Indian Journal of Dental Research

CASE REPORT
Year
: 2017  |  Volume : 28  |  Issue : 4  |  Page : 461--464

Laser-assisted multidisciplinary approach for closure and prevention of relapse of midline diastema


Amol Kamble1, Preetam Shah1, Priyam Rajesh Velani1, Ganesh Jadhav2,  
1 Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra, India

Correspondence Address:
Amol Kamble
Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed University Dental College And Hospital, Pune, Maharashtra
India

Abstract

Midline diastema, which occurs as spacing between the upper central incisors, is a common occurrence seen in the pediatric population. In the ugly duckling stage of development; no treatment is generally advocated as the diastema is a transient one. When diastemas occur due to other pathologies, they pose several problems in relation to esthetics and speech in a growing child. With the advent of time, patient's demand for esthetics has greatly increased. Along with this, a less time-consuming treatment option is a favorite. Proper diagnosis of the diastema, unfolding its etiology, helps in devising an adequate treatment plan. This eventually will lead to stability of the final result. The present case report presents a different and unique approach for the esthetic closure of midline diastema following frenectomy procedure. The approach proves to be a quick and simple option for closure of midline diastemas in cases with concomitant incisal edge irregularities.



How to cite this article:
Kamble A, Shah P, Velani PR, Jadhav G. Laser-assisted multidisciplinary approach for closure and prevention of relapse of midline diastema.Indian J Dent Res 2017;28:461-464


How to cite this URL:
Kamble A, Shah P, Velani PR, Jadhav G. Laser-assisted multidisciplinary approach for closure and prevention of relapse of midline diastema. Indian J Dent Res [serial online] 2017 [cited 2019 Nov 13 ];28:461-464
Available from: http://www.ijdr.in/text.asp?2017/28/4/461/213034


Full Text

 Introduction



Diastema, a space present between the upper central incisors, is a common problem affecting the esthetics in a child during mixed and early permanent dentition phases. Its occurrence varies according to age. For example, it is seen in approximately 98% of 6 year olds, 49% of 11 year olds and 7% of 12-18 year olds.[1] In most children, diastemas occur as a normal developmental growth characteristic as the permanent maxillary lateral incisors push the roots of the permanent central incisors away, with the canines acting in a similar manner in the mixed dentition phase. However, due to the medial eruption of the laterals and canines, the central incisor roots are pushed back together. Following the eruption of the canines, there is a normal closure of this space. In some individuals, however, the diastema closure does not occur spontaneously leading to a necessary intervention. Reasons for midline diastemas are genetic and racial predisposition, superior labial frenum attachment, oral musculature imbalances, presence of supernumerary teeth, presence of pernicious habits, and other iatrogenic factors.[2] It is complicated by the insertion of the labial frenum into the notch in the alveolar bone so that a band of heavy fibrous tissue lies between the central incisors.[3] One school of thought states that an abnormal frenum is a cause of midline diastema,[4] whereas according to the other one, a frenum is an effect and not a cause for the diastema.[5] It poses several problems related to esthetics and speech. Various treatment options available for management of midline diastemas are orthodontic corrections, use of interceptive appliances, extraction of supernumeraries, surgical correction of impeding factors, use of direct composite resin, and use of habit breaking appliances. However, all these methods when used separately have inherent limitations. As pediatric dentists come across children at the earliest, early recognition and interception of developing malocclusion could avoid long-term laborious orthodontic treatment.[6] Here, a unique approach for the esthetic closure of midline diastema is presented following frenectomy and orthodontic procedures.

 Case Report



A 13-year-old healthy Asian boy reported to the department with the chief complaint of spacing between his upper front teeth and wanted immediate management for the same. Intraoral clinical examination revealed the presence of midline diastema (1 mm) with high, fibrous labial frenal attachment [Figure 1]a. A simple blanch test was performed and positive blanching of the papilla was noted [Figure 1]a. Upper right central incisor (tooth #11), upper right lateral incisor (tooth #12), upper left central incisor (tooth #21), and upper left lateral incisor (tooth #22) showed minor incisal edge irregularities [Figure 1]a. Various treatment options and their possible limitations were explained to the patient. It was decided to perform surgical (labial frenectomy), orthodontic (orthodontic separators), and restorative (composite build-up) procedures for long-term success of management strategies. The risks, complications, and possible outcome of procedures were explained, and written informed consent was taken.{Figure 1}

Surgical procedure

A local anesthetic solution (2% lidocaine with 1:100,000 epinephrine, LOX 2% Neon Laboratory, India) was infiltrated in the soft tissue surrounding the frenum. With the appropriate parameters and settings, the Er, Cr: YSGG laser was used for labial frenectomy with the tip in slight contact with tissue. Tissue forceps was used to secure the labial frenum and to detach it carefully. Bleeding was minimal and arrested completely after applying pressure with gauze for 10 min [Figure 1]b. There was no need for sutures and only a periodontal pack was given for 7 days after which complete healing was observed [Figure 1]c.

