American Journal of ORTHODONTICS

and DENTOFACIAL ORTHOPEDICS

Founded hz 1915--Seventy-five years Volume 97 Number 6 June 1990
of conthutous publication
Copyright © 1990 by Mosby-Year Book, hzc.

CLINICIANS' CORNER

The midline: Diagnosis and treatment

Laurance Jerrold, DDS* and L. Jeffrey Lowenstein, DMD**
Massapequa and New York, N.Y.

The importance of coordinated midlines often is unappreciated as it relates to the treatment plan for
the orthodontic case. All three of the patient's midlines--facial, maxillary, and mandibular--must be
considered if ideal correction is to be achieved. Proper differential diagnosis of the cause will allow
the practitioner to appropriately use either inter- or intraarch mechanics for the resolution of midline
discrepancies. Midline correction should be undertaken from the initiation of treatment and once all
midlines are coordinated they should be maintained as a guide for any further force systems used in
completing the case. Functional, dental, and iatrogenic midline discrepancies are discussed
perlaining to their diagnosis and treatment. (AMJ ORTHOD DENTOFACORTHOP 1990;97:453-62.)

M i d l i n e coordination and relative symme-
try are basic to an appreciation of facial harmony and
balance. Although a subtle asymmetry of the midlines
is within normal limits, significant midline discrepan-
cies can be quite detrimental to dentofacial esthetics. ~
Often the orthodontist is called on to treat cases in-
volving significant facial and/or dental midline asym-
metries. Differential diagnosis and appropriate inter-
and intraarch mechanotherapy is necessary if one is to
discern the proverbial forest from the trees regarding
the cause and correction of this problem. Skeletal asym-
metries and subsequent midline discrepancies are in-
tentionally being omitted from discussion because they
usually do not lend themselves to correction by way of
orthodontic treatment alone.
REVIEW OF LITERATURE
A common cause for the majority of cases that finish
short of an ideal result is a lateral discrepancy between
the upper and lower dental center lines. 2 Once this dis-
crepancy exists in the completed case, Breakspear 2 ad-
vocates adapting the occlusion by "stoning" (occlusal
*Associate Clinical Professor of Orthodontics, New York University College
of Dentistry.
**Formerly senior resident in orthodontics, New York University College of
Dentistry, now in private practice of orthodontics, New York, N.Y.
8/1/10422
equilibration). This method of treatment allows the oc-
clusion to function more properly but may not correct
the dental or facial asymmetry. It is better to complete
the case with the midlines coincident than to deal with
this problem after active therapy has been completed.
Lewis 3 espouses a set of questions necessary for
differential diagnosis of midline discrepancies: (1)
What has caused the midline deviation? (2) How does
the deviation affect the occlusion? (3) Is it necessary
to correct it? If correction is required, he advocates a
sliding yoke and intermaxillary elastics. He states that
this common and persistent problem (a midline devia-
tion) exists mostly in Class II cases. The more frequent
causes of midline discrepancies are a mandibular shift
resulting from a posterior crossbite, tipping or drifting
of the teeth, a lateral mandibular shift without a caus-
ative crossbite (mandibular rotation resulting from oe-
clusal interferences), arch asymmetries, tooth size dis-
crepancies, or any combination of the above? 5 One
typical cause not mentioned is the overretraction of the
canines on one side, which sets the stage for a deviated
midline after the anterior teeth are injudiciously re-
tracted. This overretraction occurs because not enough
attention is paid to the coordination of all three of the
patient's midlines: facial, maxillary, and mandibular.
Most literature pertaining to midline treatment deals
with correcting any discrepancies toward the end of
453
 Am. J. Orthod. Dentofac. Orthop.
454 Jerrold and Lowenstein
June 1990

I
E.H.A.

Fig. 1. Angle is Class III elastic with tandem anterior diagonal Fig. 2. Note tandem unilateral intermaxillary and anterior di-
elastic in conjunction with area expansion for correction of mid- agonal elastic traction.
line discrepancies. From Angle EH. Malocclusion of the teeth.
Philadelphia: SS White, 1907.

