/or brain tissue along with focal hyperplasia of capillary venous or lymphatic vessels and overlying skin lesions. Patients are more likely to present to medical attention due to the unaesthetic nature of the asymmetric growth. Overgrowth syndromes can be associated with hormone imbalance, life­threatening hypoglycemia (e.g., BWS), seizures (Sotos syndrome), developmental delay (Sotos syndrome, Weaver syndrome), and an increased susceptibility to malignancy (Wilms’ tumor, hep­atoblastoma, etc.). Clinicians should therefore maintain a high index of suspicion for a prompt diagnosis.
Unilateral
Non-syndromal
One-sided overgrowth of the mandible (and often the maxilla) is known to result in facial asymme­tries and constitutes a well-recognized group of
condylar
Fig. 8.4 Facial phenotypes of non-syndromal hyperplasia. (All photographs by Meyer)
hemimandibular
hemifacial
Hyperplasias - non syndromal
bimaxillar
mandible onl
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condylar
hemimandibular hemifacial
y
y (open bite)
Fig. 8.5 Skeletal appearance of condylar hyperplasia, hemimandibular hyperplasia, and hemifacial hyperplasia. (All photographs by Meyer)
unilateral mandibular enlargements. If a one­sided open bite is missing, the maxilla has also a one-sided overgrowth situation. Non-syndromal asymmetric hyperplasias can be subclassied into condylar hyperplasia, hemimandibular hyperplasia/hemimandibular elongation, or, as a much rarer disorder, hemifacial hyperplasia (or hemifacial hypertrophy) (Fig. 8.4). In all these malformations, the facial phenotype is character­ized by prominent unilateral overdevelopment of the hard and soft tissues of the face to different extents. The affected side grows at a faster rate than the non-affected side, creating a marked asymmetry that potentially involves the skeleton and teeth (Fig.8.5), as well as all components of the associated soft tissues. Hemifacial states are often identied at birth and progress towards puberty but are not thought to alter throughout the lifetime of affected individuals (Fig.8.6).
termed as facial hemihyperplasia, partial/unilat­eral gigantism, hemimacrosomia, and hemifacial hyperplasia. Congenital hemifacial hyperplasia was rst noted by Meckel JF in 1822, and, later, the rst case was reported by Wagner in 1839 [97]. HFH affects the facial soft tissues, bone, and associated structures [98]. Later, Gesell described this lesion as being “essentially a developmental anomaly antedating birth and arising in partial deection of the normal process of birth” [99]. Asymmetry in HFH is usually obvious at birth and accentuated at the end of adolescence. The prevalence rate of HFH is 1:86,000 live births [100]. It was subclassied into true hemifacial hyperplasia (TFHF), present­ing unilateral enlargement of the viscerocranium extending superiorly from the frontal bone (not including the eye) to the inferior border of the mandible and from the midline to the pinna of the ear with enlargement of all soft tissues, teeth, and
Hemifacial Hyperplasia
Hemifacial hyperplasia (HFH) is a rare congeni­tal developmental disorder characterized by asymmetrical overgrowth of one or more body parts. Synonymously, this condition has been
bone in the area and partial hemifacial hypertro­phy (PHFH) if the enlargement is limited to one structure.
This asymmetrical overgrowth traditionally referred to as hypertrophy is more accurately
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Growth development
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from childhood
to adulthood
Fig. 8.6 Hyperplasia may be present directly after birth; they are obvious in childhood and develop markedly until adulthood (patient with hemimandibular hyperplasia). (All photographs by Meyer)
termed as hyperplasia as this pathologic process involves abnormal proliferation of cells (hyper­plasia) rather than growth of individual existing cells (hypertrophy). Radiographically, this lesion presents with hard tissue and soft tissue enlarge­ment on the affected side. These patients exhibit
premature development and alter crown and root size/shape discrepancy along with a downward slant of the occlusal plane.
The etiology of HFH is unknown. Over the last decades, several theories were suggested. However, several possible etiologic factors have
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been suggested including endocrine dysfunctions, chromosomal abnormalities, central nervous sys­tem disorders [101], vascular or lymphatic mal­formations, and somatic mutations. Few studies supported heredity as a potential cause [102]. Another study suggested disturbances in the development of the rst branchial arch over­growth [103]. An embryological hypothesis put forth by Pollock etal. postulates increased num­ber of neural crest cells on the enlarged half of the neural tube [104]. The increased number of crest cells continues through pre- and postnatal growth periods of life, resulting in unilateral overgrowth of the crest-derived structures. Gesell attributed congenital hemihyperplasia to devia­tion from normal process of twinning, which sug­gests an inequality of regulatory abilities in embryologic development leading to an aberrant twinning mechanism [99]. Noe and Berman pos­tulated as the main cause damage of mitochon­dria in an overripe one half of the fertilized egg resulting in overgeneration of cells [105]. Yoshimoto etal. concluded that the pathogenesis is thought to be due to basic broblast growth factor along with its receptor-stimulated osteo­blastic differentiation on the affected side in comparison with the normal part of the face [106]. In the 2015 study, Yamazaki etal. reported that facial overgrowth may result from a down­regulation of phosphatase-tensin homolog tran­scripts [107]. Histologically, according to Pollock etal. the overgrowth process involves an increase in the number of cells rather than in size.
