200
currence of primary and metastatic tumors in this re-
gion.
The 12 cases of metastatic esophageal cancer, in-
cluding our case, were all carcinomas. Histologically,
there were eight cases ofSCC,s,7,9.12,14 three of AC,4,6,13
and one of small cell carcinoma," Interestingly, com-
pared with AC, which metastasized to bone and in-
vaded the surrounding soft tissue, SCC metastasized
to soft tissue and invaded the bone. All the patients
were males and half were Japanese. The incidence of
esophageal cancer in Japan is high, as is its frequency
in men.
The histologic type is almost always SCc. 16 The av-
erage age at diagnosis was 55.8 years. In four of the 12
cases,6,IO,12,13 the patients had symptoms of mandibular
or maxillary pain and swelling as the initial manifes-
tation of malignant disease. The prognosis of these pa-
tients was very poor, with only one reported to be alive
when the report was published." The mean period from
the appearance of metastasis to death was 5.05 months
(Table 1).
References
I. Meyer I, Shklar G: Malignant tumors metastatic to mouth and
jaws. Oral Surg 20:350, 1965
2. Takahashi Y, Yanagisawa T, Onoe Y, et al: A case of suspected
J Oral Maxillofac Surg
51:200-204,1993
Healing of Fractures of the
Coronoid Process:
Report of Cases
YASUHARU TAKENOSHITA, DDS, DDSc,* TAKASHI ENOMOTO, DDS,t
AND MASUICHIRO OKA, MD, DMSc+
Fractures of the coronoid process are rare, and little
has been written about them because oftheir relatively
unimportance.l-' Isolated fractures in this area are ex-
ceedingly uncommon and are often the result of 10-
Received from the Second Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, Kyushu University, Fukuoka, Japan.
* Associate Professor.
t Former Resident.
* Professor.
Address correspondence and reprint requests to Dr Takenoshita:
Second Department of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Kyushu University 61, 3-1-1 Maidashi, Higashiku, Fu-
kuoka, 812 Japan.
© 1993 American Association of Oral and Maxillofacial Surgeons
0278-2391/93/5102-0018$3.00/0
HEALING OF CORONOID PROCESS FRACTURES
metastasis of small cell carcinoma oflung to the pre-auricular
region. Jpn J Oral Maxillofac Surg 37:1894, 1991
3. Thoma KH: Tumors of the condyle and temporomandibular
joint. Oral Surg 7:1091, 1954
4. Anderson RS, Peeples WJ: Mandibular osseous metastasis from
esophageal carcinoma. J Oral Maxillofac Surg 48: 188, 1980
5. Harada T, Tanaka M, Kishimoto H, Yoshimura Y: Esophageal
carcinoma metastasized to the mental region. Jpn J Oral
Maxillofac Surg 31:2415,1985
6. Jones DC: Adenocarcinoma of the esophagus presenting as a
mandibular metastasis. J Oral MaxiIlofac Surg 47:504, 1989
7. Kurashina K, Takeda S, Yamagishi K, et al: Esophageal carci-
noma metastatic to the mandible. J Jpn Stomatol Soc 30: 121,
1981
8. Miyahara H, Umatani K, Senba 0, Yoshino K.: Metastatic tumors
to the head and neck region. J Otolaryngol Jpn 86:951, 1983
9. Robinson ER, Stuteville OH: Metastatic tumors to the tongue.
Oral Surg 15:980, 1962
10. Sakashita H, Miyata M, Hayashi M, Kurumaya H: Three cases
of metastatic carcinoma in oral and neck region. J Jpn Sto-
matol Soc 39:90, 1990
II. Shimizu T, Nishimura T, Kaneko M, Morita T, Mizuno A, Su-
giyama A: Metastatic tumors to the gingiva. Jpn J Cancer
Clin 36:719,1990
12. Socolosky M, Bouquot JE, Graves RW: Esophageal carcinoma
metastatic to the oral cavity. J Oral MaxiIlofac Surg 44:825,
1986
13. Tideman H, Arvier JF, Bosanquet AG, Wilson OF: Esophageal
adenocarcinoma metastatic to the maxilla. Oral Surg 62:564,
1986
14. ZegareIli OJ, Tsukada Y, Picken JW, Greene GW: Metastatic
tumor to the tongue. Oral Surg 35:202, 1973
15. Cash CD, Royer BQ, Dahlin DC: Metastatic tumors of the jaws.
Oral Surg 14:897, 1961
16. Robbins SL, Cotran RS: Pathologic Basis of Disease (ed 2). Phil-
adelphia, PA, Saunders, 1982, p 926
calized force.4,s Concomitant fractures ofother portions
of the mandible should be looked for when coronoid
fractures are present. Very little is known about the
changes that occur in the fractured coronoid tip over
time. This article describes the findings in five cases.
Report of Cases
Five cases of coronoid process fracture were treated
in a 6-year period between 1980 and 1985 (Table I).
Follow-up showed that the patients could open their
mouths an average of 35 mm, measured as the inter-
incisal distance. The lateral excursions to both sides
were also within normal limits. Three typical cases are
described.
TAKENOSHITA, ENOMOTO, AND OKA 201

