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Cancellous osteoma of the coronoid process: report of a case
British Journal of Oral Surgery @ 1983 The British Association
(1983) 21,49-55 of Oral Surgeons
CANCELLOUS OSTEOMA OF THE CORONOID PROCESS: REPORT OF A CASE R. A. ORD, B.D.s., M.B., B.ch., F.D.s.R.c.P.s.,’ J. S. RENNIE, B.D.s., Ph.D., F.D.s.R.c.P.s.,M.R.C.P~~~.,‘D.G.MACDONALD, R.D.,B.D.s., Ph.D., M.R.C.Path.‘and K. F. Moos, B.D.S.,M.B.,B.S.,F.D.S.R.C.S.(Eng)3 ‘Oral Surgery Department, Queen Victoria Hospital, East Grinstead, Sussex; ‘Department of Oral Medicine and Pathology, Glasgow Dental Hospital and Canniesburn School, Glasgow; 30ral and Maxillofacial Surgery Department, Hospital, Glasgow Summary. A case of cancellous osteoma of the coronoid process is presented. The differential diagnosis and the surgical approach to large lesions of the coronoid process are discussed.
Introduction True osteomas of the jaws are uncommon bony neoplasms (Lewars, 1959; Spjut et or compact bone and may arise centrally within bone or in a peripheral or subperiosteal location (Lucas, 1976). Cooke (1957) reported 11 cases of osteomas, noting that cancellous osteomas occur more commonly in females and compact osteomas occur predominantly in males. This distribution of cancellous and compact osteomas appears true for the majority of reported jaw lesions (Weinberg, 1977) although Spjut et al. (1971) record an overall male:female ratio of 2: 1 for all osteomas. Osteomas are usually slowly growing and symptomless. Facial asymmetry is the most common presenting complaint although pain may be a feature of central tumours (Hitchin & White, 1955). Osteoma is most common in the fourth and fifth decades but lesions have been reported from l&79 years (Spjut et al., 1971). The neoplasm is usually solitary, but multiple tumours occur as part of Gardner’s syndrome (Gardner & Richards, 1953). The mandible is more commonly involved than the maxilla (Lucas, 1976). Worman et al. (1946) and Weinberg (1977) have reported condylar lesions and Lewars (1959) has described a compact osteoma of the coronoid process but no other case of cancellous osteoma of the coronoid process appears to have been recorded.
al., 1971), which consist of cancellous
Case History A 40-year-old Caucasian male was first seen in 1970 with a seven week history of a tingling sensation over the left zygomatico-temporal region. A history was elicited of trauma to the face some eleven months previously, with a possible fracture of the left malar complex. Examination revealed a swelling over the left side of the cheek in the zygomatico-temporal area suggestive of a bony enlargement. Paraesthesia were noted in the left zygomatico-temporal nerve distribution. Radiographs confirmed an old displaced left malar fracture. No surgery was indicated and the symptoms appeared to resolve. Three years later the patient was referred again with pain in the right ear and the left temporo-mandibular joint accompanied by difficulty in opening the mouth. (Received 26 October 1981; accepted 23 November 1981)
49
50
BRITISH
JOURNAL
OF
ORAL
SURGERY
FIG. 1. Frontal view showing swelling of left zygomatico-temporal
FIG.
region.
2. Lateral view of mandible showing enlarged coronoid process.
CANCELLOUS
FIG. 3. Bulbous
tumour
OSTEOMA
of coronoid
OF THE
process
clearly
CORONOID
PROCESS
seen on occipitomental
51
radiograph.
Examination revealed mild bilateral otitis externa and trismus limited to two finger breadths of opening. Radiographs suggested a possible ankylosis between the coronoid process and the left malar arch. A diagnosis of post-traumatic ankylosis was made. Surgery was advised, but the patient refused this. Follow-up at irregular intervals during the ensuing years revealed a slow increase in size of the swelling in the zygomatico-temporal area with increasing trismus. In 1979 the patient was referred again with pain and severe trismus. A large swelling was noted in the left zygomatico-temporal area (Fig. 1). Radiographs revealed a well defined globular enlargement of the left coronoid process (Fig. 2). The mass was radio-opaque and had a uniform pattern of calcification (Fig. 3). A provisional diagnosis was made of a slow growing benign osseous neoplasm, possibly an osteochondroma. The patient agreed to have surgery in October 1979. Under general anaesthesia a large well circumscribed bony tumour of the coronoid process was exposed through a preauricular incision extending into the temporo-frontal region (Fig. 4). Because of the size of the tumour, the malar arch was sectioned and displaced laterally to expose
52
BRITISH
JOURNAL
OF ORAL
SURGERY
FIG.4. Surgical removal of tumour following section of zygomatic arch.
