Palatal tori

Roger L. Myers DMD
Southern Georgia Oral Surgery
Hinesville, Ga. and Statesboro, Ga. Offices
www.southerngeorgiaoms.com

Torus palatinus (tori palatinus) is a bony protrusion on the palate. Palatal tori are usually present on the midline of the hard palate.  However, can be diffuse in size and shape which can encompass the palate unilaterally or bilaterally.   Most palatal tori are less than 2 cm in diameter, but their size can change throughout life.  As one ages the palatal tori can enlarge in size and cause associated issues.  Such as speech, swallowing and chewing problems of the oral cavity.
Prevalence of palatal tori ranges from 9% - 60% and are more common than bony growths occurring on the mandible, known as torus mandibularis. Palatal tori are more common in Asian, Native American and Inuit populations, and twice more common in females. In the United States, the prevalence is 20% - 35% of the population with similar findings between blacks and whites.  In my practice, I  have noticed that more African Americans exhibit palatal tori over mandibular tori.  In addition, seems the most prodominate race with this condition.
Although some research suggest palatal tori to be an autosomal dominant trait, it is generally believed that palatal tori are caused by several factors.  They are more common in early adult life and can increase in size. In some older people, the size of the tori may decrease due to bone resorption. It is believed that tori of the lower jaw are the result of local stresses and not solely on genetic influences.
Sometimes, the tori are categorized by their appearance.  Arising as a broad base and a smooth surface, flat tori are located on the midline of the palate and extend symmetrically to either side. Spindle tori have a ridge located at their midline. Nodular tori have multiple bony growths that each have their own base. Lobular tori have multiple bony growths with a common base.
Palatal tori are usually a clinical finding with no treatment necessary.  It is possible for ulcers to form on the area of the tori due to repeated trauma(As seen in the Photo).   Also, the tori may complicate the fabrication of dentures. If removal of the tori is needed, surgery can be done to reduce the amount of bone present.  If surgical intervention is warranted for placement of a denture, one has to be cognizant of the thin nature of the coving tissue.  The palatal tissue covering the tori in very thin and dehiscence after surgery is very common.  Periodic examination and will allow visualization of the tissue granulating in order to establish closure of the wound.  There is no specific time to predict the healing time, but serial evaluations are suggested as the area heals.  Upon completion of wound healing, the area should be inspected for any bony projections or prominences.  These factors alone can inhibit the placement of a denture post-operatively.

CASE STUDY:

Chief Complaint:  "I can't chew without teeth and I need a denture"
PMH:  Heart Murmur, Diabetes Type 2, Kidney Disease, HTN
Meds:  Diovan, Metoprolol, Plavix, Actos
PSHx:  None
ALL:  NKDA

Findings:  Massive palatal tori obstucting patients ability to chew, spaeak and breath.  Bilateral growth with central prominence.
Plan:
1.  Surgically remove palatal tori
2.  IV sedation/LA
3.  losure with 3.0 Vicryl suture
Result:
The procedure was performed under IV sedarion in which multiple incisions for tissue reflection and acess were made.  The palatal tori was removed and primary closure was achieved.  The patient will be seen one week post-operatively and followed until healing is complete.

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Supranumerary Teeth-Mesiodens

Southern georgia Oral Surgery-Statesbor, Ga. and Hinesville, Ga.
Oral Surgeon-Roger Myers DMD

What are Supernumerary Teeth ?

