Criteria for predicting the presence of the central papilla
by a noninvasive method
LI-CHING CHANG
Department of Dentistry, Chang-Gung University, Linkou, Taoyuan, Taiwan, ROC.
Department of Dentistry, Chang-Gung Memorial Hospital, Chiayi Branch, Taiwan, ROC.
The distance from the bone crest to the contact point is one of the most frequently studied factors
that may influence the presence of interdental papillae. The purpose of this study was to discover
additional criteria for predicting the presence of the central papilla. The central papilla was visually
assessed in 330 adults using standardized periapical radiographs of the maxillary central incisors. The
following vertical distances were measured: the bone crest to the contact point (BC–CP), the buccal
cementoenamel junction (bCEJ) to the contact point (bCEJ–CP), the proximal CEJ to the contact point
(pCEJ–CP), the papillary height (PH), the bone crest to the buccal CEJ (BC-bCEJ), and the bone crest to
the proximal CEJ (BC-pCEJ). Horizontal distances measured were the inter-root width, interdental
width, and bone crest width. Statistical analysis revealed that several factors such as a PH of ≤ 4.5 mm,
an age of > 29 years old, a BC-pCEJ distance of > 1.7 mm, a BC–bCEJ distance of > -1.1 mm, a BC-CP
distance of > 5.5 mm, a bone crest width of > 2.2 mm, and an inter-root width of > 2.3 mm could
predict the presence of the central papilla. Clinicians can use the data including the PH, BC–pCEJ
distance, and BC–bCEJ distance to predict the presence of the central papilla based on a standard
periapical radiograph and the patient’s age. These criteria may also enable clinicians to predict the
likelihood of papillary loss after prosthetic or orthodontic treatment. （J Dent Sci, 2(2)：88-96 , 2007）
Key words: age factor, central papilla, periapical radiography.
Today’s dentists face esthetic standards that
require a soft-tissue contour with intact interdental
papillae and a symmetrical gingival outline, especially
in the interdental area of the maxillary central incisors
(the central papilla)1. The interdental area comprises
the contact area, the interproximal embrasure, and the
interproximal dentogingival complex2. The interdental
papilla is the gingival portion of the interdental area.
However, the physiology of the papilla is more
complex than that of other gingival regions3. The
interdental gingiva of the incisor region is usually
shaped like pyramid, or it may appear as a slight
gingival col, depending on the location of the contact
Received: March 25, 2007
Accepted: May 11, 2007
Reprint requests to: Dr. Li-Ching Chang, Department of Dentistry,
Chang-Gung Memorial Hospital, Chiayi Branch,
6, Chia-Pu Road, Sec. West, Pu-Tzi City, Chiayi,
Taiwan 61363, ROC.
88
area and the height of the gingiva4,5. The presence of
space below the contact area can lead to esthetic
impairment, phonic problems, and food impaction1,6,7.
If papillary loss occurs due solely to soft-tissue
damage, reconstructive techniques can completely
restore it; but if severe periodontal disease and
interproximal bone resorption are the cause of the loss
of the interdental papilla, then reconstruction is
generally incomplete3,6.
The morphologies of the interdental papillae and
the osseous architecture housing the tooth can be
categorized into 2 periodontal biotypes: thin, scalloped periodontium, characterized by thin gingival
tissue and long interdental papillae; and thick, flat
periodontium, characterized by a thick osseous
structure, flat morphology, thick gingival tissue, and
short, wide papillae8-10. Individuals with the thin
periodontal biotype may have more soft-tissue
recession than do those with the thick periodontal
biotype11. Although the interdental gingival tissue
J Dent Sci 2007‧Vol 2‧No 2
Criteria for predicting the central papilla
possesses biologic tissue memory, rebound of gingival
tissue is more likely in the thick periodontium than in
the thin, scalloped periodontium, where recession is
often permanent12,13.
