Acta Odontologica Scandinavica

ISSN: 0001-6357 (Print) 1502-3850 (Online) Journal homepage: https://www.tandfonline.com/loi/iode20

Clinical management of fusion in primary

mandibular incisors: a systematic literature review

Sara Bernardi, Serena Bianchi, Guglielmo Bernardi, Jörg Philipp Tchorz,

Thomas Attin, Elmar Hellwig & Lamprini Karygianni

To cite this article: Sara Bernardi, Serena Bianchi, Guglielmo Bernardi, Jörg Philipp Tchorz,
Thomas Attin, Elmar Hellwig & Lamprini Karygianni (2020): Clinical management of fusion in
primary mandibular incisors: a systematic literature review, Acta Odontologica Scandinavica, DOI:
10.1080/00016357.2020.1734233

To link to this article: https://doi.org/10.1080/00016357.2020.1734233

Published online: 03 Mar 2020.

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ACTA ODONTOLOGICA SCANDINAVICA
https://doi.org/10.1080/00016357.2020.1734233

REVIEW ARTICLE

Clinical management of fusion in primary mandibular incisors: a systematic

literature review
€rg Philipp Tchorzc, Thomas Attind, Elmar Hellwige
Sara Bernardia , Serena Bianchia, Guglielmo Bernardib, Jo
d
and Lamprini Karygianni
a
Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy; bPrivate Dental Practice, University of
L’Aquila, L’Aquila, Italy; cDepartment of Operative Dentistry, Periodontology and Endodontology, University of Dental Medicine and Oral
Health, Danube Private University (DPU), Krems-Stein, Austria; dClinic for Conservative and Preventive Dentistry, Center of Dental Medicine,
University of Zurich, Zurich, Switzerland; eDepartment of Operative Dentistry and Periodontology, Center for Dental Medicine, Medical
Faculty, University of Freiburg, Freiburg, Germany

ABSTRACT ARTICLE HISTORY

Objective: Dental anomalies occurring in deciduous teeth can affect the eruption of the permanent Received 16 November 2019
dentition and the occlusion stability. The occurrence of dental anomalies such as double teeth during Revised 30 January 2020
the primary dentition in the daily practice might be frequent. The study aimed to qualitatively sum- Accepted 19 February 2020
marize the therapeutic management of double teeth in primary incisors.
KEYWORDS
Material and Methods: A systematic review regarding the therapy of primary fused incisors in the Primary dentition; dental
mandible was performed and the obtained data were assessed according to Preferred Reporting Items anomaly; fused tooth;
for Systematic Reviews and Meta-Analyses guidelines. The following electronic databases were double tooth; prevention
screened from 1st January, 1996 until 30th July, 2019: PubMed, Scopus, EBSCO and the archives of
paediatric dental journals. The search terms were grouped in anatomic entity: (tooth OR teeth OR inci-
sor), pathological condition: (fused OR fusion OR geminated OR double), intervention: (treatment OR
intervention OR therapy OR prevention OR control OR management OR restoration), observed parame-
ters: (primary dentition OR primary tooth OR primary teeth).
Results: Ten articles met all inclusion criteria. The data disclosed the occurrence of double teeth in
mandibular incisors. The main management of this clinical condition is either preventive or surgical
involving the extraction of fused teeth, based on the deciduous nature of the teeth, the degree of car-
ies and malocclusion development risk.
Conclusion: An early diagnosis of dental anomalies is fundamental for the application of proper pre-
ventive strategies to avoid a potential malocclusion in permanent dentition and to maintain these
teeth sound and caries-free until the eruption of the permanent dentition.

