Exeresis of bilateral mandibular torus due to speech impairment – case report

Mandibular torus is a slow-growing bone exostosis with well-defined borders, usually oval and bilateral in shape. Diagnosis is made through clinical and radiographic findings. Surgical removal is necessary when there is a prosthetic indication, recurrent trauma, and in rare cases, due to phonetic disorders. The interference in speech caused by the torus, is due to its size and location, which interferes with the usual positioning of the tongue, changing the articulation points, and thus making pronunciation difficult. Therefore, the aim of this study is to report a clinical case of excision of a bilateral mandibular torus due to speech impairment. A 47-year-old male patient sought dental care complaining of bone growth in the mandible. The clinical examination showed a bilateral increase in the lingual region of the mandible, which was unilobular on the right side and trilobular on the left side, measuring approximately 20x20mm. The patient underwent a surgical procedure to remove the torus under local anesthesia. In the 7-day postoperative period, suture dehiscence was observed, as well as traumatic ulcers and pain complaints. The patient Research, Society and Development, v. 10, n. 16, e204101623565, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i16.23565 2 reported that he did not pay attention to postoperative care. As a method of treatment of suture dehiscence, a metronidazole paste was used, as well as a laser therapy protocol, ensuring soft tissue healing. After complete healing, in the clinical evaluation, the patient did not present difficulties in pronunciation. Therefore, it is concluded that, although uncommon, the torus, due to its growth, can interfere with the positioning of the tongue and, consequently, with phonetics, which is a plausible indication for the surgical procedure. Once, the normal bony contours of the mandible are re-established, as well as repositioning and lingual function.


Introduction
Mandibular tori is an osseous projection (exostoses) with slow growth, usually asymptomatic and characterized as well-defined bone exostoses. It is more prevalent in men in the third decade of life. (Bertazzo-Silveira et al., 2017) The etiology is multifactorial and related to environmental, genetic factors, and masticatory hyperfunction. (Mendes da Silva et al., 2017;Mourão et al., 2019;Rodríguez-Vázquez et al., 2013;Singh, 2010;Sorrentino et al., 2019) Clinically the mandibular tori presents as an enlarged and well-defined lesion. Usually oval, covered by a normal mucosa, and hard on palpation. The lesion is little vascularized, and common in the lingual of the premolar region. (Bertazzo-Silveira et al., 2017) Most patients seek treatment due to phonetics disturbances, and ulcerations to any possible trauma. (Kannan, 2015;Mendes da Silva et al., 2017;Sorrentino et al., 2019) Intraoral and radiographic examination are mandatory to establish the diagnosis of mandibular tori. The relationship of both methods is needed to avoid misdiagnosis. The treatment will depend on the size and site of the lesion. Lesion exeresis is the treatment of choice. (Consolaro et al., 2019) Mandibular tori growth may lead to phonetics disturbances, due to the impairment of tongue movement. (Lúcio et al., 2013;Sorrentino et al., 2019) When something results in impairment of tongue movement or in its related structures might cause speech disturbances, due to its ability of quick change of movements and form during speech and mastication. (Mendes da Silva et al., 2017) Therefore, the aim of this work is to present a case of oral rehabilitation, of speech disturbance caused by oversized mandibular tori, through the surgical exeresis.

Case Report
A 47-year-old male patient presented at the Oral Medicine outpatient clinic complaining of bilateral growth in the floor of the mouth, causing discomfort and frequent traumas, both during hygiene and when ingesting some types of food. The patient also complained of speech impairment in pronouncing some words. On anamnesis, the patient denied comorbidities, medication use or allergies.

