Q U I N T E S S E N C E I N T E R N AT I O N A L
GENERAL DENTISTRY
Association between oral tori, occlusal force,
and mandibular cortical index
Ziad N. Al-Dwairi, BDS, MFDSRCS(Glasg), MFDSRCS Ed, PhD1/Ala’ N.F. Al-Daqaq, DDS, MclinDent (Prosthodontics)2/
Andrej M. Kielbassa, Prof Dr med dent Dr h c3/Edward Lynch, BDentSc, MA, FDSDentSc, PhD4
Objective: To assess possible associations between torus
palatinus (TP), torus mandibularis (TM), occlusal force (OF),
Klemetti’s classes, mandibular cortical index (MCI), and socio-
demographic variables in a selected sample of Jordanians.
Previous studies have suggested that oral tori are benign ana-
tomical variations probably related to several factors such as
functional stress, gender predisposition, number of teeth pres-
ent, and nutritional factors. Method and Materials: A total of
130 Jordanian adults were included. Shape, location, and
appearance of tori were recorded from study casts. Size was
measured using digital calipers. OF was recorded in Newtons.
MCI and Klemetti’s classification were assessed using panoramic
radiographs. Data were statistically analyzed, and level of signif-
Key words: Jordanian population, Klemetti’s classification, mandibular cortical index, occlusal force, oral tori
The etiology of oral tori has not been clearly determined,
and both genetic aspects1-4 and causes of multifactorial
origin are thought to be involved.2,4 Although some
1
Professor and Director of Dental Teaching Clinics, Department of Prosthodon-
tics, Faculty of Dentistry, Jordan University of Science and Technology (JUST),
Irbid, Jordan.
2 HAAD Licensed Dentist, Green Apple Dental Center, Al-Muroor st. Al-Mamoura,
Abu Dhabi University Building, Abu Dhabi, UAE.
3
Professor and Head, Centre for Operative Dentistry, Periodontology, and
Endodontology, University of Dental Medicine and Oral Health, Danube Private
University (DPU), Krems, Austria.
4 Professor and Principal Director of Biomedical and Clinical Research, School of
Dental Medicine, University of Nevada (UNLV), Las Vegas, NV, USA.
Correspondence: Professor Ziad N. Al-Dwairi, Department of Prosthodon-
tics, Faculty of Dentistry, Jordan University of Science and Technology, PO
Box 3030 code 22110, Irbid, Jordan. Email: ziadd@just.edu.jo
VOLUME 48 • NUMBER 10 • NOVEMBER/DECEMBER 2017
Ziad N. Al-Dwairi
icance was set at P < .05. Results: The mean ± SD recorded OF
was 524 ± 183 N in the tori group, compared to 417 ± 172 N in
controls (P = .001). OF was significantly higher in males com-
pared to females (P < .001), and was significantly higher in
subjects with TM only (543 ± 201 N) (P < .001). TP and TM were
predominantly more than 6 mm in size. The average OF in
subjects with Klemetti class 3 was 418 ± 174 N, while OF in
Klemetti class 1 subjects amounted to 535 ± 187 N (P = .043).
Conclusion: Average OF was significantly higher in tori sub-
jects and in males (if compared to controls and female subjects,
respectively). The presence of oral tori, Klemetti’s classification,
and MCI ratio seems to be positively correlated with OF.
(Quintessence Int 2017;48:841–849; doi: 10.3290/j.qi.a38856)
reports suggested that these nonpathologic, localized
exostoses arising from cortical bone may be related to an
autosomal4 (but nongonosomal5) dominant trait, environ-
mental and functional factors have been postulated that
may account for a more complex etiology than simply
genetics.2,6,7 Several other factors such as gender and age5-13
have been identified for oral tori, but this relationship
has not been confirmed unanimously.14-18 Beneath these
aspects, functional stresses, parafunctions, and mastica-
tory forces,12,16,19,20 temporomandibular joint (TMJ) pathol-
ogy,12 high bone mineral density (BMD),21 as well as nutri-
tional factors and marine diet5,20,22 may also be involved.
The prevalence of oral tori has been reported to be
quite common. In different ethnic groups, there is a
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wide variation, ranging from 1.3% for torus palatinus
(TP) in normal patients8 to 56.8% for torus mandibularis
