Dental Traumatology 2003; 19: 5559 Printed in Denmark.

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Copyright # Blackwell Munksgaard 2003 DENTAL TRAUMATOLOGY ISSN 16004469

Case Report

Talon cusp causing occlusal trauma and acute apical periodontitis: report of a case
Segura-EgeaJJ, Jimenez-Rubio A,Velasco-Ortega E, R| os-SantosJV. T alon cusp causing occlusal trauma and acute apical periodontitis: report of a case. Dent Traumatol 2003;19: 55^59. # Blackwell Munksgaard, 2003. Abstract ^ The talon cusp, or dens evaginatus of anterior teeth, is a relatively rare dental developmental anomaly characterized by the presence of an accessory cusp-like structure projecting from the 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 even can generate occlusal trauma and reversible acute apical periodontitis of the opposing tooth. This article reports a case of talon cusp aecting the permanent maxillary left lateral incisor that caused clinical problems related to occlusal trauma and apical periodontitis caused by a premature contact. The treatment of the occlusal interference produced by the taloned tooth is described. Juan J. Segura-Egea1, Alicia Jimenez Rubio2, Eugenio Velasco-Ortega1, Jose V. R| os-Santos1
1

Department of Stomatology, School of Dentistry, University of Seville, C/Avicena s/n; 2Department of Morphological Sciences, School of Medicine, University of Seville, Avda. Sa nchez-Pizjuan s/n, 41009-Seville, Spain

Key words: apical periodontitis; dens evaginatus; dental anomalies; occlusal interferences; occlusal trauma; talon cusp Dr Juan J. Segura-Egea, C/Cueva de Menga n81, portal 3, 68-C, 41020-Seville, Spain Tel.: 34 95 4670883 e-mail: segurajj@wanadoo.es Accepted 2 April, 2002

The tooth developmental anomaly characterized by the occurrence of an extra cusp is nominated as dens evaginatus (1). Mitchell (2) rst described this dental anomaly as aprocess of horn-like shape curving from the base downward to the cutting edge on the lingual surface of an upper central incisor of a female patient. Mellor & Ripa (3) named the dens evaginatus of anterior teeth as talon cusp because of its resemblance in shape to an eagles talon. In canines and incisors, dens evaginatus originates usually in the palatal cingulus as a tubercle projecting from the palatal surface; however, the anomaly has been also described aecting the labial surface of the tooth (4, 5). The anomalous talon cusp is composed of normal enamel and dentin with varying extensions of pulp tissue. Shay (6) reported that pulp tissue can extend to the center of the tubercle and, once fractured, the pulp is exposed. T alon cusp occurs more frequently in permanent than in the primary dentition. A review of the literature shows that 75% of the cases exhibited talon cusp in their permanent dentition and 25% of the cases in the primary dentition (7).T alon cusp shows a predi-

lection for the maxilla over the mandible.The maxillary lateral incisors are the most frequently involved (67%) followed by the central incisors (24%) and canines (9%) (8, 9). There are several dates in the literature that suggest the hereditary character of talon cusp: family histories of cases reported previously revealed that sometimes talon cusp aected patients who had consanguineous parents (7); the anomaly has been described aecting two siblings (10, 11), two sets of female twins (12), and two family members (13); and the prevalence of talon cusp is high in some racial groups (14^17). Moreover, talon cusp is associated with other dental anomalies (13).These ndings support the concepts that genetics may be a major causative factor of talon cusp. The cases reported inthe literature as talon cusp are very dierent since this anomaly varies widely in shape, size, structure, location, and site of origin (18). Davis & Brook (19) stated that talon cusp may represent the extreme of a continuous variation progressing from a normal cingulum to an enlarged cingulum to a small accessory cusp to a talon cusp.

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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 possibility of exposure of the dentin^pulp complex and, consequently, pulp necrosis (20). This article reports a case of talon cusp aecting the 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 A10-year-old boy sought treatment for the chief complaint of pain in the region of the left mandibular lateral incisor. The patient appeared healthy and of normal physical development for his age. There was no reported history of orofacialtrauma.The occlusion was a Class I molar relationship with bilateral openbite (Fig.1). The mandibular left lateral incisor did not present any carious lesion or fracture, showed normal color and responded normally to thermal pulp tests. However, the tooth was sensitive to percussion. The periapical radiograph did not show enlargement of the periodontal space but the lamina dura was poorly dened. A thorough intraoral examination of the tooth displayed the presence of a wear facet on the distal aspect of its incisal edge.The facet was produced by the contact with the opposing tooth, the 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 (labiolingually). The talon cusp was pyramidal in shape and
Fig. 2. A prominent accessory cusp on the palatal surface of the left lateral incisor is evident.

located on the mesial half of the crown, with the tip of the cusp attached to the crown.The accessory cusp extended from the cemento^enamel junction more than halfway tothe incisal edge. Non-carious developmental grooves were present at the junction of the talon cusp and the palatal surface of the tooth. The tooth responded normally to thermal pulp tests. A periapical radiograph (Fig.3) showed a V-shaped radiopaque structure superimposed on the image of the aected crown, with the point of the V towards the incisal edge. Pulp extension could not be traced radiographically. On the other hand, a large cusp of Carabelli on the maxillary right rst molar was evident (Fig.4).

