Talon Cusp Causing Occlusal Trauma and Acute Apical Periodontitis: Report of a Case

Case Report Talon cusp causing occlusal trauma and acute apical periodontitis: report of a case

Segura-EgeaJJ, Jime¤ nez-Rubio A,Velasco-Ortega E, R|¤os-SantosJV. Juan J. Segura-Egea1, Alicia Jime¤ nez- Talon cusp causing occlusal trauma and acute apical periodontitis: Rubio2, Eugenio Velasco-Ortega1, Jose¤ report of a case. DentTraumatol 2003;19: 55^59. # Blackwell V. R|¤os-Santos1 Munksgaard, 2003. 1Department of Stomatology, School of Dentistry, University of Seville, C/Avicena s/n; 2Department of Abstract ^ The talon cusp, or dens evaginatus of anterior teeth, is a Morphological Sciences, School of Medicine, relatively rare dental developmental anomaly characterized by the University of Seville, Avda. Sa¤ nchez-Pizjuan s/n, presence of an accessory cusp-like structure projecting from the 41009-Seville, Spain cingulum area or cemento^enamel junction.This occurs in either maxillary or mandibular anterior teeth in both the primary and permanent dentition. One of the main problems caused by accessory cusps are occlusal interferences.The anomalous cusp Key words: apical periodontitis; dens evaginatus; dental anomalies; occlusal interferences; occlusal even can generate occlusal trauma and reversible acute apical trauma; talon cusp periodontitis of the opposing tooth.This article reports a case of Dr Juan J. Segura-Egea, C/Cueva de Menga n81,portal talon cusp a¡ecting the permanent maxillary left lateral incisor 3, 68-C, 41020-Seville, Spain that caused clinical problems related to occlusal trauma and apical Tel.: þ34 95 4670883 periodontitis caused by a premature contact.The treatment of the e-mail: [email protected] occlusal interference produced by the taloned tooth is described. Accepted 2April, 2002

The tooth developmental anomaly characterized by lection for the maxilla over the mandible.The maxil- the occurrence of an extra cusp is nominated as dens lary lateral incisors are the most frequently involved evaginatus (1). Mitchell (2) ¢rst described this dental (67%) followed by the central incisors (24%) and anomaly as a‘process of horn-like shape curving from canines (9%) (8, 9). the base downward to the cutting edge on the lingual There are several dates inthe literature that suggest surface of an upper central incisor of a female patient. thehereditarycharacteroftaloncusp: familyhistories Mellor & Ripa (3) namedthe dens evaginatusofante- of cases reported previously revealed that sometimes rior teeth as talon cusp because of its resemblance in talon cusp a¡ected patients who had consanguineous shape to an eagle’stalon. In canines and incisors, dens parents (7); the anomaly has been described a¡ecting evaginatus originates usually in the palatal cingulus two siblings (10,11), two sets of female twins (12), and as atubercle projecting from the palatal surface; how- two family members (13); and the prevalence of talon ever, the anomaly has been also described a¡ecting cusp is high in some racial groups (14^17). Moreover, the labial surface of the tooth (4, 5).The anomalous talon cusp is associated with other dental anomalies talon cusp is composed of normal enamel and dentin (13).These ¢ndings support the concepts that genetics with varying extensions of pulp tissue. Shay (6) may be a major causative factor of talon cusp. reported that pulp tissue can extend to the center of The casesreportedinthe literature astaloncuspare the tubercle and, once fractured, the pulp is exposed. very di¡erent since this anomaly varies widely in Talon cusp occurs more frequently in permanent shape, size, structure, location, and site of origin (18). than in the primary dentition. A review of the litera- Davis & Brook (19) stated that talon cusp may repre- ture shows that 75% of the cases exhibited talon cusp sentthe extreme ofacontinuousvariationprogressing in their permanent dentition and 25% of the cases from a normal cingulum to an enlarged cingulum to in the primary dentition (7).Talon cusp shows a predi- a small accessory cusp to a talon cusp. 55 Segura-Egea et al.

When talon cusp interferes with the normal occlusion, the premature contact caused by the anomalous cusp can generate occlusal trauma and reversible acute apical periodontitis of the opposing tooth. In these cases an occlusal adjustment by grinding the palatal projection must be performed, with the possi- bility of exposure of the dentin^pulp complex and, consequently, pulp necrosis (20). This articlereportsacase oftaloncuspa¡ectingthe permanent maxillary left lateral incisor that caused occlusal trauma of the opposing tooth.The treatment of the occlusal interference produced by the taloned tooth is described.

