Dx: Torus Mandibularis

KEY FACTS

Terminology Synonyms: Mandibular torus/tori Definition: Exophytic proliferation of cortical and trabecular bone on lingual aspect of mandible in premolar areas Imaging Round or nodular, well-defined, can be multiple Intraoral plain film findings Bilateral radiopacities without radiolucent halo Occasionally unilateral CBCT findings Bilateral, exophytic, high-density areas lingual to mandibular premolars Top Differential Diagnoses Idiopathic osteosclerosis Sialolith in Wharton duct Buccal exostosis Osteoma Pathology Associated with exostoses and torus palatinus Hereditary with overlay of environmental influence: Occlusal stress, parafunctional habits Clinical Issues Male > female Rare before 1st decade, usually 4th decade May slowly increase in size Prognosis excellent; no malignant potential Tori are removed when consistently traumatized or interfere with function Diagnostic Checklist Consider Gardner syndrome if radiopacities not in expected location for tori
TERMINOLOGY

Synonyms Mandibular torus/tori Definitions Exophytic proliferation of cortical and trabecular bone located on lingual aspect of mandible, usually in premolar areas
IMAGING

General Features Best diagnostic clue: Bilateral well-defined radiopacities without radiolucent halo on intraoral films Location Lingual of mandible in premolar area; may extend posteriorly to molars or anteriorly to canine Above mylohyoid ridge

Occasionally unilateral Size Variable from very small (< 2 mm) to extremely large Size may be increased by long-term use of phenytoin, which functions as osteogenic agent Morphology: Round or nodular, well-defined, can be multiple Imaging Recommendations Best imaging tool: Periapical or occlusal views; CBCT imaging Radiographic Findings Intraoral plain film: Bilateral well-defined radiopacities at midroot of mandibular premolars CT Findings CBCT: Bilateral, exophytic, high-density areas lingual to mandibular premolars
DIFFERENTIAL DIAGNOSIS

Idiopathic Osteosclerosis (Enostosis) Plain film Dense sclerotic bone with irregular outline Occurs in locations other than mandibular premolar CBCT: High-density areas within confines of buccal and alveolar cortices Sialolith in Wharton Duct Plain film: Calcifications in Wharton duct may appear similar to tori CBCT: Calcifications lingual and separate from mandible Buccal Exostosis Plain film: Well-defined radiopacity on buccal alveolar bone more cervical than tori CBCT: Exophytic bony protuberances on buccal alveolar processes Osteoma Exophytic nodules more common on ramus and inferior border of mandible May be multiple; consider Gardner syndrome
PATHOLOGY

General Features Etiology: Hereditary with overlay of environmental influence: Occlusal stress, parafunctional habits, consumption of fish containing omega-3 fatty acids and vitamin D, which encourage bone growth Genetics: Autosomal dominant Associated abnormalities: Up to 36% associated with buccal or palatal exostoses; up to 50% associated with torus palatinus Microscopic Features Hyperplasia of mature cortical and trabecular bone
CLINICAL ISSUES

Presentation Most common signs/symptoms: Asymptomatic unless traumatized Other signs/symptoms: Large tori may cause difficulty eating and speaking Demographics Age: Rare before 1st decade, usually 4th decade

Gender: Male > female Epidemiology: Occurrence may be higher in certain ethnic groups: Mongols, Eskimos Natural History & Prognosis May slowly increase in size Prognosis excellent; no malignant potential Treatment Tori are removed when consistently traumatized or interfere with function or fabrication of prostheses
DIAGNOSTIC CHECKLIST

Consider Consider Gardner syndrome if radiopacities not in expected location for tori