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Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach
Int. J. Oral Maxillofac. Surg. 2010; 39: 188–191 doi:10.1016/j.ijom.2009.12.004, available online at http://www.sciencedirect.com
Case Report TMJ Disorders
Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach
V. V. Kumar Dept. of Maxillofacial Surgery, Swami Devi Dyal Hospital and Dental College, Barwala, Panchkula, Haryana, India
V. V. Kumar: Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach. Int. J. Oral Maxillofac. Surg. 2010; 39: 188–191. # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. This article presents an interesting case of osteochondroma of the mandibular condyle with multiple projections in a 42-year-old man. Owing to the large size of the lesion, surgical condylectomy was performed using a transzygomatic approach.
Accepted for publication 7 December 2009 Available online 13 January 2010
Osteochondroma is considered as a hamartomatous proliferation of cartilaginous tissue and is also known as osteocartilaginous exostosis. It is the commonest benign tumour of the long bones but is relatively rare in the mandible with fewer than 50 cases reported worldwide2,4,6. Many of these cases have been described as a hyperplasia of the condyle and not as a discrete mass that arises away from the long axis of the mandibular condyle3. Osteochondroma of the mandible is more common in the coronoid process, followed by the condyle and rare in other parts. In the condyle, it presents mostly on the medial and anterior aspects and rarely from the superior or lateral aspect3. In most reports the size of the lesion has not been given. These lesions have been treated by resection or condylectomy, but resection has been associated with recurrence in three cases6,7. The surgical approach used
canting, nor was there any bowing of the inferior border of the mandible. A CT scan revealed a well-defined 50 mm 45 mm 35 mm sized irregular pedunculated bony lesion with multiple projections arising from the medial margin of left condyle (Fig. 1). One of the outgrowths was projecting anteromedially into the infratemporal fossa and extending up to the posterolateral wall of the maxillary sinus. A superior projection of the lesion extended to the greater wing of sphenoid, which it had thinned, and laterally the lesion extended to the zygomatic arch. There was also a small inferior projection. An anterior subluxation of the left temporomandibular joint was noted. The scan findings were more suggestive of an osteochondroma of the left mandibular condyle owing to the pedunculated nature. A three-phase bone scan scintigraphy, carried out with 20 mCi of 99MTc-MDC revealed an increased uptake of the left
0901-5027/020188 + 04 $36.00/0
is generally a preauricular or a submandibular approach either alone or in combination. As these lesions are usually not large, the use of a transzygomatic approach has not been described in the literature. This article reports a case of a large osteochondroma in a 42-year-old man treated by condylectomy using a transzygomatic approach. Case report
A 42-year-old man presented with a complaint of progressive deviation of the mandible to the right side of 3 years duration (Fig. 1). Clinically the mandible had deviated 14 mm. Mouth opening was restricted to 24 mm and the patient could not protrude the mandible to the left side. The mandible deviated further onto the right when opening the mouth. Posterior cross bite on the right side was also noted when in occlusion. There was no occlusal
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Large osteochondroma of the mandibular condyle
Fig. 1. (a – top left) Clinical presentation of the patient; (b – top right) coronal section of CT scan showing extent of lesion and erosion of the greater wing of sphenoid. (c and d – bottom left and right) Successive sagittal sections of CT scan demonstrating multiple projections of the lesion.
mandibular condyle with increased vascularity on blood pool images, and the rest of the body showing normal radiotracer uptake. This ruled out multiple osteochon-
dromas. The blood chemistry studies were within normal limits. The patient was posted for resection of the tumour along with a condylectomy.
