Management of diastemas in

orthodontics
Samir E. Bishara, B.D.S., D. Orth., KS.*
Iowa City, Iowa

D iastemas are spaces or gaps between two or more consecutive teeth.

They can occur anywhere in the upper or lower dental arches, and they can be
caused by different etiologic factors. It is the purpose of this article to discuss
some of the causes as well as the treatment of the diastemas commonly seen in an
orthodontic practice.
From an orthodontic standpoint, diastemas can be divided into two cate-
gories : (1) those present before the beginning of orthodontic treatment, and (2)
those present either before the removal of the bands but after the teeth are moved
to their desired anteroposterior and vertical relations or after the bands and/or
retainers are removed or discontinued.

Diastemas not caused by orthodontic treatment

1. In the deciduous dentition diastemas are a common and normal occurrence.

Spacing may be seen between several teeth or in localized areas, usually distal
to the upper deciduous lateral incisors and lower deciduous canines. These spaces
are called primate spaces.
2. In the permanent dentition diastemas may be the result of one or any
combination of the following factors :
A. Diastemas usually are a normal stage in the development of the
dentition, specifically between the ages of ‘7 and 12 years. Usually these
diastemas close completely after eruption of the permanent maxillary
canines.
B. Diastemas due to genetic factors may be localized, as between maxil-
lary central and/or lateral incisors (Fig. 1) , or generalized, such as those
present with small teeth in relatively large jaws. Under this heading one
can include spaces caused by tooth-size discrepancies, and these can be
subdivided as follows :

*Assistant Professor of Orthodontics, College of Dentistry, University of Iowa.

56 Bishnra Am. J. Orthod.
January1972

Fig. 1. Diastemas due to genetic factors.

(1) Interarch discrepancies (for example, when t,he total mesio-

distal diameter of the teeth in one arch is relatively larger than that of
the opposing arch). Such a discrepancy might be limited to the anterior
segments, as reflected in an accentuated overbite or overjet, or in the
posterior segments, as reflected in a less than optimal interdigitation.
(2) Interarch discrepancies (for example, peg-shaped lateral in-
cisors or congenitally missing teeth.) (Figs. 2, B and 5, A).
C. Ethnic or racial characteristics, such as interincisor diastemas which
are more frequently seen in Negroes than in Caucasians. This may or
may not be related to the tendency of Negroes to have a bimaxillary
dental protrusion.
D. Labial frenums preventing the maxillary central incisors from
moving toward each other, even after eruption of the remaining dentition
(Fig. 3). The labial frenum in such situations is seen to be attached to
the crest of the premaxillary ridge and/or the incisal papilla. One
diagnostic test that helps determine the role of the frenum, according to
Graber,l is the “blanche test” in which blanching of the tissues just lingual
to the maxillary central incisors can be noted when the upped lip is pulled
up. The presence of a midline alveolar cleft between the two central in-
cisors in a periapical roentgenogram may help in confirming the diagnosis.
E. Rotated teeth, which may cause diastemas to appear.
F. A supernumerary tooth or supernumerary teeth (for example,
mesiodens which are frequently discovered between the separated maxil-
lary central incisors).
EzT:r6: Management of diastemas in orthodontics 57

Fig. 2. A, Diastemas due to congenitally missing maxillary lateral incisor. B, Space opened.
C, Temporary denture and retainer.

G. Certain pathologic conditions, such as extensive proximal decay,

may give the appearance of a diastema. Periodontitis, cysts, and tumors
may cause separation of teeth. Spaces might be caused by the removal of
teeth, followed by migration of the neighboring teeth into the extraction
space.
H. Thumb-sucking, lip biting (Fig. 4, A), and tongue-thrusting habits
may cause maxillary and/or mandibular anterior teeth to tip labially.
Diastemas associated with or appearing after orthodontic treatment

1. Diastemas may result from the removal of teeth to obtain stable results. If
teeth are tipped into the extraction spaces, diastemas often open as soon as the
58 Bkhara Am. J. Orthod.
Jantm-y1972

Fig. 3. Diastema due to labial frenum.

arch wires are removed and the patient is put into retention. These spaces are
most frequently seen between canines and second premolars when first premolars
are extracted.
2. Orthodontic treatment often necessitates the removal of dental units from
the maxilla and/or mandible. The sizes of the teeth removed are not necessarily
equal either in the same arch or between opposing arches. The amount of the
discrepancy varies, and consequently the amount of residual spaces varies. Such
discrepancies are usually apparent toward the end of orthodontic treatment (Fig.
4, B). These spaces are usually observed between the maxillary lateral incisors
and canines after completion of the retraction of the anterior segment.
Treatment

