|Year : 2021 | Volume
| Issue : 1 | Page : 31-35
The interrelation among configuration of embrasure and recession of median papilla
Arti Jayman Raval
Department of Dentistry, Medical College Baroda, Vadodara, Gujarat, India
|Date of Submission||02-Sep-2020|
|Date of Decision||09-Sep-2021|
|Date of Acceptance||25-Sep-2020|
|Date of Web Publication||25-Feb-2021|
Arti Jayman Raval
B-404, Radhe-Shyam Residency, GERI Road, Behind Yash Complex, Gotri, Vadodara - 390 021, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The aim of this study was to find interrelation among embrasure configuration and recession of median papilla was. To assess impact of extent from the point of contact to bone crest (BC) on the existence of the interproximal papilla by radiographic method and to evaluate the extent between the papilla tip (PT) to the BC by comparing clinical and radiographic methods were the objectives. Methods: With the use of periapical radiographs (paralleling cone technique in RVG with grid) of the maxillary central incisors, the central papilla was evaluated in 100 adults. To evaluate and compare the extent between PT and BC, bone sounding was used. The vertical measurements were: papilla recession, contact point (CP) to BC, CP to proximal cement-enamel junction (pCEJ), and papilla height. The interdental width was the horizontal measurement. According to width interproximally and pCEJ to point of contact extent, total four study groups were divided: long narrow, short narrow, long wide, and short wide. Results: The comparison among radiographic method and clinical method revealed that there was statistically no significant difference between two methods among long-narrow and short-wide group. However, statistically significant difference was noted among short-narrow and long-wide group. Conclusion: Median papilla recession was associated with a wide-long type of embrasure configuration. Although many features such as periodontal phenotype and shape of teeth may influence the probability of the existence of the inter-proximal papilla, therefore the interconnections between these factors are not clear and require further research.
Keywords: Dental, dental, digital, esthetics, gingiva, gingival recession, radiography
|How to cite this article:|
Raval AJ. The interrelation among configuration of embrasure and recession of median papilla. J Dent Res Rev 2021;8:31-5
|How to cite this URL:|
Raval AJ. The interrelation among configuration of embrasure and recession of median papilla. J Dent Res Rev [serial online] 2021 [cited 2021 Apr 21];8:31-5. Available from: https://www.jdrr.org/text.asp?2021/8/1/31/310189
| Introduction|| |
A harmonious gingival form and an undamaged interdental papilla are need for increased esthetic demands in dentistry. The maintenance of the interdental papilla is very important for periodontists, esthetic dentists, and patients, particularly in the interdental region which is present in the middle of central incisors of upper jaw (known to be central papilla). We may call it as “Median Papilla.” When the embrasure is completely filled, the papilla is regarded as present. However, the papilla is considered missing if space is apparent apical to the contact point (CP)., The point of contact to the crest of bone distance of 5 mm should be present for the papilla to be present.
Dental papilla secures against the microflora occupation and any trauma. Therefore, its loss encourages impaction of food., As the space beneath the contact area permits passage of the air/saliva, it may result in speech difficulties. Papilla is very necessary for esthetics. The papilla presence, mainly between central incisors of maxilla, the most visible portion of the teeth is a key esthetic feature in any person.
Until now, labial recession was considered clinically more important compared to interdental recession (less noticeable clear spaces: BLACK TRIANGLES DISEASE).
There are numerous factors which can affect the presence or absence of interdental papilla for example size of the space that embrasure occupies, dimension of interproximal space (extent from CP to the alveolar crest), the crown shape, crestal alveolar bone height, contact areas (e.g., triangular verses square), tooth malpositioning, high muscle attachments and frenal pull, anterior versus posterior teeth, etc. The extent from the crest of bone to point of contact is recurrently investigated among these, but in aesthetic dentistry, it's very much necessary to find the factors which are risky for recession including the interrelation between configuration of embrasure and the recession of median papilla on which this study emphasizes.
