A CASE REPORT

1 2 3Dr. Shubha Ranjan Dutta , Dr. Don Verghese , Dr. Amar Bhuibhar4Dr. Ronak Desai

ABSTRACT :

Exostosis, a slow growing, benign bony outgrowth, is a common clinical finding and not usually an issue with patients. However, when removable prosthesis is placed either adjacent to or over these areas, abrasion, ulceration, or limited tongue space can occur due to pressure. This article describes a case report of surgical excision of exostosis. A 52 years old man had soft tissue irritation caused by abrasion from food in the lingual posterior right & left quadrant. The aim & objective of this case report and review is to inform practitioners about Torus Mandibularis – Indications for removal, Radiographic interpretation & its management. Generally, surgical resection is not required for mandibular torus, as long as the condition remains asymptomatic. However, treatment is indicated when subjective symptoms such as discomfort, pain, articulation disorder, or problems in the insertion of dentures are present.

MANDIBULAR EXOSTOSIS

INTRODUCTION

Exostosis, termed torus mandibularis

(commonly called mandibular tori), is a

common clinical finding. Most are

asymptomatic, benign bony outgrowths

that slowly grow over the patient's

lifetime. They consist of dense, cortical 1,4bone and are avascular in nature. An

incidence of 9% to 60% has been reported

in various ethnic groups, and it has been

reported in the literature for over 180

years. Both genetic and environmental

factors have been implicated as the

causative factors, and the true cause may 1 be multifactorial. Tori mandibularis arises

on the tongue side of the lower jaw, in the

region of the premolars / bicuspids

generally (and above the location of the

mylohyoid muscle's attachment to the

mandible) & may extend to molar region.

They are typically (90% of cases) bilateral

(i.e on both sides) forming hard, rounded

swellings. These are bony exophytic 1,2,3,4growth.

Despite the fact that these bony tubercles

have been under study, the apparent

1,3,4,Post Graduate Student, Department of Oral and Maxillofacial Surgery

2

Vyas Dental College & Hospital, Jodhpur

Assistant Professor, Department of Oral and Maxillofacial Surgery

Vyas Dental College & Hospital, Jodhpur

Corresponding Author: , Email :drshubharanjand Dr. Shubha Ranjan Dutta @gmail.com

28

ISSN 2249-5436 DENTAL IMPACT

Dental Impact Vol. 5, Issue 1, June 2013

Key words: Torus mandibularis, Mandibular torus, Tori

4 cause is not yet known. An exostosis is a

non pathologic outgrowth of bone. It is

believed that this is one way of bone

responds to stresses applied to it. The

suggested et io logic factors are

masticatory hyperfunction genetic factor.

Environmental factors, and continuous

growth. Recently the etiology of tori has

been postulated to be an interplay of

multifactorial genetic and environmental 1,5 factors. It is generally believed that the

growth of mandibular tori is most rapid in

the second and third decades of life. The

case to be presented here might be

considered rather unique, since the

growth period continued through the 6 fourth, fifth, and sixth decades.

Tori can be categorized by their 2appearance

1.Flat tori - Arising as a broad base and a

smooth surface, are located on the

midline of the palate and extend

symmetrically to either side.

2.Spindle tori - Have a ridge located at

their midline.

3.Nodular tori - Have multiple bony

growths that each have their own base.

4.Lobular tori - Have multiple bony

growths with a common base.

2Indication for removal of mandibular tori

1. Interfere with tongue positioning.

Torus

mandibularis (TM) is a known benign

osseous protuberance. It is seldom seen in 7children under ten years of age.

2. Speech interference.

3. Prosthodontic reconstruction.

4. Patient with poor oral hygiene around

the lower posterior teeth.

5. Cancer phobia.

6.Traumatic ulceration from mastication.

CASE REPORT :

A 52 years old male patient, reported to

the department of Oral & Maxillofacial

surgery ,Vyas Dental College & Hospital,

Jodhpur, complaining of bony growth on

his lower jaw below the tongue (Fig.1). He

noticed this growth 2 years ago, which

increased gradually to attain the present

size. He complained of pain while eating

and food lodgement. The patient denied

ulceration, bleeding and drainage.

