Midline diastema closure...

2. CASE PRESENTATION
Dr. M.Arsalan Zubair
MDS Trainee (Semester III)
Operative Dentistry Department
Dow Dental College
DUHS

3. PATIENT’S PERSONAL DATA
• Age: 35 years
• Sex: Female
• Address: malir
• Occupation: nil (house wife)
• Religion: Islam

4. PRESENTING COMPLAINT
Complain of gap between central and lateral incisor, which gives an
unpleasant appearance and also has sensitivity in upper right posterior
teeth
HISTORY OF PRESENTING
COMPLAINT
The gap was present since her childhood
And the sensitivity was since one year.

5. MEDICAL HISTORY
Not significant.
FAMILY HISTORY
Not significant
DENTAL HISTORY
Extractions:
66
Patient recently visited dow dental college for scaling

6. Extraoral examination
• TMJ examination:
- Symmetry: Symmetrical
- Deviation: Absent
- Clicking sound: Absent
- Tenderness: Absent
• Lymph node examination: Normal
• Swelling: Absent

7. CLINICAL EXAMINATION
• Teeth present:
• Teeth Missing:
• Carious Teeth:
8,7,5,4,3,2,1 1,2,3,4,5 6,7
7,5,4,3,2,1 1,2,3,4,5,7
6,8
7 (class 1)
INTRA ORAL EXAMINATION
8
8,6
7 (Class 1)
7 (Class 1)

8. Dynamic:
Group function Canine guidance
• Static:
• (I) (I) (I) (I)
• Canine C I I C
• Incisor
• Over jet : 4mm
• Overbite: 3mm
Occlusal Examination

9. Periodontal Examination
Pocket Depths
11 0.5 0.5 0.5 1 0.5 1
12 0.5 0.5 1 0.5 0.5 0.5
13 0.5 0.5 0.5 0.5 0.5 0.5
14 2 1 2 0.5 0.5 0.5
15 2 1 2 2 1 2
16 2 1 2 2 1 2
No: F(Mes) Mid Distal P(Mes) Mid Distal
17 1 2 2 2 1 1
18 1 1 1 1 1 1

10. 21 0.5 1 0.5 0.5 0.5 0.5
22 0.5 0.5 0.5 0.5 0.5 0.5
23 0.5 1 1 0.5 0.5 0.5
24 2 0.5 1 0.5 0.5 0.5
25 0.5 0.5 0.5 0.5 0.5 0.5
26 1 0.5 0.5 0.5 0.5 0.5
27 1 1 1 2 1 1

11. 31 0.5 0.5 0.5 0.5 0.5 0.5
32 0.5 0.5 0.5 0.5 0.5 0.5
33 0.5 0.5 0.5 0.5 0.5 0.5
34 0.5 0.5 0.5 0.5 0.5 0.5
35 0.5 0.5 0.5 0.5 0.5 0.5
37 0.5 0.5 0.5 0.5 0.5 0.5
41 0.5 0.5 0.5 0.5 0.5 0.5
42 0.5 0.5 0.5 0.5 0.5 0.5
43 0.5 0.5 0.5 1.5 0.5 0.5
44 0.5 0.5 0.5 0.5 0.5 0.5
45 1.5 0.5 0.5 0.5 0.5 0.5
47 0.5 0.5 0.5 0.5 0.5 0.5

12. Plaque and Gingival index
A film of plaque adhering to the free gingival margin and
adjacent area of the tooth, which can not be seen with
the naked eye. But only by using disclosing solution or by
using probe
No plaque
Moderate accumulation of deposits within the gingival
pocket, on the gingival margin and/ or adjacent tooth
surface, which can be seen with the naked eye
Abundance of soft matter within the gingival pocket
and/or on the tooth and gingival margin.
No inflammation
Mild inflammation, slight change in color, slight
edema, no bleeding on probing.
Moderate inflammation, moderate glazing, redness,
bleeding on probing
Severe inflammation, marked redness and
hypertrophy, ulceration, tendency to spontaneous
bleeding
0
1.
3
2
1.
3
2
0

13. • On the basis of above criteria the plaque status was
“2” because plaque was observed with the naked eye
and gingival status was given score 1 because mild
inflammation was seen.
• No mobility of tooth was observed

17. Smile analysis

18. • Canine to canine can be seen easily
• Part of mid-incisal area of lower mandibular
teeth can be seen
• Patient gums are also seen which make it a
gummy smile.
• Central incisors are prominent

19. Clinical findings
• In maxillary arch ,spacing is seen in Maxillary
central incisors
• Space is also present between central incisors
and lateral incisors as well but this space is
smaller than central incisors
• Space is also observed between lateral incisors
and canine as well, which is very large and
cannot be closed by restoration. Orthodontic
intervention is mandatory for closing this
space.

