The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015 5. Batsakis JG, el-Naggar AK, Hicks MJ. Epithelial choristomas and teratomas of the tongue. Ann Otol Rhinol Laryngol 1993;102: 567–569 6. Dimtsas S, Theologie-Lygidakis N, Iatrou I. Intralingual dermoid cyst in an infant presenting swallowing and sleeping difficulties. J Clin Pediatr Dent 2010;34:335–337 7. Dutta M, Saha J, Biswas G, et al. Epidermoid cysts in head and neck: our experiences, with review of literature. Indian J Otolaryngol Head Neck Surg 2013;65(suppl 1):14–21 8. Jain H, Singh S, Singh A. Giant sublingual dermoid cyst in floor of the mouth. J Maxillofac Oral Surg 2012;11:235–237 9. Babuccu O, Işiksaçan Ozen O, Hoşnuter M, et al. The place of fine-needle aspiration in the preoperative diagnosis of the congenital sublingual teratoid cyst. Diagn Cytopathol 2003;29:33–37 10. Bonilla JA, Szeremeta W, Yellon RF, et al. Teratoid cyst of the floor of the mouth. Int J Pediatr Otorhinolaryngol 1996;38:71–75 11. Said-Al-Naief N, Fantasia JE, Sciubba JJ, et al. Heterotopic oral gastrointestinal cyst: report of 2 cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88:80–86 12. Celik M, Akkaya H, Arda IS, et al. Congenital teratoma of the tongue: a case report and review of the literature. J Pediatr Surg 2006; 41:e25–e28
An Osteochondroma of the Mandibular Condyle Xi-Hu Yang, MD,* Ping Zhang, PhD,†‡ Jian-Hui Xu, PhD,* Yong-Jie Hu, MD†‡ Objective: Osteochondroma is rarely seen in the facial region, especially around the condyle. Here, we report a case of condylar osteochondroma, aiming to assist the diagnosis and treatment of the tumor. Methods: A case of osteochondroma of the left mandibular condyle in a 49-year-old man was presented. Medical records with x-ray, computed tomographic scan, and bone scan of histologically proven osteochondroma of mandibular condyle were obtained. Results: The patient underwent a surgical resection and had fewer functional changes as well as less dysfunction of the temporomandibular joint. Conclusions: The current study highlights the fact that, despite its rarity in the mandibular condyle, surgical resection is an effective treatment method. The decision, however, depends on how much swing of the mandible is required after surgery for correction of asymmetry and occlusion. From the *Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu; †Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine; and ‡Shanghai Key Laboratory of Stomatology, Shanghai, China. Received July 27, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Yong-Jie Hu, MD, Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai 200011, China; E-mail: [email protected] Supported by Project of National Natural Science Foundation of China (grant no. 30772433). The authors report no conflicts of interest. Xi-Hu Yang and Ping Zhang contributed equally to this work. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001331
Brief Clinical Studies
Key Words: Osteochondroma, mandibular condyle, radical surgery
A
n osteochondroma (OC) or osteocartilaginous exostosis is considered to be the most common benign tumor of bones but is rarely found in the facial skeleton because of the intramembranous origin of most craniomaxillofacial bones.1,2 Despite the OC's predilection for long bones, they may occur in any bone that develops by endochondral ossification.3 This rare incidence of the mandible usually occurs at the unilateral condyle or coronoid process. The etiologies of OC are unclear. Typical clinical features of condylar OC includes facial asymmetry, temporomandibular joint dysfunctions, malocclusion (ipsilateral posterior open bite, contralateral crossbite), and even hearing loss and pain.4–8 We report the diagnosis and treatment of an OC in the left condylar region, pushing the condyle seriously to the anterior direction, thus producing facial asymmetry and malocclusion.