(TM) in those with genetic predisposition,1 and with a
slight preponderance of mandibular tori.14,17,23 With an
increasing number of teeth, the frequency of bony pro-
tuberances would seem to be higher,24-26 but the latter
have been observed even with edentulous patients.10,27
There is a strong relationship between mandibular and
maxillary tori.7,17,21-23,27,28
It has been reported that panoramic radiographs
could be useful for identifying patients with low BMD
or osteoporosis.29,30 A simple method to classify the
radiographic image of the mandible is the mandibular
cortical index (MCI),31-34 which can be defined as the
ratio of the thickness of the inferior mandibular cortex
in the mental region over the distance between the
lower border of the mandible and either the inferior or
the superior border of the mental foramen.32 The
morphology of the mandibular inferior cortex can be
determined by observing both sides of the mandible
distally from the mental foramen using the classifica-
tion published by Klemetti and colleagues.34-36 The MCI
has been developed to assess osteoporosis in the corti-
cal area of the mandible based on panoramic radio-
graphs.35 MCI readings reflect the solidity of cortical
bone in the mandibular base, since structural changes
in cortical bone tissue are manifested by the resorption
both on the outer and inner sides of the mandibular
cortical layer.36 Both MCI and Klemetti’s classification
have been considered to be simple methods to assess
the radiographic image of the mandible as they can be
easily and effectively used by general practitioners and
dental specialists.35
Previously, there has been controversy regarding
the etiology of tori, even though their existence, histol-
ogy, and prevalence have been thoroughly investi-
gated. In particular, the relationships between oral tori,
occlusal force (OF), morphology of the inferior mandib-
ular cortex (Klemetti’s classification), and MCI have not
been previously studied. Therefore, this study aimed to
assess associations between TP and TM with age, gen-
der, body mass index (BMI), chewing side, OFs, Klemet-
ti’s classification, and MCI in a selected sample of Jorda-
842
nians. The null hypothesis stated that no relationship
exists between the OF and the occurrence of oral tori
and MCI in adult Jordanians. This null hypothesis was
tested against the alternative hypothesis of a difference.
METHOD AND MATERIALS
After obtaining ethical approval by the Institutional
Review Board of Jordan University of Science and Tech-
nology (Vote Number: GM7601), 130 subjects were
enrolled in this study (65 with TP and/or TM, and 65
controls matched for age and sex). Demographic data
obtained included age, gender, and chewing side. Sub-
jects’ ages ranged between 20 and 50 years. BMI of the
patients was classified according to the formula used
by the Centers for Disease Control and Prevention37 as
follows:
• Underweight: BMI ≤ 18.5
• Normal: 18.5 ≤ BMI ≤ 24.9
• Overweight: 25 ≤ BMI ≤ 29.9
• Obese: BMI ≤ 30.
Subjects were recruited from different areas in Jordan,
and examination was carried out at the Department of
Prosthodontics of the Jordan University of Science and
Technology. Participants included undergraduate and
graduate students, as well as patients seeking regular
dental treatment at the Faculty of Dentistry.
Subjects presenting with TP and/or TM, and having
at least a full set of first molars were included in the
study. Edentulous patients with partial or complete
dentures, subjects who were reported to have diurnal
or nocturnal bruxism or TMJ dysfunction, and subjects
with systemic disorders affecting bone density (endo-
crine, metabolic, or skeletal disorders, or any local bone
pathology) were excluded.
Clinical examination
Extraoral examination of the muscles of mastication
and TMJ was carried out to test for the presence of
pain, TMJ sounds, TMJ locking, ear pain, or headaches.
Tori were examined by clinical inspection and digital
palpation. This was followed by maxillary and mandib-
VOLUME 48 • NUMBER 10 • NOVEMBER/DECEMBER 2017

