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Etiology and Treatment of Midline Diastema: a Review of Literature

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Etiology and Treatment of Midline Diastema: a Review of Literature REVIEW ARTICLE POJ 2013:5(1) 27-33 Etiology and treatment of midline diastema: A review of literature Umar Hussaina, Ali Ayubb, Muhammad Farhanc Abstract Introduction: Midline diastema can be physiological, dentoalveolar, due to a missing tooth, due to peg lateral, midline supernumerary teeth, proclination of the upper labial segment, prominent frenum or due to a self-inflicted pathology by tongue piercing. The treatment involves observation and follow up, active orthodontic tooth movement, combined orthodontic and surgical approach, restorative treatment and Mulligan’s technique of overcorrection. Material and Methods: Hand and electronic searching was done for 55 articles for this review of literature. Results: Midline diastema is common dental anomaly having multiple causes and various orthodontic and surgical options for management. Conclusions: Midline diastemas require proper diagnosis and timing for better care of patients. Keywords: spacing; gap; diastema causes Introduction The extent and the etiology of the diastema must be properly evaluated. In some cases space between adjacent teeth is called a interceptive therapy can produce positive A “diastema”. Midline diastemata (or results early in the mixed dentition. Proper diastemas) occur in approximately 98% of 6 case selection, appropriate treatment year olds, 49% of 11 year olds and 7% of 12– selection, adequate patient cooperation, and 18 year olds.1 In most children, the medial good oral hygiene all are important.8-10 erupting path of the maxillary lateral incisors Eruption, migration and physiological and maxillary canines, as described by readjustment of the teeth, labial and facial Broadbent results in normal closure of this musculature, development into the beauty- space.2 In some individuals however, the conscious teenage group, the anterior diastema does not close spontaneously. The component of the force of occlusion and the continuing presence of a diastema between increase in the size of the jaws with the maxillary central incisors in adults often is accompanying increase in tonicity of the facial considered an esthetic or malocclusion musculature all tend to influence closure of problem.3 Midline diastema’s can be the midline dental space.11 The mandibular physiological, dentoalveolar, due to a missing diastema is not a normal growth tooth, due to peg shaped lateral, midline characteristic. The spacing, though seen less supernumerary teeth, proclination of the frequently than maxillary diastema, often is upper labial segment, prominent frenum and more dramatic. No epidemiologic data have due to a self-inflicted pathology by tongue been published on its prevalence. The piercing.4,5 Angle and Sicher6 stated that an primary etiologic factor in mandibular abnormal frenum is a cause of midline diastema is tongue thrust in a low rest diastema, while Tait7 in his study reported position.12 that frenum is an effect and not a cause for Many patients seek closure of a diastema for the incidence of diastema. aesthetic reasons. In the case of normal a,c BDS; House Officer in Khyber college of dentistry. physiological development, diastemas of less b BDS, FCPS; Lecturer in orthodontics KCD Peshawar. than 2mm in nine-year-old children generally 27 POJ 2013:5(1) 27-33 close spontaneously.13 If they do not do so, Discussion small diastemas (less than 2mm) can be The midline diastema is a space (or gap) closed with finger springs on a removable greater than 0.5mm between the mesial appliance or with a split Essix plate, as surfaces of maxillary central incisors. The described by Sheridan.14 In adults with wider space can be a normal growth characteristic diastemas, fixed appliances are required for during the primary and mixed dentition and correction so that crown and root angulations generally is closed by the time the maxillary are controlled.15 canines erupt. For most children, with the The etiology, pathogenesis and diagnosis of eruption of canine normal closure of this maxillary median diastema have been somewhat controversial over the years. The space occurs. For some individuals, however, 16 purpose of this paper is to review the the diastema does not close spontaneously. published information and controversies Midline diastema’s can be genetical, regarding the etiology and treatment of the physiological, dentoalveolar, due to a missing midline diastema in order to give the tooth, due to peg shaped lateral, midline practitioner an overview to direct effective supernumerary teeth, proclination of the diagnosis and treatment. upper labial segment, prominent frenum and due to a self-inflicted pathology by tongue Material and Methods piercing.17,18 Computer