Journal of Dentistry Oral Health and Preventive

Measures

Case Report

Closure of The Midline Diastema With Direct Composite

Resin Restorations After Frenectomy: Case Report And 1
Year Follow-Up
Mediha Büyükgöze Dindar1*, Ece AÇIKGÖZ2 and Meltem TEKBAŞ ATAY1
Trakya University Faculty of Dentistry, Department of Restorative Dentistry, Edirne
1

Trakya University Faculty of Dentistry, Department of Periodontology, Edirne

2

Abstract
Objective: In this case report, the aesthetic treatment approach to the 25-year-old female patient who has anterior diastemas due to hypertrophic maxillary labial
frenum and one year follow-up is reported.
Case: A 25-year-old woman applied to our clinic with aesthetic complaints due to opaque stains and gaps between her upper anterior teeth. The clinical and
radiographic examinations revealed that the midline diastema due to hypertrophic maxillary labial frenum and enamel hypoplasia were present in the upper central
incisor teeth. The patient who did not have any systemic disease, undergo frenectomy and crown-lengthening procedure in the periodontology department. At
the end of the two-week recovery period, the patient was planned to perform direct aesthetic restorations in the upper anterior incisors for a short-term and cheap
treatment option. After the tooth surfaces were cleaned with a polishing brush, the hypoplasic areas in teeth 11 and 21 were removed and included in the restorations.
Restoration surfaces were applied by self-etch adhesive (Optibond All-in-one, Kerr, Italy), and direct composite resin restorations (Charisma Smart A2, Heraeus
Kulzer, Germany) were completed. The patient was given oral hygiene and periodical follow-up appointments for 6 months were planned.
Conclusion: Direct composite resin restorations are effective, fast and low cost treatment option for the closure of the diastemas in the anterior teeth with aesthetic
problems.

Introduction factors; inappropriate fusion of premaxilla(32.9%) and hypertrophic

The spaces between the teeth are called diastema [1]. According
to Keen, diastema is defined as the presence of more than 0.5 mm
space between proximal surfaces of adjacent teeth [2]. The presence of
diastemas during primary and mixed dentition is natural; these spaces
are usually closed by lateral and canine eruption [3]. However, in
some cases, diastemas do not close spontaneously, and this may cause
aesthetic, psychological and functional disorders. Diastema almost
always creates an unpleasant appearance in patients and, depending
on the width of the diastema, it affects the speech, especially the
pronunciation of the ‘S’ sound.
Diastemas are more common in the median plane of the maxilla
and are therefore called median or midline diastema [4]. The incidence
of midline diastema according to the Keene is 14.8% in maxilla, 1.6% in
mandible, while according to Al-Rubayee is 22.5% in maxilla and 2.3%
in mandible [2,5]. The frequency of diastema may vary according to
race and age. Diastema is present in almost all of the six-year-olds (97-
98%), and the frequency of diastema decreases with age [6]. Diastema
prevalence in adults has been reported to vary from 1.6% to 25.4% in
various studies [7]. It is also possible that the frequency of midline
diastema depends on gender. There are studies reported that at the
age of 14, the frequency of mid-line diastemas is higher in boys than
in females [3]. In a study, the incidence of diastema in men (40%) was
higher than in women (16%) [5].
The etiology of diastemas is multifactorial. In a study in which the
frequency of diastemas were investigated; the most common etiological
frenulum (24.4%) were reported [8]. Microdontia, presence of
mesiodens, peg-shaped lateral, lateral incisor agenesis, presence of
cyst in the midline, dental and skeletal anomalies, muscle deficiencies,
finger sucking, tongue thrusting or lip sucking habits, bolton tooth-
jaw incompatibility are among the factors that can cause diastema
[9]. In addition, periodontitis, trauma, congenital tooth deficiencies,
hormonal diseases such as acromegaly can also cause diastemas.
Another etiological factor of diastemas is genetic. Some researchers
have suggested that midline diastemas have autosomal dominant
inheritance [10]. Although no specific gene for genetic etiogenesis
has been found, there are many syndromes and congenital anomalies
that cause midline diastema; Ellis-van Creveld syndrome, like Pai
Syndrome etc [11,12].
Frenum is a mucosal fold that connects the lips and cheeks to
the alveolar mucosa, gingiva and underlying periosteum [13]. A
hypertrophic labial frenum may cause patients have difficulties to
achieve oral hygiene thereby cause periodontal problems. The treatment
of hypertrophic frenulum is excision. Although there are cases in
*Correspondence to: Mediha BÜYÜKGÖZE DİNDAR, Department of
Restorative Dentistry, Trakya University Faculty of Dentistry, Edirne, E-mail:
medihabuyukgoze@trakya.edu.tr
Received: November 14, 2018; Accepted: November 16, 2018; Published:
November 21, 2018
Key words: Diastema, Direct Composite Laminate Veneer, Hypertrophic Frenum

Journal of Dentistry Oral Health and Preventive Measures, 2018 Volume 1(1): 1-4
 Dindar MB (2018) Closure of The Midline Diastema With Direct Composite Resin Restorations After Frenectomy: Case Report And 1 Year Follow-Up

which the diastema is closed after application of frenectomy alone in

children, in adults, orthodontic, restorative or prosthetic treatment is
required after frenectomy [6]. Physical, psychological and economic
restrictions should be taken into consideration when selecting
appropriate treatment modalities and materials [14]. Application of
direct composite laminate veneers in diastema closure cases is cheap,
aesthetic and conservative.
In this case report, the aesthetic treatment approach to the 25-year-
old female patient who has anterior diastemas due to hypertrophic
maxillary labial frenum and a one year follow-up is reported.
Figure 3: Frenectomy and crown-lengthening procedure.
Case Report
As a result of clinical and radiographic examinations of a 25-year-
old woman applied to our clinic with aesthetic complaints due to gaps
between the upper anterior teeth and opaque stains, midline diastemas
and enamel hypoplasia were found in the upper central incisor teeth.

