Chu Et Al Papillae

The International Journal of Periodontics & Restorative Dentistry

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

An interdisciplinary team approach tomultidisciplinary therapies in estheticrestorative treatment has becomecommonplace in the dental profession.The perception of dental esthetics,however, varies significantly amongdental professionals, although sub-stantial efforts have been made toestablish common standards. Severaltextbooks have sought to help guideclinicians in optimizing esthetic results.Rufenacht,1,2 for example, discussedthe fundamentals of esthetics anddescribed procedures for integratingdental restorations into the individualfacial composition with respect to bio-logic and functional requirements, notmerely esthetics. Goldstein3 attemptedto establish principles to help practi-tioners achieve esthetic results anddevelop a rationale for esthetic dentaltreatment. Fradeani4 described a sys-tematic approach to esthetic analysis,evaluation, and treatment based ongeneral principles and illustrated thatthe height of the interdental papillaedecreased from anterior to posteriorteeth. Despite these efforts, there isstill little consistency among clinicians’perspectives of what constitutes anesthetic smile.5–11 With an increased

Papilla Proportions in the MaxillaryAnterior Dentition

Stephen J. Chu, DMD, MSD, CDT*Dennis P. Tarnow, DDS**

Jocelyn H.-P. Tan, DDS***

Christian F. J. Stappert, DDS, MS, PhD****

Two hundred forty interdental papilla sites in 20 healthy patients were investigat-ed. Interdental papilla heights of maxillary anterior teeth were measured from thegingival zenith, along with clinical crown lengths. Percentages of papilla height tocrown length were computed and defined as papilla proportion, mesial papillaproportion (MPP), and distal papilla proportion (DPP). Mean interdental papillaheights of maxillary anterior teeth were 4 mm mesially and 4.1 mm distally. MeanMPP was 42% (n = 120), and mean DPP was 43% (n = 120). No significant differ-ences were found between MPP and DPP for maxillary incisors (P ≥ .5). Caninesdemonstrated a trend toward increased distal papilla heights. Papilla proportionswere approximately 40% for all tooth groups. A more apical position of distalpapilla heights from anterior to posterior teeth, mentioned in the literature, wasnot confirmed by the present data. (Int J Periodontics Restorative Dent2009;29:385–393.)

*Clinical Associate Professor, Department of Periodontology and Implant Dentistry, NewYork University College of Dentistry, New York, New York.

**Professor and Chairman, Department of Periodontology and Implant Dentistry, New YorkUniversity College of Dentistry, New York, New York.

***General Practice Resident, New York Hospital Queens, Flushing, New York.****Assistant Professor, Department of Periodontology and Implant Dentistry, Department of

Biomaterials and Biomimetics, New York University College of Dentistry, New York, New York;Associate Professor, Department of Prosthodontics, Albert-Ludwigs-University, Faculty ofDentistry, Freiburg, Germany.

Correspondence to: Dr Stephen J. Chu, Department of Periodontology and ImplantDentistry, New York University College of Dentistry, Arnold and Marie Schwartz Hall ofDental Sciences, 345 East 24th Street, New York, NY 10010; fax: +1-212-995-4081;email: [email protected].

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Volume 29, Number 4, 2009


awareness and understanding ofesthetic dentistry, patients todayrequire natural-looking teeth and gin-gival architecture in the esthetic zone.

It is the interdental appearance ofthe papillae in an apicocoronal loca-tion that is critical during smiling thatresults in positive gingival architectureesthetics,12,13 although the supra-coronal tissues might not always bevisible in patients with a low smile line.LaVacca et al14 conducted a study toevaluate the impact of symmetric alter-ations in interdental papilla length onesthetic perceptions. The authorsreviewed the importance of interden-tal papilla location for optimal esthet-ics and its assessment by dental pro-fessionals and patients. Althoughdental specialists were more consis-tent than patients in their evaluation ofthe impact of interdental papilla lengthon the perception of esthetics, thisstudy demonstrated that there is still aneed to enhance communication andstandardize evaluation among dentalspecialists to achieve consistent treat-ment planning goals.

