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Case Report

Closure of midline diastema through combined

surgical and Removable orthodontic approach

Deepak Chauhan, Bimal Kirtaniya1, Avantika Tuli1, Tripti Chauhan2

Department of Pedodontics and Preventive Dentistry, H.P. Government Dental College, Shimla, 2Department of Community Medicine,
Indira Gandhi Medical College and Hospital, Shimla, 1Department of Pedodontics and Preventive Dentistry, Himachal Dental College,
Sunder Nagar, Himachal Pradesh, India

ABSTRACT
Midline diastema is a common aesthetic problem in mixed and permanent dentition. Many
innovative therapies are varying from restorative procedures such as composite build-up
to surgery (frenectomy) and orthodontics are available. A high frenum attachment is often
the cause of persistent diastemas. Presented herewith is a case report of a 13-year-old
girl with a high frenal attachment that had caused spacing of the maxillary central incisors.
This case report demonstrates the removal of the abnormal labial frenum attachment
through surgery and subsequent closure of maxillary diastema following removable
orthodontic treatment.

Key words: High frenum, frenectomy, maxillary midline diastema

Introduction distally because of the crowding of the roots. With the

Maxillary anterior spacing or diastema is a common
aesthetic complaint of patients or parents and is frequently
seen in the mixed and permanent dentition stage. Keene
described midline diastema as anterior midline spacing
greater than 0.5 mm between the proximal surfaces of
adjacent teeth. He reported that the incidences of maxillary
and mandibular midline diastema are 14.8% and 1.6%,
respectively.[1] Midline diastema may be considered normal
for many children during the eruption of the permanent
maxillary central incisors. When the incisors first erupt,
they may be separated by bone and the crowns incline
Address for correspondence:
Dr. Deepak Chauhan,
Department of Pedodontics and Preventive Dentistry,
H.P. Government Dental College, Shimla - 171 001,
Himachal Pradesh, India.
E-mail: drchauhan30@gmail.com
Access this article online
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Website:
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DOI:
10.4103/0976-433X.116836
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SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
eruption of the lateral incisors and permanent canines, the
midline diastema reduces or even closes. Taylor reported
the incidence of midline diastema in 5 year olds as high as
97% and seen decreasing with age.[2,3] Maxilla had a higher
prevalence of midline diastema than the mandible.[4] Angle
concluded the presence of abnormal frenum as the cause
for midline diastema and this view was supported by other
researches.[5-8]
Weber listed the causes for spacing between the maxillary
incisors as: A result of high frenum attachment; microdontia;
macrognathia; supernumerary teeth; peg laterals; missing
lateral incisors; midline cysts and habits such as thumb
sucking, mouth-breathing and tongue-thrusting.[9]
An accurate diagnosis is necessary before treatment can be
initiated. No treatment should be initiated if the diastema
is physiological and usually if the canines have not erupted.
Different treatment modalities for midline diastema include
removal of etiology and simple removable appliances
incorporating finger springs or split labial bow. Gleghorn
reported a direct composite restoration technique to correct
unaesthetic diastema.[10] Munshi and Munshi reported
extraction of mesiodens subsequently followed by the
space closure utilizing simple fixed orthodontic therapy.[11]
Nakamura et al., reported a ceramic restoration of anterior
teeth without proximal reduction. Here, we present a case
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Chauhan, et al.: Closure of midline diastema
of spontaneous closure of midline diastema after frenectomy
with removable orthodontic appliances.[12]
Case report
An 13-year-old girl reported to the Department of Pedodontics
and Preventive Dentistry of Himachal Dental College and
Hospital, Sunder Nagar with the chief complaint of spacing
in the upper front region. Patient’s medical history did not
reveal any systemic diseases. Intra-oral periodical radiograph
(X-ray) was taken to find out the cause of diastema and to
rule out the presence of any unerupted mesiodens. On intra-
oral examination revealed presence of high frenal attachment
and midline spacing between maxillary central incisors
(8 mm) [Figure 1]. A simple diagnostic test, i.e., blanching
test was performed for an abnormal high frenum by observing
the location of the alveolar attachment when intermittent
pressure was exerted on the frenum. If a heavy band of tissue
with a broad, fanlike base is attached to the palatine papillae
and produces blanching of the papilla, it is safe to predict
that the frenum will unfavorably influence the development
of the anterior occlusion.
After obtaining informed written consent from the parents,
decision was made to remove high frenal attachment by a
Figure 1: Pre-operative photograph showing high frenal
attachment with midline diastema
Figure 3: Sutures being placed
SRM Journal of Research in Dental Sciences | Vol. 4 | Issue 1 | January-March 2013
surgical technique [Figure 2]. Frenectomy was carried out
under local anesthesia with incision using No. 11 Bard Parker
blade. In this technique, lateral incisions were made on either
side of the frenum to the depth of the underlying bone.
The free marginal tissues on the mesial side of the central
incisors were not disturbed. The wedge of tissue was picked
up with tissue forceps and excised with tissue shears at the
area close enough to the origin of the frenum to provide a
desirable cosmetic effect. Sutures were placed to identify the
free tissue margins on either side of the removed tissue and
periodontal pack was placed for a week. Patient was advised
to return after a week for suture removal and periodical
follow-up once a month. Patient was followed-up for a
period of 4 months, at the end a remarkable improvement
in the aesthetics was observed due to spontaneous closure
of midline diastema.
Sutures were placed for a week [Figure 3]. The patient was
advised to return after a week for suture removal [Figure 4]
and finger springs appliance with anterior bite plane was
delivered and periodic follow-up advised [Figure 5]. In the
meantime incisal capping and flaring of the lower incisors
Figure 2: Incision given
Figure 4: Post surgical photograph
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Chauhan, et al.: Closure of midline diastema

