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Case Report Involving Temporomandibular Dysfunction, Eagle’S Syndrome and Torus Mandibularis —Multidisciplinary Approaches

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Case Report Involving Temporomandibular Dysfunction, Eagle’S Syndrome and Torus Mandibularis —Multidisciplinary Approaches Open Journal of Stomatology, 2013, 3, 338-343 OJST http://dx.doi.org/10.4236/ojst.2013.37057 Published Online October 2013 (http://www.scirp.org/journal/ojst/) Case report involving temporomandibular dysfunction, eagle’s syndrome and torus mandibularis —Multidisciplinary approaches Takami Hirono Hotta1, Cássio Edvard Sverzut2, Marcelo Palinkas3*, César Bataglion3, Melissa Oliveira Melchior3, Patrícia Tiemy Hirono Hotta4, Sérgio Olavo Petenusci5, Simone Cecilio Hallak Regalo5 1Department of Dental Materials and Prosthodontics, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto, Brazil 2Department of Oral and Maxillofacial Surgery and Periodontology, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto, Brazil 3Department of Restorative Dentistry, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto, Brazil 4Department of Surgery, Prosthodontics and Maxillofacial Traumatology, São Paulo Dental School, University of São Paulo, São Paulo, Brazil 5Department of Morphology, Stomatology and Basic Pathology, Ribeirão Preto School of Dentistry, University of São Paulo, Ribeirão Preto, Brazil Email: *[email protected] Received 6 August 2013; revised 6 September 2013; accepted 23 September 2013 Copyright © 2013 Takami Hirono Hotta et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Syndrome; Torus Mandibularis; Electromyography; Bite Force The prevalence of torus mandibularis, Eagle’s syn- drome and parafunctional activity was reported to be higher in patients with temporomandibular joint 1. INTRODUCTION dysfunction and might be useful as an indicator of Torus mandibularis (TM) is an exophytic bone growth increased risk of temporomandibular disorders. This that usually occurs bilaterally along the lingual surface of study case report was to evaluate a 62-year-old fe- the premolar area of the mandible, superior to the mylo- male patient, with limited mandibular and cervical hyoid ridge [1,2]. In patients who are completely or par- movements, articular and muscular pain, ear fullness, tially edentulous, the occurrence of TM can interfere irritation of the lingual mucosa, discomfort associated with the prosthetic treatment plan in dentate patients. TM with movement of her tongue, involving temporo- can interfere with masticatory and speech functions. mandibular dysfunction, torus mandibularis and Ea- Therefore, even when asymptomatic, the surgical re- gle’s syndrome. The treatment comprehended the moval of the tori is indicated in these cases [3,4]. collection of data of Helkimo’s Clinical Dysfunction The etiology of TM has been investigated by several Index, electromyographic activity of the masseter and authors; however, no consensus has been reached. It is temporalis muscles in rest position and bite force, generally accepted that genetic factors contribute to the masticatory efficiency, speech evaluation and oclusal occurrence of TM [5-8]. splint, after the excision of the stylohyoid process and The prevalence of both TM and parafunctional activity mandibularis torus. The authors found a decrease in has been reported to be higher in patients with tem- electromyographic activity of masticatory muscles, a poromandibular joint dysfunction [9], and therefore, reduction of painful symptoms throughout the region these factors may be useful indicators of an increased muscular and joint pains, an increase in the ampli- risk of temporomandibular disorders in some patients. tude of mandibular movements, an improvement in Eagle’s syndrome affects the head and neck structures masticatory efficiency and an increase in bite force. and produces headache, earache, changes in swallowing and speech, and facial, cervical and eye pain [10-14]. Keywords: Temporomandibular Dysfunction; Eagle’s Symptoms may also occur along the distribution of the *Corresponding author. external and internal carotid artery branches due to com- OPEN ACCESS T. H. Hotta et al. / Open Journal of Stomatology 3 (2013) 338-343 339 pression at points on the vessels, affecting vascular cir- areas of abrasive lesions were often observed. Further- culation and irritating the sympathetic nerves of the arte- more, the tongue rest position and the functional activi- rial sheath [15]. ties of the masticatory system were abnormal, promoting It is often difficult to establish a definitive diagnosis of muscular pain. The patient revealed that this pain often Eagle’s syndrome due to the similarity of these symp- occurred after the mastication of hard food; she also re- toms to the other pathologies that affect