Midline diastema and its aetiology--a review

Associations between maxillary labial frenum Morphology, Attachment, and Patient-Related clinical factors in Saudi Arabian Adults: Cross-sectional study

Objective

This study investigated the prevalence of maxillary labial frenum morphologies and attachment types and their associations with various patient-related clinical variables in a population of Saudi Arabian adults.

Methods

This study comprehensively examined 100 participants of both genders to categorize frenum types and attachment sites. The following clinical variables were recorded: probing depth, clinical attachment loss, attached gingiva width, overjet, overbite, diastema width, central incisor condition, occlusion, previous orthodontic treatment, and the incidence of gummy smile.

Results

The mean age was 32.6 years, and the average diastema width was 0.23 mm. The study found that the simple frenum type was the most common morphology (57 %), and gingival attachment was the most frequent attachment type (54 %). Simple frenum was significantly associated with class I occlusion (p = 0.018), and frenum with nichum was significantly associated with class II occlusion (p = 0.019). Females were more likely to exhibit simple frenum with nodule frenum than males (p = 0.042). Mucosal frenum attachment was significantly correlated with the absence of previous orthodontic treatment (p = 0.042).

Conclusion

The study identified a relationship between the features of the maxillary labial frenum and occlusion as well as previous orthodontic treatment. Our findings suggest that understanding each patient's unique frenum features can lead to more effective and personalized dental care, thus improving patient satisfaction.

Comparison of pleasant and unpleasant smile characteristics in the perception of the laypeople in an Iranian population

INTRODUCTION

This study aimed to compare the characteristics of pleasant and unpleasant smiles from the perception of laypeople.

METHODS

Two-hundred posed smile photographs were obtained from adult participants with no anomaly, restoration, or severe crowding and spacing in anterior teeth. Photographs were shown to 26 judges to give each photograph a score for attractiveness. Upper and lower quartiles for the most and least rated smiles were determined, and variables including gingival display, smile arc, midline deviation, buccal corridor, smile width, tooth rotation or malposition, diastema, upper and lower vermilion show, and tooth form were measured. Independent-sample t test and Pearson chi-square analysis were used to determine the differences between the pleasant and unpleasant groups for quantitative and qualitative variables, respectively. The linear regression model revealed variables with the most significant impact on the mean score.

RESULTS

All quantitative and qualitative variables except tooth form significantly differed between pleasant and unpleasant smile groups (P <0.05). The consonant smile arc was associated with an increase of 12.59% in mean scores compared with the inconsonant smile arc. Each tooth reported with malposition was correlated with a decrease of 9.37% in the scores. In the same way, each 1-mm increase in midline diastema and occlusal cant coincided with a drop of 8.73% and 3.59% in scores, respectively.

CONCLUSIONS

The results of this study suggested that smile arc, tooth malposition, midline diastema, and occlusal plane canting had the most impact on smile esthetics and should be given priority by orthodontists in the treatment plan of choice.

Associations among the occurrence or types of maxillary canine impaction, labial frenum attachment types, lateral incisor anomalies, and midline diastema in patients with and without impaction: A case-control study

INTRODUCTION

We tested whether the labial frenum attachment types may affect the occurrence or type of maxillary canine impaction.

METHODS

This case-control study was performed on 96 subjects (48 with maxillary canine impaction [20.50±4.99 years, 32 females], 48 controls [21.94±3.79, 31 females]). Types of canine impaction (buccal/palatal, bilateral/unilateral, left/right), types of upper lip middle frenums (mucosal, gingival, papillary), the anatomy of lateral incisors (impacted, peg shaped, small, normal), and the midline diastema were evaluated clinically and radiographically. Associations were examined using multiple binary logistic regression, 3-way repeated-measures ANCOVA, and Fisher tests (α=0.05, β=0.2).

RESULTS

The numbers of mucosal, gingival, and papillary frenums in the case group were '29, 14, and 5', respectively; in the control group, they were '25, 21, and 2' (Fisher, P=0.248). The numbers of mucosal, gingival, and papillary frenums were respectively '25, 11, and 1' in the palatally impacted canine subgroup; they were '4, 3, and 4' in the buccally impacted subgroup (Fisher, P=0.010). Abnormal laterals were present in 12 cases and 4 controls; normal laterals were observed in 36 cases and 44 controls (Fisher, P=0.053). Abnormal laterals were seen in 10 cases with palatally impacted canines and 2 cases with buccally impacted canines; normal laterals existed in 27 cases with palatally impacted canines and 9 cases with buccally impacted canines (Fisher, P=0.705). Lateral anatomy was not associated with frenum attachment (Fisher, P=0.827). Greater midline diastemas were seen in cases with maxillary canine impaction, papillary frenums, and abnormal laterals (ANCOVA, P≤0.016).

CONCLUSIONS

Buccal type of canine impaction is positively associated with papillary labial frenums. Canine impaction is 3.6 folds more prevalent in cases with lateral abnormality. Midline diastema is positively and independently associated with canine impaction, papillary frenums, and abnormal laterals.

