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Synovial chondromatosis is a rare, benign, chronic, progressive and proliferative lesion that usually affects large joints. This disease is characterized by the development of cartilaginous nodules within the space of synovial joints, tendon sheaths or cases; the nodules subsequently degrade, detach and form free-floating, calcified bodies within the joint space. In 1933, Axhausen described the first case of synovial chondromatosis affecting the temporomandibular joint. The aetiology still remains unknown, but a history of trauma and inflammation is often found. Clinical symptoms of chondromatosis affecting the TMJ are often characterized by swelling, pain, headache, crepitation, malocclusion and joint dysfunction. The big challenge concerning synovial chondromatosis is to suspect and establish a correct diagnosis. These nonspecific initial signs and symptoms may mimic other nonspecific TMJ’s diseases and can easily lead to a delay in diagnosis or a misdiagnosis. Here we present a case of synovial chondromatosis of the TMJ and the appropriate diagnostic and treatment performed.
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Diagnosis and treatment of synovial chondromatosis of the TMJ: a clinical case
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Diagnosis and treatment of synovial chondromatosis of the TMJ: a clinical case
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                                                                                                                   Case report



                   Diagnosis and treatment of synovial
                   chondromatosis of the TMJ: a clinical case




                                                                                                                                 li
                                                                                  na
                   Valentino Valentini, MD, PhD                           Introduction
                   Paolo Arangio, MD, PhD




                                                                                io
                   Sara Egidi, MD                                         Synovial chondromatosis is a rare, benign, chronic,
                   Marco Capriotti, MD                                    progressive and proliferative lesion that usually af-
                   Valentino Vellone, MD                                  fects large joints (1). This disease is characterized by
                   Marco Castrechini, MD




                                                                             az
                                                                          the development of cartilaginous nodules within the
                   Giulio Bosco, MD                                       space of synovial joints, tendon sheaths or cases; the
                   Piero Cascone, MD                                      nodules subsequently degrade, detach and form free-
                                                                          floating, calcified bodies within the joint space. In




                                                                          rn
                                                                          1933, Axhausen (2) described the first case of syn-
                   Maxillo-facial Surgery Unit                            ovial chondromatosis affecting the temporomandibu-
                   “Sapienza” University of Rome, Italy                   lar joint. The aetiology still remains unknown, but a
                                                                          history of trauma and inflammation is often found (3,




                                                                       te
                                                                          4). Clinical symptoms of chondromatosis affecting the
                   Corresponding author:                                  TMJ are often characterized by swelling, pain,
                   Valentino Vellone                                      headache, crepitation, malocclusion and joint dys-
                   Maxillo-facial Surgery Unit                            function. The big challenge concerning synovial chon-
                   “Sapienza” University of Rome
                   Viale del Policlinico, 155
                                                                    In    dromatosis is to suspect and establish a correct diag-
                                                                          nosis. These nonspecific initial signs and symptoms
                   00161 Rome, Italy
                                                                          may mimic other nonspecific TMJ’s diseases and can
                   E-mail: valentino.vellone@gmail.com
                                                                          easily lead to a delay in diagnosis or a misdiagnosis.
                                                                          Here we present a case of synovial chondromatosis
                                                             ni

                                                                          of the TMJ and the appropriate diagnostic and treat-
                                                                          ment performed.
                   Summary
                                              o

