Periodontics
Influence of periodontal biotype on the presence
of interdental papillae
Alexandre Barboza de Lemos, DDS, MSD n Sergio Kahn, DDS, MSD, PhD n Walmir Junio de Pinho Reis Rodrigues, DDS
Marcos Barceleiro, DDS, MSD, PhD
The absence of interdental papillae can be a negative influence in aesthetics.
Periodontal biotype (PB) is one of the factors that can possibly influence this
relation and has to be considered in periodontal diagnosis and treatment
planning. The objective of this study was to evaluate the influence of the
periodontal biotype on the presence and absence of interdental papillae.
Forty-seven patients were included in this transversal clinical study. The PB,
presence and height of interdental papilla, loss of papillary height, and the
distance between the base of the contact point and bone crest (CP-BC)
were evaluated. The chi-square test was used to verify the significance
level of the PB distribution frequency between groups. The Mann-Whitney
test was used to compare the CP-BC measures between the different PB
T
he number of patients seeking
esthetic periodontal treatments,
beyond the treatment of the bacterial component of periodontal disease,
has increased over the past decades. One
of the factors involved in this esthetic
demand is the presence of an intact and
harmonious gingival contour.1,2
Interdental papillae (also known as
gingival papillae) occupy the space
between adjacent teeth. Morphologically,
the papillae were described first in 1959.3
Before this time, an interdental papilla’s
sole function was to deflect interproximal
food debris. Now it is understood that the
physiology of the papilla is more complex.
It not only acts as a biological barrier in
protecting the periodontal structures, but
groups, and the correlation test was used to verify the relation between the
CP-BC distance and the presence of papillae. The thin PB group presented a
significantly higher presence of papillae (71.1%) than did the thick PB group
(59.6%, P < 0.05). An inverse and proportional correlation between the CPBC distance and the presence of papillae was found. The authors concluded
that the PB influenced the presence and height of interdental papillae.
Received: January 10, 2013
Accepted: April 29, 2013
also plays a critical role in the esthetics of
teeth. Hence, it is very important to respect
papillae integrity and minimize their
removal during dental procedures as much
as possible.4
Today’s dentists face esthetic standards
that require a soft-tissue contour, with
intact papillae and a symmetrical gingival
outline, especially in the interdental area
of the maxillary central incisors (defined
as the central papillae).5 The presence of
a space below these contact areas can lead
to esthetic defects, speech impairment,
and food impaction.6 Several efforts have
been undertaken to treat and restore
missing interproximal papillae. If the loss
of a papilla is related to soft tissue damage
only, reconstructive techniques are able
Fig. 1. Frontal photograph of teeth exhibiting a thin PB.
20
September/October 2013
Key words: dental papilla, periodontal biotype,
gingival anatomy, gingival histology
General Dentistry
www.agd.org
to restore it completely. If the loss of an
interdental papilla is caused by severe
periodontal disease with interproximal
bone resorption, complete reconstruction
is generally not achieved.7 Different
surgical and nonsurgical approaches are
proposed in the periodontal literature to
provide satisfactory interdental papillae
reconstruction. Unfortunately, although
more and more sophisticated approaches
showing good clinical results have been
proposed to restore the lost interdental
papillae, the predictability of various
procedures has not been completely documented, and no data on long-term success rates are available in the literature.8
Therefore the probability of loss should
be anticipated before treatment, and the
Fig. 2. Frontal photograph of teeth exhibiting a thick PB.
Fig. 3. Frontal photograph of a normal
papilla.
Fig. 4. Frontal photograph of a Class
I LPH.
patient should be informed of the consequences of the loss of interdental papillae.
Aspects related to the periodontal
biotype (PB) are frequently not considered during periodontal treatment
planning.9,10 The relationship between
PB and the presence or absence of interdental papillae is not well-documented.
Thus, the aim of this study was to evaluate the influence of the PB on the presence and absence of interdental papillae.
Materials and methods
Forty-seven patients (21 male and 26
female), between the ages of 18 and 63
(mean 36 ± 11.14), were included in the
present study.
The following inclusion criteria were
used: presence of contact points between
maxillary canines and incisors, and no
interproximal and/or root surface restorations. The exclusion criteria were: a
gingival index (GI) >1, smoking, transplantation, uncontrolled systemic disease,
orthodontic treatment, and/or taking
medication known to interfere with periodontal tissue health.11,12
Each patient signed an informed consent after the risks and benefits of the
associated procedures were explained. The
study protocol was approved by the Veiga
de Almeida University Ethical Committee
under the number 100/08.
