Sleep Breath
DOI 10.1007/s11325-013-0905-5
ORIGINAL ARTICLE
Mandibular tori size is related to obstructive sleep apnea
and treatment success with an oral appliance
Emma Palm & Karl A. Franklin & Marie Marklund
Received: 13 June 2013 / Revised: 15 October 2013 / Accepted: 16 October 2013
# Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose Obstructive sleep apnea (OSA) is a common
disorder characterized by repetitive upper airway obstruction
during sleep. We aimed to investigate whether mandibular
tori, exostoses that appear on the lingual surface of the lower
jaw, are related to OSA and the effect of an oral appliance
(OA) in OSA patients.
Methods Six hundred snoring patients with a mean age of
52 years (range 23–75 years) and a mean respiratory
disturbance index (RDI) of 15 (range 0–76), who were
consecutively referred for OA treatment, were included. The
size of the tori was measured on plaster casts with a digital
sliding caliper.
Results Twenty-seven percent of the patients had mandibular
tori, with a similar prevalence in snorers and patients with
mild, moderate and severe OSA. Tori size differed between
severity groups. Thick tori (≥2.9 mm) were associated with an
RDI of <30, odds ratio (OR) 4.7 (p =0.01), adjusted for age,
gender and body mass index (BMI; kg/m 2). Complete
treatment response with OA was related to thick tori, OR=
2.5 (p =0.02), adjusted for disease severity, age, gender, BMI
(kg/m2), weight changes (kg) and mandibular repositioning.
Conclusions Patients with milder disease are more likely to
have larger tori than patients with severe OSA. Treatment
success with an OA occurs more frequently in patients with
larger tori than in patients with no tori or small tori.
E. Palm
Folktandvården Alingsås, Västra Götalandsregionen, Alingsås,
Sweden
K. A. Franklin
Department of Surgery, Umeå University, Umeå, Sweden
M. Marklund (*)
Department of Orthodontics, Umeå University, 901 87 Umeå,
Sweden
e-mail: marie.marklund@odont.umu.se
Keywords Mandibular tori . Obstructive sleep apnea .
Mandibular advancement device . Oral appliance
Abbreviations
RDI respiratory disturbance index
BMI body mass index (kg/m2)
OA oral appliance
OSA obstructive sleep apnea
Introduction
Obstructive sleep apnea (OSA) is a common disorder
characterized by repetitive partial or complete airway
collapse, which causes nightly desaturations, disrupted
sleep and symptoms such as daytime sleepiness and
morning headaches [1]. Patients with OSA run an
increased risk of cardiovascular disease, metabolic
dysfunction and motor vehicle accidents [1]. Oral
appliances (OAs) that hold the mandible forwards in
order to improve upper airway patency during sleep
are usually recommended for the treatment of patients
with snoring, mild to moderate OSA, supine-dependent
sleep apnea and those who do not tolerate continuous
positive airway pressure (CPAP) [2–9].
Mandibular tori are hyperostoses located on the lingual
surface of the lower jaw (Fig. 1) [10–13]. They appear from
early adolescence and gradually grow until the third to sixth
decade of life [11, 14–17]. Most of them are small and appear
bilaterally, but larger ones exist to varying degrees in different
populations [11, 15–17]. The larger mandibular tori are clearly
visible in a mirror, but they can also be palpated or felt by the
tongue. The etiology of mandibular tori is unclear and both
genetic and environmental factors have been proposed [18]. It

