Midline diastema and its aetiology--a review

Maxillary midline diastema is a common aesthetic complaint of patients. Treating the midline diastema is a matter of concern for practitioners, as many different aetiologies are reported to be associated with it. The appearance of midline diastema as part of the normal dental development makes it difficult for practitioners to decide whether to intervene or not at an early stage. The aim of this article is to review the possible aetiology and management options which will help the clinician to diagnose, intercept and to take effective action to correct the midline diastema. The available data shows that an early intervention is desirable in cases with large diastemas. Treatment modality, timing and retention protocol depends on the aetiology of the diastema. Therefore, priority needs to be given to diagnosing the aetiology before making any treatment decisions. Clinical Relevance: This article aims to determine and evaluate the aetiology and possible treatment options of midline diastema.

Modified frenectomy: a review of 3 cases with concerns for esthetics

The maxillary labial frenum is a normal anatomical structure in the oral cavity. An abnormal labial frenum causes localized gingival recession and midline diastema, both of which can interfere with oral hygiene procedures, and eventually affect esthetics. When the frenum maintains its high papillary attachment, frenectomy is the treatment of choice. Though this technique has undergone many modifications, the zone of attachment and esthetics in the anterior maxillary region have been neglected. This article highlights a new frenectomy technique that results in good esthetics, excellent color match, gain in attached gingiva, and healing by primary intention at the site of thick, extensive abnormal frena.

Labial dystonia after facial and trigeminal neuropathy controlled with a maxillary splint

A 27-year-old woman with bruxism suffered a spider bite (Loxosceles rufescens) on the left cheek that caused severe local cellulitis, facial palsy, and painful hyperesthesia over the two lower trigeminal nerve divisions. Facial but not trigeminal neuropathy improved, and she developed a labial dystonia that only corrected while pressing the right medial incisor. A specially designed maxillary splint that continuously pressed it suppressed both dystonia and related spontaneous firing of motor unit potentials in electromyography. Overstimulation of the contralateral trigeminal territory possibly compensated for the altered left trigeminal nerve input, balanced proprioceptive influences at the central inhibitory-excitatory circuitry, and controlled dystonia.

Frequency and location of traumatic ulcerations following placement of complete dentures

PURPOSE

To determine the location of mucosal injuries that appear following placement of complete dentures, as well as the number of adjustments necessary to achieve patient comfort. The frequency of mucosal injuries in female and male patients and their connection with clinical anatomic features were also investigated.

MATERIALS AND METHODS

Sixty-one completely edentulous healthy patients who wore dentures (47 women and 14 men) took part in the study; 122 newly fabricated complete maxillary and mandibular dentures were investigated. All patients were seen for a 1-week adjustment appointment. Areas where signs of denture-induced mucosal injuries appeared were marked on an anatomic illustration. The follow-up period was in 1-week increments as deemed necessary by the patient. Associations between variables were analyzed with analysis of variance. Results were recorded as mean + SD. Statistical significance was set at P < or = .05.

RESULTS

Eighty-seven percent of the dentures required adjustment at week 1, 50% at week 2, and only 7% at week 3. No patients required a further visit. Most frequently injured maxillary areas were the vestibular sulcus (41%), maxillary tuberosity (21%), and hamular notch (12%). In the mandible, the most frequently injured areas were the retromylohyoid area (17%), lingual sulcus (14%), and vestibular sulcus (13%). Denture-induced irritations were detected in a higher ratio in the mandible (P < .001), especially in male denture wearers at the first adjustment (P < .05). Men had a higher ratio of lesions at the region of the maxillary vestibular sulcus between the labial and buccal frenum and at the mandibular vestibular sulcus of the buccal shelf region (P < .001).

CONCLUSIONS

Denture-induced irritations appeared most often in the vestibular sulcus of the maxilla and mandible, indicating that it is necessary to evaluate the area of the facial seal of the prosthesis by applying a medium- or a heavy-pressure indicator paste to the borders, and to make adjustments at the delivery stage and subsequent adjustment appointments. Denture placement must not be the final patient-clinician encounter when treating with complete dentures. Denture adjustments are very important clinical phases of denture fabrication and essential in patient care.

