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 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

Case of dental concrescence associated with Dens evaginatus  
on a mandibular permanent molar 

Rafalimino HN1,2, Rakotonirina FP1,3,Andrianjafinoro TH1,2,Randriamalala NC1,4,Ramaroson J1. 

1Sub-section of Conservative Odontology Endodontic at the Tropical Odonto-Stomatological Institute 
of Madagascar (IOSTM), University of Mahajanga 

² University Hospital Profesora Zafisaona Gabriel Androva Mahajanga Madagascar, 
3Oral Health Center, Ministry of Industrialization, Trade and Consumption Antananarivo, 

Madagascar, 
4 University Hospital Joseph Dieudonné Rakotovao, Befelatanana Antananarivo, 

 
Corresponding author: Rafalimino Holy Nasandratra1, 2 

1Sub-section of Conservative Odontology Endodontic at the Tropical Odonto-Stomatological Institute 
of Madagascar (IOSTM), University of Mahajanga 

Summary 

Our objective was to present an unusual clinical case of a dental concrescence that comes 
with a Dens evaginatus on a mandibular left sector molar. This is about a description of this 
dental morphologic anomaly. The content of this article includes the clinical, radiological and 
anatomy morphological features of this anomaly of dental development of a 19-year-old 
female patient. The particularity of our case was its rarity, its installation on a posterior 
mandibular tooth, its localization on the mesial dental side, and finally the association of 
both cases of dental development anomalies. The treatment decision is based on the tooth 
conservation priority. The lack of its antagonist to preserve dental occlusion and strengthen 
the masticatory system, a preventive treatment is made to block all decay progression, 
combined with a prosthetic and orthodontic treatment recommendation. 

Key words: dental anomaly, concrescence, Dens evaginatus, permanent molar 

1. Introduction 

Dental anomalies are generally classified into developmental, eruption and structural 
anomalies. Dental concrescence is a developmental anomaly defined by the fusion of two 
adjacent teeth at the cementum level, whereas Dens evaginatus is a morphological anomaly 
that generates an additional cusp projected from the amelo-cemental junction surface 
towards the occlusal border1,2,3. The concrescence is of mechanical origin, due to 
compression of the germ, lack of space or neighboring infection. If cemental fusion occurs 
during root development, it is called true concrescence; if it occurs after root formation, it is 
called acquired post-inflammatory concrescence. It can only be discovered by taking an X-
ray. The etiology can be genetic, hormonal or systemic, and the impact can affect both 
temporary and permanent teeth. This anomaly may be generalized or localized, affecting 
only the crown, only the root, or both the crown and the root. Its usual location is often 

IJO JOURNALS

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

between the upper permanent molars, and sometimes between a molar and a 
supernumerary tooth3,4. 

Dens evaginatus comes from a developmental defect during the morphological 
differentiation stage, generating an additional cusp projected from the amelo-cemental 
junction surface. It generally affects permanent teeth and is rarely observed in temporary 
dentition, in Mongolian descendants and exceptionally in blacks. The malformation affects 
the buccal and occlusal surfaces of the teeth, and is frequently located on the anterior teeth 
and premolars4, 5,6,7. These morphological malformations make the tooth susceptible to a 
high risk of decay. Their therapeutic treatment consists of either conservative or radical 
treatment of the anomaly, calling essentially on the practitioner's clinical sense. Apart from 
the dentistry conservative practice, this sometimes requirescollaboration between the 
orthodontist and the prosthetic technician, in order to restore aesthetics and maintain 
function. The main objective of our article is to report an unusual case of dental 
concrescence associated with Dens evaginatus and located on a permanent molar in the 
mandibular left sector. It is about to describe the clinical, radiological and pathological 
features of the anomaly, and justify our treatment choice. 

2.Observation 

Our observation concerned a 19-year-old Malagasy female patient who came to  

a specialized odontostomatology center of the Mahavoky Atsimo University Hospital in 

Mahajanga Madagascar. Her consultation reason was odontalgia stimulated by a brief 

thermal variation in the posterior left sector of the mandible.  During the anamnesis,  

the patient does not have any general health problems, except for asthma. During  

the intraoral clinical examination, the reason for consultation was the left lower second 

molar. By a random discovery, we observed a coronal malformation on the mesial side  

of this same tooth, in association with occlusal dentin decay. Clinically, on the mesial side,  

a double protuberance projects from the amélo cemental junction towards the occlusal 

surface of the tooth (Figure 1 and Figure 2).  

