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Case Report

Bilateral Buccal Exostosis Evaluated by Cone‑beam Computed

Tomography: A Rare Accidental Finding
Humaira Siddiqui, Dhirendra Kumar Singh, Silpiranjan Mishra1, Arnab Mandal
Departments of Periodontics and Oral Implantology and 1Oral Medicine and Radiology, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India

Abstract
Buccal exostoses are broad-based, non-malignant surface growth occurring on the outer or facial surface of the maxilla and/or mandible, found
usually in the premolar and molar region. Etiology is still not established, but it has been suggested that the bony overgrowth can be because
of abnormally increased masticatory forces to the teeth. Compensatory response to periodontal disease has been proposed to explain some
cases of exostoses; they tend to appear in early adolescence and may very slowly increase in size with time. They are painless, self-limiting
and may increase patient concern about poor esthetics, inability to perform oral hygiene procedures, and compromised periodontal health by
causing food lodgment. The following article presents a very rare case of bilateral buccal-sided maxillary and mandibular exostoses in the
anterior region which was an accidental finding in a chronic generalized periodontitis patient.

Keywords: Bony exostoses, buccal exostoses, cone‑beam computed tomography, exostoses, tori

Introduction due to retention of food while chewing instead of flushing

Exostosis or hyperostoses are localized cortical bone growth
on the mandible and maxilla. It is usually found along the
alveoli or on the hard palate and depending on the location
and extent; they can be classified as torus mandibularis (TM),
torus palatinus (TP), buccal, or lingual maxillary exostosis.[1]
Most common types of intraoral osseous overgrowths are TP
and TM.[2,3] Buccal and lingual maxillary exostoses are a rare
finding. When found on alveoli, exostosis most frequently
tends to be thickest next to molars, extending anteriorly
sometimes as far as second premolar and in rare cases, up
to the canine and incisors  (Hrdlicˇka 1940; Tadakuma and
Ogasawa 1969).[1] Exostoses and tori are well known by
anthropologists, and the first article on them was published
by Fox.[4] These occur as bilateral, smooth bony growth along
the facial aspect of the maxillary and/or mandibular alveolus.
It appears in the premolar‑molar region commonly. Exostoses
are hard bony masses on palpation. The overlying mucosa
appears normal color stretched but intact. Due to trauma
or any injury ulcerations may be seen on the mucosa. They
tend to develop during teenage and may gradually enlarge
over the years. Buccal exostoses may be seen as self‑limiting
and painless bony masses. The increased size may be a
contributing factor to periodontal disease of adjacent teeth
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away. The treatment of bony exostosis is usually not required,
unless it is affecting the periodontal condition or causing pain
or discomfort to the patient, or when causing pseudo‑swelling
over the lip. Only, then conservative surgical excision can be
performed.[5]
The etiology of tori has not been established yet. Most probable
reasons include genetic factors, environmental factors,
masticatory hyperfunction, and continued jaw bone growth.[6,7]
Diagnosis, treatment, and prognosis
The diagnosis of a buccal exostosis is based on the clinical
examination along with radiographic interpretations. The torus
may appear clinically as numerous rounded protuberances or
calcified multiple lobules, whereas the exostosis is a single,
smooth broad‑based mass, may have a sharp, pointed bony
projection producing tenderness just beneath the mucosa.[8]
Lesions may slowly enlarge up to 3–4 cm in greatest diameter;
Address for correspondence: Dr. Humaira Siddiqui,
Department of Periodontics and Oral Implantology,
Kalinga Institute of Dental Sciences, Campus‑5, KIIT University,
Patia, Bhubaneswar ‑ 751 024, Odisha, India.
E‑mail: drhumaira07@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and
build upon the work non‑commercially, as long as the author is credited and the new creations
are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Siddiqui H, Singh DK, Mishra S, Mandal A.
10.4103/IJDS.IJDS_95_16 Bilateral buccal exostosis evaluated by cone-beam computed tomography:
A rare accidental finding. Indian J Dent Sci 2017;9:34-7.

34 © 2017 Indian Journal of Dental Sciences | Published by Wolters Kluwer - Medknow

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Siddiqui, et al.: Bilateral buccal exotosis evaluated by CBCT

Figure 2: Labial view of the mandible.

Figure 1: Labial view of the maxilla.

Figure 3: Digital orthopantomogram.

Figure 4: Axial section of the maxilla.

Figure 5: Axial section of the mandible.

however, it does not have malignant transformation potential.

