The Restorative Management of Microdontia

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The restorative management of microdontia

D. P. Laverty*1 and M. B. M. Thomas2

InIn brief brief Provides an understanding of the classification of Discusses the multidisciplinary treatment approach Highlights the restorative treatment options available microdontia. to treat microdontia

Microdontia is a dental abnormality that will often present to the dental practitioner due to the aesthetic concerns of the patient. Treatment is therefore aimed at addressing the aesthetics issue of the patient and this can present a number of challenges which may require a multidisciplinary approach in its management. This article presents the restorative management of localised and generalised microdontia.

Management of microdontia True generalised microdontia is rare, and third molars but it can affect any of the teeth has been reported in child patients receiving (Fig. 4). The overall prevalence of peg-shaped Microdontia is a condition in which one or radiotherapy or chemotherapy treatment maxillary permanent lateral incisors is around more teeth appear dimensionally smaller during tooth development (Fig. 3),4 pituitary 1.8%.7 Maxillary peg-shaped laterals occur outside the usual limits of variation.1,2 This dwarfism3 and Fanconi’s anemia.5 It is also asso- more frequently in women than men7 and can pose primarily an aesthetic concern, with ciated with a variety of syndromes including is more common in patients suffering with patients attending with complaints of having Gorlin-Chaudhry-Moss syndrome, Williams’s Down’s syndrome and patients with clefting teeth which appear smaller in size or shape to syndrome, Ullrich-Turner syndrome, of the lip and/or palate most frequently the adjacent teeth or in comparison to others, Rothmund-Thomson syndrome, Hallermann- occurring on the cleft side.8 Microdontia has and the presence of gaps between the teeth. Streiff and Orofaciodigital syndrome (type 3) Occasionally, the patient may present with and a variety of other syndromes.6 functional difficulties such as food trapping The most common teeth affected by micro- associated with the microdont teeth and may dontia are the maxillary lateral incisor and the also attend complaining of malocclusions associated with the microdontia such as impacted canines. Microdontia can be classified into three types according to Shafer et al.:3 1. Single tooth microdontia – for example, maxillary ‘peg-shaped’ lateral (Fig. 1) Fig. 3 An OPT radiograph showing the 2. Relative generalised microdontia – the dentition of a 16-year-old patient after receiving chemoradiotherapy as a child appearance of small teeth within large jaws when the dentition was developing that has (Fig. 2) resulted in microdontia, hypodontia and 3. True generalised microdontia – is when all Fig. 1 Peg lateral 22 altered root development the teeth are smaller than normal.

1ACF/StR in Restorative Dentistry, Birmingham Dental Hospital, Pebble Mill Road, Birmingham, West Midlands, B5 7SA; 2Consultant in Restorative Dentistry, Cardiff University Dental Hospital, Heath Park, Cardiff, South Glamorgan, CF14 4XY *Correspondence to: D. Laverty Email: [email protected] Fig. 4 Intra-oral photgraph showing patient Refereed Paper. Accepted 1 July 2016 with hypodontia and microdontia of the first DOI: 10.1038/sj.bdj.2016.595 ©British Dental Journal 2016; 221: 160-166 Fig. 2 Relative generalised microdontia premolars and the upper left wisdom tooth

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Fig. 6 Pre-operative model and duplicated model with diagnostic wax up

Fig. 5 Intra-oral photograph showing microdontia and localised upper anterior spacing with absent 24 and 25 and ectopically positioned 23 also been closely associated with hypodonita (Fig. 5).9–11 The cause of microdonita is related to the disturbance in the odontogenesis process. This complex process12 if disturbed can lead Fig. 7 Intra-oral mock up so that the patient can visualise the proposed restorative to abnormalities in tooth morphology, number treatment and form and with this affect the function, form and aesthetics of the dentition. In the majority of patients microdontia is associated with a genetic basis and has been shown to run through families.13 It has also been identified in spontaneous or isolated cases, where no cause can be identified.14 Treatment options vary in the management of microdont teeth and are dependent on a number of factors but are heavily influ- enced by the severity of the condition and the patients presenting complaint. The patient Fig. 8 22 peg lateral with straight distal axial wall positioned distally to accommodate presenting compliant, where possible, needs restorative treatment14 to be addressed and an appreciation of the patient’s expectations needs to be evaluated at the planning stage of treatment to ascertain whether the treatment will meet the patient’s expectations. If the treatment will not meet the expectations then this needs to be discussed and modified so that the patients can under- stand the limitations of the dental treatment. Diagnostic wax ups followed by mock ups in the patient’s mouth can be a useful visual and diagnostic tool for the patient, clinician and Fig. 9 Pre-operative and post-operative – direct composite placement on microdont 11, 21 technician and forms part of the informed and 22 before orthodontic treatment to assist with idealising tooth position consent process (Figures 6‑8). The type of treatment should be selected based on functional and aesthetic require- 2. Restorative treatment – using direct and Orthodontics ments and a thorough dental assessment is indirect techniques on the microdont tooth required which often includes an orthodontic or teeth An orthodontic opinion should be sought which assessment. 3. Joint orthodontics and restorative treatment can either be the sole treatment in management of Treatment options for the comprehensive 4. Extraction of the microdont tooth or teeth microdontia or to help accommodate the restora- management of microdontia, which may also and orthodontics and tooth replacement if tive treatment by idealising tooth position.15 include hypodontia, vary but broadly include required Microdont lateral incisors have been associ- the following: 5. Extraction and tooth replacement ated with impacted upper canines16 so ortho- 1. Orthodontic treatment – to idealise tooth 6. No treatment – which is unlikely to be dontic treatment may have been carried out position of the microdont tooth or teeth acceptable. during childhood.

