TORUS PALATINO Y MANDIBULAR

Introduction:

Since the last century different authors, such as Fox (1809) and Danniels (1884),
tried to define the Torus from a clinical and histopathological point of view, while for
the 1950s, Woo (1950) does so according to its location. According to Shafer and
Levi in 1983 and Stafne in 1987, torus are defined as protuberances or exostoses
that are located in the buccal region, while Antoniades et al. and Sapp et al. in
1998 agree that torus are non-neoplastic excrescences, which can be located in
the jaws of the same bone.

Although its etiology is unknown, several multifactorial, but not exclusive, theories
have been formulated that explain genetic nature.

Garguilo and Arrocha in 1967 and Czuszah et al., 1996, describe that after
performing free gingival grafts, torus or exostosis formation could be observed in
areas where such grafts were performed. Hegtvedt in 1990, proposes three
theories that explain the existence of these bony bumps after performing gum-free
grafts.

Torus and exostoses usually appear in women of the third decade of life, age, in a
female ratio: 2:1 male.In children they are extremely rare.

Classification:

The torus has been classified according to their size, location and number. Small
torus, they reach sizes no larger than 3mm, while medium torus range from 3 to
5mm. Large ones, on the other hand, will be characterized by reaching sizes larger
than 5 mm.

The location of these bone excrescences can be palatal, mandibular and multiple
zones in the form of exostosis. The palatal torus palatinos are slow-growing bony
bumps, whose base is flat and can be seen in the midline of the hard palate, rising
in the margins of the palatal apophysis at the midline of the palate, involving both
sides of the palate suture.

According to their form, they have been classified into four large groups. The
planes are presented as a smooth symmetrical convexity and broad base; the
fusiforms are more pronounced and sometimes with a groove in the midline.
Nodulars have several bumps with individual base and lobes have a broad,
common base for the different lobes.

According to the number, they can be single, multiple (Stafne, 1987) unilateral and
bilateral.

Clinical Characteristics:

Palatine torus: they are presented as an outward growth located in the midline of
the palate and can take various forms such as flat, spindle-shaped, nodular or
lobular. Its mucous membrane is intact, although sometimes it can be seen pale. If
this mucous membrane is traumatized, it becomes ulcerated easily and takes time
to heal . The size of the bump can vary, ranging from those that are only detected
through palpation to those that occupy the entire palate interfering with phonation.
Their location may vary although they are often observed in the central part of the
midline, they may also be confined to the anterior or posterior region of the palate
and in some cases the entire midline may be taken from the anterior palatal fossa
to the end of the hard palate .Its growth is slow until the third decade of life and
then stabilizes.
The mandibular torus is a growth observed on the lingual surface of the jaw which
is present above the milohioid line opposite to the premolars, rising from the
internal oblique line. Sometimes they extend to the distal third molar and mesial
side of the lateral incisor. They come in various shapes and sizes, being able to
observe the mucous membrane that covers them pale pink or whitish. Such bumps
may be single or multiple.

Multiple exostoses: form nodular bumps that occur more frequently on the buccal lamina
over premolars. They can be observed in nodular, rounded or oval shapes. Its size ranges
from very small to very large that interfere with the aesthetics of the patient. The mucous
membrane that covers it is often seen pale.
Histopathological Characteristics:

Histopathologically they are described as an exophysical nodular exophysical

excrescence of the dense cortical bone and a spongy bone center in which
calcified areas can be observed forming thin bands separated by occupied bone
marrow spaces.

According to Seah 1995; in a cross section of a large palatal torus, several layers
can be observed. These layers are compact, spongy and buccal nasal, while in
small torus these same layers tend to be fused. The spongy tissue layer in the
palatal torus develops at the expense of the mid-palatal suture, and in the
mandibular torus this layer can only be seen when they are large.

Radiographic characteristics:

Radiographically, those exostoses that are composed of compact bone can be

observed as a uniform radiopacity while those that contain a large spinal space can
be easily observed bone trabeculae.

The palatal torus palatinos can be demonstrated in an occlusal x-ray, which shows
oval-shaped opacity in the midline. And the body of these torus appears as
radiopaque masses with abundant details of obliterations in the teeth and maxillary
sinuses.

The mandibular torus, unlike the palatal torus, can be seen on both periapical and
occlusal x-rays. They occur as well circumscribed areas of high radiopacity in the
roots of teeth.

Diagnosis:

In order to make a truthful and accurate diagnosis, we must use the clinical
examination, performing palpation and evaluation of the mucous membrane, vitality
tests on the teeth involved, aspiration of the lesion, radiographic examinations and
histopathological studies.

Differential Diagnostics:

On many occasions the torus may have been confused with abscess formations,
neoplasms of bone, vascular and salivary gland origin.
Treatment:

Exostoses and torus have no pathological significance and are rarely clinically
significant. The treatment of choice is exeresis as long as the lesion is within the
following indications:

Prosthetic Requirements: all those exostoses and torus with sufficient volume
interfering with the insertion of a prosthetic appliance, such as palatal torus when
extended backwards, can adversely affect the posterior palatal seal of the total or
partial denture and when the stability of the prosthesis is compromised. In the case
of mandibular torus mandibularis, the mucous membrane covering the mandibular
torus is usually thin and susceptible to chronic irritation of the base or major
connector of the prosthesis, which represents an obstacle to sealing the edges of
the denture.

Relationship with phonation: when exostoses are so large that they interfere with
the patient's normal speech.

Relationship with mucosal trauma: if its size reaches a large size, it can cause
inflammation, ulceration and constant traumatism of the lining of the torus
membrane.

When patient hygiene is compromised: when the torus reaches lobular forms,
especially the mandibular torus, they can produce areas of food accumulation and
produce halitosis in the patient.

When the patient's aesthetics are compromised.

When associated with infectious processes such as osteomyelitis and neoplastic

processes such as Carcinomas.

Complications for removal of the torus:

Complications in surgical removal of the torus have rarely been reported. These
can usually occur when mucoperiosteum is lifted. Wharton or submaxillary duct
sectionations, floor lacerations of the mouth and other anatomical structures that
may require surgical repair may also occur. Damage to the lower dental nerve and
lingual nerve should be avoided as lacerations of the lower dental nerve can lead
to paresthesia in the patient. When performing the removal of a torus palatino, the
palatal artery must be kept intact and not provoke oral-sinusal communication with
the maxillary sinus. Post-surgical infections when removing a torus are also a
complication in these patients if care is not taken

Conclusions:

Torus or exostoses are non-neoplastic bone excretions which have an unknown

etiology, which can be diagnosed through clinical, radiographic and
histopathological examination. Although these bone excrescences have no
pathological significance as such, various indications for their treatment have been
proposed in order to satisfy all the patient's needs. It is of great importance to be
familiar with these bone structures as they tend to be confused many times with
benign and malignant neoplastic lesions and it is in our field to know them from
every point of view in order to plan the treatment plan of our patients.