The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Brief Clinical Studies
REFERENCES
FIGURE 3. Histopathologic and immunohistochemical examinations of the tumor. A, Histopathologic study with hematoxylin-eosin staining demonstrated variable chondroid elements with what appeared to be immature irregular chondrocytes, containing eosinophilic cytoplasm and surrounded by fibrous myxoid intercelluar matrix (A). This soft tissue tumor was heterogeneous in both cell types, which consisted of stellate and spindle-shaped cells, as well as chondroid, myxoid, and fibrous elements (B). Immunohistochemical examinations showed the tumor cells were negative staining with glial fibrillary acidic protein (GFAP) (C) and positive staining with vimentin (D).
Based on the radiographic features, there were multiple differential diagnostic considerations, including chondrosarcomas, chondroblastoma, enchondroma, and chordoma. Predominantly, the histopathologic features of CMF as defined by the World Health Organization are that CMF is “a benign tumor characterized by lobules of spindle-shaped or stellate cells with abundant myxoid or chondroid intercellular material separated by zones of more cellular tissue rich in spindle-shaped or round cells with varying numbers of multinucleated giant cells of different sizes.”5,7 Chondrosarcoma can be differentiated from CMF by its invasive pattern of growth and presence of mitosis. Furthermore, presence of a well-formed hyaline matrix and absence of fibrous component are other features distinguishing chondrosarcomas from CMFs.7,8 Chondroblastoma is another benign tumor with cartilaginous differentiation, but it generally lacks a lobular pattern and perilobular fibrous component.3,7 Enchondromas show lobular architecture as in CMFs, but the lack of welldifferentiated hyaline cartilage helps to exclude the diagnosis of CMF.7 Similarly, chordoma, although it bears a superficial resemblance, lacks the degree of cellularity and other architectural features of CMFs.6,7 In addition, the routine use of immunohistochemistry plays a very limited role in resolving the differential diagnosis because the above tumors mentioned may express vimentin and S100 protein.7 Complete surgical resection is considered to be the optimal treatment for intracranial CMF.2 Curettage is recommended when complete resection is not possible.9 Despite the benign behavior of CMF, recurrence rate has been reported to be as high as 11% even in case of complete surgical resection.3 Nevertheless, the rate could increase up to 80% when surgical excision is incomplete.10 Recurrences tend to show identical morphology of the original tumor without histological evidence of dedifferentiation or progression.11 The severe functional and cosmetic morbidities after wide resection of the tumor should be kept in mind, and cranioplasty should be performed for prevention of cosmetic bone defect in the frontal area.5 The administration of radiotherapy is controversial, because it has been associated with an increased risk of malignant transformation and a potential long-term sequelae.2 Given the benign nature of CMF and its excellent response to surgical resection, radiotherapy should be reserved only for recurrences or primary tumors that are surgically difficult to reach.2 In conclusion, CMF is a rare, benign neoplasm occasionally occurring in the skull bone, with very rare occurrence in the frontal bone. Histopathologic diagnosis is essential to provide the patient with an accurate management of the pathology. Complete surgical resection remains the main and best treatment modality for patients with CMF of the frontal bone.
