Restoring the Peg Lateral Incisor
Dennis Hartlieb
Restoring the Peg Lateral Incisor
I want to share with you today my thoughts and considerations for treating the maxillary peg lateral incisor. While at first glance, the maxillary peg lateral restoration may seem to be pretty straight forward, there are several factors to consider when evaluating these patients for cosmetic dental treatment.
Commonly, other teeth in the maxillary arch are smaller than normal. Research by Jane Wright for her master thesis at Marquette University School of Dentistry, found that the teeth in the maxillary arch can be significantly narrower than average, from 2nd bicuspid to 2nd bicuspid.
Unfortunately, it has been my experience for orthodontists to ignore the issue that many other teeth are narrower than average, and close all spaces, leaving a very large diastema between the canine and the peg lateral. This will most often create a non-restorable clinical situation for the restorative dentists.
Commonly, other teeth in the maxillary arch are smaller than normal. Research by Jane Wright for her master thesis at Marquette University School of Dentistry, found that the teeth in the maxillary arch can be significantly narrower than average, from 2nd bicuspid to 2nd bicuspid.
Unfortunately, it has been my experience for orthodontists to ignore the issue that many other teeth are narrower than average, and close all spaces, leaving a very large diastema between the canine and the peg lateral. This will most often create a non-restorable clinical situation for the restorative dentists.
Therefore, it is absolutely paramount that all teeth in the maxilla be measured to understand if tooth proportions are appropriate in the esthetic zone, and thus determine if there should be ‘sharing’ of spacing with other teeth to minimize the non-restorable oversized diastema.
Orthodontic Positioning of Teeth
Improved Orthodontic Positioning ‘Sharing’
I have also found that it is not uncommon for one or more maxillary teeth to have atypical form in the peg lateral patient. I see this with cuspids especially, but also with the central incisors. It is not unusual that the central incisors are not symmetrical in these peg lateral cases. These aberrant tooth forms will dictate that other teeth, beyond the peg lateral incisors, may need to be treated to create naturally appearing restorations.
Abnormal Tooth Form Right Maxillary Canine.
Finally, and I think a very big issue, I frequently see that there is altered passive eruption, or incomplete gingival tissue migration related to the maxillary dentition, in these peg lateral patients. These patients will often present with short clinical crowns and a gummy smile.
Based on research by Dr. Bill Robbins, we should anticipate that the free gingival margins of the maxillary teeth should be close to the CEJ’s, when the adolescent is around 16 years old.
To differentiate between just a short clinical crown, and to evaluate if there is altered passive eruption, I use an explorer and run the tip under the free gingival margin into the sulcus. I feel for the transition between the smooth enamel surface, and the more ‘pebbly’ feel of the root surface. If, while moving the explorer under the surface, I only feel smooth enamel, likely, the soft tissue has not migrated apically, exposing the full clinical crown of the tooth.
For reference, the average unworn maxillary central incisor is between 10.5-11.5 mm long (based on research by Belser, Magne and others). A normal lateral incisor should be about 9.5 mm, and a canine should measure similar to the maxillary central incisor. In many situations, esthetic crown lengthening is necessary before the cosmetic treatment, to create naturally appearing restorations.
Based on research by Dr. Bill Robbins, we should anticipate that the free gingival margins of the maxillary teeth should be close to the CEJ’s, when the adolescent is around 16 years old.
To differentiate between just a short clinical crown, and to evaluate if there is altered passive eruption, I use an explorer and run the tip under the free gingival margin into the sulcus. I feel for the transition between the smooth enamel surface, and the more ‘pebbly’ feel of the root surface. If, while moving the explorer under the surface, I only feel smooth enamel, likely, the soft tissue has not migrated apically, exposing the full clinical crown of the tooth.
For reference, the average unworn maxillary central incisor is between 10.5-11.5 mm long (based on research by Belser, Magne and others). A normal lateral incisor should be about 9.5 mm, and a canine should measure similar to the maxillary central incisor. In many situations, esthetic crown lengthening is necessary before the cosmetic treatment, to create naturally appearing restorations.
‘Gummy’ smile demonstrating altered passive eruption.
Crown lengthening procedures completed.
Final bonded restorations canine and lateral incisor.
In conclusion, regardless of the restorative material that you will be using to restore the peg lateral incisor, evaluate the other teeth in the arch for tooth size and form to determine if other teeth need cosmetic restorative treatment to create normal tooth form. Additionally, consider if the tissue height is appropriate and if crown lengthening procedures should be recommended before restoring the case.
Yours for better dentistry,
Yours for better dentistry,
Dennis Hartlieb, DDS, AAACD
DOT Founder
Join 3,000+ dentists who get monthly restorative dentistry tips
Share this page
Latest from our blog
Our vision is to provide online continuing education workshops and mentorship that are comprehensive for dentists learning at all career levels. DOT is developed for dentists that love to learn online.
CONNECT
Write your awesome label here.
Join over 10,000+ dentists who get restorative tips bi-weekly!
Check your inbox! We will send you the video in the next few minutes.
Materials Included
Light Brown tints, Enamelize, Unfilled Resin Flexidiscs, Flexibuffs 1/2", #1 artist’s brush, Silicone Polishing Points, IPC Off Angle Short Titanium Coated Composite Instrument
Materials Needed, not Included
- Loupes
Meet Dr. Dennis Hartlieb
Dr. Dennis Hartlieb owns his own practice in Chicago,IL and has been teaching dentistry for over 30 years. Dr. Hartlieb is the CEO and the main instructor at Dental Online Training. He is an active member in the American Academy of Cosmetic Dentistry where he’s both an Accredited Member and Examiner for Accreditation.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Meet Dr. Angela Luek
Dr. Angela M. Lueck is a Wisconsin native and was the youngest female in her class from Marquette University in 1998. Since completing her residency she has consistently taken more than 100 hours a year of continuing education to keep current on the latest trends, techniques, and materials available in dentistry.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
Meet Clare O'Neill
Clare O’Neill is the Director of Operations at Dental Online Training and has a professional background in digital marketing. Clare has certifications in content marketing and digital advertising. Clare has expertise in social media marketing, email marketing, content marketing, website management, and project management. Clare has been using Canva for over 5 years and is a self-proclaimed Canva Queen.
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Meet Dr. Jim Mckee
Dr. McKee is a member of the Spear Resident Faculty. He has maintained a private practice since 1984 in Downers Grove, Illinois where he treats a wide variety of cases with a focus on predictable restorative dentistry. He is a member of the American Academy of Restorative Dentistry and former president of the American Equilibration Society.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
Meet Kirk Behrendt
Kirk Behrendt is a renowned consultant and speaker in the dental industry, known for his expertise in helping dentists create better practices and better lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
Meet Dr. Melissa Seibert
Melissa Seibert is a comprehensive dentist proudly serving in the Air Force. She holds a dual faculty appointment at Uniformed Services University and Creighton Dental School. She serves on the editorial board for Inside Dentistry.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Meet Olivia Wisden
Olivia Wisden is the founder & CEO of TwoLips Creative. What started as an events discovery app pivoted into a creative agency that specializes in working with startups, small businesses, and organizations who are looking for bold, impactful designs and strategies.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
Meet Dr. Sofya Kats
Dr. Sofya Kats is local to Milwaukee, WI. She grew up in Bayside and attended Nicolet HS, UW-Milwaukee and Marquette University School of Dentistry. Dr. Kats is a member of the Greater Milwaukee Dental Association, Wisconsin Dental Association, American Dental Association, and The Forum Study Club (oldest Dental Study Club in the United States).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Materials Included
Materials Needed, not Included
- Loupes