ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10019-1343 |
A Trichotomous Relation between Papilla Proportion, Gingival Zenith, and Facial Profile
1-3,5,6Department of Periodontology and Oral Implantology, AME’s Dental College & Hospital, Raichur, Karnataka, India
4Consulting Periodontist, Trivandrum, Kerala, India
Corresponding Author: S Gomathi Sai Krishna, Department of Periodontology and Oral Implantology, AME’s Dental College & Hospital, Raichur, Karnataka, India, Phone: +91 7901267872, e-mail: gomathisureddy111@gmail.com
ABSTRACT
Aims and objectives: Gingival morphology, that is, the contour, thickness, height of the papilla, proportion of the papilla, plays a vital role in smile designing and esthetics. These anatomical landmarks may vary based on race, gender, and ethnicity, so understanding, evaluating, and correcting these variations is the utmost important aspect when planning for smile designing as well as in anterior teeth rehabilitation. The main objective of this study was to evaluate papilla height and papilla proportion as a useful parameter for treatment planning in different facial profile subjects (concave, convex, straight).
Materials and methods: Diagnostic casts were made using alginate impressions for 32 periodontally healthy subjects including males and females (age range 18-50 years) having sound anterior teeth. Gingival zenith was marked by using the method described by Chu and Stappert. Papilla height was measured and papilla proportion was calculated by the mathematical equation given by Chu and Stappert. The data obtained were subjected to statistical analysis.
Results: Papilla height and papilla proportion were higher in concave profile subjects when compared to convex as well as straight profile subjects. The mean papilla proportion of right central incisor among various facial profiles (convex, straight, and concave) was 34.93% ± 5.40, 34.64% ± 7.38, and 37.58 ± 8.27, respectively and for the left central incisor were 34.74% ± 5.56, 34.05 ± 7.59, and 37.21 ± 8.37, respectively.
Conclusion: Facial, dentogingival, dentofacial, and dental are the factors involved in the esthetic analysis. Multidisciplinary approaches are often required to increase the treatment predictability.
How to cite this article: Aspalli S, Krishna SGS, Gaddale R, et al. A Trichotomous Relation between Papilla Proportion, Gingival Zenith, and Facial Profile. Int J Prosthodont Restor Dent 2021;11(4):173-177.
Source of support: Nil
Conflict of interest: None
Keywords: Facial profile, Gingival zenith, Papilla height, Papilla proportion
INTRODUCTION
Dental art is an essential element of esthetics where the dentist plays a major role in conserving or creating an esthetically pleasing smile.1 Dentogingival complex is a part of the dentofacial esthetic paradigm.2 The attractiveness of a smile can be defined by various factors that involve both the teeth as well as the surrounding soft tissues. Pink esthetics has always been a vital component of a beautiful smile. Superior restorations which are bounded by unpleasing gingival tissues will have a negative impact on the smile.1
The ideal gingival architecture has been described as the one that consists of knife-edged gingival margins that adapt tightly to the teeth with interdental grooves as well as the cone-shaped interdental papilla.3 Nordland and Tarnow’s classification of the abnormal interdental papilla fills the embrasure space to the apical extent of the interdental contact area.3,4
The interdental appearance of the papillae in an apicocoronal location, which is considered to be critical during smiling, will lead to a positive gingival architecture.5,6 The digression from the normal interdental papilla results in an unesthetic gingival “black triangle,” and also the disproportion in gingiva causes visual stress and imbalance.7
Gingival zenith plays a pivotal role in esthetics. Gingival zenith is described as the most apical aspect of the free gingival margin (FGM). For the central and lateral incisors, the location of the gingival zenith was found distally to the vertical bisected midline (VBM) and for the canine, it coincides with the VBM.3
Bhatsange et al.8 conducted an evaluation of the position of the gingival zenith in different facial forms and concluded that firstly the clinicians may need to evaluate the patient’s facial form and then decide to distalize the gingival zenith position in relation to VBM.
The morphology of gingiva, that is, gingival contour, along with facial and smile components must be in harmony; therefore, any deviations must be corrected by surgical intervention or orthodontic treatment.9
The study aimed to quantitatively evaluate the papilla height and interdental papilla proportion mathematically as a percentage ratio of clinical crown length, thereby establishing a useful parameter for the treatment, in various facial profiles (convex, straight, concave).
MATERIALS AND METHODS
A sample population of 36 patients ranging in age from 18-50 years with good systemic health was enrolled. The study was elucidated to the subjects, written, and verbal consent was obtained and also ethical clearance certificate was procured from the institution.
Subjects with healthy maxillary central incisors, teeth with no anterior crowding or spacing, no visible signs of gingival recession, gingival overgrowth, excessive incisal attrition, or altered eruption, and with no loss of interdental papilla were included in the study.
