Prevalence of Torus Mandibularis in

Young Healthy Dentate Adults

Koji Morita, DDS, PhD,* Hiroki Tsuka, DDS, PhD,y Tomoaki Shintani, DDS, PhD,z
Mitsuyoshi Yoshida, DDS, PhD,x Hidemi Kurihara, DDS, PhD,k
and Kazuhiro Tsuga, DDS, PhD{
Purpose: There have been only a few reports on the prevalence of torus mandibularis (TM) in young
adult patients, and TM can have various adverse effects on oral and occlusal states in middle-age patients.
This study was designed to determine the association between TM status and oral and occlusal states in
young healthy dentate adults.
Materials and Methods: This was a cross-sectional study; the sample population included students at
Hiroshima University (Hiroshima, Japan) who participated for practical education. The predictor variables
in this study included oral symptoms (temporomandibular joint noise, tooth clenching and grinding,
buccal mucosa ridging, dental attrition, and tongue habit), oral anatomy (occlusal vertical dimension),
and oral function (average occlusal pressure, occlusal contact area, and maximum voluntary tongue pres-
sure). The outcome variable was TM status (present or absent). Additional variables were demographic in
nature and included age, number of residual teeth, body weight, and gender. These variables were
compared among participants with and without TM using univariate analysis and multiple logistic regres-
sion analysis. Statistical analyses were carried out using SPSS Statistics 19 for Windows (IBM Corp, Armonk,
NY); a P value less than .05 was considered significant.
Results: Of 204 participants included in the study, 50% were men and 50% were women. The mean age
was 22.4  2.7 years. TM was present in 119 (58.3%). Multiple logistic regression analysis showed that TM
status was associated with dental attrition and occlusal contact area (P < .05).
Conclusions: This study showed that TM was present in more than half the young healthy dentate
participants and was closely associated with dental attrition and occlusal contact area. This study will
provide readers with useful information to help prevent the development of TM before middle age.
Ó 2017 The Authors. Published by Elsevier Inc. on behalf of American Association of Oral and Maxil-
lofacial Surgeons. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
J Oral Maxillofac Surg 75:2593-2598, 2017

*Assistant Professor, Department of Advanced Prosthodontics,
Applied Life Sciences, Institute of Biomedical and Health Sciences,
Hiroshima University, Hiroshima, Japan.
yAssistant Professor, Department of Advanced Prosthodontics,
Applied Life Sciences, Institute of Biomedical and Health Sciences,
Hiroshima University, Hiroshima, Japan.
zAssistant Professor, Center of Oral Clinical Examination,
Hiroshima University Hospital, Hiroshima, Japan.
xAssociated Professor, Department of Advanced Prosthodontics,
Applied Life Sciences, Institute of Biomedical and Health Sciences,
Hiroshima University, Hiroshima, Japan.
kProfessor, Center of Oral Clinical Examination, Hiroshima
University Hospital, Hiroshima, Japan.
{Professor, Department of Advanced Prosthodontics, Applied
Life Sciences, Institute of Biomedical and Health Sciences,
Hiroshima University, Hiroshima, Japan.
Conflict of Interest Disclosures: None of the authors have a rele-
vant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Morita:
Department of Advanced Prosthodontics, Applied Life Sciences,
Institute of Biomedical and Health Sciences, Hiroshima University,
1-2-3 Kasumi, Minami-Ku, Hiroshima, 734-8553, Japan; e-mail:
moritak@hiroshima-u.ac.jp
Received December 26 2016
Accepted April 24 2017
Ó 2017 The Authors. Published by Elsevier Inc. on behalf of American
Association of Oral and Maxillofacial Surgeons. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
0278-2391/17/30500-1
http://dx.doi.org/10.1016/j.joms.2017.04.044