Many studies have shown that the distance from
the bone crest to the contact point (BC-CP distance) is
significantly related to the presence of interdental/
inter-implant papillae1,3,7,14,15. Many clinicians often
predict the presence of papillae using the BC-CP
distance. In addition to the BC-CP distance, other
factors such as age, angulation of the roots of adjacent
teeth, the shape of the crown, the space between
adjacent teeth, the volume of the embrasure space, and
so on also help determine whether the interdental
papilla is present1,3,7,14-17. The purpose of this study was
to find other criteria for predicting the presence of the
central papilla by means of a simple, noninvasive
method.
MATERIALS AND METHODS
Subjects
Between July 2004 and December 2005, 360
adults with fully erupted permanent dentition were
randomly selected from the Dental Department of
Chang-Gung Memorial Hospital, Chiayi Branch.
Inclusion criteria were a healthy gingiva with a
plaque-and-gingival index of 0~118 and well-aligned
maxillary central incisors (natural teeth). Exclusion
criteria were systemically compromised patients (e.g.,
pregnancy or a history of taking medications known to
increase the risk of gingival hyperplasia), central
incisors with an artificial crown, proximal/cervical
restorations or abrasion, a history of surgery in the
anterior maxillary area, or open contact or crowding
(as observed with the naked eye). Thirty subjects were
excluded because of conditions such as an angular
bone crest (in the mesiodistal direction), open contact
depicted on radiographs, and a distance from the bone
crest to the contact area exceeding 10 mm.
Data collection
One periodontist performed the visual examinations to detect the papilla and to make
radiographic measurements. If no space was visible
apical to the contact area, the papilla was recorded as
being present. If a space was visible apical to the
J Dent Sci 2007‧Vol 2‧No 2
contact area, it was filled with a temporary radiopaque
restorative material (Caviton, GC Corporation, Tokyo,
Japan)16,17. Periapical radiographs were obtained using
a paralleling technique with a film holder (XCP, Rinn
Corporation, Elgin, IL, USA). The subjects’ gender
and age were recorded. The following vertical distances were measured:
1. h1 (bCEJ-CP) -- the length of a vertical line from
the buccal cementoenamel junction (CEJ) line of
the 2 central incisors to the apical point of the
contact area;
2. h2 (pCEJ-CP) -- the length of a vertical line from
the proximal CEJ line of the 2 central incisors to
the apical point of the contact area;
3. h3 (BC-CP) -- the length of a vertical line from the
bone crest to the apical point of the contact area;
4. h4 (PH) -- the length of a vertical line from the
apical margin of the space filled with the temporary
hydraulic restorative agent to the crest of the bone;
5. h5 (BC-bCEJ) -- the length of a vertical line from
the crest of the bone to the buccal CEJ line of the 2
central incisors; and
6. h6 (BC-pCEJ) -- the length of a vertical line from
the crest of the bone to the proximal CEJ line of the
2 central incisors.
Vertical lines were measured along the long axis
of an adjacent tooth.
The following horizontal measurements were
made:
1. w1 (inter-root width) -- the width between the roots
of the central incisors at the buccal CEJ level;
2. w2 (interdental width) -- the width between the 2
central incisors at the proximal CEJ level; and
3. w3 (crest width) -- the width between the 2 central
incisors at the bone crest level.
The vertical and horizontal distances were
measured on periapical radiographs using an electric
measuring ruler (Kinglife Corporation, Taipei,
Taiwan). All of the measurements were rounded to
the nearest 0.1mm. (Figures 1, 2). The average
magnification used by the method was 1.06 times.
Statistical analysis
Commercially available statistical software
(SPSS vers. 11.5; SPSS, Chicago, IL, USA) was used
to analyze the data. Data are presented as the mean ±
standard deviation (SD). A parametric independentsamples t-test was used to compare differences
between groups, i.e., a group with and one without
89
L.C. Chang
BC
h5
h6
bCEJ
pCEJ
h1
h4 h3
PT
h2
CP
Figure 1. Horizontal lines indicate the following locations, from top to bottom: bone crest (BC), buccal
cementoenamel junction (bCEJ), proximal CEJ (pCEJ), papillary tip (PT), and contact point (CP). The
distance between the CP and the bCEJ is the bCEJ-CP distance (h1), the distance between the CP and the
pCEJ is the pCEJ-CP distance (h2), the distance between the BC and the CP is the BC-CP distance (h3), and
the distance between the BC and the PT is the papillary height (h4). The distance between the BC and the
bCEJ is the BC-bCEJ distance (h5 = h3 – h1), and the distance between the BC and the pCEJ is the
BC-pCEJ distance (h6 = h3 – h2).
