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\begin{document}


\def\RunningAuthor{Sumathi Felicita A et al.}
\firstPage{847}
\articleType{Original Article}
\receivedDate{10 Aug 2020}
\acceptedDate{17 Sep 2020}
\revisedDate{15 Sep 2020}
\journalVolume{2020, 11 (SPL3)}
\journalDoi{ijrps.v11iSPL3.3035}
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\title{\textbf{Prevalence of midline diastema and its correlation with high Frenal attachment}}
\author{Shivanni~S~S\textsuperscript{1},  
            Sumathi~Felicita~A\textsuperscript{*}\textsuperscript{2}, 
            Balakrishna~R~N\textsuperscript{3}~\\[5pt]{\textsuperscript{1}Saveetha dental college and hospitals, Saveetha institute of medical and technical sciences, Saveetha University, Chennai-600077, Tamil Nadu, India}~\\{\textsuperscript{2}Department of Orthodontics, Saveetha dental college and hospitals, Saveetha institute of technical and medical sciences, Saveetha University, Chennai-600077, Tamil Nadu, India}~\\{\textsuperscript{3}Department of oral and maxillofacial surgery, Saveetha dental college and hospitals,  Saveetha institute of technical and medical sciences, Saveetha University, Chennai-600077, Tamil Nadu, India}}

\begin{abstract}
The aim of this study is to assess the prevalence of midline diastema in the South Indian population and to find its correlation with high frenal attachment. The study includes patients visiting the department of orthodontics. The data was collected from the digital archives of the institution. Intraoral photos were assessed. A total 305 patients who reported to the department of orthodontics from June 2019 to March 2020 were screened. The causes of diastema namely presence of high frenal attachment, generalised spacing and periodontal disease, were evaluated. The results were statistically analysed using chi-square tests and graphs were tabulated. A total of 305 patients were screened, among which midline diastema was present in 22.3\% (68) of the cases. High frenal attachment  was found in 52\%, generalised spacing in 36\% and periodontal disease in 12\% of the cases.  The mean age of the patient was 23\ensuremath{\pm}5.25 years. The incidence of midline diastema was found to be 22\%. High frenal attachment was found to be the most common etiology. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Midline diastema,\newline High frenal attachment,\newline Generalised spacing,\newline Periodontal disease
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sumathi~Felicita~A~\\ Phone:\ ~\\  Email:\ sumifeli@hotmail.com 
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
The presence of diastema between the maxillary central incisors in adults is often considered as an aesthetic or malocclusion problem \unskip~\citep{877379:20255074}. Midline diastema is a dento-alveolar disorder that causes special concerns to patients \unskip~\citep{877379:20255084}. It is also known as open teeth or gapped teeth \unskip~\citep{877379:20255084,877379:20255090}. It is the spacing in the anterior midline region measuring more than 0.5mm between the proximal surfaces of central incisors \unskip~\citep{877379:20255086}. 

Nainar \textit{et al} \textit{. } define true midline diastema to be one without periodontal or periapical factors and with the presence of all anterior teeth in the arch \unskip~\citep{877379:20255086,877379:20255081} whereas, Attia defines it as spaces of varying magnitude between the crowns of fully erupted incisors \unskip~\citep{877379:20255092}.

Maxillary midline diastema is aesthetic problem appearing in children and affecting adults and adolescents irrespective of gender and ethnicity \unskip~\citep{877379:20255081,877379:20255092}. 

Midline diastema is caused by many etiological factors like the disproportion between teeth sizes and dental arch length, abnormal labial frenum attachment between central incisors \unskip~\citep{877379:20255075,877379:20255073}. Also, congenitally missing or extracted incisors or canine impaction, peg lateral incisors can also be minor causes.\ensuremath{^{}}

This study aims in finding the prevalence of midline diastema and its etiology among patients reporting to our institution.
    
\section{Materials and Methods}
The study was conducted in the department of orthodontics of our institution. A total of 305 patients attending the department of orthodontics from June 2019 to March 2020 were screened. 68 patients were diagnosed with midline diastema and were assessed for etiology. Intraoral photographs of the patients were collected from the digital archives of the Dental Information Archive System of the institution and assessed for etiology. The distribution among male and female patients was assessed and evaluated. The most common cause of midline diastema namely high frenal attachment, generalised spacing and periodontal disease were assessed. The data obtained were subjected to statistical analysis using SPSS software version 25. Descriptive analysis and chi-square tests were performed and graphs were tabulated.
    