Introduction during the embryological period. If the fusion is complete,

the crown appears clinically large, without any substantial
Tooth anomalies are a class of dental disorders affecting the
groove. In this case, the pulp chamber is not different from
dental teeth both in primary and permanent dentition [1].
common teeth. If the fusion is incomplete, the crown
The aetiology of dental anomalies has not been fully under-
appears with a separating groove mainly situated on the ves-
stood yet. However, environmental and genetic factors can tibular surface [7]. The pulp chamber in case of an incom-
be considered as basic contributors to the manifestation plete fusion can appear bifid or separated [8].
of dental anomalies [2–4]. Based on their type, they can be The term ‘double tooth’ is a general term to indicate the
distinguished in anomalies in structure (amelogenesis imper- clinical presentation of an anomaly of the crown morph-
fecta, dentinogenesis imperfecta, enamel hypoplasia), anoma- ology. However, the pathogenesis of this anomaly called
lies in number (hypodontia, hyperodontia), anomalies in either ‘gemination’ or ‘fusion’ can be attributed to two differ-
size (microdontia, macrodontia), anomalies in eruption ent pathogenic mechanisms. According to the Mader’s two
(transposistion, delayed or anticipated timing of eruption), tooth rule [9], if the tooth presenting the anomaly is counted
and anomalies in shape (concrescence, gemination, fusion, as ‘two teeth’ and the consequent teeth quantity in the den-
dilaceration, double teeth) [5,6]. tal arch is normal, then the anomaly is called ‘fusion’. If the
The anomalies of shape are the most frequent class of abnormal tooth is counted as ‘two teeth’ and the resulting
anomaly a general dentist can encounter in the daily prac- number of teeth in the dental arch is higher than normal,
tice. The dental anomaly named as double tooth (Figure 1) then the anomaly is called ‘gemination’. In order to avoid
derives from the fusion of two or more adjacent tooth germs confusion in the present review, we want to point out that

CONTACT Lamprini Karygianni lamprini.karygianni@zzm.uzh.ch Clinic for Conservative and Preventive Dentistry, Center of Dental Medicine, University of
Zurich, Plattenstrasse 11, Zurich 8032, Switzerland
ß 2020 Acta Odontologica Scandinavica Society
2 S. BERNARDI ET AL.

Figure 1. Clinical presentation of a fused primary tooth (82). (a) Vestibular view. (b) Occlusal view

the term ‘double teeth’ was used to indicate the shape Search strategy
anomaly of the conjoined teeth and not the underlying
In order to search for relevant reports on fused anterior teeth
pathogenic mechanisms.
in the primary mandibular dentition, the following electronic
Although the aetiological factors of the fused or double
databases were screened from 1st January, 1996 until 30th
teeth are not fully understood, diverse genetic and physical
July 2019 in order to detect eligible papers: PubMed, Scopus
forces (e.g. traumas) seem to play a fundamental role in the
and EBSCO as well as the electronic archives of the following
tooth germs fusion [5]. This clinical anomaly can be also a
secondary appearance of various syndromic disorders, such paediatric dental journals: International Journal of Paediatric
as chondroectodermal dysplasia, focal dermal hypoplasia, Dentistry, Paediatric Dentistry, Journal of Dentistry for
achondrodysplasia, median cleft facial syndrome, oral-facial- Children, as well as Journal of Indian Society of Pedodontics
digital syndrome, otodental dysplasia and Russel-Silver syn- and Preventive Dentistry. The Journals Clinical Paediatric
drome [10]. Dentistry, European Journal of Paediatric Dentistry and
As far as the prevalence, pattern and clinical presentation European Archives of Paediatric Dentistry were pre-screened
of double teeth is concerned, this type of dental anomaly can but not taken into consideration since they contained solely
involve both primary and permanent teeth, but its incidence epidemiological studies on geminated teeth.
has been found to be higher in anterior primary teeth [11].
More specifically, the geminated teeth occurred more in the Search terms
mandibular primary incisors, unilaterally and bilaterally [12].
In literature, there are few reports on the incidence [13] The search terms for retrieving articles related with fused
and management [6,8] of primary fused teeth. The reason is teeth in primary dentition were divided in the following
due to the temporary nature of the primary teeth which are groups: anatomic entity: (tooth OR teeth OR incisor), patho-
usually extracted in case of complications, and thus, no evi- logical condition: (fused OR fusion OR geminated OR double),
dence of possible treatment modalities has been reported so intervention: (treatment OR intervention OR therapy OR pre-
far. As reported by Guimar~aes Cabral et al. the assessment of vention OR control OR management OR restoration), observed
the presence of the double teeth is important in relation to parameters: (primary dentition OR primary tooth OR primary
the associated clinical problems such as caries, delay in the teeth).
exfoliation, impactation of the subsequent permanent teeth,
presence of supranumerary teeth, presence of permanent
Criteria for study selection
double teeth, aplasya of the correspondent permanent teeth
and tooth misalligment, with a predispotion to a future mal- Reports included in the present review consisted of random-
occlusion [12]. Indeed, the anterior teeth play a key role in ized controlled trials (RCTs), as well as all other types of clin-
the morphological development of the jaws and the facial ical studies, such as clinical reports (case series, case reports),
type [14,15]. Finally, a systematic review was conducted in and retrospective studies. Only reports regarding solely fused
order to qualitatively summarize the therapeutic manage- primary incisors and eventual fusion with the canines in case
ment of double teeth in primary incisors. To the best of our of lateral incisors in mandibular jaws were included in this
knowledge, this is the first systematic review of the treat- systematic review. Other literature- and systematic reviews,
ment options of double anterior teeth in the primary abstracts and conference proceedings were excluded.
dentition. Furthermore, studies relating to other dental anomalies or
 ACTA ODONTOLOGICA SCANDINAVICA 3

