Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission.

— https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

Torus Lesions of the Jaw: Diagnosis and Clinical Implications

Gary Ghahremani1 , David Naimi2 , and Zohreh Ghahremani3
1
University of California San Diego
2
US Naval Hospital Camp Pendleton
3
Northwestern University

September 10, 2020

Abstract
Summary Background: Torus is a protuberant and lobulated exostosis that develops on the lingual aspect of the jaws or hard
palate in 10-30% of adults. They can interfere with mastication, speech, oral hygiene, and denture placement. Their enlarge-
ment with advancing age may also lead to superficial ulceration, inflammation, osteonecrosis and various other complications.
Methods: A retrospective analysis of the authors’ experience with 17 adults who had large symptomatic tori was performed.
The patients were examined by intraoral imaging and radiographic or computed tomography of their maxillofacial bones. Their
dental and medical records were reviewed along with the pertinent literature concerning the prevalence and reported compli-
cations of this entity. Results: This series included 6 men and 11 women, ranging in age from 36 to 85 years (Mean age: 56.5
years).There were 6 patients with torus mandibularis, 8 with torus palatinus, and 3 with torus maxillaris. Four of our 17 patients
required surgical excision of their tori because of large size, recurrent superficial erosions and associated symptoms. Conclusion:
The majority of tori are asymptomatic and incidental finding, but the more prominent tori are prone to mucosal inflammation
and ulceration that may require surgical removal of the lesion. Large tori can also interfere with mastication, speech, dental
hygiene, placement and function of prosthetic dentures, and may cause snoring, sleep apnea or other complications. Therefore,
the practicing physicians should be familiar with the appearance, radiological features, clinical implications and management
of tori.

Torus Lesions of the Jaw: Diagnosis and Clinical Implications

1
Gary G. Ghahremani David R. Naimi2 Zohreh K. Ghahremani 3

1
Department of Radiology, University of California-San Diego Medical Center, San Diego, CA, USA
2
Department of Internal Medicine, Naval Hospital Camp Pendleton, Oceanside, CA, USA
3
Dental Office of Dr. Z. Ghahremani, La Jolla, CA, USA
Correspondence
Gary G. Ghahremani, Department of Radiology, University of California-San Diego Medical Center, 200 W.
Arbor Drive, San Diego, CA 92103, USA;
E-mail: [email protected]
Running title: Torus Lesions of the Jaw
Torus Lesions of the Jaw: Diagnosis and Clinical Implications
Summary
Background: Torus is a protuberant and lobulated exostosis that develops on the lingual aspect of the jaws
or hard palate in 10-30% of adults. They can interfere with mastication, speech, oral hygiene, and denture

1
 placement. Their enlargement with advancing age may also lead to superficial ulceration, inflammation,
osteonecrosis and various other complications.
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

Methods: A retrospective analysis of the authors’ experience with 17 adults who had large symptomatic tori
was performed. The patients were examined by intraoral imaging and radiographic or computed tomography
of their maxillofacial bones. Their dental and medical records were reviewed along with the pertinent
literature concerning the prevalence and reported complications of this entity.
Results: This series included 6 men and 11 women, ranging in age from 36 to 85 years (Mean age: 56.5
years).There were 6 patients with torus mandibularis, 8 with torus palatinus, and 3 with torus maxillaris.
Four of our 17 patients required surgical excision of their tori because of large size, recurrent superficial
erosions and associated symptoms.
Conclusion: The majority of tori are asymptomatic and incidental finding, but the more prominent tori
are prone to mucosal inflammation and ulceration that may require surgical removal of the lesion. Large tori
can also interfere with mastication, speech, dental hygiene, placement and function of prosthetic dentures,
and may cause snoring, sleep apnea or other complications. Therefore, the practicing physicians should be
familiar with the appearance, radiological features, clinical implications and management of tori.
What’s known
Torus is an exostosis protruding from the lingual aspect of the jaws or hard palate. It develops in 10-30% of
patients usually during their puberty and grows with advancing age.
What’s new
Torus interferes with mastication, speech, dental hygiene, Placement of dentures, and may also lead to
snoring and sleep apnea. An enlarged torus is prone to mucosal inflammation, ulceration, osteonecrosis and
various other complications.
1 INTRODUCTION
Torus is a common benign exostosis of the jaw bones that develops in about 10-30% of the world population.1-5
This pathologic condition is usually manifested around the age of puberty and continues to grow during
adulthood. These lesions appear as lobulated protuberances on the lingual side of the jaws or hard palate.
Most of them are asymptomatic and first noticed by the patients or detected incidentally by the dentists.
However, large tori are often subject to traumatic mucosal inflammation and ulceration, as well as a wide
spectrum of other complications that are described in this article. There are also instances when the patients
seek advice from their primary care physician because of concern that an enlarging or ulcerated torus may
represent an oral malignancy. Such cases can pose as a diagnostic challenge to the practicing clinicians who
may not be well-informed about the appearance and potential implications of this abnormality.
2 METHODS
2.1 Study population
This retrospective study was based on a series of 17 adult patients with longstanding history of large symp-
tomatic torus of their mandible, maxilla, or hard palate. Other cases of tori that were small or did not cause
any subjective or objective symptoms were excluded. The reviewed 17 patients had been evaluated initially
at the private dental office or university clinic, where their demographic data and symptoms were recorded
and intraoral photographs of the torus lesions were obtained. They were then referred to our medical center
for radiological examination. All had subsequent oral surgery consultation for possible removal of their tori.
2.2 Imaging techniques
Computed tomography of the maxillofacial region had been performed on 14 patients, and 5mm cross-
sections of their jaws and hard palate were obtained. Plain radiographs of the same affected bones were
done in frontal and lateral projections in 11 patients. Eight patients had both examinations, whereas 6 had

