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Torus Palatinus & Torus Mandibularis

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Lobulated torus palatinus has slowly enlarged to fill much of the palatal vault, leaving numerous undercut regions in which food may become impacted and produce infection.

* Dedicated to Thomas Bond Jr., MD, of Baltimore, Maryland -- Father of Oral Pathology
New Editor: J. E. Bouquot, D.D.S., M.S.D., Director of Research, The Maxillofacial Center


 

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Detailed Review

Palatal & Mandibular Torus, & Exostosis

Note: click on underlined words for more detail or photos.

While not technically soft tissue masses, the torus palatinus, torus mandibularis and bony exostosis (buccal exostosis) are all lesions which present as surface masses and are removed with minimal disturbance of deeper cancellous bones. As such, they are submitted to the pathologist as palatal or alveolar masses and might be confused with peripheral ossifying fibroma or other bone-producing soft tissue masses of the oral mucosa. For this reason, it is included in the present section.

The torus is considered to be a developmental anomaly, although it does not present until adult life and often will continue to grow slowly throughout life. It may be the outcome of mild, chronic periosteal ischemia secondary to mild nasal septum pressures (palatal torus) or the torquing action of the arch of the mandible (mandibular torus) or lateral pressures from the roots of the underlying teeth (buccal exostosis), but this is largely speculation. The most similar bony growth outside the jaws is the bunion of the lateral foot, and the earliest dental journal report of a torus palatinus was probably in an 1857 essay by Parmentier relating to tumors of the palate.  The prevalence rate for tori is 27/1,000 adults (Table 1).

Clinical Features: These entities are all very site-specific. The palatal torus is found only in the midline of the hard palate (Figures 1 & 2). The mandibular torus is found only on the lingual surface of the mandible, near the bicuspid teeth (Figures 3 & 4). The buccal exostosis is found only on the facial surface of the alveolar bone, usually the maxillary alveolus.7 Bony surface proliferations found in another site are typically given the generic diagnosis of bony exostosis or osteoma, i.e. are considered to be trauma-induced inflammatory periosteal reactions or true neoplasms. Unless such a bony prominence is specifically located, is pedunculated or is associated with an osteoma-producing syndrome such as the Gardner syndrome, there may be no means by which to differentiate an exostosis from an osteoma, even under the microscope.

As previously stated, these lesions are not present until the late teen and early adult years, and many, if not most, continue to slowly enlarge over time. Fewer than 3% occur in children. Taken as a group, these lesions are found in at least 3% of adults and are more common in females than in males. The torus may be bosselated or multilobulated but the exostosis is typically a single, broad-based, smooth-surfaced mass, perhaps with a central sharp, pointed projection of bone producing tenderness immediately beneath the surface mucosa. Lesions may become 3-4 cm. in greatest diameter, but are usually less than 1.5 cm. at biopsy. A definite hereditary basis, usually autosomal dominant, has been established for some cases of tori and Asians, especially Koreans, have a much higher prevalence rate than do other racial groups.

Pathology: On cut surface the torus and exostosis show dense bone with a lamellar or laminated pattern (Figure 5). They are usually comprised of dense, mature, lamellar bone with scattered osteocytes and small marrow spaces filled with fatty marrow or a loose fibrovascular stroma. Some lesions have a thin rim of cortical bone overlying inactive cancellous bone with considerable fatty or hematopoietic marrow present. Minimal osteoblastic activity is usually seen, but occasional lesions will show abundant periosteal activity. Large areas of bone may show enlarged lacunae with missing or pyknotic osteocytes (Figure 6), indicative of ischemic damage to the bone. Ischemic changes such as marrow fibrosis and dilated veins may also be found in the marrow, with rare examples showing actual infarction of fatty marrow.

Treatment & Prognosis: Neither the torus nor the bony exostosis requires treatment unless it becomes so large that it interferes with function, interferes with denture placement, or suffers from recurring traumatic surface ulceration (usually from sharp foods, such as potato chips or fish bones). When treatment is elected, the lesions may be chiseled off of the cortex or removed via bone bur cutting through the base of the lesion.

Slowly enlarging, recurrent lesions occasionally are seen, but there is no malignant transformation potential. The patient should be evaluated for Gardner syndrome should he or she have multiple bony growths or lesions not in the classic torus or buccal exostosis locations. Intestinal polyposis and cutaneous cysts or fibromas are other common features of this autosomal dominant syndrome.

