Int. J. Oral Maxillofac. Surg.

2012; 41: 1483–1489

http://dx.doi.org/10.1016/j.ijom.2012.03.029, available online at http://www.sciencedirect.com

Systematic Review Paper

TMJ Disorders

Coronoid process hyperplasia: C. H. Mulder, S. I. Kalaykova,

R. A. Th. Gortzak
Department of Oral and Maxillofacial Surgery,

a systematic review of the Leiden University Medical Center, The

Netherlands

literature from 1995

C. H. Mulder, S. I. Kalaykova, R. A. Th. Gortzak: Coronoid process hyperplasia: a
systematic review of the literature from 1995. Int. J. Oral Maxillofac. Surg. 2012; 41:
1483–1489. # 2012 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The objective of this study was to review the literature and compare
different surgical methods for the management of coronoid process hyperplasia. A
literature search was performed for publications since 1995. Case characteristics
were extracted (age, sex, duration of symptoms, form, maximal mouth opening and
treatment) and entered into a database for analysis. The data were split into two
groups (coronoidectomy and coronoidotomy). Maximal mouth opening
measurements before and after surgery were analyzed with several statistical tests.
61 cases were entered into the database. The mean age was 23 years and mean
duration of symptoms 7 years. The bilateral form occurred 4.1 times more
frequently than the unilateral form. The male–female ratio was 3.3 to 1. In 94% of
the cases the approach was intra-oral. 84% of the cases received a coronoidectomy.
Keywords: Coronoid process hyperplasia; Cor-
Statistical analysis showed that the preoperative and postoperative differences
onoidectomy; Coronoidotomy; Limited mouth
between the groups were significant. The results were not significant when corrected opening.
for the preoperative difference. Postoperative therapy was not comparable due to
heterogeneity. Cases that received a coronoidotomy had slightly better Accepted for publication 20 March 2012
postoperative results. Available online 17 May 2012

Mandibular coronoid process hyperplasia
(CPH) is a rare condition causing a slow,
progressive reduction of mouth opening.1
CPH is defined as an abnormal elongation
of the mandibular coronoid process con-
sisting of histologically normal bone.1
This leads to impingement of the coronoid
process on the body or arch of the zygo-
matic bone on opening of the mouth.2,3
To date, mainly single case reports of
CPH have been published. In the most
recent complete review published in
1995 by Mcloughlin et al.,1 31 new cases
of coronoid hyperplasia were reported
together with a meta-analysis of previous
data. They emphasized the normal histol-
ogy of the resected coronoid process to
distinguish it from other pathology. It was
found that the condition most often
affected adolescent men. Surgery was
the treatment of choice, although the out-
come was generally disappointing, possi-
bly due to the formation of a haematoma
or intra-oral fibrosis. The authors hypothe-
sized that the extra-oral approach might
cause less fibrosis, but too few extra-oral
surgeries were performed to compare their
postoperative measures with those of
intra-oral surgeries. Postoperative phy-
siotherapy (stretching exercises) were
considered to be essential for the preser-
vation of the increased mouth opening.1
In this article, a systematic review of
cases published since the review of
Mcloughlin et al.,1 is presented. The main
objective is to compare the results of
different surgical methods (e.g. intra-oral
vs extra-oral, coronoidectomy vs. coronoi-
dotomy).

0901-5027/01201483 + 07 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1484 Mulder et al.
Materials and methods
A systematic search in the Pubmed data-
base was conducted to find related articles.
In the search, the following Medical Sub-
jects Headings (MeSH) terms were used:
‘coronoid’, ‘hyperplasia’, and ‘mandible’.
The following free-text terms were
entered as synonyms. For the term ‘cor-
onoid’, synonyms ‘coronoid process’,
‘processus coronoideus’ and ‘processus
muscularis’ were entered. For the term
‘hyperplasia’, synonyms ‘elongation’,
‘impingement’ and ‘enlargement’ were
entered, as well as the MeSH term ‘hyper-
trophy’. For ‘mandible’, ‘mandib*’ and
‘lower jaw’ were entered as synonyms.