not referring to the occurrence and/or therapy of fused teeth Table 1. Table-tool used for the evaluation of the methodological quality of
case reports and case series [17].
were filtered out of this review. Finally, case reports on fused
Domains Leading explanatory questions
permanent incisors/molars, fused primary molars and maxil-
Selection 1. Does the patient(s) represent(s) the whole experience of
lary incisors were not taken into account. the investigator (centre) or is the selection method
unclear to the extent that other patients with similar
presentation may not have been reported?
Study selection Ascertainment 2. Was the exposure adequately ascertained?
3. Was the outcome adequately ascertained?
Two independent examiners (SB, LK) conducted the primary Causality 4. Were other alternative causes that may explain the
observation ruled out?
literature research using the main search terms. The same 5. Was there a challenge/rechallenge phenomenon?
researchers re-evaluated the selected titles and abstracts in a 6. Was there a dose–response effect?
second screening round, in which the studies not adapting 7. Was follow-up long enough for outcomes to occur?
Reporting 8. Is the case(s) described with sufficient details to allow
to the established eligibility and inclusion principles were other investigators to replicate the research or to allow
omitted. Subsequently, the remaining reports were intro- practitioners make inferences related to their own
practice?
duced into a third screening round, in which the full-text
articles were further appraised for compatibility. In case of
any disagreement between the examiners after independent
evaluation, consensus was reached by re-evaluation and dis- Study selection process
cussion. In the event of discrepancies in the data, when pos- The study selection process followed the PRISMA workflow,
sible, reference paper authors were contacted by email, for as showed in Figure 2. After running searches through the
further explanation. The remaining studies were finally intro- selected databases, a total number of 107 relevant articles
duced into the final review step of qualitative synthesis. was detected. After discarding the duplicates, 100 articles
were further screened by title and abstract. A total of 83 full-
Data organization text articles were then excluded for not meeting the inclu-
sion criteria. Seventeen eligible studies published from 1998
The data were systematically listed in a standard document until the 2019 were examined during the final review step
containing the authors’ names, year of publication, study and finally ten studies were selected [12,18–26]. Summarized
design, involved teeth with dental anomaly, type of interven- information on the selected reports is listed in Table 2.
tion, main outcomes and conclusions. The dental libraries of
the Universities of Zurich (Switzerland), Freiburg (Germany),
and L’Aquila (Italy) were used for further interpretation of
Results
the extracted data when required. Furthermore, to guarantee
the validity of the extracted data, the selected source studies Methodology assessment
were evaluated twice. No further classification was necessary
Nine of the ten studies were classified as fair quality and
because of the small number of the selected studies.
only one fulfilled all of the domains. Indeed, the majority of
the papers missed a reasonable follow-up and only one
Data quality evaluation reported specifically the follow-up’s details (Table 3).

