|Year : 2016 | Volume
| Issue : 2 | Page : 92-97
Management of developmental anomalies in maxillary lateral incisors: A case series
Ganesh Ranganath Jadhav1, Priya Mittal2, Umesh Dharmani3
1 Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
3 Department of Conservative Dentistry and Endodontics, Dental College, RIMS, Imphal, Manipur, India
|Date of Web Publication||18-Apr-2016|
Ganesh Ranganath Jadhav
Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Talons cusp and palate-radicular groove are commonly occurring developmental anomalies in permanent maxillary lateral incisors. These anomalies present with various esthetic and functional complications that require prophylactic and definitive treatment plans. It is essential to have a thorough knowledge of these anomalies for their correct diagnosis and successful management. This case series presents etiology and various treatment modalities for the management of these commonly occurring developmental anomalies in the maxillary lateral incisors.
Keywords: Intentional replantation, palate-radicular groove, talons cusp
|How to cite this article:|
Jadhav GR, Mittal P, Dharmani U. Management of developmental anomalies in maxillary lateral incisors: A case series. Saudi Endod J 2016;6:92-7
| Introduction|| |
Permanent maxillary lateral incisors show developmental anomalies more than any other tooth except the third molar. Various developmental anomalies seen in maxillary lateral incisor are turner hypoplasia, dens invaginatus, talons cusp, palate-radicular groove (PRG), and microdontia. Dens evaginatus is a developmental aberration of a tooth resulting in the formation of an accessory cusp showing enamel covering a dentinal core that usually contains pulp tissue.  If it is present in the anterior teeth, it is known Talons cusp. Talon cusp was first described in 1892 by Mitchell, named by Mellor and Rispa in 1970, commonly affects maxillary lateral incisors. , It causes esthetic compromise, occlusal problems, mucosal lesions, increased risk of caries, pulpal, periapical, and periodontal diseases.  Prophylactic management of evaginatus includes occlusal grinding followed by fluoride application or sealing with flowable light cure resin depending on the degree of its expression. If pulpal or periodontal involvement is seen, then pulpotomy or root canal treatment along with periodontal therapy may be needed.
PRG is a developmental anomaly that starts near the cingulum of the tooth and runs down the cementoenamel junction apically at various lengths and depths. The proposed theories for its formation are - it is a mild form of dens invaginatus, it is formed due to an incomplete attempt of a tooth to form another root or an alteration of genetic mechanisms. , The groove is responsible for the development of a combined endodontic-periodontal lesion due to communication between the root canal system and the periodontium through the accessory canals.  Depending on the location, depth, extent of groove, and the amount of periodontal destruction, the treatment modalities include curettage of the affected tissue, elimination of the groove by grinding (saucerization), or sealing with a variety of filling materials like glass ionomer cement (GI) or mineral trioxide aggregate (MTA).  If the groove extends beyond the middle-third of the root, surgical intervention is needed, that include guided tissue regeneration, bone graft, or intentional replantation. This case series reports various treatment modalities for the management of commonly occurring developmental anomalies in the maxillary lateral incisors.
| Case reports|| |
A 35-year-old healthy male was referred to the Endodontic Clinic by an Oral Surgeon to manage the weeping canal of the left maxillary lateral incisor (number 22). The surgeon enucleated the cystic lesion involving upper anterior six teeth. Careful preoperative clinical examination of tooth number 22 revealed presence of a PRG [Figure 1]a. The apical extent of the groove was evaluated using radiographic examination which showed its extension until middle one-third of root [Figure 1]b. The patient was informed regarding the aberrant corono-radicular morphology associated with the tooth number 22 and the surgical need for sealing the PRG to which he agreed. The risks, complications, and possible outcome of treatment procedures were explained, and written informed consent was taken.
