SCIENTIFIC ARTICLES

Stomatologija, Baltic Dental and Maxillofacial Journal, 17: 35-40, 2015

Multifactorial etiology of Torus mandibularis:

study of twins
Adomas Auškalnis, Vygandas Rutkūnas, Olaf Bernhardt, Mantas Šidlauskas,
Loreta Šalomskienė, Nomeda Basevičienė

SUMMARY

Objective. The aim of this study is to investigate the multifactorial etiology of mandibular tori
analyzing the influence of genetics, occlusal overload, various clinical variables and their interactions.
Methods. Overall, plaster casts of 162 twins (81 twin pairs) were analyzed for the presence or
absence of mandibular tori. Atypical wear facets on canine tips or incisors were recorded to diagnose
bruxism. Angle Class, any kind of anterior open bite and positive, negative or flat curve of Wilson
were recorded. Zygosity determination was carried out using a DNA test.
Results. Mandibular tori were found in 56.8% of the cases. In 93.6% of all monozygotic twin
pairs both individuals had or did not have mandibular tori (κ=0.96±0.04; p<0.001), compared to
79.4% concordance of mandibular tori in dizygotic co-twins (κ=0.7±0.12; p<0.001). Prevalence of
mandibular tori was significantly higher in the group of bruxers (67.5%) compared to non-bruxers
(31.3%) (p<0.001). Significant association between mandibular tori and negative or flat curve of
Wilson in the maxillary second premolars and first molars was found (OR=2.55, 95% CI (1.19-5.46),
p=0.016). In all monozygotic bruxers, 97.1% showed concordance of mandibular tori presence in both
co-twins compared to 78.9% dizygotic bruxers, and this difference is statistically significant (p=0.007).
Conclusion. Our results suggest that the mandibular tori are of a multifactorial origin. Mandibular
tori seem to have genetic predisposition, and may be associated with teeth grinding as well as with
negative or flat CW in region of maxillary second premolar and first molar.

Key words: torus mandibularis, twins, zygosity, genetic factor, bruxism.

Introduction

Torus mandibularis (TM) is a common oral bony of trabecular bone and fibrofatty marrow (1, 2). It is
outgrowth formed by compact bone with small amount mostly found bilaterally in the lingual surface of the
mandible, in the region of canines or premolars (2).
1
Department of Dental and Oral Diseases, Medical Academy, Lithua- Records in the incidence of TM vary inconsistently
nian University of Health Sciences, Kaunas, Lithuania from 0.54% to 64.4% depending on the ethnic group,
2
Department of Prosthodontics, Institute of Odontology, Faculty
of Medicine, Vilnius university, Vilnius, Lithuania
race, or the investigated sample (3). These bony pro-
3
Department of Restorative Dentistry, Periodontology and tuberances are non pathological and usually do not
Endodontology, Center of Oral Health, University produce any symptoms, therefore, the cases of surgical
of Greifswald, Greifswald, Germany removal are rare (4, 5).
4
Clinic of Orthodontics, Medical Academy, Lithuanian University Various possible causes were discussed to explain
of Health Sciences, Kaunas, Lithuania
5
Institute of Biology Systems and Genetics, Veterinary Academy,
the etiology of TM, but the accepted model for the
Lithuanian University of Health Sciences, Kaunas, formation of these bony protuberances is still under
Lithuania question. Historically, the dominant focus is on genet-
ics, and the heredity of TM has been analyzed using
Adomas Auškalnis1 – D.D.S.
Vygandas Rutkūnas2 – assoc. prof., PhD
familial (6, 7), regional studies (8, 9), or comparing
Olaf Bernhardt3 – prof., Dr. med. dent. Habil. ethnic groups (10-12).
Mantas Šidlauskas4 – D.D.S. However, the heredity does not explain all the
Loreta Šalomskienė5 – PhD cases of TM. As stated by Eggen (13), genetic deter-
Nomeda Basevičienė1 – assoc. prof., PhD mination of TM was estimated to be 30%, whereas
Address correspondence to Adomas Auškalnis, Department of Dental 70% of the causes could be explained by influence of
and Oral Diseases, Medical Academy, Lithuanian University of occlusal overload and other clinical variables. In the
Health Sciences, Eivenių str. 2, 50009 Kaunas, Lithuania.
E-mail address: adomas.auskalnis@gmail.com studies analyzing TM etiology, occlusal overload is

Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2 35
A. Auškalnis et al. SCIENTIFIC ARTICLES

mostly described as bruxism (14-17) or heavy food DNA analysis. The sample consists of 47 monozygotic
consumption (8, 18). In most of the studies association and 34 dizygotic twin pairs. There were 100 females
between TM and occlusal overload was found. and 62 males in the sample. The age of the subjects
Other clinical variables related with the occlusal ranged from 12 to 51 years (mean age of 20.3±0.9 y.).
characteristics, malocclusion and oromaxillofacial Zygosity determination was carried out us-
function (e. g. Angle class, open bite, buccal overjet, ing a DNA test. The polymerase chain reaction set
curve of Spee etc.) were hypothesized as possibly AmpFℓSTR® Identifiler® (Applied biosystems, USA)
having a role in creating TM (19), but the studies are was used to amplify short tandem repeats and 15
limited. Significant links between TM and Eichner In- specific DNA markers (D8S1179, D21S11, D7S820,
dex, occlusal support at the premolar and molar areas, CSF1PO, D3S1358, TH01, D13S317, D16S539,
occlusal force and presence of TM were found (14). D2S1338, D19S433, vWA, TROX, D18S51, D5S818,
Moreover, number of teeth and adequately developed FGA) and the Amel fragment of the amelogenin gene
jaws were also positively related with the incidence of were used for comparison of genetic profiles. The
TM (20). In the literature, significant relation between zygosity determination using this molecular genetic
TM occurrence and temporomandibular disorders was technique reaches 99.9% accuracy.
reported as well (15, 17). Plaster casts were chosen as a reliable method to
These controversial findings of multifactorial diagnose TM, bruxism, and various occlusal variables
nature give much space for the discussions about (26, 27). Two calibrated observers (periodontologist
the origins of TM. The key to explain multifactorial and general dentist) evaluated the data manually
etiology of TM could be functional matrix hypoth- analyzing the plaster casts and looking for TM. The
esis (21). It is based on Wolff’s law, which state that nodular bone protuberance on the lingual surface of
loading force prompts remodeling and strengthening the mandible in the region of canines or premolars
of the bone (22, 23). According to functional matrix was considered as TM. Bruxism was diagnosed by
hypothesis, compressive stresses may lead to buckling recording the atypical wear facets on incisors and
of the mandible in the mental foramen region, which canine tips or non-functional surfaces. Eccentric wear
has a reduced bone volume. Osteogenic periosteum in facets, arising only during extreme extrusive mandible
these regions is stretched and this tension leads to new movements, were taken as an evidence for teeth grind-
bone formation in the form of tori (19). This functional ing (2, 28-32).
matrix hypothesis considers heredity as well, since Occlusal variables such as Angle Class, any kind
children inherit jaw form from parents (19). However, of anterior open bite in habitual occlusion and positive,
this multifactorial hypothesis of TM occurrence still negative or flat curve of Wilson (CW) on the maxillary
lacks evidence. premolars and molars were recorded. To identify Angle
Therefore, the primary purpose of this research Class, relationship between first molars was recorded.
is to investigate the multifactorial etiology of TM, In a case of Angle Class II subdivision or Angle Class
studying the influence of genetics, occlusal overload III subdivision, when molar relationship was asym-
and other clinical variables taking twins as an investi- metrical and was Class I on the one side and Class II
gation sample. Explanation of the potential causes for or III on the other, the cases were considered as Angle
TM formation may give valuable knowledge about the Class II or Angle Class III (33). CW was considered flat
biomechanical mechanisms improving bone quality when the tips of vestibular and palatal cusps were at the
(24, 25). same level on the both sides of the maxillary premolars
or molars. Patients with negative CW exhibited longer
MATERIAL AND METHODS vestibular cusps compared to palatal cusps, and on the
contrary for the patients with positive CW.
A total 162 pairs of maxillary and mandibular For calibration purposes two examiners were
plaster casts of individuals (81 pairs of twins) were trained for better reliability diagnosing TM, bruxism
examined. The plaster casts were collected using the and occlusal variables. After training, the examiners
database of Orthodontic Department and Scientific evaluated 10 plaster casts, not belonging to the study
Twin Center at the Lithuanian University of Health sample, twice. Recorded Kappa (κ) index for inter-
Science. Plaster models were selected from nationwide rater agreement was >0.8, and intraclass correlation
population-based database randomly. coefficient (ICC) was >0.8 for all parameters.
We used the criteria for inclusion, which were The obtained data were analyzed using the IBM
described as follows: a) subjects have to be with per- SPSS Statistics 22 (SPSS, Inc, Chicago, IL). The inter-
manent dentition; b) no orthodontic treatment has to dependence of qualitative evidence was evaluated by
be performed; and c) zygosity has to be confirmed by Chi-square (χ2) criteria. Risk estimates were calculated