Fig. 1 Large mandibular tori
has been suggested that increased muscle activity with
masticatory stress causes mandibular tori [19–22].
A large or retropositioned tongue, mandibular retrognathia,
large tonsils or fat deposits diminish airway size, increase
pharyngeal resistance and cause snoring and OSA. Mandibular
tori can sometimes reach a size at which they interfere with the
space for the tongue [13]. We hypothesized that mandibular tori
can intrude on the space in the upper airway and promote sleep
apneas. One case report describes a patient with large tori who
had OSA, but so far there are no studies of the influence of
mandibular tori on the frequency of sleep apneas [23]. It is also
unknown whether larger mandibular tori influence the efficacy
of an OA in patients with OSA.
The aim of the present study was to test the hypothesis that
the presence and increasing size of mandibular tori are related
to more severe OSA. A second objective was to test whether
large mandibular tori are related to a poorer effect by an OA in
patients with OSA.
Methods
Participants
All 613 patients who were referred for treatment with OAs
because of snoring or OSA were included [9]. Thirteen of the
patients were excluded due to missing study casts. There were
112 women and 488 men in the sample. Seventy patients had
severe OSA with a respiratory disturbance index (RDI) of
>30, and 530 patients were snorers or had mild or moderate
OSA (Table 1). The measurements were made on study casts
that were fabricated before OA treatment was initiated.
Approval for the study was obtained from the Medical Ethics
Committee at Umeå University [9].
Methodology
The thickness, height and length of each torus were measured
with a digital sliding caliper to the nearest 0.1 mm. The
thickness was defined as the greatest prominence in the
bucco-lingual direction (Fig. 2a). The height was identified
Sleep Breath
as the largest extension of the torus in the superio-inferior
direction (Fig. 2b). The length of each torus was defined as its
largest size in the anterior–posterior direction. The combined
length of all the tori in each patient was also calculated and
used in the analysis. The largest torus in each dimension
respectively was used in the analysis. Thick, high or long tori
were defined by a value at or above the median thickness,
height or combined length of the tori. The study casts were
also inspected for the presence of torus palatinus in the
midline of the palate. Lower dental arch length was estimated
by measuring the distance from the midline between the lower
central incisors to the mesial surface of the first molar
(Fig. 2a). The mean value between the right and left side
was used in the analyses. All measurements were made blind
to the results of the sleep apnea recordings.
Level 3 sleep apnea recordings were performed during one
night before treatment and during another night on OA
treatment. The recordings included nasal and oronasal air flow
using a three-way thermistor (Nihon Kohden Ze-732A,
Tokyo, Japan), abdominal and chest movements (Resp-EZ;
EPM Systems, Midlothian, VA, USA), finger oximetry
(Ohmeda Biox 3740, Louisville, CO, USA), body position
(Vitalog Monitoring Inc., Redwood City, CA, USA) and
electrocardiograms (V5). An obstructive event was scored if
respiratory efforts continued during apnea. An apnea was
defined as a cessation of air flow lasting at least 10 s, while
a hypopnea was defined as a decrease of 50 % or more in the
thermistor tracing compared with baseline, combined with an
oxygen desaturation of 3 % or more. The estimated sleep time
was evaluated from the respiratory sleep recordings and body
position sensors [24]. The RDI was the average number of
apneas and hypopneas per hour of estimated sleep time.
Patients with an RDI of <5 were defined as snorers and
patients with OSA were subdivided into mild (5≤RDI<15),
moderate (15≤RDI<30) and severe (RDI≥30). An RDI of <5
defined complete treatment success with the OA.
The monoblock mandibular advancement devices were
fabricated from SR-Ivocap® or SR-Ivocap elastomer®
(Ivoclar, Bendererstrasse 2, FL-9494 Schaan, Liechtenstein)
from duplicate initial casts of the teeth and construction bites
taken by the dentist.
Statistical analysis
The chi-square test, one-way ANOVA including Bonferroni
post-hoc analysis and the Kruskal–Wallis H test were used to
analyze patients’ characteristics and tori size in relation to
disease severity. The Mann–Whitney U test for independent
samples was used to compare the background data between
patients who were excluded and those who were included in
the study and between patients with complete treatment
response and non-responders. Pearson or Spearman
correlation coefficients were used to describe the relationships
Sleep Breath

Table 1 Patient characteristics in the severity groups (n =600)

OSA

Snorers (n =138) Mild (n =233) Moderate (n =159) Severe (n =70) p value

RDI 2.25 (0.00–4.90) 9.50 (5.00–14.90) 21.00 (15.00–29.90) 43.25 (30.10–76.00) <0.001
Agea 47.72±9.15 52.34±9.38 53.40±9.30 53.39±0.69 <0.001
BMI (kg/m2)b,c 27.14±3.80 27.70±3.59 27.71±3.59 29.41±4.56 0.001
Overjet (mm)d 3.0 ±1.8 2.9 ±1.8 3.2 ±1.6 3.3 ±2.1 0.260
Overbite (mm)d 3.2±1.9 3.0±1.9 3.2±1.9 3.5±2.0 0.353
Lower arch length (mm)e,f 39.0±2.3 38.7±2.2 38.9±2.3 39.7±2.4 0.063
Tori present (%) 30 25 29 23 0.562
Female gender (%) 23 19 16 19 0.527