Initiation of orthodontic treatment to close diast,emas should be done after

close evaluation of certain aspects of the problem. The specific question to be
answered is : Does the diastema affect esthetics and speech, and is the patient
aware of its presence? If he is self-conscious about it, does he want to do some-
thing about it? Next, is the diastema self-cleansing, or are food impaction and
inflammation of the interdental tissues present? Finally, if spaces are mechani-
cally closed, would they stay closed or would they relapse?
The ultimate success in keeping the spaces closed after removal of the active
appliance and retainers will depend upon the following factors :
1. Removal of the cause of the diastema, when possible.
2. The inherent tendency of the tissues, whether periodontal or muscu-
lar, to regain their original shape and position, either partly or com-
Volume 61 Management of diastemas in orthodontics 59
Number 1

Fig. 4. A, Diastema due to lip biting. B, Diastema due to interarch tooth-size’ discrepancy
before hands are removed. C, Diastema appearing after case is put in retention.

pletely. This will depend on whether the new tooth position is in balance
with the surrounding tissues and also on whether retention time was
enough to allow adaptive changes in the tissues to occur, thus stabilizing
teeth in their newly acquired positions.
3. The fulf?llment of all orthodontic treatment objectives, including
the positioning of the teeth in a balanced position with optimal interdigita-
tion and axial inclinations.
These three factors, separately or combined, will greatly influence prognosis,
treatment planning, and retention. Accordingly, when deemed pertinent, the
 Am. J. Orthod.
60 Bishara Januar2/1972

above-mentioned generalized points will be considered in discussing the treat-

ment outlines of the different diastemas.

Treatment of diastemas not caused by orthodontic treatment

1. Diastemas present as part of the manifestation of the normal develop-

mental stage of the dentition should not be closed for fear of deflecting the roots
of the maxillary central incisors in the path of eruption of the lateral incisors.
The consequences of such an attempt are well known to the practicing ortho-
dontist. Moreover, such diastemas usually close when eruption of the permanent
canines is completed. This phenomenon has been termed by some as the “ugly
duckling” stage of dental development..
2. Diastemas caused by supernumerary teeth, cysts between the teeth, or the
presence of a fibrous epulis pushing the teeth apart should not be closed before
removal of the pathologic condition. This will prevent further damage to the
tissues and, at the same time, will greatly improve the chances of retaining the
treatment results.
3. The prognosis for diastemas caused by habits (thumb- and finger-sucking,
lip-biting, and tongue-thrusting) may range from good to poor, depending on
whether the patient is willing and/or able to stop his deleterious habit. Relapse
of these diastemas recurs in a greater percentage of those tongue-thrust cases in
which the cause of the habit is both unknown to the practitioner and difficult,
if not impossible, to treat. On the other hand, if the child stops the habit,
diastemas may close without help but, when needed, orthodontic treatment should
be considered.
4. If an abnormal labial frenum is diagnosed as the cause rather than the
result of the malocclusion at hand, surgical excision or permanent retention by
splinting together of the teeth should be considered if permanency of the ortho-
dontic results is to be attained. There is some disagreement as to whether surgical
treatment should be done before or after closure of the spaces. It seems preferable
to close the spaces orthodontically as early as possible during treatment and
then to perform the surgical procedure. The reason for such a sequence is to let
healing of the tissues occur with the teeth in their newly established and accept-
able positions.
5. Diastemas resulting from migration of teeth in residual spaces from con-
genitally missing or extracted teeth may be treated by one of two different ap-
proaches :
A. Use of an orthodontic appliance to open the space for the missing
tooth, followed by bridging of the space (Fig. 2, B) .
B. Orthodontic closure of all spaces in the arch. For example, if maxil-
lary lateral incisors are congenitally missing, the maxillary canines can be
moved into the position of the lateral incisors and the dentition treated to
a Class II molar interdigitation (Fig. 5, B). Or, if extraction of lower
first premolars is deemed necessary, the dentition can be treated to a Class
I molar relation. In either case, reshaping of the maxillary canines to re-
semble the lateral incisors is necessary.
Volume 61 Management of diastemas in orthodontics 61
Number 1

Fig. 5. A, Diastemas due to congenitally missing maxillary lateral incisors. 6, Diastemas

opening after complete closure. C, Connected pin onlays on maxillary anterior teeth. D,
Case in permanent retention.

It should be remembered that slight spacings may tend to recur in these

situations between either the maxillary central incisors, (Fig. 5, B) , the central
incisors and canines, or the canines and first premolars. When this happens and
reclosure of the spaces is considered, permanent retention (Fig. 5, C) is the only
insurance for the stability of the accomplished results (Fig. 5, D) .
6. Peg-shaped maxillary lateral incisors may cause diastemas to open between
the neighboring teeth through lack of proximal support. The peg-shaped lateral
incisors may be extracted if the root is short or resorbing and then treated as
stated above, or, if the roots are of good size and shape, a crown can be con-
structed after orthodontic movement of the teeth to their proper positions. In
the latter case, very little or no relapse should be expected.
‘7. Diastemas caused by rotated teeth are difficult to retain after closure be-
cause of the tendency of the rotated teeth to return to their original positions.
Different reasons were given to explain this phenomenon and, according to
Reitaqz the circular fiber of the periodontal ligament takes a long time to re-
organize and adapt to the new position. The presence of oxytalan elastic-like
fibers is also blamed for the relapse. Whatever the cause may be, the orthodontist
is still faced with the problem. Different solutions are suggested, including
overcorrection, early correction, long retention period, permanent retention,
62 Bishara Am. J. O&hod.
January1972