......... As requlred to malntaln

desired molar relationship

Fig. 3. Space-closing elastics and Class II intermaxillary elastics applied at start of second stage of
treatment. From Begg PR, Kesling P. Begg orthodontic theory and technique, 3rd ed. Philadelphia:
WB Saunders, 1977.

Fig. 4. Double vertical spring loop auxiliary adjusted for the mass movement of the four incisor teeth
to the left. From Strang R, Thompson W. A textbook of orthodontia. Philadelphia: Lea & Febiger, 1958.
Volume 97 Clinicians' corner 455
Number 6

B J

I
C
.

D I
t
Fig. 5. A, Midline shifting arch wire. Midline is to be shifted to the patient's left. B, Midline shifting arch
wire in place. Closing loop is made as close to the left canine as possible. C, Midline shifting arch wire
activated. As the arch rebounds to its preactivated position, it will carry the four incisors with it to the
patient's left. D, Midline shifting arch wire again passive. Note space mesial to right canine.
 Am. J. Orthod. Dentofac. Orthop.
456 Jerrold and Lowenstein
June 1990

Fig. 6. A, Maxillary midline needs to be shifted to patient's left. Note passive opening loop on right
side and molar stop. Posterior segment is tip to tip. B, Note passive closing loop on left side with
canines in Class I relationship. There is sufficient space between the lateral and canine teeth for
en masse movement of the four anterior teeth. Molar stop preserves arch integrity. C, Closing loop is
activated. Had mesial leg of loop been made closer to the canine bracket, a greater range of activation
could have been achieved (not needed in this case). D, Arch wire activated by tying closing loop (not
seen) to lateral incisor. Note degree of activation of opening loop. E, One month later. Note closing
loop returned to passive position, space between lateral and canine teeth now closed; midline is
corrected; and intercuspation of the buccal segment is still Class I canine. F, Arch wire can now be
removed and the upper right posterior segment brought forward to establish a Class I canine rela-
tionship. Midline (not seen) has been corrected.
Votume 97
Number 6
treatment and most often approaches the problem by
trying to correct the mandibular midline. Sufficient at-
tention has not been paid to treating all three midlines
coincidentally from the start of treatment.
Angle 6 used a Class III elastic with a tandem anterior
diagonal elastic in conjunction with arch expansion for
the correction of midline discrepancies (Fig. 1).
Proffit7 admits that minor discrepancies in midline
coordination can be handled in the finishing stages with
asymmetric Class II and Class III elastics as opposed
tounilateral elastics or by using unilateral Class II or
Class III intermaxillary elastics in tandem with an an-
terior diagonal elastic. He also notes that it is quite
difficult to correct large discrepancies after extraction
spaces have been closed.
Alexanders advocates use of a heavy anterior di-
agonal elastic supported by a Class II or Class III elastic,
depending on whether the original malocclusion was a
Class II or Class III. This is done during the finishing
stages, except in an extraction case in which it may be
performed during space closure if there is a significant
midline discrepancy. The anterior diagonal elastic is
then attached to the closing loops (Fig. 2).
Begg and Kesling9 state that the proper balancing
of space-closing elastics coupled with appropriate Class
II traction during stage II keeps the midlines coordi-
nated with one another (Fig. 3). One may also augment
a unilateral Class II elastic, an anteiior diagonal elastic,
and a Class III elastic with uprighting springs to "walk
the teeth" and effect midline changes.
For the most part, the above-mentioned treatment
modalities seem to link midline discrepancies and their
correction with the cause being a mandibular shift or
rotation of some sort. If this shift or rotation was not
the causative factor but rather the midline deviation was
a result of a dental shifting or drifting of teeth, with
the face being symmetric, then use of such mechanics
would effect a change in mandibular position. This
would have the effect of coordinating the dental mid-
lines but leaving the face asymmetric. If the mandible
has been moved eccentrically and the joint comple x is
unable to adapt, there is the potential for TMJ dys-
function.
Gianelly and PauP ° advocated a biomechanical sys-
tem for midline correction with second-order bends
used to move teeth on one side distally and create a
space for shifting the midline. Class II and Class III
elastics "enhanced" the activity of the couple force sys-
tems. However, no mention was made of the effect on
the position of the mandible as a result of the elastic
traction used nor the differentiation between the two
pertaining to the correction achieved. Lewis 3 espouses
Clhlicians' corner 457
the use of distal spring mechanics as opposed to second-
order bends, bolstered by a sliding yoke off Class II