Comparative frenectomy with conventional scalpel and dual-waved laser in labial frenulum

Aim

The purpose of the study is to compare the labial frenectomy between the laser surgery (erbium yttrium aluminum garnet and neodymium-doped yttrium aluminum garnet (Er:YAG and Nd:YAG)) and the scalpel method.

Methods

The trial was a randomized controlled test. Thirty four patients aged from 5 to 10 years requiring the frenectomy were included in this study. Patients were randomly divided into two groups: group A: Er:YAG and Nd:YAG laser group and group B: scalpel group. In addition, this comparison considered the following factors: surgical time and Visual Analog Scale (VAS) pain score, which includes intraoperative pain, postoperative pain and complications, such as speaking and chewing, for 1 day and 7 days following labial frenectomy. After 3 months, we recorded the healing outcome by photos.

Results

There was a statistically significant difference in mean surgical time between laser surgery (mean=224±59 s) and scalpel surgery (mean=740±168 s). According to VAS scores of the intraoperative period (3 hours after the operation and 1st postoperative day of pain), chewing and speaking were statistically higher in group B than those in group A; but in the 7th postoperative day of pain, there was no significant difference in speaking and chewing. After 1 month, all of the patient results were recorded, including the healing of wound and scar. Except for one patient in group B who had a scar, all patients achieved good results.

Conclusion

Based on the results of this study, it can be concluded that Nd:YAG laser is an efficient and more comfortable alternative to the scalpel for a frenectomy in upper lip frenulum.

An interdisciplinary approach to management of diastemas: A novel classification and a case report

Diastema between the teeth negatively affects the patients' smile, psychology and daily activities by creating a disharmony in the patients' face. The development of diastema has been attributed to several factors such as labial frenulum, microdontia, mesiodens, peg-shaped lateral incisors, agenesis, cysts, habits such as finger sucking, tongue thrusting, or lip sucking, dental malformations, genetics, proclinations, dental-skeletal discrepancies, and imperfect coalescence of interdental septum. Patients often present with complex problems that require a multidisciplinary treatment approach which includes determination of the aetiological factors, soft tissue morphology, occlusion, patient demands and aesthetic consideration to achieve satisfactory outcomes. Lack of current literature on classification of diastemas and multi-disciplinary approach of management led to the proposal of a new classification the ATAC (Anatomic and Therapeutic Classification) for management of the diastema. This case report highlights the use of the proposed classification for management of diastemas, requiring a perio-restorative intervention using a Chu's proportion gauge to achieve ideal aesthetics.

Effect of maxillary median diastema on the esthetics of a smile

INTRODUCTION

With the increasing demand for facial esthetics, patients' expectations regarding dental treatment have increased. The treatment of maxillary median diastemas (MMDs) stands out as one of the most noticeable esthetic alterations performed on patients. The objectives of the present article were to evaluate the effects of MMD and its restorations on the esthetics of a smile and to determine the differences in esthetic perceptions among 3 different groups of patients: orthodontists, prosthodontists, and laypeople.

METHODS

Printed photographic images were randomly arranged in an album that contained the original photograph of the smile, 8 photographs with digitally created diastemas (0.5 mm, 1.0 mm, 1.5 mm, 2.0 mm, 2.5 mm, 3.0 mm, 4.0 mm, and 5.0 mm), and 8 with simulated restorations of these spaces. Each evaluator assigned scores to the images using a 100-mm visual analogue scale.

RESULTS

Orthodontists, prosthodontists, and laypeople presented similar perceptions regarding the levels of attractiveness of the original smiles and those of smiles involving restorations of diastemas with widths of 0.5 mm and 1.0 mm. The ratings assigned to the smiles with diastemas differed significantly from those of the corresponding restored smile with the same magnitude of diastema.

CONCLUSIONS

The prosthetic space closure of diastemas is better than leaving the space untreated. Restorations of MMD up to 1 mm perform similar to orthodontic closure. Larger MMDs are ideally treated with orthodontics because the restorative treatment is more invasive, leading to incremental damage to the dental tissues.

Evaluation of the distance between the central teeth after frenectomy: a randomized clinical study

Purpose:

The present study aimed to evaluate the periodontal status and the distance between the teeth one year after frenectomy in patients with abnormal frenums in the maxillary and mandibular midline.

Materials and methods:

This study included 50 patients (24 men and 26 women) between the ages of 13 and 53 who have frenum-induced diastemas between the incisors. The abnormal frenums were removed via conventional frenectomy. The distances between the teeth before and one year after the surgery were measured with a caliper. To determine the periodontal status, the pocket depth, plaque index, and bleeding on probing were measured from four surfaces. In addition, the amount of attached gingiva and degree of gingival recession were recorded and were statistically analysed.

Results:

A significant decrease in the distance between teeth before and after frenectomy was observed (p<0.05). There was a statistically significant difference in the amount of gingival attachment, pocket depth, degree of gingival recession, plaque index, and bleeding on probing (p<0.05).

Conclusion:

The removal of abnormal frenums with frenectomy can contribute to the reduction in the distance between the teeth. In addition, frenectomy increases the amount of gingiva and decreases the depth of the pocket, gingival recession, amount of plaque, and bleeding.