Dermoid Sinus and Cyst of the Lip

Midline dermoid cysts, although rare, typically present as nasal or glabellar masses with potential sinus tract extension to the skin or to the central nervous system. Craniofacial dermoid cysts present in varied ways, including asymptomatic puncti, infection, or seizure secondary to intracranial invasion. This article describes the previously unreported occurrence of a midline dermoid within the labial frenulum diagnosed on surgical excision of the cyst and its orocutaneous sinus tract, which extended to the skin at the base of the columella.

Midline diastema and frenum morphology in the primary dentition

PURPOSE

The purpose of this study was to determine the prevalence of different types and insertions of labial frenums as well as midline diastema in Peruvian children between 0 and 6 years of age.

METHODS

A sample of 1,355 children was selected for the study. A clinical examination was done to classify the labial frenum, measure gingival insertion levels, and quantify midline diastema. Descriptive statistics and the Spearman test were used.

RESULTS

The most prevalent frenums were the simple frenum (59%) and the persistent tectolabial frenum (25%). The level of gingival insertion moved apically with age. The midline diastema was wider in younger children and decreased with age. A significant inverse relationship (r=-0.27; P=.001) was found between the level of gingival insertion and the midline diastema.

CONCLUSION

The most prevalent frenum was the simple frenum. A significant inverse correlation between the gingival insertion level and the midline diastema was found.

Morphological, Histochemical, and Immunocytochemical Study of CO2and Er:YAG Laser Effect on Oral Soft Tissues

OBJECTIVE

The purpose of this study was to investigate the morphological, histochemical, and immunocytochemical changes of the oral mucosa after CO(2) or Er:YAG laser irradiation.

BACKGROUND DATA

There have been no comparative reports on CO(2) and Er:YAG laser effects on human oral soft tissues.

MATERIALS AND METHODS

Tissue preservation was studied in 40 oral biopsies of young patients obtained by CO(2) and Er:YAG laser surgery. Hematoxylin-eosin and Giemsa stains, PAS/diastase treatment, AE1 and AE2 cytokeratins, MiB1/Ki67, and bcl-2 immunoreactions were performed on the laser cut edges on formalin fixed, paraffin embedded biopsies.

RESULTS

CO(2) laser biopsies show blisters, clefts and erosions of the epithelium. Intracellular edema and lengthened nuclei were also seen. The glycogen content results decreased in CO(2) laser biopsies. Good expression for cytokeratins and cell-cycle proliferation markers were found in Er:YAG biopsies, on the contrary the apoptosis marker was better expressed in CO(2) laser biopsies.

CONCLUSION

The results suggest that Er:YAG laser may be routinely used in surgery, because of its minimal damage of the epithelial tissue, its low inflammatory reaction, its quicker healing process and its lower risk of scarring.

[Histomorphologic evaluation of upper lip frenum in relation to the method of treating diastema]

The aim of this study was to determine collagen density in the hypertrophic upper lip frenum and scar forming after frenectomy and to compare the results with collagen density in a normal population (autopsy specimens). Differences in collagen density may cause problems in diastema closure and may eventually result in relapse of this condition. The study was done in 47 patients treated for diastema. Histomorphology was performed in 15 patients of this group. Autopsy material was obtained from 27 persons. Histomorphometric assessment of collagen density was done after staining of collagen fibers according to van Gieson. A computerized image analysis system was used for interactive detection of stained collagen fibers on the digitized microscopic image. The percentage of positive staining expressed as ratio of positive area to whole area of the field studied was determined and recorded as an Excel file. Collagen density was increased in the pathologic frenum and in the scar as compared with the normal frenum. The difference was statistically significant. Diastema treatment with frenectomy, fixed appliance and retainer produced more stable results as compared to treatment with a removable appliance without frenectomy. The results suggest that the similar collagen density observed in hypertrophic upper lip frenum and scar after frenetomy may hinder complete closure of diastema and facilitate relapse after treatment.

