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Clinical Tip: Interincisive Diastema

posted in 11/10/2019
Clinical Tip: Interincisive Diastema
By: Liliana Ávila Maltagliati

Master and PhD in Orthodontics, FOB-USP
Adjunct Professor at UNIVERITAS-UNG University
Author of the book “Autoligado System - Theory and Practice” - Editora Plena

The interincisive diastema represents an aesthetic and psychological compromise for its patients and is often referred to as the main complaint of the patient's search for orthodontic treatment1. It is a malocclusion with very variable frequency in the population. It affects approximately between 3.7% to 36.8% 2. The etiology is diverse and often responsible for the failure in the stability of its treatment. The causes can range from anatomical dental changes, generating the so-called Bolton discrepancy to periodontal changes such as bone defect or low brake insertion. The treatment method varies depending on the extent of this diastema, and can be closed with restorative dentistry procedures or by bringing the teeth closer together orthodontically.
When opting for orthodontic closure, care must be taken with the mechanics employed to avoid incurring instability or worsening occlusal relationships such as horizontal and vertical overlapping. It is known that in the procedure of closing spaces, the moment created by the force vector used creates a pendulum movement that increases the mesial and lingual angulation. Specifically, the increase in the lingual inclination generates a lowering of the incisal surface of the incisors which ends up causing a deepening of the bite.
To control these side effects, it is suggested that the closing of the space be initiated only at the end of alignment and leveling, in more gauge wires and stainless steel alloy so that the created moment cannot express itself or is minimized by the thickness and stiffness the wire. However, because it is the main complaint of most patients who present this malocclusion and the reason for seeking treatment, delaying the solution of this anti-aesthetic condition can bring distress to the patient and wear on the professional / patient relationship. We then suggest a simple and practical method of quickly obtaining this closure, even in the early stages of treatment, using self-ligating brackets, nickel titanium wires and stops as aids to the procedure. This method aims to achieve a significant improvement of the problem, in a short time and with effective control of side effects. Orthometric brackets and wires (Ultra-P and Flexy Copper Niti) were used.

The first step is to tie only the central incisors, with a .025 ”string of ties until the patient feels pressure or ischemia of the gingival papilla, a clinical sign of ligation activation. This tie must be positioned under the wire. In the return visit and in subsequent visits, the same binding is activated until the central incisors are joined.
After closing the space between the central incisors, the ligature is removed and tightly dented stops are placed on the distal brackets of these central incisors, which will stabilize the movement, anchor for the traction of the lateral incisors and stability of the wire that does not you can rotate through the dental arch. Until that moment, the stability of the wire can be checked with the distal fold, but after placing the stops this fold becomes unnecessary. With the stops crumpled to the wire, a new binding is placed, conjugating the lateral incisor to the central, bilaterally and proceeding with the same activation protocol until the space between the lateral and the central ones closes. Then, the ties are removed and the stops are moved to the distal brackets of the lateral incisors, making a “conjugated” effect and remain so until the end of the alignment, with the installation of a rigid rectangular steel wire that can be used to close the remaining spaces that are created in the distal of the lateral incisors and that do not compromise the patient aesthetically. With this we have a quick, simple, effective and satisfying resolution.

BIBLIOGRAPHIC REFERENCES
1 - Jaija AMZ, El-Beialy AR, Mostafa YA. Revisiting the Factors Underlying Maxillary Midline Diastema. Scientifica, 2016: 1-5.

2 - Sekowska A., Chalas R., Dunin-Wilczynska I. Width of dental arches in patients with maxillary midline diastema Folia Morphol. 2018, 77 (2): 340-344.
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