CASE PRESENTATION

Dr. M.Arsalan ZubairMDS Trainee (Semester III)

Operative Dentistry DepartmentDow Dental College

DUHS

PATIENT’S PERSONAL DATA

• Age: 35 years• Sex: Female• Address: malir• Occupation: nil (house wife)• Religion: Islam

PRESENTING COMPLAINT

Complain of gap between central and lateral incisor, which gives an unpleasant appearance and also has sensitivity in upper right posterior

teeth

HISTORY OF PRESENTING COMPLAINT

The gap was present since her childhoodAnd the sensitivity was since one year.

MEDICAL HISTORYNot significant.

FAMILY HISTORYNot significant

DENTAL HISTORY

Extractions:

6 6

Patient recently visited dow dental college for scaling

Extraoral examination• TMJ examination:- Symmetry: Symmetrical- Deviation: Absent- Clicking sound: Absent- Tenderness: Absent

• Lymph node examination: Normal

• Swelling: Absent

CLINICAL EXAMINATION

• Teeth present:

• Teeth Missing:

• Carious Teeth:

8,7,5,4,3,2,1 1,2,3,4,5 6,7

7,5,4,3,2,1 1,2,3,4,5,7

6,8

7 (class 1)

INTRA ORAL EXAMINATION

8

8,6

7 (Class 1)

7 (Class 1)

Dynamic:

Group function Canine guidance • Static:• (I) (I) (I) (I)• Canine C I I C • Incisor• Over jet : 4mm• Overbite: 3mm

Occlusal Examination

Periodontal ExaminationPocket Depths

11 0.5 0.5 0.5 1 0.5 1

12 0.5 0.5 1 0.5 0.5 0.5

13 0.5 0.5 0.5 0.5 0.5 0.5

14 2 1 2 0.5 0.5 0.5

15 2 1 2 2 1 2

16 2 1 2 2 1 2

No: F(Mes) Mid Distal P(Mes) Mid Distal

17 1 2 2 2 1 1

18 1 1 1 1 1 1

21 0.5 1 0.5 0.5 0.5 0.5

22 0.5 0.5 0.5 0.5 0.5 0.5

23 0.5 1 1 0.5 0.5 0.5

24 2 0.5 1 0.5 0.5 0.5

25 0.5 0.5 0.5 0.5 0.5 0.5

26 1 0.5 0.5 0.5 0.5 0.5

27 1 1 1 2 1 1

31 0.5 0.5 0.5 0.5 0.5 0.5

32 0.5 0.5 0.5 0.5 0.5 0.5

33 0.5 0.5 0.5 0.5 0.5 0.5

34 0.5 0.5 0.5 0.5 0.5 0.5

35 0.5 0.5 0.5 0.5 0.5 0.5

37 0.5 0.5 0.5 0.5 0.5 0.541 0.5 0.5 0.5 0.5 0.5 0.5

42 0.5 0.5 0.5 0.5 0.5 0.543 0.5 0.5 0.5 1.5 0.5 0.544 0.5 0.5 0.5 0.5 0.5 0.5

45 1.5 0.5 0.5 0.5 0.5 0.5

47 0.5 0.5 0.5 0.5 0.5 0.5

Plaque and Gingival index

A film of plaque adhering to the free gingival margin and adjacent area of the tooth, which can not be seen with the naked eye. But only by using disclosing solution or by using probe

No plaque

Moderate accumulation of deposits within the gingival pocket, on the gingival margin and/ or adjacent tooth surface, which can be seen with the naked eye

Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin.

No inflammation

Mild inflammation, slight change in color, slight edema, no bleeding on probing.Moderate inflammation, moderate glazing, redness, bleeding on probing

Severe inflammation, marked redness and hypertrophy, ulceration, tendency to spontaneous bleeding

0

1.

3

2

1.

3

2

0

• On the basis of above criteria the plaque status was “2” because plaque was observed with the naked eye and gingival status was given score 1 because mild inflammation was seen.

• No mobility of tooth was observed

Smile analysis

• Canine to canine can be seen easily

• Part of mid-incisal area of lower mandibular teeth can be seen

• Patient gums are also seen which make it a gummy smile.

• Central incisors are prominent

Clinical findings

• In maxillary arch ,spacing is seen in Maxillary central incisors

• Space is also present between central incisors and lateral incisors as well but this space is smaller than central incisors

• Space is also observed between lateral incisors and canine as well, which is very large and cannot be closed by restoration. Orthodontic intervention is mandatory for closing this space.

