Idiopathic Unilateral Intracranial Condylar Dislocation: A Case Report.

Intracranial condylar dislocation to the middle fossa is rare, as it is not reported often. Known cases have an etiology, identified as erosion of the glenoid cavity from joint prostheses and/or traumatic events. As such, this case aims to offer a predisposing reason for the idiopathic condylar dislocation to the middle cranial fossa with nonfunctional limitations.

Meckel Cave: An Anatomical Study Using Magnetic Resonance Imaging.

OBJECTIVE: To our knowledge, few studies have investigated anatomy of the Meckel cave with neuroimaging modalities. The present study aimed to characterize it using magnetic resonance imaging (MRI). PATIENTS AND METHODS: Following conventional MRI examination, a total of 101 patients underwent T2-weighted imaging in thin-sliced coronal and sagittal sections, and 11 patients underwent constructive interference steady-state sequences in thin-sliced sagittal sections. Moreover, 3 injected cadaver heads were dissected. RESULTS: In the cadaver specimens, the size and extent of the cerebrospinal fluid-filled space between the Gasserian ganglion and surrounding arachnoids were difficult to define. On the T2-weighted imaging, the Meckel cave was delineated with variable morphologies and left-right asymmetry. On the sagittal images, the shape of the Meckel cave could be classified into 3 different types, bulbous, oval, and flat, with the oval being the most frequent that comprised 60%. Furthermore, on the sagittal constructive interference steady-state images, parts of the trigeminal nerve distributed in the Meckel cave were delineated in all patients. The ophthalmic, maxillary, and mandibular divisions were clearly distinguished on both sides. CONCLUSIONS: The Meckel cave is a structure characterized by diverse morphologies and left-right asymmetry. Thin-sliced T2-weighted imaging is useful for exploring the anatomy of the Meckel cave.

Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base.

PURPOSE: Treatment of tumors arising in the upper parapharyngeal space (PPS) or the floor of the middle cranial fossa is challenging. This study aims to present anatomical landmarks for a combined endoscopic transnasal and anterior transmaxillary approach to the upper PPS and the floor of the middle cranial fossa and to further evaluate their clinical application. METHODS: Dissection of the upper PPS using a combined endoscopic endonasal transpterygoid and anterior transmaxillary approach was performed in six cadaveric heads. Surgical landmarks associated with the approach were defined. The defined approach was applied in patients with tumors involving the upper PPS. RESULTS: The medial pterygoid muscle, tensor veli palatini muscle and levator veli palatini muscle were key landmarks of the approach into the upper PPS. The lateral pterygoid plate, foramen ovale and mandibular nerve were important anatomical landmarks for exposing the parapharyngeal segment of the internal carotid artery through a combined endoscopic transnasal and anterior transmaxillary approach. The combined approach provided a better view of the upper PPS and middle skull base, allowing for effective bimanual techniques and bleeding control. Application of the anterior transmaxillary approach also provided a better view of the inferior limits of the upper PPS and facilitated control of the internal carotid artery. CONCLUSIONS: Improving the knowledge of the endoscopic anatomy of the upper PPS allowed us to achieve an optimal approach to tumors arising in the upper PPS. The combined endoscopic transnasal and anterior transmaxillary approach is a minimally invasive alternative approach to the upper PPS.

Use of Vascularized Myo-Osseous Fibula Free Flap to Reconstruct a Hemimandibular Defect With a Concomitant Skull Defect Arising From Stock Condylar Prosthesis Displacement Into the Middle Cranial Fossa.

