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 Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 46-49

Closure of midline diastema through combined surgical and Removable orthodontic approach


1 Department of Pedodontics and Preventive Dentistry, H.P. Government Dental College, Shimla, Himachal Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India
3 Department of Community Medicine, Indira Gandhi Medical College and Hospital, Shimla, India

Date of Web Publication22-Aug-2013

Correspondence Address:
Deepak Chauhan
Department of Pedodontics and Preventive Dentistry, H.P. Government Dental College, Shimla - 171 001, Himachal Pradesh
India
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DOI: 10.4103/0976-433X.116836

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  Abstract 

Midline diastema is a common aesthetic problem in mixed and permanent dentition. Many innovative therapies are varying from restorative procedures such as composite build-up to surgery (frenectomy) and orthodontics are available. A high frenum attachment is often the cause of persistent diastemas. Presented herewith is a case report of a 13-year-old girl with a high frenal attachment that had caused spacing of the maxillary central incisors. This case report demonstrates the removal of the abnormal labial frenum attachment through surgery and subsequent closure of maxillary diastema following removable orthodontic treatment.

Keywords: High frenum, frenectomy, maxillary midline diastema


How to cite this article:
Chauhan D, Kirtaniya B, Tuli A, Chauhan T. Closure of midline diastema through combined surgical and Removable orthodontic approach. SRM J Res Dent Sci 2013;4:46-9

How to cite this URL:
Chauhan D, Kirtaniya B, Tuli A, Chauhan T. Closure of midline diastema through combined surgical and Removable orthodontic approach. SRM J Res Dent Sci [serial online] 2013 [cited 2019 Jul 18];4:46-9. Available from: http://www.srmjrds.in/text.asp?2013/4/1/46/116836


  Introduction Top


Maxillary anterior spacing or diastema is a common aesthetic complaint of patients or parents and is frequently seen in the mixed and permanent dentition stage. Keene described midline diastema as anterior midline spacing greater than 0.5 mm between the proximal surfaces of adjacent teeth. He reported that the incidences of maxillary and mandibular midline diastema are 14.8% and 1.6%, respectively. [1] Midline diastema may be considered normal for many children during the eruption of the permanent maxillary central incisors. When the incisors first erupt, they may be separated by bone and the crowns incline distally because of the crowding of the roots. With the eruption of the lateral incisors and permanent canines, the midline diastema reduces or even closes. Taylor reported the incidence of midline diastema in 5 year olds as high as 97% and seen decreasing with age. [2],[3] Maxilla had a higher prevalence of midline diastema than the mandible. [4] Angle concluded the presence of abnormal frenum as the cause for midline diastema and this view was supported by other researches. [5],[6],[7],[8]

Weber listed the causes for spacing between the maxillary incisors as: A result of high frenum attachment; microdontia; macrognathia; supernumerary teeth; peg laterals; missing lateral incisors; midline cysts and habits such as thumb sucking, mouth-breathing and tongue-thrusting. [9]

An accurate diagnosis is necessary before treatment can be initiated. No treatment should be initiated if the diastema is physiological and usually if the canines have not erupted. Different treatment modalities for midline diastema include removal of etiology and simple removable appliances incorporating finger springs or split labial bow. Gleghorn reported a direct composite restoration technique to correct unaesthetic diastema. [10] Munshi and Munshi reported extraction of mesiodens subsequently followed by the space closure utilizing simple fixed orthodontic therapy. [11] Nakamura et al., reported a ceramic restoration of anterior teeth without proximal reduction. Here, we present a case of spontaneous closure of midline diastema after frenectomy with removable orthodontic appliances. [12]


  Case Report Top


An 13-year-old girl reported to the Department of Pedodontics and Preventive Dentistry of Himachal Dental College and Hospital, Sunder Nagar with the chief complaint of spacing in the upper front region. Patient's medical history did not reveal any systemic diseases. Intra-oral periodical radiograph (X-ray) was taken to find out the cause of diastema and to rule out the presence of any unerupted mesiodens. On intra-oral examination revealed presence of high frenal attachment and midline spacing between maxillary central incisors (8 mm) [Figure 1]. A simple diagnostic test, i.e., blanching test was performed for an abnormal high frenum by observing the location of the alveolar attachment when intermittent pressure was exerted on the frenum. If a heavy band of tissue with a broad, fanlike base is attached to the palatine papillae and produces blanching of the papilla, it is safe to predict that the frenum will unfavorably influence the development of the anterior occlusion.
Figure 1: Pre-operative photograph showing high frenal attachment with midline diastema

