Orthodontics

Audrey Pace

Paul Jonathan Sandler and Alison Murray

Macrodont Management
Abstract: Macrodontia is an uncommon dental anomaly that can present in both primary and permanent dentition. It has often been
reported to occur concomitantly with other dental anomalies and has also been an established clinical characteristic of numerous systemic
conditions and syndromes.
The following case reports illustrate the challenges of managing macrodont teeth in view of the various treatment options available, as
well as the multiple factors that tend to influence each case individually.
Clinical Relevance: This article highlights the importance of early referral and a multidisciplinary approach to treating patients with
dental anomalies.
Dent Update 2013; 40: 18–26

Macrodontia is the term given to teeth  Relative generalized macrodontia: is vulnerable to the influence of various
which are larger in size than the normal This refers to the entire dentition and may environmental and genetic factors. Size
respective tooth type and have equally occur as a result of hormonal imbalance, for and shape of permanent teeth can be
enlarged pulp morphology, crown and root. example in pituitary gigantism.3,7 affected by altered endocrine functions, as
This dental anomaly may also be referred to  Isolated/false macrodontia: This usually well as trauma and infection in deciduous
as megalodontia or megadontia, and may affects single teeth. predecessors.8
be associated with numerous syndromes It must be remembered that The literature has never been
and medical conditions (Table 1). It can be small jaws in relation to the teeth might give very clear in defining the cause or origin of
present in both primary and secondary the impression of generalized macrodontia. macrodont teeth, however, the following
dentition. This concept still seems to create some are the two main theories that are most
controversy where early human remains are commonly described.
Classification studied. Early dental dimensions classify as Various authors have
megadont teeth, but this might not be the emphasized the importance of classifying
The following distinctions have
case when one takes into consideration the macrodontia as separate dental anomalies
been made between the various types of
small bodies of early human species.9 from fusion or gemination.4,11 Fusion occurs
macrodontia:
when two adjacent teeth join, from the
 True macrodontia: This is quite rare
dentine and/or enamel, to form one large
and occurs when most of the dentition is Epidemiology tooth. Gemination takes place when a tooth
affected, as in cases of hemi-hyperplasia or
Isolated macrodontia have been germ fails to undergo complete division.
oto-dental syndrome.7
reported to have a prevalence of 1.1% in the The resultant number of teeth within
permanent dentition of British children in the arch is usually the best indicator to
contrast to 2.5% in the Chinese population. distinguish one anomaly from the other,
The prevalence of macrodontia in the especially when both may produce the
Audrey Pace, BChD, MJD FRCS(Eng),
deciduous dentition is unknown. Males same range of clinical presentations. Incisal
Specialty Registrar in Orthodontics,
(1.2%) seem to have a higher predisposition notching in large teeth has also been
Birmingham Dental Hospital, St Chad’s
than females (0.9%).10,11,12 suggested as a clinical sign which will aid
Queensway, Birmingham. West Midlands,
Macrodontia have been found differentiation between double teeth and
Paul Jonathan Sandler, BDS(Hons),
more frequently in incisors, mandibular macrodontia.11
MSc, FDS RCPS, MOrth RCS, Consultant
premolars and third molars.7,12 This tendency Another school of thought is that
Orthodontist, Chesterfield Royal
has been reported to occur bilaterally. macrodontia can actually occur as a result
Hospital, Calow, Chesterfield S44 5BL
of fusion or gemination, and hence explain
and Alison Murray, BDS, MSc, FDS RCPS,
the production of a large-sized tooth.3,13 It is
MOrth RCS, Consultant Orthodontist, Aetiology more generally accepted that macrodontia
Royal Derby Hospital, Uttoxeter Road,
Tooth formation and describes the appearance of anomalies,
Derby DE22 3NE, UK.
differentiation is a complex process and whilst fusion/gemination are terms which
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 Orthodontics

 Malocclusion;
Pituitary gigantism Enlargement of all organs, soft tissues and
 Alteration in gingival contour;
skeleton, macrodontia due to pituitary
 Periodontal health.
overproduction3,4,6,7
The following case reports
illustrate different treatment modalities for
KBG syndrome (KBG stands for first Typical facial dysmorphism, macrodontia, skeletal
macrodontia.
3 patients reported with syndrome) anomalies, developmental delay1,6

