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& Volume 24, Number 1, January 2013

disadvantages of this technique. Liu et al11 prefabricated postauricular, mastoid, and neck regions with superficial fascia flap in
combination with tissue expanders and reconstructed the cheek
defect in the second session. They claimed that they obtained a flap
with better quality of vascularity and safety. In another study, for this
purpose, temporalis myofacial and facial-cervicopectoral flaps were
performed in combination where applicability of neck dissection
was reported to be the advantage of the technique.12
Ahmad et al10 used bipaddle pectoralis major myocutaneous flap
for the reconstruction of both the mucosa and skin in large and fullthickness cheek defects. However, the technique, which was reported
to offer an alternative method for microsurgery in large and fullthickness skin defects, has some disadvantages including nipple
and areola complex involvement, color and texture mismatch with
facial skin, bulkiness, and limitation of applicability in women and
obese patients.
The usability in large and full-thickness defects that could not be
closed by other methods, requiring single-stage procedure, raising
more than 1 skin island on the same pedicle connected to each other,
less contour irregularity than the other free flaps, and applicability
with ease are the advantages of this flap.
The 2 flaps elevated from the frontal and parietal branches of
STA, which has a good perfusion and drainage, can be used as a safe
method for the reconstruction of large and full-thickness cheek
defects. This study, where we obtained a satisfactory result in terms
of functional and aesthetic criteria, can be thought as an alternative
against other methods.

REFERENCES
1. Kroll SS. Reconstruction for large cheek defects. Oper Tech Plast
Reconstr Surg 1998;5:37Y49
2. Gonzalez Ulloa M. Preliminary study of the total restoration of the
facial skin. Plast Reconstr Surg 1954;13:151
3. Kang S-H, Nam W, Cha I-H, et al. Double continuous radial forearm
flap for the reconstruction of full-thickness buccal cheek defect. J Plast
Reconstr Aesthet Surg 2009;62:e95Ye96
4. Disa JJ, Liew S, Cordeiro PG. Soft-tissue reconstruction of the face
using the folded/multiple skin island radial forearm free flap. Ann Plast
Surg 2001;47:612Y619
5. Huang W-C, Chen H-C, Jain V, et al. Reconstruction of
through-and-through cheek defects involving the oral commissure,
using chimeric flaps from the thigh lateral femoral circumflex system.
Plast Reconstr Surg 2002;109:433Y441
6. yafak T, Akyurek M. Primary one-stage reconstruction of cheek
defect after a shotgun blast to the face: use of the latissimus dorsi
musculocutaneous free flap for soft-tissue repair and facial reanimation.
Ann Plast Surg 2001;47:438Y441
7. Loeffelbein D J, Holzle F, Wolff K-D. Double-skin paddle perforator
flap from the lateral lower leg for reconstruction of through-and-through
cheek defectVa report of two cases. Int J Oral Maxillofac Surg
2006;35:1016Y1020
8. NasNr S AydNn MA. Versatility of free SCIA/SIEA flaps in head and neck
defects. Ann Plast Surg 2010;65:32Y37
9. Barthelemy I, Martin D, Sannajust J-P, et al. Prefabricated superficial
temporal fascia flap combined with a submental flap in NomaSurgery.
Plast Reconstr Surg 2002;109:936Y940
10. Ahmad QG, Navadgi S, Agarwal R, et al. Bipaddle pectoralis major
myocutaneous flap in reconstructing full thickness defects of
cheek: a review of 47 cases. J Plast Reconstr Aesthet Surg
2006;59:166Y173
11. Liu Y, Jiao P, Tan X, et al. Reconstruction of facial defects using
prefabricated expanded flaps carried by temporoparietal fascia flaps.
Plast Reconstr Surg 2009;123:556Y561
12. Chen W, Zeng S, Li J, et al. Reconstruction of full-thickness cheek
defects with combined temporalis myofacial and facial-cervico-pectoral