2593
2594
Torus mandibularis (TM) is a form of exostosis caused
by the development of extra bone mainly observed in
the lingual region of the mandibular bone in middle-
age patients.1,2 TM is frequently encountered in
clinical practice but is not considered a pathologic
condition.3 However, TM can affect pronunciation,
interfere with swallowing, and cause pain in the
mucosa under improperly designed prostheses.4
Moreover, it has been associated with temporoman-
dibular disorder, orofacial pain, and bone grafting for
implant treatment.5,6
The development of TM can be due to genetic fac-
tors, including gender and ethnicity; environmental
factors, such as the survival rate of teeth and malnutri-
tion; or functional factors, such as clenching and
grinding.7-10 However, only a few studies have
reported on the prevalence of TM in young adults. In
addition, to the best of the authors’ knowledge, no
studies have evaluated oral and occlusal status in
relation to TM. The purpose of this study was to
measure the difference in oral and occlusal status of
young healthy dentate adults with and without TM.
The authors hypothesized that young adults with TM
would have a specific oral and occlusal status. If
true, then this study could provide useful
information to prevent the development of TM in
patients until middle age. The specific aim of this
study was to determine differences in oral
symptoms, oral anatomy, and oral functions related
to TM.
Materials and Methods
STUDY DESIGN AND SAMPLE POPULATION
To address the research purpose, the authors de-
signed and implemented a cross-sectional study. The
study population consisted of dental students who
presented at the Hiroshima University School of
Dentistry (Hiroshima, Japan) from June 20, 2015
through June 20, 2016. The prospective study partici-
pants included all students who participated to ac-
quire early practical exposure. Participants who met
the following criteria were included in this study: 1)
younger than 40 years, 2) complete dentition with
no symptoms, and 3) no history of orthodontic treat-
ment. The exclusion criteria were severe periodonti-
tis, tooth pain, or history of orthodontic treatment;
no participants were excluded. Before this study, the
authors explained the purpose and methodology of
the study to the participants. All participants signed
a consent form before being enrolled. This study was
approved by the medical ethics committee of Hirosh-
ima University Hospital (number 920) and conformed
to Strengthening the Reporting of Observational
Studies in Epidemiology (STROBE) guidelines.11
TORUS MANDIBULARIS IN HEALTHY DENTATE ADULTS
STUDY VARIABLES AND DATA COLLECTION
METHODS
The predictor variables in this study included oral
symptoms (temporomandibular joint [TMJ] noise,
tooth clenching and grinding, buccal mucosa ridging
[BMR], dental attrition [DA], and tongue habit), oral
anatomy (occlusal vertical dimension [OVD]), and
oral function (average occlusal pressure [AOP],
occlusal contact area [OCA], and maximum voluntary
tongue pressure [MVTP]). Four dentists examined the
participants. One performed interviews (K.K.); one
performed oral examinations (H.T.); one measured
OVD, AOP, and OCA (K.M.); and one measured
MVTP (T.S.).
All participants were interviewed using the authors’
original questionnaire on oral symptoms, such as TMJ
noise and tooth clenching or grinding. The presence
or absence of oral symptoms, including TMJ sounds,
tooth clenching or grinding, and tongue habit, were
determined with the following questions: 1) Have
you ever noticed a clicking or crepitus sound while
opening or closing your jaw? 2) Have you ever been
aware of tooth clenching or grinding during the day
or at night? 3) Does the apex of your tongue touch
your teeth during swallowing?12-15
BMR was defined as linear thickening where the
teeth occlude on the buccal mucosa, according to a
previous report.16 DA was defined as atypical wear pat-
terns on the incisal edges and cusp tips; the degree of
wear was scored from 1 to 4 in accordance with a
modified version of the Smith and Knight Tooth
Wear Index.17,18 OVD was measured as the distance
from the subnasal point to the chin using vernier
calipers (Tsubone Bite Gauge, YDM Corporation,
Tokyo, Japan). The oral function test was performed
as follows: the Frankfort horizontal plane of each
participant while sitting in a dental chair was parallel
to the horizontal plane, and participants were asked
to bite down on pressure measurement film (Dental
Prescale 50H, GC, Tokyo, Japan) for 3 seconds with
maximum voluntary effort. AOP and OCA were
analyzed by measuring the density and area of red
patches on the film from the 3 readings collected
from the occluding pressure measurements using an
occlusal force measuring system (Occluser 709, GC,
Tokyo, Japan). The validity, reliability, and
reproducibility of this method have been described
previously.19,20 Each intraclass correlation (ICC) for
AOP and OCA showed excellent single agreement
(ICC, 0.956; 95% confidence interval [CI], 0.945-
0.966; ICC, 0.917; 95% CI, 0.872-0.947).
