hemisection and vital treatment of a fused tooth – literature review and case report

8/3/2019 Hemisection and vital treatment of a fused tooth literature review and case report

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F.inlod Dciii 'Dtiunuiiol IW^: /.?,' 253 2>SPrimed In Pi'iiniciik . .Ul n\;lil\ rcscm'd

C()pyrii;lu Miinksi^aiird 199Endodontics &Dental Traumatology

ISSN 0109-2502

Review ar t ic l

H em isec tion and v ita l trea tm en t o f a f usedt o o t h - lite ra ture rev iew and case rep o r tH i i l s m a n n M , B a h r R , G r o h m a n i i U . H e m i s e c t i o n a n d v i t a lt r e a t me n t o f a fu se d t oo th l i t e r a t u r e r e \ i e \ v a nd e a s e r e po r t .Endod De n t Tra um a to l 1997; 13: 253 258. Munksga a rd , 1997.

Abs t r a e t Fusion a ne l g e mi na t i on o f p e r ma ne n t t e e t h a r e d e x e l op -me n t a l a noma l i e s of the de n t a l ha rd t i ssues wh i e h m ay l - equi r e (Midodon t i e a nd su rg i e a l t r e a tme n t fo r fune t i on a l , o r t hodon t i e o r a e s -t h e t i e r e a sons . Fo ll ow ing a r e \ i e w of t h e d e n t a l l i t e r a t u r e on t oo thfusion a nd gem ina t ion , a e a se of fusion of a ma x i l l a r \ e e n t r a l in -e i sor a nd a supe rnum e r a ry t oo th a nd i t s e ndodon t i e a nd su rg ie a lt r e a t m e n t is p r e s e n t e d .

M. Huismann\ R. Bahr\U. Grohmann^^ De p a r t m e n t o f O p e ra t i v e De n t i s t ry a n d^ De p a r t m e n t o f Or t h o d o n t i c s , Un i v e r s i t y o fG o t t i n g e n , G o t t i n g e n , G e rm a n y

K e y w o r d s : e n d o d o n t i e t r e a t m e n t ; g e m i n a t i o n ;h e m i s e c t i o n ; t o o t h f u s i o nM ic h a e l H u l s m a n n , De p t. o f Op e ra t i v e De n t i s try ,Univers i ty o f Got t ingen, Rober t -Koch-Str 40,D-37075 Got t ingen, GermanyAccepted Ju ly 2, 1997

Tooth fusion is de f ined a s a un ion be t w e e n the de n-t i ne a n d / o r e n a m e l o f t w o or m o r e s e p a r a t e d e v e l o p-ing t e e t h (1 3). Ih e fusion ma y be pa r t i a l o r to t a lde pe nd ing on the s t age of too th de \ e l opme nt a t thet im e of unio n. 1 he ae t io logy of th is auom a ly is s ti l lunknow n: the influenc e of p r e ssu r e o r physi c a l for c e sp r o d u c i n g c l ose c o n ti t c t b e t w e e n t w o de v e l o p i ng t e e t hand thus resul t ing in fus ion is diseussed as one poss-ible r ea son (2). Low e l l & Solom on (4) suggest tha tc l ose c on t a c t b e tw e e n tw o t oo th g e rms l e a ds t o n e -c ros i s of t l i e in t e r \ ' en ing t issue ., a l low ing the ena me lo rgan and the den t a l ] ) a ] ) i l l a to un i t e . Gene t i t a l de t e r -mina t ion i s e v iden t i t i some of the c a se s p r e se t i t (x l i t it h e l i t e r a t u r e (5 ) .

