Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 50-52

Jaw pain secondary to atypical maxillary torus near the incisive canal: A cone beam computed tomography study


Department of Radiology, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA

Date of Web Publication9-Jul-2018

Correspondence Address:
Mr. Anthony Albert
240 S. 40th St, Philadelphia, PA 19103
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jofs.jofs_44_18

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  Abstract 


Pain in the anterior maxilla can be odontogenic or nonodontogenic. If it is not related to the teeth, then the differential diagnosis is based on a clinical exam, radiographic exam, and often, on advanced imaging. This case report is based on a 58-year-old male with a chief complaint of chronic pain with acute exacerbations in the region of the rugae of the maxillary central incisors. Clinical examination and planar radiography led to the suspicion of a cyst in the region of the incisive foramen. The patient was referred for advanced imaging. Cone beam computed tomography imaging confirmed the presence of an unusual tori in the region of the incisive foramen that led to periodic inflammation in the region. A differential diagnosis of the pain included pain secondary to a localized inflammation of the incisive canal and nasopalatine duct, and an inflammation of the soft tissue interdental col in the region of the central incisors as well as the benign and malignant minor salivary gland tumors. Because the rugae is attached to the palate, any expansion of the soft tissues in this region causes pain that must be diagnosed accurately to treat the cause.

Keywords: anterior maxillary torus, cone beam computed tomography, jaw pain, maxilla, maxillary torus, palatal torus


How to cite this article:
Albert A, Mupparapu M. Jaw pain secondary to atypical maxillary torus near the incisive canal: A cone beam computed tomography study . J Orofac Sci 2018;10:50-2

How to cite this URL:
Albert A, Mupparapu M. Jaw pain secondary to atypical maxillary torus near the incisive canal: A cone beam computed tomography study . J Orofac Sci [serial online] 2018 [cited 2018 Dec 17];10:50-2. Available from: http://www.jofs.in/text.asp?2018/10/1/50/236206




  Introduction Top


Pain in the anterior maxilla can arise from a multitude of sources. The differential diagnosis list for pain in the anterior maxilla includes a nasopalatine duct cyst, benign or malignant tumors, and atypical facial pain. A nasopalatine duct cyst, also known as an incisive canal cyst, is the most prevalent nonodontogenic cyst of the gnathic bones,[1] with a prevalence of 32.8%.[2] Pain associated with the nasopalatine duct cysts is secondary to trauma and infection.[1] The benign and malignant tumors of the maxillary region can also be associated with pain in the anterior maxillary region.[3] Atypical facial pain is a complex disorder with a poor prognosis that can be difficult to diagnose.[4] This case report focuses on a patient with the chief complaint of pain in the anterior maxilla secondary to inflammation near the incisive foramen.


  Case Report Top


In this case, a 58-year-old male presented for a cone beam computed tomography (CBCT) study to rule out a nasopalatine duct cyst in the anterior maxilla region. The patient reported intermittent pain in the anterior palatal region near the rugae. On a pre-CBCT reexamination of the patient, the mass near the nasopalatine duct was noted as swollen and slightly inflamed. Upon palpation of the protuberance, there was a hard, bony exostosis-like area with mild-to-moderate pain upon palpation. A CBCT was obtained using Carestream CS9300 machine (Carestream Inc, Atlanta, GA) operating at 90 kV and 4 mA. The volume was acquired at a resolution of 250 μm. Upon review of the CBCT, a hyperdense bony exostosis was noted slightly superior to the incisive foramen attached to the hard palate. The sagittal, axial, and coronal views of the CBCT study (multiplanar reconstructions) are shown in [Figure 1], [Figure 2], and [Figure 3], respectively. [Figure 4] depicts a 3D reconstruction denoting the torus palatinus, torus maxillaris, and anterior maxillary torus. A differential diagnosis of this mass included a nasopalatine duct cyst, a supernumerary tooth, or an osteoma. Upon review of the CBCT, there was no evidence of a nasopalatine duct cyst or incisive canal cyst. The pain in the anterior maxillary torus region was determined be related to trauma from sharp or bony food items that the patient may have consumed, leading to pressure and inflammation in the rugae area. The patient concurred with similar experiences in the past. Incidentally, the patient also had maxillary tori (torus maxillaris) in the region of tuberosities bilaterally as well as palatal torus (torus palatinus).
Figure 1: Sagittal CBCT slice in the region of the nasopalatine canal showing the anterior maxillary torus (arrow)

