American Journal of ORTHODONTICS and DENTOFACIAL ORTHOPEDICS

Founded hz 1915--Seventy-five years of conthutous publication Volume 97 Number 6 June 1990 Copyright 1990 by Mosby-Year Book, hzc.

CLINICIANS' CORNER

The midline: Diagnosis and treatment

Laurance Jerrold, DDS* and L. Jeffrey Lowenstein, DMD** Massapequa and New York, N.Y.
The importance of coordinated midlines often is unappreciated as it relates to the treatment plan for the orthodontic case. All three of the patient's midlines--facial, maxillary, and mandibular--must be considered if ideal correction is to be achieved. Proper differential diagnosis of the cause will allow the practitioner to appropriately use either inter- or intraarch mechanics for the resolution of midline discrepancies. Midline correction should be undertaken from the initiation of treatment and once all midlines are coordinated they should be maintained as a guide for any further force systems used in completing the case. Functional, dental, and iatrogenic midline discrepancies are discussed perlaining to their diagnosis and treatment. (AMJ ORTHOD DENTOFACORTHOP 1990;97:453-62.)

M i d l i n e coordination and relative symmetry are basic to an appreciation of facial harmony and balance. Although a subtle asymmetry of the midlines is within normal limits, significant midline discrepancies can be quite detrimental to dentofacial esthetics. ~ Often the orthodontist is called on to treat cases involving significant facial and/or dental midline asymmetries. Differential diagnosis and appropriate interand intraarch mechanotherapy is necessary if one is to discern the proverbial forest from the trees regarding the cause and correction of this problem. Skeletal asymmetries and subsequent midline discrepancies are intentionally being omitted from discussion because they usually do not lend themselves to correction by way of orthodontic treatment alone. REVIEW OF LITERATURE A common cause for the majority of cases that finish short of an ideal result is a lateral discrepancy between the upper and lower dental center lines. 2 Once this discrepancy exists in the completed case, Breakspear 2 advocates adapting the occlusion by "stoning" (occlusal
*Associate Clinical Professor of Orthodontics, New York University College of Dentistry. **Formerly senior resident in orthodontics, New York University College of Dentistry, now in private practice of orthodontics, New York, N.Y. 8/1/10422

equilibration). This method of treatment allows the occlusion to function more properly but may not correct the dental or facial asymmetry. It is better to complete the case with the midlines coincident than to deal with this problem after active therapy has been completed. Lewis 3 espouses a set of questions necessary for differential diagnosis of midline discrepancies: (1) What has caused the midline deviation? (2) How does the deviation affect the occlusion? (3) Is it necessary to correct it? If correction is required, he advocates a sliding yoke and intermaxillary elastics. He states that this common and persistent problem (a midline deviation) exists mostly in Class II cases. The more frequent causes of midline discrepancies are a mandibular shift resulting from a posterior crossbite, tipping or drifting of the teeth, a lateral mandibular shift without a causative crossbite (mandibular rotation resulting from oeclusal interferences), arch asymmetries, tooth size discrepancies, or any combination of the above? 5 One typical cause not mentioned is the overretraction of the canines on one side, which sets the stage for a deviated midline after the anterior teeth are injudiciously retracted. This overretraction occurs because not enough attention is paid to the coordination of all three of the patient's midlines: facial, maxillary, and mandibular. Most literature pertaining to midline treatment deals with correcting any discrepancies toward the end of 453

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Fig. 1. Angle is Class III elastic with tandem anterior diagonal elastic in conjunction with area expansion for correction of midline discrepancies. From Angle EH. Malocclusion of the teeth. Philadelphia: SS White, 1907.

Fig. 2. Note tandem unilateral intermaxillary and anterior diagonal elastic traction.

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As requlred to malntaln desired molar relationship

Fig. 3. Space-closing elastics and Class II intermaxillary elastics applied at start of second stage of treatment. From Begg PR, Kesling P. Begg orthodontic theory and technique, 3rd ed. Philadelphia: WB Saunders, 1977.

Fig. 4. Double vertical spring loop auxiliary adjusted for the mass movement of the four incisor teeth to the left. From Strang R, Thompson W. A textbook of orthodontia. Philadelphia: Lea & Febiger, 1958.

