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J Am Dent Assoc, Vol 139, No 3, 301-303.
© 2008 American Dental Association
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CLINICAL PRACTICE

A Mass in the Temporomandibular Joint

Deepak Kademani, DMD, MD, FACS and Christopher Bevin, DMD, MD


   THE CHALLENGE
TOP
 THE CHALLENGE
THE DIAGNOSIS
 CONCLUSION
 REFERENCES
 
A 55-year-old woman with a three-year history of progressive migraine headaches developed a right-sided posterior open bite and right preauricular facial swelling. Several primary and specialty medical and dental practitioners evaluated her case and made a diagnosis of intractable migraine headaches.

Because of her progressive symptoms, she had been referred to the Division of Oral and Maxillofacial Surgery, Mayo Clinic (Rochester, Minn.), for further evaluation. The patient’s medical and surgical histories were unremarkable, including any history of facial trauma. Her facial pain and migraines had been treated with a range of over-the-counter and prescription analgesics, with limited success. At examination, the patient had a mild degree of right-sided preauricular facial swelling that was mildly painful to palpation and was associated with a malocclusion of approximately 3 millimeters on the right side and a posterior open bite with continued and progressive ipsilateral headaches.

Panoramic plain radiography showed a space-occupying lesion in the right temporomandibular joint (TMJ) (Figure 1Go). A computed tomographic scan with intravenous contrast material disclosed a hypoattenuated mass occupying the right TMJ space, with cortical erosion and destruction of the glenoid fossa (Figure 2Go). The cortical architecture of the temporomandibular condyle was well-preserved, although it was displaced significantly and inferiorly, leading to the development of malocclusion. Cranial nerves were grossly intact, with no evidence of neurologic deficit in the trigeminal or facial nerve distributions. There was no evidence of involvement of the middle ear canal, and hearing was preserved.


Figure 1
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  		Figure 1. Panoramic radiograph showing the inferior displacement of the right mandibular condyle, resulting in malocclusion.

 

Figure 2
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  		Figure 2. Computed tomogram showing a large, space-occupying, hypoattenuated mass in the right temporomandibular joint space.

 
In the absence of a histologic diagnosis, the treating surgeon (D.K.) performed a right TMJ arthroplasty for open joint exposure and exploration. Upon entry into the TMJ space, the surgeon noted a large volume of cartilaginous foreign bodies in the intra-articular joint space. The articular surface of the mandibular condyle appeared to be well-preserved; however, there was significant erosion and disruption of the glenoid fossa superiorly, with a small focus of intracranial extension. Despite a limited dural exposure, there was no significant cranial extension or cerebrospinal fluid leak. After removing the tumor, the surgeon repositioned the mandibular condyle within the glenoid fossa, resulting in improved occlusion.

Can you make the diagnosis?

  1. synovial chondromatosis
  2. osteosarcoma
  3. chondrosarcoma
  4. degenerative osteoarthritis
  5. osteoma


   THE DIAGNOSIS
TOP
 THE CHALLENGE
 THE DIAGNOSIS
CONCLUSION
 REFERENCES
 
A. synovial chondromatosis Synovial chondromatosis is a rare benign process that typically affects the large joints. A detailed search of the medical literature from 1969 to 2007 revealed a total of 31 reports and case series.1–3 This disease process is characterized by the development of cartilaginous nodules within the synovial space from the synovial connective tissue matrix; the nodules subsequently degrade, detach and form free-floating, calcified bodies within the joint space (Figures 3Go and 4Go). Clinical symptoms often are characterized by joint swelling, pain and joint dysfunction.


Figure 3
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  		Figure 3. Appearance of the right temporomandibular arthroplasty for surgical access with mass occupying the space between the glenoid fossa and the mandibular condyle.

 

Figure 4
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  		Figure 4. Complete removal of the entire volume of the mass.

 
Primary cases of synovial chondromatosis do not have a specific cause and typically are somewhat more aggressive in biologic behavior than are secondary cases of synovial chondromatosis. Secondary cases in the large joints are more common and are associated with inflammatory joint disease. In most cases, a specific cause often is elusive,1 so these cases can be considered primary in nature.

TMJ involvement with synovial chondromatosis was first described in 1933.32 One of the most challenging features of synovial chondromatosis is suspecting and establishing the diagnosis. Patients with synovial chondromatosis in other major joints are predominantly male, but most patients with TMJ involvement are female (female-to-male ratio of 4:1)5,12 as is the case with other forms of TMJ disease. The clinical signs and symptoms of synovial chondromatosis often are nonspecific, including joint swelling, pain, crepitation, development of malocclusion and preauricular facial swelling. These nonspecific initial signs and symptoms may mimic those of parotid gland tumors. Intracranial extension with biologically aggressive tumors also has been reported and may contribute to the development of headaches.17 In the absence of physical signs, the development of nonspecific pain and headaches can lead to a delay in diagnosis or a misdiagnosis of other more common causes of headaches. The advances in imaging with computed tomography and magnetic resonance have improved the ability to delineate temporomandibular disease markedly, particularly with use of coronal section imaging.

Differential diagnosis. This case highlights the importance of a complete and thorough evaluation, particularly with the use of diagnostic imaging for the evaluation of TMJ intra-articular disease, which can appear to be a cause of non-specific headaches. Intra-articular temporomandibular pain most commonly is due to degenerative osteoarthritis resulting from bone-on-bone contact, which typically is a progressive disease, is seen more frequently in women and may be associated with several preceding years of isolated TMJ symptoms. Meniscal perforation in late-stage disease often will lead to direct bone-on-bone contact and thus to degeneration of the mandibular condyle. Significant condylar resorption may lead to a change in occlusion. Osteosarcoma and chondrosarcoma are malignant disease processes that can arise within the TMJ.

Chondrosarcoma is the most frequent malignant process and may manifest as a solid tumor with cortical bone destruction. Typically, malignant disease of the TMJ does not manifest with multiple loose bodies within the joint space, as seen in this case. Osteoma is a benign tumor that can affect the TMJ. Benign tumors of the TMJ tend to occur with less frequency than does malignant disease. Osteoma typically will manifest as a homogeneous expansion of the mandibular condyle as compared with the contralateral side.


   CONCLUSION
TOP
 THE CHALLENGE
 THE DIAGNOSIS
 CONCLUSION
REFERENCES
 
Synovial chondromatosis is a rare, benign pathologic entity that should be included in the differential diagnosis for patients with a preauricular mass that radiographically is heterogeneous and is seen arising from the intra-articular surface of the TMJ.


   FOOTNOTES
 

Dr. Kademani is an assistant professor of surgery, Division of Oral Diagnosis and Oral and Maxillofacial Surgery, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minn. 55905, e-mail "kademani.deepak{at}mayo.edu". Address reprint requests to Dr. Kademani.


At the time this patient was treated, Dr. Bevin was a resident in Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn. He currently is in private practice in Bennington, Vt.


Disclosure: Neither of the authors reported any disclosures.


Diagnostic Challenge is published in collaboration with the American Academy of Oral and Maxillofacial Pathology and the American Academy of Oral Medicine.


   REFERENCES
TOP
 THE CHALLENGE
 THE DIAGNOSIS
 CONCLUSION
 REFERENCES
 

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