ular irreversible hydrocolloid impressions (Algeniux,
Major Prodotti Dentari). A study cast poured using
gypsum material (Elite Model, Zhermack) was used to
evaluate the location and size of TP and/or TM.
Occlusal force measurement
A portable OF gauge (GM10, Nagano Keiki) consisting
of a hydraulic pressure gauge, and a biting element
made of a vinyl material encased in a polyethylene
tube was used to measure the OF, which was displayed
digitally in Newtons.
Before recording the OF, subjects were seated in an
upright position and asked to perform their strongest
bite over the device (after previous training). The
OF-meter bite fork (GM10, Nagano Keiki) was covered
with a disposable plastic cap to prevent the individuals
from cross infection. The measurements were exclu-
sively performed at the first molar region. Two readings
were recorded on both the right and the left sides, re-
spectively, and an average was obtained.
Assessment of oral tori
Tori were assessed both clinically and on the casts for
size and site (unilateral or bilateral). The size of tori was
measured twice at the highest elevation of the out-
growth using calipers (Model 505, Mitutoyo) to the
nearest 0.01 mm. The average size of tori was recorded
and categorized according to the classification by
Reichart et al:18
• small (< 3 mm)
• medium (3–6 mm)
• large (> 6 mm).
Measuring MCI and Klemetti’s classification
All subjects were assessed for the MCI using an ortho-
pantomogram based on Klemetti’s classification.34 Pan-
oramic radiographs of subjects were obtained (Cranex
Tome Ceph, Soredex) at 63 to 83 kV and 10 mA for 10
seconds. The head of each subject was positioned so
that the line from the tragus to the outer canthus was
parallel to the floor; the anteroposterior position of the
subjects was ensured by placing the incisal edges of
their maxillary and mandibular incisors into the bite
VOLUME 48 • NUMBER 10 • NOVEMBER/DECEMBER 2017
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Al-Dwairi et al
block. All films were processed in an automatic x-ray
processor (Periomat Plus, Dürr Dental) with a process-
ing time of 2.45 minutes. Panoramic radiographs with
diagnostic contrast and density, and absence of pos-
itioning errors, were evaluated by two consultant
radiologists. The morphology of the mandibular infer-
ior cortex was determined by assessing both sides of
the mandible distally from the mental foramen.34
• C1: The endosteal margin of the cortex is even and
sharp on both sides (Fig 1a)
• C2: The endosteal margin shows semilunar defects
(resorption cavities) with cortical residues one- to
three-layers thick on one or both sides (Fig 1b)
• C3: The cortical layer contains heavy endosteal cor-
tical residues and is clearly porous (Fig 1c).
Panoramic radiographs of the two groups were mixed,
and calculations of MCI and Klemetti class morpholo-
gies were carried out independently by the two radiol-
ogists (with assured 1-week intervals). Each radiologist
examined the panoramic radiograph under the same
environment and using the same viewer. The MCI was
calculated for both right and left sides of the mandible
on panoramic radiographs as the ratio of the thickness
of the inferior mandibular cortex in the mental region
over the distance between the lower border of the
mandible and either the inferior or the superior border
of the mental foramen, as shown in Fig 2.
Statistical analysis
Data were analyzed using SPSS software application
(version 22.0, IBM). The weighted kappa index was used
as a measure of inter-observer agreement for Klemetti
class evaluation, while Pearson’s correlation coefficients
were used as a measure of inter-observer agreement in
the MCI measurements. Means ± standard deviations
(SDs) were calculated for continuous variables (such as
OF and age). A frequency distribution of categorical
variables was provided. One-way analysis of variance
(ANOVA) and independent sample’s t test analysis were
used to compare individual continuous variables by
presence of tori. Categorical variables’ association with
presence of tori was analyzed using chi-square
cross-tabulations together with Fisher’s exact test in
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Fig 1a Panoramic radiograph indicating Klemetti class 1: The
endosteal margin of the cortex is even and sharp on both sides.
Fig 1c Panoramic radiograph indicating Klemetti class 3: The
cortical layer contains heavy endosteal cortical residues and is
clearly porous.
case of cell counts less than 5. Values of continuous
variables are expressed as means ± SD, while categor-
ical distributions were expressed as n (%). The level of
significance was set at P < .05.
RESULTS
Controls were selected to match the tori subjects with
regard to gender, age, chewing side, and BMI. For this
reason, these aspects did not reveal any significant dif-
ferences (Table 1). In subjects with tori, OF on the right
side had a mean ± SD of 520 ± 190 N compared to
416 ± 188 N in the control group (P = .001), while the
mean on the left side was 582 ± 192 N compared to
417 ± 179 N in controls (P = .002). The average OF in
males was 572 ± 190 N and 411 ± 155 N in females
(P < .001). There was no significant association between
the average OF and any of the two chewing sides
(P = .273). In addition, there was a significant increase in
844
Fig 1b Panoramic radiograph indicating Klemetti class 2: The
endosteal margin shows semilunar defects (resorption cavities) with
cortical residues one- to three-layers thick on one or both sides.
the average OF from Klemetti class 3 to class 1 on both
