1. Intentional partial pulpotomy to talon cusp for
tooth crown morphology correction in orthodontic
treatment : case report ;Pediatric dentistry
Deepthi
Paediatric dentistry
3. Introduction
The cuspal morphology of teeth exhibits minor
variations among diff populations:
1. Cusp of carabelli
2. Talon cusp
3. Dens evaginatus
3
5. Definition
◈supernumerary accessory talon-shaped cusp projecting from
the lingual or facial surface of the crown of a tooth and
extending for at least half the distance from the cemento-
enamel junction to the incisal edge
5
12. 1.HATTAB’S ET AL-degree of formation and extension
◈ Type 1 (True
talon)
◈ Type 2
(Semi talon):
◈ Type 3 (Trace
talon):
12
Talon Cusp: A Case Report and Literature Review:R Kalpana, 2M Thubashini Oral and
Maxillofacial Pathology Journal, January-June 2015;6(1):594-596
14. PREVALENCE
◈ Max LI- 55%
◈ Max CI- 33%
◈ CANINE 4%
◈ Mand – rare 14
PERMANENT
- 75%
PRIMARY -
25%
MAX-
90%
MAND-
10%
0.04% to 10%
Talon Cusp: A Prevalence Study of Its Types in Permanent Dentition and Report of a Rare Case of Its
Association with Fusion in Mandibular Incisor Gaurav Sharma1 and Archna Nagpal
Maxillary central
incisors
Type I talon cusp and type II talon cusp were the
most prevalent types
15. 15
Talon cusp in primary dentition Ren-Jye Chen, B.D.S., (ORAL SURG. ORAL MED.
ORAL PATHOL. 62~67-72, 1986)
23. R/F
◈ V shaped
23
Talon Cusp Type I: Restorative ManagementRafael Alberto dos Santos Maia, Hindawi
Publishing Corporation Case Reports in DentistryVolume 20151
24. Syndromes associated
◈ Sturge-Weber syndrome,
◈ Rubinstein-Taybi syndrome,
◈ orofacialdigital syndrome II (Mohr syndrome),
◈ incontinentia pigmenti achromens,
◈ Ellis Van Creveld syndrome,
◈ Berardinelli-Seip syndrome 24
Labial and Lingual Talon Cusps of a Primary Lateral Incisor:A Case Report J.
Jeevarathan, BDS M.S. Muthu, MDS2Pediatric Dentistry – 27:4, 2005
28. 1. gradual, periodic reduction
2. fluoride or desensitizing agents
3. restoring tooth morphology or complete
removal of tooth.
4. If pulpal exposure - endodontic treatment
should be done
5. Review every 3 months 28
29. “
Hattab et al
◈ Type 3- sealing of developmental
grooves
◈ Cavity- remove decay and
conventional restoration
29
30. “
Hattab et al
◈ Type 1- gradual reduction 6-8
week interval + dentinal
desensitizers
30
31. 31
Gradual Grinding of a Talon Cusp During Orthodontic Treatment PADMAJA SHARMAJournal
of Clinical Ortho/FEBRUARY 2012
36. Indications
◈ 1. Tooth has no history of spontaneous pain.
◈ 2. Tooth has acute minor pain that subsides with
analgesics.
◈ 3. Tooth has no discomfort to percussion, no vestibular
swelling and no mobility.
◈ 4. Radiographic examination shows normal appearance of
periodontal attachment.
36
Partial pulpotomy for immaturepermanent teeth, its present and future :
review Cheng et al(Pediatr Dent 24:29-32, 2002
37. ◈ 5. Pulp is exposed during caries removal or
subsequent to recent trauma.
◈ 6. Tissue appears vital.
◈ 7. Bleeding from the pulp excision site stops
with isotonic saline irrigation within 2
minutes.
