Open Journal of Stomatology, 2013, 3, 338-343 OJST Published Online October 2013 (
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,
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: *
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.
The prevalence of torus mandibularis, Eagle’s syn-
drome and parafunctional activity was reported to be
higher in patients with temporomandibular joint
dysfunction and might be useful as an indicator of
increased risk of temporomandibular disorders. This
study case report was to evaluate a 62-year-old fe-
male patient, with limited mandibular and cervical
movements, articular and muscular pain, ear fullness,
irritation of the lingual mucosa, discomfort associated
with movement of her tongue, involving temporo-
mandibular dysfunction, torus mandibularis and Ea-
gle’s syndrome. The treatment comprehended the
collection of data of Helkimo’s Clinical Dysfunction
Index, electromyographic activity of the masseter and
temporalis muscles in rest position and bite force,
masticatory efficiency, speech evaluation and oclusal
splint, after the excision of the stylohyoid process and
mandibularis torus. The authors found a decrease in
electromyographic activity of masticatory muscles, a
reduction of painful symptoms throughout the region
muscular and joint pains, an increase in the ampli-
tude of mandibular movements, an improvement in
masticatory efficiency and an increase in bite force.
Keywords: Temporomandibular Dysfunction; Eagle’s
Syndrome; Torus Mandibularis; Electromyography; Bite
Torus mandibularis (TM) is an exophytic bone growth
that usually occurs bilaterally along the lingual surface of
the premolar area of the mandible, superior to the mylo-
hyoid ridge [1,2]. In patients who are completely or par-
tially edentulous, the occurrence of TM can interfere
with the prosthetic treatment plan in dentate patients. TM
can interfere with masticatory and speech functions.
Therefore, even when asymptomatic, the surgical re-
moval of the tori is indicated in these cases [3,4].
The etiology of TM has been investigated by several
authors; however, no consensus has been reached. It is
generally accepted that genetic factors contribute to the
occurrence of TM [5-8].
The prevalence of both TM and parafunctional activity
has been reported to be higher in patients with tem-
poromandibular joint dysfunction [9], and therefore,
these factors may be useful indicators of an increased
risk of temporomandibular disorders in some patients.
Eagle’s syndrome affects the head and neck structures
and produces headache, earache, changes in swallowing
and speech, and facial, cervical and eye pain [10-14].
Symptoms may also occur along the distribution of the
external and internal carotid artery branches due to com-
*Corresponding author.
T. H. Hotta et al. / Open Journal of Stomatology 3 (2013) 338-343 339
pression at points on the vessels, affecting vascular cir-
culation and irritating the sympathetic nerves of the arte-
rial sheath [15].
It is often difficult to establish a definitive diagnosis of
Eagle’s syndrome due to the similarity of these symp-
toms to the other pathologies that affect the head and
neck areas. Therefore, the use of an occlusal splint, nor-
mally applied in the treatment of TMD, can be helpful
during the process of differential diagnosis [16].
Eagle’s syndrome affects approximately 27% of the
population, and elderly females show a greater preva-
lence of an elongated stylohyoid ligament complex
[18,19]. Additionally, the presence of an elongated sty-
lohyoid ligament complex was found in approximately
19.6% of Brazilian human skulls [17]. This syndrome is
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.
A 62-year-old woman was referred to the Occlusion,
Temporomandibular Dysfunction and Orofacial Pain in
Patients with Especial Care Course, School of Dentistry
of Ribeirão Preto, University of São Paulo, complaining
of limited mandibular and cervical movements, articular
and muscular pain, ear fullness, irritation of the lingual
mucosa, and discomfort associated with movement of
her tongue. Earlier, she received a medical diagnosis of
Eagle’s syndrome, and surgical removal of the styloid
process was suggested.
The patient was informed about the treatment plan and
study procedures by the investigators and signed the in-
formed consent. The study was approved by the Ethics
Committee of the School of Dentistry of Ribeirão Preto,
University of São Paulo (process n 2006.1.971.58.5).
A physical examination of the oral cavity revealed
general dental wear and extensive bony overgrowths
along the lingual surface in the premolar area of the
mandible (Figure 1). At the time of examination, the
mucosa that was overlying the tori appeared normal;
however, during later preoperative appointments, small
areas of abrasive lesions were often observed. Further-
more, the tongue rest position and the functional activi-
ties of the masticatory system were abnormal, promoting
muscular pain. The patient revealed that this pain often
occurred after the mastication of hard food; she also re-
ported occasional bruxism.
The first stage of the treatment plan involved the col-
lection of relevant data with the following analyses: Hel-
kimo index [22], electromyographic activity of the mas-
seter and temporalis muscles in rest position (Table 1),
bite force (Ta ble 2 ) [23], masticatory efficiency [24] and
speech evaluation [25].
