PaediatricDentistry

Amera B Ammari

Rhona G Young, Richard R Welbury and Diane E Fung

A Report of Treatment of a Fused

Permanent Central Incisor and
Supplemental Lateral Incisor
Abstract: A 9-year-old boy presented with a fused maxillary right permanent central incisor and displacement of the right permanent
lateral incisor palatally. An unerupted supplemental maxillary left permanent lateral incisor was noted radiographically. The maxillary
fused right permanent central incisor was sectioned under general anaesthesia. The distal portion was extracted as planned; a vital partial
pulpotomy was carried out on the distal aspect of the retained portion. Fixed orthodontic treatment commenced after 28 months to align
the maxillary anterior segment. After completion, the maxillary right permanent central incisor was built up with composite to resemble
the adjacent incisor.
Clinical Relevance: This case highlights the treatment options of a fused tooth and the need for multidisciplinary planning and treatment.
Dent Update 2008; 35: 636-641

Developmental anomalies of the dental
hard tissue include the following:1
Fusion;
Gemination; and
Concrescence.
Fusion
Tooth fusion is the union
between dentine and/or enamel of two
or more separately developing teeth,1-8
resulting in a single large tooth.1,6 It leads
A B Ammari, BDS, MSc, MFDS RCS,
MPaed Dent RCS, Specialist in Paediatric
Dentistry, R G Young, BDS, DDOrth, RCPS,
Associate Specialist in Orthodontics,
R R Welbury, MBBS, BDS, PhD, FDS
RCS, FDS RCPS, Professor in Paediatric
Dentistry, D E Fung, BDS, LDS RCS, FDS
RCS, Consultant in Paediatric Dentistry,
Paediatric Dentistry Department,
Glasgow Dental Hospital and School, 378
Sauchiehall Street, Glasgow G2 3JZ, UK.
to a reduction in the total number of
teeth,5,8 unless the fusion occurs between
a tooth and a supernumerary. The exact
aetiology of this anomaly is still unknown.
A possible cause could be the influence of
pressure and/or physical force producing
close contact between two developing
tooth germs resulting in fusion.1,2,3,4 Fusion
may be partial, including only the tooth
crowns, or total, involving tooth crowns
and roots, depending on the stage of tooth
development at the time of union.3 Similarly,
the pulp chamber may be common to both
parts or separate from each part of the
affected tooth.9,10 Some authors suggest
that close contact between tooth germs
leads to necrosis of the intervening tissue,
allowing the dental organ and the dental
papilla to unite.10
The prevalence of tooth fusion
has been reported to be between 0.10.9%
in the primary dentition.8 There have
been a number of studies examining the
prevalence of double teeth in the mixed
dentition. The figures range from 0.08%, in a
sample of Saudi Arabian children,11 to 0.47%
of children in Minnesota in the United
States.12 The prevalence of double teeth is
less in the permanent dentition, ranging
from 00.2%.8 Both genders are affected
with equal frequency.9 The most frequently
affected teeth in the primary dentition are
the lower incisors,9 whilst in the permanent
dentition the maxillary central incisors
followed by the mandibular lower third
molars are the most often affected.2 A study
by Hamasha and Al-Khateeb2 showed that
the maxillary permanent central incisor
was the most affected tooth, followed by
the maxillary permanent lateral incisor.
Distribution of double teeth was similar in
both genders.
There is a 3050% chance of a
dental anomaly occurring in the permanent
dentition in a patient who had a double
tooth in the primary dentition.9
Gemination
Gemination is an attempt
by a single tooth bud to divide. There is
usually an abortive attempt for the teeth

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to separate completely, resulting in a range
of clinical presentations varying from a
macrodont with a minor incisal notch,
a bifid crown, to almost two completely
separate teeth.2,9,13 When counting the
double tooth as one unit, a full complement
of teeth will be present.13 Gemination is
more prevalent in the primary dentition,
and most commonly occurs in the incisor
and canine regions.14
Many investigators used the
term double teeth to describe either fusion
or gemination because of the difficulty
in clinical differentiation and because the
definition of both conditions is debatable.2,3
However, many authors have rejected
the term double tooth as it does not
appropriately describe what really occurs.3
In cases when the diagnosis is not clear
owing to the presence of supernumeraries
or multiple missing teeth, then the term
double tooth could be used. A double
tooth describes the anomaly itself without
considering what caused it.
Concrescence
In concrescence, the roots of
two or more teeth have been united by
cementum alone after formation of the
crowns and during tooth development.
