Maxillary anteri-

lowest incidence in A B S T R A C T or spacing, or dipeople of Chinese astemas, are a descent (1.7 perBackground. Maxillary midline diastemas are a comcommon esthetic cent).3 mon esthetic problem that dentists must treat. Many innovative complaint of paIn a study of therapies have been used, varying from restorative procedures to tients. Although a 5,307 patients, surgery (frenectomies) and orthodontics. At times, these procefew entertainment Richardson and dures have been performed by the dentist without full appreciacelebrities have colleagues4 found tion of the factors contributing to the diastemas. used a midline the incidence of Case Description. Before the practitioner can demaxillary diastema termine the optimal treatment, he or she must consider the conmaxillary midline as a successful diastemas to be tributing factors. These include normal growth and development, trademark, many higher in blacks tooth-size discrepancies, excessive incisor vertical overlap of difpeople find it esthan in whites and ferent causes, mesiodistal and labiolingual incisor angulation, thetically displeashigher in boys than generalized spacing and pathological conditions. A carefully deing. In fact, a rein girls of the same veloped differential diagnosis allows the practitioner to choose cent study race at age 14 the most effective orthodontic and/or restorative treatment. involving European Clinical Implications. The differential diagnosis years. They found adults found that the incidence to be leads to a treatment approach that most effectively addresses the patients with a 26 percent in black patient’s problem. By treating the cause of the diastema, rather broad midline diboys, 19 percent in than just the space, the dentist enhances both the patient’s denastema were perblack girls, 17 pertal function and appearance. ceived as being less cent in white boys socially successful and of lower intelligence.1 In and 12 percent in white girls. Keene’s study of that study, maxillary anterior spacing was equal 183 white male Navy recruits found that 8 perto crowding and even more of an esthetic liability cent of them had diastemas greater than 0.5 milthan excessive overjet or protruding incisors. limeters.5 The esthetic importance of maxillary anterior Another study of nearly 10,000 patients in South spacing varies both culturally and racially as well India, however, found an incidence of only 1.6 peras with the incidence of diastemas within a given cent.6 It is clear that the incidence of midline dipopulation. The incidence of diastemas varies astemas varies greatly with the population and age greatly with age and race. In 5-year-olds, the incigroup studied, but diastemas are a significant maldence has been reported to be as high as 97 perocclusion factor in some population groups. cent,2 with the incidence decreasing with age. A Maxillary midline diastemas generally have study from Great Britain reported a higher incibeen studied by lumping them into one large dence of maxillary midline diastemas in blacks group, with little consideration given to the con(5.5 percent) than in whites (3.4 percent), and the tributing factors. However, not all maxillary midJADA, Vol. 130, January 1999 Copyright ©1998-2001 American Dental Association. All rights reserved. 85





After the eruption of the central incisors. The cross-sectional studies of Richardson and colleagues. generalized spacing. frenums and pathological conditions are less frequent. NORMAL GROWTH AND DEVELOPMENT Maxillary anterior diastemas are a normal part of dental de86 velopment. A common method is the Bolton analysis. Spacing in the full primary dentition is normal and an indicator of space available for the eruption of permanent teeth. we examine the various contributing factors. a diastema is frequently created and often persists throughout the mixed dentition until the canine teeth erupt (Figure 1). There are at least two methods of determining whether tooth-size discrepancies are present. In adults. In the approximately 10 percent of the sample with persistent diastemas. in fact. Incisor mesiodistal angulation. Eighty-three percent of the patients with a diastema at 9 years of age had no diastema at 16 years of age. Variations from Class I create other anterior space problems that are associated with Class II and Class III malocclusions. January 1999 Copyright ©1998-2001 American Dental Association. Bolton analysis.4 Gardiner7 and Weyman8 all show a decrease in the incidence of diastemas with increasing age through the mixed dentition phase. The most common tooth-size discrepancy is small or peg-shaped maxillary lateral incisors. As the above studies found. normal development. The small maxillary lateral incisors allow distal drifting of the maxillary central incisors and create a midline diastema. A mismatch between the maxillary and mandibular teeth is commonly called a Bolton discrepancy and. Only diastemas larger than 2 mm10 and diastemas in patients with generalized spacing are at risk of not closing with normal development.CLINICAL PRACTICE determine changes in the incidence of maxillary midline diastemas. 