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Aberrant talon cusps: Report of two cases
RAYEN R.a, MUTHU M. S.b, SIVAKUMAR N.c
Abstract
Talon cusp is an uncommon anomaly seen both in primary and permanent dentition. In most instances they are associated
with other clinical problems such as occlusal interferences, poor esthetics and caries susceptibility. Management of such
instances requires a comprehensive knowledge of the clinical entity as well as the problems associated with it. Here, we
present two cases of talon cusps.
Key words: Occlusal interference, talon cusp
Introduction
Tooth development is a complex process. Any aberrations in
the different stages of tooth development can result in unique
manifestations. Disturbances during histodifferentiation stage
of tooth development results in amelogenesis imperfecta, den­
tinogenesis imperfecta and disturbances during
morphodifferentiation stage can result in, mulberry molars,
peg laterals, and talon cusps.[1]
Talon cusp was first recognized by Mitchell in 1892. He de­
scribed this entity as a prominent accessory cusp like struc­
ture on the lingual surface of a maxillary incisor.[2] Gorlin and
Goldman later defined talon cusp as a very high accessory
cusp, which may connect with the incisal edge to produce a T-
form or a Y-shaped contour.[3] This accessory cusp is often
referred to as Talon cusp, as it is said to resemble an eagle’s
claw.[4] It is usually composed of normal enamel, dentin and
contains a horn of pulp tissue.[5]
The prevalence of talon cusp varies in different populations.
Prevalence of 0.17% in the United States, 0.06% in Mexico,
5.2% in Malaysia and 7.7% in northern Indian population has
been reported.[6] A striking predilection of maxilla over the
mandible has been noted, with more than 90% of the reported
cases in maxilla. About 77% of the affected teeth have been in
permanent dentition. Among them 55% of the cases involved
lateral incisors, 33% central incisors, and 4% canines. A gender
ratio of male/female had an almost equal sexual predilection
in almost all races in which studies have been performed. In
the primary dentition it was first reported by Henderson in
1977.[8] Since then thirty cases have been documented in pri­
mary dentition.[9]
Case 1
A seven year old female patient reported to the department of
a
Senior Lecturer, bAssociate Prof., cFormer Prof. and Head,
Department of Pediatric Dentistry, Meenakshi Animal Dental College
and Hospital, Chennai - 600 095, Tamil Nadu, India
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ISSN 0970 - 4388
Pedodontics and Preventive Dentistry, Meenakshi Ammal Den­
tal College, Chennai, with the complaint of pain and decay in
left lower back tooth region. Clinical examination revealed
grossly carious mandibular second primary molars on both
sides with no other carious lesions. Examination also revealed
an enamel projection on the mandibular left central incisor,
which extended from the cingulum up to the incisal edge of
the tooth, deviating towards the left [Figure 1]. The tooth ap­
peared T-shaped when viewed incisally. The mandibular talon
cusp merged smoothly with the lingual surface of the tooth.
The deep developmental groove, which is normally seen at
this junction, was not present. The margins of the talon cusp
were smooth and did not cause any irritation to the ventral
surface of the tongue. Caries was not detected and no func­
tional or esthetic problems were present. A periapical radio­
graph of this tooth showed an inverted V-shaped radiopaque
structure arising from the cingulum, with immature closure
of the root apices [Figure 2].
On the basis of its characteristic clinical and radiographic
appearance, a diagnosis of talon cusp was made. As the tooth
did not pose any significant clinical problems, corrective treat­
ment for the tooth was not instituted. However the right and
left lower second primary molars were extracted and bilateral
band and loop space maintainers were placed and patient was
advised for a periodic recall visit [Figure 3].
Case 2
An 8 year old boy reported to the department of Pedodontics
and Preventive dentistry, Meenakshi Ammal Dental College,
Chennai with the complaint of malaligned erupting front teeth
in the lower jaw. Intraoral examination revealed lingually erupt­
ing mandibular right and left laterals with the left lateral placed
at a more lingual position than the corresponding contralat­
eral tooth [Figure 5]. Maxillary arch revealed an extra promi­
nent accessory cusp in the left upper central incisor. This tooth
had a highly exaggerated conical enamel projection, which
extended almost from the cervical third of the crown to the
incisal edge [Figure 4]. In occlusion the talon cusp was inter­
fering with the alignment of mandibular lateral incisor.
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Aberrant talon cusps

