2 INSIDE DENTISTRY—APRIL 2009 CLINICAL A review from the experts. TREATMENT optioNs Treatment Options for the Significant Dental Midline Diastema Michael R. Sesemann, DDS, FAACD From the beginning of time people stymata are prominently displayed in the his dental midline diastema. A compre- have noticed, and perhaps passed judg- mouths of many famous and successful hensive dental examination revealed excel- Michael R. Sesemann, DDS, FAACD ment on, people with prominent spaces people from all walks of life, including lent overall oral health. The only treatment President-Elect and in their dentitions. In France, the teeth David Letterman, Elton John, Eddie Mur- recommendation, made for the purpose Accredited Fellow on either side of a space or gap are called phy, Madonna, Lauren Hutton, Michael of maintenance, was for the replacement American Academy of “dents du bonheur” or “lucky teeth.” In Strahan,Arnold Schwarzenegger,and Con- of a few older restorations that were show- Cosmetic Dentistry Nigeria, a dentition sporting gaps be- doleezza Rice, to name a few. However, ing signs of marginal deterioration. tween teeth is considered an exception- there remain a significant number of peo- When asked to smile, the patient’s lip Private Practice ally attractive physical trait. In early English ple who do wish to eliminate a diastema retraction capability was moderately dy- Omaha, Nebraska societies, the presence of a gapped-tooth if it is part of their dentition. namic, yet high enough to yield a clear presentation in a female smile was equat- Because of the varying perceptions, a view of a midline diastema measuring ed with lustful connotations. person may decide to make a dental mid- 1.79 mm at its most coronal aspect, wid- In Western society, ambivalence ex- line diastema part of who they are or they ening to 2 mm at the height of the cen- with the condyles in centric relation (CR).5,6 ists as to whether a diastema is a favor- may wish to eliminate it. If a person de- tral papilla (Figure 1). When in repose, Clinically, upon analysis of the patient’s oc- able physical trait or not. A small midline cides not to livewith their diastema and the patient’s maxillary incisorswere hid- clusion, it was determined that maximum diastema is usually not considered unat- they seek dental intervention, the task of den fromview (Figure 2). intercuspation (MI) of the patient’s den- tractive by any group of people.1 How- finding a dental solution that eliminates The maxillary incisors were diminutive tition was different than the patient’s oc- ever, as the size of the gap increases to a the space in a responsible way is placed in size with the central incisors measur- clusion when his temporomandibular more easily seen physical trait, the level squarely on the dental professional. ing approximately 8.5 mm in height to 8 joints were placed in a CR position. of comfort someone has in personally Many clinical options exist that can mm in width, giving a height-to-width This discrepancy was meticulously car- possessing a “gapped-tooth appearance” be used for a given situation. The deci- ratio of 94%. The prevailing height-to- ried over to the mounting of the patient’s may decrease to the point of creating a sions that are ultimately made in render- width ratio was significantly distanced study models in the laboratory. When feeling of self-consciousness. If the con- ing the appropriate treatment solution from a visually pleasing range of 75% the models were mounted using the CR dition develops an outward self-conscious- are ones that the patient will have to live to 80%, with 78% being the ideal.4 All bite registration from the data collection ness in relation to the way a person feels with for the rest of their lives, particu- six maxillary anterior teeth had incurr- appointment, MI and CR occlusion were about a personal physical trait they pos- larly if the treatment solution chosen is ed slight wear over the patient’s lifetime, not coincident. When the mandibular sess, it can affect the way that person acts one involving irreversible tooth prepa- with the incisors exhibiting enough wear study model was closed to occlude against in life. This, in turn, could have a negative ration. Therefore, it is extremely impor- of the incisal enamel to expose dentin the maxillary study model, early occlusal influence in certain career and social sit- tant that the dentist and patient discuss (Figure 3). contact occurred on the mesial marginal uations in which they are placed. all of the treatment options in detail to ridges of the maxillary first bicuspids, There can be wide variations of per- identify the pertinent and important DATA COLLECTION AND mimicking the clinical presentation seen ception concerning the significance of a ramifications