Embrasure and Central Pappila
Embrasure and Central Pappila
Embrasure and Central Pappila
Abstract
Objective: To discover the association between embrasure morphology and central
papilla recession.
Material and Methods: The central papilla was visually assessed in 330 adults using
standardized periapical radiographs of the maxillary central incisors. The following
vertical distances were measured: papilla recession [i.e., the distance from the papilla
tip (PT) to the contact point (CP)], bone crest (BC) to contact point (BC–CP), proximal
cementoenamel junction (pCEJ) to contact point (pCEJ–CP), and papilla height (PH).
The horizontal distance measured was the inter-dental width. Subjects were divided
into four groups according to inter-dental width and pCEJ-CP distance, respectively:
narrow-long, narrow-short, wide-long, and wide-short.
Results: A statistically positive relationship was evident between central papilla
recession and age, and a statistically negative relationship was evident between age
and PH in all study groups.
Conclusions: Central papilla recession as a result of ageing is most frequently
Key words: age factors; dental morphology;
associated with a wide inter-dental width and long pCEJ–CP distance. However, other embrasure; inter-dental papilla; radiography
factors affect the likelihood of the presence of the inter-dental papilla, and further
study of the interaction among these factors is warranted. Accepted for publication 29 January 2007
In dentistry, increased aesthetic demands buccal, and lingual. The inter-dental The morphologies of the inter-dental
require a soft-tissue contour with an papilla occupies the cervical embrasure papilla and the osseous architecture
intact papilla and a symmetric gingival (Prato et al. 2004). housing the tooth can be categorized into
outline. The presence of a papilla be- The inter-dental gingiva of the incisor two periodontal biotypes (Oschsenbein &
tween the maxillary central incisors is a region usually assumes the shape of Ross 1969, Becker et al. 1997, Weisgold
key aesthetic factor in any individual a pyramidal papilla, or it may appear 1997). The first periodontal biotype is
(Kokich 2006). The inter-dental area com- as a slight gingival col, depending on the thin and scalloped periodontium,
prises the contact area, inter-proximal the location of the contact area and on which is characterized by thin gingival
embrasure, and inter-proximal dentogin- the height of the gingiva (Cohen 1959, tissue and long inter-dental papillae.
gival complex (Takei 1980). The inter- 1962, Fiorellini et al. 2006). The existence The second periodontal biotype is the
dental space is a physical space between of a space below the contact area can lead thick and flat periodontium, which is
adjacent teeth, which comprises four to aesthetic impairment, phonic problems, characterized by a thick osseous struc-
pyramidal embrasures: cervical, occlusal, and food impaction (Tarnow et al. 1992, ture, flat morphology, thick gingival
Prato et al. 2004). If papilla loss occurs tissue, and a short, wide papilla. Indivi-
solely due to soft-tissue damage, recon- duals with the thin periodontal biotype
structive techniques can be completely may have more soft-tissue recession
Conflict of interest and source of restorative. If, however, severe periodontal than those with the thick periodontal
funding statement disease and inter-proximal bone resorption biotype (Olsson & Lindhe 1991). While
The authors declare that they have no cause the loss of inter-dental papilla, the inter-dental gingival tissue possesses
conflict of interests. reconstruction is generally incomplete biologic tissue memory, rebound of
(Prato et al. 2004, Zetu & Wang 2005). gingival tissue is more likely in the thick
432 r 2007 The Author. Journal compilation r 2007 Blackwell Munksgaard
Embrasure morphology and papilla recession 433
periodontium than in the thin and Data collection with the temporary hydraulic restorative
scalloped periodontium, where reces- agent to the apical point of the contact
