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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 394-395
Assessment of gingival contours for esthetic diagnosis and treatment: A clinical study


Department of Periodontology, HKES's S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga, Karnataka, India

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Date of Submission13-Sep-2012
Date of Decision07-Jul-2013
Date of Acceptance11-Dec-2012
Date of Web Publication12-Sep-2013
 

   Abstract 

Background: The purposes of this study were to quantify some clinical parameters that are useful as esthetic guidelines when the gingival contour is modified and to compare the left and right sides of the six maxillary anterior teeth.
Materials and Methods: Two hundred and forty interdental papilla sites in 20 healthy patients were evaluated. Interdental papilla heights of maxillary anterior teeth were measured from the gingival zenith, along with clinical crown lengths. Percentages of papilla height to crown length were computed and defined as papilla proportion, mesial papilla proportion (MPP) and distal papilla proportion (DPP).
Results: Mean interdental papilla heights of maxillary teeth was 3.83 mm mesially and 3.8 mm distally. Mean MPP was 43.69% ( n = 120) and DPP was 44.57% ( n = 120). No significant differences were found between MPP and DPP for maxillary incisors ( P ≥ 0.5).
Conclusion: Papilla proportions were approximately 44% for all tooth groups. Canines demonstrated a trend toward increased distal papilla heights. In the present study the average MPP and DPP of the central incisor (CI), lateral incisor (LI) and canine (CA) measured were 43%, 41%, 46%, 40%, and 42% 51% respectively.

Keywords: Gingival zenith, interdental papilla, papilla proportion

How to cite this article:
Patil VA, Desai MH. Assessment of gingival contours for esthetic diagnosis and treatment: A clinical study. Indian J Dent Res 2013;24:394-5

How to cite this URL:
Patil VA, Desai MH. Assessment of gingival contours for esthetic diagnosis and treatment: A clinical study. Indian J Dent Res [serial online] 2013 [cited 2019 Nov 20];24:394-5. Available from: http://www.ijdr.in/text.asp?2013/24/3/394/118005
Beauty has been defined as a combination of qualities that give pleasure to the senses or to the mind. It is a philosophical concept, the aspects of which are studied under the term esthetics, derived from the Greek word for perception (aisthesis). Esthetics, therefore, is the study of beauty and, to a lesser extent, its opposite and the ugly. It involves both the understanding and evaluation of beauty, proportions and symmetry. The human perception of facial beauty may have genetic, environmental or multifactorial foundations. [1]

Esthetics is not an art or science but fusion of the two. It is difficult segregating dental esthetics into distinct units, since all variables are interdependent and interrelated. Dental esthetics is not all about the white esthetics i.e., tooth but pink esthetics, i.e., gingiva also is of indispensible importance, as both are incomplete if not in harmony. The perception of dental esthetics varies among dental professionals; however several substantial efforts have been made to establish common standards. Despite of these efforts there is a slight discrepancy among clinicians as of what constitutes an ideal esthetic smile. [2]

The position of the interdental papilla in the apico-coronal dimension holds a critical place in the esthetics of smile and confers positive gingival architecture. Another significant feature of the gingival morphology is the gingival zenith. Gingival zenith is the most apical aspect of the free gingival margin. [3]

Before any type of esthetic treatment, the esthetic evaluation always starts with the smile analysis. The essentials of a smile involve the relationships among the teeth, the lip framework, and the gingival scaffold. To predict the final esthetic result and achieve optimum results in gingival contour rehabilitation (crown lengthening, implant and orthodontic therapy), it is important to take gingival contours into account during treatment planning. [4]


   Aim of the Study Top


To quantify the interdental papilla location mathematically as a percentage ratio of clinical crown length of six maxillary anterior teeth.


   Materials and Methods Top


A sample population of 20 patients (15 women, 5 men) was studied. The study was performed at the Department of Periodontology, HKES's S.N Institute of Dental Sciences and Research, Gulbarga. The patients ranged in the age group of 18 to 30 years. Subjects were informed of the nature of the study and a written informed consent was obtained.

Inclusion criteria

Non-restored maxillary anterior teeth with good periodontal health (probing depths <2 mm and width of the keratinized tissue >3 mm) and no loss of interdental papillae.

