Dental Anomalies Part 2 **Dr Jilen Patel** *BDS* (Hons) *WA, DClin*Dent, MRACDS, *FADI, FICD, FPFA, SFHEA* Specialist Paediatric Dentist Consultant, Perth Children's Hospital Senior Lecturer, UWA Dental School **Dr Jilen Patel** *BDS (Hons) WA, DClinDent, MRACDS, FADI, FICD, FPFA, SFHEA* - Specialist Paediatric Dentist - Consultant, Perth Children's Hospital - Senior Lecturer, UWA Dental School **Dr Jilen Patel** **Paediatric Dentistry** **THE UNIVERSITY OF WESTERN AUSTRALIA** | Dental Anomaly | Stage of Tooth Development | | :--- | :--- | | Anodontia | Initiation stage | | Hypodontia | Bud stage | | Supernumerary teeth | Bud stage | | Fusion | Bud to cap stage | | Gemination | Bud to cap stage | | Evaginatus | Cap to bell stage | | Taurodontism | Bell stage | | Dens invaginatus | Bell stage | | Talon cusp | Bell stage | | Concrescence | Eruption stage | | Dilaceration | Root formation stage | | Hypercementosis | Root formation stage | **Early thickening** **Bud** **Early cap** (Images showing histological sections of tooth development labeled 1, 2, and 3) **Late cap** **Bell** (Images showing histological sections of tooth development labeled 4 and 5) Labeling from image (Image labeled 5): oral epithelium dental lamina outer enamel epithelium stellate reticulum inner enamel epithelium dental follicle dental papilla **Cobourne & Sharpe 2003**   #### Correlation of Anomalies to Developmental Stages | Dental Anomaly | Stage of Tooth Development | | :--- | :--- | | Anodontia | Initiation stage | | Hypodontia | Bud stage | | Supernumerary teeth | Bud stage | | Fusion | Bud to cap stage | | Gemination | Bud to cap stage | | Evaginatus | Cap to bell stage | | Taurodontism | Bell stage | | Dens invaginatus | Bell stage | | Talon cusp | Bell stage | | Concrescence | Eruption stage | | Dilaceration | Root formation stage | | Hypercementosis | Root formation stage | #### Histological Stages of Development Tooth development progresses through the following sequential stages: 1. Early thickening 2. Bud 3. Early cap 4. Late cap 5. Bell #### Anatomical Structures in the Bell Stage According to Cobourne & Sharpe (2003), the following structures are identifiable during the bell stage of development: - Oral epithelium - Dental lamina - Outer enamel epithelium - Stellate reticulum - Inner enamel epithelium - Dental follicle - Dental papilla Table mapping 'Dental Anomaly' to 'Stage of Tooth Development'. Columns list specific conditions like Anodontia, Hypodontia, Supernumerary teeth, Fusion, Gemination, Evaginatus, Taurodontism, Dens invaginatus, Talon cusp, Concrescence, Dilaceration, and Hypercementosis alongside their corresponding developmental stages. Panel of histological micrographs illustrating the stages of tooth development. Includes labels for 'Early thickening', 'Bud', 'Early cap', 'Late cap', and 'Bell'. Image 5 contains detailed callouts identifying oral epithelium, dental lamina, outer enamel epithelium, stellate reticulum, inner enamel epithelium, dental follicle, and dental papilla. Source cited as Cobourne & Sharpe 2003. # Anomalies of Shape Double tooth - Fusion - Geminatio Double tooth anomalies include: - Fusion - Gemination **Definition:** Double teeth are formed of two or more elements diagnosed clinically by evidence of incisal notching with labial grooving and radiographically by pulpal bifurcation (Winter, 1969) **Alternative terminology** * Connate (Tomes, 1859) * Linking tooth (Sprinz, 1953) * Schizodontia (DeJonge, 1955) * Fusion (Levitas, 1965) * Geminatioon (Levitas, 1965) * Connation (Hitchin and Morris, 1966) * Dichotomy (Schulze, 1970) * Others * conjoined teeth * double formations <img>Double Tooth slide from University of Western Australia including definitions and terminology list<img> #### Clinical and Radiographic Definition Double teeth are formed of two or more elements diagnosed clinically by evidence of incisal notching with labial grooving and radiographically by pulpal bifurcation (Winter, 1969). #### Alternative Terminology - Connate (Tomes, 1859) - Linking tooth (Sprinz, 1953) - Schizodontia (DeJonge, 1955) - Fusion (Levitas, 1965) - Gemination (Levitas, 1965) - Connation (Hitchin and Morris, 1966) - Dichotomy (Schulze, 1970) - Conjoined teeth - Double formations **Double Tooth** **Etiology** * Inherited * Local factors * the union may be the result of fusion of two adjacent tooth buds * the partial splitting of one into two * tooth germ move together because of crowding or trauma (Milano et al. 1999) #### Etiological Factors - Inherited factors - Local factors: - The union may be the result of fusion of two adjacent tooth buds - The partial splitting of one tooth bud into two - Tooth germs moving together because of crowding or trauma (Milano et al. 1999) # Double Tooth ## Prevalence - M = F - Primary dentition: 0.1 – 3.0% (Brook, 1974; Buenviaje, 1984; Cheng, 2003; Sekerci et al. 2011) - Permanent dentition: 0.1-0.8% (Chung et al. 1972; Brook, 1974; Tsai, 1996) - The occurrence can be unilateral or bilateral - Predominantly in the <b>incisor and canine</b> region - More common in the maxilla - <b>Bilateral in primary dentition</b>: greater likelihood of the subject having anomalies in the permanent dentition #### Prevalence and Distribution - Gender distribution: Equal occurrence in males and females (M = F) - Primary dentition: 0.1 – 3.0% (Brook, 1974; Buenviaje, 1984; Cheng, 2003; Sekerci et al. 2011) - Permanent dentition: 0.1 – 0.8% (Chung et al. 1972; Brook, 1974; Tsai, 1996) #### Clinical Characteristics - Occurrence can be unilateral or bilateral. - Predominantly located in the incisor and canine region. - More common in the maxilla. - Bilateral occurrence in the primary dentition indicates a greater likelihood of the subject having anomalies in the permanent dentition. # **Double Tooth** ## **Clinical Presentation** * It varies considerably from a minor notch in the incisal edge of an abnormally wide incisor to the appearance of almost two separate crowns * If the ‘double tooth’ is present together with a normal complement of teeth in the same quadrant : **geminaton** (*Geminaton is corrected from OCR ambiguity.*) * If the number of teeth is reduced in the same quadrant : **fusion** ###### (A) Geminaton ###### (B) Fusion ###### Ramezani et al 2021 ## **Radiographs** * Necessary to determine if there is a union of the pulp chambers ***THE UNIVERSITY OF WESTERN AUSTRALIA***  #### Clinical Appearance Presentation varies considerably from a minor notch in the incisal edge of an abnormally wide incisor to the appearance of almost two separate crowns. #### Differential Diagnosis - **Gemination**: If the "double tooth" is present together with a normal complement of teeth in the same quadrant. - **Fusion**: If the number of teeth is reduced in the same quadrant. #### Radiographic Assessment Radiographs are necessary to determine if there is a union of the pulp chambers. Labeled clinical diagram comparing two tooth anomalies: (A) Geminaton shows a single tooth with a bifurcated crown but one root; (B) Fusion shows two distinct crowns sharing a common root structure. Labels include '(A)', '(B)', 'Geminaton', and 'Fusion'. The source citation 'Ramezani et al 2021' appears in blue text below the fusion illustration. # Double Tooth - Fusion <details> **THE UNIVERSITY OF WESTERN AUSTRALIA** T4A3 **Definition** - It is a result of the embryological persistence of the dental lamina between the two tooth buds (Hitchen and Morris, 1966) - It is the result of an unsuccessful attempt of two tooth buds to fuse into one (Kelly, 1978) - If it occurs **early in odontogenesis**: - the two developing teeth will unite to form a single tooth of almost normal size - If it occurs **late in odontogenesis**: - one tooth (which can be as much as twice the size of the normal tooth) - or a tooth with a bifid crown can result </details>  #### Developmental Definitions - Fusion is a result of the embryological persistence of the dental lamina