37
40. “
◈ Ozcelik and Atila -reported radical
reduction treatment followed by
desensitizing paste
◈ Indicated -chronic occlusal
interference with the antagonist
teeth 40
59. ◈ Esthetic problem during ortho – intervention
needed – intentional partial pulpotomy
◈ Advantage – maintaining tooth in vital state
◈ r/f (CBCT) confirmed presence of pulp
◈ Partial pulpotomy 59
60. ◈ Ca(OH) 2 is a traditional medicament used
in the pulpotomy, and is still commonly used
and easily available
◈ Mineral trioxide aggregate has been shown
to induce hard-tissue formation more
predictably than Ca(OH)2 in shallow
pulpotomy procedures 60
62. ◈ An intentional partial pulpotomy can be
effective for recontouring the tooth crown in
cases with a large talon cusp that includes a
dental pulp cavity.
◈ A CBCT examination is important to clearly
visualize the internal structure when performing
tooth crown morphological correction of an
abnormal structure such as a talon cusp. 62
69. ◈ MTA has replaced calcium hydroxide
because of its biocompatibility, excellent
sealing ability, antibacterial properties and
property to induce hard tissue formation in
pulpal tissue
69
70. Conclusion
◈ Use of MTA pulpotomy can be a possible
single-sitting treatment option for
management of talon cusp.
70
76. ◈ Under certain conditions, less conservative
methods can be used such as complete
reduction in the cusp followed by calcium
hydroxide pulpotomy for an immature tooth
or root canal treatment (Gungor et al. 2000,
Nadkami et al. 2002).
76
77. ◈ Cvek et al. (1987) originally proposed the
use of calcium hydroxide (CaOH2) to be
applied directly to the pulpal surface to
create an environment that stimulates the
formation of a dentine bridge
77
78. ◈ Some investigators have asserted that
Ca(OH)2 starts to soften over time, resulting
in leakage through the original seal (Cox et
al. 1985)
◈ As a result, pulpal healing and hard-tissue
formation are delayed, and a potential for
symptoms exists 78
79. ◈ Mineral trioxide aggregate has been shown
to induce hard-tissue formation more
predictably than Ca(OH)2 in shallow
pulpotomy procedures (Koh et al. 2001).
79
th anomaly. Talon cusp is a subset of dens evaginatus presenting similar developmental, morphological, and histological characteristi
Talon cusp is an uncommon odontogenic anomaly comprising of an accessory cusp like structure, more commonly seen on the palatal surfaces of the maxillary
incisors
This unusual dental anomaly showing an accessory cusp-like structure projecting from the cingulum to the cutting edge was first described by
Mitchell in 1892. Talon cusp was first recorded by Mitchell in 1892. She described this accessory cusp on the lingual surface of a maxillary central incisor as ‘a process of a horn-like shape curving from the base downward to the cutting edge’ in a female patient.3,4 Mellor and Ripa
named this condition as ‘talon cusp’ in 1970.5[1] due to its resemblance to an eagle’s
talon
In Case 1 the anomaly was recognized prior to eruption. As seen in Fig. l.,
its radiographic appearance resembles that of a supernumerary tooth, and
misdiagnosis could result in an unwarranted surgical procedure.
Cases 2 and 3 were seen after the anomalous teeth had erupted. The extra
cusps extended beyond the incisal edges of the teeth, creating occlusal and
esthetic problems (Fig. 2). In these cases removal of the cusps was necessary.
The pulp tissue was inevitably exposed, and pulpal therapy was required.
In Case 4 the principal problem was created by the developmental groove between the tooth and the cusp. This susceptible area became carious, requiring
excavation and restoration (Fig. 3).
Hattab’s et al classified talon’s cusp based on the degree of formation and extension into three categories.
Type 1 (True talon): A well-delineated additional cuspthat predominantly projects from the palatal or lingual surface of an anterior tooth and extends half wayfrom cementoenamel junction to the incisal edge.
