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© 2020 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow	 2577
Introduction
Germinationandfusionarerarebutimportantastheseanomaliesare
potentiallyinfluencinganyotherteeth.[1]
Fusionisdefinedasaunion
of twoseparatetoothbudsduringthetoothdevelopmentstageand
the amount of fusion of dentin, pulp canal, and pulp chambers are
in confluence with the stage at which union occurs.[2]
As a result of
fusion, the counting will be one tooth less than the normal count.
Oncontrary,thegerminationisanattemptof asingletoothgermto
divide and hence it results in the appearance of a large single tooth
usually with bifid crown and a common root and the root canal.[2,3]
This results in a tooth with a bifid crown, while the total number
of teeth is normal.[4]
In the present article, a case of germination in
mandibular third molar has been reported; it is a rare entity by itself,
showing the atypical coronal and radicular morphology.
Case Report
A 30‑year‑old female reportedwithacomplaintof paininherright
lower back tooth region since 1 month. There was no contributory
medical and dental history. The intraoral examination revealed
partialeruptionof themesialcuspof thecrownof 48withswelling
and redness of the pericoronal flap. The provisional diagnosis of
pericoronitis with impacted 48 was made and differential diagnosis
of periodontitis and odontogenic cyst was made. On radiographic
examination,orthopantomography (OPG)revealedthepresenceof
Rare case of gemination of mandibular third molar—A
case report
Sandeep S1
, Jeevan Kumar G2
, Suraj Potdar3
, Rishabh Bhanot4
,
Amit S. Vathare5
, Rahul V. C. Tiwari6
, Harshitha B7
1
Department of Oral and Maxillofacial Surgery, C.K.S. Theja Institute of Dental Sciences and Research, Tirupati,
Andhra Pradesh, 2
Consultant Oral and Maxillofacial Surgeon, Tirupati, Andhra Pradesh, 3
Department of Orthodontics and
Dentofacial Orthopedics, Vasantdada Patil Dental College and Hospital, Kavalapur, Maharashtra, 4
Consultant Oral and
Maxillofacial Surgeon, Jyoti Kendra General Hospital, Ludhiana, Punjab, 5
Prosthodontist and Implantologist, Jaysingpur,
Shirol, Kolhapur, Maharashtra, 6
Consultant Oral and Maxillofacial Surgeon, CLOVE Dental and OMNI Hospitals,
Visakhapatnam, Andhra Pradesh, 7
Department of Periodontics, Sri Sai college of dental surgery, Vikarabad, Telangana, India
Abstract
Fusion and germination are the anomalies that occur due to some developmental eccentricity during the time of morpho‑differentiation
of the tooth bud and have a close resemblance to each other. The gemination is an attempt of the division of a single tooth into
two and, hence, appears as an enlarged single tooth while the tooth count is normal when the affected tooth is counted as one. Its
exact pathogenesis is ambiguous. This anomaly has been observed mostly in deciduous dentition as compared to that in permanent
dentition. Gemination is rarely associated with the third molar and, hence, the terminology is arguable when this condition is seen
in relation to the third molar. In the present article, a case of germination of mandibular third molar has been reported.
Keywords: Double teeth, fusion, gemination
Case Report
Access this article online
Quick Response Code:
Website:
www.jfmpc.com
DOI:
10.4103/jfmpc.jfmpc_117_20
Address for correspondence: Dr. Sandeep S,
Department of Oral and Maxillofacial Surgery, C.K.S.
Theja Institute of Dental Sciences and Research, Tirupati,
Andhra Pradesh, India.
E-mail: sansim9999@gmail.com
How to cite this article: Sandeep S, Kumar GJ, Potdar S, Bhanot R,
Vathare AS, Tiwari RV, et al. Rare case of gemination of mandibular third
molar—A case report. J Family Med Prim Care 2020;9:2577-9.
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is
given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Received: 19-01-2020		 Revised: 12-03-2020
Accepted: 15-03-2020		 Published: 31-05-2020
[Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]
Sandeep, et al.: Rare gemination of mandibular third molar
Journal of Family Medicine and Primary Care	 2578	 Volume 9 : Issue 5 : May 2020
apartiallyeruptedatypicaltoothinthethirdmolarregion [Figure 1].
