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Rev Esp Cir Oral Maxilofac 2009;31,4 (julio-agosto):277-281 2009 ergon

Pgina del Residente

Cul es su diagnstico?

What would your diagnosis be?

Paciente varn de 16 aos de Male patient 16 years old, comes to


edad que acude a nuestra consulta our consult because of a history of
por presentar historia de dolor en pain in both TMJs over the past year.
ambas ATM de un ao de evolucin, The pain has increased over the last
que se ha incrementado en los lti- few months and there are bilateral
mos meses, ruidos biltarales y limita- noises and progressively limited oral
cin progresiva de la apertura oral. opening. The only pre-existing con-
Como nico antecedente de inters dition of interest is that he had 5
refiere tratamiento ortodncico A years of orthodontic treatment (from
durante 5 aos (10-15 aos). 10-15 years). During the physical
En el examen fsico, observamos exam we measured a Maximum Oral
MAO: 25 mm, movimiento de pro- opening of 25mm, 0mm protrusion
tusin 0 mm, movimiento lateral movement, 6mm right lateral move-
derecho de 6 mm y movimiento late- ment and 6mm left lateral move-
ral izquierdo de 6 mm. Presenta dolor ment. The patient experiences pain
a la palpacin en ATM izquierda y upon palpation on the right and left
derecha, ruidos bilaterales en aper- TMJ and bilateral noises upon oral
tura oral compatibles con DDCR. opening that is compatible with
Clase I de Angle con buena oclusin. DDCR. Angles Class I with good
El paciente refiere inicio de los snto- occlusion. The patient reports start-
mas tras finalizar el tratamiento orto- ing to notice the symptoms after fin-
dncico. En la ortopantomografa se B ishing orthodontic treatment. In the
aprecia ambas ATM sin cambios sig- Figura 1. A. aumento de tamao de apfisis coronoide izquier- ortopantomography both TMJs
nificativos. En la RMN se observa una da B. elongacin anormal de apfisis coronoide derecha. appear to be without significant
limitacin de movimiento en la aper- Figure 1. 3D CAT: A. increase in size of left coronoid process B. changes. The MRI shows limited
tura de ambos cndilos mandibula- abnormal elongation of right coronoid process. movement of opening in both
res, sin signos de sinovitis ni infla- mandible condyles and no signs of
macin en partes blandas inflammation in the soft parts.
Segn los hallazgos radiolgicos y clnicos el diagnstico del According to radiological and clinical discoveries we diag-
paciente fue de bloqueo crnico bilateral de ATM. Acorde con este nosed the patient with bilateral close lock of the TMJ. In
diagnstico realizamos una artoscopia bilateral en la que no encon- accordance with his diagnosis we carried out bilateral
tramos hallazgos significativos, por lo que se realiza lisis- lavado y arthroscopy where no significant discoveries were found.
posterior infiltracin con cido hialurnico. El postoperatorio inme- Therefore we carried out a lysis lavage and posterior infil-
diato transcurri sin incidencias. tration with hyaluronic acid. There were no immediate con-
Un mes despus de la ciruga el paciente presenta una apertu- sequences in post op.
ra de 26 mm con importante dolor en ambos msculos masete- One month after surgery the patient has an opening
ros de forma bilateral (Fig. 2). Dada la evolucin se solicita TAC 3D of 26 mm with major pain in both bilateral masseters (Fig-
para descartar un origen extra-articular del bloqueo articular. ure 2). Given this progress we request a 3D CT in order to
rule out the possibility of an extraarticular cause of the joint
block.
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Rev Esp Cir Oral Maxilofac 2009;31,4 (julio-agosto):277-280 2009 ergon