\section{Results and Discussion}
The mean age of the patient was 23\ensuremath{\pm}5.25 years. 


\begin{table*}[!htbp]
\caption{\boldmath {Shows the frequency and percentage of midline diastema among the study population} }
\label{tw-cd5c57bc2724}
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\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack Prevalence of midline diastema}\\
\rowcolor{kwdboxcolor} & Frequency  & Percent\\
\tblmidrule 
midline diastema  &
  68  &
  22.3 \\
no midline diastema  &
  237  &
  77.7 \\
Total  &
  305  &
  100.0 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Shows the frequency and percentage of etiology of midline diastema among the study population} }
\label{tw-319fcca2ef8f}
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\tbltoprule \rowcolor{kwdboxcolor}\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{\cAlignHack Etiology of Midline Diastema }\\
\rowcolor{kwdboxcolor} & Frequency  & Percent \\
\tblmidrule 
High frenal attachment  &
  36  &
  3.6l \\
Generalised spacing  &
  25  &
  2.5 \\
Periodontal disease  &
  7  &
  .7 \\
Total  &
  68  &
  6.8 \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Shows the frequency and percentage of the gender distribution of the study population} }
\label{tw-084b996e8b1f}
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\rowcolor{kwdboxcolor} &  & Frequency & Percent \\
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\multicolumn{1}{p{\dimexpr(.22509999999999998\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{Valid }} &
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  5.0 \\
 &
  Female  &
  18  &
  1.8 \\
 &
  Total  &
  68  &
  6.8 \\
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\begin{table*}[!htbp]
\caption{\boldmath {Shows the chi-square test conducted to assess the correlation between the etiology of midline diastema gender among the study population} }
\label{tw-9e2235192d8a}
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\tbltoprule \rowcolor{kwdboxcolor} &  & \multicolumn{2}{p{\dimexpr(.2384\linewidth-2\tabcolsep)}}{\cAlignHack Gender } & Total & Sig.\\
\rowcolor{kwdboxcolor} &  & \cAlignHack Male  & \cAlignHack Female &  & \\
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 &
   &
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  \cAlignHack \\
\multicolumn{1}{p{\dimexpr(.30380000000000003\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{Etiology of Midline Diastema }} &
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  \cAlignHack 25  &
  \cAlignHack 11  &
  36  &
  0.52 \\
 &
  Generalised spacing  &
  \cAlignHack 20  &
  \cAlignHack 5  &
  25  &
  \\
 &
  Periodontal disease  &
  \cAlignHack 5  &
  \cAlignHack 2  &
  7  &
  \\
\multicolumn{2}{p{\dimexpr(.5606\linewidth-2\tabcolsep)}}{Total } &
  \cAlignHack 50  &
  \cAlignHack 18  &
  68  &
  \\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

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\caption{\boldmath {Shows the frequency distribution of the midline diastema among the study population}}
\label{f-af1b8a99d11b}
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\caption{\boldmath {Shows the frequency distribution of etiology of midline diastema among the study population}}
\label{f-0b4afeef8ae2}
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\caption{\boldmath {Shows the Gender distribution of the study population}}
\label{f-7c25065c0430}
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\caption{\boldmath {Shows correlation between the etiology of midline diastema and gender among the study population}}
\label{f-8eec5dc5f114}
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\textbf{Prevalence of midline diastema }

Out of 305 patients, 68 patients had midline diastema, which is about 22.3\% which included both males and females. Table~\ref{tw-cd5c57bc2724} and Graph~\ref{f-af1b8a99d11b} shows the prevalence of midline diastema. 

\textbf{Etiology of midline diastema }

Among the patients diagnosed with midline diastema, the etiology was found to be high frenal attachment in 52\%, generalised spacing in 36\% and periodontal disease in 12\% of the cases. Table~\ref{tw-319fcca2ef8f} and Graph~\ref{f-0b4afeef8ae2} shows the different etiologies of midline diastema prevalent among the population.

\textbf{Gender predilection }

It was found that male distribution was predominant with 73\% of cases whereas females were only about 27\%.

