Management of ‘double teeth’ in children and adolescents

DOI: 10.1111/j.1365-263X.2011.01209.x

Management of ‘double teeth’

R EV IE WR EV IE W

in children and adolescents

PURVI SHAH1, JUNE M. L. CHANDER2, JOSEPH NOAR3 & PAUL F. ASHLEY4

1Whittington Health, London, UK, 2The Orthodontic Centre, Swansea, UK, 3Orthodontic Unit, Eastman Dental

Hospital ⁄ Institute, London, University College London Hospitals NHS Trust, London, UK, and 4Unit of Paediatric Dentistry,

UCL Eastman Dental Institute, London, UK

International Journal of Paediatric Dentistry 2012

Background. Abnormally, large teeth are often

referred to as ‘double teeth’. These can pose

numerous challenges for the clinician. There is no

published protocol on the management of double

teeth.

Aim. To review the published literature and also

patients managed at the Eastman Dental Hospital

(EDH) and to develop a clinical protocol for the

management of double teeth in children and ado-

lescents.

Design. Literature was searched (Medline and

Embase) and data collated. Patient notes of cases

managed at the EDH were reviewed.

Correspondence to:

Purvi Shah, BDS, MFDSRCS(Eng), MPaed Dent RCS(Eng),

22 Aspen Grove, Pinner, Middlesex HA5 2NL, UK.

E-mail: [email protected]

� 2012 The Authors

International Journal of Paediatric Dentistry � 2012 BSPD, IAPD and Bla

Results. Eighty-one teeth from 53 papers and 22

patients were included in the review. Success cri-

teria were only reported in 32 papers and were

variable. Twenty-three papers had no follow-up

period. The main factor in determining the man-

agement of a double tooth was root and root

canal system morphology. The treatment of choice

in teeth with separate roots was hemisection and

in those with a single root was crown modifica-

tion or extraction.

Conclusion. It was not possible to determine the

best management strategies because of the vari-

able reporting in the literature. The authors have

proposed a protocol for management and a data

collection sheet for essential information needed

when reporting on double teeth cases.

Introduction

The term ‘double tooth’ has been used to

refer to a form of developmental abnormality

of size where a tooth is abnormally large. The

prevalence of these teeth is low, 0.1% in the

permanent dentition and 0.5% in the primary

dentition with no difference between males

and females1.

Clinicians faced with this dental anomaly

have often endeavoured to classify and assign

a definitive diagnosis using conventional

descriptive classifications such as gemination,

fusion, concrescence, megadontia and macro-

dontia. Gemination has been referred to as

‘an incomplete attempt of the tooth bud to

divide into two’2. Depending on the extent of

the gemination, the affected tooth may have

two crowns or one large partially separated

crown with an incisal notch. Fusion is

defined as a complete or partial union

between the dentine and ⁄enamel of two or

more separate developing teeth2. Concres-

cence refers to the situation where the roots

of two or more teeth are united by cementum

after the formation of the crowns2. Finally,

macrodontia ⁄megadontia refers to teeth that

are larger than usual3. The exact aetiology

and pathogenesis of double teeth is difficult

to determine unless the clinician is able to

witness the embryological events during

odontogenesis that led to the development of

the anomaly4. For these reasons, the term

‘double tooth’ is therefore a more appropriate

diagnostic term for all dental conjoining

defects. In this article, all conjoining cases will

be referred to as double teeth.

Double tooth anomalies pose numerous

management challenges for the clinician espe-

cially if they involve anterior teeth. Most sig-

nificantly, they will result in very poor

aesthetics, partly because of their appearance

but also because they will cause significant

anterior crowding. They may also be associ-

ated with caries and periodontal problems if

ckwell Publishing Ltd 1

2 P. Shah et al.

the fissure or union line extends subgingival-

ly making cleaning difficult5. Double teeth

can also be a feature of syndromes such as

KBG syndrome. There is no robust evidence-

based research on the effective management

for this dental anomaly to date.

