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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 34-37

Bilateral buccal exostosis evaluated by cone-beam computed tomography: A rare accidental finding


1 Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India
2 Department of Oral Medicine and Radiology, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India

Date of Web Publication6-Mar-2017

Correspondence Address:
Humaira Siddiqui
Department of Periodontics and Oral Implantology, Kalinga Institute of Dental Sciences, Campus-5, KIIT University, Patia, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_95_16

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  Abstract 

Buccal exostoses are broad-based, non-malignant surface growth occurring on the outer or facial surface of the maxilla and/or mandible, found usually in the premolar and molar region. Etiology is still not established, but it has been suggested that the bony overgrowth can be because of abnormally increased masticatory forces to the teeth. Compensatory response to periodontal disease has been proposed to explain some cases of exostoses; they tend to appear in early adolescence and may very slowly increase in size with time. They are painless, self-limiting and may increase patient concern about poor esthetics, inability to perform oral hygiene procedures, and compromised periodontal health by causing food lodgment. The following article presents a very rare case of bilateral buccal-sided maxillary and mandibular exostoses in the anterior region which was an accidental finding in a chronic generalized periodontitis patient.

Keywords: Bony exostoses, buccal exostoses, cone-beam computed tomography, exostoses, tori


How to cite this article:
Siddiqui H, Singh DK, Mishra S, Mandal A. Bilateral buccal exostosis evaluated by cone-beam computed tomography: A rare accidental finding. Indian J Dent Sci 2017;9:34-7

How to cite this URL:
Siddiqui H, Singh DK, Mishra S, Mandal A. Bilateral buccal exostosis evaluated by cone-beam computed tomography: A rare accidental finding. Indian J Dent Sci [serial online] 2017 [cited 2019 Jan 18];9:34-7. Available from: http://www.ijds.in/text.asp?2017/9/1/34/201642


  Introduction Top


Exostosis or hyperostoses are localized cortical bone growth on the mandible and maxilla. It is usually found along the alveoli or on the hard palate and depending on the location and extent; they can be classified as torus mandibularis (TM), torus palatinus (TP), buccal, or lingual maxillary exostosis.[1] Most common types of intraoral osseous overgrowths are TP and TM.[2],[3] Buccal and lingual maxillary exostoses are a rare finding. When found on alveoli, exostosis most frequently tends to be thickest next to molars, extending anteriorly sometimes as far as second premolar and in rare cases, up to the canine and incisors (Hrdlicˇka 1940; Tadakuma and Ogasawa 1969).[1] Exostoses and tori are well known by anthropologists, and the first article on them was published by Fox.[4] These occur as bilateral, smooth bony growth along the facial aspect of the maxillary and/or mandibular alveolus. It appears in the premolar-molar region commonly. Exostoses are hard bony masses on palpation. The overlying mucosa appears normal color stretched but intact. Due to trauma or any injury ulcerations may be seen on the mucosa. They tend to develop during teenage and may gradually enlarge over the years. Buccal exostoses may be seen as self-limiting and painless bony masses. The increased size may be a contributing factor to periodontal disease of adjacent teeth due to retention of food while chewing instead of flushing away. The treatment of bony exostosis is usually not required, unless it is affecting the periodontal condition or causing pain or discomfort to the patient, or when causing pseudo-swelling over the lip. Only, then conservative surgical excision can be performed.[5]

The etiology of tori has not been established yet. Most probable reasons include genetic factors, environmental factors, masticatory hyperfunction, and continued jaw bone growth.[6],[7]

Diagnosis, treatment, and prognosis

The diagnosis of a buccal exostosis is based on the clinical examination along with radiographic interpretations. The torus may appear clinically as numerous rounded protuberances or calcified multiple lobules, whereas the exostosis is a single, smooth broad-based mass, may have a sharp, pointed bony projection producing tenderness just beneath the mucosa.[8] Lesions may slowly enlarge up to 3–4 cm in greatest diameter; however, it does not have malignant transformation potential. Buccal exostoses are usually found only on the facial surface of the maxillary alveolar bone, especially in the posterior segment. Radiographically, exostosis appears as well-defined round or oval calcified structure superimposing the roots of teeth. Biopsy should be performed if there is any dilemma regarding diagnosis. The patients having multiple bony growths or lesions which are not in the classic torus or buccal exostosis locations should be evaluated for Gardner syndrome. This autosomal dominant syndrome shows other features such as intestinal polyposis and cutaneous cysts or fibromas.[2],[7] No bony exostosis or tori requires treatment unless it becomes large enough to interfere with periodontal health, denture placement, or cause recurrent traumatic ulcerations.


  Case Report Top


A male patient who was aged 54 years reported to the Department of Periodontics, Kalinga Institute of Dental Sciences College and Hospital, Bhubaneswar, Odisha, India, for a routine checkup and oral prophylaxis. On clinical examination, it was found that his oral hygiene status was poor, and multiple bony nodules were found in the lower and upper anterior region of his maxilla and mandible as seen in [Figure 1] and [Figure 2]. The patient had not previously noticed the “nodules” and he was otherwise healthy. He had a medical history of hypertension since 3 years, for which he was taking medicine regularly, and there was also no history of any other family illness or any tissue tumors which were suggestive of any syndrome.
Figure 1: Labial view of the maxilla.