Boolean operator OR was applied between
synonyms. The operator AND was used
between the three search terms.
The search was limited to articles in
English describing cases, published in, or
after, 1995. Titles and abstracts were
assessed to select relevant articles, and
then the full-text articles were retrieved.
The reference lists of the selected articles
were manually checked to trace additional
cases. Throughout the search, cases were
excluded if no hyperplasia with impinge-
ment was present, and/or histology and
morphology of the coronoid process was
characteristic for an osteochondroma.
From the included articles, specific
case-characteristics were extracted and
entered into a database as numerical or
categorical data. Numerical data included
age at diagnosis, duration of symptoms,
maximum mouth opening (MMO) before,
during and after the operation and length
of follow-up. Categorical data consisted of
uni- or bilateral CPH form, sex, diagnostic
method, surgical method, and whether
additional physiotherapy was performed.
Two additional variables were calculated:
age at onset and MMO improvement.
To evaluate if there was a statistically
significant association between sex and
uni- or bilateral type of CPH, a x2-test
was performed. The authors carried out
several statistical tests on the outcome data.
They split the surgery types into two
groups: coronoidectomy and coronoidot-
omy groups. Cases were filtered out that
had an extra-oral approach or underwent
additional masseter stripping to make the
coronoidectomy group more homogenous.
After testing normality of the distribution
with a residuals histogram, an independent t
test was done to compare the means of the
preoperative MMO, final MMO and MMO
difference. A univariate analysis of var-
iance (UNIANCOVA) was performed on
the final MMO with the preoperative MMO
as covariate. Differences were considered
to be significant if p < 0.05. Management
of the database and statistical analyses were
performed using SPSS for Windows ver-
sion 17.0.
Results
The literature search was performed on 4
June 2010. The search led to 39 hits of
which 35 articles were considered rele-
vant. The full text of 5 articles could not be
retrieved. With additional cross-referen-
cing 5 relevant articles were found of
which 4 were retrieved. Of the 34 articles
that were assessed in full text,2–34 8 arti-
cles were excluded. In two articles, no
cases were described.25,31 Six articles
reported cases which were excluded based
on the exclusion criteria.6,12,17,18,30 One
case was excluded from an article that
reported two cases.35 From the selected
articles, 58 cases were entered into the
database. Information from the 3 cases
at the authors’ institution was entered.
61 cases in total were analyzed (Table 1).
Epidemiology and clinical presentation
No epidemiological studies and therefore
no incidence and prevalence numbers
regarding CPH were found.
The mean age at diagnosis was 23 years
(range 0–61 years, SD = 14.4). To analyze
the age distribution, cases were categor-
ized in groups of 5 years. A peak in cases
was noted in the 15–19 years group. In 4
cases the condition appeared to be con-
genital11,16,34 and symptoms were appar-
ent shortly after birth. 9 cases were
diagnosed under the age of 10 years,
and in this early form the movement lim-
itation was usually more severe (mean
MMO 9.6 mm).11,13,16,19,28,34
Usually in CPH, a considerable period
is present between disease onset and diag-
nosis. In 28 cases (46%) the duration of
symptoms was recorded anamnestically
and retrospectively. The average duration
was 7 years (range 1–20 years, SD = 6),
and the authors calculated that the onset of
symptoms was around adolescence, with a
mean age of 14 years. Several factors may
contribute to the delay in diagnosis.
Patients may not have sought medical
advice, because they did not notice the
inhibition or because of the insidious
course.21 Some were diagnosed with and
unsuccessfully treated for temporoman-
dibular dysfunction.1,5
The condition can be uni- or bilateral.
The bilateral form was reported 4.1 times
more frequently than the unilateral form.
Most CPH patients were male (male to
female ratio 3.3 to 1). The unilateral form
was slightly more frequent in women, and
the bilateral form more frequent in men.
There was no significant association
between sex and uni- or bilateral CPH
using a x2-test (p = 0.21).
