Buccal and palatal exostoses: Prevalence and concurrence with tori

Aree Jainkittivong, DDS, MS,a and Robert P. Langlais, DDS, MS, FRCD(C),b Bangkok,
Thailand, and San Antonio, Tex
CHULALONGKORN UNIVERSITY AND THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO

Objectives. The aims of this study were to investigate the prevalence and location of oral exostoses and the concurrence of
buccal and palatal exostoses with tori.
Study design. With clinical inspection and palpation, 960 Thais were examined for the presence or absence of torus palatinus
(TP), torus mandibularis (TM), and exostoses.
Results. Of the 960 subjects studied, 26.9% exhibited exostoses. Exostoses were more common in the maxilla than in the
mandible (5.1:1). In addition, most of the exostoses were located on the buccal aspect of the jaws. The prevalence of exos-
toses increased with age (P = .000). Exostoses were significantly more common in men than in women (62.4% vs 37.6%, P =
.000). Exostoses were concurrent with TM more frequently than with TP (36.2% vs 20.6%). The highest concurrence of exos-
toses with tori was observed in subjects who had both TP and TM (42.6%).
Conclusions. The occurrence of exostoses is related to increasing age. TM and exostoses may share the same causative
factors, and functional influences may contribute. Our findings lend support to the hypothesis that the etiology of exostoses
involves an interplay of multifactorial genetic and environmental factors.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:48-53)

Tori and exostoses are nodular protuberances of mature
bone, the precise designation of which depends on
anatomic location.1 Torus palatinus (TP) and torus
mandibularis (TM) are the 2 most common intraoral
osseous outgrowths.2,3 TP is a sessile, nodular mass of
bone that occurs along the midline of the hard palate.
TM is a bony protuberance located on the lingual
aspect of the mandible, commonly in the canine and
premolar areas. Buccal and palatal exostoses are
multiple bony nodules that occur less frequently than
tori.1,2,4 Buccal exostoses occur 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.2,5 The histo-
logic features of tori and other types of exostoses are
identical.2 These are described as hyperplastic bone,
consisting of mature cortical and trabecular bone.1
The etiology of tori has been investigated by several
authors; however, no consensus has been reached. Some
of the postulated causes include genetic factors,6-9 envi-
ronmental factors,10-12 masticatory hyperfunction,7,12-16
and continued growth.17 Recently, several authors have
postulated that the etiology of tori consists of an inter-
aAssociate Professor, Department of Oral Medicine, Faculty of
Dentistry, Chulalongkorn University, Bangkok, Thailand.
bProfessor, Department of Dental Diagnostic Science, The
University of Texas Health Science Center at San Antonio, San
Antonio, Texas.
Received for publication Nov 15, 1999; accepted for publication Jan
13, 2000.
Copyright © 2000 by Mosby, Inc.
1079-2104/2000/$12.00 + 0 7/13/105905
doi:10.1067/moe.2000.105905
play of multifactorial genetic and environmental
factors.2,12,18,19 Gorsky et al18 surmised that the etiol-
ogy of this common osseous outgrowth is probably
multifactorial, including environmental factors acting in
a complicated and unclear interplay with genetic
factors. The quasi-continuous genetic or threshold
theory states that the environmental factors responsible
must first reach a threshold level before the genetic
factors can express themselves in the individual; hence,
both genetic and environmental factors determine
expressivity, making the etiology multifactorial.12,19
The reported prevalence of tori varies among studies,
probably because of racial divergences or ethnic group
differences.7,9,20-22 The prevalence of TP and TM is
higher in Mongoloids than in Caucasoids.7,10,12,20,23,24
Gender differences in the prevalence of tori have also
been reported, and most authors found TP more
frequently in women, whereas TM was more common
in men.7,10,12,20,22,25-28 Tori are frequently observed in
young adults and in middle-aged persons.7,12,29 It has
been theorized that because some tori are found with
some frequency during the middle phase of life, this
indirectly suggests not only a genetic cause, but also
environmental and functional factors, particularly those
related to masticatory stress.12
Reports on the concurrence of TP and TM generally
describe a low frequency of occurrence, denoting a
nonsignificant correlation.12,20,29 However, Haugen12
reported that the probability of finding a TM in a
person with a TP was more than twice as high as in a
person without a TP, and vice versa. Based on this
evidence, Haugen12 stated that it was difficult to reject
a possible causal relationship between the occurrence

