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Int. J. Oral Maxillofac. Surg. 2012; xxx: xxxxxx 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: a systematic review of the 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; xxx: xxxxxx. # 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 malefemale ratio was 3.3 to 1. In 94% of the cases the approach was intra-oral. 84% of the cases received a coronoidectomy. Statistical analysis showed that the preoperative and postoperative differences between the groups were signicant. The results were not signicant when corrected for the preoperative difference. Postoperative therapy was not comparable due to heterogeneity. Cases that received a coronoidotomy had slightly better postoperative results.

C. H. Mulder, S. I. Kalaykova, R. A. Th. Gortzak

Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, The Netherlands

Keywords: Coronoid process hyperplasia; Coronoidectomy; Coronoidotomy; Limited mouth opening. Accepted for publication 20 March 2012

Mandibular coronoid process hyperplasia (CPH) is a rare condition causing a slow, progressive reduction of mouth opening.1 CPH is dened as an abnormal elongation of the mandibular coronoid process consisting of histologically normal bone.1 This leads to impingement of the coronoid process on the body or arch of the zygomatic 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
0901-5027/000001+07 $36.00/0

of coronoid hyperplasia were reported together with a meta-analysis of previous data. They emphasized the normal histology 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 outcome was generally disappointing, possibly due to the formation of a haematoma or intra-oral brosis. The authors hypothesized that the extra-oral approach might cause less brosis, but too few extra-oral

surgeries were performed to compare their postoperative measures with those of intra-oral surgeries. Postoperative physiotherapy (stretching exercises) were considered to be essential for the preservation 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. coronoidotomy).

# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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YIJOM-2398; No of Pages 7

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to be signicant if p < 0.05. Management of the database and statistical analyses were performed using SPSS for Windows version 17.0.
Results

Materials and methods

A systematic search in the Pubmed database was conducted to nd related articles. In the search, the following Medical Subjects Headings (MeSH) terms were used: coronoid, hyperplasia, and mandible. The following free-text terms were entered as synonyms. For the term coronoid, 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 hypertrophy. 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 impingement was present, and/or histology and morphology of the coronoid process was characteristic for an osteochondroma. From the included articles, specic 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 signicant 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 coronoidotomy groups. Cases were ltered 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, nal MMO and MMO difference. A univariate analysis of variance (UNIANCOVA) was performed on the nal MMO with the preoperative MMO as covariate. Differences were considered

The literature search was performed on 4 June 2010. The search led to 39 hits of which 35 articles were considered relevant. The full text of 5 articles could not be retrieved. With additional cross-referencing 5 relevant articles were found of which 4 were retrieved. Of the 34 articles that were assessed in full text,234 8 articles 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

was slightly more frequent in women, and the bilateral form more frequent in men. There was no signicant 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 232 mm, SD = 7). In 93% of the cases it was 25 mm or less and in 77.8% 20 mm or less. With the unilateral form, facial asymmetry and deviation towards the affected side can be present.10,34 The mouth opening limitation sometimes interfered with eating, speaking 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 pressure 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

No epidemiological studies and therefore no incidence and prevalence numbers regarding CPH were found. The mean age at diagnosis was 23 years (range 061 years, SD = 14.4). To analyze the age distribution, cases were categorized in groups of 5 years. A peak in cases was noted in the 1519 years group. In 4 cases the condition appeared to be congenital11,16,34 and symptoms were apparent shortly after birth. 9 cases were diagnosed under the age of 10 years, and in this early form the movement limitation 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 diagnosis. In 28 cases (46%) the duration of symptoms was recorded anamnestically and retrospectively. The average duration was 7 years (range 120 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 temporomandibular 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

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 support 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 brous bands were palpated at the insertion of temporalis muscles.24 This was visualized in another report by means of a preoperative magnetic resonance imaging (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 objectied by histology of resected masseter specimens. It showed brous changes and calcications, 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 syndrome, which is characterized by facial musculature paralysis at birth.11 In these

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YIJOM-2398; No of Pages 7

Coronoid process hyperplasia: a systematic review of the literature from 1995

Table 1. Case summaries. Age (yrs) 34 22 41 25 14 15 14 13 32 16 25 17 20 17 15 16 23 28 61 17 1 0 7 14 14 26 8 5 17 15 13 35 17 24 36 55 34 28 53 38 52 18 4 28 56 23 2 18 35 45 5 14 16 24 39 28 20 3 41 14 29 History (yrs) 17 4 NS 10 2 1 2 3 17 2 8 NS 7 5 5 NS NS NS NS 14 1 NS NS NS NS 3 8 NS 1 2 1 18 NS NS 20 NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS 13 13 NS 2 6 2 14 Preoperative MMO (mm) 19 5 15 16 13 15 12 18 20 20 24 18 13 17 18 19 NS NS NS 22 8 10 17 2 25 22 6 17 25 25 27 15 14 27 20 32 18 13 NS 7 22 NS NS NS 25 10 10 16 5 10 4 15 14 18 8 30 12 5 15 6 20 Peroperative MMO (mm) 35 NS 25 NS 22 NS NS NS NS NS NS 28 20 NS NS 25 NS NS NS 48 NS NS NS NS NS 35 33 NS 40 40 40 NS NS NS 30 NS 44 NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS 40 50 30 NS 25 40 40 Final MMO (mm) NS 20 25 30 37 41 48 38 38 45 43 35 27 39 40 38 NS NS NS 45 25 40 NS NS NS 22 30 40 40 46 45 35 NS NS 38 NS 38 40 30 35 NS 30 30 30 NS 23 25 30 31 31 32 33 40 40 31 43 35 35 22 30 39