the whole of the tumour. The coronoid process was sectioned at the level of the sigmoid notch and then easily delivered. No ankylosis was present. The malar arch was wired back in place and the pterygoid space was drained. The patient made a satisfactory post-operative recovery and when reviewed one year after surgery was well with good opening, normal movements of the jaw and no signs of a recurrence. There was some residual weakness of the left occipito-frontalis muscle. Pathology The specimen consisted of a slightly nodular bony tumour measuring 40 x 35 x 20 mm. Decalcified sections showed prominent trabeculae of mature lamellar bone (Fig. 5). The intertrabecular area consisted mainly of fatty tissue although some haemopoietic marrow was also noted. The lesion was largely surrounded by a highly cellular periosteum and new appositional bone growth was occurring in relation to this periosteum. No cartilaginous cap, such as is found in an osteochondroma, was noted although small isolated areas of endochrondral ossification were present (Fig. 6). These formed in total less than four per cent of the surface of the tumour. The possibility was considered that this lesion was a burnt out osteochrondroma, but because of the progressive growth over many years and the presence of continued appositional bone growth it was felt that this lesion was more accurately designated as a cancellous osteoma.
CANCELLOUS
5. Low power photomicrograph
OSTEOMA
OF THE
CORONOID
PROCESS
showing fine trabecullar pattern of bone with fatty marrow. H. &E. x 9.5.
FIG. 6. (A). Highly cellular periosteum
with appositional bone growth. H. & E. x 115. (B). Area of endochondral ossification. H. & E. x 70.
54
BRITISH
JOURNAL
OF
ORAL
SURGERY
Discussion
Some authors have doubted the existence of osteoma of the jaws as an independent neoplastic entity. Jaffe (1958) considered it most likely that ‘highly ossified solitary lesions of the jawbones’ be included in the category of fibrous dysplasia. Similarly Dahlin (1978) and Lucas (1976) both noted the wide variety of nonneoplastic conditions previously designated ‘osteoma’. Reactive changes from trauma, infection, exostoses and ancient osteochrondromas have all been included in this group. In addition earlier reported jaw lesions almost certainly contain examples of cementoblastoma (Tratman, 1940) and focal sclerosing osteomyelitis (Versnel, 1956; Hitchin & White, 1955), a view supported by the history of tooth extraction and the success of antibiotic therapy. To add to the confusion there are a number of reports which rely totally on the radiographical appearances and lack histological confirmation (Cooke, 1957; Worman, Waldron & Radisch, 1946). There are, however, convincing examples of osteomas of the jaws (Lewars, 1959; Leopard, 1972; Nelson, Gross & Miller, 1972; Wienberg, 1977) and it seems likely that the osteoma of the jaws exists as a true benign neoplasm of bone. Lucas (1976), discussing the nature of jaw lesions which have been designated as osteochrondromas, indicated that these may not all be of the same type. Some are analagous to the hyperplastic lesions of long bones while a few may be neoplastic. In the case described in this paper it was felt that the lesion was neoplastic and that the continued growth was by apposition of new bone and not through endochrondral ossification of a growing cartillaginous cap, although small foci of cartilage were present. The diagnosis of cancellous osteoma appeared more appropriate to describe this lesion. It was felt that the episode of facial trauma noted in the history had drawn attention to the slowly growing neoplasm but played no part in the aetiology. The surgical approach to the coronoid process may be intra-oral, submandibular or preauricular (James, Alexander & Traver, 1974). With large lesions of the coronoid process, osteotomy of the malar arch may be required (Simon, Kendrick & Whitlock, 1977) and good access to this region has been obtained using the bicoronal flap (Eveson, MacDonald & Moos, 1977). A less radical approach is the extended preauricular incision which was used in this case. This approach gave good access and allowed removal of the tumour without sectioning of the tumour mass. References Cooke, B. E. D. (1957). Benign fibro-osseous enlargements
of the jaws. II Neoplastic enlargements.
British Dental Journal, 102, 49. Dahlin, D. C. (1978). Bone Turnours. 3rd Edition p. 71. Springfield, Illinois, Charles C. Thomas.
