Year : 2006 | Volume
: 24 | Issue : 5 | Page : 7--10
Aberrant talon cusps: Report of two cases
Roshan Rayen, MS Muthu, N Sivakumar
Department of Pediatric Dentistry, Meenakshi Animal Dental College and Hospital, Chennai - 600 095, Tamil Nadu, India
Department of Pediatric Dentistry, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 600 095, Tamil Nadu
Talon cusp is an uncommon anomaly seen both in primary and permanent dentition. In most instances they are associated with other clinical problems such as occlusal interferences, poor esthetics and caries susceptibility. Management of such instances requires a comprehensive knowledge of the clinical entity as well as the problems associated with it. Here, we present two cases of talon cusps.
|How to cite this article:|
Rayen R, Muthu M S, Sivakumar N. Aberrant talon cusps: Report of two cases.J Indian Soc Pedod Prev Dent 2006;24:7-10
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Rayen R, Muthu M S, Sivakumar N. Aberrant talon cusps: Report of two cases. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2020 Sep 21 ];24:7-10
Available from: http://www.jisppd.com/text.asp?2006/24/5/7/26028
Tooth development is a complex process. Any aberrations in the different stages of tooth development can result in unique manifestations. Disturbances during histodifferentiation stage of tooth development results in amelogenesis imperfecta, dentinogenesis imperfecta and disturbances during morphodifferentiation stage can result in, mulberry molars, peg laterals, and talon cusps.
Talon cusp was first recognized by Mitchell in 1892. He described this entity as a prominent accessory cusp like structure on the lingual surface of a maxillary incisor. Gorlin and Goldman later defined talon cusp as a very high accessory cusp, which may connect with the incisal edge to produce a T-form or a Y-shaped contour. This accessory cusp is often referred to as Talon cusp, as it is said to resemble an eagle's claw. It is usually composed of normal enamel, dentin and contains a horn of pulp tissue.
The prevalence of talon cusp varies in different populations. Prevalence of 0.17% in the United States, 0.06% in Mexico, 5.2% in Malaysia and 7.7% in northern Indian population has been reported. A striking predilection of maxilla over the mandible has been noted, with more than 90% of the reported cases in maxilla. About 77% of the affected teeth have been in permanent dentition. Among them 55% of the cases involved lateral incisors, 33% central incisors, and 4% canines. A gender ratio of male/female had an almost equal sexual predilection in almost all races in which studies have been performed. In the primary dentition it was first reported by Henderson in 1977. Since then thirty cases have been documented in primary dentition.
A seven year old female patient reported to the department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College, Chennai, with the complaint of pain and decay in left lower back tooth region. Clinical examination revealed grossly carious mandibular second primary molars on both sides with no other carious lesions. Examination also revealed an enamel projection on the mandibular left central incisor, which extended from the cingulum up to the incisal edge of the tooth, deviating towards the left [Figure 1]. The tooth appeared T-shaped when viewed incisally. The mandibular talon cusp merged smoothly with the lingual surface of the tooth. The deep developmental groove, which is normally seen at this junction, was not present. The margins of the talon cusp were smooth and did not cause any irritation to the ventral surface of the tongue. Caries was not detected and no functional or esthetic problems were present. A periapical radiograph of this tooth showed an inverted V-shaped radiopaque structure arising from the cingulum, with immature closure of the root apices [Figure 2].
On the basis of its characteristic clinical and radiographic appearance, a diagnosis of talon cusp was made. As the tooth did not pose any significant clinical problems, corrective treatment for the tooth was not instituted. However the right and left lower second primary molars were extracted and bilateral band and loop space maintainers were placed and patient was advised for a periodic recall visit [Figure 3].
An 8 year old boy reported to the department of Pedodontics and Preventive dentistry, Meenakshi Ammal Dental College, Chennai with the complaint of malaligned erupting front teeth in the lower jaw. Intraoral examination revealed lingually erupting mandibular right and left laterals with the left lateral placed at a more lingual position than the corresponding contralateral tooth [Figure 5]. Maxillary arch revealed an extra prominent accessory cusp in the left upper central incisor. This tooth had a highly exaggerated conical enamel projection, which extended almost from the cervical third of the crown to the incisal edge [Figure 4]. In occlusion the talon cusp was interfering with the alignment of mandibular lateral incisor.
A periapical radiograph revealed a V-shaped radiopaque cusp like structure with a pulpal extension within it [Figure 6]. On the basis of its characteristic features, a diagnosis of talon cusp was made.
As there was an obvious clinical sign of crowding, study casts were made [Figure 7]. The crowding was due to a combination of arch discrepancy and the occlusal interference of the talon cusp. In view of the interference in occlusion and the groove present on either side of the cusp, selective cuspal grinding was done followed by fluoride application and sealant [Ultraseal XT TM Ultradent products] placement [Figure 8]. An orthodontic opinion was also obtained and bilateral extraction of the mandibular primary canines was carried out under local anaesthesia [lignocaine hydrochloride 2%, with adrenaline 1: 80000] to facilitate alignment of lower permanent incisors [Figure 9]. The patient was later scheduled for a periodic 3-month recall visit to assess the eruption status of lower incisors.
One-year follow up revealed a satisfactory alignment of the mandibular anterior teeth [Figure 10],[Figure 11]. Timely extraction of the primary canines and selective grinding of the talon cusp helped us to achieve this alignment. Patient was adviced a periodic evaluation to monitor the resorption status of the mandibular first primary molars and to guide the eruption of the permanent canines.