the head and ported occasional bruxism. neck areas. Therefore, the use of an occlusal splint, nor- The first stage of the treatment plan involved the col- mally applied in the treatment of TMD, can be helpful lection of relevant data with the following analyses: Hel- during the process of differential diagnosis [16]. kimo index [22], electromyographic activity of the mas- Eagle’s syndrome affects approximately 27% of the seter and temporalis muscles in rest position (Table 1), population, and elderly females show a greater preva- bite force (Table 2) [23], masticatory efficiency [24] and lence of an elongated stylohyoid ligament complex speech evaluation [25]. [18,19]. Additionally, the presence of an elongated sty- The orofacial muscles (masseter, temporalis, pterygoid) lohyoid ligament complex was found in approximately and the condyle lateral pole were bilaterally palpated in 19.6% of Brazilian human skulls [17]. This syndrome is order evaluate pain upon palpation using a numeric scale. more prevalent in the elderly because the aging process promotes the development of a tendinosis at the junction of the stylohyoid ligament and the lesser horn of the hy- oid bone [20]. The underlying mechanisms for this life-long process may involve variability in the length and shape of the second branchial arch cartilage, which may explain cases of styloid complex ossification in adults and the elderly. It is also possible that the ossification of the branchial cartilages is a part of the normal aging process, as it also occurs in other derivatives of the branchial arches, such as the laryngeal cartilages [21]. The aims of this present study were to demonstrate different approaches for the resolution of a clinical case involving temporomandibular dysfunction, torus man- dibularis and Eagle’s syndrome in an elderly woman. 2. CASE REPORT A 62-year-old woman was referred to the Occlusion, Figure 1. Extensive bony overgrowths Temporomandibular Dysfunction and Orofacial Pain in in the premolar area of the mandible. Patients with Especial Care Course, School of Dentistry of Ribeirão Preto, University of São Paulo, complaining Table 1. Numeric values of the electromyographic activities of of limited mandibular and cervical movements, articular the masseter and temporalis muscles, before (E1) and after (E2) and muscular pain, ear fullness, irritation of the lingual treatments. mucosa, and discomfort associated with movement of Rest Position (µV) her tongue. Earlier, she received a medical diagnosis of Right Left Right Left Phases Eagle’s syndrome, and surgical removal of the styloid Masseter Masseter Temporalis Temporalis process was suggested. E1 10.5 4.8 4.3 4.6 The patient was informed about the treatment plan and E2 6.1 2.7 4.3 4.1 study procedures by the investigators and signed the in- formed consent. The study was approved by the Ethics Table 2. Means of the maximal bite force in the left and right Committee of the School of Dentistry of Ribeirão Preto, molar regions, before (E1) and after (E2) treatments. University of São Paulo (process n 2006.1.971.58.5). A physical examination of the oral cavity revealed Site Evaluation Bite Force (N) general dental wear and extensive bony overgrowths E1 34.3 Right Molar along the lingual surface in the premolar area of the E2 46 mandible (Figure 1). At the time of examination, the E1 67.6 mucosa that was overlying the tori appeared normal; Left Molar however, during later preoperative appointments, small E2 88.2 Copyright © 2013 SciRes. OPEN ACCESS 340 T. H. Hotta et al. / Open Journal of Stomatology 3 (2013) 338-343 This scale consisted of 11 points, beginning with “0” (no blocked with 1.8 ml of anesthetic solution containing pain) and ending in “10” (the worst imaginable pain) [26] mepivacaine (2 percent) and epinephrine (1:100.000), (Table 3). applied to each side. The surgical approach consisted of Using the Hugoson Index [27], the observed occlusal an intrasulcular incision that extended from one first wear was classified as level 1 (attrition of enamel down molar to the other. Afterward, a full-thickness flap was to dentin spots), confirming the presence of bruxism that carefully elevated, exposing both TMs and preserving was reported earlier by the patient. the insertion of the genioglossus muscles. The delimita- Maximum mouth opening and the right and left lateral tion of the TMs was performed using a surgical length movements were measured with a millimeter ruler. To #702 taper fissure crosscut carbide bur. Afterward, a thin, measure the maximum mouth opening movement, the straight chisel was positioned into the gap and lightly patient was requested to open her mouth, and the dis- hammered twice, resulting in the easy removal of the tance between the incisal borders was measured. The TMs. The bone irregularities
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