A thorough medical and dental history was

taken along with a clinical examination

and occlusal (Fig.2) & intraoral periapical

radiograph. On examination bilateral

sublingual bony hard growth covered in

29Dental Impact Vol. 5, Issue 1, June 2013

Fig. 1: Bony growth below the tongue

normal oral mucosa in relation to

premolar & 1st molar region was elicited.

There were no lymphadenopathy & the

growth were non tender and also without

discharge or fluctuance. The growth was

located in the lingual cortical plate

extending from 35 to 36 & 45 to 46 region ,

measuring about 1.3 cm x 1.2 cm x 0.8 cm.

A f t e r e xp l a i n i n g a l l p o ten t i a l

complications and obtaining written

informed consent from the patient, local

anesthetic 2% Lignocaine with 1:80,000

adrenaline was administered to the

patient, after intraoral preparation with

chlorhexidine mouthwash. Before starting

surgical procedure full mandibular &

maxillary arch impression was taken for

surgical stent fabrication. A crevicular

incision was then given in relation to

mandibular second premolar to midline

bilaterally. Full thickness mucoperiosteal

flap was raised & tori exposed bilaterally.

Surgical bur & chisel mallet was used for

complete exc i s ion. Edges were

smoothened by bone file & hemostasis

achieved. Approximately 40 to 60 ml of

sterile saline was used for irrigation.

Wound was closed by 3-0 mersilk suture.

Surgical stent fixed in position to reduce

hematoma formation (Fig.3-6). Post

operative instructions, antibiotics and

analgesics were prescribed to the patient.

By the fifth post operative day the sutures

were removed and the wound was found to

be healing uneventfully, with no

associated functional deficits.

30Dental Impact Vol. 5, Issue 1, June 2013

Fig. 2: Occlusal Radiograph

Fig. 3: Exposure of tori

Fig. 4: Complete excision performed

DISCUSSION :

Generally, surgical resection is not

required for mandibular torus, as long as

the condition remains asymptomatic.

Slowly enlarging, recurrent lesions

occasionally are seen, but there is no

malignant transformation potential.

Mandibular tori does not require

treatment unless it becomes so large 2that.

? It interferes with function or denture placement.

? Suffers from recurring traumatic surface

ulceration (usually from sharp foods, such

as potato chips or fish bones).

? Contributing to a periodontal condition.

Large mandibular tori can prevent

complete seating of impression trays and

denture. Abrams et al fabricated a new

m a n d i b u l a r c o m p l e t e d e n t u r e

incorporating a combination of soft acrylic 3 flanges and liners. Pynn reported that

majority of these exostoses are

asymptomatic, benign bony outgrowths

remain undisturbed over the patient's

lifetime. However, the tori occasionally 8 need to be removed. We decided to

complete l y exc i se ra ther than

recontoring. Earlier the size of the growth

was smaller then it gradually increased.

Choi & Park reported that mandibular tori 9 seem to change with aging. We used

surgical bur with chisel mallet for

excision. Wada reported a newly devised

retractor half spoon shaped head and was

applied to various cases of mandibular 10 torus for its evaluation. Goracy ES, Rissol

A recently introduced a reciprocating saw 11 which makes this procedure feasible. We

are not used the excised bone as a

autogenous graft material. Hassan & Alagl

concluded that the use of mandibular tori

as autogenous bone graft seemed to be

effective in the treatment of intrabony 12,13 defects. Ganz described a technique

that mandibular tori as local donor sites 12,14,15 for onlay graft augmentation. Sonnier

& Horning presented on their study the

need for exostosis removal and to the

31Dental Impact Vol. 5, Issue 1, June 2013

Fig. 5: 3-0 Mersilk sutures placed

Fig. 6: Surgical stent fixed

potential use of the mandibular and

palatal tori as sources of autogenous 16,12cortical bone.

In the case presented, the patient had a

clear concept of the procedure prior to

providing the informed consent, the

procedure was uneventful, and the

patient was satisfied with the result. The

authors emphasized that rarity of the

anatomic site of mandibular lingual

exostosis involved in this case should not

be ignored and carefully should be

diagnosed from other conditions.

CONCLUSION

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