(Un cas singulier de cuspide linguale sur des dents géminées)
• Faiez N. Hattab, BDS, PhD • Sommaire
L’article fait la description d’un cas rare d’excroissance
cuspidienne sur des dents géminées. En plus d’une dentition peu esthétique,
ces anomalies de croissance entraînent des problèmes cliniques, notamment une
interférence occlusale, le déplacement des dents touchées, l’attrition, des
parodontopathies, l’irritation de la langue, une perte d’espace et la
malocclusion. On y présente les caractéristiques cliniques et radiologiques de
ces anomalies et les traitements préconisés. La reconnaissance et le
diagnostic précoces de ces anomalies sont importants si l’on veut éviter les
Mots clés MeSH : case report; child; incisor/abnormalities; tooth
© J Can Dent Assoc 2001; 67:263-6
Sommaire L’article fait la description d’un cas rare d’excroissance cuspidienne sur des dents géminées. En plus d’une dentition peu esthétique, ces anomalies de croissance entraînent des problèmes cliniques, notamment une interférence occlusale, le déplacement des dents touchées, l’attrition, des parodontopathies, l’irritation de la langue, une perte d’espace et la malocclusion. On y présente les caractéristiques cliniques et radiologiques de ces anomalies et les traitements préconisés. La reconnaissance et le diagnostic précoces de ces anomalies sont importants si l’on veut éviter les complications.
Mots clés MeSH : case report; child; incisor/abnormalities; tooth crown/abnormalities
© J Can Dent Assoc 2001; 67:263-6
The prevalence of talon cusp varies considerably among populations, ranging from 0.06% to 7.7%.6,7 In addition to the ethnic variation, the lack of precise criteria to classify an accessory cusp as a “talon” has contributed to the extensive variations in prevalence.1 The permanent dentition is affected more frequently than the primary dentition, and the anomaly is more common in males than in females.1,4,5,8,9 Almost 92% of the affected (taloned) teeth in the permanent dentition have been found in the maxilla, with the lateral incisors being the most frequently involved (55%) followed by the central incisors (36%) and the canines.1,9
The etiology of talon cusp is not well understood, but appears to have both genetic and environmental components.1,4 Similar to other abnormalities of tooth shape, talon cusp originates during the morpho-differentiation stage of tooth development. It may occur as a result of outward folding of inner enamel epithelial cells and transient focal hyperplasia of the peripheral cells of mesenchymal dental papilla. The talon cusp can occur as an isolated finding or in association with other dental anomalies such as peg-shaped lateral incisor, agenesis or impacted canines, mesiodens, complex odontomes, megadont, dens evaginatus of posterior teeth, shovel-shaped incisors, dens invaginatus and exaggarated Carabelli cusp.1-5 The talon cusp has not been reported as an integral part of any specific syndrome, although it appears to be more prevalent in patients with Rubinstein-Taybi syndrome, Mohr syndrome, Sturge-Weber syndrome, incontinentia pigmenti achromians and Ellis-van Creveld syndrome.1,8,10 Geminated teeth are developmental anomalies of tooth shape that arise from an abortive attempt by a single tooth bud to divide, resulting in a bifid crown. They are found more frequently in the primary than in the permanent dentition, with a prevalence of approximately 1% and 0.1% respectively in Caucasian groups.11-13 There seems to be no gender differences in occurrence. Gemination, however, is most often seen in the maxillary primary incisors and the canines.
The etiology of geminated teeth remains unknown. Spouge suggests that the condition may result from trauma to the developing tooth bud.14 Evidence from case history studies suggests that the anomaly exhibits a hereditary tendency, similar to that affecting the dental lamina and resulting in hyperdontia.15 The mode of inheritance is probably either autosomal recessive or dominant with very little penetrance.12 It appears that gemination is caused by complex interactions among a variety of genetic and environmental factors.