between the two tooth buds (Hitchen and Morris, 1966). - It is the result of an unsuccessful attempt of two tooth buds to fuse into one (Kelly, 1978). #### Timing of Odontogenesis - **Early occurrence**: The two developing teeth will unite to form a single tooth of almost normal size. - **Late occurrence**: Results in one tooth that can be as much as twice the size of a normal tooth, or a tooth with a bifid crown. Educational slide from The University of Western Australia titled 'Double Tooth - Fusion'. The slide provides a textual definition and explanation of dental fusion. It includes two citations (Hitchen and Morris, 1966; Kelly, 1978) and details the outcomes based on the timing of odontogenesis: early fusion results in a single tooth of normal size, while late fusion results in a larger tooth or one with a bifid crown. **Double Tooth - Fusion** The University of Western Australia **Clinical manifestations** * Fused teeth might have one or two pulp chambers * Fused teeth commonly exhibit labial and lingual vertical grooves on the crown surface * If the affected tooth is counted as one, there is usually one tooth less than normal for a given dental age   #### Clinical Manifestations of Fusion - Fused teeth might have one or two pulp chambers. - Fused teeth commonly exhibit labial and lingual vertical grooves on the crown surface. - If the affected tooth is counted as one, there is usually one tooth less than normal for a given dental age. Clinical intraoral photograph showing fused teeth (fusion). The image displays the crown surfaces of anterior teeth with visible labial and lingual vertical grooves, consistent with the clinical manifestations described in the text. The fused tooth appears as a single unit but shows signs of developmental fusion. Radiograph (X-ray) illustrating double tooth - fusion. The image shows two adjacent teeth that are fused together, forming a single entity with one or more pulp chambers. This radiographic view complements the clinical photo by revealing internal anatomical structures such as root morphology and pulp chamber configuration, which are key diagnostic features for identifying fusion versus gemination. **Double Tooth - Gimation** **Gemination** * Gemination is the formation of two teeth from the same follicle (Ravn, 1971) * There is one common pulp chamber (Kelly, 1978) * Gemination is more common in maxilla * In permanent dentition these teeth are usually macrodents * Diagnosis of root canal morphology may be aided by use of CBCT as plain films are difficult to interpret  #### Characteristics of Gemination - Gemination is the formation of two teeth from the same follicle (Ravn, 1971). - There is one common pulp chamber (Kelly, 1978). - Gemination is more common in the maxilla. - In the permanent dentition, these teeth are usually macrodonts. - Diagnosis of root canal morphology may be aided by the use of CBCT, as plain films are difficult to interpret. Clinical photo of a patient's upper anterior teeth showing bilateral gemination. The image displays two central incisors on each side that appear fused or doubled from the same follicle, consistent with the definition provided in the OCR text. The caption 'Bilateral Gemination' is visible below the image. Double Tooth - Geminational Upper Central Incisor Malalignment and Hypoplasia of Adjoining Teeth due to Hereditary Epithelial Dysplasia Journal of the Particularity of Science (1705) 4(3), pp. 14-17 The University of Western Australia www.uwa.edu.au    Double Tooth - Geminational Upper Central Incisor Malalignment and Hypoplasia of Adjoining Teeth due to Hereditary Epithelial Dysplasia Journal of the Particularity of Science (1705) 4(3), pp. 14-17 Clinical photo of the maxillary anterior teeth showing a geminated central incisor (double tooth) with a deep developmental groove. The title 'Double Tooth - Geminational Upper Central Incisor' applies to this image. Clinical photo of the maxillary anterior teeth demonstrating malalignment and hypoplasia of the adjacent lateral incisors due to hereditary epithelial dysplasia, as referenced in the OCR text. Dental radiograph (periapical view) of the upper anterior teeth. It shows the internal structure of the geminated tooth, revealing two separate pulp chambers within a single crown, confirming the diagnosis of gemination over fusion. Double Tooth - Geminatio   Double Tooth - Geminatio Clinical intraoral photograph showing a double tooth (geminatio). The image displays two fused crowns with a single root structure visible in the adjacent radiograph context. The tooth appears to have a large restoration or filling on the occlusal surface. Dental radiograph showing gemination of a molar tooth. A black arrow points to the bifurcation of the crown into two lobes while maintaining a single root canal system, characteristic of gemination rather than fusion. Adjacent teeth show normal anatomy. **Double Tooth - Concrescence**  Double Tooth - Concrescence Clinical photographs demonstrating dental concrescence (Double Tooth). The left panel shows a large fused tooth structure with two distinct crowns and roots, measured against a ruler indicating approximately 1.5 cm in width. The right panel displays multiple smaller specimens of fused teeth on a blue background, illustrating various presentations of the condition. **Double Tooth** - Clinical problems associated with double tooth: - Caries in the groove dividing the bifid crown - Periodontal disease due to extension of the groove to the root surface - Excess arch space and diastema occurs when normal teeth are fused - Crowding of the dental arch, if the fusion involves one normal tooth and a supernumerary tooth - Aplasia of the permanent successor in case of fusion - Delayed exfoliation and root resorption of primary double teeth - Impaction of the permanent successor - Malocclusion - Esthetic problems Hattab, 2014 #### Associated Clinical Problems - Caries in the groove dividing the bifid crown. - Periodontal disease due to extension of the groove to the root surface. - Excess arch space and diastema occurring when normal teeth are fused. - Crowding of the dental arch if the fusion involves one normal tooth and a supernumerary tooth. - Aplasia of the permanent successor in cases of fusion. - Delayed exfoliation and root resorption of primary double teeth. - Impaction of the permanent successor. - Malocclusion. - Esthetic problems. (Hattab, 2014) ## **Double Tooth** ### **Management** - Fissure sealant - Flowable composite resin - Hemi-section - Reshaping or reduction of a double tooth with a single canal ? - Orthodontic treatment and/or prosthetic replacement - Extraction and replacement with an implant #### Management Strategies - Fissure sealant - Flowable composite resin - Hemi-section - Reshaping or reduction of a double tooth with a single canal - Orthodontic treatment and/or prosthetic replacement - Extraction and replacement with an implant <img>Paediatric dental decay<img>  Paediatric dental decay Clinical photo of the lower dental arch showing severe early childhood caries. The image displays multiple primary molars with extensive decay, particularly on the left side where teeth exhibit large cavitations and dark discoloration. The context from OCR identifies this as 'Paediatric dental decay'. Thumbnail (abstract): Dr Jilen Patel, Paediatric Dentistry  Dr Jilen Patel, Paediatric Dentistry Clinical intraoral photograph of the lower anterior dentition showing a primary central incisor (likely tooth 41) with extensive carious destruction. The crown is severely undermined and discolored, appearing black and brown, indicating advanced decay. Adjacent teeth show some staining but appear structurally intact. The image includes the gingival margin and surrounding soft tissue. **Talon Cusp** * Definition “process of horn-like shape” curving from the base to the “cutting edge” on the palatal surfaces of the incisors *(Mitchell, 1892)* * The term “talon cusp” was