|Figure 1: Tooth number 22 showing deep palato-radicular groove clinically (a) and radiographically (b). After palatal flap reflection (c) and its stabilization using sling suture, the groove was sealed with mineral trioxide aggregate (d). Guided tissue regeneration (e) was carried out with the help of osseous grafting and collagen membrane which was sutured firmly against the tooth (f). Suturing was completed, and periodontal pack was used (g). Radiographs taken after the obturation and sealing of the groove (h)|
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Under rubber dam isolation (Hygienic, Coltène Whaledent Inc., USA), access opening was re-defined using ultrasonic tips (Pro Ultra Endo Tips No. 2 and 3, Dentsply Maillefer, New York, USA). A large oval canal was debrided along with copious irrigation with 2.5% sodium hypochlorite solution (Cmident, India). Working length was determined using apex locator (Root ZX; Morita, Tokyo, Japan) was 21 mm with an initial apical file size of number 25 K file and master apical file (MAF) size number 50 K file. Cleaning and shaping of the canal were done by crown-down technique. Canal was irrigated using 2.5% sodium hypochlorite solution (Cmident, India) followed by normal saline and 2% chlorhexidine digluconate (R4, Septodont, Saint Maur des Fosses, France) was used as the final irrigant. The canal was dried with sterile paper points (Dentsply Maillefer, Tulsa, OK, USA). Calcium hydroxide (Prime Dental Products Pvt. Ltd., Mumbai, India) was used as an interappointment medicament. The access cavity was sealed temporarily with the intermediate restorative material (IRM, Caulk Dentsply, Milford, DE, USA). The patient was recalled after a week. The root canal was irrigated with distilled water to remove the intracanal dressing of calcium hydroxide then dried. Obturation was done by a lateral condensation technique with the use of Gutta-percha cones and epoxy resin-based root canal sealer (AH plus sealer, Dentsply Maillefer, Tulsa, OK, USA). The tooth was restored using light-cured composite resin (Z100; 3M Dental Products). The patient was recalled after 2 days for a surgical procedure. Under greater palatine nerve block, intrasulcular horizontal envelope incision was given and palatal mucosa was reflected using periosteal elevator [Figure 1]c. Tightly bound palatal mucosa was stabilized using sling suture. Cortical bone of the palatal aspect of tooth number 22 was removed using round carbide bur under abundant water cooling irrigation so as to expose the groove completely. PRG was roughened using ultrasonic tips and was sealed using freshly mixed MTA [Figure 1]d. Hydroxyapatite bone grafting (Perio Bone G; Top Notch-Health Care Products, Aluva, Kerala, India) was placed over the groove, and it was covered using a resorbable collagen barrier (CollaGuide, Oscotec Inc., Korea) [Figure 1]e and f. The palatal mucosa was sutured back, and the periodontal dressing was used [Figure 1]g. Antibiotic therapy (Amoxycillin 500 mg 3 times daily) as well as instructions about the importance of plaque control using chemical and mechanical methods was explained. The patient was recalled after 1 week for sutures removal.
A 29-year-old healthy male referred with the chief complaint of intermittent pus discharge from the upper gums on the left side for the preceding 6 months. On clinical examination, labial alveolar mucosa with respect to tooth number 22 exhibited a draining sinus tract and same tooth showed a deep PRG on the disto-palatal surface [Figure 2]a. It was associated with a 12 mm probing defect. The pulp did not respond to sensibility tests. An intraoral periapical radiograph revealed a large peri-radicular radiolucency extending up to the root apex [Figure 2]b. The case was diagnosed as pulp necrosis with a chronic peri-radicular abscess.
|Figure 2: Tooth number 22 showing a draining sinus(s) on the labial alveolar mucosa (a). An intraoral periapical radiograph revealed a large peri-radicular radiolucency (R) with a deep palato-radicular groove extending until apical one-third of root (b). After extraction (c), the palato-radicular groove was sealed using mineral trioxide aggregate (d). The tooth was stabilized with rigid splinting for 1 week (e). Radiograph at follow-up exhibited healing of peri-radicular radiolucency (f)|
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Considering the apical extent of a groove, a treatment strategy was planned that comprised of conventional root canal treatment, extraction with the sealing of groove using MTA, intentional replantation and deep curettage of the periodontal pocket.
The patient was explained regarding the aberrant corono-radicular morphology associated with the tooth number 22 and its treatment plan with its outcome and written informed consent was taken. Under local anesthesia (2% lidocaine with 1:1,00,000 epinephrine, LOX 2% Neon Lab, India), single visit root canal treatment was completed, and the tooth was extracted with very gentle movements using dental extraction forceps avoiding damage to cementum. PRG was roughened using ultrasonic tips and was immediately sealed using freshly mixed MTA [Figure 2]c and d. The tooth was correctly repositioned and stabilized with a rigid splint using a flowable composite (Tetric N-flow, Ivoclar Vivadent, Schaan) and a metallic wire, incorporating two teeth on both sides [Figure 2]e. Antibiotic therapy and oral hygiene instructions were explained. Follow-up showed the evidence of radiographic healing of peri-radicular radiolucency with the formation of normal bony trabeculae [Figure 2]f.
A 30-year-old healthy male referred with the chief complaint of occlusal interference in the anterior teeth. Intraoral clinical examination revealed the presence of type 1 talons cusp in association with tooth number 22 extending until the incisal edge of the crown and interfered with occlusion [Figure 3]a and b.
