Lingual Bony Protruberances - A Retrospective

Analysis
Anuradha Navaneetham*, Jeevan Aiyappa**, Dayanand Saraswathi**, Arati K Rao+

Abstract
The mandibular tori are bony protruberances present on the lingual aspect of the mandible. Most often they
pose no problems if they are small in size. However, large tori can cause various problems such as ulceration
of overlying mucosa, food retention, masticatory and speech problems, sleep apnoea, etc. We present our
experiences with mandibular tori and a brief discussion on their etiology and treatment.
Key Words : Tori, Mandible, Etiology, Speech problems, Masticatory difficulty, Surgical removal of tori.

INTRODUCTION
T he terms tori and exostosis refer to the presence of
bony protuberances. The word tori literally means
to stand out or lump in Latin. When the bony
protuberance is present on the buccal surface of the jaws
they are referred to as exostosis. The torus mandibularis
is a bony outgrowth seen on the lingual surface of the
mandible. It is usually is found above the mylohyoid
line in the region of the premolars or canines. The torus
palatinus is a growth seen on the the midline of the hard
palate 1.
Our Experiences with Mandibular Tori
The following table lists our experience in the past
three years with 10 patients with mandibular tori and
the most common reasons patients in our practice
wanted their removal.
Reason for wanting removal of tori No. of patients
Problems with phonation 2 which causes their tooth apices to exert pressure on
Problems with mastication and difficulty 3 the periodontal ligament thus, stimulating formation
in maintaining oral hygiene
Sleep apnoea 1 patients with mandibular tori exhibit presence of
Difficulty in fabricating dental Prosthesis 2
Below are the pictures of the patient who had sleep
apnoea caused due to bilateral mandibular tori
measuring around 3cm x 5cm. The surgical procedure
involved reflection of a full thickness mucoperiosteal
flap and the use of surgical burs and osteotomes for
excision of the tori. In the three years following surgery
there have been no recurrences in all 8 operated cases.
The patient with sleep apnoea caused due to large
*Prof. and Head; **Professor; +Lecturer, Department of Oral
and Maxillofacial Surgery- HOSMAT/Institute of Dental
Sciences-Bareilly, U.P. India.
tori had two other family members who also had
mandibular tori which measured around 0.25cm x 1cm.
These two patients however reported no functional
problems associated with the presence of the tori and
chose not to get them removed (Figs. 1-3).
DISCUSSION
Etiology
The exact cause for the development of tori still
remains inconclusive. Various studies propose varied
causes which, include
z Genetic factors - some studies have suggested an
autosomal dominant mode of inheritance of tori
z Environmental factors and Dietary habits –
nutritional deficiencies (avitaminosis) 2, increased
consumption of fish which have high content of vit
D, disturbances in calcium metabolism
z Masticatory hyperfunction – habitual bruxism may
cause lower teeth to tip due to horizontal forces
of new bone 3. It is of interest to note that many
abraded teeth. Some studies have also found an
association between presence of tori with associated
TMJ dysfunction which maybe explained on the
presence of parafunctional habits.
z Continued growth
Incidence
The incidence of torus mandibularis ranges from
0.5%-63.4%. It is seen most often in the age group of 35-
60 years. A few studies have reported a greater incidence
in male patients.
Size and Shape of Tori
Haugen and Eggen et al classified tori as
Small < 2mm

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 Fig. 1 : Intraoral preop view. Fig. 2 : Intraop view of tori.
Medium 2-4mm
Large > 4mm
Reichart classified them as
Grade I – upto 3mm
Grade II – upto 6mm
Grade III - >6mm
Tori are usually flat, nodular, lobular or spindle
shaped. They maybe unilateral/bilateral, single/
multiple.
The most commonly seen shape is nodular and
mandibular tori are usually bilateral.
The diagnosis of tori is almost always incidental.
Diagnosis is confirmed on clinical examination which
reveals a bony hard mass covered by thin mucosa. The
patients may not even be aware of the presence of small
tori and will give a history of slow growth of larger tori.
Radiographs will reveal radiopaque masses.
Histopathologic examination of tori reveals presence of
outer thick cortical bone and inner core of spongy bone
similar to normal bone structure. Recently tori have been
used as a source of autogenous bone graft to augment
alveolar bone prior to dental implant placement 4.
Problems Caused due to Tori
The following are some of the reasons a dentist should
refer a patient for removal of tori.
Ulceration of Overlying Mucosa
The mucosa covering tori is thin and poorly
vascularized and is susceptible to greater sensitivity and
ulceration due to mastication etc. Chronic ulceration may
cause infection, cancerophobia in patients.
Inability to Masticate Food Properly
Large tori may decrease masticatory efficiency
Speech
Many patients with large tori come to a dentist with
604
Fig. 3 : Excised tori.
problems with phonation.
Food Retention
Large irregular shaped tori cause problems with
maintenance of good oral hygiene. Retention of food in
crevices can cause foul smell.
Fabrication of Prosthesis
It is the most common reason for removal of tori.
Sleep Apnoea
There have been case reports implicating large tori
for decrease in airway space by causing the tongue to
fall back .
Difficult Laryngoscopy
Large tori cause difficulty in performing laryngoscopy
for intubation of patients requiring general anesthesia 5.
CONCLUSION
Not all tori require removal. Based on the size of the
tori and patient’s complaints a decision may be made
regarding excision of the tori. Surgical excision is
curative and recurrence is extremely rare.
REFERENCES
1. Garcia et al.Current Status of torus palatinus and torus
mandibularis. Med Oral Pathol Oral Cir Buccal 2010; 1 : 15(2)
353-60.
2. Antoniades Demetrios Z, et al. Concurrence of torus palatinus
with buccal exostoses. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1998; 85 : 552-7.
3. Ossenberg. Mandibular torus: a synthesis of new and
previously reported data and discussion of its cause.
Contribution to physical anthropology. 1918; 1 : 53-76.
4. Scott D. Ganz. Mandibular tori as a source for onlay bone
graft augmentation: A surgical procedure, The implant report
1997; 9 (9) : 974-82.
5. Takasugi et al. Difficult laryngoscopy caused by massive
mandibular tori. J Anesth 2009; 23(2) : 278-80.
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