By definition, supernumerary teeth are extra teeth, whish are typically malformed and diminutive compared to normal dentition. It is more common in the midline region of the upper or lower jaw;  Most frequently found in the region of the upper central incisors; Therefore, the occurrence rate in the mandible region is quite infrequent. The most common type of supernumerary tooth as indicated is mesiodens. Mesiodens may occur as single, multiple, unilateral or bilateral. In some syndromes, mesiodens may present as a part of the symptoms; however, this condition might be seen in normal individuals. It seems that positive family history is one of the predisposing factors .
Extra teeth have a lot of names! They are classified based upon where they are located and what they look like.
If an extra tooth is shaped like another "normal" tooth, it is called a supplemental tooth. If it is not shaped like a normal tooth, then it is known as a rudimentary tooth. Rudimental teeth are then classified based on what they look like:

• Conical Rudimentary Teeth look small or peg-shaped.
• Tuberculate Rudimentary Teeth appear to be barrel-shaped and have more than one cusp.
• Molariform Rudimentary Teeth look similar to premolar or molar teeth, but not enough to be called a supplemental tooth.

Mesiodentes are the most common supernumerary teeth, occurring in 0.15% to 1.9% of the population. Given this high frequency, the general dentist should be knowledgeable about the signs and symptoms of mesiodentes and appropriate treatment. The cause of mesiodentes is not fully understood, although proliferation of the dental lamina and genetic factors have been implicated. Mesiodentes can cause delayed or ectopic eruption of the permanent incisors, which can further alter occlusion and appearance. It is therefore important for the clinician to diagnose a mesiodens early in development to allow for optimal yet minimal treatment.

Treatment options may include surgical extraction of the mesiodens. If the permanent teeth do not erupt in a reasonable period after the extraction, surgical exposure and orthodontic treatment may be required to ensure eruption and proper alignment of the teeth. In some instances, fixed orthodontic therapy is also required to create sufficient arch space before eruption and alignment of the incisor(s). Early diagnosis allows the most appropriate treatment, often reducing the extent of surgery, orthodontic treatment and possible complications. This paper outlines the causes and modes of presentation of mesiodentes, and presents guidelines for diagnosis and management of nonsyndromic mesiodentes.

 

 

 

 

Two Most common Cysts Associated With Impacted Wisdom Teeth

Dentigerous Cyst
A dentigerous cyst or follicular cyst is an odontogenic cyst- thought to be of developmental origin - associated with the crown of an unerupted (or partially erupted) tooth.  Meaning that the cyst-like tissue may cover a portion or the entire crown of the tooth. The cyst cavity is lined by epithelial cells derived from the reduced enamel epithelium of the tooth forming organ. Regarding its pathogenesis, it has been suggested that the pressure exerted by an erupting tooth on the follicle may obstruct venous flow inducing accumulation of exudate between the reduced enamel epithelium and the tooth crown.  This can account for the fluid material in the cyst cavity.
Histologically a normal dental follicle is lined by enamel epithelium, whereas a dentigerous cyst is lined by non-keratinized stratified squamous epithelium. Since the dentigerous cyst develops from follicular epithelium it has more potential for growth, differentiation and degeneration than a radicular cyst. Occasionally the wall of a dentigerous cyst may give rise to a more ominous mucoepidermoid carcinoma. Due to the tendency for dentigerous cysts to expand rapidly, they may cause dehiscence or pathologic fracture of jaw bone.
The usual radiographic appearance is that of a well-demarcated radiolucent lesion attached at an acute angle to the cervical area of an unerupted tooth. The border of the lesion may be radiopaque. The radiographic differentiation between a dentigerous cyst and a normal dental follicle is based merely on size. Radiographically, a dentigerous cyst should always be differentiated from a normal dental follicle. Dentigerous cysts are the most common cysts with this radiographic appearance.  However, histological analysis is a more definitive method of identification. Radiographically the cyst appears unilocular with well defined margins and often sclerotic boarders. Infected cysts show ill-defined margins.
The most common location of dentigerous cysts are the Mandibular 3rd Molars and the Maxillary Canines, and they rarely involve deciduous teeth and are occasionally associated with odontomas.


