Interdental Papillary House: a New Concept and Guide for Clinicians

e87

Interdental Papillary House: A New Concept and Guide for Clinicians

Marly Kimie Sonohara Gonzalez, DDS, PhD1 The presence and regeneration Ana Lúcia Pompéia Fraga de Almeida, DDS, PhD2 of the interdental papilla is one Sebastião Luiz Aguiar Greghi, DDS, PhD3/Luiz Fernando Pegoraro, DDS, PhD2 of the greatest challenges to im- José Mondelli, DDS, PhD4/Tatiana Moreno, DDS5 proving the gingival contour in areas where esthetics is a major concern. Even though the anatomi- Surgical and nonsurgical techniques have been proposed to regenerate cal and morphologic characteris- interdental papillae. The results are influenced by the morphology of the tics of the interdental gingiva are interdental space, which is the housing for the papilla. The concept of very well known and scientifically the interdental papillary ”house” has been established not only to allow documented, predictable restora- diagnosis of the causes of papillary loss, but also to manage and predict tion of the lost interdental papilla reconstruction of the interdental gingival tissue. The adjacent teeth in contact, remains an unsolved problem. involving the proximal contact, contour and shape of the teeth, course of the Interdental gingival tissue is formed cementoenamel junction, interdental distance, and underlying bone crest, determine the outline of the house. Since the components are combined, by a dense connective tissue cov- an understanding of each allows adequate treatment planning involving ered externally by oral gingival interdisciplinary procedures. This new concept serves as a guide and teaching epithelium and internally by junc- aid for the practitioner. (Int J Periodontics Restorative Dent 2011;31:e87–e93.) tional and oral sulcular epithelia. The architecture of this apparatus not only acts as a biologic barrier in protecting the periodontal struc- tures, but also plays a critical role in esthetics and phonetics.1 From a 1Professor, Rosario Circle of Dentistry, Santa Fe, Argentina. 2Professor, Department of Prosthodontics, Bauru Dental School, University of São Paulo, facial point of view, the interdental São Paulo, Brazil. papilla appears pyramidal in shape 3 Professor, Department of Periodontology, Bauru Dental School, University of São Paulo, (Fig 1) and occupies a space cre- São Paulo, Brazil. 4Professor, Department of Operative Dentistry, Bauru Dental School, University of São Paulo, ated between two adjacent teeth São Paulo, Brazil. in contact with one another. This 5Private Practice in Periodontics, Curitiba, Paraná, Brazil. space, comprising the contact point or area, proximal tooth surfaces, Correspondence to: Dr Marly Kimie Sonohara Gonzalez, Al. Dr Octávio Pinheiro Brisolla, 9-75, Departamento de Prótese, 17012-901 Bauru, São Paulo, Brazil; email: clinica@ course of the cementoenamel junc- marlysonohara.odo.br. tion (CEJ), interdental distance,

Volume 31, Number 6, 2011

© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e88

Fig 1 (left) Clinical aspect of the interdental papilla. The interdental papilla extends from the incisal tip to a line tangent to the gingival margins of the two adjacent teeth in contact (dotted line). Its presence determines the scalloped outline of the gingival margin.

Fig 2 (right) The outline of the interdental space is similar to the shape of a house.