189
Owing to the size of the lesion and its extension into the infratemporal fossa, a transzygomatic approach was considered (Fig. 2). A hemicoronal incision ending in a preauricular extension up to the lobule of the ear was made through the skin, subcutaneous tissue and galea. In the temporal region this incision was up to the superficial layer of the temporalis fascia. At the root of the zygomatic arch, the superficial layer of the temporalis fascia was incised anterosuperiorly at a 45 angle. The periosteum was then incised to expose the zygomatic arch. Two plates were adapted, bridging the proposed osteotomy sites and screw holes marked. The zygomatic arch was osteotomized, hinged inferiorly on the masseter exposing the inferior aspect of the temporalis muscle, which was retracted anteriorly to expose the tumour mass (Fig. 3). Inferiorly, anterior retraction of the temporalis brought about a clear exposure of the subcondylar and infratemporal region. An osteotomy cut was made inferior to the origin of the tumour at the condylar neck region. The tumour was then removed by stripping the attachments of the lateral pterygoid. The condylar stump was then reshaped and the wound closed in layers. Arch bars with guiding elastics were fixed for 1 month postoperatively to train the mandible. Histopathologic examination (Fig. 3) of the excised specimen revealed an outer lining composed of a broad layer of partially loose periosteal collagen tissue, attached by small amounts of cartilaginous differentiated tissue. Adjacent cancellous bone with trabeculae of variable size and cartilaginous inclusions were also visible.
Fig. 2. Surgical approach. (a – left) Relationship of the tumour mass (in dotted outline and marked as TU) to the zygomatic arch (Z), masseter muscle (M), and temporalis muscle (TE). (b – right) Tumour mass exposed (TU) after zygomatic arch osteotomy (with arrows denoting the osteotomy sites and Z denoting the residual part of the arch) and anterior retraction (R depicting a retractor) of the temporalis muscle (TE).
190
Kumar
Fig. 3. (a – top) Tumour mass exposed following zygomatic arch osteotomy, broad arrow depicting the osteotomized zygomatic arch, thin arrow pointing to the condylar process and its osteotomy margin, T denotes tumour mass; (b – bottom left) excised specimen showing the tumour mass (T), condylar stump (thin arrow); histopathologic features suggestive of osteochondroma; (c – bottom center) shows cancellous bone (B) covered with a proliferative cap of cartilage (C); (d – bottom right) shows cartilaginous inclusions (C) in variably sized cancellous bone trabeculae (B).
These features were suggestive of osteochondroma of the condyle. At 2-year follow-up (Fig. 4), the patient presented with good facial symmetry and a stable, proper occlusal relationship. Mandibular function was good with a maximal incisal opening of 40 mm with very mild deviation on opening to the left. There was no evidence of recurrence on an orthopantamogram, although a CT scan, which is an ideal method of ruling out recurrence, was not carried out. Discussion
Fewer than 50 cases of osteochondroma affecting the mandibular condyle have been described in the English literature, and many of these cases probably describe condylar hyperplasia as the clinical presentation of both conditions is similar. Condylar hyperplasia is seen in a younger population and consists of a progressive generalized enlargement of the entire condyle, which arrests after the growth period.
Osteochondromas are pedunculated or sessile lesions that generally grow away from the native site of growth, usually along the muscles and tendons attached to the native bone. They continue to grow even after the patient attains skeletal maturity. Osteochondroma of the condyle usually manifests during the fourth decade with a mean age of 38.5 years2. It has a marginal female predilection of 1.2:1.0. Most patients present with a chief complaint of progressive deviation of the jaw or asymmetry of the face. Pain, reduced mouth opening, joint noises and posterior open bite have also been reported as the presenting complaints. A clear differentiating factor of osteochondroma from condylar hyperplasia, which is well illustrated in the present case, is that this lesion is clearly pedunculated. It seemed to have caused a purely anterior translatory movement of the condyle, and features of downward displacement of the condyle were absent (contrary to cases of long standing condylar/hemi-
mandibular hyperplasia). There was no occlusal canting or lateral open bite or a compensatory hypertrophy of the mandibular dentoalveolus to close the open bite (if there had been a tendency towards the same). The aetiologies of these lesions are largely unknown and several hypotheses have been proposed1. In the case reported here, the lesion arose from the region of the insertion of the lateral pterygoid muscle and had multiple processes that formed articulations with the greater wing of the sphenoid and the posterolateral wall of the maxilla. The articulating ends of all the projections of the lesion were smooth and covered with a cartilaginous cap which looked as if the lesion was generating multiple articulations towards surrounding bony structures. The author would like to opine that this lesion is a hamartomatous proliferation of a whole condylar unit (bone covered by cartilage) by which this pathology extends to make multiple articulations with surrounding bony structures.
