Osteochondroma of the mandibular condyle Case
report
and
its management
G. T. Simon, M.S.D.(lJ.S.A.), R. W. Kendrick, P.D.S., R.C.P.S.(Glas.), B.D.S.(Lmd.), and R. I. H. Whitlock, M.D.S.(Lond.), P.D.S., R.C.S.(Eng.), F.P.D., R.C.S.(I.), Belfast, Northem Ireland NORTHERN
IRELAND
PLASTIC
AND
MAXILLOFACIAL
SERVICE,
THE
ULSTER
HOSPITAL
A case of osteochondroma of the temporomandibular joint simulating a unilateral condylar hyperplasia is presented. Treatment is discussed. This tumor should be kept in mind when patients present with symptoms of unilateral condylar hyperplasia.
T
rue tumors of the condyle and temporomandibular joint are best known for their rarity. The following tumors and tumorlike lesions have been reported in this area at various times’ : (1) OSt eoma, (2) chondroma, (3) benign giant-cell tumor, (4) myxoma, (5) fibro-osteoma, (6) fibrous dysplasia, (7) fibrosarcoma, and (8) metastatic tumors. The embryonic development of the temporomandibular joint must be kept in mind for an understanding of the pathology of this region. The condyle, being primarily cartilaginous in origin,2q 3 is more likely to give rise to chondromas, osteomas, and osteochondromas than any of the other tumors listed. When they do arise, they are likely to simulate unilateral condylar hyperplasia in exhibiting the following feature+ 5 : (1) striking facial asymmetry ; (2) malocclusion with (a) open-bite on the affected side a,nd (b) shearing bite, or cross-bite, on the other side ; (3) prognathic deviation with the chin pushed to the opposite side. The following is a case report of a patient with an osteochondroma which had the features of a unilateral condylar hyperplasia. CASE REPORT The patient, a 49-year-old woman, presented on Jan. 18, 1971, complaining of a recurrent self-reducing dislocation in the left temporomandibular joint. The complaint had been present for the past 2 years. She had noticed that her chin protruded to the right side. This had been present for the past 8 years, judging from an old photograph. The last dislocation had occurred that day, and she had been able to reduce it herself.
18
Volume Number
43 I
Osteochondroma
Fig. 1. Preoperative
facial
Fig. 8. Preoperative
of mandibular
condyle
19
appearance.
occlusion.
On examination, her chin was to the right of the facial midline (Fig. 1) ; on opening, there was deviation to the right, but there were satisfactory opening and adequate lateral excursions. Her occlusion (Fig. 2) showed a cross-bite with compensatory overeruption of some of the teeth, typical of condylar hyperplasia. There was bowing of the lower border, but there were no signs to suggest any embryonic abnormality, Radiographic examination (Figs. 3 and 4) showed a large radiopaque mass capping the left condyle, with a distinct outline. There was an appearance of joint formation between the base of the skull and the inner aspect of the growth, which was not in continuity with the glenoid f ossa. A provisional diagnosis of a slow-growing tumor in relation to the condyle was made. It was thought to be an osteoma or osteochondroma. The patient was admitted to the hospital on Jan. 26, 1971; on the following day, the surgical approach, as for a conclylectomy, was used to expose the temporomandibular joint area. It was found that the condyle had been pushed anteriorly and laterally out of the glenoid
Oral January,
Pig. 3. Posteroanterior
view of mandible
with condylar
surg. 1977
mass outlined.
fossa by a large mass attached to its medial surface. A pin (as used in extraoral pin fixation) was inserted into the mass, and the neck of the condyle was divided. When the mass proved to be too large to be removed through the opening available, a section of the zygomatic arch was removed and this allowed the mass to be removed intact. The section of zygomatic arch was then wired back into position and the wound was closed in layers with a latex rubber drain in place. The teeth were wired in occlusion, with the midline correct, to rest the affected area. Postoperatively the drain was shortened after 24 hours and removed entirely after 48 hours. Healing was uneventful and the intraoral wiring was removed on Feb. 4, 1971. Opening was of the order of 3 cm. between the in&al edges, and there were prematurities in the occlusion on8 7 4 5. Occlusal grinding was commenced and the patient was discharged on Feb. 7, 1971. + She has been followed regularly since, is very happy, and has good masticatory function; there has been no recurrence of the dislocation. There is some weakness of the left supraorbital region, the eyelids and below being unaffected. On opening, there is deviation to the left side, but this is minimal. The patient has no complaints and is very pleased with the result (Figs. 5 to 7). Biopsy
report
A bony specimen, measuring 3.5 by 2 by 1.5 cm. (Fig. 8), on cross section (Fig. 9, a), showed a pyramid-shaped mass spread over what appeared to be the head of the condyle. The surface of this mass was capped in part by a layer of blue-white hyaline cartilage varying in thickness from 1 to 3 mm. Histologic examination (Fig. 9, B) showed a thickened and cellular periosteum deep to which there was a sheet of proliferating cartilage cells. The undersurface of the cartilaginous cap showed a zone of ossification resulting in the formation of cancellous
Volume Number
43 1
Osteochondroma
Fig. 4. Part of orthopantomogram
Fig. 5. Postoperative
facial
bone, the marrow spaces of which showed both a fatty were those of a solitary gsteochondroma.