Data are presented as the mean ± standard deviation (SD) or median (min–max)
a
Snorer vs. mild, moderate or severe, p <0.001
b
n =594
c
Severe vs. snorer, p <0.001; severe vs. mild, p =0.006; severe vs. moderate, p =0.010
d
n =599
e
n =412
f
Severe vs. mild, p =0.047

between tori thickness, height and combined length with RDI.
Logistic regression analysis was used to assess the
relationship between disease severity and the size of
mandibular tori, with adjustments for patients’ characteristics
and estimated by odds ratios (ORs). This test was also used to
evaluate the association between complete treatment success
with an OA and the size of mandibular tori. The method error
was assessed by repeat measurements after 1 month of 30
randomly selected tori, using the formula √∑d 2/2n [25]. A
paired-samples t-test was used to evaluate whether there were
any differences between the measurements. Descriptive data
were reported as the mean ± standard deviation (SD) or as the
median with minimum and maximum values for non-
normally distributed variables. The SPSS 21 Statistical
Software Package (SPSS; Chicago, IL, USA) was used in all
calculations; a p value of <0.05 was considered significant.

Results

Patients with severe OSA were heavier than the patients in the
other severity groups (p ≤0.01; Table 1). Snorers were younger
than the subgroups with OSA (p <0.001). Lower arch length
was larger in patients with severe OSA compared with patients
with mild OSA (p <0.05). The thirteen patients who were
excluded from the study due to missing study casts did not differ
from the study sample in terms of age, RDI and BMI (kg/m2).
The method errors were 0.4 mm for the measurement of
tori width, 1.0 mm for the height and 1.7 mm for tori length.
The result did not differ between the two measurements
regarding tori width and height, but it was larger for tori height
(p =0.01) on the second occasion.

Prevalence and size of tori

Fig. 2 Measurements of: a torus thickness (T), torus length (L) and One hundred and sixty-three of the 600 patients (27 %) had
lower arch length (A); b torus height (H) mandibular tori, comprising 25 % of the women and 28 % of
 Sleep Breath

Table 2 Mandibular tori characteristics in the severity groups (n =163)

OSA

Snorer (n =42) Mild (n =59) Moderate (n =46) Severe (n =16) p value

Largest tori size (mm)

Heighta 6.0 ±1.7 6.5 ±1.8 6.4 ±1.8 5.1 ±1.4 0.029
Width 2.7 (1.3 –5.7) 3.1 (1.5 –6.1) 3.0 (1.7 –9.1) 2.2 (1.2 –3.5) 0.003
Combined length 12.5 (4.3 –37.6) 22.4 (3.8 –47.7) 18.0 (6.3 –44.8) 9.4 (2.9 –21.4) <0.001

Data are presented as the mean ± standard deviation (SD) or median (min–max)
a
Severe OSA vs. mild OSA, p =0.031; severe OSA vs. moderate OSA, p =0.057

the men (p =0.57). There was no difference in the prevalence 2.9 mm in all 303 tori that were found among the 163 patients
of mandibular tori between snorers and patients with mild, who had tori. High tori had a height of 6.2 mm or more. Long
moderate or severe OSA (Table 1). A thick torus was tori had a combined length of 17.0 mm or more. Only four
identified by a value at or above the median value of, patients (1 %) had a torus in the upper jaw, torus palatinus.

Fig. 3 Relationships between RDI and: a highest torus, b thickest torus, c combined tori length
Sleep Breath

Table 3 Relationships between

an RDI of<30 and mandibular Univariate logistic regression Model
tori size (n =600)
OR 95 % CI p value OR 95 % CI p value

Thick torus (≥2.9 mm) 4.57 1.41–14.85 0.012 4.72 1.44– 15.45 0.010
High torus (≥6.2 mm) 2.79 1.18– 6.62 0.020
Long tori (≥17.0 mm) 3.91 1.20–12.75 0.024
Age 0.98 0.95– 1.01 0.116
BMI (kg/m2) 0.89 0.84– 0.95 < 0.001 0.89 0.83– 0.94 < 0.001
Female gender 1.01 0.53– 1.91 0.983