The aim of this study was to review both

the literature on the management of double

teeth and cases managed at the Eastman Den-

tal Hospital (EDH) to develop a clinical proto-

col for the management of double teeth in

children and adolescents.

Materials and Methods

Literature review

A search was carried out on Medline and

Embase for the following search terms: ‘dou-

ble teeth’, ‘gemination’, ‘macrodontia’,

‘megadont’, ‘fused teeth’, ‘schizodontia’, ‘con-

nation’ and ‘twinned teeth’.

Articles in English that described the man-

agement of the teeth in the anterior perma-

nent dentition in patients under the age of 18

were included. Exclusion criteria were as fol-

lows:

1 Articles not in English.

2 Management of double tooth cases in

adults.

3 Examples of cases of double teeth where

treatment was not described or provided,

for example, prevalence studies.

4 Double teeth cases in the primary denti-

tion.

5 Double teeth cases in the premolar and

molar teeth.

6 Review articles (though, the references of

these were used to search for more arti-

cles).

A pilot data collection sheet was developed

and used on ten articles. This was then modi-

fied to record the following:

1 Age

2 Gender

3 Ethnicity

4 Family History

5 Tooth affected

6 Width of tooth

7 Type of anomaly

8 Root canal morphology

International Journal of Pa

9 Treatment provided

10 Success criteria

11 Follow-up period

Patient notes review (EDH)

Cases seen from 2001 to 2009 on the joint

Orthodontic–Paediatric (OP) Dentistry clinic

at EDH were reviewed. In addition, members

of the Paediatric Dentistry department were

contacted to locate any other cases that may

not have been referred to the OP clinic for

treatment planning. A modified version of

the data collection form used to extract data

from published papers was used to extract

data from the clinical notes. This form had

been piloted on 10 sets of notes.

The following additional information was

recorded:

1 Dental development

2 Presence of photographs and radiographs

3 Malocclusion

4 Proposed treatment plan

5 Actual treatment to date

Analysis

The management of each double tooth was

looked at individually, even in cases where

there was bilateral presentation. The teeth

were grouped together depending on their

reported developmental abnormality, root

morphology and root canal system. The man-

agement of the double teeth was analysed

based on the clinical and radiographic pheno-

type rather than on the reported develop-

mental abnormality, as it was evident that

this was the most important factor in deter-

mining the management strategy used.

Results

A total of 139 articles were found in the ini-

tial search. Fifty-four articles describing the

management of double teeth in children and

adolescents were found and were included in

the final review. Reasons for exclusion of the

remaining articles were primary or posterior

teeth reported (n = 46), no description of

management (n = 15), described management

in adults (n = 10), prevalence only (n = 9)


ediatric Dentistry � 2012 BSPD, IAPD and Blackwell Publishing Ltd

Table 2. Success criteria used.

Criteria used

List of papers(See references fordetails of paper)

Asymptomatic 5–13,36No clinical ⁄ radiologicalsigns of pathology

5,6,8,13–20,36,52

Positive sensibility reading 5,7,9,11,12,15,17–25,52Normal colour 12,20,23Good aesthetics 25–27,52

Management of double teeth 3

and review articles (n = 6). Data from sixty

cases were extracted from the remaining 53

articles.

A further 22 cases were treatment planned

or managed at the EDH. These were com-

bined with the articles to give a total of 82

cases and 110 teeth (in bilateral cases, each

tooth was looked at individually). Data from

both groups are shown in Table 1.

Restored function 26Further root development 5,7,9,12,18,21,28No root resorption 6,14,16,20,28,29Healthy periodontal tissues 10,11,18,20,23,24,30–32Good bone levels 7,20,23,29Attachment gain 21No pocketing 11,15,16,20,23,29,33Bone regeneration 12,23Resolution of chronic inflammation 34No mobility 11,12,31Patient and parent satisfaction 25Stable orthodontic treatment 35

Reporting of data – success criteria and follow-up

When reviewing the success criteria used and

the follow-up period, only the literature was

reviewed as the cases managed at the EDH

were still either undergoing treatment or

were being managed outside of the hospital.