proposed because of the shape of the anomaly resembling an eagle’s talon *(Mellor and Ripa, 1970)* * A cusp-like projection from the palatal surface of an anterior tooth that extended at least half the distance from the cemento-enamel junction to the incisal edge *(Davis and Brook, 1985)* - **Definition**: A "process of horn-like shape" curving from the base to the "cutting edge" on the palatal surfaces of the incisors (Mitchell, 1892). - **Etymology**: The term "talon cusp" was proposed because the shape of the anomaly resembles an eagle’s talon (Mellor and Ripa, 1970). - **Clinical Criteria**: A cusp-like projection from the palatal surface of an anterior tooth that extends at least half the distance from the cemento-enamel junction to the incisal edge (Davis and Brook, 1985). # Talon Cusp **THE UNIVERSITY OF WESTERN AUSTRALIA** **Alternative terminology** - Cusp-like projection \ \t(Mitchell, 1892) - Hyperplastic cingulum \ \t(Worth, 1963) - Palatal accessory cusp \ \t(Ooshima et al. 1996) - Projection on the facial surface of the anterior teeth \ \t(Tsutsumi 1991) - Evaginated odontome \ \t(Lee, 1968) - Cusped cingulum \ \t(Barnes, 1969) - Accessory cusp \ \t(Schulze, 1970) - Dens evaginatus \ \t(Shey and Eytel, 1983) - Supernumerary lingual tubercle \ \t(Harris and Owsley, 1991) - Others: T-cingulum, Y-shaped cingulum The following terms are used synonymously with talon cusp: - Cusp-like projection (Mitchell, 1892) - Hyperplastic cingulum (Worth, 1963) - Palatal accessory cusp (Ooshima et al. 1996) - Projection on the facial surface of the anterior teeth (Tsutsumi 1991) - Evaginated odontome (Lee, 1968) - Cusped cingulum (Barnes, 1969) - Accessory cusp (Schulze, 1970) - Dens evaginatus (Shey and Eytel, 1983) - Supernumerary lingual tubercle (Harris and Owsley, 1991) - T-cingulum - Y-shaped cingulum # Talon Cusp **Frequency** - Male > Female (al-Omari et al. 1999) - Male : Female = 1.9 : 1 (Lee et al. 2007) - Rare in the primary dentition - **Primary dentition**: 0.5 – 0.6% (Chen, 1986; Ooshima et al. 1996; Liu, 1996) - **Permanent dentition**: 1 – 2.5% (Ooshima et al. 1996; Mavrodisz et al. 2003; King et al. 2010) - It is observed only in the maxillary anterior teeth and involves the incisors and canines #### Prevalence and Distribution - **Gender Predilection**: More common in males than females. - Male : Female ratio = 1.9 : 1 (Lee et al. 2007; al-Omari et al. 1999). - **Dentition Type**: - **Primary dentition**: Rare, occurring in 0.5 – 0.6% of cases (Chen, 1986; Ooshima et al. 1996; Liu, 1996). - **Permanent dentition**: Occurs in 1 – 2.5% of cases (Ooshima et al. 1996; Mavrodisz et al. 2003; King et al. 2010). - **Location**: Observed only in the maxillary anterior teeth, specifically involving the incisors and canines. **Talon Cusp** **Etiology** * Unknown * Multifactorial involving both genetic and environmental factors (Davis and Brook, 1986; al-Omari et al. 1999) * May occur because of an outward folding of the inner enamel epithelial cells and a transient focal hyperplasia of the mesenchymal dental papilla (Hattab et al. 1996) * Hyperactivity of the dental lamina (commonly in the anterior region) (Rantanen, 1971) * Due to the fusion of a normal and a supernumerary tooth (Hennekam and Van Doorne, 1990) #### Proposed Theories - The exact etiology remains unknown. - **Multifactorial**: Involves both genetic and environmental factors (Davis and Brook, 1986; al-Omari et al. 1999). - **Morphological Development**: May occur due to an outward folding of the inner enamel epithelial cells and a transient focal hyperplasia of the mesenchymal dental papilla (Hattab et al. 1996). - **Dental Lamina**: Hyperactivity of the dental lamina, commonly in the anterior region (Rantanen, 1971). - **Fusion**: May result from the fusion of a normal tooth and a supernumerary tooth (Hennekam and Van Doorne, 1990). # Talon Cusp **THE UNIVERSITY OF WESTERN AUSTRALIA** ## Classification * **Type 1 - Talon:** A morphological well-defined additional cusp that prominently projects from the palatal surface of a primary or permanent anterior tooth and extends at least half the distance from the cemento-enamel junction to the incisal edge **Hattab et al. 1996**  #### Hattab et al. (1996) Classification - **Type 1 - Talon**: A morphologically well-defined additional cusp that prominently projects from the palatal surface of a primary or permanent anterior tooth and extends at least half the distance from the cemento-enamel junction to the incisal edge. Clinical intraoral photograph of the maxillary anterior dentition showing a prominent talon cusp on the central incisor. The image demonstrates the morphological features described in the text: a well-defined additional cusp projecting from the palatal surface that extends more than halfway to the incisal edge. **Talon Cusp** **Classification** - Type 2 - Semi-talon: An additional cusp of a millimeter or more but extending less than half the distance from the cemento-enamel junction to the incisal edge. It may blend with the palatal surface or stand away from the rest of the crown Hattab et al. 1996  #### Hattab et al. (1996) Classification (Continued) - **Type 2 - Semi-talon**: An additional cusp of a millimeter or more but extending less than half the distance from the cemento-enamel junction to the incisal edge. It may blend with the palatal surface or stand away from the rest of the crown. Clinical photo of a Talon Cusp (Type 2 - Semi-talon). The image shows the palatal view of anterior teeth with an additional cusp on one of the central incisors. The cusp is described as extending less than half the distance from the cemento-enamel junction to the incisal edge and may blend with the palatal surface or stand away from the rest of the crown. Talon Cusp Classification * **Type 3 - Trace talon:** presents as an enlarged and prominent cingulum and its variations (i.e. conical, bifid, or tubercle-like) Hattab et al. 1996  #### Hattab et al. (1996) Classification (Continued) - **Type 3 - Trace talon**: Presents as an enlarged and prominent cingulum and its variations (e.g., conical, bifid, or tubercle-like). Clinical intraoral photograph showing the anterior maxillary dentition from a superior view. The image demonstrates Type 3 'Trace talon' cusp morphology as described by Hattab et al. (1996), characterized by enlarged and prominent cingula on the central incisors that appear conical or tubercle-like. **Talon Cusp** **Modified classification** Hsu et al. 2001 * **Type 1 - Major talon:** A morphologically well-defined additional cusp that projects from the facial or palatal / lingual surface of an anterior tooth and extends at least half the distance from the cemento-enamel junction to the incisal edge * **Type 2 - Minor talon:** A morphologically well-defined additional cusp that projects from the facial or palatal/lingual surface of an anterior tooth and extends more than one fourth, but less than half the distance from the cemento-enamel junction to the incisal edge * **Type 3 - Trace talon:** Enlarged or prominent cingula and their variations which occupy less than one fourth the distance from the cemento-enamel junction to the incisal edge Facial, lingual, facial and lingual (Mallineni et al. 2014)   #### Modified Classification (Hsu et al. 2001) - **Type 1 - Major talon**: A morphologically well-defined additional cusp projecting from the facial or palatal/lingual surface extending at least half the distance from the CEJ to the incisal edge. - **Type 2 - Minor talon**: A morphologically well-defined additional cusp projecting from the facial or palatal/lingual surface extending more than one-fourth, but less than half the distance from the CEJ to the incisal edge. - **Type 3 - Trace talon**: Enlarged or prominent cingula occupying less than one-fourth the distance from the CEJ to the incisal edge. #### Location Variations - Can occur on facial, lingual, or both facial and lingual surfaces (Mallineni et al. 