Quick Review #268 - #surgery #surgeon #doctorgallagher #oralsurgery #oralsurgeon #omfs #dentist #dentistry #dental #coronoidectomy

2.26.25

Indications:

• Coronoid process hyperplasia

• Trismus secondary to coronoid impingement (e.g., post-traumatic ankylosis, temporalis muscle hyperactivity)

• Access to zygomatic arch fractures

Surgical Steps

1. Preoperative Considerations

• Assess mouth opening and obtain preoperative imaging (CT scan preferred).

• Consider IV steroids to reduce postoperative edema.

2. Anesthesia and Patient Positioning

• General anesthesia with nasal intubation to maximize intraoral access.

• Head tilted slightly toward the contralateral side.

3. Intraoral Incision and Exposure

• Use a mouth prop to maintain jaw opening.

• A mucosal incision is made over the anterior border of the ramus, extending superiorly into the maxillary vestibule.

• Subperiosteal dissection exposes the coronoid process, preserving the buccal fat pad to minimize fibrosis.

• Retract the temporalis muscle superiorly to visualize the coronoid.

4. Osteotomy and Removal of the Coronoid Process

• Identify the coronoid process and ensure adequate exposure.

• Use a reciprocating saw or osteotome to perform an osteotomy at the coronoid base, just superior to the sigmoid notch.

• Remove the coronoid segment with forceps, taking care to avoid excessive traction on the temporalis.

• If necessary, additional bone resection may be performed to improve range of motion.

5. Hemostasis and Closure

• Irrigate the site thoroughly to remove bone debris.

• Achieve hemostasis with electrocautery or hemostatic agents.

• Close the mucosal incision with absorbable sutures.

Pearls

* Adequate exposure – Proper subperiosteal dissection minimizes bleeding and facilitates visualization.

* Preserve mucosal integrity – Avoid excessive stripping of periosteum to reduce fibrosis risk.

* Controlled osteotomy – Use a reciprocating saw for a precise cut to avoid unnecessary trauma.

* Immediate mobilization – Early physiotherapy prevents postoperative fibrosis and ankylosis.

* Hemostasis – Cauterization of the pterygoid venous plexus minimizes bleeding.

Pitfalls

* Inadequate exposure – Poor visualization increases risk of damaging the temporalis muscle.

* Excessive traction on the temporalis – May lead to postoperative pain and muscle dysfunction.

* Injury to maxillary artery branches – Risk of excessive bleeding if deep dissection is not controlled.

* Failure to initiate early physiotherapy – Can result in trismus and scar formation.

* Over-resection – Removing excessive bone can weaken the mandible structurally.

References:

1. Ellis, E. III, & Schubert, W. (n.d.). Coronoid process fractures. AO Surgery Reference.

2. Roy, T., & Reid, R. (2021). A novel approach to coronoidectomy: The modified Keen technique. Journal of Craniofacial Surgery, 32(3), 1150-1151.

3. ChatGPT. 2025

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