Figure 4: At the end of the two-week recovery period.

After the tooth surfaces were cleaned with a polishing brush, the
hypoplasic areas in teeth 11 and 21 were removed and included in the
restorations. Restoration surfaces were applied by self-etch adhesive
(Optibond All-in-one, Kerr, Italy) and direct composite laminate
Figure 1: Facial view of initial status
veneers completed with a composite resin (Charisma Smart A2,
After the periodontology consultation and due to the papillary Heraeus Kulzer, Germany). The patient was given oral hygiene training
tip becoming ischemic and mobile by tension test, it was decided that and called for a 6-month follow-up.
the midline diastemas were caused by hypertrophic maxillary labial
frenum. Due to the large diastema, in order to achieve the aesthetics
when the size of the central incisors were enlarged after restoration, it
was decided to enlarge the dimensions of the lateral incisors with the
crown-lengthening procedure.

Figure 5: Ater rubber-dam application and restoration.

Figure 2: Ischemic papillary tip.

The patient who did not have any systemic disease, underwent
frenectomy and crown-lengthening procedure in the periodontology
clinic. At the end of the two-week recovery period, aesthetic
restorations were planned in the upper anterior teeth of the patient
who did not want orthodontic treatment and demanded a short-term
and inexpensive treatment option. Figure 6: After restoration

Journal of Dentistry Oral Health and Preventive Measures, 2018 Volume 1(1): 2-4
 Dindar MB (2018) Closure of The Midline Diastema With Direct Composite Resin Restorations After Frenectomy: Case Report And 1 Year Follow-Up
In 6 months and 1 year follow-up of the patient’s restoration, the
wear and coloration was observed to be clinically acceptable. Patient
satisfaction is very high and the restoration is still being followed.
Figure 7: 6 month follow-up.
Figure 8: 1 year follow-up.
Discussion
The midline diastemas may be transient or may occur by
developmental, pathological or iatrogenic factors such as mesiodens,
microdontia, hypodontia, abnormal oral habits. For diagnosis of
diastema due to the potential for multiple etiologies; comprehensive
medical / dental history, clinical examination and radiographic
research should be performed [15]. Once the source of diastema has
been found, a treatment plan for the cause should be made.
One of the most common causes of maxillary midline diastema is
hypertrophic labial frenum as in our case. Tension and Blanche tests are
used in the diagnosis of hypertrophic labial frenum. Papillary activity
during lip stretching (Tension test) and / or the occurrence of ischemic
area at the tip of the papilla (Blanche Test),indicate the presence
of hypertrophic frenum [16]. According to Miller, if the frenum is
unusually wide, if there is insufficient amount of attached gingiva at
the midline and if the interdental papilla is moving when the frenum
is stretched, it should be evaluated as pathological [17]. However, it is
sometimes difficult to assess the borderline cases.
When hypertrophic maxillary labial frenum is detected, frenectomy
should be performed for aesthetic, psychological and functional
reasons [18]. There are different treatment options for diastema closure
after frenectomy. Orthodontic or restorative treatment can be applied
to diastemas.
Diastemas can be treated by removable or fixed orthodontic
treatment. In the permanent dentition, when the diastema is less
than 2 mm, it can be successfully treated with removable orthodontic
appliances. In most cases where diastema is greater than 2 mm, more
complex treatment is needed with fixed orthodontic appliances [19].
Journal of Dentistry Oral Health and Preventive Measures, 2018
Orthodontic treatment is an expensive, long-term treatment option
and there is a risk of relapse [7,20]. In the cases where diastema is larger
than 2 mm, the risk of relapse is increased and in the literature, relapse
is reported in almost 50% of the closed diastemas [20,21].
Restorative closure of diastemas can be accomplished with metal
ceramic crowns, full ceramic crowns, porcelain laminate veneers,
indirect composite laminate veneers or direct composite laminate
veneers [22]. Metal-ceramic crowns are not preferred in the anterior
region because they are not aesthetic enough. Full ceramic crowns are
more aesthetic than metal ceramic crowns, but due to the high amount
of tissue loss during the preparation, in this case it is not preferred.
Today, porcelain or composite laminate veneers are mostly
preferred in diastema closure in the anterior region. Although porcelain
laminate veneers are highly aesthetic and resistant to abrasion [23],
they are not preferred in this case because of their cost, requirement
of sensitive laboratory and cementation procedures [24]. In addition,
a small amount of tissue loss occurs because they require preparation.
Indirect laminate veneers were not suitable for this case because they
require laboratory procedures and increased number of sessions
[25,26].
Direct composite laminate veneers, which are the most conservative
approach to correct the tooth shape, can be applied without preperation
and are preferred in this case because of their aesthetic, low cost and
only one session requirement [27]. Due to the high discoloration and
wear of the direct composite laminate veneers compared to the other
restorations [28], the patient was called for follow-up every 6 months.
After 1 year offollow-up, clinically acceptable coloration and wear were
observed in the restorations. Further studies are needed in long-term
follow-up of direct composite laminate veneer restorations.
Conclusıon
Direct composite resin restorations are effective, fast and low cost
treatment option for the closure of the diastemas in the anterior teeth
with aesthetic problems after frenectomy.
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