Journal of Indian Society of Pedodontics and Preventive Dentistry
Journal of Indian Society of Pedodontics and Preventive Dentistry
                                                   Official journal of the Indian Society of Pedodontics and Preventive Dentistry                           
Year : 2022  |  Volume : 40  |  Issue : 1  |  Page : 90--93

Talon's cusp in a primary maxillary central incisor: A report of a rare odontogenic anomaly


Virat Galhotra, Santhosh Rao, Pallavi Goel 
 Department of Dentistry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Correspondence Address:
Prof. Virat Galhotra
Department of Dentistry, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
India

Abstract

Talon's cusp, a type of dens evaginatus (DE) in a primary tooth, is a rare odontogenic anomaly which is reported sparingly in the literature. We report this case describing the presence of a talon's cusp on the right primary maxillary central incisor in a 2-year-old boy precipitating discomfort, owing to occlusal interference. The treatment plan involved pulpectomy and reduction of the lingula DE extension under general anesthesia.



How to cite this article:
Galhotra V, Rao S, Goel P. Talon's cusp in a primary maxillary central incisor: A report of a rare odontogenic anomaly.J Indian Soc Pedod Prev Dent 2022;40:90-93


How to cite this URL:
Galhotra V, Rao S, Goel P. Talon's cusp in a primary maxillary central incisor: A report of a rare odontogenic anomaly. J Indian Soc Pedod Prev Dent [serial online] 2022 [cited 2022 Jul 4 ];40:90-93
Available from: https://www.jisppd.com/text.asp?2022/40/1/90/343015


Full Text



 Introduction



The successful development of a tooth depends on the complex interaction between dental epithelium and the underlying ectomesenchyme.[1] Any deviation from the typical sequence leads to an anomaly of the tooth. Dens evaginatus (DE) is one such anomaly or an aberration during the bell stage of tooth development characterized by abnormal proliferation of inner enamel epithelium into the stellate reticulum of the enamel organ, resulting in the formation of an additional or accessory cusp.[2] Morphologically, the DE has been described as protuberance, elevation, excrescence, abnormal tubercle, or a bulge. When such DE occurs in the anterior tooth, it usually produces abnormal growth on the lingual surface of the tooth, which is described as talon's cusp.[3]

Although Mitchell recognized this anomaly in 1892, it was Mellor and Ripa who named this anomaly talon's cusp due to its resemblance to an eagle's talon.[4] DE is termed using different terms based on its occurrence in the dentition. It is called talons' cusps in anterior teeth, Leong's premolar in the premolars and cusp of carabelli on maxillary molars and so on. As recommended by Oehlers in 1967, the preferred terminology currently of all these anomalies is DE.[5] This uncommon anomaly projects above the adjacent tooth surface, exhibiting enamel covering a dentinal core that usually contains pulp tissue, occasionally having a slender pulp horn that extends to various distances within the dentinal core.

Hattab et al. classified talon's cusps into three types based on the degree of cusp formation and extension:[6]

Type 1: Talon – refers to a morphologically well-delineated additional cusp that prominently projects from the palatal (or facial) surface of a primary or permanent anterior tooth and extends at least half the distance from the cementoenamel junction to the incisal edgeType 2: Semi talon – refers to an additional cusp of a millimeter or more extending less than half the distance from cementoenamel junction to the incisal edge. It may blend with the palatal surface or stand away from the rest of the crownType 3: Trace talon – enlarged or prominent cingula and their variations, i.e., conical, bifid, or tubercle-like.

Talon's cusp in the primary incisor is as rare as a hen's teeth. Only four cases among the Indian population and only 39 cases worldwide have been documented in the primary dentition to date. This anomaly has more commonly been reported in permanent dentition, with a prevalence ranging from 0.06% to 7%.[7]

The DE or talon's cusp may fracture or be abraded as soon as the tooth comes into occlusion, exposing the pulp. Functional complications such as occlusal interference, trauma to the lip and tongue, speech problems, and displacement of teeth may accompany talon's cusp. The deep grooves which join the cusp to the tooth may also act as stagnation areas for plaque and debris, become carious, and cause subsequent periapical pathology. Hence, early recognition of this anomaly and prompt treatment should be instituted to prevent endodontic/occlusal complications.[8]

 Case Report



A 2-year-old boy reported, along with his mother, to our outpatient department, with a chief complaint of projection from the upper front tooth causing discomfort while biting. The medical and family history was noncontributory to the present condition. The child had a normal growth pattern as per his age without any facial dysmorphism. Intraorally, the presence of an extra cusp in the form of a tubercle projecting from the palatal aspect of the crown of the primary maxillary right central incisor (Type 1 talon's cusp) was noted [Figure 1] and [Figure 2]. No other anterior tooth had this projection. It was observed that the crown of the same tooth was tilted buccally owing to the occlusal interference, further predisposing to unpleasant esthetics and discomfort. Radiographic evaluation of the central incisor revealed an abnormally shaped radiopaque structure composed of normal enamel and dentin and with pulp extension and normal periapex [Figure 3]. Based on clinical and radiographic examination, the treatment plan was formulated to perform pulpectomy and reduction of the lingula DE extension.{Figure 1}{Figure 2}{Figure 3}

