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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 214-217

Masking of midline diastema-a smokescreen approach

1 Department of Periodontics, CSICDSR, Madurai, Tamil Nadu, India
2 Department of Endodontics and Conservative Dentistry, CSICDSR, Madurai, Tamil Nadu, India

Date of Submission11-Jun-2019
Date of Decision28-Jun-2019
Date of Acceptance02-Sep-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Yamini Rajachandrasekaran
Department of Periodontics, CSICDSR, 32 Ragavendra Street, Balaji Nagar, Thirupparankundram, Madurai - 625 005, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_64_19

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Midline diastema is a common esthetic problem in both mixed and permanent dentition. Many innovative therapies vary from restorative procedures such as composite build-up to surgery (frenectomy), and orthodontic corrections are also available. A high frenum attachment is often the cause of persistent diastemas. Presented herewith is a case report of a 43-year-old female with a high frenal attachment that had caused spacing of the maxillary central incisors. The need for treatment in this case is mainly attributed to esthetic and psychological reasons, rather than functional ones. This case report demonstrates the removal of the abnormal labial frenum attachment through surgery and subsequent closure of maxillary diastema following prosthetic as well as restorative approach.

Keywords: Esthetics, frenectomy, high frenal attachment, midline diastema

How to cite this article:
Rajachandrasekaran Y, Kottai Gandhi GD. Masking of midline diastema-a smokescreen approach. Indian J Dent Sci 2019;11:214-7

How to cite this URL:
Rajachandrasekaran Y, Kottai Gandhi GD. Masking of midline diastema-a smokescreen approach. Indian J Dent Sci [serial online] 2019 [cited 2020 Sep 24];11:214-7. Available from: http://www.ijds.in/text.asp?2019/11/4/214/268421

  Introduction Top

Maxillary anterior spacing or diastema is a common esthetic complaint of patients or parents and is frequently seen in the mixed and permanent dentition stage. Maxilla had a higher prevalence of midline diastema than the mandible, with an incidence of 14.8% and 1.6%, respectively.[1] This spacing is considered normal for many children during the eruption of the permanent maxillary central incisors and occurs in approximately 98% of 6-year-olds, 49% of 11-year-olds, and 7% of 12–18-year-olds, and thus, with the eruption of the permanent lateral incisors and canines, the diastema reduces or even closes.[2] Thus, the cause for midline diastema can be a physiological or dentoalveolar, i.e., presence of mesiodens, supernumerary teeth, physiological spacing between teeth, abnormal frenal attachment. Angle [3] stated that an abnormal frenum is a cause of midline diastema, while Tait [4] in his study reported that frenum is an effect and not a cause for the incidence of diastema.

Hence, an accurate diagnosis is necessary before the treatment procedure, but it is not advisable to treat cases of midline diastema with physiological cause until the canines have erupted completely. Numerous treatment modalities are available for the closure of midline diastema; the appropriate technique and material depend on the time, physical, psychological, and economic limitations of the patient. The width-to-length ratio of central incisors plays an important role in esthetic rehabilitation because it determines on the amount of proximal reduction, placement of prominences and concavities, and decision for composites or full crowns, veneers. This case report describes the removal of the etiology followed by closure of midline diastema through prosthetic and restorative approach.

  Case Report Top

A 43-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, Sree Balaji Dental College and Hospital, Chennai, with the chief complaint of a gap in her upper anterior teeth which gave her a poor esthetic appearance. Clinical examination revealed the presence of a discolored tooth in 21 due to trauma before 30 years and was diagnosed as nonvital tooth with the help of pulp sensibility test (cold test) which revealed no response in relation to 21, and hence, root canal treatment (RCT) was carried out in 21 followed by management of midline diastema. Patient's medical history did not reveal any systemic diseases. Radiographic examination ruled out presence of any unerupted supernumerary tooth or mesiodens. Intraoral examination revealed the presence of 4 mm midline diastema associated with high frenal attachment extending till the palatine papilla [Figure 1]a, and hence, a simple diagnostic test, i.e., blanching test, was performed for an abnormal high frenum by observing the location of the alveolar attachment when intermittent pressure was exerted on the frenum.[Figure 1]b. Blanching test was found positive.[5] The type of frenal attachment in this case is papillary penetrating frenum [Figure 2]. Various treatment options were discussed with the patient such as fixed orthodontic appliances and the patient's affordability in terms of treatment time was discussed in detail. However, due to prolonged treatment and esthetic issues related to these appliances, the patient did not give her consent to these treatment modalities. The space was managed with a conservative, esthetic procedure using ceramic crowns and composite restorations along with removal of the high frenal attachment surgically after getting informed consent from the patient.
Figure 1: (a and b) Intraoral photographs of midline diastema between central incisors

