CASE REPORT

Endodontic treatment of a geminated

maxillary second molar using an
endoscope as magnication device
T. Weinstein, G. Rosano, M. Del Fabbro & S. Taschieri
Department of Health Technologies, IRCCS Istituto Ortopedico Galeazzi, Universita` degli
Studi di Milano, Milano, Italy
Abstract
Weinstein T, Rosano G, Del Fabbro M, Taschieri S. Endodontic treatment of a geminated
maxillary second molar using an endoscope as magnication device. International Endodontic
Journal, 43, 443450, 2010.
Aim To describe endodontic treatment for a rare case of gemination.
Summary A case of complex endodontic treatment in a geminated tooth is presented.
With the assistance of microinstruments and magnication devices, a geminated maxillary
second molar was successfully treated. In such a case, ultrasonic tips and the use of an
endoscope were essential to detect the peculiar anatomy of the tooth involved.
Key learning points
Knowledge of anomalies concerning fused teeth is essential.
Using an endoscope as a magnication device is useful during the inspection of pulp
chambers.
Ultrasonic tips are safe and useful to detect canal orices.
Keywords: endodontic treatment, endoscope, fusion, gemination, maxillary sec-
ond molar, ultrasonic tips.
Received 10 February 2010; accepted 12 February 2010
Introduction
Gemination is a rare morpho-anatomic anomaly that develops when the bud of a single
tooth attempts to divide (White & Pharoah 2000). Such a developmental anomaly is often
confused with fusion. In fact, gemination and fusion are anomalies with similar clinical
presentation and unclear aetiology (Tsesis et al. 2003).
Fusion might be dened as a condition in which two separate tooth buds have a joined
crown that resembles a bid crown, whilst gemination as an attempt by the tooth bud to
divide. Union or division might be total or partial and might concern the dentine and/or the
doi:10.1111/j.1365-2591.2010.01714.x
Correspondence: Dr Massimo Del Fabbro, Department of Health Technologies, Istituto
Ortopedico Galeazzi, Universita` degli Studi di Milano, Via R. Galeazzi, 4, 20161 Milano, Italy
(Tel.: +39 02 50319950; fax: +39 02 50319960; e-mail: massimo.delfabbro@unimi.it).
2010 International Endodontic Journal International Endodontic Journal, 43, 443450, 2010 443
enamel or even the pulp (Tannenbaum & Alling 1963, Grover & Lorton 1985). To
distinguish between fusion and gemination, it has been suggested that the teeth in the
arch be counted with the anomalous crown counted as one. A full complement of teeth
indicates gemination, whilst one tooth less than normal indicates fusion (Milazzo &
Alexander 1982, Camm & Wood 1989). This rule cannot be applied if a normal tooth fuses
with a supernumerary tooth (Croll et al. 1981, Peyrano & Zmener 1995, Kayalibay et al.
1996). In such a case, differentiating fusion from gemination might be clinically difcult if
not impossible.
The prevalence of these anomalies is <1%, occurring, predominantly in incisors and
canines, in normal dentition or between a normal tooth and a supernumerary (Levitas
1965).
There are four types of fusion anomalies (Tadahiro 1981): (i) concrescent teeth: two
teeth fused by coalescence of their cementum; (ii) fused teeth: teeth joined by dentine in
their developmental stage, resulting in the union of two (or more) adjacent teeth; (iii)
geminated teeth: fusion of a tooth with a supernumerary one and (iv) dens in dente:
malformation of a tooth probably resulting from an infolding of the dental papilla during
dental development.
The aetiology of such dental anomalies is unclear; possibilities include genetic
predisposition, racial differences, trauma and environmental factors such as thalidomide
embryopathy, foetal alcohol exposure or hypervitaminosis A of the pregnant mother
(Cetinbas et al. 2007).
The purpose of this article is to describe a successful root canal treatment in a maxillary
second molar with gemination anomalies.
