A Perio-Aesthetic-Restorative Multiphase Management of Midline Diastema: A Case Report

ABSTRACT

Midline diastema is a major aesthetic concern for patients. Etiology includes abnormal frenum attachment, oral habits and various dental anomalies. Treatment involves correct diagnosis and a multidisciplinary intervention relevant to its specific multiple etiologies. A 19 year old girl presented with the chief complaint of midline diastema. The high frenum attachment and the residual interseptal tissue present an additional obstacle and its removal was the part of the solution to the aesthetic problem. The treatment plan called for perio- restorative approach which was used to manage the case and achieve a attractive smile.

KEYWORDS

Midline diastema, high frenum, restorative approach


INTRODUCTION

Midline diastema is described as midline spacing greater than 0.5 mm between the proximal surfaces of adjacent teeth.1 Tait listed causes like ankylosed central incisor, flared or rotated central incisors , anodontia, macroglossia, dentoalveolar disproportion, localized spacing, closed bite, facial type, ethnic and familial characteristics, inter-premaxillary suture and midline pathology.2 Weber reported macrognathia, supernumerary teeth, peg laterals ,missing lateral incisors, midline cysts and habits such as thumb sucking, mouth breathing and tongue thrusting.3Angle concluded the presence of abnormal frenum as the cause for midline diastema.4 Keene reported the incidences of maxillary and mandibular midline Diastema are 14.8% and 1.6% respectively. During mixed dentition stage a transient midline diastema develops.1 Treatment involves correct diagnosis and a early intervention relevant to its specific etiology. Different treatment modalities include orthodontic removable or simple fixed appliances, excision of the frenum, restoration techniques with direct composites, laminates, veneers, ceramic restorations, extraction of mesiodens, habit breaking appliances etc.

CASE REPORT

A 19 year old female patient presented with a single diastema between maxillary central incisors (fig 1).The Diastema had been a aesthetic concern for an extended period of time. Medical and dental histories were completed and reviewed, care was taken to evaluate the complaint from the view point of the patient. Intraoral examination revealed presence of high frenum attachment and midline spacing between maxillary central incisors of 4mm. Tension test was done to confirm the attachment of the frenum to the marginal gingiva. Intraoral periapical radiograph was taken to rule out the presence of mesiodens. The attainment of a proportional aesthetic result required careful treatment planning and pretreatment identification of all potential treatment limitations. A Perio-Aesthetic-Restorative Multiphase Management was planned for the case and a informed consent was taken from the patient.

Perio – Aesthetic Management of Frenum
Mucogingival health is reflected in the periodontal aesthetic outcome and is also responsible for the restorative result. Here high frenum attachment was the major etiological factor causing midline spacing and precluded the maintenance of oral hygiene. Frenectomy was performed under local anesthesia. The frenum was engaged with a hemostat inserted to the depth of the vestibule. Incision was given with Bard Parker blade no.15 along the upper surface of the hemostat, extending beyond the tip. A similar incision was given along the undersurface of the hemostat. The triangular resected portion of the frenum was removed with the hemostat. This exposed the underlying brush like fibrous attachment to the bone (fig 2)A horizontal incision, separated the fibers. Sutures are given (fig 3).The field of operation was cleaned and packed with periodontal pack. The pack is removed after 2 weeks (fig 4).One month is usually required for the formation of an intact mucosa with the frenum attached in its new position. Insufficient healing time does not allow for complete collagen maturation, gingival shrinkage and alteration in interdental papilla shape and contour. Periodontal health should therefore be present prior to initiation of any restorative procedure.

