Clinical Dentistry

Clinical Dentistry

Endodontics

Dr. Abhijit Wagh MDS, Assistant Professor

Dr. Vijaya A. Wagh MDS, Professor & Head, Dept of Prosthetic Dentistry

SYNODONTIA BETWEEN PERMANENT MAXILLARY LATERAL INCISOR AND A SUPERNUMERARY TOOTH

Abstract
|| Brief Background The paper discusses the salient features of fusion and germination and their management with special consideration to access cavity preparation, location of canal orifices, managing dilacerations, post selection, cementation and finally prosthetic rehabilitation. || Materials and Methods Clinical and radiographic examination suggested a fusion between the lateral incisor and a supernumerary tooth with a dilacerated root. The treatment plan entailed endodontic treatment followed by restorative rehabilitation. || Discussion The factors that help to distinguish between fusion and gemination are discussed in detail followed by a brief discussion of the endodontic and restorative management of the case. || Summary and Conclusions Synodontia or fusion is the union of two independently developing primary or secondary teeth. The case presented an abnormally large tooth in the place of maxillary right lateral incisor with a molar like clinical crown showing a deep carious lesion and peri-apical involvement. following endodontic treatment, restorative rehabilitation was done with a prefabricated carbon fiber post, Luxa Core followed by a PfM crown to achieve good aesthetics. || Key Words Synodontia or fusion, endodontic and restorative management.

Correspondence Address Dr. Abhijit Wagh Dept. of Conservative Dentistry and Endodontics Sinhgad Dental College & Hospital, Pune 411044

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|| Introduction Tooth fusion also termed asSynodontiaarises through union of two or more normally separated tooth germs. It is defined as the union between the dentin and/or enamel of two or more separate developing teeth.1,2. The fusion may be partial or total depending upon the stage of tooth development at the time of union, a distinguishing feature between fusio-totalis, partialis-coronaries and partialisradicularis.3,4. If the contact occurs before the calcification stage, the teeth unite completely and form one large tooth. Incomplete fusion may be at root level if the contact and union occurs after formation of crown. The union between the teeth results in an abnormally large tooth, or union of the crowns, or union of the roots only, and must involve the dentin. The root canals may be separate or fused. Prevalence of tooth fusion is estimated at 0.5-2.5% in the primary dentition with a lower prevalence in permanent dentition.3. In addition to affecting two normal teeth, fusion may also occur between a normal tooth and a supernumerary tooth4. Clinically, a fusion results in one less tooth in the dental arch unless the fusion occurred with a supernumerary tooth. The involvement of a supernumerary tooth makes it impossible to differentiate fusion from gemination. The etiology of fusion is still an enigma and many different views have been put forward. Shafer et al5 speculated that pressure produced by some physical force prolongs the contact of the developing teeth causing fusion. Lowell and Soloman6 believe that fused teeth result from some physical action that causes the young tooth germs to come in contact, thus producing necrosis of the intervening tissue, thus allowing the enamel organ and dental papilla to fuse together. Many authors have also suggested hereditary involvement as an autosomal dominant trait with reduced penetrance7. fusion may be unilateral or bilateral and most commonly occurs in primary teeth with more predilection for anterior teeth8. Clinically fused anterior teeth frequently have a groove or notch on the incisal edge that goes in buccolingual direction and radiographically, the dentin of fused teeth always appears to be joined in some region with separate pulp chambers and canals. Supernumerary teeth develop as a consequence of proliferation of epithelial cells from dental lamina with

the incidence ranging from 0.5 to 3.8% and maxillary anterior region in males being more affected.9 Endodontic therapy of such teeth is a challenge even to the experienced professional because the morphology of fused teeth varies so greatly that one can only decide on an individual basis. The restorative aspect of these teeth after endodontic therapy is equally demanding. Since these teeth are mesiodistally as well as facio-lingually wide, it is quite a challenge to achieve good aesthetics within the given parameters and restorative protocols. || Case Report A 17 year old girl in good health reported with a chief complaint of sharp, shooting continuous pain in the upper right front region. Intra-oral examination revealed a large carious lesion on the maxillary right lateral incisor. The tooth was very wide mesio-distally as well as facio-palatally and had an abnormal molar like crown morphology with a deep carious lesion in the centre (fig-2, fig-3).