Lichen sclerosus et atrophicus manifesting with localized loss of periodontal attachment

Lichen sclerosus et atrophicus (LSA) is a chronic mucocutaneous inflammatory disorder of uncertain aetiology that is clinically characterized by the appearance of well delimited white plaques or papules, preferentially affecting the skin and genitals, and more rarely the oral cavity. We present the case of a woman with LSA limited to the oral cavity in the form of a well delimited, flat whitish lesion affecting the vestibular gingiva of the right upper incisors and left central incisor, and extending towards the vestibular fundus and frenulum of the upper lip. Widening of the periodontal space was observed, with gingival recession and attachment loss limited to these teeth. Local corticosteroid injections caused the mucosal lesion but not the periodontal alterations to resolve. Emphasis is placed on the importance of knowledge of this condition in relation to establishing a diagnosis, and on its periodontal repercussions.

The aetiology of gingival recession

Gingival recession affects a large proportion of the adult population. This paper discusses the aetiology and mechanisms behind the formation of gingival recession, and considers the relevance of gingival recession to both orthodontics and restorative dentistry. It is followed by a second paper on the management of gingival recession.

Mandibular deviations in TMD and non-TMD groups related to eye dominance and head posture

This study was designed to determine whether eye-dominance affects head posture (rotation) and in turn, whether head posture is associated with mandibular frenum midline deviation, in both TMJ and control subjects. Eye dominance was determined using three tests: Porta, Hole, Point tests. Natural head posture was evaluated using the Arthrodial protractor. Mandibular frenum deviation was recorded as left, right or no deviation. Fifty female subjects were included in the study, 25 TMJ patients attending the Gelb Craniomandibular Pain Center and 25 non-TMJ control subjects. The findings indicate that eye dominance and direction of head rotation are strongly associated in both TMJ and control subjects. Further, in TMJ subjects mandibular deviation occurred in greater frequency than in controls and tends to occur in the contra lateral direction of head rotation.

Unilateral complete cleft lip and palate repair using lip adhesion and passive alveolar molding appliance

To manage a unilateral complete cleft lip and palate, lip adhesion along with the positioning of a passive alveolar molding appliance was performed in infants at 3 to 6 weeks of age. The lip adhesion creates a force acting on the cleft alveolus. There-after, the greater segment of the alveolus is guided by the appliance, while the lesser segment of the alveolus is prevented from collapsing. Definite cheiloplasty was then performed at 5 to 6 months of age and palatoplasty at 12 to 14 months of age. Fifteen patients with a unilateral complete cleft lip and palate were treated using this protocol from April 1995 to October 1998. Nine were female and six were male. The mean follow-up period was 13 months. The lip adhesion failed in one patient and was performed again 1 month later. Thirteen patients developed good or fair symmetrically aligned alveolar segments plus a symmetric platform for the nose. However, two patients developed poor maxillary orthopedics because of the displacement of the appliance by the patient. The resulting lip scar was aesthetically acceptable in most patients.

Nonsurgical and nonextraction treatment of skeletal Class III open bite: its long-term stability

Two female patients, aged 14 years 5 months and 17 years 3 months with skeletal Class III open bite and temporomandibular dysfunction are presented. They had previously been classified as orthognathic surgical cases, involving first premolar removal. The primary treatment objective was to eliminate those skeletal and neuromuscular factors that were dominant in establishing their malocclusions. These included abnormal behavior of the tongue with short labial and lingual frenula, bilateral imbalance of chewing muscles, a partially blocked nasopharyngeal airway causing extrusion of the molars, with rotation of the mandible and narrowing of the maxillary arch. Resultant occlusal interference caused the mandible to shift to one side, which in turn produced the abnormal occlusal plane and curve of Spee. As a result, the form and function of the joints were adversely affected by the structural and functional asymmetry. These cases were treated by expanding the maxillary arch, which brought the maxilla downward and forward. The mandible moved downward and backward, with a slight increase in anterior facial height. Intruding and uprighting the posterior teeth, combined with a maxillary protraction, reconstructed the occlusal plane. A favorable perioral environment was created with widened tongue space in order to produce an adequate airway. Myofunctional therapy after lingual and labial frenectomy was assisted by vigorous gum chewing during and after treatment, together with a tooth positioner. Normal nasal breathing was achieved.