It has been suggested that this has been
caused by lack of space.13 Concrescence
may involve primary or secondary teeth,
and is most frequently noted in maxillary
molars; it is rarely seen in the mandible.15
Several syndromes and
conditions have been reported in the
literature to be associated with double
teeth, either in the primary or permanent
dentition. This includes:
Russell-Silver syndrome;16
Oral-facial-digital syndrome;17
Otodental syndrome;18
Median cleft facial syndrome;19
VACTERL association (Vertebral, Anal,
Cardiac, Tracheal, Esophageal and Limb);20
Syndactyly and nail disorders.5
The presence of a double tooth
in the primary dentition may result in caries
at the junction of fusion.5 Dental prevention
and close monitoring is very important.
Occasionally, exfoliation is delayed, leading
to retarded eruption of the permanent
successor.9 On the other hand, observation
is important for treatment planning, since
the presence of a primary double tooth
November 2008
pg636-641 A fused permanent incisor.indd 2
PaediatricDentistry
with a full complement of primary teeth is
often associated with supernumerary teeth
in the permanent dentition.9 The presence
of a double primary tooth with hypodontia
in the primary dentition is often associated
with hypodontia in the permanent
dentition.9 This may have implications for
dental treatment in the future.
Common clinical problems
associated with fused teeth are:
Caries at the junction of fusion (due to
Figure 1. Intra-oral view of the upper anterior
plaque accumulation); region showing fused maxillary right permanent
Crowding or spacing; central incisor.
Aesthetics;5 and
Periodontal problems, as the fusion
groove may continue to the root surface.3
Management, for the
permanent dentition in particular, requires
a multidisciplinary approach to decide
whether to retain the double tooth, attempt
to separate it or to extract. A number of
factors need to be considered including:
Age of the patient;
Extent of fusion;
Pulpal involvement;
Figure 2. Intra-oral view of the upper arch showing
Spacing;
fused maxillary right permanent central incisor
Crowding;
and displacement of the right permanent lateral
Caries; incisor palatally.
Aesthetics;
Hypodontia;and
Supernumeraries.
In addition, double teeth are
occasionally associated with other dental
anomalies such as generalized hypodontia,
supernumeraries, and dens in dente.5
The prevalence of supernumeraries per
se has been reported as 1.53.5% in
the permanent dentition and there is a
male to female ratio of approximately
2:1.9 Supernumeraries can be classified
according to the site or shape. Those
located in or near the midline of the maxilla
are known as mesiodens and those located
in the maxillary or mandibular molar region
are known as paramolars. Supernumeraries
occuring distal to the normal molar
sequence are known as distomolars. If the
supernumerary resembles a normal tooth Figure 3. Upper anterior occlusal radiograph
it is known as supplemental, while those of showing the unerupted supplemental maxillary
less typical form can be termed as accessory left permanent lateral incisor between the
supernumerary tooth.9 maxillary left permanent central incisor and the
erupted maxillary left permanent lateral incisor.
Case report
A 9-year-old Caucasian boy
was referred by his General Dental right permanent maxillary central incisor.
Practitioner for management of a double His medical history was non-contributory.
DentalUpdate 637
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 PaediatricDentistry
He was a regular dental attender with no
past history of dental treatment since he
was caries free. The patient noticed the
anomaly at age 8 years, and was concerned
about his appearance. There was no
family history of supernumerary teeth or
other dental anomalies. Oral examination
revealed a fused maxillary right permanent
central incisor and displacement of the
right permanent lateral incisor palatally
(Figures 1 and 2). Radiographic examination
revealed the presence of an unerupted
supplemental maxillary left permanent
lateral incisor between the maxillary left
permanent central incisor and the erupted
maxillary left permanent lateral incisor.
The latter was rotated through 90 degrees
(Figures 2 and 3). The root morphology of
the fused maxillary right permanent central
incisor showed two roots connected at the
cervical third which appeared amenable for
separation (Figure 3). His molar relationship
was Angles Class I on the right and half a
unit Class II on the left side.
The patient was seen on a joint
Orthodontic/Paediatric Dental Consultation
Clinic where a number of possible
treatment options were discussed with the
patient and his parents. These included
surgically splitting the maxillary right fused
permanent central incisor and retaining the
mesial portion (with possible pulp therapy).
