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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 119-124

Retrospective study for performing high condylar shaving as preservative treatment of mandibular condyle osteochondroma


Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta, Egypt

Date of Submission07-Feb-2020
Date of Acceptance16-Jun-2020
Date of Web Publication30-Oct-2020

Correspondence Address:
Ahmed S Naguib
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tanta University, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tdj.tdj_4_20

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  Abstract 

Purpose
The aim of this study was to evaluate the efficiency of conservative condylectomy with articular disc repositioning for the treatment of temporomandibular joint (TMJ) condylar osteochondroma.
Patients and methods
Seven adult patients with unilateral TMJ condylar osteochondroma were involved in this study, four patients were male and three patients were female. Their ages ranged from 27 to 45 years with a mean of 35 years. All patients were evaluated preoperatively both clinically and radiographically. All the clinical and radiographic parameters were performed immediate, 1, 3, and 6 months postoperatively.
Results
The visual analog pain scale revealed no pain after 6 months follow-up periods in all patients. Regarding to occlusal disturbances, during the period of follow up only two cases (case no. 2 and no. 7) suffered from slight occlusal disturbances after 1 month. All cases had no occlusal disturbances at the end of 6 months follow-up period. There was improvement in mouth opening (the interincisal distance was found to be 38 mm 6 months postoperatively). No extraoral or intraoral swelling was detected in the region of condyle in all cases at the end of 6 months postoperatively. No obvious deviation of the mandible was detected during mouth opening in all cases through the follow-up period. All the treated patients had satisfactory facial symmetry during the postoperative follow-up period. Radiographic evaluation revealed that the treated condyle had normal configuration in all cases and fits properly within the extent of glenoid fossa and there was no evidence of recurrence of the lesion nor any evidence of condylar resorption in any of the operated cases.
Conclusion
A conservative condylectomy with articular disc repositioning is considered as an option for treatment of the TMJ condylar osteochondroma.

Keywords: computerized tomogram, magnetic resonance image, temporomandibular joint, visual analog scale


How to cite this article:
Naguib AS, Bedier RR. Retrospective study for performing high condylar shaving as preservative treatment of mandibular condyle osteochondroma. Tanta Dent J 2020;17:119-24

How to cite this URL:
Naguib AS, Bedier RR. Retrospective study for performing high condylar shaving as preservative treatment of mandibular condyle osteochondroma. Tanta Dent J [serial online] 2020 [cited 2020 Nov 27];17:119-24. Available from: http://www.tmj.eg.net/text.asp?2020/17/3/119/299630


  Introduction Top


Osteochondroma can be considered as a hamartomatous proliferation of the cartilaginous tissue[1].

It is a slowly growing benign tumor that originates from the cortical part of the bone. It can be termed as a cartilage capped bony exophytic lesion which originates from the cortical layer of the bone[2].

The incidence of ostchondroma constitutes about 36% of the bony benign tumors and about 9% from all the bony tumors. It usually develops in the long bones or axial skeleton but in the head and neck region its incidence of accuurance is rare as most of the craniomaxillofacial bones are intramembranous in origin[3].

As the temporomandibular joint (TMJ) is formed by cartilaginous ossification so it is the most commonly affected site in oral and maxillofacial region[4].

Craniofacial osteochondromas are common in males more than in females and tends to affects young adults than the elderly peoples[5]. The craniofacial osteochondroma is usually not detected until the clinical symptoms occurs such as jaw deviation, limitations in mouth opening, unilateral open bite, occurrence of facial asymmetry, pain with varying intensity, clicking and crepitation of the affected TMJ and alteration in the morphology of the affected condyle[6].

The following lesions can be considered during performing differential diagnosis to osteochondroma; chondroma, osteoma, unilateral condylar hyperplasia, fibrous dysplasia, fibro-osteoma, myxoma, and fibrosorcoma[7].

Radiographically, osteochondroma appears as a radiopaque globular labulated mass that changes the normal architecture of the condylar process of the mandible[8].