• Facial midline shift was also observed

• Right central Incisor is labially placed to the arch form

• Spacing is also observed in the right canine and premolar as well

• Palate is shallow• Maxillary arch is large.• No spacing is observed in Mandibular arch.

DIFFERENTIAL DIAGNOSIS

• Midline diastema

• Distal crown inclination

• Missing teeth

• Peg shaped laterals

Comparison between distal crown inclination & diastema

• Crowding is not observed

• Both the centrals are separated with each other

• No inclination is observed

• Crowding Is observed

• Both the centrals are in contact at the cervical area of the crown

• Distal inclination is observed

• Lateral incisors are present

• Lateral incisors are congenitally absent

Comparison between Congenitally missing teeth & diastema

• Peg shaped laterals are observed

• Mal-aligned teeth are observed

Comparison between Peg-shaped laterals & diastema

• No Peg shaped laterals are observed

• No Mal-aligned teeth are observed

Diagnosis

Midline diastema

Causes of midline diastema• Genetics • Superior labial frenum• Anterior traumatic bite• Oral habits• Supernumerary teeth • Tooth and arch size discrepancy• Pathologic migration of teeth• Odontomas occuring in the maxillary midline• Developmental cyst in the oro-facial midline• Flaccid lips

Bishara SE, Jakobsen JR. Individual variation in tooth size-arch length. World J Orthod 2006

Etiology of my case

Tooth and Arch Size Discrepancy because all the teeth are of normal size and spacing is also

observed generally.

Lamberton CM, Reichart PA, Triratananimit. Tooth size-arch length changes from the primary to permanent dentitions. World J Orthod 2009

Measurements and Investigation

• Length and width of right central incisors = 9mm• Length and width of right central incisors = 9mm• Length and width of right central incisors = 7mm

Midline space

• Space between central incisors are seen which was measured and found to be 1.5mm

Midline shift

• Midline shift was also observed which was about 1.5mm away from the mid line

Cast

Bite registration

TREATMENT PLAN (initial)• Oral hygiene instructions

• Diet modification

• Fluoridated tooth paste and mouth wash

• Topical fluoride application

• Ultrasonic scaling

Prediction of the fate of midline diastema

• It claimed to have an accuracy of 88%Sanin’s prediction is as follows:

Space between mixed dentition Possibility of space closure

1mm 99%

1.5mm 85%

1.85mm 50%

2.7mm 1% ( Treatment either ortho or restorative approach is mandatory)

Dent Update 2014; 41: 457–464

Treatment options

• Different treatment modalities include restoration, orthodontics, prosthodontics, surgery, and various combinations

• Direct composite restoration • Orthodontic and porcelain laminate

placement • Orthodontic procedures

Willhite C. Diastema closure with freehand composite: Controlling emergence contour. Quintessence Int 2005;36:138-4

Classifying Diastema according to treatment Plan

Diastema Size Treatment

Mild 1mm or less Direct composite( with enamel shade only)

Moderate More than 1mm but less than 2.5 mm

Direct composite restoration ( with enamel along with dentine shade is used)

Severe size More than 2.5 mm Direct veneering + orthodontic movement

Summit’s fundamental of Operative Dentistry 4th edition

Treatment Plan of my Case

• According to the above table, my case falls in moderate category of midline diastema. So the final treatment plan will be direct composite restoration ( enamel + dentine shade are used)

Final treatment plan was done according to severity

Midline Diastema can be closed by direct composite restoration.

1. First the Diagnostic wax-up is made in order to judge the favourable outcome. So wax is added to the distal surface of right and left central incisor.

2. In the First step, the composite shade selection is done which is A2 Enamel and Dentine.

3. No preparation is done.

4. Adequate isolation is needed so rubber dam is placed, quadrant isolation is done from 1st premolar to 1st premolar of both the arches

5. Then the basic steps of restorations is followed

6. Then rubber dam is removed

7. Then finishing of the composite is done

Cast Mock up

Shade selection

Quadrant isolation is done from 1st premolar to 1st premolar

Midline diastema along with lateral diastema closed

Before

After

Midline shift corrected

Problems

• Both the incisors get more prominent due to increase in size

• Shade selection was not that adequate• Normal squarish shape of both the incisors is

not followed

Thank you