Gap coronoidotomy for management of coronoid process hyperplasia of the mandible

doi:10.1016/j.tripleo.2011.03.040

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Volume 112, Issue 6, December 2011, Pages e1-e4

https://doi.org/10.1016/j.tripleo.2011.03.040 Get rights and content

Patients with coronoid process hyperplasia of the mandibular area are rare. The treatment of this disease is to increase the patient's mouth opening by surgery. There are various, but controversial, methods to treat it. We present a modified (gap) coronoidotomy procedure in detail and compare it with other conventional methods to treat coronoid process hyperplasia.

Section snippets

Surgical Procedure of Gap Coronoidotomy

The gap coronoidotomy is removal of a bone segment from the coronoid process instead of only cutting the coronoid process through. The patient is in a supine position under general anesthesia, and an incisional line is made anterior to the ramus. Then the periosteum is reflected from the anterior border of the ramus to the outer surface of the middle part of the ramus, upward to the inner and outer surface of the coronoid process ∼1 cm above the sigmoid notch. The lower border of the reflected

Discussion

Coronoid process hyperplasia is a rare disorder of uncertain etiology that can occur in both unilateral and bilateral forms. It appears as a slow but progressive reduction in mouth opening. A definitive diagnosis is established by the findings of a detailed history review, physical examination, panoramic radiographic analysis, and 3-dimensional computerized tomography image. In 1 CPH patient, mouth opening limitation was caused by interference of the coronoid process movement by the zygoma7, 8;

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Cited by (11)

