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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 4  |  Issue : 2  |  Page : 82-85

Condylar osteochondroma: Report of a case with literature review


1 Department of Oral Pathology and Microbiology Himachal Pradesh Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla, Himachal Pradesh, India
3 Department of Oral Pathology and Microbiology, Mahatma Gandhi post graduate institute of dental sciences, Puducherry, India

Date of Web Publication22-Oct-2013

Correspondence Address:
Anita Singhal
Department of Oral Pathology and Microbiology, Himachal Pradesh Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
India
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DOI: 10.4103/0976-433X.120185

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  Abstract 

Osteochondroma is one of the most common benign tumors of the skeleton, but osteochondroma of the mandibular condyle is relatively rare and may cause signs and symptoms similar to those seen in patients with temporomandibular joint (TMJ) dysfunction. This article aims to describe a case of osteochondroma of the mandibular condyle in a 30-year-old male with complaints of facial asymmetry, crossbite to the contralateral side, changes in condylar morphology, and malocclusion. Generally, management of these lesions includes total condylectomy or local resection. Conservative condylectomy with reshaping of the remaining condylar neck and repositioning of the articular disk was performed on the patient who is presently on routine follow-ups.

Keywords: Mandibular condyle, osteochondroma, TMJ


How to cite this article:
Singhal A, Venkatpathy R, Singhal P. Condylar osteochondroma: Report of a case with literature review. SRM J Res Dent Sci 2013;4:82-5

How to cite this URL:
Singhal A, Venkatpathy R, Singhal P. Condylar osteochondroma: Report of a case with literature review. SRM J Res Dent Sci [serial online] 2013 [cited 2019 Nov 17];4:82-5. Available from: http://www.srmjrds.in/text.asp?2013/4/2/82/120185


  Introduction Top


Osteochondroma is an exophytic lesion that arises from the cortex of bone and is capped with cartilage. [1] It is a well-recognized entity in the axial skeleton, but it is an uncommon benign tumor of jaws. Most gnathic examples are seen in the condyle, coronoid process, and very rarely in tongue. [2] The embryonic development of the temporomandibular joint (TMJ), by the endochondral ossification, makes this area the most frequent facial site for this type of tumor. [3],[4],[5] The etiology and pathogenesis of the lesion is not fully understood and neither is its developmental, neoplastic, or reparative nature. [3],[6],[7] Although, condylar osteochondroma can present several different clinical characteristics like facial asymmetry, malocclusion, deviation of chin, and crossbite in the contralateral side; mouth opening disturbance are the most common manifestations of this disease. [8],[9] It is a painless, slow growing tumor. [9] This tumor is of much clinical importance because it may undergo malignant transformation after remaining quiescent for a very long time. [10]


  Case Report Top


A 30-year-old male patient was reported with difficulty in biting onto the teeth and asymmetry of the lower jaw since last 1.5 years. The patient also complained of mild facial swelling in the right side preauricular region for the past 2-3 months. There was a history of trauma to the right side of the face 5 years back. There was no associated pain except a mild discomfort in the lower jaw and there was no difficulty in opening the mouth. On extra oral examination, facial asymmetry was noticed due to mild swelling in the right side preauricular region. Borders of the swelling were ill-defined, surface appeared smooth, regular with normal skin color [Figure 1]. Swelling was hard in consistency, nontender on palpation. On opening and closing of jaw, mild tenderness was felt. Clicking and crepitation sounds were heard on auscultation of TMJ. Mandible deviated towards the left side at resting position. Anterior edge to edge bite and posterior cross bite in relation to the left quadrant were present [Figure 2]. Orthopantomogram (OPG) showed a radiopaque mass measuring approximately 3 × 3 cm on the right side condylar head [Figure 3]. TMJ program showed the attachment of the radiopaque mass with the condyle and its movement along with the condyle on opening and closing jaw movements [Figure 4]. Clinically the lesion was diagnosed as osteochondroma. Other differentials included were: Osteoma, chondroma, giant cell tumor, myxoma, fibroosteoma, fibrous dysplasia, and osteosarcoma. Under general anesthesia, a modified temporal incision was given and the lesion was totally excised. The excision site of the condylar region was curetted sufficiently to remove any remaining tumoral cells and the condylar neck was reshaped and repositioned underneath the preserved TMJ disk. Finally, a drain was placed and all tissues were sutured with 3.0 catgut and 5.0 nylon (skin). Histopathologically, the lesion consisted of cartilaginous tissue, bony tissue, and fibrous component. Cartilaginous component was prominent in some areas [Figure 5], [Figure 6], and [Figure 7]. Considering the clinical, radiographical, and the histopathological features; the lesion was finally diagnosed as osteochondroma.
Figure 1: Mild swelling on right side of face

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Figure 2: Deranged occlusion

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Figure 3: Radiopaque mass attached on right side of condylar head

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Figure 4: Attachment of the radiopaque mass with the condyle and its movement along with the condyle on opening and closing jaw movements

