Diastemas

DIASTEMA

1. DIASTEMAS PRESENTED BY: Dr. Pallavi Goel SR (Department of Dentistry and Maxillofacial Surgery)

2. CONTENTS Introduction Causes & Types Diagnosis Multidisciplinary Management Periodontal Orthodontic Restorative: Composite buildup (Principles of Smile design) Prosthetic : Veneers, Crowns. Recent advances Digital smile design software Conclusion References

3. A diastema can be defined as a space >0.5mm between the proximal surfaces of the two adjacent teeth. The spaces usually distort a pleasing smile by concentrating the observer’s attention not on the overall dental composition, but on the diastema . The patient’s needs, demands, and expectations must be considered to ensure satisfaction with the treatment outcomes. INTRODUCTION Dietschi D. Free hand composite resin restorations: a key to anterior aesthetics. Pract periodontics Aesthet Dent 1995; Sep 7(7):15-25. Diastema . Dent Clin N Am 2011:265-281.

4. CAUSES OF MIDLINE DIASTEMA 1)TRANSIENT MALOCCLUSION (BROADBENT PHENOMENON) A midline spacing mixed dentition period associated with the eruption of permanent canines UGLY DUCKLING STAGE corrects itself P ermanent canines erupt furthe r . American academy of Pediatric Dentistry 1995;17:3

5. TOOTH MATERIAL ARCH LENGTH DISCREPANCY: M issing teeth , M icrodontia, P eg shaped laterals , M acrognathia, E xtractions UNERUPTED MESIODENS: Microdontia Unerupted mesiodens

6. ABNORMAL FRENAL ATTACHMENT: The presence of a thick and fleshy labial frenum can give rise to midline diastema. PERNICIOUS HABITS: Proclination of a teeth as a result of habits such as thumb sucking , lower lip biting or tongue thrusting can cause midline diastema along with genralised spacing. Abnormal frenum attachment Proclination

7. 6) MIDLINE PATHOLOGY: Soft tissue and hard tissue pathologies such as cysts , tumors, odontomes may cause midline diastema. 7) IATROGENIC CAUSE: Midline diastema can occur when certain therapeutic procedures such as rapid maxillary expansion are undertaken.

8. RACIAL PREDISPOSITION: N egroid race ECTOPIC MAXILLARY CANINES: Absence of canines from their normal position can facilitate distal drift & tilt of incisors with space opening .

9. 10. OTHERS: Defects in the intermaxillary suture Accentuated overbite Dentoalveolar discrepancies Physiologic or pathologic dental migration Tooth loss. Contemporary orthodontics-4 th edition- by:-William R Proffit,Henry W.Fields,David M.Sarver Orthodontics current principle techniques- 4 th edition-by:-Thomas M. Graber,Robert L. Vanarsdall,Katherine W.L. Orthodontics The Art and Science-4 th edition by:- S.I.Bhalaji Textbook of Orthodontics-2 nd edition-by:- Gurkeerat singh

10. DIAGNOSIS A proper history and clinical examination should be done. Blanch test-done Lift the upper lip and pull in outward and look for blanching of the soft tissue lingual to and between two central incisors. Periapical radiograph- Presence of notching in the interdental alveolar bone as seen on a radiograph is also diagnosing midline pathology that cause spacing. `  Check for any pernicious oral habit.

11. MANAGEMENT OF MIDLINE DIASTEMA CAN BE DONE IN THREE PHASES:- R E T E N T ION 4/19/2012 11 R EM O V A L OF CAUSE ACTIVE T R E A T M E N T

12. 1. TREATMENT OF ETIOLOGIC FACTOR S.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)

13. 4 Peg shaped lateral After orthodontic treatment or sometimes before Composite build up crowns 5 Tooth material deficiency After orthodontic treatment V e neers (porcelain/composite crowns)

14. ETIOLOGY TREATMENT PLAN 6. Overbite First intrusion of the maxill a ry incisors followed by retraction of incisors to close the diastema . 7. Frenal attachments D iastema should be closed as far as possible before going in for frenectomy. If s urgery is performed before,the surgical scar tissue maintains the diastema.

15. ETIOLOGY TREATMENT PLAN 8. Tooth anomalies a. supernumerary tooth , b. absence of laterals R emoval - closure of the diastema is done . a ) I nitially be maintained and at later that be replaced with fixed prosthesis . b) Orthodontically mo v e the canine into the space of the missing laterals, followed by a careful recont ou ring of the cuspid & the first bicuspid.

16. II. SECOND PHASE- ACTIVE TREATMENT R emovable appliances or fixed appliances . R eciprocal anchorage The types of movement are either bodily or more commonly by tipping.

17. REMOVABLE FIXED APPLIANCES P alatal finger springs - loop is opposite to the direction of movement . S plit labial bow Disadvantage -space may be created between the laterals. Fixed appliance incorporating elastics or springs - most rapid correction . Elastics M shaped springs

18. OT HER TREATMENT MEASURES Direct closure with composite layering technique. Laminate veneers Crowns Micro magnetic retainers.

19. ESTHETIC PARAMETERS Width to length ratio Proportionality The Science and Art of Porcelain Laminate Veneers Gürel , Galip . Recurring dental proportion

20. Location of zenith points is another important consideration in diastema correction.

21. COMPOSITE BUILD UP : B uild up on mesial aspect of the central incisors & stripping of the distal surface .

22. Veneers Direct : Composite (time consuming) Indirect : Processed composite veneers Etched porcelain veneers (Cost) Crowns Ceramic crown Porcelain fused to metal crown Sturdevent’s Art & Science of operative dentistry, 4 th edition

23. RECENT ADVANCES 1. The use of posterior stainless-steel matrix has been described in order to facilitate the building of the proximal anatomy. 2. Teflon band to isolate the adjacent tooth, which has the single benefit of preventing the adhesion of proximal walls of the adjacent teeth.

24. 3. The most typical one relies on creating a wax-up restoration, in order to simulate the diastema closure, and building a silicone index to guide the final composite resin restoration. J Esthet Restor Dent. 2018;30:275–280

25. DIGITAL SMILE DESIGN The Digital Smile Design is a multi-use tool that can assist the restorative team throughout treatment Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry. QDT.2012 T he placement of references lines and other shapes over extra and intraoral digital photographs Three basic photographic views are necessary: Full face with a wide smile and the teeth apart, Full face at rest, Retracted view of the full maxillary arch with teeth apart

26. CONCLUSION The presence of diastema between teeth is a common feature found in the anterior dentition. Many forms of therapy can be used for diastema closure. A carefully documented diagnosis and treatment plan are essential if the clinician is to apply the most effective approach to address the patient’s needs.