Type 2 (Semi talon): An additional cusp of a millimeteror more but extending less than half the distance from cementoenamel junction to incisal edge. It may blendwith palatal surface or strand away from the crown.
• Type 3 (Trace talon): Enlarged cingulum and may present as conical bifid or tubercle shaped
Major talons: Well-delineated cusps that project froman anterior tooth’s facial or palatal/lingual surfaceand extends at least half the distance from the
cementoenamel junction to the incisal edge.
• Minor talons: Which occur on the same surfaces, butextend more than one fourth and less than half thedistance from the cementoenamel junction to theincisal edge
• Trace talons: Enlarged prominent cingula and theirvariations, which occupy less than one fourth thedistance from the cementoenamel junction to theincisal edge.4
The prevalence of talon cusp varies with race, age, and the criteria used to define this abnormality. A review of the literature suggests that 75% of the cases are in the permanent dentition and 25% in the primary dentition.
This anomaly has a greater predilection in the maxilla (with more than 90% of the cases reported) than in the mandible (only 10% of the cases).7
In the permanent dentition, 55% of the cases involved maxillary lateral incisors, 33% involved central incisors and 4% involved canines.4
10 month old boy
6nhalf year old girl
frequency of talon cusp might range from
one to eight per cent of the population
The exact etiology of talon cusp remains unknown. Various hypotheses regarding its etiology have been put forward.12 It is thought to arise during the morpho differentiation stage of tooth development, as a result of out folding of the enamel organ or hyperproductivity of the dental lamina.1,13
Developmentally, it may arise as a result of out folding of inner enamel epithelial cells (precursors of ameloblasts) and
transient focal hyperplasia of the
mesenchymal dental papilla (precursors of odontoblasts).14
Another hypothesis suggests genetics to be a causative
factor of talon cusp based on its occurrence in a family.
Trauma and other localized forces on tooth germ have
also been held responsible for talon cusp.12 Because of
susceptibility of the maxillary lateral incisors to anomalies, compression of its tooth germ by the adjacent central
incisor and canine is also discussed. Compression could
cause out-folding of the dental lamina in case of talon
cusp, or infolding of the dental lamina in case of dens
invaginatus. Occurrence of the talon cusp in central incisor
and canine is opponent to the compression hypothesis.
and transient focal hyperplasia of the mesenchymal dental papilla (precursors of odontoblasts).14
Another hypothesis suggests genetics to be a causative factor of talon cusp based on its occurrence in a family.
Trauma and other localized forces on tooth germ have also been held responsible for talon cusp.12 Because of
susceptibility of the maxillary lateral incisors to anomalies, compression of its tooth germ by the adjacent central
incisor and canine is also discussed. Compression could cause out-folding of the dental lamina in case of talon cusp, or infolding of the dental lamina in case of dens invaginatus. Occurrence of the talon cusp in central incisor
and canine is opponent to the compression hypothesis
similar to a normal tooth in that it is composed of enamel and dentine and contains a horn of pulpal tissue. The cusp blends smoothly with the rest of the tooth, except where it joins the sloping lingual surface of the incisor. At this junction there is a deep developmental groove. Its length varies, and it may extend past the incisal edge of the tooth
Radiographically, when the talon is located in the maxilla,it is characterized by a “V”-shaped structure with greaterradiopacity in the dental crown. Characteristically, the talonor semituber comes from the cervical third of the toothcrown. The higher radiopacity of this structure should overlap with the “V” structure on the crown of the tooth image
In cases that present with a characteristic inverted “V” in thejaw, there may be overlapping images of features described inthe maxilla.This appearance may vary in shape and size basedon the angle at which the ray is taken
The talon cusp results in complications related to fourbasic categories: diagnosis, function, aesthetics, and pathology. If the talon cusp is not diagnosed correctly and isconfused with other pathologies, such as odontoma o rsupernumerary tooth, this may result in unnecessary surgery.