To determine MVTP, participants were asked to
compress the balloon of the probe against their palate
with maximum voluntary effort for 7 seconds. MVTP
was evaluated as the average of 3 measurements using
MORITA ET AL
a handy tongue pressure-measuring device and a
disposable balloon probe (TPM-01, JMS, Hiroshima,
Japan). The authors also confirmed the reliability of
MVTP measurements in this study. The validity, reli-
ability, and reproducibility of this method have been
described in previous reports.21,22 The ICC for MVTP
showed good single agreement (ICC, 0.882; 95% CI,
0.854-0.906).
The other variables were demographic and
included age, number of residual teeth, weight, and
gender. All participants were interviewed using the au-
thors’ original questionnaire, including demographic
information.
The outcome variable was the presence of TM. TM
status was identified with the naked eye and palpation
of the unilateral or bilateral form. Determination of the
presence or absence of TM was scored from 0 to 3 in
accordance with the Igarashi Torus Index.23 This in-
dex denotes class 0 as no TM recognized visually or
by palpation, class 1 denotes TM recognized only by
palpation, class 2 denotes a visually perceptible TM
high enough for a clear shadow to be seen on the sur-
face of the mandible, and class 3 denotes a visually
perceptible TM whose contour can be completely
traced visually around the base of the TM. This study
used the same scale in which class 0 was defined as
the absence of TM and classes 1 to 3 denoted detection
of TM.
DATA ANALYSES
Spearman rank correlation coefficient test, c2 test,
and Mann-Whitney U test were used for the compari-
son of each variable in participants with versus
without TM; a P value less than .05 was considered sig-
nificant. After adjusting for confounders, odds ratios
and 95% CIs were calculated using multiple logistic
regression analysis to show the association between
predictor variables and the outcome variable. Statisti-
cal analyses were conducted using SPSS Statistics 19
for Windows (IBM Corporation, Armonk, NY).
Results
In total, 204 participants were included in this study,
consisting of 102 men and 102 women with a mean
age of 22.4  2.7 years, a mean number of residual
teeth of 28.8  2.0 and a mean body weight of
57.7  9.9 kg (Table 1). The association between
age, number of residual teeth, weight, and gender
and the predictor variables is presented in Table 2.
TM was identified in 119 participants (58.3%) and
absent in 85 (41.7%). The association between age,
number of residual teeth, weight, and gender and
the outcome variable is presented in Table 3. The re-
sults of the multivariate analysis between all predictor
variables and TM status are presented in Table 4. Some
2595
partial correlation coefficients were negative, suggest-
ing multicollinearity. The multiple logistic regression
analysis showed that DA and OCA were significantly
associated with TM (P < .05) in Table 5.
Discussion
The purpose of this study was to measure the differ-
ence of oral and occlusal states in young healthy den-
tate adults with and without TM. The authors
hypothesized that young adults with TM would have
specific oral and occlusal states. If so, then this study
should provide useful information to prevent the
development of TM until they reach middle age. The
specific aim of the study was to determine differences
in oral symptoms, oral anatomy, and oral function. The
results of this study showed that TM status was closely
associated with DA and OCA in young healthy dentate
adults. Multiple logistic regression analysis showed
that participants with TM had markedly increased
DA and OCA.
TM was not associated with TMJ sounds, tooth
clenching or grinding, or tongue habit among the par-
ticipants in this study. These oral parafunctions are
strongly associated with bruxism.24-26 Bruxism can
change oral and occlusal states, such as BMR, DA,
AOP, and OCA, over time.16,27-30 It could be the
reason TM status has been strongly associated with
TMJ sounds and tooth clenching or grinding in
middle-age patients. In addition, there was no relevant
difference in OVD in participants with versus without
TM. OVD has been reported to be closely associated
with jaw size, which was one of the genetic factors
examined in this study.31,32 This result suggests that
TM status might not be due solely to genetic factors
such as OVD.
These results suggest that TM status is closely asso-
ciated with DA and OCA. DA and OCA also were
closely associated with masticatory ability.33 Mechani-
cal stimulation from a large number of occlusal
contacts from mastication could induce the
Table 1. DESCRIPTIVE SUMMARY OF STUDY SAMPLE
Study Variables Descriptive Statistics
Sample 204 (100)
Age (yr) 22.4  2.7
Residual teeth (n) 28.8  2.0
Body weight (kg) 57.7  9.9
Men 102 (50.0)
Note: Data are presented as number (percentage) or
average  standard deviation.
Morita et al. Torus Mandibularis in Healthy Dentate Adults. J Oral
Maxillofac Surg 2017.
2596 TORUS MANDIBULARIS IN HEALTHY DENTATE ADULTS

