Managing a facial talon: A rare morphological variation on maxillary permanent central incisor

Supreet Shirolkar; Monalisa Das; Khooshbu Gayen; Santanu Mukhopadhayay; Subir Sarkar; Somen Roychowdhury

doi:10.4103/jdrr.jdrr_115_21

CASE REPORT

Year : 2021 | Volume : 8 | Issue : 3 | Page : 217-220

Managing a facial talon: A rare morphological variation on maxillary permanent central incisor

Supreet Shirolkar, Monalisa Das, Khooshbu Gayen, Santanu Mukhopadhayay, Subir Sarkar, Somen Roychowdhury
Department of Pedodontics and Preventive Dentistry, Dr. R Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission	26-Jun-2021
Date of Acceptance	13-Jul-2021
Date of Web Publication	23-Aug-2021

Correspondence Address:
Khooshbu Gayen
Department of Pedodontics and Preventive Dentistry 2C, Dr. R.Ahmed Dental College and Hospital, Kolkata, West Bengal
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdrr.jdrr_115_21

Abstract

Talon cusp or Eagle's Talon is a developmental anomalous structure that is thought to arise due to evagination of the coronal surface of a tooth before the commencement of calcification. The facial form of talon cusp is a rare morphological variation occurred on the facial surface of incisors that are often associated with clinical problems such as poor esthetic, soft tissue irritation, and caries susceptibility. We report a case of facial talon cusp on permanent maxillary right central incisor in a 9-year-old girl who visited our department with esthetic concern. The patient was managed with a minimally invasive approach by selective grinding followed by the application of fluoride varnish at a regular interval. Direct resin-based composite restoration performed to achieve esthetic rehabilitation, demonstrated satisfactory clinical and radiographic treatment outcomes.

Keywords: Anomaly, esthetics, incisor, talon cusp

How to cite this article:
Shirolkar S, Das M, Gayen K, Mukhopadhayay S, Sarkar S, Roychowdhury S. Managing a facial talon: A rare morphological variation on maxillary permanent central incisor. J Dent Res Rev 2021;8:217-20

How to cite this URL:
Shirolkar S, Das M, Gayen K, Mukhopadhayay S, Sarkar S, Roychowdhury S. Managing a facial talon: A rare morphological variation on maxillary permanent central incisor. J Dent Res Rev [serial online] 2021 [cited 2023 Apr 1];8:217-20. Available from: https://www.jdrr.org/text.asp?2021/8/3/217/324411

Introduction

A talon cusp is a well-defined phenotypic accessory cusp-like irregular structure that projects from the cementoenamel junction or the cingulum area. In 1892 Mitchell described a talon cusp on a woman's upper central incisor as “a process of horn-like shape curving from the base downwards to the cutting edge.”^[1] The exact cause of the talon's cusp is yet unknown. Both environmental and genetic factors are thought to play a role in the etiopathology of this morphological variation.^[2] It is hypothesized that a transient focal hyperplasia of the mesenchyme of dental papilla (odontoblastic precursors) and outward folding of the inner enamel epithelial cells (ameloblastic precursors).^[3] There is evidence of association of talon cusps with other syndromes such as Mohr Syndrome (orofacial digital syndrome, Type 2), Rubinstein Taybi syndrome, Sturge-Weber syndrome (encephalotrigeminalangiomatosis) incontinentiapigmentiachromians.^[4] Mayes in 2007 classified facial talon cusps into 3 stages beginning with the slightest to the most extreme forms.^[5]

Occlusal interference and aesthetic compromise caused by talon cusps could lead to accidental fractures in the cusp, caries associated with developmental grooves, speech problems, tongue and lip irritation, food stagnation, and periodontal problems due to excessive occlusal forces.^[6] Current article report an unusual case of facial talon cusp affecting maxillary permanent right central incisor.

Case Report

A 9-year-old female patient reported to the outpatient department of pedodontics and preventive dentistry with a chief complaint of unesthetic appearance of an upper right front tooth. The patient did not complain of any pain in association with the tooth. Family and medical history were noncontributory. Thorough intra-oral examination showed fair oral hygiene and no carious lesion. The presence of the accessory cusp was found to be extending from the cement-enamel connection to the incisal edge of the facial side of the permanent central right incisor [Figure 1]a and [Figure 1]b.

Figure 1: Preoperative clinical photograph (a) vestibular view of facial talon cusp, (b) incisal view of facial talon cusp talon cusp interfering lip posture, (c) study model with marking focusing on talon cusp

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The accessory cusp was 7 mm × 5 mm in diameter and was isolated from the rest of the crown by a noncarious developmental groove. An intra-oral periapical (IOPA) radiograph exhibited a “V” shaped radio-opaque structure superimposed on the image of the maxillary right central incisor.[Figure 2]a The pulp tissue's radiolucency into the cusp did not indicate a connection to the pulp chamber. To make a definitive diagnosis, a three-dimensional cone-beam computed tomography (CBCT) of tooth 11 was performed; CBCT demonstrated the multifaceted anatomy of tooth 11 and showed that there is a prominent distinction between the pulp chamber and the accessory cusp [Figure 2]b, [Figure 2]c, [Figure 2]d. After a thorough examination, the diagnosis of Type 3 talon cusp was made. Maxillary and mandibular impression was taken with alginate material and the cast were poured with Type 4 dental stone to make study models for documentation purposes [Figure 1c].

