Abstract
This study is a retrospective review of the records of all cases treated in the authors’ department since 1991 to identify patients with condylar masses diagnosed as osteochondromas. In 2186 cases of benign and malignant cysts/tumours of the maxillofacial region (1560 malignant and 626 benign), 8 osteochondromas of the mandibular condyle were identified. These 8 cases and the current English literature are reviewed.
Osteochondroma of the mandibular condyle is relatively rare. In 1995, V ezeau et al. found only 29 cases reported in the English language literature. In 2001, S aito et al. identified 38 cases, and in 2005 K arasu et al. found 37 cases of this tumour to be documented, although K arasu had not included S aito et al.’s case and four other case reports since 1999 in their review. They also fail to add three small series of cases; 2 cases reported by M artinez – lage et al. in 2004, 5 cases reported by H olmlund et al. in 2004, and 6 cases reported by W olford et al. in 2002. It is probably more accurate to say that by 2005 at least 55 cases had been reported. Since then there have been four case reports and the authors current report of 8 cases which would bring the total of osteochondromas of the condyle in the literature to 67. The authors’ small series appears to be the largest in the literature representing slightly more than 10% of all reported cases. The authors will review the clinical features, diagnosis and management of this condition based on the literature and their own experience.
Materials and methods
This study is a retrospective review of the records of all cases treated in the authors’ department since 1991 to identify patients with condylar masses diagnosed as osteochondromas. In 2186 cases of benign and malignant cysts/tumours of the maxillofacial region (1560 malignant and 626 benign), 8 osteochondromas of the mandibular condyle were identified. These 8 cases ( Table 1 ) and the current English literature are reviewed.
| Case # | Age | Sex | Duration of complaint | Clinical signs | Treatment | Follow up | Outcome |
|---|---|---|---|---|---|---|---|
| 1 | 70 | M | 2 years | Mandibular deviation, TMJ dislocation and asymmetric prognathism | Condylectomy and costo-chondral reconstruction | 4 years | No recurrence |
| 2 | 51 | M | ? | Left preauricular swelling and mandibular deviation | Subsigmoid osteotomy, tumour resection and repositioning of the proximal segment | 3 years | No recurrence. Transient marginal mandibular weakness |
| 3 | 57 | M | 5 years | Right preauricular swelling and mandibular deviation | Subsigmoid osteotomy, tumour resection and repositioning of the proximal segment | 6 months | No recurrence. Transient marginal mandibular weakness and transient inferior alveolar nerve anesthesia |
| 4 | 32 | F | 18 months | Left preauricular swelling and mandibular deviation (asymmetric prognathism) | Subsigmoid osteotomy, tumour resection & repositioning of the proximal segment. Contralateral sagittal split osteotomy | 1 year and 9 months | No recurrence |
| 5 | 24 | F | 1 year and 6 months | Mandibular deviation, ipsilateral posterior open bite | Subsigmoid osteotomy, tumour resection and repositioning of the proximal segment | 5 months | No recurrence. Restricted opening (2 fingers) |
| 6 | 27 | F | 3 years | L facial asymmetry and ipsilateral posterior open bite | Patient declined surgery. Observation. Subsequent condylectomy and costo-chondral graft | 3 months | Good range of motion and no pain, with stable occlusion |
| 7 | 49 | M | 11 months | TMJ dislocation, dull pain, malocclusion and mandibular deviation (asymmetric prognathism) | Subsigmoid osteotomy, tumour resection and repositioning of the proximal segment | 3 months | Restricted opening (2 fingers) |
| 8 | 31 | F | 1 year | Left preauricular swelling, mandibular deviation (asymmetric prognathism) and ipsilateral posterior open bite | Subsigmoid osteotomy, tumour resection and repositioning of the proximal segment | 1 year and 6 months | No recurrence. Transient marginal mandibular weakness and transient inferior alveolar nerve anesthesia |
Case reports
Case 1
A 70-year-old man was referred in August 1997 with a 2-year history ‘that his jaw was off to one side’ and worsening subluxation of the right temporomandibular joint (TMJ). His jaw now dislocated on eating and yawning and he was unable to close his teeth together to bite anything solid. Examination showed an obvious facial asymmetry with the chin point deviated 1 cm to the left. His mouth opening was 3 finger breadths and he appeared to have a mandibular dislocation. He was edentulous but his prosthetic occlusion showed an asymmetric prognathism. A CT scan showed a large bony mass with significant medial extension. A clinical diagnosis of osteochondroma was made with a differential of low grade osteosarcoma or chondrosarcoma. In September, a biopsy via a preauricular approach was reported as benign. In October he underwent condylectomy and costo-chondral graft reconstruction. In view of the size of the lesion, hemicoronal and submandibular incisions were used and the patients’ dentures wired in place to allow for intermaxillary fixation to establish the occlusion. Histology showed osteochondroma. When last seen, 4 years postsurgery, he had excellent opening, occlusion and function with no sign of recurrence.