2
 only computed tomography and 3 had only radiographs. The images were then correlated with the intraoral
color photographs of the tori. Five illustrative cases were selected for presentation in this report.
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

2.3 Search strategy

An electronic search of medical and dental literature was conducted through PubMed bibliographic database
for publications concerning the etiology, prevalence, complications, and management of tori. A total of 18
articles with relevant information that had been published during 1981-2019 period were selected for the
cited references.
3 RESULTS
3.1 Demographic data and presenting symptoms
This series consisted of 6 men and 11 women, ranging in age from 36 to 85 years (Mean age: 56.5 years). All 17
patients were initially seen because of dental problems, but most of them also complained about longstanding
symptoms that were directly related to the existing tori. These included ill-fitting dentures, interference
with proper mastication and oral hygiene, impaired speech, and recurrent ulceration and inflammation of
the gingival mucosa over the prominent tori. The majority of our patients had first noticed the development
of tori in their third decade of life, with gradual enlargement throughout their adulthood.
3.2 Anatomic location of the lesions
A. Torus mandibularis
The 6 patients with torus mandibularis (TM ) were 3 men and 3 women. On visual inspection their
TM appeared as multi-lobulated masses on the inner aspect of bicuspid and premolar regions, with almost
symmetrical extent on both sides. They measured 3-4 cm long, up to 1.5 cm thick, and covered by intact
gingival mucosa. CT demonstrated the TM as lobulated exophytic masses of dense cortical hyperostosis,
located bilaterally above the mylohyoid line (Figures 1 and 2).
B. Torus palatinus
Torus palatinus (TP) was present in 8 of our 17 patients and 6 of them were women. They had developed
fungating masses of variable size and configuration that protruded into the oral cavity from the center of
hard palate. The core of TP was a dense and lobulated exostosis as seen on radiographs and CT images
(Figures 3 and 4). The mucosal coverage of TP was inflamed and ulcerated in 2 patients, but others had
also experienced the same problem following repeated traumatic erosion by hard food items.
C. Torus maxillaris
Torus maxillaris (TMAX ) had developed in 3 patients, one man and 2 women. These tori appeared
bilaterally as prominent and lobulated masses arising from the medial aspects of the upper jaw. In contrast
to TM, these were located more posteriorly along the molar regions. These tori were very firm on palpation
and consisted of marked cortical hyperostosis on CT sections. One patient also had a coexisting TP as
illustrated by CT and intraoral images (Figure 5).
3.3 Surgical intervention and follow- up
Four of our 17 patients required surgical resection of their tori because of their large size, recurrent super-
ficial erosions and associated problems such as ill-fitting denture and periodontal disease caused by torus
interference with oral hygiene. The excised lesions included 2 TP and 2 TM. The postoperative recovery of
these patients was uneventful, with complete resolution of their prior symptoms. The other 13 patients had
conservative management. Their follow up dental evaluation over a period of 5 to 8 years revealed stable
appearance and size of the tori despite their often recurrent subjective symptoms related to the persistent
torus abnormality.
4 DISCUSSION

3
 4.1 Etiological consideration
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