Eveson, J. W., Moos, K. F. & MacDonald, D. G. (1977). Aneurysmal bone cyst of the xygomatic arch. British Journal of Oral Surgery, 15, 259. Gardner, E. J. & Richard, R. C. (1953). Multiple cutaneous and subcutaneous lesions occurring simultaneously with hereditary polyposis and osteomatosis.American Journal ofHuman Genetics, 5,139. Hitchin, A. D. & White, J. W. (1955). Central osteoma of the mandible. Oral Surgery, Oral Medicine, Oral Pathology, 8,694.
Jaffe, H. L. (1958). Tumours and Tumorous Conditions of the Bone and Joints. p. 136. Philadelphia; Lea & Febiger. James, R. B., Alexander, R. W. & Traver, J. G. (1974). Osteochrondroma of the mandibular coronoid process. Report of a case. Oral Surgery, Oral Medicine, Oral Pathology, 31, 189. Leopard, P. J. (1972). Osteoma of the maxillary antrum. British Journal of Oral Surgery, 10,73. Lewars, P. H. (1959). Osteoma of the mandible. British Journal of Plastic Surgery, 12, 277. Lucas, R. B. (1976). Pathology of Tumours ofthe Oral Tissues. 3rdEdition. p. 193. Edinburgh; Churchill Livingstone. Nelson, D. F., Gross, B. D. & Miller, F. E. (1972). Osteoma of the mandibular condyle. Report of a case. Journal of Oral Surgery,
30, 761.
CANCELLOUS
OSTEOMA
OF THE
CORONOID
PROCESS
55
Simon, G. T., Kendrick, R. W. & Whitlock, R. I. H. (1977). Osteochondroma of the mandibular condyle. Case report and its management. Oral Surgery, Oral Medicine, Oral Pathology, 43, 18. Spjut, H. .I., Dorfman, H. D., Fechner, R. E. &Ackerman, L. V. (1971). Tumours ofBomand Cartilage pp. 117-119. Armed Forces Institute of Pathology, Washington D.C. Tratman, E. K. (1940). Central osteoma of the mandible. British Dental Journal, 68, 14. Versnel, J. C. (1956). Osteomas of the oral cavity. Journal of Oral Surgery, 14, 61. Weinberg, S. (1977). Osteoma of the mandibular condyle. Report of a case. Journal of Oral Surgery, 35, 929.
Worman, H. G., Waldron, C. W. & Radisch, D. F. (1946). Osteoma of the mandibular condyle with deviation prognathic deformity: Report of a case. Journal of Oral Surgery, 4, 27.
(1983) 21,49-55 of Oral Surgeons
CANCELLOUS OSTEOMA OF THE CORONOID PROCESS: REPORT OF A CASE R. A. ORD, B.D.s., M.B., B.ch., F.D.s.R.c.P.s.,’ J. S. RENNIE, B.D.s., Ph.D., F.D.s.R.c.P.s.,M.R.C.P~~~.,‘D.G.MACDONALD, R.D.,B.D.s., Ph.D., M.R.C.Path.‘and K. F. Moos, B.D.S.,M.B.,B.S.,F.D.S.R.C.S.(Eng)3 ‘Oral Surgery Department, Queen Victoria Hospital, East Grinstead, Sussex; ‘Department of Oral Medicine and Pathology, Glasgow Dental Hospital and Canniesburn School, Glasgow; 30ral and Maxillofacial Surgery Department, Hospital, Glasgow Summary. A case of cancellous osteoma of the coronoid process is presented. The differential diagnosis and the surgical approach to large lesions of the coronoid process are discussed.
Introduction True osteomas of the jaws are uncommon bony neoplasms (Lewars, 1959; Spjut et or compact bone and may arise centrally within bone or in a peripheral or subperiosteal location (Lucas, 1976). Cooke (1957) reported 11 cases of osteomas, noting that cancellous osteomas occur more commonly in females and compact osteomas occur predominantly in males. This distribution of cancellous and compact osteomas appears true for the majority of reported jaw lesions (Weinberg, 1977) although Spjut et al. (1971) record an overall male:female ratio of 2: 1 for all osteomas. Osteomas are usually slowly growing and symptomless. Facial asymmetry is the most common presenting complaint although pain may be a feature of central tumours (Hitchin & White, 1955). Osteoma is most common in the fourth and fifth decades but lesions have been reported from l&79 years (Spjut et al., 1971). The neoplasm is usually solitary, but multiple tumours occur as part of Gardner’s syndrome (Gardner & Richards, 1953). The mandible is more commonly involved than the maxilla (Lucas, 1976). Worman et al. (1946) and Weinberg (1977) have reported condylar lesions and Lewars (1959) has described a compact osteoma of the coronoid process but no other case of cancellous osteoma of the coronoid process appears to have been recorded.
