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Straight Talk: Microdontia with Delayed Development

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Microdontia with Delayed Development

An 11-year-old patient was referred by a pediatric dentist for orthodontic evaluation with several unusual findings: microdontia, severe developmental delay in eruption, and several positional concerns. Clinical and radiographic examination revealed a retained tooth in the upper right quadrant, suspected to be either a primary tooth or a supernumerary permanent lateral. The upper right first molar was ectopic, appearing to be “caught” beneath the retained tooth, and the upper left first molar had not erupted at all. Additional findings included a full posterior right crossbite and evidence of overall dental delay compared with age norms (Figs. 1–3).

The referral question centered on whether any extractions were indicated and how best to sequence treatment given the delayed eruption of the permanent molars.
Microdontia with Delayed Development
Fig. 1
Microdontia with Delayed Development
Fig. 2
Microdontia with Delayed Development
Fig. 3


Initial considerations
Community discussion on an Orthotown message board emphasized the importance of differentiating between normal but delayed eruption and true asymmetry that could signal pathology. Both maxillary first molars had yet to erupt, which suggested a developmental lag rather than an isolated failure of eruption. Contributors noted that bilateral delay was less concerning than if one side had erupted normally while the other lagged behind by more than six months.

Treatment timing was another concern. Launching into Phase I orthodontics while key permanent teeth remained unerupted was viewed as risky, since this could prolong treatment unnecessarily. The consensus leaned toward a conservative approach: monitor closely, and intervene only as eruption patterns became clearer.


Supernumerary tooth vs. retained primary
One point of discussion was the nature of the retained upper right tooth. On closer inspection of the radiographs, several practitioners suggested that the tooth resembled a supernumerary permanent lateral rather than a retained primary, given the similarity in root morphology between the two teeth present in that area. Regardless of its classification, the consensus was that the tooth should be removed, as it was interfering with eruption of the adjacent permanent molar and could complicate arch development if left untreated.


Additional factors: Tongue tie and transverse deficiency
The case also raised questions about a possible tongue tie. Some clinicians suggested that, if the frenulum appeared to restrict tongue mobility, release could be considered—either surgically or with a soft-tissue laser. Others felt it was not the primary concern at this stage, but acknowledged it could play a role in oral function and should not be overlooked.

The patient also presented with a full posterior right crossbite. While this raised concerns about skeletal constriction, the availability of modern expansion options, including MARPE in later adolescence, gave orthodontists confidence that transverse correction could be delayed if necessary. The key was to avoid rushing into early, prolonged treatment when skeletal maturity might later allow for more definitive correction.


Suggested approach
The prevailing recommendation was to proceed cautiously:
  • Extract the suspected supernumerary tooth in the upper right quadrant.
  • Recall in six months to reassess eruption of the upper first molars and maxillary canines.
  • Consider a short course of limited treatment with upper and lower 2×4 appliances if space management is needed for the canines, but plan to discontinue until more teeth have erupted.
  • Continue monitoring the transverse relationship, with the understanding that skeletal expansion can be addressed later if needed.
  • Evaluate the tongue tie further and consider release only if functional limitation is observed.

Conclusion
This case highlights the complexities of diagnosis and timing in patients with both microdontia and delayed dental development. The community consensus was that restraint is often the best strategy—extracting obstacles to eruption but otherwise allowing growth and development to guide the timing of treatment. Regular monitoring, careful evaluation of eruption symmetry, and readiness to adapt treatment plans remain the cornerstones of managing these challenging cases.

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