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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 4  |  Page : 212-214

Anterior maxilla: A site for multiple dental anomalies

1 Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Satara, Maharashtra, India
2 Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Satara, Maharashtra, India

Date of Web Publication16-Apr-2019

Correspondence Address:
Dr. S R Ashwinirani
Department of Oral Medicine and Radiology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Satara, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_12_18

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Due to aberrations during the different stages of odontogenesis, various types of developmental anomalies such as dens evaginatus, dens invaginatus, bifid root, fusion, gemination, and dilacerations can occur. This article presents multiple anomalies in the anterior maxillary region.

Keywords: Dens invaginatus, maxilla, mesiodens, talon cusp

How to cite this article:
Ashwinirani S R, Suragimath G. Anterior maxilla: A site for multiple dental anomalies. J Datta Meghe Inst Med Sci Univ 2018;13:212-4

How to cite this URL:
Ashwinirani S R, Suragimath G. Anterior maxilla: A site for multiple dental anomalies. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2020 May 25];13:212-4. Available from: http://www.journaldmims.com/text.asp?2018/13/4/212/256203

  Introduction Top

The process of development and formation of the tooth and its supporting structures is called as odontogenesis. Due to aberrations during the different stages of odontogenesis, various types of developmental anomalies such as dens evaginatus, dens invaginatus, bifid root, fusion, gemination, and dilacerations can occur. Talon cusp and dens invaginatus are such developmental dental anomalies.[1]

In the year 1892, talon cusp was first described by Mitchell due to its resemblance to an eagle's talon. Later, Mellor and Ripa termed this anomaly as talon cusp. In permanent dentition, it occurs with a frequency of 0.04%–10% and more common in permanent dentition than the primary dentition.[2],[3] Males are commonly affected than females. In permanent dentition, it occurs most commonly in the maxillary lateral incisor, whereas in primary dentition, it occurs in the maxillary central incisors. It occurs more commonly in maxillary teeth than mandibular teeth. Talon cusp occurs most frequently on the lingual aspect of the anterior teeth, less frequently on the labial surface, and occasionally both.[4]

The complications associated with talon cups are varied including irritation of the tongue, occlusal interference, necrosis of pulp, caries, dental attrition, periodontal problems, displacement of the involved tooth, breastfeeding difficulties, esthetic problems, accidental cusp fracture, and even rarely temporomandibular disorders.[5]

Dens invaginatus is another tooth anomaly resulting from an invagination in the surface of a tooth crown before its calcification. The invagination ranges from a slight pitting to an anomaly occupying most of the crown and root. It can be coronal and radicular type. It commonly occurs in the maxillary permanent lateral incisors, followed by the maxillary central incisors, premolars, canines, and less often in the molars. Cases of dens invaginatus in the supernumerary tooth are also reported in the literature.[6] The purpose of this article is to describe two cases of talon cusp with dens invaginatus in adjacent teeth.

  Case Reports Top

Case 1

A 20-year-old female patient reported to the Department of Oral medicine and Radiology with the chief complaint of pain in the upper front teeth for 15 days. The pain was continuous in nature. The patient had a history of trauma 3 months back in the maxillary anterior region. Medical and family histories were found to be noncontributory. A thorough general and extraoral examination was carried out, and no other anomalies were noticed. Intraoral examination revealed Ellis Class 3 fracture with 11, vestibular obliteration and tenderness on palpation in 11 region with talon cusp in 21 palatal region. Radiographic examination with intraoral periapical radiograph showed Ellis Class 3 fracture with 11 and ill-defined periapical radiolucency measuring about 5 mm × 6 mm suggestive of periapical abscess. A well-defined, v-shaped radiopacity was also present in 21 cingulum region suggestive of talon cusp. A root canal treatment to 11 was carried out [Figure 1].
Figure 1: Intraoral periapical radiograph showing Ellis class III fracture and periapical abscess with 11 and talon cusp with 21

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Case 2

A 12-year-old male patient came with a complaint of pain in the upper front teeth for 1 month. The pain was moderate and intermittent in nature. His past medical and dental history was noncontributory. Extraoral examination revealed no changes. Intraoral examination revealed a bulge in the palatal region of 11, deep palatal pits with 12, 11, and 21, and talon cusp with 22. Palpation in the palatal region was hard and tender. A provisional diagnosis of mesiodens was considered. Intraoal periapical radiograph showed the presence of two mesiodens teeth with one normally placed and one inverted in the periapical region of 11.21 and Type I dens invaginatus with 11, 21, and 12. A treatment of extraction of mesiodens teeth and prophylactic restoration to palatal pits were carried out [Figure 2] and [Figure 3].
Figure 2: Clinical picture showing talon cusp with 22

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Figure 3: Intraoral periapical radiograph showing Type II dens invaginatus with 11, 21, 12, two mesiodens, and talon cusp with 22

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  Discussion Top

Oral cavity is a site for many variations including hard and soft tissues. These variations may be developmental or acquired. The abnormalities usually occur individually, but rarely many abnormalities can occur in the same site, as in our cases where talon cusp and dens invaginatus occurred in the same sites.

Talon cusp exhibits a prevalence of 75% in the permanent dentition compared to 25% in the primary dentition.[2] According to the literature, 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.[7],[8],[9],[10] In both the cases, talon cusps were present in the palatal side of permanent central and lateral incisors.

