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Midline Diastema and its Aetiology − A Review

Article  in  Dental Update · June 2014

DOI: 10.12968/denu.2014.41.5.457

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Reji Abraham Geetha Kamath

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 Orthodontics

Reji Abraham

Geetha Kamath

Midline Diastema and its Aetiology −

A Review
Abstract: Maxillary midline diastema is a common aesthetic complaint of patients. Treating the midline diastema is a matter of concern for
practitioners, as many different aetiologies are reported to be associated with it. The appearance of midline diastema as part of the normal
dental development makes it difficult for practitioners to decide whether to intervene or not at an early stage. The aim of this article is to
review the possible aetiology and management options which will help the clinician to diagnose, intercept and to take effective action
to correct the midline diastema. The available data shows that an early intervention is desirable in cases with large diastemas. Treatment
modality, timing and retention protocol depends on the aetiology of the diastema. Therefore, priority needs to be given to diagnosing the
aetiology before making any treatment decisions.
Clinical Relevance: This article aims to determine and evaluate the aetiology and possible treatment options of midline diastema.
Dent Update 2014; 41: 457–464

Aesthetics and function are the two most
important goals of modern-day dentistry.1
An attractive well balanced smile and a
confident speech are valuable personal
assets. 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.2−6
Angle7 described the midline
diastema as a common form of incomplete
occlusion characterized by a space
between the maxillary and, less frequently,
mandibular central incisors. In his classical
article, Andrews8 stated that interdental
diastemas should not exist and all contacts
should be tight so that the patient has
‘straight and attractive teeth as well as a
Reji Abraham, BDS, MDS, Professor,
Department of Orthodontics and
Dentofacial Orthopaedics, Geetha
Kamath, BDS, MDS, Professor,
Department of Oral Medicine and
Radiology Sri Hasanamba Dental College
and Hospital, Hassan, Karnataka, India.
June 2014 DentalUpdate 457
correct overall dental occlusion’. To intervene or not to intervene
Maxillary anterior spacing or
A major problem for the dentist
diastema is considered unaesthetic and
in dealing with the midline diastema is the
unacceptable by the general population.
decision to intervene or not to intervene
Treating the midline diastema
during the early mixed dentition period. As
is a problem for the dental practitioner as
it is widely stated and presumed that the
many different aetiologies are reported to
midline diastema during the ‘ugly duckling
be associated with it.9,10 Many researchers,
stage’ is a normal phenomenon and is self-
like Broadbent,11 consider midline diastema
correcting, it is tempting for the dentist to
as an ‘ugly duckling stage’ and explain
suggest to the parents of the child to wait
this phase as a transitional phase in the
until the permanent canines erupt.
dental development. He also describes the
After a study on midline
closure of the diastema with the complete
diastema, Taylor14 concluded that 98%
eruption of lateral incisors and canines as
of six-year-old children presented with a
a normal stage in dental development.12
midline diastema. As age increased, the
However, the persistence of the midline
percentage significantly decreased. The
diastema, even after the eruption of the
10−11 year-old group showed a midline
permanent canines, in some cases requires
diastema in 48.7% and, in the sample
investigation into the underlying causes
of 12−18 year-old students, the figure
and possible preventive and corrective
dropped to 7%. As per the literature and
treatment options.13 The aim of this review
our personal experience, in 90% of the
article is to determine and evaluate the
cases the diastema is self-correcting. The
possible aetiology of the midline diastema
problem arises in the remaining 10% or so
and consider the management options
of the cases where the reassured patients
which may help the clinician to diagnose,
return with disappointment that the
intercept and take effective measures to
unpleasing space between their central
correct the unaesthetic diastema.
incisors has not closed, even after the
 Orthodontics
eruption of the permanent canines; as