Exclusion criteria

  • Evidence of tooth alteration, i.e., traumatic injury, occlusal wear, and cervical abrasion
  • evidence of gingival alteration, i.e., gingival hyperplasia, inflammation, altered passive eruption, attachment loss, gingival recession, or history of periodontal surgery and
  • the presence of severe crowding or marked spacing or history of orthodontic treatment.
Alginate impressions of the study subjects were made using irreversible hydrocolloid impression material (tropic algin) and immediately poured with stone (Kalabhai) according to manufacturer's instructions. A digital calliper with a lighted display (Yamayo) was used to measure the 240 papilla sites of the anterior maxillary teeth, from canine to canine. Each cast was measured by the same operator using 2.5× optical loupes (Keeler). Control measurements were performed by a second investigator. The mesial and distal interdental papilla heights in the maxillary anterior dentition, including the central incisors (CI), lateral incisors (LI) and canines (CA) were measured from the level of the gingival zenith of the corresponding tooth to the tip of the papilla (n = 240) [Figure 1] and [Table 1]. Additionally, the lengths and widths of clinical crowns were recorded for each tooth group: CI, LI, and CA (n = 120) [Table 2] and [Table 3]. Each papilla height measurement was divided by the clinical crown length of the corresponding tooth. Therefore a percentage ratio was calculated of the papilla height related to the clinical crown length [Table 4]. The percentage ratio accounted for variations in crown lengths and papilla heights was not predicated upon absolute values. The following mathematical equation was used to calculate a percentage ratio, termed papilla proportion (PP): PP = papilla height/crown length ×100%. Mesial papilla proportions (MPP) and distal papilla proportions (DPP) were calculated separately: MPP = mesial papilla height/crown length × 100%, and DPP = distal papilla height/crown length × 100%. [4]
Table 1: Absolute values of papilla heights (in mm) sorted by tooth position and divided into mesial (MPH) and distal (DPH) groups

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Table 2: Clinical crown lengths (in mm) measured in the maxillary anterior dentition, sorted by tooth position

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Table 3: Clinical crown widths (in mm) measured in the maxillary anterior dentition, sorted by tooth position

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Table 4: Percentage ratio of papilla height to crown length sorted by tooth position and divided into mesial(MPP) and distal (DPP) groups

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Figure 1: Papillary heights measured from the gingival zenith (GZ) to the tip of the mesial papilla (MPH) and distal papilla (DPH) for (left) the central incisor, (center) the lateral incisor and (right) the canine, as well as the crown length (CL)

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   Results Top


Students 't' test was used for statistical analysis. The mean absolute values (± SD) for the interdental papilla heights of maxillary anterior teeth measured from the level of gingival zenith were 3.83 ± 0.95 mm mesially and 3.88 ± 1.00 mm distally. The mean absolute interdental papilla heights (±SD) by tooth of CI, LI and CA were 4.04 ± 0.92, 3.28 ± 0.87 and 4.24 ± 0.89, respectively [Table 1] and [Figure 2]. No significant difference was found between crown lengths and widths on the right and left side (t-value > P = 0.05) [Table 2] and [Table 3].
Figure 2: Absolute values of papilla heights (lengths) by tooth position and divided into mesial papilla height(MPH) and distal papilla height (DPH). FDI tooth‑numbering system used

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Taking into account all measured sites, the mean MPP (±SD) was 43.69% ±9.06 (n = 120) and the mean DPP was 45.57% ±11 (n = 120). The MPP for CI, LI and CA were 43.17 ± 7.20, 41.37 ± 9.63 and 46.53 ± 9.38, respectively. The DPP of CI, LI and CA were 40.38 ± 8.64, 42.22 ± 11.15, and 51.17 ± 10.47 respectively [Table 4] and [Figure 3]. No significant differences were found between MPP and DPP of maxillary incisor group CI (t-value 1.57), group LI (t-value 0.36) (P ≥ 0.5) and there was a significant difference for group CA (t- value 2.09).
Figure 3: Percentage ratio of papilla height to crown length sorted by tooth position and divided in mesial papilla proportion and distal papilla proportion. FDI tooth‑numbering system used