36 Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2
SCIENTIFIC ARTICLES A. Auškalnis et al.

the P value was set at 0.05. Strength of agreement be-

tween the measurements was evaluated using Kappa
(κ) coefficient. κ values ≤0.2 were considered as
poor agreement; 0.21–0.40 fair; 0.41–0.60 moderate;
0.61–0.80 good; and 0.81–1.00 very good (34).
Ethical approval for the research was obtained
from Kaunas Regional Biomedical Research Ethics
Committee.

RESULTS

Overall, 56.8% of the subjects had TM and it

was the most frequent type of bony outgrowth in the
sample. Predominantly, subjects had TM bilaterally or
with another oral bony outgrowth, and the cases with
Fig. Distribution of TM unpaired TM are rear (Figure).
as unadjusted odds ratios (ORs) with 95% confidence Higher incidence of TM was diagnosed for fe-
intervals (CIs) using logistic regression analyses, and males and for the group over 18 years, but no statisti-
Table 1. Prevalence of TM associated with different variables cally significant differences were found
(Table 1).
TM prevalence Difference
p-value (Chi- In the investigated sample, 70.4% of
n %
squared test) the subjects were identified as bruxers.
Gender Prevalence of TM was significantly higher
Females 60 60.0 in this group compared to non-bruxers
p=0.3 (Table 1).
Males 32 51.6
Analyzing influence of the various
Age occlusal variables on TM occurrence, sig-
=<18 43 52.4 nificant association between negative and
p=0.25
>18 49 61.3 flat CW in the maxillary second premolars
Bruxism and first molars was found (OR=2.55, 95%
Bruxers 77 67.5 CI (1.19-5.46), p=0.016) (Table 2).
p<0.001 The influence of genetics on the eti-
Non-bruxers 15 31.3
ology of TM was evaluated calculating
Angle Class concordance values for the presence or
Angle Class I 21 58.3 absence of TM between first and second
Angle Class II Division 1 24 70.6 twin (co-twin) in MZ and DZ pairs. 93.6%
p=0.326
Angle Class II Division 2 29 55.8 of all MZ and 79.4% of DZ co-twins
Angle Class III 18 45.0 showed concordance in the occurrence of
investigated bony outgrowths, i.e. both
CW
individuals in the pair had or did not have
Negative or flat CW at first premolar 88 56.4 p=0.7 TM. High κ values (0.96±0.04) show very
Negative or flat CW at second premolar 77 61.6 p=0.02 good strength of agreement between the
Negative or flat CW at first molar 35 64.8 p=0.15 measurements in MZ co-twins, and good
Negative or flat CW at second molar 5 83.3 p=0.18 agreement (0.7±0.12) in DZ co-twins.
This difference is statistically significant
Negative or flat CW at second 78 61.9
p=0.01 (p<0.001) (Table 3).
premolar and first molar
The multifactorial etiology of TM was
Anterior open bite
evaluated grouping the sample into four
No open bite 73 56.6 groups: MZ bruxers, MZ non-bruxers,
Open bite between incisors 11 57.9 χ2 =3.117; DZ bruxers and DZ non-bruxers. In our
df=3;
Open bite between canine 8 66.7 p=0.44 study, 97.1% of all MZ bruxers showed
Open bite between premolars 0 0 concordance of TM presence in both co-
In bold – p<0.05. Abbreviations: TM, torus mandibularis; CW, curve of twins compared to 78.9% of all DZ bruxers
Wilson; χ2 , chi square test; df, degree of freedom (p=0.007). Significant difference between

Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2 37
A. Auškalnis et al. SCIENTIFIC ARTICLES

