Introduction
Buccal exostoses are benign bony outgrowths that occur on the buccal (outer) surface of the maxilla or mandible, most commonly in the premolar and molar regions. While generally asymptomatic and self-limiting, these bony protuberances can raise concerns for patients regarding aesthetics, oral hygiene maintenance, and potential periodontal issues. Accurate diagnosis is crucial, particularly to differentiate buccal exostoses from other oral conditions presenting with similar clinical features. This article aims to provide a comprehensive guide to the Buccal Exostosis Differential Diagnosis, enhancing the understanding for dental professionals and ensuring optimal patient care.
What are Buccal Exostoses?
Buccal exostoses are classified as non-neoplastic bony growths, essentially localized areas of hyperostosis. They are characterized by their broad base and smooth surface, typically appearing bilaterally along the facial aspect of the alveolar ridge. These growths are often discovered incidentally during routine dental examinations or when patients become aware of them due to their increasing size or cosmetic concerns. The precise etiology remains unclear, though contributing factors are believed to include genetic predisposition, environmental influences, and parafunctional habits leading to increased masticatory forces. They are distinct from tori, which are similar bony growths but occur in different locations within the oral cavity, such as the midline of the hard palate (torus palatinus) or the lingual aspect of the mandible (torus mandibularis).
Differential Diagnosis of Buccal Exostosis
The primary reason for considering a buccal exostosis differential diagnosis is to rule out other oral lesions that may present with similar clinical characteristics, but require different management strategies or indicate more serious underlying conditions. The differential diagnosis includes:
1. Tori (Torus Palatinus and Torus Mandibularis)
Tori are also benign bony protuberances, but they are differentiated from buccal exostoses by their location. Torus palatinus occurs on the midline of the hard palate, while torus mandibularis is found on the lingual aspect of the mandible, typically in the premolar region. While both are bony hard and covered by mucosa, their distinct anatomical locations usually allow for clear differentiation. However, in cases of atypical or extensive tori, or when buccal exostoses are located in less typical areas, careful examination is necessary.
2. Osteoma
Osteomas are benign bone tumors that can occur in various bones, including the jaws. Peripheral osteomas, in particular, can present as exophytic bony masses on the surface of the jaws, potentially mimicking buccal exostoses. Osteomas tend to be solitary, slow-growing, and well-circumscribed. Radiographically, they are dense, sclerotic masses. While buccal exostoses are usually multiple and bilateral, a solitary buccal exostosis could be considered in the differential diagnosis of an osteoma. Histopathological examination can definitively differentiate between the two if clinical and radiographic features are inconclusive.
3. Osteosarcoma and Chondrosarcoma
Malignant bone tumors such as osteosarcoma and chondrosarcoma, though rare in the jaws compared to benign lesions, must be considered in the buccal exostosis differential diagnosis, especially when encountering unusual presentations. These malignant tumors can present with rapid growth, pain, paresthesia, tooth mobility, and radiographic features indicative of bone destruction rather than simple overgrowth. While buccal exostoses are characteristically slow-growing and painless, any lesion exhibiting rapid enlargement, associated symptoms, or atypical radiographic findings warrants immediate investigation to rule out malignancy. Biopsy is mandatory in such cases for definitive diagnosis.
4. Gardner Syndrome
Gardner syndrome is an autosomal dominant genetic disorder characterized by multiple osteomas, intestinal polyposis (which has a high risk of malignant transformation into colorectal cancer), and cutaneous cysts or fibromas. Patients presenting with multiple osteomas in the jaws, including buccal exostoses, should be evaluated for other signs and symptoms of Gardner syndrome, especially if there is a family history of the condition. While isolated buccal exostoses are common and not indicative of Gardner syndrome, the presence of numerous osteomas in different locations of the jaws should raise suspicion and prompt further investigation and referral for genetic counseling and systemic evaluation.
5. Other Benign Bone Lesions
Several other benign bone lesions can occur in the jaws and may enter into the buccal exostosis differential diagnosis, although they are less commonly confused clinically. These include:
- Fibrous Dysplasia: This condition involves the replacement of normal bone with fibrous tissue and abnormal bone. Fibrous dysplasia can cause bony enlargement, but it typically presents as a more diffuse swelling and may have a characteristic “ground glass” radiographic appearance, unlike the well-defined, dense appearance of exostoses.
