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Case Report

Imaging of osteochondroma of the

temporomandibular joint – Report of two cases
Ruchi Gupta, Sailesh Kumar Mukul1, Abhishek Singh1, Subhash Kumar2
Department of Radiodiagnosis, IGIMS, Departments of 1Dentistry and 2Radiodiagnosis, AIIMS, Patna, Bihar, India

A B S T R A C T

Osteochondroma of mandibular condyle is an uncommon entity. In the temporomandibular region, they usually present as restriction in
mouth opening and pain in the joint. They can grow to a large size to impinge upon the cranial fossa. We present the imaging features
of two such rare cases, one was giant condylar osteochondroma and the other one was condylar osteochondroma associated with
contralateral osteochondroma of the zygomatic process of the temporal bone and congenital block cervical vertebrae. Computed
tomography, magnetic resonance imaging of the temporomandibular joint and bone scan findings are discussed in detail along with
the follow‑up of patients.

Key words: Condyle, computed tomography, giant, joint, osteochondroma, temporomandibular

Introduction Case Reports

Osteochondroma is the most common benign tumor Case 1

or tumor‑like lesion of the bone.[1] However, they are
uncommon tumors in the maxillofacial region with an
incidence of 1% of all cases.[2] Less than three hundred
cases have been reported so far.[3] Osteochondroma
contains cortical and medullary bone with the overlying
hyaline cartilage cap and shows continuity with the cortex
and medulla of the subjacent bone. These can occur as
solitary lesions or be multiple, latter are usually associated
with hereditary multiple exostosis.[1] Imaging findings
on computed tomography (CT), magnetic resonance
imaging (MRI), and nuclear scan have been discussed in
two cases, all of which have never been discussed together
before.
A 26‑year‑old male presented with chief complaints
of pain anterior to the tragus of the left ear in the
temporomandibular joint (TMJ) along with burning
sensation over the overlying skin for the past 4 years. There
was history of deviation of the mouth to the right side,
difficulty in chewing, and opening of mouth for 1 year. No
other systemic complaints were present. On examination,
bony hard swelling was seen in the left preauricular region.
Rest of the body examination was within the normal
limits. All routine blood tests were in the normal range.
Based on clinical history and examination, differentials
of TMJ bony ankylosis, condylar hyperplasia, and bony
tumor were considered as these can lead to chin deviation

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DOI: Cite this article as: Gupta R, Mukul SK, Singh A, Kumar S. Imaging of
10.4103/jomr.jomr_7_20 osteochondroma of the temporomandibular joint – Report of two cases. J Oral
Maxillofac Radiol 2020;8:16-20.

Address for correspondence: Dr. Ruchi Gupta, Flat Number 2014, Ganga 4, Jalalpur City, Gola Road, Danapur, Patna ‑ 801 507, Bihar, India.
E‑mail: drruchigupta28@gmail.com
Submission: 20-04-2020, Decision: 02-05-2020, Acceptance: 21-05-2020, Web Publication: 02-07-2020

