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Reported a Treat an MMD in a Patient with Discolored Dentition

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Reported a Treat an MMD in a Patient with Discolored Dentition CLINICAL PRACTICE CASE REPORT Treating a maxillary midline diastema in adult patients A general dentist’s perspective C.H. Chu, PhD, MAGD, ABGD; C.F. Zhang, DDS, MDS, PhD; L.J. Jin, DDS, MDS, PhD he presence of a space between the two maxillary central inci- sors—a maxillary midline ABSTRACT Tdiastema (MMD)—is considered a Background. A maxillary midline diastema (MMD) often normal developmental phenomenon in is a primary concern of patients during a dental consulta- children and requires no treatment. 1 tion. Although an MMD can be transient owing to the devel- Lindsey conducted a study, the results of oping dentition and, thus, requires no active treatment, which showed that about two-thirds of management of MMDs in the permanent dentition requires children in whom only central incisors a detailed examination and appropriate care. had erupted exhibited an MMD. An Case Descriptions. The authors present five cases of MMD of greater than 2 millimeters in MMDs in adults to illustrate a range of restorative and the mixed dentition is unlikely to close orthodontic options. In the first case, the clinician used spontaneously2 and may persist in the resin-based composite buildup to close an MMD resulting permanent dentition. An MMD can be inherited and is more prevalent in cer- from small teeth and generalized spacing in the dental arch. tain ethnic groups.2 Gass and colleagues3 In the second case, the clinician placed porcelain veneers to reviewed the literature and reported a treat an MMD in a patient with discolored dentition. In the prevalence of MMD that ranged from 1.6 third case, the clinician fitted a removable appliance to close to 25.4 percent of adults from various an MMD by tipping the incisors palatally. In the fourth case, populations and age groups. They also the clinician fitted a sectional fixed appliance to promote reported that MMDs are more common mesial bodily movement of the incisors. In the fifth case, the among African Americans than they are clinician placed a full-arch fixed appliance to treat an MMD among whites, Asians or Hispanics.3 caused by tilted incisors. Keene4 defined an MMD as a space Conclusions and Clinical Implications. Effective greater than 0.5 mm between the proximal treatment requires an accurate diagnosis and appropriate surfaces of the two central incisors because intervention. General dentists can perform a range of such a gap is noticeable. McKnight and restorative and orthodontic treatments in appropriate clin- colleagues5 reported that patients consider ical situations to address patients’ concerns. MMDs to be less esthetic than mild fluo- Key Words. Diastema; esthetic dentistry; orthodontic rosis or isolated opacity. An MMD also can space closure; orthodontic appliances; veneers; resin-based adversely affect body image and self- composites; dental restorations; orthodontics; restorative esteem, and it can be one of the most nega- dentistry; fixed prostheses; restorative dentistry. tive factors in self-perceived dental JADA 2011;142(11):1258-1264. appearance.6 Kerosuo and colleagues7 con- Dr. Chu is a clinical associate professor, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Hong Kong SAR, China, e-mail “[email protected]”. Address reprint requests to Dr. Chu. Dr. Zhang is a clinical associate professor, Faculty of Dentistry, The University of Hong Kong, China. Dr. Jin is an endowed clinical professor, Faculty of Dentistry, The University of Hong Kong, China. 1258© 2011JADA American 142(11) Dental http://jada.ada.org Association. Republished November by Medical 2011 Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 11, Page 1258-1264 48 JADA Middle East vol 3 No 1 Jan-Feb 2012 CLINICAL PRACTICE CASE REPORT ducted a study in which they showed Finnish students photographs of faces modified according to one of four dental arrangements. The authors reported that the participants ranked faces exhibiting a median diastema as less intelligent, beautiful and sexually attractive than faces with an ideal occlusion; they also judged them as belonging to a lower social class. In Figure 1. Frontal view of a maxillary Figure 2. Palatal view of resin-based addition to poor esthetics, patients who midline diastema. composite buildup. request closure of an MMD also may complain of impaired speech, lip biting and adverse psychological effects.7 Before formulating a definitive treatment plan for a patient with an MMD, the clinician needs to under- stand the etiology of the condition. It can be an anomaly in the number of teeth (such as mesiodens or hypo - dontia) or the size of teeth (such as microdontia), an enlarged labial Figure 3. Frontal view of resin-based Figure 4. Smile profile after place- frenum, abnormal oral habits (such as composite buildup. ment of resin-based composite buildup. tongue thrusting or finger biting) or advanced periodontitis. Clinicians must obtain a dentist took impressions to