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   Discussion Top


Gingival esthetics has always been an important component of a beautiful smile. Beautiful restorations surrounded by unattractive gingival tissues can negatively impact on a smile. Gingival health is among the first fundamental esthetic objectives during treatment planning; it is also essential to consider gingival morphology and contour. The ideal gingival architecture has been described as one that consists of knife-edged gingival margins tightly adapted to the teeth, interdental grooves and cone-shaped interdental papilla. [5] There is no universal guideline for clinicians to follow in creating greater conformity and a predictable esthetic smile, including ideal papilla heights. Several investigators have attempted to establish guidelines for proper papillae form to enhance and optimize soft tissue positions and esthetics. Chu [6] suggested that a mathematical correlation exists between the clinical crown widths of maxillary anterior teeth. Cho et al. [7] found that the interadicular distance and the distance between the contact point and the alveolar crest have independent and combined effects on the presence or absence of the interdental papilla. Tarnow et al. [8] examined the distance from the base of the contact area to the crest of bone in 288 sites and determined that, at 5, 6 and 7 mm the papilla was present 98, 56 and 27% of the time, respectively. Martegani et al. [9] found that the interradicular distance and the distance between the contact point and the alveolar crest have independent and combined effects on the presence or absence of the interdental papilla. Kois [10] measured interdental papilla heights from the free gingival margin to the osseous crest with a periodontal probe. Mesial sites at the maxillary right central incisor in 100 healthy patients were observed; he reported a range of 3 to 4.5 mm interproximal depth.

The goal of the study was to determine a representative value for interdental papilla heights of the maxillary anterior teeth as a percentage ratio of the clinical crown length, measured from the level of gingival zenith. The mean absolute interdental papilla heights by tooth of CI, LI, and CA were 4.04, 3.28, and 4.24 mm respectively.

In the present study the average MPP and DPP of the CI, LI, and CA measured were 43% and 41%, 46% and 40% and 42% and 51% respectively are consistent with other guidelines. [4]


   Conclusion Top


The percentage ratios of the papilla heights and crown lengths demonstrated almost equivalent papilla proportions for all tested groups of around 44%.

The findings of the current study would aid the clinician in the most complex situations demanding high aesthetic accuracy like placing the gingival contours in prosthetic or implant restorations, during cosmetic periodontal surgery and also help in the construction of surgical templates. Gingival Zenith and papillary position act as reference points, in conjunction with other subjective and objective aesthetic parameters would aid in diagnosis, treatment planning, and in reconstructing a natural smile.

 
   References Top

1.Naini FB, Moss JP, Gill DS. The enigma of facial beauty: Esthetics, proportions, deformity, and controversy. Am J Orthod Dentofacial Orthop 2006;130:277-82.  Back to cited text no. 1
[PUBMED]    
2.Ahmad I. Anterior dental aesthetics: Historical perspective. Br Dent J 2005;198:737-42.  Back to cited text no. 2
[PUBMED]    
3.BabitaPawar, Pratishtha Mishra, ParmeetBanga, Marawar PP. Gingival zenith and its role in redefining esthetics: A clinical study. J Indian Soc Periodontol 2011;15:135-8.  Back to cited text no. 3
    
4.Chu SJ, Tarnow DP, Tan JH, Stappert CF. Papilla proportions in the maxillary anterior dentition. Int J Periodontics Restorative Dent 2009;29:385-93.  Back to cited text no. 4
[PUBMED]    
5.Prichard J. Gingivoplasty, gingivectomy and osseous surgery. J Periodontol 1961;32:275-82.  Back to cited text no. 5
    
6.Chu SJ. Range and mean distribution frequency of individual tooth width of the maxillary anterior dentition. Pract Proced Aesthet Dent 2007;19:209-15.  Back to cited text no. 6
[PUBMED]    
7.Cho HS, Jang HS, Kim DK, Park JC, Kim HJ, Choi SH, 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;77:1651-7.  Back to cited text no. 7
[PUBMED]    
8.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.  Back to cited text no. 8
[PUBMED]    
9.Martegani P, Silvestri M, Mascarello F, Scipioni T, Ghezzi C, Rota C, 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;78:2260-5.  Back to cited text no. 9
    
10.Kois JC. Altering gingival levels: The restorative connection. Part I: Biologic variables. J Esthet Dent 1994;6:3-9.  Back to cited text no. 10
    

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Correspondence Address:
Veena A Patil
Department of Periodontology, HKES's S. Nijalingappa Institute of Dental Sciences and Research, Gulbarga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.118005

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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