Management of midline diastema

Midline diastoma

1. MANAGEMENT OF MIDLINE DIASTEMA Presented by:- Sudha Roll no. 72

2. CONTENTS,, 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 2 INTRODUCTION ETIOLOGY DIAGNOSIS MANAGEMENT CONCLUSION REFERENCES REMOVAL OF CAUSE ACTIVE TREATMENT RETENTION

3. INTRODUCTION 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 3

4. 3/31/2012 4 Free template from www.brainybetty.com (copyright 2007) 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.

5. ETIOLOGY 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 5

6. Main etiological factors are:- 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 6 TRANSIENT MALOCCLUSION TOOTH MATERIAL-ARCH LENGTH DESCREPENCY UNERUPTEC MESIODENS ABNORMAL FRENAL ATTACHMENT PROCLINATION MIDLINE PATHOLOGY IATROGENIC

7. 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’ 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 7

8. Ugly duckling stages 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 8

9. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 9

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11. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 11

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13. Pressure habits Habits such as thumb sucking ,tongue thrusting also predispose to midline diastema . These patient generally present with proclination and generalised anterior spacing. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 13

14. 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 . 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 14

15. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 15

16. And the expansion is highly unstable . This diastema closes as a result of trans- septal fiber traction. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 16

17. RACIAL PREDISPODITON The presence of midline spacing also has a racial and familial backgrounds. The negroid race shows the greatest incidence of midline diastema . 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 17

18. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 18

19. DIAGNOSIS 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 19

20. 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 . 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 20

21. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 21

22. MANAGEMENT 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 22

23. MANAGEMENT OF MIDLINE DIASTEMA CAN BE DONE IN THREE PHASES:- 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 23

24. removal of cause First phase involves the removal of etiology. Habbit should be eliminated using fixes or removal habit breakers Diastema due to ugly duckling stage -no treatment required 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 24

25. Active treatment 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 25 Removal appliances Fixed appliance

26. Removable appliance Simple removable appliances are- finger springs labial bows finger spring can be given to the two central incisors Split 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 26

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28. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 28

29. Tretment 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) 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 29

30. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 30

31. M shaped springs incorporating three helices can be inserted into the two central incisor brackets. The springs are activated by closing the helices 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 31

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34. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 34

35. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 35

36. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 36

37. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 37

38. 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 . 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 38

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40. 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 40

41. 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.. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 41

42. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 42

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44. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 44

45. 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. 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 45 CONCLUSION

46. REFERENCES Contemporary orthodontics-4 th edition-by:- W illiam 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 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 46

47. THANK YOU 3/31/2012 Free template from www.brainybetty.com (copyright 2007) 47