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Fig. 5. A, Midline shifting arch wire. Midline is to be shifted to the patient's left. B, Midline shifting arch wire in place. Closing loop is made as close to the left canine as possible. C, Midline shifting arch wire activated. As the arch rebounds to its preactivated position, it will carry the four incisors with it to the patient's left. D, Midline shifting arch wire again passive. Note space mesial to right canine.

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Fig. 6. A, Maxillary midline needs to be shifted to patient's left. Note passive opening loop on right side and molar stop. Posterior segment is tip to tip. B, Note passive closing loop on left side with canines in Class I relationship. There is sufficient space between the lateral and canine teeth for en masse movement of the four anterior teeth. Molar stop preserves arch integrity. C, Closing loop is activated. Had mesial leg of loop been made closer to the canine bracket, a greater range of activation could have been achieved (not needed in this case). D, Arch wire activated by tying closing loop (not seen) to lateral incisor. Note degree of activation of opening loop. E, One month later. Note closing loop returned to passive position, space between lateral and canine teeth now closed; midline is corrected; and intercuspation of the buccal segment is still Class I canine. F, Arch wire can now be removed and the upper right posterior segment brought forward to establish a Class I canine relationship. Midline (not seen) has been corrected.

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treatment and most often approaches the problem by trying to correct the mandibular midline. Sufficient attention has not been paid to treating all three midlines coincidentally from the start of treatment. Angle 6 used a Class III elastic with a tandem anterior diagonal elastic in conjunction with arch expansion for the correction of midline discrepancies (Fig. 1). Proffit7 admits that minor discrepancies in midline coordination can be handled in the finishing stages with asymmetric Class II and Class III elastics as opposed tounilateral elastics or by using unilateral Class II or Class III intermaxillary elastics in tandem with an anterior diagonal elastic. He also notes that it is quite difficult to correct large discrepancies after extraction spaces have been closed. Alexanders advocates use of a heavy anterior diagonal elastic supported by a Class II or Class III elastic, depending on whether the original malocclusion was a Class II or Class III. This is done during the finishing stages, except in an extraction case in which it may be performed during space closure if there is a significant midline discrepancy. The anterior diagonal elastic is then attached to the closing loops (Fig. 2). Begg and Kesling9 state that the proper balancing of space-closing elastics coupled with appropriate Class II traction during stage II keeps the midlines coordinated with one another (Fig. 3). One may also augment a unilateral Class II elastic, an anteiior diagonal elastic, and a Class III elastic with uprighting springs to "walk the teeth" and effect midline changes. For the most part, the above-mentioned treatment modalities seem to link midline discrepancies and their correction with the cause being a mandibular shift or rotation of some sort. If this shift or rotation was not the causative factor but rather the midline deviation was a result of a dental shifting or drifting of teeth, with the face being symmetric, then use of such mechanics would effect a change in mandibular position. This would have the effect of coordinating the dental midlines but leaving the face asymmetric. If the mandible has been moved eccentrically and the joint comple x is unable to adapt, there is the potential for TMJ dysfunction. Gianelly and PauP advocated a biomechanical system for midline correction with second-order bends used to move teeth on one side distally and create a space for shifting the midline. Class II and Class III elastics "enhanced" the activity of the couple force systems. However, no mention was made of the effect on the position of the mandible as a result of the elastic traction used nor the differentiation between the two pertaining to the correction achieved. Lewis 3 espouses

