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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 174-179

Prevalence and calcification of stylohyoid complex in North West part of India and its correlation with general and dental health condition


Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Uttar Pradesh, India

Date of Submission03-Nov-2016
Date of Acceptance08-Nov-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Shalu Rai
Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Kadrabad, Modinagar, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_135_16

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   Abstract 

Aim: This study was conducted to evaluate the variation and clinical significance of stylohyoid complex and to correlate it with general and dental health among different age groups and gender using panoramic radiographs. Materials and Methods: The study included 1,000 subjects indicated for panoramic radiographs. Styloid processes >30 mm were correlated age wise and gender wise. The morphology of the calcified stylohyoid complexes was allocated into 12 different patterns and their length was measured directly on the radiographs. Serum calcium levels and cholesterol levels were obtained from subjects with elongated styloid process and their heart rate, blood pressure measurement, weight, height, number of teeth present, and community periodontal index (CPI) was assessed. Results: Out of 978 detected styloid processes, 267 (27.3%) were more than 30 mm. The average length of the calcified styloid complex was 26.40 mm. The most common pattern of calcification was found to be E pattern, 64 (34.03%) in number which had statistically significant correlation with age (P value <0.001). Pearson's correlation coefficient association of body weight with elongated styloid process (left and right) was 0.163 (P value 0.162) and 0.300 (P value 0.001) respectively which was found to be statistically significant on right side. Twenty seven subjects who showed no elongation but evident calcification patterns according to gender and age on panoramic radiographs were also recorded and were called mineralized styloid termed as mineralization. Conclusion: Calcification of the styloid complex is commonly observed on panoramic radiographs and the present and previous studies indicate that the panoramic radiographs include information on general and dental health condition.

Keywords: Calcification, health, mineralization, panoramic, styloid process


How to cite this article:
Rai S, Misra D, Singh N, Khatri M, Tyagi K, Mallick P. Prevalence and calcification of stylohyoid complex in North West part of India and its correlation with general and dental health condition. J Indian Acad Oral Med Radiol 2017;29:174-9

How to cite this URL:
Rai S, Misra D, Singh N, Khatri M, Tyagi K, Mallick P. Prevalence and calcification of stylohyoid complex in North West part of India and its correlation with general and dental health condition. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2017 Dec 17];29:174-9. Available from: http://www.jiaomr.in/text.asp?2017/29/3/174/218710


   Introduction Top


The styloid process is a bony projection, situated immediately anterior to the stylomastoid foramen.[1] Elongation in styloid process was first described by Eagle in 1937 and is described as Eagle's syndrome. Elongation of styloid process is seen in approximately 4% of general population and is usually asymptomatic, with only 4% of subjects presenting with symptoms.[2] The exact cause of this elongation is unknown.[3] Theory of reactive hyperplasia, theory of anatomic variance, dysendocrine theory correlate anatomy, embryology, and physiology for its clear understanding.[4] The normal length of the styloid process varies greatly between individuals, but in general it is 20–30 mm long. Styloid process longer than 30 mm is considered elongated. Length of the elongated styloid process is controversial. Eagle defined the length of a normal styloid process to be 2.5–3.0 cm.[5]

Various imaging techniques such as panoramic radiography, posteroanterior skull view, lateral cephalogram, lateral oblique mandible view, Towne's view, computed tomography, and magnetic resonance imaging demonstrate the styloid process.[2],[5] The aim of the study was to evaluate the length of the styloid process, various patterns of calcification, and to correlate the elongated styloid process with a variety of parameters associated with the general and dental health of an individual.


   Materials and Methods Top


The study was an observational trial further classified as nonrandomized prospective study consisting of 1,000 subjects of either gender from age group 16–80 years reporting to the institutional OPD and indicated for panoramic radiography. The study period was from March 2013 till June 2014. Informed consent was taken along with ethical clearance from the institutional ethical committee to perform the radiograph and further use them for research purposes. The subjects were divided into three age groups, i.e., Group 1: 16–36, Group 2: 37–56, and Group 3: 57–80 years. Subjects having history of facial injury, vitamin D consumption, bleeding disorders or ectopic calcification of carotid artery, phleboliths, and lymph node were excluded from the study. The panoramic radiographs of the subjects with elongated styloid process (≥30 mm) were evaluated and included in the study.

