Maxillary and

Mandibular Exostoses:
A Clinical Review

By
Mark J. Szarejko, DDS, FAGD

Release date: December 12, 2016

Expiration date: December 11, 2019

3 clock hours will be awarded upon successful completion of this course.

 P.O. Box 1930
Brockton, MA 02303
800-438-8888
ABOUT THE AUTHOR
Mark J. Szarejko, DDS, FAGD, received a bachelor’s degree in biology from St. John Fisher College
in Rochester, New York, and a DDS from the State University of New York at Buffalo in 1985. He has
been a Fellow of the Academy of General Dentistry since 1994 and a Certified Correctional Healthcare
Professional since 2007. Dr. Szarejko has more than 30 years of dental experience in New York and
Florida. He is currently a staff dentist at the Hillsborough County Jail in Tampa, Florida, and has been
an examiner for the State of Florida dental and dental hygiene examinations since 1994. Dr. Szarejko
has presented nationally on correctional health care and has authored more than 20 continuing educa-
tion courses.
Mark J. Szarejko has disclosed that he has no significant financial or other conflicts of interest
pertaining to this course book.
Based in part on an earlier original work by John F. Kross, DMD, MSc.
ABOUT THE PEER REVIEWER
Toni M. Roucka, RN, DDS, MA, is an associate professor of restorative dentistry at Southern Illinois
University, School of Dental Medicine, Edwardsville. She maintains an active nursing license and is
a Fellow of the American College of Dentists and immediate past president of the American Society
for Dental Ethics. Dr. Roucka obtained her DDS degree from the University of Illinois at Chicago
College of Dentistry and a master’s degree in population health – bioethics from the Medical College
of Wisconsin in Milwaukee. Dr. Roucka is a nationally recognized speaker on the subject of ethics in
dentistry and has taught restorative dentistry at both Marquette University and the Southern Illinois
University School of Dental Medicine. As a volunteer, she has provided dental care to underserved pop-
ulations in Guatemala, Venezuela, the Dominican Republic, and Tanzania.
Toni M. Roucka has disclosed that she has no significant financial or other conflicts of interest
pertaining to this course book.
Dental Planner: Karen Hallisey, DMD
The planner has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book.
Copyeditor: Valerie Geary
Proofreader: Diane Hinckley
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ii
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iii
 WESTERN SCHOOLS
course evaluation
MAXILLARY AND MANDIBULAR EXOSTOSES:
A CLINICAL REVIEW
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OBJECTIVES: After completing this course, I am able to:

1. Outline the classification of exostoses of the oral cavity.
2. Describe the clinical features of exostoses.
3. Describe the radiographic features of exostoses.
4. Identify the pathophysiology of exostoses.
5. Describe the oral health implications of exostoses of the oral cavity.
6. Explain the surgical treatment and prognosis of exostoses.
COURSE CONTENT
7. The course content was presented in a well-organized and clearly written manner.
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v
 Course Evaluation—
vi Maxillary and Mandibular Exostoses: A Clinical Review

ATTESTATION
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 CONTENTS
Course Evaluation..................................................................................................................................................... v
Figures.......................................................................................................................................................ix
Introduction..............................................................................................................................................xi
Course Objectives..........................................................................................................................xi
Maxillary and Mandibular Exostoses: A Clinical Review....................................................................1
Classification of Exostoses Within the Oral Cavity.......................................................................1
Clinical Features of Exostoses........................................................................................................2
Radiographic Features of Exostoses...............................................................................................3
Pathophysiology of Exostoses........................................................................................................5
Oral Health Implications of Maxillary and Mandibular Exostoses................................................5
Surgical Treatment and Prognosis of Exostoses.............................................................................6
Surgical Reduction of Exostoses..............................................................................................6
Surgical Reduction of Torus Palatinus.....................................................................................7
Surgical Reduction of Torus Mandibularis...............................................................................8
Case Scenarios................................................................................................................................9
Case Scenario #1.......................................................................................................................9
Question..............................................................................................................................9
Discussion...........................................................................................................................9
Case Scenario #2.....................................................................................................................10
Question............................................................................................................................10
Discussion.........................................................................................................................10
Summary.......................................................................................................................................11
Exam Questions.......................................................................................................................................13
References................................................................................................................................................17

vii
 FIGURES
Figure 1: Multiple Palatal Tori....................................................................................................................2
Figure 2: Buccal Exostosis of the Maxilla and Mandible...........................................................................3
Figure 3: Radiographic Images of Torus Palatinus.....................................................................................4
Figure 4: Radiograph of Gardner’s Syndrome............................................................................................4

ix
 INTRODUCTION
COURSE OBJECTIVES
After completing this course, the learner will be able to:
1. Outline the classification of exostoses of the oral cavity.
2. Describe the clinical features of exostoses.
3. Describe the radiographic features of exostoses.
4. Identify the pathophysiology of exostoses.
5. Describe the oral health implications of exostoses of the oral cavity.
6. Explain the surgical treatment and prognosis of exostoses.