al., 1971), which consist of cancellous
Case History A 40-year-old Caucasian male was first seen in 1970 with a seven week history of a tingling sensation over the left zygomatico-temporal region. A history was elicited of trauma to the face some eleven months previously, with a possible fracture of the left malar complex. Examination revealed a swelling over the left side of the cheek in the zygomatico-temporal area suggestive of a bony enlargement. Paraesthesia were noted in the left zygomatico-temporal nerve distribution. Radiographs confirmed an old displaced left malar fracture. No surgery was indicated and the symptoms appeared to resolve. Three years later the patient was referred again with pain in the right ear and the left temporo-mandibular joint accompanied by difficulty in opening the mouth. (Received 26 October 1981; accepted 23 November 1981)
49
50
BRITISH
JOURNAL
OF
ORAL
SURGERY
FIG. 1. Frontal view showing swelling of left zygomatico-temporal
FIG.
region.
2. Lateral view of mandible showing enlarged coronoid process.
CANCELLOUS
FIG. 3. Bulbous
tumour
OSTEOMA
of coronoid
OF THE
process
clearly
CORONOID
PROCESS
seen on occipitomental
51
radiograph.
Examination revealed mild bilateral otitis externa and trismus limited to two finger breadths of opening. Radiographs suggested a possible ankylosis between the coronoid process and the left malar arch. A diagnosis of post-traumatic ankylosis was made. Surgery was advised, but the patient refused this. Follow-up at irregular intervals during the ensuing years revealed a slow increase in size of the swelling in the zygomatico-temporal area with increasing trismus. In 1979 the patient was referred again with pain and severe trismus. A large swelling was noted in the left zygomatico-temporal area (Fig. 1). Radiographs revealed a well defined globular enlargement of the left coronoid process (Fig. 2). The mass was radio-opaque and had a uniform pattern of calcification (Fig. 3). A provisional diagnosis was made of a slow growing benign osseous neoplasm, possibly an osteochondroma. The patient agreed to have surgery in October 1979. Under general anaesthesia a large well circumscribed bony tumour of the coronoid process was exposed through a preauricular incision extending into the temporo-frontal region (Fig. 4). Because of the size of the tumour, the malar arch was sectioned and displaced laterally to expose
52
BRITISH
JOURNAL
OF ORAL
SURGERY
FIG.4. Surgical removal of tumour following section of zygomatic arch.
the whole of the tumour. The coronoid process was sectioned at the level of the sigmoid notch and then easily delivered. No ankylosis was present. The malar arch was wired back in place and the pterygoid space was drained. The patient made a satisfactory post-operative recovery and when reviewed one year after surgery was well with good opening, normal movements of the jaw and no signs of a recurrence. There was some residual weakness of the left occipito-frontalis muscle. Pathology The specimen consisted of a slightly nodular bony tumour measuring 40 x 35 x 20 mm. Decalcified sections showed prominent trabeculae of mature lamellar bone (Fig. 5). The intertrabecular area consisted mainly of fatty tissue although some haemopoietic marrow was also noted. The lesion was largely surrounded by a highly cellular periosteum and new appositional bone growth was occurring in relation to this periosteum. No cartilaginous cap, such as is found in an osteochondroma, was noted although small isolated areas of endochrondral ossification were present (Fig. 6). These formed in total less than four per cent of the surface of the tumour. The possibility was considered that this lesion was a burnt out osteochrondroma, but because of the progressive growth over many years and the presence of continued appositional bone growth it was felt that this lesion was more accurately designated as a cancellous osteoma.
CANCELLOUS
5. Low power photomicrograph
OSTEOMA
OF THE
CORONOID
PROCESS
showing fine trabecullar pattern of bone with fatty marrow. H. &E. x 9.5.
FIG. 6. (A). Highly cellular periosteum
with appositional bone growth. H. & E. x 115. (B). Area of endochondral ossification. H. & E. x 70.
