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n CASE REPORT

Synovial Chondromatosis of the Temporomandibular


Joint: An Asymptomatic Case Report and Literature
Review
Denis Pimenta e Souza, D.D.S.; Caio Cesar de Souza Loureiro, D.D.S.;
Paula Felix Falchet, D.D.S.; Luiz Fernando Lobo Leandro, D.D.S., Ph.D.;
Ricardo Raitz, D.D.S., Ph.D.

0886-9634/2801-
067$05.00/0, THE ABSTRACT: Synovial chondromatosis of the temporomandibular joint (TMJ) is a rare lesion character-
JOURNAL OF
CRANIOMANDIBULAR
ized by the presence of loose bodies in the glenoid fossa. Swelling, unilateral pain, occlusal changes,
PRACTICE, clicking, crepitation, deviation, and limited mandibular function are the most common characteristics,
Copyright © 2010
by CHROMA, Inc.
although this combination is not always apparent. Radiopacities of the TMJ should be thoroughly inves-
tigated as some signals and symptoms may be not present or combined, taking months or even years
Manuscript received to confirm a diagnosis. A case report is presented here with a brief literature review, where surgical
August 19, 2008; accepted removal was the therapy of choice, calling attention to the absence of symptoms and some signals,
January 7, 2009
which may mislead final diagnosis.
Address for correspondence:
Dr. Ricardo Raitz
Av. Heitor Peneteado, 1832,
101/A
CEP: 05438-300
Sumarezinho, São Paulo-SP
Brazil
E-mail: ricardoraitz@ig.com.br

S
ynovial chondromatosis is an uncommon benign
monoarticular arthropathy characterized by the for-
mation of multiple cartilaginous or osteocartilagi-
nous metaplastic nodules in synovial and subsynovial
connective tissue of the joints. 1-10 It most frequently
affects the large articular joints such as knee, hip, elbow,
shoulder, and wrist.5-7,11-13 Although, the involvement of
the temporomandibular joint (TMJ) is rare, many cases
have been published since 1933, when Georg Axhausen
Dr. Denis Pimenta e Souza is a post reported the first case.3,10,12-15
graduate student in the oral and maxillo-
facial program, School of Dentistry,
Osteocartilaginous loose bodies of TMJ can arise as a
University of São Paulo, and an oral and direct result of the proliferative disorder of the sinovium
maxillofacial surgery assistant professor (sinovial chondromatosis), or secondary to osteochondral
in the Section of Oral and Maxillofacial
Surgery, Hospital Santa Paula, São
fractures or osteoarthritis 9,14,16,17 (secondary sinovial
Paulo, Brazil. chondrometaplasia). The primary form seems to be more
aggressive and bone erosive and probably originates from
mesenchymal remnants that become mataplastic, calcify,
and break off into the joint space. The secondary form is
associated with degenerative, inflammatory and nonin-
flammatory diseases and is a more passive process.7,8
Swelling, unilateral pain, occlusal changes, clicking,
crepitation, deviation, and limited mandibular function
are the most common characteristics, although this com-
bination is not always apparent.1,9,10,14,16,18 Since the syn-

67
SYNOVIAL CHONDROMATOSIS OF THE TMJ SOUZA ET AL.

ovial chondromatosis of the TMJ is a rare condition, teeth and severe periodontitis.
these features may be easily misdiagnosed as neoplasia or Conventional panoramic radiography demonstrated a
other pathologies.7,12,13 radiopaque mass into the glenoid fossa of the right tem-
Imaging diagnoses includes conventional x-ray exami- poral bone and around the head of the right condyle,
nation, computed tomography (CT), and magnetic reso- which showed no deformity (Figure 2). A CT scan
nance imaging (MRI). Recently, arthroscopy has been revealed the presence of multiple round-shaped, high-
used as a more conservative means of obtaining a defini- density masses, with aspect of loose bodies, located near
tive diagnosis13,16 and removing loose bodies when they the right temporal eminence occupying the joint space
are small enough for the instrument.6,12,15 Arthrotomy or where the disk should be positioned (Figure 3).
the surgical removal of the loose bodies, with or without
resection of the synovial membrane and disk2,4,12,15 are
still largely used therapies, as they dispense with using
expensive equipment and allow seeing and biopsying
critically the pathologic tissues. Here is presented a case
report where the surgical removal was the therapy of
choice, calling attention to the absence of symptoms
which may mislead final diagnosis.

