Unusual case of a Talon cusp on a supernumerary tooth in association with a hyperdontia: a view on their etiopathogenesis.
This accessory cusp shows increased predilection for males and the maxilla (2, 3). Reported review of literature has shown that talon cusp exhibits a prevalence of 75% in the permanent dentition compared to 25% in the primary dentition (3). The prevalence of talon cusp varies considerably between different ethnic groups. It has a prevalence rate of 0. 06% in Mexican, 7. 7% in North Indian, 0. 17% in American and 2. 5% in Hungarian children (4-7).
Hyperdontia is the development of an increased number of teeth and the additional teeth are termed supernumerary. Supernumerary teethis expressed by an increased number of teeth over that described by the normal dental formula I2, C1, PM2, M3 (8). The first report of a Supernumerary tooth appeared between AD 23 & 79 (9). Supernumerary teeth may vary in shape, size and structure or they can resemble the adjacent tooth (10, 11). They can be classified according to their position of the arch and their shape
Classification of supernumerary teeth is based on form and position (8). (Table. 1)
The anterior midline of the maxilla (mesiodens) is the most common site and the maxillary molar area (fourth molar or paramolar) is the second most common site. Approximately 76% to 86% of cases represent single tooth Hyperdontia (12).
CASE REPORT: 12-year-old boy reported to the private dental clinicwith a complaint of poor aesthetics and an additional tooth in the upper jaw. Intraoral examination revealed no soft tissue abnormalities. Maxillary right central incisor was slightly labially positioned with midline diastemabecause of a palatally positioned supernumerary tooth. The supernumerary tooth resembled maxillary central incisor with a mature root and pronounced mamellons and a talon cusp on the palatal surface. The talon cusp was pyramidal in shape and extended from the cementoenamel junction to the incisal edge (Figure 3 and 4). On left side there is a presence of one extra lateral incisor exhibiting hyperdontia.
The periapical radiograph (Figure 4) showed a V-shaped radiopaque structure superimposed on the image of the involved tooth crown, with the tip of the 'V' towards the incisal edge. Shallow developmental grooves were present at the junction of the talon cusp with the palatal surface of the affected tooth without any carious lesions. There is a presence of one extra Maxillary lateral incisor on left side.
DISCUSSION: Talon cusp was reported by Mitchell et al in 1892 and was given the name talon cusp by Mellor talon.
It is an accessory cusp-like structure. This anomaly varies widely in shape, size, structure, location and origin. This cusp can occur on lingual or labial surfaces of either primary or permanent anterior teeth. Occurrence of a talon cusp on the labial surface and double labial talon cusps is rare and uncommon (13). Occurrence of talon cusps on supernumerary teeth is extremely rare.
Pubmed and Medline search reveals six cases of talon cusps on supernumerary permanent (14), (15, 16) and primary (12, 15, 17) and three cases on supplemental permanent teeth (18).
Histomorphometric examination has revealed that the talon cusp has normal enamel and dentin with a substantially enlarged pulp tissue, which suggests that talon tooth, may be a developmental anomaly originating in the stage of morphodifferentiation (10).
Hattabet al. (2) categorized talon cusps into three types based on the degree of cusp formation and extension.
Type 1--Talon additional cusp extends to at least half the distance from the cementoenamel junction and the incisal edge.
Type 2--Semi-talon is an additional cusp extending to less than half the distance from the cementoenamel junction and the incisal edge.
Type-3-Trace talons present as enlarged or prominent cingulum.
The anomaly appears to be more frequent in Rubinstein-Taybi syndrome (19), Mohr syndrome (20), Sturge-Weber syndrome (21) and inconti-nentia pigmenti (22). Talon cusps may be of great clinical importance and early diagnosis may be critical. Small talon cusps are usually asymptomatic and need no treatment. On the other hand, large prominent cusps may cause clinical problems, including poor aesthetics, occlusal interference, and displacement of the affected tooth, carious lesions in the developmental grooves and pulpal exposure due to cuspal attrition, accidental cuspal fracture, pulpal necrosis, periapicalpathoses, periodontal pockets, tongue irritation and possibility oftemporomandibular joint pain (1, 2, 23, 25).
The majority of cases reported in the literature indicate that talon cusp is an isolated anomaly rather than an integral part of any disorder. Talon cusp can be found in isolation or in association with other dental anomalies such as peg-shaped lateral incisors, shovel-shaped incisors, bifid cingulum, unerupted canines and the large cusp of Carabelli, dens invagi-natus, supernumeraries and complex odon-tomas (2, 23, 26).