Authors 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 Gibbons Loh et al. Loh et al. Loh et al. Loh et al. Gerbino et al. Gerbino et al. Gerbino et al. Gerbino et al. Gerbino et al. Yamaguchi et al. Pregarz et al. Pregarz et al. Pregarz et al. Pregarz et al. Pregarz et al. Kubota et al. Kubota et al. Kubota et al. Mavili et al. Turk Turk Asaumi et al. Asaumi et al. Leonardi Colquhoun et al. Fabie et al. Mano et al. Tieghi et al. Tieghi et al. Satoh et al. Leovic et al. Kursoglu and Capa Kursoglu and Capa Gibbons and Abulhoul Mazzetto et al. Yoshida et al. Ferro et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Wenghoefer et al. Zhong et al. Yura et al. Baraldi et al. Galie et al. The authors patient The authors patient The authors patient

Year 1995 1997 1997 1997 1997 1997 1997 1997 1997 1997 1998 1998 1998 1998 1998 1998 1999 1999 1999 1999 1999 1999 2001 2001 2001 2002 2002 2005 2005 2005 2006 2006 2006 2006 2007 2007 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2008 2009 2009 2010 2010 2010 2010 2010

Type bi bi bi bi bi uni uni bi bi bi uni uni bi bi bi bi bi bi bi uni bi bi bi bi bi bi bi bi bi bi bi bi bi bi bi uni bi bi uni uni uni uni bi bi bi bi bi bi bi bi bi bi bi bi uni uni uni uni bi bi bi

Sex M M M F M M M M M M M M M M M M F F M M M NS M M M M F M F M M M M M M M F M F M M F M M M M F M M M F M M M F M F F F M M

Approach IO EO IO IO IO IO IO IO IO IO IO IO IO IO IO IO NS NS NS Endo IO IO NS NS NS IO IO IO IO IO IO NS None None IO None IO IO NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS NS IO IO IO EO IO IO IO

Type Ectomy Ectomy ectomy Ectomy Ectomy Tomy Tomy Tomy Tomy Tomy Ectomy Ectomy Ectomy Ectomy Ectomy Tomy NS NS NS Ectomy Ectomy Ectomy NS NS NS Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Tomy None None Ectomy None Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Ectomy Tomy Ectomy Ectomy Ectomy Ectomy Ectomy

Follow-up (months) NS 4 4 4 12 12 60 15 60 60 18 20 12 12 24 12 NS NS NS 8 4 NS NS NS NS 30 8 82 20 6 8 NS NS NS 12 NS 6 12 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 1215 9 15 8 18 16 4 5

NS, not stated; Uni, unilateral; Bi, bilateral; M, male; F, female; IO, intra-oral; EO, extra-oral.

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YIJOM-2398; No of Pages 7

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of CPH. In 24 patients (39%), a threedimensional (3D) reconstruction was carried 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 abnormalities. An osteochondroma has a characteristic stalked appearance also described as a mushroom or condyle shaped. The diagnosis can be conrmed with histopathology of the resected process, which shows a bony mass covered with a cartilage cap and endochondral ossication 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 risk of facial nerve damage and a visible scar are the main disadvantages. During a coronoidectomy, the temporalis muscle bres are stripped from the process after which it is entirely resected. Advantages are that the mechanical cause of the impingement is removed and histology of the specimen can be undertaken to conrm or revise the diagnosis. On the other hand, the release of the temporalis insertion can be a difcult 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 masseter muscle stripping was performed to increase mouth opening because muscles may undergo brotic changes after a signicant period of disuse.7,25 Postoperative physiotherapy is considered to play an important role in maintaining 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 coronoidotomy. 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 signicantly larger preoperative

cases, hypoplasia of the mandible and masticatory muscles was present which also contradicts the temporalis hyperactivity theory. Two reports suggest the inuence 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 hypomobility caused by the osteochondroma. Wenghoefer et al. reported two patients who had ankylosis of the TMJ and two others with arthritis beginning destruction.28 These ndings support the mandibular 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 nd 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 ossication. They suggest that a similar mechanism might occur in the temporalis tendon, although they could not conrm 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