of mandibular
condyle
21
showing mass.
appearance. and a myeloid
content.
The appearances
DISCUSSION
A number of cases have been reported as osteomas, osteochondromas, and other benign tumors which, on careful review, have proved to be hyperp1asiaa.l. 3
22
Simon, Kendrick,
Fig. 6. Postoperative Fig. 7. Postoperative
Oral January,
rrltd Whiflock
Surg. 1977
occlusion. opening.
Fig. 8. Naked-eye
appearance
of biopsy specimen.
The excessive growth at the condyle on one side results in rotation of the mandible, causing the teeth on the same side to lose contact and producing asymmetry of the face. Thoma,l in an exhaustive review of these lesions, stated that condylar tumors are rare and differentiated between osteomas and hyperplasias. “The former is characterized by a spherical or lobulated enlargement rather than an elongation of the entire condylar process.” The case reported here showed a large lobulated mass attached to the medial surface of the condyle with no real lengthening of the ramus. The condyle itself had been displaced anterolaterally by the mass. The condyle was not enlarged, and the mass appeared to cap it and was well demarcated.
Volume Number
43 1
Osteochondronza of mandibular
Fig. 9. A, Cross section of specimen. (Magnification, (Hematoxylin and eosin stain. Magnification, x6.)
x4.) B, Photomicrograph
conclyle
23
of specimen.
Condylar tumors, as well as hyperplasias, are best treated by excision of the condyle along with the mass. Previously some have treated these cases by osteotomy with excellent immediate postoperative results.fi These, however, have relapsed as the lesion has continued to grow. Large tumors may require division of the zygomatic arch to facilitate their removal. Occlusal grinding is frequently necessary following excision of the tumor or the hyperplastic condyle. This is because of the compensatory occlusal adjust-
24
Simon, Ke?ldrick,
crud Whitlock
ment found with the shifting lesions. SUMMARY
AND
and rotation
Oral Hurg. .Janu:try, 1977
to one side of the mandible with these
CONCLUSION
1. A case of osteochondroma of the temporomandibular joint simulating a unilateral condylar hyperplasia is presented. 2. The need to divide the zygomatic arch to facilitate removal of large tumors is noted. 3. The removal of the growth resulted in normal functioning of the jaws with the disappearance of the features of unilateral hyperplasia. 4. Occlusal grinding is often necessary to correct the compensatory occlusal adjustment that occurs with the rotation of the mandible in these lesions. 5. The possibility of the presence of a tumor must be kept in mind when patients present with symptoms of unilateral condylar hyperplasia. The authors wish to express their thanks to Prof. F. V. O’Brien, M.B., B.D.S., F.D.S., Head of the Department of Oral Pathology, Queen’s University, Belfast, for the pathology report and photomicrograph, and to the Photographic and X-ray Department of the Ulster Hospital for the photographs and x-rays. REFERENCES
1. Thoma, K. H.: Tumors of the Condyle and Temporomandibular Joint, ORAL SURG. 7: 1091-1107. 1954. 2. Scott, J. ‘H., and Symons, N. B. B.: Introduction to Dental Anatomy, Edinburgh and London, 1971, E. & S. Livingstone, Ltd. 3. Rushton. M. A.: Growth at the Mandibular Condvle in Relation to Some Deformities, Br. Dent. J.‘76: 57-68, 1944. 4. Rushton, M. A.: Unilateral Hyperplasia of the Mandibular Condyle, Proc. R. Sot. Med. (Sect. Odontol.) 39: 431-438, 1946. Condyle, J. Oral Surg. 9: 118-135, 1951. 5. Gottlieb, 0.: Hyperplasia of the Mandibular 6. Waldron, C. W., Peterson, R. G., and Waldron, C. A.: Surgical Treatment of Mandibular Prognathism, J. Oral Surg. 4: 61-85, 1946. Reprint
requests
to:
Dr. I. H. Whitlock Plastic and Maxillofacial Service School of Dentistry Royal Victoria Hospital Grosvenor Rd. Belfast BT 12 6BP, Northern Ireland
report
and
its management
G. T. Simon, M.S.D.(lJ.S.A.), R. W. Kendrick, P.D.S., R.C.P.S.(Glas.), B.D.S.(Lmd.), and R. I. H. Whitlock, M.D.S.(Lond.), P.D.S., R.C.S.(Eng.), F.P.D., R.C.S.(I.), Belfast, Northem Ireland NORTHERN
IRELAND
PLASTIC
AND
MAXILLOFACIAL
SERVICE,
THE
ULSTER
HOSPITAL
A case of osteochondroma of the temporomandibular joint simulating a unilateral condylar hyperplasia is presented. Treatment is discussed. This tumor should be kept in mind when patients present with symptoms of unilateral condylar hyperplasia.