The commonly performed treatment of the TMJ condylar osteochondroma is condylectomy with or without condylar reconstruction. However, if the condyle is not reconstructed, this may lead to several complications such as: decrease in the vertical dimensions of the operated side, malocclusion, facial asymmetry, unilateral open bite and deviation of the lower jaw towards the affected side and even laterognathia may develop. All these manifestations are similar to those present before performing condylar resection, but in the opposite direction[9].

Therefore, the purpose of this retrospective study was to determine the efficiency of surgical excision of the condylar osteochondroma with preservation of the mandibular condyle,


  Aim Top


The aim was to evaluate the efficiency of TMJ high condylectomy for the treatment of TMJ osteochondroma with preservation of the condyle.


  Patients and Methods Top


Seven adult patients suffered from unilateral condylar osteochondroma were included in this study. Three patients were female and four patients were male. Their ages range from 27 to 45 years old [Table 1].
Table 1: Clinical details of all included patients

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All patients in this study signed an informed consent before starting the surgical treatment. All patients have been informed about their surgical procedures including possible risk and benefits and their acceptance to participate in this research were taken according to the instruction of ethical committee of Faculty of Dentistry, Tanta University.

All patients selected from the Outpatient Clinic of Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Tanta University.

All patients in this study signed an informed consent before starting the surgical treatment. All patients have been informed about their surgical procedures including possible risk and benefits.

All patients were evaluated both clinically and radiographically preoperatively and postoperatively as follow:

Preoperative clinical evaluation

The following parameters were used to evaluate the patients:

  1. Presence of pain in TMJ: according to visual analog scale, with values from (0) (no pain) to (10) (unbearable pain)[10].
  2. Occlusion, according to Ulgesic et al.[11].
  3. Maximal mouth opening: by measuring the interincisal distance between the upper and lower central incisor with the help of a scale.
  4. Presence of extraoral or intraoral swelling related to the region of the condyle: by clinical inspection and palpation both extraorally and intraorally.
  5. Degree of deviation of the mandible during mouth opening: according to Stegenga et al.[12].
  6. Degree of facial asymmetry both preoperatively and postoperatively, through the various follow-up periods. The degree of facial symmetry was evaluated clinically by performing direct extraoral clinical examination as follow: by visual inspection of facial morphology, palpation of facial structures and contours to differentiate between bony and soft tissue defects, also by inspection of presence of symmetry between the bilateral gonial angle and comparing the contour of the mandibular body and finally by comparing the dental mid line with the facial mid line.


Radiographical evaluation

Orthopantogramic view [Figure 1], axial, coronal and three-dimensional computerized tomograms and bone scan had been performed preoperatively [Figure 2] and during the follow-up periods (immediate postoperatively, 1, 3, and 6 months postoperatively) to detect the following:
Figure 1: Preoperative orthopantogramic view showing well circumscribed radiopaque mass of osteochondroma on the left temporomandibular joint.

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Figure 2: Preoperative photograph bone scan showing: hot spot right condylar osteochondroma and preoperative three-dimensional tomographic view showing well circumscribed radiopaque mass of osteochondroma on the left temporomandibular joint.

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  1. Shape of the condylar mass preoperatively.
  2. Shape of the condylar head preoperatively (condylar morphology).


Surgical technique

All patients were operated under general aneasthesia through nasoendotracheal intubation. Antibiotic (Cefotax 1 g vial) and Dexamethasone (Epidron) were administrated preoperatively to minimize postoperative infection and edema.

All the operations were performed through a preauricular approach with temporal extension as follow:

Perform a 4 cm long incision, extending from the superior portion of the helix to the inferior portion of the ear lobe and then perform the curved temporal extension. After the skin incision was done, the underlying subcutaneous tissue was then dissected carefully. The superficial fascia was then identified and its plane was followed anteriorly and inferiorly to the region of the zygomatic arch. Then the periosteum over the zygomatic arch was incised and reflected. The superficial lobe of the parotid gland was reflected to give adequate access to the condylar mass and the connection between the tumor and condyle was exposed. Then the mass was completely separated from the mandibular condyle by the use of osteotome, taking care to not damage the peripheral anatomic structures [Figure 3].
Figure 3: Intraoperative view showing, the excised mass of osteochondroma.

