How to improve a “Pegged Laterals” smile

In this case I will show you step by step, how I improved this patient’s smile. You can see from the before and after photo, that she is not only smiling wider, but also showing more teeth with lots more confidence.

So if we focus on the top teeth to begin with, there are a number of reasons why these teeth aren’t creating a perfect smile.

The two most obvious reason are that the teeth are in the wrong positions and there is a lot of crowding.

Secondly, if the teeth did happen to be straight, these two teeth would still be out of harmony.

This is because these teeth are smaller in size and referred to as ‘pegged laterals’.

These are normal teeth but they have just developed smaller in size that they should have done.

When thinking about the perfect smile, when we look at the teeth we want them to be bigger at the front centre of the mouth and then their appearance to be smaller and less prominent as we get further towards the back of the mouth (or the corners of the smile).

With regards to the bottom teeth, the gums look raw and red which is a sign that there is gum disease present, and there are a couple of teeth that are overly stained.

This is common where a tooth position is further back and therefore it gets missed by the toothbrush.

The patient had a couple of visits with the hygienist to get rid of all this surface staining and these sessions also got rid of all the gum disease so that I was able to start the treatment.

This patient effectively has too many teeth in her mouth, and not enough space in her jaw bone to straighten everything out.

So what I did in this case was to remove a couple of teeth strategically.

Usually these are the teeth that are in the worst condition or in this patient’s case, where the teeth were all in a good condition, I took out the teeth that would give us the correct amount of space to straighten out all the remaining teeth.

In this case the patient needed to have two teeth removed from her bottom teeth and two from her top teeth.

Braces were then placed to straighten the front teeth using the spaces created, and in doing this there would be no gaps remaining at the end of treatment.

In all this took between 12 and 18 months to do.

Towards the end of the treatment the fine tuning took place.

Above, you can see that I modified the wire, and it is no longer a completely straight wire going across the teeth.

The reason for this is that I wanted to lift the gum higher on the pegged laterals (smaller teeth), and because the teeth are smaller in size, customisations have to be made to otherwise standard braces in order to get the perfect end result.

So by bending the wire I was able to push the teeth up, get them level (so the teeth are level when the patient ran her tongue against the teeth), and to get the gum line as symmetrical as possible to minimise the amount of tweaks needed in the final stage.

This is how everything looked when the braces were removed and you can see how small these pegged laterals really are.

When designing a smile, it is really important to think about the axial alignment of the teeth.

What this means is that, the back teeth need to be slanting in a slightly, while the front teeth are straighter and in a more vertical plane.

As we move from the centre of the mouth toward the back the teeth should also gradually be slanting more, giving a really nice aesthetic result.

There are slight gaps either side of the pegged lateral teeth. This is deliberately planned and I will explain this shortly.

You may also be wondering why the gum around these laterals doesn’t look right? This is because I have used a laser to painlessly sculpt the gum line to get this axial alignment.

If this wasn’t done then and the tooth was left in a more vertical plane then it would just look odd.

In this case the gum is sculpted so that the highest point is not in the middle of the tooth but rather in the direction slightly towards the back of the mouth

The patient then had two temporary veneers places over the pegged laterals, and once happy with the size and shape the final porcelain veneers were custom made and bonded in place.

This was what the final result looked like:

Overall, we came a long way from the starting point, and no one will be able to tell that she had veneers on the laterals. The only thing left is to whiten her teeth.