The Saudi Journal for Dental Research (2014) xxx, xxx–xxx

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sa
www.sciencedirect.com

REVIEW

Alveolar exostosis – revisited: A narrative review

of the literature
a,* b
K. Smitha , G.P. Smitha

a
Department of Periodontics, Government Dental College and Research Institute, Bangalore, Karnataka, India
b
Department of Oral Pathology, Raja Rajeshwari Dental College and Hospital, Bangalore, India

Received 24 November 2013; revised 28 January 2014; accepted 1 February 2014

KEYWORDS Abstract An exostosis is a localized, peripheral overgrowth of bone of unknown etiology of benign
Exostoses torus; nature. It may be a nodular, flat or pedunculated protuberance located on the alveolar surfaces of
Palatal; the jawbones. The etiology of oral bony exostosis is still not clear. Racial, autosomal dominant fac-
Torus, mandibular; tors, dental attrition, and even nutritional factors have been suggested as having an influence. In the
Tubercles, palatal; jaws, depending on the anatomic location they are named as torus palatinus (TP), torus mandibu-
Grafts, bone; laris (TM), or buccal bone exostoses (BBE). The clinical importance of exostosis lies in surgical
Surgical flaps removal of these to permit proper flap adaptation, most importantly in the posterior maxilla,
and to the potential use of the mandibular and palatal tori as sources of autogenous cortical bone
for grafting.
ª 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.1. Prevalence of exostoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.2. Histological characteristics of exostoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.3. Exostoses as a post operative squeal of dental treatment procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
1.4. Clinical management of alveolar exostosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

* Corresponding author. Tel.: +91 9449630572; fax: +91 80

26703176.
E-mail address: periosmitha@gmail.com (K. Smitha). 1. Introduction
Peer review under responsibility King Saud University.

An exostosis is a benign, localized, peripheral overgrowth of

bone of unknown etiology. It may be a nodular, flat or
Production and hosting by Elsevier pedunculated protuberance located on the jawbones’ alveolar

2352-0035 ª 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University.
http://dx.doi.org/10.1016/j.sjdr.2014.02.001

Please cite this article in press as: Smitha K, Smitha GP Alveolar exostosis – revisited: A narrative review of the literature, The Saudi Journal for
Dental Research (2014), http://dx.doi.org/10.1016/j.sjdr.2014.02.001
2 K. Smitha, G.P. Smitha

surface.1 It frequently occurs in long bones where tendons and

muscles are inserted. Exostosis or abnormal bone growth with-
in the ear canal is called as Surfer’s ear.
In the jaws, depending on the anatomic location they are
named as torus palatinus (TP), torus mandibularis (TM), or
buccal bone exostoses (BBE), TP that occurs along the midline
of the hard palate is a sessile, nodular mass of bone. TM is a
bony overgrowth located on the lingual aspect of the mandi-
ble, most commonly seen in the canine and premolar areas
(Fig. 1). BBE occurs along the buccal aspect of the maxilla
or mandible, usually in the premolar and molar areas. Palatal
exostoses are found on the palatal aspect of the maxilla, and
the most common location is the tuberosity area. Multiple
exostoses occasionally occur in the same individual. They
may appear as isolated, discrete bony overgrowths on the fa-
Figure 2 Buttressing bone formation around the teeth subjected
cial aspect of alveolar bone in young, dentate subjects or as
to trauma from occlusion.
somewhat less usually found multiple exostosis in maxilla
(torus palatinus) and in mandible (mandibular tori).2
Glickman & Smulow divided buccal alveolar bone alveolar process from the first molar to the tuberosity and cor-
enlargement into two subtypes-exostosis and lipping. Though related the presence of palatal exostoses to adverse surgical se-
their etiology is unknown, they considered it as buttressing quelae such as slow healing following palatal gingivectomies.
bone formation in response to trauma from occlusion and sug- He indicated that unrecognized palatal exostoses could impede
gested that such bone formation occurs with the purpose of pocket elimination by gingivectomy, and he described a tuber-
reinforcing bony trabeculae for functional adaptation osity flap approach to thin the palatal flap and gain access to
(Fig. 2).3 Other types of bony exostosis have been found asso- the exostoses.6 Removal of these exostoses may be difficult
ciated with unusual postoperative conditions. These exostoses when compounded by lack of access, restricted opening by
are often encountered during periodontal diagnosis and the patient, or the relative immobility of palatal tissue. Re-
treatment. moval of these exostoses can also assist with the flap adapta-
Mandibular and palatal tori are often obvious, and may re- tion during periodontal surgery. They may also serve as
quire removal for prosthetic reasons. In contrast, the more useful sources of autogenous bone for grafting during peri-
common palatal tubercle is less evident externally but is usu- odontal7 or implant surgery or for restoration of alveolar de-
ally encountered during palatal flap reflection in the posterior fects. To avoid surgical surprises, careful palpation or
maxilla. Schluger et al. stated that flat, shelf-like bony excres- sounding of the palatal alveolar bone prior to surgery should
cences are commonly found on the palatal alveolar bone from be considered to detect this common exostosis as these may
the mesial side of the second molar to the tuberosity.4 Prichard present the surgeon with special difficulties in flap manage-
also noted that discrete osseous nodules are often found on the ment. Sonnier et al.2 stated that the finding of a high frequency
palatal side of maxillary molars and may require removal dur- of palatal exostoses in their study specimens is of practical sig-
ing corrective periodontal surgery.5 He further stated the nificance with respect to planning periodontal surgery in the
importance of avoiding damage to the structures in the region posterior maxilla.
of the greater palatine foramen while removing these Buccal exostoses are significant with regards to prostho-
exostoses. The anatomic location of the tubercle is generally dontics because they may interfere with denture insertion.
immediately lateral to the greater palatine foramen and palatal Also, buccal exostoses may be traumatized and interfere with
to the second to third molar. Removal of this tubercle is often oral hygiene procedures.2 Other exostoses such as mandibular
necessary to ensure proper healing, but caution must be and palatal tori may require surgical removal for prosthetic
exercised to avoid injury to the greater palatine artery. Corn6 reasons.
also cited a high incidence of large exostoses on the palatal
1.1. Prevalence of exostoses