Table 1. Data on Patients With Fractures of the Coronoid Process

Case Age Max. Mouth Opening

No. (yr) Sex Etiology Point of Force Fracture Treatment at Follow-up (mm) Result

25 M AP Right cheek Right zygoma mandibular C >35 Separated

body DBW
MMF4W
2 16 M MC Right cheek Right zygoma DBW 40 Reattached
3 21 F AP Menton Right condylar neck DBW 35 Reattached
mandibular body Plate
MMF3W
4 46 M BC Left cheek Left zygoma TA 48 Reattached
5 18 M AD Left lower lip Right condylar neck, Plate 55 Reattached
symphysis Plate
MMF3W

Abbre viations: AP, automobile accid ent-passenger's seat; MC, motorcycle; BC, bicycle; AD, automobile accident-driver; C, conservative;
DBW, direct bone wiring; TA, Gillies' temporal approach.

Case 1 atively, the patient had good mandibular movement (Fig 6),
and her occlusion has remained stable and normal. She can
A 25-year-old man received an injury to the right cheek chew without any difficulty. A year after operat ion, the mini-
and upper lip in an automobile accident . The lower incisors plate was removed . At that time, the coronoid process and
were avulsed, and radiologic examination revealed a linear condylar neck showed osseous healing (Fig 7).
right zygomatic fracture, fracture ofthe mandible in the right
cani ne region, and a transverse fracture of the coronoid pro-
cess (Fig 1).lntraosseous wiring of the mandibular body was Discussion
performed through an intraoral route. No treatment was
provided for the fractured coronoid process. Maxillornan-
dibular fixation (MMF) was applied for 4 weeks, and the Because of their protected position under the zygo-
healing process was uneventful. matic arch or zygomaticomalar complex, coronoid
At 2-year follow-up, there was no osseous bridging of the fractures due to direct trauma are very uncommon.v'
fractured coronoid process (Fig 2). It was assumed that there WalkerS has described two types of fracture, oblique
was a fibrous union or false joint formation. The patient had and vertical, whereas Brener and Alley?classified them
no mandibular dysfunction but complained of some facial
pain. Consequently, the wires in the canine region were re- as transverse and longitudinal. These two classifications
moved. The patient had a stable occlusion, with a maximum differ in the path of the fracture line.
mouth opening of 35 mm. Several theories have been proposed to explain the
pathogenesis of these fractures . Generally, they are be-
Case 2 lieved to be caused by reflex muscular contracture of
the strong temporalis muscle, which then displaces the
A 16-year-old boy was referred to our department for the
treatment of a right zygomaticomaxillary complex fracture.
On radiologic examination, a fracture of the tip of the coro-
noid process on the right side, with slight displacement, was
noted (Fig 3). The fracture of the zygoma was reduced with
a bone hook and fixed with a single stainless steel wire at the
infraorbital rim. MMF was not applied. At l- year follow-up,
the coronoid process had healed by bony union (Fig 4), and
the patient was able to open his mouth 47 mm.

