MIDLINE DIASTEMA

Presented by :-
Dr. Manish Kumar
Bapuji Dental College & Hospital, Davangere
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CONTENTS:-

INTRODUCTION
DEFINATION
ETIOLOGY
DIAGNOSIS
MANAGEMENT
CONCLUSION
REFERENCES

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INTRODUCTION

From the beginning of time people have noticed the prominent spaces
in their dentitions.
In France, the teeth on either side of a space or gap are called dents
du bonheur or lucky teeth
Thus there are wide variations of perception in different cultures and
ethnic background.
Maxillary midline diastemas are one of the common complaints
encountered.
It has been defined as a space greater than 0.5 mm between the
proximal surfaces of adjacent teeth
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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.
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ETIOLOGY OF MIDLINE DIASTEMA

1. NORMAL DEVELOPING DENTITION
a) Physiologic median diastema/ ugly duckling
stage
b) Ethnic and familial
c) Imperfect fusion of midline of premaxilla

2. TOOTH MATERIAL DEFICIENCY
a) Microdontia
b) Macrognathia
c) Missing lateral
d) Peg laterals
e) Extracted tooth


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3. PHYSICAL IMPEDIMENT
a) Retained deciduous
b) Mesiodens
c) Abnormal labial frenum
d) Midline pathology
e) Deep bite

4. HABITS
a) Thumb sucking
b) Tongue thrusting
c) Frenum thrusting

5. ARTIFICIAL CAUSES
a) Rapid maxillary expansion
b) Milwaukee braces

6. RACIAL PREDISPOSITION

1. NORMAL DEVELOPING DENTITION

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a) Physiologic median diastema/ ugly duckling stage
It is a transient or self correcting malocclusion which is
seen in the maxillary incisor region between 8-9 years. It is
particularly seen during the eruption of the permanent
canines.
As the permanent canines erupt they displace the roots of
the lateral incisors mesially.
This causes a divergence of the crowns of the two central
incisors causing a midline spacing.
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.
It is a self correcting anomaly.
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b) Ethnic and familial
Certain group of peoples, especially negroid groups
exhibit median diastema as an ethnic norm.
Median diastema is seen in some families also.

c) Imperfect fusion at the midline
Median diastema occurs due to imperfect fusion at
the midline of the premaxilla.
A V-shaped or W shaped osseous septum may be
associated with this condition.

2. TOOTH MATERIAL DEFICIENCY

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a) Microdontia
Microdontia refers to teeth that appear smaller in
size compared to normal.
In this case the jaw size is normal but the size of
the teeth is small which produces diastema
between the teeth.
Microdontia is most frequently seen in Downs
syndrome and ectodermal dysplasia.
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b) macrognathia
It is a developmental anomaly characterized by an
abnormal large jaw. In this case the size of the tooth is
normal but because of the increase in size of jaw, it
results in diastema.
c) Missing lateral.
Due to the missing lateral there will be tooth material-
arch discrepancy as a result there will be drifting of
adjacent teeth.
d) Extracted tooth
This also results in tooth material-arch discrepancy which
causes drifting of adjacent teeth.
3. PHYSICAL IMPEDIMENT
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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.
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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.
4. HABITS

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a) Thumb sucking
Thumb sucking is defined as placement of the thumb or one
or more fingers in various depths into the mouth.
It can cause severe proclination of the maxillary anterior
teeth along with formation of diastema
b) Tongue thrusting
This is a condition in which the tongue makes contact with
any teeth anterior to the molars during swallowing.
It also causes proclination of anterior teeth along with
diastema and open bite.
c) Frenum thrusting
This habit is a self injurious habit.
If the maxillary incisors are slightly spaced apart, the child
may lock his labial frenum between these teeth and permit it
to remain in this position for several hours.
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5. ARTIFICIAL CAUSES/ IATROGENIC
CAUSES