P r e v a l ene e of too t l i fusion i s e s t im a t e d a t 0 . 5% -2.5"/() in the p r i ma ry de n t i t ion w h i l e p r e v a l enc e in thep e rm a ne n t d e n t i t i on s e e ms t o b e c l e a r l y l ow e r t h ;min the j^r im ar y de nt i t ion (6). Ac c ordi ng to a re x 'i ew l yBrook & \Vinte r (7) fus ion a nd ge tni t i a t ion oc c ur i t i0 .1" / ( ) - rVo of the p r ima iy a s we l l a s the pe rmanen td e n t i t i on .Fus e d t e e t h i n mos t c a s e s show a n a noma lousb ro a d c r ow n a nd tw o di st i t ic t r oo t c a n a l s . C l i ni c a l l )-t h e c r ow ns of t h e t e e t h l ook mo l t e n t og e t h e r w i t li asma l l g roov e b e tw e e n t h e me s ia l a nd t h e d i st a l p a r t .T l i e i - e may on ly be one pu lp chambe r d ix id ing in to

t i e sys t ems, o r one eommon pu\p cana l (2, 8) . Fusiot i i a y be p a r t i a l , i nc l ud ing o ti l y t h e t oo th e row ns , oto t a l , in \'o l \ i t ig too th c row ns and roo ts . Bi la t tn-a l ocurre nce^ ol toot h fusion is not un c om m on (9-12). tw o a d j a c e n t t e e t h a r e jc Mne d t oge t h e r by e e me n tuon ly th i s i s c a lked conc r e sc e nc e (1). Cone r e sc e nc e maa ]3pe a r du r i ng d e \ e l opme t i t o f t h e tw o t e e t h o r e v ea f te r e omp l e t e d e \ e l opme n t by hype r c e me n tosi s (fo l lo \ \i t ig r e so rp t io t i of the in t e rm e d i a t e bon e . Suct e e t h a lw a ys show tw o s e ] ) a r a t e r oo t s a nd s e p a r ac row t i pu lps .Ge mina t i on , some t ime s a l so e a l l e d ' ' t w i nn ing ' ' , iss i tn i l a r de t i t a l a noma ly a nd is d e hne d a s a n a t t e mpof the tooth Imd to dixide (1, 3). Div is ion in m oca ses i s ine ompk^e and r e su l t s in a s ing le roo t w ion ly one r oo t e a n a l bu t tw o c omp l e t e l y o r i n e oml^l e te ly s epa r a t e d c row ns (3, 6). Ge mina t io t i tnay ocur in the jM- ima iy a s we l l a s in the pe rmanen t det i t i on , a nd a h e r e d i t a r y t e nde ne y h a s b e e t i r e po r t ein some c a se s .

Sot i i e t im cs i t i s imjDossible to diffe re nt i a t e be t w eefusion and geminat ion, e.s]3ecia l ly \vhen fusion occube tw e e t i a t i o r t n a l t oo th a nd a supe rn t t t n e r a ry t oo(6). In Older to o\ercome tfic^ di l l icuft ie .s in diagnosa nd t e r mi t io logy of such c a se s the t e r t i i "do i tbtoo th" has be e n in t r odue e d (4, 5), bu t has fi e en r


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Hulsmann et al.

/'/ a h i o a d c r o w n , a l a r ^ v e n a m e l i j r o j e e l i o n a n d a l( )i i


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Hulsmann et al.

Fig. //. C Control radiograj ih .'> i iot i t hs pos(o|:)e i 'a l iv c followine a t i on o l t h e o r t hodo i t t i e a pp l i a n c e .

Fo r o r t hodon t i c a nd r e s t o r a t i v e r e a sons a d e c i s i onw as ma de to r emov e the nu^si a l pa r t of the fusedtooth. As the in te rna l ana tomy of the pt i lp .system(.s)c ou ld no t b e e x a c t l y d i a gnos e d i n t h e r a d i og r a ph i twas de c ided f i r s t to pe r fo rm a pulp e x t i r p a t i on on theme s i a l p a r t o f t h e t oo th . The t oo th w a s a n a e s t h e t i z e da nd i so l a t e d w i t h r ub l )e r d a m. An a c c e s s c a v i t y w a sp r e p a r e d i n t h e m e s i a l p a i t of the tooth and the pul j)e x t i r p a t e d (Fig. 4 ). The c a v i t y w a s i nv e s t i ga t e d w i t ha r)X magnifying" lens and a curved probe for anyc onne c t i on b e tw e e n t h e tw o roo t c a n a l syst e ms . Asn o c o m m u n i c a t i o n c o u l d b e d e t e c t e d t h e m e s i a l p a r to f t h e fu se d t oo th w a s c l e a n e d a nd sh a pe d , t e mpo r -i z e d w i t h c a l c i um hyd rox id e , a nd s e a l e d . One w e e kl a t e r t h e p a t i e n t r e p o r t e d t h a t s h e h a d b e e n e o m -p l e t e ly w i thou t a ny .symptoms, a nd the d i s t a l pa r t ofthe too th s t i l l r e s j^onded norma l ly to pu lp t e s t ing .T h e t o o t h w a s a n a e s t h e t i z e d a n d a b u c c a l a n dpa l a t a l fl a p w e r e r a i s e d . On t h e buc c a l a sp e c t somefoone w as r emov ed be low the bucc a f g roove to loc a t ethe posi t ion w he re the tw o roots se]:)a ra t e d (Fig. 5).The c row n w a s d i v i d e d w i t h a d i a mond bu r (F ig . 6)

