Facial talon cusp in multilobed mesiodens: A rarest case report

Abstract

Talon cusp is a well-delineated, talon shaped additional cusp arises during the morphodifferentiation stage of tooth development. It occurs on lingual/palatal or facial surface of either primary or permanent anterior teeth.Occurrence of talon cusp on supernumerary teeth is extremely rare. We report a case of facial talon cusp in a multilobed mesiodens in a 8-year-old girl, which is a rarest of the rare.

Keywords: Multilobed mesiodens, supernumerary teeth, talon cusp

How to cite this article:
Busnur SJ, Naik SV, Govindappa KS, Thakkilipati HC, Shanbhog SV. Facial talon cusp in multilobed mesiodens: A rarest case report. Ann Trop Med Public Health 2013;6:109-11
How to cite this URL:
Busnur SJ, Naik SV, Govindappa KS, Thakkilipati HC, Shanbhog SV. Facial talon cusp in multilobed mesiodens: A rarest case report. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Aug 8];6:109-11. Available from: https://www.atmph.org/text.asp?2013/6/1/109/115170
Introduction

Talon cusp is an accessory cusp projecting from the lingual or facial surface of primary or permanent anterior teeth in both arches and extending half the distance from cement enamel junction to the incisal edge. [1] It was first described by Mitchell in 1892 and the name ‘Talon cusp’ was given by Mellor and Ripa in 1971 due to its resemblance to an eagle’s talon. [2],[3] The exact etiology of this condition remains unknown. It is thought to occur during morphodifferentiation stage as a result of outward folding of inner enamel epithelial cells (precursors of ameloblasts) and transient focal hyperplasia of mesenchymal dental papilla (precursors of odontoblasts) or combination of genetic and environmental factors (multifactorial). [4] Talon cusp also called as dens evaginatus of anterior tooth, shows increased predilection for males, maxilla, and permanent dentition (75%). [4],[5] It predominantly occur on permanent maxillary lateral (55%) or central (33%) incisors, less frequently on mandibular canines (6%), and maxillary canines (4%). [6] Occurrence of talon cusp on supernumerary teeth is extremely rare phenomenon and the occurrence of facial talon cusp in multilobed mesiodens is rarest of the rare. We report the rarest case of facial talon cusp occurring in a multilobed mesiodens, which has caused the impaction of central incisor.

Case Report

An 8-year-old girl reported to the Oral Medicine and Radiology outpatient department with the chief complaint of unusually looking and extra tooth in the upper front teeth region. Family history was noncontributory. There was no history of trauma. There were no signs of any syndrome. Intra-oral examination revealed supernumerary tooth palatal to 11 interfering the occlusion and an unusual morphologically altered tooth with 3 lobes separated by noncarious developmental grooves [Figure 1]. Fusion between supernumerary tooth and central incisor was considered and advised for Intra-Oral Periapical (IOPA) Radiograph. IOPA radiograph revealed bilateral supernumerary teeth with completely formed roots present on either side of the midline of the anterior maxilla. Right sided supernumerary was conical in shape with bilobes.Left sided supernumerary was multilobed along with ‘V’ shaped radiopaque structure over a normal crown, indicating the talon cusp [Figure 2]. Impaction of 21 was observed in the radiograph.

Figure 1: Intra-Oral photograph showing an unusual morphologically altered tooth with 3 lobes

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Figure 2: IOPA radiograph showing ‘V’ shaped radiopaque structure over a crown of mesiodens (arrow) with multiple lobes and Impaction of 21

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Based on clinical and Radiographic findings, two supernumerary teeth were diagnosed as mesiodens, one with bilobes and another with multilobed along with facial talon cusp. Patient was managed with extraction of both mesiodens under local anesthesia, [Figure 3] as they were causing occlusal interference, poor esthetics and impaction of 21.