and bone crest, was considered Apex of the roof: Position The interdental gingiva of posterior by Takei2 as the housing for the in- and extension of the teeth, especially molars, presents a terdental papilla. When assessed contact point or area prominent gingival col,5 since the radiographically, this space pre facial-oral contact areas are broad. sents an outline in the shape of a The contact relationship between The height of the roof relates house (Fig 2). The term ”interdental adjacent teeth represents the apex to the position of the contact ar- papillary house” was chosen to un- of the papillary house’s roof and eas in the gingivo-occlusal dimen- derstand all factors and conditions determines the shape of the tip of sion and influences the facial-oral that may modify the morphology the interdental papilla. The proper contour of the interdental papilla. of the interdental papilla. Following width and location of the contact A contact area overextended in this concept, components of the point or area in facial-oral and the gingival direction can impinge interdental papillary house are the gingivo-occlusal dimensions main- upon the interdental gingiva and apex of the ”roof” (contact point or tains a stable dental arch, prevents reduce the height of the roof. area), contour of the ”roof” (proxi- food impaction in the interdental With the lack of space, the papil- mal tooth surfaces), border be- area, and creates the space need- lary tissue becomes enlarged and tween the ”roof” and “wall” (CEJ), ed for the interdental gingiva.2 All inflamed, even if proper cleansing lateral “walls” (interdental dis- teeth present contact areas facial is performed. If the contact is too tance), “floor” (bone crest), height to the central fossa line.3 The ex- high incisally/occlusally, the height of the house (measurement of the ception is between the maxillary of the interdental papilla’s roof is supracrestal gingival tissue), and molars, where the proximal contact increased and the papilla does not cleanliness of the ”roof” (plaque appears from the midpoint contact fill the space completely. When removal by the patient). area to the palatal third.2 From a fa- there is visible space apical to the This review aims to discuss cial or oral view, the contact point contact point (black space), the each component that influences the or area is situated near the occlu- papilla is deemed missing, becom- housing of the interdental papilla sal or incisal third.3,4 The only ex- ing an area of food retention and and to present a new concept to ception to this rule is between the bringing about discomfort to the guide the management and recon- maxillary molars, where the proxi- patient. For example, a mesiodis- struction of the interdental papilla. mal contact may be between the tal divergence of roots can lead to occlusal and middle thirds.3 In the coronal positioning of the contact anterior region, the tip of the pa- point. By repositioning these roots pilla is usually pyramid-shaped or and reshaping the mesial contour may present a slight gingival col.2 of the teeth, the contact point can

The International Journal of Periodontics & Restorative Dentistry

Fig 3a (left) The tip of the interdental papilla reveals a flat form due to the presence of diastema between the maxillary central incisors. Each side of the roof no longer comes into contact with the other.

Fig 3b (right) Orthodontic closure of diastema created a roof for the interdental papilla. This resulted in coronal creeping of the interdental gingival tissue and building up of the tip of the papilla to a triangular form.

be located more apically and the contact, involving proximal surfaces Several restorative procedures height of the roof can be reduced, and axial line angles, represent the modify the roof of the papillary eliminating the black space.6 In roof of the papillary house and de- house, and there is a strong ten- the presence of diastema, when termine the location of the contact dency to violate the principle of the proximal contours of adjacent point or area. The contour of the the straight line angle when a res- teeth are too far from each other, proximal tooth surface between the toration is performed by making the interdental papilla may be vis- proximal contact and the CEJ is flat the line angles somewhat convex4 ibly absent, creating both esthetic or slightly concave in the gingivo- and, consequently, a convex crown and phonetic problems (Fig 3a). occlusal (Fig 4) and facial-oral di- design (Fig 6). Therefore, the con- If periodontal health is good, the mensions.3,4 This shape should also tour of the roof directly affects the interdental gingival tissue is firmly be observed to the facial and oral biologic and morphologic features attached to the teeth and alveolar line angles. of the interdental gingiva and the bone.6 A round or flat papillary tip A line angle is formed by the scalloped outline of the gingival is observed instead of a triangular junction of two surfaces along a margin (Figs 7a and 7b). shape.7 An orthodontic approach line and derives its name from the can reduce the diastema or create combination of the two surfaces. a contact point between the adja- For instance, on a tooth, the junc- Border between roof and cent teeth (Fig 3b). In certain cases, tion of the mesial and facial sur- wall: Course of the CEJ appropriate restorative techniques faces is called the mesiofacial line can also create a contact point by angle (Fig 5).8,9 Each individual The gingival margin presents a nat- recontouring the proximal shape of tooth has four axial line angles (me- ural scalloped outline, which is de- the teeth and allowing coronal dis- siofacial, distofacial, mesio-oral, termined by the course of the CEJ placement of the interdental tissue. and disto-oral), which are parallel and, consequently, by the bone with the long axes of the tooth. level. Radiographically, the proximal These line angles are straight be- CEJ represents the border between Contour of the roof: tween the proximal contact and the the roof and lateral wall of the inter- Contour of proximal CEJ, except for the facial line an- dental papillary house. The course tooth surfaces and gles (mesiofacial and distofacial) of of the proximal CEJ depends on axial line angles maxillary incisors and the oral line the surface, type of tooth, and angles (mesio-oral and disto-oral) periodontal biotype. Seibert and The characteristics of the crown of maxillary molars, where there Lindhe10 defined the existence of contour of two adjacent teeth in may be a slight convexity.4 two markedly different periodontal