CLINICAL REPORT A 49-year-old man presented in our institution in 2013, with complaints of malocclusion and left preauricular swelling. He complained that his jaw had “shifted” for the last 15 months with increasing facial asymmetry and that his teeth had also moved. He had been having headaches and left joint noises. His mandibular dental midline was deviated by 5 to 6 mm. His mouth opening was 1 fingerbreadth, and there was a palpable mass of 2 cm 2 cm over the left condyle. Panorex film (Fig. 1) showed a bony mass on the posterolateral surface of the condyle. A computed tomographic scan (Fig. 2) revealed that the mass extended anteromedially into the infratemporal fossa. The clinical diagnosis was OC with facial deformity and malocclusion. The temporomandibular joint was accessed using a submandibular approach under general anesthesia and nasotracheal intubation. The condyle and tumor were dissected subperiosteally, and the lesion extended medially and superiorly deep into the infratemporal fossa, where it formed a pseudoarticulation with the base of the skull. A tumor of approximately 25 mm in length was excised, and the condyle was reshaped (Fig. 3). Occlusion was restored and stabilized using an occlusal splint. On histologic examination, an outer lining composed of a broad layer of partially loose periosteal collagen tissue was found, attached with small amounts of cartilaginous differentiated tissue (Fig. 4). Adjacent cancellous bone with trabeculae of varying size and cartilaginous inclusions was visible, and the final diagnosis of OC was established. These findings were consistent with OC. When last reviewed in February 2014, he still had some restriction of mouth opening to 2 fingerbreadths and was given exercises to perform. He had no headaches and improved occlusion as well as facial symmetry.
DISCUSSION Osteochondroma is the most common benign bone tumor. Condylar OCs are usually situated on the anteromedial surface of the condylar head.9 The occurrences of these tumors in the condyle are related with the theory of aberrant foci of epiphyseal cartilage on the
FIGURE 1. Panorex film shows the opaque mass on the left condylar region.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
567
Brief Clinical Studies
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
FIGURE 2. Coronal computed tomographic scans shows a large bony mass arising from the left condyle.
surface of the bone.10 We have reviewed some cases refuting the presumptions as mentioned previously that condylar OCs arise on the anteromedial condylar surface at the posteromedial location of the tumor in the condylar region.11 In addition, in our case, the posterolateral location of the tumor in the condylar region contradicts this theory. The histologic criteria for the diagnosis of an OC include chondrocytes of the cartilaginous cap arranged in clusters in parallel oblong lacunar spaces similarly to those of normal epiphysial cartilage. There are various differential diagnoses of OC of the mandibular condyle, such as from osteoma, benign osteoblastoma, chondroma, and chondroblastoma. The histologic orientation is suggestive of a benign lesion. Regular bony trabeculae produced by enchondral ossification are often seen. The exostosis is covered by periosteum that is continuous with that of the adjacent bone. In consideration of the benign nature of the tumor and its extremely low likelihood of recurrence, the aim of treatment was excision of the tumor and a swingback of the mandible to near-normal occlusion and facial midline correction. A conservative condylectomy with articular disk repositioning combined with orthognathic surgery is an acceptable option for the treatment of condylar OC.8,12 Traditional treatment of 76.67%13 reported cases was the radical resection of the tumor and total condylectomy, with or without reconstruction of superiorly repositioned vertical ramus, costal cartilage graft, or iliac bone harvest.7,11,14–19 We accepted radical resection of the tumor and total condylectomy as our basic treatment. Although conservative subtotal condylectomy can keep the shape of the condyle similar to that of the normal one, the loss of the superficial chondrocytes increased the risk for osteoarthritis. Although worried about the added risk for recurrence, Cottrell20 proposed to save as much of the condyle as possible and to base the excision on the clinical apparent margin with removal of the cartilage cap. Chen et al21 reported that 38 patients all had local resection and that there was no recurrence found in the reports of local resection. However, Peroz et al22 investigated the recurrence risk between condylectomy and noncondylectomy in 34 patients. In 26 of them, condylectomy was performed and only the OC was resected in 8 patients. No recurrence was reported in the patients treated with condylectomy, whereas 2 recurrences were observed
FIGURE 3. Total excision of OCs and condyle using the submandibular approach.