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 occlusion does the maxillary midline diastema close. A diastema between the maxillary central incisors as well as mild lower incisor crowding is normal during the mixed dentition phase. without having undergone any treatment. line diastemas are the same. the great majority of diastemas close after the eruption of the maxillary canine teeth and require no intervention by the dentist. The even more powerful longitudinal study by Popovich and colleagues9 found a similar relationship. The Popovich study used the study models of the same 471 patients at ages 9 and 16 years to Tooth-size discrepancies are a major cause of diastemas. 130.11. in descending order of frequency. but important. the lateral incisors erupt incisally along the central roots. Vol. As the permanent maxillary incisors erupt. labiolingual incisor inclination. JADA. All rights reserved.12 which mathematically compares the size of the maxillary teeth with the size of the mandibular teeth.10 It is important for dentists to recognize this often abnormal-appearing maxillary dental arrangement and not treat what is. tooth-size discrepancies and excessive vertical overlap of the incisors are the most common factors in the development of diastemas. The ultimate effect of these factors depends on whether the occlusal anteroposterior relationships are normal. TOOTH-SIZE DISCREPANCIES Figure 1. Maxillary midline diastemas are a part of normal development in children. contributing factors. In this article. generalized spacing or an initial midline diastema larger than 3 mm was present. . to enable the practitioner to make a differential diagnosis and to better tailor treatment to the patient’s specific problem.

Owing to the shape of the lingual surface of the maxillary incisor. Vol. Even though the Bolton analysis appears to be a relatively simple procedure. maxillary incisor intrusion will allow retraction of the maxillary incisor and closure of a maxillary midline diastema. B. mandibular incisor intrusion will allow retraction of the maxillary incisor and closure of a maxillary midline diastema. some variation exists among even experienced dental practitioners who measure the teeth13. Excessive anterior vertical overlap is shown.CLINICAL PRACTICE A as defined by Bolton. 130. excessive vertical overlap of the incisors can increase the circumference of the maxillary arch and result in a maxillary midline diastema. which requires mounted dental casts. If mandibular incisor overeruption is the cause of the excessive anterior vertical overlap. 87 . relates only to the relative mesiodistal dimensions of the teeth. If maxillary incisor overeruption is the cause of the excessive anterior vertical overlap. C. Diagnostic cast setup. Another method of evaluating tooth-size discrepancies is a diagnostic cast setup. the results must be viewed with caution. A. All rights reserved. The anterior teeth are removed from the cast and then waxed B C Figure 2. JADA. January 1999 Copyright ©1998-2001 American Dental Association. hence.

The best contour and esthetics are achieved if the pegshaped lateral incisor is more mesial in the space. This phenomenon occurs as a result of the wedge-shaped lingual surface of the maxillary incisors. Placement of the peg-shaped lateral incisor must be determined by the clinical requirements of the particular restorative or prosthetic procedure. When a patient has excessive Diastemas based on tooth-size discrepancy are most amenable to restorative and prosthetic solutions. Great care must be taken in not overintruding the maxillary incisor. Class I).14 EXCESSIVE ANTERIOR VERTICAL OVERLAP teeth results in an increase in the circumference of the maxillary arch (spacing) or in crowding of the lower incisors. the dentist must carefully examine the patient’s face clinically and cephalometrically. from the base of the nose to the bottom of the chin)—with the mandible rotated downward and backward—to have the maxillary alveolus Excessive anterior vertical overlap (overbite) of the anterior teeth is another common cause of excessive spacing in the maxillary arch (Figure 2). since the lip tends to lengthen with aging. All rights reserved. It is not uncommon in patients with a lack of horizontal mandibular position (that is. To evaluate the maxillary incisor. since it is greatly affected by lip length. Diastemas based on tooth-size discrepancy are most amenable to restorative and prosthetic solutions. 