dr. amwagh nov clinical dentistry synod on ti a publication

8/3/2019 Dr. AMWagh Nov Clinical Dentistry Synod on Ti a Publication

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Clinical Dentistry

C l i n i c a l D e n t i s t r y , M u m b a i • N o v e m b e r 2 0 1 042

Clinical Dentistry

Endodontics

SYNODONTIABETWEENPERMANENT MAXILLARY LATERALINCISOR AND ASUPERNUMERARY

TOOTHAbstract|| Brief Background The paper discusses the salient eatures o usion and

germination and their management with special consideration

to access cavity preparation, location o canal orices, managingdilacerations, post selection, cementation and nally prosthetic

rehabilitation.

|| Materials and MethodsClinical and radiographic examination suggested a usion

between the lateral incisor and a supernumerary tooth with

a dilacerated root. The treatment plan entailed endodontic

treatment ollowed by restorative rehabilitation.

|| Discussion The actors that help to distinguish between usion and

gemination are discussed in detail ollowed by a brie discussion

o the endodontic and restorative management o the case.

|| Summary and ConclusionsSynodontia or usion is the union o two independently

developing primary or secondary teeth. The case presented

an abnormally large tooth in the place o maxillary right lateral

incisor with a molar like clinical crown showing a deep carious

lesion and peri-apical involvement. ollowing endodontic

treatment, restorative rehabilitation was done with a pre-

abricated carbon ber post, Luxa Core ollowed by a PM crown

to achieve good aesthetics.

|| Key WordsSynodontia or usion, endodontic and restorative

management.

Dr. Abhijit Wagh

MDS, Assistant Professor

Dr. Vijaya A. WaghMDS, Professor & Head, Dept of

Prosthetic Dentistry

Correspondence Address

Dr. Abhijit Wagh

Dept. o Conservative Dentistry and

Endodontics

Sinhgad Dental College & Hospital,

Pune – 411044


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Clinical Dentistry

|| Introduction Tooth usion also termed as “Synodontia” arises through

union o two or more normally separated toothgerms. It is dened as the union between the dentin

and/or enamel o two or more separate developing

teeth.1,2. The usion may be partial or total depending

upon the stage o tooth development at the time o

union, a distinguishing eature between usio-totalis,

partialis-coronaries and partialisradicularis.3,4.

I the contact occurs beore the calcication stage,

the teeth unite completely and orm one large tooth.

Incomplete usion may be at root level i the contact

and union occurs ater ormation o crown. The union

between the teeth results in an abnormally large

tooth, or union o the crowns, or union o the rootsonly, and must involve the dentin.

The root canals may be separate or used. Prevalence

o tooth usion is estimated at 0.5-2.5% in the primary

dentition with a lower prevalence in permanent

dentition.3. In addition to aecting two normal teeth,

usion may also occur between a normal tooth and a

supernumerary tooth4.

Clinically, a usion results in one less tooth in the dental

arch unless the usion occurred with a supernumerary

tooth. The involvement o a supernumerary toothmakes it impossible to dierentiate usion rom

gemination.

The etiology o usion is still an enigma and many

dierent views have been put orward. Shaer et al5

speculated that pressure produced by some physical

orce prolongs the contact o the developing teeth

causing usion. Lowell and Soloman6 believe that

used teeth result rom some physical action that

causes the young tooth germs to come in contact,

thus producing necrosis o the intervening tissue,

thus allowing the enamel organ and dental papilla to

use together.

Many authors have also suggested hereditary

involvement as an autosomal dominant trait with

reduced penetrance7. usion may be unilateral or

bilateral and most commonly occurs in primary teeth

with more predilection or anterior teeth8. Clinically

used anterior teeth requently have a groove or

notch on the incisal edge that goes in buccolingual

direction and radiographically, the dentin o used

teeth always appears to be joined in some region

with separate pulp chambers and canals.