568
FIGURE 4. Hematoxylin-eosin stain showing endochondral ossification progressing beneath the cartilaginous cap.
among the 8 patients treated with excision of the lesion.22 Malignancy potential and risk for recurrence are the major drawbacks of the conservative procedure.23 According to the literature review of Vezeau et al,13 surgical approaches varied for lesions, but preauricular entry into the joint, alone or in combination with other approaches, was used most often. Submandibular or retromolar access was also used frequently. Removal was performed by excision without condylectomy in 23.33% of cases, whereas the majority of surgeons used a total excision with the condyle as the treatment of choice. In this case, we used the submandibular approach and total excision of OC with the condyle.
CONCLUSIONS The current study highlights the fact that, despite its rarity in mandibular condyle, surgical resection is an effective treatment method. The decision, however, depends on how much swing of the mandible is required after surgery for correction of asymmetry and occlusion.
REFERENCES 1. Murphey MD, Choi JJ, Kransdorf MJ, et al. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407–1434 2. Glick R, Khaldi L, Ptaszynski K, et al. Dysplasia epiphysealis hemimelica (Trevor disease): a rare developmental disorder of bone mimicking osteochondroma of long bones. Hum Pathol 2007;38:1265–1272 3. Tanaka E, Iida S, Tsuji H, et al. Solitary osteochondroma of the mandibular symphysis. Int J Oral Maxillofac Surg 2004;33:625–626 4. Ward BB, Pires CA, Feinberg SE. Osteochondromas of the mandible: case reports and rationale for treatment. J Oral Maxillofac Surg 2005;63:1039–1044 5. Iizuka T, Schroth G, Laeng RH, et al. Osteochondroma of the mandibular condyle: report of a case. J Oral Maxillofac Surg 1996;54:495–501 6. Koole R, Steenks MH, Witkamp TD, et al. Osteochondroma of the mandibular condyle. A case report. Int J Oral Maxillofac Surg 1996;25:203–205 7. Seki H, Fukuda M, Takahashi T, et al. Condylar osteochondroma with complete hearing loss: report of a case. J Oral Maxillofac Surg 2003;61:131–133 8. Stevao ELL. Osteochondroma of the mandibular condyle: conservative reconstruction with condylectomy. J Oral Maxillofac Surg 2003;61:65 9. Munoz M, Goizueta C, Gil-Diez JL, et al. Osteocartilaginous exostosis of the mandibular condyle misdiagnosed as temporomandibular joint dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:494–495 10. Karras SC, Wolford LM, Cottrell DA. Concurrent osteochondroma of the mandibular condyle and ipsilateral cranial base resulting in temperomandibular joint ankylosis: report of a case and review of the literature. J Oral Maxillofac Surg 1996;54:640–646 11. Ortakoglu K, Akcam T, Sencimen M, et al. Osteochondroma of the mandible causing severe facial asymmetry: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e21–e28
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015 12. Wolford LM, Mehra P, Franco P. Use of conservative condylectomy for treatment of osteochondroma of the mandibular condyle. J Oral Maxillofac Surg 2002;60:262–268 13. Vezeau PJ, Fridrich KL, Vincent SD. Literature review and report of two atypical cases. J Oral Maxillofac Surg 1995;53:954–963 14. Roychoudhury A, Bhatt K, Yadav R, et al. Review of osteochondroma of mandibular condyle and report of a case series. J Oral Maxillofac Surg 2011;69:2815–2823 15. Kumar VV. Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach. Int J Oral Maxillofac Surg 2010;39:188–191 16. Koga M, Toyofuku S, Nakamura Y, et al. Osteochondroma in the mandibular condyle that caused facial asymmetry: a case report. Cranio 2006;24:67–70 17. Saito T, Utsunomiya T, Furutani M, et al. Osteochondroma of the mandibular condyle: a case report and review of the literature. J Oral Sci 2001;43:293–297 18. Martinez-Lage JL, Gonzalez J, Pineda A, et al. Condylar reconstruction by oblique sliding vertical-ramus osteotomy. J Craniomaxillofac Surg 2004;32:155–160 19. Holmlund AB, Gynther GW, Reinholt FP. Surgical treatment of osteochondroma of the mandibular condyle in the adult. A 5-year follow-up. Int J Oral Maxillofac Surg 2004;33:549–553 20. Cottrell DA. Discussion: use of conservative condylectomy for treatment of osterchondroma of the mandible condyle. J Oral Maxillofac Surg 2002;60:268 21. Chen MJ, Yang C, Qiu YT. Local resection of the mass to treat the osteochondroma of the mandibular condyle: indications and differentmethods with 38-case series. Head Neck 2014;36:273–279 22. Peroz I, Scholman HJ, Hell B. Osteochondroma of the mandibular condyle: a case report. Int J Oral Maxillofac Surg 2002;31: 455–456 23. Aydin MA, Kucukcelebi A, Sayilkan S, et al. Osteochondroma of the mandibular condyle: report of 2 cases treated with conservative surgery. J Oral Maxillofac Surg 2001;59:1082–1089
