|Year : 2007 | Volume
| Issue : 1 | Page : 23-26
Spontaneous closure of midline diastema following frenectomy
Kiran Koora, MS Muthu, Prabhu V Rathna
Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, India
M S Muthu
Dept. of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Alapakkam Main Road, Maduravoyal, Chennai - 600 095
| Abstract|| |
Maxillary midline diastema is a common aesthetic problem in mixed and early permanent dentitions. The space can occur either as a transient malocclusion or created by developmental, pathological or iatrogenical factors. Many innovative therapies varying from restorative procedures such as composite build-up to surgery (frenectomies) and orthodontics are available. Although literature says every frenectomy procedure should be preceded by orthodontic treatment, we opted for frenectomy technique without any orthodontic intervention. Presented herewith is a case report of a 9-year-old girl with a high frenal attachment that had caused spacing of the maxillary central incisors. A spontaneous closure of the midline diastema was noted within 2 months following frenectomy. The patient was followed up for 4 months after which the space remained closed and there was no necessity for an orthodontic treatment at a later stage.
Keywords: Frenectomy, midline diastemas, spontaneous closure
|How to cite this article:|
Koora K, Muthu M S, Rathna PV. Spontaneous closure of midline diastema following frenectomy. J Indian Soc Pedod Prev Dent 2007;25:23-6
|How to cite this URL:|
Koora K, Muthu M S, Rathna PV. Spontaneous closure of midline diastema following frenectomy. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2013 May 25];25:23-6. Available from: http://www.jisppd.com/text.asp?2007/25/1/23/31985
| Introduction|| |
Maxillary anterior spacing or diastema is a common aesthetic complaint of patients and is frequently seen in children especially in the mixed dentition stage. Keene described midline diastema as anterior midline spacing greater than 0.5 mm between the proximal surfaces of adjacent teeth.  He reported that the incidences of maxillary and mandibular midline diastema are 14.8% and 1.6%, respectively. Midline diastema may be considered normal for many children during the eruption of the permanent maxillary central incisors. When the incisors first erupt, they may be separated by bone and the crowns incline distally because of the crowding of the roots. With the eruption of the lateral incisors and permanent canines, the midline diastema reduces or even closes.
Taylor reported the incidence of midline diastema in 5 year olds as high as 97 per cent, and seen decreasing with age. , Kaimenyi determined the prevalence of midline diastema and frenum attachments among school children (4-16 years) in Nairobi, Kenya. The commonest location of frenum attachment among children with lower midline diastema is at the mucogingival junction (86%), whereas with upper midline diastema to gingival region (50%). It was concluded that the maxilla had a higher prevalence of midline diastema than the mandible.  Nainar and Gnanasundaram studied nearly 9774 patients in the age group of 13-35 years in South India (Chennai) and reported an incidence of true maxillary midline diastema (1.6%), which was greater than that of true mandibular midline diastemas (0.3%). 
Angle concluded the presence of abnormal frenum as the cause for midline diastema and this view was supported by other researches. ,,, Tait stated that the frenum is an effect and not a cause for the incidence of diastema and reported other causes such as ankylosed central incisor, flared or rotated central incisors, anodontia, macroglossia, dento-alveolar disproportion, localized spacing, closed bite, facial type, ethnic and familial characteristics, inter-premaxillary suture, and midline pathology.  Weber listed the causes for spacing between the maxillary incisors as: a result of high frenum attachment; microdontia; macrognathia; supernumerary teeth; peg laterals; missing lateral incisors; midline cysts and habits such as thumb sucking, mouth-breathing and tongue-thrusting. 
An accurate diagnosis is necessary before treatment can be initiated. No treatment should be initiated if the diastema is physiological and usually if the canines have not erupted. Different treatment modalities for midline diastema include removal of aetiology and simple removable appliances incorporating finger springs or split labial bow. Gleghorn reported a direct composite restoration technique to correct unaesthetic diastema.  Munshi et al . reported extraction of mesiodens subsequently followed by the space closure utilizing simple fixed orthodontic therapy.  Nakamura et al . reported a ceramic restoration of anterior teeth without proximal reduction. Here, we present a case of spontaneous closure of midline diastema after frenectomy procedure. 
| Case Report|| |
A 9-year-old patient reported to the Department of Pedodontics and Preventive Dentistry, Meenakshi Ammal Dental College and Hospital, Chennai with the chief complaint of spacing in the upper front tooth region [Figure - 1]. The patient's medical history did not reveal any systemic diseases. Intra-oral examination revealed presence of high frenal attachment and midline spacing between maxillary central incisors (4 mm). Also she presented with deep caries in the maxillary and mandibular right and left second primary molars.
A simple diagnostic test, i.e., blanching test was performed for an abnormal high frenum by observing the location of the alveolar attachment when intermittent pressure was exerted on the frenum [Figure - 2]. If a heavy band of tissue with a broad, fanlike base is attached to the palatine papillae and produces blanching of the papilla, it is safe to predict that the frenum will unfavorably influence the development of the anterior occlusion. After obtaining informed written consent from the parents, decision was made to remove high frenal attachment by a surgical technique. 