2 to 3 mm of incisor should be visible below the vermilion border of the upper lip. 130. Possible problems are excessive vertical alveolar development of the maxillary incisors or mandibular incisors. anterior vertical overlap. the final relationship and spacing of the teeth are then evaluated and compared with the original relationships. This is critical to producing the best functional and esthetic result. the appropriate treatment is intrusion of the maxillary incisors. an increase in the vertical overlap of the anterior 88 compensate via excessive alveolar vertical development. creating diastemas (Figure 2A). However.15-17 Treatment. or a combination of both of these. If a patient has a maxillary midline diastema. with exposures as high as 5 mm being esthetically pleasing. spacing develops between the maxillary anterior teeth. mandibular retrognathia) or a long lower face (that is. inadequate vertical dimension of occlusion. the challenge for the dentist is to develop a differential diagnosis of the source of the problem. The dentist must exercise caution in repositioning the teeth so that the alignment and angulation are realistic and achievable. After orthodontic intrusion of the maxillary incisors and the resulting reduction of the vertical overlap of the incisors. When this occurs. the maxillary incisors move forward and the circumference of the maxillary arch increases as the vertical incisor overlap increases. Excessive vertical alveolar development of the maxillary incisors. the best esthetic solution may be orthodontics and orthognathic surgery to alter the maxilla. the maxillary incisors can be retracted into the horizontal space created and the midline diastema closed (Figure 2B). In patients with an upper lip of normal length. care must be taken in evaluating the maxillary incisor relative to the lip. January 1999 Copyright ©1998-2001 American Dental Association. The diagnostic setup enables the dentist to simulate intraoral positions and measure the amount of space remaining after orthodontic alignment of teeth as well as plan appropriate restorative procedures. This can be an isolated finding or part of a patient’s skeletal deformity. Treatment. Vol. When the size of the maxillary teeth match that of the mandibular teeth (no Bolton discrepancy) and the anteroposterior occlusion is normal (that is. When severely excessive incisor exposure is combined with an excessively long lower face. A key indicator of maxillary incisor vertical position is the amount of incisor exposed beneath the resting upper lip. The most appropriate treatment often requires orthodontically closing the midline diastema.CLINICAL PRACTICE back onto the casts in their proper relationship. Female patients can generally tolerate a greater amount of incisor exposure than males. A short upper lip can create the same effect as exces- JADA. excessive exposure of the maxillary incisor below the resting lip and a normal upper lip length. When there is little or no lower incisor crowding. then moving the small tooth or peg-shaped lateral incisor into a position between the central incisor and cuspid that optimizes the esthetic and restorative result. . excessive overbite.

consequently. while decreasing the incisor vertical overlap. excessive vertical alveolar development of the lower incisors can cause spacing between the maxillary incisors and. a flat mandibular plane resulting in a prominent chin. the best result is achieved when the Class II malocclusion and the anteroposterior positioning of the teeth and jaws are corrected. Frequently. Again. This can be done orthodontically by using an anterior bite plane and orthodontic appliances to enable the mandible to rotate downward and backward and to allow vertical alveolar development of the posterior teeth. 