Journal of Postgraduate Medicine, Education and Research
Volume 56 | Issue 4 | Year 2022

Bilateral Occurrence of Supernumerary Cusps on the First Permanent Molars of 6-year-old Libyan Child: Case Report

Majda T Elfseyie1, Fatimah A Mohammed2

1,2Department of Pediatric Dentistry, Faculty of Dentistry, University of Benghazi (UOB), Benghazi, Libya

Corresponding Author: Majda T Elfseyie, Department of Pediatric Dentistry, Faculty of Dentistry, University of Benghazi (UOB), Benghazi, Libya, Phone: +218924374687, e-mail:

Received on: 29 July 2021; Accepted on: 10 August 2021; Published on: 31 December 2022


Supernumerary cusps are morphological variations classified into three patterns: Carabelli’s cusp, dens evaginatus (DE), and talon cusps. DE is a disturbance of tooth formation that appears as an accessory tuberculated cusp composed of enamel, dentin, and pulp tissue. The first permanent molars (FPMs) may show alteration in their shape or structure. However, the alteration could be observed as accessory cusps on the occlusal surface or accessory roots or hypomineralization as molar incisor hypomineralization. DE is a rare dental anomaly that can occur in primary or permanent dentitions. It is infrequently seen on anterior teeth or premolars. However, their occurrence on molars is rarer. This presented a rare case of bilateral double supernumerary cusps on the right and the left maxillary FPMs of a 6-year-old Libyan boy, while the mandibular FPMs appeared with normal cusps. The aims of this study were to report and discuss the diagnostic methods and the management of this anomaly. In addition, shed light on the importance of early diagnosis and follow-up observation. That could help in reducing the potential dental problems and to improve patients’ quality of life.

How to cite this article: Elfseyie MT, Mohammed FA. Bilateral Occurrence of Supernumerary Cusps on the First Permanent Molars of 6-year-old Libyan Child: Case Report. J Postgrad Med Edu Res 2022;56(4):185-188.

Source of support: Nil

Conflict of interest: None

Keywords: Accessory cusp, Dens evaginatus, First permanent molars, Supernumerary cusps, Tooth anomalies.