The morphology of the tooth appeared like two crown structures
werefusedwithsinglebulbousradicularportion.Thepulpchamber
was large and shared by both the crowns and, thereby, appeared to
becontinuousin boththecrownswhiletworootcanalswerevisible
intheradicularportionextendingmesiallyanddistallyfromthelarge
pulp chamber. A radiographic diagnosis of gemination was made
andradiographicdifferentialdiagnosisof fusionwithsupernumerary
tooth was made. The patient was subjected to surgical extraction
of 48 under local anesthesia [Figure 2]. The extracted tooth was
examined in detail in order to differentiate it from fusion [Figure 3].
The examination of the extracted tooth revealed the continuation
of the tooth except they appeared separated by a marked groove on
thebuccalandlingualsurfaceof thetoothappeared [Figures 4].The
toothwashavingasinglerootandtherebylookedlikeanincomplete
division of the tooth. The extracted tooth was sectioned and it was
confirmed which again confirmed germination [Figure 5]. Follow
up OPG revealed healing socket [Figure 6].
Discussion
Gemination and fusion are the developmental anomalies with
unusual anatomy. Gemination of the tooth is the developmental
Figure 3: Showing morphology of the extracted 48
Figure 4: Morphology of the extracted 48 showing marked groove on
the buccal surface
Figure 1: Orthopantomography (OPG) (cropped) showing partially
erupted anomalous mandibular right 3rd
 molar
Figure 5: Showing sectioned extracted tooth Figure 6: OPG (cropped) showing healing of the extraction socket
Figure 2: Showing intraoperative (a) and postoperative (b) picture
b
a
[Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]
Sandeep, et al.: Rare gemination of mandibular third molar
Journal of Family Medicine and Primary Care	 2579	 Volume 9 : Issue 5 : May 2020
anomaly occurring in the morpho‑differentiation stage of
tooth development and it arise as a result of the failed attempt
by the single tooth bud to divide and hence thereby appear
as a double tooth or bifid crown resulting in a bifid crown.[1,5]
It is very difficult, if not impossible to differentiate between
germination and fusion clinically, especially if supernumerary
tooth is involved.[6]
Higher prevalence of such anomalies has
been seen in the deciduous dentition although it occurs in both
primary and permanent dentition with anterior region being
the most common site.[7]
It is generally found with a higher
incidence in the lower jaw and with equal sex predilection.
The prevalence rate of unilateral gemination in primary and
permanent dentition is 0.5% and 0.1%, respectively. The
prevalence rate of bilateral cases in primary and permanent
dentition is 0.01% to 0.04% and 0.02% to 0.05%, respectively.
However, in our reported case, the anomaly is unilaterally present
in the mandibular arch which is relatively rare.[8]
In 1970, Brook
and Winter proposed that these anomalies can be referred to
by an unbiased term like “double teeth.” Moreover, in 1979,
Mader (1979) highlighted the similarity of the clinical appearance
of geminated and fused teeth and recommended the term “fused
teeth” in order to refer to the teeth joined together by dentin.
It is usually very difficult to differentiate between germination
and fusion clinically. Thereby, several clinical and radiographic
criteria have been used in order to differentiate between these
entities. Fusion is an incomplete union of two tooth buds,
while gemination is the incomplete or failed attempt of one
tooth bud to divide into two. Without the involvement of the
supernumerary tooth and presence of full complement of teeth
indicate the phenomenon of germination while one toothless in
the full complement of teeth indicates fusion. Radiographically,
in case of fused teeth, there will be evidence of two distinct
pulp chambers while in case of germination, there is only one
pulp chamber.[9]
In the present case report, it was difficult to
diagnose the case clinically as fusion with supernumerary teeth
or geminated teeth. In the present case scenario, there was no
reduction in the full complement of teeth; moreover, because
of the presence of a large pulp chamber, we arrived at the
diagnosis of gemination of 48. The gemination in posterior
permanent dentition is usually an uncommon condition. It is
an extremely rare situation and thereby it is an important to
primarily diagnose this dental anomaly that could affect any
other tooth in the mouth. The present case report suggests
that more delayed the treatment can be associated with more
severe position of the impacted teeth. Since, the severity of
tooth impaction could follow different patterns while taking
into consideration various investigated factors, thereby it is
mandatory to include such factors while diagnosing the dental
impaction in primary settings and henceforth planning the
preliminary or preventive and interceptive interventions for
the patients. Such case compulsory needs primary care and
intervention. Moreover, the identification of this anomalous
condition and its radiographic evaluation is definitely required
for any primary treatment involving these variations of teeth
for their successful outcome.