Treatment of Orbital Blowout Fracture Using Porous Polyethylene With Embedded Titanium Zhuyun Qian, MD, Ai Zhuang, MD, Ming Lin, MD, Zhengkang Li, MD, Shengfang Ge, PhD, Xianqun Fan, MD, PhD Abstract: The study was performed to evaluate the effectiveness and safety of porous polyethylene with embedded titanium in the repair of orbital blowout fracture. The study was designed as a From the Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. Received August 23, 2014. Accepted for publication October 28, 2014. Address correspondence and reprint requests to Dr. Xianqun Fan, Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639, Zhi Zao Ju Rd, Shanghai 200011, China; E-mail: [email protected] The authors report no conflicts of interest. Zhuyun Qian, MD, and Ai Zhuang, MD, contributed equally to this article. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001407
Brief Clinical Studies
prospective case series. Patients who were diagnosed with orbital blowout fracture from May 2012 to March 2013 were included in the study. A composite material of porous polyethylene and titanium mesh was used. Orbital volumes before and after surgery were measured, and the results of diplopia and ocular movement were recorded. The occurrence of diplopia was grouped and compared according to the time interval between injury and surgery. The incidence of other complications was also recorded. A total of 26 patients were involved in the study. The minimal follow-up time was 12 months. All surgeries were performed uneventfully. The orbital volume significantly decreased after the surgery, and the remission rate and the elimination rate of diplopia in 12 months were 85.7% and 47.6%, respectively. Postoperative diplopia was correlated with the time interval between injury and surgery. One patient presented with undercorrection of enophthalmos, and another patient presented with acute aggravation of diplopia and exophthalmos after surgery, which was resolved with treatment. In conclusion, porous polyethylene with embedded titanium was effective and safe in the repair of orbital blowout fracture, and studies with more subjects and longer follow-up period are recommended in future studies. Key Words: Orbital blowout fracture, surgical repair, porous polyethylene with embedded titanium
B
lunt trauma with an external force often causes orbital blowout fracture.1 The sudden increase in intraorbital pressure results in damage to the thin and weak orbital walls. Complications of orbital blowout fracture include enophthalmos, diplopia, ocular dyskinesia, and eyeball displacement.2 The main target of orbital fracture surgery is to reconstruct the defective orbital walls and restore the enlarged orbital volume and visual function. Various materials can be used for orbital reconstruction, which play an important role in the outcome of the repair process. High-density porous polyethylene (HDPP) and titanium mesh are two common artificial materials used in orbital reconstruction. High-density porous polyethylene is a polymeric biomaterial, whose most prominent characteristic is the structure of interconnecting pores with an approximate diameter of 100 to 250 μm. This structure allows for vascularization, which facilitates self-fixation in surrounding tissues, and makes it easy to be trimmed during surgery.3,4 However, its characteristic radiolucency and poor malleability limit its application.5 The advantages of titanium mesh include high biocompatibility, tensile strength, and malleability.6 It can also be clearly distinguished on computed tomographic (CT) scans. However, the fibrogenic response of titanium mesh may cause the orbital adherence syndrome after surgery; it is also relatively difficult to place the mesh deep within the orbital cone because of its sharp and irregular edge.7,8 To combine the best aspects and to minimize the defects of HDPP and titanium mesh, a composite containing both materials
FIGURE 1. Measurement of bilateral orbital volumes. In each slice, the bilateral intraorbital contents were designated with different colors using Mimics 10.01 (Materialise). The left orbital contents were marked with blue; the right, with yellow. Three-dimensional models (asterisk) were reconstructed using each designated slice to calculate orbital volumes.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
