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ISSN 0970 - 4388

Spontaneous closure of midline diastema following frenectomy

KIRAN KOORAa, MUTHU M. S.b, RATHNA PRABHU V.c

Abstract

Maxillary midline diastema is a common aesthetic problem in mixed and early permanent dentitions. The space can occur either
as a transient malocclusion or created by developmental, pathological or iatrogenical factors. Many innovative therapies vary­

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ing from restorative procedures such as composite build-up to surgery (frenectomies) and orthodontics are available. Although
literature says every frenectomy procedure should be preceded by orthodontic treatment, we opted for frenectomy technique

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without any orthodontic intervention. Presented herewith is a case report of a 9-year-old girl with a high frenal attachment that

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had caused spacing of the maxillary central incisors. A spontaneous closure of the midline diastema was noted within 2 months
following frenectomy. The patient was followed up for 4 months after which the space remained closed and there was no neces­

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sity for an orthodontic treatment at a later stage.

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Key words: Frenectomy, midline diastemas, spontaneous closure

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Introduction
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cause for midline diastema and this view was supported by
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Maxillary anterior spacing or diastema is a common aesthetic other researches.[6-9] Tait stated that the frenum is an effect
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complaint of patients and is frequently seen in children and not a cause for the incidence of diastema and reported
especially in the mixed dentition stage. Keene described other causes such as ankylosed central incisor, flared or
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midline diastema as anterior midline spacing greater than rotated central incisors, anodontia, macroglossia, dento­
0.5 mm between the proximal surfaces of adjacent teeth.[1] alveolar disproportion, localized spacing, closed bite, facial
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He reported that the incidences of maxillary and mandibular type, ethnic and familial characteristics, inter-premaxillary
midline diastema are 14.8% and 1.6%, respectively. Midline suture, and midline pathology.[10] Weber listed the causes
diastema may be considered normal for many children during for spacing between the maxillary incisors as: a result
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the eruption of the permanent maxillary central incisors. of high frenum attachment; microdontia; macrognathia;
When the incisors first erupt, they may be separated by bone supernumerary teeth; peg laterals; missing lateral incisors;
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and the crowns incline distally because of the crowding of the midline cysts and habits such as thumb sucking, mouth-
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roots. With the eruption of the lateral incisors and permanent breathing and tongue-thrusting.[11]
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canines, the midline diastema reduces or even closes.

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An accurate diagnosis is necessary before treatment can be

Taylor reported the incidence of midline diastema in 5 year initiated. No treatment should be initiated if the diastema
olds as high as 97 per cent, and seen decreasing with age.[2,3] is physiological and usually if the canines have not erupted.
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Kaimenyi determined the prevalence of midline diastema Different treatment modalities for midline diastema include
and frenum attachments among school children (4-16 years) removal of aetiology and simple removable appliances
in Nairobi, Kenya. The commonest location of frenum incorporating finger springs or split labial bow. Gleghorn
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attachment among children with lower midline diastema
is at the mucogingival junction (86%), whereas with upper
midline diastema to gingival region (50%). It was concluded
that the maxilla had a higher prevalence of midline diastema
than the mandible.[4] Nainar and Gnanasundaram studied
nearly 9774 patients in the age group of 13-35 years in South
India (Chennai) and reported an incidence of true maxillary
midline diastema (1.6%), which was greater than that of true
mandibular midline diastemas (0.3%).[5]
reported a direct composite restoration technique to correct
unaesthetic diastema.[12] Munshi et al. reported extraction
of mesiodens subsequently followed by the space closure
utilizing simple fixed orthodontic therapy.[13] Nakamura et
al. reported a ceramic restoration of anterior teeth without
proximal reduction. Here, we present a case of spontaneous
closure of midline diastema after frenectomy procedure.[14]
Case Report

A 9-year-old patient reported to the Department of

P. G. Student, bAssociate Professor, cProfessor and Head, Depart
a
ment of Pedodontics and Preventive Dentistry, Meenakshi Ammal
Dental College and Hospital, Maduravoyal, Chennai, India
Pedodontics and Preventive Dentistry, Meenakshi Ammal
Dental College and Hospital, Chennai with the chief complaint
of spacing in the upper front tooth region [Figure 1]. The

23 J Indian Soc Pedod Prev Dent - March 2007

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Closure of midline space following frenectomy

patient’s medical history did not reveal any systemic diseases.