traction to distalize upper posterior teeth in cases ex-
hibiting arch asymmetry. Thus the maxillary teeth on
the Class II side are moved one by one distally until
coincident midlines are achieved.
Strang and Thompson" introduced a double verti-
cal spring loop assembly to move the four incisors
"en masse" (Fig. 4). The arch wire as originally de-
signed has somewhat limited activation potential. A
modification of this arch wire configuration using round
wire (Fig. 5, A through D) would enable the practitioner
to achieve a greater range of activation. This would
result in a faster correction without the need for sol-
dering spurs and without encountering the labiolinguai
offset difficulties associated with the use of full-sized
rectangular arch wires.
A 0.020-inch arch wire is essentially divided into
three parts: two posterior and one anterior. The arch
wire thus is segmented. The two vertical loops allow
for stabilization of the posterior segments as long as
molar stops are used; hence only anterior movement
takes place. The incorporation of a helix in each loop
provides greater flexibility and longer activation. To
activate, a ligature is passed through the circle on the
closing loop side and tied to the contralateral lateral
incisor bracket. Each tooth has been individually ligated
to the anterior section of the arch, each posterior section
having been ligated together as a unit. The closing loop
is constructed as close as possible to the canine, with
the section to be activated lying anterior to the helix.
When the closing loop is activated, the opening loop
is condensed and a push-pull reaction occurs whereby
all four anterior teeth shift "en masse" toward the de-
sired side. The use of a 0.020-inch arch wire in a wide
0.022-inch sloted Siamese edgewise bracket minimizes
the tipping of these teeth (Figs. 6, A-F). The correction
usually requires one to two visits. After anterior cor-
rection the arch wire is removed and the remaining
posterior section may be conventionally brought for-
ward according to the practitioner's individual tech-
nique.
Finally, in cases in which the midline discrepancy
is very slight (1 to 2 mm), it is tempting to tip the
anterior teeth into a position that coordinates with the
facial midline. If the lower midline is offto the opposite
side, the temptation for correction by tipping is even
greater. This is usually accomplished with uprighting
springs augmented by an anterior diagonal elastic. Al-
though this will produce a midline, the incisal aspects
of which are symmetric with the midfacial place, es-
thetically the results are poor (Fig. 7).
458 Jerrold and Lowenstein
I "J
A B
|
Fig. 7. A, Both dental midlines are off slightly to opposing sides
of facial rnidline. B, After teeth are tipped toward each other,
the incisal aspect of the midline is coincident,
Fig. 8.
Although this result may not create any problem
from a functional standpoint since the anterior teeth
can still disocclude properly and are not load-bearing
in occlusion, it certainly is not healthy from a peri-
odontal perspective. Depending on the patient's lip and
smile line couple d with the amount the teeth have been
tipped, a compromise of facial esthetics is almost in-
evitable.
CLINICAL EVALUATION
lVlidlines can be o f f in relation to one another in
many ways. The following schematics allow for easy
evaluation as to the differential diagnosis o f the midline
discrepancy and the appropriate treatment. The initial
evaluation should be directed toward the patient's face
in habitual closure; Is the face symmetric? This is easily
ascertained by dropping an imaginary plumb line from
the center of glabella. This line should bisect the nose
and philtrum, be coincident with the maxillary and man-
Am. J. Orthod. Dent~w, Orthop.
June 1990
Fig. 9. Case 1.
I
"--J I v ]
Fig. 10. Case 2.
dibular midlines, and fall directly over s o . t i s s u e po-
gonion (Fig. 8). It is important to note Whether the
patient has ever broken his or her nose or suffered from
a deviated septum. This can mislead the unwary prac-
titioner. The plumb line must bisect the dorsal nasal
ridge equidistantly unless there is an asymmetric
nose.
CASE 1
Assuming the face is symmetric, four midline variations
are possible within this group. The first variation is possible
when only the maxillary midline is off to one side or the other
(Fig. 9).
The initial visual facial evaluation of the maxillary mid-
line to the imaginary centered plumb line will show its ectopic
position. Graber and Swains state that this can also be ac-
complished by cast analysis using the midpalatal raphe and
the incisive papilla as reference points. However, during ac-
tual treatment of the case, clinical practice dictates use of the
visual method. The treatment of this condition requires max-
illary intraarch mechanics, fully supported sliding yoke (jig)
mechanics, or unilateral extraction of one tooth. The point to
be made is that elastic traction that has the potential to c o -
Voh~me 9 7 Clinicians" c or ne r 459
Number 6

