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Year : 2011  |  Volume : 29  |  Issue : 2  |  Page : 149-154

Atypical presentation of bilateral supplemental maxillary central incisors with unusual talon cusp

Department of Pedodontics, Narayana Dental College, Chinthareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication9-Sep-2011

Correspondence Address:
Sivakumar Nuvvula
Department of Pedodontics, Narayana Dental College, Chinthareddypalem, Nellore- 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.84689

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Delayed eruption of maxillary permanent central incisors in a child poses a distressing esthetic quandary to parents, by virtue of its location in the dental architecture. Well-aligned anterior teeth add confidence to smile and have enhanced self-esteem, which is critical even in early life. Impaction of the maxillary central incisors compared to third molars or the canines is less reported; bilateral supplemental maxillary central incisors related to impacted permanent maxillary central incisors are rare and one of the supplemental central incisors showing unusual talon is still infrequent. A case of impacted maxillary permanent central incisors related to supplemental maxillary central incisors, with one of them showing an unusual talon cusp, is presented.

Keywords: Bilateral supplemental incisors, delayed eruption, supernumerary teeth, talon cusp

How to cite this article:
Nuvvula S, Pavuluri C, Mohapatra A, Nirmala S. Atypical presentation of bilateral supplemental maxillary central incisors with unusual talon cusp. J Indian Soc Pedod Prev Dent 2011;29:149-54

How to cite this URL:
Nuvvula S, Pavuluri C, Mohapatra A, Nirmala S. Atypical presentation of bilateral supplemental maxillary central incisors with unusual talon cusp. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2021 Oct 18];29:149-54. Available from: https://www.jisppd.com/text.asp?2011/29/2/149/84689

   Introduction Top

Delayed tooth eruption is the appearance of a tooth into the oral cavity at a time period that departs markedly from the norms expected for different sexes, races, and ethnic groups. Impacted teeth are those prevented from erupting by some physical barrier in their path. The most common cause of failure of maxillary incisor eruption is supernumerary teeth. About 56--60% of premaxillary supernumerary teeth cause impaction of permanent incisors [1],[2] due to a direct obstacle for the eruption, tipping of the adjacent teeth toward the place of the impacted tooth, narrowing of the dental arch, displacement of the permanent teeth bud, or malformations of the unerupted tooth root. [3],[4] The most commonly impacted supernumerary teeth in pediatric patients in the order of frequency are the mesiodens, supernumerary maxillary incisors, additional or fourth molars, and supernumerary mandibular premolars. [5]

The term supplemental tooth, first used by Tomes more than a century ago, refers to an extra tooth resembling a tooth of the normal series of the dentition. [6] Ashkenazi et al. used the term "superlative" for supplemental teeth. [7] Different classifications on supernumerary teeth described supplemental teeth as normal, incisiform, or eumorphic. [8],[9],[10] Supernumerary teeth are familiar in the permanent dentition and mostly occur in the anterior maxilla. Supplemental maxillary incisors are much less common than conical or tuberculate supernumerary teeth in this region. In a study of 112 supernumerary teeth in the anterior maxilla, only six supplemental teeth were found and no mention was made as to whether they were central or lateral incisors. [11] Isolated cases of supplemental permanent maxillary central incisor have been reported [12],[13],[14] though no supplemental central incisor was found in a study of 180 adult patients with supernumerary teeth in the maxillary central incisor region. [15] Supplemental maxillary lateral incisors seem to be more commonly found than central incisors, based on a study of 8,500 school children in which eight supplemental maxillary lateral incisors and only one central incisor was found. [16]

A talon cusp was first described by Mitchell [17] in 1892 as "a process of a horn-like shape, curving from the base downward to the cutting edge" on the lingual surface of a maxillary incisor, but it was not until 1970 that talon cusps were again mentioned in the literature. Mellor and Ripa [18] named the accessory cusp as talon cusp because of its resemblance in shape to an eagle's talon. It is an uncommon developmental anomaly characterized by an accessory cusp-like structure projecting from the cingulum area or cementoenamel junction of the maxillary or mandibular anterior teeth, [19] occurs more frequently in the permanent than primary dentition showing a predilection for the maxilla over mandible [20] and maxillary lateral incisors are the most frequently involved (67%), followed by the central incisors (24%) and canines (9%). [19],[21]

