Management of midline diastema

MANAGEMENT OF MIDLINE DIASTEMA

Presented by:- Sudha

Roll no. 72

CONTENTS,,

INTRODUCTION

ETIOLOGY

DIAGNOSIS

MANAGEMENT

CONCLUSION

REFERENCES

REMOVAL OF

ACTIVE TREATME

NTRETENTI

•INTRODUCTION

• The term midline diastema refers to any

spacing or gaps existing in midline of the dental arch.

• It is generally used in reference to maxillary arch,even tough midline spacing is present in the mandibular arch.

• Maxillary midline diastema are one of the most common problems encountered.

• It has been defined as a space greater than 0.5 mm between proximal surfaces of adjacent teeth

• It is easy to treat but difficult to retain.

ETIOLOGY

Main etiological factors are:-

TRANSIENT MALOCCLUSION

TOOTH MATERIAL-ARCH LENGTH DESCREPENCY

UNERUPTEC MESIODENS

ABNORMAL FRENAL ATTACHMENT

PROCLINATION

MIDLINE PATHOLOGY

IATROGENIC

TRANSIENT MALOCCLUSION

• A midline spacing can occur during the mixed dentition period associated with the eruption of permanent canines .this stage is called ‘ugly duckling stage’

Ugly duckling stages

Tooth material-arch length descrepancy• A disparity in which the arch length exceeds the

tooth material can result in midline diastema.• This includes conditions such as:- missing teeth microdontia macrognathia• extraction ith resultant drifting of

adjacent teeth• Peg laterals and missing laterals can lead to

midline diastema

Abnormal frenal attachment

• The presence of thick and fleshy labial frenum can give rise to midline diastema.

• This kind of frenal attachment prevents the two central incisors from approximating each other due to fibrous connective tissue interposed between them.

Pressure habits

• Habits such as thumb sucking ,tongue thrusting also predispose to midline diastema. These patient generally present with proclination and generalised anterior spacing.

Midline pathology

• Spacing in the midline can be caused by soft tissue and hard tissue pathologies such as cyst,tumour and odontomes.

• Presence of an unerupted mesiodens between the roots of the two central incisor also predispode to midline diastema.

iatrogenic causes

• Midline diastema can occur when certain theraputic procedures are undertaken.appearence of midline diastema is an important prognostic signs.

• During rapid maxillary expansion and it indicates the opening of intermaxillary suture with rapid expansion at the rate of 0.5 mm to 1 mm/day 1 mm or more of expansion is obtained in two to three weeks.

• A space is created at the midpalatal suture which is filled initially by tissue fluid and hemorrhage

• And the expansion is highly unstable .

• This diastema closes as a result of trans-septal fiber traction.

RACIAL PREDISPODITON

• The presence of midline spacing also has a racial and familial backgrounds.

• The negroid race shows the greatest incidence of midline diastema.

SLOW PALATAL EXPANSION

• Approximately 0.5 mm per week is the maximum rate at which the tissue of mid palatal suture can adapt if a jackscrew device attached to the teeth is activated at the rate of 1 quarter turn of screw every other day .

• The ratio of dental to skeletal expansion isabout 1 to 1 .tissue damage and the hemorhage at the suture us minimised and the large midline diastema never appeares

DIAGNOSIS

• The proper history and clinical examination should be done .

• Measure the mesiodistal width of the teeth which will help in determining the tooth material –arch length discrepancies.

• BLANCH TEST- lift the upper lip and pull in outward and look for blanching of the soft tissue lingual to and between two central incisors.

presence of blanch indicates high frenal attachment as cause of midline diastema.

• Check for any pernicious oral habit.• Periapical radiograph- presence of

nothing in interdental bone is a diagnostic of a thick and fleshy frenum.

• Midline radiographs will help in diagnosting midline pathology

MANAGEMENT

MANAGEMENT OF MIDLINE DIASTEMA CAN BE DONE IN THREE PHASES:-

RETENTION

REMOVAL OF CAUSE

ACTIVE TREATMEN

removal of cause

• First phase involves the removal of etiology.• Habbit should be eliminated using fixes or

removal habit breakersa) Diastema due to ugly duckling stage -no

treatment requiredb) Diastema due to imperfect fusion at midline-

excision of included interdental tissue between the incisors.a flap is raised interdentally and fissure inserted gently into the cleft.with the bur the included tissue are removed and flap situated.

Active treatment

Removal appliances

• Fixed appliance

Removable appliance• Simple removable appliances are- finger springs labial bows finger spring can be given to the

two central incisorsSplit labial bow made up of 0.7 mm hard

stainless steel wire in reciprocal tooth

movement the forces applied to teeth which is equal and opposite as a resultant each unit to a normal occlusion

Hawley’s appliance

• A simple hawleys appliance incorporating two springs distal to the central incisor can close small diastemas in 3-6 months.the finger spring is made up of 0.5 or 0.6 mm diameter wire.

