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Case Report

Endodontic and restorative treatment of fused primary

anterior teeth Case report
Janaina Merli Aldrigui*1, Ana Cinthia Silva*2, Carolina Cardoso Guedes*3,
Sandra Kalil Bussadori*4 and Marcia Turolla Wanderley*1
*1 Departamento de Ortodontia e Odontopediatria, Faculdade de Odontologia,
Universidade de So Paulo USP, BRASIL
*2 Sindicato dos Odontologistas do Estado de So Paulo SOESP, BRASIL
*3 Universidade Braz Cubas UBC, Mogi das Cruzes, BRASIL
*4 Universidade Nove de Julho UNINOVE, BRASIL

Fused teeth present a high predisposition to caries, which occurs
due to the possibility of bacterial plaque accumulation in the fissures or
grooves in the union between the teeth involved. This paper reports the case
of a 2-year-old boy presented with a fused left maxillary central and lateral
incisors which crown was destroyed by caries, and the endodontic and
composite resin based restorative treatment performed, that restored aesthetics,
function and preserved the primary teeth in the dental arch until their natural

Fused teeth are recognized as the union of two
normally separated tooth germs. It is supposed that
pressing or physic strength can produce the contact
of the developing teeth and their subsequent fusion.
Depending upon the stage of the development, the
union may be complete or incomplete. Geminated
teeth are anomalies which arise from an attempt by
a single tooth germ to divide by an invagination,
with resultant incomplete formation of two teeth1).
Clinical differential diagnosis between fusion
and gemination is difficult when a normal tooth and
a supernumerary tooth are involved2,3). Radiographically, two root canals and one or two roots may be
evident in fused teeth and a single root with a single
canal is observed in geminated teeth4).
In the primary dentition, the reported prevalence
of fusion varies amongst different studies. It depends
on the criteria used to classify fused teeth, the
examination methods with or without radiographs
Received on October 7, 2010
Accepted on January 7, 2011

Key words
Dental caries,
Fused teeth,
Oral rehabilitation

and the ethnic background. It ranges from 0.14 to

5.00% with no sex predilection57). Fused teeth are
usually unilateral5,7,8) and occur more frequently in
the mandibular incisor region2).
Fusions are unaesthetic due to their irregular
morphology. They also present a high predisposition to caries, periodontal disease and spacing
problems911). Caries occurs due to the presence of
fissures or grooves in the union between the teeth
involved11,12) because the possibility of bacterial
plaque accumulation in this area is quite high9).

Case Report
A 2-year-old boy was referred to the Pediatric Clinic
of the Dentists Syndicate of So Paulo State for
dental treatment. Clinical examination showed a
carious involvement of several of his primary teeth,
including the fused left maxillary central and lateral
incisors. The carious involvement of the fused teeth
appeared to have initiated along the fusion line,
and the radiograph examination revealed pulpal
involvement. It was possible to see in the radiograph
that the two roots were fused and the two root canals


Aldrigui, J.M., Silva, A.C., Guedes, C.C. et al.

Fig. 1 Initial radiograph of a 2-year-old boy with a fused

left maxillary central and lateral incisors

Fig. 2 Radiograph after endodontic treatment of the fused


Fig. 3 Fused teeth after totally removal of decayed tissue,

endodontic treatment and the resin-modified glassionomer cement placed like a provisional material

Fig. 4 Partially removal of the resin-modified glass-ionomer


were shared (Fig. 1).

Due to the severe coronal destruction by caries
progression, it was possible to see the two entrances
from the root canals. After local anesthesia, the
decayed tissue was totally removed with a highspeed burn. The fused teeth were submitted to
endodontic treatment, and due to the connection of
the root canals near the apex, it was difficult to do
the instrumentation and the clearance, but all necrotic
pulpal remain was removed. The root canals were
obturated with an iodoform based paste (GuedesPinto Paste GPP)13), that was inserted into the
canal using a lentulo spiral mounted in a slow-speed
handpiece support to guarantee the complete fulfill
of the root canals and a thin layer of gutta-percha
was placed to isolate the root canal filling material

(Fig. 2). Resin-modified glass-ionomer cement was

placed like a provisional material (Fig. 3).
During the next appointment, the resin-modified
glass-ionomer cement was partly removed (Fig. 4),
a facet preparation was made (Fig. 5) and the tooth
was etched for 15 seconds with a 37% phosphoric
acid solution, rinsed with water and air dried. A light
cure bond agent (Single Bond 3M) was brushed
on the etched surface and photo-polymerized. In the
first place, an opaque composite resin shade (A0,5
Opallis Composite Resin Pediatric Dentistry
Kit FGM) was placed substituting the lost dentine.
Another opaque composite resin shade (DA1
Opallis Composite Resin Pediatric Dentistry Kit
FGM) was placed over the first one in circulate
form in the center of the two crowns to give body