   Case Report Top

A south Indian boy of age 14 years reported to the Department of Pedodontics and Preventive Dentistry with the chief complaint of delayed eruption and misalignment of upper front teeth. Family history, past health, and dental history were not relevant. Clinical examination showed permanent dentition with partially erupted tooth forms present in the maxillary central incisor area [Figure 1]a and b, with one on the right showing mesiopalatal/distolabial rotation (mesial in-distal out) and the other on the left, partially exposed showing a mesio-incisal angle with a palatal tubercle. These were confirmed as supplemental teeth with immature roots obstructing the mature central incisors, on orthopantomographic examination [Figure 2]. The features of left supplemental incisor were not visualized radiographically as it was superimposed over the maxillary left central incisor. On palpation labially over the attached gingiva the crowns of the unerupted maxillary central incisors were felt with the mucosal covering showing blanching.
Figure 1: Facial (a) and palatal (b) views of maxillary incisor region on initial examination

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Figure 2: Orthopantomograph showing impacted mature centrals and rotated supplemental central incisors in maxilla

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The treatment plan included oral prophylaxis, extraction of the supplemental central incisors, and surgical exposure of the impacted central incisors to promote eruption after obtaining necessary hematological values. Oral prophylaxis was performed, the supplemental teeth were extracted, and the maxillary central incisors were exposed by giving an incision over the blanching felt against the labial surfaces of the unerupted teeth under local anesthesia. A bifid talon cusp was identified on the palatal surface of the supplemental tooth extracted from the left central incisor area [Figure 3]. The supplemental tooth on the right measured about 19 mm and the one on the left measured 15 mm with a bifid talon cusp of 7 mm (from cervical line) length mesially, with a typical claw-like appearance and about 3 mm distally with conical shape. Radiographic examination of the left supplemental tooth showed pulp extending into the talons [Figure 4] a-c. The talon cusp shows the appearance of an unusual "π" shape from incisal view [Figure 5] instead of the "T" or "Y" shapes described earlier. [22]
Figure 3: Extracted supplemental incisors

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Figure 4: Distal (a) Lingual (b) and mesial (c) photographic and RVG views of the supplemental tooth with talon

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Figure 5: Incisal view of supplemental incisor with talon showing 'π' configuration

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One week after the procedure, the extraction site and gingival tissue around the exposed teeth satisfactory healing. The patient was monitored at regular intervals for 6 months and both the maxillary central incisors have erupted into position [Figure 6]. The patient is happy with the present appearance of the anterior teeth and did not show immediate interest for further orthodontic correction.
Figure 6: Six months postoperative view of maxillary anteriors

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   Discussion Top

Supernumerary incisors may cause delayed eruption of the permanent teeth, displacement or rotation of adjacent teeth or, in a small percentage, may have no effects on the dentition. [23] Betts and Camilleri [24] in a review of 47 cases of 53 unerupted maxillary incisors noted that 47% of those cases showed supernumerary teeth as the most common cause for lack of eruption of maxillary central incisors. They concluded that the maxillary incisors that fail to erupt due to the presence of supernumerary teeth have a better prognosis than unerupted teeth with less common etiologies. The most commonly impacted supernumerary teeth in pediatric patients in the order of frequency are the mesiodens, supernumerary maxillary incisors, additional or fourth molars, and supernumerary mandibular premolars. [5] The case presented showed bilateral supplemental permanent maxillary central incisors that caused delay in eruption of permanent maxillary central incisors.

The etiology of hyperodontia is unclear. The theories proposed were as follows: Atavism, a reversion to a more primitive type of dentition which was later discounted; Dichotomy of the tooth germ producing two or more separate units, according to which the tooth bud splits into two equal or unequal parts, resulting in two teeth of equal size or one normal and one abnormal tooth respectively. The phenomenon of gemination, which may be assumed to be a similar incomplete process, provides support to this thought; Continued proliferation of the remnants of the dental lamina, producing a third dentition. [10],[25] Moss-Salentijn and Hendricks-Klyvert [26] stated that the development of impacted maxillary anterior supernumerary teeth is comparable to the development of the permanent dentition. The permanent tooth buds develop as palatal proliferations of the primary tooth anlagen. The primary enamel organs form after direct downward growth of the dental lamina from the oral epithelium surface. The successors of the primary teeth form from successional dental laminae (localized further outgrowths of the dental lamina), which are palatal to the enamel organs of the primary teeth. Likewise, it was thought that maxillary anterior supernumerary teeth originate as palatal proliferations from the permanent central incisors. Gallas and Garcia [27] have presented a rare case of two sisters, in both of whom a pair of mesiodentes caused the retention of permanent incisors. They pointed out genetic factors as the possible origin of supernumerary teeth. The case presented by us showed palatal position of the supplemental supernumerary teeth in relation to the impacted permanent central incisors which is in accordance with the theory of continued proliferation of dental lamina [10],[25] and the views of Moss--Salentijn and Hendricks--Klyvert. [26] It also supports the theory of dichotomy of a tooth germ as it showed a supplemental type of supernumerary teeth.