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a) Rapid maxillary expansion
Originally rapid maxillary expansion at the mid palatal suture
was recommended to help meet this goal.
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.
A space is created at the mid-palatal suture which is filled
initially by tissue fluids and hemorrhage, and the expansion is
highly unstable.
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.
As a result there is incisor separation and a midline diastema
is formed.
This diastema closes as a result of the trans-septal fibre
traction.
b) Milwaukee braces
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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.
6. RACIAL PREDISPOSITION

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The presence of midline spacing also has a racial and
familial background.
The negroid race shows the greatest incidence of midline
diastema.
DIAGNOSIS

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a. A proper history and clinical examination should be done.
b. Measure the mesiodistal width of the teeth which will help
in determining the tooth material-arch length discrepancies.
c. BLANCH TEST:- Lift the upper lip and pull in outward and
look for blanching of the soft tissues lingual to and between
two central incisors.
Presence of blanch indicates high frenal attachment as cause
of midline diastema.
d. check for any pernicious oral habits
e. periapical radiograph:- presence of notching in the
interdental bone is a diagnostic of a thick and fleshy frenum.
f. midline radiographs will help in diagnosing midline
pathology.

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MANAGEMENT

a) REMOVAL OF CAUSE
b) ACTIVE TREATMENT
c) RETENTION
1. REMOVAL OF CAUSE

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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.
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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
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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.
2. ACTIVE TREATMENT

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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.
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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.
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FIXED APPLIANCES
Fixed appliances incorporating
elastics and springs bring about
the most rapid correction of
midline diastema.
Elastics can be stretched between
the two central incisors in order to
close the space.
Elastic thread or elastic chain can
be used between the central
incisors.
M shaped springs incorporating
three helices can be inserted into
the two central incisor brackets.
The spring can be activated by
closing the helices.
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Closure of a diastema with a fixed appliance A. , This diastema requires closure by
moving the crowns and roots of the central incisors. B , The bonded attachments and
rectangular wire control the teeth in three planes of space while the elastomeric
chain provides the force to slide the teeth along the wire. C, immediately after space
closure, the teeth are retained, preferably with, (D) a fixed lingual retainer at least
until the permanent canines erupt.
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3. RETENTION

Midline diastema is often considered easy to treat but
difficult to retain.
Retention can be achieved by:-
Lingual bonded retainers
Banded retainers
Hawleys retainer
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NEWER APPROACH
ROLE OF COSMETIC RESTORATION
Esthetic composite resins are used to close
midline diastema especially in adult patients.
It requires gradual composite build up on the
mesial surface and stripping of the distal surface
of centrals and laterals in order to achieve a
natural shape and size of the teeth.

PROSTHESIS/CROWN
Presence of peg shaped laterals or teeth with
other anomalies of shape and size require
prosthetic rehabilitation.
Missing teeth should be replaced with fixed or
removable prosthesis.

CONCLUSION
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THUS THE TREATMENT OF MIDLINE DIASTEMA WILL
IMPROVE THE ESTHETIC OF THE PERSON.

IT WILL HELP IN NORMAL ALIGNMENT OF TEETH
WHICH WILL NOT ONLY CONTRIBUTE TO THE ORAL
HEALTH BUT ALSO GOES A LONG WAY IN THE OVERALL
WELL BEING AND PERSONALITY OF AN INDIVIDUAL.
REFERENCES
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Textbook of orthodontics by S.L. BHALAJHI 4 th edition
Textbook of orthodontics by T.D. FOSTER 3 rd edition
Textbook of orthodontics by Samir.E.Bishara
Contemporary orthodontics by William R. Profitt by 4 th
edition
Orthodontics for undergraduates by H. Perry Hitchcock
Textbook of pedodontics by Shobha Tandon by 2 nd edition
European journal of orthodontics 2010
Journal of clinical orthodontics;426
Angle orthodontics 2009;634-9
Wikipedia
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Any
Questions???
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Thank you