Temporomandibular joint synovial chondromatosis with a traumatic etiology

Abstract

Synovial chondromatosis (SC) is a metaplastic disorder characterized by the formation of cartilaginous nodules inside the articular space. SC is uncommon in the temporomandibular joint (TMJ). A few reports suggest a correlation between a traumatic episode and the development of SC. The authors describe the diagnosis, treatment and follow-up of a patient with unilateral SC of the left TMJ in conjunction with bony resorption on the mandibular condyle and a clear traumatic etiology. They review and comment on previous reports in the literature.

Synovial chondromatosis (SC) is a rare condition in which there is cartilaginous metaplasia of the mesenchymal remnants of the synovial tissue of the joints, it is more of an active metaplastic process than a neoplastic one. SC is characterized by the formation of cartilaginous nodules in the synovium and inside the articular space (loose bodies). Usually only one joint is involved; this is most often the knee, and less commonly the hip, elbow, wrist, ankle or shoulder, although the temporomandibular joint (TMJ) may also be affected. The etiology of SC is unknown, but possible causes could be trauma, rheumatoid arthritis or other forms of inflammatory joint disease. The case described here presents a well-documented case for the traumatic origin of SC.

Case report

A 50-year-old man was referred with a history of facial trauma stemming from a bicycle accident. Radiological examination revealed a non-displaced fracture of the left mandibular condyle ( Fig. 1 ), which was treated by closed reduction and intermaxillary elastic fixation. After removal of the intermaxillary fixation, the patient had an uneventful postoperative course with improvement of his occlusal deficit and no pain.

Fig. 1
(A) Coronal CT examination revealed a non-displaced fracture of the left mandibular condyle (arrow). (B) The same condylar fracture at a more posterior angle.

2 years later the patient returned with a complaint of severe pain in left preauricular region and a presumptive diagnosis of post-traumatic arthritis. He reported swelling of the left preauricular area that had been evident for 2 months ( Fig. 2 A) and limitation of mandibular opening (20 mm) with deviation to the right side. On examination, the left TMJ area was swollen and crepitant, with a hard mass of about 3 cm × 3 cm. Facial nerve function was intact and there was no evidence of palpable cervical lymphadenopathy. Diagnostic imaging was performed with panoramic radiography that confirmed complete healing at site of the previous fracture ( Fig. 2 B). Computed tomography (CT) showed erosion of the left condyle, with slight bone destruction, but no destruction of the glenoid fossa or temporal bone, and an expanded articular cavity ( Fig. 2 C). Magnetic resonance imaging (MRI) revealed multiple nodules inside the superior articular cavity of an expanded TMJ, with obliteration and severe displacement and destruction of the articular disc. There was distension of the capsule and fluid in the TMJ ( Fig. 2 D).

Fig. 2
(A) Preauricular mass and swelling of the left preauricular area, 2 years later. (B) Currently, there is no evidence of mandibular fracture in the panoramic radiograph. Closer inspection reveals a line of lower density at the level of the previous fracture (arrow). (C) Coronal (C1) and Sagittal (C2) CT examination showed erosion of condylar head and expanded articular cavity but no destruction of the glenoid fossa or temporal bone and no discernible loose bodies. (D) Coronal MRI reveals multiple nodules inside the superior and inferior articular cavity of the left TMJ with the obliteration of joint space, condyle destruction and severe displacement and destruction of the articular disc (arrow).

Under general anesthesia, a preauricular incision was performed with exposure of the left TMJ ( Fig. 3 A) . The distended lateral capsule was incised and both upper and lower compartments were explored. Straw-colored synovial liquid was aspirated at operation and discectomy and high condylectomy were performed with removal of a conglomerate of 35 irregular loose bodies ( Fig. 3 B). The nodules were of a pearly white or pink hue, of varying shape and ranging in size from 2 to 10 mm ( Fig. 3 C). Condylar shaving was performed for the slight bone destruction associated with this case. The wound was drained and closed in layers. The postoperative course began with immediate articular physiotherapy after 2 days. A Michigan splint was applied at night to improve TMJ function and masticatory muscle relaxation. The patient was discharged on the fifth day postoperatively.

Fig. 3
(A) A preauricular incision was carried out with exposure of the articular capsule. (B) The distended lateral capsule was incised and upper and lower compartments were explored. Loose bodies were packed like ‘grains of rice in sushi’. (C) Removal of a conglomerate of 35 small and irregular loose bodies from the superior and inferior articular spaces. The nodules had a pearly white or pink hue, of varying shape and ranging in size from 2 to 10 mm.

Histopathological examination confirmed SC. The nodules were of cellular hyaline cartilage covered by a fine fibrous layer, and sometimes by synovial lining cells without focal osteoid formation ( Fig. 4 ).

Fig. 4
(A) Synovial chondromatosis: Cartilaginous nodule with clustered chondrocytes, covered by synovial lining cells (JS: joint space; SL: synovial lining; C: cartilage). (B) Magnified view of tissue section showing detail of chondrocytes.

2 years later the patient reported no pain and no limited jaw movements, with 48 mm of mouth opening and no deviation. Diagnostic imaging showed no local recurrence after total removal of the lesion.

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Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Temporomandibular joint synovial chondromatosis with a traumatic etiology
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