PaediatricDentistry

Ann R Harker

Sian Walley and Sondos Albadri

Conservative Management
of Macrodontia in the Mixed
Dentition Stage − A Case Report
Abstract: Macrodontia is a rare dental abnormality, which can cause cosmetic concerns. Various management techniques for this condition
have been documented in the literature. This case describes the initial management of macrodontia in the mixed dentition stage with the
use of a minimally invasive approach to treatment.
CPD/Clinical Relevance: The importance of early referral of dental abnormities is highlighted. Short- and long-term treatment options for
macrodontia are described, including the impact such anomalies can have on the developing dentition.
Dent Update 2015; 42: 960–964

Managing dental abnormalities resulting
in the alteration of tooth size and shape
can present as an aesthetic and functional
challenge to the dental practitioner.
Macrodontia, a term used to describe teeth
that are larger than would normally be
expected, is characterized by an increase
in the mesio-distal and facio-lingual tooth
dimensions.1 The aetiology of this condition
is still not fully understood, but it may
be caused by a disruption to apoptosis
during tooth development.2 Fortunately,
macrodontia is relatively rare,3 having
a prevalence of 1.1% in the permanent
Ann R Harker, BDS(Hons), MFDS RCSEd,
Clinical Demonstrator in Paediatric
Dentistry, Leeds University and General
Dental Practitioner, Sian Walley, BDS,
MFDS RCSEd, FHEA, Clinical Lecturer in
Paediatric Dentistry and Sondos Albadri,
BDS, PhD, MFDS RCSEd, MPaedDent
RCS(Eng), FHEA, FDS (Paed Dent)
RCS(Eng), Senior Lecturer/Honorary
Consultant in Paediatric Dentistry, School
of Dentistry, University of Liverpool, UK.
960 DentalUpdate
dentition.4
True macrodontia can be
classified into three types:5
1. Generalized macrodontia − where
several or all teeth are affected. This may
be associated with pituitary gigantism,
unilateral facial hyperplasia or hereditary
gingival fibromatosis.6
2. Relative generalized macrodontia − the
presence of normal-sized teeth in small
jaws.
3. Isolated macrodontia of an individual
tooth − where the remaining dentition is
considered normal.7
Descriptive terminology of
macrodontia can be confusing, but true
macrodontia of a single tooth should not be
confused with gemination or fusion of two
teeth (double teeth) early in odontogenesis,
giving the appearance of one larger
tooth.8 The term fusion is used to describe
two separately developing teeth united
via dentine and/or enamel.9 A review of
the literature by Tuna et al reported the
aetiology of this anomaly to be necrosis
of intervening epithelial tissue caused
by pressure between two developing
teeth.10 Where fusion occurs, macrodontia
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will present along with one or two pulp
chambers and typically there will be one
less tooth in the arch,11,10 unless the fusion
is between a normal and a supernumery
tooth.12 Gemination can be defined as
the formation of two teeth believed to
arise from one dental follicle attempting
to separate. In this case, there is usually
only one pulp chamber and the correct
number of teeth in the dental arch, if the
double tooth is counted as one unit.11,10
Often present is a notch or groove on the
crown.9 The prevalence of double teeth in
the Caucasian population is reported at
0.1−0.2% in the permanent dentition and
most frequently the anterior segments are
affected.4
Macrodontia is most frequently
reported to affect incisors, canines and
mandibular second premolars.5,13 The
incidence of macrodontia affecting the
maxillary central incisor, as described in this
case, is low (0.03%).14 These cases, however,
can be of particular cosmetic concern to
patients and can have a significant impact
on their psychosocial development and
interaction with peers.15 The early detection
and treatment of macrodontia cases can
December 2015

