F.inlod Dciii 'Dtiunuiiol IW^: /.?,' 253 2>S Primed In Pi'iiniciik . .

Ul n\;lil\ rcscm'd

C()pyrii;lu Miinksi^aiird

1997

Endodontics & Dental Traumatology

ISSN 0109-2502

Review article

Hemisection and vital treatment of a fused tooth - literature review and case report
Hiilsmann M, Bahr R, Grohmanii U. Hemisection and vital treatment of a fused tooth literature re\ie\v and ease report. Endod Dent Traumatol 1997; 13: 253 258. Munksgaard, 1997. Abstraet Fusion anel gemination of permanent teeth are dexelopmental anomalies of the dental hard tissues whieh may l-equire (Mido dontie and surgieal treatment for funetional, orthodontie or aesthetie reasons. Following a re\ iew of the dental literature on tooth fusion and gemination, a ease of fusion of a maxillar\ eentral ineisor and a supernumerary tooth and its endodontie and surgieal treatment is presented.
M. Huismann\ R. Bahr\ U. Grohmann^
^Department of Operative Dentistry and ^Department of Orthodontics, University of Gottingen, Gottingen, Germany

Key words: endodontie treatment; gemination; hemisection; tooth fusion Michael Hulsmann, Dept. of Operative Dentistry, University of Gottingen, Robert-Koch-Str 40, D-37075 Gottingen, Germany Accepted July 2, 1997

Tooth fusion is defined as a union between the dentine and/or enamel of two or more separate developing teeth (1 3). Ihe fusion may be partial or total depending on the stage of tooth de\ elopment at the time of union. 1 he aetiology of this auomaly is still unknown: the influence of pressure or physical forces producing close contitct between two developing teeth and thus resulting in fusion is diseussed as one possible reason (2). Lowell & Solomon (4) suggest that close contact between two tooth germs leads to necrosis of tlie inter\'ening tissue., allowing the enamel organ and the dental ])a])illa to unite. Genetit al determination is evident iti some of the cases presetit(xl iti the literature (5). Prevalenee of tootli fusion is estimated at 0.5%2.5"/() in the primary dentition while prevalence in the permanent dentition seems to be clearly lower th;m in the j^rimary dentition (6). According to a rex'iew l^y Brook & \Vinter (7) fusion and getnitiation occur iti 0.1"/()-rVo of the primaiy as well as the permanent dentition. Fused teeth in most cases show an anomalous broad crown and two distitict root canals. Clinicall)the crowns of the teeth look molten together witli a small groove between the mesial and the distal part. Tliei-e may only be one pulp chamber dixiding into two root canals, as well as two indepetident endodon-

tie systems, or one eommon pu\p canal (2, 8). Fusion tiiay be partial, including otily the tooth erowns, or total, in\'ol\itig tooth crowns and roots. Bilattn-al occurrence^ ol tooth fusion is not uncommon (9-12). If two adjacent teeth are jcMned together by eementum only this is calked concrescence (1). Conerescence may a]3pear during de\ elopmetit of the two teeth or eveti after eomplete de\ elopment by hypercementosis (1) follo\\itig resorptioti of the intermediate bone. Such teeth always show two se])arate roots and separate crowti pulps. Gemination, sometimes also ealled ''twinning'', is a sitnilar detital anomaly and is dehned as an attempt of the tooth Imd to dixide (1, 3). Division in most cases is ineompk^e and results in a single root with only one root eanal but two completely or ineoml^letely separated crowns (3, 6). Geminatioti tnay occur in the jM-imaiy as well as in the permanent dentition, and a hereditary tendeney has beeti reported in some cases. Sotiietimcs it is imjDossible to differentiate betweeti fusion and gemination, e.s]3ecially \vhen fusion occurs betweeti a tiortnal tooth and a superntttnerary tooth (6). In Older to o\ercome tfic^ dillicuftie.s in diagnosis and termitiology of such cases the tertii "doitble tooth" has been introdueed (4, 5), but has fieen rejected by ,se\-eral other attthors (2) as it does not ap-

253

Hulsmann et al.

/'/<;. /. Prc()])crati\'(' \icvv of ilic huccal aspcci ol ihc (used lodih sh()\vini> a h i o a d crown, a lar^v enamel ijrojeelion and a l()ii<i,ilu(linal ^Todve exlendiiio into the t;inij,ival snlcus.