To recognize the impact on recession of central papilla, herein, the study was carried out and the embrasure morphology was divided into four groups according to proximal cementoenamel junction (pCEJ) to CP extent and pCEJ width, respectively, longnarrow, short narrow, long wide, and short wide. The aim of the study was to establish the interrelation between median papilla recession and embrasure morphology. Objectives were to assess the effect of the extent from the crest of bone to the point of contact on the existence of the interdental papilla by radiographic method and to assess the extent between the tip of papilla to the bone crest (BC) by comparing clinical and radiographic methods.
| Methods|| |
The study design was a cross-sectional study. Random selection of completely erupted, permanent dentition, maxillary central incisors were done in 100 adult patients (age - 18–60 years). The written informed consent form was obtained from all subjects. Healthy gingiva (gingival index of 0–1, by Loe and Silness 1967) and well-aligned maxillary central incisors (e.g., without any crowding, spacing, and intrusion/extrusion) were included. The central incisors having artificial crowns, subgingivally restored cavities on proximal or cervical surfaces or abrasions, having maxillary anterior surgery history, high frenum or muscle attachment in the anterior maxilla, systemic conditions such as pregnancy or gingival hypertrophy, crowding or obviously seen midline diastema, habit of nibbling on foreign objects such as pencils, pipes, past and present history of orthodontic treatment, smokers, and faulty brushing technique, were excluded from the study.
Following two techniques were used to fulfill the aim and objectives of the study.
Bone sounding (transgingival probing, clinical method)
To decrease any edema and inflammation, scaling and root planing with oral hygiene instructions was performed 3–4 weeks earlier to measurement. The existence of the interproximal papilla was judged clinically before probing. The papilla was defined as present (central papilla) if no space appears apical to CP. After giving local infiltration anesthesia (lignocaine hydrochloride with adrenaline 1:200,000), the periodontal probe (UNC 15) was penetrated interdentally between two maxillary central incisors on labial surface till the crest of bone was sounded and recorded [Figure 1]. All the measurements were rounded off to the nearest millimeter.
After scaling, root planing, and oral hygiene instructions (3–4 weeks after), if an empty black space is apparent apical to contact area, a radiopaque material comprising 2:1 mixture of endodontic sealer and barium sulfate was applied on the tip of papilla with probe. Care was taken to prevent flowing of radiopaque material toward apical side which may alter measurements radiographically. Measurement from CP to PT was taken with UNC 15 probe during bone sounding, and after application of radiopaque material so that if material flows apical to PT, then we may wipe it off. Only a minimal amount of radiopaque material was needed since the radio-opacity was greatly enhanced by the contrast media. It was documented as median papilla recession.
Periapical radiographs of all participants were taken (70 kVp, 10 mA, 0.4 s) using parallel cone technique with a XCP (X-tension C-one P-aralleling) film holder (Endo-Bite® Senso Anterior, KerrHawe SA, Switzerland) along with grid. All the X-rays were taken in to RVG (RadioVisioGraphy) so that processing error can be minimized and computer-aided measurements can be done.
Vertical extents measured on radiograph [Figure 2] were extent from point of contact to median PT (h1), CP to pCEJ distance (h2), crest of bone to point of contact extent (h3), and crest of bone to tip of papilla extent (h4). The h1 is that parameter which shows actual length of median papilla recession and our aim of the study was to discover the association of this recession with morphology of embrasure. Horizontal measurement [Figure 3] was w2 (interdental width of upper two central incisors – cementoenamel junction proximally).
|Figure 2: Vertical extents measured on radiograph. CP: Contact point, PT: Papilla tip, pCEJ: Proximal cement-enamel junction, BC: Bone crest|
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According to w2 and h2 calculations, all participants were categorized into four groups [Figure 4].
|Figure 4: Participant groups. w2: Interdental width of upper two central incisors at proximal cement enamel junction, h2: Contact point to proximal cement enamel junction distance|
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- Narrow – long: W2 ≤2 mm, h2 >4 mm
- Wide – long: W2 >2 mm, h2 >4 mm
- Narrow – short: W2 ≤2 mm, h2 ≤4 mm
- Wide – short: W2 >2 mm, h2 ≤4 mm.