569
An Osteochondroma of the Mandibular Condyle Xi-Hu Yang, MD,* Ping Zhang, PhD,†‡ Jian-Hui Xu, PhD,* Yong-Jie Hu, MD†‡ Objective: Osteochondroma is rarely seen in the facial region, especially around the condyle. Here, we report a case of condylar osteochondroma, aiming to assist the diagnosis and treatment of the tumor. Methods: A case of osteochondroma of the left mandibular condyle in a 49-year-old man was presented. Medical records with x-ray, computed tomographic scan, and bone scan of histologically proven osteochondroma of mandibular condyle were obtained. Results: The patient underwent a surgical resection and had fewer functional changes as well as less dysfunction of the temporomandibular joint. Conclusions: The current study highlights the fact that, despite its rarity in the mandibular condyle, surgical resection is an effective treatment method. The decision, however, depends on how much swing of the mandible is required after surgery for correction of asymmetry and occlusion. From the *Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu; †Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine; and ‡Shanghai Key Laboratory of Stomatology, Shanghai, China. Received July 27, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Yong-Jie Hu, MD, Department of Oral and Maxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai 200011, China; E-mail: [email protected] Supported by Project of National Natural Science Foundation of China (grant no. 30772433). The authors report no conflicts of interest. Xi-Hu Yang and Ping Zhang contributed equally to this work. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001331
Brief Clinical Studies
Key Words: Osteochondroma, mandibular condyle, radical surgery
A
n osteochondroma (OC) or osteocartilaginous exostosis is considered to be the most common benign tumor of bones but is rarely found in the facial skeleton because of the intramembranous origin of most craniomaxillofacial bones.1,2 Despite the OC's predilection for long bones, they may occur in any bone that develops by endochondral ossification.3 This rare incidence of the mandible usually occurs at the unilateral condyle or coronoid process. The etiologies of OC are unclear. Typical clinical features of condylar OC includes facial asymmetry, temporomandibular joint dysfunctions, malocclusion (ipsilateral posterior open bite, contralateral crossbite), and even hearing loss and pain.4–8 We report the diagnosis and treatment of an OC in the left condylar region, pushing the condyle seriously to the anterior direction, thus producing facial asymmetry and malocclusion.
CLINICAL REPORT A 49-year-old man presented in our institution in 2013, with complaints of malocclusion and left preauricular swelling. He complained that his jaw had “shifted” for the last 15 months with increasing facial asymmetry and that his teeth had also moved. He had been having headaches and left joint noises. His mandibular dental midline was deviated by 5 to 6 mm. His mouth opening was 1 fingerbreadth, and there was a palpable mass of 2 cm 2 cm over the left condyle. Panorex film (Fig. 1) showed a bony mass on the posterolateral surface of the condyle. A computed tomographic scan (Fig. 2) revealed that the mass extended anteromedially into the infratemporal fossa. The clinical diagnosis was OC with facial deformity and malocclusion. The temporomandibular joint was accessed using a submandibular approach under general anesthesia and nasotracheal intubation. The condyle and tumor were dissected subperiosteally, and the lesion extended medially and superiorly deep into the infratemporal fossa, where it formed a pseudoarticulation with the base of the skull. A tumor of approximately 25 mm in length was excised, and the condyle was reshaped (Fig. 3). Occlusion was restored and stabilized using an occlusal splint. On histologic examination, an outer lining composed of a broad layer of partially loose periosteal collagen tissue was found, attached with small amounts of cartilaginous differentiated tissue (Fig. 4). Adjacent cancellous bone with trabeculae of varying size and cartilaginous inclusions was visible, and the final diagnosis of OC was established. These findings were consistent with OC. When last reviewed in February 2014, he still had some restriction of mouth opening to 2 fingerbreadths and was given exercises to perform. He had no headaches and improved occlusion as well as facial symmetry.