The main clinical symptom in all cases
is a slow, progressive reduction of mouth
opening. The mean MMO at presentation
was 16 mm (range 2–32 mm, SD = 7). In
93% of the cases it was 25 mm or less and
in 77.8% 20 mm or less. With the unilat-
eral form, facial asymmetry and deviation
towards the affected side can be pre-
sent.10,34 The mouth opening limitation
sometimes interfered with eating, speak-
ing or maintaining oral hygiene.2,16 Some
less frequent symptoms were crepitation
or clicking of the temporomandibular joint
(TMJ),26,33 and sensation of pain or pres-
sure in the zygomatic area on maximal
opening.14,23 At clinical examination,
when the mouth was passively forced
open, a non ‘elastic’ resistance was felt
on maximal opening. Over the zygoma
crepitation or grating could be
observed.2,36
Aetiology
Several theories for the aetiology of CPH
have been suggested, including increased
temporalis muscle activity, mandibular
hypomobility, and trauma.
The authors found several cases to sup-
port the temporalis hyperactivity theory.
Wenghoefer et al. found 3 cases with
temporalis hyperplasia and 2 cases with
hypertonic masticatory muscles due to a
neurological disorder.28 In another case,
thick fibrous bands were palpated at the
insertion of temporalis muscles.24 This
was visualized in another report by means
of a preoperative magnetic resonance ima-
ging (MRI) scan. It showed hypertrophy of
the insertion of the temporalis muscle.3
Other cases described the observation of
tendinous temporalis insertions during the
surgical procedure.7 In one article, the
masticatory muscle hyperactivity was
objectified by histology of resected mass-
eter specimens. It showed fibrous changes
and calcifications, which might indicate
increased stress.7 No articles described
histology of the temporalis muscle tendon.
Contradicting the temporalis hyperactivity
theory are the results of electromyography
(EMG) studies of both the temporalis and
masseter muscles of CPH patients. No
abnormalities were found when results
were compared to healthy controls.5,8 In
1999, two cases were described, in which
CPH was associated with Moebius syn-
drome, which is characterized by facial
musculature paralysis at birth.11 In these
 Coronoid process hyperplasia: a systematic review of the literature from 1995 1485

Table 1. Case summaries.

Final
Age History Preoperative Peroperative MMO Follow-up
Authors Year (yrs) (yrs) Type Sex MMO (mm) MMO (mm) (mm) Approach Type (months)
1 Gibbons 1995 34 17 bi M 19 35 NS IO Ectomy NS
2 Loh et al. 1997 22 4 bi M 5 NS 20 EO Ectomy 4
3 Loh et al. 1997 41 NS bi M 15 25 25 IO ectomy 4
4 Loh et al. 1997 25 10 bi F 16 NS 30 IO Ectomy 4
5 Loh et al. 1997 14 2 bi M 13 22 37 IO Ectomy 12
6 Gerbino et al. 1997 15 1 uni M 15 NS 41 IO Tomy 12
7 Gerbino et al. 1997 14 2 uni M 12 NS 48 IO Tomy 60
8 Gerbino et al. 1997 13 3 bi M 18 NS 38 IO Tomy 15
9 Gerbino et al. 1997 32 17 bi M 20 NS 38 IO Tomy 60
10 Gerbino et al. 1997 16 2 bi M 20 NS 45 IO Tomy 60
