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Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
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the original author and source are credited 
 

 

 

CT-Assisted Management with Biodentine Obturation and Aesthetic 
Rehabilitation of a Geminated Maxillary Central Incisor with Mid-Root 
Fracture: A Rare Case Report 

Neelam Mittal 1 , Harshitaa Aggarwal 2 , Shubham Kharat 2 , Shelly Sharma 3 , Thivyashankari 

Thangamuthu 2 , Aiyman Ayubi 2 , Silviya Samad 2     

1 Professor, Conservative Dentistry and Endodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi -221005. 

2 Junior Resident, Conservative dentistry and Endodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi -221005. 

3 Senior Resident, Conservative dentistry and Endodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi -221005. 

Article Info: 
_____________________________________________ 
Article History: 

Received   04 June 2024     
Reviewed  09 July 2024 
Accepted   24 July 2024 
Published 15 September 2024 

_____________________________________________ 
Cite this article as:  

Mittal N, Aggarwal H, Kharat S, Sharma S, 
Thangamuthu T, Ayubi A, Samad S, CT-Assisted 
Management with Biodentine Obturation and 
Aesthetic Rehabilitation of a Geminated Maxillary 
Central Incisor with Mid-Root Fracture: A Rare Case 
Report, Asian Journal of Dental and Health Sciences. 
2024; 4(3):1-4                                                                      

DOI: http://dx.doi.org/10.22270/ajdhs.v4i3.87     

Abstract 
_________________________________________________________________________________________________________________ 

Gemination, a rare aberration in tooth development, results from the incomplete division of one 
tooth germ into two. In this case report, a true geminated permanent maxillary central incisor tooth 
with a horizontal mid-root fracture is successfully treated by non-surgical endodontic treatment. To 
elucidate the intricate root canal anatomy of this rare geminated incisor, we employed computed 
tomography imaging technology, enhancing our understanding of this complex case. Utilizing 
biodentine for obturation proved pivotal, as its capacity to accelerate reparative dentin formation 
facilitated prompt healing, particularly beneficial in fracture cases. This was followed by aesthetic 
rehabilitation to achieve a pleasing mesio-distal dimension for both the central incisors using a  
zirconia-reinforced porcelain crowns.  

Keywords: Computed Tomography (CT), Gemination, Horizontal root fracture, Biodentine 
Obturation 

*Address for Correspondence:   

Dr. Harshitaa Aggarwal, Junior Resident, Conservative dentistry and Endodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi -221005. 

INTRODUCTION 

Gemination is a developmental anomaly arising from the 
unique splitting of a tooth germ by an invagination involving 
ectoderm and mesoderm, leading to incomplete formation of 
two teeth. Despite extensive study, the exact cause of 
gemination remains largely elusive. 

Its occurrence in permanent dentition is notably rare, with only 
0.1- 0.2% incidence1, most commonly affecting maxillary 
central incisor .  Aguiló et al.2 classified gemination into four 
morphological types. 
 
In the context of dental trauma, crown-root fractures occur in 
38% of the permanent dentition (Mier et al., 2013) with 
horizontal root fracture located predominantly in the middle 
third (57%). 

This case report presents a unique scenario of a geminated 
maxillary central incisor with a horizontal mid-root fracture. 
The tooth underwent endodontic treatment, followed by 
aesthetic rehabilitation using zirconia-reinforced porcelain 
crowns, emphasizing both functional and cosmetic restoration. 

 

CASE REPORT  

A 23-year-old male reported with pain in his fractured upper 
incisors following trauma due to fall 2weeks back. Clinically, a 
wide crown of the left central incisor [Figure 10] was noted 
with a buccal groove demarcating it in two incompletely fused 
crowns. Tooth mobility and periodontal probing depth were 
within normal limits. Vitality testing showed non-vital response 
in both the central incisors and the left lateral incisor.  

Preoperative radiograph showed a single root with a large pulp 
chamber and a horizontal fracture line along the mid-root of the 
malformed tooth [Figure 1]. The diagnosis of gemination was 
made clinically based on the normal number of teeth in the 
dental arch, excluding the possibility of fusion. 

A CT was advised to study root canal morphology and fracture. 
[Figures- 6, 7, 8] The cross-sectional CT images showed two 
fused crowns, a large pulp chamber with single root canal and 
a horizontal fracture line at the mid-root level in the left central 
incisor. [Figure 9].  

Based on the classification given by Aguiló et al 2, the present 
case is of type 2 gemination as inferred from the clinical and 
radiographic appearance of the tooth. The tooth presented as 

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Mittal et al.                                                                                                                                        Asian Journal of Dental and Health Sciences. 2024; 4(3):1-4 

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two fused crowns with a buccal groove running vertically, and 
a large fused pulp chamber.  