2014). Clinical intraoral photograph of anterior teeth demonstrating a 'Talon Cusp'. The image shows the upper and lower front teeth, highlighting an additional cusp projecting from the palatal surface of an upper central incisor. Periapical dental radiograph showing the root structure of anterior teeth. This visual is pertinent to the text as it demonstrates the internal anatomy associated with talon cusps (enamel/dentin projections) extending from the cervical region towards the incisal edge. # **Talon Cusp** PHOENIX AUSTRALIA THE UNIVERSITY OF WESTERN AUSTRALIA **Radiographically** * It resembles a radio-opaque v-shaped structure pointing towards the incisal edge of the tooth which is superimposed on the normal image of the crown * The cusp image is outlined by two distinct white lines, representing the enamel, converging from the cervical area towards the incisal edge   #### Imaging Characteristics - Resembles a radio-opaque V-shaped structure pointing towards the incisal edge of the tooth. - The image is superimposed on the normal crown image. - The cusp is outlined by two distinct white lines representing enamel, which converge from the cervical area toward the incisal edge. Intraoral radiograph showing a tooth with a Talon Cusp. The image demonstrates the characteristic radio-opaque V-shaped structure pointing towards the incisal edge, superimposed on the crown as described in the text. Dental panoramic radiograph highlighting a Talon Cusp on an anterior tooth (circled). An arrow points to the specific cusp feature outlined by two distinct white enamel lines converging from the cervical area towards the incisal edge. **Talon Cusp** Talon cusp prevalent in the following syndromes • Rubinstein-Taybi syndrome • Mohr syndrome [oral-facial-digital II] • Struge-Weber syndrome [encephalo-trigeminal angiomatosis] • incontinentia pigmentia achromians • Ellis-van Creveld syndrome [chondroectodermal dysplasia] • Hyopmelanosis of Ito • Alagille’s syndrome • Berardinelli-Seip • Sturge-Weber angiomaans <img>Twelve   #### Associated Conditions Talon cusp is prevalent in the following syndromes: - Rubinstein-Taybi syndrome - Mohr syndrome (oral-facial-digital II) - Sturge-Weber syndrome (encephalo-trigeminal angiomatosis) - Incontinentia pigmenti achromians - Ellis-van Creveld syndrome (chondroectodermal dysplasia) - Hypomelanosis of Ito - Alagille’s syndrome - Berardinelli-Seip syndrome Clinical photo showing the labial view of anterior teeth with a prominent talon cusp on a central incisor. The extra cusp projects from the incisal edge and extends subgingivally. Clinical photo showing an occlusal or close-up view of a tooth exhibiting a large talon cusp extending well below the gumline, demonstrating the structural anomaly described in the text. Talon Cusp Complications associated with Talon cusp - Compromised esthetics (facial talon cusp) - Traumatic occlusion - Displacement of the affected and opposing teeth - Plaque retention - Caries susceptibility in the developmental grooves delineate the cusp - Pulpal necrosis - Hypersensitivity - Periodontal problems - Attrition of the opposing teeth accidental cusp fracture - Periapical pathosis due to excessive attrition - Irritation of tongue during speech and mastication - Interference with tongue space - Speech disturbance - Breast-feeding problems - TMJ joint pain due to excessive occlusal forces Hsu, 2001 #### Clinical Complications (Hsu, 2001) - **Esthetics and Occlusion**: - Compromised esthetics (facial talon cusp) - Traumatic occlusion and attrition of opposing teeth - Displacement of affected and opposing teeth - TMJ pain due to excessive occlusal forces - **Dental Health**: - Plaque retention and caries susceptibility in developmental grooves - Pulpal necrosis and periapical pathosis (due to excessive attrition) - Hypersensitivity and accidental cusp fracture - Periodontal problems - **Functional Issues**: - Irritation of the tongue during speech and mastication - Interference with tongue space and speech disturbance - Breast-feeding problems # Talon Cusp ## Management * Fissure sealants or flowable composite resin: to prevent caries in the grooves between the various parts of the tooth * If there is **no occlusal interference**: no treatment is required * If occlusal interference is present: - gradual, periodic reduction of enamel only (to avoid pulp exposure) with fluoridation as a de-sensitising agent - elective pulpotomy - partial pulpectomy - or extraction followed by orthodontic treatment (Mellor and Ripa, 1970; Pitts and Hall, 1983) #### Treatment Options - **Preventative**: Application of fissure sealants or flowable composite resin to prevent caries in the grooves. - **Observation**: No treatment is required if there is no occlusal interference. - **Interventional (if interference exists)**: - Gradual, periodic reduction of enamel with fluoridation as a desensitizing agent (to avoid pulp exposure). - Elective pulpotomy. - Partial pulpectomy. - Extraction followed by orthodontic treatment. (Mellor and Ripa, 1970; Pitts and Hall, 1983) **THE UNIVERSITY OF WESTERN AUSTRALIA** Dr Jilen Patel Paediatric Dentistry Int J Paediatr Dent. 2007 May;17(3):178-85. **The relationship between a primary maxillary incisor with a talon cusp and the permanent successor: a study of 57 cases.** Lee CK$^1$, King NM, Lo EC, Cho SY. **Abstract** **BACKGROUND:** Most reported cases of talon cusps in the primary dentition have been on the maxillary central incisors and the permanent successors have remained unaffected. Four of the five reported cases on a maxillary lateral incisor, however, have been associated with a supernumerary permanent successor. **AIM:** This paper describes the relationship between the presence of talon cusps on a primary maxillary incisor, and the morphology and number of the permanent successors in a population of Chinese children. **DESIGN:** The dental records of children diagnosed with a talon cusp on a primary incisor were retrieved for review. The diagnoses took place in a regional school dental clinic in Hong Kong between April 2002 and August 2005. **RESULTS:** Fifty-eight primary maxillary incisors with talon cusps were found. When the central incisors were involved, 32 of the 35 (91.4%) underlying permanent successors were not found to be associated with any odontogenic abnormalities. When the lateral incisors were involved, however, 18 of the 23 cases (78.3%) showed odontogenic abnormalities, 14 of which were associated with supernumerary teeth. **CONCLUSIONS:** The present study shows that, when there is a talon cusp on a primary maxillary lateral incisor, a high proportion of the underlying permanent successors can be expected to exhibit odontogenic abnormalities. PMID: 17397461 DOI: 10.1111/j.1365-263X.2007.00823.x [Indexed for MEDLINE] #### Research Study: Primary Maxillary Incisors and Permanent Successors **Reference**: Lee CK, King NM, Lo EC, Cho SY. (2007). Int J Paediatr Dent. 17(3):178-85. - **Background**: Talon cusps in primary dentition usually affect maxillary central incisors without impacting successors. However, cases involving primary lateral incisors are often associated with supernumerary permanent successors. - **Design**: Review of dental records for Chinese children diagnosed with primary talon cusps in Hong Kong (2002–2005). - **Results** (58 primary maxillary incisors): - **Central Incisors**: 91.4% (32/35) of underlying permanent successors were normal. - **Lateral Incisors**: 78.3% (18/23) showed odontogenic abnormalities, with 14 cases associated with supernumerary teeth. - **Conclusion**: A high proportion of underlying permanent successors can be expected to exhibit odontogenic abnormalities when a talon cusp is present on a primary maxillary lateral incisor. **Dens Evaginatus** **Definition:** It is an **enamel-covered tubercle projecting from the occlusal surface** of a premolar and in rare instances canines and molars (Lau, 1955, Allright, 