Functional reconstruction of the temporomandibular joint (TMJ) is a controversial topic among oral and maxillofacial surgeons; this controversy becomes more complicated when one dives into the dilemma of the ideal reconstructive modality. TMJ defects might result from various etiologies, such as blunt or penetrating traumatic injuries, advanced degenerative joint disease, or various pathologic conditions, including benign and malignant conditions, that might arise from the TMJ or adjacent tissues. Reconstruction of the TMJ is vital because of its essential function in mastication, articulation, speech, and facial esthetics and symmetry. In the pediatric population, the TMJ acts as a growth center. TMJ reconstructive surgery might be influenced by various factors that can steer the surgeon toward adopting a specific reconstructive modality. These factors can be classified into preoperative factors that include the overall general health of the patient, expectations, and socioeconomic status that might be an obstacle in using custom-made solutions. The surgeon's experience, level of comfort, and training are crucial influencing factors. TMJ reconstructive options consist of autogenous grafts or alloplastic options. Autogenous grafts encompass 2 broad subcategories. The first is the vascularized option, and a good example is the vascularized fibula free flap. The second subcategory includes nonvascularized grafts, such as costochondral grafts and sternoclavicular grafts. Alloplastic grafts include various TMJ stock joints or custom-made patient-specific prostheses and stock condylar prostheses. The goals of TMJ reconstruction are to establish a pain-free normal range of mouth opening, stable occlusion, and absence of facial deformity. Complication rates in TMJ surgery are low and include surgical infection, nerve injury, failure or fracture of the prosthesis, or injury to adjacent structures. This report presents a case of a stock condylar prosthesis displaced into the middle cranial fossa, which was managed with a 2-stage approach of removing the displaced prosthesis and then reconstruction with a fibula vascularized free flap and a simultaneous contralateral sagittal split osteotomy.

Updated Review of Traumatic Dislocation of the Mandibular Condyle Into the Middle Cranial Fossa.

PURPOSE: Traumatic dislocation of the mandibular condyle into the middle cranial fossa (DMCCF) is a rare event after maxillofacial trauma. Treatment may be performed with closed or open reduction (with or without craniotomy), and arthroplasty procedures might be necessary for long-standing cases. The aims of this study were to perform an integrative review of traumatic DMCCF cases reported in an electronic database and to report a case in which cerebrospinal fluid leakage occurred after open treatment. PATIENTS AND METHODS: The study was carried out in 2 phases. In the first part, an electronic search was undertaken in MEDLINE (via PubMed) in April 2018, with 52 articles being included. In the second, we report a case in which cerebrospinal fluid leakage occurred through the external auditory canal after open reduction of the mandibular condyle into the middle cranial fossa in a 22-year-old male patient, with a follow-up of 5 months. RESULTS: A total of 59 cases were included. Most patients were female patients (69%), the right condyle was mostly affected, and traffic accidents (53%) were the main etiology. Closed treatment was ideally performed within 2 weeks of intrusion. Open treatment was required for cases with 2 or more weeks of impaction. The types of open treatment were open reduction, condylectomy, condylotomy, and temporomandibular joint reconstruction with alloplastic implants. The glenoid fossa was reconstructed in 28 cases, and a temporalis muscle flap with or without bone grafts was the main choice. Despite the treatment option used, mandibular deviation during opening occurred in 41% of cases. Rare complications included persistent facial paralysis, persistent hearing loss on the affected side, increased cerebral contusion after reduction, and postoperative pneumocephalus. CONCLUSIONS: Cases of DMCCF require a multidisciplinary approach based on the expertise of both maxillofacial and neurologic surgeons. Close monitoring is extremely important to mitigate complications.

Traumatic dislocation of the mandibular condyle into the middle cranial fossa treated by an intraoral approach.

Dislocation of the mandibular condyle is one of several consequences of facial trauma that can be anticipated. The condylar neck is inherently weak and likely to fracture at the time of impact before dislocating into the middle cranial fossa. A review of the literature revealed that most cases of dislocation of the mandibular condyle into the middle cranial fossa are treated by open reduction and internal fixation via an extraoral approach or are treated conservatively with closed reduction. An intraoral approach is rare. Here we present a patient with traumatic dislocation of the mandibular condyle into the middle cranial fossa who was treated successfully by condylectomy and coronoidectomy through an intraoral approach and intermaxillary fixation followed by mouth-opening exercises and rehabilitation. Stable occlusion and movement of the mandible was achieved and the long-term results have been good. The intraoral approach may be an option in patients with traumatic dislocation of the mandibular condyle into the middle cranial fossa.

