Overview on midline diastema and its unesthetic effects Presented by : Anamika Thorat Guided by : Dr. Rehan Khan Dept. of Pediatric Dentistry SDDCH PBN

1. MIDLINE DIASTEMA
Presented by: Anamika Thorat

2. CONTENTS
Definition
Causes of Midline Diastema
Diagnosis
Management of Midline Diastema

3. DEFINITION
 Definition of Diastema:
Diastema is defined as a space between adjacent
teeth.
 Definition of Midline Diastema:
Midline diastema refers to anterior midline spacing
which is greater than 0.5 mm, between the two
central incisors.

4. CAUSES OF MIDLINE DIASTEMA
1) Transient Malocclusion
A midline spacing can occur during the mixed
dentition period associated with the eruption of
permanent canines.This stage is called as ugly
duckling stage,corrects itself as the developing
permanent canines erupt further.(Broadbent
phenomenon)

5. 2) Tooth material arch length discrepancy:
Conditions such as missing teeth,microdontia,peg
shaped laterals,macrognathia,extractions with resultant
driftring of adjacent teeth may affect midline diastema.
3) Unerupted Mesiodens:
Presence of an unerupted mesiodens between the
two central incisors also predispose to midline diastema.
Microdontia Unerupted mesiodens

6. 4) Abnormal frenal attachment:
The presence of a thick and fleshy labial frenum can
give rise to midline diastema.
5) Proclination:
Proclination of a teeth as a result of habits such as
thumb sucking or tongue thrusting can cause midline
diastema along with genralised spacing.
Abnormal frenum attachment Proclination

7. 6) Midline Pathology:
Soft tissue and hard tissue pathologies such as
cysts,tumors,odontomes may cause midline diastema.
7) Iatrogenic cause:
Midline diastema can occur when certain therapeutic
procedures such as rapid maxillary expansion are
undertaken.

8. 8) Racial predisposition:
Presence of midline spacing also has a racial &
familial background.The negroid race shows the greatest
incidence of midline diastema.
9) Ectopic maxillary canines:
Absence of canines from their normal position can
facilitate distal drift & tilt of incisors with space opening &
there is the associated lack of physiological pressures to
upright the lateral & central roots that normally closes the
diastema.

9. DIAGNOSIS
 A proper history and clinical examination should be
done.
 Measure the mesiodistal width of the teeth which
will help in determining the tooth material-arch
length discrepancy.
 Blanch test-done by pulling the upper lip
outwards.Presence of a thick & fleshy frenum is
confirmed by the blanching of the tissue in the
incisive papilla region palatal to central incisor.

10. ` Check for any precious oral habit.
 Periapical radiograph-Presence of notching in the
interdental alveolar bone as seen on a radiograph is also
diagnosing midline pathology that cause spacing.

11. MANAGEMENT OF MIDLINE DIASTEMA
Treatment of midline diastema is done in three
phases:
1) Removal of cause
2) Active treatment
3) Retention.

12. 1)REMOVAL OF CAUSE:
 First phase involves removal of the etiology.
 Habits should be eliminated using fixed or removeable
habit brekers.
ETIOLOGY TREATMENT PLAN
• Normal developing dentition(ugly
duckling stage)
• Self correcting after the eruption
of permanent canines.
• Spontaneous closure seems to
occur with less frequency in-
a) generalised sparing
b) Initial diastema of more than 3
mm.
• Familial incidence • Appliance therapy
• Parafunctional habits
-flaccid lips & poor muscle tone.
a)Correction of the habits has been
known to spontaneously correct the
diastema.

13. ETIOLOGY TREATMENT PLAN
-tongue thrust may cause anterior
open bite & diastema
-thumb/digit sucking over a
prolonged period.
b)In cases of excessive
diastema,correction of the diastema
can be simultaneously carried out
with the habit breaking appliance.
• Tooth size discrepancies
a) Excessive anterior vertical
overlap.
b) Excessive vertical maxillary
alveolar growth.
c) Retrognathic mandible or a
prognathic mandible
• First intrusion of the maxillery
incisors followed by retraction of
incisors to close the diastema.
• If however cephalogram indicates
an excessively long lower face or
a class 3 growth trend.functional
therapy may be the treatment of
choice.
• Frenal attachments • Generally advocated that the
diastema should be closed as far
as possible before going in for
frenectomy.the reason cited is that
the surgery be performed
before,the surgical scar tissue
maintains the diastema.
• Mesio-distal angulation of teeth. • the correction of the crown
angulation(tipping)will close the

14. ETIOLOGY TREATMENT PLAN
• Tooth anomalies
(supernumerary tooth,peg
laterals,absence of laterals)
• Supernumerary-removal of the
supernumerary followed by a
closure of the diastema is done.
• Peg shaped laterals-the
diastema can be corrected
orthodontically followed by
esthetic restoration of the peg
shaped laterals.
• Absence of laterals-
a)The space for missing laterals if
detected early,may be initially be
maintained and at later that be
replaced with fixed prosthesis.
b)Another option is to
orthodontically more the canine
into the space of the missing
laterals,followed by a carefull
recountring of the cuspid &the first
bicuspid.
• pathological • Systemic phase (if required)
followed by appilance therapy.