The data were evaluated by statistical software, which was commercially available (Epi Info, version 6.04D, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, US.); by WHO, shown as mean ± standard deviation). To compare differences among the four study groups, a parametric analysis of variance test was utilized. T-test was used to compare between h4 and bone sounding between each embrasure group (i.e., comparison of clinical and radiographic methods). P < 0.05 was considered statistically significant.
| Results|| |
Out of 100 subjects, 48 were males and 52 were females with a mean age of 29.08 years. According to w2 and h2 measurements, [Table 1] shows the morphologic differences of all four groups. According to papillary height, age, CP-BC extent, central papilla recession, remarkable differences were evident between the groups [Table 1].
|Table 1: Characteristics of the four study groups according to age, morphologic, clinical and radiological variables|
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[Table 2] reveals that, when the extent from BC to the CP on periapical radiographs was 5 mm or less, the papilla was there about 100% of the time. The papilla was present 47% of the time when the measurement was 6 mm, and when the extent was 7 mm or more, the papilla was present 28% of the time [Table 2]. The vertical extent from CP-BC rises, probability of papilla recession would be more.
|Table 2: Presence of papilla (percentage wise) versus extent from contact point to bone crest (in mm) by radiographic method|
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[Table 3] manifests a comparison between clinical (bone sounding) and radiographic method in each embrasure group. There was statistically no significant difference between two methods among long-narrow and short-wide groups although there is a statistically significant difference was noticed among short-narrow and long-wide groups [Table 3].
|Table 3: Comparison between h4 (radiographic method) and bone sounding (clinical method) among each embrasure group (long-narrow, short-narrow, long-wide, short-wide)|
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The [Table 4] shows central papilla recession's odds ratio between the groups. As compared to other groups, it was lesser in the short-narrow group. The short-narrow group's possibility of papilla recession was 0.65 times as compared to long-narrow group's recession [Table 4]. The long-wide group's odds of papilla recession was 2.33 and short-wide group was 2.12 [Table 4].
|Table 4: Odds ratio of median papilla recession between all participant groups (long-narrow, short-narrow, long-wide, short-wide)|
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According to odds of recession of median papilla, the groups were categorized in ascending sequence: short narrow, long narrow, short wide, and long wide [Table 4].
| Discussion|| |
Central papilla recession has considerable value to dentists plus patients. In dentistry, it is a necessity esthetically to evaluate the features which are risky for the recession of median papilla, as well as the relationship among embrasure anatomy and recession of central papilla.
There were more subjects in the long-narrow and long-wide group in relation to groups in this study among the four study groups. It may show the more natural occurrence of these embrasure groups in our region. Although, short narrow embrasure morphology was more prevalent in the Chang's study. The participants were selected randomly, so the group size may be different. The group size (difference in number of patients in each group) may or may not affect the bias in outcome and require further future research.
The anterior papilla is bit distinct from the posterior interproximal papilla, anatomically and histologically. CPs are discrete in anterior regions too. Therefore, only anterior esthetic area (maxillary central incisors) was considered in this study, which represents the congruent model. Although the interproximal papillae of all the teeth were included in Tarnow's study.
Bone probing is an invading technique because delivering the local anesthesia can lead to patient discomfort and pain therefore daily practice may be cumbersome for clinician, but this technique has been confirmed as a convincing method of recording the papilla length. Lee et al. have evolved a noninvasive method with least patient cooperation, plus it is a simple, precise, and easily accepted by patients. Only in Lee et al. study both of abovementioned methods were compared and results manifested that relations between the values of radiographic length-actual length and bone probing length-actual length were respectively 0.903 and 0.931, both of which represented statistical significance at the 0.01 level. However, interproximal papilla of all teeth were incorporated in Lee's study and additionally, no embrasure groups were there in which comparison between clinical and radiographic methods could be compared. That's why, in this study, both the methods were compared and the outcome displayed that there was statistically no significant difference between two methods among long-narrow and short-wide group, but there is a statistically significant difference was distinguished between short-narrow and long-wide group. The reason for this may be different sample sizes from different regions; different group size and different equipment used, for example, RVG in this study and periapical radiograph with automatic processing in Lee's study (different study designs used in both the studies).
