CLINICAL PRACTICE
CASE REPORT |
CASE REPORT
Malocclusion associated with osteocartilaginous loose bodies of the temporomandibular joint
SOPHIA XIANG, D.D.S.,
JOE REBELLATO, D.D.S.,
CARRIE Y. INWARDS, M.D. and
EUGENE E. KELLER, D.D.S., M.S.D.
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ABSTRACT
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Background. The authors review the literature regarding osteocartilaginous loose bodies (that is, secondary synovial chondrometaplasia or secondary synovial chondromatosis) in the temporomandibular joint (TMJ), present a case report and stress the importance of early diagnosis.
Case Description. A 57-year-old woman was referred to an orthodontist with a chief complaint of bite changes that took place over several years as the patient intermittently experienced TMJ problems. The authors noted radiopacities around the right TMJ space on a panoramic radiograph. They referred the patient to an oral and maxillofacial surgeon for treatment.
Clinical Implications. Asymmetrical occlusal changes in a nongrowing adult with progressive shifts from Class I to Class III malocclusion unilaterally may indicate a space-occupying lesion in the TMJ space on the affected side.
Key Words: Temporomandibular joint; osteocartilaginous loose bodies; malocclusion; secondary synovial chondrometaplasia
Osteocartilaginous loose bodies are uncommon in the temporomandibular joint (TMJ) and affect primarily the large diarthrodial joints such as knees, hips and elbows.1 Radiographic manifestations have included a single or multiple calcified densities in the TMJ.2 According to Milgram, loose bodies are derived from the part of the tissues that lines the joint cavity, such as the synovial membrane, the articular disk and the articular surfaces of the bones that make up the joint.
Asymmetrical occlusal changes in a nongrowing adult may indicate a space-occupying lesion in the temporomandibular joint space.
The loose bodies can arise either secondary to conditions such as osteochondral fractures or osteoarthritis, or as a direct result of the proliferative disorder of the synovium termed "synovial chondromatosis." Nevertheless, in many cases, the origins of loose bodies cannot be identified on the basis of radiographic findings, clinical findings and medical history alone. An analysis of the histopathologic peculiarities of the surgical specimen is required for the clinician to make an accurate diagnosis.
Osteocartilaginous loose bodies (that is, secondary synovial chondrometaplasia) need to be differentiated from synovial chondromatosis (that is, primary synovial chondrometaplasia). In cases of secondary synovial chondrometaplasia, the initiating factors (such as underlying degenerative arthritis) usually are obvious on histopathologic analysis, and the lesions tend to be nonaggressive. Primary synovial chondrometaplasia, on the other hand, is associated with metaplastic cartilage in the synovium without any underlying disease conditions such as arthritis, usually is aggressive and has a high incidence of recurrence.4
According to Ginaldi,5 Ambroise Pare was the first to provide a brief account of this condition in 1558. In 1898, Barth provided a detailed description of loose bodies.6 However, it was not until 1933 that Axhausen7 recorded the first accurate scientific description of synovial chondromatosis, a condition that can lead to the development of loose bodies. In 1958, Jaffe8 provided a histomorphologic description and laid the groundwork for histologic diagnosis of this joint disease.
TMJ symptoms rarely are caused by loose bodies. Signs and symptoms are nonspecific, vary in degrees and may include progressive preauricular swelling, pain and persistently limited mouth opening, as in situations of disk dislocation without reduction or limited movement followed by joint clicking or crepitation.9,10
Diagnostic imaging tools include conventional radiography, computed tomography (CT), magnetic resonance imaging and arthroscopy of the TMJ. Standard treatment consists of arthrotomy of the affected joint and removal of the bodies.6 We present a case report of a patient who was diagnosed as having osteocartilaginous loose bodies.
Signs and symptoms of loose bodies are nonspecific, vary in degrees and may include progressive preauricular swelling, pain and persistently limited mouth opening.
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DENTAL AND MEDICAL HISTORY
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A 57-year-old woman was referred to one of us (J.R.) by an orofacial pain specialist for an orthodontic evaluation of her malocclusion. The patient’s chief complaint was that her molars were not touching and that she was unable to chew properly with her back teeth. Her medical history was noncontributory. Her dental history showed that the patient had suffered TMJ problems for the previous eight years, and she had noticed progressive changes in her bite during that time.
The patient initially visited an oral surgeon eight years previously because of clicking and discomfort localized around her right TMJ that developed after she underwent a crown cementation on the lower left quadrant nine months earlier. The patient reported that she sensed that the crown was high, but the oral surgeon determined that it fit properly. The patient complained of pain during yawning and while eating hard foods. The clinical examination revealed sensitivity to palpation at the right lateral pterygoid muscle and at the lateral and posterior pole of the right TMJ. The mandible deviated 6 to 8 millimeters to the right in the terminal 8 mm of opening, and the oral surgeon noted an audible pop during excursive movement.