Following fixed orthodontic treatment,
this would be built up with composite
to resemble the left central permanent
incisor. The palatally erupted right lateral
permanent incisor would then be moved
orthodontically into the lateral space. If the
maxillary right fused permanent central
incisor proved to be unsaveable it would
be extracted and the rotated maxillary
left erupted permanent lateral incisor
re-implanted into the maxillary right
permanent central incisor socket and the
maxillary left supplemental lateral would be
retained.
The patient was unable to cope
with surgery under local anaesthesia. He
attended for a daystay general anaesthetic.
A labial mucoperiosteal flap was raised and
the maxillary fused permanent right central
incisor sectioned. The distal portion had a
narrow crown and root and was extracted
as planned. On the distal aspect of the
mesial part of the fused central incisor
(double tooth) a 1 mm pulpal exposure
was noted following tooth section. A vital
638 DentalUpdate
pg636-641 A fused permanent incisor.indd 3
Figure 4. Periapical radiograph showing further
root development of the maxillary right central
incisor following surgery and partial pulpotomy.
partial pulpotomy, also known as Cvek
pulpotomy,21,22,23 was carried out where
a 13 mm of the exposed pulpal tissue
beneath the exposure was removed by
a sterile high speed bur. Pulpal bleeding
was controlled and the remaining exposed
pulp dressed with Hypocal, Ellman, NY, USA
non-setting sterile calcium hydroxide which
was covered with Dycal (Dentsply). The
distal aspect of this tooth was then built
up with composite (Z100, 3M-ESPE). The
mucoperiosteal flap was sutured closed. The
wound healing was uneventful. Preventive
advice was reinforced.
The maxillary right central
incisor was clinically and radiographically
reviewed on a regular basis, initially a week
post-operatively, then after a month and
then on a 46 monthly basis. The tooth
remained asymptomatic and there were no
clinical or radiological signs of pathology
present. All teeth in the maxillary labial
segment responded positively to sensibility
testing with the electric pulp tester and
ethyl chloride. Radiographically, further root
development was noted following surgery
and partial pulpotomy (Figure 4).
Twenty eight months after
surgery, orthodontic correction of the
Figure 5. Intra-oral view after orthodontic
treatment and before composite build up of the
maxillary right central incisor.
malocclusion was commenced, as all the
canines and premolars had fully erupted.
The maxillary left permanent supplemental
lateral incisor had subsequently erupted
and was extracted under local anaesthesia,
with no complications during the
monitoring period before orthodontic
treatment started. Orthodontic treatment
consisted of an upper fixed appliance to
align the palatally displaced maxillary right
permanent lateral incisor and the rotated
left permanent lateral incisor.
However, orthodontic treatment
was compromised in view of the patients
poor attendance and deteriorating oral
hygiene. The patient requested that the
treatment be completed in the minimum
number of visits as he was relocating some
distance from the hospital. As a result,
usual orthodontic finishes such as torquing
the maxillary right permanent lateral
incisor root was not carried out, but this
was disguised cosmetically. The original
plan included crown lengthening of the
maxillary right permanent lateral incisor
prior to composite build up.
Once orthodontic treatment was
completed, the maxillary right permanent
central incisor was built up with composite
(Z100, 3M-ESPE) to resemble the adjacent
incisor.
Unfortunately, the patient failed
to attend his review appointment as he
changed address to a town 70 miles away,
and only the post-operative picture before
the composite build up is available (Figure
5).
Discussion
A case of a fused permanent
central incisor and supplemental lateral
November 2008
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 PaediatricDentistry
incisor has been presented, demonstrating
the possibility of separating one part
of the fused tooth whilst retaining and
maintaining vitality of the other portion.
The clinical manifestation of this anomaly
may vary considerably, from a minor notch
in the incisal edge of a wide crown to
the appearance of almost two separate
crowns.9 A common problem found
with fused teeth is localized crowding,3
which is demonstrated in this case report.
The problem was made worse by the
presence of a supplemental left and right
permanent lateral incisor. In this case, the
maxillary permanent fused central incisor
tooth seemed to have fused with a right
supplemental permanent lateral, which
has contributed to the crowding in the
maxillary incisor region and the exclusion of
the right permanent lateral incisor palatally.
Oversized maxillary incisors may dictate a
slight Angle Class III buccal occlusion,3 as in
this case.
Double teeth may be associated
with other dental anomalies, such as
dens in dente, macrodontia, hypodontia,
and supernumerary teeth.5 In this case,
supplemental lateral incisors were present.
Fusion of permanent and supernumerary
teeth occurs less frequently than fusion
between permanent teeth.1 Supernumerary
teeth are generally thought to arise from
the formation of excessive tooth buds by
the dental lamina, which may then develop
into teeth of normal or rudimentary form.