Non- surgical root canal treatment followed by an aesthetic 
restoration with crown was planned for both the incisors and 
left lateral incisor with informed consent. 

Under local anaesthesia and rubber dam, endodontic access 
was prepared with Endo-Access bur and Endo-Z bur.  Working 
length was measured till fracture line [Figure 2] using #15 K-
file, cleaning was performed in a crown-down manner. 
Irrigation was done using side-vented needles inserted 3mm 
short of the level of the fracture line to prevent the flow of 
irrigants beyond the fracture line. Paper points were used to 
dry the canal, a collagen plug was placed at working length and 
obturation was done using biodentine, up to the middle third, 
just above the fracture line. [Figure 3]  

Access cavities were restored by restorative GIC and packable 
composite and tooth preparation for crown placement was 
done. Permanent crowns were given in both the incisors such 
that an aesthetic mesio-distal width for both the crowns were 
achieved. [Figure 4, 11] A 12-month post-operative periapical 
radiograph shows a healing periapical radiolucency [Figure 5] 

 

DISCUSSION 

The limitation of a two-dimensional radiograph is the 
compression of 3D anatomy into a two-dimensional image. This 
necessitates additional imaging modalities like CT scans to 
provide a comprehensive assessment of the anatomy of the root 
canal for a more effective endodontic intervention.3, 4 

In this present case, the canal preparation is confined to only 
above the fracture line leaving the apical segment untouched 
due to the perceived vitality as there were no periapical signs 
of inflammation or bone resorption, etc., and pulp necrosis was 
limited to the coronal fragment. 

Biodentine, chosen for its unique properties, has a 
micromechanical adhesion as due to its high pH it causes 
organic tissues of the dentin tubule to dissolve and itself gets 
keyed into these spaces as innumerable microscopic cones, 
creating a stable anchorage and a bacteria-tight seal.6, 7 
Moreover, its application also induces mineralization by 
expressing odontoblastic markers & increases TGF- β1 
secretion from pulpal cells enabling early mineralization in the 
form of reparatie dentin formation.5 These factors expedite 
healing, especially beneficial in scenarios of tooth fracture, 
where delayed healing can lead to re-infection of the root canal 
space and thus compromise the prognosis.

 

 

Figure 1: Pre-operative IOPA radiograph   Figure 2: Working length IOPA radiograph 

 

Figure 3: Biodentine obturation IOPA Radiograph        Figure 4: Radiograph following crown placement 



Mittal et al.                                                                                                                                        Asian Journal of Dental and Health Sciences. 2024; 4(3):1-4 

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Figure 5: Radiograph after 12- month follow-up period 

 

Figure 6-9: CT images of fractured geminated central incisor 

 

Figure 10: Pre- operative Intra-oral image          Figure 11: Intra-oral image following crown placement 



Mittal et al.                                                                                                                                        Asian Journal of Dental and Health Sciences. 2024; 4(3):1-4 

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CONCLUSION 

Gemination presents as a challenge in endodontic management 
due to its unusual root canal morphology. However, with 
thorough clinical and radiographic assessment, successful 
management is achievable.  

This case report demonstrates the effective endodontic 
management of a rare and complex scenario of horizontal mid-
root fracture of a geminated maxillary central incisor.  

Authorship Declaration 

Hereby we acknowledge that all authors mentioned above have 
contributed significantly, and all the authors are in agreement 
with the submission of this manuscript to the journal-  
Asian Journal of Dental Sciences 

Author’s Contribution 

Dr. Neelam Mittal: Conceptualization, Supervision, Validation, 
Visualization, Project administration, Writing – review & 
editing. 

Dr. Harshitaa Aggarwal: Data curation, Methodology, 
Investigation, Writing – original draft, Writing – review & 
editing. 

Dr. Shelly Sharma: Validation, Writing – review & editing. 

Dr. Shubham Kharat: Investigation. 

Dr. Thivyashankari Thangamuthu: Investigation. 

Dr. Aiyman Ayubi – Investigations 

Dr. Silviya Samad - Investigations 

Acknowledgment: None  

Financial Support: Nil 

Conflicts of Interests: The authors deny any conflicts of 
interest 

Abbreviations: IOPA – Intraoral Periapical Radiograph, 
CT- Computed Tomography 

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https://doi.org/10.1016/0030-4220(87)90121-6
https://doi.org/10.1046/j.1365-263x.1999.00131.x
https://doi.org/10.1111/j.1365-2591.2011.01995.x
https://doi.org/10.9790/0853-13131317
https://doi.org/10.1111/j.1600-0722.1980.tb01241.x
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