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Figure 5: Mixed up cartilaginous and bony tissue as well as fibrous component

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Figure 6: Cortical bone is noticed

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Figure 7: Cartilaginous component is prominent

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  Discussion Top


Osteochondroma is not a common tumor of oral and maxillofacial skeleton. [9],[11] Mandibular condylar osteochondroma is thought to be a relatively rare lesion with only 90 cases documented in the English language literature till date. [12] Reported prevalence of osteochondromas in craniofacial region is 0.6%. [13] Its causes are still unclear and symptoms vary depending on the location of the tumor. A study of 34 patients of condylar osteochondroma; reported that different condylar areas can be involved such as the medial aspects (55.9%), anterior-superior (11.8%), posterior-superior (11.8%), lateral (8.8%), and generally enlarged (11.8%). The tumor formed a pseudojoint under the anterior eminence in 55.9%; the affected mandible presented normal shape in 58.8%; and horizontal mandibular deviation was caused by the tumor or elongated ramus in 70.6%. [14] In the present case, whole of the condyle was involved. The pathogenesis of osteochondroma has been the subject of much debate. There have been controversies if such lesions should be considered developmental, neoplastic, or reparative in nature. The most commonly accepted view is a metaplastic change of the periosteum and/or the osteochondral layer in the condyle, leading to production of cartilage, which subsequently ossifies. [15] Trauma and inflammation have been suggested as contributory factors. [16],[17] The patient in the present case also gave history of trauma. Common clinical manifestations of the osteochondroma of the mandibular condyle include facial asymmetry, swelling of the TMJ region, disturbance of mouth opening, and joint pain. In present case the patient had facial asymmetry, mild pain, and malocclusion. The growth of an osteochondroma is usually slow, causing gradual displacement, and elongation of the mandible. [17] Seki et al., [7] reported a case of condylar osteochondroma with complete hearing loss. In the present case, the patient had not experienced any ear infection. A careful assessment of the patient's history might provide valuable information for the diagnosis and treatment of facial asymmetry. [18] The diagnosis of osteochondroma was proposed based on clinical and radiographic findings. Orthopantomograph at best can be considered as a screening tool in the detection of these lesions. [9] Imaging techniques can be of valuable tool for accurately diagnosing and determining treatment for a variety of diseases and are supportive to clinical examination. [11],[19] In most cases, plain radiographs are sufficient for making the diagnosis. However, for lesions in the spine, pelvis, or shoulder; the spiral and cross-sectional computed tomographs allow reconstruction of slices to get an accurate picture. Increased exposure to radiation is a drawback with computed tomography (CT) scans. T2-weighted magnetic resonance imaging (MRI) is helpful in identifying the size and nature of the cartilage cap and other associated soft tissues, but cannot be used in claustrophobic patients and those with pacemakers. [20]

Ultrasonography can be used to assess cartilage cap and associated complications such as arterial or venous thrombosis, aneurysm, and bursitis; but, cannot be used to assess underlying bone. [20]

Angiography is standard for assessing the vascular occlusion and malignant nature of lesion; but, is invasive and may lead to anaphylaxis or renal toxicity due to the contrast medium used. Radionuclide scanning has a high sensitivity but low specificity and also does not help to distinguish between osteochondroma and osteosarcoma. It is not easily available. Experience with 2 [fluorine 18]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) is limited. It is not easily available and is expensive. [21]

The treatment of the lesion lies in surgical excision of the tumor. Condylar examples of osteochondroma are treated by condylectomy. Large size of the lesion may dictate the need for doing surgical condylectomy using transzygomatic approach. [22] But, total condylectomy cannot be recommended as routine in all cases. Conservative condylectomy procedure with reshaping of the remaining condylar neck and repositioning of the articular disk has been suggested. [23] If the tumor involves only a limited area of the condylar surface, then preservation of the remaining portion of the condyle and reshaping should be done. The combined use of computer-assisted three-dimensional surgical planning and simulation with vertical ramus osteotomy to reconstruct the condyle for patients with osteochondroma after excision of the tumor makes the surgery more accurate and more convenient, and avoids damage to vital structures. [24] Reasons for not taking such a conservative approach are the possibilities of malignancy and the risk of recurrence. There was no recurrence after 3 years of follow-up in the present case. It is imperative to do regular clinical and radiological check-up after surgery to detect any signs of recurrence.