15. ETIOLOGY TREATMENT PLAN
• Unerupted mesiodens • Extraction

16.  Second phase-active treatment
a) It can be done using removeable appliances or
fixed appliances.
b) The principle applied here is of reciprocal
anchorage(in fixed)
c) The types of movement are either bodily or more
commonly by tipping.

17. 2)REMOVEABLE APPLIANCES
 An active plate can be utilized for this purpose.the
plate incorporates palatal finger springs passing
distally to the central incisors, such that the loop is
opposite to the direction of movement.
 A split labial bow is a modification which can be
utilized to close the diastema,(made up of 0.7mm
hard stainless steel wire.
Disadvantage-space may be created between the
laterals.
in split labial bow,bows are extended upto the
buccal aspect of the opposite central incisors.

18.  In cases where there is an increased overjet
accompying the diastema, a hawley’s plate with an
active labial bow can be used to retract the incisors
& thus close the space.
 Drawback of using removeable appliance-
only tipping movements can be achieved.

19. 3)FIXED APPLIANCES
 Fixed appliance incorporating elastics or springs
bring about the most rapid correction of midline
diastema.
 Elastics can be streched between the two central
incisors in order to close the space.
 M shaped springs incorporating helices can be
inserted into the central incisors brackets.the spring
is activated by closing the helices.
 A stainless steel band with a bracket or more
commonly a bracket may be banded to tooth and
elastics utilised to bring the central incisors
towards each other.

20.  For the purpose of bodily movement of the teeth, it
is suggested than an edgewise bracket with a
simple looped partial archhwire made from a
retangular wire be tied under the tension into both
the brackets.

21.  Midline diastema treated with fixed appliances:

22.  Third phase of treatment involves retaining the
treated malocclusion.
4)RETENTION
 Midline diastema is easy to treat but difficult to
retain.
 In order to prevent a relapse,a long term retention
is required in these cases.

23.  Most orthodontic recommended long term retention
using suitable retainers.
 Since prolonged retention is indicated,it is advisable
to use lingual bonded retainers.
 The other retainers that can be used include
bonded retainers & hawley’s retainer.

24. OTHER TREATMENT MEASURES
 Role of cosmetics restorations:
a) Esthetic composite resins are generally used to
close the midline diastema especially in adult
patients.
b) It requires gradual composite build up on the
mesial surface & stripping of the distal surface of
central & lateral incisors in order to achieve a
natural shape & size of teeth.

25. COMPOSITE BUILD UP:
a)Composite build up on
mesial aspect of the
central incisors & stripping
of the distal surface-
b)Composite build up on
the mesial aspect of the
lateral incisors & stripping
of the distal surface-

26. c)Composite build up on the mesial aspect of the
canines-

27.  Prosthesis/crowns:
a) Presence of peg shaped laterals or teeth with
other anomalies of shape & size require prosthetic
rehabilitation.
b) Missing teeth should be replaced with fixed or
removeable prosthesis.
c) Crowns on central incisors can close a midline.

28. CONCLUSION
 Midline diastema although being a transient
condition become persistent at times which needs
to be treated with special care & concern due to the
high propencity of relapse.
 Treating midline diastema efficiently & effectively is
important for overall well being of individual as it
affects the esthetics of the person & has an
important effect on overall personality of an
individual.

29.  Effective diastema treatment requires correct
diagnosis of its etiology & intervention relevant to
the specific etiology.
 Correct diagnosis includes medical & dental
histories, radiographic & clinical examinations, and
possibly tooth size evaluations.
 Timing is often important to achieve satisfactory
results.

30. RECENT ADVANCES IN CLOSURE OF MIDLINE
DIASTEMA:
 Direct closure with composite layering technique.
 Laminate veneers.
 Adhesive Restorations.
 Micro magnetic retainers.

31. REFRENCES
Textbook of Pedodontics ; Shobha Tandon ; 2nd edition
Textbook of Orthodontics ; S. I. Bhalajhi ; 6th edition