Based on the degree of cusp formation and extension, Hattab et al.[2] categorized talon cusps into three types. Type I: Talon additional cusp extends to at least half the distance from the cementoenamel junction and the incisal edge. Type II: Semi-talon is an additional cusp extending to less than half the distance from the cementoenamel junction and the incisal edge. Type III: Trace talons present as enlarged or prominent cingulum. Mayes classified[11] talon cusps into three stages, starting from the slightest to most extreme forms as follows: Stage 1 is the slightest form, consisting of a slightly raised triangle on the labial surface of an incisor extending the length of the crown; Stage 2 is a moderate form, consisting of a raised triangle on the labial surface of an incisor that extends the length of the crown, and it may reach the incisal edge and can be observed clearly and palpated easily at this stage; and Stage 3 is the most extreme form, consisting of a free-form cusp extending from the cementoenamel junction to the incisal edge on the labial surface of an incisor. In our cases 1 and 2, Hattab et al. Type III talons and Type I talon were present.

Talon cusp can occur alone 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 invaginatus, supernumeraries, and complex odontomas. It appears to be more prevalent in patients with Sturge– Weber syndrome More Details, orol-facial-digital syndrome Type II, and Rubinstein–Taybi syndrome. The patients in our cases were evaluated thoroughly and were found to be nonsyndromic.[12],[13]

Small talon cusps are usually asymptomatic, necessitating no treatment. However, large prominent talon cusps need definitive treatment because they may cause esthetic, occlusal, periodontal, and carious problems. In both the cases, treatment for talon cusps was not done since it was not having any symptoms.

The prevalence of dens invaginatus is between 0.3% and 10% with symptoms in 0.25%–26.1% of individuals.[14] In our case 2, Type II dens invaginatus was present in 11, 12, and 22 which was asymptomatic. According to Oehlers, dens invaginatus was classified into three forms as given below:[15]

  • Type I: Invagination ends in a blind sac, limited to the dental crown
  • Type II: Invagination extends to the cementoenamel junction, also extending in the blind sac. It may or may not extend into the root pulp
  • Type III: Invagination extends to the interior of the root, providing an opening to the periodontium, sometimes presenting another foramen in the apical region of the tooth.

Treatment of dens invaginatus includes simple prophylactic restoration to conventional endodontic treatment. Extraction is indicated in some cases of failure root canal-treated cases and in supernumerary teeth associated with dens invaginatus. In case 2, prophyalctic restoration was done for 11, 12, and 21. Thorough examination helps in diagnosis of talon cusp and dens invaginatus cases. Early diagnosis and prompt treatment may prevent the complications associated such as caries, periodontal disease, and malocclusion.

  Conclusion Top

Diagnosis of anomalies at the earliest improves the prognosis of treatment and minimizes the future complication. Most of the times, dens invaginatus will be difficult to diagnose clinically, and so in these cases, radiographs help in diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mishra G, Mishra A, Arora S. Bilateral talon cusp: A case report. Indian J Stomatol 2011;2:187-9.  Back to cited text no. 1
Hattab FN, Yassin OM, al-Nimri KS. Talon cusp in permanent dentition associated with other dental anomalies: Review of literature and reports of seven cases. ASDC J Dent Child 1996;63:368-76.  Back to cited text no. 2
Lee CK, King NM, Lo EC, Cho SY. Talon cusp in the primary dentition: Literature review and report of three rare cases. J Clin Pediatr Dent 2006;30:299-305.  Back to cited text no. 3
Batra P, Enocson L, Hagberg C. Facial talon cusp in primary maxillary lateral incisor: A report of two unusual cases. Acta Odontol Scand 2006;64:74-8.  Back to cited text no. 4
Gupta R, Thakur N, Thakur S, Gupta B, Gupta M. Talon cusp: A case report with management guidelines for practicing dentists. Dent Hypotheses 2013;4:67-9.  Back to cited text no. 5
  [Full text]  
Ashwinirani SR, Suragimath G, Christopher V, Sawardekar VA. Dens invaginatus: A series of case reports. J Oral Res Rev 2017;10:20-3.  Back to cited text no. 6
Sedano HO, Carreon Freyre I, Garza de la Garza ML, Gomar Franco CM, Grimaldo Hernandez C, Hernandez Montoya ME, et al. Clinical orodental abnormalities in Mexican children. Oral Surg Oral Med Oral Pathol 1989;68:300-11.  Back to cited text no. 7
Chawla HS, Tewari A, Gopalakrishnan NS. Talon cusp – A prevalence study. J Indian Soc Pedod Prev Dent 1983;1:28-34.  Back to cited text no. 8
Buenviaje TM, Rapp R. Dental anomalies in children: A clinical and radiographic survey. ASDC J Dent Child 1984;51:42-6.  Back to cited text no. 9
Mavrodisz K, Budai M, Tarján I. Prevalence of talon cusp in patients aged 7-18. Fogorv Sz 2003;96:257-9.  Back to cited text no. 10
Mayes AT. Labial talon cusp: A case study of pre-European-contact American Indians. J Am Dent Assoc 2007;138:515-8.  Back to cited text no. 11
Sharma A. Dens evaginatus of anterior teeth (talon cusp) associated with other odontogenic anomalies. J Indian Soc Pedod Prev Dent 2006;24 Suppl 1:S41-3.  Back to cited text no. 12
Balcioǧlu HA, Keklikoǧlu N, Kökten G. Talon cusp: A morphological dental anomaly. Rom J Morphol Embryol 2011;52:179-81.  Back to cited text no. 13
Thakur S, Thakur NS, Bramta M, Gupta M. Dens invagination: A review of literature and report of two cases. J Nat Sci Biol Med 2014;5:218-21.  Back to cited text no. 14
Oehlers FA. Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol 1957;10:1204-18.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]


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