Mandibular tori and OSA
Tori size differed significantly between the four severity
groups (Table 2; Fig. 3a–c). Tori height was smaller in patients
with severe OSA than in patients with mild OSA (p =0.03)
and tended to be smaller in patients with severe OSA
compared with patients with moderate OSA (p = 0.06)
(Table 2). Tori height correlated with RDI, adjusted for BMI
and age (r =−0.17) (Fig. 3a). Tori width or combined length
did not correlate with RDI (Fig. 3b and c). There was a
relationship between an RDI of <30 and the presence of thick
tori (≥2.9 mm) after controlling for age, BMI (kg/m2) and
gender, with an OR of 4.7 (p =0.01) (Table 3).
Mandibular tori and OA treatment success
A total of 217 patients with an RDI of ≥10 before treatment
were re-evaluated with the device in place. The degree of
mandibular advancement was a median of 5.5 mm (min–
max; 0.0–10 mm) and the mandibular opening was a median
of 11 mm (min–max; 4–17 mm) in the re-evaluated patients.
The average time between the recording without the OA and
with it was 568 (SD, ±541) days. Characteristics of the
complete responders and the non-responders are presented in
Table 4. Complete treatment success defined as an RDI of <5
using the OA was more common in patients with thick tori
(≥2.9 mm) (p =0.04) (Table 5). Thick tori were independently
related to complete treatment response with an OA adjusted
for age, gender, BMI (kg/m2), weight changes (kg), RDI <30
and mandibular repositioning, with an OR of 2.5 (p =0.02).
Discussion
Twenty-seven percent of the 600 patients in this study had
mandibular tori. There was no difference in the prevalence of
mandibular tori in relation to disease severity. Patients with an
RDI of <30 more frequently had thick tori compared with
patients who had an RDI of ≥30. There was also a greater chance
of complete treatment success with an OA among patients with
thick tori, adjusted for age, gender, BMI (kg/m2), weight
changes (kg), disease severity and mandibular repositioning.
The present findings contrast with our hypothesis that large
tori might relocate the tongue backwards and cause more sleep

Table 4 Characteristics of OSA

patients (RDI≥10) treated with Complete responders (n =99) Non-responders (n =118) p value
OA (n =217)
Median Min–max Median Min–max

Age 53.90 25.30 to 72.90 53.25 28.30 to 71.30 0.537

BMI (kg/m2) 26.90 20.24 to 37.64 27.38 20.45 to 38.66 0.643
RDI 19.3 10.10 to 67.50 22.20 11.00 to 74.00 0.005
Weight change (kg) 1.00 −18.00 to 10.00 1.00 −5.50 to 15.00 0.096
Torus height (mm) 6.1 4.1 to 12.2 6.0 2.3 to 8.9 0.172
Torus width (mm) 3.2 1.3 to 5.8 2.7 1.2 to 4.7 0.163
Tori length (mm) 18.3 6.9 to 42.5 12.9 2.9 to 31.2 0.043
Advancement (mm) 5.5 0.0 to 10.0 5.0 0.0 to 8.0 0.278
Opening (mm) 11.0 7.0 to 17.0 11.0 4.0 to 16.0 0.527
Women (%) 25 12 0.011
Thick torus (≥2.9 mm) (%) 22 12 0.041
High torus (≥6.2 mm) (%) 24 16 0.134
Data are presented as the median Long tori (≥17 mm) (%) 18 9 0.056
(min–max)
 Sleep Breath

Table 5 Relationships between

complete treatment success Univariate logistic regression Model
from OA and mandibular tori size
in patients with OSA (RDI≥10) OR 95 % CI p value OR 95 % CI p value
(n =217)
Torus present 1.47 0.80–2.67 0.212
Thick torus (≥2.9 mm) 2.12 1.02–4.41 0.044 2.53 1.13–5.70 0.025
High torus (≥6.2 mm) 1.67 0.85–3.27 0.136
Long tori (≥17.0 mm) 2.16 0.97–4.83 0.060
RDI 0.98 0.96–1.00 0.290
Age 0.99 0.96–1.01 0.303
BMI (kg/m2) 0.98 0.91–1.06 0.620
Weight change (kg) 0.89 0.82–0.97 0.008 0.89 0.82–0.97 0.009
Female gender 2.51 1.22–5.15 0.012 2.87 1.34–6.13 0.007
Advancement (mm) 0.84 0.69–1.02 0.119 1.19 0.99–1.42 0.061
Opening (mm) 1.07 0.94–1.21 0.300

