Treating a maxillary midline diastema in adult patientsjada.ada.org/pb/assets/raw/Health Advance/journals/adaj/Case_Report... · diastema (MMD)—is considered a normal developmental

48 JADA Middle East vol 3 No 1 Jan-Feb 2012

1258 JADA 142(11) http://jada.ada.org November 2011

C A S E R E P O R TC L I N I C A L P R A C T I C E

The presence of a space betweenthe two maxillary central inci-sors—a maxillary midlinediastema (MMD)—is considered a

normal developmental phenomenon inchildren and requires no treatment.Lindsey1 conducted a study, the results ofwhich showed that about two-thirds ofchildren in whom only central incisorshad erupted exhibited an MMD. AnMMD of greater than 2 millimeters inthe mixed dentition is unlikely to closespontaneously2 and may persist in thepermanent dentition. An MMD can beinherited and is more prevalent in cer-tain ethnic groups.2 Gass and colleagues3

reviewed the literature and reported aprevalence of MMD that ranged from 1.6to 25.4 percent of adults from variouspopulations and age groups. They alsoreported that MMDs are more commonamong African Americans than they areamong whites, Asians or Hispanics.3

Keene4 defined an MMD as a spacegreater than 0.5 mm between the proximalsurfaces of the two central incisors becausesuch a gap is noticeable. McKnight andcolleagues5 reported that patients considerMMDs to be less esthetic than mild fluo-rosis or isolated opacity. An MMD also canadversely affect body image and self-esteem, and it can be one of the most nega-tive factors in self-perceived dentalappearance.6 Kerosuo and colleagues7 con-

Dr. Chu is a clinical associate professor, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Hong Kong SAR, China, e-mail “[email protected]”. Address reprint requests to Dr. Chu. Dr. Zhang is a clinical associate professor, Faculty of Dentistry, The University of Hong Kong, China.Dr. Jin is an endowed clinical professor, Faculty of Dentistry, The University of Hong Kong, China.

Treating a maxillary midline diastema in adult patientsA general dentist’s perspective

C.H. Chu, PhD, MAGD, ABGD; C.F. Zhang, DDS, MDS, PhD; L.J. Jin, DDS, MDS, PhD

AB ST RACTBackground. A maxillary midline diastema (MMD) often

is a primary concern of patients during a dental consulta-

tion. Although an MMD can be transient owing to the devel-

oping dentition and, thus, requires no active treatment,

management of MMDs in the permanent dentition requires

a detailed examination and appropriate care.

Case Descriptions. The authors present five cases of

MMDs in adults to illustrate a range of restorative and

orthodontic options. In the first case, the clinician used

resin-based composite buildup to close an MMD resulting

from small teeth and generalized spacing in the dental arch.

In the second case, the clinician placed porcelain veneers to

treat an MMD in a patient with discolored dentition. In the

third case, the clinician fitted a removable appliance to close

an MMD by tipping the incisors palatally. In the fourth case,

the clinician fitted a sectional fixed appliance to promote

mesial bodily movement of the incisors. In the fifth case, the

clinician placed a full-arch fixed appliance to treat an MMD

caused by tilted incisors.

Conclusions and Clinical Implications. Effective

treatment requires an accurate diagnosis and appropriate

intervention. General dentists can perform a range of

restorative and orthodontic treatments in appropriate clin-

ical situations to address patients’ concerns.

Key Words. Diastema; esthetic dentistry; orthodontic

space closure; orthodontic appliances; veneers; resin-based

composites; dental restorations; orthodontics; restorative

dentistry; fixed prostheses; restorative dentistry.

JADA 2011;142(11):1258-1264.