Supernumerary teeth develop as a consequence o

prolieration o epithelial cells rom dental lamina with

the incidence ranging rom 0.5 to 3.8% and maxillary

anterior region in males being more aected.9

Endodontic therapy o such teeth is a challenge

even to the experienced proessional because the

morphology o used teeth varies so greatly that one

can only decide on an individual basis. The restorative

aspect o these teeth ater endodontic therapy is

equally demanding. Since these teeth are mesio-

distally as well as acio-lingually wide, it is quite a

challenge to achieve good aesthetics within the

given parameters and restorative protocols.

|| Case ReportA 17 year old girl in good health reported with a

chie complaint o sharp, shooting continuous painin the upper right ront 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 acio-palatally and had an abnormal molar

like crown morphology with a deep carious lesion in

the centre (ig-2, ig-3).

Fig. ( 1 ) Classifcation

Fig. ( 2 ) Labial view



Clinical Dentistry

Fig. ( 3 ) Occlusal view Fig. ( 5 ) Occlusal Xray

Fig. ( 4 ) OPG

The tooth was tender on percussion and exaggerated

response to electric pulp tester. A clinical diagnosis

o acute irreversible pulpitis secondary to caries was

made.

Radiographic investigation revealed a bulbous

dilacerated root with peri-apical widening o the

lamina dura (ig-6). Mesial and distal angulation IOPA

x-rays were also taken to radiographically evaluate

extra canals or root curvatures (ig-7, ig-8). OPG

and Maxillary occlusal x-rays were taken to conrm

whether it is gemination or usion (ig- 4, ig-5).

usion is oten conused with the process o

gemination. Gemination occurs when, during the

prolierative stage o dental development, a single

tooth germ attempts to divide by invagination. These

two can be dierentiated by the below parameters10.

Morphology: Gemination results in mirror

images o the coronal halves, whereas usion takes

place at an angle causing a crooked appearance.

Anatomy : Pulpal anatomy is very useul in

diagnosing the type o double teeth. used teethwould mostly have separate pulp chamber and

root canals while geminated teeth usually have

one big pulp canal.

Location by jaw: usion is common in mandible

and gemination in maxilla but usion between

supernumerary and normal tooth is more

common in the maxilla.

Crowding: used teeth would more oten

cause ectopic eruption and geminated teeth

would cause more o crowding. However, when a

normal tooth is used with a supernumerary tooth,

crowding and even impaction o other teeth may

result. So this actor is n good diagnostic eature.

Number of teeth: usion is counted as one

tooth and thus diminishes the number o teeth

whereas the number is increased in gemination.

According to Mader11, the ‘two tooth rule’ is

helpul in dierentiating usion rom gemination.

I the resulting dental structure is counted as two

teeth and the normal number o teeth are present

in the region, the case probably represents an

example o usion. I, however, the abnormal

dental structure is counted as two teeth and i an extra tooth is present in the region, then the

case may represent an example o gemination

between a normal and a supernumerary tooth.

All the above actors, the abnormal large crown

morphology, the pulpal anatomy having two distinct

root canals and according to the rule o two along

with the radiographic ndings conrmed the

diagnosis o usion between maxillary lateral incisor

and a supernumerary tooth.

|| Endodontic ManagementAccording to Wole12, used anterior teeth in the



Clinical Dentistry

Fig. ( 6 ) Pre-operative IOPA X-ray

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

Fig. ( 9 ) Access cavity prepared Fig. ( 7 ) Pre-operative Mesial angulation IOPA X-ray

maxilla, oten have canals in the acio-palatal

direction. This predilection is attributed due to the

act that these teeth and the supernumerary tooth

develop most oten on the palatal side. Endodontic

access cavity was prepared ater removal o all caries

under rubber dam isolation (ig-9). Two canals were

located in acio-palatal direction.

The canals were scouted using 10 No K le and coronal

pre-faring was done using GG drills. A crown down

approach was employed or shaping the canals. Glide

path was secured (ig-6) and working length was

conrmed and noted (ig-10). It was also noted that

the palatal canal was the straighter canal. Thorough

cleaning and shaping was done till 2 ProTaper

nishing les13. Canals were copiously irrigated with

NaOCl-5.25% and alternated with 17% aqueous EDTA.