Clinical parameters
The following measurements were
recorded by a single calibrated examiner:
PB, presence of interdental papilla (PIP),
loss of papillary height (LPH), distance
between the base of the contact point and
bone crest (CP-BC).6,10,13
Fig. 5. Frontal photograph of a Class II LPH.
PB was visually classified as thin or
thick, according to Kao & Pasquinelli
(Fig. 1 and 2).10 When evaluating PIP,
the papilla was considered present when
there was no visible space apical to the
contact point and LPH was identified
using the system proposed by Nordland &
Tarnow as follows: Normal – interdental
interdental papilla fills the embrasure
space to the apical extent of the interdental contact point/area; Class I – the
tip of the interdental papilla lies between
the interdental contact point and the
most coronal extent of the interproximal
cementoenamel junction (CEJ); Class
II – the tip of the interdental papilla lies
at or apical to the interproximal CEJ but
coronal to the apical extent of the facial
CEJ; Class III – the tip of the interdental
papila lies level with or apical to the facial
CEJ (Fig. 3-6).6,13
The CP-BC distance was measured
using a 15 mm periodontal probe
(Pcpunc, Hu-Friedy Mfg. Co., LLC) and
approximated to the upper whole millimeter, if necessary (Fig. 7).6 A bilateral
infraorbital nerve block was performed,
using 2% lidocaine with epinephrine
1:100,000 (DFL Industria e Comercio).
After 10 minutes, the area was dried for 30
seconds and the measurements were taken
using a bone sounding technique.6 The
probe was positioned as parallel as possible
to the long axis of the tooth.
All papillae were grouped by PB and
by tooth region: papillae between canines
and premolars (CA/PM), papillae between
lateral incisors and canines (LI/CA),
papillae between central incisors and
lateral incisors (CI/LI), papillae between
central incisors (CI/CI).
www.agd.org
Fig. 6. Frontal photograph of a Class III LPH.
Fig. 7. Frontal photograph showing
measurement CP-BC.
Table 1. Number of papillae
evaluated by periodontal
biotype and tooth region.
Tooth region
Thick PB Thin PB
Total
CA/PM
36
38
74
LI/CA
40
38
78
CI/LI
38
39
77
CI/CI
22
20
42
Abbreviations: PB, periodontal biotype; CA/PM,
papillae between canines and premolars; LI/CA,
papillae between lateral incisors and canines; CI/LI,
papillae between central incisors and lateral incisors;
CI/CI, papillae between central incisors.
Statistical analysis
The chi-square test was used to verify the
significance level of the PB distribution
between groups. The Mann-Whitney test
was used to compare the CP-BC measures between the different PB groups.
The correlation test was used to verify
the relation between the CP-BC distance
and the presence of a papilla.
Results
The thick PB was found in 25 patients
(13 male and 12 female) and the thin
PB was found in 22 patients (8 male and
14 female). Two hundred seventy-one
papillae were evaluated (136 in the thick
PB group and 135 in the thin PB group)
(Table 1).
The PIP results showed that the thin
PB group presented a significantly greater
presence of papillae (71.1%) than did the
thick PB group (59.6%, P < 0.05). The
thin PB group presented a significantly
greater presence of papillae at the CA/
General Dentistry
September/October 2013
21
Periodontics Influence of periodontal biotype on the presence of interdental papillae
Chart 1. Distribution frequency
(%) for LPH by PB.
80
Thick PB
Thin PB
70
Table 2. Presence of interdental papillae (%) by periodontal biotype
and tooth region.
60
50
Thin PB
40
Presence
Absence
Presence
Absence
CA/PM*
92.1
7.9
75.0
25.0
LI/CA*
84.2
15.8
57.5
42.5
CL/LI
53.8
46.2
63.2
36.8
20
CI/CI
40.0
60.0
31.8
68.2
10
* Statistically significant difference between PB groups ( P < 0.05)
Abbreviations: PB, periodontal biotype; CA/PM, papillae between canines and premolars; LI/CA,
papillae between lateral incisors and canines; CI/LI, papillae between central incisors and lateral
incisors; CI/CI, papillae between central incisors.
September/October 2013
30
0
Normal
Class I Class II Class III
Abbreviations: LPH, loss of papillary height;
PB, periodontal biotype.
Chart 2. Distribution frequency (%) for LPH by PB and tooth region.
