EMS Dentistry Journal

Review Article

Maxillary Midline Diastema: A Contemporary Review

Sanjay Prasad Gupta*1

1
Department of Dentistry, Tribhuvan University Teaching Hospital, Institute of Medicine, Tribhuvan
University, Kathmandu, Nepal.

*
Corresponding author : Dr. Sanjay Prasad
Gupta, Assistant Professor, Orthodontics and
Dentofacial Orthopedics unit, Department of
Dentistry, Tribhuvan University Teaching Hos-
pital, Institute of Medicine, Tribhuvan Univer-
sity, Kathmandu, Nepal,
Tel no. +977-9843585923;
Email: sanjayagupta2000@gmail.com
Received: 15-07-18
Accepted: 25-07-18
Published: 5-08-2018
Copyright: © 2018 Sanjay Prasad Gupta
Abstract
Maxillary midline diastema is a common esthetic problem of patient during dental
consultation. It can be either transient owing to the developing dentition or created
due to various etiologies, thus it requires no active treatment or management in the
permanent dentition requires either restorative treatment or orthodontic treatment
and/or along with surgery. Treatment depends upon correct diagnosis of etiology
and its early intervention.
The etiology, pathogenesis, and diagnosis of maxillary median diastema have been
somewhat controversial over the years. The purpose of this paper is to review the
possible etiology and management options available in order to give the practitioner
an overview to direct effective diagnosis and treatment.
Keywords: Midline Diastem; Orthodontic Treatment; Etiology; Hypertrophic Fre-
num

Introduction

Diastema is the presence of space between the proximal sur-

face of anterior teeth. It occurs more frequently in the median
plane of the maxillary arch between the two central incisors
and hence called the median, central or midline diastema
[1,2]. The presence of a diastema between the maxillary cen-
tral incisors in adults often is considered an esthetic or mal-
occlusion problem [3]. Keene defined an maxillary midline
diastema (MMD) as a space greater than 0.5 mm between
the proximal surfaces of the two central incisors because
such a gap is noticeable [4]. McKnight and colleagues report-
ed that patients consider MMDs to be less esthetic than mild
fluorosis or isolated opacity [5]. An MMD also can adversely
affect body image and self-esteem, and it can be one of the
most negative factors in self-perceived dental appearance [6] Figure. 1 A 20 year old female with a maxillary midline dias-
(Fig.1). tema. Note: an enlarged and low frenum.

The space can be a normal growth characteristic during the

primary and mixed dentition and generally is closed by the
time the maxillary canines erupt [7]. For most children, the
medial erupting path of the maxillary lateral incisors and

Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
maxillary canines, as described by Broadbent, results in nor-
mal closure of this space [8]. For some individuals, however,
the diastema does not close spontaneously. If it is to be closed
satisfactorily by orthodontics an understanding of the aetiol-
ogy is essential [1,2,9,10].
The spaces usually distort a pleasing smile by concentrating
the observer’s attention not on the overall dental composi-
tion, but on the diastema [11]. However, not every diastema
should be viewed by the practitioner as needing correction.
The patient’s needs, demands, and expectations must be con-
sidered in the process of treatment planning to ensure satis-
faction with the treatment outcomes [12].
Aesthetics and function are the two most important goals of
modern-day dentistry [13]. If the diastema is large, it is ad-
visable to close the space using orthodontic appliances. In
most cases, simple removable appliances incorporating fin-
ger springs or a split labial bow can give good results [14].
Epidemiology
Maxillary midline diastema is one of the most frequently seen
malocclusions and its incidence ranges from 1.6% to 25.4%
and is inversely proportional to age [15].
According to epidemiological investigations by Taylor, Gar-
diner, and Weyman, the prevalence of median diastemas is
high in children, decreases dramatically between 9 and 11
years of age, and continues a gradual decrease up to 15 years
of age. Again, this pattern follows the normal eruption pat-
tern of the permanent maxillary lateral incisors and canines
[16-19].
Racial and gender differences also exist for diastemas. Lavelle
and associates reported the prevalence of the maxillary me-
dian diastema was greater in Africans (West Africa) than
in Caucasians (British) or Mongoloids (Chinese from Hong
Kong and Malaya) [20]. Horowitz Reported that black chil-
dren,10 to12 years old, exhibit a higher prevalence (19%) of
midline diastema than do white children (8%) [21]. Becker
confirmed racial differences and stated that blacks and Med-
iterranean whites exhibit the midline diastema as an ethnic
norm [22]. Richardson and coworkers found females in both
races showed a higher prevalence than males at age 6; how-
ever, at age 14, males had a higher prevalence in both races
[19].
In general, maxillary midline diastemas occur in approxi-
mately 50% of children between 6-8 years of age but de-
crease in size and prevalence with age. Females exhibit a
greater prevalence at this age; however, males show a greater
rate by age 14.