Ekman-Westborg & Julin trait Macrodontia, multituberculism, pulpal Case 1

invaginations, single conical roots, central
A 9-year-old boy was originally
cusps5,6,7
referred to an orthodontic practice by
the general dental practitioner for the
Hemihypertrophy/hemihyperplasia Asymmetrical growth of all or parts of the
management of an unusually large
body including the teeth7
‘odontome-like’ incisor. Subsequently, he
was referred to the orthodontic department
Insulin resistant diabetes Endocrine disturbances, premature eruption,
at Chesterfield Royal Hospital for further
multiple macrodontia7
management.
Medical history revealed Type I
Otodental syndrome Globodontia, high frequency sensorineal hearing
diabetes, with no relevant family history of
loss, eye coloboma4,7
any dental anomalies. Dental examination
revealed an early mixed dentition, with a
47,XYY syndrome Tall stature, learning disabilities, macrodontia,
Class II division 2 malocclusion complicated
facial anomalies4,6
by UL1 fused to a supplemental incisor. This
tooth had a mesiodistal width of 14 mm
Berardinelli-Seip syndrome Endocrine disturbances, dental anomalies
(Figure 1 a–c). All other permanent teeth
including macrodontia, talon cusps and
were present and of normal morphology.
generalized crowding8
The upper labial segment was potentially
crowded and the lower arch was moderately
Dubowitz syndrome Growth retardation, dysmorphic facial features,
crowded. The patient had an overjet of 3 mm
dental anomalies, including macrodontia,
and complete overbite.
hypodontia, delayed eruption, midline diastema2
Radiographs showed that the
macrodont UL1 had two roots, however, the
OFCD syndrome Eye anomalies, facial abnormalities, cardiac
pulp morphology was deemed unfavourable
(Oculofaciocardiodental syndrome) anomalies, dental abnormalities, including
for endodontic treatment with subsequent
canine radiculomegaly, delayed eruption,
root sectioning (Figure 1d). Possible
microdontia/macrodontia, oligodontia
treatment options were discussed in a joint
Table 1. Medical conditions and syndromes associated with macrodontia. orthodontic/restorative dental consultation
clinic. The UL1 was extracted in an atraumatic
way under general anaesthetic in view of
the patient’s medical history (Figure 1e, f).
explain the embryological cause of such Macrodont premolars tend The initial plan was to allow UL2 to erupt in
anomalies.14 to have an ovoid molariform crown with order to assess aesthetics fully and to analyse
numerous cusps and irregular fissures. space requirements. On the following review
Incisors, on the other hand, are usually appointment, it was discovered that the
Clinical appearance shovel-shaped with abnormally wider patient had a supernumary upper central
Macrodont teeth are usually crowns than their counterparts. It is not incisor, which had not been noted on the
significantly larger than the normal uncommon for a patient to have other dental original orthopantomogram (OPT) and this
corresponding tooth size. Where a normal anomalies when macrodonts are present. was labial to the UR2 (Figure 1g).
central incisor measures an average of The patient was fortunate
8.6mm, macrodont central incisors have that both these central incisors were of
been reported to measure between 12 mm Management similar sizes and in a manageable position.
to 14.5 mm, mesiodistally.15 In the case of The major complaints associated It was decided to use fixed appliances to
premolars, the average-sized tooth is 7.3 mm with macrodontia include: move UR1 to UL1 position and to move
in mesiodistal and 8.2 mm in buccolingual  Eruption problems; the supplemental incisor into the space
dimension, whilst reported macrodont  Caries; originally occupied by the UR1 (Figure 1h-l).
premolars have measured up to 15.2 mm  Crowding; This successfully resulted in four reasonable-
mesiodistally and 13.1 mm buccolingually.12  Poor aesthetics; sized incisors in acceptable positions.
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 Orthodontics

