CLINICAL ARTICLE
Management of a Facial Talon Cusp on a Maxillary Permanent Central Incisor: A Case Report and Review of the Literature ˘ LU, DDS, PhD*, HAS¸MET ULUKAPI, DDS, PhD† OKTAY YAZICIOG
ABSTRACT Background: A talon cusp is a morphologically well-delineated accessory cusp. This case report discusses the unusual appearance of a talon cusp on the facial surface of the maxillary right permanent central incisor, which was conservatively treated and followed up for a period of 1 year. Methods: A 21-year-old female was referred for the treatment of a maxillary right central incisor that caused an esthetic problem. Intraoral examination and radiographic and computerized tomographic investigation indicated that there was no connection between the pulp chamber, a “V”-shaped radiopaque structure, and three radiolucent globe areas. The accessory cusp was treated by selective cuspal grinding, followed by resin-based composite placement. The restoration was clinically evaluated 1 week after placement, as a baseline, and after 1 year. The restoration did not exhibit postoperative sensitivity at the 1-year evaluation. No difference was observed in the color match, marginal discoloration, marginal adaptation, or anatomic form compared with the baseline evaluation. Conclusion: The management and treatment outcome of a talon cusp depends on its size, presenting complications and patient cooperation. The present case report outlines the conservative management of a talon cusp.
CLINICAL SIGNIFICANCE This paper outlines a viable esthetic treatment option and a review of the relevant literature with regards to managing a facial talon cusp. (J Esthet Restor Dent ••:••–••, 2014)
INTRODUCTION Mitchell was the first to describe a talon cusp on an upper central incisor of a woman as “a process of horn-like shape curving from the base downwards to the cutting edge” in 1892.1 This phenomenon was later named a “talon cusp” by Ripa and Mellor due to the cusp’s resemblance to an eagle’s talon.2 A talon cusp is a morphologically well-delineated, accessory cusp-like anomalous structure projecting from the cingulum area or cementoenamel junction and extending to at least half of the distance to the incisal
edge of the maxillary or mandibular anterior teeth in both primary and permanent dentition. The cusp is composed of normal enamel, dentin, and varying extensions of pulp tissue, but its composition is difficult to determine because of the cusp’s superimposition on the main pulp chamber.3,4 The exact etiology of talon cusps is still unknown. There is strong evidence for a multifactorial etiology involving both genetic and environmental factors.5 The development of a tooth is a very complex process that is divided into six morphologic stages and five physiologic processes. Any deviations in these
*Assistant professor, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey † Professor, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12101
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stages/processes of tooth development can result in unmatched results. Disturbances during the morphodifferentiation stage can be result in anomalies, such as talon cusps, fusion, mesiodens, dens invaginatus, peg laterals, and mulberry molars.6 The term to describe this situation in the anterior teeth is not clearly defined in the relevant literature, which employs various names such as talon cusp, accentuated cingulum (when it affects the lingual or palatal surface), or dens evaginatus (the term that is usually used when it is present in the posterior teeth). In dens evaginatus, the verrucose protuberance on the occlusal surface of the affected teeth may be composed of enamel; enamel and dentine; or even enamel, dentine, and a small extension of the pulp tissue.4 Talon cusps have also been reported in patients with Mohr syndrome, Sturge–Weber syndrome, Rubinstein–Taybi syndrome, incontinentia pigmenti achromians, or Ellis–van Creveld syndrome.3 The reported prevalence is 0.06% in Mexicans, 7.7% in a northern Indian population, and 1.2% in the Turkish dental patient population. Talon cusps have also been found to be relatively common in the Chinese5 and in Arabs.7 A review of the literature shows 25% of cases in primary dentition and 75% of cases in permanent dentition.7 Males typically show a higher frequency than females, and the cusp may be unilateral or bilateral, with a predilection for the maxilla over the mandible.8 Maxillary lateral incisors in permanent dentition and maxillary central incisors in primary dentition are the most commonly involved. The other affected teeth in permanent dentition are central incisors, premolars, canines, and molars. The anomaly has been rarely reported in the mandible.8,9 Hattab and colleagues7 described 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 to at least one half of the distance from the cementoenamel junction to the incisal edge.
