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Association between central papilla recession and gingival and interdental

smile line

Article in Quintessence international (Berlin, Germany: 1985) · November 2017

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 Q U I N T E S S E N C E I N T E R N AT I O N A L

ESTHETIC DENTISTRY

Abhay P. Kolte

Association between central papilla recession

and gingival and interdental smile line
Abhay P. Kolte, MDS1/Rajashri A. Kolte, MDS2/Anshuka A. Agrawal, BDS3/Tushar Shrirao, MDS4/Kamal Mankar, MDS4

Objective: Interdental soft tissues play a critical role in pink patients exhibited presence of central papilla, whilst 63
esthetics. The presence and preservation of the interdental patients had central papilla recession with variable extent. The
papillae in the esthetic zone is as crucial as the shape and con- male patients predominantly had presence of central papilla in
tour of the anterior teeth in achieving an esthetically pleasing both the age groups, with 86% and 64%, compared with 74%
smile. The present study determines the association of central and 50% in females, respectively. High gingival smile line was
papilla recession with gingival and interdental smile line in seen in the majority of the patients (62%), and this trend was
periodontally healthy patients of different age groups. similar to high interdental smile line (82% of the patients).
Method and Materials: The present study included 200 Conclusion: Esthetics is affected in individuals having papilla
patients equally divided into 21 to 40 years and 41 to 60 years recession along with high gingival smile line and interdental
age groups. The clinical and photographic evaluation of the smile line as compared to individuals with low or cupid bow
central papilla, with midfacial gingiva, and its relationship with gingival smile line and interdental smile line. (Quintessence Int
the vermilion border was performed. Results: In total, 137 2018;49:181–188; doi: 10.3290/[Link].a39375)

Key words: central papilla, esthetics, gingival recession, gingival smile line, interdental smile line, midfacial gingiva

Achieving an esthetically pleasing smile has long been over the underlying alveolar bone and adjacent to
considered as one of the therapeutic and practical out- tooth structures, represented by an intact interdental
comes in any periodontal, restorative, and implant papilla occupying complete embrasure spaces, consti-
surgical procedure. Accurate blending of soft tissues tutes ideal pink esthetics.1,2 Absence of gingival papilla
results in open gingival embrasure or black triangles,
which are mostly unacceptable and contribute towards
1 Professor and Head, Department of Periodontics and Implantology, VSPM Den- food retention, adversely affecting the health of the
tal College and Research Centre, Nagpur, India.
periodontium and phonetic problems.3,4 Several etio-
2 Professor, Department of Periodontics and Implantology, VSPM Dental College
and Research Centre, Nagpur, India. logic factors have been identified in recession of the
3
Postgraduate Student, Department of Periodontics and Implantology, VSPM gingival papillae and are categorized as anatomical,
Dental College and Research Centre, Nagpur, India.
physiologic, pathologic, and mechanical factors.5,6 The
4 Associate Professor, Department of Periodontics and Implantology, VSPM Dental
College and Research Centre, Nagpur, India. extent and prevalence of papillary recession has been
Correspondence: Dr Abhay P. Kolte, Professor and Head, Department found to increase with age,7,8 and some studies show
of Periodontics and Implantology, VSPM Dental College and Research greater prevalence in males as compared to females.9,10
Centre, Digdoh Hills, Hingna Road, Nagpur-440019, India.
Email: drabhaypkolte@[Link] Clinicians are therefore required to understand the