© 2011 American Dental Association. Republished by Medical Online Publication SAL with permission of American Dental Association. All rights reserved. JADA 2011, Volume 142, No 11, Page 1258-1264

49JADA Middle East vol 3 No 1 Jan-Feb 2012


ducted a study in which they showedFinnish students photographs of facesmodified according to one of four dentalarrangements. The authors reportedthat the participants ranked facesexhibiting a median diastema as lessintelligent, beautiful and sexuallyattractive than faces with an idealocclusion; they also judged them asbelonging to a lower social class. Inaddition to poor esthetics, patients whorequest closure of an MMD also maycomplain of impaired speech, lip bitingand adverse psychological effects.7

Before formulating a definitivetreatment plan for a patient with anMMD, the clinician needs to under-stand the etiology of the condition. Itcan be an anomaly in the number ofteeth (such as mesiodens or hypo -dontia) or the size of teeth (such asmicrodontia), an enlarged labialfrenum, abnormal oral habits (such astongue thrusting or finger biting) oradvanced periodontitis. Clinicians must obtain acomprehensive medical history, including theduration of the diastema, any changes in sizeand any previous orthodontic treatment, as wellas a comprehensive family history.

The clinical examination should includeinspection of the dentition and occlusion, labialfrenum and lips and an assessment of perio-dontal condition. Full-mouth periapical radio-graphy is necessary to assess periodontal sup-port. The clinician also should make studymodels, and he or she can use a diagnostic wax-up to illustrate the possible results of treatment.In general, the dentist can use the “golden pro-portion” (8:5)—the ratio of the mesiodistal crownwidth of the central incisor to that of the lateralincisor—as a guideline for esthetic evaluation.Last, but not least, the patient’s preferences,which are affected by psychological, physical,financial and time factors, are key to performingsuccessful dental treatment.

We present five cases to illustrate the man-agement of MMDs in general dental practices.

REPORT OF CASES Case 1. Description. A 20-year-old woman vis-ited her dentist (C.H.C.) because she wasunhappy with her smile and the spacing in hermaxillary teeth, particularly between the twocentral incisors (Figure 1). The clinical exami-nation revealed generalized spacing in the maxil-lary and mandibular teeth due to a discrepancyin the size of her teeth and dental arches. The

dentist took impressions to prepare a study castand diagnostic wax-up. After discussing treat-ment options with the patient, the dentist placedresin-based composite buildups on her four max-illary incisors to close the spacing. He cleanedthe incisors with pumice but did not prepare theteeth. The clinician added resin-based composite(A2 shade, Vita Classical Shade Guide, Vident,Brea, Calif.) to the proximal surfaces of the inci-sors to close the space between the central andlateral incisors. The clinician followed the emer-gence profile of the incisors in the cervicalregions during buildup of the resin-based com-posite to ensure a smooth lingual-to-buccal finish(Figure 2). He thinned the restoration andmerged its margin with the enamel surface. Thepatient was satisfied with this simple noninva-sive treatment (Figure 3) even though thespacing between her mandibular teeth persisted(Figure 4).

Discussion. Making a diagnostic wax-up andstudy cast requires an extra appointment, butthey serve as a record, aid in communicationand allow ample time for the patient to evaluatethe intended treatment outcome outside thedental office. Moreover, the clinician can fabri-cate a silicon index from the study cast to aid inbuildup of the resin-based composite. Dalvit andcolleagues8 advocated a simple chairside try-in

ABBREVIATION KEY. MMD: Maxillary midlinediastema. NiTi: Nickel-titanium. SNA: Sella, nasion,A point. SNB: Sella, nasion, B point.

Figure 1. Frontal view of a maxillarymidline diastema.

Figure 2. Palatal view of resin-basedcomposite buildup.

Figure 3. Frontal view of resin-basedcomposite buildup.

Figure 4. Smile profile after place-ment of resin-based composite buildup.



method with the use of orthodontic wax, butthis method may require considerable chairsidetime to evaluate the intended outcome. In addi-tion, once the wax is removed, the patientcannot reevaluate the proposed outcome.

Building up the incisors with resin-basedcomposite is a simple, direct and relatively low-cost restorative treatment. It also is reversibleand does not preclude orthodontic treatment inthe future. Willhite9 proposed three criteria forsuccessful diastema closure: an increased emer-gence profile with natural contours at the inter-face between the gingiva and tooth; a completelyclosed gingival embrasure (that is, no black tri-angle); and a smooth subgingival margin thatdoes not catch on or shred dental floss.

