A CASE REPORT

1 2 3
Dr. Shubha Ranjan Dutta , Dr. Don Verghese , Dr. Amar Bhuibhar
4
Dr. 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
1,4
bone 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
1,2,3,4
growth.
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 eti ol ogi c f actors 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
2
appearance
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.

2
Indication for removal of mandibular tori
1. Interfere with tongue positioning.
Torus
mandibularis (TM) is a known benign
osseous protuberance. It is seldom seen in
7
children 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
29 Dental 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.

Af t er expl ai ni ng al l pot ent i al
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
compl ete exci si on. Edges wer e
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.
30 Dental 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
2
that.
?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
ma n d i b u l a r c o mp 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
compl et el y exci s e r at her t han
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
31 Dental 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
16,12
cortical 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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