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Fig. 10 Pre-operative and post-operative composite layering technique for a dens in dente 12 with a silicone guide to assisit composite placement. Reproduced from Dental Update (ISSN 0305-5000), with permission from George Warman Publications (UK) Ltd

A Kesling set-up can be carried out as part and will make the placement of the restoration The apical-coronal position can also affect of the orthodontic assessment to determine easier. It will also reduce plaque accumulation the occlusion and where possible single the effects of opening or closing the arch space by minimising the steepness of the emergence microdont teeth should have minimal or for the microdont tooth/teeth on the overall profile at the cervical margin of the tooth no contact in excursive movements as these malocclusion.14 It can also help visualise the which can act as a plaque retentive factor. teeth often have shorter roots and may be less proposed orthodontic and restorative end However, care needs to be taken when adapted to occlusal load. point17 and the aesthetics can be visualised restoratively increasing the mesio-distal width and any potential compromises acknowledged as it can lead to a tooth that appears wide and Labial-palatal position early on in the treatment planning process. short and appears un-aesthetic – the restora- The labial-palatal position will dictate the Microdont teeth may be restoratively tion may need to also increase the length of the gingival margin as discussed previously, it may modified before, during, or immediately after, tooth to optimise the aesthetics and diagnostic also help in providing adequate space to restore orthodontic tooth treatment.18 Restorative wax ups can help in this regard. Conversely, the microdont teeth. By placing the tooth treatment is often left until after orthodontic one of the disadvantages of positioning a slightly palatal, space can be created labially so treatment is completed, however microdont microdont centrally in the space may be the that restorations can be placed with adequate teeth can be built up to a more desirable size requirement to place both a mesial and distal thickness reducing the need for preparation and shape with composite before orthodon- restoration to close space. This would double or overcontoured/bulky restorations where tic treatment begins – this will help facilitate the restorative maintenance need. preparation is avoided. bracket placement and helps the orthodontist place the tooth in the exact position to facilitate Apical-coronal position Restorative treatment restorative treatment later (Fig. 9).19 Apical-coronal or ‘vertical’ positioning of the Restorative treatment options for microdont It is vital, particularly towards the end of teeth can dictate the position of the gingival teeth include: orthodontic treatment that the restorative margin and the materials used to restore the 1. Direct restoration dentist reviews the patient20 before debond to teeth. The material being used to restore the 2. Indirect restoration ensure orthodontic positioning of the crowns microdont tooth or teeth needs to be con- 3. Extraction and tooth replacement. and roots of the teeth can accommodate the sidered, so that the tooth can be adequately proposed restorative treatment. If this is not positioned to accommodate the restoration Direct restorations the case then further orthodontic treatment is where possible. When using porcelain such Composite based restorations can be used as a required or the restorative treatment plan re- as a veneer, intruding the microdont tooth by reversible material to build-up and modify the evaluated to accommodate the compromised 2mm apically will create space for the porcelain morphology of the microdont tooth or teeth.21 tooth positioning. veneer with adequate thickness incisally to Direct composite has been shown to be Orthodontics can help accommodate ensure structural integrity without the need aesthetic, non-invasive, well-tolerated by restorative management by opening/closing for preparing the tooth. If a direct composite pulpal tissue, minimally abrasive to opposing the spacing and idealising tooth position in a based restoration is being used then it may be teeth and easy to repair and adjust, however, it mesio-distal, bucco-lingual and apical-coronal advised to position the microdont tooth in is prone to staining/discolouration, accelerated position. occlusal contact so that there is reduced risk wear rate of material in comparison to metal of fracture/chipping of the weaker composite and ceramic based material, bulk fractures, Mesio-distal position based restoration14 if this is not attainable then complexity and challenging application with In the majority of cases the tooth is positioned providing at least 2 mm to accommodate the optimal moisture control required.22 in the middle of the space with equal spacing restoration is advised. Direct composite veneers can provide mesially and distally and is particularly true The gingival margin position will need to adequate aesthetics and studies have shown of teeth with parallel axial walls. Where one of be considered so that it is in harmony with the that both direct composite and porcelain can the axial walls flare out it may be off benefit to adjacent teeth, particularly the contralateral be just as aesthetic.23 orthodontically position the straightest axial tooth.14 There needs to be a balance between When placing direct composite restorations wall fully in contact with the adjacent tooth optimal incisal position and the desired it is recommended that the final labial contour (see Fig. 8).14 This will help with the aesthetics gingival margin position.14 is best placed in one increment to avoid voids24