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Figure 2: Intraoral photograph showing papillary penetrating frenum

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Treatment protocols

The first management for the midline diastema closure is removal of the etiology; hence, the patient was referred to the Department of Periodontics where frenectomy was carried out under local anesthesia with incision using No. 11 Bard-Parker blade [Figure 3]a and [Figure 3]b. In this technique, lateral incisions were made on either side of the frenum to the depth of the underlying bone.[5],[6] The free marginal tissues on the mesial side of the central incisors were not disturbed. Tissue forceps were used to pick up the wedge of the tissue, and excision of the tissue was done at the area closer enough to the frenal attachment to provide a desirable cosmetic effect. Sutures were placed, and the patient was advised to report back after a week for suture removal and periodical follow-up. During the next appointment, after the healing of the surgical site was satisfactory, impressions were taken using irreversible hydrocolloid* for making diagnostic wax-up models [Figure 4]. The mesiodistal width of 11 and 21 was 8 mm which was measured using a vernier caliper scale and smile design was carried out, and the space was closed by adding wax on the mesial sides of 11 and 21 in such a way that mesial line angles of both 11 and 21 did not further shift toward the midline, which would otherwise affect the anterior esthetic zone by changing the proportionality. Since this patient had an inappropriate width-to-length ratio, the outcome of the treatment was clearly explained to the patient; once the patient got satisfied, informed consent was signed and the treatment procedures were initiated [Figure 5]. Crown preparation was performed in 21 and sent to the laboratory with detailed information of the modifications to be fabricated in crown £2 with a slight mesially over contoured crowns [Figure 6]a and [Figure 6]b. Before luting of the leucite-reinforced ceramic crowns © crown was etched they were silanized with a silane coupling agent and luted with a self-adhesive cement [Figure 7]. The mesial aspect of 11 was roughened with a coarse cut tapered fissure bur, and composite build-up was done incrementally. Bite was checked finishing and polishing was done with smooth tapered diamond bur and supersnap polishing kit η [Figure 8].
Figure 3: (a) Frenectomy procedure, (b) surgical site after frenum removed

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Figure 4: Simple interrupted sutures placed at surgical site

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Figure 5: Postoperative photograph after 1 week after frenectomy

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Figure 6: (a and b) Negative replica of crown preparation in relation to 21

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Figure 7: Prosthetic all-ceramic crowns luted in relation to 21

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Figure 8: Restorative treatment of midline diastema by light cure composite resin in 11

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  Discussion Top

Because of various etiological factors which prevail for the midline diastema,[7] an accurate diagnosis is important. Based on the etiological factors, midline diastema can be managed either by surgical, orthodontic, periodontal, restorative, and prosthetic procedures or by the combination of procedures. Thus, etiology plays a key role in the treatment planning of midline diastema cases. Before the treatment plan, it is important to evaluate both hard and soft tissue parameters, such as the tooth proportions, midline, gingival zenith point, and interproximal contact area. These parameters aids in establishing esthetics in the anterior zone based on the individuals facial and dental appearance and helps in redefining the smiles.

Till date, orthodontic therapy has proven to be an excellent and predictable means of achieving tooth movement to address both the esthetics and functional concerns. However, in this case of maxillary midline diastema, the patient refused for the orthodontic treatment due to the occupational limitation of time and due to the age factor which gives an unaesthetic appearance during the treatment. Hence, this case was managed by combination of surgical, restorative, and prosthetic approach to meet the esthetic demand of the patient as well as a long-term success after the procedure.

