Padgett 2010.4


25

Dental fusion of the primary dentition is a rare 
congenital anomaly.  Examples in the literature of 
bioarchaeology are exceedingly scarce.  Skeletal remains 
of an infant from the Law’s Site (1MS100), in Marshall 
County, Alabama, presents a clear case of triple fusion of 
the primary dentition.  This is a highly unusual condition, 
and thus a significant find for the fields of dental 
anthropology and bioarchaeology.

LITERATURE REVIEW

Examples of dental fusion in the anthropological 
literature are uncommon, and texts on dental anthropology, 
developmental osteology, and paleopathology give the 
topic little or no attention (Aufderheide and Rodríguez-
Martín, 1998; Hillson, 1996; Ortner, 2003; Scheuer and 
Black, 2000).  Two fused deciduous mandibular incisors 
are shown in Figure 1.1 of The Anthropology of Modern 
Teeth (Scott and Turner, 1997: 5), but neither the defect nor 
the provenance of the specimen is discussed in detail.  A 
rare “talon cusp” found on a deciduous lateral incisor was 
the primary topic of a case report of a juvenile skeleton 
excavated in England, though the report states that “the 
affected incisor also shows abnormal widening, probably 
representing a double tooth”, and mentions the presence 
of a supernumerary permanent incisor (Mays, 2004:206).  
It is unclear if this “double tooth” is an actual case of 
dental fusion, or a case of gemination, defined as the 
unsuccessful or incomplete division of one tooth germ 
into two (Canut Brusola, 1988; Oliván Rosas et al. 2004).  
Some authors agree that distinction between fusion and 
gemination can sometimes be confusing, and the term 
“double teeth” should be used when the diagnosis is 
inconclusive (Andlaw and Rock, 1999; Gonzalez Marquez 
and Mendez-Nuñez, 1993; Killian and Croll, 1990; Oliván 
Rosas et al., 2004; Uys and Morris, 2005).

Although there is little in anthropological sources 
concerning the topic of dental fusion, there have been 
some relevant clinical studies on modern populations, 
and some patterns have been documented regarding 
this dental anomaly.  These clinical studies agree that 
fusion in the primary dentition usually affects two teeth 

Triple Fusion in the Primary Dentition from Law’s Site, 
Alabama (1MS100):  A Case Report
Brian D. Padgett

Frankfort, KY

Correspondence to:  Brian D. Padgett, 313 Juniper Drive, 
Frankfort, KY 40601
E-mail: boneyard90@hotmail.com

ABSTRACT    Dental fusion of the primary dentition is 
a rare congenital anomaly.  Evidence in the literature of 
bioarchaeology is scarce. Burial MS100-14 was recovered 
from Law’s Site on Pine Island, in Marshall County, 
Alabama.  Analysis of the remains found that MS100-14 

presented a clear case of triple fusion of primary dentition 
in the maxilla. This appears to be the first case of triple 
fusion reported from among prehistoric Native American 
remains in the Southeastern United States. Dental 
Anthropology 2010;23(1):25-27.

unilaterally in the mandibular arch, and most often in the 
anterior region; that is, either two incisors, an incisor and 
a canine, or a supernumerary tooth fused with an incisor 
(Barberia et al., 2001; Cheng et al., 2003; Favalli et al., 1998; 
Modrizuki et al., 1999; Oliván Rosas et al., 2004; Yonezu et 
al., 1997).

Studies among European, (Asian) Indian, and Turkish 
populations reveal a prevalence of less than 1% for double 
fusion in primary dentition (Aquiló et al., 1999; Barberia 
Leache and Boj Quesada, 2001; Boj Quesada 1990; Bruce 
et al., 1994; Erdem et al., 2001; Reddy and Munshi, 1999).  
North American populations have a prevalence ranging 
from 0.14 to 3% (Hagman, 1988).  A study in Shenyang city, 
China, reported 1.52% prevalence among children there 
(Cheng et al., 1999).  The prevalence appears to be highest 
in Japan, where 4.1 to 5% of children studied presented 
this anomalous feature, and unlike other populations, 
there was a tendency regarding sex, as a significantly 
higher proportion of boys displayed congenital dental 
fusion (Modrizuki et al., 1999; Yonezu et al., 1997).

As rare as double fusion appears to be, it is not 
surprising that triple fusion of primary dentition is even 
less common. In the study of Indian children (n = 4,205), 
there was no case of triple fusion (Reddy and Munshi, 
1999), though a separate team from India reports the 
case of a child with triple fusion involving two ipsilateral 
incisors and a supernumerary tooth (Prabhakar et al., 
2004).  Among Chinese children studied (n = 4,286), 
only one case of triple fusion was found, involving two 
ipsilateral incisors and the adjoining canine (Cheng et al., 
1999).  The prevalence of “triplication of primary teeth” 
among Turkish children was stated as 0.02% (Erdem et al., 
2001).

Problems associated with the congenital fusion of 
primary dentition may include an increased susceptibility 
to caries in the fused teeth (Reddy and Munshi, 1999).  



