Positioning Peg Laterals & Undersized Lateral Incisors for Optimal Aesthetics 

April 14, 2023 Lee Ann Brady DMD

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.

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E1: Aesthetic & Functional Treatment Planning

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Transform your experience of practicing dentistry, increase predictability, profitability and fulfillment. The Essentials Series is the Key, and Aesthetic and Functional Treatment Planning is where your journey begins.  Following a system of…

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About Author

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Lee Ann Brady DMD

Dr. Lee Ann Brady is passionate about dentistry, her family and making a difference. She is a general dentist and owns a practice in Glendale, AZ limited to restorative dentistry. Lee’s passion for dental education began as a CE junkie herself, pursuing lots of advanced continuing education focused on Restorative and Occlusion. In 2005, she became a full time resident faculty member for The Pankey Institute, and was promoted to Clinical Director in 2006. Lee joined Spear Education as Executive VP of Education in the fall of 2008 to teach and coordinate the educational curriculum. In June of 2011, she left Spear Education, founded leeannbrady.com and joined the dental practice she now owns as an associate. Today, she teaches at dental meetings and study clubs both nationally and internationally, continues to write for dental journals and her website, sits on the editorial board of the Journal of Cosmetic Dentistry, Inside Dentistry and DentalTown Magazines and is the Director of Education for The Pankey Institute.




The Importance of the Pre-clinical Interview 

April 7, 2023 Daren Becker DMD

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.

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About Author

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Daren Becker DMD

Dr. Becker earned his Bachelors of Science Degree in Computer Science from American International College and Doctor of Dental Medicine from the University of Florida College of Dentistry. He practices full time in Atlanta, GA with an emphasis on comprehensive restorative, implant and aesthetic dentistry. Daren began his advanced studies at the Pankey Institute in 1998 and was invited to be a guest facilitator in 2006 and has been on the visiting faculty since 2009. In addition, in 2006 he began spending time facilitating dental students from Medical College of Georgia College of Dentistry at the Ben Massell Clinic (treating indigent patients) as an adjunct clinical faculty. In 2011 he was invited to be a part time faculty in the Graduate Prosthodontics Residency at the Center for Aesthetic and Implant Dentistry at Georgia Health Sciences University, now Georgia Regents University College of Dental Medicine (formerly Medical College of Georgia). Dr. Becker has been involved in organized dentistry and has chaired and/or served on numerous state and local committees. Currently he is a delegate to the Georgia Dental Association. He has lectured at the Academy of General Dentistry annual meeting, is a regular presenter at ITI study clubs as well as numerous other study clubs. He is a regular contributor at Red Sky Dental Seminars.