T
rue tumors of the condyle and temporomandibular joint are best known for their rarity. The following tumors and tumorlike lesions have been reported in this area at various times’ : (1) OSt eoma, (2) chondroma, (3) benign giant-cell tumor, (4) myxoma, (5) fibro-osteoma, (6) fibrous dysplasia, (7) fibrosarcoma, and (8) metastatic tumors. The embryonic development of the temporomandibular joint must be kept in mind for an understanding of the pathology of this region. The condyle, being primarily cartilaginous in origin,2q 3 is more likely to give rise to chondromas, osteomas, and osteochondromas than any of the other tumors listed. When they do arise, they are likely to simulate unilateral condylar hyperplasia in exhibiting the following feature+ 5 : (1) striking facial asymmetry ; (2) malocclusion with (a) open-bite on the affected side a,nd (b) shearing bite, or cross-bite, on the other side ; (3) prognathic deviation with the chin pushed to the opposite side. The following is a case report of a patient with an osteochondroma which had the features of a unilateral condylar hyperplasia. CASE REPORT The patient, a 49-year-old woman, presented on Jan. 18, 1971, complaining of a recurrent self-reducing dislocation in the left temporomandibular joint. The complaint had been present for the past 2 years. She had noticed that her chin protruded to the right side. This had been present for the past 8 years, judging from an old photograph. The last dislocation had occurred that day, and she had been able to reduce it herself.
18
Volume Number
43 I
Osteochondroma
Fig. 1. Preoperative
facial
Fig. 8. Preoperative
of mandibular
condyle
19
appearance.
occlusion.
On examination, her chin was to the right of the facial midline (Fig. 1) ; on opening, there was deviation to the right, but there were satisfactory opening and adequate lateral excursions. Her occlusion (Fig. 2) showed a cross-bite with compensatory overeruption of some of the teeth, typical of condylar hyperplasia. There was bowing of the lower border, but there were no signs to suggest any embryonic abnormality, Radiographic examination (Figs. 3 and 4) showed a large radiopaque mass capping the left condyle, with a distinct outline. There was an appearance of joint formation between the base of the skull and the inner aspect of the growth, which was not in continuity with the glenoid f ossa. A provisional diagnosis of a slow-growing tumor in relation to the condyle was made. It was thought to be an osteoma or osteochondroma. The patient was admitted to the hospital on Jan. 26, 1971; on the following day, the surgical approach, as for a conclylectomy, was used to expose the temporomandibular joint area. It was found that the condyle had been pushed anteriorly and laterally out of the glenoid
Oral January,
Pig. 3. Posteroanterior
view of mandible
with condylar
surg. 1977
mass outlined.
fossa by a large mass attached to its medial surface. A pin (as used in extraoral pin fixation) was inserted into the mass, and the neck of the condyle was divided. When the mass proved to be too large to be removed through the opening available, a section of the zygomatic arch was removed and this allowed the mass to be removed intact. The section of zygomatic arch was then wired back into position and the wound was closed in layers with a latex rubber drain in place. The teeth were wired in occlusion, with the midline correct, to rest the affected area. Postoperatively the drain was shortened after 24 hours and removed entirely after 48 hours. Healing was uneventful and the intraoral wiring was removed on Feb. 4, 1971. Opening was of the order of 3 cm. between the in&al edges, and there were prematurities in the occlusion on8 7 4 5. Occlusal grinding was commenced and the patient was discharged on Feb. 7, 1971. + She has been followed regularly since, is very happy, and has good masticatory function; there has been no recurrence of the dislocation. There is some weakness of the left supraorbital region, the eyelids and below being unaffected. On opening, there is deviation to the left side, but this is minimal. The patient has no complaints and is very pleased with the result (Figs. 5 to 7). Biopsy
report
A bony specimen, measuring 3.5 by 2 by 1.5 cm. (Fig. 8), on cross section (Fig. 9, a), showed a pyramid-shaped mass spread over what appeared to be the head of the condyle. The surface of this mass was capped in part by a layer of blue-white hyaline cartilage varying in thickness from 1 to 3 mm. Histologic examination (Fig. 9, B) showed a thickened and cellular periosteum deep to which there was a sheet of proliferating cartilage cells. The undersurface of the cartilaginous cap showed a zone of ossification resulting in the formation of cancellous
Volume Number
43 1
Osteochondroma
Fig. 4. Part of orthopantomogram
Fig. 5. Postoperative
facial
bone, the marrow spaces of which showed both a fatty were those of a solitary gsteochondroma.
of mandibular
condyle
21
showing mass.
appearance. and a myeloid
content.