Is Coronoidectomy Superior to Coronoidotomy for Improving Maximum Incisal Opening in Patients With Oral Submucous Fibrosis?
2021, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
In addition, there is also a higher incidence of postoperative hematoma which, could lead to fibrosis and recurrence of trismus.15 Other reported complications of intraoral coronoidectomies such as jaw dislocation, unilateral facial nerve palsy, recurrence of trismus due to coronoid process reattachment,11,16 and coronoidotomy17 were not observed in our study population. In all the patients in both the groups, all the erupted third molars were extracted for prevention of irritation, and the intraoral wound reconstructions were performed using either a buccal fat pad or modified nasolabial flap.18
In the management protocol of the oral submucous fibrosis (OSMF), multiple studies have advocated that an additional step of coronoidectomy or coronoidotomy helps achieve better and more consistent postoperative results. But, there are no studies that validate if one has an advantage over the other. This study aimed to compare the outcome of the coronoidectomy with coronoidotomy for OSMF cases.
A randomized controlled trial was designed in patients with OSMF requiring operative intervention. Patients were randomized into 2 groups based on a computer-generated randomization table: group I coronoidectomy and group II coronoidotomy. The primary predictor variables were the 2 different adjunct surgical steps – coronoidectomy and coronoidotomy. The primary outcome variable was the postoperative maximum incisal opening (MIO). Secondary outcome variables were duration of surgery and blood loss.
The study sample was composed of 32 patients (16 each group). Both the groups were comparable in terms of demographic profile. The MIO after surgery was comparable throughout the study between the groups. Repeated measures analysis of variance for comparison of mouth opening within the group showed that there was a significant improvement in postoperative MIO in both the groups (group I P value <.001 and group II P value 0.004). A statistically significant difference was found in the duration of the surgery (3.5 ± 0.73 hours vs 2.06 ± 0.87 hours) and blood loss (393 .75 ± 278.6 mL vs 90.62 ± 58.36 mL) with the shorter time and less blood loss in coronoidotomy compared with coronoidectomy. All these cases were followed for 1 year.
Coronoidotomy as an adjunctive treatment in OSMF provides comparable treatment outcome in terms of MIO compared with coronoidectomy with the added advantage of shorter operating time and less blood loss.
Coronoid hyperplasia: A review
2020, Journal of Stomatology, Oral and Maxillofacial Surgery
Citation Excerpt :
Despite simplicity of this technique, it comes with the risk of coronoid process reunion with the ramus [31]. To overcome this risk, Chen et al. performed modified (gap) coronoidotomy which involved removal of a strip of bone from the base of coronoid process thus creating a gap of 5–6 mm between coronoid process and ramus [100]. Mulder and his colleagues summarized in their review that coronoidotomy had better postoperative results, although not significant, compared to coronoidectomy despite the latter being treatment of choice [6].
Coronoid hyperplasia is one of the rare causes of progressive limitation of mouth opening due to impingement of the enlarged coronoid process of the mandible on the zygomatic bone. A review was performed on all cases reports and case series on coronoid hyperplasia. Gender, age at treatment, age of onset, types of hyperplasia (unilateral/bilateral), associated history, treatment, surgical approach, preoperative mouth opening, intraoperative mouth opening, mouth opening at follow up and follow up period were recorded and analyzed. A total of 82 articles which reported 115 cases were included. Coronoid hyperplasia was commonly reported at mean age of 22.64 years old with male preponderance. Most of the cases were diagnosed and treated between the age of 11–20 years old. This condition commonly involved bilateral coronoid process of mandible. The mean width of preoperative mouth opening was 16.5 mm and was improved to a mean mouth opening of 36.3 mm intraoperatively. Mean mouth opening was 34.8 mm at an average follow up of 19 months. While the etiopathogenesis of coronoid hyperplasia is still not conclusive, treatment with either coronoidectomy or coronoidotomy produced good improvement in mouth opening.
Mandibular coronoid process tumor resembling a mandibular condyle: A case report
2019, Oral and Maxillofacial Surgery Cases
Citation Excerpt :
Coronoidotomy was conventionally used [24] for CPH treatment with good results, frequently creating a gap by upward displacement of the coronoid process after coronoidotomy, so as to prevent reunion of the two bone segments, and avoid probable relapse. The gap coronoidotomy can also be applied [25] when separation between coronoid process and the zygoma is difficult, or when complete removal of the prominent deformed coronoid process is very difficult. In the present case the coronoid process was spontaneously elongated with a curve that allowed it to exceed the zygomatic arch, thus avoiding the impaction during mouth opening.
Abnormal elongation of mandibular coronoid process, often defined as coronoid hyperplasia, is a rare condition, which is frequently associated with limited mouth opening. In some cases, the enlarged coronoid pushes the zygoma forward causing facial asymmetry. This case report describes a 16-year-old boy whose chief complaint was a progressive difficulty and deviation in mouth opening, together with a deformity appearing at maximum opening at the zygomatic area. The diagnosis was Unilateral Accessory Mandibular Condyle at coronoid process, without reduction of the mouth opening capacity. A coronoidectomy was carried out by means of piezoelectric surgery, instead of a coronoidotomy which is usually performed in these cases, due to a suspect of ramus neoplasm.
Fate of the Coronoid Process After Coronoidotomy and Its Effect on the Interincisal Opening: A Clinical and Radiologic Assessment
2017, Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The mean duration of illness for these 4 patients (13.2 years) was similar to the overall mean duration of illness (11.3 years). The primary objective of detachment of the coronoid process is to relieve the interference between an elongated coronoid and the zygoma, or any articulation between them,14 and release the action of the attached temporalis muscle fibers. Although this goal may be achieved with either a coronoidotomy or a coronoidectomy (complete excision of the coronoid process), the latter procedure has traditionally been preferred by various authors, who argue that it also eliminates the risk of impediment of mandibular movement resulting from either a superiorly displaced coronoid fragment contacting the upper part of the ramus or recurrence from reattachment of the coronoid process, subsequently decreasing the interincisal opening.
Coronoidotomy (surgical detachment of the coronoid process from the mandibular ramus) is used to treat several conditions, including coronoid hyperplasia and temporomandibular joint (TMJ) ankylosis. The stability of the outcome, however, is considered questionable because of the risk of reattachment of the coronoid process. This study aims to radiographically and clinically evaluate the long-term anatomic and physiological outcome after coronoidotomy.
In 17 patients with unilateral TMJ ankylosis, 25 coronoidotomies were performed as an additional maneuver to relieve trismus after ankylosis release. Radiologic evaluation was performed immediately and 1 year postoperatively with panoramic radiography and computed tomography to assess changes at the coronoidotomy site. Clinical assessment included measurement of the interincisal distance at the 1-, 3-, 6-, and 12-month postoperative visits.
A sharp osteotomy margin with a 3- to 10-mm gap between the ramus and coronoid process was observed immediately postoperatively in all cases. After 1 year, 23 cases (92%) showed partial (n = 5) or complete (n = 18) osseous union to the mandibular ramus, whereas in 2 cases, no evidence of fusion was observed radiographically. The mean interincisal opening achieved at 1 year was 33 mm.
Coronoidotomy is an effective but more straightforward adjunct to arthroplasty than coronoidectomy (surgical excision of the coronoid process) in the management of TMJ ankylosis, with achievement and maintenance of adequate postoperative mouth opening.
Hyperplasia of the mandibular coronoid process: A new post-surgical treatment
2015, Revista Espanola de Cirugia Oral y Maxilofacial
La hiperplasia de los procesos coronoideos mandibulares es una entidad que se caracteriza por una elongación de los procesos coronoides, que produce una limitación de la abertura oral por una traba mecánica entre el proceso coronoideo y la cara posterior del hueso malar.
El tratamiento es la coronoidectomía para que los movimientos mandibulares ya no estén restringidos. A pesar del tratamiento quirúrgico es muy importante realizar fisioterapia postoperatoria. Aquí les proponemos el uso de aparatología ortopédica funcional para mejorar la abertura oral postoperatoriamente.
Mandibular coronoid process hyperplasia is a rare condition, characterized by an enlarged coronoid process, leading to a restriction in mandibular opening due to contact of the coronoid process with the posterior surface of the malar bone.
The treatment involves coronoidectomy, gaining free movement of the mandible, and afterwards, active physiotherapy. A novel adjunctive protocol with functional orthopedic device is proposed.
Endoscopically Assisted Intraoral Coronoidectomy for Treatment of Coronoid Hyperplasia
2024, Journal of Craniofacial Surgery

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Oral and maxillofacial surgeryOnline only articleGap coronoidotomy for management of coronoid process hyperplasia of the mandible

Section snippets

Surgical Procedure of Gap Coronoidotomy

Discussion

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Craniomaxillofac Surg

Oral and maxillofacial surgery
Online only article
Gap coronoidotomy for management of coronoid process hyperplasia of the mandible