Osteonecrosis of the mandibular condyle. Pathophysiology and core decompression

Preauricular Swelling Mimicking a Tumour: Dissolution of Mandibular Capitulum Following Trauma in a 15-Year Old Child

AIM

The report is about diagnosis, therapy, and follow-up of a 15-year old boy, who experienced facial swelling and impaired mouth opening after a sport accident.

CASE REPORT

Diagnosis of mandibular damage was delayed due to inadequate clinical investigation and radiography after trauma and only became clear after a parotid swelling occurred sometime later resulting from the dissolution of the upper part of the articular process. Follow-up control over a period of three years showed a partial restoration of the articular process but some inhibition of mouth opening combined with slight deviation of the mandible to the affected side remained over the years.

CONCLUSION

This report reminds us that parotid swelling can be the result of mandibular trauma without a recent history of physical injury to this region. Therefore, the basic standards of radiologic diagnosis should be maintained and the limited restoring capacity of the condylar process in adolescence should be acknowledged.

Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management

The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.

Subarticular, cystlike lesion associated with avascular necrosis of the mandibular condyle: a case report

Little is known about avascular necrosis of the mandibular condyle, which is necrosis of the epiphyseal or subarticular bone secondary to a diminished or disrupted blood supply in the absence of infection. We present a case of a large subarticular cystlike lesion that was found using cone-beam computed tomography (CBCT). There was an absence of osteoarthrosis, and the condylar articular surface was relatively intact. The patient's history, physical examination, and magnetic resonance images supported the diagnosis of avascular necrosis of the mandibular condyle. After 4 months of conservative therapy, new bone was observed in the cystlike marrow lesion, and a smooth articular surface was reestablished. Subarticular cystlike lesions without the collapse of the articular surface of mandibular condyles may be an early indicator of avascular necrosis.

Magnetic resonance imaging evaluation of mandibular condyle bone marrow and temporomandibular joint disc signal intensity in anaemia patients

OBJECTIVES

To compare the signal intensity (SI) of mandibular condyle bone marrow (MCBM) and the temporomandibular joint (TMJ) disc in patients with chronic anaemia and healthy subjects, and to investigate the relationships between bone marrow changes, age, types of anaemia and severity of anaemia.

METHODS

MRIs of 18 patients with chronic anaemia were compared with those of 12 healthy subjects. The SI of MCBM and the TMJ disc were quantitatively evaluated. The SI of the grey matter (GM), white matter (WM) and the lateral pterygoid muscle were also investigated. Relationships between age, MCBM and TMJ disc signal-intensities and anaemia severity, and correlations between the groups, were analysed.

RESULTS

The mean MCBM SI was lower in anaemia patients (including both subgroups and also separately) than in healthy subjects (P < 0.05). No statistical significance was found for GM, WM and the muscle SI between the anaemia patients and healthy patient group (P > 0.05). No statistical significance was found between the groups with respect to the anterior band, whereas the mean SI value of the posterior band in the study group was significantly lower than in healthy subjects (P < 0.05). There were no correlations between age and MCBM SI, or between anaemia severity and MCBM SI.

CONCLUSIONS

Anaemia may cause bone marrow alterations without any internal derangement. Patients with chronic anaemia exhibit lower mandibular condyle bone marrow and posterior band SI than healthy subjects.

Osteonecrosis of the mandibular condyle as a precursor to osteoarthrosis: a case report

Osteonecrosis of the mandibular condyle is a rare condition characterized by a primary subchondral osseous breakdown of the condyle with secondary articular surface collapse. Despite these characteristics, it has proved to be difficult to diagnose. The present case of osteonecrosis of the mandibular condyle was initially diagnosed more than 2 years before. The diagnosis at that time was based on physical examination, plain film radiography, cone-beam computerized tomography, magnetic resonance imaging, and total body scintigraphy. The disease had progressed into severe osteoarthrosis at a 2-year follow-up using cone-beam computerized tomography. This report suggests that osteonecrosis may be a precursor of osteoarthrosis, and cone-beam computerized tomography may provide a sensitive radiographic technique for the diagnosis of osteonecrosis of mandibular condyle.

Condylar resorption

Idiopathic condylar resorption almost exclusively affects women. Its exact etiology and pathogenesis remain unclear. It has been associated with rheumatoid arthritis, temporomandibular joint internal derangement, condylar fractures, connective tissue or autoimmune diseases, orthodontic treatment, and orthognathic surgery. In most cases, however, there is no identifiable precipitating event, hence the term "idiopathic condylar resorption." The female predisposition to this condition may be attributed to the influence of estrogen and prolactin on the bone response. Treatment of idiopathic condylar resorption is controversial. Condylectomy and reconstruction with costochondral graft offer definitive management of active idiopathic condylar resorption.

Resorbable poly-l-lactide plates and screws for the treatment of mandibular condylar process fractures: a clinical and radiologic follow-up study

PURPOSE

The purpose of this study was to determine whether a resorbable poly-l-lactide (PLLA) miniplate system could be used to treat mandibular condylar process fracture.

PATIENTS AND METHODS

Fourteen patients (12 males, 2 females, aged 23.1 +/- 5.7 years) who had mandibular condylar process fractures treated with PLLA implants were recalled for follow-up clinical and radiologic examinations at 3 years.

RESULTS

Mouth opening recovered to more than 35 mm and occlusion was stable in all patients. There was no facial asymmetry 3 months postoperatively. Two patients had mild chronic postoperative tenderness at the implantation site; however, there was no wound infection. All fractured mandibular condyles showed anatomic good reduction and long-term stability with the use of resorbable miniplates and screws. Bone healing was satisfactory in all patients, and there was no evidence of abnormal resorption of the condylar process. The screw holes remained evident after 3 years. Screw holes in 2 patients showed enlargement on radiographic examination.