Figure 1: Intraoral view of talon cusp on mandibular left

central incisor with grossly carious second primary molars
on both sides

Figure 6: Intraoral periapical radiograph showing an inverted

V-shaped talon cusp on the maxillary left central incisor

Figure 7: Study casts showing the lingual positioning of

Figure 2: Intra oral periapical radiograph of mandibular left mandibular lateral incisor
central incisor with talon cusp

Figure 8: Selective cuspal grinding was done followed by

Figure 3: Band and loop space maintainers on both sides prophylactic placement of sealants

Figure 4: Photograph showing maxillary central incisor with Figure 9: Intraoral photograph taken after extraction of
talon cusp mandibular canines

Figure 5: Intraoral view showing severe crowding in the Figure 10: Photograph showing alignment of the mandibular
mandibular incisor region incisors after one year

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Aberrant talon cusps
Figure 11: Study model showing the alignment of mandibular
anterior teeth after one year
A periapical radiograph revealed a V-shaped radiopaque cusp
like structure with a pulpal extension within it [Figure 6]. On
the basis of its characteristic features, a diagnosis of talon
cusp was made.
As there was an obvious clinical sign of crowding, study casts
were made [Figure 7]. The crowding was due to a combination
of arch discrepancy and the occlusal interference of the talon
cusp. In view of the interference in occlusion and the groove
present on either side of the cusp, selective cuspal grinding
was done followed by fluoride application and sealant [Ultraseal
XT TM Ultradent products] placement [Figure 8]. An orthodon­
tic opinion was also obtained and bilateral extraction of the
mandibular primary canines was carried out under local ana­
esthesia [lignocaine hydrochloride 2%, with adrenaline 1:
80000] to facilitate alignment of lower permanent incisors
[Figure 9]. The patient was later scheduled for a periodic 3­
month recall visit to assess the eruption status of lower inci­
sors.
One-year follow up revealed a satisfactory alignment of the
mandibular anterior teeth [Figures 10, 11]. Timely extraction
of the primary canines and selective grinding of the talon
cusp helped us to achieve this alignment. Patient was adviced
a periodic evaluation to monitor the resorption status of the
mandibular first primary molars and to guide the eruption of
the permanent canines.
Discussion
The etiology of such a cuspal exaggeration to occur is consid­
ered by most authors to be multifactorial which has a primary
polygenetic component, accentuated by an external influ­
ence.[10] The histological picture is a clear cut outward folding
of inner enamel epithelial cells and transient focal hyperplasia
of the peripheral cells of the mesenchymal dental papilla.[3,11]
The high incidence of occurrence in the lateral incisors is due
to compression of the tooth germ during the morpho-differ­
entiation stage between the central incisors and canine.[12]
The sequelae of compression can either result in an out fold­
ing of the dental lamina or an infolding as in dens invaginatus.[13]
Hattab et al classified talon cusps as Type 1 Talon, Type 2 Semi
Talon and Type 3 Trace Talon.[13,14] After the reports of similar
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cusps being reported on the facial surfaces this classification
was later modified by Stephen-Ying et al as,[15,16,10] Type 1, Major
Talon - A morphologically well-delineated additional cusp that
prominently projects from the facial or palatal/lingual surface
of an anterior tooth and extends atleast half the distance from
the cementoenamel junction to the incisal edge.
Type 2, Minor Talon- A morphologically well-defined addi­
tional cusp that projects from the facial or palatal/lingual sur­
face of an anterior tooth and extends more than one fourth,
but less than half the distance from the cementoenamel junc­
tion to the incisal edge.
Type 3, Trace talon-enlarged or prominent cingula and their
variations, which occupy less than one-fourth the distance
from the cementoenamel junction to the incisal edge.[10]
Mader in his thorough review suggested that talon cusp might
be associated with other somatic and odontogenic anoma­
lies.[17,7] It can cause various diagnostic, functional and es­
thetic problems.[18,3,5,11] He also added that this term be re­
served only for those anomalous cusps that prominently
project from the lingual surface of a succedaneous tooth, are
morphologically well delineated and extend atleast half the
distance from the cementoenamel junction to the incisal
edge.[17]
The common problems associated with talon cusps are,[10,14,17,18]