Case report
A 28-year-old white female patient with a non-contributory medical history presented for
an endodontic consultation. Clinical examination revealed a temporary restoration in tooth
27, provided by a private practitioner, and revealed an anomalous second molar that could
have been a fusion of the maxillary left second molar with a supernumerary tooth on its
palatal aspect.
The patient reported the tooth had been treated previously for an extensive carious
lesion and reported spontaneous vague clinical symptoms. Intraoral examination revealed
an irregular morphology of the maxillary left second molar with enlargement at the buccal
aspect, suggestive of a possible union of a paramolar with the buccal portion of the crown
of tooth 27 (Fig. 1).
The soft tissues were inamed at the buccal gingival margin of the geminated tooth
where periodontal probing depth revealed a 4-mm buccal pocket; moreover, the patient
complained of difculties in maintaining oral hygiene. Radiographic examination revealed
that an access cavity in tooth 27 had already been performed (Fig. 2).
After isolating the tooth with a rubber dam, a sensibility test with cold stimuli was
performed. The response was painful. A local anaesthetic was administered by periapical
inltration with 4% articaine chlorhydrate and adrenaline 1 : 100 000 (Alfacaina N; Weimer
Pharma, Rastat, Germany).
The access cavity was rened, and four canals (two of which were mesiobuccal) were
detected with the aid of magnication loupes. The canals were then shaped with ProTaper
rotary instruments (Dentsply Maillefer, Ballaigues, Switzerland), S1 and S2 being used at
the working length and F1, F2 and F3 being used with a 0.5-mm step back technique.
The root canal system was irrigated after each instrumentation with 2.5% sodium
hypochlorite (Giovanni Ogna & gli S.p.A., Muggio` , Milano, Italy), and apical patency was
maintained throughout the whole procedure. After the instrumentation phase, nal
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irrigation was completed with 17% EDTA (ethylenediaminetetraacetic acid; Giovanni Ogna
& gli S.p.A.) for 2 min to remove the smear layer.
The root canals were dried with sterile paper points. Working lengths were determined
using an apex locator (Root Zx; J. Morita USA, Irvine, CA, USA), and specic radiographs
were taken to conrm such lengths.
Finally, an intermediate restorative material cement made of zinc oxideeugenol with
polymethyl methacrylate (IRM; LD Caulk, Milford, DE, USA) was used as a temporary
restoration.
One week later, the patient returned to complete the therapy but reported pain
exacerbated by both cold and hot stimuli. The presence of accessory canals was
suspected in the geminated portion of the tooth. Therefore, it was decided to extend the
access cavity outline to its distobuccal (DB) aspect into the geminated portion of the tooth
using an endoscope as a magnication device (Fiegert-Endotech

; Ga nsa cker 42,

Figure 1 The tooth after the rst treatment performed by a private practitioner.
Figure 2 Preoperative radiographic examination.
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Tuttlingen, Germany) and dedicated zirconium nitride-coated ultrasonic endodontic tips
(Dentsply Maillefer Instruments). Thus, two separate pulp chambers and a fth canal in
the gemination [geminated buccal (GB)] were detected (Fig. 3).
Five canal orices were found: one leading to the supernumerary tooth and four leading
to the maxillary second molar. The GB canal was found to communicate with the DB canal
and treated in the same way as the others, and the lling of all ve canals was performed
with the Thermal (Dentsply Maillefer) technique (Figs 46). A postoperative radiograph
was taken (Fig. 7). Both the access cavity and the buccal aspect of the tooth were
restored permanently (Fig. 8) with composite resin material (Enamel Plus; Micerium spa,
Avegno, Genova, Italy). The periodontal pocket was also treated and the tooth shape
modied buccally to enhance ease of cleaning (Fig. 9).
At 6-month follow-up, the tooth had no clinical signs and symptoms and, radiograph-
ically, no periradicular sclerosis or bone rarefaction was visible (rstavik 1996, Chugal
et al. 2001).