Volume 31, Number 6, 2011

Fig 4 (top left) Radiographically, proximal contours of teeth are slightly concave or flat from the CEJ to the proximal contact.

Fig 5 (right) The mesiobuccal line angle of a mandibular molar is straight between the CEJ (white arrow) and the proximal contact (black arrow).

Fig 6 (bottom left) Radiographic view of overcontoured crowns without cervical adaptation in the posterior region. The convex contour results in an excessively wide contact area in the gingivo-occlusal direction, with lack of adequate space for the gingiva and occlusal embrasure.

Fig 7a (left) Provisional crowns without marginal adaptation allowed accumulation of plaque and alterations in the gingival contour at the region of the maxillary central incisors. The outline of the papillary roof is atypical.

Fig 7b (right) A natural scalloped contour of the gingival margin was conditioned with well-adapted provisional crowns. Proper contour of the roof was reestablished. Com- plete regeneration of the interdental papilla was achieved after 14 months. biotypes: thin and thick. The com- but wide crown with relatively large Lateral walls of the house: bination of a proximal CEJ strongly proximal contact areas (Fig 9). Supracrestal interdental convex toward the occlusal or incisal The CEJ is a component of distance surfaces, sharply pointed bone crest, the papillary house and cannot be thin soft tissue and bony housing, modified by clinicians. Therefore, Another issue is the physical dis- more accentuated scalloped gingi- the dentist should identify the tance between the approximating val contour, and tapered crown form biotype before undertaking bone teeth, ie, the distance between with minute proximal contact areas surgery11 and restorative proce- the lateral walls of the house. On are tooth characteristics related to dures. For example, one can wish account of differences in the con- the thin periodontal biotype (Fig 8). to obtain a great reconstruction of formation of crowns and the incli- In the thick biotype, the tooth pres- the papilla in cases with a thick bio- nation of teeth, interdental spaces ents a flatter scalloped outline of type; others can wish to have the vary in width. The supracrestal in- the proximal CEJ facial-orally, asso- contact area near the bone level terdental distance is wider between ciated with a flatter bone crest, less when a more pronounced scal- bell-crowned teeth than between pronounced scalloped outline of loped gingival contour is present thick-necked teeth. Among anterior the facial gingival margin, and short (thin biotype). teeth, the interdental space is widest

The International Journal of Periodontics & Restorative Dentistry

Fig 8 (left) Thin periodontal biotype presents a highly scalloped gingival contour (dotted line).

Fig 9 (right) Thick biotype relates to a less-pronounced scalloped gingival outline (dotted line).

Fig 10 Disappearance of the natural contour of the gingival margin due to lack of horizontal space for the interdental papillae. Separation of the roots using orthodontic methods might be beneficial to support a proper interdental gingival configuration.