1958) **Alternative terminology** * Interstitial cusp (Yumikura and Yoshida, 1936) * **Leong premolar** (**Leong**, 1946) * Occlusal enamel pearl (Pedersen, 1949) * Dilated composite Odontome (Tratman, 1949) * Odontome of axial core type (Lau, 1955; Allwright, 1958) * Tuberculuated premolar (Ohlers, 1956) * Cone-shaped Supernumerary cusp (Moorress, 1957) * Dens evaginated (Oehlers,1967) * Evaginated Odontome (Oehlers,1967) * Mongoloid or oriental premolar (Curzon, 1970) #### Clinical Definition Dens evaginatus is an enamel-covered tubercle projecting from the occlusal surface of a premolar and, in rare instances, canines and molars (Lau, 1955; Allright, 1958). #### Alternative Terminology Various terms have been used in literature to describe this condition: - Interstitial cusp (Yumikura and Yoshida, 1936) - Leong premolar (Leong, 1946) - Occlusal enamel pearl (Pedersen, 1949) - Dilated composite Odontome (Tratman, 1949) - Odontome of axial core type (Lau, 1955; Allwright, 1958) - Tuberculuated premolar (Ohlers, 1956) - Cone-shaped Supernumerary cusp (Moorress, 1957) - Dens evaginated (Oehlers, 1967) - Evaginated Odontome (Oehlers, 1967) - Mongoloid or oriental premolar (Curzon, 1970) **Dens Evaginatus** **Etiology** * Unknown * Multifactorial: association with racial and genetic factors Abnormal proliferation of the inner enamel epithelium into the stellate reticulum of the enamel caused by: – either an outflowing of the enamel epithelium – or by a transient focal hyperplasia of the primitive pulpal mesenchyme (King et al. 2010)  #### Proposed Etiological Factors The exact etiology remains unknown, though it is considered multifactorial with strong associations to racial and genetic factors. It involves the abnormal proliferation of the inner enamel epithelium into the stellate reticulum of the enamel organ, caused by: - An outflowing of the enamel epithelium - A transient focal hyperplasia of the primitive pulpal mesenchyme (King et al. 2010) Clinical intraoral photograph showing a close-up view of posterior teeth. The image displays the occlusal surfaces of molar and premolar teeth with visible gingiva. A black arrow points to the distal cusp of one of the molars, indicating the presence of Dens Evaginatus (an extra tubercle/cusp). The visual demonstrates the specific dental anomaly discussed in the text. **Dens Evaginatus** **Prevalence** * Mostly found on permanent teeth * Typically occurs on premolar teeth * Demonstrate marked mandibular predominance * Teeth with dens evaginatus usually occur bilaterally * Prevalence between 0.1% to 4.7% * Frequently seen in Mongoloids, Asians, the Inuit, and Native Americans and rare in Whites (Lau, 1955; Goto et al. 1979; Ooshima et al. 1996; King et al. 2010) #### Clinical Presentation and Demographics - Mostly found on permanent teeth - Typically occurs on premolar teeth - Demonstrates a marked mandibular predominance - Teeth with dens evaginatus usually occur bilaterally - Prevalence ranges between 0.1% to 4.7% - Frequently seen in Mongoloids, Asians, the Inuit, and Native Americans; rare in Whites (Lau, 1955; Goto et al. 1979; Ooshima et al. 1996; King et al. 2010) Dens Evaginatus    Dens Evaginatus Clinical intraoral photograph showing occlusal view of posterior teeth. The central tooth exhibits a prominent cusp on the biting surface (cingulum area), characteristic of Dens Evaginatus. Clinical intraoral photograph showing lateral view of anterior/posterior teeth. A small, distinct cusp is visible on the occlusal surface of the central tooth in the image, demonstrating the external manifestation of Dens Evaginatus. Dental radiograph (periapical X-ray) of mandibular molars. A red circle highlights the root of the second molar from the left, which shows a bulbous or hook-shaped extension at the apex, indicating an internal dens evaginatus or associated developmental anomaly. Dens Evaginatus <THE UNIVERSITY OF WESTERN AUSTRALIA> **Classification** (Lau, 1955) **According to the location** * **Tubercle** can arise from **the lingual ridge of** the buccal cusp * **Tubercle** is located in the **center of the occlusal surface** **According to the form of the projection** The evagination may be: * **Smooth** * **Grooved** * **Terraced** * **Ridged**  #### Lau Classification (1955) **Classification According to Location** - Tubercle arising from the lingual ridge of the buccal cusp - Tubercle located in the center of the occlusal surface **Classification According to Form of Projection** The evagination may be categorized as: - Smooth - Grooved - Terraced - Ridged Set of four line-drawing diagrams illustrating the 'form of the projection' for Dens Evaginatus. Top-left shows a 'Smooth form' with a single rounded protrusion. Top-right shows a 'Grooved form' with a central ridge and flanking grooves. Bottom-left shows a 'Terraced form' with stepped ridges. Bottom-right shows a 'Ridged form' with multiple sharp peaks. Each diagram is labeled below. # Dens Evagintous ## Classification (Oehlers, 1967) Oehlers identified the evagination according to the pulp contents within the tubercle: * Wide pulp horns 34% * Narrow pulp horns 22% * Constricted pulp horns 14% * Isolated pulp horn remnants 20% * No pulp horn 10%  #### Oehlers Classification (1967) Oehlers identified the evagination according to the pulp contents within the tubercle: - Wide pulp horns: 34% - Narrow pulp horns: 22% - Constricted pulp horns: 14% - Isolated pulp horn remnants: 20% - No pulp horn: 10% A classification table based on Oehlers (1967) for Dens Evaginatus. The table lists five categories of pulp contents within a tubercle and their corresponding percentages: Wide pulp horns (34%), Narrow pulp horns (22%), Constricted pulp horns (14%), Isolated pulp horn remnants (20%), and No pulp horn (10%). # Dens Evaginatus ## Radiographic Examination - The pulp tissue in the tubercle is normal unless the tubercle has been fractured, or worn down, thereby permitting bacterial invasion, with consequent pulpal necrosis (Merrill, 1964) - Necrosis of pulp tissue can subsequently lead to: - an acute or chronic dentoalveolar abscess - Other findings includes: - Osteomyelitis (Allwright, 1958) - Thickening of the periodontal membrane - Periapical rarefaction - Incomplete root formation - Fracture of the root - Cyst formation - Dilaceration (Oehlers, 1967) THE UNIVERSITY OF WESTERN AUSTRALIA  #### Radiographic Findings and Pulpal Health - The pulp tissue in the tubercle is normal unless the tubercle has been fractured or worn down. Such damage permits bacterial invasion, leading to pulpal necrosis (Merrill, 1964). - Necrosis of pulp tissue can subsequently lead to an acute or chronic dentoalveolar abscess. #### Associated Pathologies and Observations - Osteomyelitis (Allwright, 1958) - Thickening of the periodontal membrane - Periapical rarefaction - Incomplete root formation - Fracture of the root - Cyst formation - Dilaceration (Oehlers, 1967) Radiograph of a tooth exhibiting Dens Evaginatus. The image shows the characteristic tubercle on the occlusal surface and associated periapical radiolucency consistent with pulp necrosis and abscess formation as described in the text. # Dens Evaginatus ## Management * **Composite reinforcement:** to support the sides of the tubercle with composite resin (should be performed before the tooth comes into complete occlusion) * **Grinding of tubercle:** if tubercle is cause of occlusal interference grinding of the tubercle followed by fissure sealing in some cases * Trauma or attrition to the tubercle results in pulp exposure: an elective (**Cvek**) pulpotomy can be performed in an attempt to allow normal root formation * Revascularization * Extraction of the tooth may be considered after orthodontic consultation #### Clinical Management Strategies - **Composite reinforcement:** Supporting the sides of the tubercle with composite resin; this should be performed before the tooth comes into complete occlusion. - **Grinding of