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Review Article

Midline diastema
ABSTRACT
Midline diastema is a space between the maxillary and/or mandibular central incisors. Midline diastema can be due
to various causes such as genetic, environmental, and so on. Proper history taking and correct diagnosis of the
etiology of the diastema is essential to ensure that the orthodontic correction is successful, and no future relapse
takes place. The presence of diastema between the central incisors in the adult patient has esthetics and malocclusion
concerns.

Key words: Etiology; midline diastema; stability.

Introduction misguides practitioners to a diagnosis of a diastema caused

by a hypertrophic labial frenum.[6]
Angle described the dental midline diastema as a rather
common form of incomplete occlusion characterized by Enlarged labial frena have been considered to be a
a space between the maxillary and less frequently the contributing factor for a majority of persistent diastemas,
mandibular central incisors.[1] but this has now been attributed only to the small proportion
of cases. Other etiologies related to diastema include oral
Broadbent described the maxillary midline diastema in habits, muscular imbalances, physical obstructions, abnormal
growing children as unaesthetically pleasing and termed maxillary arch structure, and various dental anomalies.[4]
it as the “ugly duckling” stage of dental development.
He considered this stage as a phase which underwent According to Taylor, 98% children 6 years of age presented
spontaneous closure with the complete eruption of lateral with a midline diastema. As age increased, the percentage
incisors and canines.[2] of diastema significantly decreased being 48.7% of children
in the age group of 10–11 years old and 7% in the age group
For some individuals, the diastema does not close of 12–18 years.[7]
spontaneously.[3]
Effective treatment of diastema requires an accurate
The extent and the cause of the diastema must be properly diagnosis of its etiology and a treatment plan that is related
evaluated. Proper case selection, appropriate treatment to that specific etiology, including medical and dental
selection, adequate patient cooperation, and good oral
hygiene are crucial to the treatment success.[4]
Ketaki Kamath M, Arun AV
Clinical diagnosis is important and should compulsorily Department of Orthodontics, Saveetha Dental College,
include a radiographic examination. During the “ugly Chennai, Tamil Nadu, India

duckling” phase, the long axes of the roots of the maxillary Address for correspondence: Ketaki Kamath M,
central and lateral incisors converge toward[5] and which often D5, Sneha Sadan, #3 Karpagam Avenue,
Chennai ‑ 600 028, Tamil Nadu, India.
E‑mail: ketaki.kamath@gmail.com
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DOI:
10.4103/2349-5243.192532 How to cite this article: Kamath MK, Arun AV. Midline diastema. Int J
Orthod Rehabil 2016;7:101-4.

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Kamath and Arun: Midline diastema - A Review

histories, radiographic and clinical examinations and probably between frenum attachment and diastema width, between
tooth‑size evaluations.[4] frenum width and diastema, or between frenum height and
frenum width. Dewel established the same results in a similar
Etiology and Effective Treatment Options study.[21]

Timing of the treatment is important to achieve satisfactory The blanching test is a simple investigative assessment to
results. Most of the researchers do not advise tooth predict whether a normal tight contact is a present between
movement until the eruption of the permanent canines.[8] the central incisors.[22]
However, in selected cases, where very large diastemas exist,
early treatment can be contemplated. Peg Laterals

Genetics Bolton discrepancy (tooth‑size discrepancy) is an alternative

cause of midline diastema regularly reported in the literature.
“Heritability” is defined as the ratio of the total genotypic Bishara,[23] Becker,[24] and Oesterle and Shellhart[25] termed
diversity to the total phenotypic diversity with values ranging tooth‑size discrepancy as one of the main causes for maxillary
from 0 to 1.[9] midline diastema. According to them, the presence of
peg‑shaped lateral incisors results in distal tipping of central
Gass et al. noted that heritability of midline diastema was 0.32% incisors, hence producing the midline diastema.[23‑25]
for the white population and 0.04% for the black population.[10]
Midline diastema caused due to peg laterals can be closed,
Incomplete palatal fusion and cystic formations have been and the space required for restoration of the peg‑shaped
attributed to the cause of midline diastema.[11] lateral can be obtained by moving the peg lateral into position
between the central incisor and the cuspid.[26,27]
Many other authors like Gardiner[12] and Schmitt et  al.[13]
suggested that genetics could be a cause for midline diastema. Anterior Traumatic Bite