A n exostosis (singular) or exostoses (plural) represents a new benign growth of bone that projects
outward from the osseous surface and can involve any bone within the body. This includes the
alveolar bone within the oral cavity proper. The hard palate and the alveolar bone on the lingual aspect
of the mandibular arch are the areas within the oral cavity that are commonly involved. Less frequent
are the exostoses that involve the buccal alveolar bone of the maxillary and mandibular arches or the
alveolar bone of the palatal arch.
Exostoses that occur intraorally manifest as different clinical presentations and locations. These are
benign, asymptomatic osseous anomalies that are documented during a comprehensive dental examina-
tion. However, dental clinicians must not view these as merely an incidental finding but rather must
consider the presence of an exostosis as an integral component of the oral anatomy that can impact
the patient’s oral health and his or her ability to utilize partial or complete dentures as well as being a
potential impediment to the ability to maintain oral hygiene. Exostoses can also be viewed in a positive
light as they are an excellent source for an autogenous bone graft that can be used to correct periodontal
defects or to provide supplemental bone for the placement of implants. This basic-level course high-
lights the varied clinical presentations of exostoses within the oral cavity, their clinical and radiographic
presentations, their pathophysiology, their implications for oral health, and options for treatment. With
this knowledge, dental professionals can address such growths if they become or could become a barrier
to oral function, interfere with a patient’s ability to maintain proper oral hygiene, or preclude the ability
to place partial or complete dentures.

xi
 MAXILLARY AND
MANDIBULAR
EXOSTOSES: A
CLINICAL REVIEW
CLASSIFICATION OF vascularity (Chandna, Sachdeva, Kochar, &
EXOSTOSES WITHIN Kapil, 2015). The various intraoral exostoses
are asymptomatic and are usually not a con-
THE ORAL CAVITY
cern to the patient unless their size and position

B efore a discussion of intraoral exostoses

can begin, it is essential to define the terms
that describe their varied clinical presentations.
interfere with speech, preclude the placement of
partial or complete dentures, or cause frequent
traumatic incidents involving the thin mucosal
An exostosis is a benign overgrowth of bone tissue that overlies these bony prominences.
that extends outward from the surface of a bone
Intraoral exostoses are the focus of this
and can involve any bone within the body. An
course, with torus palatinus and torus mandibu-
exostosis represents a solitary outgrowth of
laris being the two most common types. The
bone, whereas exostoses represent multiple nod-
other types of exostoses, affecting the buccal
ular lumps of bone. Within the oral cavity, an
aspects of the jaws (buccal and palatal exosto-
exostosis (exostoses) located on the midline
ses), are less common.
of the hard palate or on the lingual surface
Buccal exostosis, palatal exostosis, torus
of the mandibular arch is called a torus for a
palatinus (palatal torus), and torus mandibularis
solitary exostosis or tori when there are multiple
(mandibular torus) are all specific in their loca-
bony protuberances. Exostoses that occur on
tion in the maxilla and mandible. Torus palati-
the buccal (facial) aspect of the alveolar bone
nus is found in the midline of the hard palate.
of the maxillary or mandibular arches are called
Torus mandibularis is found only on the lingual
buccal exostoses. Palatal exostoses occur on
surface of the mandible, near the bicuspid teeth.
the alveolar bone of the palatal aspect of the
The buccal exostosis is found on the facial sur-
maxillary arch (Sani-Neto, Frizzera, & Roman-
face of the alveolar bone, usually the maxil-
Torres, 2014). Osteomas are bony prolifera-
lary alveolus, and less frequently on the buccal
tions that occur at other sites within the oral
surface of the mandible. Palatal exostoses are
and maxillofacial complex and are a diagnostic
found on the palatal aspect of the maxillary
component of Gardner’s syndrome, which will
arch and are usually adjacent to the tuberosity
be discussed later in this course. Histologically,
(Smitha & Smitha, 2015). Palatal exostoses are
an exostosis is composed of hyperplastic dense
cortical and trabecular bone with minimal
1