Development dental anomalies are alterations during tooth morphogenesis caused by several factors, including congenital, developmental, and acquired factors. It is classified into five categories; variation in size, shape, number, position, and structure.1 The etiology of these variations is unclear, and it may be due to the overactivity of the dental lamina or genetic factor.2 Recognition of the occlusal traits and the morphological variations of teeth play an important role in dental practice.3-6 There are two diagnostic methods of malocclusion, including intraoral and study cast. However, the impression procedure is unpleasant for the children.7,8 For this reason, the most reliable diagnostic methods of accessory cusp are the clinical examination and orthopantomogram or periapical radiographs.9 The variations in teeth shape can be seen as extra cusps or missing cusps. The FPMs usually presented with four or five cusps in case of occurrence of cusp of Carebelli.10 The permanent incisors and FPMs are the most affected teeth in syphilis; the maxillary jaw is more frequently affected than the mandible.11,12 Hutchinson’s incisors and the mulberry molars are known as classic clinical findings of syphilis infection.13,14 In congenital syphilis, the mulberry molars occur mostly but are not considered as path gnomonic.15 The mulberry molars are characterized by small-sized molars with cusps covered with globular enamel projection on the cervical and middle third. No treatment is needed if the molars are functioning normally. Nevertheless, in case of extensive deformity crown is covered or extracted with the placement of an implant or bridge.16,17 Supernumerary cusps are morphological variations classified into three patterns; Carabelli’s cusp, DE, and talon cusps.9,18 DE is a disturbance of tooth formation that is composed of enamel, dentin, and pulp, appears clinically as evaginatus odontoma, occlusal pearl, enamel pearls, tuberculated cusp, accessory tubercle, accessory cusp, and Leong’s premolar.19-21 The most inclusive classification of DE was done by Schulze in 1987; it depends on the tubercle locations to distinguish DE into five types; type I in which a cone-shaped of lingual cusp discrete in buccal direction or enlarged lingual cusp with featured marginal wrinkles or central cusp on the lingual side with marginal wrinkles integrate into cingulum. In type II, a supernumerary cusp is located on the inclined slop of the lingual cusp, while in type III, an extra cusp emerges from the occlusal surface; in type IV, an extra cusp on the lingual incline of the buccal cusp, in type V tubercle conceal the central grove on the occlusal surface18,22 The diagnosis of DE should be made carefully to differentiate from the other morphological variations such as Bolk’s cusp and talon cusp.23 Talon cusp is defined as accessory cusp projection at cingulum of anterior teeth, initially described as an accessory cusp, later on, was named talon cusp, then it has received several classifications such as exaggerated cingulated, additional cusp, supernumerary cusp, and accessory cusp.24,25 Several dental problems may be caused by dental anomalies such as malocclusion, esthetic problems, and delayed permanent teeth eruption.26 The prevalence of the supernumerary cusps on the occlusal surface of permanent molars is considered a rare clinical variation. It appears as extra cusps or central cusps, whereas the central cusps can cause clinical complications rather than the extra or accessory cusps, which rarely cause problems.19 The FPMs are considered an important tooth and the key of occlusion because of their role in establishing occlusion, and their early loss will affect the other teeth as well.27 Therefore, any variation in their shape, size, and structure could pose a significant clinical impact on endodontic and orthodontic treatment.10,28 As a result of this, the teeth become irregularly positioned or loosed.29 These variations of extra cusps frequently caused early pulpal involvement due to cusp fracture during mastication,30 thus it considered a challenge to clinics, that is why a protocol was proposed for their management, which included partial vital pulpotomy for a symptomatic tooth with mature and pulpectomy for a symptomatic tooth with immature root, while apexification is indicated for symptomatic vital or nonvital teeth with immature apex, then it followed with endodontic treatment, in case of the previous technique is failed then teeth extraction is indicated.31 The significance of this case report is to highlight the significance of the early detection of morphological variation of the FPMs. It is recommended to determine the prevalence and the frequency of these extra cusps in the Libyans population to provide adequate baseline data on the morphological anomaly of FPMs.


A 6-year-old Libyan boy was seen at the Pediatric Clinic of Faculty of Dentistry for a dental checkup. The child had a fit medical history as well as a carious-free mouth. The intraoral examination of soft tissue showed no abnormalities. However, the hard tissue showed two additional cusps on the right and left maxillary FPMs, as shown in Figure 1. The extra cusps’ diameter was 2 × 2 mm. The mandibular FPMs showed normal cusps, as shown in Figure 2. The intraoral radiographic examination revealed supernumerary cusps on the maxillary FPMs, as seen in Figure 3. The digital panoramic radiograph showed additional cusps of maxillary FPMs and normal cusps of lower FPMs (Fig. 4). The family history did not report such abnormalities.

Figs 1A to C: Intraoral clinical photographs. (A) Showed supernumerary cusps the right maxillary FPMs; (B) Left maxillary FPMs; and (C) Upper maxillary arch

Fig. 2: Intraoral clinical photograph of the right and left lower FPMs with normal cusps

Figs 3A and B: Intraoral periapical radiographs. (A) Right and (B) left maxillary FPMs showed supernumerary cusps

Fig. 4: Digital panoramic radiograph showed double supernumerary cusps on the maxillary FPMs and normal cusps of lower FPMs