Functionally, depending on the size of the talon, it can result in occlusal interference, accidental dental injury with
possible pulp exposure, soft tissue injuries (such as to the tongue during speech or chewing), speech problems andtooth mobility due to premature contacts, and pain in thetemporomandibular joints. Depending on the size of the
leaflet and its location in the dental arch, the talon can beobserved when a patient smiles or speaks, creating aestheticcomplications. Because the deep grooves that connect thejaw to the tooth can retain plaque and food debris becausecleaning is difficult, caries, subsequent periapical pathologies,
and perhaps periodontal disease can subsequently develop
[9].
pain in thetemporomandibular joints. Depending on the size of the
leaflet and its location in the dental arch, the talon can beobserved when a patient smiles or speaks, creating aestheticcomplications. Because the deep grooves that connect thejaw to the tooth can retain plaque and food debris becausecleaning is difficult, caries, subsequent periapical pathologies,
and perhaps periodontal disease can subsequently develop
[9].
The various treatment options for talon cusp are:
1. gradual, periodic reduction of the cusp;
2. application of fluoride or desensitizing agents;
3. restoring tooth morphology or complete removal of
tooth.
Hattab et al. [5] recommend that, in cases of TalonCusp Type III, which does not present with major clinical
complications, only sealing of developmental grooves should
be performed. If there is evidence of dental cavities, the
decayed tissue should be removed, and conventional restorative treatment should be provided. However, if the talon
cusp presents with occlusal interferences, usually Type I,
the authors recommended a gradual reduction procedure
in 6- to 8-week intervals to stimulate the deposition of
reparative dentin and for pulp protection; this procedure
should be accompanied by the use of a dentinal desensitizer.
In cases of pulp involvement, Thirumalaisamy et al. [8] stated
that the endodontic treatment best suited for the tooth in
question should be performed based on the degree of root
development and pulp vitality
However, if the taloncusp presents with occlusal interferences, usually Type I,the authors recommended a gradual reduction procedurein 6- to 8-week intervals to stimulate the deposition ofreparative dentinto stimulatereparative dentin deposition and to promote pulp protection while avoiding exposure of dentinal tubules that cause pain and for pulp protection; this procedureshould be accompanied by the use of a dentinal desensitizer.
In cases of pulp involvement, Thirumalaisamy et al. [8] stated
that the endodontic treatment best suited for the tooth in
question should be performed based on the degree of root
development and pulp vitality
Thirumalaisamy et al. [8] stated
that the endodontic treatment best suited for the tooth in question should be performed based on the degree of root
development and pulp vitality
The superficial layer of the exposed pulp and the surrounding dentin are excised to a depth of about 2 mm high-speed diamond bur with light touch under waterspraycooling. The surface of the remaining pulp is irrigated gently with isotonic saline until bleeding has ceased. After hemostasis, a pulpal medicament containing biologicallyavailable calcium hydroxide is applied to the wound surfaceCare should be taken to avoid a significant blood clot
developing between the wound surface and the dressingmedicament. Dry, sterile cotton pellets are used carefullywith modest pressure to adapt the medicament to the prepared cavity and to remove excess water from the paste. Theremaining coronal cavity is then restored with a material thatprovides a long-term hermetic seal. It is critical to avoidbacterial contamination to the pulp tissue during the procedures and to avoid any subsequent leakage followingrestoration.