48
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 90, Number 1
of TP and TM. In addition, Reichart et al7 and Eggen
and Natvig29 demonstrated that the concurrence TP
and TM was statistically significant in women.
As with tori, many theories describe the etiology of
exostoses. It has been suggested that the bony out-
growth represents a reaction to increased or abnormal
occlusal stress to the teeth in the involved areas.1 A
correlation between the occurrence of tori and tooth
abrasion has also been reported as significant.13
Reichart et al7 detected a strong relationship between
dental attrition and the presence of tori in Thais but not
in German subjects; however, they stated that func-
tional influences should not be overestimated by this
single observation. Kerdporn et al16 also found a strong
association between the presence of TM with occlusal
stress indicated by the documentation of the pressure
of clenching and grinding. Because buccal and palatal
exostoses and TM are similar in morphology and loca-
tion, Antoniades et al3 hypothesized that the quasi-
continuous model of inheritance may also apply to
buccal and palatal exostoses.
Bouquot and Gundlach21 reported a 0.09% preva-
lence of buccal exostoses in white Americans, and
approximately 73% of the lesions were encountered on
the maxillary alveolus. They found no sex-specific
differences in prevalence. Larato5 found palatal exos-
toses in 30% of their sample, which consisted of
human skulls of Mexican origin. The highest occur-
rence (59.1%) was in adults 55 years old and older.
Nery et al30 examined 681 skulls of 4 ethnic groups
and reported a 40.5% incidence of palatal exostoses.
There were significant differences in the prevalence of
exostoses among the 4 ethnic groups. The Oceania-
Asia specimens (representing Mongoloids) showed the
highest incidence of palatal exostoses (47.2%),
whereas the Africans exhibited the lowest incidence
(25%). Based on these findings, Nery et al30 theorized
that a gene may play an important role in the causation
of palatal exostoses. Because the highest incidence was
reported in the 40- to 55-year-old age group (50.4%),
these authors suggested that an oral environment
exposed to more rigid functional activities may be a
contributing factor. Touyz and Tau31 reported a 14.5%
incidence of palatal exostoses in the skulls of blacks,
mixed whites, and Chinese, with a male to female ratio
of 3.5:1. Sonnier et al28 reported a 56% incidence of
palatal exostoses in modern American skulls, consis-
ting of whites and African Americans, with a higher
prevalence among men of both racial groups and
among African-Americans.
In a review of the literature, we found only 3 reported
cases describing the concurrence of tori with exostoses.
One case each of TP with palatal exostoses was
reported by Topazian and Mullen17 and by Blackmore
Jainkittivong and Langlais 49
et al32 in 1975. Recently, Antoniades et al3 described a
third case of concurrence of TP with palatal and buccal
exostoses and surmised that the concurrence of tori with
exostoses in the same individual was a rare finding.
OBJECTIVES
Although exostoses are not a rare finding, relatively
few reports on these structures are available. The infor-
mation on the concurrence of tori with exostoses is
very limited because of the scarcity of cases reported in
the literature. From our observations, exostoses and the
concurrence of exostoses with tori in our Asian popu-
lation was not a rare finding (Fig 1). Thus, the aims of
this study were to investigate the prevalence and loca-
tion of the oral exostoses and the concurrence of buccal
or palatal exostoses with tori.
SUBJECTS AND METHODS
Our sample consisted of 960 Thai dental patients
attending the Oral Diagnosis Clinic in the Faculty of
Dentistry at Chulalongkom University. In order to give
equal weight to all age and sex groups, an equal number
of cases for each category was selected at random from
the accumulated data. The subjects were divided into 6
age groups: 13 to 19, 20 to 29, 30 to 39, 40 to 49, 50 to
59, and 60 years and older. The mean ages for men and
women was 40.1 ± 17.5 years and 39.9 ± 17.4 years,
respectively. All subjects were examined by 1 observer
(A. J.) for the presence or absence of tori and exostoses.
TP, TM, and buccal and palatal exostoses were diagnosed
by clinical inspection and palpation. Questionable tori or
exostoses were recorded as not present. The type of tori
and the location of the exostoses was recorded, and these
data were subsequently subjected to statistical analysis.
The chi-squared test was used to compare differences
between groups. Nonparametric correlation of variables
was tested by Kendall’s tau-b test. Significance for differ-
ences between groups was set at P < .05.
RESULTS
Exostoses
Of the 960 subjects studied, 258 (26.9%) exhibited
exostoses. There were 34 (3.5%) individuals who
presented with both maxillary and mandibular exos-
toses. Table I describes the distribution and frequency
of occurrence of exostoses in the maxilla and mandi-
ble. Exostoses were more common in the maxilla than
in the mandible (5.1:1). In addition, most of the exos-
toses were located on the buccal aspect of the jaws.
With respect to maxillary exostoses, there were 166
(17.3%) subjects with buccal exostoses, 21 (2.2%) sub-
jects with palatal exostoses, and 57 (11.9%) subjects
with both buccal and palatal exostoses. There were 48
(5%) subjects with mandibular exostoses.
50 Jainkittivong and Langlais ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2000

B C
Fig 1. Concurrence of TP and TM with multiple exostoses in Thai male, aged 56, showing large lobular TP
and extensive bilateral palatal exostoses (A), multiple nodular torus mandibularis (B), and multiple buccal
exostoses (C) along the right and left buccal surfaces of maxillary and mandibular alveolar ridges.