The mandibular diastema is not a normal growth character-
istic. The spacing, though seen less frequently than maxillary
diastema, often is more dramatic. No epidemiologic data have
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
been published on its prevalence. The primary etiologic fac-
tor in mandibular diastemas is tongue thrust in a low rest
position [23].
Etiology
Numerous etiological factors contributing to the develop-
ment of midline diastema have been reported and discussed
in the literature. There is no agreement on a single etiologi-
cal factor. The prevailing view seems to consider its develop-
ment as a multifactorial phenomenon [10,24-28].
Various etiological factors are:
1. Nomal developmental pattern
2. Midline bony cleft
3. Frenum
4. Genetic
5. Habits
6. Muscular imbalances in the oral region
7. Physical impediment
8. Abnormal maxillary arch structure
9. Tooth size discrepancy
10. Increased overbite
11. Pathological Migration
12. Iatrogenic
1. Normal Developmental Pattern:
Maxillary anterior diastemas are a part of normal dental de-
velopment. Spacing in the full primary dentition is normal
and an indicator of space available for the eruption of per-
manent teeth. As the permanent maxillary incisors erupt, a
diastema is frequently created and often persists throughout
the mixed dentition until the canine teeth erupt.
After the eruption of the central incisors, the lateral incisors
erupt incisally along the central roots, tipping the central
crowns distally and often increasing the size of the diastema
between the central incisors. Only after the cuspids erupt
down along the lateral incisor roots and finally into full oc-
clusion does the maxillary midline diastema close.
Broadbent (1941) described the maxillary midline diastema
in growing children as non-esthetically pleasing and charac-
terized it as the “ugly duckling” stage of dental development
[29]. He considered this stage as a transitional phase for the
maxillary interincisal diastema, indicating the space avail-
able for the erupting permanent dentition. Broadbent also
described the closure of this diastema with complete erup-
tion of lateral incisors and canines as a normal stage of occlu-
sal development.
The cross-sectional studies of Richardson and colleagues,
Gardiner show a decrease in the incidence of diastemas with
increasing age through the mixed dentition phase [30,31].
The longitudinal study by Popovich and colleagues (1977)
found a similar relationship [32]. The Popovich study used
the study models of the same 471 patients at ages 9 and 16
years to determine changes in the incidence of maxillary
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midline diastemas. Eighty-three percent of the patients with
a diastema at 9 years of age had no diastema at 16 years of
age, without having undergone any treatment. In the approx-
imately 10 percent of the sample with persistent diastemas,
generalized spacing or an initial midline diastema larger than
3 mm was present.
As the above studies found, the great majority of diastemas
close after the eruption of the maxillary canine teeth and re-
quire no intervention by the dentist. Only diastemas larger
than 2 mm and diastemas in patients with generalized spac-
ing are at risk of not closing with normal development. It is
important to recognize this often abnormal-appearing maxil-
lary dental arrangement and not treat what is, in fact, normal
development.
2. Midline Bony Clefts:
Imperfect fusion at the midline of premaxilla is the most com-
mon cause of the upper midline diastema according to Moy-
ers. The discontinuity of the bony plates may be superficial
or extend deeper in the alveolar process. The gap within the
maxilla is occupied by epithelial and connective tissue. Often
frenum or gingival fibres (especially interdental fibres) are
attached at that site.
Normally, interdental fibres functionally contribute in the re-
tention of the teeth in position. Because of the disturbance
of the continuity and arrangement of the interdental gingi-
val fibres, their ability to resist in expressed forces to teeth is
compromised. As a result, there is a tendency for distal move-
ment of upper central incisors, leading in some cases to the
development of midline diastema.
For the same reason, this diastema is usually accompanied
by rotation of upper lateral incisors and ectopic eruption of
canines. Moyers stated that imperfect fusion at the midline
of premaxilla is the most common cause of maxillary midline
diastema, with a rate of 32.9%. Also, Popovich (1977) et al
suggested that the combination of imperfect fusion with sev-
eral other predisposal factors is the most significant cause of
maxillary midline diastema [32].
Stubley determined that transseptal periodontal fibers from
the mesial side of the teeth proceed horizontally for a very
short distance to the midline suture and then turn upward at
90° [33]. This fiber pattern could account for the difficulty in
the diastema closing spontaneously.
The diagnosis of imperfect fusion at midline is performed
radiographically. It is fundamental for the central ray to be
precisely perpendicular to the alveolar process. The normal
radiographic image of the suture is a V-shaped structure.
3. Frenum:
The upper labial frenum begins to form in the fetus at the
tenth week of gestation. By the third month in utero the tec-
tolabial frenum of the fetus is morphologically similar to the
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
abnormal frenum of post natal life that extends as a contin-
uous band of tissue from the tuberculum on the inner side
of the lip, over and across the alveolar ridge to be inserted
in the palatine papilla [3,7,24,34-36]. Before birth, the two
lateral halves of the alveolar ridge unite and the continuous
band of tissue becomes totally enclosed by bone. It is divided
into a palatal portion (palatine papilla) and a labial portion
(superior labial frenum) by this closure [37].