Hemimandibular Hyperplasia
Hemimandibular hyperplasia is a rare disorder that involves the three-dimensional volumetric enlargement of one half of the mandible [108
112]. Affected individuals have facial asymme-
try due to abnormal growth of the involved condyle, condylar neck, ramus, and mandibular body up to and ending at the symphysis. The affected growth is accentuated towards the bony structures, whereas the soft tissue enlargement is relatively low.
Condylar Hyperplasia
Condylar hyperplasia (CH) can be dened as the excessive growth of one condyle over the contra­lateral, causing an increase in bone mass of vary­ing degrees in instances where the subject’s growth has decreased or ceased [113]. Condylar hyperplasia is known to result in facial asymme­tries and constitutes a well-recognized group of unilateral mandibular enlargements [114]. Initially, this condition was reported by Lohmann in 1918 and Gruca and Meisels in 1926 [115]. Afterwards, an extensive literature review was carried out in 1946 by Rushton, wherein a total of 32 cases were found to be reported by 1946 [116].
The etiopathogenesis is still unclear, but cer­tain theories have been suggested, which include trauma, hormonal imbalance, infection, arthrosis, hypervascularity, and possibly genetic role. CH has been reported to be a rare entity with a very few cases being reported in literature, mostly seen between 11 and 30years of age, with males and females being equally affected and having no predominance for the left or right side. It has also been reported to be a self-limiting condition, that is, the active growth can cease at any point of time [117120].
Syndromal
In contrast to hyperplasia as an isolated nding, several syndromes like Beckwith-Wiedemann syndrome, Sotos syndrome, Weaver syndrome, Proteus syndrome, and Russell-Silver syndrome demonstrate hyperplasia of branchial arch struc­tures (Fig.8.5).
Beckwith-Wiedemann Syndrome
Beckwith-Wiedemann syndrome (BWS) is a human imprinting disorder that leads to overgrowth.
Epidemiology
BWS has an estimated prevalence of 1 affected child in 10,340 live births [121], with an increased risk associated with assisted reproductive tech­nologies (ARTs) of around 1in 1100 [122124]. BWS is now considered a spectrum (BWSp)
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ranging from classic BWS to isolated lateralized overgrowth [125, 126].
Genetics
It is associated with genetic and epigenetic changes on the chromosome 11p15 region [127], which includes imprinted genes that regulate fetal and postnatal growth. BWS involves molec­ular aberrations within a cluster of imprinted genes on the chromosome 11p15.5–11p15.4 region.
Clinical Manifestation
BWS is often diagnosed neonatally or in early childhood and has a broad clinical spectrum of features that vary in severity. These features include macroglossia, abdominal wall defects, lateralized overgrowth, enlarged abdominal organs, and an increased risk for developing embryonal tumors during early childhood [125]. Macroglossia is seen in about 90% of patients with BWS [128, 129].
Bilateral
Non-syndromal
Bilateral maxillo-mandibular or facial over­growth can be found as a variance of the normal skull development. Such slight overgrowth situa­tion can be based on genetic, epigenetic, or func­tional factors. The facial phenotype contrasts with syndromal diseases not profoundly altered.
Syndromal
Simpson-Golabi-Behmel Syndrome
Simpson-Golabi-Behmel (SGB) syndrome is an X-linked prenatal and postnatal overgrowth syn­drome associated with characteristic dysmorphic features [130]. Affected individuals typically exhibit increase in all growth parameters (>97% in length, weight, and head circumference).
Epidemiology
The incidence of Simpson-Golabi-Behmel syn­drome is unknown. At least 250 people world­wide have been diagnosed with this disorder.
Fig. 8.7 Patients with typical overgrowth syndrome phenotype. Sotos syndrome. (Source: Sogaard M, BMC Medical Genetics 2005, 6:21)
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Genetics
It affects primarily males and is associated with loss-of-function variants in the growth modulator proteoglycan, GPC3 on Xq26.2 [131].
Clinical Manifestation
Macrocephaly is reported in 70% of cases; other common features include ocular hypertelorism (wide-spaced eyes) with broad upturned nose, macroglossia, macrostomia (large mouth), super­numerary nipples, pectus excavatum, and hypo­tonia. Less common features include congenital heart defect (seen in ~36%), polydactyly with nail hypoplasia, dental malocclusion, rib anoma­lies, cleft lip or palate (observed in ~13%), vis­ceromegaly, umbilical hernia, and genitourinary anomalies (cryptorchidism, gonadal dysgenesis).