were carried out to relieve the anterior deep bite [Figure 6].
Patient was followed-up for a period of 6 months, at the end
a remarkable improvement in the aesthetics was observed
due to closure of midline diastema [Figure 7].
Discussion
to correct diastema caused by tooth position or discrepancies
in the tooth size/arch development.[19]
In the present case, frenectomy was done because the
etiology was traced to high frenal attachment. Usually, the
space closure in the anterior segment is delayed till the

A diastema is a space or “gap,” most often seen between

the two upper front teeth sometimes in the lower anterior
region also. In the early and late mixed dentition stages, it
is normal to have a diastema, but it eventually closes during
further development. Often, parents are more conscious
about the spaces between front teeth of their children and
seek treatment for the aesthetic reason. However, a diastema
can also affect the speech, thereby certain sounds like “S”
is not pronounced properly. During this the tongue pushes
forward to close the space thereby a constant tongue pressure
can make the diastema worse over time. Campbell et al.,
stated that midline diastema could be transient or created by
developmental, pathological or iatrogenic factors.[13] Like oral
habits, soft-tissue imbalance, physical impediment, dental
anomalies and skeletal disharmonies. In this case, the high
Figure 5: Hawley’s appliance with finger springs & anterior
frenal attachment was the major etiological factor causing
bite plane
midline spacing. Treatment of diastema varies and it requires
correct diagnosis of its etiology and early intervention relevant
to the specific etiology. Correct diagnoses includes medical
and dental history, radiological and clinical examination
and possibly tooth size evaluation.[14] No treatment is
usually initiated if the diastema is physiological/transient
as it spontaneously closes after the eruption of permanent
maxillary canines (11-12 years). Removal of the etiologic factor
usually can be initiated upon diagnosis and after sufficient
development of the central incisor. Follin reported that some
pathological causes like supernumerary teeth and midline
cysts can be removed surgically and orthodontic closure of the
space from both sides performed with removable appliance,
leaving the remaining central incisor in the midline. A retainer
was bonded to prevent relapse.[15] According to Springate and
Sandler, the use of neodymium-iron-boron micro-magnets as Figure 6: Incisal caping for intrusion of lower incisors
a fixed retainer can be used for treating midline spacing.[16]
Putter et al., reported two combined modalities of treatment
with orthodontic and porcelain laminate placement to facilitate
diastema closure. In his report, Geristore, a dual-cure fluoride-
releasing composite was mixed to bond orthodontic brackets
in place. H-6 elastic bands were used with the orthodontic
brackets to close the diastemas sufficiently and to allow
the placement of cerinate porcelain laminates to produce a
beneficial cosmetic effect.[17] According to Attia, if the diastema
results from the congenital absence of a lateral incisor, initial
treatment is to bring the central incisors together, followed
by moving the canines forward into the lateral position or by
moving them distally to allow for prosthetic replacement.[18] In
other cases, unusually small central or lateral incisors may result
in a diastema. Here too, reconstruction by bonding or jacket
crowns will solve the problem. According to Kinderknecht and
Kupp, resin-bonded porcelain veneer restorations can be used Figure 7: Post treatment photograph of the patient

