|Year : 2016 | Volume
| Issue : 1 | Page : 60-63
Multiple maxillary anteriors with talon cusps: Report of an unusual case and review of literature
Vineeta Nikhil, Parul Bansal, Ayush Goyal
Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, Uttar Pradesh, India
|Date of Web Publication||21-Jun-2016|
Department of Conservative Dentistry and Endodontics, Subharti Dental College, Meerut, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Talon cusp is not an uncommon developmental anomaly. However, occurrence of multiple taloned teeth in the same patient is rare. This case report presents the management of four maxillary anterior teeth with talon cusps in the same patient. Hattab's classification was used for diagnosis of the type of talon in each tooth.
Keywords: Developmental anomaly; maxillary incisor; talon cusp.
|How to cite this article:|
Nikhil V, Bansal P, Goyal A. Multiple maxillary anteriors with talon cusps: Report of an unusual case and review of literature. Endodontology 2016;28:60-3
| Introduction|| |
"A hawk with talent hides its talon." However, talon cusp characterized by its peculiar appearance can seldom stay hidden from the examining eyes of an astute clinician.
According to Mader, talon cusp is defined as "a morphologically well-delineated cusp that projects from the lingual/palatal surface of the primary or permanent anterior tooth and extends at least half the distance from the cementoenamel junction to the incisal edge.  Recently, this definition of talon cusp has been extrapolated to include the facial surface also.  The first case of talon cusp was reported by Mitchell in 1892 in a female patient.  She described this "spare" cusp on the palatal surface of a maxillary central incisor as "a process of a horn-like curving from the base downward to the cutting edge." Mellor and Ripa coined the term "talon cusp" because of its resemblance to an Eagle's talon. 
Shulze characterizes talon cusp as a supernumerary cusp that may unite with the incisal edge to create a "T"- or a "Y"- shaped crown (when seen from incisal/occlusal surface). 
The incidence of talon cusp depends on ethnic background, gender, age, and the taxonomy used to characterize this abnormality. Following incidences have been found for talon cusp in various countries - United States - 0.17%, Mexico - 0.06%, Malaysia - 5.2%, and in North Indian population - 7.7%.  A review by Dash et al. reports an incidence of 25% in the primary dentition and 75% in the permanent dentition.  Greater predilection is seen in the maxillary arch. More than 90% of the cases have been reported in the maxilla and only 10% in the mandible.  In the permanent dentition, the highest incidence occurs in maxillary lateral incisors (55%), followed by central incisors (33%) and canines (4%). 
This article reports an extremely rare occurrence of four teeth with talon cusps in the same patient and their management along with a review of literature.
| Case Report|| |
A 22-year-old male patient reported to the Department of Conservative Dentistry and Endodontics in Subharti Dental College and Hospital, Meerut, with a chief complaint of multiple decayed teeth and sensitivity in relation to his upper and lower jaw. Mild sensitivity was present in all the teeth, especially to cold and sweets. Clinical examination of both arches revealed dentinal caries in relation to 11, 12, 21, 22, 23, 36, 37, and 46. Caries involving enamel was present in 16. Clinical examination also revealed the presence of talon cusps in all the four maxillary incisors [Figure 1]. Radiographic examination in relation to maxillary anteriors revealed coronal radiolucency involving enamel, dentin, and approximating pulp in relation to 12 and 22 suggestive of deep dentinal caries [Figure 2]. Caries in 21 and 23 involved enamel and dentin suggestive of dentinal caries. Based on clinical and radiographic features, a diagnosis of symptomatic irreversible pulpitis was established in 12 and 22 and reversible pulpitis in 21 and 23. Cone beam computed tomography analysis was done to determine the extent of pulp tissue in the talon cusps [Figure 3]. It was seen that there were no high pulpal extensions in any of the taloned teeth. Restorative treatment was planned for 21 and 23 and endodontic treatment for 12 and 22.
|Figure 3: Cone beam computed tomography analysis (sagittal scans) of 11, 12, 21, and 22|
Click here to view
Following endodontic (12 and 22) and restorative (21 and 23) treatments, the "talon" from each tooth was removed to restore the tooth's morphology [Figure 4] and [Figure 5].