Table 2. AGE, NRT, BW, AND MALE GENDER VERSUS PREDICTOR VARIABLES

TJN C or G BMR

Variable Present Absent P Value Present Absent P Value Present Absent P Value

Age 23.5  3.0 22.1  2.5 .003y 23.5  2.7 21.9  2.5 <.01y 22.8  2.7 21.9  2.6 .016*
NRT 28.7  1.9 28.8  2.1 .434 28.5  2.0 28.9  2.0 .132 28.7  2.0 28.8  2.1 .746
BW 57.0  11.4 57.9  9.5 .414 56.3  10.9 58.3  9.4 .096 57.9  10.7 57.4  8.6 .883
Men 18 (37.5) 84 (53.8) .048* 26 (40.6) 76 (54.3) .070 60 (49.2) 42 (51.2) .775
DA TH

Variable Present Absent P Value Present Absent P Value

Age 24.1  2.6 22.0  2.5 <.01y 22.0  2.7 22.6  2.7 .121
NRT 28.8  2.3 28.7  2.0 .742 28.8  1.9 28.7  2.1 .812
BW 59.3  9.0 57.3  10.1 .145 57.0  11.4 58.0  9.2 .279
Men 21 (53.8) 81 (49.1) .593 26 (40.6) 76 (54.3) .070
OVD AOP OCA MVTP

Variable r P Value r P Value r P Value r P Value

Age 0.060 .393 0.028 .687 0.113 .108 0.156 .026*

NRT 0.076 .278 0.046 .510 0.178 .011* 0.178 .011*
BW 0.494 <.01y 0.080 .253 0.243 <.01y 0.461 <.01y
Men 0.479 <.01y 0.061 .387 0.208 .003y 0.525 <.01y
Note: Data are presented as number (percentage), r, or average  standard deviation.
Abbreviations: AOP, average occlusal pressure; BMR, buccal mucosa ridging; BW, body weight; C, tooth clenching; DA, dental
attrition; G, tooth grinding; MVTP, maximum voluntary tongue pressure; NRT, number of residual teeth; OCA, occlusal contact
area; OVD, occlusal vertical dimension; TH, tongue habit; TJN, temporomandibular joint noise.
*P < .05; yP < .01 by Spearman rank correlation coefficient test and c2 test.
Morita et al. Torus Mandibularis in Healthy Dentate Adults. J Oral Maxillofac Surg 2017.