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Fig. 11 Pre-operative and post-operative – direct composite veneer using FILTEK™ Supreme PLUS layering composite of the 22 peg lateral (note – RBBs replacing the 45, 35)

Fig. 12 Pre and post-op – direct composite veneer using FILTEK™ Supreme PLUS Fig. 13 Pre and post-operative – direct composite veneer using FILTEK™ Supreme PLUS layering composite of the 22 peg lateral layering composite of the 13, 12, 11, 21, 22, 23, 43, 42, 41 & 31, 32, 33 with a patient with amelogenesis imperfecta and microdontia as voids can attract staining and detract from the aesthetics. Multiple-layering composite with larger pulps. Composite can also be added Ceramic veneers are useful with teeth that systems can be used which come with a range to, as apical movement of the gingivae occurs have lots of character, which composite can of shades, opacities and translucencies that can during gingival maturity. This restoration struggle to replicate.30 However, matching the provide very aesthetic results, however, getting can be used as either an interim or definitive aesthetics can be difficult to achieve.31 proficient at using these multi-layering systems restoration and can be added to, removed and The advantages of adhesive ceramic restora- comes with experience and further training modified as required. tions include, good aesthetics, good abrasion on specific hands-on courses may be recom- resistance, less susceptible to staining (in mended to assist with this (Figs 10–13). Indirect restoration comparison to composite) and a higher level of Where possible the maximal coverage Veneers allow good aesthetics while being gingival tolerance. The disadvantages include of the tooth should be used to increase the relatively conservative of tooth tissue in com- a brittle material that is prone to fracture surface area for resin bonding and where parison to crowns (Fig. 14).25 Tooth removal unless applied in bulk, potentially abrasive to possible no preparation or minimal prepara- is often required which can be destructive opposing teeth, difficult to repair and adjust, tion of the tooth to preserve tooth tissue and of reasonably sound tooth tissue,26 however, and expensive.22 allow more predictable bonding to enamel is with microdont teeth preparation may not be Survival rates for porcelain veneers over recommended. Pre-treatment of unprepared needed and if it is this is often minimal – tooth periods of up to 16 years have been estimated enamel with pumice will remove the pellicle preparation should be minimised to reduce the to vary between 64% to 100%32 with common and ensure a clean surface. This technique loss of enamel which is required to optimise reasons for failure of veneers including ceramic is particularly useful in children and young the retention of the planned aesthetic resto- fractures and large marginal defects.33 adults where growth has not fully completed; rations.27 Veneers can be either composite or Indirect composite resin restorations offer gingival maturity hasn’t been achieved and porcelain, and both have proved to be aesthetic two primary advantages over direct resto- avoids the risk of pulpal pathology in patients with high patient satisfaction.28,29 rations, which include a reduced level of

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Fig. 14 Pre and post-operative – all ceramic e.max labial veneer of the 22 peg lateral in a cleft lip patient polymerisation shrinkage (as this is carried clinical and radiographic investigations and out in the laboratory) and the ability to add even a Kessling set or diagnostic wax up to to the veneer after the initial curing phase.22 visualise the effect of extracting the tooth or The advantages include; improved control in teeth. comparison to direct composite, the ability The restorative management for the residual to add and repair intra-orally, reasonable space of the microdont tooth/teeth is similar aesthetics, less abrasive than indirect ceramic to the management if the tooth/teeth were restorations, improved strength and wear missing due to hypodontia. resistance in comparison to direct composite. If the tooth is extracted or absent the options Fig. 15 Extra-oral smile photograph showing The disadvantages include, inferior marginal fit are either to: failing veneers with associated gingival in comparison to metal and ceramic, expense, 1. Orthodontically close the space recession leading to aesthetic compromise and the cementation line may require masking 2. Orthodontically open the space and tooth with direct materials.34 For patients with a replacement thin tissue biotype and high lip line, veneers 3. Accept spacing and tooth replacement this a lifelong need for maintenance.35,36 The are at risk of aesthetic failure due to gingival 4. Leave the space unfilled. maxillary lateral incisor is the most common recession (Fig. 15).33 microdont and extraction and space closure The decision to open or close space depends to close the maxillary lateral space and sub- Extraction, orthodontics and tooth on the number of teeth missing, the degree of stitute this with the canine and disguise this replacement crowding and the type of malocclusion.35 as a lateral incisor is an option. However, a Extraction of the microdont tooth/teeth is Where there is minimal spacing resulting decision to extract this tooth should be made considered if there is a need for space or the from the extraction of the tooth/teeth it may carefully since it is often possible to restora- long-term prognosis of the microdont tooth/ not be an aesthetic concern to patients or they tively improve the appearance of this tooth, teeth is poor, which includes teeth with small may be unwilling to accept necessary correc- when optimally positioned, as described malformed crowns and lack of coronal tooth tive orthodontic and restorative procedures previously in this article.37 Substituting the tissue to restore, short, thin roots, severely rotated and the spacing is left,36 however this is very canine for the lateral incisor is restoratively and teeth and teeth with associated dental anomalies uncommon and often the tooth would be left orthodontically challenging and the resulting such as amelogenesis imperfecta or dens in dente rather than be extracted. aesthetics varies enormously. This is due to the where the teeth are deemed unrestorable. Orthodontic space closure has the major canine being pointed, wider, longer and darker A thorough assessment of the microdont advantage of avoiding a permanent restora- than the lateral incisor it replaces. It also in tooth or teeth is required which includes tion to replace the extracted tooth and with general has a gingival margin that is more