Endoscopically Assisted Middle Cranial Fossa Reconstruction Following Traumatic Intracranial Intrusion of the Mandibular Condyle.

Traumatic intracranial intrusions of the mandibular condyle are a rare injury pattern that carries significant morbid outcomes due to potential for neurological, otological, temporomandibular joint damage, or joint ankylosis. Treatment modalities involve either closed reduction, open approaches via transcranial or subtemporal approaches, or delayed total joint replacement. This paper presents a clinical report of a traumatic intracranial intrusion of the mandibular condyle treated with an endoscopically assisted preauricular approach to reconstruct the middle cranial fossa and temporomandibular articular disc. Endoscopically assisted techniques allow for minimally invasive and less morbid surgical interventions to this pathology, with greater precision than closed reduction techniques.

Atypical Intracranial Compound Simil Odontoma.

Odontoma is the most common mixed epithelial and mesenchymal tumour-like malformation which affects maxillary bones. Clinically, Odontomas present as lesions of benign behavior, causing little or no deformity, are asymptomatic, with self-limited growth and usually detected on routine radiographs. Radiographically, they are radiopaque lesions, well-demarcated surrounded by a thin soft tissue capsule. Compound odontomas consist of numerous tooth-like structures, whereas in complex odontomas it consists of a disorganized mass of calcified tissue. The aim of this article was to report an atypical case of intracranial compound odontoma, in the middle cranial fossa, reaching the sphenoidal sinus, which has been followed for 10 years.

Anatomical Examination of Mandibular Condyle Protrusion Into the Middle Cranial Fossa.

Trauma to the mandible can occasionally be a life-threatening event. Although extremely rare with only 56 reported patients in the English language, fracture of the floor of the middle cranial fossa with protrusion of the mandibular condyle into the middle cranial fossa was first reported in 1963 by Dingman. The authors review the anatomy of the temporomandibular joint in relation to the middle cranial fossa and demonstrate the possible complications due to condylar intrusion with anatomical dissection.

Superolateral dislocation of an intact mandibular condyle into the temporal fossa: case report and literature review.

Temporomandibular joint dislocation refers to the dislodgement of mandibular condyle from the glenoid fossa. Anterior and anteromedial dislocations of the mandibular condyle are frequently reported in the literature, but superolateral dislocation is a rare presentation. This report outlines a case of superolateral dislocation of an intact mandibular condyle that occurred in conjunction with an ipsilateral mandibular parasymphysis fracture. A review of the clinical features of superolateral dislocation of the mandibular condyle and the possible techniques of its reduction ranging from the most conservative means to extensive surgical interventions is presented.

Treatment Algorithm for Intracranial Intrusion Injuries of the Mandibular Condyle.

PURPOSE: Traumatic injuries of the mandible resulting in intrusion of the condyle into the middle cranial fossa are rare and treatment is often based on anecdotal experience. The objective of this study was to develop an algorithm for the management of condylar intrusion injuries by identifying factors that influenced the treatment decision of closed versus open reduction of the condyle. MATERIALS AND METHODS: This study was a systematic review of the literature on intracranial intrusion injuries of the mandibular condyle. A thorough search of the PubMed and Cochrane databases and individual maxillofacial and craniofacial journal databases was conducted using the Medical Subject Heading terms condylar impaction, condylar dislocation, condylar intrusion, and middle cranial fossa and condyle without date and language restriction. Quantitative data on the patient's age, gender, etiology of injury, and time from injury to diagnosis were analyzed using descriptive statistics. The authors studied how the predictor variables of age, etiology, time from injury to diagnosis, and associated neurologic injuries influenced the outcome variable of closed versus open reduction of the condyle. RESULTS: Forty-eight of the 62 retrieved case reports, case series, and review articles were published in the English-language literature from 1963 to 2015. Data on 51 patients with these injuries showed that 38 (75%) were female and younger than 30 years. The most common etiology of injury was motor vehicular accidents, occurring in 25 of 51 patients (49%). The mean time from injury to diagnosis was 31.2 days (0 to 106.4 days). Forty of the 51 patients (78%) were diagnosed within the first 2 weeks of injury. A good proportion of patients underwent open reduction (63%) and 18 of the 51 of patients (35%) underwent closed reduction. CONCLUSIONS: Predictor variables that influenced the treatment decision of open versus closed reduction were age of the patient, etiology of injury, and time from injury to diagnosis. Based on the present results, younger patients (0 to 15 yr old), patients who sustain condylar intrusion injuries from bicycle accidents, and those diagnosed within the first 2 weeks of injury are more likely to benefit from closed reduction. The treatment algorithm emphasizes the importance of assessment of associated neurologic injuries and an interdisciplinary approach for the management of these injuries.