Case 3
A 23-year-old woman was injured in an automobile ac-
cident. She was sitting in the passenger's seat. On radiologic
examination, a high condylar neck fracture with anteromedial
dislocation , a coronoid process fracture, and a canine region
fracture were present on the right side (Fig 5). The dislocated
condyle was repositioned and fixed by direct wiring via a
preauricular approach and a submandibular incision. In the
right canine area, a mini plate osteosynthesis was done. The
coronoid process fracture was treated conservatively. MMF FIGURE 1. Panoramic radiograph demonstrating a fracture of the
was released 3 weeks after operation and followed by phys- mandibular coronoid process on the right side with little displacement.
iotherapy for restoration of mandibular function. Postoper- Fractures in the right lower canine region and zygoma are also present.
202
FIGURE 2. The fractured tip ofthe coronoid process is in position
2 years after injury. However, note the possible formation of a false
joint appearing as radiolucent line between the tip and the ascending
ramus.
fragment upward into the infratemporal fossa.2, 10 A
similar mechanism has been proposed for fracture of
the genital tubercle of the mandible. I 1,12 The coronoid
process is also sometimes fractured during such oper-
ations as extraction of lower third molars, cystectomy,
or the sagittal split osteotomy. The frequency of coro-
noid process fractures is reported to be 1% to 3% of
the mandibular fractures?,9,13.ls and 0.6% to 4.7% of
all facial or maxillofacial fractures. 16 Isolated coronoid
fractures usually occur concomitantly, with other frac-
tures such as the neck of the condylar process or zygo-
matic bone,S,I? The symptoms of coronoid fractures
vary according to the severity of the injury. Isolated
fractures can cause lateral cross-bite, limitation of
mandibular movement, and slight to moderate swelling
in the region of the zygomatic arch. 4,16
Coronoid fractures are usually simple and linear and
show little displacement. When the traumatic force is
FIGURE 3. Panoramic radiograph showing a sharply defined ra-
diolucent line extending from the apex of the right coronoid process
to the anterior rim of the ramus (arrow). The fractured mandibular
coronoid process is rotated and elevated from its original position
by the temporalis muscle.
HEALING OF CORONOID PROCESS FRACTURES
FIGURE 4. Radiograph showing possible reattachment of the cor-
onoid process to the ramus IO months after injury.
exceedingly violent, the protective musculature may
tear and the fractured coronoid then may be displaced
into the temporal fossa." Thus, a coronoidectomy is
sometimes performed to remove the superior pull of
the temporalis muscle.'" It is difficult to diagnose the
coronoid fractures on clinical examination because
they often present minimal findings.v'? Definitive di-
agnosis, in many cases, is based on radiographic evi-
dence. These fractures can be demonstrated in lateral
oblique radiographs of the mandible and especially in
the panoramic radiograph.v'"
The muscular splinting of the temporalis is usually
sufficient to hold the fragment in position until healing
occurS.9,I3,16 Treatment is controversial and depends
on the degree ofdisplacement of the fractured coronoid
and the severity ofsymptoms. Authors such as Kruger!'
and Converse'? advocate conservative treatment when
there is minimal displacement, and others have advised
no treatment. 2,4,16,1?,19-21
Pain and reflex spasm in the muscles are undoubt-
edly relieved by limitation of mandibular movement.
The lateral cross-bite is usually self-correcting after 1
FIGURE 5. Panoramic radiograph showing an undisplaoed fracture
of the right coronoid process. No treatment was necessary except for
the fractures of right condyle and symphysis.
TAKENOSHlTA, ENOMOTO, AND OKA 203