'

fc"

Fii^. .'/. P i T ( ) ] i e r a t i \ ' e r a d m n i a p l i <>l llie h i s e d l o o l h s l i o w i n i ; i w o sejia r a t c r o o t s . N o e o i n m u n i e a l i o i i ol t h e p u l p s y s t e m s ( a n l)e d c l e c l e d fatli()<;'raphu ally.

/')/,'. 2. Pre()])erative view of the palatal as|:)e( t of lhe fused lootli wilh a .seeoiid lai'^c enamel pearl and a^ain a lon^iludiiial j^rooxc cxlendini^ into the t^inirival siileiis. Slight hlcedinL!, could hv |)n)\'<)ked l)y jioeket |:)r()l)iii^\

j)r()prialely describe what really oec iirs. Both ty])e.s of loolh sha])r anomaly clinically may rcsuh in ac.slhelie problems and ihus may reciuire some kind oi" endodontic, restorative, surgical and/or ortlioclontic treatment. Although fusion and gemination mainly occur in incisors, premolars and molars also may be involved (1).
Treatment considerations

Several treatment methods have been described in the literature with respect to the diffcMTUt types and morphological variations of fused and geminated teeth. As the majority of such teeth probably will be asymptomatic, in tnost cases no eiidodontic treatment is uecessaiy. Becatise of" their anomalous crown form some .space j)roblcms may occur. Ii two regular teeth have fused, the resulting dental structure occupies less 254

space than two single teeth, whieh may result in diastema and loss of j^roximal contact. If a regular (ooth and a supernumeraiy tooth fuse, more arch length is reqtiireci and ciowcling or even impactioti of^ ntMghbouring teeth may result (2). Additionally, the buccal and palatal grooves may continue to the root surface and present similar periodontal problems to those eaused by palatal grooves in single teeth (13). In cases with aesthetic or orthodontic proi)lems hemiscction is reconimended if the fused tooth shows two sej^arate roots (14). If the pvilp chambers are connected endodontic treatment of the remaining part of the flised tooth is neeessai^y. Sometimes the connc-ction of the pulp chambers and the need for root canal treatment only becomes evident after the hemisection procedure (12, 14). Several reports on orthograde endodontic treatment of fused teeth also describe midroot connections between the root canals which became visible only during or even after com]:)lction of endodontic therapy (13, 15). Following stirgical and endodontic treatment the remaining part of the crown has to be restored with a crown or with compf)site materials, followed by orthodontic treatment.

Tooth fusion

Fig. 5. Intraoperalixe \iew: the se|KU'alioii helween the roots e<iitlcl be jjrobed only alter osteotomy.

Fig. 4. Radiograph for determinalion ofendodonlie working length. fnlrao]jerati\ely no communication between the pulp systems ol the two tooth hakes eoukl l)e cletetted. Fig. 6. Inlrao]M'ralive \ievv following sep.ir.uion of the crowns. Thc roots .separated Ijelow the margin of the aKcolar bone.

Case report

A 10-year-old girl was iTferred by the Department of Orthodontics for consultation and treatment of an anomalous central right maxillary incisor. Her medical histoi")' was noncontributoiT. The oral investigation revealed a maxillaiy right central incisor fused to a supernumeraiy tooth. On the buccal and palatal aspects deep grooves separating both crowns extended into the gingival sulcus (Fig. 1 and 2). Additionally, large enamel pearls were detected between the two crowns. Pulp testing gave a normal response. No caries could be detected. Pocket probing revealed 4 mm pockets on the buccal and palatal surfaces below the longitudinal grooves. Oral hygiene was judged slightly deficient, resulting in gingivitis. Radiographic investigation showed a flised tooth with two distinct roots. No connection between the two separate root canal systems cotild be detected radiographically (Fig. 3). The diagnosis rnade was tooth fusion between the maxillary right central incisor and a stiperntuiierary tooth prol)al)ly with two separate root catial systems.

Fig. 7. Intraopcrati\ e \iew following suttning. Still no restoratne treatment has been performed. I h e enamel pearls ha\ e been smootliened.

Treatment was recommended because of aesthetic and orthodontic pix^hlems and m order to prevent periocloiUal disease owing to the buctal and palatal orooxes.

