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Changes in the mandible in scleroderma
Changes in the mandible in scleroderma Report of a case Shelley Nan Weiner, M.D.,* HOSPITAL
OF THE
ALBERT
and Merwin
EINSTEIN
Wo& D.D.S.,**
COLLEGE
S
oft-tissue and bone changes have been well documented in patients with scleroderma. The most common of these findings are soft-tissue calcification (usually in the extremities) and resorption of the terminal phalanges of the fingers. l, 2 Resorption of the acromial process, distal clavicle, and distal radius and ulna has also been described. 2 Recently, we saw a patient with advanced scleroderma who had resorption of the angle and ramus of the mandible with adjacent soft-tissue calcification.
Bronx, N. Y
OF MEDICINE
CASE REPORT
firm, with resorption of the distal phalanges and limitation of motion of the hands and wrists. In addition, there is marked tightness of the skin of the face with the masklike facies of classic scleroderma. An upper gastrointestinal series in 1971 demonstrated absence of peristalsis of the esophagus. The patient has been treated with prednisone. She was referred to the Department of Oral Surgery because of inability to open her mouth. A panoramic radiograph of the mandible demonstrated marked erosion of the angle and ramus of the mandible (Fig. 1) in the region of the insertion of the masseter and lateral pterygoid muscles. Amorphous calcifications in the soft tissues adjacent to the area of bone erosion were also present.
M. M., a 49-year-old white woman, has had sclerodenna for the past 9 years. The skin of her fingers is indurated and
DISCUSSION
*Department of Radiology. **Department of Oral Surgery.
Unilateral atrophy or underdevelopment of the mandible has been described in children with scleroderma.3 Atrophy of the mandible is most often associated with
Fig. 1. Ramus areas of a panoramic radiograph of the mandible demonstrating erosion of the angle andt bilaterally (large arrows) and soft-tissue calcification (small arrows). 0030. .4220/81/030329+02$00.20/0
0
1981
The C. V. Mosby Co
329
330
Weiner and Wolf
periodontal disease, pressure from dentures, and an edentulous patient.-’ Notching of the angle of the mandible and even resorption of the ramus were described by Seifert and associates5 in five out of sixteen patients with scleroderma being evaluated for temporomandibular joint pain. A similar finding was reported in one patient with Raynaud’s disease.fi Reference to erosion of the angle of the mandible in scleroderma is made by Tavaras’ in a book on temporomandibular joint disease. The case presented here offers another illustration of this littleknown finding in scleroderma. Its incidence and significance are as yet unknown. To our knowledge, there is no definitive explanation for the bone erosion observed in scleroderma. It may be related to bone ischemia or the extensive soft-tissue fibrosis which occurs in scleroderma.“-s Another contributing factor may be the loss of normal muscle action on the mandible because of fibrosis and atrophy of muscles of mastication.“. i Except for their unusual location, the soft-tissue calcifications seen in our case are probably similar to the dystrophic calcifications seen elsewhere in the soft tissues of patients with scleroderma.
Oral Surg. March, 1981 REFERENCES 1. Harper, R. A., and Kemp, Jackson D. C.: Progressive Systemic Sclerosis, Br. J. Radiol. 38: 825834, 1965. 2. Meszaros, William T.: The Regional Manifestations of Scleroderma, Radiology 70: 313-325, 1958. 3. Chipps, James, and Hirschmann, Victor R.: Scleroderma Affecting the Masticatory Apparatus. U. S. Armed Forces Med. J. 7: 1209-1213, 1956. 4. Thoma, Kurt H., and Holland, Daniel J.: Atrophy of the Mandible, ORAL SURG. 4: 1477.1495, 1951. 5. Seifert, Martin H., Steigerwald, James C., and Cliff. May M.: Bone Resorption of the Mandible in Progressive Systemic Sclerosis, Arthritis Rheum. 18: 507-515, 1975. 6. Gray, Robert G., Altman, Roy D., and Kline, Stuart: Mandibular Bone Erosion and Scleroderma, Arthritis Rheum. 19: 1371, 1976. 7. Tavaras, J.: In Schwartz, L.: Disorders of the Temporomandibular Joint, Philadelphia, 1959, W. B. Saunders Company, p. 160. 8. Bamett, Alfred .I.: Scleroderma, Springfield, Ill.. 1974. Charles C Thomas Publisher. Reprint requests to: Dr. Shelley Nan Weiner Hospital of the Albert Einstein College of Medicine 1825 Eastchester Rd. Bronx, N. Y. 10461
OF THE
ALBERT
and Merwin
EINSTEIN
Wo& D.D.S.,**
COLLEGE
S
oft-tissue and bone changes have been well documented in patients with scleroderma. The most common of these findings are soft-tissue calcification (usually in the extremities) and resorption of the terminal phalanges of the fingers. l, 2 Resorption of the acromial process, distal clavicle, and distal radius and ulna has also been described. 2 Recently, we saw a patient with advanced scleroderma who had resorption of the angle and ramus of the mandible with adjacent soft-tissue calcification.
