Saudi Dental Journal (2018) 30, 151–154

King Saud University

Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Calcification of the stylohyoid complex in Libyans

Galal Omami *

American Board of Oral and Maxillofacial Radiology, United States

University of Kentucky College of Dentistry, Department of Oral Health Practice, Division of Oral Medicine, Diagnosis
and Radiology, 800 Rose Street, Room MN-320, Lexington, KY 40536-0297, United States

Received 21 May 2016; revised 27 November 2017; accepted 16 December 2017

Available online 24 December 2017

KEYWORDS Abstract Objective: To investigate the prevalence and pattern of calcification of the stylohyoid
Calcification; complex in Libyan population.
Radiography; Material and methods: Archived digital panoramic radiographs of 3343 patients were collected;
Panoramic; 181 images were excluded for underage or poor image quality. Thus, the images of 3162 patients
Stylohyoid (1081 men, 2081 women; women-to-men ratio, 2:1; age range, 16–68 years; mean age, 36.7 years)
retrieved and assigned to one of four morphological patterns of the stylohyoid complex: regular,
elongated, calcified, and undetected. Data were analyzed with the Χ2 test using SPSS (Chicago,
IL, USA); P values lower than 0.05 were considered statistically significant.
Results: Out of 3162 images studied, the styloid process was demonstrated to be regular in 1935
(61.2%), elongated in 541 (17.2%), calcified in 565 (17.8%), and undetected in 121 (3.8%). Symmet-
ric patterns were demonstrated on 2580 (81.6%) images. An elongated stylohyoid complex was sig-
nificantly more common in women than in men (P = .0404).
Conclusion: The anatomical patterns of the stylohyoid complex in Libyans were highly variable.
Dental clinicians should recognize the various morphological patterns of the stylohyoid complex on
panoramic radiographs. Computed tomography studies are recommended for further morphomet-
ric analysis of the stylohyoid complex.
Ó 2017 The Author. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
* Address: University of Kentucky College of Dentistry, Department
of Oral Health Practice, Division of Oral Medicine, Diagnosis and The stylohyoid complex (chain) consists of the styloid process,
Radiology, 800 Rose Street, Room MN-320, Lexington, KY 40536- stylohyoid ligament and the lesser cornu (horn) of the hyoid
0297, United States. bone. It is derived from the second pharyngeal arch (Reichart’s
E-mail address: [email protected]. cartilage). The stylohyoid process projects downward, for-
Peer review under responsibility of King Saud University. ward, and slightly medially so that its tip is positioned between
the internal carotid artery, internal jugular vein, and cranial
nerves V, IX, and Langlais et al. reported that the styloid pro-
cess varies in length between patients and often between the
Production and hosting by Elsevier
two sides of the same individual (Langlais et al., 1995). They
https://doi.org/10.1016/j.sdentj.2017.12.003
1013-9052 Ó 2017 The Author. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
152 G. Omami

suggested that an elongated styloid process results from ossifi-

cation in the stylohyoid ligament.
Calcification of the stylohyoid complex is usually detected
as an incidental finding on panoramic radiographs (Monsour
et al., 1986). However, this finding may also be associated with
a group of clinical symptoms that require surgical intervention
(Eagle, 1948). O’Carroll reported that 8 of 103 (8%) patients
with an elongated styloid process presented with related symp-
toms of deep neck pain, foreign body sensation in the throat,
pain on turning the head, and odynophagia (O’Carroll, 1984).
Langlais et al. proposed a radiographic classification for the
calcified stylohyoid complex, including three patterns of radio-
graphic presentation (elongated, pseudoarticuated, segmented)
and four patterns of calcification (calcified outline, partially
calcified, nodular complex, completely calcified) (Langlais
et al., 1986). However, only a few studies have presented the
calcification of the stylohyoid complex in a manner that would
be useful for clinicians. Therefore, the aim of this study was to
investigate the prevalence and pattern of calcification of the
stylohyoid complex in a Libyan population.