Laser parameters for Er, Cr: YSGG laser (Waterlase MD: Biolase Technology, Irvin, CA, USA): - 2.25 W of power supply, 30% water flow and 30% air flow, 600 μm diameter of optical fiber tip (G6) at 20 Hz intermittently.

Orthodontic procedure

For the closure of diastema, a novel and easy technique was carried out using orthodontic separators, which were introduced interdentally on either side of both upper lateral incisors [Figure 1]d. The patient was recalled after 24 h when complete closure of the midline diastema was observed [Figure 2]a.{Figure 2}

Restorative procedure

During this visit, restoration of the irregular incisal edges of upper central and lateral incisors was planned. The separators were then removed and replaced by plastic wedges to prevent the closure of space during the restorative procedure [Figure 2]b. The incisal irregularities were restored using composite resin (3M ESPE Universal Restorative-A2 shade) [Figure 2]c. Proper interdental contacts were also restored with the same material to prevent the opening up of spaces between the incisors. Finishing and polishing were adequately performed with the help of finishing burs and discs [Figure 2]d.

 Discussion



Clinicians should understand the etiology, consequence, and the extent of the diastema as not all diastemas can be managed in the same manner with respect to timing or treatment modalities. Before going ahead with any treatment plan, the clinician should evaluate the various possible techniques as successful treatment depends on proper case selection, appropriate technique selection, adequate patient cooperation, and good oral hygiene maintenance. Effective treatment of midline diastema requires an accurate diagnosis and an intervention based on its exact etiology. Correct diagnosis includes medical and dental history along with radiological and clinical examinations [Flowchart 1]. Midline diastemas could be transient or created by developmental, pathological, or iatrogenic factors such as oral habits, soft tissue imbalance, physical impediment, dental anomalies, and/or skeletal disharmonies.[7],[8] At around 9–11 years of age, midline diastema is a normal occurrence as seen in the ugly duckling stage of development and eventually closes during further development. In such cases, no treatment is needed as diastema closes after the eruption of permanent maxillary canines [Flowchart 2]. Interceptive treatment modalities in mixed dentition phase prevent the uptake of other invasive and long-term orthodontic modalities. Pathological causes such as supernumerary teeth, abnormal frenal attachments, and midline cysts can be treated surgically and then orthodontic closure of the space can be done [Flowchart 1].[INLINE:1][INLINE:2]

An abnormally attached fibrous maxillary labial frenum between the central incisors is frequently associated with diastemas and complicates its correction. The maxillary labial frenal attachments have been classified by Placek et al. (1974) as: mucosal - when the frenal fibres are attached up to the mucogingival junction, gingival - when the fibres are inserted within the attached gingiva, papillary - when the fibres are extending into the interdental papilla, and papilla penetrating - when the frenal fibres cross the alveolar process and extend up to the palatine papilla. In cases with high frenal attachment, frenectomy proves to be useful for stability of the final result. If the frenum is removed surgically before tooth movement, then scar tissue formed during healing impedes the closure of diastema. In a laser frenectomy, wound healing does not involve any scarring and the need for suturing is also not there. Moreover, operating time and anxiety is reduced in laser-assisted surgery.[9] Hence in the presented case, Er, Cr: YSGG laser was opted for frenectomy. Moreover, tooth movement should not be delayed after surgery as it may result in a space that is even more difficult to close.[10]

In the presented case, the patient wanted an immediate result for the management of his diastema. On examination, the diastema was found to be [11] As part of a comprehensive esthetic treatment and of an overall dental treatment plan, the result of diastema closure should produce a beautiful smile and fulfill the goals of overall smile design.[12] Composite resins have proved to be very helpful in managing these goals. It is cost-effective and time-saving with minimal damage to the tooth structure. Only orthodontic correction of diastema tends to relapse [13] and it requires permanent retention. In this case, since the interdental contacts were properly established using composite restoration, it prevented the opening up of spaces and thereby chances of a relapse. Midline diastemas are a common finding in the dental office on a regular basis. Several patients are becoming more and more conscious of their appearance, thereby raising the importance and the need of esthetically pleasing results. Overcoming several limitations, such surgical, orthodontic, and restorative correction of a diastema can be successfully accomplished in patients requiring a rapid correction.

 Conclusion



Treating diastemas as early as possible prevent its worsening. A simple procedure for closure of midline diastemas which is less time consuming, less expensive, and requires minimal patient compliance should be advocated. The present case thereby depicts a noninvasive and highly effective treatment option for rapid closure of midline diastemas in cases with incisal irregularities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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