Midline Diastema Etiology and Management

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Department of Pediatric DentistryDepartment of Pediatric Dentistry
Midline diastema - EtiologyMidline diastema - Etiology
& Management& Management

IntroductionIntroduction
Midline diastema refers to
an anterior midline
spacing between two
maxillary central incisors
• It is one of the most
frequently seen
malocclusion.
• It is space present more
than 0.5 mm.
• It is easy to treat but
difficult to retain. www.indiandentalacademy.comwww.indiandentalacademy.com

EtiologyEtiology
• The midline spacing can be result of number of
causes.
1) Normal developing dentition -
• Around the age of 8 years a midline diastema is
commonly seen in the upper arch.
• Crown on the canine in young jaw impinges on
developing lateral incisor roots,
Driving the root medially and causing the crowns to
flare laterally
The roots of the central incisors are also forced together
thus causing a maxillary midline diastema.

2)Parafunctional habit -
• Flaccid lip - The upper lip is generally hypotonic
while the lower part of the face exhibit hyperactive
mentalis activity a poor muscle tone.
• Tongue thrust – May cause anterior openbite and
diastema.
• Thumb/digit sucking over a prolonged period causes
proclined anterior teeth and flaring.
3)Tooth size discrepancies -
• Excessive anterior vertical overlap.
• Excessive vertical maxillary alveolar growth.
Retrognathic mandible or a prognathic mandible.

4) Frenum attachment -
• Presence of thick & fleshy frenum.
• It prevents the two central incisors from
approximating each other due to the
fibrous connective tissue interpased
between them
5) Familial incidence -
• Heredity- The size position and shape
of the frenum is said to be genetically
influenced.
• Thus mal-occlusion such as midline
diastema that may be due to
abnormalities of the frenum are to a
large extent determined genetically.
6) Mesio-distal angulation of teeth

7) Tooth anomalies -
• Microdontia
• Congenital missing teeth
• Peg laterals
• Presence of supernumerary teeth
8) Pathological-
• Soft tissue and hard tissue pathologies such as cysts,
tumors and odontomes.
• Presence of an unerupted mesiodens between the roots of
the two central incisors.
• In case of juvenile periodontitis initially loss of
attachment and alveolar bone are seen around the
permanent incisors and first molars.

9)Trauma -
• Children are highly prone to injuries of the dento
facial region during early year of life when the learn
to crawl, walk or during play
• Most of these injuries to unnoticed and may be
responsible for
Non-Vital teeth Erupting of permanent teeth
into abnormal position

ManagementManagement
Management of mid-line diastema
Treatment
according
to its cause
Active treatment Retention
Orthodontics
Treatment
Restorative
Treatment
Removable
appliance
Fixed
appliance

Treatment according to its cause –
1)Normal developing condition
• Ugly duckling stage
• Resolves by itself with the eruption of the permanent
canines.
• Spontaneous closure seems to occur with less
frequency in :
a) Generalized spacing
b) Initial diastema of more than 3 mm.

2) Parafunctional habits -
• Correction of the habits has been known to
spontaneously correct the diastema within limits.
• In case of excessive diastema, correction carried out
with the habit breaking appliance.
• Habit breaking appliances for thumb sucking –
i) Removable habit breakers –
- The are passive removable appliances.
- Consist of crib which is anchored to the oral cavity by
means of clasps on the posterior teeth.

ii) Fixed habit breakers –
Heavy gauge stainless steel wire can be designed to
form a frame that is soldered to bands on the molars.
Other aids bandaging Thumbs
Elbow
Chemical approach – Use of bitter tasting or foul
smelling preparation places on the thumb that is sucked
can make the habit distasteful.
- Habit breaking appliances for tongue thrust –
Use habit breakers as in thumb sucking.
The child is taught correct method of swallowing.www.indiandentalacademy.comwww.indiandentalacademy.com

3) Tooth size discrepancies –
Intrusion of the maxillary incisors,
Retraction of the incisors
If cephalogram indicates an excessively long lower
face or a class III growth trend.
Functional therapy
4) Frenum attachments -
Generally advocated that the diastema should be
closed as far as possible before going in for
frenectomy. The reason cited is that should the surgery
be performed before the surgical scar tissue maintains
the diastema.
5) Mesio distal angulation of teeth -
The correction of the crown angulation will close the
diastema.

6) Tooth anomalies -
* Supernumerary teeth
Removal of the supernumerary followed by a closure of the
diastema.
* Peg shaped laterals
Orthodontically followed by esthetic restoration of peg
shaped laterals.
* Absence of laterals
i) The space for the missing laterals, if detected:
Early- may initially be maintained,
Later- replaced with fixed prosthesis.
ii) Orthodontically move the canines into the space of the
missing laterals, recontouring of the cuspid and the first
bicuspid to simulate the lateral and cuspid respectively.
7) Pathological
Systemic phase followed by appliance therapy.www.indiandentalacademy.comwww.indiandentalacademy.com

Active treatment –
1)Orthodontically
• Done using removable appliances or fixed appliances.
* Removable appliances-
- Simple removable appliances can be used for closed
midline diastema are-
i)Finger springs ii)Split labial bow.

i) Finger springs
- The most useful removable spring appliance.
- 0.5 or 0.6 mm. hard round S.S. wire is used.
- Made up of a coil or helix near the point of
attachment and a free end which moves, in a well
defined arc -
1)Free end- It is the active arm 12-15 mm in length and
is placed towards the tissue.
2)The helix- It is about 3 mm in internal diameter.
3)The retentive arm- It is placed away from the tissue
and ends in a retentive tag.