100
Normal
Class I
Class II
Class III
90
80
70
60
LPH
PM and LI/CA tooth regions (92.1%
and 84.2%, respectively) than did the
thick PB group (75.0% and 57.5%,
respectively; P < 0.05). In the CI-LI
tooth region, there was a greater, but not
significant, presence of papillae in both
PB groups (P > 0.05). While there was an
increased absence of papillae found in the
CI/CI tooth region, the results were not
significant (Table 2).
The LPH classification showed that
most papillae were classified as normal
(65.3%). The thin BP group presented a
higher number of normal papillae than
did the thick PB group (71.1% and
59.6%, respectively, P < 0.05). The Class I
group was found to be significantly more
numerous in the thick PB group (33.1%
and 20.0%, respectively, P < 0.05).13 No
statistically significant difference was
found between the PB groups for Class II
and III (P > 0.05) (Chart 1). The tooth
region analysis showed that the CA/PM
and LI/CA areas had a significantly better
LPH classification in the thin PB group
(Chart 2).13 There were no statistically
significant differences in CP-BC measures
between PB groups (Mann-Whitney U =
0.593) and tooth region (P > 0.05). The
mean CP-BC distance in the tooth regions
for the thin PB were: CA/PM = 5.11 ±
1.23, LI/CA = 5.21 ± 1.40, CI/LI = 5.21 ±
1.11, and CI/CI = 6.65 ± 1.81.
22
LPH
Thick PB
50
40
30
20
10
0
CA/PMLI/CACI/LICI/CICA/PMLI/CACI/LICI/CI
Thin PB
Thick PB
Abbreviations: LPH, loss of papillary height; PB, periodontal biotype; CA/PM, papillae between canines and
premolars; LI/CA, papillae between lateral incisors and canines; CI/LI, papillae between central incisors and lateral
incisors; CI/CI, papillae between central incisors.
For the thick PB, the CP-BC measures
were: CA/PM = 5.19 ± 1.04, LI/CA =
5.48 ± 1.04, CI/LI = 5.26 ± 1.90, and
CI/CI = 6.41 ± 2.04.
The correlation analysis showed that
there were no statistically significant differences between PB groups and tooth
General Dentistry
www.agd.org
regions at a 5 mm CP-BC distance. At a
6 mm CP-BC distance, the thin PB had
a greater presence of papillae (P < 0.05).
When the tooth regions were compared
by PB, only the CA/PM showed a statistically significant difference between
groups (P < 0.05).
Chart 3. Correlation between the CP-BC distance and the LPH distribution frequency (%) for both PB groups.
100
90
Normal
Class I
Class II
Class III
80
LPH Frequency
70
60
50
40
30
20
10
0
CP-BC CP-BCCP-BC CP-BCCP-BC CP-BCCP-BCCP-BCCP-BC CP-BCCP-BCCP-BC CP-BC
3 mm
4 mm
5 mm
6 mm
7 mm
8 mm
>9 mm 3 mm
4 mm
5 mm
6 mm
7 mm
>8 mm
Thin PB
Thick PB
Abbreviations: CP-BC, contact point and bone crest; LPH, loss of papillary height; PB, periodontal biotype.
The comparison between the 5 mm
and 6 mm CP-BC distance showed that
no significant differences were found in
the thin PB. However, significant differences were found in the thick PB group,
as the 5 mm group presented papillae in
77.5% of the sites and the 6 mm group
presented papillae in 36.8% of the sites.
The tooth region analysis showed that
there was a statistically significant difference between the 5 and 6 mm CP-BC
distances only in the thick PB group at the
CA/PM and LI/CA regions (P < 0.05).
The correlation test showed an inverse
and proportional correlation between
the CP-BC distance and the presence
of papillae: as the CP-BC distance
increased, the frequency of papillae
decreased in both biotype groups (thin
PB, r = -0.90; thick PB, r = -0.92).
Correlation tests were made between the
CP-BC distance and the LPH. The results
presented a significantly higher frequency of
normal papillae in the thin PB (P < 0.05).
The thin PB group presented a higher
frequency for the ≤6 mm CP-BC distance
and this frequency was higher for the ≤5
mm CP-BC distance in the thick PB. The
Class I LPH was more frequent in the thick
biotype group (P < 0.05). The Class II LPH
had a constant frequency for all CP-BC
distances, with an increase at the 7 mm distance in both PB groups. The Class III LPH
was observed at a ≥7 mm CP-BC distance,
with an increase in both groups at an 8 mm
CP-BC distance (with a higher frequency in
the thin BP group). The statistical analysis
of these data was not performed because of
the small number of sites (Chart 3).