a) Caries susceptibility
b) Occlusal interferences
c) Compromised esthetics, etc.
Caries susceptibility to the groove in between the cusp and
the tooth should be prophylactically sealed.[19] In case 2 pit
and fissure sealant (Ultra seal XT TM Ultradent products) was
used to seal the groove.
Occlusal interferences might necessitate selective occlusal
grinding. This should be done under highly aseptic condi­
tions since there is an increased chance of pulpal exposure for
which an endodontic procedure such as partial pulpotomy or
root canal treatment may be needed.[14,17,19] Whenever there is
occlusal interference, it can lead to rotation or displacement
of the tooth or opposing tooth. In case 2 the talon cusp was
interfering with alignment of mandibular lateral incisor. One
year after the occlusal grinding and the extraction of primary
canines the mandibular anterior teeth came into proper align­
ment. This emphasizes the need for timely intervention of
such clinical situations.
If esthetics is compromised due to a prominent talon cusp
sequential grinding or complete excision of the cusp followed
by therapeutic endodontic procedure should be done. How­
ever Fabra Campos has reported increased chances of endo­
dontic failure in a case with a palatal gingival groove in maxil­
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Aberrant talon cusps
lary lateral incisor with a talon cusp.[20]
Also other minor problems such as speech disturbances, tongue
irritation, accidental cuspal fracture and periodontal prob­
lems due to excessive occlusal forces should be treated symp­
tomatically along with cuspal management of the same de­
pending upon its severity of occurrence. In cases of talon
cusp in the primary dentition it is important to monitor regu­
larly the occlusion during the eruption of a tooth with talon
cusp as well as their opposing teeth in order to prevent poten­
tial crossbite or malposed teeth.[10,21]
In some instances talon cusp is associated with syndromes like
Mohr syndrome, Incontinenta pigmentii Achromians,
Rubinstein Taybi syndrome and Ellis Van Creveld syndrome.[22]
Sometimes it is an isolated finding. In such situations other
dental anomalies such as peg shaped lateral incisors,
unerupted canines, mesiodens or complex odontomes, as well
as supernumerary teeth, megadont and dens evaginatus
should be ruled out and a proper differential diagnosis is
made.[15,23]
Radiographically, the talon cusp is seen as a radiopaque struc­
ture, in which the enamel, dentin and occasionally the pulp
can be seen. Typically the cusp resembles a V-shaped struc­
ture superimposed over the normal image of the crown. A
definitive diagnosis of a talon cusp cannot be made based on
the radiographic findings alone because a talon cusp on an
unerupted tooth may be radiographically misinterpreted as a
supernumerary tooth, compound odontoma or dens in dente.
Both the cases presented here fulfilled Mader’s criterion re­
garding extension of the cusp and belonged to Type 1 Major
Talon according to the classification by Stephen-Ying et al.[10,17]
Only prominent cusps may cause complications and hence
requires early diagnosis and treatment to prevent clinical
problems. Small talon cusps, such as the type-3 are usually
asymptomatic and need no treatment. He also proposed that
if esthetic appearance is satisfactory, function is within nor­
mal limits, caries or advanced attrition is absent and if the
anomalous cusp is not sharp, treatment of the talon cusp is
not required.[14]
Hattab et al reported the prevalence of talon cusp in the max­
illary arch as 92%, but talon cusps of mandibular teeth were
extremely rare.[14] Two case reports by Mader and Goel fol­
lowed by a single case report on a mandibular talon cusp by
Nadkarni, Munshi and Damle have been reported on the lower
right quadrant.[21] In contrast the Talon cusp in the first case
here, was present on the lower left quadrant.
Although talon cusp may not be routinely encountered in a
dental office, proper differential diagnosis need to be estab­
lished before a definitive treatment is planned. The role a pe­
diatric dentist plays in managing a clinical case of talon cusp is
of utmost importance because the earlier the detection, the
J Indian Soc Pedod Prev Dent - Special issue 2006
minimal are the future complications and the better is the
prognosis.
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Reprint requests to:
Roshan Rayen,
Department of Pediatric Dentistry,
Meenakshi Ammal Dental College and Hospital,
Alapakkam Main Road, Maduravoyal,
Chennai - 600 095, Tamil Nadu, India
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