Total Alloplastic Joint Reconstruction in a Patient With Temporomandibular Joint Ankylosis Following Condylar Dislocation Into the Middle Cranial Fossa.

PURPOSE: Traumatic dislocation of the mandibular condyle into the middle cranial fossa is an extremely rare complication of maxillofacial injury. Management case of the of dislocation of the mandibular condyle complicated by bilateral temporomandibular joint ankylosis is presented. MATERIALS AND METHODS: A 17year old male patient presented to the outpatient clinic complaining of inability to open his mouth following a motor vehicle accident 6 months prior. Examination revealed bilateral TMJ ankylosis following left condylar head fracture and dislocation of the right condylar head into the middle cranial fossa. Bilateral total alloplastic TMJ reconstruction was performed. RESULTS: MIO at a three-year follow-up was 35mm, occlusion was intact and the patient was functioning optimally.

[Diagnosis and treatment of diffuse tenosynovial giant cell tumor arising from temporomandibular joints].

OBJECTIVE: To retrospectively analyze the clinical features, treatment and prognosis to the diffuse tenosynovial giant cell tumor (D-TSGCT) arising from the temporomandibular joint (TMJ), and to give a reference for the early diagnosis and treatment of this disease. METHODS: In this study, 15 patients finally diagnosed as D-TSGCT of TMJ histopathologically at the Peking University Hospital of Stomatology from October 2003 to August 2015 were selected and reviewed. Their clinical manifestations, imaging and histological features, diagnoses and differential diagnoses, treatments and follow-ups were summarized and discussed. RESULTS: D-TSGCT of TMJ showed obvious female predominance (12/15), the main symptoms included painful preauricular swelling or mass, limited mouth-opening and mandibular deviation with movement. D-TSGCT on computed tomography (CT) scan often showed ill-defined soft tissue masses around TMJ, enhancement after contrast administration, usually with widening of the joint spaces and with bone destruction of the condyle, the fossa and even the skull base. On magnetic resonance images (MRI), the majority of lesions on T1 weighted images and T2 weighted images both showed the characteristics of low signals (6/11). The lesions could extend beyond the joints (9/11) and into the infratemporal fossa (4/11) and the middle cranial fossa (4/11). Surgical resection was performed in 14 cases and biopsy in 1 case. Postoperative radiotherapy was performed in 3 cases. In follow-ups, 3 cases showed recurrence postoperatively. CONCLUSION: D-TSGCT arising from TMJ should be differentiated with TMJ disorders, other tumors and tumor-like lesions of TMJ and parotid neoplasms, etc. CT and MRI examinations have important values in the diagnosis and treatment design of D-TSGCT. Because of the local aggressive and extensive behavior, complete resection should be performed as soon as possible. Postoperative radiotherapy was helpful for the extensive lesions including destruction of skull base and may be a good supplementary therapy. Because of the possibility of recurrence and malignancy, long-term follow-up was suggested.

Dislocation of Mandibular Condyle Into Middle Cranial Fossa: Two Alternative Methods for Two Patients.

Dislocation of the mandibular condyle into the middle cranial fossa is rare, and the number of cases discussed in published studies is limited. Various treatment routes have been suggested, and the entire published data are based on the presentations of single cases. The present report presents 2 cases of dislocation of the mandibular condyle into the middle cranial fossa. The first case was treated with closed reduction in the early stage; however, the second case, which was treated in the late stage, required open reduction. Both the methods of reduction and the key aspects of diagnosis are discussed.

