|Sleep Apnea from an Anatomical and Developmental Perspective|
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Torus, Tori, Exostoses
Author: Brian Palmer, D.D.S.
An exostoses is just a general thickening of bone. A torus (tori-plural) is a non-pathological outgrowth of bone. Some believe (Shafer, Hine, Levy. A Textbook of Oral Pathology, Saunders, 1974:154-157.) these exostoses are genetically linked. I believe they are genetically linked only in that the personalities of the parents could be inherited. I also believe that the personality of an individual can be the result of being in the same environmental situation as the parents. I hypothesize that tori are the result of one of bone’s responses to stresses on the teeth. An individual transmits his/her stresses to the teeth in the form of clenching or squeezing of the teeth together (one directional force) and bruxing or mashing of the teeth together (lateral motions put on the teeth). I believe tori are the result of just one of the various responses the body has to stress. The bone gets stimulated by the vibrations or ionization within the bone to lay down more bone. It is the body’s response to try to prevent the rocking of the teeth by laying down more bone to help stabilize or support the teeth. Other responses to this force could be to flatten, chip, break and loosen teeth or cause sensitivity. It could also cause recession of bone and tissue.
I hypothesize that anthropologist will not find the size or numbers of tori in prehistoric skulls when compared to tori found in the present population (2004). Tori are fairly common in our population today and can usually be seen weekly, if not daily, in any dental practice in the USA today.
Challenges tori present:
1 - Tissue over the tori is usually quite thin and easily traumatized with hard food and utensils.
2 - Large tori can infringe on tongue space, which could impact breathing by forcing the tongue back into the throat. This distalization of the tongue into the throat could then infringe on airway space.
3 - Tori can make it very difficult, if not impossible, to fabricate a partial or full denture over them. In some cases the tori would have to be surgically removed. I would strongly recommend that people with tori have extra good oral hygiene so they do not need partials or dentures.
Note: The fingers you see in these illustrations are those of the patients who are assisting by holding back their lips.
This presentation has 106 illustrations.
Torus, Tori, Exostoses(Click on adjacent title to open presentation.)
Slide # Comments
4 and 5 - Miscellaneous research by others. Not sure of source. #5 was from the Compendium of Continuing Education but I do not know from which issue.
6 - Note exostoses at the angle of the mandible (green arrow). This thickening of the bone was stimulated by the forces on the bone by the masseter muscle. The masseter muscle is the strong jaw closing muscle that runs from the cheekbone down to the corner of the jaw (red arrow). Place your hands over your jaw in this area on both sides of your face and then squeeze your jaws together very tightly. You will feel the power of this muscle.
7 to 9 - A panoramic radiograph demonstrating similar exostoses as seen on the skull in slide 6.
10 and 11 - Many clenchers / bruxers have ‘square’ jaws like this shown in slide 10, along with thickening of the bone in the area of the mandibular angle as demonstrated in slide 11.
12 to 17 - These skulls are not prehistoric. These skulls are from the 1930-1940 era and therefore considered more contemporary.
18 to 21 - The period from which these mandibles came from was unknown. These were the only few mandibles I could find in a huge box full of mandibles with any significant exostoses or tori. In talking with some anthropologists, I had been told that Eskimos skulls did have a higher rate and size of tori than most skulls.
22 to 39 - Tori do continue to grow over time. The youngest torus that I have seen and photographed was on a 7 year old. The tori in this presentation did not just appear in one day. They developed over time but have rarely been documented (as far as I know). Tori can vary in size from small to huge. How fast they develop would make for interesting research.
40 to 58 - These are just a variety of tori I have documented over the years. They all seem to have their own shapes and ‘personalities’. They can be found in either the maxilla or mandible. As stated in slide 3, I believe tori are the result of stresses on the bone and are mainly found on nervous, anxious and driver-type personalities. Many of these people, however, deny that they clench or brux. Not until they have worn a hard acrylic splint and see all the grooves their bruxing makes do they become a believer that they are bruxers.
44 - This older lady was referred to me by her physician to treat her obstructive sleep apnea (OSA). The only morphometric feature (see presentations on obstructive sleep apnea) that I could find that I thought could contribute to her OSA was these massive tori. Reasoning: These tori take up tongue space. The only option the tongue had when she closed her mouth was to distalize (fall backward). This distalization then infringed on her airway space and contributed to her OSA.
62 to 72 - This patient has been in my practice for close to 25 years. I placed most of the gold crowns in his mouth 20-25 years ago. I usually recommend gold crowns over porcelain crowns in bruxers because gold will not fracture like porcelain will. I also believe gold is ‘gentler’ to the tooth as well as to the opposing teeth because it is ‘softer’ than porcelain and requires less reduction of tooth during preparation. If I had placed porcelain crowns in his mouth, I believe they would have all fractured. I believe these crowns have held up beautifully under these extreme bruxing forces.
97 to 99 - This lady thought everybody had tori like this. She thought it was a ‘tongue scratcher’! :-)
100 to 102 - Another dentist had done some beautiful dentistry for this little old lady - especially under the extreme conditions this case had. She usually only came in when she had challenges - like a bridge coming off as seen in slides 101 and 102.
103 and 104 – I recommend heavy bruxers consider wearing a hard, flat-planed splint. The splint absorbs the forces being exerted by the teeth and distributes the forces within the appliance - rather than the forces being exerted directly into other teeth and bone.
105 – I also recommend bruxers / clenchers memorize this small ‘ditti’ – "Lips together – teeth apart". Every once in a while I have them ask themselves "Where are my teeth"? If the teeth are touching, they then apply – "Lip together –teeth apart".
I hope this presentation has helped answer any questions you might have had regarding tori.
For Better Health!
Brian Palmer, D.D.S.
Leawood, Kansas, USA