 
  References Top

1.Avinash KR, Rajagopal KV, Ramakrishnaiah RH, Carnelio S, Mahmood NS. Computed tomographic features of mandibular osteochondroma. Dentomaxillofac Radiol 2007;36:434-6.  Back to cited text no. 1
    
2.Ghom AG. Text book of Oral Medicine. 2 nd ed. New Delhi: Jaypee Brothers Medical Publishers; 2010. p. 308.  Back to cited text no. 2
    
3.Ortakoglu K, Akcam T, Sencimen M, Karakoc O, OzyigitHA, Bengi O. Osteochondroma of the mandible causingsevere facial asymmetry: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e21-8.  Back to cited text no. 3
    
4.Lizuka T, Schroth G, Laeng RH, Ladrach K. Osteochondroma of the mandibular condyle: Report of acase. J Oral Maxillofac Surg 1996;54:495-501.   Back to cited text no. 4
    
5.Tanaka E, Lida S, Tsuji H, Kogo M, Morita M. Solitaryosteochondroma of the mandibular of the mandibularsymphysis. Int J Oral Maxillofac Surg 2004;33:625-6.  Back to cited text no. 5
    
6.Wu W, Hu X, Lei D. Giant osteochondroma derived from pterygoid process of sphenoid. Int J Oral Maxillofac Surg 2007;36:959-62.  Back to cited text no. 6
    
7.Seki H, Fukuda M, Takahashi T, Iino M. Condylar osteochondroma with complete hearing loss: Report of a case. J Oral Maxillofac Surg 2003;61:131-3.  Back to cited text no. 7
    
8.Karras SC, Wolford LM, Cottrell DA. Concurrent osteochondroma of the mandibular condyle and ipsilateral cranial base resulting in temporomandibular joint ankylosis: Report of a case and review of the literature. Oral Maxillofac Surg 1996;54:640-6.  Back to cited text no. 8
    
9.Kumaraswamy, Kedarnath NS, ManuPrasad S, Jayachandra MG, Shailendra M, Vijayanath V. Osteochondroma at the site of untreated condylar fracture. Int J Curr Res 2011;33:146-50.  Back to cited text no. 9
    
10.Ribas Mde O, 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;8:52-9.  Back to cited text no. 10
    
11.Villanueva J, González A, Cornejo M, Núñez C, Encina S. Osteochondroma of the coronoid process. Med Oral Pathol Oral Cir Bucal 2006;11:e289-91.  Back to cited text no. 11
    
12.Roychoudhury A, Bhatt K, Yadav R, Bhutia O, Roychoudhury S. Review of osteochondroma of mandibular condyle and a report of case seriesJ Oral Maxillofac Surg 2011;69:2815-23.  Back to cited text no. 12
    
13.Ramos-Murguialday M, Morey-Mas MÁ, Janeiro-Barrera S, García-Sánchez A, Molina-Barraguer I, Iriarte-Ortabe JI. Osteochondroma of the temporomandibular joint: Report of 2 cases emphasizing the importance of personalizing the surgicaltreatment. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:e41-7.  Back to cited text no. 13
    
14.Meng Q, Chen S, Long X, Cheng Y, Deng M, Cai H. The clinical and radiographic characteristics of condylar osteochondroma. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;114:e66-74.  Back to cited text no. 14
    
15.Koole R, Steenks MH, Witkamp TD, Slootweg PJ, Shaefer J. Osteochondroma of the mandibular condyle: A case report. Int J Oral Maxillofac Surg 1996;25:203-5.  Back to cited text no. 15
    
16.Henry CH, Granite EL, Rafetto LK. Osteochondroma of the mandibular condyle: Report of a case and review of the literature. J Oral Maxillofac Surg 1992;50:1102-8.  Back to cited text no. 16
    
17.Melarkey DW, Roffinella JP, Kaplan H. Osteocartilagenous exostosis (Osteochondroma) of the mandibular condyle. J Oral Surg 1966;24:271.  Back to cited text no. 17
    
18.Haag U, Wong R, Ng AF. Facial asymmetry. The Orthodontist's viewpoint. Dental Asia 2007;19-24.  Back to cited text no. 18
    
19.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;33:549-53.  Back to cited text no. 19
    
20.Navaneetham A, Rao KA, Kumaran S, Baweja HH. A unique case of multiple osteochondroma: Mandibular symphysis and femur. Ann Maxillofac Surg 2012;2:182-4.  Back to cited text no. 20
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21.Bernard SA, Murphey MD, Flemming DJ, Kransdorf MJ. Improved differentiation of benign osteochondromas from secondary chondrosarcomas with standardized measurement of cartilage cap at CT and MR imaging. Radiology 2010;255:857-65.   Back to cited text no. 21
    
22.Kumar VV. Large osteochondroma of the mandibular condyle treated by condylectomy using a transzygomatic approach. Int J Oral Maxillofac Surg 2010;39:188-91.  Back to cited text no. 22
    
23.de Melo WM, Pereira-Santos D, Sonoda CK, de Moura WL, de Paulo-Cravinhos JC. conservative condylectomy for management of osteochondroma of the mandibular condyle. J Craniofac Surg 2013;24:e209-e211.  Back to cited text no. 23
    
24.Yang X, Hu J, Zhu S, Liang X, Li J, Luo E. Computer-assisted surgical planning and simulation for condylar reconstruction in patients with osteochondroma. Br J Oral Maxillofac Surg 2011;49:203-8.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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