1. Jaffe HL, Lichtenstein L. Chondromyxoid fibroma of bone; a distinctive benign tumor likely to be mistaken especially for chondrosarcoma. Arch Pathol 1948;45:541–551 2. McClurg SW, Leon M, Teknos TN, et al. Chondromyxoid fibroma of the nasal septum: case report and review of literature. Head Neck 2013;35:E1–E5 3. Wu CT, Inwards CY, O’Laughlin S, et al. Chondromyxoid fibroma of bone: a clinicopathologic review of 278 cases. Hum Pathol 1998;29:438–446 4. Hammad HM, Hammond HL, Kurago ZB, et al. Chondromyxoid fibroma of the jaws. Case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:293–300 5. Hakan T, Vardar Aker F. Chondromyxoid fibroma of frontal bone: a case report and review of the literature. Turk Neurosurg 2008;18:249–253 6. Kadom N, Rushing EJ, Yaun A, et al. Chondromyxoid fibroma of the frontal bone in a teenager. Pediatr Radiol 2009;39:53–56 7. Karkuzhali P, Chithralekha S, Muthuvel E, et al. Chondromyxoid fibroma of the parietal bone. Neuropathology 2005;25:84–88 8. Sharma M, Velho V, Binayake R, et al. Chondromyxoid fibroma of the temporal bone: a rare entity. J Pediatr Neurosci 2012;7:211–214 9. Schajowicz F, Gallardo H. Chondromyxoid fibroma (fibromyxoid chondroma) of bone. A clinico-pathological study of thirty-two cases. J Bone Joint Surg Br 1971;53:198–216 10. Gherlinzoni F, Rock M, Picci P. Chondromyxoid fibroma. The experience at the Istituto Ortopedico Rizzoli. J Bone Joint Surg Am 1983;65:198–204 11. Shek TW, Peh WC, Leung G. Chondromyxoid fibroma of skull base: a tumour prone to local recurrence. J Laryngol Otol 1999;113:380–385
Treatment of Mandibular Symphyseal Fracture Combined With Dislocated Intracapsular Condylar Fractures Xiaofeng Xu, MDS, Jun Shi, MD, Bing Xu, DDS, Jiewen Dai, MD, Shilei Zhang, MD Objectives: To evaluate the treatment methods of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures (MSF&DICF) and to compare the effect of different treatment methods of condylar fractures. From the Department of Oral and Cranio-maxillofacial Science, College of Stomatology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China. Received October 19, 2014. Accepted for publication December 1, 2014. Address correspondence and reprint requests to Bing Xu, DDS, Department of Craniomaxillofacial Science, Shanghai Ninth People's Hospital, School of Dentistry, Shanghai Jiaotong University, 639 Zhizaoju Rd, Shanghai, China 200011; E-mail: [email protected]; or Jun Shi, MD, Department of Craniomaxillofacial Science, Shanghai Ninth People's Hospital, School of Dentistry, Shanghai Jiaotong University, 639 Zhizaoju Rd, Shanghai, China 200011; E-mail: [email protected] The authors report no conflicts of interest. The authors declare that there are no competing interests and that they have no support or funding to report. Dr Bing Xu and Dr Jun Shi contributed equally to this work and they should be considered co–corresponding authors. Copyright © 2014 by Mutaz B. Habal. MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001451
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e181
Brief Clinical Studies
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Methods: Twenty-eight patients with MSF&DICF were included in this study. Twenty-two sites were treated by open reduction, and all the medial condylar fragments were fixed with titanium screws; whereas the other 22 sites underwent close treatment. The surgical effect between these 2 groups was compared based on clinical examination and radiographic examination results. Results: Seventeen of 22 condyle fractures were repositioned in the surgery group, whereas 4 of 22 condyle fractures were repositioned in the close treatment group. Statistical difference was observed between these 2 groups (P < 0.01). Functional outcomes of the patients treated in the surgical treatment group also were better than those in the close treatment group. Conclusions: The dislocated intracapsular condyle fractures should be treated by surgical reduction with the maintenance of the attachment of lateral pterygoid muscle, which is beneficial to repositioning the dislocated condyle to its original physiological position, to closure of the mandibular lingual gap, to restore the mandibular width. Key Words: Condylar fracture, mandibular widening, condylar dislocation
M
andibular symphyseal fracture combined with intracapsular condylar fracture (MSF&DICF) is one of the most common fractures in the craniofacial region.1–3 A common characteristic of MSF&DICF was condyle dislocating from the fossa and combining with the expanded mandibular arch. The clinical examinations usually found that there was a widening lower face, malocclusion, and limitation of mouth opening in these patients. The treatment of MSF&DICF is still a challenge because the dislocated condyle is often difficult to reset into the fossa, and the transverse dimension of the mandible is hard to restore. Thus, MSF&DICF usually leads to the emergence of a variety of complications, especially when no appropriate and timely treatment is applied. For MSF&DICF, the Association for the Study of Internal Fixation (AO/ASIF) suggests that reduction and stabilization of the anterior fracture is crucial for the restoration of the transverse dimension of the mandible. If the exact dimension is not restored, the transverse dimension of the subcondylar region could never be restored. Thus, anterior osteosynthesis should be performed with a strong plate (such as reconstruction plate and lag screws), and some overbending is required to close the lingual gap.4 However, the AO/ASIF method showed several disadvantages. First, this method only discusses the treatment and the osteosynthesis of symphyseal fractures, whereas the treatment of