Frenectomy was carried out under local anaesthesia with incision using No. 11 Bard Parker blade. In this technique, lateral incisions were made on either side of the frenum to the depth of the underlying bone. The free marginal tissues on the mesial side of the central incisors were not disturbed. The wedge of tissue was picked up with tissue forceps and excised with tissue shears at the area close enough to the origin of the frenum to provide a desirable cosmetic effect. Sutures were placed to identify the free tissue margins on either side of the removed tissue, and periodontal pack (Coe-pak) was placed for a week [Figure - 3].  The patient was advised to return after a week for suture removal and periodical follow-up once a month. The patient was followed up for a period of 4 months, at the end a remarkable improvement in the aesthetics was observed, due to spontaneous closure of midline diastema [Figure - 4].
| Discussion|| |
A diastema is a space or "gap," most often seen between the two upper front teeth. At some stages of dental development, it is normal to have a diastema but it eventually closes during further development. Often, parents are more conscious about the spaces between front teeth of their children and seek treatment for cosmetic reasons even during preschool period. However, a diastema can also affect the speech, thereby certain sounds like "S" is not pronounced properly. During this the tongue pushes forward to close the space thereby a constant tongue pressure can make the diastema worse over time.
Campbell et al . stated that midline diastema could be transient or created by developmental, pathological or iatrogenic factors.  Like are oral habits, soft tissue imbalance, physical impediment, dental anomalies and/or skeletal disharmonies, as well as normal dentoalveolar development. In this case, the high frenal attachment was the major aetiological factor causing midline spacing. The low attachment of fleshy maxillary labial frenum is often associated with midline diastema and has the following characteristics:
- A frenum, which is unsightly, being visible as a pendulous piece of tissue in the midline of the upper lip.
- Its presence precludes maintenance of good oral hygiene.
- Where there is a direct attachment of the frenum at the gingival margin, it might increase the rate of periodontal destruction in the presence of pre-existing periodontal disease. This was confirmed by positive indication of the blanching test.
Treatment of diastema varies and it requires correct diagnosis of its aetiology and early intervention relevant to the specific aetiology. Correct diagnosis includes medical and dental history, radiographical and clinical examinations and possibly tooth size evaluation.  No treatment is usually initiated if the diastema is physiological/transient as it spontaneously closes after the eruption of permanent maxillary canines (11-12 years). Removal of the aetiologic factor usually can be initiated upon diagnosis and after sufficient development of the central incisor. Follin reported that some pathological causes like supernumerary teeth and midline cysts can be removed surgically and orthodontic closure of the space from both sides performed with fixed appliance, leaving the remaining central incisor in the midline. A retainer was bonded to prevent relapse. 
According to Springate and Sandler, the use of neodymium-iron-boron micro-magnets as a fixed retainer can be used for treating midline spacing.  Putter et al . reported two combined modalities of treatment with orthodontic and porcelain laminate placement to facilitate diastema closure. In his report, Geristore, a dual-cure fluoride-releasing composite was mixed to bond orthodontic brackets in place. H6 elastic bands were used with the orthodontic brackets to close the diastemas sufficiently and to allow the placement of cerinate porcelain laminates to produce a beneficial cosmetic effect.  According to Yves Attia, if the diastema results from the congenital absence of a lateral incisor, initial treatment is to bring the central incisors together, followed by moving the canines forward into the lateral position or by moving them distally to allow for prosthetic replacement.  In other cases, unusually small central or lateral incisors may result in a diastema. Here, too, reconstruction by bonding or jacket crowns will solve the problem. According to Kinderknecht and Kupp, resin-bonded porcelain veneer restorations can be used to correct diastema caused by tooth position or discrepancies in the tooth size/arch development.  In the present case, frenectomy was done because the aetiology was traced to high frenal attachment.
Usually the space closure in the anterior segment is delayed till the eruption of the permanent canine. This is because there is going to be mesial migration during the active stage of canine eruption. But according to Yamaoka et al ., the orientation of the unerupted canine was assessed using the orthopantomographs of 9854 patients who sought consultation between April 1984 and March 1993. A total of 38 canines in 32 patients, all aged 11 years or older, were identified as unerupted canines.  The features of the patients with unerupted canine showed no significant relation to diastema closure status, but some patients had unerupted horizontal or inverted canine without diastema even in the absence of a history of orthodontic treatment, suggesting the presence of a mechanical force due to some phenomenon other than canine eruption as a factor in diastema closure. Moreover, when a pathological cause is identified between the central incisors, the mesial movement during canine eruption is also impeded.
Thus, in our case, an attempt was made to remove the aetiology, even though the patient was only 9-year-old, considering the fact that there will be maximum active mesial movement of tooth during eruption. This resulted in the spontaneous closure of the midline diastema in 2 months. The patient was followed up for 4 months during which there was no change in the closed midline space but there developed a new space between the central and lateral incisors, which could be due to the eruption of permanent canine [Figure - 3]. The patient has been followed up through regular recall for monitoring any changes in the anterior region.
Generally abnormal frenal attachment may require removal either before orthodontic treatment or at the end of active treatment. The advantage of excision prior to orthodontic treatment is the ease of surgical access. If the surgery is performed before the orthodontic procedure, the scar tissue might impede the closure of diastema but the noted advantages of excision after orthodontic tooth movement is the scar tissue formation which to helps maintain closure of diastema. Spilka and Mathews stated that in spite of the success and excellent results, orthodontists have had a problem in correcting dental abnormalities, one particular area, which lends itself to relapse, is the diastema between the incisors.  The surgical correction of a diastema has been successfully accomplished without orthodontic treatment in patients excepting a rapid correction.
Hence, in present case, the advantages of timely intervention during active tooth eruption has prevented orthodontic treatment at a later stage; further, this procedure is less time consuming, less expensive and requires minimal patient compliance.
Early developing malocclusion should be intercepted with the goal of restoring a normal occlusion. The timing and degree of interception are the major problems in interceptive stages, which if dealt properly, can produce positive results in the mixed dentition as seen in the present case.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
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