Case 2
A 51-year-old man presented in 2001 with complaints of malocclusion, left preauricular swelling and ‘plugging of the left ear’. He had mild facial pain. Examination showed no limitation of jaw movements. His mandibular dental midline was deviated by 2–3 mm. Panorex showed a 2 cm × 3 cm osseous mass arising from the anterior portion of the left condyle. A CT scan revealed the mass extended anteromedially into the infratemporal fossa. There was no change of the vertical height of the condyle. In the operating room (OR), a subsigmoid osteotomy was performed in conjunction with disarticulation through a conventional preauricular approach. The condylar segment was removed preserving the disc, the osteochondroma was resected and the condyle was recontoured. It was then repositioned in the fossa and a pre-bent reconstruction plate was secured to the distal mandibular segment. The patient’s bite was normal and function was good postoperatively. There was a transient marginal mandibular weakness that resolved at 3 months.
Case 3
A 57-year-old man was referred in June 2004 with ‘TMJ problems’. 5 years previously he had had discomfort in his right TMJ with possible dislocation. He had no further symptoms until 4 months prior to presentation when he had severe pain in his right joint. MRI showed a mass from the antero-medial aspect of the right condyle extending to the pterygoid muscles with erosive changes along the inferior aspect of the middle cranial fossa. A CT scan confirmed a bony mass fused to the medial aspect of the condyle. On examination, the patient’s chin point was 5 mm to the left and he had a bony mass palpable in the right preauricular area. His mandibular dental midline was half a unit to the left. A clinical diagnosis of osteochondroma was made. In August 2004 a subsigmoid osteotomy via a submandibular approach was carried out and the proximal mandibular segment was delivered ( Fig. 1 a ). The tumour was removed under direct vision with preservation of the condylar head ( Fig. 1 b and c). The patient was placed in intermaxillary fixation (IMF) and the proximal segment of the mandible replaced as a free bone graft and plated to the ramus using pre-adapted plates ( Fig. 1 d). Histology confirmed a diagnosis of osteochondroma. Postoperatively the patient’s mouth opening and occlusion was normal. There was an initial traction weakness of the mandibular branch of the facial nerve and numbness of the lower lip from inferior alveolar nerve traction. 6 months later these had resolved with normal lip function and sensation.
Case 4
A 32-year-old woman was referred with a ‘tumour of her condyle’ in November 2005. She complained that her jaw had ‘shifted’ over the last 18 months with increasing facial asymmetry and that her teeth had also moved. She had been having headaches and left joint noises. On examination she had an asymmetry with displacement of the chin 1.5 cm to the right, and an asymmetric prognathism with a midline shift of more than 1 unit. Her lower right canine and first premolar were in cross-bite ( Fig. 2 a and b ). Her mouth opening was two and a half fingerbreadths and there was a 2 cm × 2 cm mass palpable over the left condyle. Panorex film showed a bony mass on the superior surface of the condyle ( Fig. 2 c). A CT scan confirmed the presence of a bony expansion of the left condyle. The clinical diagnosis was osteochondroma with facial deformity and malocclusion.