There is no universal guideline forclinicians to follow in creating greaterconformity and a predictable estheticsmile, including ideal papilla heights.It may be possible to mathematicallyquantify certain esthetic componentsto establish a standard that is satisfyingto both patients and clinicians.

Chu15 suggested that a mathe-matical correlation exists between theclinical crown widths of maxillary ante-rior teeth. The investigation unveiledthat variations of tooth width existedmore frequently (~68%) than meanaverages (~32%). It was concludedthat individual clinical crown size must

be identified prior to treatment to pro-mote a more esthetic result. Accord-ingly, it may be feasible to quantify theheights of the interdental papillae ofthe maxillary anterior teeth as mea-sured from the level of the zenith of thelabial free gingival margin (gingivalzenith).

Several investigators haveattempted to establish guidelines forproper papillae form to enhance den-ture esthetics, optimize soft tissue posi-tion, improve surgical and nonsurgicaltechniques to treat soft tissue defor-mities, and to better manage inter-proximal spaces following toothextraction or implant placement.16–20

Spear17 presented a clinical techniquefor maintaining papilla height and formfollowing anterior tooth removal. Hebelieved that the presence of adjacenttooth attachment and the size of thegingival embrasure formed by theseteeth were responsible for papilla pres-ence and height. Tarnow et al21 exam-ined the distance from the base of thecontact area to the crest of bone in 288sites and determined that, at 5 mm,6 mm, and 7 mm, the papilla was pre-sent 98%, 56%, and 27% of the time,respectively. Cho et al22 and Marteganiet al23 found that the interradiculardistance and the distance betweenthe contact point and the alveolar cresthave independent and combinedeffects on the presence or absence ofthe interdental papilla. Based on thisinformation, clinicians are able to influ-ence and maintain papilla develop-ment more effectively, but they mustrely on the alveolar crest as a referencepoint.

The height of the interdental pa-pillae between the maxillary anterior

teeth, with reference to the crest ofthe gingival zenith, remains undefined.To date, no investigation has deter-mined what the representative value ofthe anatomical location of the inter-dental papilla should be from the gin-gival zenith. There are currently nostudies designed to evaluate or quan-tify this location. Therefore, the pur-pose of this pilot study was to quantifythe interdental papilla location math-ematically as a percentage ratio of clin-ical crown length, thereby establish-ing a useful parameter for treatment.

Method and materials

A sample population of 20 patients(13 women, 7 men) was studied. Thepatients, who ranged in age from 20 to47 years (mean, 27.7 years), were ingood systemic health. The samplepopulation were included on the basisof nonrestored maxillary anterior teeth,no loss of interdental papillae, no ante-rior crowding or spacing, no incisalattrition, no periodontal disease, andno gingival recession (Fig 1).

Alginate impressions of the studysubjects were made using irreversiblehydrocolloid impression material(Jeltrate, Dentsply Caulk) and immedi-ately poured with stone (Resin Rock,Whip Mix Corp). A digital caliper witha lighted display (SAE/Metric) was usedto measure the 240 papilla sites of theanterior maxillary teeth, from canineto canine (Avenger Measuring Tools).Each cast was measured by one oper-ator using 2.5� optical loupes. Controlmeasurements were performed by asecond investigator. The caliper wascalibrated prior to each measurement.

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The mesial and distal interdentalpapilla heights in the maxillary anteriordentition, including the central incisors(CI), lateral incisors (LI), and canines(CA), were measured from the level ofthe gingival zenith of the correspond-ing tooth to the tip of the papilla (n =240) (Fig 2). Additionally, the lengthsand widths of clinical crowns wererecorded for each tooth group: CI, LI,and CA (n = 120). Each papilla heightmeasurement was divided by the clin-

� 100%. Mesial papilla proportions(MPP) and distal papilla proportions(DPP) were calculated separately: MPP= mesial papilla height/crown length �100%, and DPP = distal papillaheight/crown length � 100%.