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Brief Clinical Studies

flaps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2007;103:e10Ye15
Imanishi N, Nakajima H, Minabe T, et al. Venous drainage
architecture of the temporal and parietal regions: anatomy of the
superficial temporal artery and vein. Plast Reconstr Surg
2002;109:2197Y2203
Upton J. Surgical anatomy and blood supply of the fascial layers of
the temporal region [discussion].Plast Reconstr Surg 1986;77:25
Lei T, Xu DC, Gao JH, et al Using the frontal branch of the superficial
temporal artery as a landmark for locating the course of the temporal
branch of the facial nerve during rhytidectomy: an anatomical
study. Plast Reconstr Surg 2005;116:623Y629
Chen TH, Chen CH, Shyu JF, et al. Distribution of the superficial
temporal artery in the Chinese adult. Plast Reconstr Surg
1999;104:1276
Abul-Hassan HS, von Drasek Ascher G, Acland RD. Surgical
anatomy and blood supply of the fascial layers of the temporal region.
Plast Reconstr Surg 1986;77:17
Tan O, Atik B, Ergen D. Temporal flap variations for craniofacial
reconstruction. Plast Reconstr Surg 2007;119:e152Ye162

Aggressive Condylar Resorption

Kaustubh Sansare, BDS, MDS,* Mamta Raghav, BDS,*
Sanjay Mallya, MDS, PhD, Nilesh Mundada, BDS,*
Freny Karjodkar, BDS, MDS,* Pallavi Randive, BDS, MDS,*
Deepashri Meshram, BDS, MDS,* Pankaj Shirsat, BDS, MDS*
Abstract: This article describes the clinical and radiographic findings
in a patient with unilateral aggressive condylar resorption that was
diagnosed as osteoarthritis. We present a comprehensive documentation of the clinical manifestations, the appearance on conventional
and advanced imaging, and the histopathologic findings. We discuss
the systematic approach to develop a differential diagnosis, with
specific emphasis on osteoarthritis and idiopathic condylar resorption. Finally, we also discuss the factors that play a role in management of this condition.
Key Words: Condyle, resorption, temporomandibular joint

ondylar resorption and bone erosion are frequently observed in

osteoarthritis (OA).1 A subset of patients with OA presents with
severe and rapidly progressing condylar resorption. A similar manifestation is also observed in a group of conditions labeled idiopathic
condylar resorption (ICR), where the etiology remains unknown.2 A
case with rapid, progressive unilateral condylar resorption, with clinical
and imaging features that mimic those of ICR, is presented.
The aim of this article was therefore to alert the dental practitioner
on the possibility of such a presentation in routine dental practice.

From the *Nair Hospital Dental College, Mumbai, and the School of
Dentistry, University of California, Los Angeles.
Received August 7, 2012.
Accepted for publication October 11, 2012.
Address correspondence and reprint requests to: Kaustubh Sansare, MDS,
Nair Hospital Dental College, Dr. A.L. Nair Road, Mumbai, India;
E-mail: kaustubhsansare@yahoo.com.
The authors report no conflicts of interest.
Copyright * 2013 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3182798eff

* 2013 Mutaz B. Habal, MD

Copyright 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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& Volume 24, Number 1, January 2013

CLINICAL REPORT
A 30-year-old male patient was referred to the oral medicine and
radiology unit for evaluation of pain and stiffness in relation to the
right temporomandibular joint (TMJ). The patient also complained of
tenderness and swelling in the right TMJ region. Pain and swelling
was present since 6 years, for which patient was prescribed medication by a private practitioner. The patient was not aware of the nature
of prescription. The swelling subsided after medication but pain
persisted. The patients medical and trauma history was noncontributory. The mouth opening was restricted, with a maximum interincisal
opening of 25 mm. The maxillary and mandibular dental midlines
coincided, but the mandible deviated to the right on opening. There
was no complain of change in bite; however, clinical intercuspation on
the left side was abnormal. There was a small palpable depression over
the right TMJ and no joint sounds on auscultation of both TMJs. The
patient also denied any pulsation or paraesthesia over the TMJs.
Panoramic radiograph showed severe resorption of right condylar
head and its articular surface (Fig. 1). Limited field-of-view conebeam computed tomography showed severe irregular resorption
involving the entire condylar head and regions of the articular surface of glenoid fossa and articular eminence. The margins of the
condylar head were noncorticated and irregular with absence of any
subarticular sclerosis. Small amorphous opacities, with the radiodensity of bone, were noted adjacent to the anteromedial aspect of
the right condylar head (Fig. 2). T1-weighted magnetic resonance
imaging (MRI) showed a low-signal intensity and loss of the normal
marrow signal in the right condylar head. T2-weighted MRI showed
a hyperintense signal in the right joint space, suggestive of effusion
(Fig. 3). Gradient echo sequence did not reveal any blooming effect.
Cultures of the joint fluid were negative for bacterial and fungal
growth. Laboratory investigations for rheumatoid arthritis and tuberculosis were negative
Considering the clinical and imaging features, coupled with the
laboratory investigations, a tentative diagnosis of condylar resorption secondary to OA or ICR was established.
The final diagnosis after histopathologic examination was degenerative disease of TMJ.