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References (Chronologic Order)

Note: Click on underlined author's names for additional detail.

General references:

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Philadelphia, W. B. Saunders; 1995.

Elder D, Elenitsas R, Jaworsky C, Johnson B Jr. Lever's Histopathology of the skin, 8th edition. Philadelphia; Lippincott-Raven, 1997.

Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. Mosby; St. Louis, 1997.

Odell EW, Morgan PR. Biopsy pathology of the oral tissues. London; Chapman & hall Medical, 1998.

Specific references:

Parmentier. Essay on tumors in the palatine region. Am J Dent Sc 1857; 7 (new series): 324-339, 456-465, 545-561.

Miller SC, Roth H. torus palatinus: a statistical study. J Am Dent Assoc 1940; 27:1950-1957.

Johnson CC, Gorlin RJ, Anderson VE. Torus mandibularis; a genetic study. Am J Hum Genet 1965; 17:433-422.

Rezai RF, Jackson JT, Salamat K. Torus palatinus, an exostosis of unknown etiology: review of the literature. Compend Contin Educ Dent 1985; 6:149-152.

Indignities DZ, Bailees M, Papanayiotou P. Concurrence of torus palatinus with palatal and buccal exostoses: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85:552-557.

 

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Table 1: Gender-specific prevalence rates per 1,000 population for selected oral masses and surface alterations in U.S. adults, ranked by total frequency. Modified from Bouquot JE. Common oral lesions found during a mass screening examination. J Am Dent Assoc 1986; 112:50-57, and Bouquot JE, Gundlach KKH. Oral exophytic lesions in 23,616 white Americans over 35 years of age. Oral Surg Oral Med Oral Pathol 1986; 62:284-291.

Diagnosis

Number of lesions per 1,000 population*

Males

Females

Total

Leukoplakia

43.2

20.9

28.9

Torus palatinus 

13/2

21.7

18.7

Irritation fibroma

13.0

11.4

12.0

Fordyce granules

17.7

5.2

9.7

Torus mandibularis 9.6 7.9 8.5

Hemangioma

8.4

4.1

5.5

Erythema, inflammatory 4.5 4.8 4.7

Papilloma

5.3

4.2

4.6

Epulis fissuratum

3.5

4.4

4.1

Varicosities, lingual

3.5

3.4

3.5

Fissured tongue 3.5 3.1 3.2
Benign migratory glossitis 3.4 3.0 3.1
Aphthous ulcer 3.3 3.0 3.1

Papillary hyperplasia

1.7

3.8

3.0

Mucocele

1.9

2.6

2.5

Herpes labialis (herpes simplex) 2.4 2.6 2.5
Traumatic ulcer 2.1 2.1 2.1
Angular cheilitis 1.8 1.9 1.9
Smokeless tobacco keratosis 4.3 0.2 1.7
Hematoma or ecchymosis 2.0 1.4 1.6

Enlarged lingual tonsil

2.4

1.2

1.6

Chronic cheek bite 0.7 1.4 1.2

Lichen planus

1.2

1.1

1.1

Squamous cell carcinoma 2.5 0.1 0.9
Amalgam tattoo 0.6 1.0 0.9

Buccal exostosis

0.9

0.9

0.9

Leaf-shaped fibroma 0.4 1.2 0.9

Median rhomboid glossitis

0.8

0.5

0.6

Hairy tongue 1.2 0.3 0.6
Nicotine palatinus 1.2 0.2 0.6
Atrophic glossitis (smooth tongue) 0.6 0.5 0.6

Epidermoid cyst

0.7

0.4

0.5

Oral melanotic macule

0.5

0.3

0.4

Oral tonsils (except lingual)

0.5

0.3

0.4

Leukoedema 0.4 0.3 0.3

Lipoma

0.2

0.1

0.2

Ranula

0.2

0.1

0.2

Gingival hyperplasia 0.1 0.1 0.1

Buccinator node, hyperplastic

0.1

0.1

0.1

Pyogenic granuloma

0.0

0.07

0.04

Nasoalveolar cyst

0.0

0.07

0.04

Neurofibroma

0.0

0.07

0.04

* total examined population = 23,616 adults over 35 years of age 

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