MZ non-bruxers (91.7%) and DZ non-bruxers (80.0%) Data on TM prevalence in the groups of females
was found as well (p<0.001). and males (60.6% and 50.8% respectively, but no
Multiple logistic regressions analysis did not show statistically significant differences) do not confirm the
significant increase in TM occurrence for the bruxers X chromosome-linked heritability of TM and support
with negative or flat CW in region of maxillary second some previous reports (14, 39). Moreover, our study
premolar and first molar (p=0.089). did not show statistically significant differences of TM
prevalence according to age. These findings differ from
DISCUSSION other reports showing gradual growth of oral bony
outgrowths, which is greater in second or third decade
Prevalence of life (12, 36). Thus, our results may be influenced by
This report demonstrates that TM is dominant oral the young mean age (20.3±0.9 y) of the sample, which
bony outgrowth and has a high incidence (56.8%) in dominates in the database of Scientific Twin Center.
the investigated sample of Lithuanian twins. In the Seeking to evaluate the age dependency on TM preva-
worldwide studies, prevalence of TM has a wide varie- lence more epidemiological studies including various
ty in rates – between 0.54% to 64.4% (3). Higher preva- age groups should be implemented.
lence of TM in our study may be partially explained by
method of data collection. Plaster cast analysis leads to Bruxism
more precise data collection and possibility to calibrate In our study the prevalence of TM is significantly
the examiners, to recalculate and compare the cases correlated with teeth grinding, and these findings are
seeking for maximum accuracy. After training and consistent with other studies (13, 14, 16). The diagnos-
calibration procedure inter-rater agreement (weighted tics of bruxism is controversial and various methods
Kappa) and ICC between researchers diagnosing TM are known (2). In our study bruxism was diagnosed
were 0.82 and 0.97 respectively.
Table 2. Association between TM and different variables
Genetics Variables OR* 95% CI P value
TM dominates in Japanese, Age (>18 years) 1.43 0.77-2.68 0.258
Spanish, Ghanaian populations Gender (women) 1.41 0.74-2.66 0.296
(14,35,36). On the other hand, Ger-
Bruxism 4.58 2.22-9.46 <0.001
man, Norwegian, Croatian, Thai,
Angle Class II Division 1** 1.71 0.64-4.62 0.287
Malaysian populations were re-
ported to have torus palatinus more Angle Class II Division 2** 0.9 0.38-2.13 0.811
commonly (11, 16, 27, 37). Conse- Angle Class III** 0.58 0.24-1.45 0.247
quently, researchers suggest genetics Anterior open bite 1.04 0.48-2.26 0.919
as responsible factor in the etiology Negative or flat CW at first premolar*** 0.65 0.12-3.64 0.621
of TM and other bony protuberances. Negative or flat CW at second premolar*** 2.35 1.11-4.98 0.025
However, until now the influence Negative or flat CW at first molar*** 1.65 0.84-3.24 0.146
of genetics was mostly analyzed Negative or flat CW at second molar*** 3.97 0.45-34.74 0.213
using regional, ethnicity research,
Negative or flat CW at second premolar 2.55 1.19-5.46 0.016
or familial studies (6-8,10-12). The and first molar***
present study gives a new perspec- * Unadjusted odds ratio of logistic regression.
tive since it takes the sample of twins ** Compared to Angle Class I.
as an object to verify the influence *** Compared to positive CW.
In bold – p<0.05. Abbreviations: OR, unadjusted odds ratio; CI, confidence inter-
of genetic factor on the occurrence vals; CW, curve of Wilson.
of TM for the first time. MZ twins
are genetically identical and are ex- Table 3. Concordance values of TM in twin pairs
pressing more similar traits than DZ Concordance values of TM Discordance values of TM
twins. If genes determine the trait, First and second twin with First twin with TM and
agreement between traits (Kappa) TM, or first and second second twin without TM, κ value
in both individuals is close to 1.0 in twin without TM or first twin without TM
MZ twin pair and near to 0.5 in DZ and second twin with TM
twins (38) (0.96 and 0.7 respectively n % n %
in our research). The results of our MZ twins 44 93.6 3 6.4 0.96±0.04
study prove influence of genetic fac- DZ twins 27 79.4 7 20.6 0.7±0.12
tor in TM etiology. Abbreviations: TM, torus mandibularis; MZ, monozygotic; DZ, dizygotic.