The oral surgeon obtained a panoramic radiograph to aid in evaluation. He made the diagnosis of degenerative joint disease and recommended treatment consisting of nonsteroidal anti-inflammatory medications and a soft diet. He asked the patient to return if her symptoms worsened.
Two years later, the patient returned to the same oral surgeon because the pain and clicking of the right TMJ had increased and were accompanied by occasional locks of the TMJ. The patient complained of a dull ache occurring intermittently throughout the week. The clinical examination revealed slight tenderness in the right preauricular region. Clinical findings supported the diagnosis of right TMJ internal derangement, and the oral surgeon gave the patient instructions for pain management at home.
One year before she visited the orthodontist, the patient sought help from an orofacial pain specialist owing to the reappearance of pain that had disappeared several years earlier. Despite the cessation of pain, the patient noted progressive changes in her occlusion and difficulty in eating. Plain film tomograms of the TMJ demonstrated moderate-to–early advanced arthritic changes in the right TMJ, which the clinician thought possibly had been a contributing factor in the patient’s malocclusion. The orofacial pain specialist recommended that the patient see an orthodontist for treatment of her malocclusion.
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ORTHODONTIC EXAMINATION
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The physical examination of the patient revealed a mesocephalic facial type with lip competence. The orthodontist (J.R.) noted slight facial asymmetry with chin deviation to the left of the facial midline, as well as some preauricular swelling on the right side of the face (Figure 1
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Figure 1. Photograph of the patient depicting facial asymmetry with a slight chin point deviation to the left side and mild preauricular swelling on the right side of the face.
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The intraoral examination revealed good oral hygiene practices and complete permanent dentition with no third molars (Figure 2). The range of motion of the mandible was normal, and the mandible shifted to the left from the initial point of contact in centric relation to the maximum intercuspal position (MIP), with the mandibular dental midline deviating 2 mm to the left in MIP. In centric relation, the patient exhibited a Class III molar and canine relationship on the right side and a Class I buccal segment on the left side, with an edge-to-edge incisor relationship and minimal overjet. The patient also had a bilateral posterior open-bite malocclusion.
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Figure 2. Intraoral photograph of the patient shows the mandibular dental midline deviated to the left of the maxillary dental midline and posterior open-bite malocclusion.
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The orthodontist obtained the patient’s radiographic records to develop treatment options for the malocclusion. The records included a full-mouth series, a panoramic radiograph, and lateral and posteroanterior cephalometric radiographs. The full-mouth series revealed normal dentition and periodontium, while the cephalometric analysis revealed an asymmetric skeletal Class III discrepancy. However, the clinician noted radiopacities around the right joint on the panoramic radiograph (Figure 3), and he obtained CT scans (Figure 4).
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Figure 3. Panoramic radiograph at the time of orthodontic examination reveals radiopacities in the area of the right temporomandibular joint and an enlarged joint space.
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Figure 4. High-resolution computed tomographic scan (coronal view) clearly demonstrates radiopaque bodies in the right temporomandibular joint, compared with the left joint.
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The radiologic report described an extensive degenerative disease of the right TMJ. Erosion of the condylar head was evident, as was extensive calcification within the joint space. The ossification extended along the lateral margin of the TMJ and appeared to expand the joint space, with the right mandibular condyle slightly displaced. The clinician observed minimal disease on the left condyle. He referred the patient back to the oral surgeon for a surgical consultation. A biopsy and removal of the suspicious mass around the right TMJ were indicated. The oral surgeon explained the procedure to the patient, and he informed her of the risks, benefits and potential complications of the surgery.
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SURGERY
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After administering nasotracheal general anesthetic, the oral surgeon made an incision in the right preauricular area at the height of the auricle. In a preauricular skin crease, he performed dissection down through the skin and subcutaneous fat, exposing the parotid-masseteric fasciae and temporal fasciae. The surgeon then exposed the posterior zygomatic arch and lateral TMJ fossa cortex via subperiosteal dissection. While exposing the lateral capsule of the joint, the oral surgeon excised a few tumorlike masses and submitted them for surgical pathological evaluation. They were returned with an initial diagnosis of synovial chondromatosis (that is, primary synovial chondrometaplasia).