Fig. ( 1 ) Classification

Fig. ( 2 ) Labial view

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Clinical Dentistry

Fig. ( 3 ) Occlusal view

Fig. ( 5 ) Occlusal Xray

root canals while geminated teeth usually have one big pulp canal. Location by jaw: fusion is common in mandible and gemination in maxilla but fusion between supernumerary and normal tooth is more common in the maxilla. Crowding: fused teeth would more often cause ectopic eruption and geminated teeth would cause more of crowding. However, when a normal tooth is fused with a supernumerary tooth, crowding and even impaction of other teeth may result. So this factor is n good diagnostic feature. Number of teeth: fusion is counted as one tooth and thus diminishes the number of teeth whereas the number is increased in gemination. According to Mader11, the two tooth rule is helpful in differentiating fusion from gemination. If the resulting dental structure is counted as two teeth and the normal number of teeth are present in the region, the case probably represents an example of fusion. If, however, the abnormal dental structure is counted as two teeth and if an extra tooth is present in the region, then the case may represent an example of gemination between a normal and a supernumerary tooth. All the above factors, the abnormal large crown morphology, the pulpal anatomy having two distinct root canals and according to the rule of two along with the radiographic findings confirmed the diagnosis of fusion between maxillary lateral incisor and a supernumerary tooth. || Endodontic Management According to Wolfe12, fused anterior teeth in the

Fig. ( 4 ) OPG

The tooth was tender on percussion and exaggerated response to electric pulp tester. A clinical diagnosis of acute irreversible pulpitis secondary to caries was made. Radiographic investigation revealed a bulbous dilacerated root with peri-apical widening of the lamina dura (fig-6). Mesial and distal angulation IOPA x-rays were also taken to radiographically evaluate extra canals or root curvatures (fig-7, fig-8). OPG and Maxillary occlusal x-rays were taken to confirm whether it is gemination or fusion (fig- 4, fig-5). fusion is often confused with the process of gemination. Gemination occurs when, during the proliferative stage of dental development, a single tooth germ attempts to divide by invagination. These two can be differentiated by the below parameters10. Morphology: Gemination results in mirror images of the coronal halves, whereas fusion takes place at an angle causing a crooked appearance.

Anatomy : Pulpal anatomy is very useful in diagnosing the type of double teeth. fused teeth would mostly have separate pulp chamber and

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Fig. ( 6 ) Pre-operative IOPA X-ray Fig. ( 8 ) Pre-operative Distal angulation IOPA X-ray

Fig. ( 7 ) Pre-operative Mesial angulation IOPA X-ray

Fig. ( 9 ) Access cavity prepared

maxilla, often have canals in the facio-palatal direction. This predilection is attributed due to the fact that these teeth and the supernumerary tooth develop most often on the palatal side. Endodontic access cavity was prepared after removal of all caries under rubber dam isolation (fig-9). Two canals were located in facio-palatal direction. The canals were scouted using 10 No K file and coronal pre-flaring was done using GG drills. A crown down approach was employed for shaping the canals. Glide path was secured (fig-6) and working length was confirmed and noted (fig-10). It was also noted that

the palatal canal was the straighter canal. Thorough cleaning and shaping was done till f2 ProTaper finishing files13. Canals were copiously irrigated with NaOCl-5.25% and alternated with 17% aqueous EDTA. Recapitulation and patency verification was done after each instrument. A final irrigation of 17% EDTA for 3 minutes followed by a 5 minutes irrigation with NaOCl-5.25%, which was followed by irrigation with 2% Chlorhexidine gluconate for 2 minutes. Canals were thoroughly dried and master cone selection was done. Canals were obturated using the warm vertical condensation technique (fig-11).

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Fig. ( 12 ) Post Cemented

Fig. ( 10 ) Diagnostic X-ray

Fig. ( 13 ) Occlusion verified before curing

Fig. ( 11 ) Post obturation

Fig. ( 14 ) Core Build-Up with Luxa-Core

It was observed that an apical delta was obturated. Temporary coronal sealing was done with an eugenolfree cement. || Restorative Management As discussed earlier, the palatal canal was selected for placement of the prefabricated carbon fiber post as it was the straighter canal14. Carbon fiber post

was selected as it is passive parallel serrated post with good radiographic appreciation and with a view to preserving more amount of residual dentin and good matching with the already prepared canal. The length and the diameter of the post were selected and accordingly the minimal required post space preparation was done keeping 5mm of GP apically15. The selected post was sand-blasted and a coat of bonding agent was applied and kept. The