Subjects with a habit of smoking, with systemic health conditions, undergoing orthodontic treatment and on medications that have an effect on periodontal soft tissue were excluded from the study.
The study subjects were further divided into three groups based on their profile that includes group A—convex profile, group B—straight profile, and group C—concave profile.
Facial Profile Determination
The facial profile was determined by the method given by Legan and Burstone.10 The facial profile was determined by using three soft tissue points with two reference lines. The three soft tissue points are glabella, point A: philtrum and point B: pogonion which is marked at the highest point over the contour of the chin, and the two reference lines are the first line that connects the glabella with point A and the second line that connects the point A with pogonion.
Depending upon the alignment of the three points and two reference lines, the profile can be straight when the two reference lines coincide in the straight line, when the two reference lines form an angle in such a way that the concavity facing toward the tissue, then it is said to be convex profile, and when the two reference lines form an angle resulting in convexity facing toward the tissue, then it is said to be concave profile.
Impressions of all the study subjects were made using irreversible hydrocolloid impression material and immediately poured with dental stone. A diagnostic cast was made for all the study subjects. Digital callipers were used to measure the papilla height of maxillary central incisors.
The most apical point of the contour of gingiva for each tooth gives the gingival zenith point (GZP). Thus, the GZP was identified and marked for the central incisors of the maxilla (Fig. 1) and the two zenith points were joined to form a gingival zenith line (Fig. 2). A line was drawn from the gingival zenith point to the incisal edge of the corresponding teeth (Fig. 3) and was measured with the help of digital callipers (Fig. 4).
Fig. 1: Marking of gingival zenith
Fig. 2: Gingival zenith line
Fig. 3: Clinical crown length from the gingival zenith point of the respective tooth
Fig. 4: Measurement of the clinical crown length using the digital calliper
The mesial height of the papilla for the central incisors in the maxillary anterior dentition was measured from the gingival zenith line midpoint of the respective tooth till the tip of the papilla using digital callipers (Fig. 5). Additionally, the crown height of both the central incisors was recorded for each study subject for all the three groups. Papilla height of each subject was obtained and divided by the length of the clinical crown of the corresponding tooth to obtain a percentage ratio of proportion of papilla. The following mathematical equation was used to calculate a percentage ratio, termed papilla proportion (PP):
Fig. 5: Measurement of the papilla height from the midpoint of gingival zenith till the tip of the papilla using the digital calliper
PP = papilla height/crown length × 100
The obtained data were tabulated and subjected to statistical analysis. The data obtained were statistically analyzed using t-test.
Result
-
Total of 36 casts were evaluated for variations in papilla heights as well as papilla proportion among three different facial profiles (straight, convex, and concave) for maxillary anterior teeth (central incisors).
Table 1 depicts the mean comparison of papilla heights of central incisors among three different facial profiles. The mean absolute values (± SD) for the interdental papilla heights of maxillary anterior teeth (central incisors) measured from the midpoint of gingival zenith line to the tip of the papilla among different facial profiles (convex, straight, and concave) were 3.19 ± 0.42, 3.02 ± 0.81, and 3.31 ± 0.74, respectively. The difference in the papilla height of central incisors among three different facial profiles was not statistically significant (p -value = 0.525).
| Profile | Sample size (N) | Min | Max | Mean | SD | F value | p value |
|---|---|---|---|---|---|---|---|
| Convex | 12 | 2.40 | 3.90 | 3.19 | 0.42 | 0.655 | 0.525 NS |
| Straight | 12 | 1.80 | 4.20 | 3.02 | 0.81 | ||
| Concave | 12 | 2.10 | 4.70 | 3.31 | 0.74 |
Statistical analysis, ANOVA one-way test; S, Statistically significant at the 0.05 level; NS, Not significant
Although there is no statistically significant difference observed, it is found that the papilla height is higher in case of concave profile subjects and the least was observed for straight profile subjects.
Table 2 depicts the comparison of papilla proportion consorted by tooth position 11 among three different facial profiles (convex, straight, and concave). The mean absolute values (± SD) for the papilla proportion of maxillary anterior teeth (central incisor 11) measured mathematically as a percentage ratio of clinical crown length among different facial profiles (convex, straight, and concave) were 34.93% ± 5.40, 34.64% ± 7.38, and 37.58 ± 8.27, respectively. The difference in papilla proportion irt 11 among three different facial profiles was not statistically significant (p -value = 0.491). The variation of papilla proportion was found to be higher in case of concave profile subjects irt 11 and the least was observed in case of straight profile subjects.
