Hamartomatous/Hyperplastic Bony Opacities and Prominences Involving the Jaws










Atlas of Oral and Maxillofacial Radiology, First Edition. Bernard Koong.
© 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.
97
7.1 Torus palatinus (Figures7.1 and7.2)
Midline bony prominence at the oral aspect of the hard palate.
Variable size and shape. Often very slow increase in size.
Normal overlying mucosa, which may be traumatised.
20% of US population. Variable incidence in various ethnic groups.
More common in females.
Usually identified in the young adult or older.
The nature of palatine torus is often clinically apparent,
requiring radiological investigation only when there is clinical
doubt, patient concern or alteration of the overlying mucosa,
including ulcers and exposed bone.
Usually no treatment unless the torus compromises the design/
retention of a denture or there is an associated chronic ulcer.
Radiological features
If imaging is clinically indicated, multidetector computed
tomography (MDCT) or cone beam computed tomography
(CBCT) is recommended.
Poorly depicted on a panoramic radiograph, demonstrating
a blurred opaque appearance often projected over the roots
of the maxillary teeth.
Bony prominence centred at the oral surface of the palatal
midline.
Variable morphology, ranging from a small sessile appearance
to one with an asymmetric lobulated surface.
Usually internally homogeneous and isodense with corti-
calbone. Larger tori may demonstrate internal trabecular
bone.
CHAPTER 7
Hamartomatous/Hyperplastic Bony Opacities
andProminences Involving theJaws
Appearance of large tomographically blurred
opacity superimposed over the roots of the
maxillary teeth bilaterally reflects one
large torus palatinus
Figure7.1 Torus palatinus: cropped panoramic radiograph.

98 Atlas of Oral and Maxillofacial Radiology
Lobulated bony prominence at
the palatal midline largely isodense
with cortical bone. It is contiguous with
the palatal cortex
(c)
(a) (b)
Figure7.2 Torus palatinus: sagittal (a), axial (b) and coronal (c) MDCT images.
7.2 Torus mandibularis (Figures7.3 and7.4)
Bony prominence(s) at the lingual aspect of the body of the
mandible.
Variable in number, size and shape. Often very slow increase
in size. Normal overlying mucosa, which may be traumatised.
Most often seen in the premolar regions.
Less common than the torus palatinus. Variable incidence in
various ethnic groups.
More common in females.
Usually identified in the adult.
The nature of these tori (torus) is often clinically apparent,
requiring radiological investigation only when there is clinical
doubt, patient concern or alteration of the overlying mucosa,
including ulcers and exposed bone.
Usually no treatment unless the torus compromises the design/
retention of a denture or there is an associated chronic ulcer.
Radiological features
If imaging is clinically indicated, MDCT or CBCT is
recommended.
Poorly depicted on intraoral and panoramic radiographs,
demonstrating opaque appearance(s) projected over the
tooth roots at the level of the alveolar crest.
Bony prominence(s) at the lingual surface of the mandibular
alveolar process.
Variable number, size and morphology, ranging from a small
sessile unilateral prominence to multiple bilateral large shelf‐
like protuberances.
Usually internally homogeneous and isodense with cortical
bone. Larger tori may demonstrate internal trabecular
bone.

