Учебники / Color atlas of temporomandibular joint surgery Quinn
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Chapter Eight |
Pathology of the Temporomandibular Joint |
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A, A 12-year-old girl with rapid (i.e., over a period of approximately 4 to 6 months) onset of a unilateral open bile. B, Intraoral occlusal photograph showing marked posterior open bite. Note that the midlines are still symmetric, which is consistent with ihe nonrelational form of condylar hyperplasia. C, Panorex x-ray film showing posterior open bite on the right side, with elongation of the condylar neck. The postoperative panorex (D) shows correction of the open bite with an intraoral vertical subsigmoid osteotomy and simultaneous correction of the symphyseal deviation via genioplosty and interpositional hydroxylapatite block.
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FIG. 8 . 2 0
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FIG. 8 . 2 0 , C O N T ' D
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C, Preoperative posterior-anterior skull film depicting the canting of the mandibular plane. F, G, Lateral skull films showing right posterior open bile before and after surgical correction. H, I, Mandibular asymmetry secondary to condylar hyperplasia in a 36-year-old woman. Note the size differential on the axial and coronal CT scans. The condyle appears to have normal relative dimensions but is clearly enlarged in relation to the contralateral condyle. J, Axial CT scan showing enlargement of condylar heod.
Chapter Eight |
Pathology of the Temporomandibular Joint |
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K, L, Occlusal films depicting condylar hyperplasia before and after cor-ection by mandibular osteotomies.
Although space-occupying benign or malignant lesions can displace the condyle from the fossa and cause asymmetry with malocclusion, condylar hyperplasia can have similar presenting symptoms. Although the actual cause of this disorder is not fully understood, histologic events involve the abnormal presence of hyaline cartilage, which undergoes ossification and results in abnormal growth. In the normal condyle the articular surface is composed of fibrocartilage that undergoes appositional growth instead of endochondral ossification. Two types of condylar hyperplasia exist. In the Type I deformity, or hcmimandibular elongation, the mandible is asymmetric, with deviation of the chin to the contralateral side. In the Type II deformity, or hcmimandibular hypertrophy, deviation of the chin is not a prominent feature but a marked vertical open bite is present on the side of the hyperplasia. Condylar hyperplasia is not a true neoplasia but actually a self-limit- ing disorder. Radionuclide bone scans with technetium 99m can be helpful in differentiating between active and inactive disorders. Some researchers favor the use of a high condylar shave to remove the zone of abnormal tissue if the disorder is diagnosed early in its active stages. Removal of only 5 or 6 mm of the most superior condylar surface is usually adequate, and condylectomy is unnecessarily aggressive. Surgeons sometimes must perform a recontouring of the inferior border and angle of the mandible in conjunction with this procedure to address the inferior component of the mandibular asymmetry. When the bone scan shows that the process is inactive, orthognathic procedures such as an intraoral vertical subsigmoid osteotomy can be useful in closing the open bite while maintaining a functional joint articulation.
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FIG. 8.20, CONT,D
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Color Atlas of Temporomandibular Joint Surgery |
F I G S . 8 . 2 1, 8 . 22 |
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A 4-year-old boy with hemifacial microsomia. Condylar hyperplasia is not difficult to differentiate from hemifacial microsomia when there is full expression of the syndrome, but it may be difficult to differentiate condylar hyperplasia from the more mild variants of hemifacial microsomia, in which the only clinical manifestation is a diminution in the size of the condyle and ramus on the affected side.
FIG. 8 . 2 3
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Gross deformity of right condyle, with hypoplasia and deformity of ramus and condyle secondary to a compression deformity from neurofibromatosis.
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A, B, Coronal CT scans depicting gross deformity of condyle and angle region in a 14-year-old patient with facial asymmetry. A biopsy proved this lesion to be fibrous dysplasia, a type of deformity that must be differentiated from condylar hyperplasia.
Chapter Eight |
Pathology of the Temporomandibular Joint |
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A, Condylar hyperplasia with some deformity of the condylar head, as depicted in the coronal CT scan.
