Page 8 - GP Spring 2020

Asymmetric Condylar Osteoarthritis: A Case Report and Review

By Harold I. Sussman, DDS, MSD, FACD, Paul Springs, DMD,
Michael Perrino, DDS, MD, Cleber Silva, DDS and Arthur Volker, DDS

Background: Osteoarthritis is the most es within the TMJ may increase with consistent with muscle fatigue, myospasm,
common disease associated with aging. advanced age. myofascial trigger points, or referred pain
Temporomandibular joint osteoarthritis 3. The choice of imaging modality to of any kind.
is characterized by progressive cartilage diagnose the form of TMJOA, in this
degradation, subchondral bone remodel- case, was cone beam computed tomog- The patient’s occlusion demonstrated a
ing and chronic inflammation in the syno- raphy (CBCT), as it produces multiple posterior cuspal edge-to-edge relation-
vial tissue. images of the TMJ’s bony components ship on the right side, with a severe buc-
in axial, coronal and sagittal planes. cal crossbite on the left side such that no
Case Description: A 76-year-old man with A multi-axial view eliminates a great teeth on that side were occluding anywhere
previous mild, chronic osteoarthritis of the deal of the guesswork, as it allows di- in the envelope of function. The occluding
temporomandibular condyles presented rect and unambiguous visualization of upper right cuspid and lateral incisor resto-
with osteoarthritis of the right condyle, suf- the specific diagnostic features of the rations had clear fractures on their incisal
ficient to dramatically change his occlusal disease. That said, it is worth noting edges. The patient demonstrated unilateral
relationship. Treatment was delayed due to that changes on the radiographs alone mastication only on the right posterior seg-
overriding patient health concerns, but the should never be the impetus for treat- ment.
condition turned out to be self-limiting. ing a patient. Radiographic changes
are not reliably correlated with symp- Cone Beam CT and the Diagnosis of
Practical Implications: Clinical and ra- toms or dysfunction and vice versa. It TMJOA
diographic criteria for a differential and is important to remember that while the In order to render a definitive diagnosis of
final diagnosis are discussed. This case re- radiology can aid diagnosis of the spe- the patient’s condition, he was referred to
port of asymmetric condylar osteoarthritis cific disease etiology, as clinicians, we Columbia Presbyterian Hospital for a full
will illuminate this subject in depth for the treat patients and not radiographs. workup and maxillomandibular CBCT.
dental practitioner. CBCT analysis of TMJ is limited to demon-
The following case report documents and stration of the osseous changes within the
Key Words: Temporomandibular Joint describes a case of asymmetrical bilateral condyle and/or fossa. It is an appropriate
Disorders, Osteoarthritis, Computed condylar osteoarthritis that was diagnosed image modality for confirming the pres-
Tomography, Occlusion, Diagnostics via CBCT. ence of subcortical cysts, osteophytes, scle-
rosis, loss of articular cortication, flattening
The most common joint disease associated Asymmetric Condylar Osteoarthritis - of the articular surfaces and erosion. 3-7
with aging is osteoarthritis (OA), which can Case Report
cause pain and dysfunction in any joint. The patient, a 76-year-old Caucasian Soft tissue investigations must be deferred
1
The pathogenesis of temporomandibular male, presented with the chief complaint to MRI or MDCT scanning. Further, the
8
joint osteoarthritis (TMJOA) is character- of intermittent “right jaw joint pain when relationship between clinical symptoms
ized by progressive cartilage degradation, chewing.“ His discomfort had started a and radiographic findings of TMJOA is at
subchondral bone remodeling and chronic few months prior, but the pain had been in- best equivocal -- there is no particular sign
inflammation in the synovial tissues. The creasing of late, especially while chewing clinically evident in all cases of TMJOA
best known diagnostic radiographic find- hard foods. His secondary complaint was among both symptomatic and asymptom-
ing of TMJOA is flattening of the condylar that his bite was “shifting,” with the reali- atic patients. This explains the reason why
head, though this case study will further ex- zation that the teeth on the left side of his most TMJ osseous findings are inciden-
3,4
plore this and other little-known accompa- jaw were no longer occluding at all. tal. The influence of TMD in open bite
nying signs such as condylar irregularities, and malocclusion on TMD is extensively
osteophytes, Ely’s cysts, and narrowing of The patient’s medical history included discussed in the literature. 9-12
the joint space. The goal of this article is Type II diabetes, controlled by diet and
2
to illuminate a subject that is rarely under- Metformin. He had suffered a myocardial Results of Diagnostic Testing (Figures
stood in any depth by dental practitioners. infarction two months prior, managed with 1-4):
the placement of middle anterior descend- Following imaging and lab testing, a de-
It is important to recognize that: ing arterial cardiac stents. His current med- finitive diagnosis was determined. The di-
1. TMJOA can be either unilateral or bi- ications included Metformin, Plavix, low- agnostic data below were considered to be
lateral, and the signs accompanying dose aspirin and Lipitor. pathognomonic for bilateral TMJOA. Each
each of these two forms are notably dif- finding is listed along with a description of
ferent. A chief diagnostic determinant Clinical examination revealed a slight pro- its appearance as well as how it relates to
between the two is that the masticatory trusion of the lateral pole of the right con- the pathogenesis of TMJOA.
muscles of unilateral TMJOA patients dyle directly anterior to the tragus. Direct
are perceptibly fatigued during sus- joint palpation elicited complaints of ten- 1. Lab tests are inconclusive - In a case
tained clenching. derness. By comparison, the left TMJ area of OA, no specific lab tests are diagnos-
2. OA is classified as an age-related and was flat and asymptomatic, with the left tic for the condition. Hence, radiologic
degenerative disease. Hence, the pro- lateral condylar pole intruded 2mm under findings are needed to rule out other dis-
gression and severity of osseous chang- the temporal bone. A comprehensive cer- ease entities.
vicofacial muscle exam produced no pain

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