 

  
Figure 1: Preoperative photograph of 37 

showing dens evaginatus in (a) and (b) on the 
mesial aspect. Occlusal view 

[Rafalimino,2019]. 

Figure 2:Preoperative photograph of 37 with 
coronal dental anomaly. In (a) and (b) on the 

mesial surface. Vestibular view 
[Rafalimino,2019]. 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

During our clinical examination, the survey allowed us to reveal a groove around the entire 

coronal margin and a groove around both protuberances, interrupted by the huge 

protuberance at the amelo-cemental junction. These areas are ideal niches for dental 

plaque.We noticed the presence of dentin decay in these grooves. The mandibular first 

molar had already been extracted six years previously. The mandibular second molar has 

three normal vestibular cusps.Retro alveolar radiography confirmed that the mesial root  

of 37 was cemental fused to the occlusal surface at the root half, with the root  

of a supernumerary tooth on its distal surface, and that the two roots bifurcated at the root 

apical third (Figure 3).We also note the absence of pulpal extension at the coronal level  

of the fused supernumerary tooth. Due to the presence of a mesial coronal malformation 

with bacterial plaque accumulation in the sulcus, in order to halt the carious process and 

prevent the reinstallation of caries on this tooth, our treatment plan was a dentin capping at 

the occlusal dentinite level combined with a preventive treatment of fluid composite 

placement around the evagination to ensure the durability of the tooth and prevent the 

evolution of dental caries (Figure 4).The patient was advised for a monthly visit to check for 

the presence of new decay, and the patient was referred to an odontostomatology 

specializing in prosthetics and orthodontics to study the management of the edentulous 

mandibular first molar. 

 

 
 

Figure 3: Preoperative retro alveolar radiograph 
of 37 showing dental concrescence at the 

cementum level of the mesial root of 37 in (a) 
with the root of a supernumerary tooth on the 

distal surface in (b) [Rafalimino,2019]. 
 

Figure 4: Postoperative photograph of 37 
receiving preventive treatment on the coronal 
tooth evagination and conservative composite 

treatment on the occlusal 
surface[Rafalimino,2019]. 

3.Comments 

Concrescence anomaly is positively detected after radiography. This anomaly is defined by 

one of the common anomalies of tooth shape occurring in the posterior maxillary sector 

characterized by the union between adjacent teeth, only through cementum and not 

dentin7,8,9.Our clinical case was diagnosed as an association between dental concrescence 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

and dens evaginatus. According to the location of the anomaly, which involves the vestibular 

cusps, this case of Dens evaginatus was group 2 according to Lau's classification9. According 

to Ohelers' classification, based on the histological appearance of the pulp, our case was 

identified as anomalies without pulpal horn10. According to the literature, the complications 

associated with this anomaly are of three steps: carious pathologies, traumatic pathologies 

and complications linked to the presence of malocclusions and disharmonious tooth 

movement. In our case, the most anfractuous tooth morphology, combined with the 

presence accessory cusp contributes to plaque retention.Dens evaginatus (DE) is a dental 

anomaly with a supernumerary tubercle projection that typically contains dentin and pulp 

tissue. However, the tubercle projection can fracture, exposing the dentin and potentially 

the dental pulp, which induces pulpal diseases. This situation increases the risk of caries 

infiltration, which can lead to pulpal damage11. For this reason, the presence of this 

morphological anomaly calls for easier oral hygiene procedures. Root fusion can complicate 

endodontic treatment. In terms of pick-up of charge, a number of therapeutic variants have 

been suggested, depending on their usefulness. Surveillance therapy has been described as 

useful for early detection of complications. A preventive treatment would be the 

development of fluoridation or placement of Sealant or composite flow in pits and cracks, or 

a "grinding" treatment alone or with fluoridation.  Conservative dentistry will be chosen in 

cases of carious pathology, or when polishing techniques are disrupted by the morphological 

anomaly. Endodontic treatment is chosen when pulpal complications or coronal fractures 

with pulpal exposure are present. Prosthetic and orthodontic treatment may be chosen 

depending on the therapeutic objective. Finally, surgical treatment may be chosen if the 

anomaly causes other, more iatrogenic anomalies8,9. According to the study by Dankner and 

all, this anomaly is predominant in the maxillar12. Depending on anatomical location, 

Mallinenne and his colleagueshave suggested that mandibular installation is rare13. Coronal 

morphological anomalies can lead to caries complications9. The clinical cases presented by 

Yoon and his colleaguescorroborate our own. Increased plaque retention in the pits and 

cracks created by the accessory cusp, leading to increased caries risk 14. 