| Discussion|| |
Talon cusp is a cusp-like extension of hard tissue which stems from the cingulum area of maxillary or mandibular anterior teeth. Etiology of this condition has remained elusive. Disturbances during the morphodifferentiation stage of odontogenesis might affect the tooth's anatomy.  Hattab and Yassin proposed that this anomaly might be caused by out folding of the enamel organ.  Hyperactivity of the anterior portion of dental lamina is also a possible etiological factor.  Sarkar et al. showed talons in many members of a family showing hereditary or genetic pattern.  Maxillary lateral incisor develops 7 months after the canine, and hence, its tooth germ may be compressed by the contiguous central incisor and canine in the morphodifferentiation stage.  Thus, maxillary lateral incisors are the most commonly affected teeth. On the other hand, this cannot happen in primary teeth as all the incisors develop at the same time and the lateral incisor matures before the canine develops.
Based on the length of "talon," a clinical classification was given by Hattab et al.  Type 1 refers to talon cusps that are well-delineated cuspal projections from the palatal surface of primary or permanent anterior teeth and extend at least half the distance from the cementoenamel junction to the incisal edge. If the projection extends less than half the distance from the cementoenamel junction to the incisal edge, they are referred to as type 2 semi-talon cusps. Type 3 that is trace talon cusps are just prominent and well-developed cingula. According to this classification, teeth 11 and 21 in our case would be described as type 1 and teeth 12 and 22 as type 2.
Since talon cusps can occur on either facial and/or palatal surface of either dentition, the authors suggest an alternate definition - "a true talon cusp is a morphologically well-delineated cusp that projects from the facial and/or lingual/palatal surface of the primary or permanent anterior tooth and extends at least half the distance from the cementoenamel junction to the incisal edge, containing varying degrees of pulp tissue."
Considering the number of cases reporting facial talon cusps, Chin-Ying included facial talons also in their classification.  Type 1 talons are well-defined cusps projecting from an anterior tooth's facial or palatal/lingual surface and extend at least half the distance from the cementoenamel junction to the incisal edge and are called major talons. Type 2 talons are minor talons that occur on the same surfaces but extend more than one-fourth and less than half the distance from the cementoenamel junction to the incisal edge. Trace talons are third type, which is enlarged prominent cingula which occupy less than one-fourth the distance from the cementoenamel junction to the incisal edge.
Although talon cusps usually occur as an isolated entity, they can also be associated with other dental anomalies such as impacted canines, peg-shaped laterals, hypodontia, supernumerary teeth, dental/skeletal crossbite, retrognathic mandible, complex odontoma, and Leong's premolar.  However, no such oddity was found in the present case. It can be unilateral or bilateral. Noticeably, the occurrence of talons cusps in the present case was bilateral, affecting all the maxillary incisors.
Tendency of talon cusp increases in syndromes such as Mohr syndrome (orofacial digital syndrome II), Rubinstein-Taybi syndrome, Sturge- Weber syndrome More Details More Details, incontinentia pigmenti achromians, Berardinelli-Seip syndrome, and Ellis-van Creveld syndrome More Details.  No syndrome was seen in this patient.
Talon cusp predisposes the tooth to dental caries, can interfere with occlusion, may lead to tongue irritation during speech and mastication, and compromises esthetics and painful periodontium due to traumatic occlusion.  In the present case, taloned teeth were not interfering with occlusion but developed extensive caries owing to increased plaque retention combined with poor oral hygiene.
Depending on individual case, treatment options available for talon cusps are as follows:
- Do nothing
- Fluoride application
- Gradually grinding the cusp and restoring the tooth's morphology
- Endodontic treatment if pulpal exposure occurs during the cusp reduction.
In the present case, the most appropriate treatment was option 3 since the talons of all the teeth did not contain any pulp tissue. The talons were simply reduced to attain a normal morphology. Final restorations were done with resin composite, followed by fluoride varnish application. Oral hygiene instructions were given to the patient, and the patient was kept on a periodic recall every 6 months.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]