RestorativeDentistry

Matthew B M Thomas

Christine Mary Greenhalgh and Liam Addy

Double-Veneers A Novel
Approach to Treating Macrodontia
Abstract: Macrodontia is a relatively rare but cosmetically challenging dental anomaly with different aetiologies. Where surgical
interventions are inappropriate, minimal restorative interventions may be indicated. A case is described of a teenager with macrodontic
central incisors who was treated with indirect composite double veneers. The aesthetic outcome was excellent without unnecessary loss of
teeth.
Clinical Relevance: Knowledge of the use of indirect composite veneers provides another treatment option for aesthetic problems in the
management of tooth anomalies, including macrodontia.
Dent Update 2008; 35: 479-484

Dental anomalies are surprisingly common.
It has recently been found that 40.8% of a
population attending a dental hospital had
a dental anomaly radiographically.1 Dental
anomalies are more common in males than
females.1 Aside from differences in tooth
number, dental anomalies include:2
Macrodontia
Microdontia
Dilaceration
Taurodontism
Connation (Double teeth) dentition, for example, in association with
Concresence
Disturbances of structure of enamel and
dentine.
The size of the teeth within the
Matthew B M Thomas, BDS Hons(Wales),
MFDS RCS(Eng), Specialist Registrar in
Restorative Dentistry, Cardiff University
Dental Hospital, Christine Mary
Greenhalgh, RDT LCGI, Dental Technical
Instructor, School of Dentistry, Liam Addy,
BDS, MFDS RCS, MPhil, FDS(Rest Dent)
RCS, Consultant in Restorative Dentistry,
Cardiff University Dental Hospital, School
of Dentistry, Wales College of Medicine,
Cardiff University Dental Hospital, Heath
Park, Cardiff, CF14 4XY, UK.
jaws is determined by genetic factors. Tooth size
is diagnosed as anomalous when the norms
for the sex and racial group are exceeded.3
Macrodontia describes the situation when teeth
are enlarged based on these norms, although
no strict boundaries have been defined.
Macrodontia (Megadontia) involving a single
tooth has an overall prevalence in British school
children of 1.1% in the permanent dentition,3
and has been described in the literature since
1970.4 Macrodontia may involve the entire
crowding and aesthetics.
gigantism, but more commonly affects one
or two teeth symmetrically in the mouth.5
Classically, it involves both central incisors.In a
Chinese population, single tooth macrodontia
involving a central or lateral incisor was found to
have a prevalence of 2.5%.6
Within the literature, there
appear to be two schools of thought on the
classification of the macrodont. Welbury
stated that macrodont maxillary incisors can
be distinguished from double teeth through
the absence of incisal notching and frequently
occur bilaterally.3 However, Gazit and Lieberman
reported that macrodontia may result from
fusion or gemination (ie double teeth).7 Fusion
occurs between two normal teeth or involves
a supernumerary and may reveal two roots
radiographically. These teeth may have a
single or two pulp chambers and will result in
a reduction in the number of teeth within the
arch.5
Gemination is the aborted
attempt of a tooth germ to divide, which may
result in varying depths of coronal notches or
grooves.7 The number of teeth within the arch is
unchanged.5 Although the diagnosis of dental
twinning abnormalities can be confusing,5 there
is no doubt that macrodontia causes problems
of plaque accumulation within coronal notches,
Macrodontia, if caused by fusion
or partial gemination, may require a combined
surgical, restorative or orthodontic treatment
plan. Where the macrodontia is solely because
of an increase in the size of a tooth, or with
minimal notching, a more conservative
approach is appropriate. The case is presented
of an adolescent with anterior macrodontia that
was treated with an ultra conservative approach
using indirect composite veneers.
Case history
A 17-year-old male was referred to
Cardiff University Dental Hospital with concerns
regarding the appearance of his maxillary
anterior teeth. There was a history of some
difficulties at school, owing to his appearance,

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 RestorativeDentistry

a b c

Figure 1. Pre-operative view showing: (a) macrodont maxillary incisors; (b) palatal groove and two cingulums 1/; (c) low lip line.