Restorative Management of the Midline Diastema
Patient demand for aesthetic treatment with minimally invasive procedures. This has resulted in the extensive utilization of composite resin for the anterior teeth. The development of composite resins with natural fluorescence and polishability allows the clinician to mimic the natural dentition. Composite resins allow for conservative treatment and long lasting restorations. In order to achieve a natural appearing composite restoration, the clinician must have a knowledge of the properties of composites, and which materials to use in each clinical situation. There are a variety of materials to choose from including, microfills, hybrids, microhybrids, and the newer nanotechnology materials. Today's composite resins exhibit dramatically improved physical and optical properties, rendering them the ideal materials to facilitate restorations that are indistinguishable from the natural dentition This case report demonstrates how current materials, techniques, and equipment can create subtle changes that will develop a new smile and meet a patient’s desired goals. Diastema closure required addition of composite to adjacent teeth. Gingival retraction was achieved by placing a plastic matrix subgingival while holding it against the lingual tooth surface. Diamond burs prepared tooth structure creating a rough surface for improved bond strength and to produce bevels that show through tooth color at restoration cavosurface areas. Cross section of enamel rods improves enamel bond strength. Depending on operator preference, either tooth could be restored first. The most challenging part of this procedure is to get an excellent color match. Blending composite color to tooth color is achieved by proper composite selection, placement and preparation design. The left central incisor was acid etched for 20 seconds , rinsed and air dried. The enamel exhibited an excellent etch pattern. Bonding agent was applied and spread uniformly with air spray. No dentin was exposed; therefore only Dentin/ Enamel resin was used. The material is usually placed in small increments and sculpted free hand to the desired shape. The final restoration is cured for 40 seconds. A layer of translucent composite is placed across the facial aspect, shaped with hand instruments and light cured. Final shaping and polishing is achieved with composite finishing burs. Mesial distal dimension is measured on the restored tooth and compared to the distal mesial dimension of the adjacent tooth and space. Adjustments are made to the restored tooth with burs or sandpaper disks.
Restoration of the adjacent tooth is achieved using the same technique. Close approximation of composite to composite on the adjacent tooth is achieved by holding the matrix against the adjacent composite with an instrument and light curing (fig 5). Another problem with Diastema is that papilla is usually flat. This leads to the dual challenge creating a pointed papilla & completely closing the little black hole in the gingival embrasure. If the contact is extended gingivally & towards the lingual it can be used to create volume with the composite which will then push the papilla forward & incisally into the gingival embrasure on the facial of the contact.
The back of the mouth is a dark area because it receives no light. Composite must block out darkness or a restoration appears dark. A opaque material placed on the lingual aspect so a natural looking restoration is achieved that is not influenced by this darkness. Restoring small diastemas or restoration of teeth that have a large buccal lingual dimension do not require placement of lingual opaque composite.
Composite resin is an ideal material when restoring diastema closures. It is highly polishable, long lasting, and mimics natural tooth structure. It is a conservative alternative to an indirect restoration. Freehand bonding gives total control to the operator. Thus a favorable synergy between esthetics and function was achieved that would enhance the potential to have increased longevity in the life of the restorations.

Conclusion

When a patient presents to a dentist wishing to eliminate a diastema, the situation requires a systematic evaluation that can determine all of the esthetic, functional, and biologic implications that apply to the particular case. The dentist and patient should work together to analyze all of the options and identify a proper course of treatment for the individual and their circumstances. When a proper course of action is taken, an optimal result with favorable esthetic, functional, and biologic consequences can be provided. The patient’s goal was not complex, in this case but with some simple, conservative procedures she had a final result that exceeded her treatment expectations. Understanding current materials and appropriate use of the latest technologies can open the door to a conservatively based aesthetic practice.

Conflicting interest – Nil
Support – Nil
References
1. Keene HJ. Distribution of diastemas in the dentition of man. Am J Phys Anthropol 1963;21: 437-41
2. Tait CH. The median frnum of the upper lip & it’s influence on the spacing of the upper central incisor teeth.Dental cosmos1934;76:991-2.
3. Weber. Orthodontic principles & practice.GraberTM 3rd edi.WB Saunders Co:1972.
4. Angle EH. Treatment of malocclusion of the teeth.7th edi. SS white dental manufacturing Co.Philadelphia.1907:103-4.
5. Carranzas Periodontolgy 9th edi.WB Saunders Co:2003.
6. Dietschi D. Free-hand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7(7):15-25.

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