Conclusion
Gemination and fusion of teeth are rare but at the same time
clinically important because of their potential side effects and
implications on the other teeth. The post‑surgical complications
of such cases can be prevented and clinical management can be
facilitated by carefully making pertinent and appropriate diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published and
due efforts will be made to conceal their identity, but anonymity
cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1.	 Rajendran R, Sivapathasundaram B. Shafer’s Textbook of
Oral Pathology. 7th
 ed. New Delhi: Elsevier; 2012.
2.	 Nelson SJ, Ash MM Jr. Wheeler’s Dental Anatomy, Physiology
and Occlusion. 9th
 ed. St. Louis: Saunders; 2012.
3.	 Krishnamurthy M, Kumar V N, Leburu A, Jeddy N. Fusion of
maxillary central incisors with mesiodens. J Oral Maxillofac
Pathol 2018;22:131-4.
4.	 Goutham B, Bhuyan L, Chinnannavar SN, Kundu M, Jha K,
Behura SS. Prevalence of dental anomalies in Odisha
population: A panoramic radiographic study. J Contemp
Dent Pract 2017;18:549‑53.
5.	 Bilge NH, Yeşiltepe S, Törenek Aǧırman K, Çaǧlayan F,
Bilge OM. Investigation of prevalence of dental anomalies by
using digital panoramic radiographs. Folia Morphol (Warsz)
2018;77:323‑8.
6.	 Dang HQ, Constantine S, Anderson PJ. The prevalence of
dental anomalies in an Australian population. Aust Dent J
2017;62:161‑4.
7.	 Fekonja A. Prevalence of dental developmental anomalies of
permanent teeth in children and their influence on esthetics.
J Esthet Restor Dent 2017;29:276‑83.
8.	 Gurbuz O, Ersen A, Dikmen B, Gumustas B, Gundogar M.
The prevalence and distribution of the dental anomalies in
the Turkish population. J Anat Soc India 2019;68:46‑51.
9.	 Venkatesh A, Mitthra S, Prakash V, Prasad TS. Gemination
or Fusion? – A case report. Biomed Pharmacol J 2016;9:
1225-8.
[Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]

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177th publication jfmpc- 6th name

  • 1. © 2020 Journal of Family Medicine and Primary Care | Published by Wolters Kluwer ‑ Medknow 2577 Introduction Germinationandfusionarerarebutimportantastheseanomaliesare potentiallyinfluencinganyotherteeth.[1] Fusionisdefinedasaunion of twoseparatetoothbudsduringthetoothdevelopmentstageand the amount of fusion of dentin, pulp canal, and pulp chambers are in confluence with the stage at which union occurs.[2] As a result of fusion, the counting will be one tooth less than the normal count. Oncontrary,thegerminationisanattemptof asingletoothgermto divide and hence it results in the appearance of a large single tooth usually with bifid crown and a common root and the root canal.[2,3] This results in a tooth with a bifid crown, while the total number of teeth is normal.[4] In the present article, a case of germination in mandibular third molar has been reported; it is a rare entity by itself, showing the atypical coronal and radicular morphology. Case Report A 30‑year‑old female reportedwithacomplaintof paininherright lower back tooth region since 1 month. There was no contributory medical and dental history. The intraoral examination revealed partialeruptionof themesialcuspof thecrownof 48withswelling and redness of the pericoronal flap. The provisional diagnosis of pericoronitis with impacted 48 was made and differential diagnosis of periodontitis and odontogenic cyst was made. On radiographic examination,orthopantomography (OPG)revealedthepresenceof Rare case of gemination of mandibular third molar—A case report Sandeep S1 , Jeevan Kumar G2 , Suraj Potdar3 , Rishabh Bhanot4 , Amit S. Vathare5 , Rahul V. C. Tiwari6 , Harshitha B7 1 Department of Oral and Maxillofacial Surgery, C.K.S. Theja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, 2 Consultant Oral and Maxillofacial Surgeon, Tirupati, Andhra Pradesh, 3 Department of Orthodontics and Dentofacial Orthopedics, Vasantdada Patil Dental College and Hospital, Kavalapur, Maharashtra, 4 Consultant Oral and Maxillofacial Surgeon, Jyoti Kendra General Hospital, Ludhiana, Punjab, 5 Prosthodontist and Implantologist, Jaysingpur, Shirol, Kolhapur, Maharashtra, 6 Consultant Oral and Maxillofacial Surgeon, CLOVE Dental and OMNI Hospitals, Visakhapatnam, Andhra Pradesh, 7 Department of Periodontics, Sri Sai college of dental surgery, Vikarabad, Telangana, India Abstract Fusion