DISCUSSION Osteochondroma is the most common benign bone tumor. Condylar OCs are usually situated on the anteromedial surface of the condylar head.9 The occurrences of these tumors in the condyle are related with the theory of aberrant foci of epiphyseal cartilage on the
FIGURE 1. Panorex film shows the opaque mass on the left condylar region.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
567
Brief Clinical Studies
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
FIGURE 2. Coronal computed tomographic scans shows a large bony mass arising from the left condyle.
surface of the bone.10 We have reviewed some cases refuting the presumptions as mentioned previously that condylar OCs arise on the anteromedial condylar surface at the posteromedial location of the tumor in the condylar region.11 In addition, in our case, the posterolateral location of the tumor in the condylar region contradicts this theory. The histologic criteria for the diagnosis of an OC include chondrocytes of the cartilaginous cap arranged in clusters in parallel oblong lacunar spaces similarly to those of normal epiphysial cartilage. There are various differential diagnoses of OC of the mandibular condyle, such as from osteoma, benign osteoblastoma, chondroma, and chondroblastoma. The histologic orientation is suggestive of a benign lesion. Regular bony trabeculae produced by enchondral ossification are often seen. The exostosis is covered by periosteum that is continuous with that of the adjacent bone. In consideration of the benign nature of the tumor and its extremely low likelihood of recurrence, the aim of treatment was excision of the tumor and a swingback of the mandible to near-normal occlusion and facial midline correction. A conservative condylectomy with articular disk repositioning combined with orthognathic surgery is an acceptable option for the treatment of condylar OC.8,12 Traditional treatment of 76.67%13 reported cases was the radical resection of the tumor and total condylectomy, with or without reconstruction of superiorly repositioned vertical ramus, costal cartilage graft, or iliac bone harvest.7,11,14–19 We accepted radical resection of the tumor and total condylectomy as our basic treatment. Although conservative subtotal condylectomy can keep the shape of the condyle similar to that of the normal one, the loss of the superficial chondrocytes increased the risk for osteoarthritis. Although worried about the added risk for recurrence, Cottrell20 proposed to save as much of the condyle as possible and to base the excision on the clinical apparent margin with removal of the cartilage cap. Chen et al21 reported that 38 patients all had local resection and that there was no recurrence found in the reports of local resection. However, Peroz et al22 investigated the recurrence risk between condylectomy and noncondylectomy in 34 patients. In 26 of them, condylectomy was performed and only the OC was resected in 8 patients. No recurrence was reported in the patients treated with condylectomy, whereas 2 recurrences were observed
FIGURE 3. Total excision of OCs and condyle using the submandibular approach.
568
FIGURE 4. Hematoxylin-eosin stain showing endochondral ossification progressing beneath the cartilaginous cap.
among the 8 patients treated with excision of the lesion.22 Malignancy potential and risk for recurrence are the major drawbacks of the conservative procedure.23 According to the literature review of Vezeau et al,13 surgical approaches varied for lesions, but preauricular entry into the joint, alone or in combination with other approaches, was used most often. Submandibular or retromolar access was also used frequently. Removal was performed by excision without condylectomy in 23.33% of cases, whereas the majority of surgeons used a total excision with the condyle as the treatment of choice. In this case, we used the submandibular approach and total excision of OC with the condyle.