As the patient is 2-year-old kid, we preferred general anesthesia over sedation as general anesthesia is much safe in terms of airway securing, deeper analgesia and sedation, and minimal postoperative sequelae. We work in a hospital setup; we have a dedicated anesthesia team to cater all our patients, so we preferred general anesthesia in the safe interest of this patient. The same was discussed with the parents, and consent was obtained to perform the same under general anesthesia. After a thorough preanesthetic workup, as per our institutional protocol and clearance for general anesthesia, the patient was taken under general anesthesia through nasotracheal intubation. Although rubber dam isolation is ideal, we could not use the same, but instead, we used high-power suction and cotton roll for isolation in this case. After adequate coronoplasty, the pulpectomy using Metpex (Meta Biomed) for obturation was done [Figure 4] and [Figure 5]. Postendodontic restoration was done using composites. The postoperative phase was uneventful. Further evaluation on periodic follow-up if need arises full coverage of the tooth shall be done.{Figure 4}{Figure 5}

 Discussion



The reported incidence of DE varies from 1% to 4%, and the Mongoloid and the Neo Asiatic racial groups are commonly affected but DE has also been observed in Chinese and Caucasians.[9] The first reported case in the primary dentition is by Sawyer et al. (1976) found in the archeological remains of prehistoric times.[10] The first clinical case in the primary dentition was reported by Henderson in 1977 in a 4-year-old Filipino girl.[7] Most of the cases of talon's cusp go unnoticed and are accidentally diagnosed on routine dental checkups. DE appears to be more prevalent in patients with Rubinstein–Taybi syndrome, Mohr syndrome (oral-facial-digital syndrome, Type II), Sturge–Weber syndrome (encephalotrigeminal angiomatosis), or incontinentia pigmenti achromians.[11],[12]

Small talon's cusps are asymptomatic and require no intervention. Large talon's cusps may cause occlusal interference and other clinical problems such as irritation of the tongue during speech and mastication, carious lesions in the developmental grooves that delineate the cusp, pulp necrosis, periapical pathosis, attrition of the opposing tooth, and periodontal problems due to excessive occlusal forces.[13] In cases of talon's cusp in erupting primary teeth, it is important to monitor occlusion regularly to prevent potential cross-bite.[14] The presence of the talon's cusp does not warrant dental treatment always unless it is associated with any problems such as occlusal interference, periodontal problems, caries, compromised esthetics, or irritation of soft tissues during speech or mastication.

Prophylactic treatment can be considered as the preferred mode of approach. Application of desensitizing/rematerializing agent containing 0.2% sodium fluoride following the gradual and periodic reduction of bulk of extra cusp reduces sensitivity, stimulates reparative dentin formation, and allows the tooth to remain vital, especially in the permanent teeth with open apices. However, in teeth with already diagnosed occlusal interferences, grinding and subsequent fluoride treatment or pulpotomy or pulpectomy might be required.[15]

 Conclusion



DE deserves clinical importance as it provides chances of early pulp pathosis. Early and correct diagnosis of DE by clinicians is essential to preserve the esthetics and optimum function. The child is just developing speech and timely intervention has prevented any abnormal habits/speech issues from developing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Thesleff I. Epithelial-mesenchymal signaling regulating tooth morphogenesis. J Cell Sci 2003;116:1647-8.
2Levitan ME, Himel VT. Dens evaginatus: literature review, pathophysiology, and comprehensive treatment regimen. J Endod 2006;32:1-9. PMID: 16410059.
3Sharma A. Dens evaginatus of anterior teeth (talon cusp) associated with other odontogenic anomalies. J Indian Soc Pedod Prev Dent 2006;24 Suppl 1:S41-3.
4Sarraf-Shirazi A, Rezaiefar M, Forghani M. A rare case of multiple talon cusps in three siblings. Braz Dent J 2010;21:463-6.
5Shrestha A, Marla V, Shrestha S, Maharjan IK. Developmental anomalies affecting the morphology of teeth – A review. RSBO 2015;12:68-78.
6Hattab FN, Yassin OM, al-Nimri KS. Talon cusp in permanent dentition associated with other dental anomalies: Review of literature and reports of seven cases. ASDC J Dent Child 1996;63:368-76.
7Kapur A, Goyal A, Bhatia S. Talon cusp in a primary incisor: A rare entity. J Indian Soc Pedod Prev Dent 2011;29:248-50.
8Oredugba FA. Mandibular facial talon cusp: Case report. BMC Oral Health 2005;5:9.
9Shekhar MG, Vijaykumar S, Tenny J, Ravi GR. Conservative management of dens evaginatus: Report of two unusual cases. Int J Clin Pediatr Dent 2010;3:121-4.
10Sawyer DR, Allison MJ, Pezzia A. Talon cusp: a clinically significant anomaly in a primary incisor from pre-Columbian America. Medical College of Virginia Quarterly 1976;12:64- 66.
11Tulunoglu O, Cankala DU, Ozdemir RC. Talon's cusp: Report of four unusual cases. J Indian Soc Pedod Prev Dent 2007;25:52-5.
12Rao DG, Vasudevan V, Venkatappa M, Jeyavelpandiyan N. Talon's cusp in primary incisors: A rarity. J Indian Acad Oral Med Radiol 2012;24:230-1.
13Segura-Egea JJ, Jiménez-Rubio A, Velasco-Ortega E, Ríos-Santos JV. Talon cusp causing occlusal trauma and acute apical periodontitis: Report of a case. Dent Traumatol 2003;19:55-9.
14AlHumaid J. Bilateral maxillary palatal talon cusps in deciduous central incisors. BMJ Case Rep 2019;12:e227596. PMCID: PMC6381969.
15Dankner E, Harari D, Rotstein I. Dens evaginatus of anterior teeth. Literature review and radiographic survey of 15,000 teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81:472-5.