the use of distal spring mechanics as opposed to secondorder bends, bolstered by a sliding yoke off Class II traction to distalize upper posterior teeth in cases exhibiting arch asymmetry. Thus the maxillary teeth on the Class II side are moved one by one distally until coincident midlines are achieved. Strang and Thompson" introduced a double vertical spring loop assembly to move the four incisors "en masse" (Fig. 4). The arch wire as originally designed has somewhat limited activation potential. A modification of this arch wire configuration using round wire (Fig. 5, A through D) would enable the practitioner to achieve a greater range of activation. This would result in a faster correction without the need for soldering spurs and without encountering the labiolinguai offset difficulties associated with the use of full-sized rectangular arch wires. A 0.020-inch arch wire is essentially divided into three parts: two posterior and one anterior. The arch wire thus is segmented. The two vertical loops allow for stabilization of the posterior segments as long as molar stops are used; hence only anterior movement takes place. The incorporation of a helix in each loop provides greater flexibility and longer activation. To activate, a ligature is passed through the circle on the closing loop side and tied to the contralateral lateral incisor bracket. Each tooth has been individually ligated to the anterior section of the arch, each posterior section having been ligated together as a unit. The closing loop is constructed as close as possible to the canine, with the section to be activated lying anterior to the helix. When the closing loop is activated, the opening loop is condensed and a push-pull reaction occurs whereby all four anterior teeth shift "en masse" toward the desired side. The use of a 0.020-inch arch wire in a wide 0.022-inch sloted Siamese edgewise bracket minimizes the tipping of these teeth (Figs. 6, A-F). The correction usually requires one to two visits. After anterior correction the arch wire is removed and the remaining posterior section may be conventionally brought forward according to the practitioner's individual technique. Finally, in cases in which the midline discrepancy is very slight (1 to 2 mm), it is tempting to tip the anterior teeth into a position that coordinates with the facial midline. If the lower midline is offto the opposite side, the temptation for correction by tipping is even greater. This is usually accomplished with uprighting springs augmented by an anterior diagonal elastic. Although this will produce a midline, the incisal aspects of which are symmetric with the midfacial place, esthetically the results are poor (Fig. 7).

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Fig. 9. Case 1.

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Fig. 7. A, Both dental midlines are off slightly to opposing sides of facial rnidline. B, After teeth are tipped toward each other, the incisal aspect of the midline is coincident,

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Fig. 10. Case 2.

Fig. 8.

Although this result may not create any problem from a functional standpoint since the anterior teeth can still disocclude properly and are not load-bearing in occlusion, it certainly is not healthy from a periodontal perspective. Depending on the patient's lip and smile line couple d with the amount the teeth have been tipped, a compromise of facial esthetics is almost inevitable.
CLINICAL EVALUATION

dibular midlines, and fall directly over s o . t i s s u e pogonion (Fig. 8). It is important to note Whether the patient has ever broken his or her nose or suffered from a deviated septum. This can mislead the unwary practitioner. The plumb line must bisect the dorsal nasal ridge equidistantly unless there is an asymmetric nose.
CASE 1

lVlidlines can be o f f in relation to one another in many ways. The following schematics allow for easy evaluation as to the differential diagnosis o f the midline discrepancy and the appropriate treatment. The initial evaluation should be directed toward the patient's face in habitual closure; Is the face symmetric? This is easily ascertained by dropping an imaginary plumb line from the center of glabella. This line should bisect the nose and philtrum, be coincident with the maxillary and man-

Assuming the face is symmetric, four midline variations are possible within this group. The first variation is possible when only the maxillary midline is off to one side or the other (Fig. 9). The initial visual facial evaluation of the maxillary midline to the imaginary centered plumb line will show its ectopic position. Graber and Swains state that this can also be accomplished by cast analysis using the midpalatal raphe and the incisive papilla as reference points. However, during actual treatment of the case, clinical practice dictates use of the visual method. The treatment of this condition requires maxillary intraarch mechanics, fully supported sliding yoke (jig) mechanics, or unilateral extraction of one tooth. The point to be made is that elastic traction that has the potential to c o -

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Fig. 11. Case 3.

Fig. 12. Case 4.

ordinate the midlines by means of mandibular repositioning or rotation is contraindicated since the deformity is in the maxilla and treatment should be so directed.
CASE 2

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Case 2 demonstrates a situation in which both dental midlines are coincident with each other but not with the face--the facial one being correct (Fig. 10). This is usually caused by dental shifting as a result of unerupted Or missing maxillary and mandibular teeth on the same side. A classic example is where primary upper and lower canines on one side have been removed to facilitate the eruption of lingually displaced lateral incisors.
CASE 3

Fig. 13. Case 5.

Case 3 (Fig. I 1) is similar to case 2 in that the facial midline is still centered; however, the maxillary midline is off to one side with the mandibular midline off to the other side. This is often caused by premature loss of primary teeth as a result of decay or extraction. Lack of appropriate space maintenance has allowed the anterior teeth to drift into the edentulous area. Treatment of these two situations requires correcting the midlines back to center by intraarch mechanotherapy, coordinating them with the facial midline, and then reevaluating the direction, amount, and mechanics necessary for completion of space closure while maintaining proper midline position.
CASE 4

The final midline variation that may accompany facial symmetry is seen in case 4 in which the facial and maxillary midlines are coordinated but the mandibular midline is eccentric (Fig. 12). Again the causative factor is primarily from extraction of one lower primary canine or from premature loss of any dental units on that side allowing the loss of intraarach dental integrity. Again treatment should be directed toward the use of intraarch mechanics and not unilateral intermaxillary elastics since they may coordinate the midlines well but subsequently create a resulting facial asymmetry.