Few cases of bilateral supplemental maxillary central incisors were described in the literature; [12],[13],[15],[28],[29] though the commonest type of maxillary supplemental tooth is the supplemental lateral incisor with bilateral cases being rare, making up 8% of the total. [15],[30] Bodin et al.[31] stated that the supplemental supernumerary refers to duplication of teeth in the normal series and is found at the end of a tooth series, with the most common supplemental tooth being permanent maxillary lateral incisor, though supplemental premolars and molars also occur. The majority of supernumerary teeth found in the primary dentition is of supplemental type and are seldom impacted. They also noted that the supplemental teeth form a small proportion of all supernumerary teeth, with only 4.1% of the maxillary incisor supernumeraries were normal in size and shape. [31] The percentage of supplemental teeth observed in another study was 6.9%. [3] Hyun et al. in a retrospective radiographic study of 919 patients with 1200 mesiodentes showed that the percentage of supplementary mesiodentes was 9.52% with a male/female ratio of 2.74:1. Delayed eruption of permanent successors was shown in 20.60%, displacement in 16.60%, rotation in 11.02% of cases. [32] The case presented by us shows bilateral supplemental maxillary central incisors causing delayed eruption of the permanent central incisors.

Talon cusps occur most commonly in permanent incisors, with 90% of them in maxilla and maxillary lateral incisors being the most commonly affected. They occur as an isolated finding or may be associated with other dental anomalies like peg-shaped laterals, unerupted canines, and odontomes. No definite diagnostic criteria for talon cusp has been documented, although Mader [33],[34] has suggested that the definition of this anomaly should be "an additional morphologically well-delineated cusp that projects prominently from the lingual surface and extends atleast half distance from the cementum-enamel junction (CEJ) to the incisal edge of the primary or permanent anterior teeth." The etiology of talon cusp is unknown, though it is thought to be a combination of genetic and environmental factors. They may be a result of an outfolding of enamel organ or hyperproductivity of the dental lamina during morphodifferentiation stage of odontogenesis. [35] Males are more commonly affected than females and more predominance in Chinese population. Syndromes associated with talon cusp include Mohr syndrome, Incontinentia pigmenti achromians, and Rubinstein--Taybi syndrome. [36] Hattab et al.[20] proposed a classification system for these anomalous cusps, on the basis of the degree of cusp formation and extension: type 1 (talon) is the structure that projects from the palatal surface of the tooth and extends at least one-half the distance from the cementoenamel junction to the incisal edge; type 2 (semitalon) is the additional cusp with a length of 1 mm or more, but extending less than one-half the distance from the cementoenamel junction to the incisal edge; type 3 (trace talon) is an enlarged and prominent cingulum. Al-Omari et al.[37] revealed that permanent teeth are affected by talon cusp three times more frequently than primary teeth. They described two unusual cases of talon cusp, one on a supernumerary tooth causing impaction of the central incisor, and the other a double-fused cusp on a geminated tooth. Nadakarni et al.[38] reported the presence of a maxillary right supernumerary incisor with talon cusp in a 12-year-old boy. The case presented showed bifid talon in one of the supplemental maxillary central incisors which is in accordance with the theory of outfolding of enamel organ or hyperproductivity of the dental lamina during morphodifferentiation stage of odontogenesis. [35]

Apart from obstruction owing to supernumerary teeth, mucosal barrier has also been suggested as an etiologic factor in delayed tooth eruption. [39],[40] Any failure of the follicle of an erupting tooth to unite with the mucosa will entail a delay in the breakdown of the mucosa and constitute a barrier to emergence. Histologic studies have shown differences in the submucosa between normal tissues and tissues with a history of trauma or surgery. [39] The approaches regarding the methods of treatment for supernumerary teeth causing impaction of permanent teeth are summarized by Mitchell and Bennett [41] as follows: remove supernumerary tooth/teeth only; removal of supernumerary teeth and bone overlying impacted teeth and replacement flap if the tooth is deeply placed or exposure if superficially placed; remove supernumerary teeth and expose unerupted tooth in all cases, with or without bonded attachment for orthodontic traction. Ibricevic et al.[42] support the second method of management addressed by Mitchell and Bennett while discussing about two cases of impacted incisors due to supernumerary teeth in two boys aged 11 years and 8 years. Al-Omari et al.[37] indicated extractions and exposure of the impacted tooth as the treatment for the supernumeraries causing impaction and observed that the impacted central incisor was partially erupted 2 months later. According to Tiwana and Kushner, [5] if the root of the impacted incisor is fully formed, the management includes exposure and orthodontic traction to move the tooth into the contiguous arch. The immature root should have eruption potential remaining, and it is not illogical to expose the tooth and allow for spontaneous eruption to take place over the following 8 weeks. The incision is made on the crestal aspect of alveolar ridge with reflection of the tissue labially or palatally, depending on the radiographic assessment of location or physical confirmation of tooth location. The crown of the tooth is exposed with removal of the surrounding follicular tissue and bone reduction to below the gingival third of the crown. The tooth can be allowed to erupt spontaneously or be bonded for orthodontic traction.