2 Maxillary and Mandibular Exostoses: A Clinical Review
a separate entity and are not a continuum with
the midline torus palatinus.
Bony surface proliferations found in another
site are typically given the generic diagnosis
of bony exostosis or osteoma (they are consid-
ered trauma-induced inflammatory periosteal
reactions or true neoplasms). In most cases,
unless such a bony prominence is pedunculated,
located at a specific site, or is associated with an
osteoma-producing syndrome such as Gardner’s
syndrome, there may be no means by which to
differentiate an exostosis from an osteoma, even
under the microscope.
CLINICAL FEATURES
OF EXOSTOSES
O ral exostoses are usually not present be-
fore the age of 10 and are more preva-
lent in people between the ages of 11 and 30
(Dominguez et al., 2016). Many, if not most,
continue to slowly enlarge over time, at which
point they are detected by a healthcare profes-
sional or the patient. Conclusions about the
prevalence of tori within the population are a
reasonable estimate as these anatomic features
may not be recorded in a dental patient’s chart,
and those that are may not be a part of the
population for a given study. The prevalence
of torus palatinus and torus mandibularis can
vary depending upon the population studied;
however, within the United States, the general
prevalence of torus palatinus is 20% while it is
6% for torus mandibularis (Mupparapu, 2016).
Torus palatinus is the most common exostosis
and is more prevalent than torus mandibularis
(Doran, 2014). Buccal exostoses are rare, occur-
ring in about 3% of adults, and they occur more
frequently in males than females (Chandna et
al., 2015).
A definite hereditary basis, usually autoso-
mal dominant, has been established for some
cases of tori. In one study of 162 Lithuanian
twins (81 twin pairs), torus mandibularis had
a 56.8% incidence in both twins (Auskalnis
et al., 2015). A further analysis of this study
revealed that among monozygotic (identical)
twins, torus mandibularis was either present in
both twins or absent in both twins 93.6% of the
time. Among dizygotic (fraternal) twins, there
was a 79.4% concordance for the presence or
absence of torus mandibularis. This study shows
that the development of an exostosis such as a
torus mandibularis has a genetic predisposition,
yet the extent to which genetics is a factor in
the development of torus mandibularis or other
exostoses is uncertain.
In terms of the clinical appearance, the torus
may be bosselated (numerous rounded protuber-
ances) or multilobulated, but the exostosis is
typically a single, broad-based, smooth-surfaced
mass, perhaps with a central sharp, pointed pro-
jection of bone producing tenderness immedi-
ately beneath the surface mucosa.
Torus palatinus is found only in the midline
of the hard palate. In most cases a single torus
is present, but in rare instances multiple tori
can grow on the palate, giving a multilobulated
appearance (see Figure 1). Lesions may become
FIGURE 1: MULTIPLE PALATAL TORI
Maxillary and Mandibular Exostoses: A Clinical Review 3
3 to 4 cm in their greatest diameter but are usu-  IGURE 2: BUCCAL EXOSTOSIS
F
ally less than 1.5 cm at biopsy. OF THE MAXILLA (TOP) AND
MANDIBLE (BOTTOM)
Torus palatinus and torus mandibularis are
generally first noticed in patients between the
ages of 34 and 39 (Morrison & Tamimi, 2013).
Torus palatinus occurs more commonly in
women than men, with virtually all studies from
around the world showing a 2:1 female to male
predilection ratio (Neville, Damm, Allen, &
Chi, 2016). It is always located in the midline,
and it is an extension of the bone of the hard
palate and not a true neoplasm. Although torus
palatinus is benign and rarely needs treatment,
occasionally it is removed because it interferes
with the fitting of dentures.
Torus mandibularis is similar to torus pala-
tinus and always grows on the lingual surface
of the mandible, near the bicuspid (premolar)
teeth. Mandibular tori are usually bilateral and
symmetrical, although they can also be unilat-
eral (Santhanakrishnan & Rangarao, 2014).
Buccal exostoses are benign, broad-based
surface masses of the outer or facial aspect of
the upper jaw (maxilla) or, less commonly, the RADIOGRAPHIC
lower jaw. They are usually found in the pre­ FEATURES OF
molar and molar region (Medsinge et al., 2015;
EXOSTOSES
see Figure 2).
Buccal exostoses begin to develop in early
adulthood and, like tori, may very slowly
T orus palatinus, the most common exostosis
of the jaws, occurs in the midline of the
palate. On intraoral radiographs it appears as
enlarge over the years. They are painless and
a well-demarcated radiopacity superimposed
self-limiting but occasionally may become sev-
over the maxillary molar roots and the maxillary
eral centimeters across. These larger buccal
sinus, as in Figure 3. It commonly has a smooth,
exostoses can contribute to food impaction and
lobulated appearance.
periodontal problems of adjacent teeth by forc-
ing food in toward the teeth during chewing Radiographically, torus mandibularis is a sim-
instead of away from them, as is normally the ilar outward projection of bone, but it occurs
case. Buccal exostoses do not usually require on the lingual aspect of the mandible in the pre­
treatment, but lesions contributing to a perio­ molar region, often bilaterally, and thus appears
dontal condition can be removed by conserva- as a well-demarcated radiopacity superimposed
tive surgical excision. There is no malignant in this region. The radiopacity of large tori may
potential to this lesion. make it difficult to visualize and interpret the