Thirty-three articles reported some sort of

success criteria, but there was a great variabil-

ity in the criteria used, with some articles

only using one of the criteria whereas others

used multiple criteria. Cases of hemisection

and autotransplantation generally had better

reporting of success than other treatment

modalities. Table 2 gives a list of the success

criteria used in the different papers. Twenty-

three articles did not report on the follow-up

period14,17,22,25,27,36,37–40,41–46,47,48–51 of the

remaining articles, follow-up periods varied

from 0.25 to 120 months, 25 of these articles

reporting a follow-up of >12 months.

Owing to this variability in measurement of

success and follow-up period, it was impossi-

ble from reviewing the literature to determine

the optimal management option for different

presentations of double teeth. The various

management options used are described later.

Table 1. Patient demographics (literature review and EDHpatients).

Male 66Female 16Mean age 10.71 ± 2.67(SD)

EthnicityNot recorded 32Caucasian 42Other ethnic group 8

Family history of dental anomaliesNot recorded 67No family history 15Unilateral presentation 54Bilateral presentation 28



Management options

Management options were classified as hemi-

section with crown modification, crown modi-

fication only, extraction, orthodontics only,

endodontics only or nothing. Extraction was

the most common option used (n = 32, 29%).

Root and root canal system morphology was

the biggest factor determining management;

therefore, description of management options

is split into two groups, management of teeth

with separate roots and management of teeth

with partially or completely fused roots

(single root).

Separate roots (n = 52)

Most of these types of double tooth (n = 32,

62%) were managed with the hemisection of

the tooth and crown modification. Eighteen

of these teeth had endodontic treatment

either before or after the hemisection. In the

remaining hemisected teeth, no endodontic

treatment was carried out; however, two of

these teeth needed direct pulp caps following

hemisection (one with MTA9, one with cal-

cium hydroxide and zinc oxide eugenol31).

These pulp capped teeth were still vital at 42

and 48 months, respectively. In three cases,

the tooth was extracted before being hemi-

sected and then replanted10,29,32 with the root

ckwell Publishing Ltd

4 P. Shah et al.

filling also carried out extra-orally in two of

these29,32. Both cases reported a successful

outcome at 6 years32 and 5.5 years29 clinically

and radiographically. The latter case, how-

ever, was only successful after undergoing

extensive periodontal treatment because of

external bone resorption.

Comprehensive orthodontic treatment was

undertaken in 14 cases after hemisection with

or without endodontic treatment.

In the remaining cases with separate roots,

12 (23%) were extracted, 3 (6%) had crown

modification only, 2 (4%) had orthodontics

only, 2 (4%) endodontics only and 1 (1%)

no treatment.

Single root (n = 58)

These double teeth were commonly managed

by crown modification (n = 21, 36%) or

extraction (n = 20, 34%).

Crown modification usually referred to the

reduction in the mesial–distal width of the

tooth. This was commonly performed over

several visits.

Where teeth were extracted, several differ-

ent approaches were taken to manage the

spaces. Five teeth were extracted followed by

orthodontic treatment and prosthetic replace-

ment and five just with prosthetic replace-

ment. In another case, the bilateral double

upper central incisor teeth were extracted

and orthodontic treatment utilised to close

the spaces with the subsequent crown modifi-

cation of the lateral incisors and canines35. At

the EDH, two bilateral cases and one unilat-

eral case were managed with the extraction

of the double teeth followed by subsequent

orthodontic treatment with no prosthetic

replacements. Finally, two teeth in the litera-

ture review and one tooth at the EDH were

extracted with no further treatment provided.

In two cases from the literature review, the

double tooth was extracted and a supernu-

merary tooth from the same patient was

transplanted into the socket as a replacement

(autotransplantation)18,28. These teeth were

not root treated and were followed up

24 months later with further root develop-

ment and positive response to sensibility tests.