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The patient had gone in speech therapist before presented to outpatient clinic, due the difficulty of pronouncing words containing the following letters: L, R, Z, S, T, D and N. Since that the mandibular tori was precluding the tongue movement, such as shortening lingual frenulum. Therefore, the mandibular tori surgery was indicated to reestablish the patient's oral phonetics

Case management
The surgical procedure was performed under local anesthesia. Intrasulcular incision and detachment from along the second molar to the lower lateral incisors, on both sides, to expose the exostosis. A channel bordering the entire length of the mandibular torus contour with the aid of a 702 drill mounted at high speed, under copious irrigation with saline solution was performed. In the right side, complemented channels in the interlobular region were performed to complete the osteotomy.
Thus, with the aid of a Maxicut drill, the surgical sites were regularized under abundant irrigation avoiding sharp angles or bone spikes. Interpapillary suture was performed for re-application of the flaps with Vicryl® 4/0. Preemptive Antibiotic and dexamethasone was administered one hour before the surgery.
In the five-day follow-up, the patient showed up to the dental clinic presenting sublingual ecchymosis, compatible to the postoperative time. Although, on the 7th day after surgery, the patient returned to the dental clinic complaining of pain in the surgery region. On intraoral examination, the surgery site presented suture dehiscence with bone exposure on both sides and multiple traumatic ulcers in the mandibular mucosa. (Figure 4) The patient reported to have neglected the postoperative guidelines, ingesting hard foods and acidic liquids on the 6th day.

Source: Authors.
To treat the suture dehiscence was prescribed a paste composed by metronidazole (10%), Lidocaine (2%), mint essence (0.5%) and Lanolin (20g) for application on dehiscence region, 3-5 times/day every day, after oral hygiene. In addition, the patient underwent intraoral laser therapy three times a week, with red light, wavelength of 660 nm and power of 140mw with 39s/point in the dehiscence region for photobiomodulation in order to optimize tissue repair and wound closure.

Discussion
Speech impediment due to mandibular tori was first described in 1954. (Springer, 1954) Since then, there were only two cases relating the interference of the tongue movement and its structures by mandibular tori. (Casenave et al., 2021;Shimahara et al., 2007) Both cases did not report which speech impairment complaint the patient had. In the present case, the patient reported difficulties to pronounce words containing the letters R, L, T, D, Z, S and N. Thus, multidisciplinary evaluation is needed for a better treatment of choice.
The production of alveolar tap can be harmed by some factors, including the frenulum shortening. The alveolar tap is of clinical interest, since the impairment of tap function would result in speech disorder, due to less amplitude of the articulators. (Camargo et al., 2013) Thus, the L, R, Z and S sound would be distorted due to the impairment function of linguo-alveolar articulatory target, and T, D, and N sound was distorted due to the impairment function of linguo-dental articulatory target. (Faria et al., 2019;Suzart & Carvalho, 2016;Walsh & McKenna Benoit, 2019) Given the lesion features of the case presented, greater the size of the lesion, the greater the chance of harming the positioning of the tongue and the lingual frenulum. (Auškalnis et al., 2015;Casenave et al., 2021;Mourão et al., 2019;Springer, 1954) The frenulum fold the floor of the mouth and the tongue, the lingual praxis depends on its complete function. When there is something preventing its complete functioning, problems arise in the articulatory movements of the tongue and, consequently, speech problems interfere with the quality of life. (Suzart & Carvalho, 2016) The treatment of mandibular tori is through surgical intervention, when necessary. ((Jeff) Wang et al., 2016;García-García et al., 2010;Rastogi et al., 2013;Sorrentino et al., 2019) According to surgical management, even some authors have been suggesting the indications of general anesthesia, it was performed the local anesthesia, chosen by patient and the team. The procedure of cutting tori was performed as shown in literature. Due to the large surgery site after resection, the post operative care is needed, which was neglected by the patient. However, the suture dehiscence was seen in the follow up. The treatment of choice was the use of metronidazole paste and laser therapy, which show significant progress. (Casenave et al., 2021;Consolaro et al., 2019)

Conclusion
Mandibular tori depending on size and location can initiate different imbalances in the stomatognathic system, which is unaware by the patient until the speech impairment occurrence or diagnosed in dental routine evaluation. The main treatment in case of mandibular tori speech impairment is the excision, requiring good care by the patient due to handling the large amount of tissue and the complexity of surgical process. After removal, for oral rehabilitation, the functional aspects are resumed.

Ethical approval
Ethical approval was not applicable due to non-exposure of any information of the patient. The photos of the case report did not show facial identification or characteristics.