apneas, as well as reducing the opportunity to achieve treatment
success with an OA. In addition, small intraoral dimensions
might further interfere with tongue space. Lower dental arch
length tended, however, to be larger in our patients with severe
OSA, who also had less voluminous tori. Previous research has
indicated that the dental arches may adapt to increased needs
and widen with increased tongue volume [26]. Furthermore,
dental arch sizes were unrelated to treatment success with an
OA [27]. Although we did not measure the oral cavity
dimensions in the same way as these previous authors and data
were missing in our sample because of teeth loss, our results are
in accordance with previous conclusions that relationships
between the anatomic environment and OSA are complex
[28]. Measurements of the overall volume of mandibular tori
in relation to oral cavity size in combination with other
anthropometric data are needed in future research.
The size and appearance of mandibular tori vary
considerably, ranging from small knobs to bulky protuberances
with a smooth surface or with bony projections [16, 17]. A torus
may appear in single, multiple or fused form. Measurements of
these structures are difficult, because it is sometimes hard to
identify the exact margin of the exostosis. We therefore used
the combined length of all tori and categorized the
measurements taking account of the largest thickness, height
and combined length.
It has been suggested that mandibular tori are markers of
increased craniofacial muscle activity. They have been
suggested to develop in response to heavy mastication as a
protective mechanism for microfractures in the bone [11,
19–22]. The results of studies of heel spurs, also known as
calcaneal exostoses, have shown that the bone develops close
to various types of tissue such as muscles and connective
tissue [29]. The bone trabeculae of the spur are aligned not
in the direction of the soft-tissue traction but in the direction of
the stress imposed on the calcaneus [29]. These findings
indicate that heel spurs develop to improve the strength of
the bone. Mandibular tori are usually located in the curvature
of the lower jaw between the anterior section that contains the
incisor teeth and the longer lateral parts that enclose the
molars. They extend in a posterior direction to varying
degrees. These structures might improve the strength of the
bone to enable it better to withstand the forces from various
sources. Our findings of larger tori in patients with milder
OSA are in accordance with this theory, since higher upper
airway dilator muscle activation has been suggested to be a
protective mechanism against the increased resistance of the
upper airways [30]. It is possible that patients with milder
disease are able better to protect themselves from pharyngeal
collapse during sleep by more pharyngeal dilator muscle
activity, compared with patients who suffer from more severe

Table 6 Prevalence of tori in various populations

Author Country Year n Men (%) Torus mandibularis Torus

(%) palatinus (%)

