What is the diagnosis and management for ribs along the bottom of the mouth, bilaterally along the mandible?

Mandibular Tori: Diagnosis and Management

The bilateral protrusions along the mandible are most likely mandibular tori (torus mandibularis), which are benign bony growths that require no treatment unless they interfere with function or cause discomfort. 1

Diagnosis

Mandibular tori are characterized by:

• Bilateral bony protrusions on the lingual (inner) surface of the mandible
• Usually located in the premolar region, above the mylohyoid line
• Typically asymptomatic
• Hard, non-tender bony outgrowths covered by normal oral mucosa
• Variable in size and shape (can be nodular, flat, lobular, or spindle-shaped)

Differential Diagnosis

Several conditions should be considered when evaluating bony prominences along the mandible:

1. Mandibular tori - Benign bony outgrowths on the lingual surface of the mandible 1
2. Slipping rib syndrome - Affects ribs 8-10 in the anterior chest wall, not the mandible 2, 3
3. Painful rib syndrome - Characterized by pain in lower chest/upper abdomen with tender spots on costal margins 4
4. Mandibular fractures - Associated with trauma, pain, malocclusion, and mobility 5
5. Metastatic lesions - Rare, but can present as mandibular masses 6
6. Osteoradionecrosis - Occurs in patients with history of radiation therapy to the head and neck 5

Diagnostic Approach

1. Clinical examination:

   • Visual inspection and palpation of the mandibular prominences
   • Assessment of symmetry, size, and any associated symptoms
   • Evaluation of overlying mucosa for ulceration or inflammation

2. Imaging (if clinically indicated):

   • Panoramic radiography - First-line imaging for mandibular lesions
   • CT maxillofacial - If more detailed evaluation is needed; provides excellent delineation of osseous structures 5
   • Ultrasound - Not typically used for mandibular tori evaluation

Management

Management of mandibular tori depends on:

1. Asymptomatic tori:

   • No treatment required
   • Patient education and reassurance
   • Regular dental follow-up

2. Symptomatic tori (when causing problems):

   • Surgical removal indicated if:
     • Interfering with denture placement or fit
     • Causing trauma to overlying mucosa
     • Interfering with speech or mastication
     • Causing psychological distress to the patient

3. Surgical considerations:

   • Local anesthesia is typically sufficient
   • Careful mucoperiosteal flap elevation
   • Removal of exostosis with bone burs or chisels
   • Primary closure of the mucoperiosteal flap

Follow-up

• Regular dental check-ups
• Monitor for recurrence if surgically removed
• Assess for any changes in size or symptoms

Important Considerations

• Mandibular tori are not pathological and represent a normal anatomical variant 1
• They do not typically require treatment unless causing functional problems
• If dentures are needed in the future, surgical removal may be necessary
• Surgical removal carries risks of bleeding, infection, and nerve damage
• Recurrence after surgical removal is possible but uncommon

In summary, bilateral bony prominences along the mandible are most likely mandibular tori, which are benign anatomical variants requiring no treatment unless they cause functional problems or discomfort.