the left (P = .010) and the right side (P = .043) (Table 2).
Overall, there was a significant correlation between the
average MCI ratio and OF on both left and right sides of
the mandible (P > .010) (Table 3).
The majority of oral tori (50% of TP and about 72%
of TM) were more than 6 mm in size, while only 16.7%
of TP and 10% of TM were less than 3 mm. There was a
significant difference between males and females in
the distribution of Klemetti classes on both the right
and the left sides of the mandible (P < .001). However,
Klemetti classes did not differ significantly with regard
to the preferred chewing sides (P < .050).
In addition, there was no significant difference
between the control and tori groups regarding average
MCI (P = .227). In females, the average MCI value was of
0.375, whilst in males it was 0.378 (P = .818). As for the
chewing side, there was no significant difference
between right and left sides regarding the average MCI.
In Table 4, with subjects of Klemetti class 1, the right
side MCI had a mean of 0.386 ± 0.1 in the tori group
compared to 0.364 ± 0.1 in the control group (P = .521).
In subjects with Klemetti class 2, the right side MCI had
a mean of 0.409 ± 0.1 in the tori group compared to
0.377 ± 0.1) in the control group (P = .146). However,
within each of the tori and control groups there was a
significant increase in the average MCI value from Kle-
metti class 3 to class 2 to class 1 (P > .05). A high level of
agreement (76%) was found between the two radiolo-
gists regarding Klemetti’s classification ratings and
calculation of the average MCI (P < .001).
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DISCUSSION
Several previous studies have been conducted to deter-
mine the prevalence of oral tori.1,3,5,7-11,13-18,20-25,27,28,38-40
The reasons behind the selection of the specific age
group assessed in the current study was related to the
hypothesis that oral tori occur in early adult life,6,17 as a
result of maturation of the dentition,26 the strength of
the jaw-closing muscles, the pain threshold of the sub-
jects,25 and/or the risk of reduction in BMD as result of
increased age.41,42
With regard to Jordanian patients, the prevalence of
TP and TM was studied in 338 edentulous subjects in
Jordan, and has been recorded as 29.8% for TP and
42.6% for TM. Both types of tori were associated with
each other in 27.7% of cases, with no significant differ-
ences between males and females, implying that a sex-
based factor has negligible influence on the prevalence
of tori.16 Based on these data, the tori and non-tori
(control) groups were matched in the present study
(see Table 1).
The requirement for a full set of first molars in the
present study was based on the effect the number of
teeth have on the presence of tori, as proposed by sev-
eral studies.24,26 In the first molar area, however, wide
variations in human OF measurement have been
recorded.43-45 Those variations can be explained by the
fact that these studies have been performed on differ-
ent populations using different measuring instruments
and techniques.46 The selection of first molars as the
preferred site for OF measurements was based on the
well-accepted concept that OF is regarded as highest in
that area, with a majority of vertical vectors of force. In
addition, variations in OF that can occur within differ-
ent regions of the oral cavity make the first molar area
the first choice position for maximum voluntary OF
measurements.47
The OF-meter used in the present study has been
recommended for measuring the OF of subjects in den-
tal research.43 In comparison to other devices such as
deformation sensitive piezoelectric film (bite fork),
novel miniature OF recorder, pressure-sensitive sheet
and tube, gnathodynamometer, quartz and foil force
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Fig 2 Calculating MCI on panoramic radiographs: The ratio of
the thickness of the inferior mandibular cortex in the mental
region (B) over the distance between the lower border of the
mandible (a) and either the inferior (I) or the superior (S) border
of the mental foramen.
transducer, strain gauge OF transducer, force sensitivity
resistor, or electromyogram, the GM10 OF-meter was
considered to be simple and accurate, and has repeat-
able measurements at the center of the bite element.
Its accuracy is position-sensitive, in particular in an-
terior/posterior areas to the center; the device does not
need a special mounting procedure, has a small thick-
ness (4.5 mm), does not interfere with the tongue, is
easy to change and to disinfect, and is easy to use and
carry around.44 The GM10 comprises an 8.6-mm-thick
bite fork and digital body. It has a high-precision load
cell and uses an electronic circuit for indicating force
providing precise measurements that are easy to read
from its digital screen. Moreover, this appliance pres-
ents a scale in Newtons.43
It is well known that OFs in living Inuits is surpris-
ingly high (if compared to non-circumpolar popula-
tions),48 and Alaskan Eskimos present high prevalence
rates of oral tori.18,38 Consumption of dry, raw, or frozen
food can lead to the production of increased loads,
and this would explain an increase in OF levels.49 In the
current investigation, the type of diet was not
recorded as all subjects were from the same demo-
graphic area, thus sharing similar eating habits. In a
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Table 1 Distribution of the study population by age, sex, body mass index (BMI), and chewing side