Aesthetic results were more than adequate The patient presented with a have a complete dental arch without the
once minor restorative adjustments to the Class II division 2 incisor relationship and need of any permanent prostheses. Another
clinical crowns had been carried out. Towards an overjet of 3 mm on a mild skeletal II option was to allow the UR3 to erupt into its
the end of treatment, the patient requested base. He was still in the mixed dentition ideal position, and prepare the geminated
a frenectomy to reduce the prominent and stage and had mild crowding in the upper UR2 space for a single tooth implant or an
malpositioned upper labial frenum (position arch. Intra-orally, the UR2 was found to be adhesive bridge. Though this would result
indicated on Figure 1g and subsequently macrodont and radiographic examination in an ideal appearance, it would definitely
on Figure 1k). This malposition occurred as showed that this excessive tooth width entail an extended treatment time. Finally,
a direct result of the unusual movements extended all the way up to the root (Figure it was decided to review the case in a year
of the incisors required during the 2a). This meant that a full coverage crown which would also give plenty of time for
comprehensive fixed appliance treatment restoration would have never matched the the patient and his parents to decide which
(Figure 1 m-o). This case has been finished to UL2 satisfactorily at the gingival margin. treatment option would be ideal for them.
an acceptable standard as illustrated in the The OPT revealed that the rest of the When the patient was
final photographs (Figure 1 p-u). dentition was chronologically still only subsequently seen at the next review
about nine years of age. appointment the canines were not yet fully
After examination on a joint erupted, so it proved difficult to predict
Case 2 orthodontic/restorative dental consultation their final position. Judicious incisal edge
A fit and well 11-year-old boy was clinic, all possible treatment options trimming, as well as mesial and distal discing
referred to Chesterfield Royal Hospital for an were discussed with the patient and his of the geminated UR2 was carried out at
orthodontic opinion. His main complaint was parents. This included extraction of the this appointment to reduce the horizontal
the unaesthetic appearance of one of the macrodont UR2 with replacement by the width of the tooth in order to gain a little
upper front teeth. UR3, which meant that the patient could more space for the canines to erupt and to

a b c

d e

f g

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 Orthodontics

h i j

k l m

n o p

q r

s t u

Figure 1. (a–u) Case 1.

improve aesthetics (Figure 2b). explained that the option of further Case 3
The patient was reviewed alignment of the teeth with fixed Patient 3 was referred for
once again after 8 months, when the appliances was still possible, but both an orthodontic assessment by the GDP.
canines were found to have erupted the patient and parents were happy She disliked the general appearance of
nicely into the correct position and with the result and did not wish for her teeth and was keen for orthodontic
the appearance of the reduced UR2 further orthodontic treatment (Figure treatment. This 11-year-old girl was
appeared quite acceptable. It was 2c, d). medically fit and well, with no history of
January/February 2013 DentalUpdate 23
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 Orthodontics

a c other associated dental anomalies, as well as

rule out other associated systemic conditions,
such as the ones shown in Table 1, which may
also require consideration.

Age of patient and motivation

Motivation and compliance
are two important factors that tend to vary
b d with younger patients and this has to be
taken into consideration before embarking
upon a lengthy treatment plan. The patient
must be able to achieve high levels of oral
hygiene before the start of treatment in order
to get long-lasting successful outcomes, if
comprehensive fixed appliance treatment is
to be used.

Figure 2. (a–d) Case 2.