The occurrence may be single or multiple,
unilateral or bilateral and in either jaw.12
Supernumerary teeth may fail to erupt
and may delay eruption of a permanent
tooth which is developing deeper within
the jaw.9 The presence of supernumeraries
could cause localized crowding, plaque
accumulation causing caries and
periodontal problems, and affects the
aesthetics if present in the anterior region.
It has been documented in the
literature that connection between pulps
of the fused teeth may occur and that the
connection varies from minor to midroot to
more severe. Most commonly, the severity is
properly assessed at the time of sectioning,3
as with this case.
A vital partial pulpotomy (Cvek)
was carried out on the distal portion of
the fused maxillary incisor. The objective
of performing a vital pulpotomy was
maintenance of a vital pulp to allow normal
640 DentalUpdate
pg636-641 A fused permanent incisor.indd 5
root maturation.21 A five-year follow-up
study in exposed, caries-free, immature
incisors has shown a very high success
rate of pulpotomy with respect to pulp
survival, irrespective of the stage of root
development using calcium hydroxide.22
This treatment is the treatment of choice
for injured permanent incisor teeth with
an exposed vital pulp, regardless of the
size of exposure or the maturity of the
root,23 as the treatment preserves pupal
function, thus allowing continued root
development.22
The success of a partial
pulpotomy in a non-carious tooth is
quoted at 97% using calcium hydroxide.9
This usually results in the formation of a
mineralized barrier or dentine bridge in
vital pulpotomies.24,25 This bridge appears
to be a product of odontoblasts and
connective tissue cells.25 Mineral Trioxide
Aggregate (MTA) could have been used
instead of the calcium hydroxide as recent
studies showed that MTA pulpotomies are
suitable alternatives to calcium hydroxide
pulpotomies.26,27 In one animal study, the
MTA pulpotomies displayed hard tissue
bridges in 84% of the teeth.28 At the time
of treatment, MTA long term success was
not proven and therefore a technique and
material with a higher success rate was
used.
In this case, orthodontic
treatment was postponed until the
eruption of the premolars and canines.
Meanwhile, the patient was seen regularly
for monitoring of the maxillary right
permanent central incisor. If this tooth
had become non-vital, it could then
have been root-filled with non-setting
calcium hydroxide during orthodontic
intervention. A further back-up would
have been to transplant the maxillary left
permanent lateral incisor into the maxillary
right permanent central incisor socket,
should the latter have required extraction,
followed by orthodontic alignment of
these teeth, including the maxillary left
supplemental lateral. This option would
have been less successful. A study of 20
patients, who have received orthodontic
treatment with the objective of closing
the space for missing central incisors, were
examined for biological features and for
clinical appearance of the re-countoured
lateral incisor replacing the missing central
incisor. These were compared with the
neighbouring intact central incisor. Certain
aspects of the re-countoured incisor
crown, such as the width at the gingival
margin, mismatches the appearance of
the neighbouring central incisor. There
was some increased mobility and probing
pocket depth on the mesial aspect of the
re-countoured incisor.29
The patient and his parents were
fully informed about the possible treatment
options, the prognosis and length of
treatment, and the risks associated with the
general anaesthesia and the surgery. Since
a general anaesthetic was required, the
risks involved and alternatives (ie inhalation
sedation and local anaesthetic) were
discussed as recommended by Patel.30
Conclusion
It is important for the general
dental practitioner to refer patients with
dental anomalies to a specialist as soon
as an anomaly has been recognized in
order that the patient can be treated at the
appropriate time. This case also highlights
the importance of a multi-disciplinary
approach in the treatment of this type of
dental problem. In addition, it highlights
that a patients circumstances and attitudes
to dental treatment, over a prolonged
treatment period, can change, resulting in
a less than ideal outcome. From the patient
point of view, he was very happy with the
results although, from a clinician point of
view, the final outcome was compromised.
References
1. Kim E. A supernumerary tooth fused
to the facial surface of a maxillary
permanent central incisor: case report.
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2. Hamasha A, Al-Khateeb T. Prevalence
of fused and geminated teeth in
Jordanian adults. Quintessence Int 2004;
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3. Hlsmann M, Bahr R, Grohmann U.
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4. Mancusa A. The treatment of fusion
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of maxillary central incisor: case
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7. Atasu M, Cimilli H. Fusion of the
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dermatoglyphic study. J Clin Pediatr
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8. Duncun W, Helpin M. Bilateral fusion
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9. Crawford PJM, Aldred MJ. Chapter
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10. Lowell R, Solomon A. Fused teeth.