Buccal exostoses are usually found only on the facial surface
of the maxillary alveolar bone, especially in the posterior
segment. Radiographically, exostosis appears as well‑defined
round or oval calcified structure superimposing the roots of
teeth. Biopsy should be performed if there is any dilemma
regarding diagnosis. The patients having multiple bony
growths or lesions which are not in the classic torus or
buccal exostosis locations should be evaluated for Gardner
syndrome. This autosomal dominant syndrome shows other
features such as intestinal polyposis and cutaneous cysts or
fibromas.[2,7] No bony exostosis or tori requires treatment
unless it becomes large enough to interfere with periodontal
Figure 6: Three‑dimensional view frontal.
health, denture placement, or cause recurrent traumatic
ulcerations.
Case Report
A male patient who was aged 54  years reported to the
Department of Periodontics, Kalinga Institute of Dental
Sciences College and Hospital, Bhubaneswar, Odisha, India,
for a routine checkup and oral prophylaxis. On clinical
examination, it was found that his oral hygiene status was

Indian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 1 ¦ January-March 2017 35

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Siddiqui, et al.: Bilateral buccal exotosis evaluated by CBCT
poor, and multiple bony nodules were found in the lower and
upper anterior region of his maxilla and mandible as seen in
Figure 7: Three‑dimensional view left lateral.
Figure 8: Three‑dimensional view right lateral.
Figure 9: Sagittal section.
36
Figures 1 and 2. The patient had not previously noticed the
“nodules” and he was otherwise healthy. He had a medical
history of hypertension since 3 years, for which he was taking
medicine regularly, and there was also no history of any other
family illness or any tissue tumors which were suggestive of
any syndrome.
On examination, the patient was found to be apyrexic, and
there was no lymphadenopathy intraorally, an intact dentition
was present, and all the mucosal surfaces appeared to be
healthy. Multiple bony protuberances were evident along the
labial aspect of the maxilla and mandible. The approximate
diameter of the bony swellings varied from 5 to 6 mm. On
palpation, 10 round, firm, raised, nontender protuberances were
diagnosed in the maxillary arch and six‑rounded protuberances
in the mandibular arch. An orthopantomogram was taken to
confirm the presence of multiple radiopaque masses along the
middle thirds of roots of maxillary central incisors to second
premolars on both the right and left side, and mandibular
anterior region, which extended from canine to canine, that
demonstrated a buccolingual growth of the alveolar bone in the
region of the bony swellings as seen in Figure  3. Radiolucencies
were seen in between these teeth, and clinically, no mobility
in the teeth was present. To reach a confirmed diagnosis, a
cone‑beam computed tomography (CBCT) was taken.
CBCT is a helpful diagnostic tool to identify anatomical
variations. Multiple radiopaque masses seen on the labial
aspect of maxillary anterior, measuring approximately 5 mm
with loss of labial cortical plate 7 mm approximately below
the cementoenamel junction giving a beaded appearance over
the anterior maxilla and mandible suggestive of bony exostoses
as depicted in Figures 4‑8. In the CBCT, it was apparent that
buccal cortical plate was missing in the areas of exostoses as
seen in Figure 9. Maybe compensatory response to periodontal
disease can be proposed to explain this case of exostoses as
suggested by Glickman and Smulow 1965.[9]
Indian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 1 ¦ January-March 2017
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Siddiqui, et al.: Bilateral buccal exotosis evaluated by CBCT
Discussion
Buccal exostoses are nonmalignant lesions having little clinical
significance. The multiple masses in the maxilla are consistent
with multiple buccal exostoses. These are bony protuberances
that arise from the cortical plates in the maxilla and mandible.
The clinical, radiographic, and CBCT findings confirm the
diagnosis of buccal exostosis. Nery et al. in 1977 reported that
the Asian population show higher frequency of exostoses and
presumably carry alleles in a greater frequency.[10] A biopsy
for diagnostic support is usually not recommended. It remains
important to distinguish exostoses from early osteosarcomas
and chondrosarcomas. Furthermore, the patients with multiple
bony growths should be evaluated for Gardner syndrome.
Intestinal polyposis and cutaneous cysts or fibromas are
other common features of the autosomal dominant Gardner
syndrome. [2,6] Neither the torus nor the bony exostosis
requires treatment unless it becomes large enough to interfere
with normal function or causes recurring traumatic surface
ulceration  (usually from sharp food) or can be used to get
autograft as it is a potent donor site.[11]
Conclusion
The case report presented above illustrates a unique and rare
presentation of exostoses on the buccal side of the maxillary
and mandibular anterior‑premolar region, bilaterally.
Exostosis is rarely found on the facial surface of maxilla and
mandible thus should not be ignored and should be carefully
differentially diagnosed.
Indian Journal of Dental Sciences ¦ Volume 9 ¦ Issue 1 ¦ January-March 2017
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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