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Case Report

Mandibular third molar gemination: A rare anomaly

Harsha Vardhan Talla, Shailendar Reddy Adamala, Sudhir Surapaneni1, Deepa Chillakuru2
Department of Oral Medicine and Radiology, Meghna Institute of Dental Sciences, Nizamabad, Telangana, 1Department
of Oral and Maxillofacial Surgery, Gandhi Dental College, Bhubaneswar, Odisha, 2Department of Oral and Maxillofacial
Pathology, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

ABSTRACT

Gemination and fusion are anomalies which have close similarity. These anomalies may develop during tooth bud
morphodifferentiation as a result of a developmental aberration of the ectoderm and mesoderm. The incidence of these
anomalies was reported to be less than 1%, occurring predominantly in incisors and canines with equal distribution in the
maxilla and mandible. Gemination and fusion are generally asymptomatic and do not require treatment. However, there
could be poor aesthetics, periodontal destruction, or caries leading to pulp necrosis. This article reports a rare occurrence
of fusion/gemination in the third molar region.
Key words: Ectoderm, fusion, gemination, mesoderm

Introduction possible. Gemination is an attempt of the tooth bud to

divide. This partial division is arrested before tooth

M
orpho-anatomical undulations in teeth can be
grouped according to the site of occurrence,
i.e. crown, root, and root canal of the tooth.[1]
Gemination and fusion are anomalies which have close
similarity. These anomalies may develop during tooth
bud morphodifferentiation as a result of a developmental
aberration of the ectoderm and mesoderm.[2] Severity of
this anomaly depends on the stage of development of
the tooth involved. The incidence of these anomalies was
reported to be less than 1%,[3] occurring predominantly in
incisors and canines with equal distribution in the maxilla
and mandible. These anomalies are more common in
deciduous teeth and very rare in permanent molars.[3,4]
development is completed.[3] The end result is a single
tooth with a bifid crown, and the total number of teeth
is normal. Fusion is a condition in which two separate
tooth buds join together to form a large crown. When
counted, the number of teeth is reduced by one. Four
types of these anomalous teeth have been reported:[5]
1. Concrescent teeth — two teeth fused by coalescence
of their cementum;
2. Fused teeth — teeth joined by dentine in their
developmental stage;
3. Geminated teeth — fusion of a tooth with a
supernumerary one; and
4. Dens in dente.

According to the stage of tooth development, different This is an open access article distributed under the terms of the
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degrees of union of cementum, dentin, and enamel are
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DOI: How to cite this article: Talla HV, Adamala SR, Surapaneni S,
10.4103/0972-1363.170145
Chillakuru D. Mandibular third molar gemination: A rare anomaly.
J Indian Acad Oral Med Radiol 2015;27:241-4.

Address for correspondence: Dr. Harsha Vardhan Talla, H. No: 1-2-133, 3rd lane, JKC Nagar, Guntur - 522 006, Andhra
Pradesh, India. E-mail: thvreddy@gmail.com
Received: 17-12-2014  Accepted: 14-10-2015  Published: 21-11-2015

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Talla HV et al.: Mandibular third molar gemination

The etiology of fusion and gemination remains unclear.
Grover and Lorton (1985)[2] claim that local metabolic
interference, which occurs during morphodifferentiation
of the tooth germ, may be the cause. They suggest
that there could be a relationship among gemination,
twinning, and odontoma. Another possibility is trauma.[6]
Gemination and fusion are generally asymptomatic and
do not require treatment. However, there could be poor
aesthetics, periodontal destruction, or caries leading to
pulp necrosis.[7] This article reports a rare occurrence of
fusion/gemination in the third molar region.
Case Report
A 25-year-old female reported to the outpatient
department with a complaint of pain in the right lower
back tooth region since 1 month. Past medical and
dental histories were not contributory. On intraoral
examination, partial appearance of the crown of 48
was noted with redness of the gingiva surrounding the
tooth and swelling of the pericoronal flap of gingiva
[Figure 1]. Considering the inflamed gingiva and the
partial appearance of 48, a provisional diagnosis of
pericoronitis with impacted tooth in relation to 48 was
made. A radiographic examination was done.
Orthopantomograph (OPG) revealed the presence of an
anomalous tooth in the third molar region [Figure 2].
It appeared like two crown structures which were
fused and the root portion having three roots. The pulp
chamber appeared to be continuous for both the crowns,
and the root canal of the middle root appeared to be large
when compared to the other two roots. A radiographic
diagnosis of gemination was arrived at. The patient was
subjected to surgical extraction and tooth was examined
thoroughly to differentiate it from fusion.
The occlusal surface of the tooth appeared to be
continuous [Figure 3], but on the buccal and lingual
surfaces [Figures 4 and 5], the two crowns were separated
by a marked groove which caused incomplete division
of the tooth. There was a common root for both the
crowns, which confirmed incomplete division of
the tooth. The extracted tooth was imaged using
radiovisiography (RVG) [Figures 6 and 7] which again
confirmed gemination. Diagnosis of gemination of the
tooth in relation to 48 was thus confirmed.