18.11I up 18... up

right an~

38 .11I 28 .,

right
38 11I11I

-58.. dewn -58.. dewn

Front~l Horizont~l S~gitt~l

[SHIMIZU-1J
870715
FIGURE 6. Mandibular kinesiogram tracing 8 months postoperatively. The patient's mandibular function is normal.

to 2 weeks. The temporalis and masseter muscles will case ofa fractured coronoid process with displacement
act as a balance against displacement of the fragment, toward the temporal fossa due to a periosteal tear,
just as with subcondylar fractures. Limitation of man- function is usually completely restored without any
dibular movement improves as the primary inflam- treatment. 17
mation subsides. In general, a broad contact between the fractured
Coronoid process fractures can be treated simply fragments usually ensures consolidation. Allen et al 22
with a soft, nonchewy, diet. A head bandage or MMF studied the healing following coronoidotomy in an an-
may be used if the fracture is symptomatic.P:" MMF imal model and concluded that bony union with the
for about 3 weeks relieves discomfort and encourages
prompt healing.2,4,17, 19,20 In the case ofa severely com-
minuted fracture of the zygoma, it must be remem-
bered that mobilization of the mandible should be en-
couraged to prevent ankylosis. 16,20 Walker, 1,8 however,
warns that any active movement undoubtedly increases
the displacement and delays union.
Surgical exposure usually is not indicated. However,
when the fragment is large enough and impedes man-
dibular function, or if there is marked lateral displace-
ment that prevents osseous contact with the ramus,
intraoral open reduction and intraosseous wiring has
been advised. 3,13,16 If reduction of the fragment is not
feasible, it should be removed. However, there is no
justification for an operation to do this when there is
already fibrous union.
In the cases with limitation of movement due to the
fibrosis of the temporalis muscle, removal of the coro- FIGURE 7. Postoperative panoramic radiograph showing bony
noid process is recommended.? However, even in the union of the fracture of the coronoid process.
204
ramus may be due to the minimal amount of separa-
tion. On the other hand, clinically it has been described
that following coronoidotomy the coronoid process
may retract into the temporal fossa and remain separate
or possibly form a false joint with the ramus: IO,22,23
Currarr'" described a 24-year-old woman treated with
bilateral coronoidotomy in whom union of the coro-
noid processes took place in an acceptable position.
On the other hand, Taylor-Monks" reported a case of
a false joint 12 years after coronoidotomy. Shepherd"
reported that in two out of 13 patients, the sectioned
coronoid process remained separated after 5 years or
more. Furthermore, nonunion in fractures ofthe coro-
noid process may be more common than generally
supposed." In our series, case I showed that the coro-
noid process remained separate without any compli-
cations.
References
I. Walker DG: Fractures of the ramus, condyloid and coronoid
process of the mandible. Br Dent J 122:265, 1942
2. Zaydon TB, Brown JB: Early Treatment of Facial Injuries. Phil-
adelphia, PA, Lea & Febiger, 1964
3. Thoma KH: Oral Surgery, vol I (ed 5). St Louis, MO, Mosby,
1969 .
4. Schultz KC: Facial Injuries(ed 2). Chicago, IL, Year Book Med-
ical, 1977
5. Schwenzer N, Grimm G: Zahn- Mund- und Kiefer-heilkunde.
Band 2, Spezielle, Chirurgie, Stuttgart, Georg Thieme Verlag,
1981
6. Stanley RB: Pathogenesis and evaluation of mandibular fractures.