Figure 2. A maxillary midline diastema associated with an en-
larged frenum.
With time the frenum appears to recede up the labial surface
of the alveolar process. This movement actually is relative
during the primary dentition, as new bone deposits increase
the height of the alveolar ridge while the frenal attachment
remains in place. With eruption of the permanent maxillary
central incisors, the maxillary arch enters another period of
vertical growth acceleration [37,38]. The permanent maxil-
lary central incisors are flared laterally at this time because
the unerupted lateral incisors constrain the roots of the cen-
trals. The median diastema, formed is self corrected after the
eruption of canines (Fig. 2).
In some cases the series of events just described does not
occur. The two central incisors may erupt widely separat-
ed from one another and the rim of bone surrounding each
tooth may not extend to the median suture. In such cases, no
bone is deposited inferior to the frenum. A V-shaped bony
cleft develops between two central incisors, and an “abnor-
mal” frenum attachment usually results [37,39]. Transseptal
fibers fail to proliferate across the midline cleft, and the space
may never close [3,39,40].
In 1907, Angle suggested the frenum as a cause of midline
diastema and outlined a method for its removal. The assump-
tion that an enlarged labial frenum was the sole etiologic
agent led to advocating frenectomies in patients presenting
with midline diastemas. By the middle 1900s, the abnormal
labial frenum was believed to be an effect rather than a cause.
In 1924, Tait stated that the frenum has no function and that
its action, if any, in relation to the maxillary incisors is surely
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passive [41].
Ceremello (1953) compared the frena of two groups, one
with diastemas and the other without. He found no cor-
relation between frenum attachment and diastema width,
between frenum width and diastema, or between frenum
height and frenum width. Dewel found the same results in a
similar study [38].
Popovich et al (1977) suggested that the presence of the dias-
tema leads to the abnormal fraenum and not the reverse [42].
Shashua and Artun (1999) found that there is a relation be-
tween the width of the maxillary midline diastema and the
abnormal labial fraenum [43].
Adams (1954) suggested that a specific type of fraenum,
which is not necessarily large but interrupts the continuity of
interdental fibres, forms the factor that inducts the reactions
for the development of the diastema [3].
The disruption of the interdental (transseptal) gingival fibres
continuity, due to the frenum, is considered as presupposing
for the development of a pathological diastema. Edwards
(1977) supported the presence of a strong but not absolute
correlation between the frenum and the upper midline dias-
tema [34].
Enlarged and low frena do exist in the absence of a median
diastema. Also, diastemas can exist without an abnormal fre-
num. Bergastrom and coworkers (1973) studied the effect of
superior labial frenectomy and found that although closure
progressed more rapidly in the frenectomized group than in
the unoperated group, there was no difference in the final
results after 10 years [44]. These results intimate that frena
may exert passive resisting mesial pressure, but are not an
important etiologic factor in midline diastemas.
4. Genetic:
Midline diastema shows hereditary pattern. Gass et al. (2003)
noted that preliminary results from thirty families show a
possible genetic basis for this diastema. Data from family
trees suggest a autosomal dominant hereditary type [45].
Shashua and Artun (1997) report that genetic predisposition
is a probable precondition contributing to midline diastema
development [43].
Nainar and Gnanasundaram (1997), in their study of mid-
line diastemas in a South India population sample, examined
9774 individuals from 13 to 35 years of age in order to de-
termine the consequences and possible etiological factors of
this feature [46]. The relatively increased frequency of famil-
ial occurrence led the authors to propose the presence of a
genetic factor contributing to midline diastema expression.
Schmitt (1982) described eight members of a family who, for
more than three generations, presented a syndrome includ-
ing bilateral triphalangeal thumbs, radial hypoplasia, hypo-
spadias (congenital abnormality of the urethra) and maxil-
lary diastema [47]. All family members with the disease had
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
a midline diastema and the authors concluded, on the basis of
the hereditary pattern, that the syndrome follows the autoso-
mal dominant type.
5. Tooth Size Discrepancies:
Tooth-size discrepancies are a major cause of diastemas. The
most common tooth-size discrepancy is small or peg-shaped
maxillary lateral incisors. The small maxillary lateral incisors
allow distal drifting of the maxillary central incisors and cre-
ate a midline diastema.
6. Missing Maxillary Laterals:
Missing maxillary laterals leads to space in maxillary anterior
region leading to midline diastema.
7. Habits:
Prolonged pernicious habits can change the equilibrium
of forces among the lips, cheeks, and tongue and cause un-
wanted dentofacial changes. The outward pressure from pro-
longed oral habits (light continuous force over 6 hour) with
inadequate lips seal can cause the maxillary incisors to flare
out, which leads to the midline diastema [30]. Examples in-
clude: lower lip biting and digit sucking.