The superficial layer of the exposed pulp and the surrounding dentin are excised to a depth of about 2 mm using ahigh-speed diamond bur with light touch under waterspray cooling
After hemostasis, a pulpal medicament containing biologicallyavailable calcium hydroxide is applied to the wound surface
. However,definitive endodontic obturation in an immature tooth arrests physiologic dentin deposition, resulting in a root witha thin dentinal wall and predisposition to fracture
Complete pulpotomy (also known as cervical pulpotomy)6 is the removal of coronal pulp tissue and the placement of a wound dressing on the canal orifice. Complete pulpotomy will arrest dentin formation in immature permanent teeth and can result in obliteration of the rootcanals.7,8 It should be followed by complete endodontic therapy when root development is completed.9-11 Partialpulpotomy (also known as pulp curettage),12-14 removal of
only the outer layer of damaged and hyperemic tissue inexposed pulps, is considered to be a procedure staged between pulp capping and complete pulpotomy
One of the advantages of partial pulpotomy, when compared to cervical or complete pulpotomy, is the preservation
of cell-rich coronal pulp tissue. This tissue possesses better
healing potential and can maintain the physiologic deposition of dentin in the cervical are
Increasing age of a patient may negatively affect clinical
success. Studies have shown that in older patients, the typically more fibrous dental pulp has a reduced ability to
overcome insult.9
Intrapulpal medicament: A. Calasept ( Scania Dental AB, Knivsta, Sweden ); B. New Calvital ( Neodental Chemical Product, Tokyo,Japan); C. Calcium
hydroxide paste ( not specific ); D. Calxyl (Dental Preparation, Otto & Co., Frankfurt / Main, FRG); E. Dycal ( L. D. Caulk Co., Milford, Delaware, USA ).
However, we opted for the radical treatment reported by
Ozcelik and Atila [14]; the two leaflets were reducted in a single session using a diamond cutter with high-speedintermittent movement and cooling while the patient was properly anesthetized. The option for radical treatment wachosen because of the presence of first-degree tooth mobilityand chronic occlusal interference with the antagonist teeth,thereby aiming to reduce this mobility and restore theocclusal balance.
After complete removal of the leaflets did not createpulp exposure, desensitizing materials (Colgate Duraphat) were applied to block the exposure of the dentinal tubules,thereby generating no sensitivity to the patient.
An 11-year-old boy was referred to our clinic by a localorthodontist for treatment to improve an abnormal cusp onthe right maxillary lateral incisor, as it was thought to possiblyimpede future orthodontic treatmentThe patient did not haveany history of medical treatment or relevant family history.
Intraoral findings included a talon cusp on the lingual surfaceof the right maxillary lateral incisor (Fig. 1), which protruded
from the cingulum area and extended over approximately twothirds of the crown length. Although no occlusal interferencewith mandibular anterior teeth was observed, the abnormacusp appeared likely to impede orthodontic treatment. Nodental caries or fractures in the talon cusp were found, and no
subjective symptoms were noted. The patient was in the latemixed dentition stage and crowding of the maxillary anteriorteeth was exhibited. A Nance holding arch had been fitted to maintain arch length.
Dental radiography findings of the right maxillary lateral
incisor suggested the possibility of a dental pulp cavity in the
talon cusp
thus cone-beam computed tomography(CBCT) was performed to investigate the interior in detail.Those images indicated a single dental pulp cavity in the rootcanal of the lateral incisor, which was then divided into two Pulp cavities nearly at the cervical margin extending into both
the tooth crown and talon cusp
Methods for correcting the shape of the lateral incisor wereconsidered. Since the talon cusp was large and contained a dental pulp cavity, it was considered difficult to satisfactorilycorrect the tooth shape without operating on the dental pulp. Furthermore, we intended to avoid a highly invasive pulpectomy on the immature permanent tooth, which exhibited nodental caries or pulpitis. An intentional partial pulpotomy,
which we had previously performed for a similar case andobtained a favorable result [15], was finally chosen. Advantages of this technique include an ability to maintain thedental pulp in a vital state as well as removal of a sufficient amount of the talon cusp for morphological correction
Under local anesthesia, a rubber dam was applied to the lateral incisor (Fig. 3A), then the talon cusp was resected near the tooth cervix using a high-speed air turbine and diamondbur (101, Shofu Inc., Kyoto, Japan) under a water coolant condition.
The small round-shaped surface of the exposed pulp chamber was confirmed to be close to the center of the resected surface (Fig. 3B).