11 Yamaguchi et al. 1998 25 8 uni M 24 NS 43 IO Ectomy 18
12 Pregarz et al. 1998 17 NS uni M 18 28 35 IO Ectomy 20
13 Pregarz et al. 1998 20 7 bi M 13 20 27 IO Ectomy 12
14 Pregarz et al. 1998 17 5 bi M 17 NS 39 IO Ectomy 12
15 Pregarz et al. 1998 15 5 bi M 18 NS 40 IO Ectomy 24
16 Pregarz et al. 1998 16 NS bi M 19 25 38 IO Tomy 12
17 Kubota et al. 1999 23 NS bi F NS NS NS NS NS NS
18 Kubota et al. 1999 28 NS bi F NS NS NS NS NS NS
19 Kubota et al. 1999 61 NS bi M NS NS NS NS NS NS
20 Mavili et al. 1999 17 14 uni M 22 48 45 Endo Ectomy 8
21 Turk 1999 1 1 bi M 8 NS 25 IO Ectomy 4
22 Turk 1999 0 NS bi NS 10 NS 40 IO Ectomy NS
23 Asaumi et al. 2001 7 NS bi M 17 NS NS NS NS NS
24 Asaumi et al. 2001 14 NS bi M 2 NS NS NS NS NS
25 Leonardi 2001 14 NS bi M 25 NS NS NS NS NS
26 Colquhoun et al. 2002 26 3 bi M 22 35 22 IO Ectomy 30
27 Fabie et al. 2002 8 8 bi F 6 33 30 IO Ectomy 8
28 Mano et al. 2005 5 NS bi M 17 NS 40 IO Ectomy 82
29 Tieghi et al. 2005 17 1 bi F 25 40 40 IO Ectomy 20
30 Tieghi et al. 2005 15 2 bi M 25 40 46 IO Ectomy 6
31 Satoh et al. 2006 13 1 bi M 27 40 45 IO Ectomy 8
32 Leovic et al. 2006 35 18 bi M 15 NS 35 NS Tomy NS
33 Kursoglu and Capa 2006 17 NS bi M 14 NS NS None None NS
34 Kursoglu and Capa 2006 24 NS bi M 27 NS NS None None NS
35 Gibbons and Abulhoul 2007 36 20 bi M 20 30 38 IO Ectomy 12
36 Mazzetto et al. 2007 55 NS uni M 32 NS NS None None NS
37 Yoshida et al. 2008 34 NS bi F 18 44 38 IO Ectomy 6
38 Ferro et al. 2008 28 NS bi M 13 NS 40 IO Ectomy 12
39 Wenghoefer et al. 2008 53 NS uni F NS NS 30 NS Ectomy 12–15
40 Wenghoefer et al. 2008 38 NS uni M 7 NS 35 NS Ectomy 12–15
41 Wenghoefer et al. 2008 52 NS uni M 22 NS NS NS Ectomy 12–15
42 Wenghoefer et al. 2008 18 NS uni F NS NS 30 NS Ectomy 12–15
43 Wenghoefer et al. 2008 4 NS bi M NS NS 30 NS Ectomy 12–15
44 Wenghoefer et al. 2008 28 NS bi M NS NS 30 NS Ectomy 12–15
45 Wenghoefer et al. 2008 56 NS bi M 25 NS NS NS Ectomy 12–15
46 Wenghoefer et al. 2008 23 NS bi M 10 NS 23 NS Ectomy 12–15
47 Wenghoefer et al. 2008 2 NS bi F 10 NS 25 NS Ectomy 12–15
48 Wenghoefer et al. 2008 18 NS bi M 16 NS 30 NS Ectomy 12–15
49 Wenghoefer et al. 2008 35 NS bi M 5 NS 31 NS Ectomy 12–15
50 Wenghoefer et al. 2008 45 NS bi M 10 NS 31 NS Ectomy 12–15
51 Wenghoefer et al. 2008 5 NS bi F 4 NS 32 NS Ectomy 12–15
52 Wenghoefer et al. 2008 14 NS bi M 15 NS 33 NS Ectomy 12–15
53 Wenghoefer et al. 2008 16 NS bi M 14 NS 40 NS Ectomy 12–15
54 Wenghoefer et al. 2008 24 NS bi M 18 NS 40 NS Ectomy 12–15
55 Zhong et al. 2009 39 13 uni F 8 40 31 IO Ectomy 9
56 Yura et al. 2009 28 13 uni M 30 50 43 IO Tomy 15
57 Baraldi et al. 2010 20 NS uni F 12 30 35 IO Ectomy 8
58 Galie et al. 2010 3 2 uni F 5 NS 35 EO Ectomy 18
59 The authors’ patient 2010 41 6 bi F 15 25 22 IO Ectomy 16
60 The authors’ patient 2010 14 2 bi M 6 40 30 IO Ectomy 4
61 The authors’ patient 2010 29 14 bi M 20 40 39 IO Ectomy 5
NS, not stated; Uni, unilateral; Bi, bilateral; M, male; F, female; IO, intra-oral; EO, extra-oral.