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options will also be dictated by the amount of space available to accommodate the tooth replacement options, this is particularly true of implant based restorations. As there is a close link between microdontia and hypodontia this patient group may present with multiple teeth of the permanent dentition missing and may have missing or retained deciduous teeth that often require replacement. The management of these patients necessitates careful joint multi-disciplinary planning with orthodontics, Fig. 16 Radiograph and CBCT of 22 space, the 22 was a microdont and was extracted after restorative and in some instances paediatrics the 21 and 23 failed to erupt and were surgically exposed and orthodontically positioned. The radiograph and CBCT revealed a reduced mesio-distal space to accommodate an implant and oral and maxillofacial specialties. fixture and unfavourable root curvature Implant-based prosthesis An assessment should be carried out to see whether an implant-based solution is viable – where microdont teeth have been extracted there is a risk of a lack of bone volume to accommodate an implant and grafting techniques may be required to accommodate this. In addition, those with generalised hypodontia may have a lack of mesiodistal space between crowns and roots. An implant should be Fig. 17 Implant placement 12 & 22 with pre-operative orthodontics to idealise spacing and placed 1.5‑2 mm from the adjacent teeth since position of the adjacent teeth and roots to accommodate implant placement. (Note that placement too close to the adjacent tooth can inter-root distance is at the limits for narrow diameter implant placement) cause resorption of the interproximal alveolar crest41 and with this leads to a lack of support for the interdental papilla42 leading to a poor aesthetic result. This must also be considered when evaluating the position of the roots of the adjacent teeth and where a lack of space exists, either orthodontic intervention is required to create the space or an implant-based solution is not viable (Figs 16 and 17). The advantages of using implants are that it avoids using teeth as bridge abutments; they are also useful in patients with a spaced dentition Fig. 18 During treatment and post-op with RBBs cantilevered from the 13 and 23. 12 was where they can stand alone with spacing without microdont and the 22 was missing, the 12 was extracted during exposure and bonding of the unerupted 13 and orthondontics carried out idealise tooth positioning before tooth the aesthetic compromise of closing the gap or replacement creating a contact with abutment teeth when using bridgework. They are also useful where abutment teeth are unfavourable.35 apically positioned. By selective grinding the • Resin bonded bridge cusp tip and possible interproximal reduction, • Partial denture Removable partial dentures (RPDs) bleaching and using direct composite material • Implant retained prosthesis Removable partial dentures can be used where a satisfactory result can be achieved.38–40 • Conventional fixed prosthesis. there are large numbers of teeth missing, however, Opening the space is the preferred options for a single tooth or a small number of teeth that when there is little or no crowding, especially Spacing needs careful consideration to need replacing a partial denture isn’t regarded where orthodontic treatment does not need achieve an aesthetic result, the amount of as the first line tooth replacement option. It is to make use of the space and attempts could spacing is dictated by the aesthetics and also often used as a temporary tooth replacement lead to undesirable aesthetic and orthodontic what tooth replacement options are being option or space maintainer. RPDs are often bulky outcome. However, it commits the patient to considered. From an aesthetic perspective the with potential movement and are functionally the long term care and maintenance associated space created is dictated by the dimensions of and socially unacceptable to many patients as a with restorative tooth replacement.35 contralateral tooth so that symmetrical aesthet- definitive restoration as is their potential to harm The tooth replacement options, if the space ics are achieved when replacing the extracted the remaining teeth and periodontal tissues35 is to be prosthetically restored, are: microdont tooth. The tooth replacement particularly in young patients.

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