A partial pulpotomy was then performed through this access using a high-speed air turbine anddiamond bur (440, Shofu Inc., Kyoto, Japan) with water coolant.
The resected surface underwent combined irrigation with 10% sodium hypochlorite and 3% hydrogen peroxide solution to achieve chemical amputation (Fig. 3C).
A calcium hydroxide preparation (Calvital Neo Dental Chemical Products, Tokyo, Japan) was placed on the amputated pulp (Fig. 3D)
and the cavity was lined with photo-polymerizated type glassionomer cement (Fig. 3E).
Next, the cavity was sealed with composite resin (Fig. 3F).
Then after removing the rubber dam (Fig. 3G), crown restoration was achieved with composite resin(Fig. 3H).
The tooth was able to be corrected to a nearly normal shape with a favorable space from the opposing tooth during occlusion
), then the talon cusp was resected near the tooth cervix using a high-speed air turbine and diamondbur (101, Shofu Inc., Kyoto, Japan) under a water coolant condition
The small round-shaped surface of the exposed pulp chamber was confirmed to be close to the center of the resected surface
A partial pulpotomy was then performed through this access using a high-speed air turbine anddiamond bur (440, Shofu Inc., Kyoto, Japan) with water coolant.
The resected surface underwent combined irrigation with 10% sodium hypochlorite and 3% hydrogen peroxide solution to achieve chemical amputation (Fig. 3C).
A calcium hydroxide preparation (Calvital Neo Dental Chemical Products, Tokyo, Japan) was placed on the amputated pulp (Fig. 3D)
and the cavity was lined with photo-polymerizated type glassionomer cement (Fig. 3E).
Next, the cavity was sealed with composite resin (Fig. 3F).
Dentalradiography performed at the one-year follow-up examination indicated no abnormal finding
Now, three yearspostoperatively, the patient has never complained of any symptoms or discomfort. Additionally, no abnormal findingshave been noted in X-ray images and electric pulp testing hasshown a vital reaction (
The present patient was undergoing orthodontic treatment,and a talon cusp may have caused problems with aestheticalignment of the anterior tooth in the future. When the cusp islarge, orthodontic treatment to move the teeth into alignmentand achieve a good occlusal relationship will result in occlusalinterference
performing anintentional partial pulpotomy
advantage of thismethod is maintenance of the dental pulp in a vital state whileachieving major morphological correction of the tooth crownmorphology
First, the presence of large cusp indicated thata significant amount of tissue would need removal. Furthermore, some dental pulp was confirmed within the cusp inCBCT images and a small amount of exposed pulp surfacewas expected once the cusp was removed. Finally, the dentalpulp was in a healthy state.
The present patient was undergoing orthodontic treatment,and a talon cusp have caused problems with aestheticalignment of the anterior tooth in the future. So decided to performing anintentional partial pulpotomy
advantage of thismethod is maintenance of the dental pulp in a vital state whileachieving major morphological correction of the tooth crownmorphology
. Furthermore, some dental pulp was confirmed within the cusp inCBCT images and a small amount of exposed pulp surfacewas expected once the cusp was removed. Finally, the dentalpulp was in a healthy state.
The diameter of dental pulp exposed area of this case waspredicted to be about 1 mm by CT measurement. This size is about the same as dental pulp exposed are of the deciduous molars where the pulpotomies are generally performed
A better prognosis is expected for a pulpotomy with a smaller amputated surface, thus it was decided to treat the patient with a partial
pulpotomy.
Although a calcium hydroxide preparation was employed, a similar result would likely be achievedwith MTA. Mineral trioxide aggregate has been shown toinduce hard-tissue formation more predictably than Ca(OH)2 in shallow pulpotomy procedures [16]. In this case, a calcium hydroxide preparation that is common in Japan was used. Ca(OH) 2 is a traditional drug used in the pulpotomy, and is still commonly used and easily available.