1486 Mulder et al.
cases, hypoplasia of the mandible and
masticatory muscles was present which
also contradicts the temporalis hyperactiv-
ity theory.
Two reports suggest the influence of
mandibular hypomobility. Zhong et al.
reported a case where an osteochondroma
was found on one side and CPH on the
other.33 In this case the hyperplasia could
have developed secondarily to the hypo-
mobility caused by the osteochondroma.
Wenghoefer et al. reported two patients
who had ankylosis of the TMJ and two
others with arthritis beginning destruc-
tion.28 These findings support the mandib-
ular hypomobility theory.
Some authors suggested trauma was
associated with this condition.33 In the
present authors’ database, only one case
(2%) reported trauma,20 so they did not
find evidence to support this theory.
A new hypothesis on aetiology was
mentioned by Wenghoefer et al. They
investigated the occurrence of ankylosing
spondylitis (AS) in CPH and found it to be
present in 4 of 16 patients.28 The main
feature of AS is sacroiliitis and subsequent
ossification. They suggest that a similar
mechanism might occur in the temporalis
tendon, although they could not confirm
this with histopathology. It is known that
in patients with AS the TMJ can also be
affected, which was the case in those four
patients.
No conclusive evidence was found to
support or discard the abovementioned
theories, and the true aetiology of CPH
remains unclear.
Diagnostic tools
Orthopantomography (OPT) was carried
out in 87% of the cases in the database as a
diagnostic imaging method to recognize a
coronoid abnormality. Coronoid hyperpla-
sia is suspected on OPT when its height
exceeds that of the condyle9 Levandoski
panographic analysis can be conducted to
calculate the ratio between the length of
the coronoid and condylar process. Kubota
et al. found this ratio in 3 cases with CPH
to be significantly higher than the ratio in a
control group9 It was concluded that if the
ratio exceeded 1.1, additional imaging to
confirm CPH was needed.
Computed tomography (CT) is the pre-
ferred method to visualize CPH, because a
CT can accurately visualize the relation
between osseous structures, such as the
coronoid process and zygoma.2,3 In parti-
cular, a scan with an opened mouth can
prove and depict the exact location of
impingement.32 In 51 cases (84%), CT
was carried out to confirm a diagnosis
of CPH. In 24 patients (39%), a three-
dimensional (3D) reconstruction was car-
ried out. 3D CT can be used to evaluate the
morphology in more detail.3,13 In 30% of
the reports, zygomatic exostoses were
described at the location of impingement,
on the medial surface of the zygomatic
arch or dorsal surface of the zygomatic
body.2 In CPH, the coronoid process is
elongated but relatively normal in shape.
CT imaging is useful for differentiating
between CPH and other coronoid abnorm-
alities. An osteochondroma has a charac-
teristic stalked appearance also described
as a mushroom or condyle shaped. The
diagnosis can be confirmed with histo-
pathology of the resected process, which
shows a bony mass covered with a cartilage
cap and endochondral ossification at the
deep aspect. In 74% of the cases from the
database the removed specimens were sent
for histopathology and all were stated to
consist of normal bone tissue. In 3 cases, a
preoperative MRI scan was taken because a
TMJ abnormality was suspected.4,15
Treatment
The condition is treated by surgery,
because the restriction is principally
caused by a mechanical obstruction. Both
intra-oral and extra-oral approaches have
been described. Two types of surgery are
performed: coronoidectomy and coronoi-
dotomy.
The intra-oral approach usually pro-
vides enough exposure to remove the
hyperplastic process and leaves no visible
scar. The biggest disadvantage is the risk
of a postoperative haematoma and fibro-
sis. Several extra-oral approaches have
been described, such as submandibular,
pre-auricular, (bi)temporal3,4 or endosco-
pically assisted.10 Supposed advantages
are less fibrosis and/or haematoma forma-
tion, no intra-oral scarring and better
exposure to resect the coronoid process
and release the temporalis muscle. The
Table 2. Outcome measures for different surgery types.