Discussion
This study aimed to evaluate if there is a
correlation between PB and the presence
or absence of interdental papilla. Current
esthetic periodontal treatments are driven
by the search for techniques where success is measured not only by the quality
of postoperative symptoms, including
the lack of scars, but also by the predictability of results.14 This requires the use of
diagnostic methods to examine the surrounding tissues to determine periodontal
defects and consider thoroughly the
biologics of the involved gingiva.15 To this
end, the PB determination is critical for
professionals who perform procedures in
www.agd.org
the esthetic zone, since the identification
of the periodontium could predict future
periodontal defects, determine different
manipulation strategies of the soft tissues,
and help in correcting existing problems.
The present study used the classification
proposed by Kao & Pasquinelli.10 However,
a precise periodontium evaluation requires
controlled trials to determine a thickness
pattern, since most studies use clinical
observations to classify the PB.10,11,16-18
Generally, the thicker periodontium is
characterized by a fibrous, dense gingival
tissue, and a wide band of keratinized tissue.
The flat topography suggests a thick bony
architecture. The thick bone/gingival pattern
provides more resistance to tissue injury, and
also allows for more predictable surgical procedures, resulting in less postoperative bone
remodeling and gingival recession, which
can help predict future tissue positioning.
On the other hand, the thin periodontium
is characterized by a delicate, friable gum,
and a narrow strip of keratinized tissue. The
topography is scalloped, suggesting a very
thin bone, with possible areas of dehiscence
and fenestrations. There is a greater tendency toward gingival recession.14
General Dentistry
September/October 2013
23
Published with permission by the Academy of General Dentistry. © Copyright 2013
by the Academy of General Dentistry. All rights reserved. For printed and electronic
reprints of this article for distribution, please contact [email protected].
The influence of the distance between
the contact point and the bone crest in the
presence of interdental papillae was investigated by Tarnow et al.6 Those authors
observed that the presence of interdental
papillae decreased with an increased
CP-BC distance. The results of the present
study also demonstrated this relationship.
Nevertheless, most of the CP-BC distances
in the present study ranged between 4
and 6 mm, while the range in the study
by Tarnow et al was between 5 mm and 7
mm.6 Previous authors observed a 4.5 mm
mean CP-BC distance in cadavers.19 In the
present study, the mean CP-BC distance
was 5.57 mm and 5.86 mm in the thin
and thick PB groups, respectively.
The presence of interdental papillae in
the current study was similar to previous
results, with a greater presence of papilla
for the ≤5 mm distances, but with different percentages, since the present study
reported 88.9%, 92.7%, and 78.3% for
distances of 3, 4, and 5 mm, respectively;
other authors found the presence of interdental papillae at these distances to be
100%, 100%, and 98%, respectively.6
The LPH analysis demonstrated that
the presence of normal papillae was influenced by the CP-BC distance in both
PB groups, with a positive and inversely
proportional correlation, especially for
the thin PB at a CP-BC distance of 6
mm.13 This can be related to the presence
of elongated teeth in thin PBs, with coronal contact points, thereby increasing the
CP-BC distance.11,15,18,20
The presence of a Class I LPH was more
frequent in the thick PB group for the 6
and 7 mm CP-BC distances. This could
be explained by the observation that the
CP-BC distance would interfere with
the presence of papilla only at ≤3 mm
distances, which is related to square teeth
with wide roots, with the horizontal bone
loss compromising the presence of papilla.
The Class II LPH at the 6 and 7 mm
CP-BC distances was higher in the thin
PB group. This could be related to the fact
that severe bone loss can lead to papillary
loss and formation of black spaces.10 The
fibrotic configuration, square teeth, and
an apical contact point of the thick BP can
be responsible for maintaining the papilla
contour in severe bone loss.
24
September/October 2013
The Class III LPH was present only for
>7 mm CP-BC distances, and was more
prevalent in the thin PB group. Other
reports observed the loss of papillary tissue
in wide and long interproximal spaces,
which are common in thin PB.5
Differences in crown anatomy, root
anatomy, and height of contact point can
be related to the differences observed in
the presence of papilla at the CA/PM and
LI/CA sites between thin and thick PBs.