suggested earlier by the dentist.
Prediction of the fate of midline
diastema
The decision to intervene early
during the mixed dentition period depends
on knowing whether the diastema will
close on their own as age increases. Sanin
et al15 developed a method that could
predict whether the space would close
spontaneously in the developing dentition.
This method is based on millimetre
measurements in the early mixed dentition
and is claimed to have an accuracy of
88%. As the size of the diastema increases
the possibility of space closure without
treatment reduces.
Sanin’s prediction is as follows:
 For a 1 mm space in the early mixed
dentition the possibility of spontaneous
space closure is 99%;
 For a 1.5 mm space the possibility is 85%;
 For a 1.85 mm diastema it is 50%;
 For a 2.7 mm space the possibility of
closure without treatment is only 1%.
The measurement should be
made after the eruption of the lateral
incisors. Hence it is advisable to intervene
early if the midline diastema is more
than 1.85 mm after the eruption of the
permanent lateral incisors.
Aetiology and effective
treatment options
To treat the midline diastema
effectively, an accurate diagnosis of the
aetiology and an intervention relevant to
the specific aetiology is necessary. Timing
of the treatment is important to achieve
satisfactory results. Most of the researchers
do not recommend tooth movement until
the eruption of the permanent canines.16
But in certain cases, where very large
diastemas exist, treatment can be
initiated early.
The following are the well
established and narrated causes and
treatment options for the midline diastema
in the literature.
Genetics and midline diastema
Gass et al,17 after a study
on 30 extended families, came to the
458 DentalUpdate June 2014
conclusion that genetics has a possible role the frenum will unfavourably influence the
in the presentation of midline diastema. development of the anterior occlusion.
Heritability was estimated at 0.32% for a It is performed by applying intermittent
white and 0.04% for a black population. pressure on the frenum by elevating the
Nainar and Gnanasundaram18 noted in lip. If a heavy band of tissue with a broad
their study of midline diastemas on 9774 fan base is attached to the palatine papilla,
Southern Indian individuals, that there and if it blanches on applying pressure, it
was a relatively increased frequency of can be concluded that the frenum is at an
familial occurrence and hence proposed unfavourable position for the existence of
the presence of a genetic factor in the
expression of midline diastema. Shashua
and Artun,19 after a study about the
causes of midline diastema, concluded
that the family tree of the diastema was
one of the two important risk factors for
diastema relapse. The other factor was
diastema size before treatment. Many
other authors, like Gardiner20 and Schmitt
et al,21 also consider genetics as a main
cause for the midline diastema. Treatment
methods include orthodontic correction
with a fixed or removable appliance and
prosthetic correction with composites and
crowns (Figure 1). If the diastema is large,
it is advisable to close the space using
orthodontic appliances. In most cases,
simple removable appliances incorporating
finger springs or a split labial bow can give
good results.22
Figure 1. (a) A case with midline diastema. (b)
Superior labial frenum
Closure of midline diastema with composite
A hypertrophic labial frenum
restoration.
may be considered as a major aetiological
factor for midline diastema.23,24 In a thick
and fleshy labial frenum, the fibro-elastic
band crosses the alveolus and inserts
into the incisive papilli, preventing the
approximation of the maxillary central
incisors (Figure 2).
Most of the researchers, like
Angle,7 Sicher,25 Gardiner,20 and Edwards,26
are of the opinion that superior labial
frenum causes midline diastema. Some
researchers, like Popovich et al, believe that
there is an inverse relationship between
high frenal attachment and midline
diastema.27According to them, labial frenum
persists owing to the existing diastema and,
as the dentition applies little or no pressure
on the tissues, there is little or no atrophy
of the frenum.28 But most of the researchers
agree that removal of the high bulbous
labial frenum is important for the stability
after the closure of the midline diastema.29
The blanching test (Figure 3) is Figure 2. Midline diastema due to high frenal
a simple diagnostic test to predict whether attachment.