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Chauhan, et al.: Closure of midline diastema

eruption of the permanent canine, but in the present case
permanent canines were already erupted. This is because
there is going to be mesial migration during the active
stage of canine eruption. Thus, in our case, an attempt
was made to remove the etiology; this resulted in the
spontaneous closure of the midline diastema in 6 months.
Patient was followed-up for 3 months during which there
was no change in the closed midline space. The patient has
been followed-up through regular recall for monitoring any
changes in the anterior region. In general, abnormal frenal
attachment may require removal either before orthodontic
treatment or at the end of active treatment. The advantage of
excision prior to orthodontic treatment is the ease of surgical
access. If the surgery is performed before the orthodontic
procedure, the scar tissue might impede the closure of
diastema, but the noted advantages of excision after
orthodontic tooth movement is the scar tissue formation,
which helps to maintain closure of diastema. Spilka and
Mathews stated that in spite of the success and excellent
results, orthodontists have a problem in correcting dental
abnormalities, one particular area, which lends itself to
relapse, is the diastema between the incisors.[20] The surgical
correction of a diastema has been successfully accomplished
with removable orthodontic treatment in patients excepting
a rapid correction. Hence, in present case, the advantages
of timely intervention leads to less expensive treatment
and requires minimal patient compliance. Early developing
malocclusion should be intercepted with the goal of restoring
a normal occlusion. The timing and degree of interception
are the major problems to be dealt properly, which can
produce positive result as seen in the present case.
ACKNOWLEDGMENTS
We acknowledge the cooperation of all individuals who participated
in this study.
2. Taylor JE. Clinical observations relating to the normal and abnormal
frenum labii superians. Am J Orthod 1939;25:646-60.
3. Oesterle LJ, Shellhart WC. Maxillary midline diastemas: A look at
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4. Kaimenyi JT. Occurrence of midline diastema and frenum
attachments amongst school children in Nairobi, Kenya. Indian J
Dent Res 1998;9:67-71.
5. Angle EH. Treatment of Malocclusion of the Teeth. 7 th ed.
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6. McCoy JD. Applied Orthodontia. 2nd ed. Philadelphia: Lea and
Febiger; 1946. p. 72, 96-7.
7. Stones HH. Oral and Dental diseases. 2nd ed. Edinburgh: E and S
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8. Sicher H. Oral Anatomy. 2nd ed. St. Louis: The C.V. Mosby Co.;
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9. Graber TM. Orthodontic principles and practice. 3rd ed. Philadelphia:
WB Saunders Co.; 1972. p. 189-202. Available from: http://www.
abebooks.co.uk/9780721641829/Orthodontics-Principles-Practice-
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10. Gleghorn T. Direct composite technique for a smile makeover. Dent
Today 1997;16:40, 42, 44.
11. Munshi A, Munshi AK. Midline space closure in the mixed dentition:
A case report. J Indian Soc Pedod Prev Dent 2001;19:57-60.
12. Nakamura T, Nakamura T, Ohyama T, Wakabayashi K. Ceramic
restorations of anterior teeth without proximal reduction: A case
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13. Campbell PM, Moore JW, Matthews JL. Orthodontically corrected
midline diastemas. A histologic study and surgical procedure. Am
J Orthod 1975;67:139-58.
14. Huang WJ, Creath CJ. The midline diastema: A review of its etiology
and treatment. Pediatr Dent 1995;17:171-9.
15. Follin ME. Orthodontic movement of maxillary incisor into the
midline. A case report. Swed Dent J 1985;9:9-13.
16. Springate SD, Sandler PJ. Micro-magnetic retainers: An attractive
solution to fixed retention. Br J Orthod 1991;18:139-41.
17. Putter H, Huberman A, Scherer W. Diastema closure: A case report.
J Esthet Dent 1992;4 Suppl:9-11.
18. Attia Y. Midline diastemas: Closure and stability. Angle Orthod
1993;63:209-12.
19. Kinderknecht KE, Kupp LI. Aesthetic solution for large maxillary
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References How to cite this article: Chauhan D, Kirtaniya B, Tuli A, Chauhan T.

Closure of midline diastema through combined surgical and Removable
orthodontic approach. SRM J Res Dent Sci 2013;4:46-9.
1. Keene HJ. Distribution of diastemas in the dentition of man. Am J
Source of Support: Nil, Conflict of Interest: None declared
Phys Anthropol 1963;21:437-41.

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