2. Material and methods

Records of digital panoramic radiographs treated at the

University of Benghazi College of Dentistry between January
2010 and December 2013, were retrieved and evaluated for Fig. 1 O’Carroll’s classification of the stylohyoid complex:
the prevalence and pattern of calcification of the stylohyoid Patterns A through D, regular; Pattern E, elongated; Patterns F
complex. Patients younger than 16 years of age were excluded through K, calcified; and Pattern L, absent.
from the analysis as these patients would not have reached
skeletal maturity. Radiographs with positioning or exposure
errors were also excluded from the study. The panoramic software—iPhoto (Apple, Cupertino, CA, USA) on a 27-in.
images were generally obtained as part of routine radiographic monitor (iMac, Apple) with a screen resolution of 2560  14
screening for oral diagnosis. Therefore, no specific history 40 pixels.
related to the stylohyoid complex, e.g., tonsillectomy or cervi-
cal trauma, was obtained, so that it was not possible to diag- 3. Results
nose Eagle syndrome or stylohyoid syndrome. The images
were taken using paX-i (Vatech, Seoul, Korea) set at 60–80 The digital panoramic radiographs of 3343 patients were col-
kVp, 8–10 mA, and 10.1 s. lected; 181 images were excluded because the patient was
The native population of Libya is mainly a mixture of younger than 16 or because the image quality was poor as
Arab-Imazighen ethnicities, with large minorities descending the result of errors in positioning or exposure. Thus, the
from African and Turkish origin. However, it was not possible images of 3162 patients (1081 men, 2081 women; women-to-
to determine the ethnic background of each patient. men ratio, 2:1; age range, 16–68 years; mean age, 36.7 years)
The classification of the stylohyoid complex used in this were included in the study.
study was modified from MacDonald-Jankowski’s study The detailed distribution of the 12 patterns of O’Carroll’s
(MacDonald-Jankowski, 2001). He classified the stylohyoid classification4 is shown in Table 1. The styloid process was
complex according to the center of calcification as following: classified as regular (Patterns A, B, C, and D) in 1935 images
Region 1, tympanohyal; Region 2, stylohyal; Region 3, cerato- (61.2%), elongated (Pattern E) in 541 (17.2%), calcified
hyal; Region 4, hypohyal. (Patterns F, G, H, I, J, K) in 565 (17.8%), and undetected
The classification used in this study is as following: the sty- (Pattern L) in 121 (3.8%). However, 2580 (81.6%) of the reg-
loid process was considered ‘‘regular” when it did not extend ular, elongated, calcified, or undetected patterns were symmet-
below the mandibular foramen (Patterns A to D); ‘‘elongated” rical on both sides. According to O’Carroll’s classification,
when it extended below the mandibular foramen and appeared Pattern D was the most common symmetrical pattern (964,
to be continuous with skull base (Pattern E); ‘‘calcified” when 30.5%), whereas Pattern D-C was the most common asymmet-
it extended below the mandibular foramen and did not appear rical pattern (180, 5.7%). The elongated stylohyoid complex
to be continuous with the cranial base (Patterns F to K); ‘‘un- pattern occurred significantly more frequently among women
detected” when it could not be seen on the panoramic image (P = .0404). However, there was no significant difference
(Figs. 1 and 2). All radiographs were de-identified and between men and women in the occurrence of the calcified
reviewed by a board-certified oral and maxillofacial radiologist stylohyoid complex (P = .0669).
under ambient room lighting using the standardized Apple
Calcification of the stylohyoid complex in Libyans 153

Fig. 2 Classification of the stylohyoid complex used in this study: a, regular; b, elongated; c, calcified; d, undetected.

Table 1 Patterns of calcification of the stylohyoid complex in Libyans.

Pattern A B C D E F G H I J K L
Side Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt Rt Lt
Number 99 93 263 246 309 403 1297 1160 528 554 54 57 122 121 21 15 203 251 64 69 76 77 126 116
Total 192 509 712 2457 1082 111 243 36 454 133 153 242
Percentage 3 8 11 39 17 2 4 0.5 7 2 2.5 4
RT, right; LT, left.

4. Discussion whether other patterns of the stylohyoid complex are in

essence pathologic conditions; instead, they seem to be normal
This study evaluated the calcification pattern of the stylohyoid variants commonly observed on panoramic radiographs. How-
complex on panoramic radiographs as this imaging modality is ever, the criteria of definitions used in this study corresponded
widely used by dental clinicians. To the best of the author’s to those used in MacDonald-Jankowski’s study (MacDonald-
knowledge, the size of the sample in this study is the largest Jankowski, 2001). The elongated and calcified patterns of the
ever included in studies of the stylohyoid complex. The fre- stylohyoid complex occured at quite similar rates in this study
quency of a calcified stylohyoid complex in this analysis was (elongated, 17.2%; calcified, 17.8%). The frequency of the cal-
relatively higher than that found in previous studies cified pattern was similar to that reported among the Hong
(MacDonald-Jankowski, 2001; Jung et al., 2004; Oztas et al., Kong Chinese (MacDonald-Jankowski, 2001). However, the
2012). A relatively recent study reported that only 6% of sub- frequencies at which other patterns occurred were generally
jects with a calcified stylohyoid complex had related symptoms different from those reported in studies investigated subjects
(Ilguy et al., 2005). Therefore, the calcification of the stylohy- of different ethnic backgrounds including Hong Kong Chi-
oid complex on panoramic radiographs should be based on nese, Londoners, and Turkish populations (MacDonald-
clinical findings. Jankowski, 2001; Alpoz et al., 2014). However, O’Carroll
Various classification techniques have been used to evaluate reported no particular ethnic predilection in his study involv-
the stylohyoid complex (MacDonald-Jankowski, 2001; Oztas ing subjects from the United States (O’Carroll, 1984). Interest-
et al., 2012; Okabe et al., 2006; Kursuoglu et al., 2005). In ingly, the frequency of Pattern L (absent stylohyoid complex)
the present study, the stylohyoid complex was simply classified was similar among Libyans, Hong Kong Chinese, Londoners,
according to 4 patterns (regular, elongated, calcified, and and Turkish populations (2.5–3.8%) (Monsour, 1986;
undetected). This classification system is of more clinical value MacDonald-Jankowski, 2001). However, it is unclear whether
than sorting the stylohyoid complex into one of 12 anatomic this type of stylohyoid complex was actually absent or was
patterns, as in O’Carroll’s classification (Fig. 1). For instance, simply unseen because of technical reasons; hence, the current
in the context of related symptoms, the clinician will essentially study used the term undetected rather than absent. However, a
need to ascertain the pattern of the stylohyoid complex in cadaveric study did not find a single case in which the styloid
terms of elongation and calcification. The current study used process was completely absent, although a vestigial process
the term regular rather than normal, because it is unclear was identified (Frommer, 1974).
154 G. Omami

The elongated stylohyoid complex was significantly more Conflict of interest

common among females than among males. However, there
was no significant difference between males and females in The author declared that there is no conflict of interest.
the frequency of the calcified stylohyoid complex. In agree-
ment with other reports (Monsour, 1986; Omnell, 1998),
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