CONCLUSIONS The current study highlights the fact that, despite its rarity in mandibular condyle, surgical resection is an effective treatment method. The decision, however, depends on how much swing of the mandible is required after surgery for correction of asymmetry and occlusion.
REFERENCES 1. Murphey MD, Choi JJ, Kransdorf MJ, et al. Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407–1434 2. Glick R, Khaldi L, Ptaszynski K, et al. Dysplasia epiphysealis hemimelica (Trevor disease): a rare developmental disorder of bone mimicking osteochondroma of long bones. Hum Pathol 2007;38:1265–1272 3. Tanaka E, Iida S, Tsuji H, et al. Solitary osteochondroma of the mandibular symphysis. Int J Oral Maxillofac Surg 2004;33:625–626 4. Ward BB, Pires CA, Feinberg SE. Osteochondromas of the mandible: case reports and rationale for treatment. J Oral Maxillofac Surg 2005;63:1039–1044 5. Iizuka T, Schroth G, Laeng RH, et al. Osteochondroma of the mandibular condyle: report of a case. J Oral Maxillofac Surg 1996;54:495–501 6. Koole R, Steenks MH, Witkamp TD, et al. Osteochondroma of the mandibular condyle. A case report. Int J Oral Maxillofac Surg 1996;25:203–205 7. Seki H, Fukuda M, Takahashi T, et al. Condylar osteochondroma with complete hearing loss: report of a case. J Oral Maxillofac Surg 2003;61:131–133 8. Stevao ELL. Osteochondroma of the mandibular condyle: conservative reconstruction with condylectomy. J Oral Maxillofac Surg 2003;61:65 9. Munoz M, Goizueta C, Gil-Diez JL, et al. Osteocartilaginous exostosis of the mandibular condyle misdiagnosed as temporomandibular joint dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:494–495 10. Karras SC, Wolford LM, Cottrell DA. Concurrent osteochondroma of the mandibular condyle and ipsilateral cranial base resulting in temperomandibular joint ankylosis: report of a case and review of the literature. J Oral Maxillofac Surg 1996;54:640–646 11. Ortakoglu K, Akcam T, Sencimen M, et al. Osteochondroma of the mandible causing severe facial asymmetry: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e21–e28
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015 12. Wolford LM, Mehra P, Franco P. Use of conservative condylectomy for treatment of osteochondroma of the mandibular condyle. J Oral Maxillofac Surg 2002;60:262–268 13. Vezeau PJ, Fridrich KL, Vincent SD. Literature review and report of two atypical cases. J Oral Maxillofac Surg 1995;53:954–963 14. Roychoudhury A, Bhatt K, Yadav R, et al. Review of osteochondroma of mandibular condyle and report of a case series. J Oral Maxillofac Surg 2011;69:2815–2823 15. Kumar VV. Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach. Int J Oral Maxillofac Surg 2010;39:188–191 16. Koga M, Toyofuku S, Nakamura Y, et al. Osteochondroma in the mandibular condyle that caused facial asymmetry: a case report. Cranio 2006;24:67–70 17. Saito T, Utsunomiya T, Furutani M, et al. Osteochondroma of the mandibular condyle: a case report and review of the literature. J Oral Sci 2001;43:293–297 18. Martinez-Lage JL, Gonzalez J, Pineda A, et al. Condylar reconstruction by oblique sliding vertical-ramus osteotomy. J Craniomaxillofac Surg 2004;32:155–160 19. Holmlund AB, Gynther GW, Reinholt FP. Surgical treatment of osteochondroma of the mandibular condyle in the adult. A 5-year follow-up. Int J Oral Maxillofac Surg 2004;33:549–553 20. Cottrell DA. Discussion: use of conservative condylectomy for treatment of osterchondroma of the mandible condyle. J Oral Maxillofac Surg 2002;60:268 21. Chen MJ, Yang C, Qiu YT. Local resection of the mass to treat the osteochondroma of the mandibular condyle: indications and differentmethods with 38-case series. Head Neck 2014;36:273–279 22. Peroz I, Scholman HJ, Hell B. Osteochondroma of the mandibular condyle: a case report. Int J Oral Maxillofac Surg 2002;31: 455–456 23. Aydin MA, Kucukcelebi A, Sayilkan S, et al. Osteochondroma of the mandibular condyle: report of 2 cases treated with conservative surgery. J Oral Maxillofac Surg 2001;59:1082–1089