Bronx, N. Y
OF MEDICINE
CASE REPORT
firm, with resorption of the distal phalanges and limitation of motion of the hands and wrists. In addition, there is marked tightness of the skin of the face with the masklike facies of classic scleroderma. An upper gastrointestinal series in 1971 demonstrated absence of peristalsis of the esophagus. The patient has been treated with prednisone. She was referred to the Department of Oral Surgery because of inability to open her mouth. A panoramic radiograph of the mandible demonstrated marked erosion of the angle and ramus of the mandible (Fig. 1) in the region of the insertion of the masseter and lateral pterygoid muscles. Amorphous calcifications in the soft tissues adjacent to the area of bone erosion were also present.
M. M., a 49-year-old white woman, has had sclerodenna for the past 9 years. The skin of her fingers is indurated and
DISCUSSION
*Department of Radiology. **Department of Oral Surgery.
Unilateral atrophy or underdevelopment of the mandible has been described in children with scleroderma.3 Atrophy of the mandible is most often associated with
Fig. 1. Ramus areas of a panoramic radiograph of the mandible demonstrating erosion of the angle andt bilaterally (large arrows) and soft-tissue calcification (small arrows). 0030. .4220/81/030329+02$00.20/0
0
1981
The C. V. Mosby Co
329
330
Weiner and Wolf
periodontal disease, pressure from dentures, and an edentulous patient.-’ Notching of the angle of the mandible and even resorption of the ramus were described by Seifert and associates5 in five out of sixteen patients with scleroderma being evaluated for temporomandibular joint pain. A similar finding was reported in one patient with Raynaud’s disease.fi Reference to erosion of the angle of the mandible in scleroderma is made by Tavaras’ in a book on temporomandibular joint disease. The case presented here offers another illustration of this littleknown finding in scleroderma. Its incidence and significance are as yet unknown. To our knowledge, there is no definitive explanation for the bone erosion observed in scleroderma. It may be related to bone ischemia or the extensive soft-tissue fibrosis which occurs in scleroderma.“-s Another contributing factor may be the loss of normal muscle action on the mandible because of fibrosis and atrophy of muscles of mastication.“. i Except for their unusual location, the soft-tissue calcifications seen in our case are probably similar to the dystrophic calcifications seen elsewhere in the soft tissues of patients with scleroderma.
Oral Surg. March, 1981 REFERENCES 1. Harper, R. A., and Kemp, Jackson D. C.: Progressive Systemic Sclerosis, Br. J. Radiol. 38: 825834, 1965. 2. Meszaros, William T.: The Regional Manifestations of Scleroderma, Radiology 70: 313-325, 1958. 3. Chipps, James, and Hirschmann, Victor R.: Scleroderma Affecting the Masticatory Apparatus. U. S. Armed Forces Med. J. 7: 1209-1213, 1956. 4. Thoma, Kurt H., and Holland, Daniel J.: Atrophy of the Mandible, ORAL SURG. 4: 1477.1495, 1951. 5. Seifert, Martin H., Steigerwald, James C., and Cliff. May M.: Bone Resorption of the Mandible in Progressive Systemic Sclerosis, Arthritis Rheum. 18: 507-515, 1975. 6. Gray, Robert G., Altman, Roy D., and Kline, Stuart: Mandibular Bone Erosion and Scleroderma, Arthritis Rheum. 19: 1371, 1976. 7. Tavaras, J.: In Schwartz, L.: Disorders of the Temporomandibular Joint, Philadelphia, 1959, W. B. Saunders Company, p. 160. 8. Bamett, Alfred .I.: Scleroderma, Springfield, Ill.. 1974. Charles C Thomas Publisher. Reprint requests to: Dr. Shelley Nan Weiner Hospital of the Albert Einstein College of Medicine 1825 Eastchester Rd. Bronx, N. Y. 10461