MTA is expensive, and the Pharmaceutical Affairs Law of Japan does not permit use otherthan pulp capping. Therefore, in Japan, it is common to use Ca
(OH) 2 for the pulpotomy. For this reason, Ca (OH) 2, which is commonly used in Japan, was used in this case. The tooth crown was able to be recontoured to an appropriate shape and the dental pulp remained in a vital state at three years after the procedure
n intentional partial pulpotomy can be effective for recontouring the tooth crown in cases with a large talon cusp that includes a dental pulp cavity. A
CBCT examination is important to clearly visualize the internalstructure when performing tooth crown morphological correction of an abnormal structure such as a talon cusp.
11 yr old boy reported with esthetic problem – noted that the tilting of 21 due to occlusal interference of talon cusp
extending from the cervical margin of the tooth toward the incisal edge [Figure 2]. It occluded on lower central incisor causing significant labial displacement of tooth #21.
An intraoral periapical radiograph of tooth revealed a typical V-shaped radiopaque structure arising from cingulam of central incisor with its pulpal extension superimposed over the image of an affected crown without any signs of periapical pathology
Complete single sitting reduction of talon cusp was planned. Tooth was anesthetized by local infiltration of 2% Xylocaine with 1:100,000 epinephrine. Isolation was achieved with rubber dam. Cusp reduction was performed using a sterile diamond bur with copious water coolant. A 5-mm deep pulpotomy was performed at the exposure site with a sterile #2 round bur. Hemorrhage was carefully controlled by 3% sodium hypochlorite. Mineral trioxide aggregate (MTA) (Dentsplywas mixed as per manufactures instructions and placed directly onto exposed pulp [Figures 4 and 5]. Cavity was restored with glass ionomer cement at the same appointment.
At
4-year follow-up, patient was asymptomatic without any
radiographic signs of periapical pathology [Figure 6].
When occlusal interference is severe, a complete reduction of cusp followed by vital pulp therapy or endodontic therapy can be completed in a single visit. Vital pulp therapy has a higher success rate compared to endodontic treatment, irrespective of the size of exposure. Success rates of 91% for pulpotomy was seen in comparison to 80% in direct pulp capping when performed under aseptic conditions and has been attributed to removal of inflamed pulp and reduction in bacterial load. MTA has replaced calcium hydroxide because of its biocompatibility, excellent sealing ability, antibacterial
properties and property to induce hard tissue formation in pulpal tissue
A south Indian girl aged 11 years reported to the Department of Pedodontics andPreventive Children Dentistry,concerned about her appearance and alsocomplained of associated food trapping, difficulty in brushing and interference duringspeech and mastication.
NRH medical and dentalThe clinical examination revealed a talon cusp on the palatal aspect of left maxillary central incisor; the tooth was displaced labially. A developing distal occlusion of the left lateral incisor was also noticed
The talon cusp was pyramidal in shape and measured 8.5 mm in length (incisocervically), 3.3 mm in width(mesiodistally) and 3.1 mm in thickness (labiolingually).
. Periapical radiography showed a V-shaped radiopaque structure superimposed on the image of the affected crown, with the point of the ‘V’ towards the incisal edgeA pulp extension could be traced radiographically to the middle of the cuspThe patient was scheduled for complete reduction of the talon cusp in a singleappointmenDeep carious grooves were debrided ofcarious tissue using a number eight round bur mounted on a slow-speed handpiecerestored witglass–ionomer cementA pinpoint pulp exposure occurred. Haemostasis was established with a sterile cotton pellet soaked in saline solution and MTA was applied. A final restoration of glass–ionomer cement (Fuji II GC; Universal Restorative, GC Corporation) was placed
arly diagnosis of taloncusp is important, and, in most cases, a definitive treatment is required. If the grooves are
carious, the lesion should be removed and the cavity restored. In cases of premature
contact and occlusal interference, the talon cusp should be reduced gradually on
consecutive visits over 6- to 8-week intervals to allow time for deposition of reparative
dentine for pulpal protection (Danesh et al. 2007).