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11. Salem G. Prevalence of selected
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Abstract
IS IT REALLY ALL IN THE MIND?
Is it the injection device or the anxiety
experienced that causes pain during dental
local anaesthesia? Kuscu OO, Akyuz S.
International Journal of Paediatric Dentistry
2008; 18: 139145.
The authors observe at the start of this
paper that pain is a highly complex
and multidimensional phenomenon,
not necessarily dependent upon tissue
damage but possibly generated by
conditioned stimuli such as the gentle
touch of a needle or even the sound of
a drill. This paper looked at the painful
November 2008
pg636-641 A fused permanent incisor.indd 6
14. Santos LM, Forte FDS, Rocha MJC.
Pulp therapy in a maxillary fused
primary central incisor report of
a case. Int J Paediatr Dent 2003; 13:
274278.
15. Gunduz K, Sumer M, Sumer AP,
Gunhan O. Concrescence of a
mandibular third molar and a
supernumerary fourth molar: report
of a rare case. Br Dent J 2006; 200:
141142.
16. Bedi R, Moody, G. A primary double
molar tooth in a child with Russell-
Silver syndrome. Br Dent J 1991; 171:
284286.
17. King N, Sanares A. Oral facial digital
syndrome, Type 1: a case report.
J Clin Paediatr Dent 2002; 26:
211215.
18. Colter J, Sedano H. Otodental
Syndrome: a case report. Pediatr
Dent 2004; 27: 482485.
19. Montero M, Maroto MR, Bravo
Gonzalez LA, Sanchez Del Pozo J.
New dental findings in the median
cleft facial syndrome. J Am Dent
Assoc 2005; 136: 631634.
20. Topper DC, Zallen RD, Kluender RL.
A dental and facial anomaly not
previously reported with VACTERL
association: report of case. J Dent
Children 1990; 3: 216219.
21. American Academy of Pediatric
Dentistry. Guideline on pulp
therapy for primary and young
permanent teeth. Pediatr Dent 2004;
26: 115119.
22. Sarsi S. Cvek Pulpotomy: report of a
case with five year follow up. ASCD J
response of children aged 914 years,
as reported with visual analogue
scales, with two different injection
devices, a conventional syringe and
a computerized device, the Wand
(Milestone Scientific, Livingston NJ, USA),
and related the findings to the anxiety
state of the subjects.
The results showed no
significant difference between the two
injection devices. However, there was
significant correlation between the
stated anxiety of the child and the pain
reported. The experiment was repeated
on three occasions. Anxiety reduction
PaediatricDentistry
Dent Child 2002; 69: 2730.
23. de Blanco LP. Treatment of crown
fractures with pulp exposure. Oral
Surg Oral Med Oral Pathol Oral Radiol
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24. Caliskan MK. Clinical reliability of
the dentine bridge formed after
pulpotomy: a case report. Int
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25. Foreman P, Barnes, I. A review of
calcium hydroxide. Int Endodont J 1990;
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26. El-Milgy OA, Avery DR. Comparison
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calcium hydroxide as pulpotomy
agents in young permanent teeth
(apexogenesis). Pediatr Dent 2006; 28:
399404.
27. Witherspoon DE, Small JC, Harris GZ.
Mineral trioxide aggregate
pulpotomies: a case series outcomes
assessment. J Am Dent Assoc 2006; 137:
610618.
28. Holland R, De-Souza V. Healing process
of Dog Dental pulp after pulpotomy
and pulp covering with mineral
trioxide aggregate or Portland cement.
Braz Dent J 2001; 12: 109113.
29. Czochrowska EM, Skaare AB, Stenvik A,
Zachrisson BU. Outcome of
orthodontic space closure with a
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597603.
30. Patel AM. Appropriate consent and
referral for general anaesthesia a
survey in the paediatric day care
unit, Barnsley DGH NHS Trust, South
Yorkshire. Br Dent J 2004; 196: 275277.
procedures were carried out following
the first experimental stage, and by the
third stage the reported pain levels had
diminished, although anxious children
were always found to be more susceptible
to pain perception than non-anxious
children.
The authors recommend that
all clinicians treating children are aware
of anxiety reduction procedures and
behaviour management techniques as, in
todays clinical environment, there should
be no excuse for a painful injection!
Peter Carrotte
Glasgow Dental School
DentalUpdate 641
5/11/08 14:36:04