Aesthetics
Aesthetics is a treatment
aspiration on which few patients are willing
trauma or habitual dental behaviour. comprehensive fixed appliance treatment to compromise. Management, however, has
On examination, the patient had (Figure 3 c–j). This case took no more than 20 to be tailored to the patient’s needs and
a Class I occlusion on a skeletal I base with months to complete. it is important to keep the patient’s main
competent lips and moderate crowding. complaint in focus. The resultant appearance
The overjet was 3 mm and the overbite was might be acceptable for one particular
increased and complete. Both upper and Discussion patient but not for another. In case 2, the
lower centrelines coincided with each other patient was happy with the appearance of
One can appreciate the
and her facial midline. There was a midline the macrodont incisor once enamel reduction
importance of a multidisciplinary approach in
diastema with a low fraenum attachment, had allowed full eruption of adjacent teeth,
the management of macrodont permanent
which blanched on tension. Dentally, the UL6 even though the orthodontist was keen to
teeth, as shown in the cases illustrated above.
was hypoplastic and satisfactorily restored. carry out fixed appliance treatment.
This is not only essential for the patient to get
Both lower second premolars had unusual Other important aesthetic
the best possible treatment outcome, but also
morphology, being wider mesiodistally than considerations before treatment include the
to allow anticipation of and prevention of any
an average sized premolar (Figure 3a). patient’s smile line, facial asymmetry and the
future complications.
Radiographic examination amount of incisor on show at rest and on
The major treatment dilemmas are
excluded any other cause for the diastema smiling.15
whether to:
other than the fraenum and showed the  Retain;
presence of all other permanent teeth,  Retain with restorative adjustments; Pulpal morphology
including the developing molars (Figure 3b).  Enamel reduction/stripping; Radiographic investigations at
The treatment plan included  Endodontic treatment followed by surgical the start of treatment can often determine
extraction of both upper first permanent hemisection; which treatment options are viable and
molars, having taken into consideration the  Extraction and closure of space; which are not in a particular case scenario.
poor prognosis of the hypoplastic UL6. After  Extraction and prosthetic replacement. It is particularly important to identify when
six months, an upper Nance palatal arch The decision will depend on pulp and root morphology are unsuitable for
was fitted to the then fully erupted second various other important factors. predictably successful endodontic treatment
molars, together with upper and lower fixed and subsequent sectioning to take place.
appliances. A fraenectomy was also carried
out under local anaesthetic, in order to Associated dental anomalies
facilitate the closure of the diastema. The presence of a supplemental Spacing, crowding and underlying
In the lower arch it was decided supernumerary tooth in Case 1 led to a more malocclusion
that enamel stripping alone would not elegant solution than originally expected Space analysis is most
allow sufficient tooth tissue reduction, as following the removal of the massive upper important where orthodontic treatment
the premolars were too wide mesiodistally. central incisor. This extra tooth allowed for is being considered because all aspects of
For this reason, both lower macrodont reproduction of the ‘normal’ number of the malocclusion have to be addressed.
second premolars were extracted and the incisors in the premaxillary area. One has to Treatment planning may become quite
spaces were satisfactorily closed during analyse the entire dentition thoroughly for complex, as in Case 3, where a diastema is
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 Orthodontics

a b

d g h

i j

Figure 3. (a–j) Case 3.

present, as well as crowding elsewhere in anatomical reshaping, using composite resin

the arch. or even crown or veneer provision. It has
If the macrodont tooth is been reported that an average of 0.4mm
situated in an unobtrusive position in the of enamel can be safely stripped from a
jaw, it is sometimes appropriate to accept tooth without any major complications.16
f this tooth in the arch and just address other This is also a commonly applied technique
complaints the patient might have. This in orthodontics to gain space for tooth
is rarely the case, however, because the alignment.
abnormal size usually requires significant Crown division and/or surgical
restorative adjustment to satisfy functional hemisection might be the ideal treatment
and aesthetic requirements. Intervention option if a macrodont tooth has resulted
might range from enamel stripping to radical from fusion or gemination. Radiographic