The present study provides a bilateral occurrence of double supernumerary cusp on the left and right permanent maxillary molars, which are rare. So far, in Libya, there is no such reported case. However, in India, a case was reported of a 14-year-old male with the presence of two unilateral supernumerary cusps on maxillary FPMs; one was found on the oblique ridge, and another on the mesiolingual cusps.18 In contrast, an 11-year-old Indian male, was observed with a single extra cuspal projection on the occlusal surface of the left and right maxillary FPMs; the projection size was 3 × 3 mm with a rhomboid base.19 A similar finding was revealed in Japan, a case of a 9-year-old child with the occurrence of bilateral central projection on the occlusal surface of maxillary FPMs and maxillary primary second molars.2 In Nepal, a reported case of a 20-year-old female with the occurrence of bilateral tubercle cusp on lower premolars with pulpal involvements; therefore, root canal treatment and cusps reduction was performed to preserve the teeth.30 In Japan, a case report of a 20-year-old male with the presence of DE on the occlusal surface of maxillary second molar with pulpal involvement due to tubercular fracture.32 On the other hand, the previous studies in India reported that the occurrences of five cusps on the FPMs were 32.6%, whereas four cusps were 67.08% and only 0.32% with three cusps.10 Another study in India reported the prevalence of seven cusps on mandibular FPMs was 11.25%.28 Another morphological variation was reported by Koneru et al. in 201833 in the case of a 6-year-old Indian boy with occurrences’ of mulberry molars on both upper and lower FPMs. However, the patient’s mother showed negative results of both the VDRL test and Treponema pallidum hem agglutination; therefore, the causes could be multifactorial.33 Dental anomaly may occur alone or in association with other anomalies, as in Mexico, a case of a 15-year-old female with four dens invaginatus in the lower incisors and one in the upper left central incisor, and another finding was a mulberry molar on left mandibular FPMs with no family history of similar finding.17 A case of a 26-year-old Chinese female was reported with multiple DE on the upper right and left second molars as well as lower second premolars. However, the patient had no symptoms; thus, shallow reduction of the opposite teeth was made with a periodic reduction of tubercle cusp then the preventive resin was applied to preserve pulp vitality and stimulation reparative dentin formation as well.23 Similarly, a reported case of a 15-year-old Indian girl with the presence of an oblique ridge and buccal cusp on the mandibular second molar, which looks like the maxillary molar with Carabelli cusp.34 Another two cases of dens invaginatus on the palatal surfaces of the upper lateral incisors were reported in 6 and 9 years, Indian girls. The treatment options for such anomalies included preventive sealer, root canal treatment, and apical surgery, and tooth extraction may be recommended as well.35 A study reported 5-year-old boy with an incidence of central cusps on both the maxillary second primary molars.36 Another case was reported of an Indian girl aged 20-year-old with an accessory cusp on the upper lateral incisor, which caused occlusal interference. Therefore, occlusal reduction with pulp therapy was considered.25


Dens evaginatus is a dental anomaly that commonly involves premolars. However, this reported a case of bilateral double supernumerary cusp on the right and left maxillary FPMs. The finding observed, in this case, is rare, and it is considered the first case of bilateral supernumerary cusps of FPMs in Libya. The child is caries free; thus, preventive measures such as topical fluoride and pit and fissure sealant are applied. Since the additional cusps were rounded, the occlusal interferences were not observed; therefore, the reduction is not recommended. The parents were informed about the extra cusps and their complications; thus, the child will be on follow-up observation.

Clinical Significance

Early detection of this anomaly will help in reducing dental complications. As the extra cusps easily fracture, the pulp will be exposed and infected too. The patient and parents were informed about the potential problems. Furthermore, to increase the knowledge regarding the importance of the differential diagnosis of such anomaly to reduce the misdiagnosis which may lead to an inappropriate treatment plan.


