A Unique Approach for the Closure of Midline Diastema Following Orthodontic and Frenectomy Procedures

ABSTRACT

Midline diastema that occurs as a spacing between the upper central Incisors, most commonly seen in pediatric population, during mixed and early permanent dentition phases. At around 9-11 years of age, midline diastema is a normal occurrence as seen in the ugly duckling stage of development. No treatment is needed in such cases, as diastema closes after the eruption of permanent maxillary canines. However in some individuals, the diastema closure does not occur spontaneously leading to a necessary intervention.When diastema occurs due to other pathologies,they lose several problems in relation to esthetics and speech in a growing child.Interceptive treatment modalities in mixed dentition phase prevent the uptake of other invasive and long term Orthodontic modalities. Various treatment options available for management of midline diastema are Orthodontic corrections, use of interceptive appliance, extraction of supernumeraries, surgical correction of impeding factors,use of direct composite resin and use of habit breaking appliance.Proper diagnosis of the diastema,unfolding its etilogy helps in devising an adequate treatment plan.Here I have presented a unique approach for the closure of midline diastema following Orthodontic and Frenectomy procedures.

CASE REPORT

A 19 yr old, male patient reported with the chief complaint of spacing between the upper anterior teeth presenting a large diastema between the upper central Incisors affecting the smile and complete esthetics of the patient.

CLINICAL EXAMINATION

1. Pernicious Oral Habits(Tongue thrusting,MouthBreathing)
2. Soft Tissue Imbalance
3. Improper Dental Alignment (Excessive Overjet/Overbite ,Rotated Teeth)
4. Curve of Spee
5. Missing teeth or other Dental Anomalies
6. Blanching Test to detect Frenal Attachments
7. Pathological Iatrogenic Factors
a. Mesiodens
b. Cystic Lesions
i. Radicular Cyst
ii. Globule maxillary cyst
c. Advance Periodontitis -to rule out pathological tooth migration

IN THE PRESENTED CASE

• Midline Diastema was found with high frenal attachment with thick and wide labial frenum, clinically seen as papillary penetrating type, where the frenal attachment crossed the alveolar bone and extended into the palatal papilla.
• This was further confirmed by a positive blanch test(blanching of tissue due to ischemia at the site)and was the major causative factor leading to the midline spacing in the patient.

Upper right Central Incisor (tooth 11), upper right lateral incisor (tooth 12), upper left Central Incisor (tooth 21), upper left lateral incisor (tooth 22)showed labial flaring.

The treatment plan of the presented case was decided two steps-

ORTHODONTIC TREATMENT

In such a case the Treatment option for successful restoration of such teeth to patients satisfaction is
a. Mesial tipping movement of Incisors
b. Mesial bodily approximation of Incisors
c. Treatment involving the decrease of an enlarged overjet
d. Closing the space as part of more comprehensive Orthodontics that includes the teeth alignment between the upper incisors reducing the space between the upper anteriors.Creating a good tooth to tooth proportion that would minimises the diastema space between the upper central Incisors.

Frenectomy

The Frenectomy procedure was decided to be performed after alignment of the flared upper anteriors to simplify the space closure later with the ongoing Orthodontic Treatment. Labial Frenectomy performed after anterior teeth alignment, since diastema closure and interdental papilla compression may act as a stimulus to promote atrophy of the fibrous tissues imposed between incisors.

LABIAL FRENECTOMY

Frena are mucosal folds that attach the lips or the cheeks to the alveolar mucosa, gingiva,or underlying periosteum.
Frenectomy is defined as complete elimination of the frenum and it’s attachment.
Four types of frenal attachments-
1. Mucosal,where the frenal attachments extend anteriorly to the mucogingival junction
2. Gingival,where the frenal attachments enter the attached gingiva
3. Papillary,where the frenal attachments extend into the papilla
4. Papillary penetrating,where the frenal attachments cross the alveolar bone and extend to the palatal papilla