Ameloblastoma

Ameloblastoma is a rare, benign tumor of odontogenic epithelium (ameloblasts, or outside portion, of the teeth during development) much more commonly appearing in the lower jaw than the upper jaw.  The lesion usually is associated in the lower posterior mandible and can be affiliated with any molar tooth in this region.
While these tumors are rarely malignant or metastatic (that is, they rarely spread to other parts of the body), and progress slowly, the resulting lesions can cause severe abnormalities of the face and jaw. Additionally, because abnormal cell growth easily infiltrates and destroys surrounding bony tissues, wide surgical excision is required to treat this disorder.
Ameloblastomas are often associated with the presence of unerupted teeth. Symptoms include painless swelling, facial deformity if severe enough, pain if the swelling impinges on other structures, loose teeth, ulcers, and periodontal (gum) disease. Lesions will occur in the mandible and maxilla,although 75% occur in the ascending ramus area and will result in extensive and grotesque deformitites of the mandible and maxilla. In the maxilla it can extend into the maxillary sinus and floor of the nose. The lesion has a tendency to expand the bony cortices because slow growth rate of the lesion allows time for periosteum to develop thin shell of bone ahead of the expanding lesion. This shell of bone cracks when palpated and this phenomenon is referred to as "Egg Shell Cracking" or crepitus, an important diagnostic feature. Ameloblastoma is tentatively diagnosed through radiographic examination and must be confirmed by histological examination (e.g., biopsy). Radiographically, it appears as a lucency in the bone of varying size and features—sometimes it is a single, well-demarcated lesion whereas it often demonstrates as a multiloculated "soap bubble" appearance. Resorption of roots of involved teeth can be seen in some cases, but is not unique to ameloblastoma. The disease is most often found in the posterior body and angle of the mandible, but can occur anywhere in either the maxilla or mandible.
Ameloblastoma is often associated with bony-impacted wisdom teeth—one of the many reasons some dentists recommend having them extracted

7 Complications Associated with Wisdom Tooth Removal

 7 Complications Associated With Wisdom Tooth Removal

Southern Georgia Oral Surgery
WWW.SouthernGeorgiaOMS.com
Roger Myers DMD

Requiring removal of wisdom teeth can be an anxious moment. In most cases, we seek treatment because of pain, swelling and other related issues.
Before one makes the decision to have wisdom teeth removed, the risks and complications of the procedure should be identified.

1) Bleeding- Bleeding is inherent to most surgical procedures and can be dealt with accordingly. Lower wisdom teeth are sometimes difficult to remove and bleeding will occur post-operatively. After an extraction, the patient should bite on guaze for intervals of 10 minutes until the bleeding stops. If after and hour, I usually instruct my patients to bite on a wet tea bag. The tea bag has tannins which facilitate a clot(this method has also worked on patients taking anticoagulants).
2) Nerve Numbness- There are three different degrees of nerve injury
a) Neuropraxia- Crushed or piched, transient loss of sensation 1-3
months
b) Axonotemesis- Partial nerve tear, regian feeling 3-6 months
c) Neurotemesis- Complete tear of nerce bundle, repair required with
no definte nerve recuperation
3) Swelling- The presence of swelling can result in limited opening and increased post-operative pain. A hot water bottle is the method of reducing the swelling expediantly, because the warmth diffuses the fluid collection that causes swelling.
4) Damage to adjacent teeth- Having any tooth removed can result in damage of an adjacent tooth. Whether the damage is a fracture or luxation of the adjacent tooth, it can and does happen.
5) Jaw Fractue- Whether the tooth is an upper or lower wisdom tooth, the bone can be fractured during the extraction process.
6) Tooth Fragments- Attempting to remove a tooth can cause afracture of the root. If the root fragment is less than 1mm, it can remain without incident. But, if the fragment is significant the remaining tooth portion must be removed. By remaining the tooth fragment acts as a nidus for infection and thereby icrease the risk of infection for the patient.
7) Infection- Any surgery that results in bleeding and exposure of the patient to the external environment can result in an infection. The oral cavity have a plethora of bacterial typoes and antibiotics chould be given after any extraction is complete.