W3
W1
W2
90
Figure 2. The horizontal distance
between the central incisors at the
level of the top line is the bone crest
width (w3); the horizontal distance
at the middle line (buccal cementoenamel junction (CEJ)) is the
inter-root width (w1), and the
horizontal distance at the lower line
(proximal CEJ) is the interdental
width (w2).
J Dent Sci 2007‧Vol 2‧No 2
Criteria for predicting the central papilla
papillary recession. The χ2 test was used for
categorical variables (i.e., gender), and the receiver
operating characteristic (ROC) analysis was used to
define cutoff points for the diagnostic tests. Logistic
regression was applied when outcome variables were
binary (odds of papillary recession). The level of
statistical significance was p < 0.05.
RESULTS
There were 330 subjects in this study, including
193 males and 137 females. The mean age was 40.8
(range, 18~72) years. Table 1 shows the incidence of
the presence of papillae by age and gender. The
incidence of the papillary presence was significantly
related to a subject’s age. Papillae were present in >
50% of those younger than 30 but in < 10% of those
aged 40 or older. The incidence of the central papilla
decreased with age (Table 1).
Many factors such as the vertical distance
between the bone crest and contact point, papillary
height, the vertical distance between the bone crest
and the buccal CEJ, the vertical distance between the
bone crest and the proximal CEJ, the bone crest width,
the inter-root width, and age, but not gender, were
significantly related to the presence of the central
papilla (Table 2). The criteria with statistical significance in Table 2 are analyzed in Table 3.
Table 3 shows the values for the predictive value
of various criteria. Some criteria were able to predict
whether the central papilla had receded or not, namely
age, the BC–CP distance (h3), the papillary height
(h4), the BC–bCEJ distance (h5), the BC–pCEJ
distance (h6), the inter-root width (w1), the interdental
width (w2), and the bone crest width (w3). The
sensitivity and specificity of the different criteria are
also given in Table 3.
The results of further analysis of the odds using
the cutoff points of the ROC curve are presented
in Table 4, and for criteria that had statistical
significance in Table 3 (Table 4). For example, when
a subject was older than 29 years, the likelihood of
central papillary recession was 13.78 times greater
than for a younger subject. When the papillary height
was < 4.5mm, the likelihood of central papillary
recession was 37.98 times greater than when papillary
height was > 4.5mm. When the BC–bCEJ distance
was > –1.1mm (h5 = h3 – h1, i.e., a BC–bCEJ
distance of –1.1mm means that the bCEJ line is more
apical than the bone crest level by about 1.1mm; see
Figure 3), papillary recession was 13.53 times more
likely than when the BC–bCEJ distance was
< –1.1mm. Furthermore, when the BC–pCEJ distance
was > 1.7mm (h6 = h3 – h1, i.e., the pCEJ line is more
coronal than the bone crest level by about 1.7mm),
papillary recession was 13.52 times more likely than
when the BC–pCEJ was < 1.7mm.
DISCUSSION
The presence or recession of the interdental
papilla, especially in the area of the central maxillary
incisors, is of great concern to dentists and patients.
Many studies have shown that the distance from the
bone crest to the contact point (the BC-CP distance)
is significantly related to the presence of interdental/
Table 1. Incidence (percent) of the presence of the central papilla by age and gender
Age (years)
Group
< 20
(n = 17)
20~29
(n = 62)
30~39
(n = 67)
40~49
(n = 96)
50~59
(n = 63)
> 60
(n = 25)
Male
PR(-)
PR(+)
6 (75)
2 (25)
17 (54.8)
14 (45.2)
7 (16.7)
35 (83.3)
6 (10.5)
51 (89.5)
0 (0)
38 (100)
0 (0)
17 (100)
Female
PR(-)
PR(+)
7 (77.7)
2 (22.3)
17 (54.8)
14 (45.2)
7 (28)
18 (72)
1 (2.6)
38 (97.4)
1 (4)
24 (96)
0 (0)
8 (100)
13 (76.5)
4 (23.5)
34 (54.8)
28 (45.2)
14 (20.1)
53 (79.9)
7 (7.3)
89 (92.7)
1 (1.6)
62 (98.4)
0 (0)
25 (100)
Male and female
PR(-)
PR(+)
PR(-), without papillary recession (papilla presence); PR(+), with papillary recession.
