Dr.

Agrawal ET AL: Effect of Periodontal Biotype on Gingival Esthetics World J Adv Sci Res

Assessment Of Effect Of Periodontal Biotype On Gingival

Esthetics - A Study In North Gujarat Population

Dr. Charu Agrawal*, Dr. Hiral Parikh**, Dr. Priya Patel***, Dr. ShilpaDuseja****, Dr. Mishal
Shah*****, Dr. Siddhi Patira***

*Professor, **Professor and HOD, ***Postgraduate student, ****Reader, *****Senior Lecturer

Department of Periodontology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat,
India

ABSTRACT

BACKGROUND

Nowadays Pink & White esthetic terms are coined in advanced dentistry. Periodontal biotype is one of the
factors that can possibly influence this relation and has to be considered in periodontal diagnosis and
treatment planning. The absence of normal interdental papillae affects gingival esthetics and can be
influenced by the PB, making it an important factor in the evaluation of a patient’s esthetics. To evaluate the
influence of thick versus thin periodontal biotype on presence or absence of interdental papillae &To
determine the influence of the distance from the contact point to the crest of bone on the presence or absence
of interdental papillae.

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MATERIALS & METHODS

500 patients were included in this transversal clinical study. The periodontal biotype, presence and height of
interdental papilla, loss of papillary height, and the distance between the base of the contact point and bone
crest were evaluated. The chi-square test was used to verify the significance level of the PB distribution
frequency between groups. The Mann-Whitney test was used to compare the CP-BC measures between the
different PB groups, and the correlation test was used to verify the relation between the CP-BC distance and
the presence of papillae.

RESULTS

The thick PB group presented a significantly higher presence of papillae than did the thin PB group. An
inverse and proportional correlation between the CP-BC distance and the presence of papillae was found.

CONCLUSION

So the present study states that the PB influenced the presence and height of interdental papillae.

Keywords: Interdental papilla, Periodontitis, Esthetics.

INTRODUCTION

Periodontitis is defined as an inflammatory disease of the supporting tissues of the teeth caused by
groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and
alveolar bone with pocket formation, recession or both. The number of patients seeking esthetic periodontal
treatments, beyond the treatment of the bacterial component of periodontal disease, has increased over the
past decades.
One of the factors involved in this esthetic demand is the presence of an intact and harmonious
gingival contour.1, 2
Interdental papillae (also known as gingival papillae) occupy the space between
adjacent teeth. (Figure - 1)Morphologically, the papillae were described first in 1959.3It not only acts as a
biological barrier in protecting the periodontal structures, but also plays a critical role in the esthetics of
teeth. Hence, it is very important to respect papillae integrity and minimize their removal during dental
procedures as much as possible.4

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Dr. Agrawal ET AL: Effect of Periodontal Biotype on Gingival Esthetics World J Adv Sci Res

Figure.1- Periodontal biotype

Today’s dentists face esthetic standards that require a soft-tissue contour, with intact papillae and a
symmetrical gingival outline, especially in the interdental area of the maxillary central incisors defined as
the central papillae.5(Figure - 2) The presence of a space below these contact areas can lead to esthetic
defects, speech impairment, and food impaction.6 Several efforts have been undertaken to treat and restore
missing interproximal papillae. If the loss of a papilla is related to soft tissue damage only, reconstructive
techniques are able to restore it completely. If the loss of an interdental papilla is caused by severe
periodontal disease with interproximal bone resorption, complete reconstruction is generally not achieved.7

Figure.2– Thick & Thin Biotype

Aspects related to the periodontal biotype (PB) are frequently not considered during periodontal
treatment planning.8, 9 The relationship between PB and the presence or absence of interdental papillae is not
well-documented. Thus, the aim of this study was to evaluate the influence of the PB on the presence and
absence of interdental papillae.

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Dr. Agrawal ET AL: Effect of Periodontal Biotype on Gingival Esthetics World J Adv Sci Res

MATERIALS AND METHODS

500 patients (both male and female) between the ages of 20 to 65 years were included in the present
study.

