Double right laterals

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.

styleitaliano style italiano with supernumerary lateral incisor

Fig.1
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.

styleitaliano style italiano smile with supernumerary tooth

Fig.2
On the side view the misalignment appears clearly on the right side.

styleitaliano style italiano smile with supernumerary incisor

Fig.3
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.

styleitaliano style italiano intraoral picture analyzing smile curve

Fig.4
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.

styleitaliano style italiano intraoral picture before direct esthetic restorations

Fig.5
Side view with two mal-aligned lateral incisors.

styleitaliano style italiano two different designs to mask supernumerary tooth

Fig.6
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.

styleitaliano style italiano preparation area for inclination correction

Fig.7
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.

styleitaliano style italiano highlights of preparation area

Fig.8
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.

styleitaliano style italiano custom shade guide for direct composite restoration

Fig.9
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.

style italiano styleitaliano white dental beauty composite system
style italiano styleitaliano white dental beauty composite system
styleitaliano style italiano split dam isolation

Fig.10
Split dam isolation is mandatory to provide a clean environment. The cervical part will be sealed by using the Unica matrix.

styleitaliano style italiano prepared lateral supernumerary under rubber dam isolation

Fig.11
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.

styleitaliano style italiano etching enamel surfaces

Fig.12
As with all restorative work on the enamel surface, total etching was done for 30 seconds for entire labial and incisal surfaces.

styleitaliano style italiano light curing of bonded surfaces

Fig.13
A Universal adhesive was applied by active rubbing on the surface and light curing for 20 seconds using the Curing Pen by Eighteeth.

curing pen light style italiano styleitaliano eighteeth
curing pen light style italiano styleitaliano eighteeth
styleitaliano style italiano direct restoration color scheme

Fig.14
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.

styleitaliano style italiano incisal palatal build up

Fig.15
In absence of a silicone index, the palatal shell was built using mylar strips supported palatally by a finger with good pressure and inclination.

styleitaliano style italiano unica matrices for incisor contouring

Fig.16
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.

style italiano styleitaliano polydentia matrix
style italiano styleitaliano polydentia matrix
styleitaliano style italiano composite contour for direct veneering

Fig.17
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.

styleitaliano style italiano unica minideep for lateral restorations

Fig.18
Unica Minideep matrix is perfect for the second lateral. Note the adaptability to the desired shape.

styleitaliano style italiano finished composite restorations before polishing

Fig.19
After layering dentin shades and making mamelons, a small space is left for the enamel layer and incisal third characterizations.

styleitaliano style italiano raw composite restorations

Fig.20
Side view after layering and ready for the finishing process.

styleitaliano style italiano scheme for buccal finishing of composite veneers

Fig.21
Correction of the tooth inclinations and contours respecting the labial curvature of the teeth and mesiodistal inclinations.

styleitaliano style italiano highlighted line angles

Fig.22
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.

styleitaliano style italiano surface texturing of composite veneers

Fig.23
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.

styleitaliano style italiano rubber wheel for composite polishing

Fig.24
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.

styleitaliano style italiano lucida star felt and paste for glossy composite

Fig.25
The Lucida™ Star and The DiaShine Lucida™ Paste, two allow for a singlestep polishing of composite restorations giving high gloss within seconds.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
styleitaliano style italiano polished composite veneers

Fig.26
Immediately after polishing with a highly glossy surface.

styleitaliano style italiano smile after composite veneering

Fig.27
Immediately after the restoration.

styleitaliano style italiano scheme for correction of direct veneers

Fig.28
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.

styleitaliano style italiano corrected direct veneering with supernumerary tooth

Fig.29
The patient’s new smile, after the final modification, appears better than the first option, and the second lateral is less noticeable.

styleitaliano style italiano direct composite veneers

Fig.30
The side view shows the new alignment, shape modification, and the beautiful incisal embrasures of the right side.

styleitaliano style italiano smile with direct veneers

Fig.31
The retracted view shows the composite veneers from canine to canine with enhanced smile curve and incisal edges.

styleitaliano style italiano detail of direct veneer restorations

Fig.32
Left side view.

styleitaliano style italiano smile after direct veneering with supernumerary tooth

Fig.33
Right smile view.

Conclusions

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.

Bibliography

1. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc 2001; 132:39–45.
2. Blitz N. Criteria for success in creating beautiful smiles. Oral Health 1997; 87: 38–42
3. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent. 2010 Spring;5(1):102-24.
4. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012.
5. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr.Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.
6. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: A new concept in composite layering – Part II. Odontostomatol Trop 2014; 37(47): 5-13
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8. Hosaka K, Tichy A, Motoyama Y, Mizutani K, Lai WJ, Kanno Z, Tagami J, Nakajima M. Postorthodontic recontouring of anterior teeth using composite injection technique with a digital workflow
9. Nordquist GG, McNeill RW. Orthodontic vs. restorative treatment of the congenitally absent lateral incisor-long term periodontal and occlusal evaluation. J Periodontol 1975;46:139-143.
10. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.
11. Heintze SD, Rousson V, Hickel R. Clinical effectiveness of direct anterior restorations-a meta-analysis. Dent Mater 2015;31(5):481-95
12. Arandi NZ, Abu-Ali A, Mustafa S Supernumerary teeth : A retrospective cross-sectional study from Palestine. Pesqui Bras Odontopediatr Clin Integr 2020;20:1-9.
13. Primosch RE Anterior supernumerary teeth – assessment and surgical intervention in children. Pediatr Dent 1981;3:204-15.
14. Mallineni SK, Kumar S Supernumerary teeth: Review of the literature with recent updates. Conf Pap Sci 2014;2014:1-6.
15. Wedrychowska-Szulc B, JaniszewskaOlszowska J The supernumerary lateral incisorsmorphology and concomitant abnormalities. Ann Acad Stetin 2007;53:107-13.
16. Khandelwal P, Rai AB, Bulgannawar B, Hajira N, Masih A, Jyani A Prevalence, characteristics, and morphology of supernumerary teeth among patients visiting a dental institution in Rajasthan. Contemp Clin Dent 2018;9:349-56.
17. Amini F. Prevalence and pattern of accessory teeth (Hyperdontia) in permanent dentition of Iranian orthodontic patients. Iran J Public Health 2013;42:1259-65.

style italiano styleitaliano Essential Dentistry kit online on demand course
style italiano styleitaliano Essential Dentistry kit online on demand course

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