b e e n r e m o v e d d u r i n g s e p a r a t i o n ; t h e r e m a i n i n g pw e r e s m o o t h e n e d . As t h e p r o c e d u r e h a d t a k e n mlonge r t h a n e xpe c t e d ow ing t o t h e d e p th o f t h e s e pa t i ng po in t a nd a r oo t f r a c t u r e du r i ng e x t r a c t i on , fl a p w a s su tu r e d a nd t h e ope r a t i on fi n ishe d w i t hl l u t he r c orona l r e s tora t ion (Mg. 7). yVga in, 1 wl a t e r t h e su t ur e s w e r e r e m o v e d , a n d t h e t oa n a e s t h e t i z e d a n d i s o l a t e d w i t h r u b b e r d a m . Tc row n of t h e r e ma in ing t ooth w a s r e s t o r e d a f t e r ae t c h ing us ing a den t ina l bond in g .syst em a nd a hybc o m p o si t e . At t h e r e c a l l a p p o i n t m e n t 1 w e e k l a t e r pa t i e n t com pla ine d of s l igh t hype rsens i t i v i ty and pu lp s t i l l r e sponded pos i t i v e to s ens i t i v i ty t e s tW ound h e a l i ng w a s une v e n t fu l . Th r e e mon ths lthe or thod ont ic a ]3]3li ances w e re p ut in pla ce (Fig.S ix mon ths pos tope r a t i v e l y t h e o r t hodon t i c t h e rh a d r e su lt e d i n a n a r r ow ing of t h e sp a c e b e tw e e n d i st a l pa r t of the fused too th and the l e fl c e n t r a l c i so r (F ig. 9 a nd 10). 'F l i is t r e a tm e n t w as c on t inu'Fhe h e mi s e c t e d t oo th r e sponde d no rma l l y t o s e nt iv i ty t es t ing and the h\q3ersensi t iva ty had resolv

/'ig. 'i. ( ion i t o l () months l a t e r : the loo l l i has bee n re s to re de ()m| : )()s i t e ma t e r i a l . Or thodont i c t r e a tment has a l r e ady re sn l t e rluu t ow ing o l the c l i a s t cma bc lvve t 'n the e e t i t t a l i iu i so ts .


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Tooth fusio

J'ig. II. C l o nt r o l t a d i o g r a p h t a k e n (i t n o n t l i s p o s t o p e t ali\ (.'K. Nos i g n s ol p e r i a | i K ' a l | ) a t h ( ) s i s are \ t s i l ) l e ; p t i l p t e s t i t i g ts p o s i t i x c . I hew i c l e t i i n g ol the p e t t o d o t i t a l l i g a t n e n l s p a e ( ~ is due to the o r t h o d o t i -t i e I r e a t t i i e n t ol lhe t o o l h .

'Fhe radic :)graph show ed no signs of ]:)(MiapicaI pa-t hos i s , a l though a s light w ide n ing of the en t i r e ]3e r i -odon t a l l i g a me n t spa c e w a s v i s ib le ow ing to the o r t h o -d o n t i c m o v e m e n t of the tooth (l ' ig. 11).