54
BRITISH
JOURNAL
OF
ORAL
SURGERY
Discussion
Some authors have doubted the existence of osteoma of the jaws as an independent neoplastic entity. Jaffe (1958) considered it most likely that ‘highly ossified solitary lesions of the jawbones’ be included in the category of fibrous dysplasia. Similarly Dahlin (1978) and Lucas (1976) both noted the wide variety of nonneoplastic conditions previously designated ‘osteoma’. Reactive changes from trauma, infection, exostoses and ancient osteochrondromas have all been included in this group. In addition earlier reported jaw lesions almost certainly contain examples of cementoblastoma (Tratman, 1940) and focal sclerosing osteomyelitis (Versnel, 1956; Hitchin & White, 1955), a view supported by the history of tooth extraction and the success of antibiotic therapy. To add to the confusion there are a number of reports which rely totally on the radiographical appearances and lack histological confirmation (Cooke, 1957; Worman, Waldron & Radisch, 1946). There are, however, convincing examples of osteomas of the jaws (Lewars, 1959; Leopard, 1972; Nelson, Gross & Miller, 1972; Wienberg, 1977) and it seems likely that the osteoma of the jaws exists as a true benign neoplasm of bone. Lucas (1976), discussing the nature of jaw lesions which have been designated as osteochrondromas, indicated that these may not all be of the same type. Some are analagous to the hyperplastic lesions of long bones while a few may be neoplastic. In the case described in this paper it was felt that the lesion was neoplastic and that the continued growth was by apposition of new bone and not through endochrondral ossification of a growing cartillaginous cap, although small foci of cartilage were present. The diagnosis of cancellous osteoma appeared more appropriate to describe this lesion. It was felt that the episode of facial trauma noted in the history had drawn attention to the slowly growing neoplasm but played no part in the aetiology. The surgical approach to the coronoid process may be intra-oral, submandibular or preauricular (James, Alexander & Traver, 1974). With large lesions of the coronoid process, osteotomy of the malar arch may be required (Simon, Kendrick & Whitlock, 1977) and good access to this region has been obtained using the bicoronal flap (Eveson, MacDonald & Moos, 1977). A less radical approach is the extended preauricular incision which was used in this case. This approach gave good access and allowed removal of the tumour without sectioning of the tumour mass. References Cooke, B. E. D. (1957). Benign fibro-osseous enlargements
of the jaws. II Neoplastic enlargements.
British Dental Journal, 102, 49. Dahlin, D. C. (1978). Bone Turnours. 3rd Edition p. 71. Springfield, Illinois, Charles C. Thomas.
Eveson, J. W., Moos, K. F. & MacDonald, D. G. (1977). Aneurysmal bone cyst of the xygomatic arch. British Journal of Oral Surgery, 15, 259. Gardner, E. J. & Richard, R. C. (1953). Multiple cutaneous and subcutaneous lesions occurring simultaneously with hereditary polyposis and osteomatosis.American Journal ofHuman Genetics, 5,139. Hitchin, A. D. & White, J. W. (1955). Central osteoma of the mandible. Oral Surgery, Oral Medicine, Oral Pathology, 8,694.
Jaffe, H. L. (1958). Tumours and Tumorous Conditions of the Bone and Joints. p. 136. Philadelphia; Lea & Febiger. James, R. B., Alexander, R. W. & Traver, J. G. (1974). Osteochrondroma of the mandibular coronoid process. Report of a case. Oral Surgery, Oral Medicine, Oral Pathology, 31, 189. Leopard, P. J. (1972). Osteoma of the maxillary antrum. British Journal of Oral Surgery, 10,73. Lewars, P. H. (1959). Osteoma of the mandible. British Journal of Plastic Surgery, 12, 277. Lucas, R. B. (1976). Pathology of Tumours ofthe Oral Tissues. 3rdEdition. p. 193. Edinburgh; Churchill Livingstone. Nelson, D. F., Gross, B. D. & Miller, F. E. (1972). Osteoma of the mandibular condyle. Report of a case. Journal of Oral Surgery,
30, 761.
CANCELLOUS
OSTEOMA
OF THE
CORONOID
PROCESS
55
Simon, G. T., Kendrick, R. W. & Whitlock, R. I. H. (1977). Osteochondroma of the mandibular condyle. Case report and its management. Oral Surgery, Oral Medicine, Oral Pathology, 43, 18. Spjut, H. .I., Dorfman, H. D., Fechner, R. E. &Ackerman, L. V. (1971). Tumours ofBomand Cartilage pp. 117-119. Armed Forces Institute of Pathology, Washington D.C. Tratman, E. K. (1940). Central osteoma of the mandible. British Dental Journal, 68, 14. Versnel, J. C. (1956). Osteomas of the oral cavity. Journal of Oral Surgery, 14, 61. Weinberg, S. (1977). Osteoma of the mandibular condyle. Report of a case. Journal of Oral Surgery, 35, 929.
Worman, H. G., Waldron, C. W. & Radisch, D. F. (1946). Osteoma of the mandibular condyle with deviation prognathic deformity: Report of a case. Journal of Oral Surgery, 4, 27.