III Mathog RH (ed): Maxillofacial Trauma. Baltimore, MD,
Williams & Wilkins, 1984, pp 136-147
7. Johnson RL: Unusual (coronoid) fracture of mandible; report
of case. J Oral Surg 16:73, 1958
J Oral Maxillofac Surg
51:204·205, 1993
Probable Cocaine-Induced Hyperthermia
in an Anesthetized Patient:
A Case Report
VENKATA S. RAVI, MD,* WALTER P. ZMYSLOWSKI, MD,*
AND JOSEPH MARINO, DMDt
Received from Boston City Hospital and Boston University School
of Medicine.
* Staff Anesthesiologist, Boston City Hospital; Assistant Clinical
Professor in Anesthesiology, Boston University School of Medicine.
t Chief Resident in Oral and Maxillofacial Surgery.
Address correspondence and reprint requests to Dr Ravi: City of
Boston Department of Health and Hospitals, 818 Harrison Ave, Bos-
ton, MA 02118.
© 1993 American Association of Oral and Maxillofacial Surgeons
0278-2391/93/5102-0019$3.00/0
PROBABLE COCAINE-INDUCED HYPERTHERMIA
8. Walker DG: Fractures of the ramus, condyloid and coronoid
process of the mandible. Br Dent J 123:1, 1943
9. Brener MD, Alley RB: Longitudinal fracture of the coronoid
process of the mandible. Oral Surg 29:676, 1970
10. Banks P: Killey's Fractures ofthe Mandible (ed 3). Bristol, Wright
PSG, 1983
II. Rowe NL, Williams JLl: Maxillofacial Injuries, vol I. Edinburgh,
Churchill Livingstone, 1985
12. Takenoshita Y, Horinouchi Y, Yamamoto M, et al: Mental spine
(genial tubercle) fracture; report of three cases [in Japanese].
Jpn J Oral Maxillofac Surg 35:187, 1989
13. Kruger GO: Textbook of Oral Surgery (ed 4). St Louis, MO,
Mosby, 1974
14. Grabb WC, Smith JW: Plastic Surgery (ed 3). Boston, MA, Little,
Brown, 1979
15. Anderson L, Hultin M, Kjellman 0, Nordenram A, Rastrom
G: Jaw fractures in the country of Stockholm (1978-1980).
Swed Dent J 13:201, 1989 .
16. Rapidis AD, Papavassiliou D, Papadimitoriou J, et al: Fractures
of the coronoid process of the mandible, an analysis of 52
cases. Int J Oral Surg 14:126, 1985 •
17. Converse JM: Kazanjian & Converse's Surgical Treatment of
-Facial Injuries (ed 3). Baltimore, MD, Williams & Wilkins,
1974
18. Peterson U, Ellis EIII, Hupp JR, Tucker MR: Contemporary
Oral and Maxillofacial Surgery. St Louis, MO, Mosby Com-
pany, 1988
19. Dingman RO, Natvig R: Surgery of Facial Fractures. Philadel-
phia, PA, Saunders, 1964
20. Spiessl B, Schroll K: Spezielle Frakturen- und Luxationslehre.
Bandl/I, Gesichtsschaedel, Stuttgart, Georg Thieme Verlag,
1972
21. Waite DE: Textbook of Practical Oral Surgery (ed 2). Philadel-
phia, PA, Lea & Febiger, 1978
22. Allen PG, Reade PC, Steidler NE: Healing following coronoid-
ectomy in rats. Int J Oral Maxillofac Surg 18:109, 1989
23. Taylor-Monks F: Bilateral hyperplasia of the mandibular coro-
noid processes; a case report. Br J Oral Surg 16:31, 1978
24. Curran JB: Coronoid surgery after subcondylar osteotomy, report
of cases. J Oral Surg 29:344, 1971
25. Shepherd JP: Changes in the mandibular ramus following os-
teotomy-A long-term review. Br J Oral Surg 18:189, 1980
Cocaine ingestion is a growing problem in society
at large and any acute medical service, including the
anesthesiology department serving a surgical trauma
unit, can expect to see patients with acutely high levels
of this drug. With the increasingly large numbers of
medical complications due to cocaine ingestion, health
care providers must be aware of possible alterations in
normal physiology. We wish to document the intra-
operative occurrence of hyperthermia associated with