sion is often permanent (van der One periodontist performed visual exam- area (the distance is the central papilla
Velden 1982, Kan & Rungcharassaeng inations to detect inter-dental papilla recession). h2 represented the proximal
2001). between maxillary central incisors (de- cementoenamel junction to contact point
It has been noted that papilla are almost fined as central papilla). If no space was distance (pCEJ–CP); the length of a ver-
always present when the distance between visible apical to the contact area, the tical line from the proximal CEJ line of
the contact point (CP) and bone crest papilla was recorded as being present two central incisors to the apical point of
(BC) is 5 mm or less, but that papilla without central papilla recession. If a space the contact area. h3 represented the BC to
are typically absent when the CP–BC was visible apical to the contact area, contact point distance (BC–CP); the
distance is 7 mm or more (Tarnow et al. which was gently filled with a tempor- length of a vertical line from the BC to
1992). In addition to the CP–BC distance, ary soft, radiopaque restorative material the apical point of the contact area. Final-
other, less well understood, factors also (Caviton, GC Corporation, Tokyo, Japan), ly, h4 represented the BC to papilla tip
help determine whether the inter-dental it was recorded as central papilla recession. distance (BC–PT); the length of a vertical
papilla will be present; these include The age of each subject was recorded. line from the crest of the bone to the
angulation of the roots of adjacent teeth, Periapical radiographs of maxillary cen- papilla tip (the distance is the papilla
crown shape, space between adjacent tral incisors of all subjects were obtained height). Vertical lines were measured
teeth, volume of the embrasure space, using a paralleling technique with an XCP along the long axis of an adjacent tooth.
and the course of the cementoenamel film holder (Rinn Corporation, Elgin, IL). Horizontal measurements included
junction (Tarnow et al. 1992, Choquet Further measurements made on the radio- w2; the width between the two central
et al. 2001, Kurth & Kokich 2001, graphs were carried out using an electric incisors at the proximal CEJ level (inter-
Gastaldo et al. 2004, Prato et al. 2004, measurement ruler (King Life Technol- dental width).
Zetu & Wang 2005). The purpose of this ogy, Taipei, Taiwan) (Figs 1 and 2). All subjects were divided into four
study was to clarify the association Vertical distances measured on radio- groups according to their w2 and h2
between the embrasure morphology graphs included h1, h2, h3, and h4. h1 measurements, respectively: narrow-long
and central papilla recession by means represented the papilla tip to contact point (w242 mm and h244 mm), narrow-short
of a method that is simple to use and is distance (PT–CP). More specifically, the (w242 mm and h244 mm), wide-long
less invasive than the sounding method. distance was the length of a vertical line (w242 mm and h244 mm), and wide-
The radiographic method presented from the apical margin of the space filled short (w242 mm and h244 mm) (Fig. 3).
herein is considered to be relatively
noninvasive.
Statistical analyses
Subjects
Fig. 3. Subject groups. (a) Narrow-long group: w242 mm and h244 mm; (b) narrow-short group: w242 mm and h244 mm; (c) wide-long
group: w242 mm and h244 mm; (d) wide-short group: w242 mm and h244 mm.
Subjects 82 110 86 52
PR(–)/PR(1) 23/59 32/78 8/78 4/48
Morphologic variables
pCEJ–CP distance (h2) 4.64 0.53 3.34 0.47 4.77 0.56 3.70 0.23 o0.01n
Inter-dental width (w2) 1.63 0.29 1.57 0.31 2.45 0.40 2.35 0.19 o0.01n
Other variables
Age 36.06 13.04 40.69 13.14 42.06 12.48 46.40 10.91 o0.01n
PT–CP distance (h1) 2.18 1.67 1.81 1.29 3.03 1.39 2.43 1.32 o0.01n
BC–CP distance (h3) 6.45 1.06 5.42 1.02 6.93 1.17 6.17 1.13 o0.01n
BC–PT distance (h4) 4.27 1.24 3.62 0.92 3.9 0.97 3.74 1.02 o0.01n
Results (except subject number) are expressed as the mean SD.
n
Statistically significant.
Statistical method: ANOVA.