Talon cusp on geminated tooth is a very rare finding. A review of the literature revealed only 2 previous reports.16,17 The purposes of this article are to present a case of talon cusp on geminated maxillary central that caused clinical problems and to describe treatment modalities.
Case Report A 9-year-old Jordanian-Arab boy presented to the dental clinic complaining of large, unsightly maxillary central incisors, irritation to the tongue, incising problems, food impaction and bleeding gums.
The patient was the sixth of 7 siblings of parents with no history of consanguinity. No other member of the family was affected by similar dental anomalies. The patient appeared healthy and of normal physical development for his age. There was no reported history of orofacial trauma.
Intraoral examination revealed gingivitis in the anterior region. The occlusion was a Class I molar relationship. In this mixed dentition, the following permanent teeth were erupted: the first molars, the maxillary central incisors and the mandibular incisors. The maxillary central incisors were rotated, and the left central incisor was labially displaced, with medial diastema measuring 5.3 mm (Fig. 1).
The maxillary left central incisor had a large and bifid crown with talon cusp on the palatal aspect. The mesiodistal crown diameter was 2.4 mm larger than the adjacent right central incisor (11.1 mm vs. 8.7 mm) and 20% larger than its counterpart in the normal population (average 8.9 mm, range 7.1 mm to 10.3 mm).18 The tooth was not fully erupted, with crown height measuring 8.6 mm. The crown of the taloned tooth was partially split and had a notch on the incisal edge that extended labiolingually to the middle of the crown (Fig. 1). On the palatal aspect, the crown exhibited a pronounced, well-defined accessory cusp extending from the cementoenamel junction to within 0.5 mm of the incisal edge. The talon cusp was pyramidal in shape and located on the mesial half of the crown, with the tip of the cusp attached to the crown (Fig. 2). The cusp measured 4.5 mm in length (incisocervically), 3.3 mm in width (mesiodistally) and 3.1 mm in thickness (labiolingually). Noncarious developmental grooves were present at the junction of the talon cusp and the palatal surface of the tooth. The distal groove was deep and packed with dental plaque. The affected tooth responded normally to electric and thermal pulp tests. A periapical radiograph (Fig. 3) showed a V-shaped radiopaque structure superimposed on the image of the affected crown, with the point of the “V” toward the incisal edge. The talon cusp was outlined by 2 distinct white lines converging from the cervical area of the affected tooth toward the incisal edge. Pulp extension could be traced radiographically to the middle of the cusp. The geminated-taloned tooth had a single enlarged pulp chamber, one root and bifid crown appearance. An occlusal radio graph revealed the presence of lateral incisors, with the affected tooth impeding the eruption of the adjacent lateral incisor. Based upon clinical and radiographic findings, a diagnosis of talon cusp on geminated tooth was made.
After diagnosis, it was decided to extract the mobile left primary lateral incisor, which, with the anomalous central incisor, formed a site for food impaction and plaque accumulation (Fig. 2). Approximately 1 mm of the talon cusp was ground off, without exposing the pulp, to eliminate the source of tongue irritation and occlusal interference. The ground surface was treated with fluoride varnish (Duraphat, Woelm Pharma Co., Eschwege, Germany), as a desensitizing agent. The mesial and distal aspects of the affected tooth were reduced 1 mm on each side to enhance esthetics and to create a space for eruption of the left lateral incisor. The notch in the crown was restored with composite resin.
The patient was scheduled to complete reduction of the talon cusp on 2 consecutive appointments of 6 to 8 weeks apart to allow deposition of reparative dentin for pulpal protection and to avoid pulp exposure. Meanwhile, a sectional fixed orthodontic appliance was implemented for alignment of the maxillary central incisors and reduction of the medial diastema. After 2 sessions, the talon cusp was essentially removed, without exposing the pulp or compromising the vitality of the tooth (Fig. 4). Three months after orthodontic treatment, alignment of the maxillary right central incisor was complete and the medial diastema had been reduced to approximately 2 mm. The maxillary right central incisor was enlarged by placing composite resin on the mesial aspect of the tooth, yielding a mesiodistal crown width of 9.2 mm. Treatment for 5 months resulted in marked improvement in the size, shape and position of the central incisors as well as enhancement of periodontal health and appearance (Fig. 5). The patient was scheduled for subsequent orthodontic assessment for the palatally erupting maxillary left lateral incisor.