20. • Facial midline shift was also observed

21. • Right central Incisor is labially placed to the
arch form
• Spacing is also observed in the right canine
and premolar as well
• Palate is shallow
• Maxillary arch is large.
• No spacing is observed in Mandibular arch.

22. DIFFERENTIAL DIAGNOSIS
• Midline diastema
• Distal crown inclination
• Missing teeth
• Peg shaped laterals

23. Comparison between distal crown
inclination & diastema
• Crowding is not observed
• Both the centrals are
separated with each other
• No inclination is observed
• Crowding Is observed
• Both the centrals are in
contact at the cervical area of
the crown
• Distal inclination is observed

24. • Lateral incisors are
present
• Lateral incisors are
congenitally absent
Comparison between Congenitally
missing teeth & diastema

25. • Peg shaped laterals are
observed
• Mal-aligned teeth are
observed
Comparison between Peg-shaped
laterals & diastema
• No Peg shaped laterals
are observed
• No Mal-aligned teeth
are observed

26. Diagnosis
Midline diastema

27. Causes of midline diastema
• Genetics
• Superior labial frenum
• Anterior traumatic bite
• Oral habits
• Supernumerary teeth
• Tooth and arch size discrepancy
• Pathologic migration of teeth
• Odontomas occuring in the maxillary midline
• Developmental cyst in the oro-facial midline
• Flaccid lips
Bishara SE, Jakobsen JR. Individual variation in tooth size-arch length. World J Orthod 2006

28. Etiology of my case
Tooth and Arch Size Discrepancy
because all the teeth are of normal size and
spacing is also observed generally.
Lamberton CM, Reichart PA, Triratananimit. Tooth size-arch length changes
from the primary to permanent dentitions. World J Orthod 2009

29. Measurements and Investigation
• Length and width of right central incisors = 9mm
• Length and width of right central incisors = 9mm
• Length and width of right central incisors = 7mm

30. Midline space
• Space between central incisors are seen which was
measured and found to be 1.5mm

31. Midline shift
• Midline shift was also observed which was about 1.5mm
away from the mid line

32. Cast

33. Bite registration

34. TREATMENT PLAN (initial)
• Oral hygiene instructions
• Diet modification
• Fluoridated tooth paste and mouth wash
• Topical fluoride application
• Ultrasonic scaling

35. Prediction of the fate of midline
diastema
• It claimed to have an accuracy of 88%
Sanin’s prediction is as follows:
Space between mixed dentition Possibility of space closure
1mm 99%
1.5mm 85%
1.85mm 50%
2.7mm 1% ( Treatment either ortho or
restorative approach is
mandatory)
Dent Update 2014; 41: 457–464

36. Treatment options
• Different treatment modalities include
restoration, orthodontics, prosthodontics,
surgery, and various combinations
• Direct composite restoration
• Orthodontic and porcelain laminate
placement
• Orthodontic procedures
Willhite C. Diastema closure with freehand composite: Controlling emergence contour.
Quintessence Int 2005;36:138-4

37. Classifying Diastema according to
treatment Plan
Diastema Size Treatment
Mild 1mm or less Direct composite( with
enamel shade only)
Moderate More than 1mm but less
than 2.5 mm
Direct composite
restoration ( with enamel
along with dentine shade is
used)
Severe size More than 2.5 mm Direct veneering +
orthodontic movement
Summit’s fundamental of Operative Dentistry 4th edition

38. Treatment Plan of my Case
• According to the above table, my case falls in
moderate category of midline diastema. So the
final treatment plan will be direct composite
restoration ( enamel + dentine shade are used)

39. Final treatment plan was done
according to severity
Midline Diastema can be closed by direct
composite restoration.
1. First the Diagnostic wax-up is made in order to
judge the favourable outcome. So wax is added to
the distal surface of right and left central incisor.
2. In the First step, the composite shade selection is
done which is A2 Enamel and Dentine.
3. No preparation is done.

40. 4. Adequate isolation is needed so rubber dam is
placed, quadrant isolation is done from 1st
premolar to 1st premolar of both the arches
5. Then the basic steps of restorations is followed
6. Then rubber dam is removed
7. Then finishing of the composite is done

41. Cast Mock up

42. Shade selection

43. Quadrant isolation is done from 1st
premolar to 1st premolar

44. Midline diastema along with lateral
diastema closed

45. Before
After

46. Midline shift corrected

47. Problems
• Both the incisors get more prominent due to
increase in size
• Shade selection was not that adequate
• Normal squarish shape of both the incisors is
not followed

48. Thank you