4 Maxillary and Mandibular Exostoses: A Clinical Review

 IGURE 3: RADIOGRAPHIC IMAGES

F The panoramic radiograph in Figure 4 shows
OF TORUS PALATINUS multiple osteomas of the mandible, possibly
involving the left posterior area of the maxilla.
The arrow indicates an impacted supernumer-
ary tooth between the mandibular left canine
and the lateral incisor. Another supernumerary
tooth can be seen partially erupted buccal to the
maxillary right lateral incisor. The diagnosis of
Gardner’s syndrome is established when there
are concurrent findings of intestinal or colorec-
tal polyposis and osseous pathologies within the
jaws (Dereci, Ay, Yesilova, & Pasaoglu, 2015).
Patients with Gardner’s syndrome have a
30% to 75% occurrence of dental abnormalities
and a 68% to 82% occurrence of osteomas. The
mandible and the paranasal sinuses are the most
common locations of oral and maxillofacial
osteomas (Cankaya et al., 2012). They also may
occur in the skull and the long bones (Boffano,
Bosco, & Gerbino, 2010). Multiple osteomas
precede clinical and radiologic evidence of
colonic polyposis; therefore, they may be sensi-
tive markers for the disease. Cutaneous findings
include epidermoid cysts, desmoid tumors, and
other benign tumors (Singhal, 2016).

 IGURE 4: RADIOGRAPH OF
F
GARDNER’S SYNDROME
root anatomy of the contiguous teeth. This can
complicate procedures such as oral surgery and
endodontics.
On a radiograph, osteomas of the jaws may
appear as well-delineated or diffuse radiopacities
of various sizes and shapes. Multiple osteomas
of the jaws and unerupted supernumerary teeth
are common findings in Gardner’s syndrome.
Gardner’s syndrome is a disease of genetic
(autosomal dominant) origin that is character-
ized by systemic and maxillofacial involve-
ment. For the clinician, multiple osteomas of the
jaws and unerupted supernumerary teeth should
raise the suspicion of Gardner’s syndrome.
Maxillary and Mandibular Exostoses: A Clinical Review 5
The prognosis for patients with Gardner’s
syndrome varies with the signs and symptoms
of the disease and the age of diagnosis. By 35
years of age, 95% of patients with Gardner’s
syndrome have colorectal polyps, which rapidly
increase in number, and colon cancer is inevita-
ble unless a colectomy is performed (Jasperson
& Burt, 2014). Dental clinicians who have a
patient who does not have Gardner’s syndrome
listed as an existing illness on his or her medical
history but whose panoramic film reveals super-
numerary teeth, impacted teeth, and osteomas
must refer the patient to his or her physician or
a gastroenterologist immediately.
PATHOPHYSIOLOGY
OF EXOSTOSES
E xostoses are considered to be a develop-
mental anomaly, although they usually do
not present until adult life and often continue
to grow slowly into adulthood (Morrison &
Tamimi, 2014). The exact etiology of exosto-
ses has not been determined. However, some
of the proposed causes include genetic factors,
environmental factors, and masticatory hyper-
function and occlusal parafunctional habits
(Sani-Neto et al., 2014). The formation of bone
in response to trauma from occlusion is another
postulated etiology of exostoses (Smitha &
Smitha, 2015). The functional matrix hypothesis
has suggested that the formation of torus man-
dibularis is the result of compressive stresses in
the mental foramen (bicuspid) area of the man-
dible. This area has a reduced volume of bone,
and new bone in the form of a torus mandibu-
laris is formed as a response to the continual
compressive stresses (Auskalnis et al., 2015).
The histologic features of tori and other kinds
of exostoses are identical (Smitha & Smitha,
2015). The torus is dense cortical bone that is
covered with a thin and poorly vascularized oral
mucosa (Lee, Lee, & Lee, 2013). The dense bone
outgrowth is of a laminated pattern that features
small spaces in which thick bone marrow or
scattered fibrovascular stroma exist. There is a
minimum of osteoblastic and periosteal activity
(Sinisterra, Alvarez, & Molano, 2013).
Despite these diagnostic features, there may
be no means by which to differentiate an exos-
tosis from an osteoma, even under the micro-
scope, unless the bony prominence is specifically
located, is pedunculated, or is associated with an
osteoma-producing syndrome such as Gardner’s
syndrome.
ORAL HEALTH
IMPLICATIONS
OF MAXILLARY
AND MANDIBULAR
EXOSTOSES
T he presence of a torus palatinus, a mandibu-
lar torus (or tori), or buccal or palatal exo­
stoses is usually an incidental finding during a
routine dental examination. Generally, patients
have become accustomed to their presence, and
complaints about their existence are relatively
few. However, there are some oral health issues
that exostoses can complicate. Buccal exo­stoses
can feature single or multiple protuberances and
invaginations, which can retain food debris and
cause halitosis. The chronic impaction of food
against the teeth adjacent to an exostosis can
increase the risk of the development of perio­
dontal disease and carious lesions. Patients with
this problem have the option to remove the
exostoses surgically. If the patient forgoes the
surgical option, he or she should be instructed
to cleanse the surface of the exostoses in an
atraumatic fashion. The mucosa that overlies the
exostoses is very thin and is easily traumatized
by conventional tooth brushing. Commercially
available oral hygiene aids with a sponge-like

