Oral Manifestations and Maxillo-Facial Features in the Acromegalic Patient: A Literature Review

Background: Acromegaly is a chronic disease caused by an abnormal secretion of growth hormone (GH) by a pituitary adenoma, resulting in an increased circulating concentration of insulin-like growth factor 1 (IGF-1). The main characteristics are a slow progression of signs and symptoms, with multisystemic involvement, leading to acral overgrowth, progressive somatic changes, and a complex range of comorbidities. Most of these comorbidities can be controlled with treatment. The literature reveals that the most evident and early signs are those related to soft tissue thickening and skeletal growth, especially in the head and neck region. Methods: The authors reviewed the available literature on the clinical oro-dental features of acromegaly, selecting articles from PubMed and Google Scholar. The aim of this review was to summarize all the reported clinical oro-dental features of acromegalic patients. Results: The most common facial dimorphisms involved the maxillo-facial district, with hypertrophy of the paranasal sinuses, thickening of the frontal bones, and protruding glabella, which may be associated with joint pain and clicks. Regarding the oro-dental signs, the most frequent are dental diastema (40–43%), mandibular overgrowth (22–24%), mandibular prognathism (20–22%), and macroglossia (54–58%). These signs of acromegaly can be significantly reduced with adequate treatment, which is more effective when initiated early. Conclusions: Increased awareness of acromegaly among dentists and maxillo-facial surgeons, along with the early identification of oro-facial changes, could lead to an earlier diagnosis and treatment, thereby improving patients’ quality of life and prognosis.

A comparative study on cephalometric differences in maxillofacial morphology between skeletal Class III cases with and without acromegaly: a pilot study

OBJECTIVES

The most typical maxillofacial feature of patients with acromegaly is mandibular protrusion. This study aimed to determine differences in maxillofacial morphology between skeletal Class III patients with and without acromegaly using cephalometric analysis.

METHODS

Cephalograms of 37 patients with acromegaly (Acro), 37 age-matched non-acromegalic patients with skeletal Class III malocclusion (C-III), and 37 age-matched Class I malocclusion patients (C-I; control) were retrospectively collected. The skeletal and dental morphology of each group was analyzed using cephalometric analysis, which included linear and angular measurements and facial profilograms. In addition, we analyzed diagnostic performance and cutoff values for discriminating acromegaly from skeletal Class III malocclusion using receiver operating characteristic (ROC) curve analysis.

RESULTS

The mandibular ramus height was larger in the Acro group than in the other groups. The increase in L1/MP in the Acro group, which represented labial inclination of the mandibular central incisors, was the most characteristic feature in this study. ROC curve analysis indicated that a cutoff value of 88.4° for L1/MP had the highest diagnostic performance in discriminating acromegaly from non-acromegalic Class III malocclusion.

CONCLUSIONS

Acromegaly was characterized by a greater degree of bimaxillary prognathism than was non-acromegalic Class III malocclusion. Focusing on labial inclination of the mandibular central incisors would be the most useful way to differentiate acromegaly from non-acromegalic Class III malocclusion.

Rehabilitation of Occlusal Vertical Dimension in a Patient with Acromegaly: A Clinical Report

Acromegaly is a rare acquired disorder caused by excessive growth hormone production. Dentists play an important role in the diagnosis of this disorder because of intraoral and extraoral symptoms such as extreme growth of the mandible, enlargement of the maxilla, diastema between teeth, a tendency toward malocclusion, a wide and thick nose, a marked malar bone, and thick lips. The prosthetic treatment of these patients is challenging because growth in the condyles and rami can lead to the development of a severe class III jaw relationship. This case report describes the prosthetic treatment of a patient with acromegaly. A decreased occlusal vertical dimension and class III jaw relationship were determined by intraoral and extraoral examinations and cephalometric radiography. The occlusal vertical dimension was reestablished by increasing it approximately 10 mm, as per the esthetic and functional needs of the patient. Four years after treatment, the patient was functioning well, and neither occlusal disharmony nor temporomandibular disorder was observed.