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Kolte et al

factors that have an influence over the papilla form, so patients categorized with low gingival smile line dis-
as to prevent papillary deficiencies, and to mitigate the played interdental papillae upon smiling. It is, however,
challenges for regenerating lost gingival papillae. felt that the age group covered in this study is too
Papillary recession gains more relevance and is extensive (from 10 to 89 years) and had an unequal
esthetically critical in patients exhibiting certain smile gender distribution, which limits drawing specific con-
lines, especially high and average smile lines. A few clusions. A differentiation between ISL and gingival
reports have stressed the visible size and location of smile line (GSL) is pertinent, as they differ regarding the
midfacial teeth and the display of gingival tissues rela- extent of visibility of the gingival tissue. ISL considers
tive to the maxillary lip.11,12 Smile guideline standards only interdental gingiva, whilst GSL encompasses mid-
were set for the first time in the profession in the mid- facial gingival tissues along with the interdental papilla.
1980s, and accordingly smiles were classified into three It is believed that diagnosis of specific deformities in
basic categories: high, average, and low, depending on the interdental papillae along with knowledge of pre-
the visibility of the midfacial cervical margin of the clin- disposing factors would enable the clinician to adopt a
ical crown relative to the vermilion border of the maxil- suitable interdisciplinary reconstructive and predict-
lary lip. The majority of one study population had an able treatment procedure. The present study was
average smile line (69%), followed by a low smile line planned to determine the display of central papilla and
(20%), with a high smile line (11%) being the least prev- midfacial gingival tissues in the maxillary anterior teeth
alent.13 This study evaluated patients between 20 and during smiling.
30 years of age, with single frontal full-face posed
images. Greater tooth display while smiling was
observed in females as compared to males.13,14 In the
METHOD AND MATERIALS
present cross-sectional hospital-based observational Between July 2015 and September 2016, 200 adult
study, the smile categorization was based primarily on periodontally healthy and dentate patients between 21
the relative position of the vermilion border of the max- and 60 years of age were selected from the Department
illary lip to the total clinical crown length. The relation- of Periodontics and Implantology, Vidya Shikshan
ship between the position of the maxillary lip and the Prasarak Mandal’s Dental College and Research Centre,
interdental papillae was not assessed for these patients Nagpur, India. The study protocol was approved by the
independently. Institutional Ethics Committee and adhered to the pro-
It has been proposed that patients display more visions of the Helsinki Declaration. The patients were
tooth structure during spontaneous smiling when com- informed about the purpose of the study and consent
pared to posed smiling, and the amount of tooth dis- was obtained from each of them.
play may have been underestimated.12 The relationship In a study by Kotsakis et al,16 the authors reported
between soft tissue and anterior dentition indicated a the prevalence of visible papillary recession as 38.4%.
significant reduction of tooth display during smiling Referring to this reported prevalence and assuming
with increasing age. that the visible papillary recession prevalence in the
The term interdental smile line (ISL) has been sample population may range approximately between
defined by Hochman et al15 as the position of the ver- 35% and 40% for 7% error, a sample estimate of 185
milion border of the maxillary lip relative to the inter- was required to obtain the results with 95% confidence
dental papilla. The authors proposed two basic cat- and 80% power. The sample was rounded to 200.
egories: high interdental smile line (HISL) and low The patients were segregated into two groups
interdental smile line (LISL). These exclusively assess depending on the age range: from 21 to 40 years
the position of labial tissues to that of interdental pap- (Group I) and from 41 to 60 years (Group II). Each group
illary gingival tissues. It was revealed that 87% of had an equal number of males and females.

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Kolte et al

a b
Figs 1a and 1b Gingival smile line. (a) High gingival smile line. (b) Low gingival smile line.

a b
Figs 2a and 2b Interdental smile line. (a) High interdental smile line. (b) Low interdental smile line.

