Philip P, et al: Diastema closure by Mulligen’s method: Criteria for case selection

Short communications

Diastema closure by Mulligen’s method: Criteria for case

selection
Pramod Philip, Subraya Mogra
Email: pramodphilip@gmail.com

Abstract
Spacing among the anterior teeth can be due to a variety of factors such as: tooth size-arch length discrepancy,
microdontia, habits like thumb sucking, tongue thrusting, midline pathologies, etc. Irrespective of the etiology,
it almost always creates an unesthetic appearance necessitating treatment. The treatment options can vary from
a simple cosmetic build up using light cured resins to fixed orthodontic therapy for space closure. Criteria for
case selection for each of the procedures include age of the patient, amount of space present, time frame with
in which the patient needs the correction, micro esthetics, etc. Space closure by orthodontic means almost often
necessitates the placement of a permanent bonded retainer to retain the correction. Thomas Mulligen advocated
the mesial tipping of the incisors with the help of a V bend in a sectional arch wire inserted to edgewise
brackets for diastema closure. The present article explains the guidelines for considering diastema closure using
Mulligen’s method with the help of a case report.

Introduction 1. A space of 1-2 mm is usually managed by

Midline diastema of varying dimensions is a very
common occurrence in day to day clinical practice.
Some consider it as a good omen, where as some
others find it unacceptable esthetically. Etiologies
of the diastema are many and varied. It may be
due to a variety of factors such as: tooth size-arch
length discrepancy, microdontia, habits like thumb
sucking, tongue thrusting, midline pathologies, etc.
Cases with a midline diastema may or may not be
associated with other malocclusions like generalized
spacing or proclinations.
When a patient presents with only a midline diastema
and has normal inclinations of the upper and lower
incisors, with class I canine relations, normal overjet
and overbite, one of the following methods is the
treatment of choice.
Pramod Philip
Professor and Head Department of Conservative Dentistry and
Endodontics, Kannur dental college, Anjarakandy, Kannur
Subraya Mogra
PG student department of Conservative Dentistry and Endodontics
Kannur Dental College, Anjarakandy, Kannur
* Corresponding Author
restorative build up of the central incisors
provided; the “tooth proportions” are not grossly
disturbed. In cases with small sized lateral
incisors, it is advisable to close the midline
diastema by orthodontic tooth movement,
followed by the restorative build up of lateral
incisors.
2. A space of 2-4 mm is usually associated with
a papillary attachment of frenum; frenectomy
needs to be considered along with orthodontic
redistribution of spaces and cosmetic build up
of all the incisors if optimal results have to be
achieved.
3. A space of more than 4 mm is generally
associated with anomalous shapes and/or size of
the incisors or midline pathology like mesiodens
and may require elaborate treatment procedures.
The term “tooth proportions” denote the following
things:
a) Individual tooth proportion: It is accepted that
the width to length ratio of a maxillary central
incisor in a pleasing smile is in the range of 75
percent to 80 percent. 1

How to cite this article: Pramod Philip, Subraya Mogra. (2017). Diastema closure by Mulligen’s method: Criteria for case
selection, 2(1), 18-22.

18 Manipal Journal of Dental Sciences | April 2017 | Volume 2 | Issue 1

 Philip P, et al: Diastema closure by Mulligen’s method: Criteria for case selection

b) Proportion of the width between central and lateral

incisors: Lombardi suggested the use of “golden
proportions” (1.618:1) while considering the
esthetic build up of the teeth. The ‘recurring
esthetic dental proportion’ concept (proportion
of the successive widths of the teeth as viewed
from the frontal aspect, should remain constant
as one moves distally) proposed by Ward has
gained popularity over the absolute proportions,
as it takes into account the perceived size of the
incisors as compared to the actual size.2 Figure 2: 0.018 X 0.02511 Nitinol wire inserted into slots of
standard edgewise brackets.
c) Also, the dimensions of the incisors should be
in proportion with the facial dimensions and A second visit after six weeks showed that the
consistent to the arch. diastema had closed with a good contact between
the incisors (Figure 3). The teeth were bonded with
Thomas Mulligen advocated the closure of midline
a lingual retainer to hold the teeth in position.
diastema with mesial tipping of the crowns with a
centered V bend placed on a sectional wire inserted
into the edgewise slots of brackets bonded on the
incisors.3 He also advocated the mesial tipping of
the lateral incisors with a bypass arch inserted into
the bracket of only the lateral incisors which will
enhance the stability of the achieved result. His
suggestion was based on the logic that a tooth tipped
mesially or distally will occupy more space than an
upright tooth.

Case report
A 24 years old female presented with a midline Figure 3: Post space closure shows an optimal contact
diastema of 1.5 mm with Angles Class I molar
Discussion
relation with normal overjet and overbite (Figure
Though Mulligen advocated the placement of a
1). Considering the amount of space and the incisor
V bend, authors preferred angulating the brackets
anatomy it was decided to close the space by mesial
to the required level (3-5 degree) while bonding,
crown tipping. Central incisors were bonded with
followed by placement of a Nitinol wire. In addition
standard edgewise brackets (0.022 slot) which were
to preventing a possible bond failure (which occurs if
angulated while bonding. A sectional Nitinol wire
a rectangular wire with V bend is placed immediately
(0.018x0.025) was inserted (Figure 2).
after bonding), it reduces the patient’s discomfort.
A sectional rectangular wire is preferred to a round
wire as it will not rotate in the slot. Care should be
taken to have similar angulations while bonding the
brackets to avoid any vertical forces that could come
into play, as it happens with an off centered V bend.4

Clinical guidelines before considering space closure

with “V bend mechanics”:
Figure 1: Well aligned arch showing a midline diastema of 1.5 1. Anatomy of the incisor crown: Incisors which have
mm.
their maximum mesio-distal width at the middle

Manipal Journal of Dental Sciences | April 2017 | Volume 2 | Issue 1 19

 Philip P, et al: Diastema closure by Mulligen’s method: Criteria for case selection
third of the crown are ideally suited as this
allows establishment of a proper contact even
after mesial tipping. Incisors with maximum
width at the incisal third will open up dark
triangles after space closure (Figure 4).
Figure 4: Unfavorable crown morphology with maximum width
at the incisal edges.
2. Mesio-distal angualtion of the tooth: Incisors
with distal crown inclination before treatment
are ideally suited for the procedure. If they
present with an existing mesial inclination,
establishment of a proper contact will require
proximal slicing of the mesio-incisal edge,
20
which will create additional space problems.
Also, the excessive mesial tip of central incisors
might compromise the esthetics.
Conclusion
Closure of midline diastema by mesial tipping of
crowns as advocated by Mulligen is a viable option
if the space is minimal (1-1.5 mm) and the tooth
proportions are acceptable. But, due considerations
have to be given to the anatomy of the crowns and
the mesio-distal angulations of the adjacent incisors.
References:
1. Gurel G. The Science and Art of Porcelain
Laminate Veneers. London: Quintessence; 2003.
2. Ward DH. Proportional smile design using the
recurring esthetic dental proportion. Dent Clin
North Am 2001; 45:143 - 54.
3. Mulligen T. Understanding and applying wire
bracket angles. J Clin Orthod. 2008; 42:563 - 73.
4. Burstone CJ, Koenig HA. Creative wire bending-
the force system from step and V bends. Am J
Orthod Dentofac Orthop 1988; 93:59 - 67.
Manipal Journal of Dental Sciences | April 2017 | Volume 2 | Issue 1