Radiographic examination revealed the presence of a high pulp horn in the talon cusp and normal periapex [Figure 3]c. Pulp sensibility testing was carried out for the involved tooth which did not elicit any response (necrotic). It was decided to manage the case using odontoplasty and conventional root canal treatment. Under local anesthesia, odontoplasty was carried out [Figure 3]d using flame-shaped diamond points so as to remove the occlusal interference [Figure 3]e. The rubber dam was applied, and access opening was done using round diamond points. Working length was determined using apex locator (Root ZX; Morita, Tokyo, Japan) and chemo-mechanical preparation was done using crown down technique with hand files till MAF size number 45 was reached. Canal was irrigated using 2.5% sodium hypochlorite solution (Cmident, India), normal saline, and 2% chlorhexidine digluconate (R4, Septodont, Saint Maur des Fosses, France). The canals were dried with sterile paper points (Dentsply Maillefer, Tulsa, OK). Calcium hydroxide (Prime Dental Products Pvt. Ltd., Mumbai, India) was used as an inter-appointment medicament. The access cavity was sealed temporarily with intermediate restorative material (IRM, Caulk Dentsply, Milford, DE, USA). The patient was recalled after a week and the root canals were irrigated with distilled water to remove the intracanal dressing of calcium hydroxide. Canals were dried. Obturation was done by a lateral condensation technique with the use of Gutta-percha cones and epoxy resin-based root canal sealer (AH plus sealer, Dentsply Maillefer, Tulsa, OK) [Figure 3]f. The tooth was restored using light-cured composite resin (Z100; 3M Dental Products).
|Figure 3: Tooth number 22 showing type 1 talon cusp (a) that was interfering with the occlusion (b). Preoperative radiograph of the tooth (c) shows normal periapex. Odontoplasty of talon cusp was carried out (d) to relieve the traumatic occlusion (e) and root canal treatment was completed (f)|
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A 22-year-old Asian girl with noncontributory medical and dental histories attended the clinic for a routine dental check-up. Intraoral clinical examination revealed the presence of well-defined talons cusp which is separated from the crown by a carious developmental groove on the palatal surface of tooth number 22 [Figure 4]a. According to Hattab et al.,  this was type 2 talon cusp extending less than half the height of the tooth crown. Talons cusp was interfering with occlusion. It was managed by grinding of talons cusp and elimination of carious groove followed by restoration with an acid-etched flowable light-cured resin (Z100; 3M Dental Products) [Figure 4]b-e.
|Figure 4: The palatal surface of tooth number 22 showing type 2 talon cusp with a carious developmental groove (a). Groove was eliminated (b) and sealed with acid-etched flowable light-cured resin (c). Radiographs before (d) and after (e) sealing the groove|
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| Discussion|| |
Various genetic and environmental factors are responsible for the formation of developmental anomalies in teeth such as variations in size, shape, number, structure, and eruption pattern of teeth. Types of aberrations seen in tooth depend upon the stage of tooth morphogenesis at which these factors act. Anomalies in a number of teeth are seen due to disturbance during the initiation or proliferation stage while tooth size, shape, and structural aberrations are seen due to a disturbance occurring at the morpho-differentiation stage.  Various factors like hormonal changes, premature loss, or over-retained deciduous teeth are responsible for abnormalities in the eruption pattern of permanent teeth. The common occurrence of developmental anomalies in maxillary lateral incisor can be related to the effect of forces generated by the central incisor and canine tooth germs on the lateral incisor tooth germ, which develop 7 months later. , Such localized pressure causes either out-folding or in-folding of the dental lamina of maxillary lateral incisor which ultimately lead to the formation of various developmental anomalies.
PRG is a rare developmental anomaly with a prevalence of 2.8-8.5%.  Case 1 was managed using the surgical approach as groove was extending until the middle third of the root. The groove was sealed with MTA as it provided excellent marginal adaptation.  It has good biocompatibility and appears to induce a favorable tissue response.  Guided tissue regeneration is a technique for enhancing and directing cell growth to repopulate specific parts of the periodontium that have been damaged by periodontal diseases, root canal infection, or trauma. In the given case, use of a resorbable collagen membrane barrier along with bone grafting was done. This barrier prevented apical migration of gingival epithelial and connective tissue cells onto the denuded root surface to facilitate the re-population periodontal ligament (PDL) progenitor/stem cells on the damaged root surface so that they differentiate into PDL cells and cementoblasts. Bone graft acted as osteoinductive biomaterials for regeneration of bone loss.