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Figure 2: Labial view of the mandible.

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On examination, the patient was found to be apyrexic, and there was no lymphadenopathy intraorally, an intact dentition was present, and all the mucosal surfaces appeared to be healthy. Multiple bony protuberances were evident along the labial aspect of the maxilla and mandible. The approximate diameter of the bony swellings varied from 5 to 6 mm. On palpation, 10 round, firm, raised, nontender protuberances were diagnosed in the maxillary arch and six-rounded protuberances in the mandibular arch. An orthopantomogram was taken to confirm the presence of multiple radiopaque masses along the middle thirds of roots of maxillary central incisors to second premolars on both the right and left side, and mandibular anterior region, which extended from canine to canine, that demonstrated a buccolingual growth of the alveolar bone in the region of the bony swellings as seen in [Figure 3]. Radiolucencies were seen in between these teeth, and clinically, no mobility in the teeth was present. To reach a confirmed diagnosis, a cone-beam computed tomography (CBCT) was taken.
Figure 3: Digital orthopantomogram.

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CBCT is a helpful diagnostic tool to identify anatomical variations. Multiple radiopaque masses seen on the labial aspect of maxillary anterior, measuring approximately 5 mm with loss of labial cortical plate 7 mm approximately below the cementoenamel junction giving a beaded appearance over the anterior maxilla and mandible suggestive of bony exostoses as depicted in [Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8]. In the CBCT, it was apparent that buccal cortical plate was missing in the areas of exostoses as seen in [Figure 9]. Maybe compensatory response to periodontal disease can be proposed to explain this case of exostoses as suggested by Glickman and Smulow 1965.[9]
Figure 4: Axial section of the maxilla.

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Figure 5: Axial section of the mandible.

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Figure 6: Three-dimensional view frontal.

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Figure 7: Three-dimensional view left lateral.

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Figure 8: Three-dimensional view right lateral.

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Figure 9: Sagittal section.

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  Discussion Top


Buccal exostoses are nonmalignant lesions having little clinical significance. The multiple masses in the maxilla are consistent with multiple buccal exostoses. These are bony protuberances that arise from the cortical plates in the maxilla and mandible. The clinical, radiographic, and CBCT findings confirm the diagnosis of buccal exostosis. Nery et al. in 1977 reported that the Asian population show higher frequency of exostoses and presumably carry alleles in a greater frequency.[10] A biopsy for diagnostic support is usually not recommended. It remains important to distinguish exostoses from early osteosarcomas and chondrosarcomas. Furthermore, the patients with multiple bony growths should be evaluated for Gardner syndrome. Intestinal polyposis and cutaneous cysts or fibromas are other common features of the autosomal dominant Gardner syndrome.[2],[6] Neither the torus nor the bony exostosis requires treatment unless it becomes large enough to interfere with normal function or causes recurring traumatic surface ulceration (usually from sharp food) or can be used to get autograft as it is a potent donor site.[11]


  Conclusion Top


The case report presented above illustrates a unique and rare presentation of exostoses on the buccal side of the maxillary and mandibular anterior-premolar region, bilaterally. Exostosis is rarely found on the facial surface of maxilla and mandible thus should not be ignored and should be carefully differentially diagnosed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pechenkina EA, Benfer RA Jr. The role of occlusal stress and gingival infection in the formation of exostoses on mandible and maxilla from Neolithic China. Homo 2002;53:112-30.  Back to cited text no. 1
    
2.
Neville BW, Damm DD, Allen CM, Bouquot JE, editors. Oral and Maxillofacial Pathology. Philadelphia: WB Saunders Co.; 1995. p. 17-20.  Back to cited text no. 2
    
3.
Antoniades DZ, Belazi 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;85:552-7.  Back to cited text no. 3
    
4.
Fox J. The natural history and diseases of the teeth. London; part I J M Caxery, Printer Black Horse Court, Fleet Street London 1814.  Back to cited text no. 4
    
5.
Medsinge SV, Kohad R, Budhiraja H, Singh A, Gurha S, Sharma A. Buccal exostosis: A rare entity. J Int Oral Health 2015;7:62-4.  Back to cited text no. 5
    
6.
Jainkittivong A, Langlais RP. Buccal and palatal exostoses: Prevalence and concurrence with tori. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:48-53.  Back to cited text no. 6
    
7.
Horning GM, Cohen ME, Neils TA. Buccal alveolar exostoses: Prevalence, characteristics, and evidence for buttressing bone formation. J Periodontol 2000;71:1032-42.  Back to cited text no. 7
    
8.
Bouquot JE. Bond's Book of Oral Diseases. 4th ed. Philadelphia: Churchill-Livingstone; 1988.  Back to cited text no. 8
    
9.
Glickman I, Smulow JB. Buttressing bone formation in the periodontium. J Periodontol 1965;36:365-70.  Back to cited text no. 9
    
10.
Nery EB, Corn H, Eisenstein IL. Palatal exostosis in the molar region. J Periodontol 1977;48:663-6.  Back to cited text no. 10
    
11.
Puttaswamaiah RN, Galgali SR, Gowda VS. Exostosis: A donor site for autograft. Indian J Dent Res 2011;22:860-2.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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