The clinician can round the mesial surface ofthe natural teeth into the facial surface to pro-vide a natural bevel for the restoration. Theresin-based composite should be nonsticky andnonslumping, and it should contain a high (> 65percent) filler content by volume and a particlesize smaller than 5 micrometers. Because thecolor of resin-based composite changes acrosstime, and leakage may occur around the margin,touch-ups usually are required every seven to 10years.10 In addition, a proper bonding techniqueand good moisture control are essential to pre-vent fracture or debonding of the restorativematerial. Limiting exposure to direct force onthe incisal edge minimizes the risk of fracturesubstantially.11 Before performing the procedure,the dentist should discuss possible deterioration(that is, shade and texture) and dislodgment ofthe restorations with the patient.

Case 2. Description. A 28-year-old man vis-ited one of us (C.H.C.) with a complaint of anMMD visible when he smiled. His teeth also hadbeen discolored by tetracycline staining (Figure5). To close up the MMD and mask the discol-oration, the dentist placed porcelain veneers onthe incisors, canines and premolars.

To accommodate the thickness of the porce-lain veneer, the clinician removed an enamellayer of about 0.5 mm in thickness with diamond

burs. The clinician prepared the incisal edge andextended it minimally onto the palatal surfaceas a heavy chamfer; however, it extended intothe gingival proximal area for esthetic reasons.He was careful not to create undercut areas andexpose the dentin unnecessarily. Proximal con-tact areas were not part of the preparation.

The clinician prepared the teeth by using athree-step bonding agent (Scotch Bond MP, 3MESPE, St. Paul, Minn.) before taking an impres-sion. Because the patient wanted to save moneyand was satisfied with his appearance duringtreatment, the dentist did not place temporaryrestorations. The veneers were made of pressedporcelain ingots (IPS Empress, IvoclarVivadent, Schaan, Liechtenstein).

At the patient’s next appointment, the clini-cian cleaned the teeth with pumice and selectedthe correct shade by using water-soluble try-inpaste (Variolink II, Ivoclar Vivadent). He used alight pink opaquer to produce a Vita shade ofA3.5 (Vita Classical Shade Guide). The cliniciancemented a total of 10 veneers, beginning withthe two central incisors and then the lateral inci-sors, ensuring correct positioning duringbonding. After about two seconds of light curing,the clinician removed the excess cement beforeperforming a final thorough curing of at least 40seconds. He examined the patient one week later(Figure 6), and the patient was satisfied with theveneers (Figure 7). The clinician prescribed anightguard for the patient after explaining tohim that the veneers can fracture as a result ofexcessive chewing and grinding.

Discussion. Because the color of the enamellayer comes from the dentin, preparing tetracycline-stained teeth makes the enameldarker owing to an increased chroma and areduced value. Thus, fabricating a porcelainveneer with good esthetics is challenging, andthe clinician must assess the patient’s estheticexpectations before treatment. Porcelain is farsuperior to resin-based composite with regard tomechanical properties and esthetics. It alsolasts longer and exhibits little staining. If

Figure 5. Frontal view of a maxillarymidline diastema.

Figure 6. Postoperative view of theporcelain veneers.

Figure 7. Smile profile showing porcelainveneers.



appropriate tooth preparation is not carried out,the teeth could appear overcontoured and bulky,which might induce gingival inflammation. Inaddition, it is desirable that at least one-half ofthe prepared surface area remain in enamelbecause porcelain veneer bonded to dentin isprone to fracture.12

To minimize food trapping and irritation to thetongue, the dentist performed proximal prepara-tion of the central incisors to create appropriatemesiopalatal contours. To minimize postopera-tive dentin hypersensitivity, Magne and col-leagues13 advocated immediate dentin sealingbefore taking the working impression. To achievesuccessful veneer treatment, practitioners needto consider the following elements in estheticdesign: facial midline, incisal embrasures, axialinclinations, shade progression, tooth reveal,vestibular space and the smile line.14

