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PREVALENCE OF TORUS MANDIBULARIS AMONG VARIOUS ETHNIC GROUPS

IN KARACHI CITY: A CROSS SECTIONAL STUDY

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 Prevalence of torus mandibularis

ORIGINAL ARTICLE

PREVALENCE OF TORUS MANDIBULARIS AMONG VARIOUS ETHNIC

GROUPS IN KARACHI CITY: A CROSS SECTIONAL STUDY
DAUD MIRZA, BDS, MSC (Oral Pathology)
1

2
NADEEM HAFEEZ KHOKHAR, DMD, MDSC (Dental Materials)
3
SHAH JAHAN KATPAR, BDS, MCPS, FCPS (Maxillofacial Surgeon)
4
YAWAR KHAN, BDS, (MSC) (Prosthodontics)
5
SAMAN HAKEEM, BDS, FCPS (Prosthodontics)
6
MOHAMMAD AYUB MUSANI, MBBS, DLO, FCPS (ENT Surgeon)
ABSTRACT

The aim of this study was to determine the prevalence of torus mandibularis in dental patients
with regard to ethnic population in Karachi city. This study was undertaken at a dentistry teaching
hospital of Karachi. Eight hundred subjects were clinically examined, presenting for their common
dental health issues with the diagnosis of torus mandibularis (TM). This study was conducted from
January 2011 to March 2012. The location, position and clinical presentation of torus mandibularis
were recorded, related to age and sex of various ethnic populations. Subjects participated in the study
were 365 (45.6%) males and 435 (54.3%) females. Its overall prevalence in the study subjects was 8.6%.
The mean age of patient was 41.79 and STD±16.61. Torus mandibularis was observed in both genders
with females having predominance. Urdu speaking population showed higher frequency of TM as
compared to other ethnic sample.
Keywords: Prevalence, torus mandibularis, mandible, exostosis, Pakistan

INTRODUCTION lateral in location.2 It is the most common intraoral

exostosis found composed of cancellous bone covered
Torus mandibularis (TM) is a known benign os-
by compact bone which may be laminated. Generally
seous protuberance, which is most commonly located speaking, TM begins to grow slowly and gradually. It
on lingual surface of the mandible above mylohyoid
tends to develop in early adult life and enlarges with
line. It is usually found in the mandibular cuspid-
the passage of time.3 It is seldom seen in children
premolar region.1 TM arises in oral cavity and its under ten years of age.4
clinical presentation may appear as unilateral or bi-
Castro Reino and colleagues found that the TM is
Correspondence: Dr Daud Mirza, 1Assistant Professor & HOD formed as a result of over activity of the osteoblast
of Oral Pathology, Bahria University Medical and Dental College,
Karachi, Pakistan. Mailing Address: B-304, Block N, North cells, leading to deposition of bone on the hemimandi-
Nazimabad, Karachi. E mail: dr.daud_mirza@hotmail.com bular bodies. Histopathology of TM is similar to that of
Cell Number: +92322 3934985
2
Associate Professor & HOD Dental Materials, Hamdard College
normal compact structure of bone and is composed of
of Medicine & Dentistry, Karachi, Pakistan. slightly spongy structure with marrow spaces.5 TM is
3
Consultant Maxillofacial Surgeon, Bahria University Medical usually an intraoral bony mass, which is easily diag-
and Dental College, Karachi.
4
Lecturer, Prosthodontics, Hamdard College of Medicine & Den- nosed clinically on naked eye examination and are
tistry, Karachi. discovered incidentally during oral clinical examina-
5
Assistant Professor & HOD Prosthodontics, Bahria University
Medical and Dental College, Karachi, Pakistan.
tion. This is a painless bony growth ranging from few
6
Associate Professor, Department of ENT, Karachi Medical & millimeters to several centimeters in size, which usu-
Dental College Karachi. ally presents as well-rounded, smooth surfaced, hard,
Received for Publication: May 14, 2013
bony projections, covered with normal or blanched
Revision Received: May 25, 2013
Revision Accepted: June 2, 2013 mucosa.6

Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 277
 Prevalence of torus mandibularis

The etiopathogenesis of sublingual torus mandibu-
laris is not well understood. Several investigators
believed that it is interplay of genetic and envoirmental
factors particularly the nutritional factors in the patho-
genesis of TM.7,8 Literatures supported that TM is
strongly associated with parafunctional habits such
as, clenching of teeth.9 We feel that insignificant re-
search has been done in our country on this particular
topic. Therefore, the aim of this study is to determine
the frequency and location of torus mandibularis among
various Pakistani ethnic samples. The study further
investigates the relationship between age and sex in
the sample population.
patients was 41.79 and STD±16.61. The median was
41.00. Result of the present study showed that TM was
higher in females (Table 1). The age range of both
gender were 10-80 years. Majority of TM were noted in
21-30 and 41-50 years age group and least were re-
ported in 10-20 and 61-80 years of age group. Consis-
tent presence of TM was seen between 41-60 age
groups. The presence of TM was also investigated
among various Pakistani ethnic study populations.
Out of 69 subjects showing TM, Urdu speaking com-
munity showed highest expression 51(73.9%) and it
was lowest observed in Balochis that was 1 (1.4%)
(Table 2).

METHODOLOGY The distribution of torus mandibularis in relation

to placement was also analyzed and it is shown in
A cross sectional study using subjects attending
Figure 1. In this study predominantly bilaterally sym-
Hamdard University Dental Hospital (HUDH), Ham-
dard University Karachi. Subjects were randomly metrical pattern was observed in middle premolar
region 49 (71.0%). 15 cases (21.7%) were reported in
screened for dental examination. Total eight hundred
anterior part and 5 cases (7.2%) in posterior part. In
and twenty four (824) patients participated in the
study which was conducted from January 2011 to the current study it was also observed on unilateral
right and unilateral left side with the ratio of 18 (2.2%)
March 2012. Twenty four patients were excluded from
and 15 (1.9%) respectively.
the study because they refused to give consent. Study
criteria and proforma was designed on the basis of TABLE 1: DISTRIBUTION OF TM ACCORDING
previous research done on torus mandibularis. In- TO GENDER AND AGE
formed consent was taken prior to the patient’s exami-
Age Gender Presence and Absence of
nation and data were collected on specially designed Groups TM
recording form. This composed of name, age, sex, and
Yes (%) No Total
section of visual and digital examination that showed
10-20 Male 2 (8.0%) 23 25
presence or absence of TM, location (right, left or pre-
Female 2 (6.7%) 28 30
sent on both sides).
21-30 Male 8 (11.3%) 63 71
The entry criteria were patients from both sexes of Female 10 (8.8%) 103 113
all ages. The patient’s age groups were classified into 31-40 Male 6 (9.5%) 57 63
seven groups ranging from 10-80 years. The existence Female 2 (2.2%) 91 93
of torus was systematically and routinely ruled out by
41-50 Male 6 (8.8%) 62 68
visual inspection and palpation. Examination was Female 11 (12.4%) 78 89
done on a dental chair in hospital setting using steril-
51-60 Male 4 (6.3%) 59 63
ized dental examination instrument and performing
Female 9 (12.3%) 64 73
aseptic measures. Data from the case records were
coded for entry into a database using the Statistical 61-70 Male 3 (6.3%) 45 48
Female 2 (8.7%) 21 23
Package for Social Sciences (SPSS) version 15.
71-80 Male 3 (11.5%) 23 26
RESULTS Female 1 (6.6%) 14 15
Total 69 (8.6%) 731 800
Out of the total subjects 365 (45.6%) were males
and 435 (54.3%) females. Of 800 subjects studied, 69 Key:
(8.6%) had torus mandibularis. The TM was observed TM: Torus mandibularis
in 32 male and 37 female patients. The mean age of n= Total number of study population (800)

Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 278
 Prevalence of torus mandibularis