The orthopantomogram used for making panoramic radiographs was 8000C (Kodak) having radiographic sensor of charged couple device (CCD) type, voltage (80 kVp), current (12 mA), time scan (17 s), focal spot size (0.5 mm), and magnification factor (1.29). The software used was Kodak Dental Imaging System (KDIS) version 6.13.0. Bilateral styloid processes were studied on the panoramic radiographs by an experienced dentomaxillofacial radiology specialist. The images were evaluated in a darkened quiet room with dual monitors (HP LP2475W, resolution 1920 × 1200; Hewlett-Packard, Houston, USA). Each viewing session lasted 30 min.

The styloid process was measured using the measurement method of Jung et al.[6] for lengths of bilateral styloid processes [Figure 1]. In brief, the measurement was taken on the frontal side of the temporal bone. In this area on the panoramic radiographs a thin transparent line is generally visualized between the shadows of these processes and the tympanic bone. This transparent line corresponds to the cleft between them and the tympanic plate of the temporal bone. The tip of the styloid process is its bony end, including mineralized parts of the ligament. Its apparent length was measured with the help of measuring tools.
Figure 1: Elongated styloid process on left side

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The pattern of calcification was studied according to method described by MacDonald-Jankowski [7] (2001) [Figure 2]. The pattern of calcification was described according to the center of calcification involved; Region 1 tympanohyal; Region 2 stylohyal; Region 3 ceratohyal; Region 4 hypohyal. The 12 patterns were derived from the pattern of calcification in the regions and whether the regions were continuous or distinct. The presence of the lesser horn of the hyoid bone was not recorded. The symmetry was determined by reference to the pattern based on the four regions. In those cases where asymmetry was present, the pattern that was most advanced was taken to define the pattern for that patient. The terms used in this report were defined as follows: calcification was “normal” where it did not extend below the mandibular foramen (Patterns A to D). A normal styloid process was considered “classical” where it presented as a continuous radiopacity composed of Regions 1 and 2 (Pattern D). An “elongated styloid process” was defined as extending below the mandibular foramen (Pattern E). Calcification of the stylohyoid ligament was defined as occurring when calcification which extended below the mandibular foramen did not appear to be continuous with the base of the skull (Patterns F to K) [Figure 3].
Figure 2: Mac Donald classification of elongated styloid process

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Figure 3: Types of Calcification patterns as seen on OPG

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In our study, we found few radiographs showing calcification of styloid process which was similar to the type of presentation reported by Langlais et al.[8] Hence, we modified classification by adding 13th and 14th variant of calcification pattern which is nodular (N) and partially calcified (P) [Figure 3]. The serum calcium levels and cholesterol levels were obtained from fresh venous blood mixed with ethyline diamine tetra acetic acid (EDTA) collected from the subjects. The serum calcium levels were measured by calcium assay kit and serum cholesterol levels were measured by Erba cholesterol kit (Transasia Bio-Medicals Ltd., India).

The heart rate was measured by palpating radial artery of the subjects. The mercury sphygmomanometer was used for blood pressure measurement, weighing machine was used for weight measurement, and height of the subject was measured using fixed height ruler (Sterling, An ISO certified unit health scale). The number of teeth present were counted using FDI (Fédération Dentaire Internationale) nomenclature and community periodontal index (CPI) was used to assess loss of attachment, periodontal pockets, gingival bleeding, and calculus in the mouth of subjects. The patients were also questioned about clinical symptoms related to elongated styloid process.

Statistical analysis

The data were analyzed by using statistical software statistical package of social sciences (SPSS) version 16.0 IBM, U.S. The probability value P < 0.05 was considered as significant, P < 0.01 and P < 0.001 were considered as highly significant and value P > 0.05 was considered as not significant.