6 Maxillary and Mandibular Exostoses: A Clinical Review
texture can be used to minimize trauma to the
overlying mucosa and to remove debris from
these areas. Supplemental irrigation with over-
the-counter mouth rinses will enhance this
effort (Sani-Neto et al., 2014).
The surgical removal of a palatal torus,
mandibular tori, or buccal or palatal exostoses
is usually in conjunction with preprosthetic
surgery and is dependent on the size of the
exostoses. Partial dentures or complete den-
tures can usually be designed to bypass smaller
exo­stoses; however, larger exostoses can chal-
lenge or preclude the ability to use these pros-
theses. The progressively large size of a palatal
torus will cause instability or a “rock” in the
denture. The application of pressure against a
palatal torus can cause the overlying mucosa
to be constantly ulcerated. U-shaped complete
dentures can be made to bypass a palatal torus,
but they are more prone to flexion and fracture
and will require the use of adhesive for reten-
tion. Mandibular tori offer challenges simi-
lar to those of the palatal torus; however, it
is more difficult for a complete denture to
bypass a protruding mandibular torus (or tori).
Preprosthetic treatment planning for patients
with a palatal torus, mandibular tori, or buc-
cal or palatal exostoses must evaluate their
size and location relative to the anticipated
prostheses. Surgical removal of any exostoses
is indicated when these osseous areas would
interfere with the placement, retention, or sta-
bility of the prostheses (Rastogi, Verma, &
Bhushan, 2013). If the exostoses are removed
surgically, adequate healing time should be
allowed before the final prosthetic impressions
are taken. Teeth that are adjacent to buccal
or palatal exostoses or mandibular tori can be
more difficult to extract given the additional
density and thickness of the contiguous bone.
If a surgical extraction is indicated, care must
be taken in preparing a surgical flap, because
the overlying tissue is thin and can be torn
easily if it is not manipulated carefully. Torn
mucosal tissue can have a compromised blood
supply that will delay healing and could lead
to an inflammatory response or necrosis of the
involved tissue (Urolagin, Kale, & Patil, 2010).
SURGICAL TREATMENT
AND PROGNOSIS
OF EXOSTOSES
A
n accurate diagnosis is important to guide an
appropriate treatment. Osteoma-producing
syndromes such as Gardner’s syndrome should
be ruled out. The patient should be evaluated
for Gardner’s syndrome should he or she have
multiple bony growths or lesions not in the clas-
sic torus or buccal exostosis locations. As noted,
intestinal polyposis and cutaneous cysts or fibro-
mas are other common features of this auto­
somal dominant syndrome. Exostoses are benign
overgrowths of bone that do not undergo malig-
nant transformation. As such, most exostoses are
innocuous and do not need to be removed surgi-
cally. Dental clinicians should record the location
and size of any exostoses via an intraoral photo­
graph to establish an initial baseline and com-
pare the images at subsequent visits to determine
whether growth of the exostoses is occurring.
They should also ask the patient if the exostoses
are interfering with the patient’s ability to main-
tain oral hygiene or functions such as mastication
or phonation (Burkhart & DeLong, 2015).
Surgical Reduction of Exostoses
The surgical procedure for handling bony
lesions or other hard tissues of the oral cavity is
not particularly different from any other surgi-
cal procedure. The same careful and meticulous
technique is indicated for all surgery. However,
the removal of such conditions is among the
most difficult to execute of the bony surgical
Maxillary and Mandibular Exostoses: A Clinical Review 7
procedures, and it can produce prolonged post-
operative problems if not performed correctly.
Dental clinicians who are inexperienced in the
surgical removal of an exostosis, regardless of
its location, should refer these patients to an
oral surgeon. Removal of a torus palatinus with
excessive pressure can fracture the bone and
lead to the exposure of the maxillary sinus. The
removal of a mandibular torus (or tori) must be
done with extreme care to avoid iatrogenic dam-
age to the tongue, adjacent teeth, or the tissues
in the floor of the mouth. Accidental slippage
of an instrument or a bur from a high-speed
surgical handpiece in the floor of the mouth can
cause severe tissue damage and bleeding that is
difficult to control.
The operative approach to these calcified
structures is by means of a flap, exposing them
for excision by either the chisel, bur, or laser sur-
gery (Imada et al., 2014). Some can be removed
in total, but others require a sectioning technique,
usually with a bur. In the case of an exostosis, the
intent may not always be complete removal but
rather simply trimming or smoothing the bulky
mass to accommodate a prosthesis.
Recurrent lesions occasionally may be seen,
but there is no potential for malignant trans-
formation, and these recurrent lesions can be
treated similarly, that is, conservatively or by
surgical reduction if indicated.
Surgical Reduction of Torus Palatinus
There is no evidence in the literature of
torus palatinus ever having been reported as a
malignant growth; it is removed primarily to
prevent irritation to the overlying mucosa and to
permit the reception of a prosthesis.
Trauma may be a common complaint. Torus
palatinus takes considerable abuse from the
compression of food against the roof of the
mouth by the tongue during the masticatory
cycle and from food passing through the oral
cavity. In addition, torus palatinus may compli-
cate the creation of a prosthesis because it may
extend posteriorly as far as the post dam of the
maxillary denture and may also interfere with a
prosthesis by preventing the peripheral seal of
the maxillary denture.
The surgical management for the reduction
of the torus can be done under local or general
anesthesia. A single “Y” or a double “Y” inci-
sion provides surgical access, with the latter
incision being more common and the former
decreasing the risk of injury to the nasopala-
tine and anterior palatine nerves (Imada et al.,
2014). This flap design preserves the nerves
and blood supply to the flap entering from the
nasopalatine and the bilateral greater palatine
foramina. However, the mucoperiosteal flap is
extremely thin and tears easily, so it must be
handled gently. A traction suture may be helpful
to keep the delicate flap away from the exposed
bone to be reduced.
The injection of local anesthetic near the
base of the bony protuberance helps control
hemorrhage into the area and, at the same time,
balloons the tissues sufficiently to make dissec-
tion easier. Once the flap is retracted to ensure
adequate access, the mass can be sectioned into
segments by means of a high-speed drill, with
each segment removed separately. A chisel
may also be used to remove the individual seg-
ments. A surgical chisel must be used with a
minimum of force and preferably by an operator
with experienced hands as the magnitude and
direction of the force of a surgical chisel can be
difficult to control (Garcia-Garcia, Martinez-
Gonzalez, Gomez-Font, Soto-Rivadeneira, &
Oviedo-Roldan 2010). Even a small amount
of excessive force can cause the unintentional
removal of a large segment of bone and can
also damage the contiguous mucosal tissues and
teeth. A large torus should not be removed in