a normal tight contact between the central
incisors.29
There is also confusion as to
whether to carry out a frenectomy (Figure
4) before or after orthodontic space
closure. As one study has shown, in some
cases, some midline space closure is seen
after a frenectomy without orthodontic
treatment.21 This makes it tempting for
the dentist to advise patients to undergo
this procedure before the orthodontic
space closure. However, another author
advises a frenectomy procedure after the
correct positioning of the central incisors
when the diastema is closed.30 The basis
behind this thought is that, if the excess
tissue is removed after the teeth have been
squeezed together, the healing and the scar
tissue will be formed around the closed
teeth. If a frenectomy is done prior to the
orthodontic space closure, the scar tissue is
formed between the teeth, increasing the
risk of relapse.
Anterior traumatic bite
Excessive anterior overbite
is another major contributing factor for
midline diastema.10 As a result of trauma to
the maxillary anteriors from the mandibular
incisors, the maxillary incisors procline.
This results in an increase of the upper arch
circumference, leading to a diastema (Figure
5). Practitioners should not fail to identify
deep bite as an aetiology for the diastema.
Any attempt to close the midline spacing
without correcting the deep bite and
anterior traumatic bite will lead to a speedy
relapse of the condition.
Possible causes underlying
the deep bite can be excessive vertical
alveolar development of the mandibular or
the maxillary incisors, inadequate vertical
dimension of posterior occlusion (molars)
and skeletal conditions like increased ramal
height.31 Proper orthodontic evaluation and
apt treatment modalities, like intrusion of
anteriors, extrusion of posteriors or even
surgical intervention may be necessary.
Oral habits
Oral habits such as tongue
thrusting and finger sucking can be other
aetiological factors for the appearance of the
midline diastema.32,33 According to Proffit and
Fields,34 tongue position at rest may have
June 2014 DentalUpdate 459
Orthodontics
a greater impact on tooth position than
tongue pressure, as the tongue only briefly
contacts the lingual surface of the anterior
teeth during thrusting. The tongue pushes
the anterior teeth to a forward position,
increasing the circumference which results in
spacing (Figure 6).
An abnormal habit of the
tongue can be detected by the tip of
the tongue popping out through the
anterior spacing when the patient is asked
to swallow. In cases of anterior open Figure 3. Blanching test.
bite, the tongue may be seen thrusting
between incisal edges of the maxillary and
mandibular incisors. Patients with tongue
thrust often produce a snap sound on
swallowing and also have hyperactivity of
the orbicularis oris muscle.
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. Figure 4. Post frenectomy.
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 (Figure 7). 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 (Figure
8). In such cases, surgical trimming may
have to be considered in order to attain
stability in the dental occlusion.35 Figure 5. Proclination of maxillary anteriors and
Deleterious habits have to midline diastema due to anterior traumatic bite.
be corrected by using habit-breaking
appliances and by psychological
approaches. The use of fixed tongue cribs
are found to be effective in breaking the
tongue-thrusting habit.36
Peg-shaped laterals
A common cause of tooth size
discrepancy is the peg-shaped maxillary
lateral incisors (Figure 9). The reduced size
of the maxillary lateral incisor will allow Figure 6. Diastema due to tongue thrusting.
the distal drifting of the central incisors,
creating a midline diastema.
If the reason for midline
diastema is peg laterals, the space
between the central incisors is closed;
respecting the midline and the space
necessary for the prosthetic restoration
of the peg-shaped lateral is created by
moving the peg lateral into a position
between the central incisor and the
cuspid. The best contour and aesthetics Figure 7. Extended tongue.
 Orthodontics
will be achieved if the peg lateral is more
mesial in space. This can be done by
simple removable orthodontic appliances
incorporating finger springs or split labial
bows. Depending on the complexity of the
occlusion, a fixed orthodontic appliance
can also be considered.37.38
Supernumerary teeth/mesiodens
A mesiodens is a supernumerary
tooth which is present in the midline
between the two maxillary central incisors
(Figure 10).39 A mesiodens accounts for
80% of all supernumerary teeth.40 It may
erupt normally, remain impacted, appear
inverted or take a horizontal position.41,42
The presence of a mesiodens can prevent
the close approximation of the central
incisors leading to a midline diastema and
can also lead to several other complications,
such as impaction, delayed and ectopic
eruption of adjacent teeth, crowding, axial
rotation, displacement, radicular resorption
of adjacent teeth and dentigerous cyst.43
Russel and Folwarczna have suggested
the extraction of a mesiodens in the early
mixed dentition period. According to
them this will help in better alignment of
teeth and will also minimize the need for
orthodontic treatment.44 Some authors,
like Mitchell and Bennett, have advocated
the late extraction of mesiodens when
the adjacent permanent incisors have
completed their root formation.45 If the
mesiodens exists during the permanent
dentition period, extraction of the
mesiodens followed by space closure
utilizing fixed orthodontic appliances will
be the line of treatment.46
Tooth size, arch size discrepancy
Tooth size, arch size
discrepancy is another major cause for
diastema.47 The combination of large
jaws, normal or small teeth can be due to
inherited characteristics. But in some cases
it can be due to endocrine imbalances.
Conditions such as acromegaly can cause
abnormally large jaws relative to the