   Results Top


A total of 978 styloid processes were detected in 1,000 subjects. Total 537 (54.9%) and 441 (45.1%) styloid processes were detected in males and females respectively, which were further classified age wise into three age groups, i.e., 16–36, 37–56, and 57–80 years. The correlation of gender wise distribution of styloid process with age wise distribution: Among male subjects, 288 (48.6%) styloid processes were detected in age Group 1, 158 (62.2%) in age Group 2, and 91 (69.5%) in age Group 3. Among female subjects, 305 (51.4%) were detected in Group 1, 96 (37.8%) in Group 2, and 40 (30.5%) in age Group 3. According to age wise distribution 593 styloid processes were detected in age Group 1, 254 in age Group 2, and 131 in age Group 3 [Table 1].
Table 1: Correlation of gender wise and age wise distribution of detected styloid process (N=978)

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Out of 978 detected styloid process, 267 (27.3%) were elongated, i.e., ≥ more than 30 mm. The minimum, maximum, and mean length of stylohyoid complex were 10 mm, 42.80 mm, and 26.40 mm, respectively. Correlation of gender wise distribution of 267 elongated styloid process with age wise distribution: For male subjects, total 173 (64.7%) elongated styloid processes were present, amongst them 95 (61.6%) styloid processes were detected in Group 1, 52 (71.7%) in age Group 2, and 26 (63.5%) in age Group 3. For female subjects total 94 (35.3%) elongated styloid processes were detected; among them 59 (38.4%) were detected in Group 1, 20 (28.3%) in Group 2, and 15 (35.3%) in Group 3. According to age wise distribution within age Group 1, 154 styloid processes were detected in age Group 1, 72 in age Group 2, and 41 in age Group 3 [Table 2].
Table 2: Correlation of gender wise and age wise distribution of elongated styloid process >30 mm (N=267)

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On evaluating the gender and age based distribution pattern of calcification we found that the most common pattern in 267 elongated styloid processes was E pattern (64). The age wise distribution was found to be 2 (0.3%) in Group 1, 36 (14.2%) in Group 2, 26 (19.8%) in Group 3; and gender wise, 35 (5%) in males and 29 (10.8%) in females. The least common pattern of calcification was determined as C pattern (0.4%) in age Group 2 of females. The age wise correlation with pattern of calcification yielded statistically highly significant result (P ≤ 0.001), however, no statistically significant correlation could be established between gender and types of calcification [Table 3] and [Table 4].
Table 3: Age wise distribution of calcification in detected styloid (N=978)

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Table 4: Gender wise distribution of calcification in detected styloid (N=978) (>30 mm styloid process)

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In our study, Pearson's correlation coefficient was done to assess association of age with elongated styloid process (left and right side) which was found to be 0.319 (P< 0.001) and 0.347 (P< 0.001), respectively and was seen to be statistically highly significant. Pearson's correlation coefficient was also used to find association of blood pressure (systolic) with elongated styloid process (left and right side) and was found to be 0.112 (P = 0.330) and 0.026 (P = 0.785), respectively which was statistically nonsignificant. Association of diastolic blood pressure with elongated styloid process (left and right side) was also calculated using Pearson's correlation coefficient and it came out to be 0.137 (P = 0.235) and 0.059 (P = 0.529), respectively which was also statistically nonsignificant [Table 5] and [Table 6].
Table 5: Correlation of left side styloid process with general and dental health

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Table 6: Correlation of right side styloid process with general and dental health

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Pearson's correlation coefficient association of heart rate with elongated styloid process (left and right side) was inferred as 0.201 (P = 0.081) and 0.125 (P = 0.181), respectively which was found to be statistically nonsignificant. Pearson's correlation coefficient was also used to find association of serum cholesterol with elongated styloid process (left and right side) and came out to be 0.004 (P = 0.971) and 0.086 (P = 0.370), respectively which was also found to be statistically nonsignificant [Table 5] and [Table 6].

Pearson's correlation coefficient association of serum calcium with elongated styloid process (left and right side) was 0.152 (P = 0.204) and 0.051 (P = 0.596), respectively which was again found to be statistically nonsignificant. Association of body height with elongated styloid process (left and right side) was found to be 0.213 (P = 0.064) and 0.060 (P = 0.518), respectively using Pearson's correlation coefficient and was found to be statistically nonsignificant [Table 5] and [Table 6].