Case 3. Description. A 19-year-old man vis-ited one of us (C.H.C.) because he wanted clo-sure of the space between his two maxillary cen-tral incisors (Figure 8). Cephalometric analysisrevealed normal anatomical landmarks such assella, nasion, A point (SNA); sella, nasion, Bpoint (SNB); and mandibular plane angles. How-ever, the patient also had an increased anglebetween the upper incisors and maxillary plane.The mandibular teeth were well aligned.

The treatment plan was to close the MMD byusing a removable upper appliance containing aRoberts retractor. The clinician trimmed theacrylic baseplate to allow retraction of the centralincisors. He checked the extension and position ofthe Roberts retractor to make sure it rested onthe buccal sulcus with no distortion, and headjusted the loop of the retractor to prevent itfrom contacting the attached or free gingivae.

The dentist instructed the patient to wear theremovable orthodontic appliance 24 hours a dayand examined the patient the following day tocheck for any discomfort. At the next follow-upappointment four weeks later, the patient hadcomplied fully with the 24-hour regimen; thespace was closed after three months (Figure 9).

The patient wore a Hawley-type removableretainer 24 hours a day for six months and thenabout 12 hours every night for another sixmonths. At the 12-month examination, thepatient was satisfied with the results (Figure10), and the dentist encouraged him to continuewearing the heat-cured retainer at night to pre-vent relapse.

Discussion. Although most patients whoreceive a removable orthodontic appliance can betreated with a fixed appliance, a removable appli-ance can be a good option for those who want aless expensive option. In addition, oral hygiene issimpler for patients wearing removable appli-ances. In this case, the clinician closed the MMDby tipping the incisors palatally and reducing thewidth of the upper arch. Root repositioning wasnot required. Generally, MMDs should be no morethan 3 mm wide for this type of treatment to beeffective.2 Ample room must exist between theupper and lower anterior incisors for palatalretraction of the upper incisors to occur. In addi-tion, the patient’s periodontal condition must begood and stable. A slightly increased overjet,reduced overbite and proclined upper incisors aredesirable because these will be lessened withretraction of the incisors. Case selection is vitalfor a successful outcome, as is the patient’s adher-ence to the treatment regimen. Apart from thepatient’s wearing the retainer, good periodontalsupport of posterior teeth is needed to maintainthe treatment outcome.

A removable appliance has three main com-ponents. The first is the retention device, whichin this case was achieved with an Adams claspplaced on the maxillary first molars. The secondis the active component, in this case a Robertsretractor designed to tip the incisors palatallyfor space closure. The removable appliance tipsteeth with little bodily movement. The optimalforce used is 25 to 40 grams; a smaller or largerforce will affect tooth movement. The final com-ponent is the acrylic baseplate, which joins thecomponents together. The Roberts retractor ismade of 0.5-mm stainless steel wire reinforced

Figure 8. Smile profile showing a maxil-lary midline diastema.

Figure 9. Removable appliance with aRoberts retractor.

Figure 10. Smile profile after orthodontictreatment.



by tubes on both sides for rigidity. A loop isincluded for greater resilience and ease ofadjustment. To ensure a comfortable fit, theacrylic baseplate, which is not a denture, shouldnot extend as far as the soft palate. A routineoral hygiene maintenance program (includingregular scaling and polishing and oral hygienereinforcement) should be scheduled to ensuregood plaque control. Because the patient wasinstructed to wear the retainer for an extendedperiod, his dentist (C.H.C.) made a heat-curedretainer to increase polymerization and reduceporosity.