Treatment

Orthopantomography (OPT) was carried out in 87% of the cases in the database as a diagnostic imaging method to recognize a coronoid abnormality. Coronoid hyperplasia 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 signicantly higher than the ratio in a control group9 It was concluded that if the ratio exceeded 1.1, additional imaging to conrm CPH was needed. Computed tomography (CT) is the preferred 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 particular, 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 conrm a diagnosis

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 coronoidotomy. The intra-oral approach usually provides enough exposure to remove the hyperplastic process and leaves no visible scar. The biggest disadvantage is the risk of a postoperative haematoma and brosis. Several extra-oral approaches have been described, such as submandibular, pre-auricular, (bi)temporal3,4 or endoscopically assisted.10 Supposed advantages are less brosis and/or haematoma formation, 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. Surgery type Coronoidectomy Intra-oral N Percentage Mean nal MMO (mm) Range (mm) MMO  30 mm (%) MMO  35 mm (%) Mean DMMO (mm) 34 75.5 34.0 2246 79.4 52.9 19.5 Extra-oral 3 6.6 33.3 2045 66.6 66.6 22.7 Total 37 82.2 34.0 2046 78.4 54.1 19.7 8 17.8 40.8 3548 100 100 22.1 45 100 35.2 2048 82.2 62.2 20.2 Coronoido-tomy Total

N, number of cases; Range, minimum and maximum.

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YIJOM-2398; No of Pages 7

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Fig. 1. Scatterplot of preoperative and nal MMO measurements, illustrating the difference in MMO distribution for the two surgery types. Circles and squares represent separate cases.

(p = 0.003) and nal 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 signicant. With this test the outcome was corrected for the signicant difference in preoperative MMO (Fig. 1). An independent t test was also performed on the MMO difference, which conrmed the difference between the groups was not signicant (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 postoperative measurements at different time points were reported. The length of follow-up was specied 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 ndings from 61 cases. A comparison of results after coronoidectomy or coronoidotomy has not been made in previous literature. Other ndings 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 questioned 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 principally caused by the coronoid process impinging on the zygoma. Leonardi et al. conducted the Levandoski panographic analysis in 10 patients with nevoid

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 published 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 diagnosis 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 inuenced by the range. With the age at onset calculation the authors observed the highest case count is in an even younger group. This nding 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 inuence of the temporalis muscle has been suggested by numerous authors. Isberg et al. found that coronoid process elongation could be induced by mandibular hypomobility and temporalis hyperactivity from a study in monkeys.35 Other ndings supporting these theories are the shortened muscle tendon units in trismus pseudocamptodactyly syndrome,25 brous and hypertrophied masticatory muscle tendons3,7,24 and hypertrophic or hypertonic temporalis muscles.28 These features

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process reattached to the ramus, requiring a re-operation,39 but in 5 cases the coronoid had repositioned and reattached in a posterior 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 particularly 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 diagnosis. Thus, because of the slightly better results and an easier procedure it seems useful to perform more coronoidotomies to evaluate if those outcome measures support the observation. It was difcult to compare the postoperative therapy data due to heterogeneity 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 postoperative therapy options, but this seems impossible because the abnormality occurs so infrequently. In the cases analyzed, follow-up data were diverse. In the authors cases a considerable dip was present in the postoperative course. At some point in the early postoperative course the MMO was even smaller than the preoperative measurement, despite adequate exercising. With intensication and continuation of rehabilitation 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, especially for the rst 3 months, so patient compliance and therapy can be improved. In the literature it was stated that the results after surgery were generally disappointing. The question arises what outcome should be regarded as being disappointing. According to the AAOMS impairment guidelines a MMO of 35 mm or more was considered to be an acceptable interincisal distance.40 Others considered 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 rst criterion is used was fairly disappointing (62%). The other criterion results in an 82% success rate. So it is of great inuence 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 conrm or discard this nding.9
Funding

are not present in every CPH patient and several EMG studies revealed no abnormalities. Nevertheless more ndings were reported supporting this theory than opposing it. All 3 of the authors patients had prominent mandibular angles as was seen on the OPT. One of them had apparent masseter hypertrophy. The other two had parafunctional 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 appearance 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 processes, 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 hyperactivity was suggested to have an inuence.35 This indirectly supports the temporalis hyperactivity theory for CPH because the masticatory muscles are closely related. No conclusive evidence was found afrming the aetiology of either of these conditions. For the MMO analysis, the authors used the last stated MMO after surgery for the nal 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 compare the intra-oral approach with the extraoral one.1 Since their review, only 3 extraoral 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 coronoidotomy). The authors found a signicant difference in preoperative and nal MMO, but not in the MMO improvement. The power of these ndings is limited by the fact that the group sizes were not equal (30 vs 8) and the postoperative therapy measures 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

None.
Competing interests

None declared.
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Not required.
References
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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

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Please cite this article in press as: Mulder CH, et al. Coronoid process hyperplasia: a systematic review of the literature from 1995, Int J Oral Maxillofac Surg (2012), http://dx.doi.org/10.1016/j.ijom.2012.03.029