databases, including PubMed, Midline spacing has a racial and familial Science direct and Google advance search background.19 Although no specific genes were searched. Internationally published have been investigated for its genetic research literature, review articles and etiogenesis but there are many syndromes relevant citations were included. After the and congenital anomalies which contained electronic literature search, a hand search of midline diastema one of their component e.g. key orthodontic journals was undertaken to Ellis-van Creveld syndrome,20 Pai Syndome,21 identify recent articles. The review was lateral incisor agenesis22 and cleft restricted to articles dealing with the etiology palate,23median cyst.24 and management of maxillary midline Midline diastema may be considered normal diastema. Exclusion criteria included articles for many children during the eruption of the that did not follow the objective of this review permanent maxillary central incisors. When and articles in a language other than English. the incisors first erupt, they may be separated by bone and the crowns incline distally Results because of crowding of the roots. With the A broad search of published articles (The eruption of lateral incisors and permanent Angle Orthodontist, American Journal of canines, midline diastema reduces or even Orthodontics and Dentofacial Orthopedics, closes (ugly duckling stage).25 British Dental Journal, European Journal of A maxillary midline diastema may be caused Orthodontics, Journal of clinical pediatrics, by the insertion of the labial frenum into the Journal of Oral Pathology Pakistan oral and notch in the alveolar bone, so that a band of Dental Journal, Journal of dental association) heavy fibrous tissue lies between the central was done using both the electronic database incisors.26 The two central incisors may erupt and hand searching. A total of 55 studies widely separated from one another and the were retrieved initially. 45 studies were rim of bone surrounding each tooth may not closely related to study objective were used to extend to the median suture. In such cases, no write the review of literature for the etiology bone is deposited inferior to the frenum. A V- and management of midline diastema. shaped bony cleft develops between two 28 POJ 2013:5(1) 27-33 central incisors, and an "abnormal" frenum suture but it is temporary and closes by itself attachment usually results.27 Transseptal in most cases.38 fibers fail to proliferate across the midline An open midpalatal suture or skeletal cleft cleft, and the space may never close.28 Angle may prevent normal space closure and and Sicher stated that an abnormal frenum is present as midline diastema.3 a cause of midline diastema,29,30 while Tait in An object can deflect the eruption pattern of his study reported that frenum is an effect the maxillary central incisors or physically and not a cause for the incidence of move diastema.31 the incisors laterally to create midline V-shaped midline bony clefts may interrupt spacing. Examples include: the formation of transseptal fibers and have Retained primary tooth, midline pathology been suggested as a cause of diastemas. (cysts, fibromas), Foreign body and associated Higley32 suggested that a slight cleft of periodontal inflammation intercrestal bone can hold the teeth apart. Moyers stated that imperfect fusion at the Orthodontic relapse has been correlated with midline of premaxilla is the most common severity of maxillary bony notching.33 cause of maxillary midline diastema. The Patients with supernumerary teeth had normal radiographic image of the suture is a delayed or failed eruption of permanent teeth, V-shaped whereas inverted supernumeraries were more Structure.11 likely to be associated with bodily Because of the potential for multiple displacement of the permanent incisors, etiologies, the diagnosis of a diastema must median diastema and torsiversion.11 be based on a thorough medical/dental Conditions associated with tooth size-arch history, clinical examination, and length discrepancy such as anodontia, radiographic survey. Diagnostic study oligodontia, microdontia, peg shaped laterals, models also may be necessary for analysis macrognathia may cause midline diastema. If and measurement when the diastema may be due to malocclusion, or tooth and/ arch size the lateral incisors are small or absent, the discrepancy. The medical/dental history extra space can allow the incisor teeth to should investigate any pertinent medical move apart and create a diastema.34 conditions (such as hormonal imbalances), Prolonged pernicious habits can change the oral habits, previous dental treatment and/or equilibrium of forces among the lips, cheeks, surgeries, and family history of diastemas or and tongue and cause unwanted dentofacial other related dental problems. The clinical changes tooth
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