When restoring peg laterals and laterals that are undersized, great goals are to optimize the final aesthetics and not have to do any tooth preparation prior to adding restorative material. In this blog, I’d like to discuss where we should have the orthodontist optimally position the laterals prior to restoration.

True Peg Laterals

In the case of a true peg lateral, I think of the tooth like I would an implant abutment. In my mind’s eye, I visualize the tooth as a fixture with an abutment on it.

When I talk with the orthodontist, I communicate that I want a minimum of 1 mm and a maximum of 1.5 mm of space between the mesial on the lateral incisor and the distal on the central incisor.

If there is excess space, it is going to be on the distal. We always hide excess space or insufficient space on the distal side of an upper anterior tooth. We always want to perfect the effect on the mesial so we achieve a perfect emergence profile.

And then I communicate that I want the labial of that peg lateral to be positioned about 1 mm to the lingual of where the final facial of the tooth position will be so that I can add material–composite or ceramic, without having to prep the tooth. This position is going to ideally position the free gingival margin of the tooth exactly where I want it based on the free gingival margin of the canine and central incisor. The CEJ is going to be placed exactly where I want the CEJ.

Undersized Lateral Incisors

Often, we have lateral incisors that are not true peg laterals. They’re just undersized lateral incisors. In this case, we must do a thought process about how much restorative material will be added and calibrate how much forward dimension will be added to the tooth. If I’m going to have .5 mm of material on the labial, then I will have the orthodontist position the tooth .5 mm lingually.

If the emergence profile is perfect, then the orthodontist should make it touch the central and all the added material will go on the distal. If not, then a little material will be added to the mesial and to the distal.

Often, for me, the process is thinking, “Where do I want to add restorative material and how much material do I want to add?” Then, I think about where to position the tooth in the space so I will not need to remove any of the tooth structure.

Every patient has a story that makes their case unique. When we embrace their path to treatment and make an effort to understand their motivations, we can provide even more excellent care.

A great example of this simple lesson came in the form of my patient Anne. I knew Anne well, as she ‘grew up’ in our practice and had been a regular patient for many years. This fact added an unexpectedly challenging element to her case. I knew I needed to re-familiarize myself with her interests and background instead of taking our past relationship for granted.

Restorative Case For a Future Hygienist

Anne is nineteen and currently training to become a dental hygienist. Her personal dental experiences spurred her interest in the field. She’s excited to provide patient care that improves both oral health and self-image.

All of these details about Anne informed how I approached her treatment. Her primary esthetic concerns were a peg lateral #7 and a congenitally missing #10. She also had canted axial alignment, mottled enamel, and uneven gingival zeniths with a high smile line.

We decided on comprehensive restorative treatment approach that would correct these problems and provide her with a result she could readily show off. The treatment consisted of orthodontics, an implant for #10, and periodontal surgery to reposition gingival levels. We also moved ahead with occlusal equilibration and a diagnostic wax up.

To round out the case, we did tissue sculpting on #10 in addition to esthetic/functional testing and refinement via provisionals. Anne got beautiful e.max veneers on #5, 6, 7, 8, 9, 11 and 12. Finally, she got an implant supported e.max crown on #10.

Matt Roberts CDT handled the lab side of Anne’s case and did a stellar job. She can now go forth confidently into her career and help others embrace treatment that can change their lives.

What case put a smile on your face recently? We’d love to hear what you think in the comments!