B, Rotational variant of condylar hyperplasia, with midline deviation of the mandible away from the affected side. C, Rigid fixation used to reposition the distal proximal segments after an exlraoral subsigmoid osteotomy was performed to correct condylar hyperplasia.
FIG. 8 . 2 4
Clinicians must be careful to ensure that they arc dealing with actual condylar hyperplasia before making this diagnosis in patients with facial asymmetry. Congenital disorders such as hemifacial microsomia and traumatic deformities on the contralateral side can be confused with condylar hyperplasia. Computer tomographic imaging in both the axial and the coronal planes should help clinicians distinguish between these disorders. Moreover, other pathologic conditions can also cause enlargement of the condyle with mandibular asymmetry and acquired malocclusions. For example, fibrous dysplasia, which can occupy the entire ramalcondyle complex, sometimes resembles condylar hyperplasia but is easily differentiated by radiologic examination.
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Color At Lis of Temporomandibular joint Surgery |
FIG. 8 . 2 5
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A, A 17-year-old patient with large, palpable preauricular mass. B, C, Axial and coronal MRI scan depicting a large moss of the condylar head displacing medial pterygoid and masseter muscles. D, E,
Soft tissue and bone CT scans depicting irregular spicules of bone radiating outward on the periphery of the lesion. This produces the so-called sun-ray appearance of osteogenic sarcoma. F, Osteogenic sarcoma surgical specimen with 2-cm bony margins.
Chapter Eight Pathology of the Temporomandibular Joint |
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FIG. 8 . 2 5, CONT'D
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G, Porotidectomy type of incision with temporal extension. Biopsy site was excised with mass by extending temporal incision into an endaural incision to elliptically incise biopsy site. H, After resection of lesion and placement of temporary reconstruction plate with condylar head. Note the vessel loops identifying the facial nerve, which was dissected to protect it during the surgical procedure. Because the bulk of the masseter muscle was excised, the sternocleidomastoid flap was rotated anteriorly and superiorly for soft tissue cover of the reconstruction plate. I, Wound closure with surgical drain in place.
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FIG. 8 . 2 6
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Color Athis of Temporomandibular Joint Surgery
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A, An 11-year-old boy undergoing open biopsy of soft tissue mass of the temporomandibular joint capsule. Infiltration into the base of skull and medial pterygoid space was apparent. B, Coronal MRI scan showing soft tissue mass of some patient. Note the erosion into the base of the skull, the deep and superficial temporal spaces, and the medial pterygoid space. C, Axial CT scan showing erosion of zygomatic arch from osteogenic sarcoma. D, Axial MRI scan showing residual mass medial to the condylar neck after initial phase of chemotherapy. E, Intraoral approach to medial pterygoid space for biopsy of residual lesion that proved to be residual osteogenic sarcoma. The patient was treated with radiation therapy and a second course of chemotherapy.
Chapter Eight |
Pathology of the Temporomandibular Joint |
In addition to tumor infiltration of the temporomandibular joint apparatus, trismus, pain, and swelling can be caused by infectious or myeloproliferative disorders. Septic arthritis of the temporomandibular joint is easily diagnosed by computer tomographic and magnetic resonance imaging, which show a high signal collection within the joint space. Infiltrates from leukemia or lymphomas can cause diffuse enlargement of the tissues of the masticator space; fine-needle aspiration or open biopsy is of great help in diagnosing these disorders.
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FIG. 8 . 27
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A, A 61-year-old man with painless masseteric space enlargement. B, MRI scan showing diffuse infiltrate of entire pterygoid masseteric spread. C, D, MRI and CT scans depicting diffuse enlargement of masseler and medial pterygoid muscles, with loss of fat planes in the entire masticator space. Incisional biopsy proved this to be a non-Hodgkin's lymphoma, which was treated with chemotherapy.
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Color Atlas of Temporomandibular Joint Surgery |
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A, B, Lateral and posterior views of a 55-year-old man with an exophytic preauricular mass. C, Axial soft tissue CT scan showing infiltrative lesion of right temporomandibular joint with extracapsular spread. This was subsequently diagnosed as metastatic adenocarcinoma secondary to a colon tumor.
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