Relapse after orthodontic correction of maxillary median diastema: a follow-up evaluation of consecutive cases

An evaluation of 96 treated orthodontic patients with maxillary median diastema ranging from 0.50 mm to 5.62 mm (mean 1.22, SD 0.85) was performed 4.0 to 9.0 years after completion of active treatment. Pre- and posttreatment data were gathered from available records. Follow-up data were gathered from records and interviews of 37 patients, and from phone interviews of 59 patients. The incidence of diastema relapse was 49% when scored as either presence of a measurable space at follow-up, a history of orthodontic or prosthetic retreatment to close a reopened space, or continued use of a retainer to control relapse tendency. Logistic regression analysis revealed that pretreatment diastema size and presence of a family member with a similar condition were the only significant risk factors for relapse (p<0.05), while pretreatment spacing in the maxillary anterior dentition approached significance (p = 0.10). No association was found between relapse and presence of an abnormal frenum or an osseous intermaxillary cleft, although patients with an abnormal frenum had a wider pretreatment diastema than those with a normal frenum (p<0.05). Fremitus of the maxillary incisors was the only parameter at follow-up associated with space reopening (p<0.01).

Three-dimensional analysis of cleft palate topology in newborn infants with reference to the cranial skeleton

OBJECTIVE

To describe a method of determining the three-dimensional topology of the palatal crest relative to a reproducible anthropomorphic coordinate system in newborn infants with unilateral cleft palate. For this purpose, physical models of the maxilla and face were analyzed by computer morphometry.

DESIGN

The study was limited to infants referred to the craniofacial center during the first 11 days after birth.

SETTING

The study was performed at a craniofacial center servicing a large geographic area.

PARTICIPANTS

The method was applied to 12 infants with unilateral cleft lip, alveolus, and palate (eight patients with left-side clefts and four with right-side clefts).

MAIN OUTCOME MEASURES

The three-dimensional topology of the palatal crest referenced to an anthropometric coordinate system was the primary outcome measure. The anthropometric reference system is defined by the tragus points and the midpoint of a line connecting the endocanthia.

RESULTS

The topology of the maxillary crests of the patients was characterized by considerable variability. The center of the premaxilla as defined by the attachment of the frenulum was frequently displaced by several millimeters from the midsagittal plane. The displacement was to the left in infants with right-side clefts and to the right in infants with left-side clefts. The premaxilla can be rotated by more than 30 degrees relative to the normal position. No significant retroposition of the minor segment as determined by the location of the tuber points was found. Several morphometric anomalies were found to be correlated linearly.

CONCLUSIONS

We propose that the morphologic deviations are in part caused by the neuromotor activity of the tongue and of the interrupted M. orbicularis oris. The data can serve as the starting point for a longitudinal study of craniofacial development in children with cleft palate and for studies on the efficacy of different therapeutic approaches.

Creeping attachment associated with the connective tissue with partial-thickness double pedicle graft

The occurrence of creeping attachment has been documented with epithelialized autogenous masticatory mucosa grafts (free gingival grafts) and suggested in other root coverage techniques. The purpose of this study was to examine whether or not creeping attachment occurred after a connective tissue with partial-thickness double pedicle graft had been performed. This study examined 22 defects, in 19 patients, treated where less than complete root coverage was obtained at 4 weeks postoperative. Creeping attachment occurred in 21 of the 22 defects (95.5%), in 18 of the 19 patients (94.7%). Complete root coverage occurred in 17 of the 22 defects (77.3%), in 15 of 19 patients (78.9%). The mean creeping attachment obtained was 0.8 mm. Additionally, it was the goal of this study to see if any factor could be associated with creeping attachment. This study did not find any factors that could be associated with the amount of creeping attachment seen. Creeping attachment seems to occur commonly, but complete root coverage is not predictable.