Table I. Distribution of subjects with exostoses in
maxilla and mandible
Location Buccal Palatal Buccal/palatal
Maxilla 166 (17.3%) 21 (2.2%) 57 (11.9%)
Mandible 48 (5%) – –
There were 34 patients with exostoses in both maxilla and mandible.
Table II shows the distribution of exostoses for various
locations according to sex. Exostoses were more
common in men than in women (1.66:1). Men also
showed a higher occurrence of exostoses in nearly all
locations. These differences between these findings were
highly significant at all levels of confidence (P = .000).
Table III shows the prevalence and distribution of
exostoses in 6 age groups. The highest incidence was
found in the 60 years and older group (21.7%),
whereas the 13- to 19-year-old age group displayed the
lowest frequency of occurrence (7.8%). The 30 to 39,
40 to 49, and 50 to 59 year age groups demonstrated a
similar frequency of occurrence. Thus the prevalence
of exostoses increases with age, indicating a relation-
ship between age and the occurrence of exostoses
(correlation coefficient = .123, P = .000).
Total
Concurrence of tori with exostoses
244 (25.4%)
48 (5%)
Table IV shows the association between the presence
or absence of tori and exostoses. Of 258 subjects with
exostoses, 234 (90.7%) had tori concurrent with exos-
toses, and only 24 (9.3%) subjects had no tori but
exhibited exostoses. This difference showed a strong
association between the occurrence of exostoses and
the presence of tori (correlation coefficient = .129, P =
.000). Also, exostoses were concurrent with TM signif-
icantly more frequently than with TP (39.5% vs 28.5%,
P = .000).
Table V summarizes the occurrence and location of
exostoses in subjects who had tori. Of the 418 subjects
with TP, 86 (20.6%) exhibited exostoses. In this TP
group, there were 84 (20.1%) subjects with maxillary
exostoses and 7 (1.7%) with mandibular exostoses.
With respect to maxillary exostoses, 62 (73.8%)
subjects had buccal exostoses, 10 (11.9%) subjects had
palatal exostoses, and 12 (14.3%) subjects had both
buccal and palatal exostoses.
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Jainkittivong and Langlais 51
Volume 90, Number 1

Table II. Distribution of exostoses for various locations according to sex

Maxilla
Sex Subjects with exostoses Buccal Palatal Buccal/palatal Mandible Buccal
Men* 161 (62.4%) 99 10 41 37
Women* 97 (37.6%) 67 11 16 11
Total 258 (100%) 166 21 57 48
Some subjects exhibited exostoses in more than one location.
*Chi-squared value = 21.711; degree of freedom = 1; P = .000.

Table III. Distribution of exostoses for various locations according to age groups
Maxilla
Age group (y) Subjects with exostoses Buccal Palatal Buccal/palatal Mandible Buccal
13-19 20 (7.8%) 12 2 6 1
20-29 40 (15.5%) 26 3 10 2
30-39 44 (17.1%) 22 6 16 9
40-49 50 (19.4%) 32 7 7 9
50-59 48 (18.6%) 33 2 9 16
60 and older 56 (21.7%) 41 1 9 11
Total 258 (100%) 166 21 57 48
Some subjects exhibited exostoses in more than one location.
Correlation coefficient = .123; P = .000.

