Oral and Maxillofacial Surgery

https://doi.org/10.1007/s10006-020-00876-1

CASE REPORT

Can four-dimensional computed tomography support diagnosis

and treatment planning?: a case report before and
after coronoidectomy
Wensu Huang 1 & Masaya Akashi 1 & Takuro Nishio 2 & Noriyuki Negi 2 & Akira Kimoto 1 & Takumi Hasegawa 1

Received: 17 April 2020 / Accepted: 29 June 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Introduction Elongated mandibular coronoid process is a rare condition defined as enlargement of the coronoid process. The
only useful way to treat the mouth-opening limitation is resection of the elongated coronoid process. Four-dimensional CT
(4DCT; three spatial dimensions plus time axis) is a novel imaging technique. Its usefulness of for evaluation of dynamic
movements such as joint motion has been reported. Here, we show the potential usefulness of 4DCT evaluation in a patient
with elongated mandibular coronoid process.
Case presentation A 59-year-old female who suffered from mouth-opening difficulty and pressure during mouth opening was
referred to our department. Elongation of the right coronoid process was evident in a panoramic X-ray image. The mandibular
movement and temporal muscle motility before and after coronoidectomy in this patient on 4DCT could be evaluated.
Conclusions 4DCT is useful in the diagnosis and surgical outcome of elongated coronoid process.

Keywords Four-dimensional computed tomography (4DCT) . Elongated coronoid process . Temporal muscle

Introduction opening of 25 mm or less [1]. Other less frequent symptoms

Elongated mandibular coronoid process, also known as man-
dibular coronoid process hyperplasia, is a rare condition de-
fined as enlargement of the mandibular coronoid process. The
most common symptom is mouth-opening limitation due to
impingement of the coronoid process and the zygomatic arch
[1, 2]. In a previous systematic review, the mean maximum
mouth opening in patients with elongated coronoid process
was 16 mm (range, 2–32 mm), and 93% of patients had mouth
are sensations of pain or pressure in the zygomatic area on
forced mandibular opening, but no pain or tenderness over the
temporomandibular joint (TMJ) and masticatory muscles in
adolescents [3, 4]. Diagnosis of elongated mandibular
coronoid process can be achieved radiographically [2].
When the height of the coronoid process exceeds the height
of the condyle on a panoramic X-ray image, elongated
coronoid process should be suspected [1]. Computed tomog-
raphy (CT), especially a three-dimensional reconstruction, can

Electronic supplementary material The online version of this article

(https://doi.org/10.1007/s10006-020-00876-1) contains supplementary
material, which is available to authorized users.

* Masaya Akashi Akira Kimoto

akashim@med.kobe-u.ac.jp akimoto@med.kobe-u.ac.jp
Takumi Hasegawa
Wensu Huang
hasetaku@med.kobe-u.ac.jp
sky.high.sky.june24@gmail.com
Takuro Nishio 1
Department of Oral and Maxillofacial Surgery, Kobe University
sn_y_81@yahoo.co.jp Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku,
Kobe, Japan
Noriyuki Negi
2
noriyuki@med.kobe-u.ac.jp Department of Radiology, Kobe University Hospital, Kobe, Japan