16 © 2020 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow
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Gupta, et al.: Imaging of osteochondroma of the temporomandibular joint
as well as may present as bony hard swelling in the TMJ
region. The patient was advised orthopantomogram for the
evaluation of bony hard swelling. Panorex image showed
a radiopaque lesion in the left condylar head region with
sclerotic margins, and the condyle was not seen separately
from the lesion [Figure 1]. Subsequently, CT revealed the
presence of bony outgrowth from the left condylar head
with medulla and cortex contiguous with the condyle.
The lesion measured 3 cm × 2 cm in size. The bony
outgrowth was seen medial to the condyle and pointing
upward causing marked thinning and remodeling of the
floor of middle cranial fossa and foramen ovale [Figure 2].
There was a cystic component of the lesion within the
glenoid fossa. There was deviation of the chin to the
opposite side [Figure 2d]. The bone scan revealed intense
uptake of technician methyldiamine pertechnate (Tc99
MDP) in the left temporomandibular region to suggest
osteoblastic lesion. There was normal uptake in rest of
the skeleton [Figure 3]. Diagnosis of left condylar giant
osteochondroma was made. The surgery was planned with
the following objectives to address: (1) surgical removal of
the lesion through complete excision, (2) correction of
occlusal changes (open and crossbite) due to growth of
the lesion, and (3) correction of resulted facial deformity.
Single‑stage surgery was done for the excision of the
a b
Figure 1: (Case 1) Panorex cropped image 1 (a) right (b) left side show bony
lesion in the region of left condyle of the mandible showing sclerotic margins
Figure 3: (Case 1) Technician methyldiamine pertechnate bone
scan (axial, sagittal, and coronal plane) shows increased uptake in the left
temporomandibular region to suggest osteoblastic activity
Journal of Oral and Maxillofacial Radiology / Volume 8 / Issue 1 / January‑April 2020
lesion and correction of the facial deformity [Figure 4a].
On histopathological examination, peripheral fibrous
periosteum covering the chondroid mass with chondrocytes,
central bony trabeculae, and central fibrovascular stroma
was seen [Figure 4b]. After 1‑year follow‑up, there was no
recurrence of the lesion, and the patient had no significant
complaints.
Case 2
A 22‑year‑old female presented with progressively increasing
difficulty in mouth opening for the past 4–5 years. She was
not able to chew or speak properly. On further asking for
systemic complaints, the patient replied she had difficulty
in bending neck since childhood. On clinical examination,
bony swelling was palpable in the region of bilateral TMJs,
which was fixed to the bone. There was no tenderness at
the site of swelling. The patient was fairly built and had
no other systemic complaints. Clinical differentials were
bilateral TMJ bony ankylosis or bony tumor. Further
imaging was done to confirm the diagnosis. CT revealed
a b
c d
Figure 2: (Case 1) a 26‑year‑old male (a) Coronal bone window image shows
bony outgrowth from the head of the condyle on the left side with the cortex
and medulla contiguous with the condyle. (b) Coronal bone window image
shows bony outgrowth impinging upon middle cranial fossa and foramen
ovale (yellow arrow). (c) Volume rendered image shows partially cystic
component of the growth within the glenoid fossa (red arrow). (d) Volume
rendered image shows deviation of the chin to the right side
a b
Figure 4: (Case 1) (a) Intraoperative image showing the osteochondroma
of the left mandibular condyle. (b) H and E stain shows chondroid mass (blue
arrow), osteoid mass (black arrow), and fibrovascular stroma (green arrow)
to confirm the diagnosis of osteochondroma
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Gupta, et al.: Imaging of osteochondroma of the temporomandibular joint

the presence of bony protrusion from the right mandibular

condyle with medulla and cortex contiguous with that of
the lesion, obliterating the sigmoid notch and projecting
anterior, inferior, and lateral to sigmoid notch. The right
condylar head was flattened with reduced TMJ space. There
was another bony protrusion on the left side from the
a b
articular eminence part of the zygomatic arch just anterior
to the mandibular condyle projecting over the sigmoid
notch [Figure 5]. C2–C6 cervical vertebral bodies were
fused along with their fused posterior elements to suggest
block vertebrae.[Figure 5d] The posterior arch was not
seen, and anterior arch rachischisis was seen [Figure 5e].
c d e
MRI revealed the absence of cartilage cap in both the
Figure 5: (Case 2) volume rendered images images (a) show bony protrusion
lesions to suggest burnt out cartilage cap [Figure 6]. The from right mandibular condyle obliterating sigmoid notch (black arrow). (b)
final diagnosis of right mandibular osteochondroma Another bony protrusion seen from articular eminence on the left side
projecting over the sigmoid notch (red arrow). (c) Coronal computed
with secondary degenerative changes, left zygomatic tomography bone window image shows the bony outgrowth on both
osteochondroma, and multiple cervical block vertebrae sides (black arrowhead on right and red on left). (d) Sagittal computed
with atlas arch anomalies were made. Surgical removal of tomography image shows multiple cervical block vertebrae (red star). (e) Axial
bone window image shows anterior arch rachischisis (yellow arrow), absent
bilateral bony outgrowth and bilateral TMJ interpositional posterior arch (green arrow), and right condylar osteochondroma (blue arrow)
arthroplasty with temporalis muscle and bilateral intraoral
distractor placement was done [Figure 7]. The patient has
been kept on regular physiotherapy and follow‑up.