8. Muscular Imbalances in the Oral Region:
The dentition is in balance or equilibrium among various
forces from the intraoral and extraoral soft tissues. The mus-
cular imbalances in the oral region can break this balance and
cause the teeth to move until the forces reach a new equilibri-
um. The soft tissues imbalances imbalances can be caused by:
macroglossia due to a syndrome, or lymphangioma; flaccid
lip muscles; and tongue thrust.
If these muscular conditions do not change,a dramatic re-
opening of the diastema immediately following any ortho-
dontic closure of the space may occur.
For long-term stability causative conditions should be elimi-
nated if possible; otherwise, some type of permanent reten-
tion should be considered [23].
An abnormal tongue size is a severe problem which may
create difficulties in retaining the orthodontically corrected
midline diastema. Macroglossia can be detected by simple
observations. The patient can be asked to touch the tip of the
nose with his tongue and, if he/she is able to do that, it is an
indication of an extended tongue. In the same way, if tooth
indentations are seen on the lateral borders of the tongue, it
can be an indication of an enlarged tongue. In such cases, sur-
gical trimming may have to be considered in order to attain
stability in the dental occlusion [48].
9. Physical Impediment:
An object can deflect the eruption pattern of the maxillary
central incisors or physically move the incisors laterally to
create midline spacing [26].
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Orthodontic diastema closure may be needed later for pa-
tients whose diastemas do not completely close sponta-
neously after removing the physical impediment.
Examples include:
a. Supernumerary teeth (e.g., mesiodens), retained primary
tooth
b. Persistent enlarged labial frenum
c. Other midline pathology (cysts, fibromas)
d. Foreign body and associated periodontal inflammation.
The current consensus among clinicians is that the diastema
needs to be corrected initially with orthodontic treatment
and subsequent retention [34,49].
10. Abnormal Maxillary Arch Structure:
Tooth-size arch length discrepancies are caused by excessive-
ly large maxillary arch size (rather than small teeth) or bony
defects that inhibit approximation of the incisors [26]. These
abnormal maxillary arch structures include:
a. Open suture, W-shaped, or spade-shaped.
b. Idiopathic midpalatal suture due to orthodontic or ortho-
pedic treatment (e.g., rapid palatal expansion, Milwaukee
Brace).
c. Excessive skeletal growth (associated with certain physical
conditions such as cerebral palsy and endocrine imbalances
such as acromegaly).
d. Loss of bone support (periodontal disease, systemic dis-
ease).
11. Dental Anomalies and other Malocclusion:
Abnormal shape, or position of adjacent teeth can leave spac-
es between them that are not the result of other forces (e.g.,
muscular imbalances, excessive frenum tissue, etc.) [26].
These etiologies include:
a. Tooth and/or arch size discrepancies including peg laterals
b. Missing teeth (congenital, from caries, or orthodontic
treatment)
c. Abnormal occlusal patterns such as rotated incisors, class
II division 1 malocclusion.
12. Excessive Anterior Vertical Overlap:
Excessive anterior vertical overlap (overbite) of the anterior
teeth is another common cause of excessive spacing in the
maxillary arch. When the size of the maxillary teeth match
that of the mandibular teeth (no Bolton discrepancy) and the
anteroposterior occlusion is normal (that is, Class I), an in-
crease in the vertical overlap of the anterior teeth results in
an increase in the circumference of the maxillary arch (spac-
ing) or in crowding of the lower incisors. This phenomenon
occurs as a result of the wedge-shaped lingual surface of the
maxillary incisors.
When there is little or no lower incisor crowding, the maxil-
lary incisors move forward and the circumference of the max-
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
illary arch increases as the vertical incisor overlap increases.
When this occurs, spacing develops between the maxillary
anterior teeth, creating diastemas.
Patients with excessive vertical alveolar development of
mandibular incisors have a normal lower facial height, a nor-
mal relationship between the maxillary incisors and the low-
er border of the upper lip and a pronounced lower curve of
spee. Frequently, a pronounced step in the occlusal plane is
present in the lower cuspid or incisor area. This is not un-
common in Class II malocclusions when either the maxillary
teeth are labial to their normal position or the mandibular
teeth are lingual to their normal position. In a Class II maloc-
clusion, the best result is achieved when the Class II maloc-
clusion and the anteroposterior positioning of the teeth and
jaws are corrected.
Fine suggests that in a patient with a Class II malocclusion,
dental prematurities may cause a forward shift of the man-
dible that can result in progressive splaying or spacing of the
anterior teeth; he suggests occlusal equilibration to a centric
relationship position. When the arches are in the proper re-
lationship in an anteroposterior direction, excessive vertical
alveolar development of the lower incisors can cause spacing
between the maxillary incisors and, consequently, a midline
diastema.