255

Hulsmann et al.

been removed during separation; the remaining parts were smoothened. As the procedure had taken much longer than expected owing to the depth of the separating point and a root fracture during extraction, the flap was sutured and the operation finished without lluther coronal restoration (Mg. 7). yVgain, 1 week later the sutures were removed, and the tooth anaesthetized and isolated with rubber dam. The crown of the remaining tooth was restored after acid etc hing using a dentinal bonding .system and a hybrid composite. At the recall appointment 1 week later the patient complained of slight hypersensitivity and the pulp still responded positive to sensitivity testing. Wound healing was uneventful. Three months later the orthodontic a]3]3liances were put in place (Fig. 8). Six months postoperatively the orthodontic therapy had resulted in a narrowing of the space between the distal part of the fused tooth and the lefl central incisor (Fig. 9 and 10). 'Fliis treatment was continued. 'Fhe hemisected tooth responded normally to sensitivity testing and the h\q3ersensitivaty had resolved.

Fig. //. C Control radiograjih'.'>tiiotiths pos(o|:)ei'alivc followin eation ol the orthodoittie appliance.

For orthodontic and restorative reasons a decision was made to remove the nu^sial part of the fused tooth. As the internal anatomy of the ptilp .system(.s) could not be exactly diagnosed in the radiograph it was decided first to perform a pulp extirpation on the mesial part of the tooth. The tooth was anaesthetized and isolated with rubl)er dam. An access cavity was prepared in the mesial pai t of the tooth and the pulj) extirpated (Fig. 4). The cavity was investigated with a r)X magnifying" lens and a curved probe for any connection between the two root canal systems. As no communication could be detected the mesial part of the fused tooth was cleaned and shaped, temporized with calcium hydroxide, and sealed. One week later the patient reported that she had been eompletely without any .symptoms, and the distal part of the tooth still resj^onded normally to pulp testing. The tooth was anaesthetized and a buccal and palatal flap were raised. On the buccal aspect some foone was removed below the buccaf groove to locate the position where the two roots se]:)arated (Fig. 5). The crown was divided with a diamond bur (Fig. 6) and the mesial part of the tooth was removed. 'Fhe ])alatal and buccal enamel pearls had already partially

/'ig. 'i. (ionitol () months later: the loolli has been restored with e()m|:)()site material. Orthodontic treatment has already resnlterl in luutowing ol the cliastcma bclvvet'n the eetittal iiu isots.

lug. 10. View from the i^alatal asj^ect.

256

Tooth fusion

J'ig. II. Clontrol t a d i o g r a p h taken (i tnontlis postopet ali\ (.'K. N o signs ol peria|iK'al |)ath()sis are \tsil)le; ptilp testitig ts positixc. I he wicletiing ol the pettodotital ligatnenl spae(~ is d u e to the orthodotitie Ireattiient ol lhe toolh.

In some of the easels presented in the dental literature on this anotiialy, c-ndodontic treatment had to be performed as the pulp systems of both tooth halves v\ere connected in a common pulp chamber or communication existed between the two root canals (8, 15, 18), followed only by recontouriug of the crowns. Stillwc^ll & Coke (12) desciibe a case of bilateral fusion between the central ntaxillary incisors and supcrnumcraiy teeth. Footh separation was performed on bcnh fused teeth without l^rior endodc^ntic treatment. Dtuitig removal of an enamel ])rojection, pul]^ cxpostuvs occurred on two of the teeth, which were treated witli partial pulpotomies. Ovsing to irreversible ptilpitis root canal treatment had to be performed on two of the four incisors 45 days ])ostopcrativcly. Clem & Natkin (17) rej)ort on the successful remcn'al of one tooth hall~ in a fused tooth, maintaining \itality of the remainitig pai1, whereas iti other cases of separation endodontic treatment of the remaining tooth half was undertaken before stu;gical intcrvc-ntion (US). A few ease reports deseribe jjostoperative complications such as hypersensitivity, irreversible pulpitis, and external root resc:iptioii (16, 19). In the ]:)resent ease, until 6 months postoperatively, only an initial slight hvpersensitivity occurred, probably dtie to the dclavcd rcstc^ration of the ex]:)osed dentine of" the rc^maining tooth jxirt. Follov\ing restoration with dentine bonding and a conij^ositc material this hvpersensitivity resolved during the fbllowing weeks, and no signs ol" periapical jDathosis or external resorption were diagnosed at a (>month recall.
References

'Fhe radic:)graph showed no signs of ]:)(MiapicaI pathosis, although a slight widening of the entire ]3eriodontal ligament space was visible owing to the orthodontic movement of the tooth (l'ig. 11).
Discussion