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After obtaining informed written consent from the parents, decision was made to remove high frenal attachment by a surgical technique [Figure 2]. Frenectomy was carried out under local anesthesia with incision using No. 11 Bard Parker blade. In this technique, lateral incisions were made on either side of the frenum to the depth of the underlying bone. The free marginal tissues on the mesial side of the central incisors were not disturbed. The wedge of tissue was picked up with tissue forceps and excised with tissue shears at the area close enough to the origin of the frenum to provide a desirable cosmetic effect. Sutures were placed to identify the free tissue margins on either side of the removed tissue and periodontal pack was placed for a week. Patient was advised to return after a week for suture removal and periodical follow-up once a month. Patient was followed-up for a period of 4 months, at the end a remarkable improvement in the aesthetics was observed due to spontaneous closure of midline diastema.
Figure 2: Incision given

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Sutures were placed for a week [Figure 3]. The patient was advised to return after a week for suture removal [Figure 4] and finger springs appliance with anterior bite plane was delivered and periodic follow-up advised [Figure 5]. In the meantime incisal capping and flaring of the lower incisors were carried out to relieve the anterior deep bite [Figure 6]. Patient was followed-up for a period of 6 months, at the end a remarkable improvement in the aesthetics was observed due to closure of midline diastema [Figure 7].
Figure 3: Sutures being placed

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Figure 4: Post surgical photograph

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Figure 5: Hawley's appliance with finger springs & anterior bite plane

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Figure 6: Incisal caping for intrusion of lower incisors

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Figure 7: Post treatment photograph of the patient

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  Discussion Top


A diastema is a space or "gap," most often seen between the two upper front teeth sometimes in the lower anterior region also. In the early and late mixed dentition stages, it is normal to have a diastema, but it eventually closes during further development. Often, parents are more conscious about the spaces between front teeth of their children and seek treatment for the aesthetic reason. However, a diastema can also affect the speech, thereby certain sounds like "S" is not pronounced properly. During this the tongue pushes forward to close the space thereby a constant tongue pressure can make the diastema worse over time. Campbell et al., stated that midline diastema could be transient or created by developmental, pathological or iatrogenic factors. [13] Like oral habits, soft-tissue imbalance, physical impediment, dental anomalies and skeletal disharmonies. In this case, the high frenal attachment was the major etiological factor causing midline spacing. Treatment of diastema varies and it requires correct diagnosis of its etiology and early intervention relevant to the specific etiology. Correct diagnoses includes medical and dental history, radiological and clinical examination and possibly tooth size evaluation. [14] No treatment is usually initiated if the diastema is physiological/transient as it spontaneously closes after the eruption of permanent maxillary canines (11-12 years). Removal of the etiologic factor usually can be initiated upon diagnosis and after sufficient development of the central incisor. Follin reported that some pathological causes like supernumerary teeth and midline cysts can be removed surgically and orthodontic closure of the space from both sides performed with removable appliance, leaving the remaining central incisor in the midline. A retainer was bonded to prevent relapse. [15] According to Springate and Sandler, the use of neodymium-iron-boron micro-magnets as a fixed retainer can be used for treating midline spacing. [16] Putter et al., reported two combined modalities of treatment with orthodontic and porcelain laminate placement to facilitate diastema closure. In his report, Geristore, a dual-cure fluoride-releasing composite was mixed to bond orthodontic brackets in place. H-6 elastic bands were used with the orthodontic brackets to close the diastemas sufficiently and to allow the placement of cerinate porcelain laminates to produce a beneficial cosmetic effect. [17] According to Attia, if the diastema results from the congenital absence of a lateral incisor, initial treatment is to bring the central incisors together, followed by moving the canines forward into the lateral position or by moving them distally to allow for prosthetic replacement. [18] In other cases, unusually small central or lateral incisors may result in a diastema. Here too, reconstruction by bonding or jacket crowns will solve the problem. According to Kinderknecht and Kupp, resin-bonded porcelain veneer restorations can be used to correct diastema caused by tooth position or discrepancies in the tooth size/arch development. [19]

