A Suggested Butterfly Design for

Mandibular Tori in Partially

Edentulous Patient: Clinical Case
Report

Ezzat AKH, Tayel SB and Al-Khiary YM

PRESENTED BY
DR. JENNIFER VINCENT
PG 1ST YEAR
DEPARTMENT OF PROSTHODONTICS
 INTRODUCTION

– Tori are non-pathological nodular protuberance of mature

bone whose precise occurrence destination depends on
anatomical location. Tori can be easily diagnosed and no
biopsy is necessary, its Surgical removal is not required unless
in case of chronic trauma or interference that interfere with
oral functions or with the replacement of a denture base or
framework.
•Tori are asymptomatic and exhibit slow growth during the
second and the third decade of life. Racial differences appear
significant, with higher prevalence in Asians and Eskimos.

•Torus palatinus is found more frequent in women whereas

torus mandibularis affects more men. Etiology of tori has been
investigated and several factors have been proposed including
genetic factor environmental factors, masticatory hyper
function and continued growth. Recent study showed positive
association between the presence of torus mandibularis and
bone mineral density.
 CASE REPORT

– C/C: A (76) years old female patient came to the prosthodontics

outpatient clinic at Faculty of Dentistry, King Abdul-Aziz University
complaining of being edentulous for a long period of time and
seeking for a solution for her problem.
– Medical and dental histories revealed that she is diabetic with
congested heart failure due to chronic hypertension more than 15
years back. She visited many dental clinics and all her treating
dentists told her that she needs surgery to remove bilateral
mandibular tori to replace her teeth.
– Intraoral examination revealed presence of maxillary class 1 kennedy`s
partially edentulous arch opposed with mandibular class I modification
(1) kennedy`s classification. Remaining mandibular teeth No (33, 34 43,
44 and 45) and some calculus deposits detected in the anterior lingual
mandibular segment. Decayed tooth No. 33 which needs class (v)
composite filling. Bilateral big sized mandibular tori covered with thin
layer of mucosa were detected lingually on both sides of the premolar
regionsof
depth of (12
themm length,
lingual 4 mm height and extends to occupy the full
sulci)
and making the construction
of conventional removable
partial denture (RPD)
impossible as the lingual bar
or plate of the framework
will interfere and traumatize
the whole lingual sulci.
− Investigations: Panoramic
radiograph was used to detect any
oral pathology

− Treatment planning: Scaling and

root planning for the remaining
teeth were done as their
periodontal health condition is good
and they can share in bearing an
(RPD) as revealed by the panoramic
x-ray. Polishing of the teeth for
proper shade guide selection and oral hygiene regime was
prescribed at home in the form of mouth wash, tooth paste and a
soft tooth brush. Class (V) composite filling for the decayed tooth
No (33) was done. Referral for her physician to describe a suitable
tranquilizer to calm her down and to assure her that no surgery will
be done.
− Prosthodontics procedures: The planned treatment was placement of
definitive maxillary class 1 denture and mandibular class1 modification
(1) Kennedy`s classification cobalt chromium based RPDS. Maxillary &
mandibular alginate impressions in stock trays were made to get the
study casts. Tripod marks were used to record the position of the
mandibular cast, teeth No 34, 45 were selected as the main abutments
and the favorable path of insertion and removal was selected. After
primary surveying, the design was drawn. It was in the form of a
butterfly framework away from
sites of the tori with bilateral
saddle areas extended at the
most distal parts of lingual sulci,
labial bar as major connector,
gingival approaching clasps on
abutment teeth No. 34, 45,
cingulum rests on teeth No. 33,
34 and mesially placed occlusal
rests on teeth No. 34 & 45.
The necessary abutments preparations were done
inside the patient mouth. Acrylic special trays were
border molded using modeling plastic impression
compound and final impressions were taken with
polyvinyl siloxane impression material. Impressions
were poured in hard dental stone. On the
mandibular master cast after final surveying the
unnecessary undercuts were obliterated, the saddle
areas and the labial section is relieved to accept a
labial bar as a major connector, ledges were
prepared for the selected clasps and the duplicate
(working cast) is obtained. The drawing design on the
work authorization sheet with color coding was sent
to the laboratory for construction of the metallic
framework.
The metallic framework was tried in the patient mouth and the
necessary adjustments done until the framework fitted well and the
patient was satisfied. An altered cast impression technique was made
using zinc oxide and euginol impression paste to record the functional
form of the saddle areas. It was sent to the laboratory to make
maxillary and mandibular record blocks. Jaw relation records & face
bow transfer were recorded and the shade guide was selected.
The casts were
mounted in semi
adjustable articulator
for the final teeth
arrangement. The
occlusion was designed
following the concept
of lingualized occlusion.
After trial insertion, the denture was sent to
the laboratory for processing. The upper and
lower finished dentures were inserted and the
necessary occlusal adjustment was made. The
patient expressed her comfort. She was able to
She was able to insert and remove the
prosthesis easily. Esthetics were good and she
was able to was able to pronounce and reads
some phrases properly. The patient was
instructed for oral hygiene measures, how to
use and maintain her dentures at home and a
follow up was scheduled after 24 hours if she
feels pain and after 48 hours is given for any
further necessary occlusal adjustment or to
relieve any complaint.
 DISCUSSION