Large osteochondroma of the mandibular condyle
191
graphic studies. The author would also like to acknowledge Dr Dhawal V. Goyal, Dr Deepashree Meshram and Dr Gunjan H. Shah for documentation and surgical help. Acknowledgements to Dr Sandip Kulkarni for histopathologic interpretation.
References
Fig. 4. Pictures taken 2 years postoperatively. (a – left) Clinical picture showing patient’s mouth opening, (b – top right) postoperative occlusion and (c – bottom right) postoperative orthopantamogram showing no signs of recurrence.
Treatment for these lesions has been shaving of the condyle or a radical excision of the lesion by a condylectomy. The latter may be associated with a loss of vertical dimension, occlusal interference and a deviation on mouth opening, but has been definitely curative with no recurrences or malignant transformation4. Shaving of the condyle has been associated with a high recurrence rate (three of six cases in the last 15 years). The surgical approaches have been preauricular or submandibular, either alone or in combination. Owing to the large size of this tumour (approx. 50 mm 45 mm 35 mm), a transzygomatic approach was necessary to remove it in its entirety by performing a condylectomy. The approach used was similar to the one described by OBWEGESER5, the difference being that the temporalis muscle was not dissected or stripped but was retracted anteriorly to gain sufficient access to the tumour mass, resulting in less postoperative discomfort and less morbidity. At long-term followup, the patient was asymptomatic, with good facial symmetry and only a mild deviation of the mandible to the left on wide mouth opening. The patient had a stable occlusal relationship and no loss of
vertical dimension or occlusal interference on follow-up of up to 2 years. Owing to these findings, reconstruction of the condyle was not considered. Smaller lesions (and condylar hyperplasias) may be removed by shaving, but large lesions may require a condylectomy for complete removal. This case is probably the largest osteochondroma of the condyle reported in the English literature. Further studies on more cases are required when deciding the optimal treatment plan for these rare lesions. Funding
None declared. Competing interests
None. Ethical approval
Not required. Acknowledgements. The author would like to acknowledge Dr Neeraj Sharma and Dr Pratik Dedhia for carrying out the radio-
1. Brien EW, Mirra JM, Luck JV. Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology. II. Juxtacortical cartilage tumors. Skeletal Radiol 1999: 28: 1– 20. 2. De Oliveira Ribas M, Martins WD, De Sousa MH, Zanferrari FL, Lanzoni T. Osteochondroma of the mandibular condyle: literature review and report of a case. J Contemp Dent Pract 2007: 4: 052–059. 3. 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. 10.1016/ j.ijom.2004.01.006. 4. Iizuka T, Schrith G, Laeng RH, Ladrach K. Osteochondroma of the mandibular condyle: report of a case. J Oral Maxillofac Surg 1996: 54: 495–501. 5. Obwegeser HL. Temporal approach to the TMJ, the orbit, and the retromaxillary– infracranial region. Head Neck Surg 1985: 7: 185–199. 6. Peroz I, Scholman HJ, Hell B. Osteochondroma of the mandibular condyle: a case report. Int J Oral Maxillofac Surg 2002: 31: 455–456. 10.1054/ijom. 2002.0234. 7. Vezeau PJ, Fridrich KL, Vincent SD. Osteochondroma of the mandibular condyle: literature review and report of two atypical cases. J Oral Maxillofac Surg 1995: 53: 954–963. Address: 5C Cheloor Towers Poothole Thrissur 680004 Kerala India Tel: +91 9646772883 E-mail: [email protected]
Case Report TMJ Disorders
Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach
V. V. Kumar Dept. of Maxillofacial Surgery, Swami Devi Dyal Hospital and Dental College, Barwala, Panchkula, Haryana, India
V. V. Kumar: Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach. Int. J. Oral Maxillofac. Surg. 2010; 39: 188–191. # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. This article presents an interesting case of osteochondroma of the mandibular condyle with multiple projections in a 42-year-old man. Owing to the large size of the lesion, surgical condylectomy was performed using a transzygomatic approach.