                   Synovial chondromatosis is a rare, benign, chron-
                   ic, progressive and proliferative lesion that usual-
                                                                          Case report
                                          izi


                   ly affects large joints. This disease is character-
                   ized by the development of cartilaginous nodules       A 60 year-old Caucasian woman referred to our De-
                   within the space of synovial joints, tendon            partment of Maxillofacial surgery, swelling in the left
                   sheaths or cases; the nodules subsequently de-         pretragic preauricular region (Fig. 1).
                           Ed




                   grade, detach and form free-floating, calcified        Her medical history revealed, nonspecific pain, maloc-
                   bodies within the joint space. In 1933, Axhausen       clusion and headaches. She didn’t receive any specific
                   described the first case of synovial chondromato-      diagnosis during the years and she was subjected to
                   sis affecting the temporomandibular joint. The ae-     many orthpanoramic x-ray (Fig. 2) and orthodontic
                   tiology still remains unknown, but a history of        treatment for many years without any improvement be-
                   trauma and inflammation is often found. Clinical       fore admission in our department.
               C




                   symptoms of chondromatosis affecting the TMJ           She was subjected to a MRI of the TMJ, which reported
                   are often characterized by swelling, pain,             on the left side a huge serous effusion involving the su-
    CI




                   headache, crepitation, malocclusion and joint          perior compartment, above ligaments of the retrodiscal
                   dysfunction. The big challenge concerning syn-         tissue. The liquid component of the spillage was even
                   ovial chondromatosis is to suspect and establish       studied through dynamic acquisitions showing its mobil-
                   a correct diagnosis. These nonspecific initial         ity and its morphological changes resulting from condy-
                   signs and symptoms may mimic other nonspecif-          lar and meniscal movements.
                   ic TMJ’s diseases and can easily lead to a delay       The patient referred us that she performed arthrocente-
©




                   in diagnosis or a misdiagnosis. Here we present a      sis (5) and anti-inflammatory therapy yet in another
                   case of synovial chondromatosis of the TMJ and         medical structure without any benefits. After a year of
                   the appropriate diagnostic and treatment per-          worsening symptoms, the patient performed CT scan,
                   formed.                                                which showed the presence of reactive tissue, fluid
                                                                          content in the joint capsule and fragmentation of the
                   Key words: temporomandibular joint, chondrocalci-      cortical bone (Fig. 3).
                   nosis, TMJ surgery.                                    According to the patient’s history we decided then to

                   Annali di Stomatologia 2013; IV (3-4): 269-272                                                              269
8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 270




                   V. Valentini et al.




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                                                                                  Figure 3. CT scan image.




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                   Figure 1. Patient with left pretragic preauricular swelling.
                                             o               ni
                                         izi
                          Ed




                   Figure 2. Orthopanoramic x-ray.


                   treat her with TMJ open surgery (6). The patient’s left        Figure 4. White, gritty and parenchymatous mass removed.
                   TMJ was explored through a preauricular approach;
                   the joint capsule was opened to expose the upper
               C




                   joint space. A white, gritty and parenchymatous mass           Discussion
                   was removed from the anteromedial aspect of the up-
    CI




                   per joint space to the condyle head (Fig. 4). This ma-         Synovial chondromatosis is a rare, benign process that
                   terial was sent for histologic and citologic examina-          typically affects large joints of young adults. Although it
                   tion together with portion of articular capsule. Minimal       more commonly involves the knee, elbow, and hip, it
                   remodeling of the glenoid fossa was performed.                 may occur in the temporomandibular joint (TMJ). This
                   No recurrence was apparent six months after the op-            disease is characterized by the development of carti-
                   eration.                                                       laginous nodules within the synovial space from the
©




                   Histologic examination of the material composed of             synovial connective tissue matrix (8); the nodules sub-
                   fibrocartilage showed a focal cluster of hematoxylin           sequently degradated, detached and become fluctuat-
                   crystalline deposition in proximity to neoangyogene-           ing intrarticular bodies tending to calcify in the joint
                   sis area and little chronic inflammation cells (7). This       space. The involved joint space may also become
                   suggested a nonspecific chondrocalcinosis.                     widened, and articular erosions may occur, eventually
                   The patient showed good functional recovery after              leading to secondary osteoarthritis. In 1933, Axhausen
                   surgery and a complications free follow-up (Figs. 5, 6).       described the first case of synovial chondromatosis af-

                   270                                                                            Annali di Stomatologia 2013; IV (3-4): 269-272
8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 271




                   Diagnosis and treatment of synovial chondromatosis of the TMJ: a clinical case


                                                                                 cal signs, the development of nonspecific pain and
                                                                                 headaches can lead to a delay in diagnosis or to a mis-
                                                                                 diagnosis of other more common causes of headaches.
                                                                                 However, CT is now being used with great success to
                                                                                 evaluate TMJ disorders.