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Atlas of Oral and Maxillofacial Radiology, First Edition. Bernard Koong. © 2017 John Wiley & Sons Ltd. Published 2017 by John Wiley & Sons Ltd.977.1 Torus palatinus (Figures7.1 and7.2)• Midline bony prominence at the oral aspect of the hard palate.• Variable size and shape. Often very slow increase in size. Normal overlying mucosa, which may be traumatised.• 20% of US population. Variable incidence in various ethnic groups.• More common in females.• Usually identified in the young adult or older.• The nature of palatine torus is often clinically apparent, requiring radiological investigation only when there is clinical doubt, patient concern or alteration of the overlying mucosa, including ulcers and exposed bone.• Usually no treatment unless the torus compromises the design/retention of a denture or there is an associated chronic ulcer.Radiological features• If imaging is clinically indicated, multidetector computed tomography (MDCT) or cone beam computed tomography (CBCT) is recommended. ◦Poorly depicted on a panoramic radiograph, demonstrating a blurred opaque appearance often projected over the roots of the maxillary teeth.• Bony prominence centred at the oral surface of the palatal midline.• Variable morphology, ranging from a small sessile appearance to one with an asymmetric lobulated surface.• Usually internally homogeneous and isodense with corti-calbone. Larger tori may demonstrate internal trabecular bone.CHAPTER 7Hamartomatous/Hyperplastic Bony Opacities andProminences Involving theJawsAppearance of large tomographically blurred opacity superimposed over the roots of the maxillary teeth bilaterally reflects onelarge torus palatinus Figure7.1 Torus palatinus: cropped panoramic radiograph. 98 Atlas of Oral and Maxillofacial RadiologyLobulated bony prominence atthe palatal midline largely isodensewith cortical bone. It is contiguous withthe palatal cortex (c)(a) (b)Figure7.2 Torus palatinus: sagittal (a), axial (b) and coronal (c) MDCT images.7.2 Torus mandibularis (Figures7.3 and7.4)• Bony prominence(s) at the lingual aspect of the body of the mandible.• Variable in number, size and shape. Often very slow increase in size. Normal overlying mucosa, which may be traumatised. Most often seen in the premolar regions.• Less common than the torus palatinus. Variable incidence in various ethnic groups.• More common in females.• Usually identified in the adult.• The nature of these tori (torus) is often clinically apparent, requiring radiological investigation only when there is clinical doubt, patient concern or alteration of the overlying mucosa, including ulcers and exposed bone.• Usually no treatment unless the torus compromises the design/retention of a denture or there is an associated chronic ulcer.Radiological features• If imaging is clinically indicated, MDCT or CBCT is recommended. ◦Poorly depicted on intraoral and panoramic radiographs, demonstrating opaque appearance(s) projected over the tooth roots at the level of the alveolar crest.• Bony prominence(s) at the lingual surface of the mandibular alveolar process.• Variable number, size and morphology, ranging from a small sessile unilateral prominence to multiple bilateral large shelf‐like protuberances.• Usually internally homogeneous and isodense with cortical bone. Larger tori may demonstrate internal trabecular bone. Hamartomatous/Hyperplastic Bony Opacities andProminences Involving theJaws 99Sessile bony prominences with smooth periosteal surfaces. Internally homogeneous and isodense with cortical bone. Contiguous with the lingual cortex The appearance of superior bony prominences of the mandibular tori in this view is related to the typically negative angulation of the tube in panoramic radiography (a) (b)Figure7.3 Bilateral torus mandibularis: panoramic radiograph (a) and axial CBCT image (b).Bony prominences with lobulated morphology. Internally homogeneous and isodense with cortical bone. Contiguouswith the lingual cortex (a) (b)(c) (d)Figure7.4 Torus mandibularis: axial (a, c) and coronal (b, d) CBCT images. 100 Atlas of Oral and Maxillofacial Radiology7.3 Exostoses (Figures7.5–7.7)• In relation to the jaws, this term usually refers to cortical bony prominences associated with the alveolar processes, occasion-ally with internal trabecular bone. There is no cartilaginous cap. Some consider the maxillary and mandibular tori as exostoses. ◦It should be noted that the term exostoses is sometimes used synonymously with osteochondromas, although the latter demonstrate a cartilaginous cap. Hereditary multiple exostoses is a condition characterised by the development of multiple osteochondromas. ◦In the region of the head, bony exostoses, isodense with cortical bone, may also be seen within the external auditory canals (swimmer’s/surfer’s ear).