In order to evaluate the yielded data the guidelines of the

Preferred Reporting Items for Systematic Reviews and Meta-
Aalyses (PRISMA, (http://www.prisma-statement.org/state-
Qualitative synthesis
ment.htm) were applied [16]. Two independent examiners In this review, only journals reporting the clinical treatment
(SB, LK) were responsible for systemising the extracted data of the primary double teeth were considered. The ten
and assessing their quality to limit probable inconsistencies. selected reports describe cases of fused mandibular incisors
as well as their clinical treatment. From the qualitative syn-
thesis of the articles, it appears that depending on the pres-
Assessment of methodological quality
ence of caries on the fused teeth, the selected treatment
The quality assessment of the studies’ methodology was per- approach had either a preventive [22,24–26] restorative [25]
formed by two independent reviewers (SB, LK.) according to or surgical (extraction) nature [21,24]. When the involved
the methodological assessing tool designed by Murad et al. tooth was caries-free or considered to be at low caries risk,
[17]. A quality score was given according basing of the fulfil- preventive measures such as recall programmes with specific
ment of the tool requirement. If all of the domains were ful- intervals e.g. every 3 months, restoration of the grooves or
filled (Table 1) the study would be classified as ‘good fluoride application were chosen. When the fused tooth was
quality’; if three of the domains were fulfilled the study affected by caries, caries removal and restoration with a com-
would be classified as ‘fair quality’. If only two or one of the posite filling was conducted. When the tooth caused ortho-
domains were fulfilled the study would be classified ad ‘poor dontic disorder such as crowding, the extraction of the tooth
quality’. was performed independently of the caries risk.
4 S. BERNARDI ET AL.

Figure 2. Flowchart of the search strategy, study selection and data management procedures.

No approach reported on topical application of fluoride. Tewari et al. [25]

filled the very deep incisal groove with a flowable composite
A total of six studies [12,19,20,23–25] reported the diagnosis
for the purpose of a preventive approach, and followed a
of the anomaly and primarily focussed on the increase of 3-month recall programme. Sekerci et al. [24] also suggested
awareness of the parent or the guardian about this condition. the prophylactic filling of the deep grooves with flowable
This was mainly accomplished by providing general prevent- composite and the fluoride application as a further prevent-
ive advice. The diagnostic process was successfully reached ive approach. Again no specific fluoride concentration was
by clinical observation and conventional radiographs (OPG, mentioned in their report. Prabhu et al. [22] proposed the
intra-oral periapical) [12,19,20,23,26] and model cast [23]. One application of topical fluoride, specific dietary changes and
study reported a unilateral triple fusion between two primary periodic follow-ups as the preventive approach of choice.
teeth and a supernumerary tooth [26] Regarding the radio- One study [25] reported a restorative approach regarding the
graphic diagnosis, the degree of tooth mobility must be con- treatment of fused primary incisors. A carious lesion was not-
sidered. In case the tooth mobility is progressive, the able on the gingival third of the labial surface of the fused
permanent tooth will substitute the primary tooth soon and tooth 82–83. The treatment included the removal of the car-
therefore no additional measures must be taken. ies and restoration with flowable composite.

