Etiological Factors Of Midline Diastema - A Retrospective Study
Reshma Harikrishnan1, Nivethigaa B2*, Balaji Ganesh. S3
1 Graduate Student, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077,
Tamil Nadu, India.
2 Senior Lecturer, Department of Orthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
3 Senior Lecturer, Department of Periodontology, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077, Tamil Nadu, India.
*Corresponding Author
Dr. Nivethigaa. B,
Senior Lecturer, Department of Orthodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai 600077,
Tamil Nadu, India.
Tel: 9791972324
E-mail: nivethigaab.sdc@saveetha.com
Received: July 30, 2021; Accepted: August 11, 2021; Published: August 18, 2021
Citation:Reshma Harikrishnan, Nivethigaa B, Balaji Ganesh. S. Etiological Factors Of Midline Diastema - A Retrospective Study. Int J Dentistry Oral Sci. 2021;8(8):4119-4123. doi: dx.doi.org/10.19070/2377-8075-21000841
Copyright:Dr. Nivethigaa. B©2021. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Aesthetics has become one of the major concerns worldwide, in children, adolescents and adults. Malocclusion is a morphological variation that may or may not be associated with pathological conditions. Anomalies in the tooth position, number, form and developmental position of the teeth beyond normal limits will all contribute to malocclusion. A “diastema” is the space between adjacent teeth. Maxillary midline diastema is a common esthetic problem in both mixed and permanent dentition. It can occur as either a transient malocclusion or due to developmental, pathological and iatrogenic causes. Some other causes include genetic, physiological, supernumerary teeth, abnormal frenum attachment, habits, tooth material, pathology, iatrogenic, etc. The aim of this study was to assess the common etiological factors that are associated with midline diastema. With this knowledge, it would be easier for dentists to diagnose cases with better understanding of the cause and also formulating an ideal treatment plan. They can eliminate the malocclusion at earlier stages. A retrospective study was done in an institutional setting to study the various etiological factors in the occurrence of a midline diastema. Among patients who visited the dental facility, the records of patients within the time period of June 2019 to March 2020 were chosen for this study. The patients detailed case sheets were analyzed using parameters such as age, gender and etiology. The data was sorted and was tabulated in excel. Analysis of the data was done in SPSS software. The association between age with etiology and gender with etiology were evaluated. A total of 236 patients were considered for this study. 69.9% being males and 30.1% being female patients with midline diastema. Midline diastema was seen to be more prevalent in the age groups of 20-40 years. It was least prevalent in 61-75 years age groups. The most common etiological factor that seemed to cause a midline diastema in the population was due to a high frenum attachment (39.83%). 23.31% of the patients had this as a generalized spacing due to habits, 12.29% of the patients had the presence of mesiodens. 10.17% of the patients were partially edentulous, 1.69% of the patients had peg laterals. Rotation of 11 and 21 was seen in 12.71% of the patients. Majority of the patients within the age group of 20-40 years had high frenum attachment. Patients within the age group of 61-75 years had a midline diastema due to their partial edentulism. The most common etiology for midline diastema was the presence of a high frenum attachment. The presences of various etiological factors have been overlooked. Regular dental visits can prevent such negligence and aid in improving esthetics.
2.Introduction
3.Conclusion
4.References
Keywords
Diastema; Esthetics; Etiology; Malocclusion; Midline.
Introduction
Esthetic concern is a major factor that drives patients to seek orthodontic
correction may it be children, adolescents and adults.
Most people equate their success in many pursuits to be associated
with their appearance. An acceptable, normal and attractive
appearance is socially acceptable by many individuals [1, 2]. Malocclusion
is a morphological variation which may or may not be
associated with pathological conditions.
Malocclusion can occur when the relationship between the upper
and lower arch is altered. Anomalies in tooth position, number,
form and developmental position of teeth beyond normal limits
can cause malocclusions, along with factors such as genetics, environmental factors and various deleterious oral habits [3].
Malocclusion is not a single condition rather this may lead to
development of further complications such as functional limitations,
physical pain, social disability, poor maintenance of oral
hygiene etc.,[3-7]. It brings several fold increase in periodontal
health, chances of dental caries, any other traumatic dental injuries
or in worst cases it can even lead to TMJ problems [8-10].
