Article Type: Case Report
Received : 14/11/2018
Accepted : 16/11/2018
Published : 21/11/2018
*Correspondence to: Mediha BÜYÜKGÖZE DİNDAR, Department of Restorative Dentistry, Trakya University Faculty of Dentistry, Edirne,
Article Type: Case Report
Received : 14/11/2018
Accepted : 16/11/2018
Published : 21/11/2018
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.
Key words: Diastema, Direct Composite Laminate Veneer, Hypertrophic Frenum
The spaces between the teeth are called diastema.According to Keen, diastema is defined as the presence of more than 0.5 mm space between proximal surfaces of adjacent teeth. The presence of diastemas during primary and mixed dentition is natural; these spaces are usually closed by lateral and canine eruption. 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. 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. Diastema prevalence in adults has been reported to vary from 1.6% to 25.4% in various studies. 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. In a study, the incidence of diastema in men (40%) was higher than in women (16%).
The etiology of diastemas is multifactorial. In a study in which the frequency of diastemas were investigated; the most common etiological factors; inappropriate fusion of premaxilla(32.9%) and hypertrophic frenulum (24.4%) were reported. 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. 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. 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. 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 which the diastema is closed after application of frenectomy alone in children, in adults, orthodontic, restorative or prosthetic treatment is required after frenectomy.Physical, psychological and economic restrictions should be taken into consideration when selecting appropriate treatment modalities and materials. 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.
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.
After the periodontology consultation and due to the papillary tip becoming ischemic and mobile by tension test, it was decided that 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.
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.
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 veneers completed with a composite resin (Charisma Smart A2, Heraeus Kulzer, Germany). The patient was given oral hygiene training and called for a 6-month 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.
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. 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. 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. 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. 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. 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.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, they are not preferred in this case because of their cost, requirement of sensitive laboratory and cementation procedures. 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. Due to the high discoloration and wear of the direct composite laminate veneers compared to the other restorations, 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.
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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