There was minimal maxillary cant and the decision was made to treat the malocclusion in the mandible. The patient underwent surgery in January 2006. Via a submandibular approach on the left side, a subsigmoid osteotomy was undertaken and the proximal segment delivered into the neck. The tumour was removed preserving and recontouring as much of the condyle as possible. Following this, a sagittal split was carried out on the right side and the mandible placed into the prefabricated splint. The osteotomy was fixed with 4 screws on the right and the condyle replaced into the fossa on the left via a preauricular approach with the proximal segment plated to the mandible ( Fig. 2 d and e). Histology showed osteochondroma. She underwent postoperative orthodontic therapy. 1 year and 9 months after the procedure, her incisor and molar occlusion was stable with a minimal open bite in the premolar region only. Mouth opening was normal with no sign of recurrence.
Case 5
A 24-year-old woman was referred in October 2006 with a complaint of increasing headaches/migraines up to five times a week associated with clicking from her TMJs. She felt that her bite had changed. A panorex film had revealed a possible tumour on the condyle. On examination, her mouth opening was normal with some deviation to the right. The dental midline was shifted to the right 1.5 units, and the chin point 4 mm. There was a lateral open bite on the left. CT scanning confirmed a bony mass anterior and medial on the condyle. The clinical diagnosis was osteochondroma. Model analysis showed that a good occlusion could be obtained and the patient did not want preoperative orthodontics.
She underwent surgery with a submandibular approach and subsigmoid osteotomy. The proximal segment was delivered and the tumour on the medial side of the condyle resected preserving the condylar head. The proximal segment was then repositioned with the condyle in the fossa and fixed with pre-adapted plates. When last reviewed in March 2007 she still had some restriction of mouth opening to 2 fingerbreadths and was given exercises to perform. She had no headaches and improved occlusion as well as facial symmetry.
Case 6
A 27-year-old woman was referred in August 2006 with a diagnosis of probable osteochondroma of the condyle. One month previously she had developed pain in her face and a panorex film showed a condylar mass confirmed on CT (an earlier panorex film from 2003 also showed the condylar mass). On further questioning the patient had noticed her jaw was ‘slanted’ for a long time. She had had orthodontic treatment without any change. On examination her left face was asymmetric, with a marked left posterior open bite. Her dental midline was nondisplaced. The patient was not keen on surgery as she no longer had pain and was not over concerned by her asymmetry. An isotope scan was obtained to see whether the mass was still growing and to predict if the asymmetry would be progressive. This showed increased uptake in the left condyle but the patient wanted observation only. On follow up she reported progressive changes. Given the amount of condylar involvement, she underwent condylectomy with costo-chondral reconstruction in August 2009. Her pain has resolved and she has excellent range of motion and a stable occlusion.
Case 7
A 49-year-old man was referred in August 2007 with a mass in the left condyle. He reported intermittent dislocation, a dull pain and altered bite for 11 months. On examination his chin point was 6 mm to the right with an asymmetric prognathism. The dental midline was displaced by one tooth with a lateral open bite on the left side and a cross-bite on the right. Panorex film showed an exostosis arising from the anterior of the left condyle, confirmed on CT scan. He underwent a left subsigmoid osteotomy from a submandibular approach. The proximal segment was delivered and the tumour excised with reshaping of the condylar head. The proximal segment was replaced as a free bone graft, the condyle seated into the fossa and then plated to the mandible. Histology confirmed an osteochondroma. At the 3-month review (January 2007) he had a two finger breadth mouth opening and had been prescribed a TheraBite exerciser. His occlusion was a little premature on the left side, which was corrected by occlusal adjustment.
Case 8
A 31-year-old woman was referred in February 2008 for evaluation and treatment of a left condylar mass identified on a panoramic radiograph. The patient reported a 1-year history of a slowly enlarging, painless, left preauricular swelling. She described a left sided deviation of the mandible on opening and a progressive change in her bite. Clinical examination ( Fig. 3 a ) revealed a mandibular asymmetry with a 3 mm displacement to the right side. There was a bony mass palpable over the left condyle ( Fig. 3 a). She had a 3 mm left posterior open bite ( Fig. 3 b), and her mandible deviated to the left on opening. A CT scan ( Fig. 3 c) demonstrated a bony mass mushrooming superiorly and anteriorly from the left mandibular condyle displacing the condyle 14 mm inferiorly.