development of TM. However, TM status was not asso-

Table 4. ALL PREDICTOR VARIABLES VERSUS TORUS
ciated with MVTP. MVTP has been shown to be closely MANDIBULARIS STATUS
associated with masticatory function in previous re-
ports.34 Further studies are necessary to show the as- Variable OR 95% CI P Value
sociation between TM status and masticatory
function to confirm this hypothesis. Oral symptoms
With TJN 0.583 0.271-1.256 .168
With C or G 1.268 0.593-2.712 .540
With BMR 1.846 0.941-3.622 .074
Table 3. AGE, NRT, BW, AND MALE GENDER VERSUS With DA 2.905 1.160-7.275 .023*
OUTCOME VARIABLE With TH 1.340 0.680-2.641 .397
Oral functions
With TM Without TM OVD (mm) 0.990 0.932-1.052 .742
Variable (n = 119) (n = 85) P Value AOP (N/mm2) 1.003 0.989-1.018 .642
OCA (mm2) 1.092 1.023-1.165 .008y
Age (yr) 22.7  2.6 21.9  2.7 .02* MVTP (kPa) 1.025 0.988-1.063 .186
NRT 28.9  2.0 28.6  2.0 .31
BW (kg) 58.8  10.1 56.2  9.5 .05 Note: Logistic regression analysis was used for all variables.
Men 65 (54.6) 37 (43.5) .12 Abbreviations: AOP, average occlusal pressure; BMR,
buccal mucosa ridging; C, tooth clenching; CI, confidence
Note: Data are presented as number (percentage) or interval; DA, dental attrition; G, tooth grinding; MVTP,
average  standard deviation. maximum voluntary tongue pressure; OCA, occlusal contact
Abbreviations: BW, body weight; NRT, number of residual area; OR, odds ratio; OVD, occlusal vertical dimension; TH,
teeth; TM, torus mandibularis. tongue habit; TJN, temporomandibular joint noise.
* P < .05 by Mann-Whitney U test and c2 test. *P < .05; yP < .01.
Morita et al. Torus Mandibularis in Healthy Dentate Adults. J Oral Morita et al. Torus Mandibularis in Healthy Dentate Adults. J Oral
Maxillofac Surg 2017. Maxillofac Surg 2017.
MORITA ET AL
Table 5. SUMMARY OF REGRESSION MODEL
Variable OR 95% CI P Value
Age 1.057 0.938-1.190 .364
DA 2.527 1.069-5.977 .035*
OCA 1.106 1.044-1.171 <.01y
Note: Stepwise logistic regression analysis was used.
Abbreviations: CI, confidence interval; DA, dental
attrition; OCA, occlusal contact area; OR, odds ratio.
*P < .05; yP < .01.
Morita et al. Torus Mandibularis in Healthy Dentate Adults. J Oral
Maxillofac Surg 2017.
This study had limitations. The study sample was
relatively small and included predominantly Japanese
students at Hiroshima University, which could limit
the ability to extrapolate the results to young adults
of all races. However, the prevalence of TM status
without gender differences was similar to results of
other studies.35-37 Therefore, the difference of race
might not have strongly influenced the results. The
authors did not examine malocclusion factors,25
such as crowding, overjet, overbite, or crossbite, other
parafunctions,29 eating habits,38 or genetic factors.36
However, to the best of the authors’ knowledge, no
studies have examined the influence of oral and
occlusal states on the development of TM, and this
study showed the association between TM status and
some oral and occlusal states for the first time.
TM was recognized in more than half the young den-
tate participants and was closely associated with DA
and OCA. Oral conditions, including mastication,
were found to be relevant factors in the development
of TM, even in young adults. Therefore, these factors
must be evaluated using longitudinal studies to deter-
mine a cause-and-effect relation.
Acknowledgments
The authors thank all the medical staff at the Department of
Advanced Prosthodontics, Hiroshima University for data collection
and engaged participation.
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