Fig. 5 Teeth prepared to receive the composite resin


Fig. 6 Opaque composite resin shade

Fig. 7 Final fused teeth restoration

Fig. 8 Aesthetic final result

to the tooth (Fig. 6). In the end, an enamel layer of

two composite resin shades (EA1 and T-neutral
Opallis Composite Resin Pediatric Dentistry Kit
FGM) was placed. The restoration was made
following the cervical curve by the remaining
structure, resulting on a fused teeth form.
After completion of the composite placement
and polymerization, the occlusal adjustment was
made, and the fused teeth were finely modeled,
finishing and polishing using diamond points (KG
Sorensen) and Soft Lex discs (3M) (Figs. 7 and 8).
The child and parents were instructed on the
importance of oral hygiene and proper dietary to
preserve the primary teeth and for the prevention of
new caries lesions. They were also motivated to
attend periodic clinical and radiographic follow-up
of the treated teeth to monitor root resorption and
exfoliation, besides the appearance of infection


signs what leads to a new intervention.

According to Shafer1), in fused teeth, separate pulp
chambers and root canals are typically seen and in
geminated teeth there is only one pulp chamber and
one root canal. On the radiograph made after the
endodontic treatment in this present case, it is easy
to observe that the root is fused and the root canals
are shared. Because of the severely damaged fused
teeths crown, it is impossible to know if the pulp
chambers were shared, but we can believe that they
were because of the presence of two root canals
entrance. It is a complete fusion of the left maxillary
central and lateral primary incisors.
Due to the possibility of bacterial plaque accumulation in the fissures or grooves in the union


Aldrigui, J.M., Silva, A.C., Guedes, C.C. et al.

between the teeth involved, the pediatric patient

with fused teeth must take part in an oral hygiene
maintenance follow up. The use of sealants in the
line of fusion of the crowns can be an alternative to
prevent the caries development in sound fused teeth.
If the caries lesion already exists, the decayed tissue
must be removed and the fused teeth restored.
In cases of pulpal injury or necrosis, endodontic
treatment must be performed12,14,15). In this case, due
to the severe coronal destruction, the endodontic
treatment was performed in each root canal as if
it were a single root. There is no methodological
difference in endodontic treatment between fused
teeths root and a single root. However, the connection of the root canals near the apex difficult
instrumentation, clearance and total filling of the
canals with the iodoform based paste. So, the
dentists experience is a factor that may influence the
final result of endodontic treatment of fused teeth.
The composite resin is used to restore carious
fused teeth12,14) due to its proper aesthetics. The
color of the fused teeth crown, like the others
teeth depends on internal as well as on external
crown structure, and because of the complexity of
the dental tissue it is impossible to perform the
reconstruction of the destroyed fused teeth in only
one color shade of the composite resin. Concerned
with this, to restore the fused teeth, it was used four
composite resin shades: two opaque shades like
dentinal tissue and two enamel shades.
The use of rubber dam is very important in
pediatric dentistry, especially when endodontic treatment and composite resin restoration is performed.
In this case it was impossible to use the rubber dam
due to the cervical destruction of the fused teeth
that interfered in its adaptation, and could impair
the endodontic treatment and the reconstruction of
the tooth. The isolation of the operating site was
performed efficiently, using cotton wool rolls placed
alongside the tooth, mouth opener and suction
apparatus with an assistant help.
The patients parents believed that the fused
teeth would have to be extracted, so they were very
satisfied with the maintenance of the teeth and with
the aesthetic final result, that according to them, was
similar to the teeth before the destruction. Besides
the aesthetics, the reconstruction of the fused teeth
re-established the patients masticatory function,
returning the ability of bitting and cutting food.
In the radiograph examination of the patient,
we could notice the aplasia of the permanent lateral

incisor successor of the fused teeth. According to

Aguil et al.16), aplasia of the permanent lateral
incisor was related to double teeth involving two
adjacent teeth (32.1%). Others studies had also
shown this association of aplasia and fused teeth8,17).
The successors are usually present in case of
The two major alternatives in treating aplasia of
the permanent lateral incisors are orthodontic space
closure or space opening for prosthodontic replacements, what require the interaction between various
specialists. So, in the future, for the successful treatment of orthodontic-restorative, an interdisciplinary
team effort is vital18).
Maintenance of the primary teeth in the dental
arch until their exfoliation is assumed to be an
important goal in pediatric dentistry15). In this case,
periodic clinical and radiographic follow-up are
important until the exfoliation of the fused teeth to
monitor the endodontic treatment, the eruption of
the permanent central incisors, and to plan what will
be done about the aplasia of the permanent lateral
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