J Dent Sci 2007‧Vol 2‧No 2
91
L.C. Chang
Table 2. Statistical relationships of the central papilla to various criteria
†
‡
All subjects
Mean ± S.D.
PR(–)
Mean ± S.D.
PR(+)
Mean ± S.D.
p value
40.8 ± 13.0
27.8 ± 9.3
44.2 ± 11.6
< 0.001*
Male
193 (58.48%)
36 (52.17%)
157 (60.15%)
0.232
Female
137 (41.52%)
33 (47.83%)
104 (39.85%)
bCEJ–CP (h1)
7.18 ± 0.90
7.11 ± 0.93
7.20 ± 0.90
0.50
pCEJ–CP (h2)
4.09 ± 0.80
4.02 ± 0.94
4.11 ± 0.76
0.50
BC-CP (h3)
6.19 ± 1.23
5.21 ± 0.95
6.45 ± 1.17
< 0.001*
PH (papillary height: h4)
3.87 ± 1.06
5.21 ± 0.95
3.52 ± 0.77
< 0.001*
BC-bCEJ (h3 – h1)
–0.99 ± 1.25
–1.90 ± 0.75
–0.75 ± 1.25
< 0.001*
BC-pCEJ (h3 – h2)
2.10 ± 1.03
1.19 ± 0.57
2.34 ± 0.99
< 0.001*
Inter-root width (w1)
2.23 ± 0.61
1.99 ± 0.48
2.30 ± 0.62
< 0.001*
Interdental width (w2)
1.94 ± 0.51
1.69 ± 0.42
2.00 ± 0.52
< 0.001*
Bone crest width (w3)
2.18 ± 0.67
1.84 ± 0.48
2.27 ± 0.68
< 0.001*
Age
Gender
Vertical distance
Horizontal distance
* Statistically significant.
†
PR(-), without papillary recession (papillary presence).
‡
PR(+), with papillary recession (papillary absence).
h1 (bCEJ-CP), the length of a vertical line from the buccal cementoenamel junction (CEJ) line of the 2 central incisors to the apical point of the
contact area.
h2 (pCEJ-CP), the length of a vertical line from the proximal CEJ line of the 2 central incisors to the apical point of the contact area.
h3 (BC-CP), the length of a vertical line from the bone crest to the apical point of the contact area.
h4 (PH), the length of a vertical line from the apical margin of the space filled with the temporary hydraulic restorative agent to the crest of the
bone.
h5 (BC-bCEJ), the length of a vertical line from the crest of the bone to the buccal CEJ line of the 2 central incisors.
h6 (BC-pCEJ), the length of a vertical line from the crest of the bone to the proximal CEJ line of the 2 central incisors.
w1 (inter-root width), the width between the roots of the central incisors at the buccal CEJ level.
w2 (interdental width), the width between the 2 central incisors at the proximal CEJ level.
w3 (crest width), the width between the 2 central incisors at the bone crest level.
92
J Dent Sci 2007‧Vol 2‧No 2
Criteria for predicting the central papilla
Table 3. Cutoff points of different criteria using the receiver operating characteristics (ROC) analysis
Area under the ROC curve
p value
Cutoff point
Sensitivity ( % )
Specificity ( % )
0.872
< 0.001*
> 29 years
85.1
90.4
BC-CP distance (h3)
0.778
< 0.001*
> 5.5
77.0
70.6
Papillary height (h4)
0.922
< 0.001*
≤ 4.5
91.2
82.4
BC-bCEJ (h3 - h1)
0.769
< 0.001*
> -1.1
60.8
100.0
B-pCEJ (h3 - h2)
0.807
< 0.001*
> 1.7
70.9
Inter-root width (w1)
0.623
0.01*
> 2.3
45.3
79.4
Interdental width (w2)
0.644
0.003*
>2
48.0
79.4
Bone crest width (w3)
0.66
0.001*
> 2.2
51.4
79.4
Age
Vertical distance
79.4
Horizontal distance
* Statistically significant.