Treatment of Orbital Blowout Fracture Using Porous Polyethylene With Embedded Titanium Zhuyun Qian, MD, Ai Zhuang, MD, Ming Lin, MD, Zhengkang Li, MD, Shengfang Ge, PhD, Xianqun Fan, MD, PhD Abstract: The study was performed to evaluate the effectiveness and safety of porous polyethylene with embedded titanium in the repair of orbital blowout fracture. The study was designed as a From the Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China. Received August 23, 2014. Accepted for publication October 28, 2014. Address correspondence and reprint requests to Dr. Xianqun Fan, Department of Ophthalmology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639, Zhi Zao Ju Rd, Shanghai 200011, China; E-mail: [email protected] The authors report no conflicts of interest. Zhuyun Qian, MD, and Ai Zhuang, MD, contributed equally to this article. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001407
Brief Clinical Studies
prospective case series. Patients who were diagnosed with orbital blowout fracture from May 2012 to March 2013 were included in the study. A composite material of porous polyethylene and titanium mesh was used. Orbital volumes before and after surgery were measured, and the results of diplopia and ocular movement were recorded. The occurrence of diplopia was grouped and compared according to the time interval between injury and surgery. The incidence of other complications was also recorded. A total of 26 patients were involved in the study. The minimal follow-up time was 12 months. All surgeries were performed uneventfully. The orbital volume significantly decreased after the surgery, and the remission rate and the elimination rate of diplopia in 12 months were 85.7% and 47.6%, respectively. Postoperative diplopia was correlated with the time interval between injury and surgery. One patient presented with undercorrection of enophthalmos, and another patient presented with acute aggravation of diplopia and exophthalmos after surgery, which was resolved with treatment. In conclusion, porous polyethylene with embedded titanium was effective and safe in the repair of orbital blowout fracture, and studies with more subjects and longer follow-up period are recommended in future studies. Key Words: Orbital blowout fracture, surgical repair, porous polyethylene with embedded titanium
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lunt trauma with an external force often causes orbital blowout fracture.1 The sudden increase in intraorbital pressure results in damage to the thin and weak orbital walls. Complications of orbital blowout fracture include enophthalmos, diplopia, ocular dyskinesia, and eyeball displacement.2 The main target of orbital fracture surgery is to reconstruct the defective orbital walls and restore the enlarged orbital volume and visual function. Various materials can be used for orbital reconstruction, which play an important role in the outcome of the repair process. High-density porous polyethylene (HDPP) and titanium mesh are two common artificial materials used in orbital reconstruction. High-density porous polyethylene is a polymeric biomaterial, whose most prominent characteristic is the structure of interconnecting pores with an approximate diameter of 100 to 250 μm. This structure allows for vascularization, which facilitates self-fixation in surrounding tissues, and makes it easy to be trimmed during surgery.3,4 However, its characteristic radiolucency and poor malleability limit its application.5 The advantages of titanium mesh include high biocompatibility, tensile strength, and malleability.6 It can also be clearly distinguished on computed tomographic (CT) scans. However, the fibrogenic response of titanium mesh may cause the orbital adherence syndrome after surgery; it is also relatively difficult to place the mesh deep within the orbital cone because of its sharp and irregular edge.7,8 To combine the best aspects and to minimize the defects of HDPP and titanium mesh, a composite containing both materials
FIGURE 1. Measurement of bilateral orbital volumes. In each slice, the bilateral intraorbital contents were designated with different colors using Mimics 10.01 (Materialise). The left orbital contents were marked with blue; the right, with yellow. Three-dimensional models (asterisk) were reconstructed using each designated slice to calculate orbital volumes.
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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