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Osteochondroma of the mandibular coronoid process: a rare cause of limited mouth opening
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
Short communication
Osteochondroma of the mandibular coronoid process: a rare cause of limited mouth opening Osman A. Etöz a,∗ , Alper Alkan a , Ali Yıkılmaz b a
Department of Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry Kayseri, 38039 Kayseri, Turkey b Department of Radiology, Erciyes University Faculty of Medicine Kayseri, Turkey Accepted 31 October 2008 Available online 19 January 2009
Keywords: Jacob’s disease; Osteochondroma; Piezosurgery
Enlargement of the coronoid process of the mandible was first described by Langenbeck in 1899,1 but Jacob reported the pseudojoint between an enlarged mushroom-shaped mandibular coronoid process and the zygoma, now known as Jacob disease.2 The hyperplastic structure of the coronoid process in this disease is rare, and the development of an encapsulated osteochondroma and formation of a joint is unique.3 The symptoms of painless restricted mouth opening and an elongated coronoid process of the mandible seen on panoramic radiographs can be confused with those of temporomandibular dysfunction, ankylosis of the temporomandibular joint, and myofascial pain. Three-dimensional computed tomography (CT) is the gold standard for accurate diagnosis.4
Case report A 43-year-old otherwise healthy woman was referred to our clinic with painless, restricted mouth opening (14 mm) of more than 10 years’ duration. She had been treated for temporomandibular dysfunction with anti-inflammatory drugs and arthrocentesis at various centres, but all treatments had failed and her condition had worsened. Panoramic radiography showed an elongated right mandibular coronoid process (Fig. 1A) and three-dimensional CT showed a mushroomshaped hyperplastic enlargement of the coronoid process ∗
Corresponding author. Tel.: +90 352 437 49 37; fax: +90 352 438 06 57. E-mail address: [email protected] (O.A. Etöz).
that extended under the zygoma and had caused the right inferior lateral orbital wall to expand (Fig. 2). We used piezosurgery to remove the enlarged portion of the coronoid process under local anaesthesia (Fig. 3A). Histopathological evaluation of the lesion confirmed an osteochondroma (Fig. 3B). Postoperative healing was uneventful. Aggressive physical treatment was given to improve function and maximum mouth opening had increased to 30 mm at 6 months follow-up.
Discussion Coronoid and condylar processes of the mandible have been described as the most common sites for the growth of osteochondroma within the facial bones.5 While it is known to arise from metaplastic cartilage that is generated by periosteum,6 it has been reported that excessive stress caused by tension of the temporalis muscle might be its cause.7 This may explain the predisposition of the coronoid process of the mandible for its growth. Removal of the enlarged portion of the coronoid process is the definitive treatment, and recurrence after adequate excision is rare.8 Many surgeons are reported to prefer the extraoral approach, while others choose a combination of intraoral and extraoral approaches.6 Emekli et al.8 reported two cases, one of which was treated intraorally, and the other with a combined intraoral and extraoral approach. They preferred the combined approach because the enlarged coronoid process was trapped over the zygomatic arch.
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.10.021
410
O.A. Etöz et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
Fig. 1. (A) Preoperative and (B) postoperative panoramic views of the patient (white arrow indicates the elongated coronoid process).
Roychoudhury et al.6 also did not recommend an intraoral approach because the mushroom-shaped lesion was difficult to remove. Preoperative three-dimensional reconstruction by CT is essential to establish the exact extent of the lesion, and to decide whether an intraoral or extraoral approach will be used. An intraoral approach alone may be considered
favourable even under local anaesthesia because of a shorter operating time, rapid healing, lack of scar formation, or possible nerve damage. We chose piezosurgery under local anaesthesia, but intraoral removal of the mushroom-shaped mass was difficult as the wider portion of the lesion was below the zygoma. Patients should be informed that the intraoral approach might be unsuitable particularly for
Fig. 2. Computed tomograms showing (A) expansion at the lateral orbital wall caused by the lesion; (B) mushroom-shaped lesion below the zygoma; (C) elongated coronoid process of the mandible; (D) axial section of the joint formation between the lesion and the zygoma (white arrows indicate the lesion).
