ORAL MEDICINE Dr. Ali Al-

Ibrahemy

NORMAL ANATOMICAL VARIANTS

1. Linea Alba Linea alba is a normal linear elevation of the buccal mucosa extending

from the corner of the mouth to the third molars at the occlusal line. Clinically,

it present as a bilateral linear elevation with normal or slightly whitish color and

normal consistency on palpation. It occurs more often in obese persons,

habitually cheek biters. The oral mucosa is slightly compressed and adjusts to

the shape of the occlusal line of the teeth.

2. LeukoedemaLeukoedema is a normal anatomic variant of the oral mucosa due to

increase thickness of the epithelium and increase of intracellular edema. As a

rule, it occurs bilaterally and involves most of the buccal mucosa and rarely the

lips and tongue. Clinically, the mucosa has an opalescent or grayish-white color

with slight wrinkling, which disappears if the mucosa is distended by pulling or

stretching of the cheek. Leukoedema has normal consistency on palpation, and it

should not be confused with the leukoplakia or lichen planus.

3. Normal Oral PigmentationMelanin is a normal skin and oral mucosa pigment produced by

melanocytes. Increased melanin deposition in the oral mucosa may occur in

various diseases, however areas of dark discoloration may often be a normal

finding in black or dark-skinned persons. The degree of pigmentation of the skin

and oral mucosa is not necessarily significant. In healthy persons there may be

clinically asymptomatic black or brown areas of varying size and distribution in

the oral cavity, usually on the gingiva, buccal mucosa, palate, and less often on

the tongue, floor of the mouth, and lips. The pigmentation is more prominent in

areas of pressure or friction and becomes more intense with aging. The

differential diagnosis includes Addison’s disease, pigmented nevus, melanoma,

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smoker’s melanosis, heavy metal deposition, pigmentation caused by drugs,

Peutz-Jeghers syndrome, and Albright’s syndrome.

4. Lingual TonsilsLingual tonsil is large foliate papilla on the side of the tongue which may

be mistaken for a lesion. This tonsil enlarged with viral infection and

occasionally noted by patient. It appear clinically as round smooth well defined

at the lateral side of the tongue covered by normal color mucosa.

DEVELOPMENTAL ANOMALIES1. Fordyce’s Granules

Fordyce’s granules are a developmental anomaly characterized by

collections of heterotopic sebaceous glands in the oral mucosa. Clinically, there

are many small, slightly raised whitish-yellow spots that are well circumscribed

and rarely coalesce forming plaques. They occur most often in the mucosal

surface of the upper lip, commissures, and buccal mucosa adjacent to the molar

teeth in a symmetrical bilateral pattern. They are a frequent finding in about

80% of persons of both sexes. These granules are asymptomatic and come to the

patient’s attention by chance. With advancing age, they may become more

prominent but should not be a cause for concern. The differential diagnosis

includes lichen planus, candidosis, and leukoplakia.

2. Congenital Lip PitsCongenital lip pits represent a rare developmental malformation that may

occur alone or in combination with commissural pits, cleft lip, or cleft palate.

Clinically, they present as bilateral or unilateral depressions at the vermilion

border of the lower lip. A small amount of mucous secretion may accumulate at

the depth of the pit. The lip may be enlarged and swollen. Treatment is surgical

excision for esthetic purposes.

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3. AnkyloglossiaAnkyloglossia, or tongue tie, is a rare developmental disturbance in which

the lingual frenum is short or is attached close to the tip of the tongue. In these

cases the frenum is often thick and fibrous. Rarely, the condition may occur as a

result of fusion between the tongue and the floor of the mouth or the alveolar

mucosa. This malformation may cause speech difficulties. Treatment is surgical

cutting of the frenum corrects the problem.

4. Cleft LipCleft lip is a developmental malformation that usually involves the upper

lip and very rarely the lower lip. It frequently coexists with cleft palate and it

rarely occurs alone. The incidence of cleft lip alone or in combination with cleft

palate varies from 0.52 to 1.34 per 1000 births. The disorder may be unilateral

or bilateral, complete or incomplete. Treatment plastic surgery as early as

possible corrects the esthetic and functional problems.

5. Cleft PalateCleft palate is a developmental malformation due to failure of the two

embryonic palatal processes to fuse. The cause remains unknown, although

heredity may play a role. Clinically, the patients exhibit a defect at the midline

of the palate that may vary in severity. Bifid uvula represents a minor

expression of cleft palate and may be seen alone or in combination with more

severe malformations. Cleft palate may occur alone or in combination with cleft

lip. The incidence of cleft palate alone varies between 0.29 and 0.56 per 1000

births. It may occur in the hard or soft palate or both. Serious speech, feeding,

and psychological problems may occur. Treatment is early surgical correction is

recommended.

6. Bifid TongueBifid tongue is a rare developmental malformation that may appear in

complete or incomplete form. The incomplete form is manifested as a deep

furrow along the midline of the dorsum of the tongue or as a double ending of

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the tip of the tongue. Usually, it is an asymptomatic disorder requiring no

therapy. It may coexist with the oral-facial digital syndrome.

7. Double Lip

Double lip is a malformation characterized by a protruding horizontal

fold of the inner surface of the upper lip. It may be congenital, but it can also

occur as a result of trauma. The abnormality becomes prominent during speech

or smiling. Frequently, it may be part of Ascher's syndrome. Treatment is

surgical correction may be attempted for esthetic reasons only.

8. Torus PalatinusTorus palatinus is a developmental malformation of unknown cause. It is a

bony exostosis occurring along the midline of the hard palate. The incidence of

torus palatinus is about 20% and appears in the third decade of life, but it also

may occur at any age. The size of the exostosis varies, and the shape may be

spindle like, lobular, nodular, or even completely irregular. The exostosis is

benign and consists of bony tissue covered with normal mucosa, although it may

become ulcerated if traumatized. Because of its slow growth, the lesion causes no

symptoms, and it is usually an incidental finding during physical examination.

No treatment is needed, but problems may be anticipated if a total or partial

denture is required.

9. Torus mandibularisTorus mandibularis is an exostosis covered with normal mucosa that

appears on the lingual surfaces of the mandible, usually in the area adjacent to

the bicuspids. The incidence of torus mandibularis is about 6%. Bilateral

exostoses occur in 80% of the cases. Clinically, it is an asymptomatic growth

that varies in size and shape. Treatment. Surgical removal of torus mandibularis

is not indicated, but difficulties may be encountered if a denture has to be

constructed.

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10. Multiple ExostosesMultiple exostoses are rare and may occur on the buccal surface of the

maxilla and the mandible. Clinically, they appear as multiple asymptomatic

small nodular, bony elevations below the muccolabial fold covered with normal

mucosa. The cause is unknown and the lesions are benign, requiring no therapy.

Problems may be encountered during denture preparation.

11. Fibrous Developmental MalformationFibrous developmental malformation is a rare developmental disorder

consisting of fibrous overgrowth that usually occurs on the maxillary alveolar

tuberosity. It appears as a bilateral symmetrical painless mass with a smooth

surface , firm to palpation , and normal or pale color. Commonly , the

malformation develops during the eruption of the teeth and may cover their

crowns. The mass is firmly attached to the underlying bone but on occasion may

be movable. The classic sites of development are the maxillary alveolar

tuberosity region, but rarely it may also appear in the retromolar region of the

mandible and on the entire attached gingiva. Treatment is surgical excision is

required if mechanical problems exist.

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