Case report Fig. 2. A prominent accessory cusp on the palatal surface of the left lateral incisor is evident. A10-year-old boy sought treatment for the chief com- plaint of pain in the region of the left mandibular lateral incisor. The patient appeared healthy and of located on the mesial half of the crown, with the tip normal physical development for his age. There was of the cusp attached to the crown.The accessory cusp noreportedhistoryoforofacialtrauma.The occlusion extended from the cemento^enamel junction more was a Class I molar relationship with bilateral open- thanhalfwaytotheincisaledge.Non-cariousdevelop- bite (Fig.1). The mandibular left lateral incisor did mental grooves were present at the junction of the not present anycariouslesion or fracture, showednor- talon cusp and the palatal surface of the tooth. The mal color and responded normally to thermal pulp tooth responded normally to thermal pulp tests. A tests. However, the tooth was sensitive to percussion. periapical radiograph (Fig.3) showed a V-shaped The periapical radiograph did not show enlargement radiopaque structure superimposed on the image of of the periodontal space but the lamina dura was the a¡ected crown, with the point of the ‘V’ towards poorly de¢ned. A thorough intraoral examination of the incisal edge. Pulp extension could not be traced the tooth displayed the presence of a wear facet on radiographically. On the other hand, a large cusp of the distal aspect of its incisal edge.The facet was pro- Carabelli on the maxillary right ¢rst molar was evi- duced by the contact with the opposing tooth, the dent (Fig. 4). maxillary left lateral incisor that showed an unusual dental anomaly, talon cusp. The maxillary left lateral incisor was rotated and labially displaced, showing an accessory cusp on the palatal aspect (Fig.2).The accessory cusp measured 4.4 mm in length (incisocervically),3.0 mm in width (mesiodistally), and 2.8 mm in thickness (labiolin- gually).The talon cusp was pyramidal in shape and

Fig. 3. Periapical radiograph showing a V-shaped radiopaque Fig. 1. Facial view showing bilateral openbite. structure superimposed on the image of the affected crown. 56 Talon cuspcausing occlusal trauma

Fig. 4. A prominent Carabelli tubercle in the maxillary right Fig. 6. Talon cusp after the grinding performed in the first app- first molar is evident (mirror photograph). ointment.

Fig. 5. The occlusal interference provoked for the premature Fig. 7. Talon cusp after the final appointment. contact of the accessory cusp with its opposing tooth is showed.

Theaccessorycuspinterferedthenormalocclusion, the vitality of the tooth, and the occlusal interference causing a premature contact between the taloned was disappeared (Fig.8). Clinical symptoms on the maxillary left lateral incisor and the mandibular left opposing tooth had vanished after the ¢rst occlusal lateral incisor (Fig.5). Openbite was evident in the adjustment. maximal interocclusal position. Occlusal trauma of the mandibular left lateral incisor, consecutive to its premature contact with the accessory cusp of the taloned tooth, was diagnosed. Thus, an occlusal adjustment by grinding the talon cusp of the lateral incisor was performed.Toavoid a pulp exposure and to allow the formation of reparative dentin, the accessory cusp was ground o¡ gradually during three consecutive appointments of 6 weeks apart. In each visit, a small amount of hard dental tissue was removed and the ground surface was treated with £uoride varnish (Duraphat, Woelm Pharma Co., Eschwege, Germany),as a desensitizing agent (Figs.6 and 7). After the ¢nal appointment, the residual accessory cusp was covered with resin composite. The talon cusp had been reduced approximately 3.0 mm, without exposing the pulp or compromising Fig. 8. The occlusal interference has disappeared. 57 Segura-Egea et al.