Under certain conditions, less conservative methods can be used such as complete
reduction in the cusp followed by calcium hydroxide pulpotomy for an immature tooth or
root canal treatment (Gungor et al. 2000, Nadkami et al. 2002). Cvek et al. (1987) originally
proposed the use of calcium hydroxide (CaOH2) to be applied directly to the pulpal surface
to create an environment that stimulates the formation of a dentine bridge. Studies have
demonstrated that the healing is more predictable when there is no bacterial contamination of the pulp (Kakehashi et al. 1965). Some investigators have asserted that Ca(OH)2
starts to soften over time, resulting in leakage through the original seal (Cox et al. 1985).
Because of its caustic action (pH approximately 11.0–12.5), a localized area of coagulation
necrosis occurs in the tissues immediately subjacent to the medicament (Banchs & Trope
2004). As a result, pulpal healing and hard-tissue formation are delayed, and a potential for
symptoms exists. Adjacent to the zone of necrosis of up to 0.7 mm, cells in the pulp
differentiate into odontoblasts that elaborate the matrix for the dentine bridge (Heys et al.
1981). The resultant dentine bridge is most often porous (Cox et al. 1996), and
subsequent bacterial leakage through the porosities may result in pulpal inflammation
and necrosis (Saito et al. 2004).
Mineral trioxide aggregate is an endodontic cement composed of several mineral oxidesand is constituted by fine hydrophilic particles (Lessa et al. 2010). When mixed with water,it initially forms a gel that achieves a rigid set (Bogen & Kuttler 2009).
Mineral trioxide aggregate has been shown to induce hard-tissue formation morepredictably than Ca(OH)2 in shallow pulpotomy procedures (Koh et al. 2001). There is lesspulpal inflammation (Junn et al. 1998), and the lack of any localized tissue necrosisfollowing the application of MTA to pulpal tissue may be a result of the more rapid set of the hydrophilic material, as compared to Ca(OH)2 that maintains a local state of alkalinity
for a longer period.
Mineral trioxide aggregate has excellent sealing properties (Torabinejad et al. 1993),actively promotes hard-tissue formation (Parirokh & Torabinejad 2010a), is biocompatible(Torabinejad & Parirokh 2010) and upon setting has higher mechanical strength and better adhesion to dentine and restorative materials compared with Ca(OH)2 (Parirokh &Torabinejad 2010b). Histological examination of the dentine bridge formed following MTAapplication to the pulp reveals the bridge to form immediately adjacent to the MTA (Nairet al. 2008, Parirokh & Torabinejad 2010a). The MTA bridge begins to form sooner,becomes thicker and has less porosity than the hard tissue induced by Ca(OH)2 (Junnet al. 1998). The clinical data available on MTA pulp capping of cariously exposed
permanent teeth are limited to two studies that have reported a high rate of success,
which ranges from 93% to 98% (Farsi et al. 2006, Bogen 2008).Following the set of the MTA, glass–ionomer cement (Fuji II GC, Universal Restorative;
GC Corporation) was placed directly onto the surface of MTA creating a protective barrierfrom potential breakdown by acid-etch gels (Levitan & Himel 2006). Acid-etch procedures affect the compressive strength and surface microhardness of MTA (Kayahan et al. 2009).
Early diagnosis of taloncusp is important, and, in most cases, a definitive treatment is required. If the grooves arecarious, the lesion should be removed and the cavity restored. In cases of prematurecontact and occlusal interference, the talon cusp should be reduced gradually onconsecutive visits over 6- to 8-week intervals to allow time for deposition of reparativedentine for pulpal protection Under certain conditions, less conservative methods can be used such as completereduction in the cusp followed by calcium hydroxide pulpotomy for an immature tooth or root canal treatment