1. Bilge NH, Yeşiltepe S, Ağırman KT, et al. Investigation of prevalence of dental anomalies by using digital panoramic radiographs. Folia Morphol (Warsz) 2018;77(2):323–328. DOI: 10.5603/FM.a2017.0087

2. Rahul M, Ashima G, Singh S, et al. Multiple accessory cusps in maxillary primary second molars and permanent first molars and its clinical implications. J Postgrad Med Edu Res 2018;52(3):143–146. DOI: 10.5005/jp-journals-10028-1289

3. Elfseyie M, Hassan MIA, Al-Jaf NMA, et al. Prevalence of malocclusion and occlusal traits of Malay adults (18-23 years) in Shah Alam, Malaysia. Int J Dent 2020;5(2):81–85. DOI: 10.31254/dentistry.2020.5211

4. Felemban NH, Manjunatha BS. Prevalence of the number of cusps and occlusal groove patterns of the mandibular molars in a Saudi Arabian population. J Forensic Leg Med 2017;49:54–58. DOI: 10.1016/j.jflm.2017.05.013

5. Elfseyie MTM, Abdullah NM, Hassan MIA. Occlusal features of 12 years old Malaysian Malay school-children in Shah Alam. Compendium Oral Sci 2014;1(2):6–12. DOI: 10.24191/cos.v1i0.17529

6. Elfseyie MT, Al-Jaf NMA, Hassan MIA. Prevalence and gender differences of buccally displaced canines of 12 years school children and 18-23 years adults in Shah-Alam, Malaysia. Int J Dent Res 2021;6(2):39–42. DOI: 10.31254/dentistry.2021.6204

7. Ovsenik M, Farcnik FM, Verdenik I. Comparison of intra-oral and study cast measurements in the assessment of malocclusion. Eur J Orthod 2004;26(3):273–277. DOI: 10.1093/ejo/26.3.273

8. Elfseyie MTM. A study of occlusal features of Malay adults and 12 year old school children/Majda TM Elfseyie [Master thesis]. Malaysia: Universiti Teknologi MARA; 2013.

9. Cruz CV, Soares AL, Braga DN, et al. Diagnosis and surgical management of nonsyndromic nine supernumerary teeth and Leong’s tubercle. Case Rep Dent 2016;2016(3):8641867. DOI: 10.1155/2016/8641867

10. Jain S. Variation in cuspal morphology in maxillary first permanent molar with report of 3 cusp molar- a prevalence study. J Clin Diagn Res 2016;10(9):ZC34–ZC36. DOI: 10.7860/JCDR/2016/18668.8459

11. Leão JC, Gueiros LA, Porter SR. Oral manifestations of syphilis. Clinics 2006;61(2):161–166. DOI: 10.1590/S1807-59322006000200012

12. Nortjé C. Maxilo-facial radiology case 145. S Afr Dent J 2016;71:425.

13. Ronald P, Jean L, Joseph L. Dermatology. Set. St. Louis: Mosby Press; 2008.

14. Casamassimo P, Fields H, McTigue D, et al. Pediatric dentistry infancy through adolescence. Elsevier. 2005;4th Edition 648.

15. Lauc T, Fornai C, Premužić Z, et al. Dental stigmata and enamel thickness in a probable case of congenital syphilis from XVI century Croatia. Arch Oral Biol 2015;60(10):1554–1564. DOI: 10.1016/j.archoralbio.2015.07.002

16. Hillson S, Grigson C, Bond S. Dental defects of congenital syphilis. Am J Phys Anthropol 1998;107(1):25–40. DOI: 10.1002/(SICI)1096-8644(199809)107:1<25::AID-AJPA3>3.0.CO;2-C

17. Sedano HO, Ocampo-Acosta F, Naranjo-Corona RI, et al. Multiple dens invaginatus, mulberry molar and conical teeth. Case report and genetic considerations. Med Oral Patol Oral Cir Bucal 2009;14(2):E69–E72.

18. Thakur NS, Thakur S. Double dens evaginatus on permanent maxillary first molar: a case report of this rare occurrence. Indian J Dent Sci 2017;9(2):114–116. DOI: 10.4103/IJDS.IJDS_84_16

19. Roopa KB, Poornima P, Pathak S, et al. Bilateral supernumerary cusps on deciduous and permanent molars: a case report with a short review. Int J Contemp Dent Med Rev 2015;2015:1–3. DOI: 10.15713/ins.ijcdmr

20. Echeverri EA, Wang MM, Chavaria C, et al. Multiple dens evaginatus: diagnosis, management, and complications: case report. Pediatr Dent 1994;16(4):314–317.