130. The difference between overerupted mandibular incisors and lack of vertical dimension of occlusion is that the lower face is shorter than normal when there is a lack of vertical dimension of occlusion. Loss of the vertical dimension of occlusion is commonly caused by loss of posterior teeth. the maxillary incisors can be retracted and the midline diastema closed (Figure 2C). . Orthodontically uprighting tipped molars and replacing the missing teeth with fixed prostheses or implants is the preferred way to increase and maintain the vertical dimension of occlusion. a midline diastema. he suggests occlusal equilibration to a centric relationship position. incisors. January 1999 Copyright ©1998-2001 American Dental Association. These measurements are an indication of soft-tissue height and can be made clinically on the patient or on the cephalometric radiograph. When the arches are in the proper relationship in an anteroposterior direction. This is another possible cause of increased vertical overlap of the incisors (Figure 2C). with an excessive vertical overlap of the incisors. the maxillary incisors can be moved lingually into the overjet (horizontal space) created. an increased anterior vertical overlap due to insufficient posterior vertical dimension). Treatment. In a patient JADA. Patients with this condition have a normal lower facial height. Characteristics of a short lower face include a short lower anterior facial height. This can occur either developmentally or as a result of tooth loss. Excessive vertical alveolar development of the mandibular incisors. If the patient has a long lower face. The appropriate treatment for excessive vertical development of the mandibular incisors is lower incisor orthodontic intrusion. Treatment. Lack of vertical dimension of occlusion. the above treatment 89 The mesiodistal angulation of the incisors is another critical factor that dentists must evaluate when contemplating treatment for midline diastemas. dental prematurities may cause a forward shift of the mandible that can result in progressive splaying or spacing of the anterior teeth. a normal relationship between the maxillary incisors and the lower border of the upper lip and a pronounced lower curve of Spee. and the perioral lip and facial creasing traits of inadequate vertical dimension. Measuring the patient’s lower face relative to the height of the upper face will also diagnostically demonstrate a short lower face. In a Class II malocclusion. once the vertical overlap of the incisors is decreased. which decreases incisor vertical overlap. In the typical patient. The treatment of choice for a maxillary midline diastema with excessive vertical incisor overlap due to a deficient vertical dimension of occlusion is to increase the vertical dimension of occlusion.CLINICAL PRACTICE sive maxillary alveolar vertical development. Fine18 suggests that in a patient with a Class II malocclusion. The dentition frequently appears like that of overerupted mandibular with normal facial height relationships. the upper lip is approximately one-half the distance from the pupil to the base of the nose (subnasale). Vol. the distance from the greatest prominence of the forehead (the glabella) to the lower border of the upper lip (the stomion) is equal to the distance from the upper lip to the lowest point on the soft-tissue chin. the maxillary incisors can be retracted and the diastema closed. Another vertical problem that can lead to a maxillary midline diastema is a lack of vertical dimension of occlusion (that is. thus decreasing the circumference of the maxillary arch and closing the maxillary midline diastema. Once this is done. a pronounced step in the occlusal plane is present in the lower cuspid or incisor area. This is not uncommon 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. All rights reserved. After the vertical relationship is corrected.

particularly on flat-sided central incisors. increase any tendency toward a Figure 3. Downward and backward rotation of the mandible in patients with an already excessive lower facial height will have a detrimental effect on facial esthetics. Vol. Dentists must avoid using molar uprighting. All rights reserved. B. In these patients. all efforts must be made to avoid increasing the length of an already long lower face. Excessive distal crown angulation. Mesiodistal crown angulation is shown. Maxillary incisor crowns that are mesially inclined occupy more space in the arch than do upright crowns. which allows molar extrusion. C. January 1999 Copyright ©1998-2001 American Dental Association. A. or an anterior bite plane. 130. creating an apparent diastema while the incisors are nearly in contact in the cervical area of the teeth.CLINICAL PRACTICE of rotating the mandible downward and backward is not indicated. Mesially inclining the crowns of the maxillary incisors is one method of increasing the effective tooth mass of the upper incisors and creating sufficient arch circumference to close a diastema when the maxillary teeth are slightly smaller than the mandibular teeth. which allows the mandible to rotate downward and backward. A B C 90 JADA. but at a gingival level. . can give the appearance of a diastema when the central incisor crowns are in contact. A patient exhibiting excessive mesial root angulation of the maxillary incisors.