Accepted for publication 7 December 2009 Available online 13 January 2010
Osteochondroma is considered as a hamartomatous proliferation of cartilaginous tissue and is also known as osteocartilaginous exostosis. It is the commonest benign tumour of the long bones but is relatively rare in the mandible with fewer than 50 cases reported worldwide2,4,6. Many of these cases have been described as a hyperplasia of the condyle and not as a discrete mass that arises away from the long axis of the mandibular condyle3. Osteochondroma of the mandible is more common in the coronoid process, followed by the condyle and rare in other parts. In the condyle, it presents mostly on the medial and anterior aspects and rarely from the superior or lateral aspect3. In most reports the size of the lesion has not been given. These lesions have been treated by resection or condylectomy, but resection has been associated with recurrence in three cases6,7. The surgical approach used
canting, nor was there any bowing of the inferior border of the mandible. A CT scan revealed a well-defined 50 mm 45 mm 35 mm sized irregular pedunculated bony lesion with multiple projections arising from the medial margin of left condyle (Fig. 1). One of the outgrowths was projecting anteromedially into the infratemporal fossa and extending up to the posterolateral wall of the maxillary sinus. A superior projection of the lesion extended to the greater wing of sphenoid, which it had thinned, and laterally the lesion extended to the zygomatic arch. There was also a small inferior projection. An anterior subluxation of the left temporomandibular joint was noted. The scan findings were more suggestive of an osteochondroma of the left mandibular condyle owing to the pedunculated nature. A three-phase bone scan scintigraphy, carried out with 20 mCi of 99MTc-MDC revealed an increased uptake of the left
0901-5027/020188 + 04 $36.00/0
is generally a preauricular or a submandibular approach either alone or in combination. As these lesions are usually not large, the use of a transzygomatic approach has not been described in the literature. This article reports a case of a large osteochondroma in a 42-year-old man treated by condylectomy using a transzygomatic approach. Case report
A 42-year-old man presented with a complaint of progressive deviation of the mandible to the right side of 3 years duration (Fig. 1). Clinically the mandible had deviated 14 mm. Mouth opening was restricted to 24 mm and the patient could not protrude the mandible to the left side. The mandible deviated further onto the right when opening the mouth. Posterior cross bite on the right side was also noted when in occlusion. There was no occlusal
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Large osteochondroma of the mandibular condyle
Fig. 1. (a – top left) Clinical presentation of the patient; (b – top right) coronal section of CT scan showing extent of lesion and erosion of the greater wing of sphenoid. (c and d – bottom left and right) Successive sagittal sections of CT scan demonstrating multiple projections of the lesion.
mandibular condyle with increased vascularity on blood pool images, and the rest of the body showing normal radiotracer uptake. This ruled out multiple osteochon-
dromas. The blood chemistry studies were within normal limits. The patient was posted for resection of the tumour along with a condylectomy.