• Most commonly seen at the buccal aspects of the maxillary alveolar process, sometimes palatally. Mandibular exostoses are more often seen buccally, although this may be the result of lingual prominences often being considered to be mandibular tori.• Variable number, size and morphology. Overlying mucosa is normal unless traumatised.• The nature of these prominence(s) is often clinically apparent, requiring radiological investigation only when there is clini-cal doubt, patient concern or alteration of the overlying mucosa, including ulcers and exposed bone.• Exostoses of the alveolar processes of the jaws do not usually require treatment unless they compromise the design/reten-tion of a denture or there is an associated chronic ulcer.Radiological features• If imaging is clinically indicated, MDCT or CBCT is recommended. ◦Poorly depicted on intraoral and panoramic radiographs, demonstrating opaque appearance(s) projected over the tooth roots, often approximating the alveolar crests.• Variable number, size and morphology.• Usually internally homogeneous and isodense with cortical bone. May demonstrate internal trabecular bone, especially larger prominences.Bony prominencebuccal to 15/14Bony prominencepalatal to 27Labial bonyprominences at the anteriormandible (a) (b)(c) (d)Figure7.5 Maxillary and mandibular exostoses: axial (a, c), coronal (b) and sagittal (d) CBCT images. Hamartomatous/Hyperplastic Bony Opacities andProminences Involving theJaws 101Lobulated bony prominencesinternally largely isodensewith cortical bone Appearance of a tomographicallyblurred opacity reflects theexostoses, which are poorlyexamined in these views (a) (b)Figure7.6 Palatal exostoses, right maxilla: panoramic radiograph (a) and axial MDCT image (b).Lobulated bonyprominences Lobulated bonyprominences Figure7.7 Bilateral buccal/labial exostoses, maxillary and mandibular alveolar processes: surface‐rendered CBCT image.7.4 Bone island (Figures7.8–7.19)• Synonym: enostosis (pl. enostoses).• A focus of mature compact bone within cancellous bone. Generally considered to be hamartomas.• Affects any bone. When seen within the jaws, it is more common in the mandible.• Variable size.• Asymptomatic and does not require treatment. Usually identified incidentally.• Often diagnosed radiologically (in the absence of symptoms), not requiring biopsy.Radiological features• MDCT or CBCT is recommended if 2D radiographic appearances are not classical and there is doubt about the true identity of the opacity. CT is also recommended if there is suggestion of a surrounding lucent margin or if there aremultiple opacities where the appearances are not typical of bone islands.• Well‐defined opacity often with an irregular border. Many borders demonstrate thorny appearances (brush‐like border), where these radiating spicules blend with the adjacent normal trabecular bone.• Internally usually homogeneously isodense with cortical bone. Some demonstrate heterogeneity with variable patterns with regions which are hypodense to cortical bone.• In the jaws, bone islands often extend to the cortices with no expansion. When adjacent to teeth, they are usually contiguous with the lamina dura with preservation of the periodontal ligament space.• May slowly increase in size over time.• There may be more than one bone island; occasionally four or five may be seen in the jaws. However, if there are also opaci-ties within other facial bones, the skull base or cervical spine in the appropriate clinical setting, malignant osteoblastic metastases should be considered. Multiple bone islands have been seen in a few cases of Gardner syndrome.• Occasionally associated with root resorption, usually only seen with larger bone islands.• Associated displacement of teeth or interruption of eruption is extremely rare. 102 Atlas of Oral and Maxillofacial RadiologyWell-defined opacity isodensewith cortical bone. Note thebrush-like border mesially.It is difficult to evaluate the relationship with the laminadura of 36 and 35 in this view Anterior loop of the mandibular canal and mental foramen Figure7.8 Bone island, left mandible: cropped panoramic radiograph.Differential diagnosisKey radiological differencesOther entities which may appear opaque, including:Dense reactive sclerosis associated with periapical inflammatory lesionsUsually centred at the root apices. While a small inflammatory periapical lucency or subtle inflammatory widening of the apicalperiodontal ligament space may not be appreciated on 2D radiography, these changes are almost always demonstrated with MDCT or CBCT.Mature