although the incisors are actually in contact (Figure 3). . the contact point of the central incisors moves gingivally. the teeth may move and stay in a labial or buc91 JADA. thumb or finger habits. or missing or impacted teeth. can create an unesthetic distraction from an otherwise esthetic result. The combination of large jaws and normal or small teeth is usually due to inherited characteristics. MESIODISTAL ANGULATION The mesiodistal angulation of the incisors is another critical factor that dentists must evaluate when contemplating treatment for midline diastemas. This dark space. unfilled by gingival tissues. while maintaining good anteroposterior relationships with the mandibular incisors and optimum anterior guidance. can cause abnormally large jaws relative to the size of the teeth. Conversely. The amount of crown angulation that can be placed in the upper incisors is determined by both esthetics and root position. Muscles. We believe the best treatment is to change the incli- Generalized spacing in the dental arches can result from discrepancies between tooth size and jaw size. Root position is an even more critical factor. it is important for the dentist to evaluate the crown angulation of the four maxillary incisor teeth. Mesiodistal crown angulation also influences the amount of arch length or space between the cuspids. orthodontically changing the angulation of the crowns to a more distal inclination will move the contact more occlusally and treat the apparent diastema. When the maxillary incisor crowns are distally inclined. Less maxillary arch circumference is present when the incisors are upright mesiodistally. or missing or impacted teeth. For a patient with a maxillary midline diastema. the greater the possibility of anterior spacing. With excessive distal crown angulation. the more arch length or arch circumference is increased (Figure 3C). Generalized spacing is seen as spaces. thus creating an interdental space that the gingival papilla cannot fill. the more upright the crowns. thumb or finger habits. All rights reserved. while incisors with a more convex mesial surface are more forgiving and tend to maintain their contact point at a more incisal level. In patients with flaccid lips and little muscle tone. 130. nation of the maxillary incisor crowns. excessive crown angulation can detract from upper incisor esthetics. Thus. in some patients. such as acromegaly. Too much mesial crown angulation may cause the roots of the central incisors to contact the roots of the lateral incisors. the less likely the incisors will appear to have no contact. The more convex the mesial surface of the maxillary central incisor. Closing the midline diastema in these patients can be done by orthodontically increasing the mesial crown angulation to occupy greater arch circumference. the more mesially inclined the crowns. muscle imbalances. a diastema may appear to be present. Lip habits or muscle weakness can also contribute to generalized spacing. not only between the anterior teeth. Endocrine imbalances that result in excesses of growth hormone. Forced root contact during orthodontic treatment can result in root resorption of both contacting teeth. Vol. A and B). While mesial crown angulation enhances the smile line of the upper incisors. Treatment. January 1999 Copyright ©1998-2001 American Dental Association. leaving what appears to be a diastema at the incisal edge of the teeth (Figure 3. muscle imbalances. but also between the posterior teeth in both the maxillary and mandibular arches. or the roots of the overangulated lateral incisors to contact the roots of the cuspids. the less likely that there will be space between the teeth. Therefore.CLINICAL PRACTICE Class II malocclusion and decrease posttreatment esthetics and stability. GENERALIZED SPACING Generalized spacing in the dental arches can result from discrepancies between tooth size and jaw size. but it can be a sign of endocrine imbalances. 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. normally sized jaws with abnormally small teeth can also contribute to generalized spacing of the dentition. The more the crowns are angulated mesially. Another consideration is the spacing that develops below the contact point of the maxillary central incisors when they are excessively mesially inclined.

thus increasing the arch circumference and creating a maxillary midline diastema. Vol. Tongue position. use of bonded restorative materials and more lingual inclination of the cuspid root to avoid the usual cuspid root prominence can minimize this problem. Spacing in the maxillary arch can also be caused by missing or impacted teeth. Upright maxillary incisors are often combined with excessive vertical development of the maxillary or mandibular incisors. further exacerbates the increase in maxillary arch circumference and increases the likelihood of a JADA.19 Other habits that can contribute to a maxillary midline diastema include thumb or finger sucking or any habits that result in a long-term protruding or separating force on the maxillary anterior teeth. Another possible muscular cause may be tongue position. creating excessive anterior vertical overlap of the incisors. tongue position at rest can affect tooth position.23 Maintaining closure of the diastema requires that arch integrity be restored and all arch spaces closed. cal position. Even missing second bicuspids can create sufficient space in the arch to allow the incisors to drift distally. however.22. which are replaced with a cuspid tooth. If an impacted cuspid is the cause of excessive maxillary spacing and it is not severely impacted. This has been done successfully with missing maxillary lateral incisors. resulting in an increase in arch circumference and the possibility of maxillary incisor spacing. Lip habits in which the patient habitually positions the lower lip behind the upper incisors can also result in the movement and maintenance of the maxillary incisors in a labial position. However. which. may be attributed to a tooth-size discrepancy (Figure 4). the dentist should uncover the cuspid and bring it into proper alignment. ovoid arches and a lack of interproximal tooth contact.21 Esthetics can be a problem because of the larger size and different shape of the cuspid. LABIOLINGUAL ANGULATION Labiolingual angulation of the maxillary incisors also has an effect on anterior arch circumference and can create a maxillary midline diastema. All rights reserved. January 1999 Copyright ©1998-2001 American Dental Association. Another option is to orthodontically close the space. the maxillary incisor roots and contact points will be displaced anteriorly. Maxillary incisors that are excessively upright labiolingually have their contact points in a more anterior position than normally inclined incisors. One treatment option is to orthodontically realign the teeth. thus creating a midline diastema.20. Treatment. Missing or impacted teeth. . 130. Labiolingual angulation is shown. This overlap. combined with upright maxillary incisors. careful reshaping of the cuspid. create space for the missing tooth and insert a replacement tooth to maintain proper arch dimensions and diastema closure. but the maxillary incisors are excessively upright. Missing lateral incisors enable the central incisors to drift distally and create a midline diastema. at first glance. creating a midline diastema. Tongue thrusting has been discounted as a problem because of the short contact times. Im92 pacted cuspids can also allow incisors to drift distally.24 This can result in maxillary arch spacing.CLINICAL PRACTICE Figure 4. These patients exhibit wide. If the overjet and posterior occlusion are ideal (Class I). creating a midline diastema.