that are associated with ANALYSIS in the operatory. midline diastema when translated through each particular choice. After the new patient examination and in- A diagnostic laboratory equilibration different cultures, socioeconomic groups, itial consultation, the patient returned for of the CR-mounted study models dem- and ethnic backgrounds.2 Indeed, unfair CASE STUDY further data collection which included onstrated that very little tooth structure and ill-perceived judgments are leveled at A 42 year-old man in excellent physical polyvinylsiloxane impressions, a maxil- would need to be eliminated through se- people who possess certain physical traits. health and no medical compromises pre- lary arch registration with the Kois Dento- lective odontoplasty to make MI and the When testing the perceptions of subjects sented to the dental office seeking informa- Facial Analyzer System (Panadent Corp, patient’s CR occlusion coincident. Be- viewing anonymous faces with certain tion and possible treatment to eliminate Colton, CA), and a bite registration taken cause of the necessity to have an optimally features, including dental midline dia- stemas, the subjects ranked the individ- uals in the images to be significantly less intelligent, beautiful, and sexually attrac- tive. Inaddition, the anonymous faces werejudgedtobelong to a lower socioe- conomic class than the same faces with an ideal occlusal presentation.3 This find- ing illustrated that a social disadvantage was wrongly implied, simply on the ap- pearanceof one’s dentition—even if it was a healthyone. Figure 1 Patient’s smile appearance exhibiting Figure 2 Patient’s oral presentation when lips Figure 3 Occlusal view of the maxillary arch The decision whether to live with one’s a dental midline diastema of 1.79 mm to 2 mm. were in repose. showing wear of the incisors through to dentin. diastema or not is a personal one. Dia- INSIDE DENTISTRY—APRIL 2009 3 posterior teeth in lateral and functional movements, it was time to fabricate a di- agnostic wax-up to see what clinical di- mensions the incisor restorations could be while using the natural maxillary cus- pids for protection. Initially, the wax-up illustrated that the size of the central in- cisors could be increased to a dimension of 10.85 mm in height without contact in functional movement (Figure 4 through Figure 6). This was important because Figure 4 through Figure 6 The diagnostic wax-up showing possible dimensions of the proposed incisor restorations and their interplay with the mandibular the width of the central incisors would be teeth when the mandible is in lateral excursive movements. increasing to compensate for the restora- tive elimination of the midline diastema. Any further increase in the width of the restorations, without an increase in their height, would not allow us to reach a de- sirable height-to-width ratio. The last factor to work out in the diag- nostic wax-up was the appropriate dimen- sions of the lateral incisors. Specifically, what dimensions would the lateral incisors have to be to complement the proposed new dimensions of the central incisors, Figure 7 The patient’s gingival levels before gin- Figure 8 Gingivoplasty procedures carried out Figure 9 Palatal silicone putty preparation and how far would they need to extend givoplasty procedures. with consideration of the future restoration size and guide tried in before tooth preparation. mesially to portray a favorable and har- intended gingival zenith location. monic dimensional change? This deter- mination was critical because it would dictate the commensurate distal exten- sion of the central incisor restorations. This in turn would decide whether or- thodontics would be necessary to spatial- ly arrange the incisors by moving the central incisors mesially for an optimal restorative solution. It would also affect the choice of material options available. The completed laboratory analysis via the diagnostic equilibration and wax-up Figure 10 Labial silicone putty preparation Figure 11 Preparations finalized after periodon- Figure 12 Margin placement on the prepared provided a great deal of information: guide allowing visualization of critical interproximal tal gingivoplasty and frenectomy. tooth relative to interproximal alveolar crest verified contact location. through “sounding” procedure. • The number of restorative units need- ed to optimally eliminate the patient’s the provisional prototypes, to make sure dental midline diastema would equal that the new restorations would be com- four (on teeth Nos. 7 through 10). patible with habitual movements such as • The wax-up illustrated how the indi- those that occur in mastication8 and vidual restorations would appear di- speech.9 The steepness of the interarch mensionally and whether