21. Levitan ME, Himel VT. Dens evaginatus: literature review, pathophysiology, and comprehensive treatment regimen. J Endod 2006;32(1):1–9. DOI: 10.1016/j.joen.2005.10.009

22. Shrestha A, Marla V, Shrestha S, et al. Developmental anomalies affecting the morphology of teeth - a review. RSBO 2015;12(1):68–78. DOI: 10.21726/rsbo.v12i1.732

23. Rao YG, Guo LY, Tao HT. Multiple dens evaginatus of premolars and molars in Chinese dentition: a case report and literature review. Int J Oral Sci 2010;2(3):177–180. DOI: 10.4248/IJOS10052

24. Maia RA, de Souza-Zaroni WC, Mei RS, et al. Talon cusp type I: restorative management. Case Rep Dent 2015;2015:425979. DOI: 10.1155/2015/425979

25. Devi KM, Kiran G, Jyothsna M. Talon cusp / dens evaginatus of anterior teeth : a case report of a developmental dental anomaly. Indian J Dent Res 2014;6(3):1629–1633. DOI: 10.5866/2014.631629

26. Saberi EA, Ebrahimipour S. Evaluation of developmental dental anomalies in digital panoramic radiographs in Southeast Iranian population. J Int Soc Prev Community Dent 2016;6(4):291–295. DOI: 10.4103/2231-0762.186804

27. Elfseyie M, Alaskandrani R, Huew R, et al. Evaluation of health status of the first permanent molars of children aged 6 to 12 years in Benghazi, Libya. Int J Manag Soc Sci Res 2020;2(4):110–116.

28. Gupta SK, Saxena P. Prevalence of cusp 7 in permanent mandibular first molars in an Indian population: a comparative study of variations in occlusal morphology. J Investig Clin Dent 2013;4(4):240–246. DOI: 10.1111/j.2041-1626.2012.00154.x

29. Kocsis GS, Marcsik A, Kókai EL, et al. Supernumerary occlusal cusps on permanent human teeth. Acta Bio Szeged 2002;461(1-2):71–82.

30. Ayer A, Vikram M, Suwal P. Dens evaginatus: a problem-based approach. Case Rep Dent 2015;2015(9):1–4. DOI: 10.1155/2015/393209

31. Stecker S, DiAngelis AJ. Dens evaginatus: a diagnostic and treatment challenge. J Am Dent Assoc 2002;133(2):190–193. DOI: 10.14219/jada.archive.2002.0143

32. Morinaga K, Aida N, Asai T, et al. Dens evaginatus on occlusal surface of maxillary second molar: a case report. Bull Tokyo Dent Coll 2010;51(3):165–168. DOI: 10.2209/tdcpublication.51.165

33. Koneru A, Hunasgi S, Manvikar V, et al. Nonsyphilitic occurrence of mulberry molars: a rare case report. J Oral Maxillofac Pathol 2019;23(1):106–110. DOI: 10.4103/jomfp.JOMFP_74_18

34. Sakamuri S, Mallineni S. An unusual mandibular second molar mimicking maxillary first molar – a Rare occurrence. Periodon Prosthodon 2018;4(1):1–3. DOI: 10.21767/2471-3082.100037

35. Shekhar MG, Vijaykumar S, Tenny J, et al. Conservative management of dens evaginatus: report of two unusual cases. Int J Clin Pediatr Dent 2010;3(2):121–124. DOI: 10.5005/jp-journals-10005-1067

36. Chandra B, Das M. Accessory central cusp in the maxillary second primary molars: a rare entity among the rare. Int J Clin Pediatr Dent 2014;7(3):202–205. DOI: 10.5005/jp-journals-10005-1265

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