This study was conducted accord-ing to the Declaration of Helsinki forclinical investigations. Statistical analy-sis was performed by independent-sample t tests and binomial tests (� = .05).

ical crown length of the correspondingtooth. Therefore a percentage ratiowas calculated of the papilla heightrelated to the clinical crown length.The percentage ratio accounted forvariations in crown lengths and papillaheights and was not predicated uponabsolute values.

The following mathematical equa-tion was used to calculate a percent-age ratio, termed papilla proportion(PP): PP = papilla height/crown length

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Fig 2 Height measurements were made from the level of the gingival zenith (GZ) to the tip of the mesial papilla (MPH) and distal papilla(DPH) for (left) the central incisor, (center) the lateral incisor, and (right) the canine, as well as for clinical crown length (CL).

Fig 1 Healthy patient with sound maxillary anterior dentition andinterdental papillae between central and lateral incisors as well ascanines.

MPH DPH

CL

GZ GZGZ

MPH DPH

CL

MPH DPH

CL


Results

The mean absolute values (± SDs) forthe interdental papilla heights of max-illary anterior teeth measured from thelevel of the gingival zenith were 4.0 ±0.8 mm mesially and 4.1 ± 0.8 mm dis-tally. The mean absolute interdentalpapilla heights (± SDs) by tooth of CI,LI, and CA were 4.3 ± 0.7 mm, 3.7 ±0.8 mm, and 4.4 ± 0.7 mm, respec-tively. Taking into account all measured

sites, the mean MPP (± SD) was 42%± 6% (n = 120), and the mean DPP was43% ± 7% (n = 120). The measure-ments demonstrated a normal distri-bution, which accounted for about68% of the data for one standard devi-ation from the mean (± SD). The MPPfor the CI, LI, and CA were 40.8%,40.8%, and 43.3%, respectively. TheDPP of the CI, LI, and CA were 41.5%,41.1%, and 45.4%, respectively (Fig3). Table 1 demonstrates the absolute

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Fig 3 Percentage ratio of papilla height to crown length sorted bytooth group and divided into mesial papilla proportion (MPP) anddistal papilla proportion (DPP). CI = central incisors; LI = lateralincisors; CA = canines.

Table 1 Absolute values of papilla heights (in mm) sorted bytooth position and divided into mesial (MPH) and distal (DPH) groups

Toothposition n Group Mean ± SD Min Max

Right CA 20 MPH 4.2 ± 0.87 2.9 6.2Right CA 20 DPH 4.5 ± 0.74 3.3 6.0Right LI 20 MPH 3.5 ± 0.69 2.4 5.0Right LI 20 DPH 3.6 ± 0.98 2.0 5.1Right CI 20 MPH 4.3 ± 0.71 3.1 5.8Right CI 20 DPH 4.3 ± 0.62 3.4 5.8Left CI 20 MPH 4.2 ± 0.82 2.9 5.7Left CI 20 DPH 4.2 ± 0.60 3.3 5.6Left LI 20 MPH 3.8 ± 0.78 2.4 5.7Left LI 20 DPH 3.8 ± 0.83 2.4 5.7Left CA 20 MPH 4.3 ± 0.33 3.7 5.0Left CA 20 DPH 4.4 ± 0.73 3.3 5.7

CI = central incisor; LI = lateral incisor; CA = canine.

CI LI CATooth group

464544434241403938

Pap

illa

pro

por

tion

(%) MPP

DPP


values of interdental papilla heightssorted by tooth position (Fig 4). Table2 shows the descriptive data of clinicalcrown lengths and crown widthsaccordingly. MPP and DPP values aregiven in Table 3 (Fig 5). No significantdifferences were found between MPPand DPP for the maxillary incisors(groups CI and LI) (P ≥ .51). The caninesdemonstrated a trend toward greaterdistal papilla lengths and higher DPP;this difference was significant for the

right canine (P = .04) and was not sig-nificant for the left canine (P = .24). Themean difference between MPP andDPP for all values (n = 240) was 1%, butnot significant (P = .06). The mean dif-ference between distal and mesialmeasures aggregated over all teethwas 0.1 mm (P = .054). Because of thecanine measures, the difference wasnearly significant.