Figure 3. Study model demonstrating tooth Figure 4. Diagnostic wax-up of planned

dimensions. camouflage.

macrodontia of the maxillary central incisors was

made with probable fusion of 1/ and 2/.
An orthodontic opinion was
sought during the treatment planning stage.
The combined orthodontic/restorative option
Figure 2. Periapical radiograph demonstrating included reduction in mesiodistal width of the
two pulp canals within 1/. upper left central incisor by approximately
3 mm, followed by fixed appliance therapy
Figure 5. Minimal preparation of labial surface.
to correct the centre lines and distribute the
spacing more favourably. This would allow the
causing social embarrassment. Clinical
use of veneers to improve the appearance and
examination revealed a low lip line and excellent
size of the upper left lateral and upper right and he was happy to proceed.
oral hygiene, with no evidence of previous caries
central incisors. The patient was not keen on Teeth 1/12 were minimally prepared
activity. His occlusion was Class I, with the upper
fixed appliance therapy and it was felt that on the labial surface, providing a shallow but
centre line displaced to the right-hand side.
mesiodistal width reduction was of such a definite finish line. The finish line was placed
Of particular note were large bilateral central
dimension it may expose dentine, therefore this approximately 1 mm from the gingival margin,
incisors. The right central incisor measured 14
option was not chosen. to maintain gingival health. The incisal edge
mm mesiodistally and the left central incisor 12
Taking into consideration the was reduced by 1 mm (Figure 5). Impressions
mm. There was an associated midline diastema,
patients age, unrestored dentition and location were taken using polyvinylsiloxane impression
2/ was absent, but the dentition was otherwise
of the lip line on wide smiling, a non-surgical, material. The shade was taken using True Shade
unremarkable in terms of tooth size and number.
conservative approach was preferred. A (Optident Dental Products, UK). Shade A2 was
Closer examination of the 1/ revealed a palatal
treatment plan was formulated to include: chosen, incorporating white enamel opacities at
notch and two cingulums (Figure 1).
Study models (Figure 3). the incisal tips. Although the original diagnostic
Periapical radiographs revealed
Diagnostic wax-up of appearance of wax-up included the placement of gingivae-
that the left central incisor was single rooted.
camouflaging 1/12 to look like 21/123 (Figure 4). coloured composite, it was subsequently
Although the right central incisor also had
Composite veneers with appearance of decided to place the finishing lines remote
a large single root, there was evidence of a
21/123 following ultraconservative preparations from the gingival margin such that the use of
centrally located dentine wall within the root
of the central incisors and left lateral incisor. gingivae-coloured composite was not indicated.
and two partially separated root canals. The
The treatment plan was discussed This decision was supported in this case because
presence of two cingulums is also confirmed
with the patient using the diagnostic wax-up of the patients low lip line (Figure 1c). The
on the radiograph (Figure 2). A diagnosis of
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Figure 6. Cosmetic result of first set of veneers
showing good aesthetic outcome assisted by low
lip line.
Figure 7. Finished veneer restorations.
Figure 8. Extra-oral appearance of completed
restorations with patient smiling. Compare with
Figure 1c.
diagnostic wax-up was still of value in giving
the patient an impression of achievable tooth
dimensions.
The patient felt the first set of
veneers were too bulky (Figure 6) and so a
second set was constructed taking account of
this, but warning of a slightly compromised
appearance. The patient was very pleased with
the second set and these were adhesively
cemented with a dual cure composite (Figure
7). The final extra-oral result is shown in Figure
8, demonstrating the favourable position of
the smile line and pleasing appearance. The
patient was warned of the likely maintenance of
composite veneers and need for replacement in
the future. The patient is currently under review
and, when replacement of the veneers becomes
September 2008
pg479-484 Double veneers.indd 5
RestorativeDentistry
necessary, at such time that the gingival margin resistance between direct and indirect
is stable, this will be completed using porcelain composite laminate veneers.13 One concern with
laminate veneers. indirect composite veneers is the potentially
lower bond strength.14 This is a result of fewer
bond sites within the veneer owing to a