Discussion ling, or infolding of the dental lamina as in dens invaginatus (27). Occlusal forces cancausechanges inthe alveolarbone According to the classi¢cation by Hattab et al. (7), andperiodontalconnectivetissueboth inthepresence the anomalous cusp, pyramidal in shape and extend- and in the absence of periodontitis (21). In the case ing from the cemento^enamel junction more than reported here the traumatic occlusion caused by the halfway to the incisal edge that has been presented premature contact of the taloned tooth produced an here, was classi¢ed as type 1or ‘talon cusp’. occlusal trauma that a¡ected the whole opposing Early diagnosis and management of talon cusp is tooth and its supporting tissues (22).The acute apical important in order to prevent occlusal interference, periodontitis provoked by the occlusal trauma compromised esthetics, carious developmental reversedwhenthe anatomicalelement ^ theaccessory grooves, periodontal problems due to excessive occlu- cusp ^ causing the premature contact was removed. sal forces, or irritation of the tongue during speech After occlusal adjustment, uncomplicated healing and mastication (13,18). and periapical repair occurred. The treatment of talon cusp implicates careful clin- The case reported demonstrates that talon cusp is ical decision. Earlier radiographic studies stated that an anomaly of great clinical signi¢cance. Small talon removal of the cusp could inevitably lead to pulp cusps are usually asymptomatic and need no treat- exposure that would require endodontic treatment ment, but large talon cusps may cause clinical pro- (3). Consequently, previous radiographic examina- blems including occlusal interference, displacement tion must be performed in all cases to ensure that a of the a¡ected tooth, irritation of the tongue during pulp horn is not present in the talon cusp. Although speech and mastication, carious lesion inthe develop- somehistological studiesofextractedtalonteethfailed mental grooves delineate the cusp, pulpal necrosis, to show the presence of a pulp horn in the talon cusp periapical pathosis, attrition of the opposing tooth, (29), Gu« ngo« r et al. (30) reported a case of bilateral and periodontal problems due to excessive occlusal talon cusp on primary maxillary central incisors forces (23). whose histological evaluation revealed the existence Talon cusp originates during the morphodi¡eren- of pulpal tissue in the anomalous cusps. The aid of tiation stage of tooth development but the etiology radiograph is essential, but radiographic tracing of of the condition remains unknown (13). In the major- the pulpal con¢guration inside the talon cusp has ity of cases reported, the talon cusp is isolated rather inherent di⁄cultiesbecause the cusp is superimposed than an integral part of any disorder. Nevertheless, over the a¡ected tooth crown (23). So, the grinding the anomaly was reported in a patient with Sturge^ of the accessory cusp must be performed carefully Weber syndrome (encephalo-trigeminal angiomato- and gradually. In the case reported here, an occlusal sis) (9), Mohr syndrome (oro-facial-digital II syn- adjustment by grinding the palatal projection of the drome) (24), Ellis-van Creveld syndrome (10), and taloned tooth was performed to eliminate the prema- Rubinstein-Taybi syndrome (25). The case reported ture contact.Wereduced1.0 mm of talon cusp in each herewasnotassociatedwithanyknownabnormalsys- appointment reducing a total of 3.0 mm without temic developmental syndrome. exposing the pulp. Other authors have removed a lar- Control of the complex processes of dental develop- ger amount of hard tissues without pulp exposure. ment appears to be multifactorial, that is, primary Thus, Pitts & Hall (31)removed 3 mm of the anoma- polygenetic with some environmental in£uence. lous cusp in one appointment without exposing the Talon cusp is usually associated with other dentalvar- pulp, and Hattab et al. (7, 8) have reduced several iations: bi¢d cingula, dens invaginatus, exaggerated times 1^1.5 mm of talon cusp in one appointment cusps of Carabelli, and particularly with shovel- without pulp exposure. However, this does not imply shaped maxillary incisors (7,13),a polygenic inherita- that all talon cusps are devoid of pulp horn. Shey & bletraitcharacterizedbyaccentuatedmarginalridges Eitel (32) recommended to reduce the accessory cusp that surround a deep lingual fossa (26). by grinding in consecutive appointments of 4 weeks As in the case of talon cusp, the maxillary lateral apart from capping the dentin exposed with calcium incisors are the most commonly a¡ected with shovel- hydroxide and resin. In the case reported here, the ling and dens invaginatus (27, 28).The susceptibility surface of dentin exposed was treated with £uoride of the lateral incisors to abnormalities could partly varnish. be related to compression of the tooth germ of the lateral incisor by the adjacent central incisor and canine, which develops about 7 months earlier than References the lateral incisor. Increased localized external pres- 1. Oehlers FA, Leek KW, Lee EC. Dens evaginatus (evagi- sure on a tooth germ during the morphodi¡erentia- nated odontome): its structure and responses to external sti- tion stage may result in either outfolding of the muli. Dent Pract Dent Rec 1967;17:239^44. dental lamina (in the case of talon cusp) and shovel- 2. MitchellWH. Case report. Dent Cosmos 1892;34:1036. 58 Talon cuspcausing occlusal trauma

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