between the necks of the central Floor of the house: Level of crestal bone has been recontoured incisors. The widest interdental dis- the bone crest through regeneration methods fol- tances are usually located between lowing the course of the CEJ. How- the molars.9 The level of the bone crest acts as ever, in cases of severe periodontal When the distance between a scaffold to support the overlying breakdown with great tissue loss the lateral walls of the house is interdental tissue (the floor of the and gingival margins at the same large and there is no contact (dia- papillary house) and has direct in- interdental level orally and facially stema), the tip of the papilla does fluence on the configuration of in- (Figs 11a and 11b), surgical papil- not assume a triangular shape (see terdental papillae.12 lary reconstruction fails to reduce Fig 3a). A close distance between The most common reason for the height of the interdental papil- the lateral walls of the papillary the loss of interdental papillae is lary house and to regenerate papil- house results in a very narrow bone the presence of plaque-associated lae. It is very difficult to transform a septum, creates inadequate space lesions with interproximal bone duplex into a house. Interdisciplin- to maintain its proper shape, and resorption. In such cases, inter- ary treatment is required to reduce impairs cleaning of the house (Fig dental papillary reconstruction is this vertical discrepancy. Coronal 10). In these cases, a proper supra- not the main goal of the compre- displacement of the bone crest crestal interdental distance to allow hensive treatment plan. The first can be achieved through applica- the presence or regeneration of the step is elimination of the marginal tion of orthodontic force. Ideally, interdental papilla is best achieved inflammation of the periodon- it would lead to creation of new with orthodontic therapy. tal tissues. The presence of black papillae.13 The esthetic appearance spaces produced by the loss of might also be clearly enhanced by interdental papillae as a result of shortening the incisal edges of the periodontal disease (nonsurgical affected teeth to apically displace and surgical therapy) is frustrating the roof level. Orthodontic treat- for both patients and dentists. The ment, in conjunction with tooth

Volume 31, Number 6, 2011

Fig 11a (left) Black space observed between the maxillary central incisors occurred following periodontal surgery. The interdental papilla is pyramid-shaped and its tip has a round form.

Fig 11b (right) Radiographically, the interdental space presents an outline of a duplex, not a house.

stripping, can be performed to re- that when adjacent teeth are pres- papilla will completely fill the inter- duce the interdental distance hori- ent, interproximal measurement of dental space when the height of zontally.14 It reduces the height of the SGT should be approximately the house is less than 5 mm. the roof to hide the soft and hard 4 mm. Coesta17 evaluated the di- If the loss of papilla is related tissue defects that may be present. mension of the SGT in proximal only to soft tissue damage, the surfaces around teeth without at- cause must be eliminated, and ad- tachment loss. The mean clinical equate plaque control is able to Height of the house: The SGT values ranged from 3.62 to regenerate it completely without concept of the supracrestal 5.00 mm. Tarnow et al12 showed any clinical manipulation (Figs 12a gingival tissue that the interdental papilla was al- and 12b). This spontaneous regen- ways present when the distance eration can also be observed after The dimension of the supracrestal between the bone crest and the remodeling of the roof (proper lo- gingival tissue (SGT; height of the contact point of two adjacent teeth cation of the proximal contact or house) may play a crucial role in es- was 3 or 4 mm. When the distance contour of the proximal tooth sur- tablishing the entire height of the was 5 mm, the papilla was present face) (see Fig 7b). Thus, the regen- papilla. It comprises connective tis- 98% of the time. van der Velden18 eration of the interdental papilla sue fibers attached to the cemen- investigated the level of the gingi- must be understood histologically tum (lateral wall of the house) and val margin 3 years following denu- as a reformation of the SGT dimen- junctional and oral sulcular epithe- dation of the interdental alveolar sions and clinically as achieving lia adhered on the enamel surface bone. The results showed that the a scalloped contour of the gingi- (roof). Based on the work of Gar- location of the gingival margin was val margin. No scientific study has giulo et al,15 the overall dimension found at a mean distance of 4.33 been developed to evaluate how of the SGT averaged 3.40 mm for mm coronal to where the bone long the soft tissue takes to com- mesial surfaces and 3.31 mm for level was defined at surgery. Such pletely fill the interdental papillary distal surfaces in human autopsy findings and recommendations house. specimens. Kois and Vakay16 found have led to the conclusion that the

The International Journal of Periodontics & Restorative Dentistry

Fig 12a (left) Loss of interdental papillae was observed after suture removal.

