CLINICIAN’S CORNER

Mandibular condylar pseudocyst:

An introduction to the orthodontist
Oded Yitschaky,a Silvina Friedlander-Barenboim,b Menahem Friedman,a Liat Tzur-Gadassi,a and Yehuda Zadikc
Jerusalem and Tel Aviv, Israel

The aims of this article are to introduce mandibular condylar pseudocysts to orthodontists, present 2 relevant
case reports, and discuss possible differential diagnoses. Condylar pseudocyst is a radiologic variant of ptery-
goid fovea, which is the site of insertion of the lateral pterygoid muscle to the head of the mandibular condyle. A
pathognomonic picture of a solitary well-defined radiolucency with radiopaque borders, located on the anterior
aspect of the condyle in an asymptomatic orthodontic patient, is characteristic. (Am J Orthod Dentofacial Orthop
2013;144:616-8)

A
panoramic radiograph is frequently used during
evaluation of orthodontic patients.1 This radio-
graph gives a broad view of the jaws with relatively
low radiation exposure. This wide view enables the clini-
cian to identify aberrant tooth numbers and impactions,
to estimate the patient's dental age, and to exclude path-
ologic lesions of the jaws. The mandibular condyles are
visualized in the panoramic radiograph and should be
screened by the orthodontist for structure and symmetry.
Radiolucent cystic findings are not uncommon in
mandibular radiography.2 True cysts, of odontogenic or
nonodontogenic origin with inflammatory or develop-
mental pathophysiology, must be differentiated from pseu-
docysts.3 Radiographically, pseudocysts are radiolucent
and well circumscribed, and mostly appear in specific loca-
tions of the mandible. With the exception of an aneurysmal
bone cyst, which requires resection,4 the management of
other pseudocysts, such as a Stafne static bone cyst or a
traumatic (simple) bone cyst, is conservative and includes
either observation only or minimal surgical intervention.3
Another location for pseudocystic appearance is the
anterior aspect of the mandibular condyle.5-9 The aims
From Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel.
a
Clinical instructor, Department of Orthodontics; private practice, Jerusalem,
Israel.
b
Head, Maxillofacial Radiology Service, Department of Oral Medicine; private
practice, Tel Aviv, Israel.
c
Chief dental officer, Israeli Air Force Surgeon General Headquarters, and Medical
Corps, Israel Defense Forces, Tel Hashomer, Israel; attending, Department of Oral
Medicine, Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Reprint requests to: Sderot Hertzel 98c, Beit Ha'kerem, Jerusalem, Israel 96347;
e-mail, oyits76@gmail.com.
Submitted, February 2012; revised and accepted, May 2013.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.05.009
616
of this article are to introduce this common
phenomenon to orthodontists, present 2 relevant case
reports, and discuss possible differential diagnoses.
CASE REPORTS
A 14-year-old boy came for an orthodontic consulta-
tion with the complaint that his anterior teeth were “not
straight.” A full orthodontic evaluation was conducted. A
panoramic radiograph showed an ovoid radiolucency
with well-circumscribed sclerotic margins in the anterior
aspect of the right mandibular condyle, with no apparent
degenerative changes (Fig 1). The lesion's location and
appearance were consistent with a condylar pseudocyst.
An orthodontic treatment was planned and offered. The
condylar finding was recorded and will be observed.
An 11-year-old girl came for an orthodontic consulta-
tion complaining about protruding maxillary incisors. A
full orthodontic evaluation was conducted. Evaluation
of the panoramic radiograph showed a radiolucent lesion
on the anterior aspect of the right condyle. In its posterior
border, the lesion was well defined with a radiopaque
margin. A radiopaque area, with central radiolucency,
was observed on the left condyle. No degenerative
changes of the condyles were observed (Fig 2). The radio-
lucency was only partially defined by the radiopaque
border. The lesion's location and appearance were consis-
tent with the diagnosis of condylar pseudocyst. An ortho-
dontic treatment was planned and offered. The condylar
findings were recorded and will be observed.
DISCUSSION
A condylar pseudocyst is a radiologic variant of a
pterygoid fovea, which is the site of insertion of the
lateral pterygoid muscle to the head of the mandibular
Yitschaky et al 617

Fig 1. Panoramic radiograph of a 14-year-old boy. A well-defined radiolucency is shown in the mandib-
ular right condyle.