Of the 105 persons with TM, 38 (36.2%) exhibited Table IV. Association between presence or absence of
exostoses. In this TM group, there were 35 (33.3%) tori and exostoses
subjects with maxillary exostoses and 12 (11.4%) with Exostoses
mandibular exostoses. Regarding the maxillary exos-
Status Presence Absence
toses, there were 27 (77.1%) subjects with buccal exos-
TP 86 (33.4%) 332 (47.3%)
toses and 8 (22.9%) subjects with both buccal and
TM 38 (14.7%) 67 (9.5%)
palatal exostoses. TP/TM 110 (42.6%) 160 (22.8%)
Of the 270 persons with TP concurrent with TM, 110 No torus 24 (9.3%) 143 (20.4%)
(40.7%) exhibited exostoses. In this TP and TM group, Total 258 (100%) 702 (100%)
there were 103 (38.1%) subjects with maxillary exos- Correlation coefficient = .129; P = .000.
toses and 26 (9.6%) with mandibular exostoses.
Regarding the maxillary exostoses, there were 61
(59.2%) subjects with buccal exostoses, 9 (8.7%) study was performed on living subjects, whereas others
subjects with palatal exostoses, and 33 (32.1%) subjects used skulls. Also, when these bony prominences are
with both buccal and palatal exostoses. very small, they may be impossible to detect in vivo
Among the subjects with exostoses, exostoses were because the area where the palatal alveolar process
found most frequently in persons with TP concurrent meets the hard palate is covered by a thick wedge-
with TM (42.6%). shaped layer of gingival tissue. Interestingly, the
present investigators found that buccal exostoses were
DISCUSSION much more common than palatal exostoses in Thai
We included buccal and palatal exostoses in this subjects. In addition, 5.9% of our subjects exhibited
study and reported a prevalence of 26.9%. Previous both buccal and palatal exostoses. Our results were in
investigators focused only on palatal exostoses, and agreement with those of other researchers28,31 in that
their reported prevalences ranged from 0.09% to exostoses were found significantly more often in men
56%.5,21,28,30,31 In our study, the prevalence of palatal than in women. Because men had a higher frequency of
exostoses was 8.1%, which is lower when compared both exostoses and TM than did women and because
with other reports.5,28,30,31 This difference may be exostoses were concurrent more with TM than TP,
attributed to the different populations studied. Racial these findings support the hypothesis that TM and
and ethnic differences have been shown in other studies exostoses may share the same causative factors. Our
of exostoses.28,30,31 Another variable may be that our results are consistent with those of Larato5 and Nery et
52 Jainkittivong and Langlais
Table V. Distribution of exostoses for various locations in subjects who had tori
Status Subjects with exostoses
TP (n = 418) 86 (20.6%)
TM (n = 105) 38 (36.2%)
TP/TM (n = 270) 110 (40.7%)
Total (n = 793) 234 (28.2%)
Chi-squared value = 52.70; distribution factor = 3; P = .000.
al,30 who found that the prevalence of exostoses
increases with age. Therefore, we have concluded that
the occurrence of exostoses is related to increasing age.
In our study, the occurrence of exostoses appeared to
be stable during the middle phases of life (30 to 59
years), increasing slightly in the 60 years and older
group. This finding is in agreement with Larato5 but
contrasts with Sonnier et al,28 who noted the preva-
lence of exostoses decreased after 50 years of age and
who correlated this decreasing trend with edentulism.
We also surmise that functional influences may
contribute to the development of exostoses. We
observed an increasing correlation between marked
exostoses and a significant attrition of teeth in some
older subjects. This may be a similar phenomenon as
that which occurs in subpontic hyperostosis, which
postulates that stress causes the crestal alveolar bone to
grow under the pontic along a vector opposing the
forces of occlusion.33,34 Therefore, altered function
may lead to exostosis development in genetically
predisposed populations.
We observed the highest concurrence of exostoses and
tori in subjects who had concurrence of TP and TM. The
concurrence of palatal and buccal exostoses was also
found in 5.9% of subjects in our study. This evidence
supports the suggestion by Nery et al30 that this group
may represent a general multiple exostoses syndrome.
Sonnier et al28 stated that the finding of a high
frequency of palatal exostoses in their study specimens
is of practical significance with respect to planning
periodontal surgery in the posterior maxilla. On the
contrary, we found more buccal exostoses than palatal
exostoses in our sample population. Buccal exostoses
are significant with regards to prosthodontics because
they may interfere with denture insertion. Also, buccal
exostoses may be traumatized and interfere with oral
hygiene procedures.
CONCLUSIONS
We have concluded that the occurrence of exos-
toses is associated with age. TM and exostoses may
share the same causative factors. Our findings
support the theory that the etiology of exostoses is
multifactorial including genetic and functional influ-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
July 2000
Maxilla
Buccal Palatal Buccal/palatal Mandible Buccal
62 10 12 7
27 0 8 12
61 9 33 26
150 19 53 45
ences. In cases of coexistence of multiple exostoses
and tori, this group may represent a general multiple
exostoses syndrome.
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Reprint requests:
Aree Jainkittivong, DDS, MS
Department of Oral Medicine, Faculty of Dentistry
Chulalongkorn University
Henri-Dunant Rd
Bangkok 10330
Thailand

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