Discussion

Osteochondroma is a developmental lesion rather than

true neoplasm. Solitary osteochondroma constitutes about
20%–50% of all benign bone tumors and 10%–15% of all
bone tumors.[1] These lesions result from the separation of
a b
fragment of epiphyseal growth plate cartilage that herniates
Figure 6: (Case 2) Sagittal proton density fat sat image (a) right (b) left show
through periosteal bone which surrounds the growth plate. absence of cartilage cap overlying the bony protrusion on both sides (red arrow)
This cartilage shows persistent growth with subsequent
enchondral ossification leading to the formation of osseous
bone with overlying cartilage cap projecting from the bony
surface. Surgery, trauma, and irradiation are other etiological
factors of osteochondroma.[1] The cartilage cap measures
about 1–3 cm in young people while it may be a few
millimeters thick or entirely absent leaving the bone exposed.[1]
Osteochondroma is extremely rare in the maxillofacial region.
In the maxillofacial region, coronoid process of the mandible
is the most commonly involved. Other sites include the body
of the mandible, maxilla, maxillary sinus, zygomatic arch,
symphysis, and condyle of the mandible.[4‑7] The tumor is
more common in the second decade of life in axial skeleton,
whereas in the TMJ region, they are more common in
the fourth‑fifth decade of life.[2] However, there are case
Figure 7: (Case 2) Intraoperative image showing the excision of the bony
reports which mention the occurrence in early life, as in our outgrowth
cases, both presented in the third decade of life.[8] The rare
occurrence of osteochondroma in this region may be because The most common location is the medial side of the
of the presence of fibrocartilage in the TMJ rather than the mandible, followed by the anterior side since the tension
hyaline cartilage.[2] created by the lateral pterygoid muscle attachment induces

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Gupta, et al.: Imaging of osteochondroma of the temporomandibular joint
the proliferation of cartilage cells.[3,9] In our case 1, the
location was medial, but in case 2, it was on the anterolateral
side of the condyle. The common symptoms include
facial asymmetry, localized mass, ipsilateral posterior open
bite, contralateral crossbite, pain, and limitation of mouth
opening.[5,10] Pain is mainly due to the impingement on
adjacent structures like nerves or fracture through the
stalk, otherwise they are painless in nature.[11] Our case 1
is a giant osteochondroma measuring about 3 cm × 2 cm
in size and directed superomedially, causing thinning and
marked remodeling of the floor of the middle cranial fossa
on the left side. Kaneda et al. also reported a case of giant
osteochondroma of the mandibular condyle.[10] Karras et al.
reported concurrent osteochondroma of the mandibular
condyle and ipsilateral skull base which resulted in TMJ
fibrous ankylosis.[7] The Case 2 which we reported included
condylar osteochondroma with contralateral zygomatic arch
osteochondroma and multiple cervical block vertebrae,
which has never been reported before. The patient did not
have similar lesions in other parts of the body.
Panoramic radiographs showed radiodense mass in the
region of condyle, and the density increases as the cartilage
cap calcifies with age. CT is valuable in revealing the character
of the lesion, its continuity with the cortex and medulla of
the condyle and relation with the surrounding structures.
MRI helps in evaluating the thickness of the cartilage cap,
and the presence of cartilage cap confirms the lesion to be
osteochondroma.[3] The bone scan can add to the diagnosis
by confirming the increased radiotracer uptake due to an
increase in osteoblastic activity as in our case done by Tc99
MDP. Furthermore, whole‑body single‑photon emission CT
rules out other osteochondromas in the skeleton.
The major differentials of osteochondroma are unilateral
condylar hyperplasia and osteoma.[2] Condylar hyperplasia
shows enlarged condylar process with longer neck on the
affected side, whereas osteochondroma appears as exophytic
bony growth from the bony surface.[8] Histologically,
normal cartilage proliferation seen in condylar hyperplasia,
whereas disordered cartilage proliferation seen in
osteochondroma.[9] Furthermore, the presence of cartilage
cap confirms osteochondroma, however cap may be absent in
older individuals and get calcified.[2] Osteoma leads to lobular
enlargement of the condyle. Histologically, the presence of
dense cortical lamellar bone is diagnostic of osteoma.[4]
In the axial skeleton, 1% of solitary osteochondroma show
malignant transformation. They most often cease growth
after puberty; hence, progressive growth in later life may
indicate sarcomatous change in long bones. However, in the
maxillofacial region, they may show slow growth even after
Journal of Oral and Maxillofacial Radiology / Volume 8 / Issue 1 / January‑April 2020
puberty.[5] The recurrence rate of overall osteochondroma
has been mentioned nearly 2%, but it is even very less in
the condylar region.[12] Hence, follow‑up and thickness
of cartilage cap is of utmost important factor to rule out
malignant transformation. In Case 2, the cartilage cap was
not seen on MRI. Both the patients got operated and have
been kept on regular follow‑up. There was no evidence of
malignancy in either of the cases.
Overall prognosis depends on the complete excision
of lesion.[12] The recommended treatment is usually
condylectomy and reconstruction. The surgical approaches
have been preauricular, submandibular, intraoral, and
combined ones.[4] In our Case 1, the giant osteochondroma
was reaching up to the skull base and causing thinning
of the floor of middle cranial fossa and foramen ovale.
The whole bony lesion was excised through combined
preauricular and submandibular approach. The residual
facial asymmetry was corrected through sliding genioplasty.
After 1‑year follow‑up, there has been no recurrence of
the lesion, whereas in Case 2, removal of bony outgrowth,
bilateral TMJ interpositional arthroplasty with temporalis
muscle, and bilateral intraoral distractor placement were
done by the department of oral and maxillofacial surgery.
Conclusion
Osteochondroma should be kept as differential
diagnosis, although rare in cases of bony growth in
the temporomandibular region. Radiological diagnosis
is confirmatory but should be accompanied with
histopathological examination to differentiate from osteoma
and condylar hyperplasia and to rule out any malignant
transformation. Follow‑up is recommended as there have
been few cases of recurrence reported in literature.
Acknowledgment
We would like to thank the CT and MRI technicians: Mr
Sanjeev Kumar and Mr Ranjeet Kumar.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. From
the archives of the AFIP imaging of osteochondroma: Variants and
complications with radiologic‑ pathologic correlation. Radiographics
2000;20:1407‑34.
19
[Downloaded free from http://www.joomr.org on Wednesday, December 23, 2020, IP: 36.79.145.151]

