Association of a Temporomandibular Disorder and Eagle’s Syndrome: Case Report

 
Elaine Angélica de SOUZA
Takami Hirono HOTTA
César BATAGLION
 
Departamento de Odontologia Restauradora, Faculdade de Odontologia de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil


Braz Dent J (1996) 7(1): 53-58 ISSN 0103-6440

| Introduction | Clinical Case | Procedures | Discussion and Conclusions | References |


We report a clinical case of Eagle’s syndrome which required dental intervention due to the presence of exacerbated symptoms indicating an association with a temporomandibular disorder. The therapeutic dental procedures used were an occlusal splint and temporary removable partial dentures. Surgical removal of the styloid process on the left side was later performed as a medical option.


Key Words: Eagle’s syndrome, temporomandibular disorder, interocclusal splint.


Introduction

The styloid process, adjacent to the stylohyoid ligament, is a thin cylindric bone projection fused with the temporal bone in front of the stylomastoid foramen (Ettinger and Hanson, 1975). Its normal length is 20 to 30 mm (Fritz, 1940; Ettinger and Hanson, 1975; Russel, 1977; Baddour et al., 1978), but it may reach 35 to 45 mm (Russel, 1977). Eagle’s syndrome is the occurrence of symptomatic elongation of this process (Russel, 1977; Baddour et al., 1978) or the ossification of the stylohyoid ligament (Shafer et al., 1983).

The signs and symptoms commonly reported are pharyngeal pain, dysphagia, earache, glossodynia, headache (Ettinger and Hanson, 1975; Russel, 1977; Shafer et al., 1983), pain along the internal and external carotid arteries (Sanders and Weiner, 1977; Shafer et al., 1983), and vague or neuralgic/lancinating facial pain irradiating to the ear and along the mandible (Ettinger and Hanson, 1975). A complete and detailed history should be taken and the patient should be submitted to palpation (Grossman and Tarsitano, 1977) or oblique lateral radiography of the mandible and of the temporomandibular joint (TMJ) and to an anteroposterior radiography (Stafne and Hollinshead, 1962). In 1948, Eagle (1949) added a panoramic anteroposterior or posteroanterior projection of the TMJ and a modified Townes position.

With respect to treatment, when the symptoms are severe the option is for surgical intervention where the styloid process is amputated or the calcified styloid ligament is resected (Fritz, 1940; Sanders and Weiner, 1977; Baddour et al., 1978; Glogoff et al., 1981). Correl and Wescott (1982) stated that the diagnosis of Eagle’s syndrome can only be confirmed by the disappearance of symptoms after excision of the elongated process.

We report here a clinical case in which Eagle’s syndrome was diagnosed and was associated with symptoms of a temporomandibular disorder.


Clinical case

A 36-year old black male was referred to our institution with a clinical and radiographic diagnosis of Eagle’s syndrome (Figure 1). His complaints, of 8 years duration, included chronic irritation of the pharynx, facial pain, headache, earache, pain in the neck and in the region of the mandibular angle, and darkened vision. Clinical examination revealed: buccal opening, 32 mm; laterality to the right, 8 mm; laterality to the left, 8 mm; protrusion, 3 mm; vertical dimension of occlusion, 59 mm; resting vertical dimension, 67 mm. Parafunctional habits consisted of diurnal and nocturnal dental clenching, with fatigue and muscle pain in the morning. There was a high index of bacterial plaque and tartar, gingival alterations (bleeding and changes in shape and consistency), deficient dental restorations, absence of teeth (14, 15, 17, 25, 26, 27, 28, 35, 36, 37, 38, 46, 47, 48), and facets of wear on the remaining teeth (Figure 2).


Figure 1 - Anteroposterior radiograph showing elongated styloid processes.


Figure 2 - A, Oral condition: upper arch. B, Oral condition: lower arch. C, Lower interocclusal splint. D, Lower interocclusal splint and temporary upper removable partial dentures.


Procedures

The following procedures were carried out:

1. Anamnesis, clinical examination and functional evaluation according to the protocol used for the specific file cards of the Service of Occlusion and Temporomandibular Joint Disorders of the Dental School of Ribeirão Preto, USP (SODAT-FORP/USP).

2. Panoramic radiography.

3. Determination of vertical dimension of occlusion, VDO: 63 mm, with a combination of techniques (phonetics, Willis compass, facial thirds).

4. Previous preparation of the mouth. Crown scraping and polishing using a Profident apparatus (Dabi-Atlante, Ribeirão Preto, Brazil) and rotary and manual instruments.

5. A neurologic evaluation for a differential diagnosis from glossopharyngeal and sphenopalatine neuralgias was requested and gave negative results.

6. Plaster casts were mounted on a semi-adjustable articulator (Gnatus 8600, Ribeirão Preto, Brazil) using a facial arch, a lower orientation plane with no. 7 pink wax rollers and a Lucia jig.

7. Waxing, inclusion and pressing of a modified interocclusal splint (adaptation to the lower arch).

8. Periodic adjustments of the splint in the positions of centric occlusion relation, laterality to the right and to the left, and protrusion (Santos Jr., 1987).

Tables 1 and 2 show the results obtained with the above-mentioned procedures initially, with the use of a splint and with the use of a splint in combination with removable partial dentures.


Discussion and Conclusions

The symptoms associated with Eagle’s syndrome may be confused with those attributed to a series of pathologies involving the head and neck, specifically in the area of occlusion and of TMJ disorders, which also present signs and symptoms such as facial pain, headache, cervical pain, eye pain, earache, as well as changes in swallowing and speech.