gingivectomies, and cutting of the gingival fibers by passing a scalpel in the

gingival SU~CUS,~thus releasing the tension of the overstretched fibers which
tends to pull the tooth back.
8. Generalized diastemas between the teeth caused by microdontia are diffi-
cult to close and retain. In general, complete closure of spaces is not advised. Two
alternatives are suggested: no treatment or full-mouth reconstruction if it is
esthetically or functionally needed and feasible.
Treatment of diattemas associated with or appearing after orthodontic treatment

1. Teeth which have been tipped into extraction sites during treatment will
tend sometimes to upright when the wires are removed and, in doing so, the
moving teeth cause spaces at the extraction site. To avoid such an undesirable
but often predictable change, it is a good policy to take a Panorex or periapical
films to check the axial inclinations of the teeth, specially those near the extrac-
tion site, before the completion of orthodontic treatment.
A similar situation exists when upper incisors are retracted by tipping the
crowns too much lingually. Unless their roots are also torqued lingually, one
may expect relapse with spacing appearing between the anterior teeth in certain
cases.
Needless to say, one of the criteria for a well-finished orthodontic case is
proper placement of the long axis of the teeth on basal bone and good relations
between the teeth and their opposing counterparts.
2. Spaces or “windows” mesial to the maxillary canines (Fig. 4, B and C),
resulting from removal of unequal tooth structure from the dental arches are
more difficult to treat. Every effort should be made to extract teeth of relatively
equal size on both sides of the same arch and from opposite arches. A diagnostic
setup may help visualize the finished product in many instances. This will prove
to be beneficial to both the orthodontist and the patient during the consultation.
The orthodontist should close such spaces, when possible, by :
A. Diminishing the overbite by intrusion of the maxillary incisors. In
doing so, the orthodontist puts the same mesiodistal diameter of the teeth
on a smaller arc; therefore, this tends to minimize or close any spaces
present. Postretention return can also be expected in some of the cases
treated in this way.
B. Lingual crown torque of the maxillary incisors, when feasible, will
put the incisal edges of the teeth on a smaller arch, in this way helping to
close spaces.
C. Distal root-tipping “artistic bends,” through minimally effective,4
are also used.
D. If the size of the maxillary lateral incisor is relatively small in com-
parison to the central incisor (but not necessarily peg shaped), oversized
crowns on the lateral incisors help solve the problem.
One should keep in mind that there is always the possibility of doing nothing
to such spaces if both patient and orthodontist are not overly concerned. In other
words, treatment is sometimes worse than the condition.
The last alternative in closing these spaces which, in my author’s opinion is
 Management of d&terms in orthodontics 63

the least desirable, would be to sacrifice posterior interdigitation to achieve

complete closure of the spaces mesial to the cuspids.
3. Constricting the dental arches and encroaching on the tongue space by
moving the teeth into an unbalanced position between the lingual and buccal
musculatures is an invitation to relapse and space opening. It should be re-
membered that the teeth in malocclusion are in a state of balance, and unless
their new position is in another state of balance with the surrounding environ-
ment posttreatment changes are to be expected. Measuring the width of the
dental arches (for example, intercanine width) before, during, and at the end
of treatment usually gives a good indication of what to expect. In most cases it
is a good treatment objective not to change the pretreatment intercanine width.
In summary, the causes of diastemas or spacings in the dentition are many.
What concerns the orthodontist is the tendency of some of these spaces to relapse
after closure. To avoid re-treatment of many of these cases, with all the associated
discomfort to both the patient and the orthodontist, every effort should be made
to diagnose properly and remove the cause of the diastema or to avoid its oc-
currence whenever this is predictable and possible.
During the original consultation, the patient and/or parents should be fully
aware of the possibility of relapse of such diastemas and should be familiar with
the different avenues available for treatment or prevention of the condition. In
certain cases (for example, microdontia or macroglossia) , orthodontic treatment
may be discouraged if spacings between the teeth are the only sign of maloc-
clusion. In extraction cases a diagnostic setup will help both the orthodontist and
patient visualize the final result of treatment in a more objective way. Needless
to say, the dentition should be placed on “basal bone” in a balanced position
between the buccal and lingual musculature with proper interdigitation and axial
inclinations.
REFERENCES

1. Graber, T. M.: Orthodontics, principles and practice, ed. 2, Philadelphia, 1968, W. B.

Saunders Company.
2. R&an, K.: The initial tissue reaction incident to orthodontic tooth movement, Acta
Odontol. &and., Supp. 6, 1951.
3. Edwards, J. G.: A surgical procedure to eliminate rotational relapse, AM. J. ORTHOD. 57:
3546, 1970.
4. Andreasen, G. F: Personal communication, August, 1971.