avoid problems with aesthetics, crowding
and caries, which can arise within the
incisal grooves of macrodont teeth.6 Early
identification and referral by the general
dental practitioner (GDP) can allow for
management via a multidisciplinary
approach, involving input from surgical,
orthodontic and restorative teams.
Case report
A healthy 7-year-old boy was
referred to Liverpool Paediatric Dental
Department by his GDP regarding the
Figure 1. Recently erupted permanent maxillary
central incisor teeth.
Figure 2. A caries free mixed dentition with
excellent oral hygiene.
Figure 3. Radiographically, the two large
maxillary central incisors appeared to each have
one pulp canal.
December 2015
appearance of his recently erupted
permanent maxillary central incisor
teeth (Figure 1). Both the patient and his
mother reported that they were unhappy
with the large size and shape of his front
teeth. Unfortunately, these teeth had
caused the patient some distress, as he felt
embarrassed by their appearance, with his
mother reporting some teasing at school.
Further questioning revealed the patient
avoided smiling and regularly covered
his mouth with his hand during talking.
There was no known family history of
macrodontia. His previous dental history
was that of regular dental examinations
in practice with no experience of any
treatment. A degree of dental anxiety
existed although his co-operation was
good.
Clinical examination revealed a
caries free mixed dentition with excellent
oral hygiene (Figure 2). Both the maxillary
right and left permanent central incisors
were found to be macrodont, with a
mesial-distal width measuring 13.5 mm
and 11.5 mm, respectively. Both incisors
had a groove/split in the centre of the
incisal edge. Radiographically, the two
large maxillary central incisors appeared to
each have one pulp canal (Figure 3), and
an OPG revealed that all the permanent
teeth were present except the third molars
and no supernumeraries were seen (Figure
Figure 4. An OPG revealed that all the permanent teeth were present except the third molars and no
supernumeraries were seen.
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PaediatricDentistry
4). His incisor relationship was Class I with
the upper right central incisor displaced
palatally in crossbite with the lower right
central and lateral incisor teeth (Figure 5).
The patient was referred for an
initial orthodontic opinion and, following
multidisciplinary discussions, the treatment
options were established as follows:
 No present treatment allowing future
review and reconsideration of treatment
options following further development
of the dentition. This was decided to be
unacceptable as the aesthetics would
remain unchanged in the near future.
 Orthodontic approximation and
reshaping of both central incisors as
a short-term compromise. Both teeth,
although smaller in width, would remain
larger than average and aesthetics
would still be sub-optimal. The effect
on the remaining permanent dentition,
including crowding, was considered
and further management in the future
would be expected following the
eruption of the permanent premolars, or
sooner if problems with eruption were
encountered. However, retention of
teeth at this stage would maintain good
alveolar bone levels and help to prevent
the exclusion of future treatment should
this be required.
 Reshaping of the upper left central
incisor and extraction of the upper
DentalUpdate 961
 PaediatricDentistry
right central incisor followed by
orthodontic treatment to align teeth
and reduce anterior spacing. The upper
right central incisor space could be
restored by the placement of a partial
removable denture, a resin-bonded
bridge or, in adulthood, a dental
implant. However, the upper left
central incisor would be slightly larger
in size than average and, owing to the
young age of this patient (7 years), and
the early mixed dentition stage, this
was not deemed a suitable option.
 Extracting both upper central incisors
and temporarily restoring the spaces
with a removable partial denture until
a bridge(s) or implants are appropriate.
Loss of teeth at this young age would
result in a reduction in alveolar
ridge height/width compromising
future prosthodontic work. Also, the
patient’s mother was keen to avoid
any extractions and thus this was
dismissed.
 Restorative camouflage alone could
include simple reshaping of the upper
central incisors and the use of direct
and indirect composite to disguise
the notches. This would not correct
the anterior crossbite, diastema or
help create space for eruption of the
permanent teeth.
Following discussion with
the patient and his family it was decided
that, as a result of the patient’s distress
arising from his dental appearance,
that treatment would be undertaken in
the early mixed dentition stage. Hence,
consent was gained for orthodontic
approximation of the maxillary central
incisors, followed by distal tooth reduction
and composite reshaping. The following
treatment was commenced and carried
out over a five-month period:
1. A sectional orthodontic fixed appliance
was used to align teeth:
a) Brackets were placed on the upper
right and left central incisors and,
firstly, a 0.014” nickel titanium wire;
b) At approximately two months the
wire was changed to an 18 × 25
neosentalloy;
c) After two further months, a 0.018”
stainless steel wire was then used with
an e-link to close the diastema (Figure
6).
2. At five months both the maxillary
962 DentalUpdate
central incisors were in alignment with appearance of his teeth and there are no