and germination are the anomalies that occur due to some developmental eccentricity during the time of morpho‑differentiation of the tooth bud and have a close resemblance to each other. The gemination is an attempt of the division of a single tooth into two and, hence, appears as an enlarged single tooth while the tooth count is normal when the affected tooth is counted as one. Its exact pathogenesis is ambiguous. This anomaly has been observed mostly in deciduous dentition as compared to that in permanent dentition. Gemination is rarely associated with the third molar and, hence, the terminology is arguable when this condition is seen in relation to the third molar. In the present article, a case of germination of mandibular third molar has been reported. Keywords: Double teeth, fusion, gemination Case Report Access this article online Quick Response Code: Website: www.jfmpc.com DOI: 10.4103/jfmpc.jfmpc_117_20 Address for correspondence: Dr. Sandeep S, Department of Oral and Maxillofacial Surgery, C.K.S. Theja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, India. E-mail: sansim9999@gmail.com How to cite this article: Sandeep S, Kumar GJ, Potdar S, Bhanot R, Vathare AS, Tiwari RV, et al. Rare case of gemination of mandibular third molar—A case report. J Family Med Prim Care 2020;9:2577-9. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com Received: 19-01-2020 Revised: 12-03-2020 Accepted: 15-03-2020 Published: 31-05-2020 [Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]
  • 2. Sandeep, et al.: Rare gemination of mandibular third molar Journal of Family Medicine and Primary Care 2578 Volume 9 : Issue 5 : May 2020 apartiallyeruptedatypicaltoothinthethirdmolarregion [Figure 1]. The morphology of the tooth appeared like two crown structures werefusedwithsinglebulbousradicularportion.Thepulpchamber was large and shared by both the crowns and, thereby, appeared to becontinuousin boththecrownswhiletworootcanalswerevisible intheradicularportionextendingmesiallyanddistallyfromthelarge pulp chamber. A radiographic diagnosis of gemination was made andradiographicdifferentialdiagnosisof fusionwithsupernumerary tooth was made. The patient was subjected to surgical extraction of 48 under local anesthesia [Figure 2]. The extracted tooth was examined in detail in order to differentiate it from fusion [Figure 3]. The examination of the extracted tooth revealed the continuation of the tooth except they appeared separated by a marked groove on thebuccalandlingualsurfaceof thetoothappeared [Figures 4].The toothwashavingasinglerootandtherebylookedlikeanincomplete division of the tooth. The extracted tooth was sectioned and it was confirmed which again confirmed germination [Figure 5]. Follow up OPG revealed healing socket [Figure 6]. Discussion Gemination and fusion are the developmental anomalies with unusual anatomy. Gemination of the tooth is the developmental Figure 3: Showing morphology of the extracted 48 Figure 4: Morphology of the extracted 48 showing marked groove on the buccal surface Figure 1: Orthopantomography (OPG) (cropped) showing partially erupted anomalous mandibular right 3rd  molar Figure 5: Showing sectioned extracted tooth Figure 6: OPG (cropped) showing healing of the extraction socket Figure 2: Showing intraoperative (a) and postoperative (b) picture b a [Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]
  • 3. Sandeep, et al.: Rare gemination of mandibular third molar Journal of Family Medicine and Primary Care 2579 Volume 9 : Issue 5 : May 2020 anomaly occurring in the morpho‑differentiation stage of tooth development and it arise as a result of the failed attempt by the single tooth bud to divide and hence thereby appear as a double tooth or bifid crown resulting in a bifid crown.[1,5] It is very difficult, if not impossible to differentiate between germination and fusion clinically, especially if supernumerary tooth is involved.[6] Higher prevalence of such anomalies has been seen in the deciduous dentition although it occurs in both primary and permanent dentition with anterior region being the most common site.[7] It is generally found with a higher incidence in the lower jaw and with equal sex predilection. The prevalence rate of unilateral gemination in primary and permanent dentition is 0.5% and 0.1%, respectively. The prevalence rate of bilateral cases in primary and permanent dentition is 0.01% to 0.04% and 0.02% to 0.05%, respectively. However, in our reported case, the anomaly is unilaterally present in the mandibular arch which is relatively rare.