DiscussionA case ol tooth fus ion be tvvcen a m a x i l l a r y c e n t r a linc i so r and a s n p c r n t u n c r a i y t o o t h has b e e n pie-s e n t e d , d e mons t r a t i ng s i t r g i c a l s e p a r a t i on of t he too tha n d e x t r a c t i o n of one t oo th ha l f wh ih^ ma in t a in ingVita l i ty of the r e m a i n i n g p a r t of the tooth. 4 'h is pro-c e d u r e is one c:)f s e v e r a l d i f l e r en t t r e a t me n t op t ions insueh c a se s . Or thodc : )n t i c , pe r iodon t a l , a e s the t i c , andfunc t iona l pro ble ms mav' l c c j u i r e e x t r a c t i on of onetcjoth hall" (13, 14, 1(), 17\ p r o v i d e d t h e r e arc tvvoc o m p l e t e l y s e p a r a t e d l o o t s . The separa t ic;)n of thefused toc:)th into two s ingle inc isors v \c)uld have beena possi b l e t r e a tm e n t me thod as de s c r i b e e ! in j ) r e v iousr e p o r t s (12), l)ut in the ] ir e s e n t c a s e w ou ld h a v e re-

In some of the e a se l s p r e sen t ed in the d e n t al i t e r a t u r e on t h i s ano t i i a ly , c -ndodont i c t r e a tmenha d to be p e r f o r m e d as the pulp systems of bothtoo th h a l v e s v \ e r e c onne c t e d in a c o m m o n p u lc h a m b e r or c o m m u n i c a t i o n e x i s t e d b e t w e e n tht w o roo t c a n a l s (8, 15, 18), fol low ed only by r e c o ntou r i ug of the c ro w ns. Stil lw c^ll & Coke (12) de s c i i ba c a s e of b i l a t e r a l fu si on b e tw e e n the c e n t r a l n t a x i ll a ry inc i so rs and supc rnumc r a i y t e e t h . Foo th s e p a ra t i on was p e r f o r m e d on bcnh fused te e t h w i thoul ^ r i o r e ndodc ^n t i c t r e a tme n t . D tu i t i g r e mov a l of anename l ] ) ro j e c t ion , pul]^ c x p o s t u v s o c c u r r e d on twof the t e e t h , w h i c h w e r e t r e a t e d w i t l i p a r t i a l pulpotomies . Ovs ing to i r r e v e r s i b l e p t i l p i t i s r oo t c a n at r e a t m e n t had to be p e r f o r m e d on two of the fouinc i so rs 45 days ] )os topc r a t i v c ly . C l em & N a t k i(17) rej)ort on the successful remcn'a l of one t oo thall~ in a fused too th , ma in t a in ing \ i t a l i ty of the rema in i t i g pai1, w h e r e a s iti o th e r c a s e s of s e p a r a t i oe n d o d o n t i c t r e a t m e n t of the r e ma in ing t oo th h a lw as unde r t a ke n be fo r e s tu;g ic a l in t c r v c -nt ion (US).

A few e a s e r e po r t s d e s e r i b e j j o s t ope r a t i v e c omp l ic a t ions such as hype rsens i t i v i ty , i r r e v e r s ib l e pu lp i t i sand exte rna l root resc :ipt io i i (16, 19). In the ]:)resene a s e , unt i l 6 mon ths pos tope r a t i v e l y , on ly an i n i t i as l igh t hvpe rs ens i t i v i ty oc cu r r ed , p robab ly d t i e to thdc l a v cd r c s t c^ r a t ion of the ex]:)osed dentine of" the rcma in ing too th jx i r t . Fo l lov \ ing r e s to r a t ion w i th dent i n e bond ing and a con i j^os i t c ma t e r i a l th i s hvpe rsensi t i v i ty r e so l v ed dur ing the fbl low ing w ee ks , and nsigns ol" per iapica l jDa thosis or e x t e rn a l r e so rp t i ow e r e d i a g no se d at a (>mon th r e c a l l .References

1. S c h u l / e (^ D e v e l o p m e n t a l a b n o r m a l i t i e s of the l e e t h .md ihj a w s . In: C i o r l i n RJ, C i o l d m a n H M . e d i t o r s . 1 h o m a ' s o r a l p a t ho l o o y . (iih ed. Si. L o u i s : . M o s b v : 1970. p. 9() I H i i