condylar fracture and its dislocation are ignored. Second, fixation with reconstruction plate needs wider exposure. Extraoral approach will produce esthetic problems such as scars, whereas intraoral approach will increase the risk of damaging the mental nerve. In addition, it is hard to recontour the reconstruction plate to perfectly fit the surface of the mandible, which lacks convenience in operation. In clinical practice, we found that if the condylar fracture did not receive surgical treatment, it is difficult to restore the transverse dimension of mandibular arch only by the deal with mandibular symphyseal fracture; the dislocated condyles still stay outside the fossa. Thus, we want to know whether processing of condylar fracture plays a crucial role in treating this kind of patients, whether selection of different treatment methods for condylar fractures will affect the treatment effect in such patients, and whether surgical treatment for condylar fractures is beneficial for the restoration of the mandibular transverse dimension. In this retrospective analysis,
e182
28 cases were collected from 2008 to 2013. The study was aimed to evaluate different treatment methods of condylar fracture that did not receive surgical treatment and to compare their influences on the treatment results.
MATERIALS AND METHODS Patients Twenty-eight patients with MSF&DICF were treated in our surgical group, the cranio-maxillofacial science department, Shanghai Ninth Hospital from 2008 to 2013. The mean age of these patients was 29.32 years, and the ratio of male to female was 20:8. Among the 28 cases, 12 cases were unilateral dislocation and 16 were bilateral dislocation. All cases were given maxillofacial computed tomographic (CT) scan and panoramic films, and definitely diagnosed as MSF&DICF. All patients demonstrated clinical findings such as malocclusion, limitation of mouth opening, and widening of the lower face. Condylar dislocation in this study is defined as condylar sagittally partial outside the articular fossa based on clinical and CT examination results and is classified into mild (dislocated condyle
Brief Clinical Studies
REFERENCES
FIGURE 3. Histopathologic and immunohistochemical examinations of the tumor. A, Histopathologic study with hematoxylin-eosin staining demonstrated variable chondroid elements with what appeared to be immature irregular chondrocytes, containing eosinophilic cytoplasm and surrounded by fibrous myxoid intercelluar matrix (A). This soft tissue tumor was heterogeneous in both cell types, which consisted of stellate and spindle-shaped cells, as well as chondroid, myxoid, and fibrous elements (B). Immunohistochemical examinations showed the tumor cells were negative staining with glial fibrillary acidic protein (GFAP) (C) and positive staining with vimentin (D).
Based on the radiographic features, there were multiple differential diagnostic considerations, including chondrosarcomas, chondroblastoma, enchondroma, and chordoma. Predominantly, the histopathologic features of CMF as defined by the World Health Organization are that CMF is “a benign tumor characterized by lobules of spindle-shaped or stellate cells with abundant myxoid or chondroid intercellular material separated by zones of more cellular tissue rich in spindle-shaped or round cells with varying numbers of multinucleated giant cells of different sizes.”5,7 Chondrosarcoma can be differentiated from CMF by its invasive pattern of growth and presence of mitosis. Furthermore, presence of a well-formed hyaline matrix and absence of fibrous component are other features distinguishing chondrosarcomas from CMFs.7,8 Chondroblastoma is another benign tumor with cartilaginous differentiation, but it generally lacks a lobular pattern and perilobular fibrous component.3,7 Enchondromas show lobular architecture as in CMFs, but the lack of welldifferentiated hyaline cartilage helps to exclude the diagnosis of CMF.7 Similarly, chordoma, although it bears a superficial resemblance, lacks the degree of cellularity and other architectural features of CMFs.6,7 In addition, the routine use of immunohistochemistry plays a very limited role in resolving the differential diagnosis because the above tumors mentioned may express vimentin and S100 protein.7 Complete surgical resection is considered to be the optimal treatment for intracranial CMF.2 Curettage is recommended when complete resection is not possible.9 Despite the benign behavior of CMF, recurrence rate has been reported to be as high as 11% even in case of complete surgical resection.3 Nevertheless, the rate could increase up to 80% when surgical excision is incomplete.10 Recurrences tend to show identical morphology of the original tumor without histological evidence of dedifferentiation or progression.11 The severe functional and cosmetic morbidities after wide resection of the tumor should be kept in mind, and cranioplasty should be performed for prevention of cosmetic bone defect in the frontal area.5 The administration of radiotherapy is controversial, because it has been associated with an increased risk of malignant transformation and a potential long-term sequelae.2 Given the benign nature of CMF and its excellent response to surgical resection, radiotherapy should be reserved only for recurrences or primary tumors that are surgically difficult to reach.2 In conclusion, CMF is a rare, benign neoplasm occasionally occurring in the skull bone, with very rare occurrence in the frontal bone. Histopathologic diagnosis is essential to provide the patient with an accurate management of the pathology. Complete surgical resection remains the main and best treatment modality for patients with CMF of the frontal bone.
