Association Of High Frenal Attachment And Midline Diastema

Keywords

Etiology; High Frenal Attachment; Midline Diastema; Orthodontic Treatment.

Introduction

Aesthetics and function are the two most important goals of modern-day dentistry [1-3]. Midline diastema is one of the most frequently seen malocclusions.Andrews described the dental midline diastema as a rather common form of incomplete occlusion characterized by a space between the maxillary and mandibular central incisors [4]. A midline diastema is generally considered a part of normal dental development during mixed dentition period [5, 6]. However, there are multiple factors which can cause diastema between the maxillary central incisors in adults, which is an esthetic problem that can be closed either orthodontically or restoratively [7-9].

The frenum is a mucous fold that serves as an attachment for lips and cheeks to the alveolar mucosa, the gingiva, and periosteum. This frena hampers the gingival health when they are attached too close to the marginal gingiva. This happens either due to an interference in the plaque control or to a pull by muscle [10, 11]. The maxillary frenum presents with aesthetic problems and can also compromise the orthodontic treatment outcome in cases of midline diastema, therefore causing recurrence after the treatment [12]. An abnormal frenum can be managed by frenectomy [13]. Abnormal frenum is detected visually by observing movement of the papillary lip after applying tension and also by blanching seen due to ischemia of the region. Midline diastema due to high frenal attachment may be caused by the attachment of the labial frenum into the notch in the alveolar bone so that a band of heavy fibrous tissue lies between the central incisors making them erupt wide apart [14, 15]. Other causes for spacing between the maxillary incisors can be microdontia; macrognathia, supernumerary teeth,peg laterals,missing lateral incisors,midline cysts and habit s such as thumb sucking, mouth-breathing and tongue-thrusting [16, 17].Treating the midline diastema is a problem for the dental practitioner as many different aetiologies are reported to be associated with it [18, 19].

The incidence of midline diastema ranges from 1.6% to 25.4% and is inversely proportional to age [20]. Exact diagnosis and removal of the etiology is the key to obtain stable results in the treatment of midline diastema [21, 22]. Therefore this study was conducted to evaluate the association of high frenal attachment and midline diastema.

Materials and Methods

This is a retrospective university setting study conducted in Saveetha dental college and hospitals. Population selection was random. Approval was obtained from the institutional study committee (IEC). The ethical approval number for the present study is SDC/SIHEC/2020/DIASDATA/0619-0320. Two examiners were involved in the study.Data of patients who reported to Saveetha Dental College were reviewed. The data was entered in the college system in a methodical manner. For the present study, data of orthodontic patients were reviewed. Clinical examination, orthodontic diagnosis and photographs of these patients were evaluated to find the presence of midline diastema and high frenal attachment. A total of 700 case records were reviewed. Cross verification of data for error was done by presence of additional reviewer and by photographic evaluation. Simple random sampling was done to minimize sampling bias.This study was generalized to the south Indian population. After reviewing 700 case records,filtering was done based on data required. The final sample size was 260 patients with midline diastema.

The data was entered in excel manually and imported to IBM SPSS software for analysis. Independent variables included age, gender and high frenal attachment. Dependent variables included midline diastema. Descriptive and inferential statistics was used. Incomplete or censored data was excluded from the study.

Results and Discussion

High frenal attachment was present in 38.8% of the individuals with midline diastema. Younger age group had more prevalence of high frenal attachment and males showed more prevalence of high frenal attachment than females.

In the age group of 10 to 35 years, 42.4% of the individuals showed high frenal attachment. High frenal attachment accounted for 37.5% in the age group of 36 to 50 years and 11.2% in the age group of about 50 years (figure1). P value was 0.034. Hence,association between age of the patients with midline diastema and high frenal attachment is statistically significant..Out of 157 males with midline diastema, 40.2% of them had high frenal attachment. Out of 103 females with midline diastema, 36.8% of them had high frenal attachment (figure 2). P value was 0.621, hence, association between gender of the patients with midline diastema and high frenal attachment is statistically not significant. High frenal attachment was prevalent in 38.8% of the patients with midline diastema. Majority, that is 61.1% of the patients with midline diastema had high frenal attachment (figure3).

Campbell et al., stated that midline diastema could be transient or created by developmental, pathological or iatrogenic factors [23]. Treatment of diastema varies and it requires correct diagnosis of its etiology and early intervention relevant to the specific etiology. Correct diagnoses include medical and dental history, radiological and clinical examination and possibly tooth size evaluation [23, 24].

In contrast to the results of this study, Kaimenyi and Adams , reported in their study that hypertrophic labial frenum is considered as a major aetiological factor for midline diastema [25]. However, some researchers, like Popovich et al, believe that there is an inverse relationship between high frenal attachment and midline diastema [26]. According to them, labial frenum persists owing to the existing diastema and, as the dentition applies minimal pressure on the tissues, there is little or no atrophy of the frenum. Kamath M K et al stated that enlarged labial frenum is considered a contributing factor for persistent diastema but is attributed only to a small proportion of cases [27].

According to Bennett et al [28] the maxillary midline diastema is caused by a high labial frenum, but the stability of space closure is not influenced by frenulum excision. Gardiner [29] also supported this view.This was contradicted by Haynes who stated that high frenum is an effect and not a cause for the incidence of diastema [30]. But most of the researchers agree that removal of the high bulbous labial frenum is important for the stability after the closure of the midline diastema [31].

Reji Abraham states that several aetiological factors are reported and discussed in the literature and no single aetiological factor is agreed upon for the development of a midline diastema [32]..

Similar to the present study, Jonathan P T et al observed high frenal attachment commonly in younger age group which he stated may be due to apical migration of frenum over time [33]. Taylor observed in his study that as age increased, the percentage of diastema significantly decreased [34]..

Spilka and Mathews stated that relapse is a major concern in the correction of midline diastema [35]. Thus exact diagnosis and removal of the aetiology is the key to obtaining a stable result in treatment of midline diastema..

This study could pave way for more research to be done on the etiology of midline diastema which will help in accurate diagnosis and provide successful treatment options.The limitations of the study are limited to certain demographics and limited study samples.

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Conclusion

Within the limitations of the study, it can be concluded that association of high frenal attachment in patients with midline diastema was significant. Also high frenal attachment in midline diastema patients was observed predominantly in males in the younger age group.