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Type 2 (semi-talon) is an additional cusp with a length of 1 mm or more but extending to less than one half of the distance from the cementoenamel junction to the incisal edge. Type 3 (trace talon) is an enlarged, prominent cingulum. Talon cusps can create problems, including compromised esthetics and occlusal interference, which may lead to accidental cusp fracture, displacement of the affected tooth, caries developmental grooves, included food stagnation, irritation of the tongue and lip, speech problems, dental sensitivity, breastfeeding problems, temporomandibular joint pain, and periodontal problems because of excessive occlusal force.6 Radiographically, a talon cusp typically appears as a “V”-shaped radiopaque structure. The radiopaque “V”-shaped structure is superimposed onto the normal image of the crown of a tooth. This appearance can change with the shape and size of the cusp and with the angle of the radiograph. The clinical management of this anomaly can be very different depending on the size and shape of the affected tooth and the problems caused by this enlarged cusp.10–12 A talon cusp is usually asymptomatic and is often diagnosed as an incidental finding during routine dental examination. If symptomatic, a talon cusp usually causes problems related to occlusion, speech, and esthetics.4 The common problems associated with a talon cusp are1 caries susceptibility,2 occlusal interference, and3 compromised esthetics.7,12 Within the limitations of these problems, conservative treatment techniques can be applied. Careful clinical and radiographic examination is necessary for correct diagnosis and treatment planning in such cases. Because of the two-dimensional limitations of radiographs, these images are not sufficient to understand the complex anatomy of the crown in such an anomaly. However, with the advent of cone-beam computed tomography
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MANAGEMENT OF A FACIAL TALON CUSP Yazıcıog˘lu and Ulukapı
FIGURE 1. Vestibule view of the teeth.
FIGURE 2. Incisal view of teeth.
(CBCT), diagnosis and correct treatment have become possible. The use CBCT has become increasingly common in numerous dental specialties. CBCT has been specifically designed to produce an undistorted three-dimensional (3-D) reconstruction of the maxillofacial skeleton and 3-D images of the teeth and their surrounding tissues.13 CBCT scans provide valuable information about dental anatomy and can help to plan treatment.14
CASE REPORT A healthy-looking, 21-year-old Turkish female reported to the Istanbul University Faculty of Dentistry’s Department of Restorative Dentistry with a chief complaint of an abnormally appearing upper front tooth. Her medical and family history was non-contributory. Oral examination showed fair oral hygiene and no caries lesions. All permanent teeth were present, and the presence of an accessory cusp on the facial aspect of the permanent maxillary right central incisor, extending from the cementoenamel junction to the incisal edge, was observed (Figures 1 and 2). The accessory cusp was separated from the rest of the crown and was approximately 2 mm in diameter. A small enamel caries lesion was detected in the incisal edge of the cusp. Radiographic (panoramic and periapical) investigation indicated a “V”-shaped radiopaque structure and three radiolucent globe areas but did not indicate a connection to the pulp chamber (Figure 3). The radiolucent globe areas did not clearly define this
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FIGURE 3. Periapical radiography of teeth.
formation. To clarify these aspects and to establish a definitive diagnosis, we decided to refer the patient for a 3-D CBCT of tooth #11. A CBCT scan of the involved teeth was performed as an examination (i-CAT CBCT scanner; Imaging Sciences International, Inc., Hatfield, PA, USA) at 120 KVp and with sections of 1.0 mm thickness. CBCT demonstrated the complex anatomy of tooth #11 and showed that the pulp chamber was distinct from the globes (Figures 4 and 5). A diagnosis of a type 1 talon cusp was made. After clinical and radiographic examination, management was directed toward eliminating the talon cusp and improving the esthetic appearance of the
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FIGURE 4. Cone-beam computed tomography (CBCT) of tooth #11 and the globes a.
FIGURE 5. Cone-beam computed tomography (CBCT) of tooth #11 and the globes b.
FIGURE 6. Grinding process and three spherical air bubbles.
FIGURE 7. Resin-based composite restoration at baseline.
anterior teeth by minimal restorative treatment. The talon cusp was gradually reduced using a water-cooled round and bullet-shaped diamond bur on a high-speed hand piece. Generally, the talon cusp area is grinded until reaching healthy tooth tissue. For this purpose, the labial surface of the tooth is painted with articulating paper. The purpose of this process is to ensure careful grinding. During the grinding process, at the level of the healthy tooth, three spherical air bubbles were encountered in the talon tubercle (Figure 6). The globes
FIGURE 8. Resin-based composite restoration after 1 year.
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in the field of dental tissue give an image of the enamel and dentin. To meet the esthetic expectations of the patient, the undercut areas were cautiously removed. The cusp was nearly completely eliminated without causing pulpal exposure. Direct resin-based composite (3M Z550, 3M ESPE, St Paul, MN, USA) was used for better esthetics (Figure 7). Enamel and dentine were etched with 37% phosphoric acid (Scotchbond etching gel, 3M ESPE) gel, then followed extensive washing with water spray, accompanied by high volume suction, in order to eliminate excess water and maintain a slightly humid surface. The adhesive system (Adper Single Bond 2, 3M ESPE) was applied according to the manufacturer’s directions and light polymerized for 20 seconds at 600 mW/cm2 (Bisco, Bisco VIP, Schaumburg, IL, USA). The restoration was formed using a universal nanohybrid resin-based composite (3M Z550, 3M ESPE) that was placed using an incremental technique. The resin-based composite restoration was polymerized for at least 2 minutes with the polymerization unit. Finishing and polishing procedures were performed by discs (Sof-Lex; 3M ESPE). The patient was followed up over a period of 1 year, and the tooth was found to be completely asymptomatic, with intact vitality intact (Figure 8). The follow-up radiograph showed healthy periapical tissues in the treated tooth and continued root formation of the maxillary right incisor (Figure 9).