1. Jaffe HL, Lichtenstein L. Chondromyxoid fibroma of bone; a distinctive benign tumor likely to be mistaken especially for chondrosarcoma. Arch Pathol 1948;45:541–551 2. McClurg SW, Leon M, Teknos TN, et al. Chondromyxoid fibroma of the nasal septum: case report and review of literature. Head Neck 2013;35:E1–E5 3. Wu CT, Inwards CY, O’Laughlin S, et al. Chondromyxoid fibroma of bone: a clinicopathologic review of 278 cases. Hum Pathol 1998;29:438–446 4. Hammad HM, Hammond HL, Kurago ZB, et al. Chondromyxoid fibroma of the jaws. Case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:293–300 5. Hakan T, Vardar Aker F. Chondromyxoid fibroma of frontal bone: a case report and review of the literature. Turk Neurosurg 2008;18:249–253 6. Kadom N, Rushing EJ, Yaun A, et al. Chondromyxoid fibroma of the frontal bone in a teenager. Pediatr Radiol 2009;39:53–56 7. Karkuzhali P, Chithralekha S, Muthuvel E, et al. Chondromyxoid fibroma of the parietal bone. Neuropathology 2005;25:84–88 8. Sharma M, Velho V, Binayake R, et al. Chondromyxoid fibroma of the temporal bone: a rare entity. J Pediatr Neurosci 2012;7:211–214 9. Schajowicz F, Gallardo H. Chondromyxoid fibroma (fibromyxoid chondroma) of bone. A clinico-pathological study of thirty-two cases. J Bone Joint Surg Br 1971;53:198–216 10. Gherlinzoni F, Rock M, Picci P. Chondromyxoid fibroma. The experience at the Istituto Ortopedico Rizzoli. J Bone Joint Surg Am 1983;65:198–204 11. Shek TW, Peh WC, Leung G. Chondromyxoid fibroma of skull base: a tumour prone to local recurrence. J Laryngol Otol 1999;113:380–385
Treatment of Mandibular Symphyseal Fracture Combined With Dislocated Intracapsular Condylar Fractures Xiaofeng Xu, MDS, Jun Shi, MD, Bing Xu, DDS, Jiewen Dai, MD, Shilei Zhang, MD Objectives: To evaluate the treatment methods of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures (MSF&DICF) and to compare the effect of different treatment methods of condylar fractures. From the Department of Oral and Cranio-maxillofacial Science, College of Stomatology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China. Received October 19, 2014. Accepted for publication December 1, 2014. Address correspondence and reprint requests to Bing Xu, DDS, Department of Craniomaxillofacial Science, Shanghai Ninth People's Hospital, School of Dentistry, Shanghai Jiaotong University, 639 Zhizaoju Rd, Shanghai, China 200011; E-mail: [email protected]; or Jun Shi, MD, Department of Craniomaxillofacial Science, Shanghai Ninth People's Hospital, School of Dentistry, Shanghai Jiaotong University, 639 Zhizaoju Rd, Shanghai, China 200011; E-mail: [email protected] The authors report no conflicts of interest. The authors declare that there are no competing interests and that they have no support or funding to report. Dr Bing Xu and Dr Jun Shi contributed equally to this work and they should be considered co–corresponding authors. Copyright © 2014 by Mutaz B. Habal. MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001451
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e181
Brief Clinical Studies
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Methods: Twenty-eight patients with MSF&DICF were included in this study. Twenty-two sites were treated by open reduction, and all the medial condylar fragments were fixed with titanium screws; whereas the other 22 sites underwent close treatment. The surgical effect between these 2 groups was compared based on clinical examination and radiographic examination results. Results: Seventeen of 22 condyle fractures were repositioned in the surgery group, whereas 4 of 22 condyle fractures were repositioned in the close treatment group. Statistical difference was observed between these 2 groups (P < 0.01). Functional outcomes of the patients treated in the surgical treatment group also were better than those in the close treatment group. Conclusions: The dislocated intracapsular condyle fractures should be treated by surgical reduction with the maintenance of the attachment of lateral pterygoid muscle, which is beneficial to repositioning the dislocated condyle to its original physiological position, to closure of the mandibular lingual gap, to restore the mandibular width. Key Words: Condylar fracture, mandibular widening, condylar dislocation