Discussion Talon cusp is an odontogenic anomaly of tooth shape that represents the extreme of continuous variation progressing from an enlarged cingulum (trace talon) through a small accessory cusp (semitalon) to a talon cusp.1 Small talon cusps are usually asymptomatic and need no treatment. Large talon cusps may cause clinical problems including occlusal interference, displacement of the affected tooth, irritation of the tongue during speech and mastication, carious lesion in the developmental grooves that delineate the cusp, pulpal necrosis, periapical pathosis, attrition of the opposing tooth and periodontal problems due to excessive occlusal forces.1-5 Talon cusps also present diagnostic and treatment difficulties. On unerupted tooth, the anomalous cusp can radiographically be mistaken for a supernumerary tooth or compound odontomas, leading to unnecessary surgical intervention. This diagnostic problem is especially significant because approximately 90% of all supernumeraries occur in the maxilla and half of these in the incisor region.19 Gemination is a partial cleavage of a single tooth germ resulting in 2 partially or totally separated crowns with enlarged pulp chamber and one root. With gemination, a normal number of teeth are maintained. The anomalous tooth has a large bifid crown and is usually found as an isolated trait, not associated with syndromes. Irrespective of their origin, dental gemination anomalies often give rise to a number of clinical problems, particularly if the anterior teeth are involved. In our patient, the anomaly caused tooth malalignment, spacing problems, arch asymmetry, unacceptable appearance, periodontal involvement and impeded the eruption of the adjacent tooth.
The treatment of talon cusp involves careful clinical judgment and review of whether the cusp contains or is devoid of a pulp horn. Earlier reports, based on radio graphic examination, stated that removal of the cusp would inevitably lead to pulp exposure that would require endodontic treatment.2 However, radiographic tracing of the pulpal configuration inside the talon cusp has inherent difficulties because the cusp is superimposed over the affected tooth crown. Similarly, histological examination of extracted talon teeth failed to show the presence of a pulp horn in the talon cusp.20-22 Pitts and Hall removed 3 mm of the anomalous cusp in one visit, without pulp exposure.23 Several times, we have reduced 1.0 mm to 1.5 mm of talon cusp in one appointment without exposing the pulp.1,5 However, this does not imply that all talon cusps are devoid of pulp horn. Reports describing the treatment of gemination are scant and inconclusive because of the rarity of the condition, particularly in the permanent dentition. In the present case, initial thought was given to reducing tooth structure mesiodistally and placing a composite restoration to give the tooth a normal appearance and to prevent plaque accumulation in the notch of the crown. In addition, orthodontic consideration was required.
Geminated-taloned teeth cause a variety of clinical problems that call for early diagnosis. Care should be taken to recognize developmental, periodontal and orthodontic effects. The patient’s expectation and degree of compliance must also be accurately assessed when determining suitable management.
Le Dr Hattab est consultant et chef des Services de soins dentaires, Soins de santé primaires, Ministère de la santé publique, Doha, État du Qatar.
Le Dr Hazza’a est professeur adjoint au département des sciences buccales, Faculté de médecine dentaire, Jordan University of Science and Technology, Irbid, Jordanie.
Écrire au : Dr Faiez N. Hattab, Services de soins dentaires, Soins de santé primaires, C.P. 7604, Doha, État du Qatar. Courriel : firstname.lastname@example.org
Les auteurs n’ont aucun intérêt financier déclaré.