Preventive/restorative approach Surgical approach

A total of 4 studies [18,22,24,25] suggested the application Two studies [21,24] suggested surgical treatment, namely
of preventive measures. In particular, Alpo €z et al. [18] extraction of fused teeth. Specifically, Milano et al. [21]
Table 2. Summary of the selected cases of fused primary incisors.
Follow-up
Study Type of study Tooth involved Type of intervention time Main Outcomes Conclusions
Favalli et al. [20] Case Report 83 Radiographic control N/A The involved teeth appeared larger in Dental practitioner should be aware of
73 their mesiodistal dimension. eventual asymmetries.
A groove without any sign of caries was Multidisciplinarry approach and accurate
situated on on the facial surface. follows-up are recommended.
Radiographic exams revealed a single
enlarged pulp canal and bifid crown.
Milano et al. [21] Case Report and 81–71 Radiographic control and N/A Presence of a smooth, large clinical Fusion anomaly can lead to
literature review eventual surgical therapy crown for each fused pair bilaterally. malocclusion, caries and periodontal
issues. In some cases the permanent
teeth can miss.
oz et al. [18]
Alp€ Case Report 82–83 Topical fluoride application N/A Absence of the permanent lateral Fused teeth can induce malocclusion,
72–73 incisor. caries and periodontal issues.
Guimar~aes et al. [12] Case Report 1st case 81–82 Information of the mother N/A Radiographic examination showed that The knowledge of the features of this
about the optimal 81 and 82 had their pulp chambers dental anomaly and a correct diagnosis
preservation of the primary individualised with normal size. help to establish an efficient
teeth. Absence of the mandibular therapy plan.
Radiographic control permanent incisor was diagnosed.
2nd case 81–82 Radiographic control N/A Periapical radiographs showed the teeth
roots had two separated pulp
chambers.
Chalakkal and Case Report 72–73 Radiographic control N/A congenital absence of the permanent Fused teeth may cause malocclusions
Thomas [19] 82–83 mandibular lateral incisors and aesthetic issues. Monitoring is
recommended.
Rajashekhara Case Report 72–73 Radiographic control and N/A The fused large teeth had buccal and Multidisciplinary approach is
et al. [23] 82–83 diagnostic cast lingual vertical grooves. fundamental to successfully treat
Permanent teeth were present. fused teeth.
Tewari et al. [25] Case Report 1st case Caries removal from the labial 3-month-recall The periapical radiographs revealed the Early pulp exposure can derive from the
72–73 surface of the 82–83. programme crowns and the roots of 72–73 and presence of deep grooves in fused
82–83 Restoration of 82–83 and 82–83 were fused with complete primary teeth.
filling of the grooves of fusion of their pulp chambers and Conservative and preventive approach
72–73 using flowable root canals. Bilateral absence of 32 together with follows-ups are
composite. and 42 was detected. advised.
2nd case topical fluoride application, 3-month-recall The crowns and the roots of 71–72
71–72 dietary changes, and programme were fused with complete fusion of
81–82 periodic follow-ups. their pulp chambers and root canals.
The fusion of 81–82 resulted in a
common pulp chamber and
separated root canals.
Permanent 31 and 41 were absent.
Sekerci et al. [24] Case report (6 Mandibular incisors orthodontic consultation, N/A Missing permanent mandibular lateral Early and efficient diagnosis of the
patients) Fissure sealing , and a incisors in three cases anomaly is of considerable
topical fluoride application. importance.
In one case the tooth has
been extracted.
Prabhu et al. [22] Case Report 72–73 topical fluoride application, N/A Missing permanent mandibular lateral Fused teeth may cause malocclusion
82–83 dietary changes, and incisors. and aesthetic issues. When the fused
periodic follow-ups. tooth hinders the euption of the
permanent successor, its extraction is
advised.
Shanthraj et al. [26] Case Report 71-S-72 Radiographic control 3 months The radiographs showed the triple Fused teeth may results asymptomatic.
ACTA ODONTOLOGICA SCANDINAVICA

follow up fusion of the involved primary teeth. However a monitoring period is

Permanent teeth were present. necessary due to the risk of
developing a further malocclusion.
5
6 S. BERNARDI ET AL.

Table 3. Quality assessment of the evidence.

Domains
Study Selection Ascertainment Causality Reporting Classification
Favalli et al. [20] X X – X Fair Quality
Milano et al. [21] X X – X Fair Quality
Alp€oz et al. [18] X X – X Fair Quality
Guimar~aes, et al. [12] X X – X Fair Quality
Chalakkal and Thomas [19] X X – X Fair Quality
Rajashekhara et al. [23] X X – X Fair Quality
Tewari et al. [25] X X – X Fair Quality
Sekerci et al. [24] X X – X Fair Quality
Prabhu et al. [22] X X – X Fair Quality
Shanthraj et al. [26] X X X X Good Quality
The significance of ‘X’ is the paper fulfil the respective item of the Table-tool used for the evaluation of the methodological
quality of case reports and case series.