M
andibular symphyseal fracture combined with intracapsular condylar fracture (MSF&DICF) is one of the most common fractures in the craniofacial region.1–3 A common characteristic of MSF&DICF was condyle dislocating from the fossa and combining with the expanded mandibular arch. The clinical examinations usually found that there was a widening lower face, malocclusion, and limitation of mouth opening in these patients. The treatment of MSF&DICF is still a challenge because the dislocated condyle is often difficult to reset into the fossa, and the transverse dimension of the mandible is hard to restore. Thus, MSF&DICF usually leads to the emergence of a variety of complications, especially when no appropriate and timely treatment is applied. For MSF&DICF, the Association for the Study of Internal Fixation (AO/ASIF) suggests that reduction and stabilization of the anterior fracture is crucial for the restoration of the transverse dimension of the mandible. If the exact dimension is not restored, the transverse dimension of the subcondylar region could never be restored. Thus, anterior osteosynthesis should be performed with a strong plate (such as reconstruction plate and lag screws), and some overbending is required to close the lingual gap.4 However, the AO/ASIF method showed several disadvantages. First, this method only discusses the treatment and the osteosynthesis of symphyseal fractures, whereas the treatment of condylar fracture and its dislocation are ignored. Second, fixation with reconstruction plate needs wider exposure. Extraoral approach will produce esthetic problems such as scars, whereas intraoral approach will increase the risk of damaging the mental nerve. In addition, it is hard to recontour the reconstruction plate to perfectly fit the surface of the mandible, which lacks convenience in operation. In clinical practice, we found that if the condylar fracture did not receive surgical treatment, it is difficult to restore the transverse dimension of mandibular arch only by the deal with mandibular symphyseal fracture; the dislocated condyles still stay outside the fossa. Thus, we want to know whether processing of condylar fracture plays a crucial role in treating this kind of patients, whether selection of different treatment methods for condylar fractures will affect the treatment effect in such patients, and whether surgical treatment for condylar fractures is beneficial for the restoration of the mandibular transverse dimension. In this retrospective analysis,
e182
28 cases were collected from 2008 to 2013. The study was aimed to evaluate different treatment methods of condylar fracture that did not receive surgical treatment and to compare their influences on the treatment results.
MATERIALS AND METHODS Patients Twenty-eight patients with MSF&DICF were treated in our surgical group, the cranio-maxillofacial science department, Shanghai Ninth Hospital from 2008 to 2013. The mean age of these patients was 29.32 years, and the ratio of male to female was 20:8. Among the 28 cases, 12 cases were unilateral dislocation and 16 were bilateral dislocation. All cases were given maxillofacial computed tomographic (CT) scan and panoramic films, and definitely diagnosed as MSF&DICF. All patients demonstrated clinical findings such as malocclusion, limitation of mouth opening, and widening of the lower face. Condylar dislocation in this study is defined as condylar sagittally partial outside the articular fossa based on clinical and CT examination results and is classified into mild (dislocated condyle