13. Mesiodistal Angulation:
When the maxillary incisor crowns are distally inclined, a di-
astema may appear to be present, although the incisors are
actually in contact. With excessive distal crown angulation,
the contact point of the central incisors moves gingivally,
leaving what appears to be a diastema at the incisal edge of
the teeth.
This phenomenon is enhanced by the mesial contour of the
incisors. Incisors that have little convexity on their mesial
surface are more affected by mesiodistal crown angulation,
while incisors with a more convex mesial surface are more
forgiving and tend to maintain their contact point at a more
incisal level. The more convex the mesial surface of the max-
illary central incisor, the less likely the incisors will appear to
have no contact.
Mesiodistal crown angulation also influences the amount of
arch length or space between the cuspids. Less maxillary arch
circumference is present when the incisors are upright me-
siodistally. The more the crowns are angulated mesially, the
more arch length or arch circumference is increased. There-
fore, the more upright the crowns, the greater the possibility
of anterior spacing; the more mesially inclined the crowns,
the less likely that there will be space between the teeth.
14. Labiolingual Inclination:
Labiolingual angulation of the maxillary incisors also has an
effect on anterior arch circumference and can create a maxil-
lary midline diastema. If the overjet and posterior occlusion
5/12
are ideal (Class I), but the maxillary incisors are excessively
upright, the maxillary incisor roots and contact points will be
displaced anteriorly. This can result in maxillary arch spac-
ing, which, at first glance, may be attributed to a tooth-size
discrepancy. Upright maxillary incisors are often combined
with excessive vertical development of the maxillary or man-
dibular incisors, creating excessive anterior vertical overlap
of the incisors. This overlap, combined with upright maxil-
lary incisors, further exacerbates the increase in maxillary
arch circumference and increases the likelihood of a maxil-
lary midline diastema.
15. Iatrogenic Diastema:
Iatrogenic diastemas also can occur. Besides the temporary
diastemas caused by some maxillary expansion appliances
(e.g., Rapid Palatal Expansion [RPE] appliance), improper or-
thodontic techniques also can create a diastema, as well as
other problems. Verluyten (1989) reported a case in which
elastic that had been placed around the central incisors to
close a diastema had worked its way subgingivally toward the
tooth apices [50]. The continuing constriction of the elastic
towards the apices caused root approximation, an increased
diastema, and a significant periodontal defect. Because of
these potential deleterious effects, this technique is not rec-
ommended for diastema closure.
Management of Midline Diastema
Because of the potential for multiple etiologies, the diagnosis
of a diastema must be based on a thorough medical/dental
history, clinical examination, and radiographic survey.
Diagnostic study models also may be necessary for analysis
and measurement when the diastema may be due to maloc-
clusion, or tooth and/or arch size discrepancy.
The medical/dental history should investigate any pertinent
medical conditions (such as hormonal imbalances), oral hab-
its, previous dental treatment and/or surgeries, and family
history of diastemas or other related dental problems.
The clinical examination should include evaluation of possi-
ble pernicious oral habits, soft tissue imbalances (e.g., macro-
glossia), improper dental alignment (rotated teeth, excessive
overbite/overjet), missing teeth, or other dental anomalies.
The “blanching test” may be used to evaluate the frenal at-
tachments.
Panoramic and periapical radiographs are necessary to eval-
uate the patient’s dental age and any physical impediments,
abnormal suture morphology, missing teeth, dental anom-
alies, improper dental alignment, or abnormal eruption
paths. In some instances, complete orthodontic records and a
Bolton’s analysis maybe necessary to rule out skeletal/dental
malocclusions as well as possible jaw size and/or dental size
discrepancies [51,52]. Wise and Nevins have described ex-
amples using Bolton’s analysis to develop appropriate treat-
ment plans [53].
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
Proper treatment of a midline diastema will depend upon
its etiology. Several treatment protocols have been proposed
ranging from the classic frenectomy [34] or orthodontic
treatment [25], to even more radical procedures of subapi-
cal osteotomies, corticoectomies, septotomies [54-56], and
reverse-bevel gingivectomies [45]. No single method can be
used to treat all diastemas cases.
The success in closing diastemas depends upon the following
treatment phases:
1. Accurate diagnosis of the specific etiology or etiologies
2. Pretreatment consideration of appropriate orthodontic
objectives
3.Treatment of the specific etiology or etiologies
4.Long-term retention and stability.
Because of racial and familial tendencies in some diastema
cases, we should consider the perception of the patient and
his/her family when discussing a diastema and the need for
treatment. Some may not see a diastema as a problem. For
others, frustration at not being financially able to proceed
with treatment should be handled professionally and com-
passionately.
Treatment Options
Many forms of therapy can be used for diastema closure. A
carefully developed diagnosis, which includes a determina-
tion of the causal elements, and advanced treatment plan-
ning, allows the most appropriate treatment to be selected
for each case. Explaining the various treatment options to the
patient, and documenting their understanding of the options,
is critical in gaining the patient’s consent and cooperation in
achieving a result that will be judged successful.