January/February 2013 DentalUpdate 25

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 Orthodontics

examination of the pulp and root Oral Radiol Endod 2008; 105: e41–47.
morphology is mandatory in order to
References 9. Fitzpatrick SM, Nelson GC, Clark G. Small
reveal whether these procedures are 1. Brancati F, Sarkozy A, Dallapiccola B. KBG scattered fragments do not a dwarf
appropriate. During tooth sectioning, pulp syndrome. Orph J Rare Dis 2006; 1: 50. make: biological and archaeological
exposure is inevitable, the complexity of 2. Chan KM, King NM. Dubowitz syndrome: data indicate that prehistoric inhabitants
the treatment depending on the details report of a case with emphasis on the of Palau were normal sized. PLoS ONE
of pulpal anatomy. This will therefore oral features. J Dent Child (Chic) 2005 2008; 3(8): e3015.
necessitate subsequent endodontic Sep–Dec; 72(3): 100–103. 10. Cameron AP, Widmer RP. Handbook of
treatment. 3. Malhotra N. Macrodontic incisors: Paediatric Dentistry. London: Mosby-
Bone loss should always be aetiology, clinical features and Wolfe, 1997: p200.
limited to the minimum necessary to management. Synopses 2006 Oct; 35: 1. 11. Thomas MBM, Greenhalgh CM, Addy
complete the surgical procedure and, 4. Neville B, Damm D, Allen C et al. Oral and L. ‘Double-veneers’ – a novel approach
when macrodont teeth are removed, the Maxillofacial Pathology 3rd edn. Chapter to treating macrodontia. Dent Update
surgeons must always be reminded of 2. Abnormalities of Teeth. Missouri, USA: 2008; 35: 479–484.
the damage they may cause if a careful Saunders (Elsevier), 2009: p83. 12. Dugmore CR. Bilateral macrodontia of
technique is not used. Excessive bone loss 5. Benjamin MR, Rodrigo FS, Gorlin RJ. mandibular second premolars: a case
has severe implications on aesthetics and Multiple macrodontic multituberculism. report. Int J Paed Dent 2001; 11: 69–73.
future treatment options. Am J Med Gen 2003; 120A: 283–285. 13. Gazit E, Lieberman A. Macrodontia of
6. Nemes JA, Alberth M. The Ekman- maxillary central incisors: case reports.
Westborg and Julin trait: report of a Quintessence Int 1991; 22: 883–887.
Conclusion case. Oral Surg Oral Med Oral Pathol Oral 14. Seehra J, Coutts F. Fusions and
Managing macrodont Radiol Endod 2006; 102: 659–662. orthodontic treatment. Ortho Update
dental anomalies can prove to be 7. Peker I, Kayaoglu G. A case of Ekman- 2010; 3: 14–16.
very challenging. Early referral to a Westborg-Julin trait: endodontic 15. Hellekant M, Twetman S, Carlsson L
multidisciplinary clinic is in the patient’s treatment of a macrodontic incisor. Oral et al. Treatment of a Class II division 1
best interest. It should always be kept in Surg Oral Med Oral Pathol Oral Radiol malocclusion with macrodontia of the
mind that achieving optimum aesthetics Endod 2009; 107(5): e89–92. maxillary central incisors. Am J Orthod
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Book Review
Ten Cate’s Oral Histology. By Antonio Nanci. an overview of the oral tissues. There is a still further, and new to this edition, is a
London: Elsevier, 2012 (377pp, £74.99 h/b). chapter on general aspects of embryology website (‘Evolve’) that readers can access and
ISBN 978-0-3230-7846-7. which precedes an account of orofacial use to avail themselves of self assessment
embryology. Further chapters include MCQs. Additionally, the Evolve website
Ten Cate’s well respected standard text on the development of the teeth and allied features over 100 labelling and ‘drag and
‘Oral Histology’ was first published in 1980 tissues, and detailed histology of the drop’ exercises, together with a library of all
and 2012 saw the publication of the 8th various dental and orofacial structures the images used in the textbook and this
edition of this textbook. including, for example, bone, dental tissues, may be particularly useful for teachers.
Over the years, the text has salivary glands, the oral mucosa and In summary, Ten Cate’s Oral
evolved significantly. A major objective of temporomandibular joint. A new chapter on Histology, 8th edition, provides a thoroughly
the latest edition, edited by Antonio Nanci, facial growth and development has been engaging and accessible account of a
was to update and simplify the subject added and the final chapter addresses repair topic that students often find difficult to
matter, making it more accessible to the and regeneration of the oral tissues. comprehend and learn. Whilst essentially
reader. There is no doubt in my mind that The text is lavishly illustrated aimed at undergraduates, this book will
this objective has been achieved. throughout, making extensive use of clinical also be of value to vocational and specialist
The text is primarily aimed at images and photomicrographs. Elegant and trainees and, indeed, it is a valuable source
undergraduates and, although the core topic informative cartoons further enhance the of reference for all those engaged in dental
is of course histology, the book embraces the reader’s ability to understand some of the healthcare.
exciting developments in molecular biology more complex concepts that the text details. The quality of the book’s
that inevitably impact on our understanding Each chapter provides an outline production and its content more than
of biological processes. of the topics to be discussed together with justifies the cost of £74.99.
The 377 page text is divided an introductory paragraph explaining the John Hamburger
across 15 chapters, commencing with context of the chapter. To enhance learning Birmingham School of Dentistry

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