[8] In 1970, Brook and Winter proposed that these anomalies can be referred to by an unbiased term like “double teeth.” Moreover, in 1979, Mader (1979) highlighted the similarity of the clinical appearance of geminated and fused teeth and recommended the term “fused teeth” in order to refer to the teeth joined together by dentin. It is usually very difficult to differentiate between germination and fusion clinically. Thereby, several clinical and radiographic criteria have been used in order to differentiate between these entities. Fusion is an incomplete union of two tooth buds, while gemination is the incomplete or failed attempt of one tooth bud to divide into two. Without the involvement of the supernumerary tooth and presence of full complement of teeth indicate the phenomenon of germination while one toothless in the full complement of teeth indicates fusion. Radiographically, in case of fused teeth, there will be evidence of two distinct pulp chambers while in case of germination, there is only one pulp chamber.[9] In the present case report, it was difficult to diagnose the case clinically as fusion with supernumerary teeth or geminated teeth. In the present case scenario, there was no reduction in the full complement of teeth; moreover, because of the presence of a large pulp chamber, we arrived at the diagnosis of gemination of 48. The gemination in posterior permanent dentition is usually an uncommon condition. It is an extremely rare situation and thereby it is an important to primarily diagnose this dental anomaly that could affect any other tooth in the mouth. The present case report suggests that more delayed the treatment can be associated with more severe position of the impacted teeth. Since, the severity of tooth impaction could follow different patterns while taking into consideration various investigated factors, thereby it is mandatory to include such factors while diagnosing the dental impaction in primary settings and henceforth planning the preliminary or preventive and interceptive interventions for the patients. Such case compulsory needs primary care and intervention. Moreover, the identification of this anomalous condition and its radiographic evaluation is definitely required for any primary treatment involving these variations of teeth for their successful outcome. Conclusion Gemination and fusion of teeth are rare but at the same time clinically important because of their potential side effects and implications on the other teeth. The post‑surgical complications of such cases can be prevented and clinical management can be facilitated by carefully making pertinent and appropriate diagnosis. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. References 1. Rajendran R, Sivapathasundaram B. Shafer’s Textbook of Oral Pathology. 7th  ed. New Delhi: Elsevier; 2012. 2. Nelson SJ, Ash MM Jr. Wheeler’s Dental Anatomy, Physiology and Occlusion. 9th  ed. St. Louis: Saunders; 2012. 3. Krishnamurthy M, Kumar V N, Leburu A, Jeddy N. Fusion of maxillary central incisors with mesiodens. J Oral Maxillofac Pathol 2018;22:131-4. 4. Goutham B, Bhuyan L, Chinnannavar SN, Kundu M, Jha K, Behura SS. Prevalence of dental anomalies in Odisha population: A panoramic radiographic study. J Contemp Dent Pract 2017;18:549‑53. 5. Bilge NH, Yeşiltepe S, Törenek Aǧırman K, Çaǧlayan F, Bilge OM. Investigation of prevalence of dental anomalies by using digital panoramic radiographs. Folia Morphol (Warsz) 2018;77:323‑8. 6. Dang HQ, Constantine S, Anderson PJ. The prevalence of dental anomalies in an Australian population. Aust Dent J 2017;62:161‑4. 7. Fekonja A. Prevalence of dental developmental anomalies of permanent teeth in children and their influence on esthetics. J Esthet Restor Dent 2017;29:276‑83. 8. Gurbuz O, Ersen A, Dikmen B, Gumustas B, Gundogar M. The prevalence and distribution of the dental anomalies in the Turkish population. J Anat Soc India 2019;68:46‑51. 9. Venkatesh A, Mitthra S, Prakash V, Prasad TS. Gemination or Fusion? – A case report. Biomed Pharmacol J 2016;9: 1225-8. [Downloaded free from http://www.jfmpc.com on Sunday, May 31, 2020, IP: 183.83.46.254]