                                                                                                                                               li
                                                                                 Progress in imaging with computed tomography and
                                                                                 magnetic resonance have improved the ability to delin-




                                                                                    na
                                                                                 eate temporomandibular disease markedly, particularly
                                                                                 with use of sagittal and coronal section imaging. It is
                                                                                 important a complete evaluation, particularly with the
                                                                                 use of diagnostic imaging for a correct evaluation of




                                                                                  io
                                                                                 TMJ intra-articular disease, which can appear to be a
                                                                                 cause of nonspecific headaches.
                                                                                 Proper treatment of synovial chondromatosis depends




                                                                               az
                                                                                 on accurate diagnosis. Although clinical diagnosis of
                                                                                 chondromatosis is possible but difficult using
                                                                                 arthroscopy, a definitive diagnosis can be made only by
                                                                                 histological examination. Many author suggest the role




                                                                            rn
                                                                                 of arthroscopy in diagnosis and treatment of chondro-
                                                                                 matosis (9-12). With larger masses, an open joint pro-
                                                                                 cedure with disc preservation may be indicated. Differ-
                                                                                 ential diagnosis is also very important. Intra-articular




                                                                         te
                                                                                 temporomandibular pain most commonly is due to de-
                                                                                 generative osteoarthritis, which is typically a progres-
                   Figure 5. Patient 6 month after operation.                    sive disease, late stage of meniscal perforation; os-
                                                                                 teosarcoma and chondrosarcoma (the most frequent)
                                                                      In         are malignant disease processes that can arise within
                                                                                 the TMJ while benign tumors tend to occur with less
                                                                                 frequency than malignant disease (13).
                                                             ni
                                                                                 Conclusion

                                                                                 Synovial chondromatosis is a rare, benign pathological
                                              o

                                                                                 entity that should be included in the differential diagno-
                                                                                 sis for patients with a preauricular, radiographically het-
                                                                                 erogeneous mass that seems to affect the TMJ. Clinical
                                          izi



                                                                                 symptoms overlap those of other TMJ diseases. These
                                                                                 often are characterized by joint swelling, pain and joint
                                                                                 dysfunction. However, its radiological identification is
                           Ed




                                                                                 extremely important, and nowadays, CT scan has be-
                                                                                 come a very important tool in TMJ imaging in associa-
                                                                                 tion with MRI and arthroscopy for the differential diag-
                                                                                 nosis of TMJ pathology. Conservative surgical excision
                                                                                 is needed for resolution.
                   Figure 6. Patient with a good mouth opening recovery.
               C




                   fecting the temporomandibular joint. The aetiology re-        Consent section: Signed publication consent was ob-
                                                                                 tained from the patient. A copy of the written consent is
    CI




                   mains unknown, but a history (2) of trauma and recur-
                   rent inflammations is often found. One of the most chal-      available for review by the Editor of this journal.
                   lenging features of synovial chondromatosis is to sus-        Competing interests: None declared.
                   pect and establish a correct diagnosis. Patients with
                   synovial chondromatosis affecting other major joints
                   are predominantly male, but most patients with TMJ in-        References
©




                   volvement are female (F:M:4:1) (3) as is the case with
                                                                                  1. Cascone P, Rivaroli A, Arangio P, Giovannetti F. Chondro-
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                   Annali di Stomatologia 2013; IV (3-4): 269-272                                                                            271
8_Vellone 5b_Riv Annali 3-4 2013 24/02/14 12:49 Pagina 272




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