Abstract
Synovial Chondromatosis (SC) of the Temporomandibular joint (TMJ) is a rare disorder with an indolent clinical course that leads to nonspecific symptoms, dysfunction, and anatomic distortion of the TMJ. A case is described of SC of the TMJ in a 56-year-old female that presented with pain in the right side of her face. The SC diagnosis was suggested after correlating the clinical and imaging findings. Open TMJ surgery was performed to remove the lesion, synovectomy, repair the perforated articular disc, and reposition the condyle into the glenoid fossa. At the 3-year follow-up appointment, the patient’s condition was significantly better with stable occlusion, elimination of pain, and an incisal opening of 35 mm. There was no clinical or radiographic evidence of recurrence. This paper review the clinical, radiological, cytological, and pathological features of this entity and relates the differential diagnosis to other cartilaginous lesions and neoplasms of the TMJ. Accurate diagnosis requires the combination of clinical, radiological and histological studies. Awareness of this disorder is important to provide adequate care and avoid delayed treatment.
Highlights
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The diagnosis of Synovial Chondromatosis of the Temporomandibular Joint is a sequence of clinical, imaging, and histologic studies.
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Signs and symptoms include pain and swelling followed by limited opening, clicking, crepitus, and occlusal changes.
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The treatment include removal of all affected synovial tissue and loose bodies via open joint surgery or arthroscopy.
1
Introduction
Synovial Chondromatosis (SC) is a benign progressive monoarticular arthropathy of unknown origin, characterized by metaplastic formation of numerous cartilaginous foci or osteocartilaginous nodules in the synovial membrane, that become pedunculated and eventually detach as loose bodies. SC normally affects the knee, elbow, wrist, shoulder, and hip. It is suggested that there are 2 possible causes of synovial chondromatosis: primary, in which the etiology is unknown, or secondary, in which it may be associated with trauma, osteoarthritis, or other inflammatory joint conditions. Primary SC is thought to be more aggressive than latter and it is associated with a higher incidence of recurrence [ , ].
Three distinct and progressive stages of SC have been described, based on the metaplastic process and the presence of loose bodies. The first stage is characterized by active synovial metaplastic activity. The second stage involves the existence of loose bodies plus metaplastic nodules. In the third stage or advanced cases, there are multiple calcified and degenerated loose bodies, without signs of active synovial disease [ ].
The involvement of the temporomandibular joint (TMJ) is rare. All publications are mainly case reports or small series. Aims of this study are to present a case of TMJ synovial chondromatosis, the diagnosis and treatment of the pathology, as well as a review of the literature.
2
Case report
A 56-year-old woman was referred in July 2010 to the maxillo-facial surgeon with a chief complaint of pain in the right side of her face. Physical examination revealed asymmetric face with a slight deviation to the left TMJ and abnormal occlusion on the right side.
The patient was treated with conservative management and symptomatic treatment. She was without monitoring, but in August 2016, she presented spontaneous mandible dislocation, not related with trauma history. Physical examination revealed normal mouth opening, slight deviation to the left and abnormal occlusion ( Fig. 1 a and b). TMJ reduction was attempted. Cone-beam computed tomography showed a calcification in the upper and posterior right joint space, the joint space increased and there is evidence of lower displacement of the mandibular condyle ( Fig. 2 ).
Open exploration of the right TMJ was performed under general anesthesia on the 25 th of October 2016 utilizing a preauricular incision with inferomedial dissection to expose the joint capsule in its entirety. Erosive changes of the condyle head and multiple sclerotic areas was seen and intrasurgical diagnosis of disc perforation was done. The surgical procedure involved synovectomy and removal of a 10 mm 4 mm loose body from the space of the TMJ. A repair of the disc and meniscopexy using a mini anchor attached with poliglactin 4-0. The condyle was repositioned into the glenoid fossa with TMJ reduction. There were no complications ( Fig. 3 a and b).
The first post-surgical follow-up was performed two weeks later. The patient’s condition improved. On examination, no infection, tenderness or abnormal pain was observed. The patient was able to have a normal diet without clicking in the right TMJ ( Fig. 4 ). The mandibular range of motion was: Maximal incisal opening 35 mm, excursive movements 3 mm left, 9 mm right and 6 mm protrusive. A paresis was detected in the right lateral portion of the eyebrow and in the superior eyelid. She was referred to physiotherapy sessions.
Histopathology of the specimen is shown in Fig. 5 . Reactive cartilaginous tissue with ossification and formation of reactive trabecular bone with inter-trabecular fibroblastic tissue was observed. The resected intra-articular loose body lesion revealed degenerative changes, hyaline cartilage covered by fibrous connective tissue and some focal calcification areas. No malignancy was reported.
Two weeks later, another check-up revealed mild paresis compared with the initial examination, normal mouth opening without changes in the occlusion. A new panoramic x-ray showed the right condyle back to its actual position ( Fig. 6 ). No recurrence chondromatosis signs were observed. Ten months later, the patient just referred minor pain on masseters, internal pterygoid and SCM muscles. The mouth opening was normal. No clicking or occlusion changes were observed.
At the third year follow-up appointment, the patient’s condition was good. Physical examination revealed there were no tenderness and clicking in the right TMJ. The patient had a normal Class I occlusion and an interincisal opening of 35 mm ( Fig. 7 ) with excursive measurements 7 mm left, 9 mm right and 8 mm protrusive. There is no clinical or radiographic signs of recurrence ( Fig. 8 ).
