Compendium 2006. A Technique for Surgical Mandibular Exostosis

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A Techniquefor Surgical
MandibularExostosisRemoval
Abstract
Exostosis, a slow-growing, benign bony outgrowth,
is a common clinical flnding and not usually an issue
with patiens. However, when removableprosthetics
must sit either adjacent to or over theseareas,pressure, food abrasion,ulceration, or Iimited tongue space
can occur. This article describesa surgical technique
for excision of exostosisthrough the presentationof a
case.An B6-year-oldwonuln had soft-tissueirritation
caused by abrasion from food in the buccal posterior
right quadrant. The removal of the exostosisis illustrated through the use ofa device that servesas an altemative to a scalpel,offering a safe,predictableoutcome.
GregoriM
KurEman,
DDS
Private
oractice
Silver
Maryland
Spring,
LeeHSilverstein,
DDS,
MS
Associate
Protessor
Clinical
Department
of Periodontology
Medical
College
ofGeorgia
Augusta,
Georgia
Private
oractice
Marietta,
Georgia
PeterCShatz,
DDS
Assistant
Professor
Clinical
Department
of Periodontology
Medical
College
ofGeorgia
Augusta,
Georgia
Private
Dractice
Marietta,
Georgia
xostosis,termed torus mandibularist (commonly
called mandibular tori), is a common clinical
finding. Most are asymptomatic, benign bony
outgrowths that slowly grow over the patient's lifetime.
They consist ofdense, cortical bone and are avascularin
nature.2Mandibular exostosisis commonly locatedlingual to the premolars and is often bilateral. It also may
be locatedon the buccalportion of the ridge, either in a
solitary location or extensively spread bilaterally. An
incidence of 9oloto 600lohas been reported in various
ethnic groups, and it has been reported in the literature
for over 180 years.tt Both genetic and environmental
factors have been implicated as the causative factors,
and the true causemay be multifactorial.6
The presenceo[ an exostosismay pose a problem in
successfulconstructionof dentures.If largeenough,an
exostosis may create speech issues becauseof limited
tongue space. Histologically, the tissue overlying the
exostosisis thinner than normal gingiva and may ulcerate easily when masticating hard or sharp foods. This
article will describe a surgical technique for excision
mandibular exostosis.
Case Presentation
An 86-year-old woman complained of soft-tissue
irritation caused by abrasion from food in the buccal
posterior right quadrant. A buccal exostosiswas present
at the first molar and had been the samesize for the 16
years the woman had been a patient of the practice
(Figure 1). After a discussion,the patient requestedthat
the exostosisbe removed to help decreasefuture food
abrasion of the thin overlying tissue.
Anesthetic was administered to block the inferior
alveolar nerve, and it was then applied locally at the
papilla to control bleeding at the surgical site.
A bipolar electrotronic surgical unita was used to
make an intrasulcular incision distal to the exostosisto
be removed and extended mesially to allow soft-tissue
reflection and exposure of the exostosis (Figure 2).
Verticalreleasingincisions are not necessaryand ifaddia Bident, King of Prussia, PA 19,106; (800) 469-6369
. october
Compendium
2006;27(1
0):520-525
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n e s s f l e r p ,w i t h t h e c n l i r c e x o s t o s i sc x p o s c d , c s p c c ia l l Y
i n f c r i o r 'l y ( F i g u r c 3 ) .
-l-he pcriosteal elcVator wzrs placed rrrferior to thc
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t io na l re l'lcction is nc c dec l.t he s ulc ular inc is ion s h o u l d
be cxtenclcd clistalll and nrcsiallv to the srrrgrcalsite.
Th e in cision may be m ade wit h a s c alpc l blade, b u t t h e
bipolar srlrgical tip rvill affirrclbctter herrostasis during
surgcry,' providing better visibility. Thc bipolar elcctrosurgical tip may be uscd in a wet {ield," ancl lhe authors
recotnmend appll,ing a water spray during cutting,
rvhrch u'ill keep the tissue hydralcclanclfield a flap rnargin that is noncharred."
