Dx: Buccal and Palatal Exostoses

KEY FACTS

Terminology Synonyms: Hyperostoses; tori maxillaris; buccal lipping Definition: Hyperplastic protuberances of normal cortical and cancellous bone Imaging Varies from small cervical marginal prominences to larger exophytic nodules More common in maxilla: ~ 10% occur palatally in 1st molar to tuberosity area Intraoral plain film findings Well-defined radiopacity without radiolucent periphery CBCT findings Exophytic high-density lesions Maxillary & mandibular buccal alveolar processes in molar & premolar areas Top Differential Diagnoses Idiopathic osteosclerosis (plain film imaging) Torus mandibularis or torus palatinus
Osteoma

Pathology Genetic with overlay of environmental factors: Occlusal stress, parafunctional habits
Torus mandibularis & torus palatinus associated

Clinical Issues Prevalence increases with age Excellent prognosis; no malignant potential Removed if traumatized or interfere with function Diagnostic Checklist Consider Gardner syndrome if not in expected location for exostoses
TERMINOLOGY

Synonyms
Hyperostoses; palatal exostoses (a.k.a. tori maxillaris); buccal lipping

Definitions Hyperplastic protuberances of normal cortical and cancellous bone

IMAGING

General Features Best diagnostic clue: Well-defined radiopacity without radiolucent periphery on intraoral images Location Maxillary and mandibular buccal alveolar processes in molar and premolar areas More common in maxilla: ~ 10% occur palatally in 1st molar to tuberosity area Prominences at buccal cervical margin (buccal lipping) more common in anterior mandible Size: Varies from small cervical marginal prominences to larger exophytic nodules

Morphology: Round, nodular, flat, or pedunculated Imaging Recommendations Best imaging tool Occlusal views will demonstrate exophytic nature CBCT imaging Radiographic Findings Intraoral plain film: Well-defined smooth radiopacity without radiolucent periphery in alveolar processes CT Findings CBCT: Exophytic areas of normal-appearing bone located close to alveolar crest
DIFFERENTIAL DIAGNOSIS

Idiopathic Osteosclerosis

Plain film: May look similar Periphery more irregular Occurs in locations other than alveolar processes CBCT: High-density areas within confines of buccal and alveolar cortices
Torus Mandibularis

CBCT: Bony protuberances off lingual mandible in premolar area

Torus Palatinus

CBCT: Bony excrescence comes off central hard palate

Osteoma

Exophytic, often pedunculated, bony protuberance More common in ramus and inferior border of mandible Multiple osteomas may signify Gardner syndrome
PATHOLOGY

General Features Etiology: Genetic with overlay of environmental factors: Occlusal stress, parafunctional habits, free gingival graft procedures Genetics: Possibly autosomal dominant or X-linked Associated abnormalities
Associated with torus mandibularis (TM) and torus palatinus (TP)

Greatest occurrence (42%) in subjects with both TM and TP Possible association with dermatofibromas Microscopic Features Dense bone with lacunae and normal osteocytes
CLINICAL ISSUES

Presentation Most common signs/symptoms: Asymptomatic unless traumatized Other signs/symptoms: Attrition of teeth may be evident, supporting theory that occlusal stress stimulates formation of exostoses Demographics Age Prevalence increases with age

Highest occurrence in patients 55 years or older Gender: Male > female Epidemiology: > in ethnic groups: Mongoloids, African-Americans Natural History & Prognosis Excellent prognosis; no malignant potential Treatment No treatment required unless traumatized or interfere with function or fabrication of prostheses
DIAGNOSTIC CHECKLIST

Consider
Gardner syndrome if not in expected location for exostoses