DISCUSSION The etiology of the formation of a talon cusp is unclear. However, it has been suggested that the hyperactivity of the dental lamina in early odontogenesis and a combination of genetic and environmental factors have a role.5 Talon cusps have been reported to affect both sexes and may be unilateral or bilateral.15,16 A review of previous reports of talon cusps in primary dentition indicated that the cusps all occur on maxillary central incisors
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FIGURE 9. Periapical radiography of teeth after 1 year.
and predominantly on the left side if the anomaly is unilateral.15 Including the present report, there were several reported clinical cases with exclusively facial talon cusps, 75% of which were observed in permanent dentition.7 In the present case, a female patient with a talon cusp on a right maxillary permanent central incisor was observed. Talon cusps usually occur on the palatal or lingual surfaces of the anterior teeth. A rare variant, also observed on the maxillary incisor, has vertical cristae (rugae adamantineae) on the facial side of the teeth.17 Rugae adamantineae defining feature is a ridge of enamel that crosses the center of the vestibular surface of the tooth in a cervical-incisal direction, as in the case described in this paper.4 The presence of a talon cusp is not always an indication for dental treatment, unless the cusp is associated with problems such as compromised esthetics, occlusal interference, tooth displacement, caries, periodontal problems, or irritation of the soft tissues during speech or mastication.16,18,19
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Only few cases of facial talon cusps that were reported in the literature received complete treatment. McNamara and colleagues performed orthodontics to close a space after extraction of a mandibular left central incisor with a talon cusp for esthetic reasons.12 de Sousa and colleagues performed an esthetic restoration following root canal therapy for a maxillary right permanent central incisor.20 A case reported by Glavina and Skrinjaric included gradual cuspal grinding and resin-based composite restoration of a facial talon cusp on a maxillary permanent left central incisor.21 Another case reported by Kulkarni and colleagues included treatment of a talon cusp using reduction every 45 days, followed by fluoride varnish application for 9 months.22 The management of talon cusps includes no treatment, sequential grinding,23 pit and fissure sealants,24 pulp therapy,2,20 restorative treatment,2,6,20 full crown coverage, and extraction of the affected tooth.12,25 In our case, the tooth fulfilled functional and esthetic requirements when first diagnosed, and the authors believe that restorative treatment was the best solution. In the present case, the patient was interested in achieving an esthetic tooth in a short time. After complete cuspal grinding, a direct resin-based composite was applied. There are advantages of using resin-based composites, such as shortening chair time, biocompatibility of the materials, low cost, and minimal hard tissue removal. Adhesion of resin-based composites to enamel and dentin has improved as a result of recent developments. By using various dentine and enamel colors and make-up techniques, it is possible to imitate the optical properties of natural teeth. Also the polishability of resin-based composites has been improved by the new developments of inorganic particle size and ratio. A definitive diagnosis of a talon cusp cannot be made based on 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.3
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A talon cusp is composed of normal enamel and dentin and may involve a pulpal extension.7 Clinical variations of talon cusp include those of location, shape, size, structure, and number.26 Various treatment regimens have been followed for the management of talon cusps depending on the absence/presence of pulpal extensions. In case of presence pulpal extension, pulpotomy can be performed using calcium hydroxide or mineral trioxide aggregate material.26 In the present case, no pulpal extension was observed and these materials were not used. The talon cusp presented in this case report extended from the cementoenamel junction to the incisal edge, which may be categorized as a type 1 or true talon. Although such large cusps, which stand away from the tooth, have been shown to contain an extension of the pulp, superimposition of the image of the cusp onto the main tooth made it difficult to determine the extent of pulp tissue involvement in the anomalous cusp. Small talon cusps are usually asymptomatic, and no treatment is required. However, large talon cusps, as in our case, may cause problems for the patient. Diagnosis and treatment planning are also difficult for the dentist.27 The treatment of talon cusps involves careful clinical examination and depends on whether the cusp is close to the pulp or contains pulp. Tracing the pulpal configuration inside a talon cusp using radiography is inherently difficult because the cusp is superimposed onto the affected tooth crown.6 In periapical radiographs, it is not always possible to determine the relationship between the cusp portion of the tooth and the pulp chamber and/or root canals with great precision. For this reason, we decided to examine the tooth by computerized tomography in three ways. The future for caries diagnosis, both proximal and pit and fissure, periodontal diagnosis, soft tissue lesion diagnosis, dentally related sinus diagnosis, implant planning and placement, oral maxillofacial surgery uses, as well as endodontic applications can be expanded. Too many clinicians do not use cone beam because they don’t have one, although there is access to a dental computed tomography scan technology in other dental offices/speciality practices. CBCT is an X-ray imaging