Supernumerary teeth may occur singly, multiply, unilaterally or bilaterally in the maxilla, mandible or both. Their shape and size may resemble the group of teeth at the site where theyare found in the jaws or there may be little or no resemblance at all. The Supernumerary tooth which bears resemblance to the tooth with which it is associated is called supplementary teeth.
Causes of Supernumerary teeth.
* Proliferation of the Dental Lamina (27-29)
* Genetic Factors (9, 29, 31-34)
* Anomalous Proliferation of External Epithelial Layer of Enamel (9, 31-34)
* Environmental Factors (27, 34)
* Hereditary Occurrence (27-29)
* Phylogenetic theory as regression to the Anthropoidswhere dentalformula has more teeth (27)
* Linked to X Chromosome (27)
* An Abnormal Reaction to a Local Traumatic Episode (27)
* Dichotomy of Tooth Germ (27)
* Atavism (9)
ETIOPATHOGESIS: Indeed, many of the molecular signalling pathways known to be involved in the normal development of the tooth germ can also give rise to additional teeth if inappropriately regulated. These include components of the hedgehog, FGF, Wnt, TNF and BMP Families, which provide a use full source of candidate genes that may potentially play a role in human supernumerary tooth formation (35).
It is assumed that cranial neural crest cells emerge and go into the first branchial arch to become teeth, through mesenchymal interaction which gives rise to the position of where the teeth will be. Then through epithelial mesenchymal interactions the shape, size and contour of the individual teeth begin to take place (36).
During early tooth development, growth morphogenic proteins BMP s and the FGF family mediate inductive signaling. These factors appear to be expressed at the right place and right time. BMP-2 and BMP-4 mimic the effects of the epithelium on the dental mesenchyme. They also include MSX-1 and MSX-2 which are regulatory genes. BMPs appear to act as essential inductive factors for tooth morphogenesis.
Supernumary teeth most probably result from continued proliferation of the permanent or primary dental lamina to form a third tooth germ. Most are isolated events, although some may be familial and others may be syndrome associated (Gardner's syndrome and cleidocranial dysplasia) (37).
The exact etiology of Talon cusp 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 a combination of genetic and environmental factors (multifactorial) (2).
The present case shows the following features: 1. unusual occurrence of talon cusp on supernumerary teeth; 2. presence of one extra left lateral incisor and midline diastema. Treatment was planned for surgical extraction of the partially erupted supernumerary tooth and regular follow up followed by orthodontic correction of remaining abnormalities.
CONCLUSION: Talon cusp is an odontogenic anomaly arising during the morphodifferentiation stage of tooth development. This accessory cusp can occur on primary or permanent anterior teeth. Occurrence of talon cusp on supernumerary teeth is rare and uncommon. Presence of a prominent talon cusp may give rise to various clinical problems, necessitating immediate intervention.
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Deepa Hugar , Sangmeshwar Sajjanshetty , Santosh Hugar , Sridevi Tamagond 
[1.] Deepa Hugar
[2.] Sangmeshwar Sajjanshetty
[3.] Santosh Hugar
[4.] Sridevi Tamagond
PARTICULARS OF CONTRIBUTORS:
[1.] Senior Lecturer, Department of Oral pathology & Microbiology, H. K. E. Society's, S. Nijalingappa Institute of Dental Science & Research, Gulbarga, Karnataka, India.
[2.] Senior lecturer Department of Pedodontics and preventive dentistry H. K. E. Society's. S. Nijalingappa Institute of Dental Science & Research, Gulbarga, Karnataka, India
[3.] Reader, Department of Conservative & Endodontics, Bharatiya Vidyapeeth Dental College and Hospital, Sangli, Maharastra, India.
[4.] Senior lecturer Department of Pedodontics and preventive dentistry Bhartiya Vidyapeeth Dental College and Hospital, Sangli, Maharastra, India.
NAME ADRRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Deepa Hugar
C/o Dr. Sangameshwar Sajjanshetty Pl. No19, Vasanth Nagar Gulbarga-585103
Date of Submission: 27/11/2013.
Date of Peer Review: 28/11/2013.
Date of Acceptance: 04/12/2013.
Date of Publishing: 11/12/2013
TABLE & PHOTOGRAPHS:
Table 1 Classification Based On Form Classification Based On Position Conical Mesiodens Tuberculate Paramolar Supplemental Distomolar Odontome Parapremolar
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|Author:||Hugar, Deepa; Sajjanshetty, Sangmeshwar; Hugar, Santosh; Tamagond, Sridevi|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Case study|
|Date:||Dec 16, 2013|
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