8 Maxillary and Mandibular Exostoses: A Clinical Review
one piece because of the possibility of fractur-
ing the nasal floor (Imada et al., 2014).
A high-speed drill may be used to reduce
the entire mass; however, copious irrigation
should be employed to avoid damaging the
bony tissue. Surgical handpieces should be used
for this procedure as they are designed to pro-
vide irrigation of the area without the simulta-
neous introduction of air into the surgical site,
which would occur with the use of a conven-
tional handpiece. A bolus of air introduced into
a surgical site can lead to a life-threatening air
emphysema (Olate, Assis, Freire, de Moraes, &
de Albergaria-Barbosa, 2013). Smoothing the
raw bony surface can be accomplished using
rongeurs and bone files followed by irrigation
with an isotonic (0.9%) sterile saline solution.
The tissues are closed with mattress sutures
(Medsinge et al., 2015).
A surgical splint is useful to protect the flap
during the postoperative period. The splint not
only physically protects the tissues from injury
and food debris but also prevents hematoma for-
mation beneath the flap, which would retard the
healing process (Kademani & Tiwani, 2016).
In preparation for the splint, the surgeon
should trim the case personally because it is
the surgeon who has examined the patient’s
mouth and can translate the clinical entity to the
torus as it appears on the model made from the
impression of the patient’s mouth. Furthermore,
the surgeon who is performing the procedure
will have a reasonable estimate of the tissue
surface post-surgically and would thus be in the
best position to trim the model and to note that
an appropriate amount of bony reduction was
accomplished during the procedure. If the relief
provided is inadequate, pressure will be exerted
against the wound, which could result in isch-
emia, ulceration, and delayed healing.
The advent of the use of lasers in dentistry
has seen clinical applicability in restorative
dentistry, periodontal treatment, endodontic
therapy, and some aspects of oral surgery,
including the removal of exostoses such as a
torus palatinus or mandibular tori. Dental cli-
nicians should have received training in den-
tal school and/or via postdoctoral continuing
education in the use of lasers for this aspect of
oral surgery before they utilize this treatment
method for the removal of tori. An Er:YAG
laser can be used. The output power, tip diame-
ter, pulse duration, and ­fluence must be adjusted
to the requirements of the clinical situation
(Rocca, Raybaud, Merigo, Vescovi, & Fornaini,
2012). The use of lasers to remove a torus pala-
tinus or a mandibular torus (or tori) can leave
furrows and pitting of the osseous surface,
which can be refined and smoothed with ron-
geurs and/or a bone file.
Surgical Reduction of
Torus Mandibularis
Mandibular tori are similar to the palatal tori
except for location, and their surgical removal is
similar. In this case, the chisel is the best tool to
use. Otherwise, sectioning, as described previ-
ously, is the safest surgical approach.
The major complicating aspect of this pro-
cedure is that of access. A sufficiently long
incision must be made to provide good vision
from the molar areas to the midline. There is
less space for hematoma formation if the mylo-
hyoid mucosa is not stripped away and the
excess flap is removed from the incised margin
and sutured firmly. The presence of the sali-
vary ducts and the lingual nerve, and the ease
with which postoperative edema and infec-
tion occur in the floor of the mouth, add to the
concern regarding any surgery in this area. A
previously constructed acrylic splint is the best
way to ensure tissue adaptation and to limit
postoperative edema and hematoma formation
(Kademani & Tiwana, 2016).
Maxillary and Mandibular Exostoses: A Clinical Review 9
The surgical removal of multiple exosto-
ses is basically no different from that for tori,
except that exostoses occur with no unifor-
mity as to location. They also appear singularly
around the arch or in multiple formation.
Although not technically soft tissue masses,
torus palatinus, torus mandibularis, and buccal
exostoses are all lesions that present as sur-
face masses and are removed with minimal
disturbance of deeper cancellous bones. The
American Academy of Oral and Maxillofacial
Pathology has indicated that any abnormal tis-
sue that is removed from a patient should be
submitted for a biopsy. Exceptions to this rec-
ommendation include tori or exostoses that are
removed for preprosthetic surgery (Melrose,
Handlers, Kerpel, Summerlin, & Tomich,
2007). Dental clinicians must utilize their own
clinical judgment to determine if this recom-
mendation should be followed. If the patient
needs a bone graft for an osseous deficit for
periodontal disease or for the placement of
an implant, the bone that is harvested upon
removal of a torus is an excellent source of an
autogenous bone graft (Santhanakrishnan &
Rangarao, 2014).
CASE SCENARIOS
Case Scenario #1
Martha has a long history of poor oral
health. Her dental history has consisted of
treating acute odontogenic pain and infections
with antibiotics and analgesics after which the
involved tooth or teeth are extracted. She is
a patient that has never had time for an ini-
tial comprehensive dental exam or for regular
periodic dental exams. Recently, the condition
of her teeth has deteriorated to a degree that
mastication of food is difficult, and the mul-
tiple carious lesions in her maxillary and man-
dibular teeth are cosmetically displeasing. She
has made an appointment with Dr. Wilson for
the extraction of all of her remaining maxil-
lary and mandibular teeth and the placement
of maxillary and mandibular immediate den-
tures. She points to the roof of her mouth and
asks about a hard lump that has been there as
long as she can remember. Martha states that it
has not increased in size, but she occasionally
traumatizes it during eating with a fork or with
hard crunchy foods such as chips. She asks Dr.
Wilson to identify the “lump” and asks if it will
influence the fit and function of her maxillary
denture. She reminds Dr. Wilson that she is on
a limited budget and that she does not want any
unnecessary surgery.
Question
What is the most probable diagnosis of the
“lump” in the roof of Martha’s mouth? What
considerations are there in the ability to wear
her new denture?
Discussion
Upon clinical examination, Dr. Wilson
has determined that Martha has a palatal torus
(torus palatinus) in the midline of the roof of
her mouth. The torus is raised only about 3 mm
from the surface of the hard palate. It is about
1 cm in length and about 7 mm in width. Dr.
Wilson has informed Martha that it would be
ideal for the palatal torus to be removed. He has
explained that if she retains this torus the maxil-
lary denture can irritate the tissue that overlies
the palatal torus and the denture may “rock”
on this unyielding structure and compromise
the retention of the denture. Dr. Wilson has
advised her that she would need to see an oral
surgeon to remove this torus, but Martha does
not want to incur the additional expense for
this procedure. Given this decision, Dr. Wilson
advises Martha that he can relieve the denture
surface that overlies the palatal torus, which
may decrease, but not eliminate, the potential