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approach that provides high-resolution 3-D images and shown great benefit in the localization and identification of tooth anatomy.28 This method is especially useful in endodontics for the identification of anatomic features and variations of the root canal system. In the present case, tomography images made it possible to observe a cusp that was not communicating with the pulp. Although periapical radiography has been used for the diagnosis of talon cusps in the past, 3-D imaging for unusual tooth anatomies can be performed with the help of CBCT, as in this case. The radiation dose produced by CBCT system is dependent on a several factors such as the nature of the X-ray beam (continuous or pulsatile), the degree of rotation of the X-ray source and detector, and the size of the field of view.29 The effective doses associated with CBCT scans, ranged from 13 μSv (anterior mandible) to 44 μSv (maxillary canine/premolar region) respectively.30 By comparison, the effective dose of a single intraoral periapical radiograph ranges from 1 to 5 μSv. These data revealed that the effective dose of CBCT is higher than conventional intraoral radiography. However, this difference is continuously narrowing, and in certain clinical scenarios, the effective dose of CBCT will approach that of periapical radiography. The patient did not report sensitivity or any symptoms. The case was followed up successfully over a period of 1 year, without any postoperative complications. No visible evidence of a crevice along the marginal adaptation was observed. The restoration was continuous with the existing anatomical form. No discoloration was observed anywhere along the margin between the restoration and the adjacent tooth, and no shade or translucency between the restoration and the tooth was noted.
CONCLUSION In conclusion, the case described in this paper includes an asymptomatic dental anomaly that did not cause any other alteration in the tooth or arch. The anomaly was the result of anomalous development of the enamel and likely of the underlying dentin. The present case report outlines the conservative management of a type 1 talon
© 2014 Wiley Periodicals, Inc.
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cusp. Conservative treatment is always encouraged. Early diagnosis and treatment are recommended to avoid complications and to maintain a healthy pulpal and periodontal status. CBCT not only can help in diagnosis but also can serve as an important aid in treatment planning and in ensuring successful results.
DISCLOSURE The authors do not have any financial interest in any of the companies whose products are included in this article.
REFERENCES 1. 2.
Mitchell WH. Case report. Dent Cosmos 1892;34:1036. Mellor JK, Ripa LW. Talon cusp: a clinically significant anomaly. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1970;29:225–8. 3. Dash JK, Sahoo PK, Das SN. Talon cusp associated with other dental anomalies: a case report. Int J Paediatr Dent 2004;14(4):295–300. 4. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 3rd ed. Philadelphia (PA): W.B. Saunders Co; 1974. 5. Davis PJ, Brook AH. The presentation of talon cusp: diagnosis, clinical features, associations and possible aetiology. Br Dent J 1986;160(3):84–8. 6. Sener S, Unlu N, Basciftci FA, Bozdag G. Bilateral geminated teeth with talon cusps: a case report. Eur J Dent 2012;6(4):440–4. 7. Hattab 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(5):368–76. 8. Dankner 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(4):472–5. 9. Tulunoglu O, Cankala DU, Ozdemir RC. Talon’s cusp: report of four unusual cases. J Indian Soc Pedod Prev Dent 2007;25(1):52–5. 10. Ekambaram M, Yiu CK, King NM. An unusual case of double teeth with facial and lingual talon cusps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105(4):63–7. 11. Segura-Egea JJ, Jiménez-Rubio A, Ríos-Santos JV, Velasco-Ortega E. Dens evaginatus of anterior teeth (talon cusp): report of five cases. Quintessence Int 2003;34(4):272–7.
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12. McNamara T, Haeussler AM, Keane J. Facial talon cusps. Int J Paediatr Dent 1997;7(4):259–62. 13. Al-Rawi B, Hassan B, Vandenberge B, Jacobs R. Accuracy assessment of three-dimensional surface reconstructions of teeth from cone beam computed tomography scans. J Oral Rehabil 2010;37(5):352–8. 14. Patel S. New dimensions in endodontic imaging: part 2. Cone beam computed tomography. Int Endod J 2009;42(6):463–75. 15. Chen RJ, Chen HS. Talon cusp in primary dentition. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1986;62(1):67–72. 16. Mader CL, Kelloll SL. Primary talon cusp. ASDC J Dent Child 1985;52(3):223–6. 17. Pindborg JJ. Abnormalities of tooth morphology. In: Pindborg JJ, editor. Pathology of dental hard tissues, 1st ed. Copenhagen: Munksgaard; 1970, pp. 15–76. 18. Jowharji N, Noonan RG, Tylka JA. An unusual case of dental anomaly: a “facial” talon cusp. ASDC J Dent Child 1992;59(2):156–8. 19. Richardson DS, Knudson KG. Talon cusp: a preventive approach to treatment. J Am Dent Assoc 1985;110(1):60–2. 20. de Sousa SM, Tavano SM, Bramante CM. Unusual case of bilateral talon cusp associated with dens invaginatus. Int Endod J 1999;32(6):494–8. 21. Glavina D, Skrinjaric T. Labial talon cusp on maxillary central incisors: a rare developmental dental anomaly. Coll Antropol 2005;29(1):227–31. 22. Kulkarni VK, Choudhary P, Bansal AV, et al. Facial talon cusp: a rarity, report of a case with one year follow up
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23. 24.
