The document discusses midline diastemas, which are spaces between the two central incisors. It defines midline diastemas and discusses their various etiologies such as normal development, tooth material deficiencies, physical impediments like habits or retained primary teeth, and iatrogenic causes from procedures like rapid maxillary expansion. The diagnosis involves a clinical exam and radiographs to identify the cause. Treatment involves removing the cause, using appliances to close the space, and retainers to maintain results. Midline diastemas can be aesthetically improved through various orthodontic or restorative techniques.

1. MIDLINE DIASTEMA Presented by :- Dr. Manish Kumar Bapuji Dental College & Hospital, Davangere 1

2. CONTENTS:- INTRODUCTION DEFINATION ETIOLOGY DIAGNOSIS MANAGEMENT CONCLUSION REFERENCES 2

4. In France, the teeth on either side of a space or gap are called ‘‘dents du bonheur’’ or ‘‘lucky teeth’’

5. Thus there are wide variations of perception in different cultures and ethnic background.

6. Maxillary midline diastemas are one of the common complaints encountered.

7. It has been defined as a space greater than 0.5 mm between the proximal surfaces of adjacent teeth 3

8. DEFINATION OF DIASTEMA A space between adjacent teeth is called a diastema. DEFINATION OF MIDLINE DIASTEMA Midline diastema refers to anterior midline spacing between the two central incisors. 4

9. ETIOLOGY OF MIDLINE DIASTEMA NORMAL DEVELOPING DENTITION Physiologic median diastema/ ugly duckling stage Ethnic and familial Imperfect fusion of midline of premaxilla 2. TOOTH MATERIAL DEFICIENCY Microdontia Macrognathia Missing lateral Peg laterals Extracted tooth 5

10. 6 3. PHYSICAL IMPEDIMENT Retained deciduous Mesiodens Abnormal labial frenum Midline pathology Deep bite 4. HABITS Thumb sucking Tongue thrusting Frenum thrusting 5. ARTIFICIAL CAUSES Rapid maxillary expansion Milwaukee braces 6. RACIAL PREDISPOSITION

12. As the permanent canines erupt they displace the roots of the lateral incisors mesially.

13. This causes a divergence of the crowns of the two central incisors causing a midline spacing.

14. This was described by Broadbent as the ugly duckling stage as children tend to look ugly during this phase of development. So it also known as Broadbent phenomenon.

19. In this case the jaw size is normal but the size of the teeth is small which produces diastema between the teeth.

21. 3. PHYSICAL IMPEDIMENT 12 a) Retained deciduous teeth. This causes ectopic eruption of tooth and formation of median diastema. b) Mesiodens Presence of an unerupted mesiodens between the two central incisors also predispose to midline diastema.

22. 13 c) Abnormal labial frenum The presence of a thick and fleshy labial frenum can cause a midline diastema.This type of fibrous attachment can prevent the two maxillary central incisors from approximating each other. d) Midline pathology Soft tissues and hard tissue pathologies such as cysts, tumors and odontomes may cause midline diastema.

28. With rapid expansion at a rate of 0.5 to 1 mm/day 1 cm or more of expansion is obtained in 2 to 3 weeks.

29. A space is created at the mid-palatal suture which is filled initially by tissue fluids and hemorrhage, and the expansion is highly unstable.

30. The opening of the mid-palatal suture is fan-shaped or triangular with maximum opening at the incisor region and gradually diminishing toward the posterior part of the palate.

31. As a result there is incisor separation and a midline diastema is formed.

32. This diastema closes as a result of the trans-septal fibre traction.b) Milwaukee braces

33. 17 A, Bilateral constricted maxilla with upper midline shift; B, type 1 RME appliance in mouth; C, end of expansion; D, correction of upper midline shift at end of retention period.

36. 20 MANAGEMENT REMOVAL OF CAUSE ACTIVE TREATMENT RETENTION

37. 1. REMOVAL OF CAUSE 21 DIASTEMA DUE TO UGLY DUCKLING STAGE No treatment required DIASTEMA DUE TO IMPERFECT FUSION AT THE MIDLINE Excision of included interdental tissue between the incisors. A flap is raised interdentally and fissure bur inserted gently into the cleft. With the bur, the included tissues are removed and flap sutured.An orthodontic appliance for closure of median diastema is given during healing process.

38. 22 DIASTEMA DUE TO MICRODONTIA AND MACROGNATHIA Such conditions can be treated by orthodontic means or by mean of jacket crowns or composite build-up. Closure by jacket crown or composite build-up is the best method. DIASTEMA DUE TO MISSING TEETH/EXTRACTED TOOTH Space can be consolidated and replaced with implant or bridge

39. 23 DIASTEMA DUE TO RETAINED DECIDUOS TEETH/MESIODENS The retained deciduous tooth or mesiodens should be extracted at the earliest. DIASTEMA DUE TO ABNORMAL FRENUM Frenectomy should be done to excise a thick fleshy frenum. DIASTEMA DUE TO MIDLINE PATHOLOGY Midline pathology like cysts has to be treated. DIASTEMA DUE TO ABNORMAL HABITS Habits should be eliminated using fixed or removable habit breakers.

40. 2. ACTIVE TREATMENT 24 REMOVABLE APPLIANCES Simple removable appliances incorporating finger springs or a split labial bow can be used. Finger springs can be given distal to the two central incisors. Split labial bow made of a 0.7mm hard stainless steel wire can be used. In a reciprocal tooth movement the forces are applied to teeth Fare equal and opposite as a result each unit moves to a normal occlusion.

41. 25 A, Closure of a midline diastema can be accomplished with a removable appliance and finger springs to tip the teeth mesially. B , The 28 mil helical finger springs are activated to move the incisors together. C , The final position can be maintained with the same appliance.

43. Elastics can be stretched between the two central incisors in order to close the space.

44. Elastic thread or elastic chain can be used between the central incisors.

45. M shaped springs incorporating three helices can be inserted into the two central incisor brackets.

48. Retention can be achieved by:- Lingual bonded retainers Banded retainers Hawley’s retainer

53. Textbook of orthodontics by T.D. FOSTER 3 rd edition

54. Textbook of orthodontics by Samir.E.Bishara

55. Contemporary orthodontics by William R. Profitt by 4 th edition

56. Orthodontics for undergraduates by H. Perry Hitchcock

57. Textbook of pedodontics by ShobhaTandon by 2 nd edition

58. European journal of orthodontics 2010

59. Journal of clinical orthodontics;426

60. Angle orthodontics 2009;634-9

62. 33 Thank you…