Discussion greater degree of polymerization within the
The average diameter of laboratory. Methods of addressing this bond
permanent central incisors has been found to strength deficiency include acid etching or sand
be approximately 8.6 mm from the mesial to blasting.14
8
the distal contact points. The case presented In 1991, Harasani et al investigated
describes central incisors that had diameters of the marginal fit of porcelain and indirect
14 and 12 mm mesiodistally. This is consistent composite veneers.15 They found that, although
with previously described macrodontia cases the marginal discrepancy at the cervical location
where central incisors varied between 12 mm was higher with composites, composites and
and 14 mm wide.7 Previously described cases porcelain had similar absolute discrepancy
of macrodontia in younger patients have been and thickness of luting cement. Welbury
managed with combined surgical, orthodontic demonstrated good survival with direct
and restorative methods.7 This is appropriate composite veneers in adolescents. In his study
where two separate roots are identifiable and of 289 direct veneers, the median survival time
amenable to division and extraction. The case was 35.6 months, with only 14% failure, of which
described had single-rooted teeth and, therefore, none was due to abrasive wear.16
surgery would have involved the extraction of The relative advantages of
healthy teeth. In this case, aesthetic camouflage porcelain, indirect composite and direct
was justified, with the main outcome being to composite veneers are summarized in Table
meet the patients aesthetic requirements whilst 1. Laboratory processed composite veneers
preserving tooth structure and maintaining have superior physical properties compared to
periodontal health. chairside composites.14 It is also easier to achieve
When considering the aesthetic correct contour and characterization. Conversely,
management of discoloured or minor with regard to direct composite veneers, there
malformations in tooth shape, three options is no requirement for a path of insertion and,
available include: therefore, usually no need for preparation at all.
Direct composite veneer; Based on their inherent advantages, composite
Indirect composite veneer; and veneers, both direct and indirect, have been
The porcelain laminate veneer. recommended in children and adolescents as an
Composite veneers have been interim restoration.3,14
reported as being less destructive but less durable A concern which restorative
than porcelain veneers.9 A systematic review of dentists may have when resolving aesthetic
the literature found that there was no reliable dental problems in teenagers or young adults is
evidence to show a benefit of one type of veneer the stability of the gingival margin. The clinical
restoration (direct or indirect) over the other crown height is the distance from the most
with regard to the longevity of the restoration apical concavity of the gingival margin to the
in treating intrinsic dental stains.10 The choice of incisal edge, and is a useful measure of the
veneer type should be made on an individual position of the gingival margin.17 A systematic
patient basis, taking into account patient-related review of clinical crown length measurements
factors such as occlusion, the patients preference confirmed that there is an increase in clinical
and the clinicians expertise.10 crown length with age that slows as age
It is apparent, anecdotally, that increases.17 Although there is movement of the
indirect composite veneers are often a forgotten gingivae itself, tooth eruption will contribute
treatment modality when it comes to the to the final position of the gingival margin.
management of aesthetic problems. In fact, Interpretation of the data within this review
reviews on both aesthetic and indirect restorative suggests that increases in crown length flatten
materials often do not even mention them.11,12 at approximately 20 years of age. Harley and
Dentists may have concerns Ibbetson remind us that the provision of
regarding the mechanical properties, marginal porcelain veneers in the adolescent patient
fit and long term retention of indirect composite will result in placement of a finish line at a
veneers. A recent study by Gresnigt and zcan time when clinical crown height is undergoing
found no significant difference in fracture rapid change and, therefore, they advocate the
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use of composite veneers.9 Although porcelain
may produce the best aesthetic and retention
time, Welbury states there is little justification to
provide a costly porcelain veneer when it may
need to be replaced in a few years.16 For the
aforementioned reason, it seems sensible to delay