periapical osseous dysplasiaThere is usually a lucent margin(which can be extremely narrow) around the opacity, with adjacent surrounding sclerotic borders.Root remnant Surrounding periodontal ligamentspace and lamina dura anda root canal may be seen internally. Morphology resembles aroot. Positioned at a site where a root would be expected to benormally located. Sometimes,differentiation canbedifficult.Osteoblastic metastasesUsually multiple and seen within more than one bone, e.g. jaws and/or skull base and/or cervical spine. Most often seen with prostate and breast metastatic lesions. It should be noted that these sclerotic malignant metastatic lesions do not always demonstrate bony destruction and may be quite benign in appearance.Bony prominences May resemble bone islands on 2D radiography. The bony prominence may be apparent clinically. A bony prominence is obviously demon-strated with MDCT and CBCT.Sialolith (salivary calculus)May be projected over the mandible on 2D radiography or panoramic radiograph. MDCT or CBCT clearly demonstrates that this opacity is not within bone.Hypercementosis Presence of periodontal ligament space and lamina dura around the opacity.Cementoblastoma Surrounding lucent margin is usually observed and is usually internally heterogeneous. Usually associated with pain.Osteoid osteoma/osteoblastomaVariable heterogeneous internal appearance. Associated with pain. Contiguous with the lamina dura withpreservation of the periodontal ligamentspaces and no root resorption Well-defined homogeneous opacity isodense with cortical bone. It is contiguouswith the buccal cortexwith no expansion (a) (b)Figure7.9 Bone island, 37: axial (a) and cross‐sectional (b) CBCT images.Well-defined homogeneous opacity with densityslightly lower than that of cortical bone.Note the brush-like borders Radiating brush-like borders (a) (b)Figure7.10 Bone island, 43 region: panoramic radiograph (a) and axial CBCT image (b).Small well-defined opacity demonstrates a few brush-likeborder appearances. The relationship with the root apex is not welldemonstrated in this view Figure7.11 Bone island, 12: periapical radiograph. 104 Atlas of Oral and Maxillofacial RadiologyThis opacity extends aroundthe mandibular canal withneither deflection norcompression Well-defined homogeneous opacity isodense with cortical bone.It is contiguous with the lingual andbuccal cortices with no expansion (a) (b)Figure7.12 Bone island: axial (a) and volume‐rendered panoramic (b) CBCT images.Irregular radiatingbrush-like borders Well-defined homogeneousopacity isodense with cortical bone.It is contiguous with the lingualand buccal cortices with no expansionMinor apical root resorptionis occasionally seen. Note the preservation of the periodontalligament space (a) (b)Figure7.13 Bone island, left mandible: axial (a) and cross‐sectional (b) CBCT images. Hamartomatous/Hyperplastic Bony Opacities andProminences Involving theJaws 105Internal heterogeneous appearanceis less commonly seen. No buccalor lingual cortical expansion Radiating brush-like borders (a) (b) (c)Figure7.14 Bone island, 46: axial (a), corrected sagittal (b) and cross‐sectional (c) CBCT images.The internal attenuation is lowerthan that of cortical bone. Unusual presentation of altered densityof the lingual cortex No deflection or compressionof the left mandibular canal demonstrated with border preservation (a) (b) (c) Figure7.15 Bone island, left mandible: axial (a) and cross‐sectional (b, c) CBCT images. 106 Atlas of Oral and Maxillofacial RadiologySevere resorptionof the adjacent rootis occasionally seenin association withbone islands Radiatingbrush-like borders (a) (b)Figure7.17 Bone island: axial (a) and corrected sagittal (b) CBCT images.Well-defined irregular opacity isodense with cortical bone.Note the brush-like borders. The mesial root resorption isoccasionally seen. The periodontal ligament space islikely preserved, not well demonstrated in this view Figure7.16 Bone island, 46: cropped panoramic radiograph. Hamartomatous/Hyperplastic Bony Opacities andProminences Involving theJaws 107Resorption of the 25 palatalroot related to the bone island,occasionally seen. The periodontal ligament space is preserved Well-defined opacity isodensewith cortical bone. Note thebrush-like borders (a) (b)Figure7.18 Bone island, 25: corrected sagittal (a) and cross‐sectional (b) CBCT images.Well-defined homogeneousopacity isodensewith cortical bone Contiguous withthe lamina dura with preservation of the periodontal ligament space and no root resorption Minimal expansion,which is rarely seen Figure7.19 Bone island, 26 palatal root: cross‐sectional CBCT image.

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