Hausen H. the ability to do this may be limited by the thickness of the anterior alveolus.26 This uncommon problem requires surgery to restore more normal interproximal anatomy to the gingival tissues before the diastema is fully closed. 3. dentists must carefully determine the contributory factors to a maxillary midline diastema in their patients. 80262. leaving a small midline fissure that maintains a diastema. the diastema must be closed (or nearly closed) orthodontically before tissue is removed to avoid the possibility of the surgical scar tissue maintaining the diastema. The cause of a diastema can be determined by evaluating several factors and making a differential diagnosis. Department of Growth and Development. Shaw WC. Oesterle is an associate professor and chair.19(p486) when removal of the excessive frenum tissue is indicated. Vol. the dentist must orthodontically move the maxillary central incisor roots lingually. can be another important contributing factor. Address reprint requests to Dr.25. To achieve the most esthetic and functional result. 93 . Eur J Orthod 1995. Denver. 130. not only in the vertical but anteroposterior dimension. Treatment. such as cysts or fibromas in the maxillary midline. In some patients. rather than across the suture. Am J Orthod 1939. The frenum may be more a result of a diastema being present than a cause of it. can be a major cause of maxillary diastemas. the diastema must be orthodontically closed. To correct a diastema created by an overly upright incisor. particularly small or peg-shaped lateral incisors. January 1999 Copyright ©1998-2001 American Dental Association. The distribution of diastemas JADA. particularly adults. Simple surgical correction of the cleft probably will not result in diastema closure. as well as missing or impacted teeth. Department of Growth and Development. with the surgical procedure occurring just before or after final space closure so that the scar tissue does not create problems. Ninth Ave.17:505-12. All rights reserved. Other factors contributing to maxillary diastemas can be pathological conditions.10 Rarely does a frenectomy close a diastema that would not have otherwise Thorough evaluation of the area of the midline diastema is critically important. 2. University of Colorado Health Sciences Center. Campus Box C284. can also prevent normal central incisor positioning. There are some rare circumstances when developmental problems do appear to be responsible for a diastema. SUMMARY maxillary midline diastema. Even in these unusual circumstances. Other pathological con- Maxillary midline diastemas are an esthetic concern for many patients. most orthodontists tend to discount their influence. Other factors that can be contributory include the inclination of teeth mesiodistally and labiolingually. s 1.9 The character of the maxillary suture between the maxillary incisors has been implicated in diastema maintenance. Another cause can be periodontal inflammation secondary to periodontal disease or foreign bodies in the periodontal ligament. Denver. Colo. muscle weakness and supernumerary or missing teeth.CLINICAL PRACTICE closed during normal development. According to Proffit and Fields. 4200 E. A larger-than-normal maxillary midline suture has been reported to create and maintain a diastema as a result of gingival fibers inserting into the suture. this can be demonstrated with an instrument or dental floss. Clinical observations relating to the normal and abnormal frenum labii superians. Discrepancies in the size of the maxillary teeth relative to the mandibular teeth. School of Dentistry. Oesterle. Lavelle CL. Excessive vertical overlap of the incisors increases the circumference of the maxillary arch and by itself can be a major factor in producing and maintaining a midline diastema. University of Colorado Health Sciences Center. Shellhart is an associate professor. FRENUMS Although excessively large labial frenums have been cited as a cause of diastemas. Dr.. ditions. Kerosuo H.25:646-60. Supernumerary teeth or mesiodens can physically prevent the maxillary central incisors from meeting in the midline. Laine T. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Taylor JE. but are a result of a failure of the midline tissues to cross the midline. PATHOLOGICAL CONDITIONS Dr. This type of movement also exerts a considerable mesial force on the posterior teeth and may move the maxillary posterior teeth forward if not carefully controlled. Periodontal and radiographic examination will disclose any abnormal findings in the midline area that might contribute to the midline diastema. The occlusion of the teeth. Midline clefts have been reported to occur in association with frenums.

