Exostosis Mandibular 91x34

ISSN 2249-5436 DENTAL IMPACT

A CASE REPORT

MANDIBULAR EXOSTOSIS Dr. Shubha Ranjan Dutta1, Dr. Don Verghese2, Dr. Amar Bhuibhar3 Dr. Ronak Desai4 1,3,4,

Post Graduate Student, Department of Oral and Maxillofacial Surgery Vyas Dental College & Hospital, Jodhpur 2 Assistant Professor, Department of Oral and Maxillofacial Surgery Vyas Dental College & Hospital, Jodhpur

Corresponding Author: Dr. Shubha Ranjan Dutta, Email :[email protected] 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. Key words: Torus mandibularis, Mandibular torus, Tori

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 bone and are avascular in nature.1,4 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 Dental Impact Vol. 5, Issue 1, June 2013

causative factors, and the true cause may be multifactorial.1 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 growth.1,2,3,4 Despite the fact that these bony tubercles have been under study, the apparent 28

cause is not yet known.4 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 etiologic factors 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 factors.1,5 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 fourth, fifth, and sixth decades.6 Torus mandibularis (TM) is a known benign osseous protuberance. It is seldom seen in children under ten years of age.7

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.

Tori can be categorized by their appearance2 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. Indication for removal of mandibular tori2 1. Interfere with tongue positioning.

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Fig. 1: Bony growth below the tongue 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

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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.

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.

Fig. 2: Occlusal Radiograph After explaining all potential complications and obtaining written informed consent from the patient, local anesthetic 2% Lignocaine with 1:80,000 adrenaline was istered 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 complete excision. Edges were smoothened by bone file & hemostasis Dental Impact Vol. 5, Issue 1, June 2013

Fig. 3: Exposure of tori

Fig. 4: Complete excision performed

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ulceration (usually from sharp foods, such as potato chips or fish bones). ? Contributing to a periodontal condition.

Fig. 5: 3-0 Mersilk sutures placed

Fig. 6: Surgical stent fixed 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 that.2 ? It interferes with function or denture placement. ? Suffers from recurring traumatic surface

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Large mandibular tori can prevent complete seating of impression trays and denture. Abrams et al fabricated a new mandibular complete denture incorporating a combination of soft acrylic flanges and liners.3 Pynn reported that majority of these exostoses are asymptomatic, benign bony outgrowths remain undisturbed over the patient's lifetime. However, the tori occasionally need to be removed.8 We decided to completely excise rather than recontoring. Earlier the size of the growth was smaller then it gradually increased. Choi & Park reported that mandibular tori seem to change with aging.9 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 torus for its evaluation.10 Goracy ES, Rissol A recently introduced a reciprocating saw which makes this procedure feasible.11 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 defects.12,13 Ganz described a technique that mandibular tori as local donor sites for onlay graft augmentation.12,14,15 Sonnier & Horning presented on their study the need for exostosis removal and to the 31

potential use of the mandibular and palatal tori as sources of autogenous cortical bone.16,12 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.

Mandibular Tori Using Three Base Materials: A Case Report. J Can Dent Assoc 2000; 66:494-6.

4. Lee KH, Lee JH, Lee HJ. Concurrence of Torus Mandibularis with Multiple Buccal Exostoses. Archives of plastic surgery July 2013;Vol. 40 (4):466-468.

5. Basha S, Dutt SC. Buccal sided mandibular angle exostosis - A rare case report. Contemporary Clinical Dentistry July-Sep 2011;2(3):237-239.

CONCLUSION Torus mandibularis is asymptomatic and usually does not require any surgical treatment, but only reassurance. In some situation these tori may need to be surgically removed when they are causing interference in the fabrication of prosthesis or functions.

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10. Wada S, Furuta I. A new retractor for surgical removal of mandibular torus. Journal of Cranio-Maxillofacial Surgery 2005;33:135–136.

16. Sonnier KE, Horning GM, Cohen ME. Palatal tubercles, palatal tori, and mandibular tori: Prevalence and anatomical features in a U.S. population. J Periodontol. 1999 Mar;70(3):329-36.

11. Goracy ES, Rissol A. Use of a Reciprocating Saw for Removal of Mandibular Tori. J Oral Maxillofac Surg 1993;51:211.

12. Hassan KS, Alagl AS, Hady AA. Torus mandibularis bone chips combined with platelet rich plasma gel for treatment of intrabony osseous defects: clinical and radiographic evaluation. Int. J. Oral Maxillofac. Surg. 2012; 41: 1519–1526.

13. Eggen S, Natvig B. Concurrence of torus mandibularis and torus palatinus. Scand J Dent Res. 1994 Feb;102(1):603.

14. Ganz SD. Mandibular Tori as a Source for Onlay Bone Graft Augmentation: A Surgical Procedure. The Implant Report 1997;9(9):973-982.

15. Godinho M, Barbosa F, Andrade F. Torus Palatinus Osteonecrosis Related to Bisphosphonate: A Case Report. Case Rep Dermatol. 2013 Jan-Apr; 5(1): 120–125. Dental Impact Vol. 5, Issue 1, June 2013

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