PR( ), without central papilla recession; PR(1), with central papilla recession; h1, papilla tip to contact point (PT–CP); the distance is the central
papilla recession; h2, proximal cementoenamel junction to contact point (pCEJ–CP); h3, bone crest to contact point (BC–CP); h4, bone crest to papilla
tip (BC–PT); the distance is the papilla height; w2, inter-dental width; the width between the two central incisors at the pCEJ level.
IL, USA) was used to analyse the data, are summarized in Table 1. Significant wide-short group were 3.85 and 4.69,
which is presented as the mean standard differences were apparent between the respectively.
deviation. A parametric ANOVA (analysis groups in criteria that included age, Considering the differences in mean
of variance) test was used to compare central papilla recession, CP–BC verti- age among the four study groups (Table
differences between the means of two or cal distance, and papillary height. 1), further analysis of odds of central
more groups (i.e., among the four study Tables 2 and 3 present the data con- papilla recession was carried out after
groups). The Pearson correlation was cerning the association between the cen- adjustment by age. The results revealed
used to measure associations for two vari- tral papilla recession and age. Age was that the groups could be ranked accord-
ables such as the relationship between positively related to papilla recess- ing to their odds of central papilla reces-
age and recession. Logistic regression ion and negatively related to papillary sion (in ascending order): narrow-short,
and multi-logistic regression were app- height in all groups. This relationship narrow-long, wide-short, and wide-long
lied when outcome variables were binary was much stronger in the wide-long (Table 5).
such as the odds of recession. The level group than in the other groups.
of statistical significance was po0.05. The odds of central papilla recession
among the groups are listed in Table 4.
There was a lower risk of central papilla Discussion
recession in the narrow-short group The presence or absence of the inter-
Results than in the other groups. The likelihood dental papilla is of great concern to den-
There were 330 subjects in this study of papilla recession in the narrow-short tists and patients (Tarnow et al. 1992),
(193 males, 137 females; mean age 40.8 group was 0.95 times the likelihood especially in the area of the central
years). The morphologic differences of of papilla recession in the narrow-long maxillary incisors. Many factors affect
the four groups that were established group. The odds of papilla recession the presence of inter-dental papilla; the
according to w2 and h2 measurements in the wide-long group and the distance from BC to CP is the most
r 2007 The Author. Journal compilation r 2007 Blackwell Munksgaard
Embrasure morphology and papilla recession 435
Table 2. Relationship between age and central papilla recession Further statistical analysis showed a
negative relationship between age and
Age Age (controlling for h3)
papilla height, both with and with-
Pearson’s correlation p-value Pearson’s correlation p value out controlling for BC–CP distance.
Vandana & Savitha (2005) observed
Papilla recession that the gingivae of younger individuals
Narrow-long 0.566 o0.001n 0.369 0.001n are significantly thicker than those of old-
Narrow-short 0.571 o0.001n 0.374 o0.001n
er individuals. This is because a dense
Wide-long 0.655 o0.001n 0.555 o0.001n
Wide-short 0.530 o0.001n 0.373 0.007n connective tissue covered by oral epithe-
lium constitutes the papilla, and ageing
n
Statistically significant. changes the oral epithelium by thinning
Statistical method: correlation. the epithelium and diminishing keratini-
h3, the distance between bone crest and contact point (BC–CP distance). zation. Traumatic oral hygiene and racial
or genetic factors may also contribute to
the inverse relationship between age and
Table 3. Relationship between age and central papilla height papillary height (Wara-aswapati et al.
2001, Litonjua et al. 2003, Prato et al.
Age Age (controlling for h3)
2004, Vandana & Savitha 2005).