Chohayeb and Volpe [33] USA 2001 448 0 39 70

Sawair et al. [17] Jordan 2009 618 57 26 15
Jainkittivong et al. [16] Thailand 2007 1,520 46 32 61
Haugen [15] Norway 1992 5,000 44 7 9
Sleep Breath
sleep apnea. This explanation means that the presence of
mandibular tori is positive for the individual.
Thick tori were also identified as an independent predictor
of complete treatment success with an OA in the present
patients with OSA (RDI≥10). Predictors based on mandibular
tori have not previously been recognized. The reason for the
improved effect by an OA in patients with larger mandibular
tori controlled for other factors might be improved muscular
response in this group of patients. It is possible that these
patients will benefit particularly from this treatment, since
increased muscle activation has been suggested as one of the
mechanisms of action from OAs [31, 32].
In clinical practice, it has been hypothesized that large
mandibular tori help to hold the tongue upwards and away
from the pharynx and subsequently reduce sleep apneas. The
question of whether this suggested mechanism should be
incorporated in OA design has therefore been raised. The
present findings of a beneficial influence of thick tori in terms
of disease severity and treatment success with an OA are in
line with this theory. Future experimental studies could be
performed to test whether special device designs that mimic
the presence of mandibular tori are of value in the treatment of
OSA. On the other hand, the presence of mandibular tori
might just be a sign of the responder’s characteristics and in
this case there would be no influence of appliance design on
the efficacy of the OA.
The prevalence of tori has also been reported to be highly
variable and differ with ethnicity (Table 6) [11, 17, 33] in
contrast to reported efficacy of OAs in various studies [2, 5,
34]. The large variability in tori frequency in different
populations could be explained by the dynamic manifestation
of tori in relation to age and functional factors. Maxillar tori
were uncommon (1 %) in the present sample. The prevalence
of mandibular tori of 27 % is close to the average of previous
findings [11, 17, 33], although it is much higher than the 7 %
that was found among five thousand Norwegians with
ethnicity and living conditions similar to those of the present
sample [15]. This might indicate a higher tori frequency in
patients with snoring and sleep apnea.
One limitation of the present study is the lack of a control
sample without snoring or sleep apnea. In addition, our
sample consisted of patients treated for OSA and snoring
and they can therefore not be regarded as a representative
selection of the population. The majority of the entire sample
(88 %) had mild to moderate disease, with an RDI of <30. It
would therefore be of interest to further study the influence of
the presence and size of tori in a larger population sample
including more patients with severe disease.
Among the patients who had been re-evaluated with the
OA in place, there was a predominance of patients with mild
to moderate disease. This patient category is the main target
group for OA therapy. The results of the logistic regression
model that indicated that thick tori were an independent
predictor of complete treatment success with an OA were
therefore based on a realistic sample of patients. The
prospective testing of tori as a predictor for treatment success
with an OA is, however, needed before it can be considered in
clinical practice.
The present results were in contrast to our original
hypothesis that tori may interfere with the space in the oral
cavity and may be related to more severe OSA and a poorer
effect of an OA. The findings in this study could be explained
by previous results suggesting that mandibular tori develop
from muscle activity to improve the strength of the bone.
Increased upper airway dilator muscle activity has been
proposed as a protective mechanism for OSA.
It is concluded that tori size is associated with the
frequency of respiratory disturbances during sleep, with the
smallest tori size in patients with severe OSA. Treatment
success with an OA occurs more frequently in patients with
larger tori than in patients with no tori or small tori.
Acknowledgments The study was conducted at the Department of
Orthodontics, Umeå University, Sweden, in collaboration with the
Department of Respiratory Medicine, Umeå University. The study was
supported by grants from the Swedish Association for Heart and Lung
Patients and the Swedish Dental Society.
Conflict of interest None of the authors has any conflicts of interests.
References
1. Chan AS, Phillips CL, Cistulli PA (2010) Obstructive sleep apnoea—
an update. Intern Med J 40:102–106
2. Marklund M, Verbraecken J, Randerath W (2012) Non-CPAP
therapies in obstructive sleep apnoea: mandibular advancement
device therapy. Eur Respir J 39:1241–1247
3. Chan AS, Cistulli PA (2009) Oral appliance treatment of obstructive
sleep apnea: an update. Curr Opin Pulm Med 15:591–596
4. Cistulli PA, Gotsopoulos H, Marklund M, Lowe AA (2004)
Treatment of snoring and obstructive sleep apnea with mandibular
repositioning appliances. Sleep Med Rev 8:443–457
5. Ferguson KA, Cartwright R, Rogers R, Schmidt-Nowara W (2006)
Oral appliances for snoring and obstructive sleep apnea: a review.
Sleep 29:244–262
6. Hoekema A, Stegenga B, De Bont LG (2004) Efficacy and co-
morbidity of oral appliances in the treatment of obstructive sleep
apnea–hypopnea: a systematic review. Crit Rev Oral Biol Med 15:
137–155
7. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D,
Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-
Chiong T, Owens J, Pancer JP (2006) Practice parameters for the
treatment of snoring and obstructive sleep apnea with oral appliances:
an update for 2005. Sleep 29:240–243
8. Lim J, Lasserson TJ, Fleetham J, Wright J (2006) Oral appliances for
obstructive sleep apnoea. Cochrane Database Syst Rev CD004435
9. Marklund M, Stenlund H, Franklin KA (2004) Mandibular
advancement devices in 630 men and women with obstructive sleep
apnea and snoring: tolerability and predictors of treatment success.
Chest 125:1270–1278