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Figure 2: Axial CBCT slice at the level of the hard palate showing the anterior maxillary torus (arrow). In addition, note the bilateral maxillary tori in the region of tuberosities

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Figure 3: Coronal CBCT slice at the level of the anterior nasal spine showing the anterior maxillary torus in this dimension (arrow)

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Figure 4: Cropped and sliced 3D rendering of the maxilla at the level of the palate showing all the tori in the maxilla. Blue arrows point to torus maxillaris, red star identifies the torus palatinus, and the yellow highlight and black arrows point to the new anterior maxillary torus that was contributing to pain in this patient

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  Discussion and Conclusion Top


Clinical examination combined with CBCT review led to the conclusion that the protuberance is an unusual anterior maxillary exostosis superior to the incisive foramen. There was no evidence of a nasopalatine duct cyst or a supernumerary tooth.

There are anatomically three types of tori in the jaws; two of them are in the maxilla, namely, torus palatinus and torus maxillaris.[5] The third torus is located in the lingual aspect of the mandible, namely, torus mandibularis.[5] The current torus was located in the anterior maxilla and separate and distinct from the rest. There was no report of such tori in the literature, and hence, this appears to be a new, yet unpublished variation of maxillary tori. The differential diagnosis of such exostoses commonly includes benign masses such as osteomas that are incidentally found in the jaws. Osteomas are distinctly separate from exostoses-like lesions. Exostoses are defined as benign bone growths in the mandibular or maxillary region, while osteomas are bone lesions with different onsets and slow growth that can be categorized into multiple categories.[6] Exostoses must be distinguished from osteomas, which can be treated differently than exostoses.[7] Atypical facial pain can be excluded from the differential diagnosis upon CBCT review, because definitive diagnosis could be made for exostosis. Atypical facial pain, or persistent idiopathic facial pain, is, by definition, a diagnosis of exclusion after all other possible diagnoses have been exhausted.[3] In this case, the patient presented with facial pain related to a novel anterior maxillary torus, which was not previously reported in the literature. The patient was made aware of the anterior maxillary torus and the possibility of getting reinjured periodically. The patient was referred back to his Oral Medicine specialist who initially had referred him for the CBCT scan. The patient was also made aware of a possible surgical intervention if the problem persisted and was advised to get the area monitored by his dentist.


  Declaration of patient consent Top


The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barros CC, Santos HB, Cavalcante IL, Rolim LS, Pinto LP, de Douza LB. Clinical and histopathological features of nasopalatine duct cyst: A 47-year retrospective study and review of current concepts. J Craniomaxillofac Surg 2018;46:264-8.  Back to cited text no. 1
    
2.
Nonaka C, Henriques A, de Matos F, de Souza L. Nonodontogenic cysts of the oral and maxillofacial region: Demographic profile in a Brazilian population over a 40-year period. Eur Arch Otorhinolaryngol 2011;268:917-22.  Back to cited text no. 2
    
3.
van der Kamp MF, Leusink FK, Al-Mamgani A, Lohuis PJ, van den Brekel MW. Pain as the primary symptom of a malignant parotid tumour. Ned Tijdschr Tandheelkd 2016;123:585-9.  Back to cited text no. 3
    
4.
Weiss A, Ehrhardt K, Tolba R. Atypical facial pain: A comprehensive, evidence-based review. Curr Pain Headache Rep 2017;21:8.  Back to cited text no. 4
    
5.
Seah YH. Torus palatinus and torus mandibular is: A review of the literature. Aust Dent J 1995;40:318-21.  Back to cited text no. 5
    
6.
Bansal M, Rastogi S, Sharma A. Multiple mandibular exostoses: A rare case report. J Clin Diagn Res 2013;7:1802.  Back to cited text no. 6
    
7.
Chaudhry SI, Tappuni AR, Challacombe SJ. Multiple maxillary and mandibular exostoses associated with multiple dermatofibromas: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:319-22.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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