the diastema closed. The fixed appliance plans for any further interventions.
was debonded and a fixed bonded
retainer was placed palatally (Figure 7). Discussion
3. Finally, minimal distal crown reduction,
The quoted average crown
of approximately 1 mm, was performed
width of a central incisor is 8 mm.16 The
and labial direct composite added to
mesial-distal widths of the two macrodont
disguise the incisal notches (Figure 8).
teeth in this case were 13.5 and 11.5 mm,
It is important to note that reduction
respectively. These values are consistent
was carried out minimally to avoid
with previous macrodontia cases, where
complications, such as pulpal necrosis.
widths of between 12 and 15 mm have
Under six-monthly review at
been reported.9 Each macrodont had an
the Paediatric Department, the patient’s
incisal notch and one root canal, making
dental development was found to be
the probable aetiological cause in this
progressing normally, both upper canines
case gemination of the upper central
palpable buccally and no sign of significant
incisors.
crowding.
Various treatment techniques
He was reviewed recently on a
have been described in the literature for
multidisciplinary paediatric-orthodontic
the management of macrodontia and
clinic, at the age of 11 years. At this time
double teeth. One review reported the
there was deemed to be sufficient space
main factor influencing management was
for all his permanent teeth to erupt.
the root and root canal morphology of
The patient underwent further minimal
double teeth. Hemisection was listed as
interproximal reduction of his upper central
the treatment of choice for teeth with two
incisors to improve the appearance and
separate roots and crown modification or
to increase space for the eruption of his
extraction was popular for teeth with only
upper permanent canines, which were
partially erupted. He is very happy with the
Figure 5. The patient’s incisor relationship Figure 7. The fixed appliance was debonded and
was Class I with the upper right central incisor a fixed bonded retainer was placed palatally.
displaced palatally in crossbite with the lower
right central and lateral incisor teeth.
Figure 8. Minimal distal crown reduction, of
approximately 1 mm, was performed and labial
Figure 6. A 0.018” stainless steel wire was used direct composite added to disguise the incisal
with an e-link to close the diastema. notches.
December 2015
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 PaediatricDentistry
one canal.17
In cases of macrodontia or
gemination, where there is only one root
canal, often the affected tooth is extracted
and the space is closed using orthodontic
measures. Such treatment modality is
described in a case by Hellekant et al, who
managed a 9-year-old boy presenting
with a Class II division 1 malocclusion and
two macrodont maxillary central incisors,
both with one enlarged pulp chamber.7
They considered conservatively reshaping
the malformed teeth but opted for their
early extraction, employing orthodontic
treatment to achieve space closure and
overjet/overbite reduction. Lateral incisors
and canines replaced the central and lateral
incisors, respectively, and the maxillary first
premolars were positioned in the canine
space. Restorative input disguised the shape
of the laterals/canines to resemble central
and lateral incisors.7 This aesthetic result
was achieved over a considerable time
period, and may not be indicated for all
malocclusions. This case example highlights
the need for early input from orthodontic
colleagues in the initial treatment planning
stage.
Thomas et al describe an ultra
conservative technique used to treat an
older 17-year-old male with macrodont
central incisors and a missing upper right
lateral incisor.18 Double composite veneers
were constructed to disguise the large
teeth and resemble a central and lateral
incisor. The authors report this technique
is particularly effective when a low upper
lip line exists. It is indicated once dental
development is complete, producing a
stable gingival margin. Data has shown that
increased clinical crown length continues
throughout the teenage years, thus having
implications for adolescent treatment
planning19 and making this option
inappropriate in our young case patient.
This could be suited to cases of fusion,
where typically there are missing lateral
incisors and two macrodont centrals.
When two root canals are
present in cases of dental fusion, previous
management strategies have involved
surgically splitting the root and associated
coronal portion, termed hemisection.
Subsequent pulp or root-canal therapy may
be required, along with crown modification
and orthodontic techniques employed to
close spaces.12
964 DentalUpdate
Timely referral of such cases can
allow development of a comprehensive
treatment plan incorporating both short-
and long-term goals. Early treatment in
the mixed dentition stage can achieve
a significant improvement in a patient’s
self esteem at this young age. As future
complications involving impeded eruption
and crowding are possible due to lack of
space, close monitoring is essential to the
success of such cases. Further interventions
are planned, but only at the appropriate
stage of dental development.
Conclusion
Early referral to a specialist
paediatric unit is essential when dental
anomalies present. As this case illustrates,
to achieve success management must
include both short- and long-term plans
and involve input from multidisciplinary
teams throughout all stages of dental
development.
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