tubercle:** If the tubercle causes occlusal interference, selective grinding followed by fissure sealing may be performed. - **Management of Pulp Exposure:** If trauma or attrition results in pulp exposure, an elective (Cvek) pulpotomy can be performed to allow normal root formation. - **Revascularization:** Consideration of regenerative endodontic procedures. - **Extraction:** May be considered after orthodontic consultation. # **Dens Invaginatus** **Definition:** An infolding of the enamel and dentin towards the pulp (Tomes, 1859) * **Alternative terminology** * Warty teeth (Salter, 1855) * Invagination of the enamel (Hallet, 1953) * Dens in dente (Salter, 1855; Shepard, 1968) * Invaginated odontome * Dilated composite Odontome (Worth, 1963) * dents telescopes (Augsberger and Brandebura, 1978) * Gestant Odontome (Augsberger and Brandebura, 1978) #### Definition An infolding of the enamel and dentin towards the pulp (Tomes, 1859). #### Alternative Terminology - Warty teeth (Salter, 1855) - Invagination of the enamel (Hallet, 1953) - Dens in dente (Salter, 1855; Shepard, 1968) - Invaginated odontome - Dilated composite Odontome (Worth, 1963) - Dents telescopes (Augsberger and Brandebura, 1978) - Gestant Odontome (Augsberger and Brandebura, 1978) **Dens Invaginatus** **Etiology:** Theories as below: * **Growth pressure:** (Euler, 1939; Atkinson, 1943) * buckling of the enamel organ might be caused by growth forces in the developing arch * disproportion between jaw size and the total length of the dental arch * **Focal growth retardation:** (Kronfeld, 1934) * invagination results from a focal failure of growth of the internal enamel epithelium. * The surrounding normal epithelium continues to proliferate and engulfs the static area, eventually enclosing it * **Focal proliferation:** (Rushton, 1937) * invagination is the result of an invasion of the dental papilla by a rapid and aggressively proliferating area of internal enamel epithelium * **Local causes:** * Trauma (Gustafson & Sundberg, 1950) * infection (Fischer 1936, Sprawson 1937) * **Genetic:** (Grahnen et al. 1959, Casamassimo et al. 1978, Hosey & Bedi 1996)  #### Etiological Theories - **Growth pressure** (Euler, 1939; Atkinson, 1943) - Buckling of the enamel organ might be caused by growth forces in the developing arch. - Disproportion between jaw size and the total length of the dental arch. - **Focal growth retardation** (Kronfeld, 1934) - Invagination results from a focal failure of growth of the internal enamel epithelium. - The surrounding normal epithelium continues to proliferate and engulfs the static area, eventually enclosing it. - **Focal proliferation** (Rushton, 1937) - Invagination is the result of an invasion of the dental papilla by a rapid and aggressively proliferating area of internal enamel epithelium. - **Local causes** - Trauma (Gustafson & Sundberg, 1950) - Infection (Fischer 1936, Sprawson 1937) - **Genetic** (Grahnen et al. 1959, Casamassimo et al. 1978, Hosey & Bedi 1996) University logo for The University of Western Australia. It features a shield with a yellow and blue design containing the number '20', flanked by books, with the university name in blue text to the right. **Dens Invaginatus** Prevalence **Primary dentition:** 0.1% (Brook, 1974) - Male = Female - Teeth: primary canine, maxillary central incisor, mandibular second molar **Permanent dentition:** 0.2- 10.0% - Male > Female - Teeth: Maxillary lateral incisors, maxillary central incisors and canines (Atkinson, 1943; Grahnen et al. 1959; Poyton and Morgan, 1966; Kong, 1972; Reprecht et al. 1986; King et al. 2010) #### Prevalence Statistics **Primary dentition: 0.1% (Brook, 1974)** - Male = Female - Commonly affected teeth: primary canine, maxillary central incisor, mandibular second molar **Permanent dentition: 0.2- 10.0%** - Male > Female - Commonly affected teeth: Maxillary lateral incisors, maxillary central incisors and canines (Atkinson, 1943; Grahnen et al. 1959; Poyton and Morgan, 1966; Kong, 1972; Reprecht et al. 1986; King et al. 2010) # Dens Invaginatus **Classification:** (Rushton, 1937) ***Coronal dens invaginatus:*** * It is anomalous infolding of enamel organ into dental papilla * It results in the folding of hard tissue within the tooth, characterized by enamel lining the fold and covering the dentin peripheral to it ***Radicular dens invaginatus:*** * It is a result of invagination of Hertwig’s epithelial root sheath, resulting in accentuation of normal longitudinal root grooves * It is lined by cementum * Root sheath may bud off sac-like invagination that results in a circumscribed cementum defect in root #### Rushton Classification (1937) **Coronal dens invaginatus** - It is anomalous infolding of enamel organ into dental papilla. - It results in the folding of hard tissue within the tooth, characterized by enamel lining the fold and covering the dentin peripheral to it. **Radicular dens invaginatus** - It is a result of invagination of Hertwig’s epithelial root sheath, resulting in accentuation of normal longitudinal root grooves. - It is lined by cementum. - Root sheath may bud off sac-like invagination that results in a circumscribed cementum defect in root. **Dens Invaginatus** **Classification:** Oehlers's, 1957 <table> <tr> <th>Dens Invaginatus</th> </tr> <tr> <td> **Type 1:** invagination confined to the crown <br><br> **Type 2 :** invagination extends beyond the CEJ but does not involve the periapical tissues <br><br> **Type 3:** Extends past CEJ & perforating laterally (type 3a) or apically (Type 3b) at a foramen </td> </tr> </table>  #### Oehlers's Classification (1957) - **Type 1:** Invagination confined to the crown. - **Type 2:** Invagination extends beyond the cemento-enamel junction (CEJ) but does not involve the periapical tissues. - **Type 3:** Extends past CEJ and perforating laterally (Type 3a) or apically (Type 3b) at a foramen. Flowchart diagram illustrating Oehlers's 1957 classification of Dens Invaginatus. The top box labeled 'Dens Invaginatus' branches into three categories: Type 1 (invagination confined to the crown), Type 2 (invagination extends beyond the CEJ but does not involve the periapical tissues), and Type 3 (extends past CEJ & perforating laterally or apically). Below each category are corresponding anatomical diagrams of teeth showing the extent of invagination for each type. **Dens Invaginus** THE UNIVERSITY OF WESTERN AUSTRALIA Dens Invaginus - Type II Dens Invaginus - Type III  Dens Invaginus - Type II Dens Invaginus - Type III Medical figure showing three radiographic images of teeth demonstrating Dens Invaginatus. Left panel shows a periapical radiograph of multiple teeth with the central tooth exhibiting internal invagination labeled 'Dens Invaginatus - Type II'. Middle and right panels show magnified views of the affected tooth in different orientations, labeled 'Dens Invaginatus - Type III', illustrating variations in the internal canal structure. Dens Invaginatus THE UNIVERSITY OF WESTERN AUSTRALIA Dens Invaginatus - Type III (b)   Dens Invaginatus - Type III (b) Panoramic dental radiograph showing a full view of the upper and lower jaws. The image is labeled 'Dens Invaginatus - Type III (b)' at the bottom, indicating a specific classification of the condition. Intraoral periapical radiograph focusing on a specific tooth with the label 'a' in the top right corner. This close-up view demonstrates the internal anatomy of a tooth affected by Dens Invaginatus, specifically Type III, where the invagination extends into the root canal system. # Dens Invaginatus **Clinical features** * Tooth crowns and roots may exhibit variations in size and form * The invagination allows entry of irritants into an area (which is separated from pulpal tissue by only a thin layer of enamel and dentine) and predispose tooth for dental caries * Pulp necrosis often occurs within a few years of eruption, sometimes even before root end closure (channels may also exist