10. Drennan MR (1937) The torus mandibularis in the Bushman. J Anat
72:66–70
11. Garcia-Garcia AS, Martinez-Gonzalez JM, Gomez-Font R, Soto-
Rivadeneira A, Oviedo-Roldan L (2010) Current status of the torus
palatinus and torus mandibularis. Med Oral Patol Oral Cir Bucal 15:
353–360
12. Pynn BR, Kurys-Kos NS, Walker DA, Mayhall JT (1995) Tori
mandibularis: a case report and review of the literature. J Can Dent
Assoc 61:1057–1058, 1063–1056
13. Seah YH (1995) Torus palatinus and torus mandibularis: a review of
the literature. Aust Dent J 40:318–321
14. Eggen S, Natvig B (1991) Variation in torus mandibularis prevalence
in Norway. A statistical analysis using logistic regression.
Community Dent Oral Epidemiol 19:32–35
15. Haugen LK (1992) Palatine and mandibular tori. A morphologic study
in the current Norwegian population. Acta Odontol Scand 50:65–77
16. Jainkittivong A, Apinhasmit W, Swasdison S (2007) Prevalence and
clinical characteristics of oral tori in 1,520 Chulalongkorn University
Dental School patients. Surg Radiol Anat 29:125–131
17. Sawair FA, Shayyab MH, Al-Rababah MA, Saku T (2009)
Prevalence and clinical characteristics of tori and jaw exostoses in a
teaching hospital in Jordan. Saudi Med J 30:1557–1562
18. Alvesalo L (2009) Human sex chromosomes in oral and craniofacial
growth. Arch Oral Biol 54(Suppl 1):S18–S24
19. Clifford T, Lamey PJ, Fartash L (1996) Mandibular tori, migraine and
temporomandibular disorders. Br Dent J 180:382–384
20. Eggen S (1992) Correlated characteristics of the jaws: association
between torus mandibularis and marginal alveolar bone height. Acta
Odontol Scand 50:1–6
21. Kerdpon D, Sirirungrojying S (1999) A clinical study of oral tori in
southern Thailand: prevalence and the relation to parafunctional
activity. Eur J Oral Sci 107:9–13
22. Sirirungrojying S, Kerdpon D (1999) Relationship between oral tori
and temporomandibular disorders. Int Dent J 49:101–104
23. Saffran AJ, Clark RF (2004) Torus mandibularis: an unusual cause of
obstructive sleep apnea. Ear Nose Throat J 83:324
Sleep Breath
24. SBU (2007) Obstructive sleep apnoea syndrome. Report of a joint
Nordic project. Statens beredning för medicinsk utvärdering (SBU),
Stockholm
25. Dahlberg G (1940) Statistical methods for medical and biological
students. Interscience Publications, New York
26. Maeda K, Tsuiki S, Isono S, Namba K, Kobayashi M, Inoue Y (2012)
Difference in dental arch size between obese and non-obese patients
with obstructive sleep apnoea. J Oral Rehabil 39:111–117
27. Mostafiz W, Dalci O, Sutherland K, Malhotra A, Srinivasan V,
Darendeliler MA, Cistulli PA (2011) Influence of oral and
craniofacial dimensions on mandibular advancement splint treatment
outcome in patients with obstructive sleep apnea. Chest 139:1331–
1339
28. Perri RA, Kairaitis K, Cistulli P, Wheatley JR, Amis TC (2013)
Surface cephalometric and anthropometric variables in OSA patients:
statistical models for the OSA phenotype. Sleep Breath. Published
online: April 2013. doi:10.1007/s11325-013-0845-0
29. Li J, Muehleman C (2007) Anatomic relationship of heel spur to
surrounding soft tissues: greater variability than previously reported.
Clin Anat 20:950–955
30. Fogel RB, Malhotra A, White DP (2004) Sleep. 2: pathophysiology
of obstructive sleep apnoea/hypopnoea syndrome. Thorax 59:159–
163
31. Johal A, Gill G, Ferman A, McLaughlin K (2007) The effect of
mandibular advancement appliances on awake upper airway and
masticatory muscle activity in patients with obstructive sleep apnoea.
Clin Physiol Funct Imaging 27:47–53
32. Kurtulmus H, Cotert S, Bilgen C, On AY, Boyacioglu H (2009) The
effect of a mandibular advancement splint on electromyographic
activity of the submental and masseter muscles in patients with
obstructive sleep apnea. Int J Prosthodont 22:586–593
33. Chohayeb AA, Volpe AR (2001) Occurrence of torus palatinus and
mandibularis among women of different ethnic groups. Am J Dent
14:278–280
34. Sutherland K, Cistulli P (2011) Mandibular advancement splints for
the treatment of sleep apnea syndrome. Swiss Med Wkly 141:13276