189
Owing to the size of the lesion and its extension into the infratemporal fossa, a transzygomatic approach was considered (Fig. 2). A hemicoronal incision ending in a preauricular extension up to the lobule of the ear was made through the skin, subcutaneous tissue and galea. In the temporal region this incision was up to the superficial layer of the temporalis fascia. At the root of the zygomatic arch, the superficial layer of the temporalis fascia was incised anterosuperiorly at a 45 angle. The periosteum was then incised to expose the zygomatic arch. Two plates were adapted, bridging the proposed osteotomy sites and screw holes marked. The zygomatic arch was osteotomized, hinged inferiorly on the masseter exposing the inferior aspect of the temporalis muscle, which was retracted anteriorly to expose the tumour mass (Fig. 3). Inferiorly, anterior retraction of the temporalis brought about a clear exposure of the subcondylar and infratemporal region. An osteotomy cut was made inferior to the origin of the tumour at the condylar neck region. The tumour was then removed by stripping the attachments of the lateral pterygoid. The condylar stump was then reshaped and the wound closed in layers. Arch bars with guiding elastics were fixed for 1 month postoperatively to train the mandible. Histopathologic examination (Fig. 3) of the excised specimen revealed an outer lining composed of a broad layer of partially loose periosteal collagen tissue, attached by small amounts of cartilaginous differentiated tissue. Adjacent cancellous bone with trabeculae of variable size and cartilaginous inclusions were also visible.
Fig. 2. Surgical approach. (a – left) Relationship of the tumour mass (in dotted outline and marked as TU) to the zygomatic arch (Z), masseter muscle (M), and temporalis muscle (TE). (b – right) Tumour mass exposed (TU) after zygomatic arch osteotomy (with arrows denoting the osteotomy sites and Z denoting the residual part of the arch) and anterior retraction (R depicting a retractor) of the temporalis muscle (TE).
190
Kumar
Fig. 3. (a – top) Tumour mass exposed following zygomatic arch osteotomy, broad arrow depicting the osteotomized zygomatic arch, thin arrow pointing to the condylar process and its osteotomy margin, T denotes tumour mass; (b – bottom left) excised specimen showing the tumour mass (T), condylar stump (thin arrow); histopathologic features suggestive of osteochondroma; (c – bottom center) shows cancellous bone (B) covered with a proliferative cap of cartilage (C); (d – bottom right) shows cartilaginous inclusions (C) in variably sized cancellous bone trabeculae (B).
These features were suggestive of osteochondroma of the condyle. At 2-year follow-up (Fig. 4), the patient presented with good facial symmetry and a stable, proper occlusal relationship. Mandibular function was good with a maximal incisal opening of 40 mm with very mild deviation on opening to the left. There was no evidence of recurrence on an orthopantamogram, although a CT scan, which is an ideal method of ruling out recurrence, was not carried out. Discussion
Fewer than 50 cases of osteochondroma affecting the mandibular condyle have been described in the English literature, and many of these cases probably describe condylar hyperplasia as the clinical presentation of both conditions is similar. Condylar hyperplasia is seen in a younger population and consists of a progressive generalized enlargement of the entire condyle, which arrests after the growth period.
Osteochondromas are pedunculated or sessile lesions that generally grow away from the native site of growth, usually along the muscles and tendons attached to the native bone. They continue to grow even after the patient attains skeletal maturity. Osteochondroma of the condyle usually manifests during the fourth decade with a mean age of 38.5 years2. It has a marginal female predilection of 1.2:1.0. Most patients present with a chief complaint of progressive deviation of the jaw or asymmetry of the face. Pain, reduced mouth opening, joint noises and posterior open bite have also been reported as the presenting complaints. A clear differentiating factor of osteochondroma from condylar hyperplasia, which is well illustrated in the present case, is that this lesion is clearly pedunculated. It seemed to have caused a purely anterior translatory movement of the condyle, and features of downward displacement of the condyle were absent (contrary to cases of long standing condylar/hemi-
mandibular hyperplasia). There was no occlusal canting or lateral open bite or a compensatory hypertrophy of the mandibular dentoalveolus to close the open bite (if there had been a tendency towards the same). The aetiologies of these lesions are largely unknown and several hypotheses have been proposed1. In the case reported here, the lesion arose from the region of the insertion of the lateral pterygoid muscle and had multiple processes that formed articulations with the greater wing of the sphenoid and the posterolateral wall of the maxilla. The articulating ends of all the projections of the lesion were smooth and covered with a cartilaginous cap which looked as if the lesion was generating multiple articulations towards surrounding bony structures. The author would like to opine that this lesion is a hamartomatous proliferation of a whole condylar unit (bone covered by cartilage) by which this pathology extends to make multiple articulations with surrounding bony structures.