A peculiar malformation of the upper lip: report of six cases

Six cases of a peculiar type of upper lip malformation have been observed by the author during the last 40 years. The malformations in this case series were remarkably similar, suggesting a single teratologic entity not been reported before. The six patients included 1-, 11-, 4-, and 6-month-old males, a 20 year-old male, and an 11-year-old female. Each was characterized by a crooked folded philtrum, a flat thin vermilion region of the upper lip, and high-positioned ala(e), that was unilateral or bilateral. The upper median incisors were separated occasionally by the thick lip frenulum without marked distortion of the nasomaxillary framework. The author speculates that these cases exhibited some disturbed penetration of the lateral nasal eminence (process) to the median part of the nasolabial region in their early embryologic development.

Congenital midline sinus of the upper lip: case report and review of literature

A case report of a congenital midline sinus of the upper lip in a 5-year-old girl is presented. The patient complained of intermittent swelling around the frenulum of the upper lip. The sinus was located on the midline of the philtrum just below the base of the columella. Excision of the sinus tract via an intraoral approach gave a satisfactory result. Microscopic examination of the resected sinus revealed it to be lined by stratified squamous epithelium with sebaceous glands and hair follicles. Fifteen other cases have been reported in the English literature and are reviewed. There are two postulates that can account for the formation of the upper lip sinus based on two major theories of the development of the face: the fusion theory and the merging theory. However, the etiology of this rare congenital sinus remains obscure.

Association of hypertrophic maxillary frenulum with hypoplastic left heart syndrome

We report a previously unrecognized association between a hypertrophic frenulum separating the alveolar portion of the maxillary palatine suture with hypoplastic left heart syndrome in one fetus and seven children. A hypertrophic frenulum was not found in 25 pediatric cardiology patients without hypoplastic left heart syndrome. This finding may provide a marker for suspecting hypoplastic left heart syndrome in the neonate.

Buccal attachment loss in Swedish adolescents

A case referent study was performed to identify factors connected with loss of buccal attachment in adolescents. The study group was identified among 18-year-olds who had participated 2 years earlier in a study of periodontal conditions in adolescents. The criterion for inclusion in the case group was buccal attachment loss (greater than or equal to 1 mm) in one or more sites. Information on 28 variables, identified earlier as being related to recessions, was collected in a clinical examination, interview and observation. The referent group consisted of 66 subjects and the case group of 71 subjects. The case group comprised 2 subgroups, one identified as having buccal attachment loss in 1987 and the other with attachment loss occurring in the years 1987-89. Statistical analyses, using the chi 2 test, logistic regression and a variance component model, were performed to detect factors related to buccal attachment loss. These factors were thin alveolar tissue, narrow width of the attached gingiva and presence of teeth with buccal displacement. The results indicate that the anatomy of the buccal alveolar process is related to the presence of buccal attachment loss in populations with a high level of oral hygiene. To evaluate the importance of possible risk factors or etiological factors for development of buccal loss of tooth support, prospective epidemiological or experimental studies are needed.

Oral manifestations of leukemia

Signs and local symptoms of leukemia in the oral cavity include paleness of the oral mucosa with gingival bleeding that develops into painless gingival hyperplasia, hemorrhages, and ulcerative necrotic lesions. These findings are common clinical manifestations of leukemias and frequently herald the onset of the disease. Because of their clinical importance, all such lesions deserve the full attention of dentists and physicians.

[Hypertrophy of the inferior labial frenum]

Hypertrophy of the inferior labial frenum, which is present in approximately 8% of the population, can give rise to prosthodontic or periodontal problems. In contrast to hypertrophy of the superior labial frenum, there is no relation to orthodontic problems. The indications for extirpation of a hypertrophic inferior labial frenum are discussed.

