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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 3  »  Endodontic and periodontal treatments of a geminated mandibular first premolar
Endodontic and periodontal treatments of a geminated mandibular first premolar
Introduction - Report.



S. Aryanpour, P. Bercy & J.-P. Van Nieuwenhuysen
Department of Dental Medicine and Stomatology, Université Catholique de Louvain, Brussels, Belgium.

Introduction.
Fusion and gemination have been described as results of developmental anomalies of dental tissues. Fusion may be defined as the union of two (or more) adjacent teeth and gemination as an attempt by the tooth bud to divide. Union or division may be total or partial and may concern the dentine and/or the enamel or even the pulp. The complete division of a tooth germ is called ‘twinning’ (Tannenbaum & Alling 1963, Pindborg 1970, Shafer et al . 1983, Grover & Lorton 1985, Hülsmann et al. 1997). It is often difficult to make a distinction between fused and geminated teeth, especially when the phenomenon is normal or supernumerary (Tannenbaum & Alling 1963, Pindborg 1970, Kelly 1978, Hülsmann et al . 1997). The exact aetiology is still unknown, but a genetic predisposition is suggested (Pindborg 1970, Shafer et al . 1983, Caliskan 1992).
According to results of epidemiologic studies cited by Schuurs & van Loveren (2000), these anomalies are more prevalent amongst primary teeth (0.6–2.8%) than amongst permanent ones (0.1–1%). But if the primary dentition is affected, there is a higher probability of abnormalities occurring in the subsequent permanent teeth (Tannenbaum & Alling 1963, Pindborg 1970, Whittington & Durward 1996, Schuurs & van Loveren 2000). Fusion is much more prevalent than gemination. The most common location is the incisor region but geminations (or fusions) have been reported in canine, premolar and even molar regions (Pindborg 1970, Grover & Lorton 1985, Duncan & Helpin 1987, Whittington & Durward 1996, Schuurs & van Loveren 2000).
This report concerns the endodontic and periodontal treatments of a geminated mandibular first premolar, which is rarely encountered and seldom reported.

Report.

Examination.
A 38-year-old white female patient with a non-contributory medical history was referred to the Department of Operative Dentistry complaining of acute continuous pain and intraoral swelling located in the mandibular right region.
Clinical examination showed a geminated first premolar with two independent separated crowns but with united roots (Fig. 1). The second premolar was normal.
The soft tissues were inflamed at the buccal proximal gingival margin of the gemination site where periodontal probing revealed a 10-mm lingual and a 6-mm buccal pocket. A slight swelling with a buccal sinus tract was also noticed adjacent to the apex.
A preoperative radiograph confirmed the incomplete cleavage of the first premolar; two distinct pulp chambers with two joined canals and a third independent canal were observed (Fig. 2). The marginal bony support appeared normal and a radiolucent lesion was visible around the apices. The tooth gave no response to pulp sensitivity tests (thermal and electric). The diagnosis of pulp necrosis and acute apical abscess was made.

Root canal treatment.
Two occlusal access cavities were prepared and two distinct pulp chambers with three canal orifices found. The mesial opening was enlarged and investigated for an extra canal. Because no extra canals were detected, size 15 K-files (Dentsply Maillefer, Ballaigues, Switzerland) were inserted into the three orifices and the working lengths established 0.5 mm from the radiographic apex. The canals were instrumented using the crown-down technique (Morgan & Montgomery 1984) to a size 25 master apical file. Rubber dam isolation and copious irrigation with 2.5% sodium hypochlorite solution were used during the preparation. The canal system was dressed with a non-setting calcium hydroxide paste and sealed temporarily with Cavit-W (ESPE, Seefeld, Germany). No antibiotics were administered.

Preoperative clinical appearance of the mandibular first premolar
Figure 1. Preoperative clinical appearance of the mandibular first premolar. Note the presence of two separate crowns.

