An unusual osteoma in the mandibular condyle and the successful replacement of the temporomandibular joint with a custom-made prosthesis: a case report
Souza et al. BMC Res Notes
An unusual osteoma in the mandibular condyle and the successful replacement of the temporomandibular joint with a custom-made prosthesis: a case report
Natalia Tavares de Souza 3
Renan Carlos Lopes Cavalcante 3
Maria Aparecida de Albuquerque Cavalcante 3
Wagner Hespanhol 3
Marcello Rodrigues de Oliveira Jr. 3
Dennis de Carvalho Ferreira 0 1 2
Thais Machado de Carvalho Coutinho 0 1
Lucio Souza Gonçalves 0 1
0 Faculty of Dentistry, Estácio de Sá University , Av. Alfredo Baltazar da Silveira, 580/cobertura, Recreio, Rio de Janeiro, RJ 22790-710 , Brazil
1 Faculty of Dentistry, Estácio de Sá University , Av. Alfredo Baltazar da Silveira, 580/cobertura, Recreio, Rio de Janeiro, RJ 22790-710 , Brazil
2 Faculty of Dentistry, Veiga de Almeida University , Rio de Janeiro , Brazil
3 Federal University of Rio de Janeiro , Rio de Janeiro, RJ , Brazil
Background: An osteoma is a benign tumor of bone with unknown etiology and is considered rare, mostly restricted to the craniofacial skeleton. Case presentation: This case report describes an uncommon condylar osteoma in a 67 years old white female patient with laterognathism to the left side, limited mouth opening, aesthetic change and pain associated with the right temporomandibular joint (TMJ). The histopathological examination confirmed osteoma. The lesion was surgically excised and immediate reconstruction was carried out using a custom-made total TMJ prosthesis. The patient has been in follow-up for 2 years, with no symptoms. Conclusions: Unilateral total TMJ prosthesis can be considered to replacement of TMJ after osteoma excision with resection of the condyle.
Osteoma; Benign tumor; Total temporomandibular joint; Prosthesis
An osteoma is defined as a benign tumor of bone
resulting from the continuous formation of cortical and
spongious bone. The etiology of the tumor is unknown, but
may be associated with trauma, response to infections
or inflammatory processes and growth abnormalities.
Osteomas are rare and mostly restricted to the
craniofacial skeleton. When they appear in the jaw region, there
is a preference for the mandible rather than the maxilla.
The most affected areas of the mandible are the body,
angle and condyle [
Osteomas in the mandible have been reported
as a cause of trismus, limitation of mouth opening,
progressive malocclusion with midline shift, contralateral
mandibular deviation and facial asymmetry, especially
when the mandibular condyle is involved. They may be
symptomatic when their growth surpasses the limits of
the bone [
]. Research shows that men are affected
two times more than women (2:1), with ages ranging
from 14 to 58 years, with an average age of 29.4 years.
Large osteomas that cause symptoms or esthetic
deformities are excised surgically. Reconstruction using
autogenous bone grafts or prosthetic joints is usually performed
when the region of the mandibular condyle is affected
]. The indications for total replacement of the
temporomandibular joint (TMJ) are more than two previous
TMJ surgeries, fibrous or bony ankylosis of the TMJ, and
postoperative condylar loss associated to neoplastic
A total TMJ prosthesis must be designed so that it
minimizes biomechanical stresses and at the same time
achieves a homeostatic equilibrium [
Finite-element modeling (FEM) has also been used to analyze the
stress distribution in TMJ components [
The custom-made total TMJ prosthesis “Promm” which
is made in Brazil and is registered with ANVISA No.
10447390006 has been designed considering functional
rehabilitation, anatomy and aesthetics of the patient.
This study reports a case of an uncommon condylar
osteoma that was identified due to an aesthetic change of
the TMJ and immediate reconstruction using a total TMJ
A 67-year-old white female patient was referred for
the evaluation of asymmetry in the left lower jaw. On
examination, the patient had laterognathism to the
left side, limited mouth opening and pain in the right
TMJ during maximum mouth opening and palpation.