Assessment of oro-dental manifestations in a series of acromegalic patients, the AcroDent study

OBJECTIVE

The dental and periodontal impact of GH/IGF-1 hypersecretion has been poorly investigated until now. Our aim is to precisely describe the oro-dental state of acromegalic patients and to study the impact of GH/IGF-1 hypersecretion on patients' reported oral health-related quality of life (OHRQoL).

METHODS

After collecting characteristics of their disease, acromegalic patients answered the GOHAI questionnaire assessing their OHRQoL, the AcroQoL questionnaire and then benefited from a complete stomatological and radiological examination (orthopantomogram systematically, retro-alveolar radiography or Cone Beam CT if necessary).

RESULTS

In total, 29 patients aged 59.1 ± 16.0 years were included. The average DMFT index (sum of Decayed, Missing and Filled Teeth per patient) was 19.0 ± 7.8. 16/29 patients had a gingivitis and 18/29 a mild to moderate chronic periodontitis, but no case of severe chronic periodontitis was found, probably because the frequency of a protective thick gingival biotype was increased (9/29). No case of generalized gingival hypertrophy or diffuse hypercementosis was observed. According to the Add-GOHAI score, only 8/26 patients had a satisfactory OHRQoL. This parameter was correlated to the acromegaly-specific quality of life according to the AcroQoL score. Interestingly, 11/29 patients had bulky oral bony outgrowths (OBO), such as large maxillary or mandibular tori and multiple vestibular exostosis.

CONCLUSIONS

The unsatisfactory OHRQoL reported by acromegalic patients contrasts with a rather good objective oro-dental state and annual oral examination seems relevant in this population. Finally, we report that huge OBO could be helpful signposts for the diagnosis of acromegaly.

Challenges in the management of late developing malocclusions in adulthood: A case report of acromegaly

The development of a malocclusion in adulthood can present as a diagnostic and management challenge to an orthodontist. It is prudent to identify the aetiology of changes to the occlusion which will influence the management plan. Uncommon causes include acromegaly. Orthodontists are in a good position to identify certain underlying disorders based on a patient's presenting malocclusion that may otherwise go unnoticed and undiagnosed until other systemic signs and symptoms present themselves at the latter stages of the condition. This case report highlights possible aetiological factors of a developing malocclusion in adulthood and presents the clinical manifestations and joint orthodontic-surgical management of a patient with a developing skeletal III base attributed to acromegaly.

GH-secreting pituitary macroadenoma (acromegaly) associated with progressive dental malocclusion and refractory CPAP treatment

Background

A link between progressive dental malocclusion, the use of a continuous positive airway pressure mask and GH-secreting pituitary macroadenoma (acromegaly) has not been previously reported. The present clinicopathological analysis stresses that tooth malposition should not be seen exclusively as a local process.

Case presentation

A 62-year-old caucasian man with no relevant medical history reported difficulty chewing food and perceived voice alteration during his annual periodontal check-up. He also referred stiffness of the tongue, face, and submandibular area. The patient had been diagnosed with obstructive sleep apnea syndrome two years previously, since when he had worn a continuous positive airway pressure device during sleep. Exploration of the occlusion revealed significant changes: an atypical left lateral and anterior open bite with major buccoversion of teeth 33, 34, 35, 36. Inspection of the soft tissue revealed only macroglossia, although external palpation indicated a subcutaneous stiffness of the submandibular area. General analytical tests, including hormone profiles, and magnetic resonance imaging confirmed the diagnosis of acromegaly induced by a pituitary adenoma. Intrasellar tumor resection via transsphenoidal approach was performed. After surgery, the patient already noted a marked improvement of all symptoms associated with the acromegaly. Desaturation data also evolved favourably and the pulmonologist advised the patient to abandon the continuous positive airway pressure treatment.