teeth size. Normal-sized jaws and small
teeth can also cause generalized spacing.
One treatment option will be to retract
the teeth in order to reduce the arch
perimeter, considering a patient’s profile
as well as aesthetic and functional aspects.
Another option will be to realign the teeth
460 DentalUpdate June 2014
and close the spaces with a combination
of orthodontic and prosthodontic
approaches.48
Missing teeth
If the diastema is due to
missing teeth, prosthetic replacement or a
combination of orthodontic and prosthetic
rehabilitation is the treatment option. If
the absence of a lateral incisor is the cause
of the diastema, there are two available
options following midline diastema closure,
ie mesial movement of the canine to the
position of the missing lateral incisor
Figure 8. Tooth indentations on the lateral
or distalization of the canine to allow borders of the enlarged tongue.
prosthetic replacement of the missing
lateral incisor (Figure 11).48,49 a
Pathologic migration of teeth
Pathologic tooth migration is
the displacement of teeth resulting from
the imbalance of the tooth retention
forces (Figure 12).50 Several factors such as
destruction of periodontium, inflammation
in the periodontal tissue, eruption force,
oral habits and occlusal forces are reported
to be responsible for pathological tooth b
migration. Inflammation in the periodontal
tissue increases hydrodynamic and
hydrostatic forces around relevant vessels
and tissues, possibly resulting in tooth
displacement.51 As extrusion is a common
clinical feature of pathologic tooth
migration, eruption force is also considered
to be a contributing factor. Treatment
options for pathological tooth migration
include removal of aetiological factors Figure 9. (a, b) Distal drifting of centrals and
and orthodontic treatment, depending on midline diastema due to peg-shaped lateral
the severity of migration, available bone incisors.
support and extent of extrusion of the
teeth.52 Active orthodontic intrusion after
basic periodontal therapy is reported to be
an effective treatment option.53
Angulation of teeth
Distal crown inclination of the
incisors can create an appearance of the
diastema even though the incisors are in
contact at the cervical region (Figure 13).
With excessive distal crown inclination,
the contact between the teeth will be
limited only in the proximal gingival region,
keeping the incisal tips farther apart,
Figure 10. Mesiodens causing rotation of the
leaving what appears to be a diastema at
maxillary right central incisor and midline
the incisal edge of the teeth. The treatment
diastema.
option in such cases will be to change the
 Orthodontics
crown angulations orthodontically so
that the incisal edge of the incisors are in
contact.54
Odontomas occurring in the maxillary midline
Odontomas are benign
odontogenic tumours composed of
enamel, dentine, cementum and pulp
tissue. Odontomas are the most frequent
odontogenic tumours, with an incidence
of 22−67% of all maxillary tumours.
They are usually asymptomatic, but
often associated with tooth eruption
disturbances.55 Odontomas can be present
between the roots of erupted maxillary
central incisors, preventing contact
between their crowns and causing large
diastemas. A radiographic examination
of the site will be beneficial in cases of a
large diastema to rule out the presence of
any midline lesions such as odontomas,
when the presence of other common
aetiological factors are not observed. The
treatment of choice is surgical removal
of the tumour and closure of the midline
diastema using composites, jacket crowns
or orthodontic appliances, depending on
the size of the diastema.56
Developmental cysts in the orofacial midline
An odontogenic keratocyst
can appear in the maxilla and can
displace teeth, leading to spacing in the
anterior region.57 A median palatal cyst
is another midline structure which is a
rare cyst originating from the epithelium
trapped along the line of fusion of the
lateral palatal maxillary process during
development.58,59
Flaccid lips
In patients with hypotonic lips
the teeth may move and stay in a labial or
buccal position due to the tongue pressure
which will lead to wide ovoid arches
without interproximal teeth contact. 60
Other less commonly occurring factors
Other factors which can
cause midline diastema include missing
or fractured teeth due to trauma and
fibromas in the maxillary midline.61,62
Rare incidents of development of midline
diastema due to the habitual placing of
a metallic tongue piercing stud between
462 DentalUpdate June 2014
Figure 11. Midline diastema due to missing
lateral incisors.
the maxillary central incisors have been
reported.63
Stability after diastema
closure
Relapse is a major concern in
the correction of midline diastema. Exact
diagnosis and removal of the aetiology is
the key to obtaining a stable result. Long-
term use of retainers or even permanent
bonded lingual retainers are advocated,
especially in cases with large diastema.64−67
Large pre-treatment diastema and the
presence of at least one family member
with a similar condition increases the risk
of relapse.19
Conclusion
Midline diastema is usually a
part of normal dental development and
hence its presence during the mixed
dentition period 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.
Several aetiological factors are
reported and discussed in the literature
and no single aetiological factor is agreed
upon for the development of a midline
diastema. A radiographic examination of
the site will be beneficial to rule out any
multifactorial aetiology. To achieve an
aesthetic and stable result, it is important
to establish the underlying cause for the
midline diastema. Retention protocol
should depend on the size and the
aetiology of the midline diastema.
Figure 12. Midline diastema due to pathologic
migration of teeth.
Figure 13. Appearance of midline diastema due
to the distal crown inclination of the central
incisors.
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