CONCLUSION

The PLLA miniplate system provides reliable stability when used for the fixation of mandibular condylar process fractures.

Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases

PURPOSE

Our goal was to study the use of 2.0-mm miniplates for the fixation of mandibular fractures.

PATIENTS AND METHODS

Records of 191 patients who experienced a total of 280 mandibular fractures that were treated with 2.0-mm miniplates were reviewed. One hundred twelve of those patients, presenting 160 fractures, who attended a late follow-up were also clinically evaluated. Miniplates were used in the same positions described by AO/ASIF. No intermaxillary fixation was used. All patients included had a minimum follow-up of 6 months. Demographic data, procedures, postoperative results, and complications were analyzed.

RESULTS

Mandibular fractures occurred mainly in males (mean age, 30.3 years). Mean follow-up was 21.92 months. The main etiology was motor vehicle accident. The most common fracture was the angle fracture (28.21%). Twenty-two fractures developed infection, for an overall incidence of 7.85%. When only angle fractures are considered, that incidence is increased to 18.98%. Although only 1 patient (0.89%) described inferior alveolar nerve paresthesia, objective testing revealed sensitivity alterations in 31.52% of the patients who had fractures in regions related to the inferior alveolar nerve. Temporary mild deficit of the marginal mandibular branch was observed in 2.56% of the extraoral approaches performed and 2.48% presented with hypertrophic scars. Incidence of occlusal alterations was 4.0%. Facial asymmetry was observed in 2.67% of the patients, whereas malunion incidence was 1.78%. Fibrous union, mostly partial, occurred in 2.38% of the fractures, but only 1 of those presented with mobility (0.59%). Condylar resorption developed in 6.25% of the fixated condylar fractures. Mean mouth opening was 42.08 mm.

CONCLUSION

The overall incidence of complications, including infections, was similar to those described for more rigid methods of fixation.

Ischemic osteonecrosis under fixed partial denture pontics: radiographicand microscopic features in 38 patients with chronic pain

STATEMENT OF PROBLEM

Previous studies have identified focal areas of alveolar tenderness, elevated mucosal temperature, radiographic abnormality, and increased radioisotope uptake or "hot spots" within the quadrant of pain in most patients with chronic, idiopathic facial pain (phantom pain, atypical facial neuralgia, and atypical facial pain).

PURPOSE

This retrospective investigation radiographically and microscopically evaluated intramedullary bone in a certain subset of patients with histories of endodontics, extraction, and fixed partial denture placement in an area of "idiopathic" pain.

MATERIAL AND METHODS

Patients from 12 of the United States were identified through tissue samples, histories, and radiographs submitted to a national biopsy service. Imaging tests, coagulation tests, and microscopic features were reviewed. Of 38 consecutive idiopathic facial pain patients, 32 were women.

RESULTS

Approximately 90% of subpontic bone demonstrated either ischemic osteonecrosis (68%), chronic osteomyelitis (21%), or a combination (11%). More than 84% of the patients had abnormal radiographic changes in subpontic bone, and 5 of 9 (56%) patients who underwent radioisotope bone scan revealed hot spots in the region. Of the 14 patients who had laboratory testing for coagulation disorders, 71% were positive for thrombophilia, hypofibrinolysis, or both (normal: 2% to 7%). Ten pain-free patients with abnormal subpontic bone on radiographs were also reviewed.

CONCLUSIONS

Intraosseous ischemia and chronic inflammation were suggested as a pathoetiologic mechanism for at least some patients with atypical facial pain. These conditions were also offered as an explanation for poor healing of extraction sockets and positive radioisotope scans.

Diagnosis and management of condylar resorption

PURPOSE

This article discusses the cause, appropriate diagnostic evaluation, and management of progressive condylar resorption.

PATIENTS AND METHODS

This retrospective study evaluated 28 adult patients with bilateral progressive condylar resorption. Investigation included serial clinical examination, lateral cephalograms, tomograms, and a technetium isotope bone scan when indicated. Twenty-two patients were managed by either condylectomy and reconstruction with a costochondral graft (n = 5 patients) or orthognathic surgery (n = 18 patients). One patient initially had orthognathic surgery and subsequently underwent condylectomy and costochondral grafting, making a total of 23 procedures on 22 patients. Six patients received no surgical treatment. All patients were observed at least 2 years postoperatively.

RESULTS

Of the 18 patients who underwent orthognathic surgery, four again demonstrated condylar resorption with recurrence of open bite and retrognathism. Four patients had a stable result, but currently have temporomandibular joint (TMJ) symptoms, whereas 10 patients had a stable result (no change in postoperative occlusion or jaw position) without TMJ symptoms. The five cases receiving condylectomy and costochondral grafting were stable and asymptomatic, with good mandibular function. Analysis of the 18 orthognathic surgery patients showed that relapse occurred in patients having bimaxillary surgery with mandibular advancements greater than 5 mm and with a preoperative posterior ramus height of less than 35 mm.

CONCLUSION

The management of progressive condylar resorption remains controversial. Orthognathic surgery in this small sample was associated with a complication rate (relapse or TMJ dysfunction) of approximately 45% (8 of 18). In contrast, condylectomy and costochondral grafting appeared to produce stable and functional results. Further long-term outcome studies for patients with condylar resorption are needed to corroborate these results.