Recapitulation and patency verication was done

ater each instrument. A nal irrigation o 17% EDTA

or 3 minutes ollowed by a 5 minutes irrigation with

NaOCl-5.25%, which was ollowed by irrigation with

2% Chlorhexidine gluconate or 2 minutes.

Canals were thoroughly dried and master cone

selection was done. Canals were obturated using

the warm vertical condensation technique (ig-11).



Clinical Dentistry

Fig. ( 10 ) Diagnostic X-ray

Fig. ( 12 ) Post Cemented

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

Fig. ( 13 ) Occlusion verifed beore curing

Fig. ( 11 ) Post obturation

It was observed that an apical delta was obturated.

Temporary coronal sealing was done with an eugenol-

ree cement.

|| Restorative ManagementAs discussed earlier, the palatal canal was selected

or placement o the preabricated carbon ber postas it was the straighter canal14. Carbon ber post

was selected as it is passive parallel serrated post

with good radiographic appreciation and with a

view to preserving more amount o residual dentin

and good matching with the already prepared

canal. The length and the diameter o the post were

selected and accordingly the minimal required post

space preparation was done keeping 5mm o GP

apically15

. The selected post was sand-blasted anda coat o bonding agent was applied and kept. The



Clinical Dentistry

Fig. ( 15 ) IOPA Xray ater Post cementation & core build-up Fig. ( 17 ) Crown preparation- Occlusal view

Fig. ( 16 ) Crown preparation-acial view

canal was etched and bonded using the 1 step sel-

etching adhesive primer system and then the post

was cemented with a resin luting cement (ig 12). The occlusion was veried beore light curing the

cemented post (ig. 13 ). Core build-up was done

subsequently with Luxa –core (ig 14). A conrmatory

IOPA was taken to veriy the placement o post and

the core (ig 15). The disto-incisal angle o 11 was also

built-up in composite. Shade selection was also done

or the subsequent PM crown at this stage only.

Crown preparation was done with an adequate

crown errule o 2mm wherever possible16 (ig-16 &

ig-17). A temporary heat cure crown was made and

cemented with an eugenol ree cement. The tooth

was temporized or 2 weeks allowing the surroundinggingiva to heal and come to normal (ig-18). A nal

impression was made in an A-Silicone elastomeric

impression material with adequate gingival retraction.

Metal coping trial was then done to veriy t (ig-

19 & ig- 20) and the nal crown was cemented

ater checking the bisque trial. Thorough scaling

and polishing was also done ater two days and

instructions were given. A post operative evaluation

o the aesthetics was done ater two weeks (ig-21

& ig 22).

|| ConclusionSynodontia in the maxillary anteriors, although

relatively inrequent in prevalence, may result in

signicant aesthetic problems. As they are oten very

wide mesio-distally as well as acio-lingual resulting in

space problems, proper inter-disciplinary treatment

planning has to be done. The occlusal or incisal

surace is oten varied with deep grooves and results

in caries. Endodontic management requires careul

evaluation o pre-operative IOPA x-rays to ascertainthe number o canals, curvatures/dilacerations.

Access cavity preparation has to be ergonomic

and judiciously done with due consideration to the

nal restorative protocol. Post placement is oten

mandatory and pre-abricated passive serrated posts

are better suited than cast posts mainly due to the

errule considerations. Subsequent porcelain crowns

either metal-ree or used to metal also determine

the selection between ber posts or metallic posts

respectively. Occasionally crown lengthening has to

be done to achieve good aesthetics.



Clinical Dentistry

Fig. ( 18 ) Tooth temporized & Disto-acial rotation o 11 aesthetically

corrected with direct composites

Fig. ( 19 ) Coping Trial – Facial view

Fig. ( 20 ) Coping Trial – Occlusal view

Fig. ( 21 ) Final crown

Fig. ( 22 ) Final crown



Clinical Dentistry

Fig. ( 23 ) Beore treatment Fig. ( 24 ) Ater treatment

|| References

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dr. amwagh nov clinical dentistry synod on ti a publication

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