proposed radiographic control and eventually the extraction canals pose great technical difficulties for the endodontists
of the fused teeth (81–82 and 71–72) to avoid any interfer- in case a root canal treatment is needed [11]. The simplest
ence with the eruption of the permanent successor teeth. pulp configuration observed in completely fused teeth is the
Sekerci et al. [24] chose the extraction as the treatment of presence of a single large pulp chamber with a voluminous
choice in a case of a primary double tooth 81–82, mainly root canal. Nevertheless, incompletely fused teeth may pre-
because of a deep caries lesion. sent a more complicated canal anatomy, as their pulp can
be diversely separated in the presence of two different
pulp chambers or roots. In particular, the existence of one
Discussion
pulp chamber with two different root canals as well as two
The term ‘double teeth’ describes a shape dental anomaly pulp chambers with one root canal is possible in teeth with
which occurrence ranges from 0.1% to 5% unilaterally and incomplete fusion. In these cases, the endodontic access cav-
from 0.01% to 0.12% bilaterally in primary dentition [27]. The ity preparation has to be adequate and the operator has to
aetiology seems to be unknown. In primary dentition the be able to fully probe the pulp chamber [30]. Additionally,
incidence of double teeth is 0.1% to 0.9% in Caucasian chil- due to its excessive size the wide double tooth crown can
dren, while it is more frequent (1.55% 3.0%) among Asian negatively affect the respective arch, thus inducing size
children. To date, no sex predilection has been found in lit- irregularity within the arch and thus, major aesthetic or even
erature [28,29]. Due to the clinical presentation, the nomen- functional concerns, such as malocclusion. Finally, the result-
clature of this type of dental anomaly still appears to be ing proclination caused by double teeth can induce an
controversial among clinicians. In literature, these teeth are unfavourable modification of the incisal guide during the
commonly referred to as ‘double teeth’. In general, the occlusion evaluation [26,30].
pathogenesis of this anomaly can follow two pathways. In To our knowledge, and according to the most recent lit-
particular, gemination occurs as a result of an attempted div- erature review performed by Shah et al. [6], the alternative
ision of a single tooth germ, whereas fusion arises through management options for double teeth in general include
the union of two normally separated tooth germs [6]. diverse treatment modalities varying from no intervention at
In order to avoid confusion in terminology, the use of the all, preventive measures (periodic recalls, local fluoride appli-
clinical definition ‘double teeth’ is suggested [11]. cation, dietary changes), orthodontic treatment, restorative
Being able to diagnose the presence of double teeth dur- treatment (endodontic therapy, composite restorations), to
ing the regular clinical controls is of great importance. This is surgical measures (crown modification with or without hemi-
because double teeth are often at risk of tooth decay, since section, extraction). A list of the suggested treatment meas-
the enamel surface appears weakened [7]. In addition, when ures for fused primary incisors as well as a clinical protocol
maxillary anterior teeth are involved, the risk of trauma is or their management are provided on Tables 4 and 5,
higher, and compromised aesthetics can cause discomfort to respectively. The determining factors for choosing the most
the patients. In 2013, Agarwal et al. [28], proposed the sili- suitable treatment for double teeth are the degree of the
cone putty guide to allow for an aesthetic restoration of a tooth mobility, the type of existing roots and the morph-
traumatized maxillary central incisor fused with a super- ology of the root canal system. In their report Shah et al. [6]
numerary tooth. However, the direct restoration with com- also underlined three additional factors to be assessed prior
posite is difficult and time-consuming. In the case reported to taking the decision on the most suitable treatment of this
by Agarwal et al. [28] the silicone putty provided an accurate dental anomaly: i) tooth prognosis, ii) patient’s expectation
guide of the incisal margins and proximal contours, proving in regard with aesthetics and iii) complications related to
to be a good technique to treat this type of dental anomaly. orthodontic therapy [6]. It seems that establishing an
Moreover, this dental anomaly does not only affect the enhanced success rate for each reported treatment is rather
external tooth morphology, but also the pulp. As a conse- impossible, due to various biases and the absence of con-
quence, the abnormal anatomy of the pulp and the root crete success criteria.
 ACTA ODONTOLOGICA SCANDINAVICA 7

