Spacing between the maxillary anterior teeth is a common concern for young patients and their parents. Patients often consider a diastema to be an annoying but minor problem; they might consult their general dentists for help, or try to address the issue themselves by applying elastic “gap bands.” Moreover, parents, without any informed consent, sometimes accept this erroneous method as an easy and inexpensive treatment approach. A 9-year-old boy had severe acute periodontitis involving the maxillary central incisors caused by the placement of an elastic band and its apical migration. Despite periodontal and surgical interventions, the maxillary central incisors were finally extracted, and the patient started orthodontic treatment. The orthodontic treatment plan included maxillary lateral incisor substitution to replace the lost central incisors and mesialization of the maxillary posterior dentition. An interdisciplinary approach with excellent cooperation among the orthodontist, general dentist, and other dental specialists obtained an esthetically pleasing and optimized functional result. Treating the diastema between the anterior teeth with elastic gap bands and without fixed orthodontic appliances should be avoided. Patients should seek proper orthodontic advice for even small-scale orthodontic problems to prevent catastrophic outcomes, as exhibited in this case report.
Highlights
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A 9-year-old boy had acute periodontitis involving the maxillary central incisors.
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An elastic band around the apices of the central incisors was found and removed.
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The teeth could not be saved and were eventually extracted.
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Lateral incisor substitution for the maxillary central incisors was chosen.
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Inappropriate use of gap bands can result in periodontal destruction and tooth loss.
Spaces in the maxillary anterior region have a variety of causes including tooth-arch and tooth-size discrepancies, abnormal frenum attachment, anteriorly proclined incisors, loss of periodontal support, and dental migration. Moreover, the diastema between the maxillary central incisors usually observed during the early mixed dentition is often spontaneously corrected with the eruption of the maxillary lateral incisors and subsequently of the maxillary canines. Parents may worry when they see such spaces in the anterior maxillary region, and seek consultation from their general dentist or family friends. Parents might be offered the “simple and inexpensive solution” of an elastic band, which the patient wears continuously or replaces daily with a new band.
Major adverse effects are associated with this approach, and young patients and their guardians should be aware of the risks. Due to the tapering anatomy of the central incisor root, the elastic band can easily slip toward the neck of the tooth and move apically along the periodontal ligament on its path to the tooth’s apex. This adverse effect is often irreversible and causes significant bone loss that jeopardizes the tooth’s stability and prognosis. Experimental studies in animal models have shown that placing an elastic band around a tooth can cause acute periodontitis.
Diagnosis and etiology
A boy, age 8 years 2 months, was brought to the Pediatric Dentistry Department of the Dental School of the National and Kapodistrian University of Athens in Greece complaining of pain and swelling around his maxillary central incisors. The clinical examination showed that the maxillary central incisors were extruded; they exhibited grade 2 mobility. The parents mentioned that they had used an elastic gap band to close the gap between the central incisors. They said that the rubber band was visible for 2 days, and then they could not see it anymore. They believed that the elastic band had most likely broken but were unconcerned since the gap was successfully eliminated, and everybody was happy with this do-it-yourself treatment. During the consultation at the pediatric dentistry department, a passive 0.018-in Australian archwire was bonded onto the labial surfaces of the maxillary central incisors and deciduous canines to stabilize the mobile teeth ( Fig 1 ). The patient was referred to the Department of Periodontology for further evaluation.
The periodontal examination of the maxillary central incisors confirmed grade 2 mobility with pocket depth measurements of 10 mm. The radiographic evaluation consisted of panoramic and periapical x-rays of the maxillary anterior region ( Fig 2 ). Vertical bone loss was shown radiographically, and the teeth were estimated to have lost more than 75% of their bone support. The periodontal diagnosis was acute severe periodontitis for an unknown reason. The rest of the dentition had no periodontal problems. The patient was seen every week, and the mobility of the incisors continued to worsen. Three weeks after the initial visit, it was decided to intervene surgically. Under local anesthesia, the periodontist performed open flap debridement with deep scaling of the roots. An elastic band around the apices of the 2 central incisors was found and removed. Emdogain was applied along the root surfaces to enhance bone turnover, ostein regeneration, and periodontal ligament reattachment. The flaps were sutured, and the patient was administered amoxicillin for a week ( Fig 3 ). A new passive wire was bonded to stabilize the maxillary central incisors, and the patient was referred to the Department of Orthodontics.
Upon orthodontic screening, the facial evaluation showed increased lower face height with a convex soft tissue profile, and lip incompetence in a relaxed position. The intraoral examination showed that the patient was in the intertransitional phase of the mixed dentition with a Class I molar relationship on the left side and a Class II molar relationship on the right side. Overjet was 3.5 mm, overbite was 7 mm, and the mandibular midline was deviated 3.5 mm to the right relative to the facial midline ( Figs 1 and 4 ). Also, according to the Moyers analysis, the patient had 1.2 mm of crowding on the maxillary left side and 0.3 mm of spacing on the right side, resulting in a total of 0.9 mm of crowding in the maxillary arch. In the mandibular arch, the tooth-arch discrepancy included 5.4 mm of crowding in the right quadrant and 1.5 mm of excess space in the left quadrant, resulting in a total of 3.9 mm of mandibular crowding. To maintain the leeway space, a mandibular lingual holding arch had been previously placed by the pediatric dentist.
The cephalometric analysis ( Fig 5 ; Table ) showed a skeletal Class I relationship (ANB angle, 3.3°) with a normally positioned maxilla and a slightly retrusive mandible. The patient had no further skeletal discrepancies, and the positions of the maxillary and mandibular incisors as well as the interincisal angle were within normal limits. His smile was unattractive because of the extruded maxillary central incisors, and mentalis muscle strain was observed upon lip closure.
| Pretreatment | Norm | Posttreatment | |
|---|---|---|---|
| Skeletal | |||
| SNA (°) | 78.4 | 82 | 77.6 |
| SNB (°) | 75.5 | 80 | 75.2 |
| ANB (°) | 2.9 | 2.8 | 2.4 |
| SNPog (°) | 77.1 | 81 | 77.8 |
| FMA (°) | 27.4 | 25 | 26.5 |
| SN-PP (°) | 10.9 | 8.5 | 13.2 |
| y-axis (°) | 54.4 | 59 | 53.9 |
| UFH/TFH (mm) | 44.4 | 44 | 45.6 |
| LFH/TFH (%) | 55.6 | 56 | 54.4 |
| GoGn-SN (°) | 35.6 | 32 | 34.1 |
| Dental | |||
| U1-FH | 109.7 | 110 | 119 |
| U1-SN (°) | 107 | 110 | 97,9 |
| U1-PP (°) | 108.8 | 110 | 120.3 |
| U1-APog (°) | 22.2 | 22 | 29 |
| U1-APog (mm) | 4.1 | 2.5 | 5.2 |
| IMPA (°) | 84.6 | 90 | 88.7 |
| L1-APog (°) | 19.5 | 23 | 25.2 |
| L1-APog (mm) | −0.2 | 0 | 1.8 |
| Interincisal angle (°) | 138.3 | 135 | 125.7 |
| Soft-tissue | |||
| Nasiolabial angle (°) | 110 | 105 | 103.5 |
| Upper lip to E-plane (mm) | −1.7 | 0 | −3.7 |
| Lower lip to E-plane (mm) | 0.8 | 1 | −2.5 |
| Z-angle (°) | 74.8 | 78 | 73.8 |
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