In 1972, Larato studied 145 skulls of Mexican origin and

found that 30% of these skulls had palatal exostoses in the
posterior maxillary alveolar process.8 These exostoses were
classified as small nodules, large nodules, spikes, sharp ridges,
and combinations of the above. No specific measurements of
size were recorded. In 1977, Nery et al. examined 680 skulls
of various ethnic origins and found that 40.5% had palatal
exostoses.9 They found the highest prevalence in the skulls of
European and Oceanic-Asian specimens (46%) while those
of African or South American origin had a prevalence of
26%. The exostoses were also classified into 5 categories with
respect to size and shape. In one study involving U.S. popula-
tion, palatal tori were more prevalent among American Indi-
Figure 1 Mandibular Tori. ans, Eskimos, and among women. Mandibular tori were also

Please cite this article in press as: Smitha K, Smitha GP Alveolar exostosis – revisited: A narrative review of the literature, The Saudi Journal for
Dental Research (2014), http://dx.doi.org/10.1016/j.sjdr.2014.02.001
Alveolar exostosis – revisited: A narrative review of the literature 3

more prevalent in Eskimos and Aleuts, but with similar prev- responsible must first reach a threshold level before the genetic
alence in males and females.10 A clinical study by King and factors can express themselves in the individual; hence, both
More reported that African-Americans had approximately genetic and environmental factors determine expressivity,
25% fewer mandibular tori than Caucasians. In this study making the etiology multifactorial.13,33 Antoniades et al
on 100 American males and 100 females, they found that hypothesized that the quasi-continuous model of inheritance
42% of females and 25% of males had palatal tori, but no sig- or threshold may also apply to BBE and palatal exostoses.33
nificant gender difference was found in the prevalence of man- The mechanism for proposed buttressing bone formation phe-
dibular tori.11 A study of 1272 dry skulls of white, black, and nomenon is still unclear, but evidence suggest that bone flexion
Chinese groups from South Africa by Touyz and Tau12 found could result in the release of bone morphogenic proteins,
that palatal exostoses occurred most frequently in whites which could stimulate bone growth, express as thickening, lip-
(35%), followed by Chinese (25%) and then in blacks (13%). ping or exostosis at a point of stress.19 Some observation sug-
Haugen found in a clinical study that females had a signifi- gest that the internal functional stresses associated with dental
cantly higher percentage of both palatal and mandibular tori, implant may also prevent otherwise expected alveolar bone
13
while Eggen and Natvig14 and Levesque15 found a greater loss.34 Studies reviewed by Marx and Garg indicated that
percentage of mandibular tori in males. Eggen and Natvig16 mechanical factor of micro strain could have a significant ef-
study found a significant correlation between the presence of fect on bone modeling. When mechanical loads are low (less
teeth and the presence of mandibular tori. Eggen17 found that than 0.2% deformation), bone atrophy occurs; when normal
in dentate patients, the presence of mandibular tori signifi- mechanical loads are experienced (0.2–0.25%) normal bone
cantly correlated to normal alveolar bone height around teeth. turnover occurs; when higher mechanical loads occur (0.25–
Kolas et al.18 found the prevalence of palatal tori to be 21%. 0.4%) bone hypertrophy occurs with increased lamellar bone
The prevalence and features of 3 types of exostoses that are and when pathologically higher loads are imposed (more than
commonly encountered during periodontal surgery were stud- 0.40%) woven bone formation occurs.7,35 These findings are
ied in a sample of 328 modern American skulls.2 The relation- consistent with those of Pietrokovsky and Massler36 who ob-
ship to teeth or other skeletal structures was also recorded. served that following extraction alveolar bone becomes
Palatal tubercles were observed in 56% of all skulls (69% of atrophic and resorbs.
