Multidisciplinary Management of a Severe Maxillary Midline Diastema: A Clinical Report Nazmiye S ¸ en, DDS, PhD & Sabire Is ¸ ler, DDS, PhD Department of Prosthodontics, School of Dentistry, University of Istanbul, Istanbul, Turkey Keywords Laminate veneers; midline diastema. Correspondence Dr. Nazmiye S ¸ en, Department of Prosthodontics, School of Dentistry, University of Istanbul, C ¸ apa/ Fatih, Istanbul 34093, Turkey. E-mail: nazmiye.sonmez@istanbul.edu.tr The authors deny any conflicts of interest related to this study. Accepted August 8, 2018 doi: 10.1111/jopr.12979 Abstract A maxillary midline diastema (MMD) is a common form of incomplete occlusion and often is a primary complaint of patients during dental consultations. MMD is considered to be a multifactorial phenomenon and can therefore be best restored with a multidisciplinary approach. This clinical report presents a multidisciplinary approach to the management of a 4.0-mm MMD by using limited orthodontics combined with periodontal and prosthodontic treatments. Diastema is defined as the gap or space between two or more consecutive teeth. 1 The presence of a diastema between ante- rior teeth is a common complaint of patients. 2,3 A diastema greater than 0.5 mm between the two maxillary central incisors is described as a common form of incomplete occlusion. 4 A maxillary midline diastema (MMD) greater than 2 mm in the mixed dentition is unlikely to close spontaneously. 1-3 An MMD can cause an unpleasant appearance, impaired speech, and lip biting. 2-4 In addition to poor esthetics, adverse psychological effects of MMDs on patients are also reported. 2,4 A carefully de- veloped diagnosis and comprehensive treatment planning are essential before restoring MMDs to ensure satisfactory and long-lasting esthetic results. 3,5 Etiological factors, the patient’s needs, and various treatment options should be considered be- fore formulating a definitive treatment plan. 2-4 Several etiologi- cal factors contributing to the development of MMDs have been reported. 3-5 Some of the causes include enlarged labial frenum, tooth size or shape discrepancy, congenital absence of lateral incisors, pathologies, hereditary or ethnic features, defects in the intermaxillary suture, and tongue and lip habits. 4-8 There is no agreement on a single etiological factor contributing to the development of MMD. 1 Thus, it is considered to be a multi- factorial phenomenon and should therefore be restored with a multidisciplinary approach. 9 Several methods have been documented for treating MMDs with the assistance of different dental disciplines including orthodontics, prosthodontics, operative dentistry, and periodontology. 4,9 Orthodontic correction represents a conservative technique to achieve a pleasant esthetic result but is expensive and time consuming. 4,10 Furthermore, orthodontic treatment alone may not be adequate to establish ideal proximal contacts with sufficient vertical and horizontal overlaps when tooth size and shape discrepancies exist. 3,6-8 Restoration of MMDs with direct bonding, laminate veneers, or crowns each provide the opportunity to control both tooth size and form. 9,10 However, a limited orthodontic treatment may help to redistribute the spaces between the maxillary anterior teeth before prosthodontic treatment to optimize results. 1 This clinical report describes a multidisciplinary approach to a clinical situation with 4.0 mm MMD by using limited orthodontic, periodontal, and prosthodontic treatments. Clinical report A 46-year-old, caries-free female patient in good health presented to the Department of Prosthodontics, School of Dentistry, University of Istanbul clinic with a chief compliant of space between her maxillary anterior teeth (Fig 1). Clin- ical examination revealed a 4.0-mm diastema between the maxillary central incisors and a Class I dental relationship. Periodontal examination revealed a thin gingival biotype, enlarged labial frenum, and a fairly symmetrical gingival architecture. The patient demonstrated good periodontal health with no periodontal pockets and 0.84 plaque index score. Over-retained and hopeless bilateral maxillary primary canines were observed during clinical examination. Radiographic 1 Journal of Prosthodontics 0 (2018) 1–5 C  2018 by the American College of Prosthodontists