Preoperative radiograph shows the partial cleavage of the mandibular first premolar and a radiolucent lesion around the apices
Figure 2. Preoperative radiograph shows the partial cleavage of the mandibular first premolar and a radiolucent lesion around the apices. Two joined mesial root canals (single foramen) and a third independent root canal.

Radiograph with master gutta-percha points placed
Figure 3. Radiograph with master gutta-percha points placed. Two joined mesial root canals (single foramen) and a third independent root canal.

Radiographic examination of the obturation shows a puff of sealer
Figure 4. Radiographic examination of the obturation shows a puff of sealer.

The patient was reviewed 2 weeks later when the tooth was symptom free and the sinus tract and intraoral swelling had disappeared. The non-setting calcium hydroxide was removed, master gutta-percha points placed and a radiograph taken. The radiograph showed a single foramen for the single canal of the mesial segment and the mesial canal of the distal segment. The second canal of the distal segment appeared to be independent (Fig. 3).
The canals were obturated with gutta-percha points and a zinc-oxide eugenol sealer using cold lateral condensation. The radiographic appearance of the root obturation was acceptable and revealed the deep extent of the mesial access opening performed in search of an extra canal (Fig. 4).
One month later the canal orifices were sealed with a light-cured glass ionomer and the crowns restored with composite resin.

Periodontal treatment.
After endodontic treatment, the patient was referred to the Department of Periodontology for the management of the periodontal problem. In this case the root surface was also abnormal so it was decided to perform flap surgery under local anaesthesia. A labial flap was raised and a marked groove between the partially cleaved root was noticed (Fig. 5). This abnormal anatomical groove constituted a major plaque retention factor. Tungstencarbide burs were used to reduce and smooth the area, the flap was repositioned and sutured. Four months later a lingual flap was raised and the lingual groove reduced and smoothed. The whole procedure was performed in order to achieve optimal periodontal healing.

Periodontal flap surgery under local anaesthesia
Figure 5. Periodontal flap surgery under local anaesthesia. Abnormal anatomical groove.

Recall periapical radiograph 12 months later demonstrating disappearance of the radiolucent lesion and the reconstitution of normal bone
Figure 6. Recall periapical radiograph 12 months later demonstrating disappearance of the radiolucent lesion and the reconstitution of normal bone.

Periapical radiograph of the fractured geminated tooth
Figure 7. Periapical radiograph of the fractured geminated tooth.

Post-operative (extraction) radiograph of the distal segment of the fractured geminated tooth
Figure 8. Post-operative (extraction) radiograph of the distal segment of the fractured geminated tooth.

The clinical appearance of the geminated tooth 3 months after extraction of the mesial segment
Figure 9. The clinical appearance of the geminated tooth 3 months after extraction of the mesial segment.

The postoperative follow-up at 6 and 12 months showed a successful progressive radiographic and clinical healing of the endodontic component (Fig. 6); the root surface correction reduced the plaque accumulation secondary to these abnormal anatomical grooves. The initial localized periodontal pocketing adjacent to the gemination site decreased to measure 6 mm lingually and 3 mm buccally.
One year later the patient returned complaining of constant discomfort located in the area of the geminated tooth over the previous 7–8 days.
On clinical examination the tooth had fractured through the lingual and buccal grooves, resulting in a complete separation of the two segments. A periapical radiograph confirmed a vertical fracture and revealed loss of the alveolar bone between the mesial and distal segments (Fig. 7). Conservation of the mesial segment was considered to have a poor prognosis. Therefore, this segment was extracted and the fractured surface of distal segment smoothed (Fig. 8). The patient returned 1 week later; she was comfortable and the tooth asymptomatic.
At the follow-up visit 3 months later, the gingival tissue surrounding the remaining part of the tooth was remodelling (Fig. 9) and the alveolar socket was remineralizing. The maintained tooth segment continued to satisfy functional demands and no prosthodontic treatment to replace the extracted segment was planned.