The surgeon then removed diseased tissues and associated metaplastic synovium. He used blunt dissection to expose the superior condyle cortex, which revealed an irregular cortical surface and advanced degenerative changes, including osteophyte formation. While exposing the TMJ fossa through the subperiosteal dissection, the surgeon found multiple lobules of cartilaginous-looking material completely surrounding the condyle and fossa in the joint space. He reduced and flattened the articular fossa and eminence using a high-speed, pear-shaped bur in a lateral to medial direction. In the process, the surgeon encountered additional segments of metaplastic cartilage. Using the high-speed bur, he reduced the superior part of the condyle by about 2 mm and recontoured the residual stump. The surgeon then recontoured the glenoid fossa and fitted it with a metal fossa-eminence implant (TMJ Implants, Golden, Colo.), which was secured to the lateral cortex with four screws (that is, hemijoint replacement).
The surgeon then made a 3-centimeter incision in the left abdomen to expose subcutaneous fat. He obtained approximately 30 cm3 of fat and split it into three segments, which he packed medially, anteriorly and laterally to the condyle to aid in healing. The wound was closed in layers. The patient tolerated the procedure well and experienced no postoperative complications.
A follow-up histopathologic evaluation of the decalcified sections of the tissue that had undergone a biopsy resulted in a conclusive diagnosis of osteocartilaginous loose bodies (Figure 5).
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Figure 5. Photomicrograph confirms the diagnosis of osteocartilaginous loose bodies (that is, secondary synovial chondrometaplasia).
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DISCUSSION
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Osteocartilaginous loose bodies that originate from degenerative joint disease may remain free in the joint space or become incorporated with the synovium, where they may continue to grow and appear as synovial chondromatosis. This secondary chondromatosis may be difficult to differentiate from the primary type, in which direct cartilaginous metaplasia within the synovium is observed on gross inspection. Only the characteristic histologic features enable the clinician to reach a conclusive diagnosis. The importance of pathological distinction is obvious, because of the high risk of recurrence for primary synovial chondrometaplasia.
Although patients can be asymptomatic on occasion, common symptoms are pain, preauricular swelling, decreased range of motion, crepitation and unilateral mandibular deviation on mouth opening.10,11 The patient described here exhibited the primary symptoms of swelling and pain on the affected side. However, her pain was not continuous and actually disappeared for a few years before the symptoms resurfaced.
The surgeon observed malocclusion in this case of TMJ osteocartilaginous loose bodies. The patient’s mandible appeared to protrude on the affected side, producing a midline shift toward the contralateral side and posterior open bite. The natural tendency of the teeth to drift and compensate for the developing skeletal discrepancy may have masked the extent of the jaw displacement by the mass occupying the right joint space.
Radiographic evidence of loose bodies may or may not be present.11 In many cases, no radiographic changes are evident on plain images such as panoramic radiographs. Because the process is insidious and may go unnoticed for years, when such pathology is suspected, clinicians should use CT12–16 or magnetic resonance imaging16 as diagnostic tools. When loose bodies are smaller than 1 mm, they often are overlooked; therefore, a high-resolution CT scan will be more diagnostic than a regular CT scan.9
When a patient has symptoms of preauricular swelling, unilateral TMJ pain and radiographic signs of radiopacity in the joint space, the differential diagnosis includes osteocartilaginous loose bodies (that is, secondary synovial chondrometaplasia), synovial chondromatosis (that is, primary synovial chondrometaplasia), osteoarthrosis,17 intracapsular fracture, rheumatoid18 and neurotrophic arthritis,19 pigmented villonodular synovitis2 and intracapsular and paracapsular chondromas.20 When an expansile lesion of the glenoid fossa is associated with calcifications on CT scans, the differential diagnosis also should encompass osteochondroma, osteoblastoma, osteosarcoma, chondroblastoma, chondrosarcoma, calcium pyrophosphate dehydrate crystal deposition disease and synovial sarcoma.6,21
This patient’s medical history and clinical examination findings initially were more consistent with a joint disorder. The presence of unilateral signs and symptoms combined with unilateral protrusive occlusal changes increased our suspicion of disease in this case. Plain imaging findings were inconclusive, and only high-resolution CT imaging provided insight into the diagnosis and led to the surgical approach to treatment. The initial surgical pathological report suggested a diagnosis of synovial chrondromatosis; however, subsequent histopathologic evaluation of decalcified tissue sections led to the conclusive diagnosis of osteocartilaginous loose bodies.
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CONCLUSION
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A 57-year-old woman who sought treatment for a chronic TMJ problem was referred to an orthodontist to alleviate her discomfort. Clinical and radiographic examination findings raised questions about the etiology of her TMJ problem. Additional radiographic imaging revealed radiopacities at the right TMJ space on CT scans, which, along with the results of the biopsy report, led us to make a diagnosis of osteocartilaginous loose bodies of the TMJ. Despite the rarity of this disease, clinicians should include it in the differential diagnosis when treating patients with unexplained unilateral preauricular swelling, pain and progressive occlusal changes.