The etiology of such a cuspal exaggeration to occur is considered by most authors to be multifactorial which has a primary polygenetic component, accentuated by an external influence. The histological picture is a clear cut outward folding of inner enamel epithelial cells and transient focal hyperplasia of the peripheral cells of the mesenchymal dental papilla., The high incidence of occurrence in the lateral incisors is due to compression of the tooth germ during the morpho-differentiation stage between the central incisors and canine. The sequelae of compression can either result in an out folding of the dental lamina or an infolding as in dens invaginatus.
Hattab et al classified talon cusps as Type 1 Talon, Type 2 Semi Talon and Type 3 Trace Talon., After the reports of similar cusps being reported on the facial surfaces this classification was later modified by Stephen-Ying et al as,,, Type 1, Major Talon - A morphologically well-delineated additional cusp that prominently projects from the facial or palatal/lingual surface of an anterior tooth and extends atleast half the distance from the cementoenamel junction to the incisal edge.
Type 2, Minor Talon- A morphologically well-defined additional cusp that projects from the facial or palatal/lingual surface of an anterior tooth and extends more than one fourth, but less than half the distance from the cementoenamel junction to the incisal edge.
Type 3, Trace talon-enlarged or prominent cingula and their variations, which occupy less than one-fourth the distance from the cementoenamel junction to the incisal edge.
Mader in his thorough review suggested that talon cusp might be associated with other somatic and odontogenic anomalies., It can cause various diagnostic, functional and esthetic problems.,,, He also added that this term be reserved only for those anomalous cusps that prominently project from the lingual surface of a succedaneous tooth, are morphologically well delineated and extend atleast half the distance from the cementoenamel junction to the incisal edge.
The common problems associated with talon cusps are,,,,
a) Caries susceptibility
b) Occlusal interferences
c) Compromised esthetics, etc.
Caries susceptibility to the groove in between the cusp and the tooth should be prophylactically sealed. In case 2 pit and fissure sealant (Ultra seal XT TM Ultradent products) was used to seal the groove.
Occlusal interferences might necessitate selective occlusal grinding. This should be done under highly aseptic conditions since there is an increased chance of pulpal exposure for which an endodontic procedure such as partial pulpotomy or root canal treatment may be needed.,, Whenever there is occlusal interference, it can lead to rotation or displacement of the tooth or opposing tooth. In case 2 the talon cusp was interfering with alignment of mandibular lateral incisor. One year after the occlusal grinding and the extraction of primary canines the mandibular anterior teeth came into proper alignment. This emphasizes the need for timely intervention of such clinical situations.
If esthetics is compromised due to a prominent talon cusp sequential grinding or complete excision of the cusp followed by therapeutic endodontic procedure should be done. However Fabra Campos has reported increased chances of endodontic failure in a case with a palatal gingival groove in maxillary lateral incisor with a talon cusp.
Also other minor problems such as speech disturbances, tongue irritation, accidental cuspal fracture and periodontal problems due to excessive occlusal forces should be treated symptomatically along with cuspal management of the same depending upon its severity of occurrence. In cases of talon cusp in the primary dentition it is important to monitor regularly the occlusion during the eruption of a tooth with talon cusp as well as their opposing teeth in order to prevent potential crossbite or malposed teeth.,
In some instances talon cusp is associated with syndromes like Mohr syndrome, Incontinenta pigmentii Achromians, Rubinstein Taybi syndrome and Ellis Van Creveld syndrome. Sometimes it is an isolated finding. In such situations other dental anomalies such as peg shaped lateral incisors, unerupted canines, mesiodens or complex odontomes, as well as supernumerary teeth, megadont and dens evaginatus should be ruled out and a proper differential diagnosis is made.,
Radiographically, the talon cusp is seen as a radiopaque structure, in which the enamel, dentin and occasionally the pulp can be seen. Typically the cusp resembles a V-shaped structure superimposed over the normal image of the crown. A definitive diagnosis of a talon cusp cannot be made based on the radiographic findings alone because a talon cusp on an unerupted tooth may be radiographically misinterpreted as a supernumerary tooth, compound odontoma or dens in dente.
Both the cases presented here fulfilled Mader's criterion regarding extension of the cusp and belonged to Type 1 Major Talon according to the classification by StephenYing et al ., Only prominent cusps may cause complications and hence requires early diagnosis and treatment to prevent clinical problems. Small talon cusps, such as the type3 are usually asymptomatic and need no treatment. He also proposed that if esthetic appearance is satisfactory, function is within normal limits, caries or advanced attrition is absent and if the anomalous cusp is not sharp, treatment of the talon cusp is not required.
Hattab et al reported the prevalence of talon cusp in the maxillary arch as 92%, but talon cusps of mandibular teeth were extremely rare. Two case reports by Mader and Goel followed by a single case report on a mandibular talon cusp by Nadkarni, Munshi and Damle have been reported on the lower right quadrant. In contrast the Talon cusp in the first case here, was present on the lower left quadrant.
Although talon cusp may not be routinely encountered in a dental office, proper differential diagnosis need to be established before a definitive treatment is planned. The role a pediatric dentist plays in managing a clinical case of talon cusp is of utmost importance because the earlier the detection, the minimal are the future complications and the better is the prognosis.
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