Table~\ref{tw-084b996e8b1f} and Graph~\ref{f-7c25065c0430} shows the gender distribution of the study population.

\textbf{Association between etiology and gender }

Among the given population, high frenal attachment was found among 25 males and 11 females, generalised spacing among 20 males and 5 females, periodontal disease among 5 males and 2 females. Table~\ref{tw-9e2235192d8a} and Graph~\ref{f-8eec5dc5f114} shows the association between etiology of midline diastema and gender among the study population.

In Graph~\ref{f-af1b8a99d11b}, X axis corresponds to the prevalence of midline diastema and Y axis corresponds to the number of patients. The colour red denotes patients without midline diastema and the colour purple denotes patients with midline diastema. Midline diastema was found in 68 patients. In table 2, The etiology of midline diastema was found to be High frenal attachment in 36 patients, Generalised spacing in 25 patients and Periodontal disease in 7 patients. The prevalence of midline diastema was found to be 22.3\% in Table~\ref{tw-cd5c57bc2724}.

In Graph~\ref{f-0b4afeef8ae2}, X axis corresponds to the etiology of midline diastema and Y axis corresponds to the number of patients. The colour pink denotes high frenal attachment, colour yellow denotes generalised spacing and colour orange denotes periodontal disease. High frenal attachment was found among 36 patients, generalised spacing among 25 patients and periodontal disease among 7 patients. In Table~\ref{tw-319fcca2ef8f}, The etiology of midline diastema was found to be High frenal attachment in 36 patients, Generalised spacing in 25 patients and Periodontal disease in 7 patients.

In Graph~\ref{f-7c25065c0430}, X axis corresponds to the gender and Y axis corresponds to the number of patients. The colour blue denotes males and colour green denotes females. There was a higher male distribution (50 cases) than females (18 patients). It shows a male distribution in 50 patients and female distribution in 18 patients in Table~\ref{tw-084b996e8b1f}.

In Graph~\ref{f-8eec5dc5f114}, X axis corresponds to the etiology of midline diastema and Y axis corresponds to the gender of the patients. The colour blue denotes male population and green denotes female population. All the etiologies were more prevalent in males than females. However, this is statistically not significant (Pearson chi-square test; P-value = 0.520 - not significant). In Table~\ref{tw-9e2235192d8a}, P-value obtained {\textgreater}0.05. It shows an insignificant association between the two parameters. (p-value = 0.520)

In the present study it was found that, among the given population, prevalence of midline diastema was found to be 22\% and the major etiological factor was high frenal attachment with a percentage of 52\%. This was similar to a study that showed prevalence of midline diastema to be 23\%, but the major causative factor was generalised spacing [39\%]  \unskip~\citep{877379:20255081,877379:20255092}. A study reported that black children exhibit a higher prevalence [19\%] of midline diastema than white children \unskip~\citep{877379:20255073,877379:20255071}. In another study, the prevalence of midline diastema was recorded to be 7.3\% and shows a higher frequency among females \unskip~\citep{877379:20255073,877379:20255068,877379:20255071}. A similar study shows the prevalence of midline diastema to be 6.8\% \unskip~\citep{877379:20255088}. A study done in Kenya shows that 35\% of the population showed midline diastema. Another study, states that the primary factors contributing to maxillary diastema appear to be degree of spacing or crowding in most cases and that the frenal attachment making a minor contribution \unskip~\citep{877379:20255072}. Considerable research has been conducted in the field of orthodontics \unskip~\citep{877379:20255080,877379:20255077,877379:20255083} with relevance to the current population under study \unskip~\citep{877379:20255079,877379:20255069,877379:20255078}. 

An attempt was made in this study to identify the prevalence of midline diastema \unskip~\citep{877379:20255087,877379:20255067} and its etiological factors among the population \unskip~\citep{877379:20255085,877379:20255091,877379:20255070}. Further studies with a larger population is advised \unskip~\citep{877379:20255089,877379:20255082,877379:20255076}.
    
\section{Conclusion}
This study shows the prevalence of midline diastema to be 22.3\%. The most common cause of midline diastema was found to be high frenal attachment, being present in 52\% of the patients.

\textbf{Conflict of Interest}

The authors declare that there is no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that there is no funding support for this study.
    

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