A “diastema” is the space between two adjacent teeth. Maxillary
midline spacing occurs in many individuals both mixed and permanent
dentition. It can occur either as a transient malocclusion
or created from developmental, pathological or iatrogenic factors
[11]. The etiology factors involved in the causation of midline
diastema include: genetics, physiological, supernumerary teeth,
abnormal frenum attachment, tooth material abnormalities, habits,
midline pathologies, or iatrogenic causes [12-16]. Studies have
shown that it occurs 98% in patients at 6 years of age and decreases
as they grow. Such a self-correcting malocclusion is also
termed as Ugly duckling stage.
The growing concern with regard to midline diastema is esthetics
and speech [1, 17]. It was found to be more prevalent in male
patients than in female patients, between 6-12 years of age. Treatment
of a midline diastema should take the patients esthetic appearance
and function into consideration [18, 9]. In case of growing
children, under the age of 8, routine dental visits and follow
ups should be made in order to detect the pathologies associated
with diastema at an early stage [17, 19]. Restorative treatment can
also be considered for mild space closure [20, 6]. Moderate and
severe cases can be treated with a combination of orthodontic
therapy, esthetic restoration and prosthetic restoration in a few
cases.
Orthodontic correction and any other dental treatment are usually
initiated by eliminating the etiology. Knowledge regarding the
various causes can help dentists better understand the problem
and can treat the patient accordingly. The aim of this study was
to assess the various etiological factors involved in the causation
of midline diastema among patients visiting the dental fraternity
for dental and orthodontic consultations. Previously our team has
a rich experience in working on various research projects across
multiple disciplines [21-34]. Now the growing trend in this area
motivated us to pursue this project.
Materials and Methods
A retrospective study was conducted in an institutional setting.
The ethical approval for the study was obtained from the Institutional
Scientific Review Board. Records of patients who visited
the dental facility between June 2019 to April 2020 were collected.
From the available data, further data of all patients with midline
diastema were chosen. Inclusion criteria for the study were patients
of all age groups; patients who were not undergoing any
treatment to correct the diastema. Exclusion criteria were patient
records that were incomplete or repetitive and patients who already
had undergone orthodontic therapy and had a relapse of
the midline diastema. There were three people involved in this
study- the guide, reviewer and researcher. All available data was
collected and sorted. The patients detailed case sheets were analyzed
using the parameters such as age, gender and etiology. Cross
verification of the data was done by the second reviewer in order
to avoid any missing or repetitive data. Further verification was
done with the aid of intraoral photographs and radiographs. The
data was manually retrieved and tabulated in excel after sorting.
Statistical analysis:
The tabulated data were analyzed using SPSS software (IBM SPSS
statistics 26.0). “Chi square test” was used to determine the statistical
significance of the results obtained.
Results & Discussion
The present study was done to assess the various etiologies of
midline diastema.
A total of 41190 patient records were analyzed. 275 patients were
diagnosed with midline diastema, out of which 236 patients had a
relevant etiology for midline diastema. Among those with a specified
etiology 189 patients were male (69.9%) and the remaining 86
were females (30.1%).
The various etiological factors that were found to be associated
with midline diastema were: Generalized spacing due to habits,
high frenum attachment, mesiodens, partially edentulous, peg
laterals, rotation of 11 and 21. 94 patients (39.83%) had a high
frenum attachment that was the most common etiological factor
of midline diastema. The least common cause was due to peg
laterals. (4 patients- 1.69%)(Figure 1).
Majority of the etiologies were seen within the age group of 20-
40 years. 94 patients (39.83%) seemed to have high frenum attachment,
55 patients (23.31%) had generalized spacing due to
habits in their upper and lower arch, 4 patients (1.69%) had peg
laterals and 24 patients (10.17%) were partially edentulous, and 30
patients (12.71%) had rotation in 11 and 21. The age groups with
the least number of etiologies were within 61-75 years. Majority
of the patients in this age group were partially edentulous, as seen
in Figure 4 (p value< 0.05)(Figure 2).
Male patients were seen to have more prevalence of midline
diastema in this study. Both male (26.27%) and female patients
(13.56%) had a higher number of cases with high frenum attachment
as an etiological factor. (p value>0.05).(Figure 3).
The present study assessed the various etiological factors that
affect midline diastema. From the results above, it was evident
that midline diastema is more common in males than in females.
There was a significant difference in the age distribution and it
was more prevalent in the 20-40 years age group. The most common
etiological factor that affects midline diastema is the presence
of a high frenum attachment.