In the present case, frenectomy was done because the etiology was traced to high frenal attachment. Usually, the space closure in the anterior segment is delayed till the eruption of the permanent canine, but in the present case permanent canines were already erupted. This is because there is going to be mesial migration during the active stage of canine eruption. Thus, in our case, an attempt was made to remove the etiology; this resulted in the spontaneous closure of the midline diastema in 6 months. Patient was followed-up for 3 months during which there was no change in the closed midline space. The patient has been followed-up through regular recall for monitoring any changes in the anterior region. In general, abnormal frenal attachment may require removal either before orthodontic treatment or at the end of active treatment. The advantage of excision prior to orthodontic treatment is the ease of surgical access. If the surgery is performed before the orthodontic procedure, the scar tissue might impede the closure of diastema, but the noted advantages of excision after orthodontic tooth movement is the scar tissue formation, which helps to maintain closure of diastema. Spilka and Mathews stated that in spite of the success and excellent results, orthodontists have a problem in correcting dental abnormalities, one particular area, which lends itself to relapse, is the diastema between the incisors. [20] The surgical correction of a diastema has been successfully accomplished with removable orthodontic treatment in patients excepting a rapid correction. Hence, in present case, the advantages of timely intervention leads to less expensive treatment and requires minimal patient compliance. Early developing malocclusion should be intercepted with the goal of restoring a normal occlusion. The timing and degree of interception are the major problems to be dealt properly, which can produce positive result as seen in the present case.


  Acknowledgments Top


We acknowledge the cooperation of all individuals who participated in this study.

 
  References Top

1.Keene HJ. Distribution of diastemas in the dentition of man. Am J Phys Anthropol 1963;21:437-41.  Back to cited text no. 1
    
2.Taylor JE. Clinical observations relating to the normal and abnormal frenum labii superians. Am J Orthod 1939;25:646-60.  Back to cited text no. 2
    
3.Oesterle LJ, Shellhart WC. Maxillary midline diastemas: A look at the causes. J Am Dent Assoc 1999;130:85-94.  Back to cited text no. 3
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4.Kaimenyi JT. Occurrence of midline diastema and frenum attachments amongst school children in Nairobi, Kenya. Indian J Dent Res 1998;9:67-71.  Back to cited text no. 4
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5.Angle EH. Treatment of Malocclusion of the Teeth. 7 th ed. Philadelphia: S.S. White Dental Manufacturing Co.; 1907. p. 103-4.  Back to cited text no. 5
    
6.McCoy JD. Applied Orthodontia. 2 nd ed. Philadelphia: Lea and Febiger; 1946. p. 72, 96-7.  Back to cited text no. 6
    
7.Stones HH. Oral and Dental diseases. 2 nd ed. Edinburgh: E and S Livingstone Ltd.; 1951. p. 19-21, 211.  Back to cited text no. 7
    
8.Sicher H. Oral Anatomy. 2 nd ed. St. Louis: The C.V. Mosby Co.; 1952. p. 185, 272-3.  Back to cited text no. 8
    
9.Graber TM. Orthodontic principles and practice. 3rd ed. Philadelphia: WB Saunders Co.; 1972. p. 189-202. Available from: http://www.abebooks.co.uk/9780721641829/Orthodontics-Principles-Practice-Graber-0721641822/plp [Last accessed Jul 2012].  Back to cited text no. 9
    
10.Gleghorn T. Direct composite technique for a smile makeover. Dent Today 1997;16:40, 42, 44.  Back to cited text no. 10
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11.Munshi A, Munshi AK. Midline space closure in the mixed dentition: A case report. J Indian Soc Pedod Prev Dent 2001;19:57-60.  Back to cited text no. 11
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12.Nakamura T, Nakamura T, Ohyama T, Wakabayashi K. Ceramic restorations of anterior teeth without proximal reduction: A case report. Quintessence Int 2003;34:752-5.  Back to cited text no. 12
[PUBMED]    
13.Campbell PM, Moore JW, Matthews JL. Orthodontically corrected midline diastemas. A histologic study and surgical procedure. Am J Orthod 1975;67:139-58.  Back to cited text no. 13
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14.Huang WJ, Creath CJ. The midline diastema: A review of its etiology and treatment. Pediatr Dent 1995;17:171-9.  Back to cited text no. 14
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15.Follin ME. Orthodontic movement of maxillary incisor into the midline. A case report. Swed Dent J 1985;9:9-13.  Back to cited text no. 15
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16.Springate SD, Sandler PJ. Micro-magnetic retainers: An attractive solution to fixed retention. Br J Orthod 1991;18:139-41.  Back to cited text no. 16
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17.Putter H, Huberman A, Scherer W. Diastema closure: A case report. J Esthet Dent 1992;4 Suppl:9-11.  Back to cited text no. 17
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18.Attia Y. Midline diastemas: Closure and stability. Angle Orthod 1993;63:209-12.  Back to cited text no. 18
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19.Kinderknecht KE, Kupp LI. Aesthetic solution for large maxillary anterior diastema and frenum attachment. Pract Periodontics Aesthet Dent 1996;8:95-102.  Back to cited text no. 19
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20.Spilka CJ, Mathews PH. Surgical closure of diastema of central incisors. Am J Orthod 1979;76:443-7.  Back to cited text no. 20
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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Abstract
Introduction
Case Report
Discussion
Acknowledgments
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