the provision of porcelain veneers until gingival
stability is assured and full clinical crown height is
achieved (1820years). This concept is supported
elsewhere.3,14
The procedure for indirect composite
veneers is as follows, and is also described clearly
in a recent text:14
Shade selection;
Minimal preparation labially to remove the
aprismatic layer;
Provision of shallow margin remote from
gingivae as definite finish line for technician;
1 mm incisal reduction;
Putty and wash polyvinylsiloxane impression;
Try in veneers;
Isolation;
Clean teeth with pumice slurry to remove
pellicle;
Etch tooth tissue;
Apply bond to tooth and veneer;
Apply translucent dual cure luting cement;
Remove excess;
Cure from all surfaces for 40 seconds;
Finish margins with appropriate composite
finishing techniques.
Conclusion
Macrodontia is a relatively rare
dental anomaly. Recognizing the aetiology of
the anomaly is important in dictating whether a
multidisciplinary or solely restorative solution is
appropriate. The case presented was treated with
minimal intervention indirect composite double
veneers. This technique is minimally invasive,
pragmatic and has virtually no biological down
sides. The authors believe it is the first example
of their use. It was only possible in this case
because of the patients favourable lip line
upon smiling, which did not show the gingival
margins. Smile height and width are an essential
part of any aesthetic treatment plan.
It is reassuring that current
techniques and materials have improved to such
an extent that an aesthetic interim restoration
can be provided for many aesthetic indications,
including macrodontia. It is hoped that, in the
future, more longevity data will be available to
promote the use of indirect composite veneers
still further.
References
1. Ardakani F, Sheikhha M, Ahmadi H.
Prevalence of dental developmental
anomalies: a radiographic study.
Community Dent Health 2007; 24:
140144.
2. Soames JV, Southam JC. Oral Pathology
3rd edn. Oxford: Oxford University Press,
2005; pp.517.
3. Welbury R, Duggal MS, Hosey M-T.
Paediatric Dentistry 2nd edn. Oxford:
Oxford University Press, 2005; pp.275276.
4. Conklin W. Macrodontia. Oral Surg Oral
Med Oral Pathol 1970; 30: 221.
5. Killian C, Croll T. Dental twinning
anomalies: the nomenclature enigma.
Quintessence Int 1990; 21: 571576.
6. Tsai S, King N. A catalogue of anomalies
and traits of the permanent dentition of
southern Chinese. J Clin Pediatr Dent 1998;
22: 185194.
7. Gazit E, Lieberman A. Macrodontia of
maxillary central incisors: case reports.
Quintessence Int 1991; 22: 883887.
8. Mcann J, Burden D. An investigation of
tooth size in Northern Irish people with
bimaxillary dental protrusion. Eur J Orthod
1996; 18: 617621.
9. Harley KE, Ibbetson RJ. Anterior veneers
for the adolescent patient: 1. General
indicators and composite veneers. Dent
Update 1991; 18: 5559.
10. Wakiaga J, Brunton P, Silikas N, Glenny AM.
Direct versus indirect veneer restorations
for intrinsic dental stains. Cochrane
Database of Systematic Reviews 2004, Issue
1. Art No: CD004347.
11. Bello A, Jarvis R. A review of esthetic
alternatives for the restoration of anterior
teeth. J Prosthet Dent 1997; 78: 437440.
12. ADA Council on Scientific Affairs. Direct
and indirect restorative materials. J Am
Dent Assoc 2003; 134: 463472.
13. Gresnigt M, zcan M. Fracture strength
of direct versus indirect laminates with
and without fiber application at the
cementation interface. Dent Mater 2007;
23: 927933.
14. Roberson TM, Heymann HO, Swift EJ. Art
and Science of Operative Dentistry. 5th edn.
USA: Mosby Elsevier, 2006.
15. Harasani MH, Isidor F, Kaabar S. Marginal
fit of porcelain and indirect composite
laminate veneers under in vitro conditions.
Scand J Dent Res 1991; 99: 262268.
16. Welbury R. A clinical study of a microfilled
composite resin for labial veneers. Int J
Paed Dent 1991; 1: 915.
17. Cleaton-Jones P, Volchansky A. Clinical
crown height (length) a review
of published measurements. J Clin
Periodontol 2001; 28: 10851090.

Direct Composite Indirect Composite Porcelain Veneers

Advantages Disadvantages Advantages Disadvantages Advantages Disadvantages
Easy to repair High level of Easier to reproduce Possible reduced bond Excellent Catastrophic failure
operator skill anatomic form strength aesthetics
Dentist controls High chairside time Easy to repair Longevity data Clinically proven Increase laboratory
contours unavailable costs
No laboratory May chip with time Lower cost compared May chip with time
fee with porcelain
No path of Increased chairside
insertion costs
required

Table 1. Advantages and disadvantages of direct and indirect aesthetic materials.

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