Parameter Control (n = 65), N (%) Tori (n = 65), N (%) P value

Female 41 (63.1) 41 (63.1)
Sex 1.000
Male 24 (36.9) 24 (36.9)
Underweight 4 (6.2) 3 (4.6)
Normal 37 (56.9) 44 (67.7)
BMI score .411
Overweight 18 (27.7) 16 (24.6)
Obese 6 (9.2) 2 (3.1)
20–29 43 (66.2) 44 (67.7)
Age group (y) 30–39 11 (16.9) 9 (13.8) .880
40–50 11 (16.9) 12 (18.5)
Both 24 (36.9) 30 (46.2)
Chewing side Left 15 (23.1) 12 (18.5) .553
Right 26 (40.0) 23 (35.4)

Table 2 The association between occlusal force (right side, left side, average) and other variables (sex, study
group, chewing side, Klemetti class)

Right side OF (N) Left side OF (N) Average OF (N)

Mean ± SD Mean ± SD Mean ± SD
Female 397.5 ± 154.3 424.0 ± 165.2 410.8 ± 154.9
Sex Male 589.4 ± 199.7 554.8 ± 209.9 572.1 ± 189.5
P value † < .001* < .001* < .001*
Control 416.4 ± 188.3 417.0 ± 178.6 416.7 ± 172.3
Group Tori 520.3 ± 189.5 527.6 ± 191.9 524.0 ± 183.0
P value † .002* .001* .001*
Both 503.3 ± 198.7 497.9 ± 198.0 500.6 ± 188.8
Left 434.5 ± 193.4 484.4 ± 203.3 459.5 ± 191.5
Chewing side
Right 448.4 ± 190.2 437.4 ± 179.5 442.9 ± 175.9
P value‡ .219 .265 .273
a a
C3 407.9 ± 193.3 419.9 ± 212.8 413.9 ± 188.3a
C2 455.1 ± 194.8a 464.9 ± 187.7ab 460.0 ± 186.2a
Klemetti class (left)
b b
C1 561.2 ± 169.6 543.5 ± 166.4 552.4 ± 154.2b
P value ‡ .006* .038* .010*
C3 415.1 ± 178.9a 421.5 ± 194.9a 418.3 ± 173.6a
C2 474.8 ± 193.3a 481.5 ± 187.6a 478.2 ± 185.1a
Klemetti class (right)
C1 539.1 ± 208.9b 531.7 ± 190.5b 535.4 ± 186.7b
P value ‡ .044* .073 .043*
†
Independent samples’ t test; *indicates significant associations (P < .05).
‡
One-way ANOVA (values with same superscript letters are not significantly different).

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Table 3 Association between occlusal force and mandibular cortical index in the study population

Parameter Right side OF (N) Left side OF (N) Average OF (N)

Pearson’s r .300** .250* .287**
Left MCI ratio P value .005 .021 .008
N 85 85 85
Pearson’s r .252* .230* .251*
Right MCI ratio P value .013 .024 .014
N 96 96 96
Pearson r .314** .67** .303**
Average MCI ratio P value .002 .008 .003
N 97 97 97
*Correlation is significant at the .05 level (two-tailed).
**Correlation is significant at the .01 level (two-tailed).

Table 4 Association between MCI value and Klemetti class on both the right and left sides of the mandible in
the study population

Control right MCI ratio Tori right MCI ratio

(mean ± SD) (mean ± SD) P value
C3 0.364 ± 0.0988a 0.386 ± 0.0711a .521
C2 0.377 ± 0.0772a 0.409 ± 0.0788a .146
Klemetti class (right)
b b
C1 0.461 ± 0.1100 0.499 ± 0.1536 .611
P value .031* .034*
C3 0.375 ± 0.0895a 0.389 ± 0.1138a .763
C2 0.372 ± 0.1034a 0.421 ± 0.0622a .058
Klemetti class (left)
C1 0.559 ± 0.1018b 0.523 ± 0.1216b .538
P value < .001* .005*
*Correlation is significant at the .05 level (two-tailed); values with same superscript letters are not significantly different.
**Correlation is significant at the .01 level (two-tailed).