Pearson's correlation coefficient association of body weight with elongated styloid process (left and right side) was 0.163 (P = 0.162) and 0.300 (P = 0.001) respectively, and was found to be statistically significant on right side. Pearson's correlation coefficient was also used to find association of CPI with elongated styloid process (left and right side) and was 0.038 (P = 0.749) and 0.114 (P = 0.234), respectively which was statistically nonsignificant. Pearson's correlation coefficient association of number of teeth with elongated styloid process (left and right side) was 0.194 (P = 0.089) and 0.082 (P = 0.373), respectively which was found to be statistically nonsignificant. [Table 5] and [Table 6].

In our study, 27 patients showed no elongation but there was evidence of calcification patterns on panoramic radiographs. Correlating these 27 styloid processes according to gender and age we found that pattern C was seen in 1 (10.0%) female subject in the age Group 2; Pattern D was seen in total 15 (55.6%) subjects, 7 (70.0%) females and 8 (47.1%) males in the age Group 2 (13 subjects) and Group 3 (2 subjects); Pattern F was found in total 2 (7.4%) subjects, 1 (10.0%) in females and 1 (5.9%) in males in Group 2 (1 subject) and Group 3 (1 subject); Pattern G in total of 1 (3.7%) subject, 1 male (5.9%) in Group 2; Pattern J in total of 2 (7.4%) subjects, 2 (11.8%) males in Group 2; Pattern N in total of 5 (18.5%) subjects, 1 (10.0%) female and 4 (23.5%) males in Group 2 (2 subjects) and in Group 3 (3 subjects); and Pattern P in total of 1 (3.7%) male subject in Group 2 [Table 7] and [Table 8].
Table 7: Gender wise distribution of various pattern of mineralization of stylohyoid complex (<30 mm styloid process)

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Table 8: Age wise distribution of various pattern of mineralization of stylohyoid complex

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On enquiring patients with elongated styloid process about association with any clinical symptoms, it was found that none of the patients in our study reported with any clinical symptoms, i.e., pain or discomfort associated with elongated styloid process.


   Discussion Top


Elongated styloid process may sometimes be asymptomatic or associated with wide range of discomfort to the subjects. The present study was carried out on 1,000 subjects who were divided into three different groups, i.e., Group 1, Group 2, and Group 3 and were subjected to pantomographic examination for evaluation of length, calcification of styloid process, and its association with the general and dental health of an individual.

A total of 978 styloid processes were detected in 1,000 subjects and were distributed according to age as follows, 593 in Group 1, 254 in Group 2, and 131 in Group 3. The gender wise distribution revealed 537 (54.9%) were males and 441 (45.1%) females. This means that more number of styloid process were detected in males as compared to females. These results were in accordance to study conducted on 296 participants by Sokler et al.[9] where they found elongated styloid process in 161 males and 135 females. However, Gokce et al.[10] in their study on 698 individuals found more number of styloid process in females (413) as compared to males (285) in Turkish population.

Out of 978 detected styloid process, 267 (27.03%) were elongated, i.e., ≥ more than 30 mm. 154 (26%) styloid processes were detected in age Group 1, 72 (28.3%) in age Group 2, and 41 (31.3%) in Group 3 which is in accordance to the study by Lins et al.[11] We found the most common pattern of calcification to be E pattern, 64 (34.03%), in which all tympanohyal, stylohyal, and ceretohyal are continuous. 29 females (45.03%) and 35 males (54.07%) showed this pattern. Similar results were found by DS Mac Donald – Jankowski [7] who found E pattern in 29 (9.6%) males and 33 in females in London population.