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Fig 4 Absolute values of papilla heights (lengths) by tooth positionand divided into mesial papilla height (MPH) and distal papillaheight (DPH). FDI tooth-numbering system used.

Table 2 Clinical crown lengths (CL) and widths (CW) (in mm)measured in the maxillary anterior dentition, sortedby tooth position


Right CA 20 CL 9.7 ± 0.9 8.3 11.1Right CA 20 CW 7.8 ± 0.62 6.8 9.4Right LI 20 CL 8.8 ± 0.9 7.2 10.5Right LI 20 CW 6.8 ± 0.68 5.3 8.2Right CI 20 CL 10.3 ± 0.8 8.7 11.9Right CI 20 CW 8.8 ± 0.55 7.7 9.6Left CI 20 CL 10.3 ± 0.71 8.9 11.8Left CI 20 CW 8.8 ± 0.56 7.7 9.7Left LI 20 CL 9.0 ± 0.83 6.8 10.4Left LI 20 CW 6.9 ± 0.68 5.6 8.2Left CA 20 CL 9.9 ± 0.73 8.8 11.4Left CA 20 CW 7.9 ± 0.49 6.9 8.8


13 12 11 21 22 23Tooth no.

5.04.54.03.53.02.52.01.51.00.5

0

Pap

illa

heig

ht (m

m)

MPHDPH


Discussion

The goal of this study was to determinea representative value for interdentalpapilla height of the maxillary anteriordentition as a percentage ratio of clin-ical crown length, as measured fromthe level of the gingival zenith. Ideally,this figure would be relevant and clin-ically applicable for practitioners striv-ing to achieve a more esthetic smile.

Furthermore, this value could be help-ful for periodontists and implant den-tists in validating and planning surg-eries concerning desired vertical softtissue height in the esthetic zone.20

The mean absolute interdental papillaheights by tooth of CI, LI, and CAwere 4.3 mm, 3.7 mm, and 4.4 mm,respectively. Values of interdentalpapilla heights in the maxillary anteriordentition have been mentioned in the

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Fig 5 Percentage ratio of papilla height to crown length sorted bytooth position and divided in mesial papilla proportion (MPP) anddistal papilla proportion (DPP). FDI tooth-numbering system used.

Table 3 Percentage ratio of papilla height to crown lengthsorted by tooth position and divided into mesial(MPP) and distal (DPP) groups


Right CA 20 MPP 43 ± 7 31 56Right CA 20 DPP 46 ± 6 34 55Right LI 20 MPP 40 ± 6 29 48Right LI 20 DPP 41 ± 8 27 55Right CI 20 MPP 41 ± 5 32 49Right CI 20 DPP 42 ± 5 32 53Left CI 20 MPP 40 ± 6 29 53Left CI 20 DPP 41 ± 5 30 50Left LI 20 MPP 42 ± 7 25 57Left LI 20 DPP 42 ± 8 25 58Left CA 20 MPP 43 ± 4 35 50Left CA 20 DPP 45 ± 7 30 58


13 12 11 21 22 23Tooth no.

474645444342414039383736

Pap

illa

pro

por

tion

(%) MPP

DPP


literature. Kois24 measured interden-tal papilla heights from the free gin-gival margin to the osseous crest witha periodontal probe. Mesial sites atthe maxillary right central incisor in100 healthy patients were observed.Kois24 reported a range of 3 to 4.5 mminterproximal depth. No additionalanterior teeth or interdental sites weremeasured.