Coronoidectomy
Intra-oral Extra-oral
N 34 3 37
Percentage 75.5 6.6
Mean final MMO (mm) 34.0 33.3
Range (mm) 22–46 20–45
MMO  30 mm (%) 79.4 66.6
MMO  35 mm (%) 52.9 66.6
Mean DMMO (mm) 19.5 22.7
N, number of cases; Range, minimum and maximum.
risk of facial nerve damage and a visible
scar are the main disadvantages.
During a coronoidectomy, the tempor-
alis muscle fibres are stripped from the
process after which it is entirely resected.
Advantages are that the mechanical cause
of the impingement is removed and his-
tology of the specimen can be undertaken
to confirm or revise the diagnosis. On the
other hand, the release of the temporalis
insertion can be a difficult and traumatic
procedure. In a coronoidotomy the process
is sectioned at the base and left in situ.
Supposedly this method leads to less
trauma, less postoperative morbidity and
better results. Disadvantages are the risk
of recurrence caused by reattachment of
the process and the inability to perform
histology. In some cases additional mass-
eter muscle stripping was performed to
increase mouth opening because muscles
may undergo fibrotic changes after a sig-
nificant period of disuse.7,25
Postoperative physiotherapy is consid-
ered to play an important role in main-
taining and increasing the MMO. Active
and passive stretching exercises with or
without the use of a bite block,20 spatulas,7
a mouth screw,2,7 a wedge,32 dynamic
devices20 and a TheraBite123,24,27,28 were
reported.
In 9 of the reported cases (15%) nothing
was stated about therapy, or the patients
refused surgery. The intra-oral approach
was used most frequently; in 47 cases
(94%). In 3 cases (6%) the approach
was extra-oral. The coronoidectomy was
the preferred method in 42 cases (84%);
the remaining 8 cases had a coronoidot-
omy. In 6 cases (12%) the surgeons
decided to perform additional masseter
muscle stripping. In 5 cases (10%) the
MMO data were incomplete, so those
could not be included for MMO analysis.
For the remaining 45 cases the results are
summarized in Table 2.
With an independent t test, the authors
calculated that the coronoidotomy group
had a significantly larger preoperative
Surgery type
Coronoido-tomy Total
Total
8 45
82.2 17.8 100
34.0 40.8 35.2
20–46 35–48 20–48
78.4 100 82.2
54.1 100 62.2
19.7 22.1 20.2
 Coronoid process hyperplasia: a systematic review of the literature from 1995
Fig. 1. Scatterplot of preoperative and final MMO measurements, illustrating the difference in
MMO distribution for the two surgery types. Circles and squares represent separate cases.
(p = 0.003) and final MMO (p = 0.016)
compared to the coronoidectomy group.
In the UNIANCOVA the preoperative
MMO was included as a covariate in the
calculation. This p-value (0.069) was not
significant. With this test the outcome was
corrected for the significant difference in
preoperative MMO (Fig. 1). An indepen-
dent t test was also performed on the
MMO difference, which confirmed the
difference between the groups was not
significant (p = 0.376).
Some form of physiotherapy was applied
in 45 of 50 cases that received surgery
(90%). In the case reports, different times
of initiating physiotherapy and exercises
and different duration were noted making
outcome comparison impossible.
Follow-up data in the articles analyzed
was diverse. In most cases, several post-
operative measurements at different time
points were reported. The length of fol-
low-up was specified in 49 cases (80%),
ranging from 4 to 60 months with a mean
of 14 months.
Regeneration of the coronoid process
after coronoidectomy was described in 2
cases in the database.21,31 Both cases were
discovered by imaging, not due to the
clinical features.