Reflectior.ro[ the soft tissue was accomplished with
arperiostealelevator.Care must be given to avoid tcaring
cxostosisto l)r()tectthe underlving s<l{ttissr.rc.
and :l surgical length carl)iclebin a high-speeclhandpiccewith watcr
\\,asLlscd1()scorea line On thc strperioraspecto[ the exostosis (Figurc 4), -Ihc sc()rclinc shoulcl be placcclclose to
thc norrnal contolrr of thc alveolar riclge.A rnonoplane
chisel w:rsplaced irr the score line, allowing thc cxostosi>
to be clcavedlrour the alveolarridgc. It is inrportant that
thc pcriostealclevatoris placedinferior to thc cxostosisto
prevent acci(lcntalslippage ol'the chisel tip ancl subseclucnttissuedamagc.Thc tip o{ the pcriostcillelevatorwas
kcpt in contaclu'ith the lxrne,zrnda gcntle tap was applicd
to tl.rechiselwith a sr.rrgical
mallet (ltrigure5).
The exostosis,ardcnse cortical bonc, ',r'ill cleavc at
thc scorc line and separatcliom thc Llndrrl),ing bone as
a singlc precc (Figr.rre6). The osseous bed will have
sharp cdges at the poinl of cleavage(Figure 7). A football dianrondlt bur was used in a high-speed handpiece
with water to smooth the alveolar ridgc and remove
any sharp eclg,es
that resulted after cleavageoI the l-rard
exostosis (Figure U). The flap was repositioned, and a
vertical rnattresssuture is placed at each papilla with
l l r r s :c Lr . 5J \anr r i l l r .L,.\ r tl l tq: ,l Otj ' S- ti i ;::
. 0ctober
(10l:520-525
Compendium
2006,27
521
Figure6-The exostosisis removedin o singlepiece
Figure7-The surgicolsib oftercleovogeof lhe exoslosis.
FigureS-Thesurgicolsiteoflersmoothing
of theoreo with o diomond
Figure1O-The surgicolsite4 weeksoftersurgeryshowslock oi inflommotionond compleleheoling.
were absent,and the tissue appearedhealed. Slight recession was noted on the mesial buccal of the first molar
(FigureI0).
Figure9-The sugicol siteofier plocemenfof the resorboblesutures.
a-0 polyglycolic acid suture (Figure 9). The surures
were left in place for 21 days. Before releasing the
patient, gentle pressurewas applied to the site with wet
ga\ze to permit a fibrin clot, helping ro rack the periosteum to lhe new osseousbed. Pressureshould be applied
for 5 minutes, which will also prevent fluid accumulation under the flap during the period immediately after
the surgery.
The patient returned 2 weeks after surgeryto check
healing, and sutures were still present. There was no
inflammation, and the patient indicated that she had minimal discomfort after surgery and that the areafelt normal
3 days after surgery A followup appointment was scheduled at 4 weeks after surgery to check the site. Sutures
522
Conclusion
Exostosis is a common occurrence as sited in the
literature. These slow-growing, dense cortical bone
deposits are not usually an issue with patiens, except
when removableprosthetics must sit either adjacent to
or over theseareas.Becausethe overlying tissue is thin,
pressureor food abrasion may causeulceration.
Excision of exostosisin the mandible is a sa[e, predictable procedurewith minimal postoperativesequela.fu
an alternative to a scalpel, the bipolar electrosurgicalunit
provides an incision without charring of the flap edgesas
would be seenwith monopolarelectrosurgicalunits.roThe
bipolar electronic surgical tip produced a smaller temperature gradient (averagedifference9.2"C) at the l-mm tissue
depth compared with the monopolar electrosurgery tip
(averagedifference l4.6oc)." Additionally, arcing that is
commonly seenwith monopolar electrosurgeryunits when
cutting near metallic restorationsor dental implans is not
observedwith the Bident bipolar surgical unit, making it
safe.t2TheBident bipolar tip also provides coagulation of
the capillariestransectedduring the incision, and hemostasis is maintained, providing better visibility in the surgical
field than would be expectedwith a scalpelincision.
. 0ctober
Gompendlum
2006;27(1
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The dense nature of the exostosis allows it to be
cleavedin a single piece with a chisel after appropriate
scoring of the bone. Use ofsurgical chiselshas decreased
over the past 20 yearsbecauseoffear ofpotential soft-tissue damageif the chisel tip were to slip.r:,r+Chiselsmay
be used safelywhen a periosrealelevatoris placedbelow
the bone to be sectioned,acting as a safetystop. An alternative to the chiselhasbeenthe useof a diamond to grind
away the entire exostosis.In the authors' opinion, this
will lead to accumulation of nonvascularosseousdebris
under the flap, which may lead ro compromisedhealing.
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