Case Report
Figure 2
A 28-year-old man was referred to the Section of Oral Pre-operative panoramic radiography revealed radiopacities in the area
and Maxillofacial Surgery at the Hospital Santa Paula of the right TMJ.
(São Paulo, Brazil) by his orthodontist who first noticed
some radiopaque particles in the region of the right TMJ,
through an orthodontic documentation. These clinical and image findings led us to a diagnos-
On clinical examination, no evidence of facial asym- tic hypothesis of synovial chondromatosis. It was decided
metry or malocclusion was noticed. There was no limita- to access the glenoid fossa surgically in order to take a
tion of mandibular movement nor mandibular deviation biopsy of the affected tissues or only remove the loose
during mouth opening (Figure 1). Swelling and crepita- bodies.
tion were noticed while palpating the right TMJ. The After induction of general anesthesia, the TMJ and
patient denied any history of trauma to the maxillofacial infratemporal fossa were approached via modified preau-
region. Intraorally, it was noted the absence of several

Figure 1
No evidence of facial asym-
metry, no limitation of
mandibular movement during
mouth opening movement,
nor mandibular deviation.

Figure 3
Axial computed tomography scan demonstrating multiple high-density
masses around the right TMJ.

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SOUZA ET AL. SYNOVIAL CHONDROMATOSIS OF THE TMJ

ricular incision (Figure 4). White, irregularly shaped


loose bodies escaped from the TMJ upper space after the
joint capsule was opened (Figure 5). The glenoid fossa
was explored, and the adherent cartilaginous mass freed
from its attachments to the fossa walls. All the loose
bodies were removed (Figure 6). Since the condyle and
the disk were macroscopically normal, condilectomy and
meniscectomy were not indicated and so closure was
obtained with preservation of the synovium, capsule, and
condyle.

Figure 6
Irregularly shaped, white, cartilaginous nodules removed from joint
Figure 4
compartment at surgery.
Modified preauricular
incision to approach
infratemporal cavity.
Postoperatively, the patient displayed decreased pain
and swelling, but some little limitation on mandibular
range of motion was noticed for 15 days. At a two-year
follow-up, the mandibular range of motion continues to
be normal, and the patient has had no symptoms.
Radiographic examination showed no signs of recurrence
(Figure 7).

Figure 5 Figure 7
Loose bodies migrated from the upper compartment after incision of Post-operative panoramic radiography at two-years follow-up, show-
the capsule. ing no recurrence of the lesion.

JANUARY 2010, VOL. 28, NO. 1 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 69


SNYOVIAL CHONDROMATOSIS OF THE TMJ SOUZA ET AL.