Figure 3 Endoscopic vision of the pulp chamber showing: mesiobuccal (MB1), mesiobuccal (MB2),
distobuccal (DB), palatal (P) and geminated buccal (GB).
Figure 4 Radiographic working length of distobuccal (DB) and palatal (P).
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Discussion
Maxillary second molar anatomy is well known: it has three roots (rarely fused) showing
three separate canals in 88% of cases; in the remaining 12% of cases, a fourth canal can
be encountered in the mesiobuccal root (Vertucci 1984).
Peikoff et al. (1996) analysed 520 root lled maxillary second molars and found six
variants of this tooth: (i) three separate roots and three separate canals (in 56.9% of
cases); (ii) three separate roots and four canals, two of which in the mesiobuccal root (in
22.7% of cases); (iii) three roots and canals, whose mesiobuccal and DB canals combine
to form a common buccal with a separate palatal canal (in 9% of cases); (iv) two separate
roots with a single canal in each (in 6.9% of cases); (v) one main root and canal (in 3.1% of
cases) and (vi) four separate roots and four separate canals including two palatal (in 1.4%
of cases).
There are only a few case reports on maxillary second molars with more than four
canals (Ozcan et al. 2009). Thus, a maxillary second molar in gemination with ve canals
represents a rare anatomical variation.
Figure 6 The four wall cavity access after endodontic treatment showing the ve canals.
Figure 5 Radiographic working length of mesiobuccal (MB1), mesiobuccal (MB2) and geminated
buccal (GB).
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From a clinical point of view, much confusion has always been generated on the
difculty of deciding whether a tooth is geminated or fused, mainly because of their
similarities.
Indeed, Brook & Winter (1970) proposed that these anomalies be referred to using the
neutral term double teeth. However, even if a differentiation between gemination and
fusion might not be clinically important for the treatment, the authors believe that a
geminated maxillary second molar has been described in the present case because of the
apical connection between the GB root canal, located in a secondary anomalous pulp
chamber, and the DB canal and of the full-arch complement of teeth (Fig. 7).
Figure 8 Access restored permanently with composite resin material: occlusal view.
Figure 7 Post-treatment radiograph.
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To evaluate such conuence, a gutta-percha cone was inserted into the cleaned and
shaped DB canal, whilst a size 08 K-le was inserted into the GB canal: a defect was
apparent in the gutta-percha. With the help of a gutta-percha cone and a small instrument,
the conuence of the DB and GB canals in a common foramen was detected. Such a
nding allowed dentine to be retained in the GB canal with less risk of causing stripping.
To negotiate all ve canals, the treatment was performed using an endoscope as a
magnication device and dedicated ultrasonic endodontic tips. Working with loupes and/or
with a surgical microscope as well as with an endoscope has become a widely accepted
practice in conventional and surgical endodontics.
An endoscope allows rapid and easy adjustment of viewing angle without the need for
dental mirrors (Von Arx et al. 2003). In addition, it is far more versatile than a microscope:
focusing and zooming using just one nger is faster and more comfortable with an
endoscope than with a microscope (Taschieri et al. 2008).
In this case, ultrasonic tips as well as the endoscope were useful for the exploration of
the access cavity in the most conservative way and for the detection of the GB
unexpected canal in the geminated portion of tooth 27. In particular, one of the most
important advantages of ultrasonic tips is that they do not rotate, thus enhancing safety
and control, whilst maintaining a high cutting efciency. This is especially important when
the pulp chamber anatomy is unclear, and a risk of perforation exists (Plotino et al. 2007).
Conclusions
In the present case, root canal treatment was complicated by an abnormal pulp chamber
anatomy. In modern endodontics, endoscopic devices as well as ultrasonic tips are
important aids for examination of morphological aspects of both the pulp chamber and
root canals from almost any perspective, whilst preserving as much tooth tissue as
possible.