O.A. Etöz et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
411
Fig. 3. (A) Excised portion of the coronoid process (note the smooth surface of the lesion indicating the joint formation), and (B) histopathological examination of the lesion (haematoxylin and eosin, original magnification 4×). (a) = bone layer; (b) = development of cartilage; (c) = overlying periosteum.
mushroom-shaped masses when it should be combined with an extraoral approach.
References 1. von Langenbeck B. Angeborene Kleinheit der Unterkiefer. Langenbeck’s Archiv 1861;1:451–6. 2. Jacob O. Une cause rare de constriction permanente des machoires. Bull et Mem de la Societe Anatomique de Paris 1899;1:917– 9. 3. Hernández-Alfaro F, Escuder O, Marco V. Joint formation between an osteochondroma of the coronoid process and the zygomatic arch (Jacob disease): report of case and review of literature. J Oral Maxillofac Surg 2000;58:227–32.
4. Akan H, Mehreliyeva N. The value of three-dimensional computed tomography in diagnosis and management of Jacob’s disease. Dentomaxillofac Radiol 2006;35:55–9. 5. Ortakoglu K, Akcam T, Sencimen M, Karakoc O, Ozyigit HA, Bengi O. Osteochondroma of the mandible causing severe facial asymmetry: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e21–8. 6. Roychoudhury A, Gupta YK, Parkash H, Karak AK. Jacob disease: report of a case and review of the literature. J Oral Maxillofac Surg 2002;60:699–703. 7. Wolford LM, Mehra P, Franco P. Use of conservative condylectomy for treatment of osteochondroma of the mandibular condyle. J Oral Maxillofac Surg 2002;60:262–8. 8. Emekli U, Aslan A, Onel D, Cizmeci O, Demiryont M. Osteochondroma of the coronoid process (Jacob’s disease). J Oral Maxillofac Surg 2002;60:1354–6.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
Short communication
Osteochondroma of the mandibular coronoid process: a rare cause of limited mouth opening Osman A. Etöz a,∗ , Alper Alkan a , Ali Yıkılmaz b a
Department of Oral and Maxillofacial Surgery, Erciyes University Faculty of Dentistry Kayseri, 38039 Kayseri, Turkey b Department of Radiology, Erciyes University Faculty of Medicine Kayseri, Turkey Accepted 31 October 2008 Available online 19 January 2009
Keywords: Jacob’s disease; Osteochondroma; Piezosurgery
Enlargement of the coronoid process of the mandible was first described by Langenbeck in 1899,1 but Jacob reported the pseudojoint between an enlarged mushroom-shaped mandibular coronoid process and the zygoma, now known as Jacob disease.2 The hyperplastic structure of the coronoid process in this disease is rare, and the development of an encapsulated osteochondroma and formation of a joint is unique.3 The symptoms of painless restricted mouth opening and an elongated coronoid process of the mandible seen on panoramic radiographs can be confused with those of temporomandibular dysfunction, ankylosis of the temporomandibular joint, and myofascial pain. Three-dimensional computed tomography (CT) is the gold standard for accurate diagnosis.4
Case report A 43-year-old otherwise healthy woman was referred to our clinic with painless, restricted mouth opening (14 mm) of more than 10 years’ duration. She had been treated for temporomandibular dysfunction with anti-inflammatory drugs and arthrocentesis at various centres, but all treatments had failed and her condition had worsened. Panoramic radiography showed an elongated right mandibular coronoid process (Fig. 1A) and three-dimensional CT showed a mushroomshaped hyperplastic enlargement of the coronoid process ∗
Corresponding author. Tel.: +90 352 437 49 37; fax: +90 352 438 06 57. E-mail address: [email protected] (O.A. Etöz).
that extended under the zygoma and had caused the right inferior lateral orbital wall to expand (Fig. 2). We used piezosurgery to remove the enlarged portion of the coronoid process under local anaesthesia (Fig. 3A). Histopathological evaluation of the lesion confirmed an osteochondroma (Fig. 3B). Postoperative healing was uneventful. Aggressive physical treatment was given to improve function and maximum mouth opening had increased to 30 mm at 6 months follow-up.