A modified retromaxillary approach to the infratemporal fossa: three case studies.

The infratemporal fossa (ITF) is an anatomically complex region with multiple neural and vascular structures entering and exiting through foramina in the skull base. The main obstacles to approaching the ITF are the zygomatic arch, the parotid gland, the facial nerve, and the ascending ramus AND condylar head of the mandible. Different surgical approaches to the ITF exist and the best approach should provide optimal visibility, minimal impairment of temporomandibular joint function, and preservation of motor and sensory nerve integrity. This report describes a modified Obwegeser retromaxillary approach to access lesions within the ITF. A multidisciplinary team was involved, which included an oral and maxillofacial surgery team, a neurosurgery team, and an otolaryngology team. Three patients with large skull base lesions, including an aneurysmal bone cyst, a giant cell tumor of the bone, and an invasive melanoma, underwent resection using this approach and were followed postoperatively. Excellent exposure of the floor of the middle cranial fossa and ITF was achieved with this approach. Functional status remained unchanged with respect to mastication, speech, swallowing, and cosmesis. Given the severity of the patients' conditions and extent of involvement of the skull base, outcomes were favorable, with minimal morbidity. This experience suggests that this approach provides safe access to an anatomically complex region and lessens challenges associated with more conventional approaches.

Juxta-articular Myxoma of the Temporomandibular Joint.

The juxta-articular myxoma represents a benign mesenchymal neoplasm that arises from tissue within or adjacent to a joint space. There have been a number of reported cases involving myxomas of the knee, shoulder, elbow, wrist, and hip. To our knowledge there, however, have been no reported cases of juxta-articular myxomas of the temporomandibular joint (TMJ). This report describes the case of a 57-year-old woman with a juxta-articular myxoma of the left TMJ extending into the infratemporal fossa (ITF). Access to the tumor was accomplished via a preauricular incision and low condylar osteotomy which allowed for displacement of the condyle for direct visualization and excision of the tumor. The postoperative course was benign and the patient demonstrated no cosmetic or functional limitation. Likewise, follow-up at 30 months showed no evidence of recurrence. Benign encapsulated tumors of the ITF can be effectively accessed by means of a modified preauricular incision, low condylar osteotomy, and anterior meniscal release. This direct approach allows for excellent surgical exposure, minimal surgical site morbidity, and maintenance of physiologic joint function and occlusion.

The Application of Surgical Navigation in the Treatment of Temporomandibular Joint Ankylosis.

OBJECTIVE: The purpose of this study was to assess the safety and the accuracy of surgical navigation technology in the resection of severe ankylosis of the mandibular condyle with the middle cranial fossa. METHODS: The computed tomography scan data were transferred to a Windows-based computer workstation, and the patient's individual anatomy was assessed in multiplanar views at the workstation. In the operation, the patient and the virtual image were matched by individual registration with the reference points which were set on the skull bone surface and the teeth. Then, the real-time navigation can be performed. RESULTS: The acquisition of the data sets was uncomplicated, and image quality was sufficient to assess the operative result in 2 cases. Both of the operations were performed successfully with the guidance of real-time navigation. The application of surgical navigation has enhanced the safety and the accuracy of the surgery for bony ankylosis of temporomandibular joint. CONCLUSIONS: The use of surgical navigation resulted in the promotion of accurate and safe surgical excision of the ankylosed skull base tissue.

Application of a computer-aided navigation technique in surgery for recurrent malignant infratemporal fossa tumors.