Intra-oral examination revealed presence of high frenal
attachment and midline spacing between maxillary central
incisors (4 mm). Also she presented with deep caries in the
maxillary and mandibular right and left second primary
molars.

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

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exerted on the frenum [Figure 2]. If a heavy band of tissue

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with a broad, fanlike base is attached to the palatine papillae

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and produces blanching of the papilla, it is safe to predict

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that the frenum will unfavorably influence the development
of the anterior occlusion. After obtaining informed written

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consent from the parents, decision was made to remove high Figure 2: Blanching test

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frenal attachment by a surgical technique.[15]

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Frenectomy was carried out under local anaesthesia with
incision using No. 11 Bard Parker blade. In this technique,

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lateral incisions were made on either side of the frenum to the
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depth of the underlying bone. The free marginal tissues on
the mesial side of the central incisors were not disturbed. The
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wedge of tissue was picked up with tissue forceps and excised

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with tissue shears at the area close enough to the origin of

the frenum to provide a desirable cosmetic effect. Sutures
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were placed to identify the free tissue margins on either

side of the removed tissue, and periodontal pack (Coe-pak)
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was placed for a week [Figure 3].[15] The patient was advised
to return after a week for suture removal and periodical
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follow-up once a month. The patient was followed up for a

period of 4 months, at the end a remarkable improvement
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in the aesthetics was observed, due to spontaneous closure

of midline diastema [Figure 4].
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Figure 3: Post surgical photograph

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Figure 1: Pre-operative photograph showing high frenal Figure 4: Post-operative photograph showing closure of midline
attachment with midline diastema diastema after frenectomy

J Indian Soc Pedod Prev Dent - March 2007 24

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Closure of midline space following frenectomy
Discussion
A diastema is a space or “gap,” most often seen between the
two upper front teeth. At some stages of dental development,
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 cosmetic reasons even during preschool
period. However, a diastema can also affect the speech,
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thereby certain sounds like “S” is not pronounced properly.
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During this the tongue pushes forward to close the space
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thereby a constant tongue pressure can make the diastema
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worse over time.
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Campbell et al. stated that midline diastema could be transient
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or created by developmental, pathological or iatrogenic
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factors.[16] Like are oral habits, soft tissue imbalance, physical
impediment, dental anomalies and/or skeletal disharmonies,
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as well as normal dentoalveolar development. In this case,
the high frenal attachment was the major aetiological factor
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causing midline spacing. The low attachment of fleshy
maxillary labial frenum is often associated with midline
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diastema and has the following characteristics:
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1. A frenum, which is unsightly, being visible as a pendulous consultation between April 1984 and March 1993. A total
piece of tissue in the midline of the upper lip.
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2. Its presence precludes maintenance of good oral
hygiene.
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3. Where there is a direct attachment of the frenum at the
gingival margin, it might increase the rate of periodontal
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destruction in the presence of pre-existing periodontal
disease. This was confirmed by positive indication of the
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blanching test.
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Treatment of diastema varies and it requires correct diagnosis
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of its aetiology and early intervention relevant to the specific
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aetiology. Correct diagnosis includes medical and dental
history, radiographical and clinical examinations and possibly
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tooth size evaluation.[17] No treatment is usually initiated if
the diastema is physiological/transient as it spontaneously
closes after the eruption of permanent maxillary canines
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(11-12 years). Removal of the aetiologic 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 fixed appliance, leaving
the remaining central incisor in the midline. A retainer was
bonded to prevent relapse.[18]
According to Springate and Sandler, the use of neodymium-
iron-boron micro-magnets as a fixed retainer can be used
for treating midline spacing.[19] 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.
25 J Indian Soc Pedod Prev Dent - March 2007
H6 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.[20] According to Yves 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.[21] 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 to correct diastema caused by tooth position or
discrepancies in the tooth size/arch development.[22] In the
present case, frenectomy was done because the aetiology
was traced to high frenal attachment.
Usually the space closure in the anterior segment is delayed
till the eruption of the permanent canine. This is because
there is going to be mesial migration during the active
stage of canine eruption. But according to Yamaoka et al.,
the orientation of the unerupted canine was assessed using
the orthopantomographs of 9854 patients who sought
of 38 canines in 32 patients, all aged 11 years or older,
were identified as unerupted canines.[23] The features of
the patients with unerupted canine showed no significant
relation to diastema closure status, but some patients had
unerupted horizontal or inverted canine without diastema
even in the absence of a history of orthodontic treatment,
suggesting the presence of a mechanical force due to some
phenomenon other than canine eruption as a factor in
diastema closure. Moreover, when a pathological cause is
identified between the central incisors, the mesial movement
during canine eruption is also impeded.
Thus, in our case, an attempt was made to remove the
aetiology, even though the patient was only 9-year-old,
considering the fact that there will be maximum active mesial
movement of tooth during eruption. This resulted in the
spontaneous closure of the midline diastema in 2 months. The
patient was followed up for 4 months during which there was
no change in the closed midline space but there developed
a new space between the central and lateral incisors, which
could be due to the eruption of permanent canine [Figure 3].
The patient has been followed up through regular recall for
monitoring any changes in the anterior region.
Generally 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 to helps maintain closure
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Closure of midline space following frenectomy

