Saturday, May 15, 2010

Torus palatinus excision

Introduction:

The word “tori” is derived from the latin word torus which means “to stand out” / “lump”.


Synonyms: Exostosis of oral cavity, Buccal exostosis.


Definition:


Torus palatinus is a sessile nodule of bone occuring commonly in midline of hard palate. It can also occur over the lingual surface of the maxilla (torus mandibularis). Torus mandibularis is a bony protruberance located on the lingual aspect of the mandible (commonly between the canine and premolar areas). These are bony masses, begining their development during early teens and gradually progresses to adult hood. These masses are slow growing and painless.


These masses are usually self limiting, rarely they may cause periodontal diseases. Periodontal disease is usually caused by the mass forcing food towards the teeth while being chewed instead of away from it. Too large torus may interfere with dentures.


Etiology:


1.Masticatory hyperfunction
2.Genetic factors (common in females)
3.Environmental factors
4.Multifactorial


Age of occurrence:


It is very rare during the first decade of life. Its increase in size occur during the second and third decades of life. According to Bruce etal the average age of presentation of tori is 34. Since there is very little literature available on this subject very little knowledge regarding age of occurrence is available.


Rate of growth:


The rate of growth of these bony masses is very slow and gradual. Studies have shown that maximum increase in size occurs during the second and third decades of life.

Role of imaging:


CT scan is virtually diagnostic.




Classification:

Oral exostosis was first classified by Haugen. He classified oral cavity exostosis according to their sizes as small, medium and large.

  1. Less than 2 mm in their largest diameter – small
  2. 2 – 4 mm in their largest diameter – medium
  3. More than 4 mm in their largest diameter

According to Haugen majority of oral cavity exostosis belonged to the small and medium categories.

Reichart in his modification of Haugen's classification suggested few changes:

Grade I – Tori up to 3 mm in their largest dimension

Grade II – Tori up to 6 mm in their largest dimension
Grade III – Tori above 6 mm belong to this group

Shapes:

Torus palatinus occur in varying shapes. It can be flat, nodular, lobular or spindle shaped. Small tori are invariable nodular and they are the most common variety encountered. Lobular shapes are pretty rare.

Indications for surgical removal:

  1. The mucosa over torus is ulcerated
  2. When it interferes with placement of dentures
  3. When there is associated periodontal disorder
  4. Where torus can be used as graft material
  5. Phonatory disturbances
  6. Sensitivity of the overlying mucosal layer
  7. Disturbances involving masticatory apparatus
  8. Esthetic reasons

Surgical removal:

Torus palatinus can be removed either under local / general anesthesia. If the surgery is tobe performed under local anesthesia the following nerves should be anesthetised using 2 % xylocaine mixed with 1 in 100,000 units adrenaline.

  1. Nasopalatine nerve should be anesthetised as it exits through the anterior palatine foramen
  2. Anterior palatine nerves should be anesthetised through posterior palatine foramen
  3. Anesthetic solution should also be infiltrated over the mass to detach the oral mucosa from the mass

To surgically remove torus mandibularis infiltration anesthesia is used over the mass. Nerve block anesthesia blocking inferior alveolar, mental and lingual nerves can also be used.

Incision:

To remove torus palatinus a double Y incision is preferred. This incision prevents damage to the nasopalatine and anterior palatine blocks of the hard palate. The incision should involve the full thickness of the muco periosteal lining.

Surgery to remove torus mandibularis involve incision over the mandibular ridge. If the incision is made above the torus it provides a good operating field. In rare cases scalloped inter dental incisons can be used.

Fissure burr is used to remove the bony torus. After removal of torus the flap could be found to be redundant and the same may also be trimmed. The flaps may be sutured back in place using absorbable suture material.

Surgical complications of torus palatinus:

  1. Perforation into the nasal cavity
  2. Secondary anesthesia due to damage to palatine nerve
  3. Palatine artery hemorrhage
  4. Laceration of palatine mucosa
  5. Fracture of palatine bone


Surgical complications of torus mandibularis:

  1. Mandibular fracture
  2. Devitalisation of teeth
  3. Injury to salivary ducts
  4. Injury to lingual nerve
  5. Flap laceration

Post op complications:

  1. Hematoma
  2. Wound infection
  3. Flap necrosis






 

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