26

There is also an association between fusion of primary 
dentition and agenesis of the corresponding permanent 
teeth; with regard to this condition, various authors cite 
percentages of incidence ranging from 20 to 75%, the 
occurrence of which may depend on which teeth are fused 
(Aquiló et al., 1999; Barberia Leache and Boj Quesada, 
2001; Boj Quesada 1990; Canut Brusola 1988; Oliván Rosas 
et al., 2004; Ostos Garrido and Peñalva Sanchez, 1996; 
Hagman, 1988; Reddy and Munshi, 1999).

MATERIALS AND METHODS

A standard osteological analysis was performed on the 
skeletal remains recovered from Law’s Site (1MS100).  The 
Law’s Site was a village on the southern end of Pine Island 
in Marshall County, Alabama.  The site was excavated 
in 1938 by the Works Project Administration (WPA) 
under the direction of Carl F. Miller (Webb and Wilder, 
1951).  Shortly thereafter, Pine Island was inundated 
when construction of Guntersville Dam was completed 
and the low-lying Guntersville Basin flooded to become 
Guntersville Lake.

The site had seen Native American occupation since 
the Archaic Period (about 8,000-1,000 B.C.) (Walthall, 
1980); though many of the burials have been convincingly 
attributed to the post-contact period, between 1540 and 
about 1715 (Fleming, 1976; Padgett, 2007; Webb and 
Wilder, 1951).  It is believed that the Native occupants 
of this latter period were the historically known Koasati, 
or Coushatta, tribe (Padgett, 2007; Swanton, 1985, 1989), 
though there is some dispute on this issue (Hudson, 1997).

CASE REPORT

Burial MS100-14 was an infant of indeterminate sex, 
aged about 9 months based on dental eruption.  No 
indications of pathological infection or physical trauma 
were found among the remains.

Burial MS100-14 exhibited fused dentition, appearing 
as a block of three teeth fused side by side in their 
standard position.  The fused set consists of the deciduous 
left maxillary central incisor, lateral incisor, and canine 
(Fig. 1). The central incisor and canine appear to be of 
normal dimensions, while the lateral incisor is reduced in 
mesiodistal width, and appears to be a conically-shaped 
“peg tooth.”

DISCUSSION

The three teeth are fused at both the enamel and the 
dentin, though all three can be recognized as distinct 
from the others (Fig. 1).  Furthermore, it is apparent that 
although the pulp cavities of the three teeth are continuous 
with each other, each tooth was maintained by its own 
root canal.  These observations support the assertion that 
this is a true case of dental fusion, rather than gemination 
of a single tooth (Oliván Rosas et al., 2004; Uys and Morris, 
2005).

Some studies have found a predilection for one sex or 
the other regarding fused teeth or peg teeth (Wu and Feng 
2005; Yonezu et al., 1997); however, no evidence relating 
to sex can be interpreted from the remains or associated 
materials of Burial MS100-14.

CONCLUSION

The expression of triple fusion in MS100-14 as a 
dental anomaly is unusual in that it occurred among 
the maxillary dentition, as other researchers have found 
that when dental fusion occurs it is predominantly in the 
mandibular arch (Cheng et al., 2003; Yonezu et al., 1997).  
The peg-shaped tooth, while an anomalous feature, is 
typical in the respect that it is a lateral incisor (Wu and 
Feng, 2005).  Burial MS100-14 represents a rare case in 
physical anthropology of triple fusion of primary dentition 
found in an archaeological context. Furthermore, the case 

Fig. 1. Fused teeth of Burial MS100-14. (Left) Labial view with the left primary central incisor (i1) to the left of the 
photograph, a conical lateral incisor (i2) in the center, and the canine (c) to the right. (Center) Lingual view of the fused 
teeth, with c to the left and i1 to the right. (Right) Alveolar (apical) view of the formative roots with c to the left and i1 
to the right of the photograph.

B.D. PADGETT



27PRIMARY TOOTH TRIPLE FUSION

of MS100-14 is significant as it appears to be the first case 
of triple fusion reported from among prehistoric Native 
American remains in the Southeastern United States.

LITERATURE CITED

Andlaw RJ, Rock WP. 1999. Manual de odontopediatría. 
Mexico City: McGraw-Hill Interamericana.

Aquiló L, Gandia JL, Cibrian R, Catala M. 1999. Primary 
double teeth: a retrospective clinical study of 
their morphological characteristics and associated 
Anomalies. Int J Pediatric Dent 9:175-183.

Aufderheide AC, Rodríguez-Martín C. 1998. The 
Cambridge encyclopedia of human paleopathology. 
Cambridge: Cambridge University Press.

Barberia Leache E, Boj Quesada JR. 2001. Odontopediatría, 
2nd ed. Barcelona: Masson.

Boj Quesada JR. 1990. Dientes Dobles. Archivos 
Odontología 6:321-325.

Bruce C, Manning-Cox G, Stanback Fryer C, Banks K, 
Gilliam M. 1994. A radiographic survey of dental 
anomalies in black pediatric patients. NDA J 45:6-13.