all dentate skulls), with higher prevalence among males and
African-Americans. Palatal tubercles were commonly associ- 1.3. Exostoses as a post operative squeal of dental treatment
ated with second and third molars, and were usually directly procedures
lateral to the greater palatine foramen and at mean of distance
of 11.4 mm from it.2 Mandibular tori were observed in 27% of Bony exostosis development secondary to soft tissue graft pro-
all skulls (42% of dentate skulls), with higher prevalence seen cedures has been reported in a small number of cases as a con-
among African-Americans and males.2 BBE are found less sequence of shallow vestibules which were treated with the use
commonly than tori.10 In contrast to this, a study on 52 skull of skin grafts37,38 subsequent to connective tissue graft39 and
with intact dentition by Horning, Cohen and Neils19 observed subsequent to free gingival grafts40–43 since 1991 when the first
the presence of BBE or lipping fairly commonly with 76.9% of two cases were described.
all the specimens having at least one. BBE were found associ- Efeoglu and Demirel state that ‘it is also possible that other
ated with 7% of all teeth and lipping was found associated clinicians might have assumed the thick gingival grafts they saw
with 17.6% of all the teeth. Basha and Dutt reported a rare during their patients’ postoperative visits were not thick soft tis-
case of BBE at the angle of the mandible.20 sue grafts, but were, in reality, exostoses.41 Czuszak et al.42 sug-
gested that this exostoses development may be coincidental
1.2. Histological characteristics of exostoses and not due to free gingival graft (FGG). Otero-Cagide et al.43
speculated that the bone formation after an FGG may be the
The histologic features of tori and other types of exostoses are result of a periosteal trauma combination during site prepara-
identical.21 These are described as hyperplasic bone, consisting tion and the activation of osteoprecursor cells contained in the
of mature cortical and trabecular bone.21,22 connective tissue of the graft.40 Chambrone and Chambrone44
Etiology: The etiology of tori has been investigated by sev- suggest that patients presenting tori or any kind of bony exos-
eral authors; however, no consensus has been reached. Some of tosis are highly susceptible to bony overgrowth responses.
the postulated causes include genetic factors,22–26 environmen- Echeverria et al.45 previously noticed that the exostoses that
tal factors,11,13,14 masticatory hyperfunction,11,16,27–29 and have been related after an autogenous FGG were most com-
continued growth.30 Several authors have postulated that the monly located in the cuspid-premolar area. They suggested
etiology of tori consists of an inter-play of multifactorial genet- that the grafted areas may be influenced by factors acting at
ic and environmental factors. 13,21,31,32 The role of nutrients in this level, e.g., excessive forces, surgical trauma and genetic
the etiology of tori has been reviewed by Eggen et al.16 who factors. Among the related reports, all the authors suggest that
suggested saltwater fish consumption in Norway possibly sup- the periosteal trauma seemed to be the main aetiological agent
plies higher levels of polyunsaturated fatty acids and Vitamin associated with the exostosis development.37–43 In cases of skin
D that is involved in bone growth which increases the chances grafts, the occurrence of periosteum fenestration after the graft
of tori. Gorsky et al.31 surmised that the etiology of this com- suture position has also been observed. This surgical trauma
mon osseous outgrowth is probably multifactorial, including can be associated with the liberation of osteoprogenitor cells
environmental factors acting in a complicated and unclear from the periosteum-bone interface inducing osteogenesis.43
interplay with genetic factors. The quasi-continuous genetic Subpontic osseous hyperplasia under fixed partial denture:
or threshold theory states that the environmental factors Caiman et al.46 showed radiographs of the first case of osseous