TREATMENT METHODS

1. V- Y Plasty
2. Z-plasty
3. Vestibular sulcus extension
4. Miller’s technique
5. Laser Frenectomy
Now proceeding with the treatment procedure-

ORTHODONTIC TREATMENT

• To begin,MBT Metal brackets with metal slots was bonded with low load deflection arch wire 0.014 NiTi , with O rings,to achieve alignment and level the arches.
• Followed by the activation procedure once in every 4 weeks
• Check for co-incident midline
• Molar and canine relation
• Curve of spee
• Future, SS wire with power chains are given subsequently after Frenectomy to eliminate the space between the central Incisors

FRENECTOMY WITH LASER

Procedure-

• The labial frenum was first sprayed with topical anesthesia followed by infiltration of local anesthtic solution (2 % lignocaine with 1:100000 epinephrine, LOX 2%, in the soft tissue surrounding the frenum.
• The laser was activated before performing the procedure.The fibre tip was activated by placing and slowly running the laser tip on a articulating paper or any newspaper.The fibre tip is initiated by blocking the light energy with the ink of articulating paper or the ink on the newspaper,hence the tip becomes a hot glass rod and works by vaporising the tissue in direct contact with the fibre tip.
• Fibre tip of 400 micrometer was used with power of 3W and was applied in contact mode.

• The laser tip was held straight and perpendicular on the operating area, keeping it in contact with the frenal mucosa,the incision was started with the frenum from the attached gingiva then extending into the interdental papilla on the labial surface between the central Incisors,crossing the alveolar bone to the palatal surface on the palatal papilla.
• Now extending upward,from inner side of upper lip to the depth of vestibule ending in a rhomboidal area causing the separation of fibres.Slow superficial horizontally movements were made opening the entire frenum
• The border of the opened frenal layer attached to the surrounding soft tissue is removed in order to avoid regrowth
• Pressure with gauze was given to avoid any bleeding and the surface was further cleaned with saline and betakind solution.Hemostasis was optimal and no sutures were given.
• Evion capsule was punctured and the oil was applied on the treated area

Post-operative Instructions to the patient –
1. Patient should take post operative analgesics if required
2. Patient should apply the oil of the Evion capsule 3times a day on the treated area for 7days
3. Patient should not take hot and spicy food for 7days
4. Patient should not consume alcohol for 7days
5. Patient should maintain proper oral hygiene and meticulously follow the oral hygiene instructions given by the dentist.
Picture taken after one month post Frenectomy Procedure.Complete healing of the surgical site is noted with normal mucosal type of frenal attachment.

The patient had no intraoperative complication such as pain, swelling, bleeding or any kind of edema post Frenectomy Surgery. Advantages of using lasers over other methods for Frenectomy
1. Use of lasers,has been reported as safe and effective procedure with advantage of shorter duration of surgery
2. Simple and less time consuming
3. Treatment is precise, less invasive, very conservative, preserving the healthy tissue while treating the infected/affected site.
4. Reduced post-operative discomfort or complications
5. Lesser pain and swelling
6. Minimal bleeding
7. Presence of a small or no scar
8. No antibiotics or suturing required
9. Requires minimal patient compliance
The Laser used during the procedure was IMDSL 7Watt Dental Diode Laser, portable, user friendly and the most stable Laser with super pulse technology that provides 980 nm wavelength having 8 – 10 higher absorption efficiency in oral tissues that gives a maximum output power as 7watt with 10,000Hz frequency hence are becoming increasingly popular and can be widely used in our daily dental practice.
Diode lasers are less invasive, that results in reduced post-operative complications or edema related to conventional treatment.The Laser works to enhance photobiologic effect.It works under four interactions

• Absorption
• Transmission
• Scattering and
• Reflection

As the Laser cuts or vaporises soft tissue,which is called ablation,it coagulates the tissue and hence becomes a bloodless procedure.The bactericides effect of the Laser energy along with the hemostatic control attained at the Laser sight,minimises the risk of infection and the need of sutures and antibiotics.Allowing faster healing,minimises inflammatory response with less postoperative discomfort.