Torus mandibularis affects the severity and position‐dependent sleep apnoea in non‐obese patients

Mandibular Oral Tori Predict the Presence but Not the Severity of Obstructive Sleep Apnoea. A Systematic Review and Meta-Analysis of the Literature

BACKGROUND

Oral torus assessment is recommended as a part of routine craniofacial examination in patients with obstructive sleep apnoea (OSA). However, there are conflicting studies on whether oral torus is associated with OSA and whether it affects OSA therapy.

OBJECTIVE

This study aimed to systematically review the effects of mandibular torus on OSA and its treatment.

METHODS

The PubMed, Embase and Cochrane Library databases were searched up to 15 July 2024. Studies that included patients with oral torus and examined the diagnosis and severity of OSA (Apnoea-Hypopnea Index [AHI], oxygen saturation, blood pressure and patient-reported outcomes), and studies that examined the effectiveness of OSA treatment in patients with oral torus were included. PRISMA guidelines were followed for data extraction.

RESULTS

Eleven studies with 1372 patients were included in the study. Patients with mandibular torus were found to have a relative risk of 1.9 (95% CI = 0.9; 4.1) for OSA. The pooled mean difference in AHI between patients with and without mandibular torus was 1.6 (95% CI = -5.3; 8.6). Large mandibular torus was found to be associated with mild and moderate OSA but not with severe OSA. A greater reduction in AHI after mandibular advancement device or soft-tissue OSA surgery can be achieved in patients with torus. However, the difference was not significant when compared to patients without it.

CONCLUSION

Patients with mandibular torus are more likely to have OSA. Larger mandibular torus may be associated with mild or moderate OSA but not severe OSA. Mandibular torus does not impede OSA treatment.

Computed Tomographic Analysis of Mandibular Tori and Their Relationship to Remaining Teeth

Objectives: Mandibular tori (bilateral, asymptomatic, lingual mandibular protuberances) often remain untreated. When considering surgical resection, understanding the shape, size, and position of the tori at the bone level is crucial. However, collecting accurate information regarding these characteristics is challenging in cases where the oral mucosa is prominent on the floor of the mouth. Methods: We conducted retrospective surveys at Fukuoka Dental College Medical and Dental General Hospital using computed tomographic (CT) image analysis software (Simplant Pro 18.0). The specific aims of this study were to evaluate the appearance rate of mandibular tori by morphological type, size, location, and CT values and their relationship with the remaining teeth in 1176 patients. These patients underwent simple mandibular CT tomography. We used t-tests to analyze the data. Results: Approximately 10% of the identified tori were pedunculated and difficult to diagnose through visual inspection alone. In all the age groups > 30 years, patients with mandibular tori had a lower rate of tooth loss and a higher rate of remaining occlusal support than healthy subjects. The mean CT value of the mandibular tori was >1350 Hounsfield units (HU). Conclusions: These findings provide insights into future classification and treatment planning for mandibular tori, including that in regard to mandibular ridge resection and factors that may contribute to mandibular torus development or progression, and validate the use of excised bone tissue as a bone graft material.

Oral Tori Findings in an Adult Albanian Population: A Single-Center Pilot Study

Tori are bony growths in the mouth caused by genetic and environmental factors. Oral tori may grow over time and interfere with oral hygiene, speech, mastication, and the application of dentures. The aim of this study was to evaluate the prevalence and patterns of torus mandibularis and torus palatinus according to age and gender among people in Albania. A single-center pilot study was conducted at Diamond Dental Hospital (DDH) from 1 February to 30 April 2024 in Tirana, Albania. Written consent was obtained from each participant. The patients were interviewed by one trained researcher and examined intraorally by one experienced examiner. Photographs were taken of any positive findings. The prevalence of oral tori in this sample from Albania was very high at 48%, and the peak incidence was in the 18-29 age group (54%). The most common type was torus mandibularis, with a prevalence of 39%. The most prevalent form of torus palatinus was flat (71%) and of torus mandibularis was solitary bilateral (48%). This single-center pilot study found a high prevalence of oral tori among people in Tirana, Albania. Its prevalence was not related to gender or bruxism. Dental professionals should note the high occurrence of oral tori and their importance in dental practice.