Figure 2: Preoperative radiographs (a) intra-oral periapical view of the tooth; (b-d) cone-beam computed tomography view of the facial talon cusp

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After radiographic and clinical examination, the first approach was directed at eliminating the talon cusp and enhancing the appearance of the anterior tooth by minimal restorative treatment. The tooth was isolated under the rubber dam to maintain a dry and sterile field [Figure 3]a. A round and flame-shaped diamond bur (MANI, Japan) was used on a high-speed airotor (K1, India) handpiece to gradually reduce the talon cusp. The undercut regions are carefully removed to meet the patient's esthetic expectations [Figure 3]b. Treatment was carried out for a period of 9 months to allow sufficient time to generate reparative dentin and to avoid exposure of pulp. The Patient was recalled every 6 weeks and cuspal reduction was performed followed by fluoride varnish application. By the end of 9 months, without any pulpal exposure, the accessory cusp was completely removed. For better esthetics resin-based direct composite restoration was done [Figure 4]a. After a 1-year follow-up, the tooth was found to be symptom-free and vital. The follow-up IOPA radiograph demonstrated healthy periapical tissue and continued root formation was observed in the treated tooth [Figure 4]b. Another IOPA was taken 6 months postrestoration showing completion of root formation with apical closure [Figure 4]c. The patient was satisfied with esthetic correction [Figure 4d]. Prior informed consent was obtained from the patient's mother before reporting the case.

Figure 3: Peroperative photographs (a) under rubber dam isolation, (b) after selective grinding of talon cusp

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Figure 4: Postoperative photographs and radiographs (a) composite resin restoration, (b) follow up intra oral periapical radiograph (c) 6 months postrestoration radiograph, (d) smile view esthetics

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Discussion

The factor that combines both the genetics and environmental influence, support the phenomenon of increased activity of dental lamina in early odontogenesis as the etiology of facial talon cusp formation. Moreover, mutations in the human gene Ectodysplasin A receptor frequently result in more severe phenotypes, including malformations and in some cases, tooth loss.^[7] The occurrence of dens evaginatus shows significant racial differences, with Mongolians having a higher prevalence. Talon cusps have been reported to affect both men and women and can be unilateral or bilateral.^[8],[9] Females have a higher prevalence of the facial talon cusp, in contrast to the palatal talon cusp. Out of the several reported cases, about 75% of facial talon cusps were found in permanent dentition, particularly on the left side in case of unilateral anomaly.^[3] However, in this present case, a facial talon cusp was observed on the right maxillary permanent central incisor in a female patient.

The talon cusp can be found on either the palatal or lingual surfaces of the anterior teeth. A rare variant having vertical cristae was observed on the facial side of the maxillary incisor (rugae adamantinae).^[10] Rugae adamantineae defines “the feature of a ridge of enamel that crosses the center of the vestibular surface of the tooth in a cervical-incisal direction,”^[10] as described in the present case report. Usually, just the mere presence of talon cusp does not always indicate treatment, unless it is a large and prominent cusp associated with problems such as occlusal interference, caries, compromised esthetics, displacement of the tooth, or irritation of soft tissue mucosa during speech or mastication. The present case was treated for only the unpleasant morphology of tooth based on the patient desire and clinical assessment.

In the literature, 28 cases of facial talon cusp were reported^[11] according to our knowledge of which only 9 cases received complete treatment. Cases of facial talon cusp in literature receiving complete treatment is given in [Table 1].

Table 1: Reported cases of facial talon cusp in literature receiving complete treatment

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McNamara et al. in 1997 reported a case in which tooth associated with talon cusp was permanent mandibular left central incisor was extracted followed by orthodontic treatment.^[12] Abbott reported on another case in 1998 showed the permanent maxillary left central incisor had a talon cusp on both the palatal and facial sides, which was treated with selective cuspal grinding and endodontic treatment.^[13] de Sousa et al. in 1999 reported a case of facial talon cusp on permanent maxillary central incisor that was treated by endodontic therapy followed by esthetic rehabilitation.^[14]

The treatment approach of the present case report is based on the studies carried out by Glavina and Skrinjarić in 2005 in which conservative management was carried out by selectively grinding the cusp followed by composite restoration on permanent maxillary left central incisors.^[15] The reported cases were followed for a period of 1 year to determine the vitality and all cases suggested the vital status of those teeth. Another case was reported by Kulkarni et al. in 2012 in which the talon cusp was reduced every 45 days, followed by the application of fluoride varnish for 9 months.^{[16][17][18][19]} Sudhakar et al. in 2017 managed the facial talon cusp of both daughter and father by gradual reduction, fluoride application and composite resin restoration.^[11]

In the present case, the prime concern for the patient was compromised esthetics, so it was conservatively managed by grinding the cusp selectively followed by fluoride varnish application to minimize the dentinal sensitivity. The selective cuspal reduction was carried out at an interval of 6 weeks, for 9 months, to allow reparative dentin to form. As the patient did not report any sensitivity or any other pathology after 9 months, direct resin composite restoration was performed for better esthetics.

Conclusion

Facial talon cusp is a very rare dental anomaly that is mostly asymptomatic but management can be initiated based on the patient desire. The present case report has outlined a conservative management approach for this morphological variation. Proper diagnosis is crucial for treatment planning of such anomalies to avoid postoperative complications and here, CBCT played an important role for the same. Conservative treatment allows the tooth a favorable time to recover and respond by forming reparative dentin, so that the vitality of pulp can be maintained. To determine pulp vitality and periodontal status, periodic postoperative case evaluation is highly recommended to avoid unexpected outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the mother has given her consent for images and other clinical information to be reported in the journal. The patient's mother understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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