previous study in Jordan, OF of subjects revealed a
mean of 573 ± 140 N.46 This was comparable to the
outcome of the current study; mean OFs of 524 ± 183 N
was measured in subjects with oral tori (compared to
417 ± 172 N in the control group), with significant dif-
ferences between males and females. The mean OF was
found to be higher in males compared to females. It has
been shown that muscle strength in males and females
was as strong and as large until puberty.50 Moreover, it
is believed that gender-related OF differences develop
during the post-pubertal period in association with
greater muscle development influenced by androgenic
steroids in males.48,49
Calibration between observers is an important issue
in measuring MCI and Klemetti’s classifications, and
many previous studies reported satisfactory levels of
inter- and intra-observer agreement.2,30,50 In the current
study, levels of inter-observer agreement were high
(76%). For the MCI measurements, inter-observer
agreement was 69% (when taking into account the
magnification coefficient based on the manufacturer’s
instructions). Moreover, BMD was significantly related
to MCI, thus indicating a direct association.
Regarding the distribution of oral tori in relation to
gender, the most common type of tori in females was
TP (compared to males). This is in agreement with pre-

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vious studies.11,22,26,28 Statistically, the tori group
revealed an increased OF of some 100 N compared to
the non-tori control group. Accordingly, the null
hypothesis stating “no relation between presence of
tori and OF” was rejected. The location of TP and TM
might suggest an exit-point for the force concentration
in these areas, and deposition of exostotic bone could
be stimulated by teeth, jaw bones, and/or muscles of
mastication, with continuing growth later during life.
This finding indeed does support the previously
reported concept that functional forces are important
factors in the etiology of oral tori.25,26
In terms of size, tori of more than 6 mm were the
most predominant finding of the present study, fol-
lowed by the 3- to 6-mm group, and finally the less
than 3-mm group. This observation is in contrast to a
previous investigation,28 and can be explained by skel-
etal and muscular maturation of an individual and the
structure and number of permanent teeth as they
reach adolescence.
Klemetti’s classification was positively correlated
with the average OFs. Also, a positive correlation was
found between MCI and the mean OF. This finding
might be interpreted as an increase in OF alters the
bone structure as morphologically observed, as an
adaptive mechanism, and this would underline the idea
of the “hard-chewing” hypothesis48 responsible for for-
mation of exostoses.
Klemetti’s class C1 was more common in males.
However, mean MCI was not statistically different
between males and females. This observation could be
related to fluctuation of hormones in females that
might affect the morphology of the cortex, thus result-
ing in more frequent observations of Klemetti’s class C3
with females (being more susceptible to reduced BMD
and osteoporosis).50
According to the present authors’ knowledge, the
MCI has not been correlated with Klemetti’s classifica-
tion or the OF in any of the previous studies. In the
present investigation, Klemetti classes and MCI meas-
urements were positively correlated with right, left, and
mean OFs. When relating the mean MCI to Klemetti’s
classification, there was an increase in the MCI mean
848
values when there was a change in Klemetti’s class
from C3 to C2 or from C2 to C1.
Dental clinicians are likely to encounter tori in daily
practice. An understanding of this condition and its
consequences may help make decisions regarding spe-
cific treatment plans. Based on the outcomes of the
current study, recording a patient’s OF using a simple
OF registration device before the initiation of treatment
may help with selection of the type of restoration and
the prediction of future problems due to high loads. It
would seem plausible to extend the same experimental
methodology to a larger sample, and to conduct a reli-
ability trial in measuring MCI (including intra-observer
reliability).
CONCLUSION
Males and patients revealing oral tori present an
increased average OF. Within the limitations of the cur-
rent study, it is concluded that the presence of oral tori,
Klemetti’s classification, and MCI ratio could be used as
indicators of an increased OF.
ACKNOWLEDGMENTS
This work was supported by Deanship of Scientific Research/Jordan
University of science and Technology (Grant Number: 2015/106). The
authors thank all who contributed to this work, especially Dr Belal
Al-Hazymieh (Department of Radiology, Ibn Al-Haytham Hospital,
Amman, Jordan), who helped with the radiologic section of the cur-
rent study.
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