Case 4. Description. A 19-year-old womanvisited her dentist (C.H.C.) for closure of herMMD, but she could not afford the timerequired for, or the expense of, a comprehensivefixed appliance. Her oral hygiene was unsatis-factory. The clinical examination revealed local-ized marked gingivitis, a rotated upper canineand an MMD. She had no other problemsregarding tooth alignment, function or esthetics.The practitioner explained treatment options tothe patient, as well as the importance of oralhygiene. After the gingival inflammation hadresolved, he closed the MMD with a sectionalfixed appliance.

The clinician bonded four orthodonticbrackets onto the upper incisors and inserted a16-mil (0.41 mm) round stainless steel wire thatwas stabilized with elastic ligatures. The dentistused loop-forming pliers to create loops at bothends of the wire to prevent lateral sliding anddislodgment of the wire. After four weeks, hereplaced the 16-mil wire with an 18-mil (0.46 mm) round stainless steel wire and usedan elastomeric chain to close the MMD. Thepower chain spanned from the mesial wing ofone lateral incisor bracket to the mesial wing ofthe other lateral incisor bracket (Figure 11).

The dentist replaced the power chain with anew chain at the one-month follow-up visit.MMD closure had occurred after three monthsof active treatment, with the spacing redistrib-uted to the proximal areas of the lateral incisor

and canine. The clinician thenapplied a metal ligature to thefour incisors to stabilize the teethfor three months. Figure 12 showsthe results after removal of thebrackets. The patient’s MMD wasclosed and her oral hygiene hadimproved. Finally, the clinicianfitted a removable retainer andgave the patient instructions onhow to wear it. She was happywith the results of this simple and

inexpensive orthodontic treatment.Discussion. When MMD is the patient’s only

concern and alignment of the teeth is acceptable,a sectional archwire can be used to close theMMD. It can be a suitable option when time andcost prohibit comprehensive treatment with afixed appliance. In this case, the incisors weremoved mesially to close the MMD. Initial use ofa 16-mil round wire allowed for better alignmentof the four incisors before active movement. The18-mil wire provided enough strength to ensurethat the incisors were pulled mesially by theelastics to achieve the desired movement. Thedentist must be careful not to overstretch thepower chain, as this can cause unwanted mesialrotation of the lateral incisors.15 The practitioneralso can use a rectangular (16 × 22 mil [0.56 mm])archwire for three-dimensional control. He or sheshould proceed with care when using the simplesectional fixed appliance because incisors may actagainst each other and produce unwanted toothmovement. An alternative approach is to use a 2 × 4 appliance (bands on the first two molars andbrackets on the four maxillary incisors), togetherwith a utility arch, to better control tooth move-ment. This latter method also prevents minorincisor flaring.

Case 5. Description. A 26-year-old womanvisited her dentist (C.H.C.) with a complaint ofan MMD. Her molar and canine had a normalClass I relationship. The two central incisorsalso were tilted distally, but there was adequatespacing in the maxillary arch. Because thepatient’s mandibular teeth were in reasonablealignment and she had no other complaints,treatment consisted of closing the MMD byrealigning the two maxillary central incisorswith a full-arch fixed appliance.

Orthodontic treatment consisted of bandingthe maxillary first molars and bonding bracketsfrom the left second premolars to the rightsecond premolars. The dentist fitted a 16-milnickel-titanium (NiTi) wire with elastic liga-tures to align the teeth horizontally and fitted aligature wire to the canine and first molar

Figure 11. Brackets and elastomericchain attached to the incisors.

Figure 12. Posttreatment frontal view.



(tieback) to prevent mesial move-ment of the canine tooth (Figure13). Two months later, he replacedthe 16-mil NiTi wire with an 18-mil NiTi wire. When initial align-ment was established, he replacedthe NiTi wire with an 18-mil stain-less steel wire to promote mesialbodily movement. The clinicianfitted a power chain to close thespace between the central incisors.The treatment took seven months,and the patient was highly satis-fied with the outcome (Figure 14).

Finally, the clinician fitted aremovable retainer and in structedthe patient in how to wear it. Aftertreatment, he studied the patient’socclusion clinically and in themounted study cast. The clinicianmade no adjustment because theupper and lower teeth hadachieved satisfactory occlusion.