The etiological factor in this case is due to an abnormal papillary penetrating frenal attachment which was first eliminated by the surgical procedure (i.e., frenectomy); next, a three-dimensional perspective was visualized with the help of diagnostic wax. It gave planning with regard to the final outcome of the treatment; it also aids in pertaining patients point of view of the outcome and reveals the need for additional treatment that may not be evident during routine examination.[8]

Smile design principles including golden proportion and esthetic contouring should be considered during the wax-up.[9] Ideally, the width-to-length ratio is 80%. A higher width/length ratio gives a square appearance and a lower ratio makes a slender/longer appearance.[10] In this case, during the diagnostic wax-up procedure, the estimation of width-to-length ratio of the maxillary anterior was critical, but the patient was satisfied with the outcome. Generally, in cases of complex midline diastema as presented here, it is not ideal to split the two central incisors width rather an illusion is created to avoid the incisors to look wider once the diastema is closed by any of the esthetic procedures.[11] Ceramic crowns were planned for the nonvital root canal treated because after RCT tooth gets weaker and fracture prone. Hence, the ceramic crown was fabricated with a modification of an increased mesially contoured by not shifting the mesial line angles beyond the optimum proportionality which gives an unaesthetic appearance. These crowns have optimal esthetics, higher translucency permitting light to pass through and superior strength. The remaining space was closed using direct composite by incremental technique and the illusion principle was applied. Prabhu [12] stated that composites had a higher success rate of 91% for the restorations made during the study period of 60 months and there is enough literature that composite restorations on anterior teeth last longer when the esthetic and functional principles of the restoration are satisfactory.[13]

  Conclusion Top

A combined approach was employed to rejuvenate the unaesthetic smile in this case. Although it is not possible to recreate an “ideal smile” because of the unproportionate width/length ratio in the anterior esthetic zone, an illusion was created to overcome this issue by not shifting the midline beyond the proportionality in order to achieve a balanced smile that was overall pleasing. Thus, keeping in mind about all the extraordinary circumstances with regard to the patient's constraint time factor and refusal for the conventional treatment procedure, this midline diastema case was treated with a combined surgical, restorative and prosthetic approach. Finally, it is important that all dentists should have a thorough knowledge from all the aspects before the treatment of esthetic cases to create a right balance to restore the form, function, esthetics which varies among each individual and this helps in redefining smiles in the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Huang WJ, Creath CJ. The midline diastema: A review of its etiology and treatment. Pediatr Dent 1995;17:171-9.  Back to cited text no. 1
Munshi A, Munshi AK. Midline space closure in the mixed dentition: A case report. J Indian Soc Pedod Prev Dent 2001;19:57-60.  Back to cited text no. 2
Angle EH. Malocclusion of the Teeth. Philadelphia: The SS White Dental Manufacturing Company; 1907.  Back to cited text no. 3
Tait CH. The median frenum of the upper lip and its influence on the spacing of the upper central incisor teeth. Dent Cosmos 1934;76:991-2.  Back to cited text no. 4
Priyanka M, Sruthi R, Ramakrishnan T, Emmadi P, Ambalavanan N. An overview of frenal attachments. J Indian Soc Periodontol 2013;17:12-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
Spilka CJ, Mathews PH. Surgical closure of diastema of central incisors. Am J Orthod 1979;76:443-7.  Back to cited text no. 6
Moyers RE. Handbook of orthodontic. 4th ed. London, Year Book Medical Publishers (Wolfe Medical); 1988. p. 196-218.  Back to cited text no. 7
Pierre L, Cobb DS. Enhancement of aesthetic treatment planning and communication using a diagnostic mock up. Cosmetic Dent 2012;3:20 4.  Back to cited text no. 8
Dawson EP. Functional Occlusion from TMJ to Smile Design. U.S: Mosby Elsevier; 2007. p. 152  Back to cited text no. 9
Abdul HA, Sulimanand Rawhi HA. Smile perception in dentistry. Cairo Dent J 2009;25:53-60.  Back to cited text no. 10
Peyton JH. Direct restoration of anterior teeth: Review of the clinical technique and case presentation. Pract Proced Aesthet Dent 2002;14:203-10.  Back to cited text no. 11
Prabhu R, Bhaskaran S, Geetha Prabhu KR, Eswaran MA, Phanikrishna G, Deepthi B. Clinical evaluation of direct composite restoration done for midline diastema closure - long-term study. J Pharm Bioallied Sci 2015;7(Suppl 2):S559-62.  Back to cited text no. 12
Ardu S, Krejci I. Biomimetic direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167-74.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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