In the case presented by us, the patient of age 14 years reported with delayed eruption of permanent maxillary central incisors. Supplemental maxillary incisors with one showing unusual talon cusps were the cause for impaction of the permanent maxillary central incisors with mature roots. Extraction of the supplemental incisors was performed along with surgical exposure of impacted central incisors as they were positioned superficially with distinct mucosal barrier as suggested in the literature, [37],[39],[40],[41],[42] and the teeth erupted into position in 6 months with satisfactory gingival and periodontal health.

   Conclusions Top

Although impaction of the maxillary central incisors is reported less frequently than that of the third molars or the canines, early referral of patients in the mixed dentition is indicated regarding delayed eruption of the permanent maxillary central incisors and most tooth eruption anomalies may be avoided by timely diagnosis and application of treatment and preventive measures. The presented case showed a rare associated anomaly of bilateral supplemental central incisors and an unusual talon cusp that is in accordance with the theory of outfolding of enamel organ or hyperproductivity of the dental lamina during morphodifferentiation stage of odontogenesis. [35]

   References Top

1.Becker A. The orthodontic treatment of impacted teeth. Second Edition. Abingdon, United Kingdom, Informa Healthcare 2007. P. 61-92  Back to cited text no. 1
2.Gregg TA, Kinirons MJ. The effect of the position and orientation of unerrupted premaxillary supernumerary teeth on eruption and displacement of permanent incisors. Int J Pediatr Dent 1991;1:3-7.  Back to cited text no. 2
3.Rajab LD, Hamdan MA. Supernumerary teeth: Review of the literature and a survey of 152 cases. Int J Paediatr Dent 2002;12:244-54.  Back to cited text no. 3
4.Smailiene D, Sidlauskas A, Bucinskiene J. Impaction of the central maxillary incisor associated with supernumerary teeth: Initial position and spontaneous eruption timing. Stomatologija 2006;8:103-7.  Back to cited text no. 4
5.Tiwana PS, Kushner GM. Management of Impacted Teeth in Children. Oral Maxillofac Surg Clin 2005;17:365-73.  Back to cited text no. 5
6.Tomes J. A System of Dental Surgery. 3rd ed. London: J and A Churchill; 1887. p. 106.  Back to cited text no. 6
7.Ashkenazi M, Greenberg BP, Chodik G, Rakocz M. Postoperative prognosis of unerupted teeth after removal of supernumerary teeth or odontomas. Am J Orthod Dentofacial Orthop 2007;131:614-9.  Back to cited text no. 7
8.Colyer F. Abnormally shaped teeth from the region of the premaxilla. Brit Dent J 1926;47:614.  Back to cited text no. 8
9.Howard RD. The unerupted incisor. A study of the postoperative history of incisors delayed in their eruption by supernumerary teeth. Dent Pract 1967;17:332-42.  Back to cited text no. 9
10.Primosch RE. Anterior supernumerary teeth: Assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15.  Back to cited text no. 10
11.Liu JF. Characteristics of premaxillary supernumerary teeth: A survey of 112 cases. J Dent Child 1995;62:262-5.  Back to cited text no. 11
12.Camilleri S. A case of bilateral supplemental maxillary central incisors. Int J Paediatr Dent 2003;13:57-61.  Back to cited text no. 12
13.Rock WP. A case of bilateral supplemental maxillary central incisors. Int J Paediatr Dent 1991;1:155-8.  Back to cited text no. 13
14.Orsech GE. Case Report. J Dent Child 1957;24:106-7.  Back to cited text no. 14
15.Stafne EC. Supernumerary upper central incisors. Dental Cosmos 1931;73:976-80.  Back to cited text no. 15
16.Tinn CA. Excess, deficiency, and gemination in the deciduous and permanent dentitions of school children. Br Dent J 1940;68:236-8.  Back to cited text no. 16