Construction –
The spring is constructed such that the helix is
positioned opposite to the direction of intended tooth
movement. The helix should also be placed along the
long axis at the tooth to be moved and perpendicular
to the direction of tooth movement.
Care should be taken to ensure that the cavity
formed by boxing does not become a food trap.
Activation-
Open the coil or moving the active area towards the
tooth to be moved about 3 mm of activation is
considered optimum.

ii) Split labial bow-
- This is a labial bow that is split in the middle.
- Made up of 0.7 mm round S.S. wire.
- It has 2 separate short buccal arms, each with ‘U’
loop ending distal to canine.
- It exhibits increased flexibility as compared to the
conventional short labial bows.
Modification-
- 2 buccal arms extend across the opposite central
incisor and engage onto its distal surface.
Activation-
- The split labial bow is activated by compressing the
U loop 1-2 mm at a time.

* Fixed appliances-
Fixed appliances incorporating elastics or springs
bring about the most rapid correction of midline
diastema. Elastics can be stretched between the two
central incisors in orders to close the space.
Fixed appliances are –
1) Closed coil springs
2) Elastics
3) Elastic chain
4) M shaped springs

1) Closed coil springs-
- Closed coil spring can be made of stainless steel or
nickel titanium alloys.
- They are used to close spaces once a spring is
stretched and attached at two ends.
- It tries to achieve its prefabricated length by
closing the gab between its points of attachment.

2) Restorative treatment-
• Historically - construction of crowns larger than the
original teeth.
• Recent technology- composite resin material and acid
etching technology.
Advantage- That is nondestructive reversible and
relatively inexpensive.
Disadvantage- Fracture and staining are possible
after 5 to 10 years.
When an adolescent patient wants a diastema closure,
whether the apace are the result of natural
development or postorthodontics discrepancies
careful evaluation and planning are necessary prior to
treatment.

It the patient is nearing completion of
orthodontics therapy but is still undergoing treatment,
the restorative dentist may advise the orthodontist
about the optimal arrangement of anterior teeth for
diastema closure.
The orthodontist may then complete active
treatment and place the patient into a retentive phase
prior to closing the diastema.
It is best to allow a minimum of a few months
between the end of active orthodontic treatment and
diastema closure therapy so that anterior teeth will be
more stable and will settle into their final position.

Important pretreatment consideration
1) The size and location of the space or spaces.
2) The size and shape of the teeth to be restored.
3) Composite resin is added to the teeth on both sides of the space.
If the width > length-teeth appears more “Square” (an
unattractive result).
Light reflections can be used to create the illusion of a
longer and narrower tooth when the composite resin is extended
to cover most or all of the facial surface of a tooth.
To create the illusion of a narrower tooth, we form mesial
and distal line angles in composite resin that are positioned
slightly nearer the middle of the tooth.
Add definite vertical anatomic highlights.
In some situations periodontal crown lengthening may be
considered to obtained a favorable width to length ratio.

Clinical Technique-
• After cleaning, shade selection and isolation
• The space to be eliminated should be carefully measured
via a periodontal probe calipers, or boley gauge.
• The entire labial surface of the tooth should be etched and
bonding agent applied.
• Composite resin should be applied, beginning at the
gingival margin of the inter proximal area.
• The entire proximal surface as well as the labial surface
can be built up and polymerized at once or incrementally.

• After this build up, finish the interproximal area to the
proper contour and polish it
• The second tooth is restored similarly.
Note: Previously warn the patient that there are chances
of fracture of restoration as the length increase

Retention
Retention is a third phase of treatment of mid-line
diastema.
Midline diastema is often considered is often
considered easy to treat but difficult to retain.
So retention is very important phase in treatment
of mid-line diastema.
Retainer use for mid-line diastema are
1. Lingual bonded retainer
2. Hawley’s retainer

Hawley’s retainer-
Hawley’s retainer, the labial bow is contoured to the
anterior teeth . The advantage is of better control over
the anterior teeth.

Conclusion :Conclusion :
Midline diastema may be quite displeasing condition for the
patient as it causes unaesthetic appearance.
If found before the eruption of permanent canine
no treatment may be needed
If found after eruption of permanent canine
treatment should be carried out immediately
followed by retention which is more important

References :References :
1) S.I Bhalajhi – Orthodontics The Art And Science.
2) Gurkeerat Singh –A Textbook of Orthodontics.
3) Pinkham, Casammassimo, Mc Tigue, Nawak – Pediatric
Dentistry
Infancy Through Adolescence.
4) Shobha Tandon – Textbook of Pedodontics.

Midline Diastema Etiology and Management

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Midline Diastema Etiology and Management