Conclusion

Progressive dental malocclusion may be associated with a systemic disease and the use of a nasal mask with premaxillary support may distort the diagnosis of acromegaly.

Craniofacial and pharyngeal airway morphology in patients with acromegaly

OBJECTIVE

The aim of this study was to assess differences in craniofacial characteristics, upper spine and pharyngeal airway morphology in patients with acromegaly compared with healthy individuals.

MATERIALS AND METHODS

Twenty-one patients with acromegaly were compared with 22 controls by linear and angular measurements on cephalograms. The differences between the mean values of cephalometric parameters were analyzed with Mann-Whitney U-test.

RESULTS

With respect to controls, anterior (p<0.05), middle (p<0.01) and posterior (p<0.05) cranial base lengths were increased, sella turcica was enlarged (p<0.001) and upper spine morphology demonstrated differences in the height of atlas (p<0.01) and axis (p<0.05) in patients with acromegaly. Craniofacial changes were predominantly found in the frontal bone (p<0.01) and the mandible (p<0.05). As for the airway, patients with acromegaly exhibited diminished dimensions at nasal (p<0.001), uvular (p<0.01), mandibular (p<0.01) pharyngeal levels and at the narrowest point of the pharyngeal airway space (p<0.001) compared to healthy controls. Soft palate width was significantly higher (p<0.001) and the hyoid bone was more vertically positioned (p<0.01) in patients with acromegaly.

CONCLUSIONS

Current results point to the importance of the reduced airway dimensions and that dentists and/or orthodontists should be aware of the cranial or dental abnormalities in patients with acromegaly.

The bite force and craniofacial morphology in patients with acromegaly: a pilot study

Objectives: Acromegaly is a metabolic disorder caused by increased growth hormone secretion. As a consequence of acromegaly some typical craniofacial morphology changes appear. This pilot study was conducted to compare the bite force and the characteristic size and shape of the craniofacial components of acromegalic patients with the healthy Turkish individuals. In additon, the correlations between bite force and craniofacial morphology of patients with acromegaly and control individuals were evaluated. Study Design: The maximum bite force of the participants was recorded with strain-gage transducer. Lateral x-ray scans were made under standard conditions, in centric occlusion. On cephalograms, the linear and angular measurements was performed. Results: Patients with acromegaly showed increased anterior and posterior total face height, ramus length, width of frontal sinuse, gonial angle and a negative difference between maxillary and mandibular protrusions. In addition, females with acromegaly showed larger lower anterior face height and sella turcica, decreased facial angle, increased mandibular plane angle. The cephalometric measurements, except one did not showed correlation with the bite force in acromegalic patients. In control group, significant correlations were observed between anterior total face height and anterior lower face height, mandibular plane angle and gonial angle. Conclusions: The greater changes were observed in the mandible. The maximum bite force of patients with acromegaly showed no difference from healthy individuals. The non-significant difference of bite force between healthy participants and acromegalic patients provide important information for dental treatment and prosthetic rehabilitation of acromegalic patients.

Key words:Acromegaly, bite force, cephalometric analysis, mandibular prognathism.

Testosterone-mediated sex differences in the face shape during adolescence: subjective impressions and objective features

Sex identification of a face is essential for social cognition. Still, perceptual cues indicating the sex of a face, and mechanisms underlying their development, remain poorly understood. Previously, our group described objective age- and sex-related differences in faces of healthy male and female adolescents (12-18 years of age), as derived from magnetic resonance images (MRIs) of the adolescents' heads. In this study, we presented these adolescent faces to 60 female raters to determine which facial features most reliably predicted subjective sex identification. Identification accuracy correlated highly with specific MRI-derived facial features (e.g. broader forehead, chin, jaw, and nose). Facial features that most reliably cued male identity were associated with plasma levels of testosterone (above and beyond age). Perceptible sex differences in face shape are thus associated with specific facial features whose emergence may be, in part, driven by testosterone.