Tori exostoses can provide unique clinical challenges. The large protuberance of bony tissue on the lingual aspect of the mandible can interfere with the patient’s diet, speech, and overall life satisfaction – and removing these protuberances can be a traumatic and difficult procedure.
Typically, these bony outcroppings should remain undisturbed but there are occasions where excision becomes a clinical necessity. This usually requires referral to an oral surgeon for excision, who then turns to traditional methods that rely on invasive methods. The procedure is completed using high-speed burs, bone chisels, and other apparatuses that while efficient and effective, can result in discomfort and trauma for the patient. As a result of these factors, most patients with mandibular tori growths postpone and even avoid clinical treatment.
A more effective, atraumatic means of ablation and excision could result in patients embracing a treatment protocol that could result in greater life satisfaction and other benefits associated with the removal of these meddlesome bony growths.
The Er,Cr:YSGG all-tissue laser (BioLase, Irvine, Calif.) has been shown to safely and effectively ablate the full spectrum of oral tissues – soft tissues, hard tissue, and bone,.
Mandibular tori are bony exophytic growths that are present on the lingual aspect of the mandible, opposite to the bicuspids. They present in early midlife and tend to grow with age. Mandibular tori occur in 6-7% of the population. The etiology of exostosis is multi factorial including genetic and functional influences. Larger versions may require removal because of their interfere with tongue positioning, speech interference, prosthodontic reconstruction, as well as with poor oral hygiene around the lower posterior teeth. One more indication for considering tori removal is cancer phobia.
Rotatory and reciprocating devices are most frequently used but have disadvantages, such as noise, vibration, and the potential for inducing thermal damage. Many patients are reluctant to be subjected to the use of an osteotome and mallet while awake, especially if repeated blows are required to separate the torus or exostosis from the bone. As a result of these factors, most patients who present with mandibular tori postpone and even avoid clinical treatment. Interest is growing in using alternatives to rotatory and manual instruments for osteotomies in oral and maxillofacial surgical procedures. Laser excision has better patient acceptance compared to conventional technique in removal of mandibular tori. Currently, there are few reports regarding the use of lasers in bone surgery and little is known about the effectiveness for bone ablation or the healing characteristics of the laser-irradiated bone tissue compared with conventional rotary instrumentation. The intention of this case report is to demonstrate the Er,Cr:YSGG laser use in a clinical setting for the atraumatic and effective excision of the mandibular lingual tori.
Currently, there are few reports regarding the use of lasers in bone surgery. The intention of this case report is to demonstrate the Er,Cr:YSGG laser use in a clinical setting for the atraumatic and effective excision of the mandibular lingual tori. The removal of the tori with the Er,Cr:YSGG laser device was done with the settings of 3.5 W, 40% water, 20% air and 20 Hz. Lasers have clinical advantages such as bacterial reduction at the surgical sites and increased comfort levels. The surgical field is cleaner, with less blood to obscure the surgeon’s field of vision. Laser technology has certain advantages, such as accuracy of the incision and absence of vibration and manual pressure during use.
A 70 years old female patient presented with lingual torus in the right side of the lower arch, which required implant placement in that region. Patient did not have any problem with tori but insisted on removal of the same. Swelling was situated in the lingual cortical plate extending from 42 to 45 region measuring about 1.4 cm x 1.1 cm x 0.8 cm. A thorough medical and dental history was completed along with a clinical examination, preoperative diagnostic casts and a panoramic radiograph. Using panoramic radiographs to evaluate bone height, it was determined that 3 endosseous implants could be used to support the desired posterior fixed restoration. Surgery was planned out to facilitate ease of placement and favorable prognosis of implant supported fixed restoration in that area.
The surgical procedure was planned by Implant placement and excision of tori in the same sitting. After aseptic preparation the area local anesthesia was administered, crestal incision (Fig 1) was given and torus was exposed with careful elevation of mucoperiosteum using periosteal elevator (Fig 2). To begin the sectioning and removal of the tori with the Er,Cr:YSGG laser device, the settings were adjusted to 3.5 W, 40% water, 20% air, and 20 Hz. Excision of tori was carried out using Er,Cr:YSGG laser, mz 6 tip at the base of the lesion ( Fig 3) with
approximately 1.0 mm from the tissue while sectioning the tori. Fig 4 showing excised torus. Implants were placed in 34, 36 and 37 region. Sutures were placed (Fig 5). After the procedure, the surgical site exhibited no edema, minimal bleeding, and no other adverse effects from the laser surgery. Postoperative instructions included: soft diet, salt water rinses and a prescription of paracetamol 500 mg thrice daily for three days. Patient was recalled for checkup on first post operative day and there was no swelling in the region. Post operative phase was uneventful and suture removal was done after 7 days. The patient was recalled again at 2 weeks and the healing appeared clinically complete.
|Figure 1: The crestal incision is placed.||23.99 KB|
|Figure 2: Exposure of tori after mucoperiosteal reflection||18.63 KB|
|Figure 3: Er,Cr:YSGG laser tip at the base of the lesion||17.19 KB|
|Figure 4: Showing excised torus.||20.25 KB|
|Figure 5: The postoperative photograph showing sutures in place||13.16 KB|
First laser was introduced in 1960 by Theodore Maiman. It is clear that in the practice of oral and maxillofacial surgery, lasers have become an important tool in armamentarium to treat cosmetic and pathologic entities.
Different approaches and tools are available for removal of mandibular tori including the osteotome and mallet, rotatory instruments with different rotation conditions, saws and microsaws, ultrasound and piezoelectric tools, and laser systems. Many patients are reluctant to be subjected to the use of an osteotome and mallet while awake, especially if repeated blows are required to separate the torus or exostosis from the bone. Mechanical drills and saws have been used efficiently to cut bone. Despite improvements in technology, metallic cutting instruments result in deposition of debris on bone, heating vibrations, noise and discomfort. Surgical burs induce an increase in the focal temperature of regions undergoing bone osteotomy, resulting in necrosis and irreversible modifications in the structure and physical properties of the bone tissue. Many studies have shown the
importance of tissue cooling to decrease thermal damage.5 Numerous studies have demonstrated that the Erbium laser cuts bone precisely, with minimal thermal damage of 5 to 30 µm.
In the present case, patient was comfortable during intraoperative period and postoperative period was uneventful. The laser has demonstrated significant advantages over other modalities for intraoral surgical procedures. With adequate training and experience, one can use this tool for efficient, bloodless and less invasive surgery.
The surgical field is cleaner, with less blood to obscure the surgeon’s field of vision. Laser technology has certain advantages, such as accuracy of the incision and absence of vibration and manual pressure during use. The laser has also been shown to have bactericidal effects in the wound.
Lasers have clinical advantages such as bacterial reduction at the surgical sites and increased comfort levels. Laser in surgical removal of exostosis appears to be justified on the grounds of reduced surgical time with more efficient cutting compared to micromotor and much better acceptance by the patients.