Closing a Gap Caused by Peg Laterals

The Patient's Journey

This patient was self-conscious about his smile and had consulted several dentists beforehand without being offered a plan he considered acceptable. That is a recognizable pattern where the visible complaint and the underlying cause are different things. A proposal addressing only the visible complaint sounds inadequate to the person living with it.

The visible complaint was spacing, including a distinct gap between the two central incisors. The cause was elsewhere.

Understanding the Challenge

His lateral incisors were peg laterals, a developmental variation in which the tooth forms narrower and more conical than normal instead of developing a full width. Two undersized teeth leave an arch containing more space than teeth to occupy it, and that surplus space redistributes itself. In his case the central incisors had drifted apart into the territory a full-width lateral would have occupied, which produced the diastema he had come in about.

The obvious proposal is veneers on the central incisors, closing the visible gap. It also leaves the laterals conspicuously undersized, and it widens two teeth that were already the widest in the arch, so the proportions deteriorate rather than improve.

Correcting the proportions properly runs into a geometric constraint. A tooth has a characteristic ratio of width to length, and widening a short tooth without lengthening it produces a square tooth that looks wrong for reasons most people cannot articulate but register immediately. The laterals could not simply be made wider. They had to become longer first.

The additional length was not available from the teeth, which were already fully erupted, so it had to come from the tissue above them, which is the only other place in the mouth where length can be obtained.

How Dr. Mehdizadeh Approached Treatment

The design came first, and it specified the finished length and width of all twelve upper restorations. Designing before any intervention is what made the remainder of the treatment measurable, because the amount of tissue repositioning required is calculated from the finished proportions rather than estimated in advance of knowing them.

The lower teeth were whitened and the shade allowed to stabilize. They were not restored. Twelve upper veneers had to be matched to natural teeth below them, and natural teeth have to reach their final color before anything is matched to them.

The gum lifting followed, providing the additional length the design required at the laterals and the centrals. Lengthening the laterals permitted a proportional increase in their width, and lengthening the centrals permitted them to be widened sufficiently to eliminate the diastema without becoming disproportionate. The width was redistributed across the arch instead of being concentrated on the two teeth that already had the most of it.

Provisional restorations were placed and revised in the mouth against the design. The approved shapes were then reproduced as twelve porcelain veneers in e.max. All of them were designed and fabricated in the practice's own laboratory by its master ceramist.

The Result After Ten Weeks

The spacing is eliminated, the diastema is closed, and the lateral incisors are proportionate to the teeth surrounding them rather than conspicuously narrow. Six appointments across ten weeks covered the design, the whitening of the lower teeth, the gum lifting and its healing period, the provisional phase and the final cementation of all twelve restorations.

Only the upper teeth carry restorations. The lower teeth are his own, whitened rather than covered with ceramic, and natural teeth gradually accumulate stain again while porcelain retains its color. Maintaining the match between the arches is therefore a matter of hygiene and occasional re-whitening rather than something concluded at cementation.