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29. 30.
and flashback on reported cases. Contemp Clin Dent 2012;3(1):125–9. Myers LC. Treatment of a talon cusp incisor: report of case. J Dent Child 1980;47:119–21. Morin CK. Talon cusp affecting the primary maxillary central incisor: report of case. J Dent Child 1987;54:283–5. Ak AT, Eden E, Ertugrul F, Sutekin E. Supernumerary primary tooth with facial and palatal talon cusps: a case report. J Dent Child 2008;75(3):309–12. Shetty P, Xavier AM. Management of a talon cusp using mineral trioxide aggregate. Int Endod J 2011;44(11): 1061–8. al-Omari MA, Hattab FN, Darwazeh AM, Dummer PM. Clinical problems associated with unusual cases of talon cusp. Int Endod J 1999;32(3):183–90. Baratto Filho F, Zaitter S, Haragushiku GA, et al. Analysis of the internal anatomy of maxillary first molars by using different methods. J Endod 2009;35(3):337–42. Durack C, Patel S. Cone beam computed tomography in endodontics. Braz Dent J 2012;23(3):179–91. Loubele M, Bogaerts R, Van Dijck E, et al. Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol 2009;71:461–8.
Reprint requests: Yazıcıog˘lu Oktay, DDS, PhD, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, 34093 Fatih/I˙stanbul, Turkey; Tel.: +90-533-416-3248; Fax: +90-212-525-0075; email: [email protected]
DOI 10.1111/jerd.12101
© 2014 Wiley Periodicals, Inc.
Management of a Facial Talon Cusp on a Maxillary Permanent Central Incisor: A Case Report and Review of the Literature ˘ LU, DDS, PhD*, HAS¸MET ULUKAPI, DDS, PhD† OKTAY YAZICIOG
ABSTRACT Background: A talon cusp is a morphologically well-delineated accessory cusp. This case report discusses the unusual appearance of a talon cusp on the facial surface of the maxillary right permanent central incisor, which was conservatively treated and followed up for a period of 1 year. Methods: A 21-year-old female was referred for the treatment of a maxillary right central incisor that caused an esthetic problem. Intraoral examination and radiographic and computerized tomographic investigation indicated that there was no connection between the pulp chamber, a “V”-shaped radiopaque structure, and three radiolucent globe areas. The accessory cusp was treated by selective cuspal grinding, followed by resin-based composite placement. The restoration was clinically evaluated 1 week after placement, as a baseline, and after 1 year. The restoration did not exhibit postoperative sensitivity at the 1-year evaluation. No difference was observed in the color match, marginal discoloration, marginal adaptation, or anatomic form compared with the baseline evaluation. Conclusion: The management and treatment outcome of a talon cusp depends on its size, presenting complications and patient cooperation. The present case report outlines the conservative management of a talon cusp.