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Then use the curettes, bone file and then large rose head surgical bur in order to remove any remaining lesion and perform adequate recontouring to the affected condyle. Finally, a rubbery suction drain was inserted and the wound layers were closed firmly. A pressure dressing was then applied immediately after surgery over the operated preauricular region. Then the excised mass was sent with a detailed report to the lab for performing histopathological examination.

Postoperative care

All patients were hospitalized for 24 h, during which the patients were maintained on a standard regimen of treatment, as antibiotic (Cefotax 1 g vial/12 h), nonsteroidal anti-inflammatory and analgesic (Cataflam 100 mg ampoule/12 h). Freeze dried proteolytic enzymatic anti edematous and anti-inflammatory (5 mg vial/12 h of lyophilized and crystalized chemoptrypsin) was also prescribed. After discharge from the hospital, patients were maintained on the same regimen of treatment for one week postoperatively.

All the patients were reviewed at the following periods:

Immediate postoperative (i.e. within 2 days after surgery), 1 month, 3 months and finally 6 months to evaluate the following variables:

Clinically

Presence of pain in the TMJ area, occlusal derangement, maximal mouth opening, presence of any swelling related to the TMJ condyle both extraorally or intraorally, degree of deviation of the mandible during mouth opening and finally to assess presence of facial asymmetry.

Radiographically

To assess the following:

  1. Condylar morphology.
  2. Condylar resorption.
  3. Recurrence.



  Results Top


Clinical results

There were no severe clinical complications in all treated patients, as shown from the following parameters throughout the follow-up period.

Presence of pain in the TMJ region

All patients had pain in the region of TMJ before surgery, but it disappeared through the follow-up period.

Occlusal disturbance according to Ulgesic et al.[11]

During 6 months postoperatively, satisfactory occlusion has been obtained in all patients, except in only two cases: case no. (2) and no. (7) which suffered from slight occlusal disturbances 1 month after surgery. These two cases showed improvement after using elastic traction, this improvement was detected during the late follow-up period.

Maximal interincisal distance

The postoperative mouth opening was improved during the 6-month follow-up period (mean = 39.8 mm). Two cases [no. (5) and (6)] suffered from limitation in mouth opening (mean = 21 mm) 1 month postoperatively, however, 3 months later, they showed significant improvement in mouth opening (mean = 38 mm) after employing physiotherapy.

Presence of any extraoral or intraoral swelling related to the region of the condyle

The result of inspection and palpation of the region of the affected condyle showed slight swelling immediately after surgery in all cases. No swelling has been detected in all cases through the late follow up.

Degree of deviation of the mandible during mouth opening

There was no obvious deviation during mouth opening in any patients, throughout the follow-up period.

Degree of facial symmetry

All the treated patients had satisfactory facial symmetry during the follow-up period.

Radiographic results

The postoperative condylar morphology and whether recurrence has occurred or not were assessed by comparing the baseline preoperative and immediate postoperative radiographs [Figure 4], with radiographs taken at 3 and 6 months postoperatively.
Figure 4: One-month postoperative three-dimensional computerized tomogram showing, excision of the mass of osteochondroma with preservation of the affected condyle.

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The radiographs showed that, the condyle had normal configuration in all patients and lies properly within the glenoid fossa and there was no apparent condylar bone resorption in any case throughout the follow-up period. No tumor recurrence has been detected in any patients during the period of observation [Figure 5].
Figure 5: Six months postoperative coronal computerized tomogram showing normally contoured condyle lying properly within the glenoid fossa.

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Histological results

The definite diagnosis of osteochondroma was confirmed in all selected cases by histopathological examination of the excised condylar mass. As this study was a retrospective study and only the cases that were confirmed as osteochondroma by histopathological examination were selected and other cases were excluded from this research.