Large osteochondroma of the mandibular condyle
191
graphic studies. The author would also like to acknowledge Dr Dhawal V. Goyal, Dr Deepashree Meshram and Dr Gunjan H. Shah for documentation and surgical help. Acknowledgements to Dr Sandip Kulkarni for histopathologic interpretation.
References
Fig. 4. Pictures taken 2 years postoperatively. (a – left) Clinical picture showing patient’s mouth opening, (b – top right) postoperative occlusion and (c – bottom right) postoperative orthopantamogram showing no signs of recurrence.
Treatment for these lesions has been shaving of the condyle or a radical excision of the lesion by a condylectomy. The latter may be associated with a loss of vertical dimension, occlusal interference and a deviation on mouth opening, but has been definitely curative with no recurrences or malignant transformation4. Shaving of the condyle has been associated with a high recurrence rate (three of six cases in the last 15 years). The surgical approaches have been preauricular or submandibular, either alone or in combination. Owing to the large size of this tumour (approx. 50 mm 45 mm 35 mm), a transzygomatic approach was necessary to remove it in its entirety by performing a condylectomy. The approach used was similar to the one described by OBWEGESER5, the difference being that the temporalis muscle was not dissected or stripped but was retracted anteriorly to gain sufficient access to the tumour mass, resulting in less postoperative discomfort and less morbidity. At long-term followup, the patient was asymptomatic, with good facial symmetry and only a mild deviation of the mandible to the left on wide mouth opening. The patient had a stable occlusal relationship and no loss of
vertical dimension or occlusal interference on follow-up of up to 2 years. Owing to these findings, reconstruction of the condyle was not considered. Smaller lesions (and condylar hyperplasias) may be removed by shaving, but large lesions may require a condylectomy for complete removal. This case is probably the largest osteochondroma of the condyle reported in the English literature. Further studies on more cases are required when deciding the optimal treatment plan for these rare lesions. Funding
None declared. Competing interests
None. Ethical approval
Not required. Acknowledgements. The author would like to acknowledge Dr Neeraj Sharma and Dr Pratik Dedhia for carrying out the radio-
1. Brien EW, Mirra JM, Luck JV. Benign and malignant cartilage tumors of bone and joint: their anatomic and theoretical basis with an emphasis on radiology, pathology and clinical biology. II. Juxtacortical cartilage tumors. Skeletal Radiol 1999: 28: 1– 20. 2. De Oliveira Ribas M, Martins WD, De Sousa MH, Zanferrari FL, Lanzoni T. Osteochondroma of the mandibular condyle: literature review and report of a case. J Contemp Dent Pract 2007: 4: 052–059. 3. 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. 10.1016/ j.ijom.2004.01.006. 4. Iizuka T, Schrith G, Laeng RH, Ladrach K. Osteochondroma of the mandibular condyle: report of a case. J Oral Maxillofac Surg 1996: 54: 495–501. 5. Obwegeser HL. Temporal approach to the TMJ, the orbit, and the retromaxillary– infracranial region. Head Neck Surg 1985: 7: 185–199. 6. Peroz I, Scholman HJ, Hell B. Osteochondroma of the mandibular condyle: a case report. Int J Oral Maxillofac Surg 2002: 31: 455–456. 10.1054/ijom. 2002.0234. 7. Vezeau PJ, Fridrich KL, Vincent SD. Osteochondroma of the mandibular condyle: literature review and report of two atypical cases. J Oral Maxillofac Surg 1995: 53: 954–963. Address: 5C Cheloor Towers Poothole Thrissur 680004 Kerala India Tel: +91 9646772883 E-mail: [email protected]