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Case Reports in Dentistry

Volume 2014, Article ID 109301, 4 pages
http://dx.doi.org/10.1155/2014/109301

Case Report
Surgical and Orthodontic Management of Fused Maxillary
Central and Lateral Incisors in Early Mixed Dentition Stage

Suresh Ramamurthy, Ramaswamy Satish, and Kalidass Priya

Department of Orthodontics, Adhiparasakthi Dental College and Hospital, Melmaruvathur, Tamilnadu 603319, India

Correspondence should be addressed to Suresh Ramamurthy; sureshortho11@gmail.com

Received 11 July 2014; Accepted 1 October 2014; Published 13 October 2014

Academic Editor: Hamdi Cem Gungor

Copyright © 2014 Suresh Ramamurthy et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Fusion is one of the developmental dental anomalies in which two adjacent teeth are joined at the crown level forming a single tooth
with an enlarged crown. Fusion causes some clinical problems such as unaesthetic appearance, pain, caries, and malocclusion. The
management of fusion often needs multidisciplinary approach to give best possible esthetic and functional outcome. This paper
reports a case of 9-year-old boy with fused maxillary left central and lateral incisors who was treated with 2 × 4 fixed orthodontic
appliances after surgical separation of fused teeth.

1. Introduction
Tooth fusion is defined as union between two or more
separate developing teeth [1]. The union may be between
enamel or enamel and dentin. The terms such as synodontia,
connate teeth, joined teeth, or double formations are often
used to describe fused teeth [1]. Fusion most commonly
occurs in the anterior region of primary dentition. It may be
seen in unilateral or bilateral region [2]. Usually fusion occurs
between two normal teeth and sometimes it is seen between
normal tooth and supernumerary tooth.
Fusion can be classified as complete and incomplete type
based upon the stage of tooth development. Complete fusion
takes place, if the contact occurs before the calcification stage,
whereas incomplete takes place at the root level after the
formation of crown. The prevalence of fusion in the primary,
permanent, and supernumerary teeth is 0.5%, 0.1%, and 0.1%,
respectively [3].
The etiology of fusion is still an enigma and many
different views have been put forward. Shafer et al. [4]
reported that fusion resulting from pressure produced by
some physical force prolongs the contact of the developing
teeth. Lowell and Soloman believe that fused teeth result
from some physical action that causes the young tooth
germs to come into contact, thus producing necrosis of the
intervening tissue, thus allowing the enamel organ and dental
papilla to fuse together [5]. Many authors have also suggested
hereditary involvement as an autosomal dominant trait with
reduced penetrance [6].
This developmental anomaly may cause clinical prob-
lems including esthetic impairment, pain, caries, and tooth
crowding [7, 8]. Treatment of fused teeth usually requires
multidisciplinary approaches. This case report presents the
surgical and orthodontic management of unilaterally fused
maxillary left central and lateral incisors in the early mixed
dentition stage.
2. Case Report
A 9-year-old boy referred to our clinic with complaint of
unaesthetic appearance of his upper anterior teeth. The
patient had a nonsignificant medical history and no case
of fusion was reported in his family. Intraoral examination
revealed localized macrodontia present in the maxillary
anterior region. Clinically maxillary left central and lateral
incisors were found to be fused and indentation running from
incisal edge to cervical margin was also observed. Maxillary
left central and right lateral incisor crowns were distally
tipped. Distolabial rotation of left lateral incisors was present.
The labial and palatal aspects of both 21 and 22 teeth were
found to be caries free and healthy periodontium. Spacing
2 Case Reports in Dentistry
(a)
(c)
Figure 1: Pretreatment intraoral photos of fused maxillary left central and lateral incisors. (a) Frontal view. (b) Close-up view. (c) Left lateral
view. (d) Maxillary occlusal view.
Figure 2: Pretreatment panoramic radiograph showing incomplete
fusion of 21 and 22 at crown level.
was present in the maxillary anterior region and distal to
lateral incisor in the lower arch (Figure 1).
Orthopantogram radiograph revealed incomplete fusion
of 21 and 22 at crown level with separate pulp chambers and
two distinct roots. Radiographic evaluation also revealed an
interference in eruption of permanent canine 23 by distally
tipped root of fused lateral incisor (22) (Figure 2). Treatment
was recommended in order to improve esthetic status of
the patient, guide the canine into normal eruption path,
and intercept developing malocclusion, which may require