Please cite this article in press as: Smitha K, Smitha GP Alveolar exostosis – revisited: A narrative review of the literature, The Saudi Journal for
Dental Research (2014), http://dx.doi.org/10.1016/j.sjdr.2014.02.001
4 K. Smitha, G.P. Smitha

hyperplasia under a fixed partial denture in 1971. In 1975, models, and whitening trays, stock impression trays often can-
Staphne and Gibilisco47 showed a similar radiograph of osse- not be seated to the depth, because of the interference by these
ous growth under the pontic of a fixed partial denture. Subse- bony anatomical variants. These bony protuberances may
quently, in 1981, Strassler48 demonstrated radiographs of a cause pain during the impression making, as there is often only
case with osseous deposition under the pontics of bilateral a thin oral mucous membrane covering these osseous protu-
bridges in the mandibular left and right molar regions. berances which is easily irritated.57 Mandibular tori can pres-
Burkes et al.49 reported clinical and radiographic findings ent significant challenges for endotracheal intubation58 and
of nine cases with bone growth in an edentulous region of laryngoscopy.59 Lingual tori and palatal exostosis may also
the posterior mandible covered with a pontic, and proposed limit the space for the tongue and can result in speech imped-
that the reasons for such bone growth could include genetic iment. Boksman and Carson presents a new approach to tak-
predetermination, functional stresses, and chronic irritation. ing impressions of exostosis, torus mandibularis, torus
Evaluation of the 12 cases reported in the above-mentioned re- palatinus and mal-positioned teeth, which incorporates the
ports revealed that osseous hyperplasia under the pontic of a use of a disposable heat mouldable tray.60 Even though these
fixed partial denture was seen only in adults, in the mandibular bony areas can create a clinical challenge with impression mak-
molar or premolar region with a variety of pontic designs. A ing, these areas are prime sites for harvesting autogenous bone
case of osseous hyperplasia under the pontics of fixed partial for bone grafting for dental implants placement,61 alveolar
dentures in right and left mandibular first molar regions was ridge augmentation and maxillary sinus lifting,62 periodontal
presented.50 Radiographs showed hemispherical radio opaci- osseous defect 63 and can be used for multiple reconstructive
ties on the alveolar ridges. Histological examination revealed uses such as nasal reconstruction.64
the lesions were composed of a dense mass of mature bone
with well-developed lamellae and haversian systems, viable 2. Conclusion
osteocytes in lacunae and a few marrow spaces filled with loose
fibrous connective tissue.50 Lorenzana and Hallmon reported a An exostosis is described as a localized peripheral overgrowth
case of subpontic osseous hyperplasia occurring on the edentu- of bone, the base of which is continuous with the original
lous ridge beneath a fixed partial denture replacing a mandib- bone. The etiology of oral bony exostosis is still not clear.
ular first molar in a 56 year old women, which was surgically Race, autosomal dominant factors, dental attrition, and even
removed. They reported no re-occurrence even after 1 year nutritional factors have been suggested as having an influence.
postoperatively.51 Islam et al. reported 3 cases of subpontic Exostoses should be differentiated from an osteoma, an
hyperplasia. Out of the 3 cases, one of the case was on bis- uncommon finding which produces a similar clinical, radio-
phosphonate and the authors speculated that the benign bone graphic, and histologic picture. Osteomas are benign, develop-
overgrowth under the pontic could be due to the medication mental neoplasms which induce proliferation of dense,
that the case received.52 Aydin et al. presented three cases of compact or coarse, cancellous bone usually in an endosteal
subpontic hyperplasia occurring on the edentulous ridge be- or periosteal location. A patient should be evaluated for Gard-
neath a fixed partial denture. One of the case presented by ner syndrome if they present multiple bony growths or lesions
them had the hyperplasia in the maxillary arch, the second case not in the classic torus or locations. Intestinal polyposis and
in the dental literature53 and the first being reported by Frazer cutaneous cysts or fibromas are other common features of this
et al.54 Conservative surgical removal with bony recontouring autosomal dominant syndrome.The clinical importance of
and with relief of prosthesis-induced mechanical stresses is the exostosis lies in surgical removal of these to permit proper flap
treatment of choice, with occasional recurrences expected. adaptation, most importantly in the posterior maxilla, and to
A case report55 reported a case of exostosis following a the potential use of the mandibular and palatal tori as sources
traumatic blow and speculated it to be due to combination of autogenous cortical bone for grafting.
of trauma, occlusal stresses and genetic factors. Another case
report56 reported a case of alveolar exostosis following ortho-
Conflict of interest
dontic implant placement.

1.4. Clinical management of alveolar exostosis None.

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Please cite this article in press as: Smitha K, Smitha GP Alveolar exostosis – revisited: A narrative review of the literature, The Saudi Journal for
Dental Research (2014), http://dx.doi.org/10.1016/j.sjdr.2014.02.001
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Please cite this article in press as: Smitha K, Smitha GP Alveolar exostosis – revisited: A narrative review of the literature, The Saudi Journal for
Dental Research (2014), http://dx.doi.org/10.1016/j.sjdr.2014.02.001