Conclusion
The PB influenced the presence of interdental papillae. The thick PB group presented a greater loss of papillary height,
and the thin biotype group presented
a greater frequency in the presence of
papillae at a 6 mm CP-BC distance, as
well as a greater loss of papillary height
at small CP-BC distances. However,
future studies are necessary to clarify the
roles of other related factors, such as the
distance between tooth roots, the shape
of the teeth, root inclination, and the
distance between the contact point and
the bone crest.
The absence of normal interdental
papillae affects gingival esthetics, and
can be influenced by the PB, making it
an important factor in the evaluation of a
patient’s esthetics.
Author information
Dr. de Lemos is a researcher, Master of
Science Program in Oral Rehabilitation,
Veiga de Almeida University, Rio
de Janeiro, Brazil, where Dr. Kahn
is a professor. Dr. Rodrigues is a
researcher, Master of Science Program
in Periodontics, Rio de Janeiro State
University, Brazil. Dr. Barceleiro is a professor, Department of Dentistry, School of
Dentistry, Fluminense Federal University,
Nova Friburgo, RJ, Brazil.
References
1. Azzi R, Etienne D, Carranza, F. Surgical reconstruction
of the interdental papilla. Int J Periodontics Restorative
Dent. 1998;18(5):466-473.
2. Choquet V, Hermans M, Adriaenssens P, Daelemans P,
Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth
dental implants. A retrospective study in the maxillary
anterior region. J Periodontol. 2001;72(10):13641371.
General Dentistry
www.agd.org
3. Cohen B. Morphological factors in the pathogenesis of
the periodontal disease. Brit Dent J. 1959;7:31-39.
4. Zetu L, Wang HL. Management of inter-dental/interimplant papilla. J Clin Periodontol. 2005;32(7):831839.
5. Chang LC. The association between embrasure morphology and central papilla recession. J Clin Periodontol.
2007;34(5):432-436.
6. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone
on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63(12):995-996.
7. Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: a review and classification of the therapeutic approaches. Int J Periodontics
Rest Dent. 2004;24(3):246-255.
8. Lee DW, Kim CK, Park KH, Cho KS. Non-invasive method to measure the length of soft tissue from the top of
the papilla to the crestal bone. J Periodontol. 2005;
76(8):1311-1314.
9. Coatoam GW, Behrents RG, Bissada NF. The width
of keratinized gingiva during orthodontic treatment:
its significance and impact on periodontal status.
J Periodontol. 1981;52(6):307-313.
10. Kao RT, Pasquinelli K. Thick vs. thin gingival tissue:
a key determinant in tissue response to disease and
restorative treatment. J Calif Dent Assoc. 2002;30(7):
521-526.
11. Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors.
J Clin Periodontol. 1991;18(1):78-82.
12. Loe H, Silness J. Periodontal disease in pregnancy. I.
Prevalence and severity. Acta Odontol Scand. 1963;
21:533-551.
13. Nordland WP, Tarnow DP. A classification system for
loss of papillary height. J Periodontol. 1998;69(10):
1124-1126.
14. de Campos GV, Bittencourt S, Sallum AW, Nociti Junior
FH, Casati MZ. Achieving primary closure and enhancing aesthetics with periodontal microsurgery. Pract
Proced Aesthet Dent. 2006;18:449-454; quiz 456.
15. Muller HP, Eger T. Masticatory mucosa and periodontal
phenotype: a review. Int J Periodontics Rest Dent.
2002;22(2):172-183.
16. Weisgold AS. Contours of the full crown restoration.
Alpha Omegan. 1977;70(3):77-89.
17. Maynard JG Jr, Wilson RD. Diagnosis and management
of mucogingival problems in children. Dent Clin North
Am. 1980;24(4):683-703.
18. Olsson M, Lindhe J, Marinello CP. The relationship between crown form and clinical features of the gingival
in adolescents. J Clin Periodontol. 1993;20(8):570577.
19. Gargiulo AW, Wentz FM, Orban B. Dimensions and
relations of the dentogingival junction in humans.
J Periodontol. 1961;32:261-267.
20. Muller HP, Kononen E. Variance components of gingival thickness. J Periodont Res. 2005;40(3):239-244.
Manufacturers
Hu-Friedy Mfg. Co., LLC, Chicago, IL
800.483.7433, www.hu-friedy.com
DFL Industria e Comercio, Rio de Janeiro, Brazil
55.21.3528.6766, www.dfl.com.br