Discussion Coronoid and condylar processes of the mandible have been described as the most common sites for the growth of osteochondroma within the facial bones.5 While it is known to arise from metaplastic cartilage that is generated by periosteum,6 it has been reported that excessive stress caused by tension of the temporalis muscle might be its cause.7 This may explain the predisposition of the coronoid process of the mandible for its growth. Removal of the enlarged portion of the coronoid process is the definitive treatment, and recurrence after adequate excision is rare.8 Many surgeons are reported to prefer the extraoral approach, while others choose a combination of intraoral and extraoral approaches.6 Emekli et al.8 reported two cases, one of which was treated intraorally, and the other with a combined intraoral and extraoral approach. They preferred the combined approach because the enlarged coronoid process was trapped over the zygomatic arch.
0266-4356/$ – see front matter © 2009 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.10.021
410
O.A. Etöz et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
Fig. 1. (A) Preoperative and (B) postoperative panoramic views of the patient (white arrow indicates the elongated coronoid process).
Roychoudhury et al.6 also did not recommend an intraoral approach because the mushroom-shaped lesion was difficult to remove. Preoperative three-dimensional reconstruction by CT is essential to establish the exact extent of the lesion, and to decide whether an intraoral or extraoral approach will be used. An intraoral approach alone may be considered
favourable even under local anaesthesia because of a shorter operating time, rapid healing, lack of scar formation, or possible nerve damage. We chose piezosurgery under local anaesthesia, but intraoral removal of the mushroom-shaped mass was difficult as the wider portion of the lesion was below the zygoma. Patients should be informed that the intraoral approach might be unsuitable particularly for
Fig. 2. Computed tomograms showing (A) expansion at the lateral orbital wall caused by the lesion; (B) mushroom-shaped lesion below the zygoma; (C) elongated coronoid process of the mandible; (D) axial section of the joint formation between the lesion and the zygoma (white arrows indicate the lesion).
O.A. Etöz et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 409–411
411
Fig. 3. (A) Excised portion of the coronoid process (note the smooth surface of the lesion indicating the joint formation), and (B) histopathological examination of the lesion (haematoxylin and eosin, original magnification 4×). (a) = bone layer; (b) = development of cartilage; (c) = overlying periosteum.
mushroom-shaped masses when it should be combined with an extraoral approach.
References 1. von Langenbeck B. Angeborene Kleinheit der Unterkiefer. Langenbeck’s Archiv 1861;1:451–6. 2. Jacob O. Une cause rare de constriction permanente des machoires. Bull et Mem de la Societe Anatomique de Paris 1899;1:917– 9. 3. Hernández-Alfaro F, Escuder O, Marco V. Joint formation between an osteochondroma of the coronoid process and the zygomatic arch (Jacob disease): report of case and review of literature. J Oral Maxillofac Surg 2000;58:227–32.
4. Akan H, Mehreliyeva N. The value of three-dimensional computed tomography in diagnosis and management of Jacob’s disease. Dentomaxillofac Radiol 2006;35:55–9. 5. Ortakoglu K, Akcam T, Sencimen M, Karakoc O, Ozyigit HA, Bengi O. Osteochondroma of the mandible causing severe facial asymmetry: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e21–8. 6. Roychoudhury A, Gupta YK, Parkash H, Karak AK. Jacob disease: report of a case and review of the literature. J Oral Maxillofac Surg 2002;60:699–703. 7. Wolford LM, Mehra P, Franco P. Use of conservative condylectomy for treatment of osteochondroma of the mandibular condyle. J Oral Maxillofac Surg 2002;60:262–8. 8. Emekli U, Aslan A, Onel D, Cizmeci O, Demiryont M. Osteochondroma of the coronoid process (Jacob’s disease). J Oral Maxillofac Surg 2002;60:1354–6.