Pgina del Residente

Hipertrofia bilateral de apfisis coronoides

Bilateral Hypertrophy of the coronoid process

S. Rosn-Gmez1, M. Muoz-Guerra2. F.J. Rodrguez-Campo2, M. Mancha de la Plata1


J.L. Gl-Dez2, F.J. Daz-Gonzlez3

Diagnstico Diagnosis

En el TAC 3D se observa una elongacin de ambas apfisis coro- The 3D CT shows elongation of both coronoid process-
noides que estn en contacto con el arco zigomtico limitando la es that are in contact with the zygomatic arch, which is lim-
apertura oral (Fig. 1). Con el diagnstico de hipertrofia de coro- iting oral opening (Fig.1). Diagnosed as Bilateral Hypertro-
noides bilateral, realizamos mediante abordaje intraoral una coro- phy of the coronoids, we use an intraoral method to carry
noidectoma bilateral La apertura intraoperatoriamente fue de 38 out bilateral coronoidectomy. The opening between opera-
mm (Fig. 4). El estudio anatomopatolgico confirm que la histo- tions was 38 mm. (Fig. 4) The histological study confirmed
loga del hueso fue normal con mnima cantidad de fibrocartlago that the bone histology was normal and had minimal fibro
en cara malar (Fig. 3). cartilage in the malar face (Fig. 3).
La terapia rehabilitadora se inici a la semana tras la ciruga y se
mantuvo durante tres meses. A los seis meses, el paciente presen- Rehabilitation therapy started the week after surgery and
ta una apertura oral de 42 mm, sin dolor y sin crecimiento de las continued for 3 months. 6 months later the patient had
apfisis coronoides. an oral opening of 42 mm without pain and without any
growth coronoid process.

Discusin Discussion

La hiperplasia bilateral de las apfisis coronoides, se define como Bilateral hyperplasia of the coronoid process is defined
una elongacin anormal del proceso coronoideo a expensas de as the abnormal elongation of the coronoid process at the
hueso histolgicamente normal. La prevalencia de esta entidad es expense of histologically normal bones. The prevalence of
del 0,5%. La disminucin progresiva no dolorosa de la apertura oral this entity is 0.5%. Its normal clinical appearance is painless
es su presentacin clnica habitual. En nuestro caso, la sintomato- progressive decrease in oral opening. In our case, the patients
loga inicial del paciente as como las pruebas radiolgicas iniciales initial symptom logy and the initial radiographic tests leads
nos orientaron hacia una disfuncin ATM. Por tanto, es importan- us towards TMJ dysfunction. Therefore it is important to think
te pensar en esta patologa como causa de disminucin progresiva of this pathology as a possible cause of the painless pro-
gressive decrease in oral opening. Also keeping in mind that
at the initial state panoramic radiographs did not give us
information, the 3D CT was the essential tool in diagnosis
1 Mdico residente
because it allowed us to quantify the longitude of the coro-
2 Mdico adjunto
3 Jefe de Servicio noid process as well as its relationship to bone and or cygo-
Servicio de Ciruga Oral y Maxilofacial. Hospital Universitario La Princesa. Madrid. Espaa matic arch.1 The etiopathogenic mechanisms of this entity
continue to be controversial despite the numerous factors
Correspondencia:
proposed in the literature. Hyperactivity of the temporal mus-
Silvia Rosn Gmez
Servicio de Ciruga Oral y Maxilofacial. cle has been described by different authors as a relevant eti-
Hospital Universitario de la Princesa ological factor in its own genesis. Since the continuous action
C/ Diego de Len, 62 of the muscles creates a change in the local vascular input
28006 Madrid. Espaa
E-mail: silviarosongo@yahoo.es
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S. Rosn-Gmez y cols. Rev Esp Cir Oral Maxilofac 2009;31,4 (julio-agosto):277-280 2009 ergon 279