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canal was etched and bonded using the 1 step selfetching adhesive primer system and then the post was cemented with a resin luting cement (fig 12). The occlusion was verified before light curing the cemented post (fig. 13 ). Core build-up was done subsequently with Luxa core (fig 14). A confirmatory IOPA was taken to verify the placement of post and the core (fig 15). The disto-incisal angle of 11 was also built-up in composite. Shade selection was also done for the subsequent PfM crown at this stage only. Crown preparation was done with an adequate crown ferrule of 2mm wherever possible16 (fig-16 & fig-17). A temporary heat cure crown was made and cemented with an eugenol free cement. The tooth was temporized for 2 weeks allowing the surrounding gingiva to heal and come to normal (fig-18). A final impression was made in an A-Silicone elastomeric impression material with adequate gingival retraction. Metal coping trial was then done to verify fit (fig19 & fig- 20) and the final crown was cemented after checking the bisque trial. Thorough scaling and polishing was also done after two days and instructions were given. A post operative evaluation of the aesthetics was done after two weeks (fig-21 & fig 22). || Conclusion Synodontia in the maxillary anteriors, although relatively infrequent in prevalence, may result in significant aesthetic problems. As they are often very wide mesio-distally as well as facio-lingual resulting in space problems, proper inter-disciplinary treatment planning has to be done. The occlusal or incisal

surface is often varied with deep grooves and results in caries. Endodontic management requires careful evaluation of pre-operative IOPA x-rays to ascertain the number of canals, curvatures/dilacerations. Access cavity preparation has to be ergonomic and judiciously done with due consideration to the final restorative protocol. Post placement is often mandatory and pre-fabricated passive serrated posts are better suited than cast posts mainly due to the ferrule considerations. Subsequent porcelain crowns either metal-free or fused to metal also determine the selection between fiber posts or metallic posts respectively. Occasionally crown lengthening has to be done to achieve good aesthetics.

Fig. ( 16 ) Crown preparation-facial view

Fig. ( 15 ) IOPA Xray after Post cementation & core build-up

Fig. ( 17 ) Crown preparation- Occlusal view

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Fig. ( 18 ) Tooth temporized & Disto-facial rotation of 11 aesthetically corrected with direct composites

Fig. ( 21 ) Final crown

Fig. ( 19 ) Coping Trial Facial view

Fig. ( 22 ) Final crown

Fig. ( 20 ) Coping Trial Occlusal view

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Fig. ( 23 ) Before treatment

Fig. ( 24 ) After treatment

|| References
1. Schulze C. Developmental anomalies of the teeth and the jaws. In Gorlin RJ, Goldman HM. (ed.) Thomas Oral Pathology. 6th ed., St. Louis, 1970, 96-183. 9. 2. Braham RL. Developmental anomalies of dentition A scientific review. Pediatric Dent J. 1995; 5:105-116. Hulsmann M, Bahr R, Grohmann U. Hemisection and vital treatment of a fused tooth Literature review and case report. Endod Dent Traumatol. 1997; 13,253-258. Peyrano A, Zmener O. Endodontic management of mandibular lateral incisor fused with supernumerary tooth. Endod Dent Traumatol.1995; 11,196-198. Shafer WG, Hine MK, Levy BM. A textbook of oral pathology. 3rd ed., Philadelphia: W B Saunders Co, 1974, 37. Lowell RJ, Soloman AL. fused teeth. J Am Dent Assoc. 1964; 68:5,762-763. Stewart R, Prescott GH. Genetic aspects of anomalous tooth development. Oral facial Genetics St. Louis: The C. V. Mosby Co, 1976; 138-142. McDonald RE, Avery DR. fusion of teeth-Dentistry for child and adolescent, 5th ed. St. Louis: CV Mosby Co, 1983; 121-122. Weber fN. Supernumerary teeth. Dent Clin North Amer 1984; 23,509-517.

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10. Schuurs AHB, Loveren C Van. Double teeth: Review of the literature. ASDC J Dent Child. 2000; Sept, 313-325. 11. Mader CL. fusion of teeths Am Dent Assoc, 1998; 98:1,6264. 12. Wolfe RE, Stieglitz HT. A fused permanent maxillary lateral incisor: endodontic treatment and restoration. NY State Dent J, 1980; 46,654-657. 13. Ruddle CJ. Current concepts for preparing the root canal system. Dent Today, 2001; 20:2, 76-83,. 14. Rosensteil S. Contemporary fixed Prosthodontics, 4th Ed. 15. Ricketts D. et al. Tooth preparation for post retained restorations. BDJ,2005;198:8,463-471 16. Ricketts D. et al. Post and core systems, refinements to tooth preparation and cementation BDJ, 2005; 198:9,533-541.

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