provide more detailed information [5]. Furthermore, a scan in
the open-mouth position can visually reveal the impingement
between the elongated coronoid process and the zygomatic
arch [6]. The only useful way to treat the mouth-opening lim-
itation is resection of the elongated coronoid process [2].
Four-dimensional CT (4DCT; three spatial dimensions
plus time axis) is a novel imaging technique. The usefulness
of 4DCT for evaluation of dynamic movements such as wrist
joint motion and velopharyngeal closure has been reported
[7]. There have also been reports on 4DCT analysis of jaw
movement in patients who underwent mandibular reconstruc-
tion [8, 9] and of condylar movement in a patient with severe
TMJ osteoarthritis (TMJOA) [7].
Here, we show 4DCT visualization of mandibular move-
ment and temporal muscle motility before and after
coronoidectomy in a patient with elongated coronoid process.
The aim of this report was to determine the usefulness of
4DCT in the diagnosis of elongated coronoid process.
Case report
A 59-year-old female who suffered from mouth-opening dif-
ficulty and pressure during mouth opening was referred to our
department. She had some systemic illnesses such as chronic
kidney disease requiring dialysis, renal anemia, hypertension,
hyperlipidemia, chronic hepatitis C, and idiopathic femoral
head necrosis that was treated with surgery 15 years previous-
ly. She was aware of trismus since she was young, and had
been pointed out the difficulty of dental treatment and intuba-
tion of general anesthesia due to trismus. Her maximum
mouth opening at the first visit was 25 mm. Lateral excursions
or protrusion was found but its range of motion was limited.
TMJ pain was not obvious. A panoramic X-ray image re-
vealed elongation of the right coronoid process, with its apex
more cranial than the zygomatic arch (Fig. 1). Her chief com-
plaints (mouth-opening difficulty and discomfort during
Fig. 1 Initial panoramic X-ray
image
Oral Maxillofac Surg
mouth opening) were suspected to arise from the right elon-
gated coronoid process rather than a TMJ disorder. However,
not only atrophy of the right condyle but also deformity of the
left condyle was observed on the panoramic X-ray image
(Fig. 1). Magnetic resonance images revealed the narrowing
of joint space without joint effusion and the disappearance of
articular disc. Because we could not completely exclude the
possibility that her symptoms were caused by left TMJOA
(hypertrophy of the condyle), this possibility needed to be
ruled out. A study aiming to evaluate jaw movement in jaw
deformity patients using 4DCT was approved by the Medical
Ethics Committee of Kobe University. Written informed con-
sent for the case to be published including images, case histo-
ry, and data was obtained from the patient for publication of
this case report, including accompanying images. 4DCT was
performed for the purpose of confirming the impingement of
the coronoid process and the zygomatic arch, and ruling out
immobility of the left condyle.
The CT examination was performed with an Aquilion ONE
(Canon Medical Systems Corporation, Otawara, Japan). The
imaging protocol was as follows: rotation time, 0.35 s/rota-
tion; slice thickness, 0.5 mm; field of view, 220 mm; tube
current, 20 mA; tube voltage, 120 kV; and scanning time,
2.5 s. All images were acquired axially with a 320-detector
row CT to allow for multiple phases of unenhanced 3D vol-
ume acquisition with 10-cm coverage. The patient’s forehead
was fixed with tape to prevent bodily movement, and she was
instructed to open her mouth during the scan to assess the
normal mouth-opening movement. The gantry was angled to
limit radiation to the eyes, and the inferior aspect of the field of
view was tailored to minimize radiation to the thyroid. The
exposure dose was within the notification range recommend-
ed by the AAPM Working Group on Standardization of CT
Nomenclature and Protocols for 4DCT (https://www.aapm.
org/pubs/CTProtocols/documents/Notification). For image
post-processing, volume rendering (VR) and multiplanar re-
construction (MPR) images were generated using commercial
Oral Maxillofac Surg
software (Ziostation2; AMIN Inc., Tokyo, Japan). The radia-
tion dose for image acquisition in the patient was as
follows: CT dose index, 12.9 mGy; dose-length product,
129.2 mGy × cm.
Figure 2 shows the lateral VR images for closing and open-
ing of the mouth. The right elongated coronoid process ap-
peared to make contact with the medial side of the
zygomatic arch during mouth opening, as shown in
Fig. 2 and Video 1. Because the 4DCT images revealed
protrusion of the left condyle (Video 1b), the possibility
that left condylar hypertrophy caused the mouth-opening
difficulty was ruled out.
A surgical intervention to relieve symptoms was proposed
and accepted by the patient. A bilateral coronoidectomy was
performed under general anesthesia. The maximum mouth
opening improved from 25 mm preoperatively to 41 mm post-
operatively (Fig. 3). Histopathological examination revealed
no fibrosis or pathological alterations in the resected speci-
mens. At 7 months postoperatively, the patient underwent
another 4DCT scan. Although smooth mouth-opening move-
ment was confirmed in the lateral VR images (Fig. 4 and
Video 2), it was noted that the left condyle protruded more
forward after surgery than before surgery (Video 2b).
Although the maximum mouth opening was reduced to
30 mm, the patient experienced relief from the pressure sen-
sation during mouth opening recognized before surgery. At
Fig. 2 Still images of the
preoperative lateral volume on
rendered four-dimensional
computed tomographic images. a
Right, closed. b Left, closed. c
Right, open. d Left, open
1 year and 3 months postoperatively, the patient was satisfied
with the procedural outcome.
Discussion
In this case report, we have demonstrated that 4DCT, an im-
aging technique enabling motion visualization, can reveal the
detailed jaw movement during mouth opening before and after
coronoidectomy in a patient with elongated coronoid process.
4DCT has two potential uses. First, it can be useful for diag-
nosis of TMJ diseases and treatment decision. Second, it can
contribute to further understanding of the underlying patho-
physiological mechanisms for symptoms in patients with
elongated coronoid process.
Previously, we reported that 4DCT has potential to assess
kinematic features and obtain critical information on the eti-
ology in TMJOA [7]. One possible cause of TMJOA is inter-
mittent friction between the condyle and the articular emi-
nence in temporal bone during normal mastication [7].
Mechanical stress caused by this friction appears to be an
exacerbating factor that induces flattening or destruction of
the condylar head. Motion visualization on 4DCT is the only
means to reveal this underlying etiology in TMJOA [7]. The
patient described in the present report is a rare case with right
elongated coronoid process and left TMJOA. Although
 Oral Maxillofac Surg