Références 1. Hattab FN, Yassin OM, al-Nimri KS. Talon cusp in permanent dentition associated with other dental anomalies: review of literature and report of seven cases. ASDC J Dent Child 1996; 63(5):368-76.
2. Mellor JK, Ripa LW. Talon cusp: a clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970; 29(2):225-8.
3. Mader CL. Talon cusp. J Am Dent Assoc 1981; 103(2):244-6.
4. Davis PJ, Brook AH. The presentation of talon cusp: diagnosis, clinical features, associations and possible etiology. Br Dent J 1986; 160(3):84-8.
5. Hattab FN, Yassin OM, al-Nimri KS. Talon cusp — clinical significance and management: case reports. Quintessence Int 1995; 26(2): 115-20.
6. Sedano HO, Carreon Freyre I, Garza de la Garza ML, Gomar Franco CM, Grimaldo Hernandez C, Hernandez Montoya ME, and others. Clinical orodental abnormalities in Mexican children. Oral Surg Oral Med Oral Pathol 1989; 68(3):300-11.
7. Chawla HS, Tewari A, Gopalakrishnan NS. Talon cusp — a prevalence study. J Indian Soc Pedod Prev Dent 1983; 1(1):28-34.
8. Chen RJ, Chen HS. Talon cusp in primary dentition. Oral Surg Oral Med Oral Pathol 1986; 62(1):67-72.
9. 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.
10. Hattab FN, Yassin OM, Sasa IS. Oral manifestations of Ellis-van Creveld syndrome: report of two siblings with unusual dental anomalies. J Clin Pediatr Dent 1998; 22(2):159-65.
11. Grahnen H, Granath LE. Numerical variations in primary dentition and their correlation with the permanent dentition. Odont Rev 1961; 12:348-57.
12. Brook AH. Dental anomalies of number, form and size: their prevalence in British schoolchildren. J Int Ass Dent Child 1974; 5(2):37-53.
13. Buenviaje TM, Rapp R. Dental anomalies in children: a clinical and radiographic survey. ASDC J Dent Child 1984; 51(1):42-6.
14. Spouge JD. Oral pathology. St. Louis: C.V. Mosby Co.; 1973.
15. Stewart RE. The dentition and anomalies of tooth size, form, structure, and eruption. In: Pediatric Dentistry: scientific foundations and clinical practice. Stewart RE and others, editors. St. Louis: C.V. Mosby Co.; 1982.
16. Cullen CL, Pangrazio-Kulbersh V. Bilateral gemination with talon cusp: report of case. J Am Dent Assoc 1985; 111(1):58-9.
17. 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.
18. Hattab FN, al-Khateeb S, Sultan I. Mesiodistal crown diameters of permanent teeth in Jordanians. Arch Oral Biol 1996; 41(7):641-5.
19. Hattab FN, Yassin OM, Rawashdeh MA. Supernumerary teeth: report of three cases and review of the literature. ASDC J Dent Child 1994; 61(5-6):382-93.
20. Natkin E, Pitts DL, Worthington P. A case of talon cusp associated with other odontogenic abnormalities. J Endod 1983; 9(11):491-5.
21. Mader CL, Kellogg SL. Primary talon cusp. ASDC J Dent Child 1985; 52(3):223-6.
22. Salama FS, Hanes CM, Hanes PJ, Ready MA. Talon cusp: a review and two case reports on supernumerary primary and permanent teeth. ASDC J Dent Child 1990; 57(2):147-9.
23. Pitts DL, Hall SH. Talon-cusp management: orthodontic-endodontic considerations. ASDC J Dent Child 1983; 50(5):364-8.
Le Centre de documentation peut fournir aux membres toutes les références énumérées dans la bibliographie qui accompagne cet article. Les membres de l’ADC peuvent communiquer avec nous en composant le 1-800-267-6354 ou (613) 523-1770, poste 2223; par télécopieur : (613) 523-6574; par courriel : email@example.com.