Fig 2. Panoramic radiograph of an 11-year-old girl. Radiolucent and radiopaque lesions are shown in
the right and left mandibular condyles, respectively.

condyle (Fig 3). The image of the fovea is magnified and

distorted in a panoramic radiograph because of the
angle of the x-ray beam, which passes obliquely through
the condylar head. Friedlander et al5 first described this
phenomenon in 1992. Obviously, after the diagnosis of
a condylar pseudocyst, no invasive treatment is needed;
the diagnosis, however, can be a challenge for the clini-
cian.5 On the one hand, surgical exploration of the
condyle to obtain a speciman for histopathologic exam-
ination can result in unnecessary functional and esthetic
damage. On the other hand, misdiagnosis of a "true"
pathologic lesion can lead to a deleterious result.
The prevalences of condylar pseudocysts were found
to be 1.8% and 1.5% in adult and young patients,
respectively.5,8 Friedlander et al5 and Collins et al8
confirmed the diagnosis by sequential panoramic radio-
graphs after 4 to 6 months or by computed tomography Fig 3. Dry specimen of a mandible. The pterygoid fovea
imaging. The differential diagnosis suggested by these is shown on the anteromedial aspect of the condyle (black
authors includes osteochondroma, multiple myeloma, dots).

American Journal of Orthodontics and Dentofacial Orthopedics October 2013  Vol 144  Issue 4
618
central giant cell lesion, simple bone cyst, aneurysmal
bone cyst, and eosinophilic granuloma.5,8 However, a
solitary radiolucent corticated cystic lesion, restricted
to the anterior aspect of the condyle in the panoramic
radiograph, is not a match with the radiographic
appearance of osteochondroma and multiple myeloma,
which are lytic lesions with undefined ragged borders,
or multiple small defined lesions with no sclerotic
borders, respectively.10 Central giant cell lesions, eosin-
ophilic granulomas, aneurysmal bone cysts, and simple
bone cysts are extremely rare in this location, with only
4, 10, 11, and 13 cases, respectively, documented so
far in the English literature.2,4,11-15 Moreover, it seems
that a simple bone cyst is a self-limited pathology;
thus, surgical intervention might not be needed.4
In our opinion, a clinician should also consider
degenerative changes of the condyle (eg, osteoarthritis)
in the differential diagnosis. However, even when radio-
logic degenerative changes of the condyle are observed in
an asymptomatic patient (a condition defined as “osteo-
arthrosis” according the Research Diagnostic Criteria for
Temporomandibular Disorders16), no medical interven-
tion is usually needed.17,18 Friedlander et al5 and Collins
et al8 further studied all the condylar cystic lesions; in all
cases, the cystic lesions were the radiologic images of the
pterygoid fovea; no true pathology was found.
The condylar pseudocyst has never been described in
the orthodontic literature and, apparently, is not known
to orthodontists. Since true cystic lesions in the mandib-
ular condyle are extremely rare and mostly manifest as
external swelling or asymmetry accompanied by pain
or tenderness, we suggest that what appears to be a sol-
itary radiolucent corticated cystic lesion, restricted to the
anterior aspect of the condylar image seen on the pano-
ramic radiograph of an asymptomatic orthodontic
patient, is sufficient for a diagnosis of condylar pseudo-
cyst.4 This eliminates the need for further imaging with
unacceptable and unnecessary radiation exposure, espe-
cially in young patients. However, comparison with pre-
vious panoramic radiographs and clinical (and during
routine orthodontic radiographic) follow-ups are
strongly recommended.
CONCLUSIONS
The identification of a possible condylar pseudocyst
should be familiar to the orthodontist, who analyzes
panoramic radiographs daily. A pathognomonic picture
of a solitary well-defined radiolucency with radiopaque
borders, located on the anterior aspect of the condyle
October 2013  Vol 144  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Yitschaky et al
in an asymptomatic orthodontic patient, is sufficient
for diagnosis.
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