Inclusion criteria for the study population were: lion border of the maxillary lip. Digital photographs of
• males and females between the age group of 21 these patients in the anterior and right and left anterior
and 60 were included in the study lateral views were evaluated independently at a stan-
• patients with fully erupted, well-aligned maxillary dardized distance of 3 feet. This distance was chosen to
incisors without any orthodontic anomaly ascertain a more natural maximum smile by not impin-
• exhibiting healthy gingiva as assessed by Plaque ging on the patient’s personal space.15 Photographs
Index17 and Gingival Index18 scores of 0 to 1. were observed under a resolution of 1,680 × 1,050 pix-
Exclusion criteria involved conditions that could alter els using Adobe Photoshop (Adobe Systems). To obtain
the status of interdental papilla, such as: standardized photographs, an enlargement ratio of
• patients with gingivitis and periodontitis 1:1.2 was adopted and the photographs included the
• history of periodontal/mucogingival surgery maxillary teeth from one canine to the other.21 All clin-
• orthodontic treatment ical evaluations were performed by the first examiner
• medications known to induce gingival hyperplasia (AK), and the photographic assessments by the second
• systemic conditions compromising gingival health examiner (AA). Both the examiners were calibrated by
• presence of artificial crowns or restorations in the repeating the respective recordings in a pilot study.
anterior sextant.
Primary outcome variables evaluated were central Gingival smile line (GSL)
papilla recession, GSL, and ISL. The secondary outcome The exhibit of midfacial gingiva on smiling was consid-
variable was the relationship of the central papilla with ered in GSL. The GSL was categorized into high GSL
the gingival and interdental smile. The patients were (HGSL; Fig 1a), which entailed display of midfacial gin-
evaluated clinically by visual examination for the pres- giva in maxillary anterior teeth; low GSL (LGSL; Fig 1b),
ence or absence of interdental papillae,19,20 and the comprising no display of the midfacial gingiva; and
midfacial gingiva and its relationship with the vermil- Cupid’s Bow GSL (CB-GSL), involving no display of

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Table 1 Demographic characteristics of the population

Parameter Group I (n = 100) Group II (n = 100) P value

Age, y (min–max) 24 (21–40) 45 (41–60) .000**
Male (n, %) 50 (50.0) 50 (50.0)
Sex .550
Female (n, %) 50 (50.0) 50 (50.0)
Worker (n, %) 42 (42.0) 65 (65.0)
Occupation .001**
Non-worker (n, %) 58 (58.0) 35 (35.0)
**Statistically highly significant.

by Pearson chi-square test. For small number, Fisher’s

Table 2 Prevalence of papillary recession exact test was applied wherever applicable. Pearson
Frequency Percentage chi-square test was used to correlate GSL with age and
Measure of papillary recession (N = 200) (%) gender. PA and GSL was correlated by using Pearson
Normal 137 68.5
chi-square test. Correlation of PA with age, gender, GSL,
Modified papillary I 24 12.0
and ISL was performed by Pearson chi-square test. ISL
recession II 8 4.0
classification III 3 1.5 was correlated with age and gender by performing the
IV 28 14.0 same test. All the tests were two sided; P < .05 was con-
Papillary recession
Yes 63 31.5 sidered statistically significant .Statistical software Stata
No 137 68.5 version 13.0 was used for data analysis (Statacorp).

midfacial gingiva of central incisors but revealing the RESULTS

midfacial gingiva of lateral incisors and/or distal teeth.15
Demographic data of the 200 patients included in the
Interdental smile line (ISL) study are shown in Table 1. Of the 200 patients,
The exhibit of interdental papillae on smiling was con- 137 patients (68.5%) were categorized as normal
sidered. ISL was categorized as: HISL (Fig 2a), which papilla, indicating the presence of a central papilla;
included display of all interdental papillae in maxillary 63 patients (31.5%) exhibited central papillary reces-
anterior teeth; LISL (Fig 2b), comprising no display of sion, the extent of which was variable. The papilla was
interdental papillae; and CB-ISL, involving no display of classified as Class I in 24 patients (12%), Class II in
central papilla but revealing papillae of lateral incisors eight patients (4%), Class III in three patients (1.5%),
and/or those of distal teeth.15 and Class IV in 28 patients (14%), as shown in Table 2.
On assessment of the central papilla according to the
Central Papilla Assessment (PA) age groups, it was revealed that normal papilla was
The clinical examination also involved assessment of found to be more predominant in the younger age
central papilla categorized according to the modified group, with 43 sites (86%) in males and 37 sites (74%)
Nordland and Tarnow classification.19 in females, compared to 32 sites (64%) in males and
25 sites (50%) in females belonging to the older age
Statistical analysis group. The comparison between the two groups
Categorical variables (PA, GSL, ISL, age, and gender) yielded differences that were highly significant
were presented as frequency and percentages. Correla- (P = .001). The central papillary recession was more
tion between PA with age and gender was performed prevalent in Group II than in Group I.