Discussion synovial intima, respectively. TGF seems to increase dif-


ferentiation of mesenchymal cells, production of proteo-
This case of Synovial chondromatosis is considered glycans, and replication of chondroblasts, while TN is
uncommon as large articular joints such as knee, hip, important for chondrogenesis in the extracellular matrix
elbow, shoulder, and wrist usually are mostly affected and the condensing mesenchyme of developing bones.
instead of the TMJ. 1-3,5-7,11-13 For the characteristics These findings support the metaplastic theory of synovial
assessed, one could conclude that this is a primary form chondromatosis in the TMJ since neither TGF nor TN are
of the pathology, which is represented as a benign carti- normally present in the synovial membrane of normal
laginous metaplasia of mesenchymal tissue with rem- joints. Sato, et al. 10 reported that different fibroblast
nants arising in the synovial membrane where fibroblasts growth factors (FGF) and their respective receptors
beneath its surface become metaplastic and deposit chon- (FGFR) may be strongly related to the development of
dromucin. Thus, a cartilaginous focus is stimulated, and synovial chondromatosis. In their study, FGF-2 and
once formed, it grows by active cellular proliferation.7,8 FGFR-1 immunoreactivities were observed in chondro-
Once the cartilaginous metaplastic and calcified nod- cytes while FGFR-3 and its specific ligand, FGF-9, were
ules4,7,14,15 arise from the synovial membrane, as well as immunohistochemically observed at the margins of the
from the fibrocartilaginous disk tissue, they extrude to the cartilage nodules. It was concluded that expression of
joint space as loose bodies, often surrounded by fibrosed FGFR-1 in chondrocytes contributes to the growth poten-
connective tissue where they are nourished by the syn- tial of synovial chondromatosis, and that the FGF-
ovial fluid,3-5,10,13,15 occupying the joint space where the 2/FGFR-1 system may play an important role, as well as
disk should be positioned, and usually causing pain. the FGF-9/FGFR-3 system, in its pathogenesis.
Surprisingly, this patient was asymptomatic and the Recently, arthroscopy of the TMJ, by providing tissue
lesion was first noticed through an orthodontic documen- for a histomorphologic analysis, has been used as a more
tation. Moreover, only preauricular swelling, and crepita- conservative means of obtaining the definitive diagnosis
tion were present in this case. These few characteristics and definitive treatment.13,15,16 However, the technique is
may lead this lesion to be misdiagnosed as neoplasia, difficult to execute; patients still have to suffer the surgi-
especially chondrosarcoma12 or other pathologies such as cal damage resultant from the insertion of the arthroscope
degenerative joint disease, rheumatoid arthritis, neu- into the joint cavity, 4 and some loose bodies are big
rotrophic arthritis, tuberculosis, and osteochondritis ossi- enough to inable this technique. Moreover, not all the sur-
ficans. 6,7 Therefore, imaging examinations such as gical services dispose from the equipment. Various other
radiographies, CT scanning, and MRI must be carried out treatments have been used. For a long time, complete
for a correct diagnosis and therapy.7,12,13,19 removal of the synovium associated or not with condylec-
Radiographic appearance is variable and may include tomy or condylotomy was the main therapy for this
widening of the joint space, manifestations of degenera- pathology.2 Nowadays, this radical approach is rarely
tive changes of the articular surfaces, and expansion of indicated. More conservative procedures such as arthro-
the joint capsule, but evidence of loose bodies is not tomy and removal of the loose bodies, partial or total syn-
always present, being found in only 60% of the cases.11,16 ovectomy, and, particularly, if both joint compartments
This was the case herein reported, where radiopaque par- are affected or if the disk is damaged beyond functional
ticles could be seen into the glenoid fossa (Figure 2). CT repair, diskectomy are the treatment of choice.3,12,13,16
plays an important role in the diagnosis of the TMJ syn- In the case reported, the surgical approach enabled the
ovial chondromatosis, since it can demonstrate soft tissue removal of either little or big loose bodies. As no signifi-
swelling, possible change of the articular surface of the cant alterations were found in the synovium, disk or
temporal bone, and define size, shape, and locations of condyle, a very conservative surgical procedure was
the loose calcified bodies2,16,19 (Figure 3). However, MRI taken, with no need of synovium or disk removal.
is mostly used to establish the expansion and thickening Radiopacities of the TMJ should be thoroughly investi-
of the joint capsule and morphologic changes in the posi- gated as some signals and symptoms may be not present
tion of the disk.16 or combined, taking months or even years to confirm a
Immunohistopathological studies have shown that dif- diagnosis.10
ferent growth factors and hormones may play an impor-
tant role in the pathogenesis of synovial chondromatosis. References
Fujita, et al.3 reported that Transforming Growth Factor β
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Maxillofac Surg 1998; 36:317-318. dent, in the Section of Oral and Maxillofacial Surgery, Hospital Santa
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Report of two cases. Int J Oral Maxillofac Surg 2002; 31:532-536.
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Dr. Luis Fernando Lobo Leandro is chief of the Section of Oral and
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Maxillofac Surg 2003; 32:143-147. Maxillofacial Surgery, Hospital Santa Paula, São Paulo, Brazil.
12. Miyamoto H, Sakashita H, Miyata M, Kurita K: Arthroscopic diagnosis and
treatment of temporomandibular joint synovial chondromatosis: report of a Dr. Ricardo Raitz is a professor of the Biodentistry post graduate
case. J Oral Maxillofac Surg 1996; 54:629-631. (M.Sc.) program of Ibirapuera University, São Paulo, Brazil; professor
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and chair of General Pathology at São Caetano do Sul University, São
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nostic, and histomorphologic findings. Oral Surg Oral Med Oral Pathol Paulo, Brazil.
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