no dolorosa de la apertura oral, which favors degenerative changes


teniendo en cuenta que en estadios and apposition of calcium with sub-
iniciales las radiografas panormicas sequent local ossification of soft tis-
no nos ofrecen informacin, siendo sues,2-5) Cp. Isberg et al. showed 8
el TAC 3D la herramienta esencial cases of TMJ dysfunction associated
para su diagnstico, permitiendo with hyperplasia of the coronoid
cuantificar la longitud de la apfisis process, correlating this hyperplasia
coronoides as como su relacin con with the incidence of chronic disc dis-
el hueso y/o arco cigomtico (Fig.1). placement of the ipsilateral TMJ, this
Los mecanismos etiopatognicos de disc pathology being the cause.
esta entidad siguen siendo contro- Many authors have also suggested
vertidos, a pesar de los numerosos that the shock, genetic alterations
factores propuestos en la literatura. or endocrine stimuli may be possi-
La hiperactividad del msculo tem- ble etiological factors.6
poral ha sido descrita por diferentes Figura 2. MAO pre-operatoria. In our case, the stimulus of ortho-
autores como un factor etiolgico Figure 2. Pre operative Maximum oral opening. dontic treatment contributed to the
relevante en la gnesis de la misma pathological development of the
ya que la continua accin de los ms- coronoids, the left side larger than
culos produce un aumento del apor- the right side just like in Jacob Syn-
te vascular local favoreciendo cam- drome.
bios degenerativos y aposicin de cal- Two surgical techniques are
cio con la subsiguiente osificacin described for the treatment of this
local de tejidos blandos,2-5 Isberg et entity: the intraoral route and the
al., presentaron 8 casos de disfuncin extra oral route. Intraoral coro-
de ATM asociada a hiperplasia de noidectomy is the technique pre-
apfisis coronoides, correlacionando ferred by many authors, despite
dicha hiperplasia con la presencia de the limited oral opening that
desplazamiento discal crnico de la patients frequently experience.7,8
ATM homolateral, siendo esta pato- This intraoral approach eliminates
loga discal causa de la misma. Los the possibility of unaesthetic exter-
traumatismos, las alteraciones gen- nal scars and minimizes the risk
ticas o los estmulos endocrinos, han Figura 3. Pieza quirrgica. of facial nerve injury. 9 Ostrofsky
sido tambin propuestos por diver- Figure 3. Surgical piece. and Lownie use the sub mandible
sos autores como otros posibles fac- approach to carry out coro-
tores etiolgicos.6 noidectomy in a case of zygomatic
En nuestro caso, el estmulo del tratamiento ortodncico con- coronoid anchylosis. It offers a good surgical area even
tribuy al desarrollo patolgico de las coronoides, con mayor tama- though there is a marginal risk of injuring the nerve,
o en el lado izquierdo que en el derecho, tal y como se presenta which is why its use has been criticized.10 The extra oral
en el Sndrome de Jacob. coronal type technique provides excellent visuals of the
Se describen dos vas de abordaje quirrgico para el tratamien- coronoid process and has an acceptable scar below the
to de esta entidad: la va intraoral y la extraoral. La coronoidectoma implant hairline. Its use is recommended when the coro-
intraoral es la tcnica preferida por mltiples autores a pesar de la noid process is too long to be performed below the cygo-
frecuente limitacin de la apertura oral que pueden presentar estos matic arch using an intraoral route, when there is bilat-
pacientes.7,8 Este abordaje intraoral evita la presencia de cicatrices eral affectation or when there is concomitant affectation
externas inestticas y minimiza el riesgo de lesin del nervio facial.9 of the TMJ that requires surgical treatment during the
Ostrofsky y Lownie emplean la va de abordaje submandibular para same operational. We propose an intraoral approach
ejecutar la coronoidectoma en un caso de anquilosis zigomatico- when the size of the coronoid process allows it. We also
coronoidea. Esta ofrece un buen campo quirrgico, si bien supone propose the use of arthroscopic techniques if there is
un riesgo de lesin del nervio marginal por lo que su utilizacin ha associated TMJ dysfunction.
sido denostada.10 El abordaje extraoral de tipo coronal aporta una The prognostic depends on initial opening and post rehab
visualizacin excelente de la apfisis coronoide con una cicatrizacin therapy. Therefore it is important to start rehab therapy with
aceptable bajo la lnea de implantacin del pelo. Se recomienda su precaution with the purpose of decreasing postsurgical fibro-
empleo cuando el proceso coronoideo es demasiado largo para sis, and the realignment of the clot and hematoma of said
ser alcanzado por debajo del arco cigomtico por va intraoral, en area.6)
CO 31-4 72 pag 19/11/09 08:48 Pgina 280