between the invagination and the pulp) * May lead to a abscess formation or cellulitis * Retention or displacement of neighbouring teeth * Cyst formation * Internal resorption #### Clinical Presentation - Tooth crowns and roots may exhibit variations in size and form. - The invagination allows entry of irritants into an area (separated from pulpal tissue by only a thin layer of enamel and dentine) and predisposes the tooth to dental caries. - Pulp necrosis often occurs within a few years of eruption, sometimes even before root end closure (channels may also exist between the invagination and the pulp). - May lead to abscess formation or cellulitis. - Retention or displacement of neighbouring teeth. - Cyst formation. - Internal resorption. Dens Invaginatus **Management** * **Preventive treatment:** fissure sealant, flowable composite * **Restorative treatment:** if caries is evident tooth should be restored with composite resin * **Endodontic treatment** - symptomatic tooth - root canal morphology favourable * **Autotransplantation** * **Extraction** - if the internal anatomy is complex and the root canal is not possible - infection - endodontic failure > orthodontic treatment planning should be carried out prior to extraction #### Management Strategies - **Preventive treatment:** Fissure sealant, flowable composite. - **Restorative treatment:** If caries is evident, the tooth should be restored with composite resin. - **Endodontic treatment:** - Indicated for symptomatic teeth. - Performed if root canal morphology is favourable. - **Autotransplantation** - **Extraction:** - Indicated if the internal anatomy is complex and root canal treatment is not possible. - Indicated in cases of infection or endodontic failure. - Orthodontic treatment planning should be carried out prior to extraction. <div style="display: flex; justify-content: space-between; align-items: flex-start; padding: 20px; font-family: 'Arial', sans-serif;"> <div style="width: 95%; font-size: 16px; line-height: 1.6;"> <span style="font-style: italic;">+ WE:</span><br> <span style="font-weight: bold; font-size: 24px; margin-bottom: 15px;">Accessory Cusps: Summary</span><br> <span style="display: block; background-color: rgb(255, 193, 7); width: 100%; height: 5px;"></span><br> <p><strong>1. Talon cusp:</strong> A talon cusp is an accessory cusp that occurs on the lingual surface of the anterior teeth. It is a relatively common developmental anomaly that is characterised by a prominent, dagger-like cusp that extends from the cingulum of the tooth towards the incisal edge.</p> <p><strong>2. Cusp of Carabelli:</strong> The cusp of Carabelli is a small accessory cusp that occurs on the mesiopalatal surface of the maxillary first molars. It can be considered a trait (rather than an anomaly) in many populations. [+]</p> <p><strong>3. Dens evaginatus:</strong> Dens evaginatus is an accessory cusp that occurs on the occlusal surface of premolars or molars. It is characterised by a small, rounded or pointed projection that extends from the occlusal surface of the tooth.</p> <p><strong>4. Dens invaginatus:</strong> Dens invaginatus occurs when the enamel organ invaginates into the dental papilla during tooth development, resulting in a deep, enamel-lined pit or groove on the occlusal or lingual surface of the tooth.</p> <p><strong>5. Supernumerary cusps:</strong> Supernumerary cusps are additional cusps that can occur on any tooth. They are a developmental anomaly and can vary in size, shape, and location.</p> <p><strong>6. Enamel pearls:</strong> Enamel pearls are small, spherical structures of enamel that can occur on the root surface of teeth. They are typically located near the furcation of the tooth.</p> </div> </div> 1. **Talon cusp:** An accessory cusp occurring on the lingual surface of anterior teeth. It is a developmental anomaly characterized by a prominent, dagger-like cusp extending from the cingulum toward the incisal edge. 2. **Cusp of Carabelli:** A small accessory cusp on the mesiopalatal surface of maxillary first molars. It is considered a trait rather than an anomaly in many populations. 3. **Dens evaginatus:** An accessory cusp on the occlusal surface of premolars or molars, characterized by a small, rounded or pointed projection. 4. **Dens invaginatus:** Occurs when the enamel organ invaginates into the dental papilla during development, resulting in a deep, enamel-lined pit or groove on the occlusal or lingual surface. 5. **Supernumerary cusps:** Additional cusps that can occur on any tooth, varying in size, shape, and location. 6. **Enamel pearls:** Small, spherical enamel structures typically located on the root surface near the furcation. # Supernumerary Cusps Singh et al. 2018 The University of Western Australia  Supernumerary Cusps Singh et al. 2018 Clinical photograph titled 'Supernumerary Cusps' (Singh et al. 2018) displaying two side-by-side intraoral views of posterior teeth exhibiting dental anomalies. Panel A shows a close-up of molars with an extra cusp forming the tooth surface. Panel B displays a similar condition on adjacent teeth, demonstrating the visual presentation of supernumerary cusps. # Enamel Pearls Lopez et al. 2015 Depending on their location enamel pearls can become a nidus for inflammation causing periodontal defects  Lopez et al. 2015 Depending on their location, enamel pearls can become a nidus for inflammation, causing periodontal defects. Clinical photo of a dental arch showing multiple teeth with visible gingival recession and inflammation. A distinct, smooth, rounded bony-like projection is present on the cervical region of one tooth, labeled as an 'Enamel Pearl' via an arrow. The image includes the citation 'Lopez et al. 2015'. According to the context, these enamel pearls can become a nidus for inflammation causing periodontal defects. **Taurodontism** - pulp cavity that tends to enlarge at the expense of the roots - first described by Sir Arthur Keith 1913 - Classification Shaw 1928  - Pulp cavity that tends to enlarge at the expense of the roots - First described by Sir Arthur Keith (1913) - Classification by Shaw (1928) Labelled diagram illustrating the classification of Taurodontism according to Shaw (1928). The visual displays four distinct morphological types of molars with enlarged pulp cavities and shortened roots: A. Cynodont (European), B. Hypotaurodont (Bantu-Boskop Hybrid), C. Mesotaurodont (Heidelberg), and D. Hyper taurodont (Krapina). # Taurodontism **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** * **Aetiology** * unknown * delay or failure of invagination of Hertwig's epithelial root sheath * **Prevalence** * **M>F** * Wide range in reported prevalence (5-60%!) * **Associated anomalies** * Amelogenesis Imperfecta * Hypodontia (35% prevalence in patients with hypodontia) * (Seow & Lai 1989) #### Aetiology - Unknown - Delay or failure of invagination of Hertwig's epithelial root sheath #### Prevalence - More common in males than females (M>F) - Wide range in reported prevalence (5-60%) #### Associated Anomalies - Amelogenesis Imperfecta - Hypodontia (35% prevalence in patients with hypodontia; Seow & Lai 1989) The image is a diagram defining taurodontism, showing a tooth and its pulp chamber with labels A, B, C, and D. **Taurodontism** A - Highest point of the pulp chamber roof B - Lowest point of the floor AB - Vertical height of the pulp chamber AC - Distance between the highest point of the roof of the pulp chamber to the apex of the longest root BD - Distance between the cemento-enamel junction and the lowest point on the floor of the pulp chamber To establish taurodontism, the following criteria are used: (AB/AC) x 100 > 20 and BD > 2.5 mm The Taurodontic Index (TI) was calculated as AB/AC x 100. The degrees of taurodontism were categorized as follows: * Hypotaurodontism: TI 20-30 * Mesotaurodontism: TI 30-40 * Hypertaurodontism: 40-75 **Shifman and Chanannel 1978**  #### Anatomical Landmarks - **A:** Highest