'1. M a d e r C ; ! . . Fu si on o l ' t e e l l i . j . \m D e n t . \ s s oe 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 a n o m a l i e s ol the d e n t i t i o n

s c i e n t i l i e r e \ i e \ v . P r d i a i r D e n t ) 199."):."): l():i U).-1 . L o w e l l Ivj. S o l o n u m . \ I , . I ' u s e d t t ' e t h . ] .\m D e n t . \ s s o

1 9 ( i 4 : ( ) M : 7 ( ) 2 .:"i. Moody 1*> Motitgomery LH. Hereditary tetideiuies in tootformation. I .\m Dent .\ssoe I!)!) 1:2 1:1 77 1 (i.

(). Hlaney I 1). Ilariwell (iR. Belli/zi R. l',ndodontie managemenof a fused tooth: a tase report . | I'.ndotl 1 9fi2:8:'2'27 '.\0.

I. B i ' o ok . M l . W i t i l e i ' ( I B . D o u b l e l e e t h . .\ t \ ~ t r ( )S ] )e i t i \ t ~ s t u d y o' g e m m a t e d " a n d " l i t s e d " t e e t h m ( h i l t l r e t i . Hr D e t uI ! ) 7 ( l : 1 2 9 : r 2 ; ^ 'M).

II. R e e h l '",S. l '" ,ldeel) M. R o o t ( a n a l m o t p h o l o g v ' of I n s e d mand t b u l a r i . u u n e an d l . u e r a l i n e i s o r . | l ' . ndod 1989: l : i : ! i ! ^ .).

9 . B n d d CS. R e i t l Di:. K u l i l d J C . W e l l e r RN. E n d o d o n t i e t r e am e i u o f a n t i n t i sn a l e a s e ol fus ion . ) l u i d o d 1 9!)2:18:1 S!-! 7.

10. D e l a t n ( JM. ( i o l d h l a t t 1.1. l u s e d t e e t h : a n u t U i d i s c i p l i t i a r x app r o a e l i to t r e a t m e n t . ) . \m D e t u . \ s s o e I 9(S 1:1 O!i:7!i2 I.

11 . D n t u a t i W'K. l l e l p i n .Ml.. H i l a t e r a l f u s i o n an d > j , e tn ina t ion :l i t e t a t u r e a t i a l y s i . s an d t a s e i c p o r i . O t a l S ur o - O r a l Me d O rP a t h o l 1 9 8 7 ; 6 4 : 8 2 7.


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H u l s m a n n e t a l .13. T a gge r M. T oo th g e mina l i on t r e a t e d by e ndodon t i c t h e r a py .J Rndod 1975; 1:181-4.14. I t ki n AB, Ba r r GS . Compre hc n .s i v c ma na ge me n t o f t h e doub l etoot h: re por t of ca .sc .J Am De nt Assoc 197.5;90:1269 72.\5. Pe y r a no A, Z me ne r O . E ndodon t i c ma na ge me n t o f ma nd ibn-l a r l a t e r a l i n c i s o r fus e d w i t h s upe rnume r a ry t oo th . E udod De n tTrauma to l 1995;11:196 8.16. Blank BS, Ogg R R , Levy AR . A fusixl c en t ra l ine i sor pe r i -

odon t a l c on .s i de r a t i ons in c ompre he t i s i v e t r e a tm e n t . J Pe r i -odontol 1985;.56:21 4.

17. Cle m VVH, Na tk in E . T r e a tm e nt of the fused t oo th . R epoa e a s e . O r a l Su rg Ora l Me d Ora l Pa t bo l 1966 ;21 :36 . 5 -7018. Libfek l H, St ahhol / A, Fr i edman S. Endodont i e the rapbi l a t e ra l ly gemina t ed ma .xi l l a iy c e n t ra l inc i sors . J l '1986;12:214-6.19. Kaya l ibay H, l l zamis M, Aka l in A. The t r e a tment of a s io ti b e tw e e n t h e t n a x i l l a i y c e n l t a l i i u i s o r a nd s t t p e m uaiy tooth: re j^orl of a case . ) Cl l in Pedia t r

I996;2O:237-4O.


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hemisection and vital treatment of a fused tooth – literature review and case report

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