CLINICAL SIGNIFICANCE This paper outlines a viable esthetic treatment option and a review of the relevant literature with regards to managing a facial talon cusp. (J Esthet Restor Dent ••:••–••, 2014)
INTRODUCTION Mitchell was the first to describe a talon cusp on an upper central incisor of a woman as “a process of horn-like shape curving from the base downwards to the cutting edge” in 1892.1 This phenomenon was later named a “talon cusp” by Ripa and Mellor due to the cusp’s resemblance to an eagle’s talon.2 A talon cusp is a morphologically well-delineated, accessory cusp-like anomalous structure projecting from the cingulum area or cementoenamel junction and extending to at least half of the distance to the incisal
edge of the maxillary or mandibular anterior teeth in both primary and permanent dentition. The cusp is composed of normal enamel, dentin, and varying extensions of pulp tissue, but its composition is difficult to determine because of the cusp’s superimposition on the main pulp chamber.3,4 The exact etiology of talon cusps is still unknown. There is strong evidence for a multifactorial etiology involving both genetic and environmental factors.5 The development of a tooth is a very complex process that is divided into six morphologic stages and five physiologic processes. Any deviations in these
*Assistant professor, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey † Professor, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, Istanbul, Turkey
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12101
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stages/processes of tooth development can result in unmatched results. Disturbances during the morphodifferentiation stage can be result in anomalies, such as talon cusps, fusion, mesiodens, dens invaginatus, peg laterals, and mulberry molars.6 The term to describe this situation in the anterior teeth is not clearly defined in the relevant literature, which employs various names such as talon cusp, accentuated cingulum (when it affects the lingual or palatal surface), or dens evaginatus (the term that is usually used when it is present in the posterior teeth). In dens evaginatus, the verrucose protuberance on the occlusal surface of the affected teeth may be composed of enamel; enamel and dentine; or even enamel, dentine, and a small extension of the pulp tissue.4 Talon cusps have also been reported in patients with Mohr syndrome, Sturge–Weber syndrome, Rubinstein–Taybi syndrome, incontinentia pigmenti achromians, or Ellis–van Creveld syndrome.3 The reported prevalence is 0.06% in Mexicans, 7.7% in a northern Indian population, and 1.2% in the Turkish dental patient population. Talon cusps have also been found to be relatively common in the Chinese5 and in Arabs.7 A review of the literature shows 25% of cases in primary dentition and 75% of cases in permanent dentition.7 Males typically show a higher frequency than females, and the cusp may be unilateral or bilateral, with a predilection for the maxilla over the mandible.8 Maxillary lateral incisors in permanent dentition and maxillary central incisors in primary dentition are the most commonly involved. The other affected teeth in permanent dentition are central incisors, premolars, canines, and molars. The anomaly has been rarely reported in the mandible.8,9 Hattab and colleagues7 described 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 to at least one half of the distance from the cementoenamel junction to the incisal edge.
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Type 2 (semi-talon) is an additional cusp with a length of 1 mm or more but extending to less than one half of the distance from the cementoenamel junction to the incisal edge. Type 3 (trace talon) is an enlarged, prominent cingulum. Talon cusps can create problems, including compromised esthetics and occlusal interference, which may lead to accidental cusp fracture, displacement of the affected tooth, caries developmental grooves, included food stagnation, irritation of the tongue and lip, speech problems, dental sensitivity, breastfeeding problems, temporomandibular joint pain, and periodontal problems because of excessive occlusal force.6 Radiographically, a talon cusp typically appears as a “V”-shaped radiopaque structure. The radiopaque “V”-shaped structure is superimposed onto the normal image of the crown of a tooth. This appearance can change with the shape and size of the cusp and with the angle of the radiograph. The clinical management of this anomaly can be very different depending on the size and shape of the affected tooth and the problems caused by this enlarged cusp.10–12 A talon cusp is usually asymptomatic and is often diagnosed as an incidental finding during routine dental examination. If symptomatic, a talon cusp usually causes problems related to occlusion, speech, and esthetics.4 The common problems associated with a talon cusp are1 caries susceptibility,2 occlusal interference, and3 compromised esthetics.7,12 Within the limitations of these problems, conservative treatment techniques can be applied. Careful clinical and radiographic examination is necessary for correct diagnosis and treatment planning in such cases. Because of the two-dimensional limitations of radiographs, these images are not sufficient to understand the complex anatomy of the crown in such an anomaly. However, with the advent of cone-beam computed tomography
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© 2014 Wiley Periodicals, Inc.
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FIGURE 1. Vestibule view of the teeth.
FIGURE 2. Incisal view of teeth.
(CBCT), diagnosis and correct treatment have become possible. The use CBCT has become increasingly common in numerous dental specialties. CBCT has been specifically designed to produce an undistorted three-dimensional (3-D) reconstruction of the maxillofacial skeleton and 3-D images of the teeth and their surrounding tissues.13 CBCT scans provide valuable information about dental anatomy and can help to plan treatment.14
CASE REPORT A healthy-looking, 21-year-old Turkish female reported to the Istanbul University Faculty of Dentistry’s Department of Restorative Dentistry with a chief complaint of an abnormally appearing upper front tooth. Her medical and family history was non-contributory. Oral examination showed fair oral hygiene and no caries lesions. All permanent teeth were present, and the presence of an accessory cusp on the facial aspect of the permanent maxillary right central incisor, extending from the cementoenamel junction to the incisal edge, was observed (Figures 1 and 2). The accessory cusp was separated from the rest of the crown and was approximately 2 mm in diameter. A small enamel caries lesion was detected in the incisal edge of the cusp. Radiographic (panoramic and periapical) investigation indicated a “V”-shaped radiopaque structure and three radiolucent globe areas but did not indicate a connection to the pulp chamber (Figure 3). The radiolucent globe areas did not clearly define this
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FIGURE 3. Periapical radiography of teeth.
formation. To clarify these aspects and to establish a definitive diagnosis, we decided to refer the patient for a 3-D CBCT of tooth #11. A CBCT scan of the involved teeth was performed as an examination (i-CAT CBCT scanner; Imaging Sciences International, Inc., Hatfield, PA, USA) at 120 KVp and with sections of 1.0 mm thickness. CBCT demonstrated the complex anatomy of tooth #11 and showed that the pulp chamber was distinct from the globes (Figures 4 and 5). A diagnosis of a type 1 talon cusp was made. After clinical and radiographic examination, management was directed toward eliminating the talon cusp and improving the esthetic appearance of the
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FIGURE 4. Cone-beam computed tomography (CBCT) of tooth #11 and the globes a.