point of the pulp chamber roof - **B:** Lowest point of the floor - **AB:** Vertical height of the pulp chamber - **AC:** Distance between the highest point of the roof of the pulp chamber to the apex of the longest root - **BD:** Distance between the cemento-enamel junction and the lowest point on the floor of the pulp chamber #### Diagnostic Indices (Shifman and Chanannel 1978) To establish taurodontism, the following criteria are used: - (AB/AC) x 100 > 20 - BD > 2.5 mm The Taurodontic Index (TI) is calculated as: (AB/AC) x 100. #### Degrees of Taurodontism - **Hypotaurodontism:** TI 20-30 - **Mesotaurodontism:** TI 30-40 - **Hypertaurodontism:** TI 40-75 Labelled anatomical diagram of a tooth illustrating the criteria for Taurodontism. The drawing shows a molar with an elongated pulp chamber and bulbous roots. Callouts point to specific locations: 'A' indicates the highest point of the pulp chamber roof; 'B' marks the lowest point of the floor; 'C' points to the apex of the longest root; and 'D' indicates the cemento-enamel junction. These labels correspond to measurements (AB, AC, BD) defined in the accompanying text. **Taurodontism** **The University of** **Western** **Australia** • **Clinical Implications** • short but very curved canals • canals difficult to visualise due to length of pulp chamber • thermoplasticised GP recommended  #### Clinical Considerations - Short but very curved canals - Canals are difficult to visualize due to the length of the pulp chamber - Thermoplasticised gutta-percha (GP) is recommended for obturation Dental radiograph showing a maxillary molar with taurodontism. The image displays the characteristic large pulp chamber extending apically, with short but curved root canals that are difficult to visualize due to the length of the pulp chamber. The tooth appears to have restorations on the crown. # Taurodontism  Taurodontism Panoramic dental radiograph (X-ray) demonstrating the condition of Taurodontism. The image displays a full view of the upper and lower jaws with teeth. Key visual features include enlarged pulp chambers and apical displacement of the pulpal floor in the posterior teeth (molars), giving them a square or rectangular appearance rather than the typical pear shape. [^1]: Original PDF page 1: [[L4- Dental Anomalies 2 DMD.pdf#page=1|L4- Dental Anomalies 2 DMD, p.1]] [^2]: Original PDF page 2: [[L4- Dental Anomalies 2 DMD.pdf#page=2|L4- Dental Anomalies 2 DMD, p.2]] [^3]: Original PDF page 3: [[L4- Dental Anomalies 2 DMD.pdf#page=3|L4- Dental Anomalies 2 DMD, p.3]] [^4]: Original PDF page 4: [[L4- Dental Anomalies 2 DMD.pdf#page=4|L4- Dental Anomalies 2 DMD, p.4]] [^5]: Original PDF page 5: [[L4- Dental Anomalies 2 DMD.pdf#page=5|L4- Dental Anomalies 2 DMD, p.5]] [^6]: Original PDF page 6: [[L4- Dental Anomalies 2 DMD.pdf#page=6|L4- Dental Anomalies 2 DMD, p.6]] [^7]: Original PDF page 7: [[L4- Dental Anomalies 2 DMD.pdf#page=7|L4- Dental Anomalies 2 DMD, p.7]] [^8]: Original PDF page 8: [[L4- Dental Anomalies 2 DMD.pdf#page=8|L4- Dental Anomalies 2 DMD, p.8]] [^9]: Original PDF page 9: [[L4- Dental Anomalies 2 DMD.pdf#page=9|L4- Dental Anomalies 2 DMD, p.9]] [^10]: Original PDF page 10: [[L4- Dental Anomalies 2 DMD.pdf#page=10|L4- Dental Anomalies 2 DMD, p.10]] [^11]: Original PDF page 11: [[L4- Dental Anomalies 2 DMD.pdf#page=11|L4- Dental Anomalies 2 DMD, p.11]] [^12]: Original PDF page 12: [[L4- Dental Anomalies 2 DMD.pdf#page=12|L4- Dental Anomalies 2 DMD, p.12]] [^13]: Original PDF page 13: [[L4- Dental Anomalies 2 DMD.pdf#page=13|L4- Dental Anomalies 2 DMD, p.13]] [^14]: Original PDF page 14: [[L4- Dental Anomalies 2 DMD.pdf#page=14|L4- Dental Anomalies 2 DMD, p.14]] [^15]: Original PDF page 15: [[L4- Dental Anomalies 2 DMD.pdf#page=15|L4- Dental Anomalies 2 DMD, p.15]] [^16]: Original PDF page 16: [[L4- Dental Anomalies 2 DMD.pdf#page=16|L4- Dental Anomalies 2 DMD, p.16]] [^17]: Original PDF page 17: [[L4- Dental Anomalies 2 DMD.pdf#page=17|L4- Dental Anomalies 2 DMD, p.17]] [^18]: Original PDF page 18: [[L4- Dental Anomalies 2 DMD.pdf#page=18|L4- Dental Anomalies 2 DMD, p.18]] [^19]: Original PDF page 19: [[L4- Dental Anomalies 2 DMD.pdf#page=19|L4- Dental Anomalies 2 DMD, p.19]] [^20]: Original PDF page 20: [[L4- Dental Anomalies 2 DMD.pdf#page=20|L4- Dental Anomalies 2 DMD, p.20]] [^21]: Original PDF page 21: [[L4- Dental Anomalies 2 DMD.pdf#page=21|L4- Dental Anomalies 2 DMD, p.21]] [^22]: Original PDF page 22: [[L4- Dental Anomalies 2 DMD.pdf#page=22|L4- Dental Anomalies 2 DMD, p.22]] [^23]: Original PDF page 23: [[L4- Dental Anomalies 2 DMD.pdf#page=23|L4- Dental Anomalies 2 DMD, p.23]] [^24]: Original PDF page 24: [[L4- Dental Anomalies 2 DMD.pdf#page=24|L4- Dental Anomalies 2 DMD, p.24]] [^25]: Original PDF page 25: [[L4- Dental Anomalies 2 DMD.pdf#page=25|L4- Dental Anomalies 2 DMD, p.25]] [^26]: Original PDF page 26: [[L4- Dental Anomalies 2 DMD.pdf#page=26|L4- Dental Anomalies 2 DMD, p.26]] [^27]: Original PDF page 27: [[L4- Dental Anomalies 2 DMD.pdf#page=27|L4- Dental Anomalies 2 DMD, p.27]] [^28]: Original PDF page 28: [[L4- Dental Anomalies 2 DMD.pdf#page=28|L4- Dental Anomalies 2 DMD, p.28]] [^29]: Original PDF page 29: [[L4- Dental Anomalies 2 DMD.pdf#page=29|L4- Dental Anomalies 2 DMD, p.29]] [^30]: Original PDF page 30: [[L4- Dental Anomalies 2 DMD.pdf#page=30|L4- Dental Anomalies 2 DMD, p.30]] [^31]: Original PDF page 31: [[L4- Dental Anomalies 2 DMD.pdf#page=31|L4- Dental Anomalies 2 DMD, p.31]] [^32]: Original PDF page 32: [[L4- Dental Anomalies 2 DMD.pdf#page=32|L4- Dental Anomalies 2 DMD, p.32]] [^33]: Original PDF page 33: [[L4- Dental Anomalies 2 DMD.pdf#page=33|L4- Dental Anomalies 2 DMD, p.33]] [^34]: Original PDF page 34: [[L4- Dental Anomalies 2 DMD.pdf#page=34|L4- Dental Anomalies 2 DMD, p.34]] [^35]: Original PDF page 35: [[L4- Dental Anomalies 2 DMD.pdf#page=35|L4- Dental Anomalies 2 DMD, p.35]] [^36]: Original PDF page 36: [[L4- Dental Anomalies 2 DMD.pdf#page=36|L4- Dental Anomalies 2 DMD, p.36]] [^37]: Original PDF page 37: [[L4- Dental Anomalies 2 DMD.pdf#page=37|L4- Dental Anomalies 2 DMD, p.37]] [^38]: Original PDF page 38: [[L4- Dental Anomalies 2 DMD.pdf#page=38|L4- Dental Anomalies 2 DMD, p.38]] [^39]: Original PDF page 39: [[L4- Dental Anomalies 2 DMD.pdf#page=39|L4- Dental Anomalies 2 DMD, p.39]] [^40]: Original PDF page 40: [[L4- Dental Anomalies 2 DMD.pdf#page=40|L4- Dental Anomalies 2 DMD, p.40]] [^41]: Original PDF page 41: [[L4- Dental Anomalies 2 DMD.pdf#page=41|L4- Dental Anomalies 2 DMD, p.41]] [^42]: Original PDF page 42: [[L4- Dental Anomalies 2 DMD.pdf#page=42|L4- Dental Anomalies 2 DMD, p.42]] [^43]: Original PDF page 43: [[L4- Dental Anomalies 2 DMD.pdf#page=43|L4- Dental Anomalies 2 DMD, p.43]] [^44]: Original PDF page 44: [[L4- Dental Anomalies 2 DMD.pdf#page=44|L4- Dental Anomalies 2 DMD, p.44]] [^45]: Original PDF page 45: [[L4- Dental Anomalies 2 DMD.pdf#page=45|L4- Dental Anomalies 2 DMD, p.45]] [^46]: Original PDF page 46: [[L4- Dental Anomalies 2 DMD.pdf#page=46|L4- Dental Anomalies 2 DMD, p.46]] [^47]: Original PDF page 47: [[L4- Dental Anomalies 2 DMD.pdf#page=47|L4- Dental Anomalies 2 DMD, p.47]] [^48]: Original PDF page 48: [[L4- Dental Anomalies 2 DMD.pdf#page=48|L4- Dental Anomalies 2 DMD, p.48]] [^49]: Original PDF page 49: [[L4- Dental Anomalies 2 DMD.pdf#page=49|L4- Dental Anomalies 2 DMD, p.49]] [^50]: Original PDF page 50: [[L4- Dental Anomalies 2 DMD.pdf#page=50|L4- Dental Anomalies 2 DMD, p.50]] [^51]: Original PDF page 51: [[L4- Dental Anomalies 2 DMD.pdf#page=51|L4- Dental Anomalies 2 DMD, p.51]] [^52]: Original PDF page 52: [[L4- Dental Anomalies 2 DMD.pdf#page=52|L4- Dental Anomalies 2 DMD, p.52]] [^53]: Original PDF page 53: [[L4- Dental Anomalies 2 DMD.pdf#page=53|L4- Dental Anomalies 2 DMD, p.53]] [^54]: Original PDF page 54: [[L4- Dental Anomalies 2 DMD.pdf#page=54|L4- Dental Anomalies 2 DMD, p.54]] [^55]: Original PDF page 55: [[L4- Dental Anomalies 2 DMD.pdf#page=55|L4- Dental Anomalies 2 DMD, p.55]]