Becker et al25 evaluated humanskulls and classified them into flat, scal-loped, and pronounced scallopedanatomical profiles according to alve-olar bone anatomy. The mean distancefrom the height of the interdental boneto the buccal alveolar crest was statis-tically significantly different when thegroups were compared (flat 2.1 mm,scalloped 2.8 mm, and pronounced4.1 mm). Spear17 concluded that theosseous scallop from facial to inter-proximal averages 3 mm in height.Taking an average of 3 mm dentogin-gival complex height into account,Spear concluded that the facial freegingival margin height equals the inter-proximal aspect of bone in a healthypatient. Therefore, he estimated thatthe average maxillary interproximalpapilla height would be 4.5 to 5.5 mmfor central incisors (Spear referred toKois24), also when measured from thefacial zenith of the free gingival margin.Spear did not provide control mea-surements for this estimate but cited astudy of van der Velden,26 whoreported interdental tissue recoveryafter surgical treatment of 4.3 mm onaverage and a mean sulcus depth of2.2 mm. An estimate of interdentalpapilla height of 4.5 mm correlateswith the current statistical findings forcentral incisors and canines, with mean

crown lengths of 10.3 mm and 9.8 mm,respectively. Lateral incisors demon-strated a smaller mean value of inter-dental papilla height of 3.7 mm, with amean crown length of 8.9 mm. Theinvestigation of Tarnow and cowork-ers21 on the influence of the contactpoint position on the presence orabsence of the interproximal dentalpapilla was reevaluated by Cho et al.22

The authors measured anterior andposterior interdental sites. The dataconfirmed the findings of Tarnow etal21 that the number of papillae thatfilled the interproximal spacedecreased with increasing distancefrom the contact point to the alveolarcrest. The authors reported that theinterdental papillae were present in89.7% of sites when the distance fromthe contact point to the alveolar crestwas 4 mm, 58.5% of sites when the dis-tance was 5 mm, 35.2% of sites whenthe distance was 6 mm, and fewer than7.5% of sites when the distance was >7 mm. Their results also suggested thatan increasing interproximal distancebetween the tooth roots has a signifi-cant decreasing influence on thepapilla presence. Unfortunately, thestudy did not provide absolute inter-dental papilla height values of the ante-rior maxillary dentition for comparison.

It is important to note that meanabsolute values are important findingsbut do not account for individual vari-ations in crown lengths and papillaheights. For esthetic anterior restora-tions, papilla heights must be propor-tional to clinical crown lengths. Hence,mathematical equations were pre-sented as proportion calculations,which accounts for variability in clinicalcrown length. The average MPP and

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DPP of the CI, LI, and CA measuredwere 41% and 42%, 41% and 41%,and 43% and 45%, respectively. Theseproportion ratios would account forvariations in clinical crown length andwould not be dependent uponabsolute tooth measurement values.Although 240 papilla sites were mea-sured, the number of investigatedpatients (n = 20) might be a short com-ing of the present study. However, thecalculated standard deviation of all PPmeasurements (n = 240) was less than7%, which equaled an esthetic naturalappearance of the papilla within a 36%to 49% PP range. The given range ofdata (min/max) represents isolatedmeasurements located at theextended tails of the bell curve. Furtherstudies are needed to verify theseresults.

The perception of beauty is verysubjective and often influenced bysocietal and/or geographic factors.Nevertheless, this study may be usedas a pilot reference, providing someguidance for clinicians. By mathemat-ically quantifying the papilla lengthfrom the gingival zenith, dental pro-fessionals can communicate more effi-ciently and with a more uniform treat-ment goal. As a result, a closer-to-idealspatial relationship between teeth andtheir respective papillae can be estab-lished to achieve optimized esthetics.

Conclusions

The percentage ratios of papillaheights and crown lengths demon-strated an almost equivalent papillaproportion for all tested tooth groupsof approximately 40%. There were no

clinically relevant differences in mesialversus distal papilla heights in the ante-rior maxillary dentition. A more apicalposition of distal papilla heights fromanterior to posterior teeth as men-tioned in the literature was not con-firmed by the present data.

Acknowledgments

The authors are grateful to Malvin Janal, PhD,Department of Psychiatry, New Jersey MedicalSchool, for carrying out the data analyses. Theyare also thankful to Andrew Pacellini, DDS,Prosthodontic Resident, New York HospitalQueens, Flushing, New York, for his supportduring data collection.

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Chu Et Al Papillae