Pearson’s correlation p value Pearson’s correlation p value Presently, the papilla recession equal-
ed the discrepancy between the BC–CP
Papilla height distance and the papilla height. Thus,
Narrow-long 0.343 0.002n 0.369 0.001n the strongest negative relation between
Narrow-short 0.275 0.004n 0.374 o0.001n
age and papilla height exists in the
Wide-long 0.423 o0.001n 0.555 o0.001n
Wide-short 0.225 0.108 0.373 0.007n wide-long group (both with and without
controlling for BC–CP distance). Further-
n
Statistically significant. more, the results of this study reveal that
Statistical method: correlation. the groups can be ranked as follows
according to their odds of central papilla
recession (in ascending order): narrow-
Table 4. Odds of central papilla recession between embrasure morphology and the short, narrow-long, wide-short, and wide-
among the four study groups central papilla recession. long after adjustment by age. The mean
Exp (B) 95% CI p-value In an attempt to further understand the age of the wide-short group was older
influences on central papilla recession, than those of other groups, which may
Narrow-long 1.00 – – herein the author divided the embrasure explain why the wide-short group pre-
Narrow-short 0.95 0.50–1.79 0.874 morphology of the study subjects into sents the highest odds of central papilla
Wide-long 3.80 1.59–9.10 0.003n four groups according to pCEJ–CP dis- recession before adjustment by age.
Wide-short 4.69 1.51–14.45 0.007n tance and pCEJ width, respectively: nar- In previous studies, papillary height
n
Statistically significant. row-long, narrow-short, wide-long, and was measured by sounding, with the pati-
Statistical method: logistic regression. wide-short. There were many more sub- ent under local anaesthesia (Tarnow et al.
jects in the narrow-short group than in any 1992, Grunder et al. 2000); however, this
of the other groups. This may reflect the method is invasive. The thickness of
Table 5. Odds of central papilla recession greater natural prevalence of the narrow- masticatory mucosa and gingivae can
among the four study groups after adjustment short embrasure morphology. However, be determined ultrasonically, but this
by age the random sampling design of the study measurement does not include inter-
Exp (B) 95% CI p-value negated any bias related to group size. dental papillary height (Muller et al.
Presently, a positive relationship be- 1999, 2000). Therefore, the author
Adjustment by Age tween age and the papilla recession was developed a noninvasive method of
Narrow-long 1.00 apparent, even after controlling for the measurement that was simple, accurate,
Narrow-short 0.47 0.21–1.03 0.058 BC–CP distance. The relationship be- and easily accepted by subjects. And,
Wide-long 2.67 0.97–7.33 0.057
tween age and the recession height was the use of radiopaque material and peri-
Wide-short 1.47 0.41–5.25 0.556
more statistically significant in the wide- apical radiographs may permit measure-
Dependent Variable: central papilla recession. long group than in the other groups. This ment of the length of the inter-dental
Statistical method: multi-logistic Regression. may have been caused by greater bone papilla in relation to the crestal bone,
loss at the same height of BC resorption, which would enable more accurate
resulting in a larger recession for the prognoses for a regenerated papilla
wide groups (wide-long and wide-short) (Lee et al. 2005).
commonly studied of these, but there than for the narrow groups (narrow-long
are many others (Tarnow et al. 1992, and narrow-short). The wide-long group
Choquet et al. 2001, Kurth & Kokich also had narrower widths than the wide-
2001, Gastaldo et al. 2004). There is an short group, so the height of the reces- Conclusions
important need in aesthetic dentistry to sion was longer in the wide-long group. The occurrence of central papilla reces-
find the risk factors for recession of the (The recession area is almost equal to sion is significantly related to age, espe-
central papilla including the association PT width PT–CP height 0.5.) cially for those with a wide inter-dental
r 2007 The Author. Journal compilation r 2007 Blackwell Munksgaard
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Clinical Relevance other risk factors for central papilla dental width and long pCEJ–CP dis-
Scientific rationale for the study: The recession. tance (‘‘wide-long’’).
distance from BC to contact point is Principal findings: This study con- Practical implications: In clinical
the most frequently studied of the firms a significant association be- practice, the ‘‘wide-long’’ embrasure
many factors that influence whether tween the occurrence of central morphology may be a risk factor for
inter-dental papilla are present. papilla recession and increased age, central papilla recession.
There is an important need in aes- and demonstrates that it is especially
thetic dentistry to understand the relevant for those with a wide inter-