| Profile | Sample size (N) | Min | Max | Mean | SD | F value | p value |
|---|---|---|---|---|---|---|---|
| Convex | 12 | 27.90 | 42.00 | 34.93 | 5.40 | 0.724 | 0.491 NS |
| Straight | 12 | 22.90 | 46.90 | 34.64 | 7.38 | ||
| Concave | 12 | 24.40 | 51.30 | 37.58 | 8.27 |
Statistical analysis, ANOVA one-way test; S, statistically significant at the 0.05 level; NS, not significant
Table 3 depicts the mean comparison of papilla proportion consorted by tooth position 21 among three different facial profiles (convex, straight, and concave). The mean absolute values (± SD) for the papilla proportion of maxillary anterior teeth (central incisor 21) measured mathematically as a percentage ratio of clinical crown length among different facial profiles (convex, straight, and concave) were 34.74% ± 5.56, 34.05 ± 7.59, and 37.21 ± 8.37, respectively.
| Profile | Sample size (N) | Min | Max | Mean | SD | F value | p value |
|---|---|---|---|---|---|---|---|
| Convex | 12 | 27.50 | 43.70 | 34.74 | 5.56 | 0.731 | 0.488 NS |
| Straight | 12 | 22.20 | 46.42 | 34.05 | 7.59 | ||
| Concave | 12 | 24.10 | 50.60 | 37.21 | 8.37 |
Statistical analysis, ANOVA one-way test; S, statistically significant at the 0.05 level; NS, not significant
The difference in papilla proportion among three different facial profiles was not statistically significant (p -value = 0.488). Even though there is no statistically significant difference observed, there is a variation of papilla proportion among different facial profiles and it was found to be higher in case of concave profile subjects.
Overall results indicate that papilla proportion was higher in concave profile subjects as compared to convex and straight profile subjects.
DISCUSSION
Gingival health is one of the prime requirement for esthetics and smile designing, so it is also important to consider the morphological features of gingiva, that is, contour, phenotype, interdental papilla height, and proportion.11 To provide more pleasing and esthetic results in a complete rehabilitation that includes the interdisciplinary intervention one needs to be very specific about the dentogingival interface.12
The esthetic impact due to uneven gingival contour height can influence the profile of the teeth, the axial inclination that affects the smile esthetics. The interdental papillae height and its relationship to the most apical point of the gingival contour are undefined. The locus of these parameters will be helpful in fabricating the esthetic restorations and also in smile designing.13
This is the first kind of study done to evaluate the interdental proportion of the papillae among three different facial profiles.
When considering papilla proportion between tooth 11 and 21 there was not much significant difference observed, and the results were in consistent with the research work done by Veena et al.14 Several investigators have attempted to establish guidelines to enhance the form of papillae and to optimize the position of soft tissue and esthetics.
Chu SJ15 suggested that a mathematical correlation was present between the crown width of maxillary anterior teeth. Cho et al.16 and Martegani et al.17 found that the distance between the roots, that is, interradicular and the distance from the alveolar crest to the contact point have independent and combined effects on the absence or presence of the interdental papilla.
Tarnow et al.18 examined the distance from the base of the contact area to the alveolar bone crest in 288 sites and determined that at 5, 6, and 7 mm the papilla was present 98%, 56%, and 27% of the time, respectively.
Ganji et al.19 reported that there is a variation of gingival zenith position in different facial profiles, and concluded that the possible variation could be due to a change in gingival morphology due to underlying skeletal or dental abnormality. Gingival zenith has a direct effect on the height and proportion of the papilla, so the variations in the papilla proportion in the current study could be attributed to the skeletal changes in various facial profiles.
Bendahmash et al.20 evaluated the perception of proportion of the maxillary anterior teeth width in relation to the position of dental papilla among the Saudi population and concluded that short dental papilla with original proportion smile was more preferable.
Nanal et al.21 conducted a study to quantify the papilla location as a percentage ratio of crown length among males and females of different genders in maxillary anterior dentition and concluded that age and gender have an influence on papilla proportion which was observed to be higher in males. The results obtained in the study with respect to the mesial papilla proportion of central incisor were inconsistent with the present study. Restoring the proper anatomy of the tooth along with the maintenance of soft tissue health should be a prime consideration during restorative procedure. An intimate relationship exists between the periodontal tissues and the restoration so adequate understanding is required to obtain proper form, function, and esthetics. The gingival health maintenance is the key factor for the longevity of the restoration.
The contour of the gingival margins must be in consonance with all the components of smile and face so alterations or asymmetries that were present will require surgical interventions.9
The aim of this study was to determine a representative value for interdental papilla heights of maxillary incisors in different facial profiles. When considering the papilla proportion in different facial profiles, although there is no statistically significant difference, it was observed to be slightly higher in case of concave profile subjects (irt 11-37.2%, irt 21-37.8%) compared to convex (irt 11-34.70%, irt 21-34.93%) and straight profile subjects (irt 21-34.05%, irt 11-34.64%).