Orthodontic correction often results in a sensible esthetic im-
provement and is well accepted by patients. However, ortho-
dontics alone often may not be able to correct the problems
associated with excessive space. In many cases, post ortho-
dontic restorative and periodontal procedures are also nec-
essary [57].
Excessive interproximal space presents a dynamic challenge.
Arch circumference or length must be decreased or tooth
structure added. Closing spaces exclusively by orthodontics
requires that arch length be decreased either by retraction
of anterior teeth, protraction of posterior teeth, or a combi-
nation of both. Envisioning the end result before adjunctive
orthodontics will define the treatment plan [58].
However, treatment plans should not be selected empirically;
they should be based on thorough documentation. Measure-
ments, models, and photographs are all parts of adequate
treatment planning.
Diastema closure must establish proper tooth proportions
that are as close to ideal as possible [61]. Orthodontic inter-
vention alone is not adequate to resolve every problem. When
dentoalveolar and Boltona discrepancies are detected, ortho-
6/12
dontic intervention is not sufficient to establish the proximal
contacts with satisfactory vertical and hori-zontal overlaps.
Restorative intervention is required to optimize results. Or-
thodontic treatment can be used, however, to redistribute
the spaces between the maxillary anterior teeth before the
restorative procedures [62].
The literature documents many methods for treating ante-
rior diastemata: porcelain laminate veneers, direct bond-
ing, and crowns, both with and without orthodontics [61].
Regardless of the treatment chosen, the patient should be
aware that along with esthetic improvement there is a con-
current change in speech [57]. The passage of air through the
oral cavity during speech will be modified when the diaste-
ma is closed. The patient should be advised before initiating
treatment that a change in speech may occur. Phonetic eval-
uation (enunciation of F, S and V sounds) is advised. If there
is a change in speech that is noticeable and troublesome, the
patient should be advised that adaptation to this new speech
pattern usually occurs within a few days [57]. Reading a loud
is a useful exercise to help the patient return to previous
speech patterns.
Orthodontic Approach
A shift from traditional orthodontic treatment goals, such as
ideal occlusion and cephalometric standards, to include goals
embodying principles of microesthetics and soft tissue har-
mony has occurred. Orthodontists now place a greater em-
phasis on gingival esthetics, tooth form, and increasingly rely
on interdisciplinary care [60].
Rosenstiel and Rashid (2002), in an Internet study concern-
ing the opinion of laypeople about anterior teeth esthetics,
showed that conditions such as diastema and midline devi-
ation received the worst ratings. Detailed analysis and un-
derstanding of malocclusion is needed by the orthodontist,
so that s/he may successfully treat midline diastema for the
patients esthetic and functional benefit. [63]
It is an error to surgically remove the frenum at an early age
and then delay orthodontic treatment in the hope that the
diastema will close spontaneously. If the frenum is removed,
while there is still a space between the central incisors, scar
tissue forms between the teeth as healing progresses, and a
long delay may result in a space that is more difficult to close
than it was previously.[64-66]
The use of orthodontic treatment alone to close a diastema is
most appropriate in those cases in which proximal contacts
can be obtained without the use of addition restorations (Fig.
3) [57]. This is possible when acceptable tooth proportion
and tooth size exist [60]. Patients with significant overjet
can often be treated with orthodontics alone as closing of the
maxillary spaces will reduce the overjet. If, however, a patient
does not exhibit excess overjet, closing the space orthodon-
tically, without restorative dentistry, may be detrimental for
the functional occlusion because of the possible over-retrac-
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
tion of the incisors [60]. This, almost certainly, will cause
multiple long-term problems such as increased occlusal wear
on the anterior teeth, crowding of the lower incisors, or re-
lapse of the spacing. Orthodontic space closure may also lead
to a constriction of the anterior arch width and adversely af-
fect smile esthetics [60].
Fig. 3 Maxillary midline diastema closed by orthodontic
treatment
Although orthodontics is capable of providing a pleasing es-
thetic result, its major disadvantage is the amount of time
and the number of appointments required to obtain the de-
sired esthetic result. In addition, orthodontic relapse may oc-
cur without proper retention and stabilization. Fixed ortho-
dontic appliances may result in an increased accumulation
of plaque, increasing caries, and periodontal susceptibility.
On the other hand, removable orthodontic appliances are
effective only if patients comply with instructions. Failing to
wear the removable appliance as directed will produce poor
results or increase the amount of time needed to obtain the
desired results [65].
When maxillary anterior teeth are not proportional to both
mandibular anterior teeth and within the arch, and spaces
exist, it is not possible to obtain proximal contacts with or-
thodontic intervention alone. A restorative approach is re-
quired to close the diastema [57].