FIGURE 2. Cone-beam computed tomography scans. Sagittal view showing

resorption of right-side condylar head and glenoid fossa. Note streaks of
amorphous calcification anteromedial to the condylar head (arrow).

FIGURE 3. T2-weighted MRI scan shows hyper intense effusion in the region
right condylar head.

is not known. However, its clinical manifestations often mimic those

of OA. In this case of aggressive condylar resorption in a young male
patient, the clinical and radiographic findings would be compatible
with descriptions of ICR. However, the age and sex are not characteristic of ICR. Interestingly, the MRI and histopathologic findings all
point to an inflammatory pathology for this condition, similar to OA.
This raises the possibility that at least a subset of cases diagnosed
as ICR in the past may actually be variants of OA with aggressive
condylar resorption. Perhaps ICR represents a variant of OA, with a
more aggressive inflammatory component. Given the unknown
etiology of ICR, future studies that investigate this possibility
would shed more light on the true nature of this condition.
In summary, this case comprehensively documents the clinical
and radiographic findings of a patient with OA with aggressive
condylar resorption.

DISCUSSION
REFERENCES
Aggressive condylar resorption is a poorly documented and inadequately understood aspect of TMJ OA. Literature reveals that
aggressive condylar resorption has been reported in only a few of the
TMJ disorders.3 Previous studies by Koyama et al4 and Ahmad et al5
have described features of condylar resorption, but do not specifically
identify aggressive condylar resorption. Given its characteristic presentation and its implications for management, it would be helpful if
this manifestation were to be specifically identified as a subset of OA.
Typically, when aggressive condylar resorption of this extent is
seen in young patients without any underlying cause, the term idiopathic condylar resorption (ICR) has been used.6 The etiology of ICR

FIGURE 1. Panoramic radiograph demonstrating severe resorption of right

condylar head.

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1. Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the

temporomandibular joint: etiology, diagnosis, and treatment.
J Dent Res 2008;87:296Y307
2. Arnett GW, Milam SB, Gottesman L. Progressive mandibular
retrusionVidiopathic condylar resorption. Part I. Am J Orthod
Dentofacial Orthop 1996:110:8Y15
3. Paniagua B, Cevidanes L, Walker D, et al. Clinical application of
SPHARM-PDM to quantify temporomandibular joint
osteoarthritis.Comput Med Imaging Graph
2011;35:345Y352
4. Koyama J, Nishiyama H, Hayashi T. Follow-up study of condylar
bony changes using helical computed tomography in patients with
temporomandibular disorder. Dentomaxillofac Radiol
2007;36:472Y477
5. Ahmad M, Hollender L, Anderson Q, et al. Research diagnostic
criteria for temporomandibular disorders (RDC/TMD): development
of image analysis criteria and examiner reliability for image analysis.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2009;107:844Y860
6. Chung CJ, Choi YJ, Kim IS, et al. Total alloplastic temporomandibular
joint reconstruction combined with orthodontic treatment in a
patient with idiopathic condylar resorption. Am J Orthod Dentofacial
Orthop 2011;140:40

* 2013 Mutaz B. Habal, MD

Copyright 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.