The second group o f cases compromises those situations in which a facial asymmetry is present with or without a midline deviation. The first step in evaluation is to determine whether the facial asymmetry is skeletal, postural, or functional. Frontal cephalometrics is a helpful diagnostic tool; however, the discrepancy is usually a result of functional interference. Clinical evaluation involves observing the patient's facial symmetry with the mouth open. If relative facial symmetry exists, the odds are good that the cause is not skeletal and that orthodontic correction can be achieved. As previously stated, true skeletal asymmetries will not be covered since surgical and possibly functional orthopedic treatment are the only treatments o f choice and are outside the scope o f this treatise. One can gently manipulate and guide the mandible during closure until the first point o f dental contact is made. At this juncture the face should be relatively symmetric and the patient should be able to tolerate this position for a short period without feeling excessive strain in the temporomandibular joint areas or in the muscles of mastication. Note that it is irrelevant at this point whether the dental midlines coincide with the new

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! Fig. 14. Case 6.

I I Fig. 16. Case 8.

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Fig. 15. Case 7.

in one direction using intermaxillary mechanics while the lower dental midline is being corrected in the opposite direction with intraarch mechanics. This is because, as the mandible becomes centered, the mandibular midline becomes eccentric and requires compensatory correction.
CASE 7

Case 7 depicts another instance of dental midline coincidence; however, both are deviated to the side of the facial asymmetry (Fig. 15).
CASE 8

correct facial midline. The clinician should be concerned only with the ability to achieve relative facial symmetry.
CASE 5

Case 5 (Fig. 13) exemplifies the most often encountered clinical situation regarding mandibular asymmetries. Here the mandible is rotated into a lateral eccentric posture, usually as a result of functional interferences. The maxillary midline is correct. This is usually treated with unilateral Class II or Class III mechanics with or without anterior diagonal elastics and with or without contralateral Class II or Class III elastics as described earlier. It is important to stabilize the maxillary midline during this phase of therapy by whatever method is suitable to the practitioner's particular mechanotherapeutic technique. If maxillary arch expansion is necessary to accommodate the new mandibular position, it should be accomplished before or in conjunction with the intermaxillary traction used.
CASE 6

After correction of the facial deviation with interarch mechanics (as previously mentioned), which usually corrects the mandibular midline if no dental shifting has occurred, the maxillary midline must now be corrected using proper intraarch mechanotherapy. Case 8 is similar to case 7 except that the original condition is such that the maxillary midline is off to the opposite side of the mandibular midline and chin point. Once again correction requires the use of particular mechanical approaches--intermaxillary traction to correct the mandibular position and intraarch mechanics to correct the position of the maxillary teeth--if one is to properly coordinate all three midlines (Fig. 16).
CASE 9

Next an easily left untreated condition exists wherein the mandible is rotated as in case 5; however, dental shifting has occurred in the mandible that is often caused by the early loss of teeth on one side. Hence the maxillary midline is coincident with the mandibular one as can be seen in case 6 (Fig. 14). In treating this condition, the mandible must be shifted

The next clinical situation, (Fig. 17, A), is unusual in that both dental midlines are coincident and yet both are off to one side of the facial midline while the mandible is rotated to the contralateral side. Etiologically, the upper and lower teeth have shifted to one side as described in case 2, while the mandible has reacted to the functional interferences or crossbite, thus assuming an eccentric posture. Correction of this situation entails not only differential midline correction mechanics as previously described, but also may require the extraction of one additional mandibular dental unit on the side toward the facial deviation because, in correcting the facial asymmetry, the lower midline becomes more laterally displaced from center than it was at the start of treatment (Fig. 17, B). Even if the midline symmetry could be established on a nonextraction basis as far as the maxillary teeth are concemed, the correction of the mandibulardental midline would

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Fig. 17, A through C. Case 9,

Fig. 18, A and B. Case 10.