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Table 3 Age and gender with papilla assessment

Group I Group II
Papilla
assessment Male Female Male Female Total P value
Normal (n, %) 43 (86.0) 37 (74.0) 32 (64.0) 25 (50.0) 137 (68.5) .001**
I (n, %) 5 (10.0) 5 (10.0) 7 (14.0) 7 (14.0) 24 (12.0) .860
II (n, %) 1 (2.0) 2 (4.0) 2 (4.0) 3 (6.0) 8 (4.0) .959
III (n, %) 0 (0.0) 0 (0.0) 1 (2.0) 2 (4.0) 3 (1.5) .293
IV (n, %) 1 (2.0) 6 (12.0) 8 (16.0) 13 (26.0) 28 (14.0) .004**
**Statistically highly significant.

Table 4 Age and gender with gingival smile line (GSL) and interdental smile line (ISL)

Group I, n (%) Group II, n (%)

Type of Type of
smile smile line Male Female Male Female Total, n (%) P value
HGSL 33 (66.0) 38 (76.0) 22 (44.0) 31 (62.0) 124 (62.0) .010*
GSL LGSL 13 (26.0) 10 (20.0) 25 (51.0) 20 (40.0) 68 (34.0) .005**
CB-GSL 3 (6.1) 2 (4.0) 2 (4.1) 1 (1.9) 8 (4.0) .791
HISL 46 (92.0) 43 (86.0) 33 (66.0) 38 (76.0) 160 (80.0) .007*
ISL LISL 3 (6.0) 5 (10.0) 16 (32.0) 10 (20.0) 34 (17.0) .003**
CB-ISL 1 (2.0) 2 (4.0) 1 (2.0) 2 (4.0) 6 (3.0) .876
*Statistically significant. **Statistically highly significant.

Table 5 Papilla assessment with gingival smile line (GSL) and interdental smile line (ISL)

Low, n (%) High, n (%) Cupid bow, n (%)

Papilla
assessment LGSL LISL HGSL HISL CB-GSL CB-ISL P value
0 31 (15.5) 17 (8.5) 104 (52.0) 118 (59.0) 2 (1.0) 2 (1.0)
1 11 (5.5) 10 (5.0) 12 (6.0) 13 (6.5.0) 1 (0.5.0) 1 (0.5)
GSL, Χ2 value = 49.3862, P < .001**;
2 4 (2.0) 4 (2.0) 2 (1.0) 3 (1.5.0) 2 (1.0) 1 (0.5)
ISL, Χ2 = 35.8853, P < .001**
3 2 (1.0) 1 (0.5.0) 1 (0.5) 1 (0.5.0) 0 (0.0) 1 (0.5)
4 20 (10.0) 2 (1.0) 5 (2.5) 25 (12.5.0) 3 (1.5) 1 (0.5)
Total 68 (34.0) 34 (17.0) 124 (62.0) 160 (80.0) 8 (4.0) 6 (3.0)
**Statistically highly significant.

On evaluating the central papilla and sex variabil- other classes did not yield statistically significant dif-
ity, presence of normal central papilla was found to be ferences.
greater in males compared with females in both the A total of 124 patients (62%) exhibited HGSL, fol-
age groups. There was also a greater central papilla lowed by LGSL in 68 patients (34%), and CB-GSL in
recession in females than male patients in almost all eight patients (4%). Gender correlation indicated more
the classes of papilla assessment. These findings were females in both the groups displayed HGSL as com-
statistically highly significant for normal papilla and pared to the males (Table 4). Similar observations were
Class IV papilla (P = .001 and P = .004; Table 3); the noted for ISL, where 160 patients (80%) displayed HISL,