Disclaimer
Whilst this article has been subjected to Editorial review, the opinions expressed, unless
specically indicated, are those of the author. The views expressed do not necessarily
Figure 9 Buccal view of the tooth restored to recreate an appropriate and physiological dental
anatomy.
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represent best practice, or the views of the IEJ Editorial Board, or of its afliated Specialist
Societies.
References
Brook AH, Winter GB (1970) Double teeth. A retrospective study of germinated and fused teeth in
children. British Dental Journal 129, 12330.
Camm JH, Wood AJ (1989) Gemination, fusion, and supernumerary teeth in the primary dentition:
report of a case. Journal of Dentistry for Children 56, 601.
Cetinbas T, Halil S, Akcam M, Sari S, Cetiner S (2007) Hemisection of a fused tooth. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and Endodontics 104, e1204.
Chugal NM, Clive JM, Spa ngberg LSW (2001) A prognostic model for the assessment of the outcome
of endodontic treatment: effect of biologic and diagnostic variables. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology and Endodontics 91, 34252.
Croll TP, Rains NJ, Chen E (1981) Fusion and gemination in one dental arch: report of a case. Journal of
Dentistry for Children 48, 2979.
Grover PS, Lorton L (1985) Gemination and twinning in the permanent dentition. Oral Surgery, Oral
Medicine, Oral Pathology 59, 3138.
Kayalibay H, Uzamis M, Akalin A (1996) The treatment of a fusion between the maxillary central incisor
and supernumerary tooth: report of a case. The Journal of Clinical Pediatric Dentistry 20, 23740.
Levitas TC (1965) Gemination, fusion, twinning, and concrescence. Journal of Dentistry for Children
32, 93100.
Milazzo A, Alexander SA (1982) Fusion, gemination, oligondontia, and taurodontism. Journal of
Periodontology 6, 1946.
rstavik D (1996) Time-course and risk analysis of the development and healing of chronic apical
periodontitis in man. International Endodontic Journal 29, 1505.
Ozcan E, Aktan AM, Ar H (2009) A case report: unusual anatomy of maxillary second molar with 3
mesiobuccal canals. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics
107, 436.
Peikoff MD, Christie WH, Fogel HM (1996) The maxillary second molar: variations in the number of
roots and canals. International Endodontic Journal 29, 3659.
Peyrano A, Zmener O (1995) Endodontic management of mandibular lateral incisor fused with
supernumereary tooth. Endodontics & Dental Traumatology 11, 1968.
Plotino G, Pameijer C, Mariagrande N, Somma F (2007) Ultrasonics in endodontics: a review of the
literature. Journal of Endodontics 33, 8195.
Tadahiro O (1981) Human Tooth and Dental Arch Development. Tokyo, Osada, Japan: Ishiyaku
Publishers, pp. 17181.
Tannenbaum KA, Alling EE (1963) Anomalous tooth development: case reports of gemination and
twinning. Oral Surgery, Oral Medicine, Oral Pathology 16, 8837.
Taschieri S, Del Fabbro M, Testori T, Weinstein R (2008) Microscope versus endoscope in root-end
management: a randomized controlled study. International Journal of Oral and Maxillofacial Surgery
37, 10226.
Tsesis I, Steinbock N, Rosenberg E, Kaufman AY (2003) Endodontic treatment of developmental
anomalies in posterior teeth: treatment of geminated/fused teethreport of two cases. International
Endodontic Journal 36, 3729.
Vertucci FJ (1984) Root canal anatomy of the human permanent teeth. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology and Endodontics 58, 58999.
Von Arx T, Montagne D, Zwinggi C, Lussi A (2003) Diagnostic accuracy of endoscopy in periradicular
surgery a comparison with scanning electron microscopy. International Endodontic Journal 10,
6919.
White SC, Pharoah MJ (2000) Oral Radiology: Principles and Interpretation, 4th edn. Louis, MO, USA:
CV Mosby.
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