There was slight obliteration of the root canal


in one tooth 24 months post-autotransplanta-

tion, but it showed normal periodontal tissue

status with no signs of root resorption28.

Extraction and autotransplantation of the

supernumerary was also carried out for one

case at the EDH. Success was measured aes-

thetically, clinically and radiographically, with

the tooth responding positively to sensibility

testing and showing normal periodontal tissue

status with no signs of root resorption at

24 month follow-up.

For 10 cases, orthodontic treatment was the

only course of treatment. Three double teeth

underwent only endodontic treatment with

one patient presenting as a bilateral case49. In

four cases, the double tooth was accepted and

no treatment was carried out. In this group,

one case from the EDH presented with bilat-

eral double teeth. In another case of bilateral

presentation, one tooth was accepted whereas

the other tooth was hemisected17.

Discussion

Quality of data – patient demographics

Recording of information on ethnicity and

family history in the review was variable,

with the majority of the papers not recording

this data. Understanding the genotype of any

dental condition could help our understand-

ing of the phenotype and therefore determine

the best treatment option.

Quality of data – success criteria and follow-up

Criteria used to measure success or failure

varied widely between studies and follow-up

periods ranged from 0 to 120 months. In

addition, it is highly likely that these case

reports would be subject to publication bias,

i.e., only cases with a successful outcome

would be published. These factors make it

impossible to determine which management

option was most appropriate for any given

scenario.

This problem could be avoided if there were

specific guidelines on success criteria and a

defined follow-up period. In this paper, we

have devised a list of essential information

that should be included when reporting on



Table 3. Essential information needed when reporting onmanagement of double teeth.

List of essential information needed when reportingon double teeth cases

Age of patientSex of patientEthnicityFamily historyMalocclusionAny other anomalies, for example, supplemental teeth,missing teeth

Crown widthRoot morphology including details on root fusion andlevel if necessary

Appropriate radiographs and other imaging (cone-beam CT)Appropriate photographs (pre and post operative)Treatment carried outSuccess criteria and reasons for the criteria usedFollow-up period (minimum – 12 months aftertreatment completion)


the management of double teeth (Table 3).

We propose that:

1 All cases should have multi-disciplinary

management

2 There should be at a minimum of at least

12-month follow-up

3 Success criteria should include clinical

(aesthetics, function, maintenance of alve-

olar bone height and gingival health) and

radiographic (no pathology) success as

well as patient satisfaction with the treat-

ment.

Management of double teeth – treatment principles

Development of evidence-based guidance for

management of these teeth is not possible

because of the issues mentioned previously

around reporting. This paper will attempt to

outline some principles based on our experi-

ence of managing these teeth.

1 Assessment

� 20

Inte

a. Quality – does the tooth have a good

longterm prognosis

b. Aesthetics – is the patient happy with

their appearance

c. Orthodontics – will the double tooth

result in a tooth number ⁄ jaw size dis-

crepancy

Assessment should include the use of cone-

beam computed tomography (cone-beam CT)

as an imaging technique in the maxillofacial

12 The Authors

rnational Journal of Paediatric Dentistry � 2012 BSPD, IAPD and Bla

region. Cone-beam CT allows 3D images of

the individual teeth and the surrounding tis-

sues including the root morphology to be cap-

tured. This would be particularly advantageous.

There has only been one case report of cone-

beam CT being used in the imaging of double

teeth52,53.

2 Management

If the decision is made to treat for func-

tional, aesthetic or orthodontic reasons, then

it is helpful to divide the teeth into two

groups – those with two separate roots and

those with one root.

If the roots are distinct then consideration

can be given to hemisectioning of the tooth.

This will require careful assessment, even

with cone-beam CT imaging, it may not be

possible to predict whether the tooth can be

hemisected until the point of surgery. Where

hemisection is considered then a multidisci-

plinary approach should be taken with sup-

port from the orthodontist, endodontist and

periodontist as appropriate.