Limitations of this study include small sample size, variations in papilla height and papilla proportion in different facial profiles can be compared with variations in the underlying skeletal profile, restriction to only central incisors; hence, further studies with larger sample size and taking into considerations the maxillary anterior esthetic zone are needed.
CONCLUSION
Interdisciplinary approaches are often required to increase the treatment efficiency and for individualized treatment planning. The knowledge of papilla proportion, gingival zenith, and facial profile is important for smile designing as well as for surgical procedures performed in the highly esthetic area to obtain optimal results. Therefore, it is important for the general dentist and specialists to have an understanding about the variations in height and proportion of the papilla and gingival zenith among the various facial profiles to provide a personalized treatment plan.
ORCID
S Gomathi S Krishna https://orcid.org/0000-0002-5179-0095
Reetika Gaddale https://orcid.org/0000-0002-3498-7400
Susan Abraham https://orcid.org/0000-0002-0265-1080
REFERENCES
1. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Carol Stream (IL): Quintessence 2002;58-64.
2. Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. Shelton: PMPH-USA; 2007.
3. Chu SJ, Tan JHP, Stappert CFJ, et al. Gingival zenith positions and levels of the maxillary anterior dentition. J Esthet Restor Dent 2009;21(2):113-120. DOI: 10.1111/j.1708-8240.2009.00242.x
4. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69(10):1124-1126. DOI: 10.1902/jop.1998.69.10.1124
5. Takei H, Yamada H, Hau T. Maxillary anterior esthetics. Preservation of the interdental papilla. Dent Clin North Am 1989;33(2):263-273.
6. Takei HH. The interdental space. Dent Clin North Am 1980;24(2):169-176.
7. Ahmad I. Anterior dental aesthetics: gingival perspective. Br Dent J 2005;199(4):195-202. DOI: 10.1038/sj.bdj.4812611
8. Bhatsange A, Mehetre V, Waghmare A, et al. A quantitative evaluation of gingival zenith position of maxillary central incisors in different facial forms. IOSR J Dent Med Sci 2015;14(1):62-65. DOI: 10.9790/0853-14116265
9. Frizzera F, Tonetto M, Cabral G, . et al Periodontics, implantology, and prosthodontics integrated: the zenith-driven rehabilitation. Case Rep Dent 2017;2017:1070292. DOI: 10.1155/2017/1070292
10. Legan HL, Burston CJ. Soft tissue cephalometric analysis for orthognathic surgery. J Oral Surg 1980;38(10):744-751.
11. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Chicago: Quintessence Publishing; 2002. 57-98.
12. Singhal M, Singhal R. A CAD-CAM prosthodontic option and gingival zenith position for a rotated maxillary right central incisor: an evaluation. Indian J Dent Res 2012;23(1):112-115. DOI: 10.4103/0970-9290.99053
13. Chander GN, Damodaran A, Balasubramanium M. Evaluation of proportion between incisal edge to gingival zenith distance and interdental papilla in maxillary anterior dentition of Indian population. J Clin Diagn Res 2016;10(3):40-41. DOI: 10.7860/JCDR/2016/16271.7449
14. Patil VA, Desai MH. Assessment of gingival contours for esthetic diagnosis and treatment: a clinical study. Indian J Dent Res 2013;24(3):394-395. DOI: 10.4103/0970-9290.118005
15. Chu SJ. Range and mean distribution frequency of individual tooth width of the maxillary anterior dentition. Pract Proced Aesthet Dent 2007;19(4);209-215.
16. Cho HS, Jang HS, Kim DK, et al. The effects of interproximal distance between roots on the existence of interdental papillae according to the distance from the contact point to the alveolar crest. J Periodontol 2006;77(10):1651-1657. DOI: 10.1902/jop.2006.060023
17. Martegani P, Silvestri M, Mascarello F, et al. Morphometric study of the interproximal unit in the esthetic region to correlate anatomic variables affecting the aspect of soft tissue embrasure space. J Periodontol 2007;78(12):2260-2265. DOI: 10.1902/jop.2007.060517
18. 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. DOI: 10.1902/jop.1992.63.12.995
19. Ganji KK, Alam MK, Alanazi AF, et al. Facial profile based evaluation of gingival zenith position in maxillary central incisors among Saudi, Indian & Bangladeshi population. Saudi Dent J 2018;30(4):342-347. DOI: 10.1016/j.sdentj.2018.05.008
20. Bendahmash M, Dhafr F, Awwad A, et al. Evaluation of Saudi population perception of the proportion of maxillary anterior teeth width ratio to the dental papilla position. EC Dental Sci 2020;19(3):01-06.
21. Nanal N, Shetty M, John N. A study to evaluate age and gender as determinants of papillary proportions in the esthetic region. J Osseointegr 2021;13(2). DOI: 10.23805/JO.2021.13.02.8
________________________
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.