Table 4 List of available treatment option to apply in case of fused primary intervals of 3 months is necessary. If the permanent successor
teeth.
teeth are missing, the mentioned preventive and/or restora-
Available treatment options in case of primary fused teeth
Preventive approach
tive treatment of the fused teeth is fundamental, so that a
Prerequisites: No tooth mobility, no root resorption, absence of caries, future prosthetic therapy can be initiated when the patient
presence or absence of permanent successor. has reached the appropriate age of 18 years [21,24]. In our
Treatment: Information of parents or guardian about the presence of this
dental anomaly, topical fluoride application, preventive sealing of the deep systematic review, all authors of the respective papers have
fissures when present and 3-month-follow-up programme. Dietary changes agreed on the necessity of a multidisciplinary approach to
may be also proposed.
In case of absence of the permanent successor, the primary fused tooth treat these rare cases. Even though the absence of caries on
should be maintained until the appropriate age for prosthodontics therapy the fused teeth could lead to the underestimation of this
has been reached. tooth anomaly, complications involving the pulp and the
Restorative approach occlusion can still occur. Therefore, the accurate monitoring
Prerequisites: No tooth mobility, no root resorption, presence of caries,
presence or absence of permanent successor is one of the most recommended initial diagnostic measures.
Treatment: Caries removal and subsequent restoration with a flowable In addition, the clinical evaluation of the tooth mobility is
composite. In case of trauma or aesthetic issue, guided restoration with
putty silicone and use of composite resin is indicated.
fundamental to understand the degree of the root resorption
Surgical approach and evaluate the timing of the eruption of the permanent
Prerequisites: Tooth mobility, root resorption, presence of deep caries, tooth.
presence or absence of permanent successor
Treatment: Extraction, also indicated when the fused tooth represents an
obstacle for the eruption of the permanent successor.
Conclusions
In conclusion, all the treatment options found in literature
Table 5. ‘What to do’ protocol in case of facing fused primary teeth cases. seem to play a key role in relevant clinical cases involving
Clinical protocol for the management of fused primary teeth primary anterior teeth, since they occur in young and grow-
1) Clinical examination, evaluation of the tooth mobility, ing organisms, and they can therefore induce significant
2) Eventual radiological and model cast analysis.
3) Information of the parent or the guardian about the presence of this alterations in the morphology of the permanent teeth and
dental anomaly. If the tooth is stable and caries-free, a 3 month-follow-up the jaw growth. Taking the rarity of this dental anomaly into
programme should be prescribed.
4) If the tooth presents demineralisation but no mobility or root resorption,
consideration, a correct diagnosis is fundamental for a suc-
1.25 % fluoride application should be prescribed, together with a 3 month- cessful interdisciplinary management of double teeth.
follow-up programme. If the tooth has a deep fissure, sealing with a
flowable composite should be performed. In case the permanent tooth is
absent, the maintenance of the tooth is fundamental until the patient has Acknowledgment
reached an appropriate age for an appropriate prosthodontic therapy.
5) If the tooth has (initial) caries in the absence of mobility or root resorption, Authors G.B. and S.B(1). Want to acknowledge the paediatric patient and
caries removal with subsequent restoration with a flowable composite
his family who was of inspiration of this paper.
should be performed and the patient should be enrolled in a 3-month-
follow-up programme.
6) If the tooth is compromised through deep caries, increasing tooth mobility
or root resorption, it should be extracted, and orthodontic therapy for Disclosure statement
space maintenance should be applied.
No potential conflict of interest was reported by the author(s).

Usually, clinical cases where the tooth has no evident ORCID

pathology are treated in a rather conservative way including
Sara Bernardi http://orcid.org/0000-0001-6130-8533
mostly preventive measures. Thereby it is expected that a Lamprini Karygianni http://orcid.org/0000-0002-7893-0393
tooth with a good prognosis do not have any clinical indica-
tion to be extracted. The preventive treatment approach for
double teeth in primary dentition includes radiographic con- Data availability
trol, local application of fluoride and the enrolment of the The datasets are available from the corresponding author on reasonable
patient in a 3-month recall programme. Nevertheless, in an request.
earlier case study, Tewari et al. [25] treated a bilateral fusion
in primary mandibular incisors by filling the very deep incisal
groove with a flowable composite, followed by a 3-month References
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