An explanation of the abbreviations is given in table 2.
inter-implant papillae1,3,7,14,15, and the present findings
agree with results from those studies. Clinicians
usually predict the presence of the interdental papilla
based on the BC-CP distance. However, there are
other factors which can affect recession of the
papilla1,3,7,14-17. Finding other criteria for predicting the
presence of the interdental papilla, especially the
central papilla, has become an important issue in
esthetic dentistry.
The results of this study showed a negative
relationship between age and the presence of the
central papilla. The effects of aging on an increased
BC–CP distance and a decreased papillary height
together cause papillary recession to progress with
age16,17. The cutoff point for the age criterion in this
study was 29 years: when a subject was older than 29,
the likelihood of central papillary recession was 13.78
times greater than that of a younger subject.
Table 4. Odds of various criteria using logistic regression
Exp (B)
95% C.I.
p value
13.78
7.38–25.72
< 0.001*
7.95
4.38–14.45
< 0.001*
Papilla height (h4)
37.98
18.46–78.13
< 0.001*
Bone level–bCEJ (h3－h1)
13.53
5.95–30.76
< 0.001*
Bone level–pCEJ (h3 – h2)
13.52
6.57–27.84
< 0.001*
Inter-root width (w1)
2.97
1.65–5.32
< 0.001*
Interdental width (w2)
7.86
1.05–58.88
0.045
Bone crest width (w3)
4.05
2.15–7.66
< 0.001*
Age
Vertical distance
Bone crest–contact point (h3)
Horizontal distance
* Statistically significant.
C.I., confidence interval.
An explanation of the abbreviations is given in table 2.
J Dent Sci 2007‧Vol 2‧No 2
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L.C. Chang
(A)
(B)
BC
bCEJ
bCEJ
BC
Figure 3. The bone crest (BC) line and the buccal cementoenamel junction (bCEJ) line positions. (A) The BC line is more coronal than the
bCEJ line in a case with a central papilla. (B) The BC line is more apical than the bCEJ line in a case without a central papilla.
Papillary height significantly differed between
subjects with and those without a papilla, with mean
heights of 5.21 and 3.52 mm, respectively. Although
women generally have thinner gingivae and palatal
mucosa than men19,20, gender was not a significant
factor in the presence of the central papilla16,17.
The present results revealed that when the
papillary height was < 4.5mm (h4 < 4.5mm), the odds
of papillary loss were 37.98 times greater than when it
was > 4.5mm. In previous studies, papillary height
was measured by sounding, with the patient under
local anesthesia; however, this method is invasive and
only allows for buccal measurement1,7. Therefore,
the author developed a noninvasive method of
measurement that was simple, accurate, and easily
accepted by subjects16,17. The results of Lee’s study
also suggest that a noninvasive method using a
radiopaque material and periapical radiographs can be
used to measure the length of the interdental papilla in
relation to the crestal bone, which would enable a
more-accurate prognosis for regeneration of the
papilla21. Lee et al. found that correlations between the
values of RL - AL (radiographic length - actual length)
94
and BPL - AL (bone probing length - actual length)
were respectively 0.903 and 0.931, both of which
showed statistical significance at the 0.01 level21.
It is interesting to note that in Tarnow’s study,
with a BC–CP distance of 5mm, the papilla was
present 98% of the time, while at 7mm it was only
present 27% of the time7. There was also statistical
significance between the group with papillary
presence and that with papillary recession in relation
to the mean BC-CP distance in this study (5.21 vs.
6.45mm). Statistical analysis revealed that the cutoff
point for the BC–CP distance was 5.5mm, and the
odds of papillary absence were 7.95 times greater
when the BC–CP distance was > 5.5mm than when it
was < 5.5 mm. However, there were still variations in
the study’s findings compared to earlier study7,
possibly due to different sample sizes, limited studies
on the central papillary area, and the use of standardized periapical radiographs7,16,17.