38 Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2
SCIENTIFIC ARTICLES A. Auškalnis et al.

analyzing plaster casts, because atypical bruxism facets TM between first and second twin in MZ bruxers pair
on plaster casts show a sum of all diurnal and nocturnal indicate multifactorial etiology of TM.  Our results
parafunctional activities retrospectively in all life peri- suggest that TM formation could be associated with
ods (26). For this reason, plaster casts analysis is more parafunctional teeth grinding, but genes may play
reliable and objective assessment than self-report of the predisposition role in TM etiology.
grinding activity (29). However, calibration of examin- Higher, but statistically insignificant TM oc-
ers and standard methods for assessment of bruxism currence rates for bruxers with negative or flat CW
has extremely important role in this regard (28). After in the region of maxillary second premolar and first
training and calibration for standard bruxism assess- molar may be explained by multicollinearity. In this
ment inter-rater agreement (Kappa) and ICC between case, two separately significant variables are highly
two examiners were 0.87 and 0.87 respectively. correlated, and are insignificant conducting multiple
Obviously, there are some limitations in this logistic regression analysis (44). In our study high
regard. Tooth wear may not be evident in all cases of multicollinearity between negative or flat CW and
bruxism and depends on the type of bruxism. Atypical, bruxism was proved by Spearman’s rho correlation
eccentric wear facets are usual for teeth grinding. On coefficient (r=0.2, p=0.009), and significant correlation
the other hand, teeth clenching and gnashing may be between the same variables was confirmed by logistic
difficult to recognize evaluating plaster casts. In fact, regression analysis (OR=2.742, 95% CI (1,27-5.92),
our study identifies bruxism only as parafunctional p=0.01). On the other hand, as it was discussed before,
teeth grinding. Therefore, extended studies analyzing negative or flat curvature of CW may provoke lingual
influence of teeth clenching and gnashing on the etiol- buckling of the mandibular teeth in static occlusion or
ogy of TM are necessary. Furthermore, teeth grinding normal group function, and this occlusal overload is
is more common for young people (2) and our study not related to parafunctional teeth grinding.
sample average age was 20.3±0.9 years. The formation of TM seems to be a compensatory
and protective bone reaction to occlusal overload in
Other clinical variables the most vulnerable mandible area. This study leads us
Some authors hypothesized that formation of TM to a discussion about tori removal and their possible
may be related to negative teeth inclination or deep use for autogenous bone grafting for dental implanta-
buccal overjet in Angle II Class.  On the other hand, tion (45, 46). Moreover, some authors report recurrent
when direction of the bite force vector is changed growth of TM following their removal due to repetitive
(e.g. in Angle Class III) TM may not be prominent bruxism (26).
(19).  Nevertheless, our study does not confirm TM Apparently, gene effects on the morphologic level
dependency on Angle Class. Moreover, our results are pleiotropic (13). Moreover, bruxism becomes al-
show that anterior open bite in habitual occlusion does most habitual function for contemporary patients (47).
not decrease TM incidence rate. Therefore, the search for other clinical and occlusal
However, significant association between nega- variables may play an important role analyzing and
tive or flat CW in the maxillary premolars and first understanding TM etiology. Further clinical investiga-
molars was found. The degree of curvature of the tions, retrospective computer tomography studies or
CW controls the inclination of occlusal guidance and finite-element analysis evaluating correlation of TM
occlusal contact point orientation (40). In case of nega- and other clinical and occlusal variables may give valu-
tive or flat CW inclination, the occlusal guiding path able knowledge for implant angulation, fabrication of
becomes steeper, and it often leads to group function teeth or implant supported posterior restorations, and
and determines greater occlusal load on teeth (40, 41). occlusal adjustment.
In addition, maxillary premolars and molars with the  
negative CW usually have negative torque and domi- CONCLUSION
nant occlusal contact in static occlusion on vestibular
slope of vestibular cusps of mandibular premolars (A Our results suggest that the etiology of TM is mul-
contact) (42). This finding supports functional matrix tifactorial. TM seems to have genetic predisposition,
hypothesis (19, 21) as shear load and lingual buckling and may be associated with teeth grinding as well as
of the mandibular teeth initiates TM formation. with negative or flat CW in region of maxillary second
premolar and first molar.
Multifactority
Scholars agree that the potential causes of TM STATEMENT OF CONFLICTS OF INTEREST
are not limited to only one factor (13-15, 43). High
concordance values for the presence or absence of The authors state no conflict of interest.

Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2 39
A. Auškalnis et al. SCIENTIFIC ARTICLES

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Received: 07 04 2014
Accepted for publishing: 25 05 2015

40 Stomatologija, Baltic Dental and Maxillofacial Journal, 2015, Vol. 17, No. 2