Discussion
This review provides an update on the
literature that has been published regarding
CPH. The authors attempted to summarize
and meta-analyze the findings from 61
cases. A comparison of results after coro-
noidectomy or coronoidotomy has not been
made in previous literature. Other findings
are similar to those reported by Mcloughlin
et al.1
The authors extracted more data than
previous reviews for the database. This is
due to more extensive documentation,
new diagnostic tools and new exercise
appliances. The authors chose to limit
the search to articles that were published
after the review by Mcloughlin et al.,1
because they provided a quite complete
review and the present authors wanted to
compare their results with those of
Mcloughlin et al. This caused a selection
based on publication date, but also a
greater chance of having a more complete
database for comparing data. The search
was limited to English literature, because
of accessibility and language.
After careful consideration some cases
were excluded, because the authors ques-
tioned whether the correct diagnosis had
been made. Izumi et al. and Murakami
et al. diagnosed their patients with CPH,
while they emphasized no impingement
was present12,18. The present authors’
view is that the MMO restriction is prin-
cipally caused by the coronoid process
impinging on the zygoma. Leonardi
et al. conducted the Levandoski pano-
graphic analysis in 10 patients with nevoid
1487
basal cell carcinoma syndrome17 and found
4 to have CPH, but the ratios they calculated
were well below the lowest ratio Kubota
et al. found in their patients.9 Based on these
facts the present authors did not include
those cases. In the latter of the excluded
cases, the diagnosis of osteochondroma was
highly suspected, because of characteristic
morphology and/or histology.6,15,30,37
CPH appears to be a rare condition but
little is known about its true incidence or
prevalence. Two studies have been pub-
lished that tried to objectify this. In 1987
Isberg et al. published a prospective study in
which they investigated patients with a
mouth opening restriction and found the
restriction was caused by CPH in 5%.36
This number does not represent the true
prevalence because selection had taken
place based on symptoms. It does indicate
that CPH should not be overlooked as a
cause for limited MMO. The second was a
retrospective study of 2000 random OPTs.38
They found unilateral hyperplasia in 1 case,
so a prevalence of 0.05%. What is debatable
is that this patient did not have restricted
mouth opening, the main feature of CPH.
The authors found the average age at
diagnosis was 23 years, near the previous
average of 25 years. The average length of
history is also in accordance with previous
data.1 The age distribution for age at diag-
nosis shows a peak in cases in a younger
age group than that which contains the
mean age. The authors think this gives
more valuable information than the mean
age alone which is influenced by the range.
With the age at onset calculation the
authors observed the highest case count
is in an even younger group. This finding
can lead to more clinical awareness of the
onset of this condition in a younger patient
group. It is hoped this will lead to a
decrease in misdiagnosis and duration of
symptoms. The ratio for uni- or bilateral
form is supported by previous literature.1
The authors also found the condition
affects men more often than women (a
ratio of 3.3 to 1), although the previously
stated ratio was 5 to 1.
Several theories have been suggested to
explain the aetiology of CPH. The influ-
ence of the temporalis muscle has been
suggested by numerous authors. Isberg
et al. found that coronoid process elonga-
tion could be induced by mandibular
hypomobility and temporalis hyperactiv-
ity from a study in monkeys.35 Other
findings supporting these theories are the
shortened muscle tendon units in trismus
pseudocamptodactyly syndrome,25 fibrous
and hypertrophied masticatory muscle
tendons3,7,24 and hypertrophic or hyper-
tonic temporalis muscles.28 These features
1488 Mulder et al.
are not present in every CPH patient and
several EMG studies revealed no abnorm-
alities. Nevertheless more findings were
reported supporting this theory than
opposing it.
All 3 of the authors’ patients had pro-
minent mandibular angles as was seen on
the OPT. One of them had apparent mass-
eter hypertrophy. The other two had par-
afunctional habits. Isberg et al. observed
bone deposition occurring in the area of
the insertion of the masseter muscle due to
hyperactivity,35 which lead to the appear-
ance of a square-shaped mandible (SQM).
Other cases of the association between
SQM and CPH have been reported in
literature. Yoshida et al. published a case
with hyperplasia of the coronoid pro-
cesses, masseter muscles and mandibular
angles.29 Murakami et al. reported 12
cases, but in their patients no coronoid
elongation or impingement was present.12
In fact only a few cases were reported that
mentioned this association. The aetiology
of hyperplastic mandibular angles is not
clearly stated. Masseter muscle hyperac-
tivity was suggested to have an influ-
ence.35 This indirectly supports the
temporalis hyperactivity theory for CPH
because the masticatory muscles are clo-
sely related. No conclusive evidence was
found affirming the aetiology of either of
these conditions.