I
! f

Fig. 11. Case 3. Fig. 12. Case 4.

ordinate the midlines by means of mandibular repositioning

or rotation is contraindicated since the deformity is in the
maxilla and treatment should be so directed.
v I v
CASE 2
Case 2 demonstrates a situation in which both dental
midlines are coincident with each other but not with the
face--the facial one being correct (Fig. 10).
This is usually caused by dental shifting as a result of
unerupted Or missing maxillary and mandibular teeth on the
same side. A classic example is where primary upper and !
lower canines on one side have been removed to facilitate the
eruption of lingually displaced lateral incisors. Fig. 13. Case 5.

CASE 3
Case 3 (Fig. I 1) is similar to case 2 in that the facial
midline is still centered; however, the maxillary midline is
off to one side with the mandibular midline off to the
other side.
This is often caused by premature loss of primary teeth
as a result of decay or extraction. Lack of appropriate space
maintenance has allowed the anterior teeth to drift into the
edentulous area. Treatment of these two situations requires
correcting the midlines back to center by intraarch mecha-
notherapy, coordinating them with the facial midline, and then
reevaluating the direction, amount, and mechanics necessary
for completion of space closure while maintaining proper
midline position.
CASE 4
The final midline variation that may accompany facial
symmetry is seen in case 4 in which the facial and maxillary
midlines are coordinated but the mandibular midline is ec-
centric (Fig. 12).
Again the causative factor is primarily from extraction of
one lower primary canine or from premature loss of any dental
units on that side allowing the loss of intraarach dental in-
tegrity. Again treatment should be directed toward the use of
intraarch mechanics and not unilateral intermaxillary elastics
since they may coordinate the midlines well but subsequently
create a resulting facial asymmetry.
The second group o f cases compromises those sit-
uations in which a facial asymmetry is present with or
without a midline deviation. The first step in evaluation
is to determine whether the facial asymmetry is skeletal,
postural, or functional. Frontal cephalometrics is a help-
ful diagnostic tool; however, the discrepancy is usually
a result of functional interference. Clinical evaluation
involves observing the patient's facial symmetry with
the mouth open. If relative facial symmetry exists, the
odds are good that the cause is not skeletal and that
orthodontic correction can be achieved. As previously
stated, true skeletal asymmetries will not be covered
since surgical and possibly functional orthopedic treat-
ment are the only treatments o f choice and are outside
the scope o f this treatise.
One can gently manipulate and guide the mandible
during closure until the first point o f dental contact is
made. At this juncture the face should be relatively
symmetric and the patient should be able to tolerate
this position for a short period without feeling excessive
strain in the temporomandibular joint areas or in the
muscles of mastication. Note that it is irrelevant at this
point whether the dental midlines coincide with the new