of diastema. Spilka and Mathews stated that in spite of
the success and excellent results, orthodontists have had a
problem in correcting dental abnormalities, one particular
area, which lends itself to relapse, is the diastema between
the incisors.[24] The surgical correction of a diastema has been
successfully accomplished without orthodontic treatment in
patients excepting a rapid correction.
Hence, in present case, the advantages of timely intervention
during active tooth eruption has prevented orthodontic
9. Sicher H. Oral anatomy. 2nd ed. The C.V. Mosby Co: St. Louis;
1952. p. 185,272-3.
10. Tait CH. The median frenum of the upper lip and its influence
on the spacing of the upper central incisor teeth. Dent Cosmos
1934;76:991-2.
11. Weber. Quoted in: Orthodontic principles and practice. Graber
TM. 3rd ed. WB Saunders Co: 1972.
12. Gleghorn T. Direct composite technique for a smile makeover.
Dent Today 1997;16:40,42,44.
13. Munshi A, Munshi AK. Midline space closure in the mixed dentition:
A case report. J Indian Soc Pedo Prev Dent 2001;19:57-60.
14. Nakamura T, Ohyama T, Wakabayashi K. Ceramic restorations

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of anterior teeth without proximal reduction: A case report.
treatment at a later stage; further, this procedure is less Quintessence Int 2003;34:752-5.

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time consuming, less expensive and requires minimal patient

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15. Newman, Takei, Caranza. Clinical periodontology. 9th
ed. WB
compliance. Saunders Co: 2003.

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16. Campbell PM, Moore JW, Mathews JL. Orthodontically corrected
midline diastemas: A histological study and surgical procedure.
Early developing malocclusion should be intercepted with the

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Am J Orthod 1975;67:139-58.
goal of restoring a normal occlusion. The timing and degree 17. Huang WJ, Creath CJ. The midline diastema: A review of its

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which if dealt properly, can produce positive results in the

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18. Follin ME. Orthodontic movement of maxillary incisor into the
midline: A case report. Swed Dent J 1985;9:9-13.
mixed dentition as seen in the present case.
19. Springate SD, Sandler PJ. Micro-magnetic retainers: An attractive

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