In the present study, we evaluated the general health conditions including serum calcium, serum cholesterol levels, height, weight, heart rate, blood pressure, and dental health parameters including CPI and number of teeth in patients with elongated styloid process. In our study comparison of mean serum cholesterol with elongated styloid process on right and left side respectively was done within different age groups using ANOVA test and was found to be statistically nonsignificant (right side P = 0.544 and left side P = 0.548, and Pearson correlation = 0.074 and 0.046 respectively). Mean serum cholesterol concentration was 240.87 mg/dL in Group 1, 252.58 mg/dL in Group 2, and 241.41 mg/dL in Group 3. Our results were in accordance with study done by Okabe et al.[12] who found no significant correlation between total serum cholesterol concentration and elongated styloid process; however, the author did not compare age with total serum cholesterol concentration of an individual.

In our study, comparison of mean serum calcium with elongated styloid process on right and left side was done within different age groups using ANOVA test and was found to be statistically nonsignificant (right side P = 0.808 and left side P = 0.279, and Pearson correlation = 0.021 and 0.131 respectively). The mean serum calcium concentration was 9.21 mg/dL in Group 1, 8.95 mg/dL in Group 2, 8.95 mg/dL in Group 3. This is in accordance with the study conducted by Ardakani et al.[13] who observed no statistically significant correlation between age and serum calcium levels in patients with elongated styloid process. Okabe et al.[12] found significant correlation between serum calcium concentration and length of styloid process and suggested an unknown mechanism may be responsible for elongated styloid process that might have a tendency for high serum calcium level in an individual.

On comparing elongated styloid process on the right and left sides with body length and weight a significant correlation between the two was found (P = 0.005 and 0.250 respectively, and Pearson correlation 0.319 and 0.094 respectively, for length, and P = 0.050 and 0.002 respectively, and Pearson correlation 0.229 and 0.293 respectively, for weight). The results were in accordance with the study by Okabe et al.[12] and Ghafari et al.[14] who also found body length and weight to be statistically significant on comparing them with elongated styloid process. The average weight of subjects with elongated styloid process was greater than the subjects with unilaterally nonelongated styloid process.

A statistically nonsignificant correlation was found between elongated styloid process and blood pressure. The findings were in accordance with the study conducted by Okabe et al.[12] who found no statistically significant results between length of styloid process and frequency of patients with elevated systolic and diastolic blood pressure. However, Ghafari et al. found statistically significant correlation between the two and found it could be due to anatomy of the area. In our study, we could not find any statistically significant correlation between elongated styloid process and heart rate which is in accordance with the study by Ghafari et al.[14] and Okabe et al.[12] (P = 0.27 and 0.834 respectively).

The muscle tension from occlusal disarrangements and changes in bone height in partial or complete edentulous subjects could be a probable factor in the incidence of elongated styloid process. The association between the number of teeth present in the mouth and the elongation of the styloid process was studied, but no significant correlation was found between the two. Our results were in accordance with a study conducted by Ghafari et al.[14] and Okabe et al.[12] There was no significant correlation found between CPI and length of the styloid process which is in accordance with the study by Okabe et al.[12] who found no relationship between the CPI and the length of the styloid process (Pearson correlation = 0.048 and P value = 0.296). In our study of 27 patients showed no elongation but evident calcification patterns according to gender and age on panoramic radiographs. Such calcifications without elongation were called as “mineralization of the stylohyoid ligaments complex” which has also been used by previous authors, Correll et al.[15] and Zaki et al.[16]


   Conclusion Top


The present and previous studies indicate panoramic radiography is useful for detection of an elongated styloid process and/or ossification of styloid ligaments in patients with or without symptoms and hence is an economical imaging modality to view the elongated styloid process. It also indicates that the panoramic radiographs include information on general health condition as well as on jaws and teeth. Therefore, we recommend long-term follow-up studies should be carried out to demonstrate more significant results correlating elongated styloid process and general health conditions of the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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Sokler K, Sandev S. New classification of the styloid process length-- Clinical application on the biological base. Coll Antropol 2001;25:627-32.  Back to cited text no. 9
    
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Ardakani FE, Khayam E, Booshehri MZ, Mohammadi AR. The evaluation of the relationship between serum calcium level and stylohyoid length in adults. Acta Med Iran 2011;49:742-7.  Back to cited text no. 13
    
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