prepare a study cast comprehensive medical history, including the and diagnostic wax-up. After discussing treat- duration of the diastema, any changes in size ment options with the patient, the dentist placed and any previous orthodontic treatment, as well resin-based composite buildups on her four max- as a comprehensive family history. illary incisors to close the spacing. He cleaned The clinical examination should include the incisors with pumice but did not prepare the inspection of the dentition and occlusion, labial teeth. The clinician added resin-based composite frenum and lips and an assessment of perio- (A2 shade, Vita Classical Shade Guide, Vident, dontal condition. Full-mouth periapical radio- Brea, Calif.) to the proximal surfaces of the inci- graphy is necessary to assess periodontal sup- sors to close the space between the central and port. The clinician also should make study lateral incisors. The clinician followed the emer- models, and he or she can use a diagnostic wax- gence profile of the incisors in the cervical up to illustrate the possible results of treatment. regions during buildup of the resin-based com- In general, the dentist can use the “golden pro- posite to ensure a smooth lingual-to-buccal finish portion” (8:5)—the ratio of the mesiodistal crown (Figure 2). He thinned the restoration and width of the central incisor to that of the lateral merged its margin with the enamel surface. The incisor—as a guideline for esthetic evaluation. patient was satisfied with this simple noninva- Last, but not least, the patient’s preferences, sive treatment (Figure 3) even though the which are affected by psychological, physical, spacing between her mandibular teeth persisted financial and time factors, are key to performing (Figure 4). successful dental treatment. Discussion. Making a diagnostic wax-up and We present five cases to illustrate the man- study cast requires an extra appointment, but agement of MMDs in general dental practices. they serve as a record, aid in communication and allow ample time for the patient to evaluate REPORT OF CASES the intended treatment outcome outside the Case 1. Description. A 20-year-old woman vis- dental office. Moreover, the clinician can fabri- ited her dentist (C.H.C.) because she was cate a silicon index from the study cast to aid in unhappy with her smile and the spacing in her buildup of the resin-based composite. Dalvit and maxillary teeth, particularly between the two colleagues8 advocated a simple chairside try-in central incisors (Figure 1). The clinical exami- nation revealed generalized spacing in the maxil- ABBREVIATION KEY. MMD: Maxillary midline lary and mandibular teeth due to a discrepancy diastema. NiTi: Nickel-titanium. SNA: Sella, nasion, in the size of her teeth and dental arches. The A point. SNB: Sella, nasion, B point. JADA Middle East vol 3 No 1 Jan-Feb 2012 49 CLINICAL PRACTICE CASE REPORT Figure 5. Frontal view of a maxillary Figure 6. Postoperative view of the Figure 7. Smile profile showing porcelain midline diastema. porcelain veneers. veneers. method with the use of orthodontic wax, but burs. The clinician prepared the incisal edge and this method may require considerable chairside extended it minimally onto the palatal surface time to evaluate the intended outcome. In addi- as a heavy chamfer; however, it extended into tion, once the wax is removed, the patient the gingival proximal area for esthetic reasons. cannot reevaluate the proposed outcome. He was careful not to create undercut areas and Building up the incisors with resin-based expose the dentin unnecessarily. Proximal con- composite is a simple, direct and relatively low- tact areas were not part of the preparation. cost restorative treatment. It also is reversible The clinician prepared the teeth by using a and does not preclude orthodontic treatment in three-step bonding agent (Scotch Bond MP, 3M the future. Willhite9 proposed three criteria for ESPE, St. Paul, Minn.) before taking an impres- successful diastema closure: an increased emer- sion. Because the patient wanted to save money gence profile with natural contours at the inter- and was satisfied with his appearance during face between the gingiva and tooth; a completely treatment, the dentist did not place temporary closed gingival embrasure (that is, no black tri- restorations. The veneers were made of pressed angle); and a smooth subgingival margin that porcelain ingots (IPS Empress, Ivoclar does not catch on or shred dental floss. Vivadent, Schaan, Liechtenstein). The clinician can round the mesial surface of At the patient’s next appointment, the clini- the natural teeth into the facial surface to pro- cian cleaned the teeth with pumice and selected vide a natural bevel for the restoration. The the correct shade by using water-soluble try-in resin-based composite should be nonsticky and paste (Variolink II, Ivoclar Vivadent). He used a nonslumping, and it should contain a high (> 65 light pink opaquer to produce a Vita shade of percent) filler content by volume and a particle A3.5 (Vita Classical Shade Guide).
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