17.Mitchell WH. Case Report. Dental Cosmos 1892;34:1036.  Back to cited text no. 17
18.Mellor JK, Ripa LW. Talon cusp: A clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.  Back to cited text no. 18
19.Hattab FN, Yassin OM, Al-Nimri KS. Talon cusp-clinical significance and management: Case reports. Quintessence Int 1995;26:115-20.  Back to cited text no. 19
20.Hattab FN, Yassin OM, Al-Nimri KS. Talon cusp in permanent dentition associated with other dental anomalies: Review of literature and report of seven cases. J Dent Child 1996;63:368-76.  Back to cited text no. 20
21.Chen RJ, Chen HS. Talon cusp in primary dentition. Oral Surg Oral Med Oral Pathol I986;62:67-72.  Back to cited text no. 21
22.Shulze C. Developmental abnormalities of teeth and jaws. In: Gorlin RJ, Goldman HM, editors. Thoma's Oral Pathology. 6 th ed. St Louis: CV Mosby Co; 1970. p. 96-7.  Back to cited text no. 22
23.Gardiner JH. Supernumerary teeth. Dent Pract 1961;12:63.  Back to cited text no. 23
24.Betts A, Camilleri GE. A review of 47 cases of unerupted maxillary incisors. Int J Paediatr Dent 1999;9:285-92.  Back to cited text no. 24
25.Grahnen H, Grahnen L. Numerical variations in primary dentition and their correlation with the permanent dentition. Odontol Revy 1961;12:348-57.  Back to cited text no. 25
26.Moss-Salentijn L, Hendricks-Klyvert M. Dental and Oral Tissues: An Introduction. 3rd ed. Philadelphia: Lea and Febiger; 1990. p. 147-57.  Back to cited text no. 26
27.Galas MM, Garcia A. Retention of permanent incisors by mesiodens: A family affair. Brit Dent J 1999;188:63-4.  Back to cited text no. 27
28.Steelman R, Wilson C, Nelson S. Maxillary incisor duplication. Oral Surg Oral Med Oral Pathol 1991;71:523.  Back to cited text no. 28
29.Trotman CA, McNamara T. Four maxillary incisors: A case report. Spec Care Dentist 1994;14:112-5.  Back to cited text no. 29
30.Johnson DB. Supernumerary lateral incisor teeth. Br J Orthod 1973;1:149-57.  Back to cited text no. 30
31.Bodin I, Julin PO, Thomsson M. Hyperdontia: III Supernumerary anterior teeth. Dentomaxillofac Radiol 1981;10:35-42.  Back to cited text no. 31
32.Hyun HK, Lee SJ, Lee SH, Hahn SH, Kim JW. Clinical characteristics and complications associated with mesiodentes. J Oral Maxillofac Surg 2009;67:2639-43.  Back to cited text no. 32
33.Mader CL. Talon cusp. J Am Dent Assoc 1981;103:244-6.  Back to cited text no. 33
34.Mader CL. Mandibular talon cusp. J Am Dent Assoc 1982;105:651-3.  Back to cited text no. 34
35.Lomcali G, Hazar S, Altinbulak H. Talon cusp: Report of five cases. Quintessence Int 1994;25:431-5.  Back to cited text no. 35
36.Davis PJ, Brook AH. The presentation of talon cusp: Diagnosis, clinical features, associations and possible aetiology. British Dent J 1986;160:84-8.   Back to cited text no. 36
37.Al-Omari MA, Hattab FN, Darwazeh AM, Dummer PM. Clinical problems associated with unusual cases of talon cusp. Int Endod J 1999;21:183-90.  Back to cited text no. 37
38.Nadkarni UM, Munshi A, Damle SG. Unusual presentation of talon cusp: Two case reports. Int J Paediatr Dent 2002;12:332-5.  Back to cited text no. 38
39.Di Biase DD. Mucous membrane and delayed eruption. Dent Pract Dent Rec 1971;21:241-50.  Back to cited text no. 39
40.Goho C. Delayed eruption due to overlying fibrous connective tissue. ASDC J Dent Child 1987;54:359-60.  Back to cited text no. 40
41.Mitchell L, Bennett TG. Supernumerary teeth causing delayed eruption--a retrospective study. Br J Orthod 1992;19:41-6.  Back to cited text no. 41
42.Ibricevic H, Al-Mesad S, Mustagrudic D, Al-Zohejry. Supernumerary teeth causing impaction of maxillary incisors: Consideration of treatment. J Clin Pediatr Dent 2003;27:327-32.  Back to cited text no. 42


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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