The appearances
DISCUSSION
A number of cases have been reported as osteomas, osteochondromas, and other benign tumors which, on careful review, have proved to be hyperp1asiaa.l. 3
22
Simon, Kendrick,
Fig. 6. Postoperative Fig. 7. Postoperative
Oral January,
rrltd Whiflock
Surg. 1977
occlusion. opening.
Fig. 8. Naked-eye
appearance
of biopsy specimen.
The excessive growth at the condyle on one side results in rotation of the mandible, causing the teeth on the same side to lose contact and producing asymmetry of the face. Thoma,l in an exhaustive review of these lesions, stated that condylar tumors are rare and differentiated between osteomas and hyperplasias. “The former is characterized by a spherical or lobulated enlargement rather than an elongation of the entire condylar process.” The case reported here showed a large lobulated mass attached to the medial surface of the condyle with no real lengthening of the ramus. The condyle itself had been displaced anterolaterally by the mass. The condyle was not enlarged, and the mass appeared to cap it and was well demarcated.
Volume Number
43 1
Osteochondronza of mandibular
Fig. 9. A, Cross section of specimen. (Magnification, (Hematoxylin and eosin stain. Magnification, x6.)
x4.) B, Photomicrograph
conclyle
23
of specimen.
Condylar tumors, as well as hyperplasias, are best treated by excision of the condyle along with the mass. Previously some have treated these cases by osteotomy with excellent immediate postoperative results.fi These, however, have relapsed as the lesion has continued to grow. Large tumors may require division of the zygomatic arch to facilitate their removal. Occlusal grinding is frequently necessary following excision of the tumor or the hyperplastic condyle. This is because of the compensatory occlusal adjust-
24
Simon, Ke?ldrick,
crud Whitlock
ment found with the shifting lesions. SUMMARY
AND
and rotation
Oral Hurg. .Janu:try, 1977
to one side of the mandible with these
CONCLUSION
1. A case of osteochondroma of the temporomandibular joint simulating a unilateral condylar hyperplasia is presented. 2. The need to divide the zygomatic arch to facilitate removal of large tumors is noted. 3. The removal of the growth resulted in normal functioning of the jaws with the disappearance of the features of unilateral hyperplasia. 4. Occlusal grinding is often necessary to correct the compensatory occlusal adjustment that occurs with the rotation of the mandible in these lesions. 5. The possibility of the presence of a tumor must be kept in mind when patients present with symptoms of unilateral condylar hyperplasia. The authors wish to express their thanks to Prof. F. V. O’Brien, M.B., B.D.S., F.D.S., Head of the Department of Oral Pathology, Queen’s University, Belfast, for the pathology report and photomicrograph, and to the Photographic and X-ray Department of the Ulster Hospital for the photographs and x-rays. REFERENCES
1. Thoma, K. H.: Tumors of the Condyle and Temporomandibular Joint, ORAL SURG. 7: 1091-1107. 1954. 2. Scott, J. ‘H., and Symons, N. B. B.: Introduction to Dental Anatomy, Edinburgh and London, 1971, E. & S. Livingstone, Ltd. 3. Rushton. M. A.: Growth at the Mandibular Condvle in Relation to Some Deformities, Br. Dent. J.‘76: 57-68, 1944. 4. Rushton, M. A.: Unilateral Hyperplasia of the Mandibular Condyle, Proc. R. Sot. Med. (Sect. Odontol.) 39: 431-438, 1946. Condyle, J. Oral Surg. 9: 118-135, 1951. 5. Gottlieb, 0.: Hyperplasia of the Mandibular 6. Waldron, C. W., Peterson, R. G., and Waldron, C. A.: Surgical Treatment of Mandibular Prognathism, J. Oral Surg. 4: 61-85, 1946. Reprint
requests
to:
Dr. I. H. Whitlock Plastic and Maxillofacial Service School of Dentistry Royal Victoria Hospital Grosvenor Rd. Belfast BT 12 6BP, Northern Ireland