10 Maxillary and Mandibular Exostoses: A Clinical Review
for the denture “rocking” on the torus. It may
also decrease the potential to irritate the mucosa
that overlies the torus. Relieving the denture in
this fashion can decrease the retention of the
maxillary denture, so Dr. Wilson has informed
Martha that she may need to use a denture adhe-
sive to enhance the retention of the denture.
Case Scenario #2
Gordon has been a dental patient of Dr.
Nathan for many years. He has never had any
carious lesions, and his periodontal health is
excellent. He has become complacent about his
regular periodic dental appointments because
his past dental appointments have demonstrated
that he has excellent oral health. Thus, he has
not seen Dr. Nathan for about 3 years. Recently,
he has become concerned about some “bumps”
that have been developing slowly on both sides
of the buccal aspects of his maxillary arch.
These “bumps” approximate the bicuspid and
molar region and have become progressively
larger over time. Although he does not smoke
and has a very low level of alcohol consump-
tion, Gordon is concerned that this could be a
form of oral cancer. He notes that he has had
no pain in these areas unless he accidentally
strikes the mucosa that overlies these areas with
a toothbrush or with an eating utensil. Food can
impact within this area, complicating his ability
to maintain optimal oral hygiene. Gordon makes
an appointment with Dr. Nathan to have these
areas evaluated.
Question
Given the location, the bilateral occurrence
and slow growth of the “bumps,” and the absence
of pain, what is a reasonable diagnosis for this
clinical case scenario? What are the oral health
considerations and the options for treatment?
Discussion
Dr. Nathan has performed an updated
complete clinical and radiographic review
of Gordon’s teeth, oral soft tissues, and the
“bumps” that have prompted Gordon to seek
dental care. There are no carious lesions or
perio­dontal pockets that would cause the devel-
opment of bilateral swelling. Palpation of these
outgrowths reveals that they are immobile,
with a thin mucosal layer that overlies dense
bone. There is no pain upon palpation of these
outgrowths. Radiographs reveal radiopaque
areas intermingled with the roots of the adja-
cent teeth. Gordon is not experiencing a loss of
sensation in these areas such as a paresthesia
or anesthesia. The borders of these outgrowths
are very defined. Based on the clinical exam,
radiographic survey, and history of the devel-
opment of these areas, Dr. Nathan’s initial
diagnosis is that of bilateral buccal exosto-
ses. Dr. Nathan has emphasized that only a
biopsy of both areas would provide a defini-
tive diagnosis. She has provided Gordon with
the name of an oral surgeon who could per-
form this procedure. The results of the biopsy
have confirmed the clinical and radiographic
initial impression: bilateral buccal exostoses.
Treatment options include the surgical removal
of the buccal exostoses on both sides or the
continued monitoring of both sites. Given the
lack of symptoms, Gordon opts for the lat-
ter option. Dr. Nathan’s hygienist has given
Gordon a mirror so he can learn hygiene pro-
cedures that promote optimal oral health in a
fashion that is atraumatic to the gingival tissues
as well as the mucosa that overlies the exosto-
ses. Dr. Nathan has emphasized the need for
dental care at regular intervals, not only as a
means to monitor any further growth or prob-
lems with the exostoses, but also as a means of
maintaining optimal oral health as a component
of optimal systemic health.
Maxillary and Mandibular Exostoses: A Clinical Review 11