The orofacial muscles (masseter, temporalis, pterygoid)
and the condyle lateral pole were bilaterally palpated in
order evaluate pain upon palpation using a numeric scale.
Figure 1. Extensive bony overgrowths
in the premolar area of the mandible.
Table 1. Numeric values of the electromyographic activities of
the masseter and temporalis muscles, before (E1) and after (E2)
Rest Position (µV)
Phases Right
E1 10.5 4.8 4.3 4.6
E2 6.1 2.7 4.3 4.1
Ta b l e 2 . Means of the maximal bite force in the left and right
molar regions, before (E1) and after (E2) treatments.
Site Evaluation Bite Force (N)
E1 34.3
Right Molar E2 46
E1 67.6
Left Molar E2 88.2
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T. H. Hotta et al. / Open Journal of Stomatology 3 (2013) 338-343
This scale consisted of 11 points, beginning with “0” (no
pain) and ending in “10” (the worst imaginable pain) [26]
(Table 3).
Using the Hugoson Index [27], the observed occlusal
wear was classified as level 1 (attrition of enamel down
to dentin spots), confirming the presence of bruxism that
was reported earlier by the patient.
Maximum mouth opening and the right and left lateral
movements were measured with a millimeter ruler. To
measure the maximum mouth opening movement, the
patient was requested to open her mouth, and the dis-
tance between the incisal borders was measured. The
patient performed right and left lateral movements, and
the distance between the mandibular and maxillary mid-
lines was measured. As there was no coincidence, a pen-
cil mark was made on the surface of the maxillary incisor,
corresponding to the mandibular midline, and a meas-
urement was later taken. The protrusion distance be-
tween the maxillary and mandibular incisal borders was
measured with a ruler (Table 4).
The patient’s masticatory efficiency was determined
using a coconut and sieve system, before and after treat-
ment. The patient received four aliquots of coconut
pieces, weighing a total of 20 g. Each piece of food was
chewed for 50 cycles. After mastication, the chewed par-
ticles were expelled into a set of five sieves (5, 4, 3, 2
and 1 mm) and were washed with water. Then, the parti-
cles were separated according to the granulometric mesh
particles contained in each sieve, and these particles were
put inside test tubes (A, B, C, D and E), according their
sizes. The test tubes were centrifuged for 5 minutes, and
the volumetric data were inserted in a mathematical for-
mula (4A + 2B + C/D + E) to obtain the index of masti-
cation (>10 = optimal, 5.0 to 9.9 = good, 2.0 to 4.9 =
regular, 1.0 to 1.9 = bad, <1.0 = terrible) (Table 5).
Afterward, the TMs were completely removed under
local anesthesia. The inferior alveolar nerves were
Table 3. Intensity of muscular and articular pain, before (E1)
and after (E2) treatments.
Masseter Temporalis Lateral
Lateral Pole
Right Left Right Left Right Left RightLeft
E1 7 5 8 3 8 7 8 2
E2 7 2 2 0 3 0 5 0
Table 4. Numeric values of the measurements of mandibular
movements, before (E1) and after (E2) treatments.
Mandibular Movements (mm)
Laterality Protrusion
E1 29 5 4 2
E2 50 8 9 3
blocked with 1.8 ml of anesthetic solution containing
mepivacaine (2 percent) and epinephrine (1:100.000),
applied to each side. The surgical approach consisted of
an intrasulcular incision that extended from one first
molar to the other. Afterward, a full-thickness flap was
carefully elevated, exposing both TMs and preserving
the insertion of the genioglossus muscles. The delimita-
tion of the TMs was performed using a surgical length
#702 taper fissure crosscut carbide bur. Afterward, a thin,
straight chisel was positioned into the gap and lightly
hammered twice, resulting in the easy removal of the
TMs. The bone irregularities were removed with a man-
ual Seldin bone file #12 to obtain a smooth surface along
the lingual cortical. The surgical field was copiously ir-
rigated with sterile saline solution, and the wound was
sutured in a non-continuous fashion with 4 - 0 black silk
thread mounted in a 1.7 cm - 12 circle needle (Ethicon,
São Paulo, Brazil). The biopsied tissues were sent to the
Department of Morphology, Stomatology and Physiol-
ogy for histopathological analysis, which confirmed the
diagnosis of TM. The patient was medicated with sodic
diclofenac (50 mg every 8 hours for 3 days) and dipiron
(500 mg every 8 hours, to prevent pain). The postopera-
tive period was uneventful, and the final result was a
After 2 months, an acrylic splint with anterior guid-
ance for disocclusion in protrusion and canine guidance
for disocclusion in lateral movements was provided to
the patient, who wore it for 6 weeks and was submitted
to weekly follow-up.