Discussion. In this case of MMDinvolving tilted maxillary centralincisors, treatment consisted of con-trolled tooth movement. Our use ofa fixed appliance was simple andfast. Alignment of the mandibularteeth was acceptable, and the max-illary space allowed for alignment ofthe upper teeth. In cases such asthis, a diagnostic setup is necessary.The clinician can assess the spaceby examining the study cast. Ifthere is mild crowding in the maxil-lary arch, midline expansion can beachieved with a screw, quad-helix orPorter arch. In general, a 1-mmmidline expansion would provide 2 to 3 mm of space in the arch.2 Thefirst molars are banded to serve asanchors, and a small-diameter arch-wire is fitted initially and supportedwith brackets. After horizontalalignment of the teeth is achieved,the clinician needs to place a rec-tangular archwire if the root posi-tions need correcting. Cliniciansshould provide patients with de -tailed explanations, including theimportance of follow-up and mainte-nance care.

DISCUSSIONMMD is not an uncommon com-plaint of adult patients. The dentist

Figure 13. Full-arch fixed appliance. Figure 14. Smile profile after ortho-dontic treatment.

CLINICAL FINDINGS TREATMENT PLAN

MaxillaryMidline

Diastema

PathologyDetected

MixedDentition

MalocclusionRequiring BodilyTooth Movement

Discoloration ofTeeth That CannotBe Treated With

Bleaching

Proclined Incisors(Can Be Retracted

by Tipping)

Resin-BasedComposite

Buildup

RemoveableOrthodonticAppliance

PorcelainVeneers

Fixed Appliance:Full Arch, SingleArch or Sectional

Regular EvaluationUntil Canines Erupt

Treatment ofUnderlying Cause

Comprehensive Assessment

Discolored Teeth

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Figure 15. Flowchart depicting treatment of patients with maxillary midline diastemas.



should perform a thorough oral examination todetermine if there are any relevant etiologic fac-tors. In addition, the dentist should talk withthe patient about his or her expectations fordental care and treatment preferences, becausethese often are key to achieving the patient’s sat-isfaction and successful treatment outcomes. Ifthe patient’s condition is complicated andrequires the opinion and care of an expert, theclinician should refer him or her to the appro-priate dental specialist. In this report, we pre-sented five cases of adults with MMDs and noobvious pathology who were treated by a generaldentist. Figure 15 is a flowchart that summa-rizes these cases and the procedures performed.General dentists can perform a range of restora-tive and orthodontic treatments in appropriateclinical situations to address patients’ estheticconcerns.

CONCLUSIONSMMDs create a dark spot within the smile, whichprompts many patients to seek treatment. Gen-eral dentists play an important role in reachingcorrect diagnoses and should consider a multidis-ciplinary approach to achieve an optimal out-come. Clinicians should perform a detailedassessment, which often includes radiographicassessment, spacing analysis and occlusalanalysis on study casts and the diagnostic wax-up. It also is essential to study the position andsize of the tongue in relation to the dental arch.

Treatment by specialists may be requireddepending on the etiologic factors. However, it isnot uncommon for clinicians to find no under-lying pathology. When comprehensive ortho-dontic care is not the patient’s choice of treat-ment and if function and alignment of the teeth

are acceptable, clinicians can perform restora-tive or simple orthodontic treatment success-fully. We have presented five cases to illustratetreatments that general dentists can perform to manage MMDs in their patients. ■

Disclosure. None of the authors reported any disclosures.

The authors thank Dr. Trevor Lane for editing the manuscript ofthis article.

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10. Ardu S, Braut V, Uhac I, Benbachir N, Feilzer AJ, Krejci I.Influence of mechanical and chemical degradation on surface gloss ofresin composite materials. Am J Dent 2009;22(5):264-268.

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Treating a maxillary midline diastema in adult patientsjada.ada.org/pb/assets/raw/Health Advance/journals/adaj/Case_Report... · diastema (MMD)—is considered a normal developmental

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