BACKGROUND: Because of the complexity of the local anatomy, tumors in the infratemporal fossa present a great challenge to oral and maxillofacial surgeons. Recurrent malignant tumors in this area are particularly difficult and precarious to resect because scars from previous operations may dislocate some important structures. METHODS: From August 2010 to December 2013, all recurrent cases of malignant infratemporal fossa tumors at Peking University Stomatological Hospital were enrolled in this study. The patients were divided into 2 groups: the navigation group and the nonnavigation group, with different managements. The following factors were evaluated: operation time, bleeding volume, tumor size, surgical approach and complications, follow-up survey, and outcomes.In addition, survival analyses were performed for all patients. RESULTS: In total, 42 patients were investigated. The mean operation time for the navigation group was not significantly longer than that of the nonnavigation group (283.64 versus 252.10 min, respectively; P = 0.393); the group's mean intraoperative bleeding volumes were similar (536.36 versus 503.87 mL, respectively; P = 0.814). The surgical approach was determined and categorized as an inferior approach (transmandibular approach, with or without splitting of the mandible), anterior approach (transmaxillary approach), lateral approach (subtemporal-preauricular approach), or combined approach. The inferior approach was most frequently used in both groups (ie, 63.6% for the navigation group and 80.6% for the nonnavigation group). The tumors were completely resected in 4 patients from the navigation group and 24 patients from the nonnavigation group. Regarding complications in the navigation and nonnavigation groups, the incidence was not significantly different (27.2% versus 41.9%, respectively; P = 0.485). The 3-year survival for patients in the navigation group was 71.6% compared with 52.9% in the nonnavigation group, with no significant difference. In the survival analysis, no significant factor was determined. CONCLUSIONS: A computer-aided navigation technique has been successfully introduced to resect infratemporal fossa tumors and was successfully applied to the resection of recurrent malignant tumors. This new technique alone does not determine the outcome of patients with recurrent malignant infratemporal fossa tumors. Although some improvements are necessary, the visible navigation during surgery could increase the accuracy and safety of the operations and enhance surgeon confidence.

The nasomaxillary complex and the cranial base in artificial cranial deformation: relationships from a geometric morphometric study.

INTRODUCTION: It is widely accepted that there is a relationship between the cranial base and the development of the nasomaxillary complex (NMC). The objective of the present study was to investigate the morphological relationship between these two anatomical units in skulls that have intentionally been subjected to one of two types of artificial deformity of the cranial vault [artificially deformed skulls (ADS)]. MATERIAL AND METHODS: A geometric morphometry study was performed on lateral cephalometric X-rays of three groups of crania: 32 with anteroposterior (AP) deformity, 17 with circumferential (C) deformity, and 39 with no apparent deformity. RESULTS: The cranial base of the ADS showed marked deformity that produced a restriction of AP growth of the NMC, alterations of the roof of the orbit as a consequence of the rotation of anterior cranial fossa, and nasal protrusion. Pronounced morphological differences were found between the three groups: increased vertical development of the maxilla occurred in both ADS groups due to growth of the alveolar process, and rotation of the maxilla and displacement of the orbital rim was observed in the C group. This confirms that the posterior facial plane is regarded as an axial structure that serves as an interface between the middle cranial base and the NMC (Enlow, D.H. and Hans, M.G. (1996) Essential of Facial Growth. WB Saunders Co., Philadelphia, PA). LIMITATIONS: It is important to take into account that these results have been obtained from an archaeological sample, with all the limitations that this implies such as being a small sample and with no absolute certainty regarding the use of the same type of deforming device within each group. Furthermore, this is a lateral two-dimensional study in which transverse development has not been analysed. CONCLUSIONS: Artificial modification of the shape of the vault has repercussions on the NMC that support the theory of an all-inclusive integration of the different cranial units in normal as well as in restricted development.

[Chondroblastoma of the Temporal Bone Removed Using a Middle Cranial Fossa Approach].

We report a case of chondroblastoma of the middle cranial fossa, probably arising from the (infra) mandibular fossa, and expanding to the attic and external auditory canal that was successfully removed using a middle cranial fossa approach. No recurrences occurred during an 8-year postoperative follow-up period. Initial biopsy findings suggested a pathological diagnosis of giant cell tumor that was later confirmed to be a chondroblastoma based on an immunohistochemical study of S-100. This case study suggests a profound understanding of the clinical features, histopathological characteristics, and possible treatment. of chondroblastoma.