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.

Occasionally we discover that we are not the right dental team for a particular patient or that the patient is not looking for what we offer. This doesn’t happen very often, but it can save a ton of time and help manage expectations if we find out before doing the comprehensive exam.

When new patients come into our practice, we always begin with a preclinical interview and then proceed to do a comprehensive exam. One new patient arrived and was seated in the consultation room. I came in and started the preclinical conversation. We started talking about her health history and dental history.

As we talked about her dental history, it becomes apparent that she had a history of “fixing things as they broke.” I explained that our exam process would allow us to find and treat issues early. I tried to help her understand that treating a cracked tooth as soon as the crack is observed could save the tooth and avoid the breakage she had experienced. I described to her what the exam would include, that I would describe and show her problems I saw, and that I would explain risk factors that could develop into future problems.

She said, “I don’t want you to do that. I just want you to make sure I don’t have any cavities and that’s it.”

I said, “Well, we can certainly do that. We can look for any teeth that have a cavity. Would you like me to tell you if I see anything else going on?”

“No,” she said, “I don’t want to know any more than that.”

We talked a little longer, and I tried to understand why she didn’t want to know. I said, “You know a tooth problem is a kind of like a tiny skin cancer they burn off instead of waiting until it grows and then you need a big Mohs procedure.”

She didn’t respond, so I said, “Let’s go to the dental chair, take a look, and see what we find, and we’ll take some x-rays.”

She said, “I don’t want x-rays.”

I explained that we couldn’t accurately diagnose cavities without x-rays. She then said, “I don’t think this is the right place for me.”

Fifteen minutes into our conversation, I heard myself say, “I think you may be right. We are here to help patients improve and maintain their oral health and to avoid having bigger problems.”

Before I could continue, she interrupted me, firmly saying, “No that’s not important to me.”

My response was, “Well then, it was nice to meet you,” and I stood up to walk her to the door.

I’ve known dentists who rush right into new patient exams without conversation in which they learn if the patient is motivated to improve and maintain their oral health. I told the team to not charge her for the appointment, and I told them, “That was the best preclinical interview we ever had because we stopped wasting her time and our time.”

Fortunately, most of the new patients who come to us have “Aha” moments during the preclinical interview and comprehensive exam. They immediately understand the value of what we are striving to do and are interested in the discoveries we make during the examination. They ask questions and want to know why conditions are the way they are. They want to know what can be done to lower risk factors. They may need nurturing over multiple appointments to accept treatment but we see them making progress with their emotions and decisions to move forward. The time we take with these patients is not wasted because it is quality time during which we build mutual trust.