|Year : 2014 | Volume
| Issue : 1 | Page : 23-27
Esthetic and endodontic management of fused maxillary lateral incisor and supernumerary teeth with all ceramic restoration after trauma
Kiranmeet Kaur Khurana1, Pardeep Khurana2
1 Department of Prosthodontics, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India
2 Department of Conservative Dentistry and Endodontics, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India
|Date of Web Publication||28-Feb-2014|
Associate Prof Department of Conservative Dentistry and Endodontics, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana
Source of Support: None, Conflict of Interest: None
Double or fusion of the teeth is a primary developmental anomaly union of two independently developing primary or permanent teeth. The tooth fusion may contribute to various significant problems such as crowding, caries and periodontal diseases. Fused teeth require an interdisciplinary approach combining the endodontic, esthetic and prosthetic treatments. All ceramic restoration meets the requirement of better appearance, biocompatibility and long life. By using restorative therapy esthetic and functional criteria were satisfied. Management of a case of fusion of a maxillary lateral incisor and a supernumerary tooth is presented.
Keywords: All ceramic restoration, esthetics, fusion, root canal treatment, supernumerary tooth
|How to cite this article:|
Khurana KK, Khurana P. Esthetic and endodontic management of fused maxillary lateral incisor and supernumerary teeth with all ceramic restoration after trauma. Saudi Endod J 2014;4:23-7
|How to cite this URL:|
Khurana KK, Khurana P. Esthetic and endodontic management of fused maxillary lateral incisor and supernumerary teeth with all ceramic restoration after trauma. Saudi Endod J [serial online] 2014 [cited 2020 Jun 5];4:23-7. Available from: http://www.saudiendodj.com/text.asp?2014/4/1/23/127983
| Introduction|| |
Double teeth refer to two teeth that are totally or partially joined by dentin and may be there pulp. These abnormal teeth are the result of germination or fusion that coined by Levitas.  Gemination is a result of either schizodontism, the splitting of a tooth germ during development or synodontism, the fusion of a normal tooth bud with one from a developing supernumerary tooth. Both forms represent abortive attempts at forming supernumerary buds.  Fused teeth arise through union of two normally separated tooth germ. It has been thought that some physical force or pressure produces contact of the developing teeth and there subsequent fusion.  Fusion of adjacent teeth can be complete or incomplete, depending on the stage of tooth development at the time of contact. True fusion always involves confluence of dentin. Fusion tend to occur in anterior region and the incisors are the teeth most often affected in the permanent dentition and in the primary dentition majority of cases involve anterior mandibular teeth. Fusion can occur between two adjacent normal teeth or between a normal tooth and a supernumerary tooth. Double teeth are more common in the primary than in the permanent dentition, the prevalence in different series ranging from 0.5% to 2.5% for the primary and 0.0 ~ 0.8% of the general population with no gender predilection for the permanent dentition. ,,
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.  In some cases, the condition has been reported to show a hereditary tendency.  The possible clinical problems related to appearance, spacing and periodontal conditions caused by fused teeth has been discussed by Mader. 
This case report presents the esthetic and endodontic management of a fused maxillary lateral incisor with a supernumerary tooth.
| Case Report|| |
A 20-year-old male patient reported to the Department of Conservative Dentistry and Endodontics in Barwala, with a history of accident 7 months back while he fell from motorcycle. Oral examination revealed mild crowding in the maxillary anterior region and supernumerary teeth on the left side with the normal set of dentition [Figure 1] and [Figure 2]. There were no soft-tissue changes in relation to involved tooth. Patient complained of mild discomfort and pain in upper anterior tooth region. There was uncomplicated crown fracture in the right and left maxillary central incisors. Maxillary left lateral incisor was fused partially through dentin in the crown area with supernumerary tooth, which was discolored due to trauma 7 months back. Periapical radiograph revealed two separated roots and crown of both teeth joined through dentin in the crown and root area [Figure 3]. Patient reported that the mandibular left canine and lateral and central incisors of the left and right side were fractured and it was extracted [Figure 4]. Soft-tissue injuries were treated at the time of the accident. Patient reported with the marks of healed sutures on the upper lip. Medical history was non-contributory with no hereditary conditions. All vital signs were found to be within the normal limits. Right and left maxillary central incisors were vital and they elicit normal response on cold and electric pulp test (Parkell Electronics, NY). There was delayed response to cold test (RC Ice, Prime Dental India) of the maxillary left lateral incisor and supernumerary tooth that had grayish discoloration. However, slightly higher discomfort was present when heated Gutta-percha stick was applied to middle third of the crown. Tenderness on percussion elicits mild pain in relation to fused teeth. On the basis of clinical and radiographic examination, diagnosis of asymptomatic irreversible pulpitis with partial necrosis of pulp along with fused left maxillary lateral incisor and supernumerary tooth was made.