In case 2, the groove was extending from cingulum to apical third of root and hence it was managed by intentional replantation. There are some advantages of intentional replantation. The procedure is less time consuming, simple, and less invasive as compared to raising a tightly adherent palatal flap. Moreover, there are fewer chances of damage to the vital structures present palatal to incisors such as nasopalatine vessels. In given case, care was taken to minimize the extra-oral time and to perform the extraction with minimal trauma to the PDL tissue. Replacement resorption and ankylosis are some of the complications seen after intentional replantation. 
Although the exact etiology of talons cusp is uncertain, both genetic and environmental factors acting at the morpho-differentiation stage of tooth development are responsible for its formation.  Hattab et al.  classified the talons cusp based on the degree of formation and extension into three types: Type 1 (talon) - additional cusp that projects from the palatal surface of anterior tooth and extends at least half the distance from the cementoenamel junction to the incisal edge; type 2 (semi talon) - an additional cusp of a millimeter or more but extending less than half the distance from the cementoenamel junction to the incisal edge; and type 3 (trace talon) - enlarged, prominent cingulum, and their variations.  Early diagnosis and prompt treatment of talon cusp are important in order to prevent the occlusal interference, carious involvement of the developmental grooves, periodontal problems, or irritation of the tongue during speech and mastication. The use of radiographs to assess the extent of a pulp horn in the talon cusp is essential to determine the various treatment options like prophylactic odontoplasty, MTA pulpotomy, or root canal treatment. In case 3, the tooth was nonvital and talon cusp was interfering with the occlusion. Hence, the case was treated by odontoplasty and endodontic intervention. In case 4, grinding of talon cusp and removal of carious developmental groove did not expose the pulp. Hence, the tooth was just restored with flowable composite resin without any endodontic intervention.
| Conclusion|| |
This case series compiles different managements of developmental anomalies (Talon cusp and developmental palatal groove) that commonly affect the maxillary lateral incisors. Depending on the degree of expression, the treatment plan for all anomalies varies. A proper comprehensive interdisciplinary treatment strategy is needed for a successful treatment outcome.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Neville B, Damm D, Allen C, Bouquot J. Oral and Maxillofacial Pathology. 2 nd
ed. Philadelphia: WB Saunders; 2002. p. 77-9.
Mitchell WH. Case report. Dent Cosm 1892;34:10368.
Mellor JK, Ripa LW. Talon cusp: A clinically significant anomaly. Oral Surg Oral Med Oral Pathol 1970;29:225-8.
Shah N, Jadhav GR, Mittal P, Logani A. Conservative management of dens evaginatus and attached supernumerary tooth/odontome in mandibular premolar with dual radiolucencies. Contemp Clin Dent 2015;6 Suppl 1:S269-73.
Gu YC. A micro-computed tomographic analysis of maxillary lateral incisors with radicular grooves. J Endod 2011;37:789-92.
Levitan ME, Himel VT. Dens evaginatus: Literature review, pathophysiology, and comprehensive treatment regimen. J Endod 2006;32:1-9.
Vishwas JR, Shaikh SY, Tambe VH, Ali FM, Mustaffa M. Management of endodontic-periodontic lesion of a maxillary lateral incisor with palatoradicular groove. Saudi Endod J 2014;4:83-6.
Ballal NV, Jothi V, Bhat KS, Bhat KM. Salvaging a tooth with a deep palatogingival groove: An endo-perio treatment - A case report. Int Endod J 2007;40:808-17.
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.
Afify AR, Zawawi KH. The prevalence of dental anomalies in the Western region of Saudi Arabia. ISRN Dent 2012;2012:837270.
Alani A, Bishop K. Dens invaginatus. Part 1: Classification, prevalence and aetiology. Int Endod J 2008;41:1123-36.
Attam K, Tiwary R, Talwar S, Lamba AK. Palatogingival groove: Endodontic-periodontal management - Case report. J Endod 2010;36:1717-20.
Hakki SS, Bozkurt SB, Hakki EE, Belli S. Effects of mineral trioxide aggregate on cell survival, gene expression associated with mineralized tissues, and biomineralization of cementoblasts. J Endod 2009;35:513-9.
Dharmani U, Jadhav GR, Kamal C, Rajput A, Dua A. Management of a rare combination of avulsion and intrusive luxation: A case report. J Conserv Dent 2014;17:587-9.
Hattab FN, Hazza'a AM. An unusual case of talon cusp on geminated tooth. J Can Dent Assoc 2001;67:263-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]