SUMMARY to maintain optimal oral hygiene, and increase

the risk of dental caries and of perio­dontal dis-

T his course has focused on a discussion of

exostoses within the oral cavity proper.
It is important that dental clinicians under-
ease. Patients who opt to retain these exostoses
rather than undergo their surgical removal must
receive oral hygiene instructions from the dental
stand the basic classification and nomencla- team that facilitates the ability to maintain opti-
ture of these osseous anomalies. The relevance mal oral hygiene in these areas. It is incumbent
of torus palatinus; torus mandibularis; buccal upon dental clinicians to advise patients with
and palatal exostoses; and osteomas, which exostoses about their nature, their relevance to
are associated with Gardner’s syndrome, have oral health, and where indicated, options for
been highlighted as they relate to oral health. their removal.
Although these exostoses are generally innocu-
ous outgrowths of bone, their removal may be
required for preprosthetic surgery, if they are
a chronic impediment to oral function, or if
they compromise the patient’s ability to main-
tain adequate oral hygiene as a noted potential
challenge with buccal exostoses. It is impera-
tive that dental clinicians be able to distinguish
among these osseous anomalies and pathologies
of a more significant concern to provide the best
overall care for their patients. The presence of
the varied exostoses can present challenges for
both the dental clinician and the patient. Buccal
exostoses represent a layered and thickened
wall of bone that can complicate the ability to
extract teeth. This can be exacerbated when
the tooth/teeth involved have extensive carious
involvement, long roots, and limited access.
The thickness of a buccal exostosis can also
interfere with the ability to discern root length
and anatomy and the extent of decay. The pres-
ence of a palatal torus and/or mandibular lingual
tori can make the placement of conventional
radiographs or the sensors for digital radiog-
raphy challenging. The ability to place these
radiographic instruments to obtain an accu-
rate radiograph without compressing these tori
and causing the patient discomfort requires a
combination of clinical excellence and patience.
Buccal exostosis and mandibular lingual tori that
approach the gingival crest can retain bacteria-
laden plaque, complicate the patient’s ability