|Figure 1: Pre-operative frontal view of fused maxillary lateral incisor and supernumerary teeth|
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|Figure 3: Diagnostic periapical radiograph of maxillary central and fused lateral incisor with supernumerary teeth having two separate roots and root canal|
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|Figure 4: Orthopantomogram radiograph after obturation of the fused maxillary lateral incisor and supernumerary teeth. Notice the healing of the lower anterior area|
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Endodontic access cavity was done on the palatal surface by using a no. 2 round bur and non-end cutting tapered fissure bur (Mani Inc., Japan). Pulp extirpation was performed and the canals of the maxillary lateral incisor and fused supernumerary tooth were thoroughly debrided with copious irrigation of sodium hypochlorite (2.5%), followed by saline (0.9%). Coronal flaring of the root canals was done by using Gates-Glidden drills no. 1-4. (Mani Inc.) The working length was determined by using apex locator (Propex; Dentsply Maillefer) and confirmed radiographically. Cleaning and shaping of the root canal system was completed by using a step-back technique and apical enlargement was done up to 40 K-file (Mani Inc., Japan) in both the canals. The canals were dried, calcium hydroxide (Ultracal XS; Ultradent, South Jordan) powder mixed with 2% chlorhexidine (Septodont, France) was placed for 1 week with lentulo spiral (Mani Inc., Japan) and the access cavity was temporized with Cavit G (3M ESPE, Germany). After a week, the tooth was asymptomatic, final rinse of canal done with alcohol and 2% chlorhixidine, root canal was obturated by using lateral condensation obturation technique and AH Plus (DeTrey, Dentsply) as a sealer [Figure 5]. The access cavity was then sealed with resin composite (Z250, Dentsply).
After the endodontic treatment was completed, the esthetic management was discussed with patient. The available treatment options included direct composite restoration, Porcelain fused to metal crowns and all ceramic crowns and veneers. Patient opted for all ceramic leucite based restoration as it was most esthetic approach [Figure 6].
|Figure 6: Frontal view of all ceramic crown and veneer cemented with dual cure resin cement|
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The tooth was asymptomatic and the crown was intact at 6 months and 3 year follow-up [Figure 7] and [Figure 8].
|Figure 7: 3 years follow-up frontal view of the cemented all ceramic crown and veneer|
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| Discussion|| |
Early contact of developing tooth germs can result in a single, large tooth; later contact can result in the union of crowns only or the union of roots only. It may be difficult to distinguish between a geminated tooth and a fusion of a normal tooth to a supernumerary tooth. These two can be differentiated by the below parameters. 
Morphology of gemination results in mirror images of the coronal halves, whereas fusion takes place at an angle causing a crooked appearance. Pulpal anatomy is very useful in diagnosing the type of double teeth. Fused teeth would mostly have separate pulp chamber and root canals while geminated teeth usually have one big pulp canal.
In the present case, supernumerary tooth has joined through dentin in coronal part of teeth with maxillary lateral incisor diagnosis is extremely confusing. Clinically, fused teeth appear as a single large crown that exhibit an observable separation. They 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. To differentiate fusion from germination, the teeth must be counted. 
Careful clinical and radiographic examination with periapical radiograph and orthopantamograph is beneficial for optimal treatment planning. Conventional intraoral periapical radiograph, which provide 2D views are an important diagnostic tool in endodontic as it provides a high definition image at a low dose. Cone beam computed tomography (CBCT) and 3D comuted tomography CT are advanced diagnostic aids, which help in assessing the root canal anatomy better in challenging cases such as resorption, pre-surgical assessment and trauma. Currently images produced with CBCT do not have a resolution of conventional radiograph and effective dosage of CBCT is considerably higher than conventional imaging technique.  The periapical radiograph taken for the present case shows the whole image of the roots and it was enough.
Calcium hydroxide was used as intracanal medicament due its high pH. It has been reported that it hydrolyze the lipid moiety of bacterial lipopolysaccharides, making them incapable of producing such biologic effects as toxicity, pyrogenicity, macrophage activation and complement activation. 
Several approaches are available for the treatment of joined teeth in the permanent dentition and the treatment of choice is determined by the patient's particular needs. In most cases surgical division, endodontic therapy was performed along with reshaping with or without placement of full crowns.  The management of the present case was similar to Rani et al. where a multi-disciplinary approach was followed. 
The degree of teeth misalignment directly influences the treatment options. There are two components to consider in every case of crowding: The mesiodistal overlap and the buccodistal overlap. The amount of overlap can be measured in millimeters, classifying dental crowding according to severity. 
In the ideal clinical situation, minor to moderate mesiodistal and buccolingual discrepancies can be corrected by restorative means. Restorative space management is an alternative treatment modality to orthodontics in the management of the crowded dentition. The benefits of restorative options include not only the apparent correction of tooth position, but also real improvement in shape, size, discoloration removal and caries elimination.  The morphology of fused teeth varies and complex forms with separated or fused coronal pulp chambers are present. Even separated chambers can meet in the radicular area or can remain separated.
Esthetic evaluation of patient is done. Esthetic principles include unity and dominance.  The size, shape and position of maxillary central incisor are the most influential factors in a harmonious anterior dentition. Creating an ideal proportion only for the central incisor may be more pleasing, allowing the lateral incisors minor differences. The lateral incisor is less noticeable and looks good provided they have symmetry. 
Patient should be made aware of treatment options patient's preference should be considered. As the patient is young more conservative treatment is preferred. Guideline for selecting restorative correction in patient of crowding rather than orthodontic treatment is free gingival margin and papillae level that are manageable without any orthodontic treatment. Biological consequences of correcting the crowding restoratively are acceptable.  Ceramic veneers are treatment of choice for moderate crowding with failure rate of 6-13% higher risk of failure on non-vital root canal treated teeth and 1.6% in vital teeth. ,
| Conclusion|| |
Developmental anomalies usually influence the morphology of the tooth that causes changes in the tooth alignment and appearance. Careful clinical and radiographic examination will help the clinician in diagnosing and treating such cases. This reported case demonstrates a predictable and successful solution toward the endodontic and esthetic management of a fused maxillary lateral incisor with a supernumerary tooth after trauma, adopting a multidisciplinary approach and using restorative corrections for maxillary anterior crowding in the most conservative way.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]