Tretment of etiologic factors.no. Etiologic factor Timing of treatment treatment

1. Tongue thrust Start before continuing orthodontic treatment proper

Tongue rake(fixed or removable)

2 Thumb sucking Start before continuing orthodontic treatment proper

Tongue rake(fixed or removable)

3 High frenal attachment During treatment Frenectomy with or without gingivoplasty

4 Peg shaped lateral After orthodontic treatment or sometimes before

Composite build up crowns

5 Tooth material deficiency After orthodontic treatment

Vneers(porcelain/composite crowns)

6 supernumerary Before starting extract

7 Missing lateral incisor After orthodontic treatment

Implants crown/bridges

fixed appliance

• Fixed appliances incorporating springs or elastics bring about the most rapid correction of midline diastema.

• Elastic thread or elastic chain can be used between the two central incisors for the same purpose.

• An alternative is to strech a closed coil spring between the two central incisor.

• M shaped springs incorporating three helices can be inserted into the two central incisor brackets.

• The springs are activated by closing the helices

ESSIX APPLIANCE

Presuming that the incisal spacing is not due to forces induced by occlusion,the essix tooth movement is unique biomechanical system involving the use of a removable appliance that is thin ,durable and particularly invisible.

Additionaly tooth movement is possible in all plane of spaces.

Technique………

• Section a canine to canine-essix appliance is fabricated from 1 mm essix type C+ plastic.in the diastema space

• Place one half of the appliance on each side of midline andextend each section 2-3 mm on to the gingive

• Place elastic attachment taps in the distal of each section .

• Attach a clear thin walled rubber band to taps and strech it tightly across the diastema space to create in a force about 150 gm to move bodily

The canine ,lateral incisor and central incisor or each side of diastemas.

• the patient wears the appliance full time with the exception of cleaning and eating and replaces the elastics everyday

• The diastema space should be closed within 4-5 weeks .at that time the midline will be closed but one half of that space will be distal to the canines and the teeth can move back into it.

this redistributed space should be filled with small composite thickness on the mesial of the first bicuspid or distal of the canine.

RETENTION

• Most orthodontist recomends long term retention using suitable retainers since

‘midline diastema is considered as

easy to treat but difficult to retain’ Prolonged retention is indicated in

lingual bonded retainer

Hawley’s retainer

• They are the retainer that are bonded on lingual aspect.stainless steel or blue elgiloy wire is adapted lingually to follow the anterior curvature the ends are curved over the canines where it is bonded

• Various prefabricated retainers are available that can be bonded to the teeth

• Minimal patient discomfort due to reduced bulk

• It is acceptable to most of the patient as it is relatively inconspicious.

fixed retainer• Indication for fixed retainer is a situation

where teeth must be permanently bonded together to maintain the closure of a space between them.

• This encountered most commonly when diastema between the maxillary central incisior has been closed.

• the best retainer for this purpose is a bonded section of flexible wire.

• The wire should be cntoured so that it lies near the cingulum to keep it out of occlusion

• An alternative of it ia a solid wire configured to avoid the tooth contact to fluctuate flossing which can incorporate stops to prevent deepening of bite..

ROLE OF COSMETIC RESTORATION

• Esthetic composite resins generally used to close midline diastema specially in adult patients.it requires a gradual composite build up on the mesial surface and stripping of distal surface of central incisors and lateral incisors in order to achieve a natural shape and size of the teeth.

PROSTHESIS OR CROWN

• Presence of peg shaped lateral or teeth with other anomalies of shape and size require prosthetic rehabilitation.

missing teeth should be replaced with fixed or removable prosthesis.

• THUS THE TREATMENT OF MIDLINE DIASTEMA WILL IMPROVE THE ESTHETICS OF THE PERSON

• IT WILL HELP IN NORMAL ALIGNMENT OF TEETH WHICH WILL CONTRIBUTE TO THE ORAL HEALTH BUT ALSO GOES A LONG WAY IN THE OVERALL WELL BEING AND PERSONALITY OF AN INDIVIDUAL.

CONCLUSION

REFERENCES

• Contemporary orthodontics-4th edition-by:-William R Proffit,Henry W.Fields,David M.Sarver

• Orthodontics current principle techniques-4th edition-by:-Thomas M. Graber,Robert L. Vanarsdall,Katherine W.L.

• Orthodontics The Art and Science-4th edition by:-S.I.Bhalaji

• Textbook of Orthodontics-2nd edition-by:-Gurkeerat singh

THANK YOU

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