TABLE 2: DISTRIBUTION OF TM ACCORDING region, Croatia and Romanos study in New York show-
TO ETHNIC ORIGIN ing higher frequency of TM in males.12,13,14 However
Ethnic Presence and Absence Firas Al Quran states that there is no gender differ-
Groups of TM ence.15
Presence Absence
In the current study, torus mandibularis was also
of TM of TM
investigated among various Pakistani ethnic study
Urdu Speaking 51(73.9%) 584
populations. Finding of this study revealed its higher
Sindhi 3 (4.3%) 39
expression in Urdu speaking and least in Balochi
Punjabi 7 (10.1%) 52 subjects. This finding should not be considered as final
Balochi 1 (1.4%) 15 because the sample size was small and it is done in
Pathan 5(7.2%) 23 Urdu speaking dominated population. Therefore, it
Others 2 (2.8%) 18 does not show a true representation of all ethnic races
Total 69 (8.6%) 731 in Pakistan. Chohayeb and Volpe demonstrated the
Key: presence of torus mandibularis in various ethnic study
TM: Torus mandibularis populations in Washington DC (USA) and their analy-
n= Total number of TM present study population (69) sis revealed slightly elevated level in Hispanics then
African Americans and least percentages in Cauca-
sians.16 This variation of findings could be due to
variation in geographical location and genetics. In
present study TM fluctuation is seen among different
age groups, with majority seen in 21-30 and 41-50
years age groups and least recorded in 10-20, 61-80
years of age group. However, previous studies re-
ported high prevalence of TM in 30-59 years of age
group.12 Sawair reported increased prevalence in fifth
decade of life which was associated with parafunctional
habits.17 This was also supported by the theory which
suggests that long term involuntary clenching or grind-
ing of teeth will produce greater load on premolar-
molar region resulting in development of bony exosto-
Fig. 1: Bilateral presence of torus mandibularis
sis due to strengthening of the occlusal forces.18 The
(arrow) in 22 year old Pakistani male
growth of intraoral exostosis may fluctuate through-
DISCUSSION out life, but some investigators believe that the devel-
opment of tori is a slow growing process which becomes
Related to torus mandibularis no reference work evident in 2-3 decade of life.19,20
has been published locally so international literature
has been used to support this study. This study is a The distribution of TM according to location was
small contribution on this topic. The findings of the also investigated. It was observed that majority of TM
present study interpret multiple aspects of torus was found in bilateral symmetrical pattern and these
mandibularis and its association with age, gender, findings are supported by Hiremath study in Malay
location and ethnical grounds. In this study, result population21 and study reported in Black South Afri-
showed its increased prevalence in females. Present can population.22 The most common location of TM was
study finding is similar to previous studies suggested premolars (middle region). TM was more on both sides
by Dosumo’s on Nigerian and Sebaie on Jordanian of lingual surface of premolar region mandible 36
subjects.10,11 On the contrary studies that disagree (4.5%). Unilateral right side of TM was more com-
with the findings of the present study include research monly seen than unilateral left side. These findings
conducted in Thai population, at central Dalmatian are in accordance with most of the studies.12

Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 279

The exact etiology of TM is unclear, but the role of
genetics cannot be totally ignored in its development.3,12
In the present study no association of torus mandibu-
laris with any systemic disease or dental anomalies
was found. However, investigators have reported as-
sociation of mandibular tori with chronic use of pheny-
toin drug treatment in Japanese samples.20 Firas from
Jordan has cited that large size of TM may cause
obstructive sleep apnea and hindrance in the denture
wearing patients.15 Durrani and Barwise reported
difficult endotracheal intubation in a patient associ-
ated with TM.23 However, the presence of tori is advan-
tageous in harvesting bone in periodontal surgical
procedures.15 Rocca and colleagues has introduced a
new technical approach for the removal of tori. They
used Er:YAG laser for the easy removal of tori and to
avoid damage to the surrounding tissues. This tech-
nique also enhances the healing process.24
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 interfer-
ence in the fabrication of prosthesis or functions.
Furthermore, larger sample size of TM may require for
true reflection of TM in Pakistani. Current study did
not show any association of Torus mandibularis with
any syndrome or systemic diseases.
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