Gupta, et al.: Imaging of osteochondroma of the temporomandibular joint

2. Saito T, Utsunomiya T, Furutani M, Yamamoto H. Osteochondroma of
the mandibular condyle: A case report and review of the literature.
J Oral Sci 2001;43:293‑7.
3. Kwon YE, Choi KS, An CH, Choi SY, Lee JS, An SY. Recurrent
osteochondroma of the mandibular condyle: A case report. Imaging
Sci Dent 2017;47:57‑62.
4. Henry CH, Granite EL, Rafetto LK. Osteochondroma of the mandibular
condyle: Report of a case and review of the literature. J Oral Maxillofac
Surg 1992;50:1102‑8.
5. Veazeau J, Fridrich KL, Vincent SD. Osteochondroma of the mandibular
condyle: Literature review and report of two typical cases. J Oral
Maxillofac Surg. 1995;53:954–63.
6. Andrade NN, Gandhewar TM, Kapoor P, Thomas R. Osteochondroma of
the mandibular condyle‑Report of an atypical case and the importance
of computed tomography. J Oral Biol Craniofac Res 2014;4:208‑13.
7. Karras SC, Wolford LM, Cottrell DA. Concurrent osteochondroma
of the mandibular condyle and ipsilateral cranial base resulting in
temperomandibular joint ankylosis: Report of a case and review of
the literature. J Oral Maxillofac Surg 1996;54:640‑6.
8. Sekhar MM, Loganathan S. Giant osteochondroma of the mandibular
condyle. J Oral Maxillofac Pathol 2015;19:407.
9. Friedrich RE, Scheuer HA, Fuhrmann A, Hagel C, Zustin J.
Osteochondroma of the mandibular condyle. Report of a case with
5‑year follow‑up. Anticancer Res 2012;32:4553‑6.
10. Kaneda T, Torii S, Yamashita T, Inoue N, Shimizu K. Giant osteochondroma
of the mandibular condyle. J Oral Maxillofac Surg 1982;40:818‑21.
11. Nanda Kishore D, Shiva Kumar HR, Umashankara KV, Rai KK.
Osteochondroma of the mandible: A rare case report. Case Rep Pathol
2013;2013:167862.
12. Koga M, Toyofuku S, Nakamura Y, Yoshiura K, Kusukawa J, Nakamura Y.
Osteochondroma in the mandibular condyle that caused facial
asymmetry: A case report. Cranio 2006;24:67‑70.

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