Management of Obstructive Sleep Apnea in Patients With Heart Failure

Sleep apnea is traditionally classified as obstructive sleep apnea (OSA), which occurs when the upper airway collapses due to the relaxation of oropharyngeal musculature, and central sleep apnea occurs when the brainstem cannot stimulate breathing. Most sleep apnea in patients with heart failure (HF) results from coexisting OSA and central sleep apnea (CSA), or complex sleep apnea syndrome. OSA and CSA are common in HF and can be involved in its progression by exposure to the heart to intermittent hypoxia, increased preload and afterload, activating sympathetic, and decreased vascular endothelial function. A majority of treatments have been investigated in patients with CSA and HF; however, less or short-term randomized trials demonstrated whether treating OSA in patients with HF could improve morbidity and mortality. OSA could directly influence the patient's recovery. This review will focus on past and present studies on the various therapies for OSA in patients with HF and summarize CSA treatment options for reasons of reference and completeness. More specifically, the treatment covered include surgical and non-surgical treatments and reported the positive and negative consequences for these treatment options, highlighting possible implications for clinical practice and future research directions.

Torus Mandibularis in Patients Receiving Hemodialysis

Reports on the prevalence of torus mandibularis among dialysis patients have been limited and inconclusive. A wide variety of oral manifestations has been found in patients with hyperparathyroidism. Furthermore, uremia-related changes in facial bone structures have been described in the literature. This prospective observational study examined 322 hemodialysis patients treated at the Chang Gung Memorial Hospital from 1 August to 31 December 2016. Two subgroups were identified: patients with torus mandibularis (n = 25) and those without (n = 297). Clinical oral examinations including inspection and palpation were employed. Our study found that most mandibular tori were symmetric (84.0%), nodular (96.0%), less than 2 cm in size (96.0%), and located in the premolar area (92.0%). Poor oral hygiene was observed among these patients, with 49.7% and 24.5% scoring 3 and 4, respectively, on the Quigley-Hein plaque index. More than half (55.0%) of patients lost their first molars. Multivariate logistic regression analysis revealed that blood phosphate level (odds ratio = 1.494, p = 0.029) and younger age (odds ratio = 0.954, p = 0.009) correlated significantly with torus mandibularis. The prevalence of torus mandibularis in patients receiving hemodialysis in this study was 7.8%. Younger age and a higher blood phosphate level were predictors for torus mandibularis in these patients.

Outcomes of multilevel upper airway surgery, including tongue base resection, in patients with torus mandibularis

By affecting the tongue position and oropharyngeal airway volume, torus mandibularis is an anatomical factor associated with obstructive sleep apnea (OSA). This study aimed to investigate the influence of torus mandibularis on the surgical outcomes of multilevel upper airway surgery with tongue base resection (TBR) in patients with OSA. Patients with OSA who underwent palatal surgery and TBR were retrospectively analyzed. The patients were divided into two groups according to the presence or absence of torus mandibularis upon physical examination or on computed tomography images. The anatomical characteristics of the upper airway and pre/postoperative polysomnography were analyzed. The control and torus mandibularis groups comprised 69 and 35 patients, respectively, with all of them showing improved sleep quality after surgery. Apnea-hypopnea index (AHI) scores decreased from 42.1 ± 22.2 preoperatively to 23.9 ± 21.4 postoperatively in the control group (p < 0.001), and from 45.2 ± 19.9 to 22.5 ± 13.5 in the torus mandibularis group (p < 0.001). Comparing the postoperative changes in AHI, the AHI of the torus mandibularis group improved by 22.7 ± 23.4, whereas that of the control group improved by 18.1 ± 19.6 (p = 0.296). Sleep efficiency improved from 90.0 ± 7.5 to 92.8 ± 6.8 in the control group, and from 90.3 ± 8.7 to 93.6 ± 6.5 in the torus mandibularis group; however, there was no statistical difference between the two groups (p = 0.816). The presence of torus mandibularis did not appear to significantly affect the surgical results in OSA patients, but it did elicit significant changes in polysomnographic parameters compared with the control group. Therefore, following the identification of torus mandibularis in OSA patients, TBR should be considered as part of planning, as it may help to predict surgical outcomes.

Giant torus mandibularis causing submandibular duct obstruction and sialadenitis

Torus mandibularis is a benign osseous overgrowth arising from the lingual surface of the mandible. It is a common, incidental finding on imaging due to its relatively high prevalence. In the majority of cases, mandibular tori are asymptomatic. We report a novel presentation of a giant torus mandibularis causing bilateral obstruction of the submandibular ducts and consequent sialadenitis. Our patient presented with progressive pain centered in the floor of his mouth and had bilateral submandibular glandular enlargement on exam. Computed tomography showed a giant right torus mandibularis, which was causing obstruction and dilation of the bilateral submandibular ducts. Although conservative management was attempted, he ultimately underwent surgical resection of his torus with symptomatic improvement. This patient highlights a novel complication of torus mandibularis and illustrates successful treatment. Though not previously described, this complication may be underreported and should be considered in the appropriate clinical setting.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.