– The butterfly design was constructed with no lingual major

connector, only the saddles extend to the most distal part of
the ligual sulci forming a butterfly shape. As mandibular toti
are covered by an extremely thin layer of soft tissue they may
be easily irritated and interfere painfully by slight movement
of the denture base in the mouth during the insertion and
removal of the mandibular RPD that explains why they are
left uncovered by the design.
– This weakness of the design was substituted with a strong
labial bar to reinforce the design.
− Gingival approaching clasps retained the prosthesis in place
offering stress breaking action on the abutments raising
their durability and their life time together with the
prosthesis.
− The indirect retention is mainly afforded by the cingulum
rests and the occlusal rest prepared on the canines and on
teeth No 43 and 44.
− The butterfly design satisfied the patient’s requirements;
avoiding her any surgery. The possible complications of
surgery includes lingual nerve damage in cases of distally
extended tori, infection and floor of mouth hemorrhage.
The latter is a rare sequel but can be life threatening and
must be managed immediately in order to prevent airway
embarrassment impairment.
Lingualized occlusion concept was applied during setting
of the cusped artificial teeth to create balanced occlusion
avoiding any premature contacts between maxillary and
mandibular teeth during the excursive movements.
Feather touch between the maxillary and mandibular
anterior teeth was performed to avoid any trauma to the
underlying maxillary anterior alveolar ridge to avoid
Kelly`s syndrome. The missing anterior maxillary teeth
were set in proper vertical and horizontal relations to the
mandibular anterior teeth for maximal esthetic and
phonetic considerations. Several trials were made till the
patient was able to pronounce some letters as (s,th,f and
z) properly and she was esthetically satisfied.
 CONCLUSION

The Proposed butterfly design may be beneficial in

bilateral big sized mandibular tori and similar cases
with medically compromised patients. The design is
comfortable to the patient, fits easily and is
esthetically accepted.
 CRITICAL APRAISAL
– The butterfly design was constructed with no lingual major connector which makes this
design week which was substituted with a strong labial bar to reinforce the design
– Patient satisfaction achieved avoiding possible complications like hemorrhage at the floor of
the mouth, lingual nerve damage, and infection.
– Gingival approaching clasps retained the prosthesis in place offering stress breaking action
on the abutments raising their durability and their life time together with the prosthesis.
– Lingualised occlusion posteriorly is given along with anterior feather touch to avoid Kelly’s
syndrome
– Theres no longer follow up
– No studies were discussed
– Only one patient case has been discussed
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THANK YOU