Dent Pract Dent Rec 1967.19:815-8. Malhotra SK.71(5):489-507.17:287-98. Am J Orthod 1977. Guidelines for managing the orthodontic-restorative patient. Coleman HT. Popovich F. Soft tissue cephalometric analysis for orthognathic surgery. All rights reserved. The diastema. Tuverson DL. Little RG. Edwards JG. Fields HW. Reliability of the Bolton tooth-size analysis when applied to crowded dentitions. 18. 21. Incidence and etiology of midline diastema in a population in south India. Keene HJ. The maxillary cuspid and missing lateral incisors: esthetics and occlusion. Am J Orthod 1970. Dent Pract Dent Rec 1967. Hines FB. Legan HL. Hicks EP. Contemporary orthodontics.6:377-96. Clinical application of a tooth-size analysis. Bergman RT. J Clin Orthod 1972. 1993. Senty EL. Disharmony in tooth size and its relation to the analysis and treatment of malocclusion.3:3-20.92(2):249-56. Burstone CJ. 486. Angle Orthod 1989. Biracial study of the maxillary midline diastema. 26. Am J Orthod 1967. Am J Orthod 1962. St. 7. Semin Orthod 1997. Am J Phys Anthropol 1963.28:11330. 12. Ben-Basset Y.46:365-71.17:27686.53:262-84. Remodeling of canines to the shape of lateral incisors by grinding: a long-term clinical and radiographic evaluation. Lange DW. J Clin Orthod 1985. The labial fraenum. Proffit WR. 11. Am J Orthod 1972. McLendon WJ.100:123-32. J Oral Surg 1980.36:34.78:530-4. 10. Henry M.59:277-82. Richardson ER. Main PA. Two treatment approaches for missing or pegshaped maxillary lateral incisors. 15. Louis: Mosby–Year Book. The six keys to normal occlusion. 8. Angle Orthod 1995. Bolton WA.65(5):327-34. Orthodontic treatment using canines in place of missing maxillary incisors. Nainar SMH. Spear FM. 24. Copyright ©1998-2001 American Dental Association. Miller: WB. Am J Orthod Dentofacial Orthop 1993. Am J Orthod Dentofacial Orthop 1991.61:50429. The maxillary interincisal diastema and its relationship to the superior labila frenum and intermaxillary suture. 128-9. 23. 4. Kluemper GT. Am J Orthod Dentofacial Orthop 1987. Thordarson A.38:744-51. Trans Eur Orthod Soc 1960.58(2):109-27. Angle Orthod 1958.43:438-43. Part I. the frenectomy: a clinical study. 16. Angle Orthod 1977. Zachrisson BU. Facial keys to orthodontic diagnosis and treatment planning. 5. Kokich VG. Midline spaces. 22. Bolton WA. Andrews LF.21:437-41. Scand J Dent Res 1970. Brin I. 2nd ed.103:299-312.62(3):296-309. Thompson GW. Adult orthodontics. 9.47:265-71. 14. Weyman J. Shellhart WC. 19. Stability of upper incisors after surgical exposure and orthodontics. Distribution of diastema in the dentition of man. the frenum. Angle Orthod 1976. 20. Kaplan AL. Angle Orthod 1973. Gardiner JH. Burstone CJ. . Arnett GW. The incidence of median diastemata during the eruption of the permanent teeth. 13. 6. Gnanasundaram N. 17. Lip posture and its significance in treatment planning.CLINICAL PRACTICE in different human population samples. Fine HS. Mjör IA. 25. Wilson HE.

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