280 Rev Esp Cir Oral Maxilofac 2009;31,4 (julio-agosto):277-280 2009 ergon Hipertrofia bilateral de apfisis coronoides

los casos de afectacin bilateral o en aque- In conclusion, hypertrophy of


llos casos en los que existe una afectacin the coronoid process is an
concomitante de la ATM que precise tra- uncommon entity but we should
tamiento quirrgico en el mismo acto be suspicious of it in cases when
operatorio.6,10 Nosotros proponemos el TMJ dysfunction does not
abordaje intraoral cuando el tamao de respond to arthroscopic treat-
la apfisis coronoide nos lo permita, y la ment. In young patients with
utilizacin de tcnicas artroscpicas si pre- painless progressively limited
senta disfuncin de ATM asociada. oral opening where arthroscopy
El pronstico depende de la apertura doesnt show pathological
inicial y de la posterior terapia rehabilita- improvements, we should con-
dora. Por tanto, es importante iniciar una sider this entity as a possible
terapia rehabilitadora mediante ejercicios cause of close lock.
de forma precoz, con el fin de disminuir
la fibrosis postquirrgica, la reorganiza-
Figura 4. MAO post-operatoria.
cin del cogulo y hematoma.6 Figure 4. Post operative Maximum oral opening.

Conclusin 4. Isberg A, Isacsson G, Nah KS. Mandibular coronoid process locking:


a prospective study of frequence and association with internal deran-
La hipertrofia de apfisis coronoides es una entidad poco gement of the temporomandibular joint. Oral Surg Oral Med Oral Pat-
frecuente, pero que debemos sospechar en casos de dis- hol 1987;63:275-9.
funcin de ATM que no responde al tratamiento artrosc- 5. Kai S, Hijiya T, Yamane K, Higuchi Y. Open-mouth locking caused
pico. En pacientes jvenes con limitacin progresiva no dolo- by unilateral elongated coronoid process: report of case. J Oral Maxi-
rosa de la apertura oral en los que la artroscopia no mues- llofac Surg 1997;55:1305-8.
tre hallazgos patolgicos debemos pensar en esta entidad 6. McLoughlin PM, Hopper C, Bowley NB. Hyperplasia of the mandi-
como causa del bloqueo crnico. bular coronoid process: an analysis of 31 cases and review of the lite-
rature. J Oral Maxillofac Surg 1995;53:250-5.
Bibliografa 7. Emekli U, Aslan A, Onel D, izmeci O, Demiryont M. Osteochon-
droma of the coronoid process (Jacobs disease). J Oral Maxillofac Surg
1. Takahashi A, Hao-Zong W, Murakami S, Kondoh H, Fujishita M, 2002;60:1354-6.
Fuchihata H. Diagnosis of coronoid process hyperplasia by threedi- 8. Gerbino G, Bianchi SD, Bernardi M, Berrone S. Hyperplasia of the man
mensional computed tomographic imaging. Dentomaxillofac Radiol dibular coronoid process: long-term follow-up after coronoidectomy.
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2. Roychoudbury A, Gupta YK, Parkash H, Karak AK. Jacob disease: report 9. Ostrofsky MK, Lownie JF. Zygomatico-coronoid ankylosis. J Oral Surg
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3. Hernandez-Alfaro F, Escuder O, Marco V. Joint formation between an plasia using the bicoronal flap. Br J Oral Surg 1989;27:487-93.
osteochondroma of the coronoid process and the zygomatic arch 11. Capote A, Rodrguez FJ, Blasco A, Muoz MF. Jacobs disease asso-
(Jacob disease): report of case and review of literature. J Oral Maxi- ciated with temporomandibular joint dysfunction: a case report. Med
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