Orofacial Myology

Huge Tori Problems

I have recently started a 44-year old woman whose tongue thrust is the “strongest tongue” ever seen by my local orthodontist and the dentist she sees. She is very compliant but was breaking wires with her tongue. On examination, she has a tori (I’ll attach the photo) centrally located on her palate. When she suctions/swallows, she can feel the food/liquid on her palate but it “v”s on either side of the tori and goes lateral to her teeth before it enters her eustachian tube. She has tried to keep it central, but the tori seems to be in the way. She tells me that she usually eats foods that are softer because she has had such problems with her molars (generally chews on right because the molars did not meet on left until this week). Her tongue was very large and wrinkled when she drew it into her mouth. It is already looking lots better and not wrinkled anymore so I know she is getting toned. She has had TMJ and bruxism, so is working on not clenching. Last week she reported that when she worked on maintaining her tongue on the spot, she’d find herself clenching, but this week, she is much better. She has severe mandibular exostosis and will have sections of her maxilla removed at the end of this month as well as having the mandible widened and rotated forward. If I understand, tori’s are not so unusual, about 20% of females have them. What can I expect fro a bolus and midline swallow. Are they possible or will I be just frustrating her trying to get them. She has learned everything every quickly and is developing great habits, so I don’t want this to throw her. What do you do differently because of the anatomy?
Thanks so much! 
 
I’m never quite sure what someone means by “strong tongue”…  How was she breaking the wires, I wonder…. From pressure against them?    Excellent photo and a good-sized, terribly positioned maxillary torus.    As far as her description of the feel and pathway of the bolus….that’s exactly what I would expect, looking at her photo.    The torus is smack in the location where the bolus belongs.  Sometimes the extra focus on tongue to “spot” calls more attention to the area and I have heard about some folks clenching more at first.    So mandibularly, she also has a lot of tissue/bone taking up precious space and on the maxilla that torus is taking up lots of needed space.   Although many may have tori, with most people, the location and size might not be anything close to hers.  And the exostosis adds a double whammy.  You ask what you could expect as far as bolus collection and midline swallow:  I would say that she cannot form and create an acceptable bolus in the standard location, etc.  I would think it’s impossible unless and until at least the torus is removed.  You wonder what can be done so as not to ask the impossible of her.  I would strongly recommend removal of that torus at the time of the other surgery, barring any risks that the doctor might know about and advise against.  She cannot chew, collect, suction and swallow the bolus since the place is already being taken up by the torus.  I wish I had some other info to offer, but two things can’t occupy the same space and that’s the bottom line, in my opinion.  It is also impossible for her to suction flat to the palate; thus, another complete obstacle to bolus control. 

You can certainly keep focusing on correct habitual tongue, lips, and mandibular rest postures.  When at rest, there should be a freeway space between her posterior teeth about 2-3 mm at the molars and 4-6 mm with the anterior dentition.  Too much freeway space creates a situation where certain teeth might over-erupt, and thus the presence of a “hanging jaw” with many patients.  Too little freeway space is really clenching/bruxing and that is also problematic.  So, be sure she maintains that small amount during quiet time practices.  

Let me know how it goes.  You are right that this is a very interesting situation and I hope the doctor is able to remove that torus so you and your patient can move ahead.

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