comprehensive orthodontic treatment in future.
The treatment plan was explained to his family and with
their consent; the periodontal envelope flap was raised after
anaesthetizing right side of the maxillary anterior region. Ini-
tially the fused teeth were separated slightly beyond cemen-
toenamel junction using long, thin diamond bur. After that,
an elevator was used to separate the fused teeth; successful
(b)
(d)
separation of 21 and 22 was confirmed by clinical mobility
of individual tooth and assessed through radiograph. The
periodontal flap was then replaced and suture placed.
After a week period, suture was removed and orthodontic
treatment with 2 × 4 fixed appliance was begun in maxillary
arch. Roth 0.022 slot brackets were bonded on maxillary
incisors and preformed molar bands with buccal tube were
cemented in 16 and 26. Initially, 0.014 nickel titanium
archwire with protective sleeve was used for alignment and
leveling (Figure 3), after that progressively archwires were
changed to 0.016 nickel titanium and 0.018 stainless steel
wire. Maxillary anterior spaces were closed with elastomeric
chain in 0.018 stainless steel wire. Fused teeth were aligned
at the end of six-month orthodontic treatment (Figure 4).
Intraoral periapical radiograph showed improvement in root
parallelism of 21 and 22 during fixed appliance treatment
(Figure 5).
3. Discussion
Developmental anomalies of teeth may occur due to abnor-
malities in the differentiation of the dental lamina and the
tooth germs or abnormalities in the formation of the dental
hard tissues [9]. Different terminologies have been used
to describe the anomaly of double teeth such as fusion,
gemination, and twinning [10]. Isolated large teeth may be
the result of union of two adjacent tooth buds or partial
splitting of one into two. Gemination is defined as an attempt
of single tooth bud to divide with the resultant formation
Case Reports in Dentistry
Figure 3: Intraoral view of 2 × 4 fixed appliance.
Figure 4: Midtreatment photograph shows correction of fused teeth.
Figure 5: Intraoral periapical radiograph shows root parallelism of
21 and 22.
of a tooth with a bifid crown and usually a common root
and root canal. Fusion is the union of two normal teeth with
separate tooth buds leading to the formation of a joined tooth
with confluence of dentin. The term twinning has sometimes
been used to designate the production of identical structures
by division resulting in one normal and one supernumerary
tooth. Various authors prefer to use the term twinning or
double tooth to describe fusion and gemination because of
difficulty in differentiating the two conditions [11].
Still confusion presents in differentially diagnosing fusion
and gemination clinically which are two different morpho-
logical dental anomalies, characterized by the formation
of a large size tooth. Careful radiographical and clinical
examinations are required to separate these two anomalies
[12]. Madder’s two tooth rule may be a practical way of
differentiating fusion and gemination. If fused tooth are
counted as one and the number of teeth in the dental arch is
less, then the term fusion is considered. However, when the
3
abnormal tooth is counted as one and the number of teeth
in dental arch is normal, then it is termed as gemination or
is a case of fusion between normal and supernumerary teeth.
This case revealed fusion of two teeth involving the coronal
surfaces with two separate roots and distinct pulp chambers
and canals.
The clinical problems associated with fusion include
abnormal shape of the tooth leading to unaesthetic appear-
ance, delayed exfoliation, occlusal disturbances, and space
discrepancies. The presence of fissures or grooves at the union
between fused teeth predisposes to caries and periodontal
disease.
The treatment of fusion depends upon the patients
esthetic and functional requirements. Three ways of treat-
ing incomplete fusion are as follows: crown width of the
fused teeth reduced by selective grinding, surgical sectioning
followed by restoration of teeth structures to normal size,
and separation and extraction of the anomalous tooth with
orthodontic closing of the space and reshaping of the teeth
[13, 14]. In this case, fused teeth were successfully separated
with long thin bur and esthetic was improved with orthodon-
tic treatment.
4. Conclusion
Early identification and timely management of fused teeth
may prevent orthodontic, periodontal, and endodontic com-
plications. Treating fusion in young patient is easy and helps
to improve self-esteem and quality of life in future.
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
4 Case Reports in Dentistry

Acknowledgment
Authors would like to thank the mentor and senior person
Dr. Srinivasan.

References
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