FIGURE 5. Cone-beam computed tomography (CBCT) of tooth #11 and the globes b.
FIGURE 6. Grinding process and three spherical air bubbles.
FIGURE 7. Resin-based composite restoration at baseline.
anterior teeth by minimal restorative treatment. The talon cusp was gradually reduced using a water-cooled round and bullet-shaped diamond bur on a high-speed hand piece. Generally, the talon cusp area is grinded until reaching healthy tooth tissue. For this purpose, the labial surface of the tooth is painted with articulating paper. The purpose of this process is to ensure careful grinding. During the grinding process, at the level of the healthy tooth, three spherical air bubbles were encountered in the talon tubercle (Figure 6). The globes
FIGURE 8. Resin-based composite restoration after 1 year.
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in the field of dental tissue give an image of the enamel and dentin. To meet the esthetic expectations of the patient, the undercut areas were cautiously removed. The cusp was nearly completely eliminated without causing pulpal exposure. Direct resin-based composite (3M Z550, 3M ESPE, St Paul, MN, USA) was used for better esthetics (Figure 7). Enamel and dentine were etched with 37% phosphoric acid (Scotchbond etching gel, 3M ESPE) gel, then followed extensive washing with water spray, accompanied by high volume suction, in order to eliminate excess water and maintain a slightly humid surface. The adhesive system (Adper Single Bond 2, 3M ESPE) was applied according to the manufacturer’s directions and light polymerized for 20 seconds at 600 mW/cm2 (Bisco, Bisco VIP, Schaumburg, IL, USA). The restoration was formed using a universal nanohybrid resin-based composite (3M Z550, 3M ESPE) that was placed using an incremental technique. The resin-based composite restoration was polymerized for at least 2 minutes with the polymerization unit. Finishing and polishing procedures were performed by discs (Sof-Lex; 3M ESPE). The patient was followed up over a period of 1 year, and the tooth was found to be completely asymptomatic, with intact vitality intact (Figure 8). The follow-up radiograph showed healthy periapical tissues in the treated tooth and continued root formation of the maxillary right incisor (Figure 9).
DISCUSSION The etiology of the formation of a talon cusp is unclear. However, it has been suggested that the hyperactivity of the dental lamina in early odontogenesis and a combination of genetic and environmental factors have a role.5 Talon cusps have been reported to affect both sexes and may be unilateral or bilateral.15,16 A review of previous reports of talon cusps in primary dentition indicated that the cusps all occur on maxillary central incisors
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FIGURE 9. Periapical radiography of teeth after 1 year.
and predominantly on the left side if the anomaly is unilateral.15 Including the present report, there were several reported clinical cases with exclusively facial talon cusps, 75% of which were observed in permanent dentition.7 In the present case, a female patient with a talon cusp on a right maxillary permanent central incisor was observed. Talon cusps usually occur on the palatal or lingual surfaces of the anterior teeth. A rare variant, also observed on the maxillary incisor, has vertical cristae (rugae adamantineae) on the facial side of the teeth.17 Rugae adamantineae defining feature is a ridge of enamel that crosses the center of the vestibular surface of the tooth in a cervical-incisal direction, as in the case described in this paper.4 The presence of a talon cusp is not always an indication for dental treatment, unless the cusp is associated with problems such as compromised esthetics, occlusal interference, tooth displacement, caries, periodontal problems, or irritation of the soft tissues during speech or mastication.16,18,19
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Only few cases of facial talon cusps that were reported in the literature received complete treatment. McNamara and colleagues performed orthodontics to close a space after extraction of a mandibular left central incisor with a talon cusp for esthetic reasons.12 de Sousa and colleagues performed an esthetic restoration following root canal therapy for a maxillary right permanent central incisor.20 A case reported by Glavina and Skrinjaric included gradual cuspal grinding and resin-based composite restoration of a facial talon cusp on a maxillary permanent left central incisor.21 Another case reported by Kulkarni and colleagues included treatment of a talon cusp using reduction every 45 days, followed by fluoride varnish application for 9 months.22 The management of talon cusps includes no treatment, sequential grinding,23 pit and fissure sealants,24 pulp therapy,2,20 restorative treatment,2,6,20 full crown coverage, and extraction of the affected tooth.12,25 In our case, the tooth fulfilled functional and esthetic requirements when first diagnosed, and the authors believe that restorative treatment was the best solution. In the present case, the patient was interested in achieving an esthetic tooth in a short time. After complete cuspal grinding, a direct resin-based composite was applied. There are advantages of using resin-based composites, such as shortening chair time, biocompatibility of the materials, low cost, and minimal hard tissue removal. Adhesion of resin-based composites to enamel and dentin has improved as a result of recent developments. By using various dentine and enamel colors and make-up techniques, it is possible to imitate the optical properties of natural teeth. Also the polishability of resin-based composites has been improved by the new developments of inorganic particle size and ratio. A definitive diagnosis of a talon cusp cannot be made based on 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.3