Figure 1: Clinical photograph showing inflamed pericoronal flap of 48 Figure 2: Section of OPG showing right posterior teeth

Figure 3: Occlusal surface of the extracted tooth Figure 4: Buccal surface of the extracted tooth

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Talla HV et al.: Mandibular third molar gemination
Figure 5: Lingual surface of the extracted tooth
Figure 6: RVG image of the extracted tooth (superoinferior view)
Figure 7: RVG image of the extracted tooth (lateral view)
Discussion
Fusion and gemination are developmental anomalies with
unusual anatomy. Geminated teeth are developmental
anomalies of the tooth shape that arise from an abortive
attempt by the single tooth bud to divide, resulting
Journal of Indian Academy of Oral Medicine & Radiology | Apr-Jun 2015 | Vol 27 | Issue 2
in a bifid crown or trifid crown. [8] Clinically, it may
be difficult, if not impossible, to differentiate fusion
from germination when supernumerary teeth are
involved.[9,10] This similarity of clinical features causes
much confusion. Brook and Winter (1970)[4] proposed
that these anomalies be referred to by a neutral term
such as “double teeth.”[11] Mader (1979)[12] emphasized
the similarity of the clinical appearance of fused and
geminated teeth and suggested to refer to teeth joined
together by dentine as “fused teeth.”
Distinguishing joined teeth as either germination or fusion
is often difficult. Several clinical and radiographic criteria
are used to differentiate between the two entities. Fusion
is the incomplete attempt of two tooth buds to fuse into
one, whereas gemination is the incomplete attempt of
one tooth bud to divide into two. In the absence of an
involvement of a supernumerary tooth, a full complement
of teeth usually means that the phenomenon represents
gemination and less than full complement of teeth usually
indicates fusion. Radiographically, in case of fusion, there
are usually two separate canals, whereas in gemination,
there is usually one large common root canal. In the case
presented here, there was no reduction in the number of
teeth; moreover, due to the presence of a large root canal in
the middle root, we arrived at the diagnosis of gemination
of 48. According to previous reports, communication
between the pulp chambers of fused or geminated teeth
is a common feature. It should be removed to facilitate a
straight-line access to the root canals.[13-16]
There are different treatment approaches. One of the
deciding factor to retain or extract these teeth, is esthetic
quality. One possible treatment involves their extraction
and conversion crowning of the adjacent teeth. The
second option is surgical division of the double teeth
when the degree of fusion is mild. The third option
is selective grinding in order to reduce the width. A
fourth option is to extract and replace these teeth. In the
present case, as the anomalous tooth was a third molar
and it was causing pericoronal infection, the patient was
subjected to surgical extraction rather than performing
conservative procedures to save the tooth.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Soames JV, Southam JC. Oral Pathology. 3rd ed. Oxford: Oxford
University Press; 1997. p. 6-7.
2. Grover PS, Lorton L. Gemination and twinning in the permanent
dentition. Oral Surg Oral Med Oral Pathol 1985;59:313-8.
243
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Talla HV et al.: Mandibular third molar gemination

3. Ferreira-Junior O, de Avila LD, Sampieri MB, Dias-Ribeiro E,
Chen WL, Fan S. Impacted lower third molar fused with a
supernumerary tooth — Diagnosis and treatment planning using
cone-beam computed tomography. Int J Oral Sci 2009:1;224-8.
4. Brook AH, Winter GB. Double teeth. A retrospective study of
‘germinated’ and ‘fused’ teeth in children. Br Dent J 1970;129:123-30.
5. Tadahiro O. Human Tooth and Dental Arch Development. Tokyo,
Osada, Japan: Ishiyaku Publishers; 1981. p. 171-81.
6. Lyroudia K, Mikrogeorgis G, Nikopoulos N, Samakovitis G,
Molyvdas I, Pitas I. Computerized 3-D reconstruction of two
“double teeth”. Endod Dent Traumatol 1997;13:218-22.
7. Tsesis I, Steinbock N, Rosenberg E, Kaufman AY. Endodontic
treatment of developmental anomalies in posterior teeth:
Treatment of geminated/fused teeth — Report of two cases. Int
Endod J 2003;36:372-9.
8. Ather A, Ather H, Sheth SM, Muliya VS. Unique case of geminated
supernumerary tooth with trifid crown. Imaging Sci Dent
2012;42:197-200.
9. Yang G. Supernumerary teeth and gemination. Br J Oral
Maxillofac Surg 2012;50:e15.
10. Menon PV, Zachariah RK, Kumar LK, Khalam SA. An unusual
case of gemination in mandibular supernumerary tooth: A case
report. Int J Sci Stud 2014;2:84-6.
11. Sekerci AE, Sisman Y, Ekizer A, Sahman H, Gumus H,
Aydinbelge M. Prevalence of double (Fused/Geminated) primary
teeth in Turkey — A study. Pak Oral Dental J 2011;31:7-13.
12. Mader CL. Fusion of teeth. J Am Dent Assoc 1979;98:62-4.
13. Rome WJ. Endodontic therapy involving an unusual case of
gemination. J Endod 1984;10:546-8.
14. Canger EM, Çelenk P, Sezgin OS. Dens invaginatus on
a geminated tooth: A case report. J Contemp Dent Pract
2007;8:99-105.
15. Rani AK, Metgud S, Yakub SS, Pai U, Toshniwal NG, Bawaskar N.
Endodontic and esthetic management of maxillary lateral incisor
fused to a supernumerary tooth associated with a talon cusp by
using spiral computed tomography as a diagnostic aid: A case
report. J Endod 2010;36:345-9.
16. Taheri JB, Baharvand M, Vahidi-Ghahrodi AR. Unilateral fusion
of a mandibular third molar to a supernumerary tooth: A case
report. J Dent (Tehran) 2005;2:33-5.

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