The histological findings showed presence of a cartilaginous cap formed from a sheet of proliferating chondrocytes covered by a thick layer of cellular periosteum, below this layer there is a zone of calcification.


  Discussion Top


The limited resection or conservative condylectomy with performing recontouring to the condylar neck is a viable option for the treatment of condylar head osteochondroma, as this preserves the vertical dimension of the ramus. This is in consistence with results reported by Wolford et al.[13], who reported that, the use of conservative condylectomy is the best option for management of osteochondromas that affects the head of the condyle.

The age of the managed patients who suffered from presence of condylar head mass ranged from 27 to 45 years. This is in partial agreement with Karasu et al.[14], who reported that osteochondroma commonly seen in second and third decade of life.

In this study, three patients were females and four patients were males. This in contrast with Karasu et al.[14], who reported that, osteochondroma commonly, affects females more than male in a ratio of 1.5: 1.

The use of preauricular incision with temporal extension gives a good exposure for the condylar tumor and the access for resection of the tumor was found to be satisfactory in all cases. This is in agreement with Zhou et al.[15], who reported that, the TMJ condylar tumor could be resected under direct vision using preauricular approach.

In this study, using visual analog scale, all cases showed pain in TMJ area before surgery and no pain had been detected in the TMJ at the end of the follow-up period. This is in agreement with Holmlund et al.[9], who reported that, pain is the main complaint of the patient preoperatively.

According to this study, no occlusal disturbances has been detected postoperatively in all treated cases by the end of follow-up period. Only two cases (case no. 2 and no. 7) showed slight occlusal discrepancy 1 month after surgery, however, they showed improvement by using elastic traction as evidenced during the late follow-up periods (i.e. after 3 and 6 months postoperatively). These results are in agreement with Holmlund et al.[9], who reported that, good occlusion has been obtained postoperatively in all treated patients by conservative condylectomy with recontouring of the remaining part of the condylar neck.

Preoperatively, there was limitation in mouth opening in all cases and the mean of interincisal distance was found to be 16.35 mm preoperatively, that was improved to 39.8 mm in 6 months postoperatively except in two cases (case no. 5 and no. 6) which suffered from limitation in mouth opening (mean = 21 mm) 1 month postoperatively. These two cases showed improvement and mouth opening was increased (mean = 38 mm) 3 and 6 months postoperatively. This is in agreement with Kawakami et al.[16], who reported that, the maximum mouth opening in the treated cases was 48 mm.

According to this study, preoperative extraoral examination of all treated patients showed presence of swelling (mean = 1 × 1.3 cm) in the TMJ region and on palpation the swelling was found to be hard in consistency and it was immobile and attached to the underlying tissue. But no swelling had been detected in all treated cases at the end of follow-up period. This was found to be consistent with Zhou et al.[17], who reported presence of preoperative swelling in all cases and this swelling was moving with opening and closing of the mouth.

All the cases of this study, showed no deviation of the mandible during the follow-up periods. This finding was in acceptance with the result of Gonzalez-Otero et al.[15], who reported that, there was no obvious deviation during mouth opening in any patient.

All the treated patients in this study had satisfactory facial symmetry during the period of the follow-up. This result was in acceptance with Sergio et al.[18], who reported high incidence of occurrence of facial asymmetry if reconstruction had not been performed after conservative resection of osteochondroma with preservation of the most of the condyle.

Radiographically, osteochondroma of the TMJ condyle appears on the plain films (opthopantogramic view) as exophytic mass with mixed density. So, computed tomography (CT) examination is mandatory to confirm the diagnosis of the case preoperatively. This result is in acceptance with Morey-Mas et al.[19], who reported that CT examination and MRI examination are mandatory to evaluate the cases properly, with possible affection of vascular and cranial structures.