460 Jerrold and Lowenstein
! I
Fig. 14. Case 6.
/
I
Fig. 15. Case 7.
correct facial midline. The clinician should be con-
cerned only with the ability to achieve relative facial
symmetry.
CASE 5
Case 5 (Fig. 13) exemplifies the most often encountered
clinical situation regarding mandibular asymmetries.
Here the mandible is rotated into a lateral eccentric pos-
ture, usually as a result of functional interferences. The max-
illary midline is correct. This is usually treated with unilateral
Class II or Class III mechanics with or without anterior di-
agonal elastics and with or without contralateral Class II or
Class III elastics as described earlier. It is important to sta-
bilize the maxillary midline during this phase of therapy by
whatever method is suitable to the practitioner's particular
mechanotherapeutic technique. If maxillary arch expansion
is necessary to accommodate the new mandibular position, it
should be accomplished before or in conjunction with the
intermaxillary traction used.
CASE 6
Next an easily left untreated condition exists wherein the
mandible is rotated as in case 5; however, dental shifting has
occurred in the mandible that is often caused by the early
loss of teeth on one side. Hence the maxillary midline is
coincident with the mandibular one as can be seen in case 6
(Fig. 14).
In treating this condition, the mandible must be shifted
Am. J. Orthod. Dentofae. Orthop.
June 1990
I
Fig. 16. Case 8.
in one direction using intermaxillary mechanics while the
lower dental midline is being corrected in the opposite di-
rection with intraarch mechanics. This is because, as the
mandible becomes centered, the mandibular midline becomes
eccentric and requires compensatory correction.
CASE 7
Case 7 depicts another instance of dental midline coin-
cidence; however, both are deviated to the side of the facial
asymmetry (Fig. 15).
CASE 8
After correction of the facial deviation with interarch me-
chanics (as previously mentioned), which usually corrects the
mandibular midline if no dental shifting has occurred, the
maxillary midline must now be corrected using proper in-
traarch mechanotherapy. Case 8 is similar to case 7 except
that the original condition is such that the maxillary midline
is off to the opposite side of the mandibular midline and chin
point. Once again correction requires the use of particular
mechanical approaches--intermaxillary traction to correct
the mandibular position and intraarch mechanics to correct
the position of the maxillary teeth--if one is to properly
coordinate all three midlines (Fig. 16).
CASE 9
The next clinical situation, (Fig. 17, A), is unusual in
that both dental midlines are coincident and yet both are off
to one side of the facial midline while the mandible is rotated
to the contralateral side. Etiologically, the upper and lower
teeth have shifted to one side as described in case 2, while
the mandible has reacted to the functional interferences or
crossbite, thus assuming an eccentric posture.
Correction of this situation entails not only differential
midline correction mechanics as previously described, but
also may require the extraction of one additional mandibular
dental unit on the side toward the facial deviation because,
in correcting the facial asymmetry, the lower midline becomes
more laterally displaced from center than it was at the start
of treatment (Fig. 17, B).
Even if the midline symmetry could be established on a
nonextraction basis as far as the maxillary teeth are con-
cemed, the correction of the mandibulardental midline would
Volume 97 Clinicians' cortter 461
let,nber 6

I t I

Fig. 17, A through C. Case 9,

Fig. 18, A and B. Case 10.

V I V
)4(

Fig. 19, A and B. Case 11.

require unilateral extraction if the deviation were severe
enough.
A less severe variation of this situation (Fig. 17, C) is
when the maxillary midline is initially correct.
Although only the lower midline correction needs t o b e
addressed, differential mechanics must still be used. It is very
easy in this type of case to only treat the dental midline shift
(with extractions, reproximation, lip bumpers, etc.) and still
leave the mandible eccentrically postured.
CASE 10
Case 10 is ,,'cry interesting in that the maxillary midline
is off to one side, the mandibular one is coincident with the
midfrontal plane, and yet the mandible has rotated or deviated
to the opposite side (Fig. 18, A).
After using appropriate intermaxiltary traction to correct
the facial midline, case 2, here Fig: 18, B, has again been
recreated and now bimaxillary intraarch mechanotherapy is
necessary for final midline coordination.
CASE 11
Case 11 depicts a situation in which an atypical extraction
sequence may be necessary (Fig. 19, A).
The maxillary midline is off to one side as a result of
factors described earlier, pogonion is off to the same side
because of functional interferences, and the mandibular mid-