She reported that she had sought medical help due
to extensive headaches. The doctor referred her to a
dentist specialized in oral and maxillofacial surgery.
The patient also reported the facial deviation that was
becoming more and more noticeable to other people,
interfering with her aesthetics (Fig. 1a). The patient
made it clear that she had had no experience of
previous trauma in the TMJ region.
Following the initial examination, a 3D CT scan was
performed and it revealed an extensive but well-defined
radiopaque lesion on the right condyle, measuring 1.5
by 2.0 cm (Fig. 1b, c). Thus, due to the size of the lesion,
the decision was to excise the tumor with resection of
the condyle and to construct a custom-made total
temporomandibular joint prosthesis for reconstruction. The
engineer and the surgeons responsible for the surgery
discussed the project of the prosthesis and the availability
of soft tissue, and the need for symmetry and aesthetics
were assessed. This type of prosthesis consist of a
component representing the glenoid fossa, which was made of
ultra-high molecular weight polyethylene cast with pure
titanium and is fixed to the mandibular fossa with
titanium bolts. The component representing the condyle was
made of a molybdenum cobalt-chromium alloy and the
titanium branch [
The accurate prototype of the patient’s skull allowed a
three-dimensional analysis of the lesion and was of
significant assistance throughout the process. A CT scan
was used to prepare the prototype and the custom-made
prosthesis for the patient (Fig. 2a, b). For surgery, the
patient underwent general anesthesia with endotracheal
Initially the movements of the mandible were studied
using Posselt’s diagram. This device tracks the
components of the cranial cavity of the prosthesis. The model of
the prosthesis in resin was approved by the surgeon and
scanned three dimensionally (3D). A computer numerical
control (CNC) program used these images to machine
the final model of the prosthesis. The mandibular
component of the Arthroplasty System Promm consists of a
condylar head made of cobalt–chromium–molybdenum
alloy (ISO 5832-12) and a mandibular body made of pure
titanium (ISO 5832-2), while the cranium component has
a cavity where the condyle is articulated and machined in
polyethylene of ultra-high molecular weight, UHMWPE
All parts received a finishing process. The mandibular
component was submitted to electro coloring,
resulting in a blue color. All Promm products are batch mark,
which allows the traceability of the raw materials the
batch, provider, trader and date of each step, as well as
the tools used for quality control of the parts.
After performing asepsis, antisepsis and installation of
drapes, the incisions were marked with a Skin Marker. At
the location of the incisions lidocaine 2% with 1:50,000
epinephrine was infiltrated to improve homeostasis
during the incision. The prosthetic joint was placed via the
preauricular access and the submandibular incision
access was used to fix the branch ramus and condyle.
After exposure of the entire mandibular ramus,
osteotomy was made with an incision safety margin until the
trailing edge of the mandibular ramus, through the
submandibular access, so that the condyle with the tumor
could be removed via the preauricular access.
The incised specimen was sent for histopathological
examination, which confirmed osteoma. Figure 3 depicts
a compact bone tissue with fibrous connective stroma at
the periphery, while Fig. 4 presents compact bone with
lacuna filled by bone marrow tissue.
After removal of the tumor, the prosthesis was adapted
without difficulty and fixed in place with the 2.4 mm screw
system. After implantation of the prosthesis the opening
and closing mouth movements were tested and were found
to be within normal limits. The patient has been in
followup for 2 years, with no painful symptoms, mouth opening
of 32 mm and she continues as an outpatient (Fig. 2c, d).