- Cemento-ossifying Fibroma: This benign neoplasm contains fibrous tissue and varying amounts of mineralized material (bone, cementum, or both). It can cause bony expansion and may be radiolucent, radiopaque, or mixed radiolucent-radiopaque. Its radiographic and potential for expansion differentiates it from typical exostoses.
- Benign Cementoblastoma: This benign odontogenic tumor is associated with the root of a tooth and causes expansion of the cortical bone. Radiographically, it appears as a radiopaque mass fused to the tooth root, surrounded by a radiolucent rim. Its association with a tooth and distinct radiographic features help differentiate it.
Diagnosis of Buccal Exostosis
The diagnosis of buccal exostosis is primarily based on clinical examination. Key diagnostic features include:
- Location: Buccal surface of the maxilla or mandible, typically in the premolar and molar regions.
- Appearance: Smooth, broad-based, bony hard swellings covered by normal-appearing mucosa.
- Palpation: Hard, non-tender, immobile bony masses.
- History: Slow-growing, often bilateral, and asymptomatic.
Radiographic examination, such as periapical radiographs or panoramic radiographs, can be helpful in confirming the diagnosis and ruling out other conditions. Buccal exostoses appear as well-defined radiopaque masses superimposed on the roots of the teeth. However, radiography is not always essential for diagnosing typical buccal exostoses.
Biopsy is generally not required for the diagnosis of buccal exostoses in classic presentations. However, incisional or excisional biopsy should be considered if there is any doubt in the diagnosis, if the lesion exhibits atypical features (rapid growth, pain, ulceration), or to rule out malignancy.
Treatment of Buccal Exostosis
In most cases, buccal exostoses do not require treatment. Management is indicated when the exostoses:
- Interfere with oral hygiene, leading to food impaction and periodontal problems.
- Cause discomfort or pain.
- Interfere with denture fabrication or placement.
- Are a cosmetic concern for the patient.
When treatment is necessary, surgical excision is the standard approach. The procedure typically involves:
- Flap Elevation: A mucoperiosteal flap is raised to expose the exostosis.
- Exostosis Removal: The bony growth is removed using burs or chisels under copious irrigation.
- Smoothing and Contouring: The surgical site is smoothed to eliminate sharp edges and promote mucosal adaptation.
- Wound Closure: The flap is repositioned and sutured.
The case report presented in the original article illustrates a successful surgical removal of bilateral maxillary buccal exostoses for aesthetic reasons. The surgical procedure was uneventful, and the patient had a satisfactory outcome.
Conclusion
Buccal exostoses are common benign bony growths that are usually easily diagnosed clinically. However, a thorough understanding of the buccal exostosis differential diagnosis is essential to exclude other benign and malignant conditions that may present similarly. By considering conditions such as tori, osteomas, malignant bone tumors, Gardner syndrome, and other benign bone lesions, dental professionals can ensure accurate diagnosis and appropriate management, providing optimal care and reassurance to their patients. While typically harmless, awareness of buccal exostoses and their potential need for intervention in specific cases remains important in comprehensive dental practice.
References
[1] Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 4th ed. Philadelphia: WB Saunders; 1983.
[2] Neville BW, Damm DD, Allen CM, Bouquot JE. Oral & maxillofacial pathology. 2nd ed. Philadelphia: WB Saunders; 2002.
[3] Regezi JA, Sciubba JJ, Jordan RC. Oral pathology: clinical pathologic correlations. 4th ed. Philadelphia: WB Saunders; 2003.
[4] Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. 2nd ed. St Louis: Mosby; 2001.
[5] Daley TD, Wysocki GP. Oral mucosal lesions: a guide to differential diagnosis. 4th ed. Hamilton: BC Decker; 2003.
[6] Jainkittivong A, Langlais RP. Buccal exostoses: prevalence and clinical observations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(1):66-72.
[7] Krolls SO, Pindborg JJ, Stoelinga PJ. Histopathology of oral lesions. 3rd ed. Copenhagen: Munksgaard; 1994.
[8] Wood NK, Goaz PW. Oral radiology: principles and interpretation. 3rd ed. St Louis: Mosby; 1992.