Fig. 3 Intraoperative views. a

Before coronoidectomy. b After
coronoidectomy

elongation of the right coronoid process was the most suspi-
cious as the cause of her chief complaint (mouth-opening
difficulty), the possibility that the left TMJOA caused trismus
could not be completely excluded. Long-standing TMJ anky-
losis is known to be associated with coronoid process hyper-
plasia [2]. However, left condylar protrusion was confirmed
on 4DCT images. Therefore, coronoidectomy was selected as
a way to treat the trismus. 4DCT can be useful to evaluate the
mobility of the condyle in TMJ diseases that cause immobili-
zation of the condyle such as TMJOA or TMJ ankylosis. If
4DCT images reveal immobility of the condyle, an interven-
tion for the condyle (e.g., condylectomy) should be selected

Fig. 4 Still images of the

postoperative lateral volume on
rendered four-dimensional
computed tomographic images. a
Right, closed. b Left, closed. c
Right, open. d Left, open
Oral Maxillofac Surg
for treatment of the trismus. From these points of view,
4DCT can be useful for the diagnosis of TMJ diseases
and treatment decisions.
It is noteworthy that patients with elongated coronoid pro-
cess have not only mouth-opening limitation but also pain or
discomfort during mouth opening. Our patient recognized a
pressure sensation during mouth opening before surgery.
Therefore, pain or discomfort during mouth opening should
Fig. 5 Still images of the sagittal and axial multiplanar reconstruction
images (soft tissue window) for the right side before and after
coronoidectomy. a Sagittal, closed, before surgery. a’ Axial, closed,
before surgery. b Sagittal, open, before surgery. b’ Axial, open, before
surgery. c Sagittal, closed, after surgery. c’ Axial, closed, after surgery. d
Sagittal, open, after surgery. d’ Axial, open, after surgery
be included in the treatment targets. As reported in a previous
study [9], 4DCT enables visualization of jaw movement in
any direction (axial, sagittal, or coronal). To understand the
underlying mechanisms for pain or discomfort during mouth
opening in our patient with elongated coronoid process, sag-
ittal and axial MPR images (soft tissue window) were con-
structed. As shown in Fig. 5b’ and Video 3c, the temporal
muscle attached to the right elongated coronoid process made
contact with the medial side of the zygomatic arch at maxi-
mum mouth opening before surgery. Although it was previ-
ously believed that the mouth-opening limitation was caused
by direct impingement of the coronoid process on the zygo-
matic arch [1], the present case report suggests that the tem-
poral muscle may be caught between the coronoid process and
the zygomatic arch during maximum mouth opening. The
resulting compression of the temporal muscle between the
coronoid process and the zygomatic arch during mouth open-
ing may cause pain or discomfort. The comparison of 4DCT
images before and after surgery (Video 3) revealed that the
loss of the right elongated coronoid process after
coronoidectomy reduced the contact area between the tempo-
ral muscle and the zygomatic arch. This alteration probably
resulted in the diminished discomfort during mouth opening
in our patient. 4DCT can visualize not only mandibular move-
ment but also surrounding soft tissue motility such as contrac-
tion and relaxation of the masticatory muscle, possibly con-
tributing to identification of the underlying causes of pain or
discomfort due to masticatory muscle impairment. 4DCT
evaluation has potential for understanding the underlying
pathophysiological mechanisms for symptoms in patients
with elongated coronoid process.
Conclusions
4DCT is useful for evaluation of condylar mobility in patients
suspicious for TMJ diseases causing immobilization of the
condyle such as TMJOA or TMJ ankylosis. 4DCT enables
visualization of jaw mandibular movement as well as
masticatory muscle motility, thereby contributing to the
identification of underlying causes of pain or discomfort
due to masticatory muscle impairment in patients with elon-
gated coronoid process.
Acknowledgments The authors thank Alison Sherwin, PhD, from Edanz
Group (https://en-author-services.edanzgroup.com/) for editing a draft of
this manuscript.
Compliance with ethical standards
Conflict of interest The authors indicate full freedom of investigation
and no potential conflicts of interest.
Financial disclosure There was no grant support for this study.

Ethical approval The study using 4DCT was approved by the Medical
Ethics Committee of Kobe University. The patient gave written informed
consent to participate in the study.
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