Canut Brusola JA. 1988 Ortodoncia Clínica. Barcelona: 
Salvat.

Cheng RB, Chen X, Liu SJ, Pan L, Wu XG. 2003. [An 
epidemiological survey on fusion of deciduous teeth 
of 4286 kindergarten children in Shenyang City.]
Shanghai Kou Qiang Yi Xue. (Shanghai J Stomatology) 
12:424-426. Translated from Chinese.

Erdem GB, Uzamis M, Olmez S, Sargon MF. 2001. Primary 
incisor triplication defect.  ASDC J Dent Child 68:322-
325.

Favalli O, Webb M, Culp J. 1998. Bilateral twinning: report 
of case. ASDC J Dent Child 65: 268-271.

Fleming VK, Jr. 1976. Historic aboriginal occupation of the 
Guntersville Basin, Alabama.  M.A. thesis, Department 
of Anthropology, University of Alabama, Tuscaloosa.

Gonzalez Marquez MI, Mendez-Nuñez M. 1993. Problemas 
de nomenclatura en alteraciones morfológicas 
dentarias. Archivos Odontoestomatología 9:197-204.

Hagman FT. 1988. Anomalies of form and number, fused 
primary teeth, a correlation of the dentitions. ASDC J 
Dent Child 55:359-361.

Hillson S. 1996. Dental anthropology. Cambridge 
University Press, United Kingdom.

Hudson C. 1997. Knights of Spain, Warriors of the Sun: 
Hernando de Soto and the South’s ancient chiefdoms. 
Athens, GA: University of Georgia Press.

Killian CM, Croll TP. 1990. Dental twinning anomalies: the 
nomenclature enigma. Quintessence Int 21:571-576.

Mays S. 2004. Talon cusp in a primary lateral incisor from 
a Medieval child. ASDC J Dent Child 71:206-208.

Modrizuki K, Yoneku T, Yakushiji M, Machida I. 1999. The 
fusion of three primary incisors: report of case. ASDC J 
Dent Child 66:421-425.

Oliván Rosas G, López-Jiménez J, Giménez-Prats MJ, 
Piqueras-Hernández M. 2004. Considerations and 
differences in the treatment of a fused tooth. Medicina 
Oral 9:224-228.

Ortner DJ. 2003. Identification of pathological conditions 
in human skeletal remains, 2nd ed. San Diego: 
Academic Press.

Ostos Garrido MJ, Peñalva Sanchez MA. 1996. Dientes 
dobles asociados a inclusión dentaria: posibilidades 
terapéuticas. Odontología Pediátrica 5:91-96.

Padgett BD. 2007. Islands in the River of Time: the 
bioarchaeology of two village sites (1MS32 and 
1MS100) in Marshall County, Alabama, with new 
interpretations of the ethnohistoric and archaeological 
records. M.A. thesis, Department of Anthropology, 
University of Alabama, Tuscaloosa.

Prabhakar AR, Marwah N, Raju OS. 2004. Triple teeth: 
case report of an unusual fusion of three teeth. ASDC J 
Dent Children 71:206-208.

Reddy NN, Munshi AK. 1999. Fusion of primary 
incisors—a report of six cases.  J Indian Soc Pedod Prev 
Dent 17:55-60.

Scheuer L, Black S. 2000. Developmental juvenile 
osteology. San Diego: Academic Press.

Scott GR, Turner CG II. 1997. The anthropology of modern 
human teeth: dental morphology and its variation in 
recent human populations. Cambridge: Cambridge 
University Press.

Swanton JR. 1985. Final Report of the United States De 
Soto Expedition Commission. Smithsonian Institute 
Press, Washington, D.C. Originally published 1939, 
U.S. Government Printing Office, Washington, D.C.

Swanton JR. 1987. The Indians of the Southeastern 
United States. Reprinted. Smithsonian Institute Press, 
Washington, D.C. Originally published 1946, U.S. 
Government Printing Office, Washington, D.C.

Uys H, Morris D. 2005. “Double” teeth—a diagnostic 
conundrum. Dental Update 32:237-239.

Walthall JA. 1980. Prehistoric Indians of the Southeast: 
Archaeology of Alabama and the Middle South. 
Tuscaloosa, AL: University of Alabama Press.

Webb WS, Wilder CG. 1951. An archaeological survey of 
Guntersville Basin on the Tennessee River in Northern 
Alabama. Lexington, KY: University of Kentucky 
Press. 

Wu H, Feng HL. 2005. [A survey of number and 
morphology anomalies in permanent teeth of 6,453 
youths between 17 to 21 years old.] Zhonghua Kou 
Qiang Yi Xue Za Zhi [Chinese J Stomatology] 40:489-
490. Translated from Chinese.

Yonezu T, Hayashi Y, Sasaki J, Machida Y. 1997. Prevalence 
of congenital dental anomalies of the deciduous 
dentition in Japanese children. Bull Tokyo Dental 
College 38:27-32.