1. S c h u l / e (^ D e v e l o p m e n t a l abnormalities of the leeth .md ihe jaws. In: Ciorlin RJ, Cioldman H M . editors. 1 h o m a ' s oral p a t h olooy. (iih ed. Si. Louis: .Mosbv: 1970. p . 9() IHii '1. M a d e r C ; ! . . Fusion o l ' t e e l l i . j . \ m Dent .\ssoe 1979:5)8:1)2 t. !i. B r a h a m RI,. l ) e \ c l o p m e n t a l anomalies ol the dentition a scientilie re\ie\v. P r d i a i r Dent ) 199."):."): l():i U). -1. Lowell Ivj. S o l o n u m . \ I , . I'used tt'eth. ] . \ m Dent .\ssoe

19(i4:()M:7()2.
:"i. Moody 1> Motitgomery LH. Hereditary tetideiuies in tooth *. formation. I .\m Dent .\ssoe I!)!) 1:'2 1:1 77 1 (i. (). Hlaney I 1). Ilariwell (iR. Belli/zi R. l',ndodontie managemeni of a fused tooth: a tase report. | I'.ndotl 1 9fi2:8:'2'27 '.\0. I. B i ' o o k . M l . W i t i l e i ' ( I B . D o u b l e l e e t h . . \ t\~tr()S])ei ti\t~ s t u d y o l ' g e m m a t e d " a n d "litsed" t e e t h m ( h i l t l r e t i . H r D e t u )

A case ol tooth fusion betvvcen a maxillary central incisor and a snpcrntuncraiy tooth has been piesented, demonstrating sitrgical separation of the tooth and extraction of one tooth half whih^ maintaining Vitality of the remaining part of the tooth. 4'his procedure is one c:)f several diflerent treatment options in sueh cases. Orthodc:)ntic, periodontal, aesthetic, and func tional problems mav' lccjuire extraction of one tcjoth hall" (13, 14, 1(), 17\ provided there arc^ tvvo completely separated loots. The separatic;)n of the fused toc:)th into two single incisors v\c)uld have been a possible treatment method as describee! in j)revious reports (12), l)ut in the ]iresent case would have required the extraction of a neiglibouring tooth to sohc the aesthetic problems.

I!)7(l:129:r2;^ 'M).
II. Reeh l'",S. l'",ldeel) M. Root ( a n a l motphologv' of Insed m a n dtbular i . u u n e a n d l.ueral ineisor. | l'.ndod 1989:l:i:!i!^ .). 9. Bndd C S . Reitl D i : . K u l i l d J C . Weller R N . E n d o d o n t i e treatmeiu o f a n tintisnal ease ol fusion. ) luidod 1 9!)2:18:1 S!-! 7. 10. Delatn ( J M . (ioldhlatt 1.1. l u s e d teeth: a nutUidisciplitiarx a p proaeli to t r e a t m e n t . ) . \ m Detu .\ssoe I 9(S 1:1 O!i:7!i2 I. 11. D n t u a t i W'K. llelpin .Ml.. Hilateral fusion a n d >j,etnination: a litetature atialysi.s a n d t a s e icpori. O t a l Suro- Oral M e d O r a l Pathol 1987;64:82 7. 12. Stillwell R I ) . C'oke J M . Hilateral fttsion o l t l i e maxillary eetittal ituisors lo sttpet tittmeraiy lec-tli: r(~port of a i ase. J .Am Detu .\ssoe 198(); 112:62 4.

257

Hulsmann et al.
13. Tagger M. Tooth geminalion treated by endodontic therapy. J Rndod 1975; 1:181-4. 14. Itkin AB, Barr GS. Comprehcn.sivc management of the double tooth: report of ca.sc.J Am Dent Assoc 197.5;90:1269 72. \5. Peyrano A, Zmener O. Endodontic management of mandibnlar lateral incisor fused with supernumerary tooth. Eudod Dent Traumatol 1995;11:196 8. 16. Blank BS, Ogg RR, Levy AR. A fusixl central ineisor periodontal con.siderations in comprehetisive treatment. J Periodontol 1985;.56:21 4. 17. Clem VVH, Natkin E. Treatment of the fused tooth. Report of a ease. Oral Surg Oral Med Oral Patbol 1966;21:36.5-70. 18. Libfekl H, Stahhol/ A, Friedman S. Endodontie therapy of bilaterally geminated ma.xillaiy central incisors. J l'jidod 1986;12:214-6. 19. Kayalibay H, llzamis M, Akalin A. The treatment of a l"usioti between the tnaxillaiy cenltal iiuisor and sttpemumeraiy tooth: rej^orl of a case. ) Cllin Pediatr Detit I996;2O:237-4O.

258