Figure 3: Showing extracted mesiodens with multiple lobes and facial talon cusp (arrow)

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Discussion

Supernumerary teeth may be defined as any teeth or tooth substance in excess of the usual configuration of 20 deciduous, and 32 permanent teeth. [7] Supernumerary teeth may be classified on the basis of position or form. [8] Positional variations include mesiodens, paramolars, distomolars, and para premolars. Supernumerary teeth may vary in form from simple conical, tuberculate tooth to a supplemental tooth or odontomes. [9] Mesiodens is the most frequently seen supernumerary teeth followed by maxillary lateral incisors and mandibular premolars. [10] Koch et al. have classified mesiodens as 56% conical, 12% tuberculate, 11% supplemental, and 12% other configuration. [11] The present case has shown the mesiodens with unusual crown morphology that is three well developed lobes including talon cusp with completely formed root, hence it can be included in the “Other Configuration” category of mesiodens.

Talon cusp with supernumerary teeth in permanent dentition is extremely rare and the occurrence of facial talon cusp in multilobed mesiodens is rarest of the rare. Pubmed and Medline search reveals eight cases of talon cusps on supernumerary permanent [12],[13],[14],[15],[16] and primary [14],[17],[18] and three cases on supplemental permanent teeth. [19] Nagaveni et al. reported a case of multilobed mesiodens with palatal talon cusp. [15] To the best of our knowledge, the presented case report seems to be the first one of facial talon cusp occurring in multilobed mesiodens. Talon cusp occurs unilaterally or bilaterally and its prevalence rate is 0.06% in Mexican, 7.7% in north Indian, 0.17% in American, and 2.5% in Hungarian children. [20],[21],[22],[23] Hattab et al. categorized talon cusp into talon, semi talon, and trace talon according to the extent of accessory cusp from cemento-enamel junction toward incisal edge. [4] Talon cusp can be found in isolation or in associationwith other dental anomalies like peg shaped lateral incisors, shovel-shaped incisors, bifid cingulum, unerupted canines and the large cusp of Carabelli, dens invaginatus, supernumeraries (as in presented case), and odontomas. [4],[24],[25] Talon cusp appears to be more frequent inRubinstein-Taybi syndrome,Mohr syndrome,  Sturge- Weber syndrome More Details More Detailsand incontinentia pigmenti. [6],[24]

Both mesiodens and talon cusp are considered as the most common dental anomalies affecting the permanent dentition. Mesiodens may cause local problems like diastema, displacement or rotation of adjacent teeth, dentigerous cyst formation, impaction of central incisors as seen in presented case, resorption of neighboring root, crowding, occlusal interference, esthetic impairment, and dilacerations of permanent teeth. [5],[11],[26] Small talon cusps are usually asymptomatic and need no treatment. Large prominant talon cusps may cause clinical problems including poor esthetics, occlusal interference, displacement of the affected tooth, carious lesions in the developmental grooves and pulpal exposure due to cuspal attrition, accidental cuspal fracture, pulpal necrosis, periapical pathoses, periodontal pockets, soft tissue irritation (tongue or labial mucosa), and possibility of temporomandibular joint pain. [4],[6],[24] Hence the presence of both the anomalies in young patients is of great concern, and early diagnosis is crucial to minimize these complications.

The management of talon cusp varies with the clinical presentations of each case and should be as conservative as possible. For deep developmental grooves, simple prophylactic measures such as fissure sealing and composite resin restoration can be done. In case of occlusal interference, reduce the bulk of the cusp gradually and periodically, and application of topical fluoride gel is indicated to reduce sensitivity and to stimulate reparative dentin for pulp protection or outright total reduction of the cusp and calcium hydroxide pulpotomy. It may also become necessary sometimes, to fully reduce the cusp, extirpate the pulp and carry out root canal therapy. Orthodontic correction may become necessary when there is tooth displacement or malalignment of affected or neighboring teeth. [4],[6] In the presented case, as the talon cusp occurred along with supernumerary mesiodens and caused several clinical problems like poor esthetics, occlusal interference, and impaction of central incisor, extraction of both the mesiodens was performed under local anesthesia. Munns suggested that the earlier the offending supernumerary tooth is removed, the better the prognosis. [27]

Conclusion

Cooccurrence of talon cusp in mesiodens is rare and uncommon. In the present case of facial talon cusp has coexisted with multilobed mesiodens, which is rarest of the rare. Early diagnosis of both anomalies has greater clinical importance as both the anomalies can give rise to various clinical complications necessitating immediate intervention.

References
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Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.11517

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[Figure 1], [Figure 2], [Figure 3]

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