Managing of diastema case by orthodontic, surgical and prosthodontic therapies

Dr. Mohammed Sarraj – Sarraj2013@hotmail.com

Introduction

Many patients present with a variety of problems such as missing teeth, drifting, crowding, malocclusion, and extrusion that require the intervention of several dental disciplines. As dental professionals, we can never assume what the patient will accept or reject as the appropriate esthetic treatment or goal.

The wise dentist develops a group of fellow practitioners of different specialties who can review the diagnostic work-up of a patient whenever there is a question of potential issues that may compromise the final esthetic result. Only the patient can determine how much time, money, and effort that he or she is willing to invest, as well as what is a personally esthetic result.¹One of the most challenging tasks of modern restorative dentistry is resolving the dilemma of spaces between anterior teeth. To some, an anterior diastema is desirable, whereas others attempt to hide it with habits such as lip or tongue posturing.²

Treatment planning to correct a diastema may include orthodontics, restorative dentistry, or a combination of several therapies. Like most esthetic problems, the treatment of a diastema requires careful analysis and occasional consultation with specialists. Diagnostic casts, radiographs, and photographs or digital imaging are necessary to thoroughly evaluate a diastema. Anterior spaces should not be closed without first recognizing and treating the underlying cause(s). ³

The etiology of diastema may be attributed to hereditary and developmental factors. ^4,5 Although hereditary determinants play a major role in causing diastemas, there is nothing that can be done to prevent them. Most of the other causes of diastema formation are preventable. Anatomic factors such as those seen in atypical frenum positions may also contribute to diastema formation.⁶ The presence of the frenum muscle fibers on the alveolar ridge influences the direction of tooth eruption and maintains separation of the adjacent teeth after eruption. Although teeth can be moved together orthodontically in the presence of a frenum, once the active appliance is removed, the teeth tend to separate, reforming the diastema unless permanent retention is provided. An adequate border of attached gingiva is essential to successful orthodontic movement. Surgical removal or repositioning of the undesirable frenum attachment (and the creation of a stable area of attached gingiva in its place) prior to orthodontic repositioning reduces frenum-related diastema relapse.^7,8 Other developmental causes of diastemas are obvious, such as the loss of a permanent tooth, or a more subtle cause, such as periodontal disease.⁹

Case History

A 20-year-old female presented with a large maxillary diastema between the small central incisors. The atypical frenum protruded. The frenum muscle fibers were sat on the alveolar ridge. The patient’s chief complaint was that the presence of a space between her incisors. (Fig. 1, 2, 3)

Although the presence of a diastema is self-evident, these spaces must not be closed without first addressing the underlying cause. the dentist should include the patient in the treatment planning process by presenting appropriate treatment alternatives, prognoses, and fees.¹⁰

In this case, the treatment is orthodontics, surgical and prosthodontic therapies. The one step, orthodontic, brackets and rubber were sat to move the central incisors the middle to create enough space for esthetic result (fig. 4, 5).¹¹

The two step, surgical (fig 6), Excision of the labial frenum is easy within the reach of the general practitioner, and may be performed with various techniques. The method usually employed is that of excision using two hemostats. In this case, the procedure used is as follows. After local anesthesia, the lip is pulled upwards, and the frenum is grasped using two curved hemostats, which are positioned at the superior and inferior margins.

The lip is then further retracted and a thin scalpel blade incises the tissue found behind the hemostat, first behind the lower hemostat and then behind the upper hemostat. The frenum is hypertrophic and there is a large space between the central incisors, the tissues found between and behind the central incisors are also removed. Interrupted sutures are placed along the lateral margins of the wound in a linear direction, after the mucosa of the wound margins is undermined using scissors.¹²

The third step, prosthodontic, after orthodontic and surgical therapy, any needed restorative treatment to achieve the final esthetic result may be performed. Diastema due to periodontal or anatomy problems cannot be corrected predictably with restorations alone, Splinting or some other method of stabilization would have to be included in the treatment plan.¹³

As patient acceptance of ideal treatment is the ultimate objective for the dentist in this phase, it is often necessary to allow the patient to visualize and judge the end result. For simple diastema closures involving restorations, the chairside application of tooth-colored wax or unbonded composite resin to the patient’s proximal tooth surfaces should provide a good indication of the result.

For complex cases that involve several teeth or combination therapies (orthodontics and restorations), a diagnostic wax-up and computer imaging may be required to enable the patient to appreciate the anticipated result of extensive treatment.

When multiple disciplines are involved, such as orthodontics, surgery, and restorative dentistry, a case presentation conference (or teleconference) with all involved clinicians and the patient may facilitate acceptance of complex treatment plans.¹⁴

Pre- and postoperative photographs or digital images can provide many benefits. Photographs of the results of treatment on other patients can be used to help current patients envision the possibilities associated with their own treatment and inspire confidence in the dentist’s abilities. Photographs document the procedure and can be used to improve the chances for reimbursement from insurance carriers in certain cases.

A duplicate set of pre- and posttreatment images given to a patient following treatment helps to prevent “buyer’s remorse” and allows him or her to serve as a marketing advocate for the office when the dramatic before and after photos are displayed to family and friends. However, it is sound practice to use computer imaging of both close-up and full-face before and after images for best patient and doctor visualization (fig. 6).²

The four incisors after preparation, a full ceramic bridge is choosed, to be sure the diastema will not relapse. (fig 7-8-9)

Conclusion

In this case, we must study the etiology of the diastema to be able to solve it. We excised the frenum using traditional surgery, then we started simple orthodontics. The orthodontic solution alone is not enough, because the form of the central incisors is atypical, consequently, the final esthetic result does not satisfy the patient and there may be relapse. We have to use prosthetic solution, ideally veneers, because they are the most conservative regarding the hard tissues. Instead we used full crown ceramic bridge prosthetics for retention and esthetics too.

References

1. Goldstein RE, Van B. Haywood, Esthetics in dentistry, 2nd Ed 2002.

2. Goldstein RE. Change you smile. 3rd edn. Chicago: Quintessence, 1997.

3. Goldstein RE. Esthetics in dentistry. 1st edn. Philadelphia: JB Lippincott, 1976.

4. Huang WJ, Creath CJ. The midline diastema: a review of its etiology and treatment, [review]. Pediatr Dent 1995

5. Oesterle LJ, Shellhart WE.

Maxillary diastemas: a look at the causes. J Am Dent Assoc 1999.

6. Leonard MS. The maxillary frenum and surgical treatment. Gen Dent 1998.

7. Goodman NR. Treatment of diastema: not always frenectomy. Dent Surv 1975.

8. Miller PD Jr. The frenectomy combined with a laterally positioned pedical graft. Functional and esthetic considerations. J Periodont 1985.

9. Towfighi PP, Brunsvold MA, Storey AT, et al.

Pathologic migration of anterior teeth in patients with moderate to severe periodontitis. J Periodont 1997.