Int. J. Oral Maxillofac. Surg. 2010; 39: 11271129 doi:10.1016/j.ijom.2010.06.022, available online at http://www.sciencedirect.

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Technical Note TMJ Disorders

Wedge subcoronoid ostectomy: an alternative to coronoidotomy

S. Prabhu: Wedge subcoronoid ostectomy: an alternative to coronoidotomy. Int. J. Oral Maxillofac. Surg. 2010; 39: 11271129. # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. While coronoidotomy and coronoidectomy remain established procedures in maxillofacial surgery, exceptionally enlarged coronoids pose a special challenge, as their intraoral retrieval may be difcult or impossible. Classical coronoidotomy alone in such situations may risk reattachment and recurrence of trismus. The technique described allows creation of sufcient gap and interpositioning at the coronoid base, allowing achievement of satisfactory mouth opening while minimising the risk for reattachment and relapse.

S. Prabhu
Oral & Maxillofacial Surgery, Peoples College of Dental Sciences, Bhopal-462037, India

Accepted for publication 9 June 2010 Available online 4 August 2010

Intraorally executed coronoidectomy and coronoidotomy are performed routinely for a variety of conditions in oral and maxillofacial surgery. The former is preferred, as the removal of the coronoid process is generally considered necessary for a more stable outcome1, otherwise the segment has a tendency for reattachment leading to recurrence of limited mouth opening. This may not always be feasible, and the fractured coronoid is then left behind. Preventing reattachment and relapse then depends on the patients commitment to physiotherapy. An alternative intraoral method is described based on excising a segment of the coronoid base.
Case report

A 23-year-old male patient presented with the chief complaint of inability to open his mouth for 15 years. He had sustained trauma to the chin when he was about 7 years old for which he never sought medical attention. He developed a progressive restriction in mouth opening.
0901-5027/1101127 + 03 $36.00/0

He had retrogenia with facial assymmetry and deviation of the chin to the right with prominent gonial angles and antegonial notching. Condylar movements were severely restricted with palpable movement on the left side and none on the right. Interincisal opening was about 4 mm, with severe malocclusion and multiple carious teeth. A CT scan showed features suggestive of an extensive bony ankylosis on the right side with marked elongation and thickening of the coronoids bilaterally. Under breoptic nasotracheal intubation and general anaesthesia, the ankyotic mass on the right side was exposed through an Al-kayat and Bramleys approach. Osteoarthrectomy and ipsilateral coronoidectomy was carried out following which 26 mm mouth opening was achieved. Wedge subcoronoid ostectomy with masseeter muscle interposition (as described below) was carried out on the contralateral (left) side through an intraoral approach, following which 41 mm mouth opening could be achieved. Temporalis muscle was interposed into the

gap (right side) where an osteoarthrectomy had been performed for excision of the ankylotic mass. The patient made an uneventful postoperative recovery and was discharged on the seventh postoperative day with mouth opening of 35 mm. At 6 month follow up, the patient was able to maintain an opening of 35 mm without assistance.
Procedure

The access for this procedure remains the same as for a conventional coronoidotomy and coronoidectomy. Following exposure of the anterior border of the ramus of mandible and coronoid process, the periosteum and muscle attachments are stripped off as high as possible. A channel retractor or a Howarths periosteal elevator is placed subperiosteally on the lateral aspect, angulating it towards the sigmoid notch. The tissues on the medial side are reected subperiosteally and protected with a periosteal elevator. With a number 702 bur or an osteotome, a horizontal

# 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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Prabhu

Fig. 1. Tracing of the CT scan showing extensive enlargement of contralateral coronoids in a patient with TMJ ankylosis patient. The shaded area denotes the segment to be removed, outlined by the superior horizontal and inferior oblique osteotomy. Fig. 3. Follow up at the end of 1 year demonstrating satisfactory mouth opening.

Fig. 2. The excised wedge of the coronoid base.

osteotomy is executed as high on the coronoid as possible. A second obliquely directed osteotomy is then executed 1 cm below the rst, taking care to terminate it at the sigmoid notch (Fig. 1). The intervening wedge of bone is then delivered intraorally (Fig. 2). After achieving adequate mouth opening, a sliver of masseter muscle from the lateral aspect is mobilised and sutured across the defect to the tissues on the medial side, so as to form a barrier against reattachment of the fractured coronoid stump (Fig. 4). Postoperatively, physiotherapy is instituted as per routine protocol.
Discussion

pathway to facilitate the removal of the coronoids2. With exceptionally enlarged coronoids, retrieval of the coronoid segment may be impossible due to the bulk of

the mass. Fracturing the coronoid process alone may not enable satisfactory achievement of mouth opening intraoperatively. The method of excising a 1 cm wedge of bone from the coronoid base, and subsequently plicating the soft tissues on the lateral and medial sides across the gap enables satisfactory, passive and stable mouth opening (Fig. 3) to be achieved (similar in concept to the principles of interpositional arthroplasty). It is important to protect the medial tissues during osteotomy as otherwise injury here may lead to signicant bleeding. The use of a sliver of pedicled masseter for interposition in the ostectomy gap has not caused any signicant restriction on postoperative mouth opening. A larger series is required to conrm this. As with other rehabilitative procedures, postoperative physiotherapy remains important.

Various methods such as a wire or sagittally placed titanium miniscrews have been used to control the coronoid process

Fig. 4. Postoperative OPG shows a satisfactory gap at the coronoid base on the left side with displaced coronoid fragment (outlined by the circle). Note the osteoarthrectomy gap on the right side.

Wedge subcoronoid ostectomy

Conict of interest Ethical approval

1129

None declared.
Competing interests

Not required.
References
1. Matthias WENGENHOEFER, Matthias MERKX, Mirjam STEINER, Werner GOTZ, Gert J MEIJER, Stefaan J BERGE. Hyperplasia of the coronoid process. Asian J Oral Maxillofac Surg 2006: 18: 5158.

2. Yoshida H, Sako J, Tsuji K, Nakagawa A, Inoue A, Yamada K, Morita S. Securing the coronoid process during a coronoidotomy. Int J Oral Maxillofac Surg 2008: 37: 181182. Tel.: +91 7554005343. E-mail: prabhuraman75@yahoo.com

None declared.
Funding

None.