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Fig. 19, A and B. Case 11.

require unilateral extraction if the deviation were severe enough. A less severe variation of this situation (Fig. 17, C) is when the maxillary midline is initially correct. Although only the lower midline correction needs t o b e addressed, differential mechanics must still be used. It is very easy in this type of case to only treat the dental midline shift (with extractions, reproximation, lip bumpers, etc.) and still leave the mandible eccentrically postured.
CASE 10

midfrontal plane, and yet the mandible has rotated or deviated to the opposite side (Fig. 18, A). After using appropriate intermaxiltary traction to correct the facial midline, case 2, here Fig: 18, B, has again been recreated and now bimaxillary intraarch mechanotherapy is necessary for final midline coordination.
CASE 11

Case 10 is ,,'cry interesting in that the maxillary midline is off to one side, the mandibular one is coincident with the

Case 11 depicts a situation in which an atypical extraction sequence may be necessary (Fig. 19, A). The maxillary midline is off to one side as a result of factors described earlier, pogonion is off to the same side because of functional interferences, and the mandibular mid-

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Fig. 20. Case 12.

line is centered. But is it? After correction of facial symmetry, the lower midline is now off to the opposite side. This was a function of the same causative factors that created the midline shift in the opposing arch. After intermaxillary corrective mechanics, case 3, here Fig. 19, B, is now recreated. Ultimate orthodontic correction may require the extraction of one tooth in each arch on opposite sides in order to create sufficient space for proper midline coordination, depending on the severity of the discrepancy.
CASE 12

teeth is the proper method of treatment in reducing the remaining intraarch spacing. This eliminates unilateral overretraction and subsequent round tripping in extraction cases. By treating all three midlines in the initial stages of treatment and keeping them coordinated throughout orthodontic therapy, many subdivision completions can be circumvented. Careful attention to midline coordination and attendant facial symmetry can aid the practitioner in achieving the following: 1. Maximum intercuspation and function 2. Stability in the finished result 3. The promotion of anterior dental and facial esthetics 4. A decrease in the potential for TMJ dysfunction 5. Maximizing self-satisfaction by achieving an increased number of ideal orthodontic results We wish to express our thanks and appreciation to Ms. Sandra Richman for her contribution in preparing the schematics for this article.
REFERENCES 1. DierkesJM. The beauty of the face: an orthodonticperspective. J Am Dent Assoc 1987(Special Issue):89E-95E. 2. Breakspear EK. Some aspects of the retractionof upper incisors by appliances. 38th Congress, European Orthodontic Society. J Eur Orthod Soc 1963:342. 3. Lewis D. The deviated midline. A.'4J OR'IqlOD1976;70:601-16. 4. Borell G. Posterior crossbites--recognition, evaluation and treatment. State Dent J 1982;48:82-6. 5. GraberT, Swain B. Currentorthodonticconceptsand techniques. Philadelphia: WB Saunders, 1975. 6. Angle EH. Malocclusionof the teeth. Philadelphia:SS White, 1907. 7. Proffit W. Contemporaryorthodontics. St. Louis: CV Mosby, 1986. 8. AlexanderRG. The Alexanderdiscipline.Glendora,Califomia: Ormco, 1987. 9. Begg PR, Kesling P. Begg orthodontic theory and technique, 3rd ed. Philadelphia:WB Saunders, 1977. 10. Gianelly AA, Paul IA. A procedure for midlinecorrection. AM J ORTnOD1970;58:264-7. 11. Strang R, Thompson W. A textbook of orthodontia. Philadelphia. Lea & Febiger, 1958.
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Case 12 is very similar to the previous one except that instead of the mandibular midline being "centered" at the initiation of treatment, it is off to the opposite side of the maxillary midline (Fig. 20). Thus, on obtaining facial symmetry by intermaxillary traction, there is even a greater mandibular midline deviation. As was described in case 9, atypical extraction therapy may be necessary to effect correction. As an alternative, one might even consider creating a new lower dental midline between central and lateral incisors in the finished case--thus setting one side in a Class I and the other side in a Class Ill molar relationship. Posttreatment occlusal equilibration, which should be routine in all cases, becomes more difficult but more essential.
SUMMARY

Once the midline deviation has been differentially diagnosed and the appropriate mechanotherapy for correction determined, a good treatment guide is to coordinate all three midlines, but primarily the facial one, as soon as possible. At this point reevaluation of any remaining spaces in each arch will determine whether retraction of anterior teeth or protraction of posterior

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