Histologic analysis of the hyperplastic maxillary anterior frenum

Fifteen biopsy specimens from hyperplastic maxillary anterior freni were examined histologically by three investigators, and tissue components were subjectively rated on a predesigned scoring sheet. The presence of calcification and ossification associated with high levels of inflammatory infiltrates and reactive connective tissue confirm the fact that surgical excision of the hyperplastic frenum is warranted.

Bilateral blind epithelized tracts associated with the inferior labial frenum

Examination of a 45-year-old man disclosed, bilateral, blind, epithelium-lined tracts on the alveolar mucosa in proximity to the inferior labial frenum. These structures were excised surgically and examined histologically. This article represents the first report of blind mucosal pits in this location. The mechanism responsible for development of these structures is not clear, but they most likely result from entrapment or persistence of epithelium during embryogenesis.

A longitudinal study of isolated gingival recession in the mandibular central incisor region of children aged 6-8 years

A 2-year longitudinal investigation of isolated gingival recession was undertaken in 42 children aged 6-8 years at the commencement of the study. Gingival inflammation was controlled by supervised tooth brushing or professional plaque control. Mandibular anterior crowding considered to have contributed to the degree of recession was untreated in 11 subjects, while in 13 subjects serial extractions had been undertaken. No attempt was made to correct frenal involvement in those subjects (9) where it might have been considered a contributing etiologic factor. After 2 years, improvement in gingival contour was most apparent in those subjects whose gingival inflammation had been controlled. This was achieved more readily with professional plaque control than with supervised tooth brushing. Improvement in arch alignment and gingival contour was greater in untreated subjects than in those receiving serial extractions. WHen gingival inflammation was controlled evidence of frenal involvement declined. Control of gingival inflammation appears to be the most important factor in the treatment of isolated gingival recession in the mandibular central incisor region.

Prevalence of narrow zone of attached gingiva and improper attachment of labial frena in youths

An epidemiologic study comprising 1542 girls and boys aged 15--17 revealed that the occurrence of the narrowest attached gingiva zone (greater than 0, less than or equal to 1 mm) was more frequent in the mandible (23.0%) than in the maxilla (2.0%). At the same time, the first type of labial frena attachment (mucosal type) was observed most often, again dominating in the mandible (71.0%).

Gingival recession in the lower incisor region of 15-year-old subjects

A sample of 1,003 children, aged 15 years, were examined for prevalence of gingival recession. It was found that 17% had pseudo gingival recession and 1% had true recession. The highest degree of association with local etiological factors was that between recession and the width of keratinized gingiva; frenal pull was the second most highly associated factor followed by tooth arch relationship and the least association existed between plaque and gingival recession. There was no association between calculus and recession.

Prognostic parameters and clinical staging criteria in the epidermoid carcinoma of the vulva

An evaluation and a critique of prognostic parameters and criteria involved in the classification and clinical staging of epidermoid carcinoma of the vulva are presented, comparing the FIGO system and a proposed more definitive system. Biostatistical as well as clinical evidence for an improved system is presented. The proposed system is based on statistically valid data, has good patient distribution, and an orderly progression for therapy and prognosis. In addition, it is well suited for computer programming and for the comparison of patients and therapy, as well as for delineating the natural history of vulvar cancer.

A postretention study of patients presenting with a maxillary median diastema

The purpose of this study was to assess postretention stability of maxillary midline diastema closure, to search for predictors of relapse, and to test for associations between relapse and other postretention changes. The sample consisted of 35 patients with pretreatment diastemas ranging from 0.9 mm to 3.0 mm (mean 1.4, SD = 0.5) following eruption of the maxillary canines. Data were gathered from treatment charts, study models, periapical radiographs, and cephalograms taken pretreatment, posttreatment, and 1 to 26 years postretention (mean 11.4, SD = 6.4). Measurable diastema relapse was observed in only 12 cases. The majority of the relapse was 0.6 mm or less, and maximum relapse was 3.0 mm. Abnormal frenums and/or intermaxillary osseous clefts did not appear to be risk factors for relapse, and no pretreatment predictors of relapse could be established. The only posttreatment change associated with diastema relapse was proclination of the maxillary incisors (p < 0.01).