Fig. 1. Facial view showing bilateral openbite.

Fig. 3. Periapical radiograph showing a V-shaped radiopaque structure superimposed on the image of the affected crown.

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Talon cusp causing occlusal trauma

Fig. 4. A prominent Carabelli tubercle in the maxillary right first molar is evident (mirror photograph).

Fig. 6. Talon cusp after the grinding performed in the first appointment.

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

Fig. 7. Talon cusp after the final appointment.

The accessorycusp interferedthe normal occlusion, causing a premature contact between the taloned maxillary left lateral incisor and the mandibular left lateral incisor (Fig.5). Openbite was evident in the 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. T avoid a pulp exposure and o 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

the vitality of the tooth, and the occlusal interference was disappeared (Fig. 8). Clinical symptoms on the opposing tooth had vanished after the rst occlusal adjustment.

Fig. 8. The occlusal interference has disappeared.

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Segura-Egea et al. Discussion Occlusal forces can cause changes in the alveolar bone andperiodontal connective tissue both inthe presence and in the absence of periodontitis (21). In the case reported here the traumatic occlusion caused by the premature contact of the taloned tooth produced an occlusal trauma that aected the whole opposing tooth and its supporting tissues (22). The acute apical periodontitis provoked by the occlusal trauma reversed whenthe anatomical element ^ the accessory cusp ^ causing the premature contact was removed. After occlusal adjustment, uncomplicated healing and periapical repair occurred. The case reported demonstrates that talon cusp is an anomaly of great clinical signicance. Small talon cusps are usually asymptomatic and need no treatment, but large talon cusps may cause clinical problems including occlusal interference, displacement of the aected tooth, irritation of the tongue during speech and mastication, carious lesion in the developmental grooves delineate the cusp, pulpal necrosis, periapical pathosis, attrition of the opposing tooth, and periodontal problems due to excessive occlusal forces (23). T alon cusp originates during the morphodierentiation stage of tooth development but the etiology of the condition remains unknown (13). In the majority of cases reported, the talon cusp is isolated rather than an integral part of any disorder. Nevertheless, the anomaly was reported in a patient with Sturge^ Weber syndrome (encephalo-trigeminal angiomatosis) (9), Mohr syndrome (oro-facial-digital II syndrome) (24), Ellis-van Creveld syndrome (10), and Rubinstein-T aybi syndrome (25). The case reported here was not associatedwith anyknown abnormal systemic developmental syndrome. Control of the complex processes of dental development appears to be multifactorial, that is, primary polygenetic with some environmental inuence. T alon cusp is usually associated with other dental variations: bid cingula, dens invaginatus, exaggerated cusps of Carabelli, and particularly with shovelshaped maxillary incisors (7,13), a polygenic inheritable traitcharacterizedbyaccentuated marginalridges that surround a deep lingual fossa (26). As in the case of talon cusp, the maxillary lateral incisors are the most commonly aected with shovelling and dens invaginatus (27, 28). The susceptibility of the lateral incisors to abnormalities could partly 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 the lateral incisor. Increased localized external pressure on a tooth germ during the morphodierentiation stage may result in either outfolding of the dental lamina (in the case of talon cusp) and shovelling, or infolding of the dental lamina as in dens invaginatus (27). According to the classication by Hattab et al. (7), the anomalous cusp, pyramidal in shape and extending from the cemento^enamel junction more than halfway to the incisal edge that has been presented here, was classied as type 1 or talon cusp . Early diagnosis and management of talon cusp is important in order to prevent occlusal interference, compromised esthetics, carious developmental grooves, periodontal problems due to excessive occlusal forces, or irritation of the tongue during speech and mastication (13,18). The treatment of talon cusp implicates careful clinical decision. Earlier radiographic studies stated that removal of the cusp could inevitably lead to pulp exposure that would require endodontic treatment (3). Consequently, previous radiographic examination must be performed in all cases to ensure that a pulp horn is not present in the talon cusp. Although some histological studies of extractedtalonteeth failed to show the presence of a pulp horn in the talon cusp (29), Gungor et al. (30) reported a case of bilateral talon cusp on primary maxillary central incisors whose histological evaluation revealed the existence of pulpal tissue in the anomalous cusps. The aid of radiograph is essential, but radiographic tracing of the pulpal conguration inside the talon cusp has inherent diculties because the cusp is superimposed over the aected tooth crown (23). So, the grinding of the accessory cusp must be performed carefully and gradually. In the case reported here, an occlusal adjustment by grinding the palatal projection of the taloned tooth was performed to eliminate the premature contact.We reduced 1.0 mm of talon cusp in each appointment reducing a total of 3.0 mm without exposing the pulp. Other authors have removed a larger amount of hard tissues without pulp exposure. Thus, Pitts & Hall (31) removed 3 mm of the anomalous cusp in one appointment without exposing the pulp, and Hattab et al. (7, 8) have reduced several times 1^1.5 mm of talon cusp in one appointment without pulp exposure. However, this does not imply that all talon cusps are devoid of pulp horn. Shey & Eitel (32) recommended to reduce the accessory cusp by grinding in consecutive appointments of 4 weeks apart from capping the dentin exposed with calcium hydroxide and resin. In the case reported here, the surface of dentin exposed was treated with uoride varnish. References
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Talon cusp causing occlusal trauma

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