462 Jerrold and Lowenstein
v I v
I
Fig. 20. Case 12.
line is centered. But is it? After correction of facial symmetry,
the lower midline is now off to the opposite side. This was
a function of the same causative factors that created the mid-
line shift in the opposing arch. After intermaxillary corrective
mechanics, case 3, here Fig. 19, B, is now recreated.
Ultimate orthodontic correction may require the extrac-
tion of one tooth in each arch on opposite sides in order to
create sufficient space for proper midline coordination, de-
pending on the severity of the discrepancy.
CASE 12
Case 12 is very similar to the previous one except that
instead of the mandibular midline being "centered" at the
initiation of treatment, it is off to the opposite side of the
maxillary midline (Fig. 20).
Thus, on obtaining facial symmetry by intermaxillary
traction, there is even a greater mandibular midline deviation.
As was described in case 9, atypical extraction therapy may
be necessary to effect correction. As an alternative, one might
even consider creating a new lower dental midline between
central and lateral incisors in the finished case--thus setting
one side in a Class I and the other side in a Class Ill molar
relationship. Posttreatment occlusal equilibration, which
should be routine in all cases, becomes more difficult but
more essential.
SUMMARY
Once the midline deviation has been differentially
diagnosed and the appropriate mechanotherapy for cor-
rection determined, a good treatment guide is to co-
ordinate all three midlines, but primarily the facial one,
as soon as possible. At this point reevaluation of any
remaining spaces in each arch will determine whether
retraction of anterior teeth or protraction of posterior
Am. J. Orthod. Dentofiw. Orthop.
June 1990
teeth is the proper method of treatment in reducing the
remaining intraarch spacing. This eliminates unilateral
overretraction and subsequent round tripping in extrac-
tion cases. By treating all three midlines in the initial
stages of treatment and keeping them coordinated
throughout orthodontic therapy, many subdivision com-
pletions can be circumvented.
Careful attention to midline coordination and atten-
dant facial symmetry can aid the practitioner in achiev-
ing the following:
1. Maximum intercuspation and function
2. Stability in the finished result
3. The promotion of anterior dental and facial es-
thetics
4. A decrease in the potential for TMJ dysfunction
5. Maximizing self-satisfaction by achieving an in-
creased number of ideal orthodontic results
We wish to express our thanks and appreciation to Ms.
Sandra Richman for her contribution in preparing the sche-
matics for this article.
REFERENCES
1. DierkesJM. The beauty of the face: an orthodonticperspective.
J Am Dent Assoc 1987(Special Issue):89E-95E.
2. Breakspear EK. Some aspects of the retractionof upper incisors
by appliances. 38th Congress, European Orthodontic Society.
J Eur Orthod Soc 1963:342.
3. Lewis D. The deviated midline. A.'4J OR'IqlOD1976;70:601-16.
4. Borell G. Posterior crossbites--recognition, evaluation and
treatment. State Dent J 1982;48:82-6.
5. GraberT, Swain B. Currentorthodonticconceptsand techniques.
Philadelphia: WB Saunders, 1975.
6. Angle EH. Malocclusionof the teeth. Philadelphia:SS White,
1907.
7. Proffit W. Contemporaryorthodontics. St. Louis: CV Mosby,
1986.
8. AlexanderRG. The Alexanderdiscipline.Glendora,Califomia:
Ormco, 1987.
9. Begg PR, Kesling P. Begg orthodontic theory and technique,
3rd ed. Philadelphia:WB Saunders, 1977.
10. Gianelly AA, Paul IA. A procedure for midlinecorrection. AM
J ORTnOD1970;58:264-7.
11. Strang R, Thompson W. A textbook of orthodontia. Philadel-
phia. Lea & Febiger, 1958.
Reprbzt requests to:
Dr. LauranceJerrold
I00 Clark Ave.
Massapequa, NY 11758