For the MMO analysis, the authors used
the last stated MMO after surgery for the
final MMO. This was not measured at the
same point in time in all cases. This might
have an effect on the analysis, although the
authors expect it to be limited because
MMO stabilizes after some time. In their
review Mcloughlin et al. wanted to com-
pare the intra-oral approach with the extra-
oral one.1 Since their review, only 3 extra-
oral approaches have been reported, so the
present authors could not compare the
results of the two approaches either.
Wenghoefer et al. reported 14 cases but
did not specify which approach was used.28
The authors assumed they used an intra-oral
incision for inclusion in the MMO analysis.
An interesting observation was made
when the outcome data were split into
two groups (coronoidectomy and coronoi-
dotomy). The authors found a significant
difference in preoperative and final MMO,
but not in the MMO improvement. The
power of these findings is limited by the
fact that the group sizes were not equal (30
vs 8) and the postoperative therapy mea-
sures could not be taken into account.
A coronoidotomy is supposed to be an
easier procedure, which results in a shorter
duration of surgery. It was thought that
the obstruction would reoccur when the
process reattached to the ramus, requiring a
re-operation,39 but in 5 cases the coronoid
had repositioned and reattached in a poster-
ior fashion not causing restriction at long
term follow-up.5 This means the supposed
main disadvantage did not occur. Another
disadvantage is that no histopathology can
be performed. This investigation was par-
ticularly useful in the differentiation from
an osteochondroma. Nowadays with help
of a 3D CT an osteochondroma can also be
recognized based on the morphology, so
histopathology is less crucial to the diag-
nosis. Thus, because of the slightly better
results and an easier procedure it seems
useful to perform more coronoidotomies
to evaluate if those outcome measures sup-
port the observation.
It was difficult to compare the post-
operative therapy data due to heterogene-
ity and limited reporting. The authors used
the TheraBite1 appliance for passive
stretching which led to satisfactory results
in those cases. There are no guidelines on
frequency of exercises or duration. Ideally
a randomized controlled trial should be
performed to evaluate different postopera-
tive therapy options, but this seems impos-
sible because the abnormality occurs so
infrequently.
In the cases analyzed, follow-up data
were diverse. In the authors’ cases a con-
siderable dip was present in the postopera-
tive course. At some point in the early
postoperative course the MMO was even
smaller than the preoperative measure-
ment, despite adequate exercising. With
intensification and continuation of rehabi-
litation measures the MMO gradually
increased to satisfying levels. In other
reports a similar course has been
described,20,24,32 so clinicians should not
be discouraged by this observation. The
authors advise regular follow-up, espe-
cially for the first 3 months, so patient
compliance and therapy can be improved.
In the literature it was stated that the
results after surgery were generally dis-
appointing. The question arises what out-
come should be regarded as being
disappointing. According to the AAOMS
impairment guidelines a MMO of 35 mm
or more was considered to be an accep-
table interincisal distance.40 Others con-
sidered a mouth opening of 30 mm or
more to be successful, so the authors also
calculated that percentage.28 The overall
success rate if the first criterion is used was
fairly disappointing (62%). The other cri-
terion results in an 82% success rate. So it
is of great influence which value is chosen
for evaluation of success.
In conclusion, the authors found that there
seems to be slightly better postoperative
mouth opening in patients who received a
coronoidotomy. This procedure is also
assumed to be faster and easier. More cases
treated in this way are necessary to confirm
or discard this finding.9
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
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Address:
R.A.Th. Gortzak
Department of Oral and Maxillofacial
Surgery
Leiden University Medical Center
P.O. Box 9600
2300 RC Leiden
The Netherlands
Tel.: +31 71 5262371
fax: +31 71 5266766
E-mail: R.A.T.Gortzak@lumc.nl