The maxillary midline diastema is a common esthetic problem
that’s faced in both mixed and permanent dentition. The major
causes that can influence its occurrence are genetic, physiological,
high frenum attachment, bony clefts, dental anomalies/tooth
anomalies, etc. It is considered both an esthetic and functional
complication[20]. It is a normal growth characteristic during the
primary and mixed dentition and closes as the canines erupt. For
few patients however, it doesn’t close spontaneously [35].
The etiology of the diastema must be determined through medical/
dental history, proper clinical examination and radiographic
findings. Medical conditions (hormonal imbalance), oral habits,
previous dental treatments, family history of diastema, etc, can be
considered while diagnosing.
Treatment for the closure of midline diastema depends on the
treatment phases of: diagnosis of specific etiology, pretreatment
considerations, treatment of the etiology and long term stability
[35, 36]. No treatment is done in case of physiological/ transient
diastema as they will close when the canines erupt. Pathological
causes such as supernumerary teeth, midline soft tissue abnormalities,
etc can be eliminated with surgical procedures. Orthodontic
intervention in the form of fixed or removable appliances
can be suggested to correct the malocclusion. When considering
the treatment, esthetics, function and speech must be given importance
[37, 38].
Midline diastema can occur both in male and female patients. The
malocclusion is said to have a tendency to happen more in females
than in males. In the present study, it was seen that the
number of patients who were diagnosed with midline diastema
that were males were more than females. 68.7% of the subjects in
the study were males. A similar study done in Nigeria stated that
females were more likely to be diagnosed with midline diastema.
In the study, 58.9% of the patients that were diagnosed were females
(Umanah et al. 2015) [39]. In some countries, artificial midline
diastemas were created with the help of cosmetic dentistry,
following a fashion trend and peer pressure. Moullas et al., [40]
stated in his review that females exhibit a higher tendency to have
midline diastema than males.
In a study conducted by Jeng Fen Liu et al., [41] in 2012 stated the
prevalence of midline diastema decreases with age. Older aged
individuals mostly have midline diastema due to missing teeth and
migration of the remaining teeth.
There are many etiologies for a midline diastema to occur. Some
of the common ones included in the present study were generalized
spacing, high frenum attachment, increased overjet, maxillary
proclination, mesiodens, partially edentulous, peg laterals, rotation of 11 and 21. The most common cause was seen to be
the presence of a high frenum attachment. A similar study done
in 2016 (Israa Elfadel et al) [42] also stated that the most common
cause for a midline diastema was due to a high frenum attachment.
Our institution is passionate about high quality evidence
based research and has excelled in various fields [43-53]. We hope
this study adds to this rich legacy.
Figure 1. Bar graph represents frequency of various etiological factors of midline diastema. X-axis represents the various etiologies of midline diastema and Y-axis represents the number of patients with midline diastema. It is seen that a high frenum attachment causing a midline diastema was the most common etiology, and peg laterals were the least common.
Figure 2. Bar graph represents association between age and etiological factors in midline diastema. X-axis represents the age groups (7-19 years, 20-40 years, 41-60 years and 61-75 years). Y-axis represents the number of patients with midline diastema. Chi-square test was done and was found to be statistically significant [p value- 0.000 (<0.05)]. Maximum prevalence of midline diastema(Blue) was observed in the age group between 20-40 years(blue).
Figure 3. Bar graph represents gender distribution of etiological factors in midline diastema. X-axis represents the gender (Male and Female). Y-axis represents the number of patients with midline diastema. Chi-square test was done and was found to be statistically ( p value- 0.543 (>0.05 - not significant)) The most common etiology was due to a high frenum attachment in and was more common in males (26.27%) than females (13.56%).
Study Limitations
The study was limited to a certain population and had a small
sample size with an unequal number of male and female patients.
The study could focus more on the particular age groups instead
of generalizing it. It could have a larger sample size.
Conclusion
Within the limits of the study, it was seen that the prevalence of
midline diastema was higher in male patients in the 20- 40 year
age group, than in female patients. The most common etiology
in both the gender was found to be due to a high frenum attachment.
Followed by that generalised spacing due to habits was in
male and female patients. In elderly patients mostly the etiology
was partial edentulism with resulting migration of the tooth. The
other etiological factors were peg laterals and mesiodens.
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