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FOOTNOTES
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At the time the manuscript was written, Dr. Xiang was a visiting student. She now is in an orthodontic residency program, University of Southern California, School of Dentistry, Los Angeles.
Dr. Rebellato is an associate professor and consultant in orthodontics, Department of Dental Specialties, Mayo Clinic, Mayo West 4, 200 First St. S.W., Rochester, Minn. 55905. Address reprint requests to Dr. Rebellato.
Dr. Inwards is an assistant professor and consultant, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
Dr. Keller is a professor and chair, Division of Oral Diagnosis and Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn.
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REFERENCES
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- Murphy FP, Dahlin DC, Sullivan CR. Articular synovial chondromatosis. J Bone Joint Surg 1962;44A:77–86.[Abstract/Free Full Text]
- Blenkinsopp PT. Loose bodies of the temporomandibular joint, synovial chondromatosis or osteoarthritis. Br J Oral Surg 1978;16(1):12–21.[Medline]
- Milgram JW. The classification of loose bodies in human joints. Clin Orthop 1977;124:283–91.
- Villacin AB, Brigham LN, Bullough PG. Primary and secondary synovial chondrometaplasia. Hum Pathol 1979;10:439–51.[Medline]
- Ginaldi S. Computed tomography feature of synovial osteochondromatosis. Skeletal Radiol 1980;5:219–22.[Medline]
- Carls FR, von Hochstetter A, Engelke W, Sailer HF. Loose bodies in the temporomandibular joint: the advantages of arthroscopy. J Craniomaxillofac Surg 1995;23:215–21.[Medline]
- Axhausen G. Pathologie und therapie des Kiefergelenks. Fortschr Zahnheilk 1933;9:171.
- Jaffe HL. Tumours and tumourous conditions of the bones and joints. London: Kimpton; 1958.
- Lustmann J, Zeltser R. Synovial chondromatosis of the temporomandibular joint: review of the literature and case report. Int J Oral Maxillofac Surg 1989;18(2):90–4.[Medline]
- Von Arx DP, Simpson MT, Batman P. Synovial chondromatosis of the temporomandibular joint. Br J Oral Maxillofac Surg 1988;26: 297–305.[Medline]
- Norman JE, Stevenson AR, Painter DM, Sykes DG, Feain LA. Synovial osteochondromatosis of the temporomandibular joint: an historical review with presentation of 3 cases. J Craniomaxillofac Surg 1988;16:212–20.[Medline]
- Boccardi A. CT evaluation of chondromatosis of the temporomandibular joint. J Comput Assist Tomogr 1991;15:826–8.[Medline]
- Kramer J, Recht M, Deely DM, et al. MR appearance of idiopathic synovial osteochondromatosis. J Comput Assist Tomogr 1993;17:772–6.[Medline]
- de Bont LG, van der Kuijl B, Stegenga B, Vencken LM, Boering G. Computed tomography in differential diagnosis of temporomandibular joint disorder. Int J Oral Maxillofac Surg 1993;22:200–9.[Medline]
- Thompson JR, Christiansen E, Hasso AN, Hinshaw DB. Temporomandibular joints: high resolution computed tomographic evaluation. Radiology 1984;150(1):105–10.[Abstract/Free Full Text]
- van Ingen JM, De Man K, Bakri I.: CT diagnosis of synovial chondromatosis of the temporomandibular joint. Br J Oral Maxillofac Surg 1990;28(3):164–7.[Medline]
- de Bont LG, Blankestijn J, Panders AK, Vermey A. Unilateral condylar hyperplasia combined with synovial chondromatosis of the temporomandibular joint: report of a case. J Maxillofac Surg 1985;13(1):32–6.[Medline]
- Papavasiliou A, Sawyer R, Lund V, Michaels L. Benign conditions of the temporomandibular joint: a diagnostic dilemma. Br J Oral Surg 1983;21:222–8.[Medline]
- Rosen PS, Pritzker PH, Greenbaum J, Holgate RC, Noyek AM. Synovial chondromatosis affecting the temporomandibular joint: case report and literature review. Arthritis Rheum 1977;20:736–40.[Medline]
- Raibley SO. Villonodular synovitis with synovial chondromatosis. Oral Surg Oral Med Oral Pathol 1977;44:279–84.[Medline]
- Allias-Montmayeur F, Durroux R, Dodart L, Combelles R. Tumours and pseudotumorous lesions of the temporomandibular joint: a diagnostic challenge. J Laryngol Otol 1977;111:776–81.
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ABSTRACT
DENTAL AND MEDICAL HISTORY