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A talon cusp is composed of normal enamel and dentin and may involve a pulpal extension.7 Clinical variations of talon cusp include those of location, shape, size, structure, and number.26 Various treatment regimens have been followed for the management of talon cusps depending on the absence/presence of pulpal extensions. In case of presence pulpal extension, pulpotomy can be performed using calcium hydroxide or mineral trioxide aggregate material.26 In the present case, no pulpal extension was observed and these materials were not used. The talon cusp presented in this case report extended from the cementoenamel junction to the incisal edge, which may be categorized as a type 1 or true talon. Although such large cusps, which stand away from the tooth, have been shown to contain an extension of the pulp, superimposition of the image of the cusp onto the main tooth made it difficult to determine the extent of pulp tissue involvement in the anomalous cusp. Small talon cusps are usually asymptomatic, and no treatment is required. However, large talon cusps, as in our case, may cause problems for the patient. Diagnosis and treatment planning are also difficult for the dentist.27 The treatment of talon cusps involves careful clinical examination and depends on whether the cusp is close to the pulp or contains pulp. Tracing the pulpal configuration inside a talon cusp using radiography is inherently difficult because the cusp is superimposed onto the affected tooth crown.6 In periapical radiographs, it is not always possible to determine the relationship between the cusp portion of the tooth and the pulp chamber and/or root canals with great precision. For this reason, we decided to examine the tooth by computerized tomography in three ways. The future for caries diagnosis, both proximal and pit and fissure, periodontal diagnosis, soft tissue lesion diagnosis, dentally related sinus diagnosis, implant planning and placement, oral maxillofacial surgery uses, as well as endodontic applications can be expanded. Too many clinicians do not use cone beam because they don’t have one, although there is access to a dental computed tomography scan technology in other dental offices/speciality practices. CBCT is an X-ray imaging
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approach that provides high-resolution 3-D images and shown great benefit in the localization and identification of tooth anatomy.28 This method is especially useful in endodontics for the identification of anatomic features and variations of the root canal system. In the present case, tomography images made it possible to observe a cusp that was not communicating with the pulp. Although periapical radiography has been used for the diagnosis of talon cusps in the past, 3-D imaging for unusual tooth anatomies can be performed with the help of CBCT, as in this case. The radiation dose produced by CBCT system is dependent on a several factors such as the nature of the X-ray beam (continuous or pulsatile), the degree of rotation of the X-ray source and detector, and the size of the field of view.29 The effective doses associated with CBCT scans, ranged from 13 μSv (anterior mandible) to 44 μSv (maxillary canine/premolar region) respectively.30 By comparison, the effective dose of a single intraoral periapical radiograph ranges from 1 to 5 μSv. These data revealed that the effective dose of CBCT is higher than conventional intraoral radiography. However, this difference is continuously narrowing, and in certain clinical scenarios, the effective dose of CBCT will approach that of periapical radiography. The patient did not report sensitivity or any symptoms. The case was followed up successfully over a period of 1 year, without any postoperative complications. No visible evidence of a crevice along the marginal adaptation was observed. The restoration was continuous with the existing anatomical form. No discoloration was observed anywhere along the margin between the restoration and the adjacent tooth, and no shade or translucency between the restoration and the tooth was noted.
CONCLUSION In conclusion, the case described in this paper includes an asymptomatic dental anomaly that did not cause any other alteration in the tooth or arch. The anomaly was the result of anomalous development of the enamel and likely of the underlying dentin. The present case report outlines the conservative management of a type 1 talon
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cusp. Conservative treatment is always encouraged. Early diagnosis and treatment are recommended to avoid complications and to maintain a healthy pulpal and periodontal status. CBCT not only can help in diagnosis but also can serve as an important aid in treatment planning and in ensuring successful results.
DISCLOSURE The authors do not have any financial interest in any of the companies whose products are included in this article.
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Reprint requests: Yazıcıog˘lu Oktay, DDS, PhD, Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, 34093 Fatih/I˙stanbul, Turkey; Tel.: +90-533-416-3248; Fax: +90-212-525-0075; email: [email protected]
DOI 10.1111/jerd.12101
© 2014 Wiley Periodicals, Inc.