Sotos Syndrome
Sotos syndrome, previously referred to as cerebral gigantism, is an overgrowth syndrome characterized by a triad of (1) overgrowth (increased height, mac­rosomia, and macrocephaly), (2) characteristic facial features, and (3) learning disabilities and intellectual disabilities [132] (Fig.8.7).
Epidemiology
The incidence of Sotos syndrome is unknown.
Genetics
Mutations in the NSD1 gene cause Sotos syn­drome. The NSD1 gene provides instructions for making a protein (histone methyltransferase) that is involved in normal growth and development. The function of this protein is unknown, how­ever. In the Japanese population, the most com­mon genetic change leading to Sotos syndrome deletes genetic material from the region of chro-
mosome 5 containing the NSD1 gene. In other
populations, small mutations within the NSD1 gene occur more frequently [133, 134]. When the phenotypic and laboratory ndings suggest the diagnosis of Sotos syndrome, molecular genetic testing approaches can include single-gene test­ing or use of a multigene panel (Fig.8.5).
Clinical Manifestation
Classic facial characteristics include frontal boss­ing, dolichocephaly (elongated occipito-frontal axis), and frontoparietal balding seen in >90% of patients. Early eruption of deciduous teeth and high-arched palate are common as well.
Weaver Syndrome
Weaver syndrome is an accelerated growth syn­drome dened by increased height and weight (>2D), advanced bone age, broad forehead with at occiput, excess loose skin, camptodactyly [bent nger(s) due to proximal interphalangeal joint abnormality], and variable degrees of intel­lectual disability (seen in 80% of patients) [135].
Epidemiology
The prevalence is estimated to be like that of Sotos syndrome, around 1in 15,000.
Genetics
Weaver syndrome is a rare autosomal dominant genetic disorder [136]. The cause for Weaver syndrome was identied in 2011 as autosomal
dominant mutations in the EZH2 gene on chro­mosome 7q36.
Clinical Manifestation
Characteristic facial appearance includes hyper­telorism (widely spaced eyes), large ears, and a “stuck-on” protruding chin. Weaver syndrome and Sotos syndrome are often mistaken for one another due to their signicant phenotypic over­lap and similarities. Features distinguishing Weaver syndrome from Sotos syndrome include broad forehead and face, ocular hypertelorism, prominent wide philtrum, micrognathia, deep-set nails, retrognathia with a prominent chin crease, increased prenatal growth, and a carpal bone age that is greatly advanced compared to metacarpal and phalangeal bone age.
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from the cells with the altered AKT1 gene
Biological development of partial overgrowth
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Table 8.4 Pathogenesis of Proteus syndrome demonstrates the complex genesis of some syndromes, indicative of the difculty to determine a correct diagnosis
Fertilized egg from which all body cells arise
U. Meyer and V. Kerkfeld
oteus syndrome
As the cells continue to
divide, the DNA in one of
the cells becomes altered
The developing baby has two types of cells. Some have the normal AKT1 gene and somehave the altered AKT1 gene
Fertilized egg divides into many cells to form an embryo
The AKT1 gene in one of the cells changes – where
GA
As the cells of the growing embryo continue to divide, the number of both the cells with a changed AKT1 gene and the cells with an unchanged AKT1 gene expand and contribute to the formation of organs and tissues
The parts of the body that developed
grow differently than normal cells. This is why the body parts of people with Proteus syndrome are unevenly affected.
the DNA code should have a ''G,'' it has an ''A'' instead
(from http://www.genome.gov/pressDisplay.cfm?photoID=20253, Public Domain) All photographs by Meyer
Partial
Proteus Syndrome
Proteus syndrome is a rare disorder with a genetic background [137] that can cause tissue over-
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growth involving all three embryonic lineages (Table8.4).
Epidemiology
Only a few more than 200 cases have been con­rmed worldwide, with estimates that about 120 people are currently alive with the condition [138].
Genetics
Lindhurst identied an activating mutation in
AKT1 kinase in a mosaic state gene [139].
Previous research had suggested the condition linked to PTEN on chromosome 10, while other research pointed to chromosome 16. Prior to the ndings regarding AKT1in 2011, other research­ers expressed doubt regarding the involvement of PTEN or GPC3, which codes for glypican 3 and may play a role in regulating cell division and growth regulation.
Clinical Manifestation
Proteus syndrome causes an overgrowth of skin, bones, muscles, fatty tissues, and blood and lym­phatic vessels. Proteus syndrome is a progressive condition wherein children are usually born with­out any obvious deformities. Tumors of skin and bone growths appear as they age typically in early childhood. The musculoskeletal manifesta­tions are cardinal for the diagnosis of Proteus syndrome. The severity and locations of these various asymmetrical growths vary greatly, but typically the skull, one or more limbs, and soles of the feet will be affected.
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