In the inclusion criteria systemically and mentally healthy patients, presence of contact points
between maxillary canines and incisors (First Quadrant), and no interproximal and/or root surface
restorations were considered while in the exclusion criteria patients with history of underlying systemic
disease, history of any periodontal treatment in the past 6 months, taking antibiotic/NSAIDs treatment in the
past 6 months, any habits, undergoing orthodontic treatment.10, 11

Each patient signed awritten consent after the risks and benefits of the associated procedures were
explained. The study protocol was based on criteria’s by IRB.

CLINICAL PARAMETERS
The following measurements were recorded by a single calibrated examiner: PB, presence of
interdental papilla (PIP), loss of papillary height (LPH), distance between the base of the contact point and
bone crest (CP-BC).6,9,12 PB was visually classified as thin or thick, according to Kao &Pasquinelli(Figure.
3 and 4).9

Figure.3- Frontal photograph of teeth exhibiting a thin PB.Figure.4- Frontal photograph of teeth exhibiting
a thick PB.

When evaluating PIP, the papilla was considered present when there was no visible space apical to
the contact point and LPH was identified using the system proposed by Nordland & Tarnow as follows:
Normal –interdental papilla fills the embrasure space to the apical extent of the interdental contact
point/area; Class I – the tip of the interdental papilla lies between the interdental contact point and the most
coronal extent of the interproximal cementoenamel junction (CEJ); Class II – the tip of the interdental

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papilla lies at or apical to the interproximal CEJ but coronal to the apical extent of the facial CEJ; Class III –
the tip of the interdental papilla lies level with or apical to the facial CEJ (Figure. 5-8).6,12

Figure.5- Frontal Figure.6 - Frontal Figure.7- Frontal Figure.8- Frontal Figure.9- Frontal
photograph of a photograph of a photograph of a Class photograph of a photograph showing
normal papilla. Class I LPH II LPH. Class III LPH measurement of CP-
BC

The CP-BC distance was measured using a calibrated and standardized periodontal probe (UNC –
15, Hufriedy) and approximated to the upper whole millimeter, if necessary (Figure. 9).6A bilateral
infraorbital nerve block was performed, using 2% lidocaine with epinephrine 1:100,000. After 10 minutes,
the area was dried for 30 seconds and the measurements were taken using a bone sounding technique.6The
probe was positioned as parallel as possible to the long axis of the tooth.
All papillae were grouped by PB and by tooth region: papillae between canines and premolars
(CA/PM), papillae between lateral incisors and canines (LI/CA), papillae between central incisors and
lateral incisors (CI/LI), papillae between central incisors (CI/CI).

STATISTICAL ANALYSIS

The chi-square test was used to verify the significance level of the PB distribution between groups. The
Mann-Whitney test was used to compare the CP-BC measures between the different PB groups. The
correlation test was used to verify the relation between the CP-BC distance and the presence of a papilla.

RESULTS

The thick PB was found in 267 patients (108 male and 159 female) and the thin PB was found in 233
patients (142 male and 91 female). Two thousand papillae were evaluated (1207 in the thick PB group and
793 in the thin PB group). (Figure. 10)

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Figure. 10- No. of Papilla Evaluated by Periodontal Biotype and Tooth Region

The PIP results showed that the thick PB group presented a statistically significant greater presence
of papillae than did the thin PB group (P< 0.05). The thick PB group presented a significantly greater
presence of papillae at the CA/PM and LI/CA tooth regions (98.1% and 95.8%, respectively) than did the
thin PB group (25.8% and 15.6%, respectively; P< 0.05). In the CI/LI and CI/CI tooth region also found the
similar results. (Table. 1)

Table 1. Presence of interdental papillae (%) by periodontal biotype and tooth region.

Thick PB Thin PB
Presence Absence Presence Absence
CA/PM* 98.1 1.9 25.8 74.2
LI/CA* 95.8 4.2 15.6 84.4
CL/LI* 96.2 3.8 23.1 76.9
CI/CI* 94.0 6.0 15.8 84.2

* Statistically significant difference between PB groups (P< 0.05)

Abbreviations: PB-periodontal biotype; CA/PM-papillae between canines and premolars; LI/CA-

papillae between lateral incisors and canines; CI/LI-papillae between central incisors and lateral
incisors; CI/CI-papillae between central incisors.