Many investigators (Douglas Jr., 1952; Russel, 1977; Sanders and Weiner, 1977; Baddour et al., 1978; Correl and Wescott, 1982) have reported cases in which a definitive diagnosis of Eagle’s syndrome was reached only after use of other treatment modalities not related to this pathology. In some cases, Eagle’s syndrome was diagnosed only by dental professionals (Glogoff et al., 1981; Winkler et al., 1981). It may be assumed that the oral condition of the patient often induces professionals to conclude that the origin of the symptoms may indeed be concentrated in this region.

In the present case, the patient arrived at SODAT-FORP/USP with a diagnosis of Eagle’s syndrome confirmed by several tests. However, his symptoms, although typical, may have been exacerbated by the oral conditions in that the patient had extensive absence of teeth, alteration of the vertical dimension of occlusion and occlusal instability. Thus, dental treatment was carried out prior to any more radical medical measure, and because the literature has reported the occurrence of elongated styloid processes without symptomatic characteristics (Ettinger and Hanson, 1975; Carrol, 1984).

The option for an interocclusal splint with a posterior support (Figure 2C) was due to the excellent results obtained in previous studies (Hotta et al., 1995; Souza et al., 1993) in which the condition of loss of posterior dental support was also present. The results obtained were considered satisfactory, but a more in-depth analysis showed that the remaining pain, although mild, persisted on the side where the patient had no teeth in contact with the splint. Thus, we sought to eliminate the symptoms with the combination of temporary removable upper partial dentures (Figure 2D) since we thought that better results would be obtained if a more efficient posterior occlusal support were offered to the patient. This was later confirmed, as shown in Tables 1 and 2.

After reestablishment of muscle tonus to a relatively normal pattern, it was possible to palpate the regions of the tonsillary fossa in an efficient manner, with the detection of perceptible elongated styloid processes that had been previously detected only on the basis of radiographic aspect and assumed to be clinically present on the basis of the analysis of observed and reported symptoms.

In view of the fact that the situation was no longer an emergency due to the highly satisfactory results obtained with dental treatment, the medical team decided to postpone surgery for the excision of the styloid processes. The patient was kept under observation but 3 months later, despite the stability of his clinical picture, he required surgery for the treatment of rhinitis and, on that occasion, the doctors opted also for the prophylactic removal of the elongated styloid process on the left side.

We agree with Correll et al. (1979) when they state that dental surgeons and medical doctors, especially in the area of Otorhinolaryngology, should be alert to this abnormality and consider it as a possible etiological factor when making a differential diagnosis of head and neck complaints. Medicine and dentistry should work together for a better understanding of Eagle’s syndrome and for an improvement of its diagnosis and treatment.


References

Baddour HM, McNear JT, Tilson HB: Eagle’s syndrome. J Oral Surg 46: 486-494, 1978

Carrol MKO: Calcification in the stylohyoid ligament. J Oral Surg 58: 617-621, 1984

Correl RW, Wescott WB: Eagle’s syndrome diagnosed after history of headache, dysphagia, otalgia, and limited neck movement. J Am Dent Assoc, 104: 491-492, 1982

Correl RW, Jensen JL, Taylor JB, Rhyne RR: Mineralization of the stylohyoid-stylomandibular ligament complex - a radiographic incidence study. J Oral Surg 48: 286-291, 1979

Douglas Jr TE: Facial pain from elongated styloid process. Arch Otolar 56: 635-638, 1952

Eagle WW: Symptomatic elongated styloid process: report of two cases of styloid process - carotid artery syndrome with operation. Arch Otolar 49: 490-503, 1949

Ettinger RL, Hanson JG: The styloid or "Eagle’s" syndrome: An unexpected consequence. J Oral Surg 40: 336-340, 1975

Fritz M: Elongated styloid process - a cause of obscure throat symptoms. Arch Otolar 31: 911-918

Glogoff MR, Baum SM, Cheifetz I: Diagnosis and treatment of Eagle’s syndrome. J Oral Surg 39: 941-944, 1981

Gossman JR, Tarsitano JJ: The styloid-stylohyoid syndrome. J Oral Surg 35: 555-560, 1977

Hotta TH, Mazzetto MO, Bataglion C: Placa interoclusal para pacientes sem suporte oclusal posterior, portadores de desordens temporomandibulares. Od Mod 22: 28-30, 1995

Russel TE: Eagle’s syndrome: diagnostic considerations and report of case. J Am Dent Assoc 94: 548-550, 1977

Sanders B, Weiner J: Eagle’s syndrome. J Oral Med 32: 44-45, 1977

Santos Jr J: Tratamento da sintomatologia craniomandibular. Pancast editorial 157-190: Férulas oclusais (placas de mordida), 1987

Shafer WG, Hine MK, Levy BM: Tratado de patologia bucal. Chapter 17, Doenças dos nervos e músculos. Dor facial atípica. 4th ed., Guanabara Koogan, Rio de Janeiro, 1983

Souza EA, Bataglion C, Hotta TH: Placa interoclusal com suporte posterior bilateral: Apresentação de caso clínico. In: Anais da 15a Jornada Odontológica de Ribeirão Preto, Universidade de São Paulo, p. 46, 1993

Stafne EC, Hollinshead WH: Roentgenographic observations on the stylohyoid chain. J Oral Surg 15: 1195-1200, 1962

Winkler S, Sammartino FJ, Sammartino Jr FJ, Monari JH: Stylohyoid syndrome. J Oral Surg 51: 215-217, 1981


Correspondence: César Bataglion, Departamento de Odontologia Restauradora, Faculdade de Odontologia de Ribeirão Preto, USP, 14040-904 Ribeirão Preto, SP, Brasil.


Accepted September 18, 1995
Electronic publication: September, 1996


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