Hypertrophic Labial Frenum Excessive anterior overbite is another chief causative factor
for midline diastema.[28] Trauma to the maxillary anteriors
The most common factor associated with maxillary midline from the mandibular incisors causes the maxillary incisors
diastema is a hypertrophic labial frenum.[14,15] to procline resulting in an increase in the upper arch
circumference, leading to diastema.
A maxillary midline diastema may be caused by the attachment
of the labial frenum into the notch in the alveolar bone so that When there is no Bolton discrepancy and the patient has an
a band of heavy fibrous tissue lies between the central incisors. Angle’s Class I occlusion, an increase in the anterior overbite
[15]
The two central incisors may erupt widely parted from one outcome will either increase the upper arch circumference
another, and the rim of bone surrounding each tooth may leading to diastema or anterior mandibular crowding. This
not extend till the median suture. In such cases, bone is not occurrence is due to the wedge‑shaped lingual surface of
deposited inferior to the frenum. A V‑shaped bony cleft exists upper central incisors.[28] Excessive anterior overbite can be
between the two central incisors, and an “abnormal” frenum due to a disproportionate vertical alveolar growth of the
attachment typically results.[16] Transseptal fibers fail to multiply mandibular or the maxillary incisors, the insufficient vertical
across the midline cleft, and space might never close.[17] dimension of posterior occlusion (molars) and skeletal
conditions such as augmented ramal height.[28]
According to Angle,[18] the maxillary midline diastema is
caused by a high labial frenum, but the stability of space Oral Habits
closure is not influenced by frenum excision. Sicher[19] and
Gardiner[12] also supported this view. Finger sucking and/or abnormal tongue movement may result
in interincisal spacing.
This was contradicted by Tait who stated that high frenum
is an effect and not a cause for the incidence of diastema.[20] According to Proffit and Fields,[29] tongue position at rest may
have a bigger impact on tooth position compared to tongue
Ceremello compared the frena of two groups, one with pressure, as the tongue only temporarily contacts the lingual
diastemas and the other without.[18] He found no association surface of the anterior teeth while thrusting. The tongue
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Kamath and Arun: Midline diastema - A Review

pushes the anterior teeth to a forward position, increasing Diagnosis and Treatment
the circumference which results in spacing.
Because of the likelihood for multiple etiologies, the
Supernumerary Teeth diagnosis of a diastema must be founded on systematic
medical/dental history, clinical inspection, and radiographic
A mesiodens is a supernumerary tooth which occurs in assessment. A nominal diastema treatment requires the
the midline between the two maxillary central incisors.[30] precise diagnosis of its etiology and a medication that is
A mesiodens accounts for 80% of all supernumerary teeth. appropriate to that specific etiology including medical and
dental histories, radiographic and clinical examinations and
The presence of a mesiodens can inhibit the close also tooth‑size evaluations.[4] Diagnostic study models also
approximation of the central incisors resulting in a midline may be essential for analysis.
diastema and can also give way to several other complications
such as impaction, delayed and ectopic eruption of adjacent The treatment objectives are principally attributed to esthetic
teeth, crowding, axial rotation, displacement, radicular and psychological reasons rather than functional reasons.
resorption of adjacent teeth, and dentigerous cyst.[31] Although it is frequently the case, treatment plan should
not be selected empirically but should rather be based on
Russel and Folwarczna have recommended the extraction of adequate scientific documentation. The ideal treatment
a mesiodens in the early mixed dentition period. According should deal not only with the diastema but also with the cause
to them, this will aid in improved alignment of teeth of the diastema. Regardless of the selected treatment, of the
and will also minimize the requirement for orthodontic stability of treatment results has always been deliberated.[39]
treatment.[32] However, some authors such as Mitchell and
Bennett prefer the late extraction of mesiodens when Various techniques can be used for diastema closure. Some
the adjacent permanent incisors have finished their root of the methods that have been proposed for the closure of
formation.[33] unaesthetic diastemas involve the usage of fixed or removable
appliances, elastics, composite build‑ups and brass wires
Developmental cysts in the orofacial midline placed around the central incisors and gradually tightened
An odontogenic keratocyst can develop in the maxilla and can until the diastema is closed.[40]
dislodge teeth, leading to spacing in the anterior region.[34]
A median palatal cyst is another midline structure which is Stability after diastema closure
a rare cyst commencing from the epithelium trapped along Relapse is a major factor to be considered in the treatment
the line of fusion of the lateral palatal maxillary process of midline diastema. Meticulous diagnosis and elimination of
during growth.[35,36] the etiology is the key to gaining a stable result. Long‑term
use of retainers or the use of permanent bonded lingual
Abnormal maxillary arch structure retainers have been encouraged, especially in cases with
Tooth size discrepancies are caused by disproportionately large large diastema.[41‑44] Large pretreatment diastema and the
maxillary arch or bony defects that impede approximation of existence of at least one family member with a related
the incisors.[4] The presence of large jaws and normal or small condition increases the risk of relapse.[45]
teeth can be attributed to inherited characteristics. However,
in a few cases, it can be due to endocrine imbalances. Conclusion
Conditions such as acromegaly can cause unusually large jaws
comparative to the teeth size. Normal‑sized jaws and small Considering the different views related to uneventful dental
teeth can also result in generalized spacing.[37] development, it is concluded that an initial presence of
midline diastema is not a matter of concern. However, when
Muscular imbalances in the oral region the diastema is larger than 2.7 mm even after the eruption of
The dentition is in equilibrium between the various forces lateral incisors, orthodontic intervention may be necessary.
from the intraoral and extraoral soft tissues. The muscular Timing often is significant to achieve satisfactory results.
imbalance in the oral region can disrupt this balance and Several etiological factors are conveyed and debated in
cause the teeth to move until the forces achieve a new literature, and no single etiological factor is decided upon
equilibrium. In patients with hypotonic lips, the teeth may for the development of a midline diastema. Elimination of the
drift and remain in a labial or buccal position owing to the etiologic agent usually can be commenced on diagnosis and
tongue pressure which leads to wide, ovoid arches deprived after the adequate development of the central incisors. Tooth
of interproximal teeth contact.[38] movement usually is postponed until the eruption of the
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Kamath and Arun: Midline diastema - A Review

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their relation to growth and development of the oral structures. Am J
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22. Koora K, Muthu MS, Rathna PV. Spontaneous closure of midline
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