Torus is a common benign exostosis that represents a developmental lesion appearing in puberty or early
adulthood and becoming larger with advancing age. It has a hereditary etiology in about a third of cases.
Curran et.al 6 found TM and TP in 3 generations of women in one family. In the study by Eggen7 ,
the genetic origin of TM was documented in 29.5% of patients. The remaining 70% were attributed to
either environmental factors or mechanical issues caused by occlusal stress.4,5 There is a predilection for
the development of TM and TMAX adjacent to the teeth receiving local stress because of excessive teeth
grinding and jaw clenching, known bruxism. 4, 5, 8
4.2 Prevalence and manifestation age
The most common age range of patients is 10-30 years at the initial onset of torus development, but its
growth may continue until the seventh decade of life.9, 10 There is a considerable variation in the prevalence
of tori among populations of different ethnicity and gender. One study of 448 female residents of Washington,
D.C., found that tori were present in 35% of African Americans, 32% of Caucasians, 30% of Hispanics, 38%
of Asians, and 20% of Native Americans.2
Another investigation involving patients from Southern States of the United States revealed that 25% of
Caucasian men and 24% of women had TM, whereas TMAX was present in 22% of men and 40% of women,
respectively. In comparison, African Americans had TM in 18% of men and 13% of women, and they had
TMX in 14% of men and 45% of women.1
A high incidence of tori has been reported among the Asian population. Morita and associates found TM in
58% of healthy students at Hiroshima University in Japan.11 Another study involving 1,520 dental patients
in Thailand showed prevalence rates of 60.5% for TP, 32.2% for TM, and concurrent tori in 23.2% of the
cases.12 Most of the published large series show a female predominance for TP and a slight male predilection
for TM.10, 13
4.3 Clinical presentations and management
The majority of tori are asymptomatic and incidental finding during oral or dental examination. As they
enlarge and become more prominent, however, they may cause a wide spectrum of problems. These include
difficulty with placement and function of dentures, interference with mastication and speech, compression
and displacement of the tongue causing snoring or sleep apnea.14 Furthermore, the tori can promote plaque
formation and periodontal disease because of food retention hindering proper dental hygiene.3, 8
Patients with large tori often experience recurrent mucosal ulceration and inflammation resulting from
trauma by hard food items (Figure 5). Prominent tori may also interfere with endotracheal intubation
during general anesthesia.15 There have been several reports concerning painful ulceration and osteonecrosis
of torus in patients receiving biphosphonate for treatment of osteoporosis.16 In some instances, the larger
symptomatic tori may necessitate surgical removal.3,17 This procedure was performed in 4 of our patients
(Figures 2 and 4). The cited indications for the torus resection include interference with phonation or masti-
cation, traumatic inflammation and ulceration, prosthetic instability, and in patients with cancerophobia.10
It may be of interest to note that a potential use of an excised torus has been its application as an autogenous
bone graft in periodontal surgery and implants elsewhere.10, 18
5 LIMITATIONS
The majority of published reports and herein cited references deal with the prevalence of tori among large
populations of different ethnical and racial groups.1,2,5,8,11,12 Our study was limited to the clinical and
radiological presentation of these lesions in a series of 17 patients that included 15 Caucasian and 2 African-
American patients. The fact that 11 of 17 patients (65%) were women is slightly higher as compared to the
reported prevalence of tori among women in the western world.1-4 Furthermore, our series of cases was small
to assess the true etiology or incidence of tori in our patient population. Nevertheless, this observational
study and clinical review will provide updated information about this entity.