The LPH classification showed that most papillae were classified as normal. The thin PB group
presented a higher number of normal papillae than did the thick PB group in CA/PM region (82.4% and
39.1%, respectively, P< 0.05). While the Class I group was found to be significantly more numerous in
the thick PB group than did the thin PB group (59% and 16.7%, respectively, P< 0.05) in the same
region.
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The thin BP group presented a higher number of normal papillae than did the thick PB group in
LI/CA region (94.1% and 49.5%, respectively, P< 0.05). While the Class I group was found to be
significantly more numerous in the thick PB group than did the thin PB group (47% and 5.4%,
respectively, P< 0.05) in the same region.

For CI/LI and CI/CI tooth region the result were found is similar and were statistically significant
(P< 0.05). The PB groups for Class II and III found less prevalence than others (P< 0.05). The tooth
region analysis showed that the all four tooth areas had a significantly better LPH classification in the
thick PB group (Figure. 11).13

Figure. 11 - Distribution frequency (%) for LPH by PB and tooth region

There were statistically significant differences found in CP-BC measures between PB groups
(Mann – Whitney U test) and tooth region (P < 0.05). For the thin PB, the CP-BC measures were:
CA/PM = 4.73 ± 1.01, LI/CA =5.25 ± 1.16, CI/LI = 4.72 ± 0.92 and CI/CI = 4.77 ± 0.60. For the thick
PB, the CP-BC measures were: CA/PM = 4.14 ± 0.73, LI/CA =4.86 ± 0.98, CI/LI = 4.58 ± 0.86 and
CI/CI = 5.08 ± 1.19. In CI/LI region only the results were not statistically significant. (P> 0.05)

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DISCUSSION

The present study aimed to evaluate if there is a correlation between PB and the presence or absence
of interdental papilla. Current esthetic periodontal treatments are driven by the search for techniques where
success is measured not only by the quality of postoperative symptoms, including the lack of scars, but also
by the predictability of results.13 This requires the use of diagnostic methods to examine the surrounding
tissues to determine periodontal defects and consider thoroughly the biologics of the involved gingiva. 14 To
this end, the PB determination is critical for professionals who perform procedures in the esthetic zone, since
the identification of the periodontium could predict future periodontal defects, determine different
manipulation strategies of the soft tissues, and help in correcting existing problems. The present study used
the classification proposed by Kao &Pasquinelli.9However; a precise periodontium evaluation requires
controlled trials to determine a thickness pattern, since most studies use clinical observations to classify the
PB.10, 15-17
Generally, the thicker periodontium is characterized by a fibrous, dense gingival tissue, and a wide
band of keratinized tissue. The flat topography suggests a thick bony architecture. The thick bone/gingival
pattern provides more resistance to tissue injury, and also allows for more predictable surgical procedures,
resulting in less postoperative bone remodeling and gingival recession, which can help predict future tissue
positioning. On the other hand, the thin periodontium is characterized by a delicate, friable gum, and a
narrow strip of keratinized tissue. The topography is scalloped, suggesting a very thin bone, with possible
areas of dehiscence and fenestrations. There is a greater tendency toward gingival recession. 13 The
influence of the distance between the contact point and the bone crest in the presence of interdental papillae
was investigated by Tarnow et al.6 Those authors observed that the presence of interdental papillae
decreased with an increased CP-BC distance.

The LPH analysis demonstrated that the presence of normal papillae was influenced by the CP-BC
distance in both PB groups, with a positive and inversely proportional correlation; this can be related to the
presence of elongated teeth in thin PBs, with coronal contact points, thereby increasing the CP-BC distance.
14, 18

In the present study, the presence of the Class I LPH was higher in the thin PB group. This could be
related to the fact that severe bone loss can lead to papillary loss and formation of black spaces. 9The
fibrotic configuration, square teeth, and an apical contact point of the thick BP can be responsible for
maintaining the papilla contour in severe bone loss.

Differences in crown anatomy, root anatomy, and height of contact point can be related to the
differences observed in the presence of papilla at different sites between thin and thick PBs.

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CONCLUSION

The PB influenced the presence of inter-dental papillae. The thin PB group presented a greater loss
of papillary height, and the thick biotype group presented. However, future studies are necessary to clarify
the roles of other related factors, such as the distance between tooth roots, the shape of the teeth, root
inclination, and the distance between the contact point and the bone crest.

The absence of normal interdental papillae affects gingival esthetics, and can be influenced by the
PB, making it an important factor in the evaluation of a patient’s esthetics.

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