Conclusion 

Dens evaginatus can be detected clinically, but the discovery of dental concrescence requires 
radiography. Depending on the morphology and volume of the anomaly to be treated, 
multiple therapeutic variants have been implemented. In terms of quality of care 
performance, many practitioners do not hesitate to combine all these options. The 
treatment of an evagination due to many possible complications is above all 
multidisciplinary. Updating the classification of concrescence associated with other 
developmental anomalies must be considered. 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

Conflicts of interests 

We, the authors of this manuscript, declare no conflicts of interest regarding the publication 

of this article. 

 

Patient consent 
The patient has given full permission for the publication other use of his clinical case and 

photographs. 

 

References 

1. Sicher S, Bhasker SN. Orban’s oral histology and embryology. CV Mosby Co. 1972; 17–37. 

2. Piette E, Goldberg M. Anomalies et malformations des dents. La dent normale et 

pathologique. 2001 ; 11. 212-34. 

3. Priddy, CarterWL, Auzins AJ.Dens evaginatus: an anomaly of clinical significance.J Endod 

1976; 2: 51-2. 

4. Echeverri EA, Wang MM, Chavaria C, Taylor DL. Multiple dens evaginatus: Diagnosis, 

management, and complications: Case report. Pediatr Dent. 1994 Jul-Aug;16(4):314–17. 

5. Shrestha A, Marla V, Shrestha S, Maharjan IK. Developmental anomalies affecting the 

morphology of teeth – a review.  RSBO. 2015; 12 (1) : 68-78. 

6. Foran D, komabayashi T, Lin LM. Concrescence of permanent maxillary second and third 

molars: case report of non-surgical root canal treatment. Journal of Oral Science. 2012; 

54 (1); 133-6. 

7. Baumgart M, Hänni  S, Suter B, Schaffner M, Lussi A. Dent invaginée (dens invaginatus) : 

revue de la littérature- recommandations diagnostiques et thérapeutiques. Rev Mens 

Suisse Odontostomatol. 2009 ; 119 : 706-14. 

8. Gernhofer KJ. Concrescence of a maxillary second and third molar. Journal of the 

California Dental Association. 2009; 479–81. 

9. Levitan ME, Himel VT.Dens Evaginatus: Literature Review, Pathophysiology, and 

Comprehensive Treatment Regimen.Journal of Endodontics. 2005 ; 32(1):1-9 

10. Kittipun L, Danuchit B, Kamolthip S, Patcharin P, Siriruk N. Current Management of Dens 

Evaginatus Teeth Based on Pulpal Diagnosis. JOE. 2023;49 (1) : 1230-36. 

11. Hllttllh FN, Yassin OM, al Nimri KS. Talon cusp. Clinical significance and management: 

case reports. Quintessence International 1995; 26:115-20. 

12. Danker E, Harari D, Rotstein 1. Dens evaginatus of anterior teeth: Literature Review and 

Radiographic survey of 15000 teeth. Oral Surg Oral Med Oral Pathol Oral Radiol 

Endod. 1996;81(4):472-5. 

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IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                       Rafalimino Holy Nasandratra1* 

https://ijojournals.com/                                                     Volume 07 || Issue 04 || April, 2024 || 

Case of dental concrescence associated with Dens evaginatus on a mandibular permanent molar 

 

 

 

13. Mallinenne SM. Supernumerary teeth: review of the literature with recent updates. 

Conference P a p e s  i n  S c i e n c e . 2014; 6. 

14. Yoon RK, Chussid S. Dental Management of a talon cusp on a primary incisor. Pediatric 

dentistry. 2007; 29 (1) 51-5. 

 

 

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