Frenal attachment and its association with oral hygiene status among adolescents in Dakshina Kannada population: A cross-sectional study

BACKGROUND AND OBJECTIVE

Frenum is a mucous membrane fold that attaches the lip and the cheek to the alveolar mucosa, gingiva, and the underlying periosteum. The frena may jeopardize the gingival health when they are attached too closely to the gingival margin, either due to interference in the plaque control or due to muscle pull. Identifying labial frenum attachment and its association with oral hygiene helps in primary prevention of gingival health. The purpose of this study was to examine the prevalence of the various types of maxillary labial frenum attachment and its association with oral hygiene status in adolescent population.

METHODOLOGY

A total of 300 adolescents between 13 and 18 years were selected randomly. They were clinically examined for maxillary frenum attachment. Placek's classification of the labial frenum attachments was used to check the origin of frenum. Oral hygiene index (simplified) was recorded and results were subjected to statistical analysis.

RESULTS

Among 300 examined children 53% were males and 47% were females. The prevalence of the maxillary labial frenum was gingival type (39%) followed by mucosal (28.3%), papillary (23.7%), and papillary penetrating type (9.0%). The gingival type of frenal attachment was statistically significant among different age of children and also between different types of frenal attachment and oral hygiene status (p value < 0.001). There was no significance between frenum attachment and gender.

CONCLUSION

The type of frenal attachment is strongly associated with oral hygiene status. as the age progresses the frenum tends to migrate apically. However, our study did not reveal any relationship between the gender and type of frenal attachment.

An Insight into the Role of the Maxillary Labial Frenum in the Growth of the Maxilla: A Systematic Review

Background: The review attempts to provide synthesis of published studies evaluating the influence of an aberrant frenum attached close to the gingival margin or with inadequate width of attached gingiva on the growth of the maxilla.

Methodology: This review was reported using the PRISMA checklist as a template. PubMed, EBSCO and Google scholar were searched for in earlier publications up to January 2019. In addition, reference lists of the included studies were hand searched. The eligibility criteria were listed out based on Population, Intervention, Comparison, Outcome, Study type (PICOS) concept.

Results: A total of 148 articles were found by database search strategies and 27 additional studies by hand search. Finally three cross sectional and one longitudinal study were selected based on the eligibility criteria. A meta-analysis was not justified. Risk of bias was assessed using AXIS tool for cross sectional studies and Newcastle-Ottawa scale for longitudinal study. Common weaknesses of the studies were failure to justify or calculate the sample size and insufficient statistical reporting.

Conclusion: This review reveals that there is a need for methodologically standardized studies that will throw light on to the physiological importance of labial frenum in the growth of the nasomaxillary complex.

Mind the gap: A novel technique for space closure - a case report

Patients presenting with severe hypodontia can be challenging to manage. They often present with significant spaces within the dental arches and the lack of permanent teeth can make anchorage control difficult. This case report demonstrates a novel technique for diastema closure in a 14-year-old with severe hypodontia. The technique allows maintenance of root parallelism during space closure in cases with reduced anchorage support. The treatment plan was agreed on a multidisciplinary hypodontia clinic and involved an upper sectional fixed orthodontic appliance to close a 7-mm midline diastema aiding subsequent partial denture provision. Treatment commenced by bonding upper primary canines and central incisors. However, attempting space closure on a 0.019 × 0.025-inch stainless-steel working archwire resulted in tipping of the incisor crowns. Two brackets were therefore placed on the labial surface of each central incisor (one incisal and one gingival). Subsequently two stainless steel working archwires and elastomeric chain were used for diastema closure. This four-bracket system provided superior control allowing space closure by bodily tooth movement. Excellent root parallelism was achieved with this innovative technique.

Prevalence of variations in morphology and attachment of maxillary labial frenum in various skeletal patterns - A cross-sectional study

Background

Maxillary labial frenum is a dynamic structure with a diverse morphology. Although an abnormal labial frenum is associated with syndromic and nonsyndromic conditions, it is often been neglected during the routine intraoral examination. The significance of various types of frenum (normal to abnormal), based on the attachment site and morphology in different skeletal patterns, has not been studied yet.

Materials and Methods

A cross-sectional study was conducted in a clinical setting on 150 participants (50 each in Class I, Class II, and Class III skeletal pattern) within the age group of 13-30 years. Frenum was examined by direct visual method and intraoral photographs were taken for all the participants.

Results

Chi-square and Fisher's exact tests were used. No gender-wise differences were found among the various frenum typologies. Mucosal type was the most prevalent in Class I and II and gingival type in Class III. Simple frenum was the common type in all the three groups. However, abnormal frenum categories based on its location and morphology were more in class III and found to be statistically significant. Papillary and papillary penetrating types are significantly associated with skeletal class III pattern and midline diastema (P < 0.05).

Conclusion

The prevalence of papillary and papillary penetrating types of frenum are significantly more in Class III skeletal pattern. A labial frenum that is attached close to the gingival margin could be an etiological factor in midline diastema, mucogingival problems, and affect the growth of the alveolar process. Hence, an early diagnosis of abnormal frenum prevents the emergence of periodontal as well as orthodontic problems.