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Mesiodens and Tetracycline Staining: Solving the Esthetic Challenge (1 CEU)

April 29, 2024
Author
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Justin Chi, DDS, CDT
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Amesiodens is a supernumerary tooth in the midline of the maxilla, usually between the two central incisors. This condition affects between 0.15% and 1.9% of the population,1 and its etiology is not fully understood. Untreated, it can lead to complications such as delayed eruption, crowding or cyst formation in addi¬tion to the esthetic challenges often caused by this limitation of facial symmetry. This case report shows the steps to treat a patient with a large mesiodens, and how I used the digital tools of the glidewell.io™ In-Office Solution to restore his smile

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Figures 1a, 1b: The patient presented with a mesiodens between teeth #8 & #9. Most of his teeth had severe intrinsic staining caused by tetra­cycline exposure. He had previously been treated with direct compos­ite veneers in an attempt to improve the esthetics.

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Figure 2: While a typical mesiodens has a smaller and more conical shape, this patient’s supernumerary tooth had fairly normal incisor anat­omy with the two centrals slightly malformed. To create an ideal situa­tion for the patient’s restorative treatment, I referred him for orthodon­tic treatment and extraction of the mesiodens.

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Figures 3a, 3b: These images show the result of the banded orthodontic treatment, extraction of the mesiodens and removal of the composite veneers.

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Figure 4: To help the patient envision the final restorative result, I completed a freehand mock-up using direct composite, defining the midline and incisal edges. The patient approved the mock-up.

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Figure 5: Using the iTero Element® 2 scanner (Align Technology, Inc.; San Jose, Calif.) I captured a pretreatment scan of the mock-up before tooth preparation. This step allowed me to use the mock-up as a reference for the crown designs.

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Figures 6a, 6b: I prepared through the mock-up to the desired depth to achieve the esthetic outcome we planned, and used direct composite to create a provisional for the patient to wear.

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Figures 7a–7c: I fabricated the final restorations for teeth #4–13 chairside with my fastmill.io™ In-Office Mill. BruxZir® Esthetic NOW veneers were chosen to provide a long-lasting and esthetic solution. Using my fastprint.io™ 3D Printing Solution, I printed a model that I used for final adjustment of the veneers after milling. Although I decided to fabricate the restorations in-office, the process is the same as if I had decided to send the scans to the laboratory to create the restorations.

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Figure 8: I placed and bonded the final BruxZir Esthetic NOW veneers on the upper arch.

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Figure 9: After completing the upper arch, lower teeth #20–30 were prepared and provisionalized with direct composite. Because of the trans­lucency of BruxZir Esthetic NOW, I applied PermaFlo™ dentin opaquing liquid (Ultradent Products, Inc.; South Jordan, Utah) at the next appoint­ment to prevent the discoloration of the tooth preparations from show­ing through the restorations.

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Figures 6a, 6b: I prepared through the mock-up to the desired depth to achieve the esthetic outcome we planned, and used direct composite to create a provisional for the patient to wear.

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Figure 11: As often happens after adult orthodontic treatment, the pa­tient required further orthodontic refinement after placement of the final restorations. Rebound from the original positions of his two centrals caused his teeth to separate. The solution was to fit him with a fiber-reinforced direct retainer, bonded on the midline at the lingual.

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Figures 6a, 6b: I prepared through the mock-up to the desired depth to achieve the esthetic outcome we planned, and used direct composite to create a provisional for the patient to wear.

CONCLUSION

This case report demonstrates the benefit of orthodontics to create an ideal situation for restorative treatment. While it would have been much simpler to treat the case by extracting the mesiodens and adding width to his centrals, the result would not have provided the same esthetic improvement.

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Reference

  1. Seladi-Schulman J. Mesiodens (extra tooth) causes and why it should be treated [Internet]. Healthline. Healthline Media; 2021 [cited 2024 Feb 1]. Available from: https://www.healthline.com/health/dental-and-oral-health/mesiodens.