Restorative Approach
Direct bonding, laminate veneers, and crowns are used to
correct diastemata. These modalities control both tooth size
and shape.
Achieving ideal tooth shape and proportion is an important
goal in diastema correction. An imbalance in the proportion
of the anterior teeth is frequently observed after the closure
of diastemata. A pleasing width to length tooth proportion is
an essential requirement for a favorable esthetic outcome.
Chu describes yet another way to relate the width of teeth
within the esthetic zone [67]. Chu proposes that the width
of the maxillary lateral incisor should be approximately 2
mm less than the central incisor and the width of the canine
7/12
should be 1 mm less than the central incisor.
Patient demand for aesthetic dentistry with minimally inva-
sive procedures has resulted in the extensive utilization of
freehand bonding of composite resin to anterior teeth [1,2].
The diastema presents itself to the dental office on a regular
basis. It may be small or large. The papilla may be long and
skinny or blunted. The size will have an effect on what mate-
rial will be chosen to achieve the desired results. When deal-
ing with a large space closure, orthodontist may be indicated
to allow for a more esthetic outcome [1,2]. When the teeth
are in proper orthodontic alignment, no preparation of the
tooth structure is necessary. If there is an alignment problem,
minor tooth preparation will be necessary to achieve proper
arch form. Composite resin is an ideal material when restor-
ing diastema closure. It is highly polishable, long lasting and
mimics natural tooth structure. It is a conservative alterna-
tive to an indirect restoration [1,2].
The arrangement and proportion of maxillary anterior teeth
are the major determinants for a pleasing appearance. To eval-
uate and describe the ideal tooth-to-tooth proportion, Levin
applied the golden proportion (proportion of 1.618:1.0) to
relate the successive widths of the anterior teeth as viewed
from the front [68].
The golden proportion implies that the maxillary central in-
cisor should be 62% wider than the lateral incisor, which is
consistent between the widths of the maxillary lateral incisor
and canines. However, Preston reported that only 17% of the
patients had the golden proportion in terms of the relation-
ship between the maxillary central and lateral incisors [69].
In addition, when using the golden proportion, the lateral
incisors and canines appeared too narrow. Therefore, Ward
indicated that the recurring esthetic dental (RED) proportion
was more appropriate to individually fit the face, gender, and
body type of each patient [70]. The average range of RED pro-
portion from 62% to 80% was considered acceptable.
Esthetics as well as occlusion must be considered in the final
orthodontic positioning of the teeth adjacent to the edentu-
lous space. To satisfy the “golden proportion” principle of es-
thetics, the space for the maxillary lateral incisor should be
approximately two-thirds of the width of the central incisor
[71,72]. However, if the patient is missing only one maxillary
lateral incisor, the space required to achieve symmetrical es-
thetics and occlusion is primarily dictated by the width of the
contralateral incisor [71]. When both laterals are congenital-
ly absent, the occlusion may influence the amount of space
required for the implant restoration and the proportional re-
lationship between the central and lateral incisors [71].
Retention
The relapse of the maxillary median diastema after ortho-
dontic space closure, however, might be as great as 50%.
Sashua and Artun observed that the initial width of the dias-
tema, a family member with diastema, and additional spaces
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
between the maxillary anterior teeth are the most predictive
factors of relapse [43].
The most appropriate solution for permanent retention is the
bonding of a multi-stranded stainless steel wire, constructed
by 6 strands of wire, with a 0.0215 inch diameter each. The
basic advantage of this retainer is that its flexibility permits
teeth to retain their physiologic movement, plus it is placed
and bonded easily. The multi-stranded wire is bonded with
resin composite, usually from canine to canine in the middle
of the palatal surface of anterior teeth. In cases where the re-
tainer interferes in functional movements of the mandible, it
can be bonded cervically or within a shallow rim constructed
to the enamel of the teeth. The retainer may be used for a spe-
cific period of time or for the patient’s whole life. According
to Lang et al, the time for retention must in every case exceed
2 years [73].
A bonded palatal fixed retainer is advisable in the majority of
cases to stabilise the result post treatment. In wider diaste-
mas this retention should be permanent. As with all bonded
retainers patients should be instructed in good oral hygiene,
including the use of floss threaders [74,75].
The authors generally provide patients who have bonded
retainers with a removable Hawley-type retainer to be worn
at night for the first few years. Mulligan in a recent report
presents a novel method of reducing retention requirements
in these cases. He moves the apices of the incisors distally
in finishing the treatment. In this way, he postulates, larger
functional moments are produced when the incisor roots are
divergent which help to keep the diastema closed. To test
the stability he removed the archwires for a six-weeks peri-
od near the end of treatment. The disto-incisal edges of the
tipped teeth are modified with the use of disks for enhanced
aesthetics. This interesting approach holds promise [75].
