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Paper text:
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 .
it was thereafter named a talon cusp by mellor and ripa due to its resemblance to an eagle 's talon .
the exact etiology is not known , but it is suggested to be a combination of genetic and environmental factors .
it is thought to arise during the morpho - differentiation stage of tooth development , as a result of outfolding of the enamel organ or hyper - productivity of the dental lamina .
it is composed of enamel , dentine , and a varying amount of pulp tissue .
reports of a mandibular talon cusp are rare in the literature . to the best of our knowledge ,
only 14 cases have been reported [ table 1 ] , of which only 2 cases are in mandibular left central incisors .
we report the second instance of a talon cusp in the lingual aspect of the mandibular left central incisor and the first such report in a patient of libyan origin . reported cases of mandibular talon 's cusp
an apparently healthy 11-year - old boy reported to the outpatient department in the faculty of dentistry , al jabal - algharbi - zawia university , zawia city , libya , for a routine dental checkup .
clinical examination revealed an accessory cusp on the lingual aspect of the mandibular left central incisor [ figure 1 ] .
it was projecting from the cemento - enamel junction and extended towards the incisal edge .
there was evidence of attrition on the lingual aspect of the maxillary left central incisor .
an intra - oral periapical radiograph revealed an inverted v shaped radiopaque structure on the mandibular left central incisor [ figure 2 ] .
the extent of pulp tissue into the cusp could not be determined from the radiograph .
treatment planning included periodic and gradual reduction of the accessory cusp to relieve the occlusal interference followed by application of topical fluoride .
clinical picture showing the type 1 talon cusp on lingual aspect of mandibular left permanent central incisor intra oral periapical radiograph showing the inverted v - shaped radiopaque accessory cusp on mandibular permanent central incisor
it has been defined as a 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 .
there is a wide variation in the size and shape of this anomaly . due to the variation , and in order to have diagnostic criteria , it has been classified into three types by hattab et al .
radiographically , it may appear typically as a v - shaped radiopaque structure , as in true talon or semi- talon , or be tubercle - like , as in trace talon , originating from the cervical third of the root .
the radiopaque v - shaped structure is superimposed over the normal image of the crown of the tooth .
this appearance varies with the shape and size of the cusp , and the angle at which the radiograph is taken .
it is composed of enamel , dentine , and a varying amount of pulp tissue .
the extent of pulp extension into the cusp is however difficult to determine because of its superimposition over the main pulp chamber .
the presence of pulp tissue within the accessory cusp has been controversial with contrasting reports of the presence and no evidence of pulp extension into the cusp .
cases with large cusps presenting away from the tooth had been shown to contain an extension of the pulp , superimposition of the image of the cusp over the main tooth made it difficult to determine the extent of pulp tissue in the anomalous cusp .
the exact etiology is not known , but it is suggested to be a combination of genetic and environmental factors . there was no associated systemic or local condition in this patient as is the case in most previous reports .
mays reported a statistically significant bias in favor of males and our patient is an 11-year - old boy which is concurrent with the literature . it is more common in the permanent dentition ( 75% ) than in the primary dentition , while 92% affect the maxillary teeth .
the maxillary lateral incisor is the most frequently affected in the permanent dentition , while the maxillary central incisor is the most affected in the primary dentition .
reports of the mandibular talon cusps are rare in the literature . to the best of our knowledge
, only 14 cases have been reported of which only 2 cases are of mandibular left central incisors [ table 1 ] .
we report the second instance of the talon cusp in the lingual aspect of the mandibular left central incisor and the first such report in a patient of libyan origin .
there are several reports in the literature that suggest the hereditary character of a talon cusp .
the presence of a talon cusp is not always an indication for dental treatment unless it is associated with clinical problems .
the complications of the talon cusp are diagnostic , functional , aesthetic , and pathological .
it includes compromised aesthetics , periodontal problems , or irritation of the soft tissues during speech or mastication .
functional complications include occlusal interference , trauma to the lip and tongue , speech problems , and displacement of teeth .
the deep grooves which join the cusp to the tooth may also act as stagnation areas for plaque and debris , become carious , and cause subsequent periapical pathology .
occlusal interference can damage the periodontium , cause infra - occlusion of the opposing tooth and also temporo - mandibular joint pain .
severe attrition or fracture of the enamel surface can cause exposure of the dentine - pulp complex and consequently , pulp necrosis . in our patient ,
the prominent lingual accessory cusp had occlusal interference with attrition facet on the opposing maxillary central incisor .
where there are deep developmental grooves , simple prophylactic measures such as fissure sealing and composite resin restoration can be carried out .
an essential step , especially in the case of occlusal interference , is to reduce the bulk of the cusp gradually and periodically and application of topical fluoride such as duraphat or acidulated phosphate fluoride ( apf ) gel to reduce sensitivity and stimulate reparative dentine formation for pulp protection , or outright total reduction of the cusp and calcium hydroxide pulpotomy .
it may also become necessary sometimes , to fully reduce the cusp , extirpate the pulp , and carry out root canal therapy .
orthodontic correction may become necessary when there is tooth displacement or malalignment of affected or opposing teeth .
our patient was treated with periodic and gradual reduction of the accessory cusp to relieve the occlusal interference followed by application of topical fluoride .
we report the second instance of the talon cusp in the lingual aspect of the mandibular left central incisor and the first such report in a patient of libyan origin .
although such instances are rare , early identification and prompt treatment of accessory cusps can prevent the complications of occlusal interference and malocclusion .
a talon cusp is a supernumerary structure projecting from the dento - enamel junction to a variable distance towards the incisal edge of an anterior tooth . 
 it consists of enamel , dentine and a variable amount of pulp tissue . 
 hyperactivity of the enamel organ during morpho - differentiation has been attributed to its formation . 
 it has esthetic and functional concerns . 
 reports of a mandibular talon cusp are rare in the literature . to the best of our knowledge , 
 only 14 cases have been reported , of which only 2 cases in mandibular left central incisors . 
 we report the second instance of a talon cusp in the lingual aspect of the mandibular left central incisor and the first such report in a patient of libyan origin . 
 a talon cusp is an odontogenic anomaly , which can cause occlusal interferences , displacement of the affected tooth and speech difficulties . 
 early diagnosis of a talon cusp helps in selecting the appropriate treatment procedure and to avoid future complications .