When the measurement through the CP to the BC was 5 mm/less, interdental-papilla was present nearly 100% (98%) of the time. When the extent was 6 mm (only 1 mm more), the papilla was present 56% of the time, and when the extent was 7 mm, the papilla was present 27% of the time or less. Wu et al. declared that when BC-CP extent was 5 mm or less, the papillae were 100% present. When the extent was 6 mm, 51% of the papillae were present, and when the extent was 7 mm or greater, only 23% of the papillae were present. Gastaldo et al. concluded in their study that the ideal extent from the CP to the BC between adjacent implant is 3 mm and between a tooth and an implant is 3–5 mm. While in this study, the papilla was there near to 100% (93%) of the time, when the BC-CP extent was 5 mm or less. When the measurement was 6 mm, the papilla was present 47% of the time, and when the extent was 7 mm or greater, the papilla was present 28% of the time [Table 2]. The cause for the difference between these studies can be because of the incorporation of both anterior and posterior teeth in Tarnow and Gastaldo study and Tarnow did not exclude those teeth with proximal restorations nor define patients who had previous surgery. Even in a study done by Saxena et al., BC-CP extent was the intense determining factor for central papilla presence.
The Chang's study claims that the groups can be categorized as follows on the basis of recession of median papilla's odds (in increasing sequence): short narrow, long narrow, short wide, and long wide. The present study also discovers the identical outcome that the groups can be classified on the basis of recession of median papilla's odds in increasing sequence – short narrow, long narrow, short wide, and long wide.
| Conclusion|| |
Radiographic method and clinical method comparison revealed that there was statistically no significant difference between two methods among long-narrow and short-wide group. However, statistically significant difference was eminent between short-narrow and long-wide group. A recession of median papilla was associated with wide-long type of embrasure configuration. Although many aspects such as periodontal phenotype and shape of teeth etc., may influence the probability of the existence of the interproximal papilla, therefore interconnections between these factors are not clear and require further research.
The authors wish to thank Dr. A. T. Leuva (Ex. Dean, Medical College Vadodara), Dr. Rajiv Daveshwar (Medical superintendent, S.S.G. Hospital, Vadodara), and Dr. Shoyeb Shaikh (HOD, Dentistry Department, Medical College Vadodara) for kind support, Dr. Vikas Doshi and Dr. Niyati Parmar for statistical help, participants for volunteering their time to participate in our study. The authors also wish to thank whole staff of department of Dentistry, Medical College Vadodara, for their kind help and support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chang LC. The association between embrasure morphology and central papilla recession. J Clin Periodontol 2007;34:432-6.
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;63:995-6.
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;72:1364-71.
Pini Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: A review and classification of therapeutic approaches. Int J Periodontics Restorative Dent 2004;24:246-55.
Zetu L, Wang HL. The management of interdental/inter implant papilla, to address factors that may influence its appearance of interproximal papilla. J Clin Periodontol 2005;32:831-9.
Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza's Clinical Periodontology. 10th
ed. Missouri: Elsevier Inc.; 2006. p. 856-70.
Chang LC. Criteria for predicting the presence of the central papilla by a noninvasive method. J Dent Sci 2007;2:88-96.
Tanaka OM, Furquim BD, Pascotto RC, Ribeiro GL, Bósio JA, Maruo H. The dilemma of the open gingival embrasure between maxillary central incisors. J Contemp Dent Pract 2008;9:92-8.
Newman MG, Takei HH, Klokkevold PR, Carranza FA. Carranza's Clinical Periodontology. 10th
ed. Missouri: Elsevier Inc.; 2006. p. 369-70.
Lee DW, Kim CK, Park KH, Cho KS, Moon IS. Non-invasive method to measure the length of soft tissue from the top of the papilla to the crestal bone. J Periodontol 2005;76:1311-4.
Wu YJ, Tu YK, Huang SM, Chan CP. The Influence of the distance from the Contact Point to the Crest of Bone on the Presence of the Interproximal Dental Papilla. Chang Gung Med J 2003;26:822-8.
Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol 2004;75:1242-6.
Saxena D, Kapoor A, Malhotra R, Grover V. Embrasure morphology and central papilla recession. J Indian Soc Periodontol 2014;18:194-9.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]