Mulligan’s Concept of Retention
Many orthodontists view permanent retention as the only
realistic approach to maintaining closure. Removable appli-
ances used for retention create back-and-forth movement as
a result of being worn “on and off”. Although many orthodon-
tists resort to frenectomies and circumferential fibrotomies,
the outcome in these cases is often frustrating because unde-
sirable side-effects still occur. Thus, even with surgical proce-
dures, some form of retention is frequently required.
Thomas F Mulligan used a new approach in which all arch-
wires are removed during treatment as a mandatory phase
of orthodontic tooth movement [76]. Such wires are removed
for at least 6 weeks, but often longer as situations demand
(e.g., summer vacation). This does not mean, however, that
archwires must be removed for every type of instability [77],
such as crossbites, open bites, overbites, and rotations. These
different areas may be checked for stability versus instability
at the same time.
8/12
When archwires are removed, teeth “rebound” but in any case
will attempt to put themselves into equilibrium with muscles
and function. Tooth position is determined by muscles, func-
tion, and habits, along with duration and related factors.
If the crowns are tipped, the occlusal forces acting on the
central incisors would take place through a greater perpen-
dicular distance from the centers of resistance in these teeth,
thus creating so-called functional moments. Although with
the central incisors the angular displacement would require
primarily root displacement, it is the increased separation of
the centers of resistance that results in these functional mo-
ments.
In the case of a diastema, the central incisor crowns can only
move together until contact is made, at which time the re-
maining movement consists of only distal movement of the
central incisor roots.
If crown widths are normal and proportionate to other teeth
in the anterior segment, the divergence of roots will result in
some overjet. After closure of the diastema, the overjet pro-
duced can be used effectively to solve other potential prob-
lems, such as the following:
• Diastemas
• Small lateral incisors
• The “dark triangle”
• Generalized spacing resulting from small lateral incisors
• Anterior “end-on” relationships
• Slight Class III anterior teeth
Treatment may involve the use of continuous arches, anterior
segments with a center bend, or a bypass segment consisting
of two off-center bends. The latter two are frequently used
in combination.
Because a continuous arch engaged into all brackets cannot
produce pure moments on the four incisor brackets, two in-
dividual segments can be used instead. One segment is re-
ferred to as a center bend and produces equal and opposite
moments. The other segment involves two off-center bends
and performs exactly the same function as the center bend.
This permits the divergence of roots on all incisors at the
same time.
After archwire removal and verification of stability, the in-
cisal edges may be contoured and the brackets repositioned
for any continuation of treatment.
Diverging incisor roots result in some degree of overjet if
teeth are normal in their mesiodistal dimensions. Therefore
interproximal reduction of the central incisors must be ac-
complished before complete closure of the diastema, to pre-
vent distal root movement instead of mesial crown move-
ment.
Cite this article: Sanjay Prasad Gupta. Maxillary Midline Diastema: A Contemporary Review. EMS Dent j 2018, 1(1):002.
In treating the dark triangle, there will be greater mesial
movement of the incisor crowns and less distal movement of
the roots, although the change in inclination will remain the
same.
Conclusion
The presence of diastema between teeth is a common fea-
ture found in the anterior dentition. MMDs create a dark
spot within the smile, which prompts many patients to seek
treatment. Many forms of therapy can be used for diastema
closure.
Several factors can cause a diastema that may require
intervention. An enlarged labial frenum has been blamed
for most persistent diastemas, but its etiologic role now
is understood to represent only a small proportion of cas-
es. Other etiologies associated with diastemas include oral
habits, muscular imbalances, physical impediments, abnor-
mal maxillary arch structure, and various dental anoma-
lies.
A carefully documented diagnosis and treatment plan are es-
sential if the clinician is to apply the most effective approach
to address the patient’s needs.
Effective diastema treatment requires correct diagnosis of
its etiology and intervention relevant to the specific etiol-
ogy. Correct diagnosis includes medical and dental histo-
ries, radiographic and clinical examinations, and possibly
tooth-size evaluations. Appropriate treatment modalities
have been described.
Timing often is important to achieve satisfactory results. Re-
moval of the etiologic agent usually can be initiated upon
diagnosis and after sufficient development of the central
incisors. Tooth movement usually is deferred until erup-
tion of the permanent canines, but can begin early in
certain cases with very large diastemas.
Midline diastema is usually a part of normal dental develop-
ment and hence its presence during the mixed dentition pe-
riod is not a matter of concern. However, if the diastema is
more than 1.8 mm, even after the eruption of lateral incisors,
an orthodontic intervention will be necessary [78].
To achieve an aesthetic and stable result, it is important to
establish the underlying cause for the midline diastema. Re-
tention protocol should depend on the size and the aetiology
of the midline diastema [79].
Finally, the high relapse risk following orthodontic treatment
in cases with midline diastema leads to the conclusion that it
is necessary to follow a more conservative retention protocol
and more specifically, that of fixed retention [80].
9/12

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