Supernumerary teeth are in excess of the normal number of teeth in either the primary or permanent dentition. They are classified into supplemental teeth resembling those of the normal series, and rudimentary teeth, with abnormal shapes. Most of the supernumerary teeth are rudimentary form, and supplemental teeth are much less common.
Supplemental teeth are most common in the permanent maxillary lateral incisor area, where they may negatively influence the esthetics of the anterior region and may affect the harmony of the dental arch due to their variable size and shape. They may cause occlusal anomalies such as excessive overjet, crowding, midline shift, or ectopic eruption. There is a variety of treatments, including extraction and orthodontic treatment, or tooth recontouring by resin build-up. In this article, we will show how we can use direct composite veneers to correct the alignment and also modify the shape of teeth to make a smile beautiful using a simplified approach, even without making mockups or waxing up with the help of the Unica matrix to predict the outer shape of the restorations.
A 32-year-old male came to the dental clinic to enhance his smile. He had a problem with the shape of the teeth and alignment, and wished to smile more confidently.
On the side view the misalignment appears clearly on the right side.
If we focus on the right view, there is something strange related to the presence of two permanent lateral incisors.
Supernumerary lateral incisors occur more frequently in the maxilla than in the mandible, and the majority occur unilaterally. Supernumerary lateral incisors are usually smaller than the adjacent normal lateral incisors.
The retracted view shows a disturbance in the smile curve as there are chipped incisal edges, proximal caries, and uneven incisal embrasures. This said, the main challenge is represented by the presence of two right lateral incisors, one proclined and the other rotated and a little retroclined. After discussing the treatment plan with the patient, we decided to use direct composite veneers to correct the shapes and alignment of the teeth.
We also offered the patient an orthodontic treatment, but he refused because of the limited time and budget.
Side view with two mal-aligned lateral incisors.
We decided to make composite veneers from canine to canine to correct shape and alignment, and to enhance the color of the teeth. As this will be done in a single visit, we decided to skip mock-up and wax up thanks to the help of the Unica matrix. We had two options:
A: bring the first lateral at the same level with centrals consider it as the third central and the second as the main lateral (straight incisal edge) and decrease it 1mm incisally from the level of the central.
B: keep both laterals as laterals, but shorten the first lateral (straight incisal edge) by 1mm, and leave the second lateral at the same level of the central incisally but with a round incisal edge to make an intermediate transition to the canine to resemble the canine.
We decided to start with A before deciding which option would look better.
First, a little preparation is mandatory on the distal area of the first lateral to correct the alignment, and also to provide even spacing for the composite material.
In the picture, you can see how placing the matrix without preparation would crush it, and lead to deformation and resulting in an improper, unhygienic contour. So the highlighted area needed to be prepared to open the space to create a new contour for both laterals. Also, gingivectomy was necessary for the second lateral to achieve good width/length proportions.
A custom Shade Guide was used to select the best dentin+enamel shade combination from the Professional CompoSite System by White Dental Beauty. A custom shade guide allows to accurately determine tooth shade for pleasing aesthetics and reliable results.
After a little preparation of the right laterals, the first lateral buccally and the second mesially, the proximal area was open and ready to fit the matrix for recontouring.
As with all restorative work on the enamel surface, total etching was done for 30 seconds for entire labial and incisal surfaces.
For the restorations, one dentin for the labial surface and enamel shade only on the incisal third were used. Simple, fast, and natural. In instances where a younger patient requires a little more brightness, the Si E shade (Enamel) is the perfect option, as it takes up the color of the body material for a natural appearance. Also when we do this, we overcome the issues related to excessive thickness of the enamel shade, like the glass effect.
In absence of a silicone index, the palatal shell was built using mylar strips supported palatally by a finger with good pressure and inclination.
A good matrix system helps recreate the natural shape of the tooth with aesthetic results. Here we used the Unica matrix for the two centrals to provide a symmetrical contour and outlines. A good outlining of the two centrals is what makes copying the outlines and contour pattern to the lateral and canines easier. This is very important because the eye focus is always at the midline.
After building the proximal walls and making a Unica frame using Si3 dentin shade, note the symmetry achieved as a result of good matrix selection.
After layering dentin shades and making mamelons, a small space is left for the enamel layer and incisal third characterizations.
Side view after layering and ready for the finishing process.
Correction of the tooth inclinations and contours respecting the labial curvature of the teeth and mesiodistal inclinations.
First, we drew the transitional lines or light lines by using a thin pencil. We used a disc that can be adapted to the proximal surface thanks to its flexibility.
We move from inside the interproximal area outwards repetitively until we have symmetrical widths.
We used the diamond Perio bur at low speed to make the secondary anatomy, wider incisally and narrower cervically. We use the body of the bur incisally and thin incline the tip of the bur towards the cervical to make the narrow part.
Here we used a rubber wheel that can be easily adapted to all surface details.
A 45° inclination from cervical to incisal with intermittent touches is ideal to remove all surface irregularities and sharp areas (but not removing the surface texture) making the restorations very smooth. The active end of the rubber is the end side, not the body as compared to the disc.
Immediately after polishing with a highly glossy surface.
Immediately after the restoration.
After evaluation of the first option, something looked weird in the appearance of the smile, so we decided to make a little correction to shorten the first lateral 1 mm incisally, and round up the second lateral to open the incisal embrasure a little more to resemble the canine.
The patient’s new smile, after the final modification, appears better than the first option, and the second lateral is less noticeable.
The side view shows the new alignment, shape modification, and the beautiful incisal embrasures of the right side.
The retracted view shows the composite veneers from canine to canine with enhanced smile curve and incisal edges.
Left side view.
Right smile view.
A supplemental lateral incisor is a rare developmental anomaly, which may have a negative influence on the esthetics of the anterior region and may disturb the dental arch harmony. Early diagnosis and treatment are mandatory to prevent orthodontic and esthetic complications. The treatment depends on the respective case and their management should be as minimally invasive as possible to be able to satisfy the patient’s needs.
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