The patient exhibited intense signs and symptoms of
dysfunctions, such as limited jaw opening, pain during
mandibular movements, and pain during articular and
muscular palpation. She received an Acute Physiology
and Chronic Health Evaluation III score (AIII) for an-
amnestic dysfunction and, after treatment, for minor
signs and symptoms of dysfunction, such as TMJ noises,
fatigue of masticatory muscles and TMJ stiffness.
The data collected on the evaluation of mandibular
movements, functional evaluation of the TMJ, pain dur-
ing mandible movements, muscular pain and articular
pain accurately demonstrated the degree of TMJ dys-
function, both before (DiIII—severe clinical symptoms
Table 5. Numeric values of the volumetric data and mastica-
tory index, before (E1) and after (E2) treatments.
Masticatory Efficiency
E Results Index
E12 4 10 10 4 1.85 bad
E23 6 10 5 1 5.66 good
Copyright © 2013 SciRes. OPEN ACCESS
T. H. Hotta et al. / Open Journal of Stomatology 3 (2013) 338-343 341
of dysfunction) and after (DiII—moderate clinical symp-
toms of dysfunction) treatments.
Orofacial pain, joint noise and limited mandibular move-
ments are symptoms commonly associated with TMD.
Other symptoms, such as headache, earache, neck pain,
tinnitus and dysphagia are also related to this disorder
[28-30]. Similar signs and symptoms may be found in
other diseases, such as Eagle’s syndrome, and it may be
difficult to establish the correct diagnosis and appro-
priate treatment [10,31].
To facilitate diagnosis, the patient should be submitted
to a group of professionals from diverse disciplines, to
provide a comprehensive assessment and consultation in
cases that present several signs and symptoms, such as
the case reported here.
The first stage of the treatment plan involved the col-
lection of data that allowed a global view of the patient’s
clinical and functional conditions. The sequence of pro-
cedures was then selected.
The surgical treatment for Eagle’s syndrome involves
the excision of the stylohyoid process [10,12]. However,
such treatment involves the possibility of associating
pathologies that may aggravate the symptoms. Therefore,
a conservative, nonsurgical approach with an occlusal
splint is often.
Dentists should be aware of the risks of surgical inter-
vention to provide a better diagnosis and therapeutic pro-
cedure [32].
Because the occurrence of bilateral TM can interfere
with masticatory and speech functions in dentate patients,
affecting their quality of life, the clinicians in this case
chose to apply surgical intervention. The favorable cli-
nical results (tongue rest position and functional active-
ties) confirmed the appropriateness of this choice.
The ability to grind food is the end product of chewing,
and several structures of the stomatognathic system work
together so that chewing can be satisfactorily performed.
To evaluate the masticatory function, which encom-
passes the efficiency of the masticatory muscles and mas-
ticatory performance, the maximum bite force is useful
in both demonstrating how the system is fully interfaced
and in revealing any anatomical changes and temporo-
mandibular disorders that lead to an imbalance of this
system [33].
After treatment, the patient’s masticatory efficiency
improved. The activity began to be pleasant, without
joint or muscular pain and without trauma to the area that
previously accommodated the mandibular tori. The pa-
tient could also chew food harder and faster.
Occlusal splint therapy was applied to treat the pa-
tient’s TMD and to assist the group of professionals dur-
ing the differential diagnosis process, as previously sug-
gested [16]. The satisfactory clinical outcomes were evi-
denced in the increased amplitude of mandibular move-
ments, decrease in muscular/articular pain and the im-
provement in functional activities.
The patient was instructed to chew pieces of test food
as usual, and it was observed that chewing was per-
formed on the left, with greater bite force on the left side.
The right side exhibited greater muscle and joint pain,
justifying the patient’s preference for chewing on the left
side. It should be noted that the magnitude of the bite
force varies when characteristics of the craniofacial com-
plex are abnormal, especially in cases of temporoman-
dibular dysfunction [34].
Electromyographical analysis of the masseter and tem-
poralis muscles may be used to compare muscular activi-
ties during rest and during clinical manipulation [18].
The results of electromyographic analyses showed that
mean muscle activity was improved after the combina-
tion of surgical therapy and the occlusal splint.
This article reports a clinical case in which a combina-
tion of surgical therapy and dental resources were used to
treat limited mandibular movements and painful symp-
toms in a patient with temporomandibular dysfunction,
Eagle’s syndrome and torus mandibularis.
In recent decades, the required care for older people
has increased in the daily practice of dental professionals.
Therefore, it is critical for clinicians to understand the
situations that lead to discomfort in older patients.
In summary, dental practitioners should understand the
causes of anatomical changes, improving their patients’
quality of life by providing a more practical approach to
the treatment of painful sintomatoligia in older people
with Eagle’s syndrome, temporomandibular disorder and
mandibular tori.
The authors wish to thank Ribeirão Preto School of Dentistry, Univer-
sity of São Paulo.
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