Discussion and conclusions
The etiology of osteoma is unknown. Many authors have
suggested that the majority of those in the maxillofacial
region were reactive bone hyperplasia or advanced
ossification. Other authors consider trauma as an important
factor. However, in this case report these possibilities
were not considered to be the etiologic factors [
Osteomas, in most cases are asymptomatic,
depending on their location and size. Lesions tend to be small,
solitary, slow-growing and painless, and are only
noticeable during routine examinations. As these lesions have
a progressive characteristic, they eventually becoming
larger and exacerbate the signs and symptoms. They can
cause facial asymmetry, contralateral mandibular
deviation, limitation of mouth opening and be painful [
These manifestations are similar to those observed in the
patient of this report.
Normally osteomas appear in isolation and alone.
However, there is a syndrome which is associated with
the appearance of multiple osteomas, called Gardner
]. This syndrome is an autosomal dominant
disorder, which has: multiple osteomas (especially in the
facial bones and long bones), epidermoid cysts on the
skin, connective tissue tumors, colorectal polyps with
a great propensity of malignant transformation,
supernumerary teeth as dental changes and malignant
thyroid neoplasm [
2, 3, 16
]. According to the site where the
tumors are formed, can be considered central or
peripheral. In this case report, the patient did not show these
signs and symptoms described in the literature.
As a differential diagnosis of these lesions, maxillary or
mandibular exostoses, osteoid osteoma, osteoblastoma,
chondroma, cemento-ossifying fibroma (COF), and
odontoma may be mentioned. Palatal and mandibular
torus are exostoses which cannot be regarded as
osteomas, although they are histologically identical [
Radiographically, osteomas show a well-circumscribed
image with an oval or round radiopaque mass. Despite
a radiographic image as described above, conclusive
diagnosis can only be confirmed with a histopathologic
Treatment for osteomas consists in complete
surgical removal of the base containing the cortical bone.
Recurrence is rare, but periodic clinical follow-ups are
recommended as well as radiographic exams after
surgical excision [
]. Our patient has been in follow up for
2 years postoperatively without any complaints
concerning mouth opening, pain or asymmetries.
The first case of a condylar osteoma was described by
Ivy in 1927 [
]. Nowadays, large osteomas that cause
symptoms or esthetic deformities are excised surgically.
When the region of the mandibular condyle is affected,
these should be reconstructed using autogenous bone
grafts or prosthetic joints.
Reconstruction of TMJ is a complex surgical procedure
and it entails improved mandibular form and function,
reduction of pain and disability, containment of excessive
treatment and cost as well as and the prevention of
further morbidity [
]. The selection of patients presents a
great challenge, since they all have different needs. Total
TMJ replacement using alloplastic prosthesis may
provide satisfactory results in cases of functional alterations
of the TMJ due to the presence of tumors and diseases
such as advanced forms of arthritis, ankylosis, and
developmental anomalies with irreversible joint damage [
]. Aagaard and Thygesen [
] highlights the benefits of
using custom made TMJ prosthesis based on
orthopedic and biomechanical principles as a safe and efficient
option when the patient presents a wide range of
temporomandibular disorders. Park et al. [
] also demonstrated
suitable outcomes of four patients who used custom
made TMJ prostheses. Other on the hand, a TMJ
prosthesis is expensive and success depends on the technique
and implant used, especially if the option is the
In conclusion, successful replacement of a TMJ with
a custom-made total temporomandibular joint
prosthesis after surgical removal of a benign tumor is possible.
Unilateral total TMJ prosthesis can be considered as a
replacement of a TMJ after osteoma excision with
resection of the condyle.
TMJ: temporomandibular joint; COF: cemento-ossifying fibroma; CNC:
computer numerical control.
WH, MROJ and TMCC carried out the collection of the isolates and
acquisition of data; NTS, RCLC, DCF have made substantial contributions
to conception, design, analysis and interpretation of data; MAAC and LSG
have been involved in drafting the manuscript and revising it critically for
important intellectual content; and DCF and LSG have given final approval
of the version to be published. All authors read and approved the final
The authors declare that they have no competing interests.
Availability of data and materials
All the relevant data, on which manuscript is based, has already been
mentioned/written in the manuscript.
Consent to publish
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images.
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