Where there is only one root then crown

modification can be considered. The success

will be dependent on the amount of tooth

substance that needs to be removed and also

on the mesial–distal dimensions at the

enamel–cemental junction. Reduction in

crown width is possible supra-gingivally but

difficult sub-gingivally. Reduction in crown

width at the level of the enamel–cemental

junction will also lead to subsequent perio-

dontal problems.

Where teeth have to be extracted then

attempts should be made to maintain alveolar

bone. If both upper incisors are affected then

we can consider extracting one and then

building up the other to resemble two teeth.

This tooth can then be moved orthodontically

to maintain aesthetics and alveolar bone until

implants become an option. If there is a sup-

plemental or suitable supernumerary tooth,

autotransplantation should also be consid-

ered.

Figure 1 shows a clinical protocol to be

used for the management of double teeth.

This protocol assumes that the patient is

being managed by a multidisciplinary team

including a paediatric dentist, orthodontist

and restorative dentist (when necessary).


Aesthetic, Patient, Clinical, Radiographic or Orthodontic concerns

Yes No

Take full clinical, radiographic, photo and study model records. Clinical and radiographic (use cone beam CT if necessary) assessment of quality of tooth, aesthetics and orthodontics.

Take full clinical, radiographic, photo and study model records. No treatment required

Single root Separate roots

Suitable supplemental tooth present

No supplemental tooth

Extraction of double tooth and autotransplantation of supplemental

Crown modification possible?

Yes No

Crown modification – reduce/increase width

Extraction and prosthetic replacement/orthodontic space closure and crown modification

Presence of pulpal communication? (Cone beam CT can help with diagnosis)

Hemisection +/–Crown modification. If extensive PDL/bone loss, consider use of guided tissue regeneration or bone substitute.

Yes No

Hemisection, endodontic treatment+/– Crownmodification. If extensive bone/PDL loss, consider use of guided tissue regeneration or bone substitute.

The above flow chart assumes that a multidisciplinary team involving a Paediatric Dentist, Orthodontist and Restorative dentist (especially if considering hemisection) is managing a double tooth in a well motivated child. When there is a bilateral presentation, each double tooth needs to be assessed separately. It must be noted that the above protocol is a guide to the treatments that have been most often used, and NOT a comprehensive list of the possible management methods for double teeth.

Fig. 1. Proposed clinical protocol for management of double teeth.

6 P. Shah et al.

Conclusions

1 Various treatment modalities and

approaches have been reported in the liter-

ature for the management of double teeth.

2 This review had aimed to bring together all

the available evidence to aid the practi-

tioner in making the most appropriate

management decisions when faced with a

patient presenting with a double tooth.

3 All cases would benefit from multidisciplin-

ary care involving a paediatric dentist,

orthodontist and restorative dentist, but

unfortunately, because of the variable

reporting of cases in the literature with dif-

ferences in success criteria and follow-up

periods, currently it is not possible to rec-

ommend any one treatment modality over

another.

4 Better collection of data is required for

patients who present with double teeth.


The treatment success should be monitored

for a minimum of 12 months and a set list

of minimal criteria used to measure the

success depending on the management

strategy used. This will enable the forma-

tion of a protocol for the best management

of various presentations of double teeth.

Why this paper is important to paediatric dentists

edi

• All the available evidence has been brought together

to aid the practitioner in making the most appropriate

management decisions when treating a child ⁄ adoles-

cent presenting with double teeth.

• A list of essential information that should be included

when reporting on the management of double teeth is

provided to ensure standardised and better case

reports.

• A protocol has been suggested for the management of

double teeth, making it easier for the Paediatric dentist

(as part of a multidisciplinary team) to assess and

treatment plan cases appropriately.


atric Dentistry � 2012 BSPD, IAPD and Blackwell Publishing Ltd


Conflict of interest

The authors declare no conflict of interest.

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Management of ‘double teeth’ in children and adolescents

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