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34 patients (17%) LISL, and six patients (3%) showed col. This morphology is mainly influenced by the pos-
CB-ISL. ition of contact point and height of gingiva.25,26 Though
The results also indicated predominance of normal important from the clinical point of view, the literature
papilla in 104 patients (52%) and 118 patients (59%) search revealed limited data regarding the magnitude
when correlated with GSL and ISL respectively. This was and percentage of papillary recession. In one of the clin-
followed by 31 patients (15.5%) and 17 patients (8.5%) ical trials by Kotsakis et al,16 amongst a study population
demonstrating normal central papilla in LGSL and LISL of 211, the authors reported central papilla deficiency in
respectively (Table 5). 46.4% of the participants. In the present clinical study,
deficiency of the central papilla was observed in 31.5%
of the patients, with 68.5% of the patients exhibiting
DISCUSSION presence of central papilla. The difference in the finding
An esthetic smile requires a harmonious and propor- can be attributed to the age group and gender of the
tionate relationship between healthy gingiva and the participants. Since there are few studies linking age and
natural dentition. The presence of gingival papilla gender as factors in central papillary recession,27 it is
within the gingival embrasures is crucial in several peri- appropriate to segregate the study population equally
odontal, restorative, and orthodontic procedures. The into different age groups and also in terms of gender. A
same principles of gingival papillae have been relevant significant difference was found between both the age
and implemented in implant treatment procedures. It groups and gender distribution. A greater percentage of
is widely considered that the appearance of interdental male patients (86% in Group I and 64% in Group II)
papilla provides a positive gingival soft tissue architec- revealed the presence of central papilla, while it was
ture and is an essential component of an esthetic present in 74% and 25% of female patients belonging to
smile.22,23 In the absence of pre-existing interdental Group I and Group II, respectively. Both the above-men-
papilla, the papilla proportion and crestal papilla pro- tioned studies utilized the modified Nordland and Tar-
portion ratios can provide guidelines for the clinician in now19 classification system, which is more comprehen-
recreating smiles.24 At the same time, the crown mor- sive in identifying the extent of papillary deficiency.
phology and successive widths of anterior teeth need Also, a greater percentage of male patients (54% in
to fulfill the principles of the golden proportion. The Group I and 38% in Group II) revealed the presence of
present study was based on findings in clinically thick and flat gingival biotype, while it was present in
healthy gingiva, so that these can be used as guidelines 40% and 32% in female patients belonging to Group I
for any restorative and periodontal treatments in and Group II, respectively suggestive of a greater
future. These findings are especially important as cur- amount of papillary recession due to thin gingival bio-
rently there are no universally accepted guidelines in type in females as compared to males. The greater
the literature pertaining to the end results of restora- amount of papillary recession can also be attributed to
tive and periodontal procedures. The display of central the fact that female patients present with thin gingival
papilla and midfacial gingival tissues was determined biotype as one of the predominant gingival characteris-
in the maxillary anterior teeth during smiling. These tics, and this is more prone to recession due to irritation
findings can be used to study the impact of papilla or trauma because of its delicate nature.3,28
recession (which can also be due to anatomical factors) Due to an emerging interest in designing an esthetic
on an individual’s smile line and esthetics. smile amongst patients requiring periodontal and re-
Within the esthetic zone, the central papilla has storative procedures, there appears to be a fundamental
been known to possess complex physiology, and shift in the focus of the clinician in identifying additional
depending on the anatomic and geometric configura- variables. It was attempted to evaluate the central papil-
tion may appear as pyramidal or as a shallow gingival lary presence in relation to the GSL and ISL. Peck et al27

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Kolte et al

examined the relationship between vermilion border of was revealed upon smiling and requires corrective
the maxillary lip and the associated central papilla dis- measures to restore papillary deficiency. It can be con-
play.27 It was revealed that patients in their twenties cluded that patients with HGSL/HISL and with central
showed sex dimorphism, with females predominantly papilla recession are more esthetically affected than
displaying gingival margins. The present study findings those with CB-ISL, LGSL, or LISL, and may be considered
confirm these results; however, the central papilla display for treatment.
was evaluated not only according to GSL but also ISL. An
overall central papilla display of 52% was recorded in
relation to the GSL. When the central papilla was assessed
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