4
 6 CONCLUSIONS
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

Torus represents a common pathologic abnormality that is well recognized by dental professionals, but this
entity has received scant mention in the medical textbooks and literature. The lesion may be detected
incidentally during a routine physical examination, or some patients may first seek medical advice because
of their concern that the enlarging or ulcerated torus could be a malignant tumor. Therefore, it is important
for the primary care physicians to be familiar with the appearance of these tori and their potential clinical
complications. There is no evidence for malignant transformation of these tori, but the larger protuberant
lesions causing significant symptoms may require referral to an oral surgeon for local resection. Although
several causal factors have been postulated for the development of tori, the exact etiology of this condition
in any individual patient may need further assessment to determine its underlying pathogenesis and possible
genetic nature.
DISCLOSURES
The authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
GGG was responsible the conception and design of the study, radiological studies and manuscript preparation;
DRN assisted in collecting clinical data and literature search; and ZKG provided the case material, dental
records and intraoral photographs. All authors reviewed and approved the final manuscript.
ORCID
Gary G. Ghahremani https://orcid.org/0000-0002-4506-4492
REFERENCES
1. King DR, King AC. Incidence of tori in three population groups.J Oral Med 1981; 36(1): 21-23.
2. Chohayeb AA, Volpe AR. Occurrence of torus palatinus and mandibularis among women of different
ethnic groups. Am J Dent 2001; 14(5): 278-280.
3. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part II. Masses and neoplasia. Am Fam
Physician 2007; 75: 509-512.
4. Choi Y, Park H, Lee JS, et al. Prevalence and anatomic topography of mandibular tori: computed
tomographic analysis. J Oral Maxillofac Surg 2012; 70(6): 1286-1291.
5. Sonnier KE, Horning GM, Cohen ME. Palatal tubercles, palatal tori, and mandibular tori: prevalence
and anatomical features in a U.S. population. J Periodonol 1999; 70(3); 329-336.
6. Curran AE, Pfeffle RC, Miller E. Autosomal dominant osteosclerosis: report of a kindred. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 1999; 87: 600-604.
7. Eggen S. Torus mandibularis: an estimation of the degree of genetic determination. Acta Odontol
Scand 1989; 47: 409-415.
8. Morrison MD, Tamimi F. Oral tori associated with local mechanical and systemic factors: a case-control
study. J Oral Maxillofac Surg2013; 71(1): 14-22.
9. Bruce I, Ndanu TA, Addo ME. Epidemiological aspects of oral tori in a Ghanaiancommunity. Int Dent
J 2004; 54: 78-82.
10. Garcia-Garcia AS, Martinez-Gonzales JM, Gomez-Font R, etal. Current status of the torus palatinus
and torus mandibularis. Med Oral Patol Oral Cir Bucal 2010; 15(2): 353-360.
11. Morita K, Tsuka H, Shintani T, et al. Prevalence of torus mandibularis in young healthy dentate
adults. J Oral Maxillofac Surg 2017; 75(12): 2593-2598.
12. Jainkittivong A, Apinhasmit W, Swasdison S. Prevalence and clinical characteristics of oral tori in
1,520 chulalongkorn university dental school patients. Surg Radiol Anat 2007; 29(2): 125-131.
13. Eggen S, Natvig B. Concurrence of torus mandibularis and torus palatinus. Scand J Dent Res 1994;
102(1): 60-63.
14. Ahn SH, Ha JG, Kim JW, et al. Torus mandibularis affects the severity and position-dependent sleep
apnoea in non-obese patients. Clin Otolayngol 2019; 44(3): 279-285.

5
 15. Durrani MA, Barwise JA. Difficult endotracheal intubation associated with torus mandibularis. Anesth
Analg 2000; 90(3): 757-759.
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

16. Godinho M, Barbosa F, Andrade F, et al. Torus palatinus osteonecrosis related to bisphosphonate: a
case report. Case Repo Dermatol 2013; 5(1): 120-125.
17. Lee KH, Lee JH,Lee HJ. Concurrence of torus mandibularis with multiple buccal exostoses. Arch Plast
Surg 2013; 40(4):466-468.
18. Ganz SD. Mandibular tori as a source for onlay bone graft augmentation: a surgical procedure. Pract
Periodontics Aesthet Dent 1997; 9: 973-982.
Captions for Illustrations
Figure 1. Torus mandibularis (TM) in a 61 year-old man. CT section shows the prominent bilateral
exostosis (arrows). Intraoral photograph (inset) demonstrates lobulated subgingival masses on the inner
aspect of premolar regions. Figure 2. Torus mandibularis (TM) in a 58 year-old woman, presenting as very
extensive osteomas on CT image (arrows), and as lobulated masses protruding medially on intraoral view
(inset). She had progressive impairment of speech and mastication due to posterior displacement of the
tongue and subsequently required surgical excision of the tori. Figure 3. Torus Maxillaris (TMAX) in a 47
year-old man. CT shows very prominent bilateral exostosis of the molar regions (large black arrows), minimal
cortical thickening anteriorly (small arrows) and a coexisting TP (white arrow). Intraoral photograph also
demonstrates the same tori (inset). Figure 4. Torus palatinus (TP) in a 72 year-old man. CT and intraoral
images demonstrate the torus as a prominent multi-lobulated mass protruding from center of the hard palate
(arrow). This torus was removed surgically because of its large size and recurrent ulceration of its mucosa.
Figure 5. Torus palatinus (TP) in a 50 year-old woman. CT section shows the lesion as an exostosis of the
hard palate. Photograph reveals superficial erosions and inflammation of its mucosal surface (arrows).

6
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.

7
Posted on Authorea 10 Sep 2020 — The copyright holder is the author/funder. All rights reserved. No reuse without permission. — https://doi.org/10.22541/au.159969691.18873522 — This a preprint and has not been peer reviewed. Data may be preliminary.