In this study, it was found that, preoperative plain (orthopantogramic view) and CT was found to be optimal to delineate accurately the anatomy of the lesion. It also provides excellent bony details and demonstrates clearly the degree of calcification in the cartilaginous cap. This result contradicts with results reported by Zhang et al.[20], who reported that, CT is not the best imaging modality for accurate detection of the uncalcified cartilage cap of the osteochondroma and it is best detected by MRI.

According to this study, no case of recurrence has been detected in any patient according to the clinical and radiographic examination through the follow-up period. This result is in agreement with Holmlund et al.[9], who reported that, although a general recurrence rate of nearly 2% had been reported for osteochondroma but no case of recurrence has been detected during a period of 5 years follow up.

In this study, postoperative plain radiograph (orthopantogramic view) and computed tomographic examination showed that, the remaining part of the condyle has normal configuration in all patients and lies properly within the glenoid fossa and there was no apparent condylar resorption in any case through the follow-up period. This result was in acceptance with Zhou et al.[15], who reported that, the pedicle of the lateral pterygoid muscle with its vessels is crucial for prevention of occurrence of resorption of the condyle.

In this study, the definite diagnosis of osteochondroma was confirmed in all cases by histopathological examination of the excised condylar mass. This agrees with Miguel-Angle et al.[19], who reported that, the histologic findings have confirmed the diagnosis of the condylar osteochondroma. This is characterized by formation of layer of thickened cellular periosteum underlying a sheet of proliferating chondrocytes (cartilaginous cap), below this cap lies a zone of calcification which is responsible for the cancellous bone formation.


  Conclusion Top


A conservative condylotomy may be considered as feasible option for treatment of the condylar osteochondroma as it allows the following:

  1. Preservation of the height of the ramus.
  2. Eliminate the need to perform reconstructive surgery to compensate the deficiency in ramus height with its sequelaes.
  3. But more cases should be operated and followed up to longer periods to gain accurate data


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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De Oliveira PJ, Ribas M, Martins WD, De Sousa MH, Zan Ferrari FL, Lanzoni T. Osteochondroma of the mandi bular condyle: literature review and report of a case. J Cont Dent Pract 2007; 4:52–59.  Back to cited text no. 1
    
2.
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9.
Holmlund AB, Gynther GW, Reinholt FP. Surgical treatment of osteochondroma of the mandibular condyle in adult. A 5-years follow-up. Int Oral Maxollofac Surg 2004; 33:549–553.  Back to cited text no. 9
    
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Stegenga B, Debant LG, De Leau WR, Boering G. Assessment of mandibular function impairment associated with temporomandibular joint osteorthrosis and internal derangement. J Orofac Pain 1993; 7:183–195.  Back to cited text no. 12
    
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Karasu HA, Ortakogla K, Okcu KM, Gunhan O. Osteochondroma of the mandibular condyle: report of a case and review of the literature. Mil Med 2005; 170:797–801.  Back to cited text no. 14
    
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Zhou H, Liao C, Hu J, Fei W. Comparison of the clinical effects of treatment of osteochondroma by two types of vertical ramus osteotomy. Br J Oral Maxillofac Surg 2018; 56:19–23.  Back to cited text no. 15
    
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Kawakami T, Inove T, Ogawa J, Morisugi T, Sanefuji N, Kirita T. Osteochondroma of the mandibular condyle. Asian J Oral Maxillofac Surg 2005; 17:125–130.  Back to cited text no. 16
    
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Gonzalez-Otero S, Navarro-Cuellar C, Escrig-de Teigeiro M, Fernandez-Alba Luengo J, Navarro-vila C. Osteochondroma of the mandibular condyle: resection and reconstruction using vertical sliding osteotomy of the mandibular ramus. Int J Oral Maxillofac Surg 2009; 14:194–197.  Back to cited text no. 18
    
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Morey-Mas M-A, Caubet-Biayna J, Iriarte-Ortabe J-I. Osteochondroma of the temporomandibular joint treated by means of condylectomy and immediate reconstruction with a total stock prosthesis. J Oral Maxillofac Res 2010; 1:1–4.  Back to cited text no. 19
    
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