Fig 12b (right) Rebuilding of the lost interdental papillae was achieved after 11 months. Effective plaque control allowed reformation of the supracrestal gingival tissue (coronal creeping).

Cleanness of the roof: all components of the interdental 10. Seibert J, Lindhe K. Esthetics and peri- Plaque control papillary house are considered by odontal therapy. In: Lindhe J (ed). Textbook of Clinical Periodontology. Co- the dentist and an attempt is made penhagen: Munksgaard, 1989:477–514. Effective plaque control also plays to visualize them during nonsurgi- 11. Becker W, Ochsenbein C, Tibbets L, Becker BE. Alveolar bone anatomic an important role in the regenera- cal and surgical techniques, the pre- profiles as measured from dry skulls. tion and preservation of the inter- dictability of successful preservation Clinical ramifications. J Clin Periodontol dental papilla. When black spaces and reconstruction will be improved 1997;24:727–731. 12. Tarnow DP, Magner AW, Fletcher P. are present, patients must be in- markedly. The effect of the distance from the structed to use dental floss or an contact point to the crest of bone on the presence or absence of the inter- interdental brush to remove plaque proximal dental papilla. J Periodontol from the lateral walls and roof of References 1992;63:995–996. the papillary house (Fig 11a). 13. Blatz MB, Hürzeler MB, Strub JR. Re- 1. Hassell TM. Tissues and cells of the peri- construction of the lost interproximal odontium. Periodontol 2000 1993;3:9–38. papilla—Presentation of surgical and 2. Takei HH. The interdental space. Dent nonsurgical approaches. Int J Periodon- Conclusions Clin North Am 1980;24:169–176. tics Restorative Dent 1999;19:395–406. 3. Burch JG. Ten rules for developing crown 14. Jarvis RG. Interproximal reduction in the contours in restorations. Dent Clin North molar/premolar region: The new ap- There is a close relationship between Am 1971;15:611–618. proach. Aust Orthod J 1990;11:236–240. 4. Burch JG. Periodontal considerations 15. Gargiulo AW, Wentz FM, Orban B. Di- these seven important aspects that in operative dentistry. J Prosthet Dent mensions and relations of the dentogin- combine to create the housing for 1975;34:156–163. gival junction in humans. J Periodontol 1961;32:261–267. the interdental papilla. Identifying 5. Cohen B. Morphological factors in the pathogenesis of periodontal disease. Br 16. Kois JC, Vakay RT. Relationship of the the etiology of the black space in- Dent J 1959;107:31–39. periodontium to impression procedures. volves understanding the concept 6. Prato GP, Rotundo R, Cortellini P, Tinti C, Compend Contin Educ Dent 2000;21: Azzi R. Interdental papilla management: 684–688. of the interdental papillary house. A review and classification of the thera- 17. Coesta PTG. A Extensão das Distân- When there are discrepancies in the peutic approaches. Int J Periodontics Re- cias Biológicas do Periodonto Marginal: Comparações Clínicas e Radiográficas components of the papillary house, storative Dent 2004;24:246–255. 7. Bichacho N. Papilla regeneration by non- [thesis]. Bauru: Faculdade de Odontolo- treatment planning involves altera- invasive prosthodontic treatment: Seg- gia de Bauru, Universidade de São Pau- tion of these components. When mental proximal restorations. Pract Peri- lo, 2003. odontics Aesthet Dent 1998;10:75–78. 18. van der Velden U. Regeneration of the there are no discrepancies in the 8. Wheeler RC. A Textbook of Dental Anat- interdental soft tissues following denu- components of the papillary house, omy and Physiology. Philadelphia: WB dation procedures. J Clin Periodontol 1982;9:455–459. the problem is related to reforma- Saunders, 1965. 9. Black GV. Descriptive Anatomy of the tion of the dimensions of the supra- Human Teeth. Philadelphia: SS White crestal gingival tissue. Therefore, if Dental Manufacturing, 1902.

Volume 31, Number 6, 2011