In addition to age, the BC–CP distance, and
papillary height, the BC–bCEJ distance and BC–pCEJ
distance predicted papillary recession with high
sensitivity and specificity. The author found that when
J Dent Sci 2007‧Vol 2‧No 2
Criteria for predicting the central papilla
the BC–bCEJ distance was > –1.1mm, central
papillary recession was 13.53 times more likely than
when the BC–bCEJ distance was < –1.1mm. When the
BC–pCEJ distance was > 1.7mm, papilla recession
was 13.52 times more likely than when it was <
1.7mm. Clinicians can predict the presence of the
central papilla from a standard periapical radiograph,
even in cases with loss of the contact point. Clinicians
may also be able to predict the likelihood of central
papillary recession after certain therapies, such as
single crown fabrication, or orthodontic closure of the
interdental space.
Although the horizontal distances (w1, w2, and
w3) had predictive values that were statistically
significant, they were less predictive of the presence
of the central papilla than were vertical distances,
owing to their lower sensitivities (45.3%~51.4%). The
proximity limitation between 1 tooth and another is
1mm22; and this study’s results showed that if the
inter-root width (w1) exceeded 2.3mm, the likelihood
of central papillary recession was 2.97 times greater
than when it was narrower than 2.3mm. The wider the
horizontal distance was, the higher the incidence of
papilla loss was.
In implant dentistry, the ideal distance from the
base of the contact point to the bone crest is 3mm
between adjacent implants and 3~5mm between a
tooth and an implant1,15. The mean height of the
interproximal soft tissue is 3.85mm between an
implant and a tooth and 3.4mm between adjacent
implants1,23. In most cases, only 2~4mm of soft tissue
height can be expected to form over the inter-implant
crest of bone23. In this study, the mean height of
the central papilla (3.87mm) was greater than the
interproximal soft-tissue height in implant dentistry. A
previous study showed that the ideal lateral spacing
between implants and between the tooth and an
implant is 3~4mm in the presence of papilla15. An
inter-implant distance of 3mm is necessary to
maintain inter-implant bone, and a distance between
the implant and a tooth of 1.5mm is necessary to
preserve the bone crest height24. In contrast to the
above study, Ryser found no significant relationship between the horizontal distance and papilla
maintenance. The distance from the implant to the
adjacent tooth did not affect the papilla classification;
rather, Ryser found that the horizontal distance may be
more critical when 2 implants are placed next to each
other25. If the bone level on the adjacent tooth remains
stable, then the papilla should be stable over time.
J Dent Sci 2007‧Vol 2‧No 2
In addition to the BC–CP distance, other criteria
that can predict the presence of the central papilla are
an age of > 29 years, a papillary height of ≤ 4.5mm,
a BC–bCEJ distance of > –1.1mm, a BC–p CEJ
distance of > 1.7 mm, a bone crest width of > 2.2mm,
and an inter-root width of > 2.3mm. Based on the
values of sensitivity and specificity, age and papillary
height have the highest predictive values, followed by
the BC–CP distance, the BC–pCEJ distance, and the
BC–bCEJ distance. The sensitivity and specificity of
these criteria were all greater than 60.0%. The
likelihoods of central papilla recession for cases that
met the criteria compared to those that did not meet
the criteria were as follows: papillary height ≤
4.5mm — 37.98; age > 29 years — 13.78; BC–bCEJ
distance > –1.1mm — 13.53; BC–pCEJ distance >
1.7mm — 13.52; and BC–CP distance > 5.5mm —
7.95.
This study found the presence of a central papilla
to be significantly related to age, papillary height,
distance from the bone crest to the buccal CEJ,
distance from the bone crest to the proximal CEJ,
distance from the contact point to the bone crest,
inter-root width, and bone crest width, but not to
gender. Based on the results of this study, clinicians
can predict the presence of a central papilla using the
patient’s age and standard periapical radiography, by
examining papillary height, the BC–pCEJ distance, or
the BC–bCEJ distance as a reference. These results
may also enable clinicians to predict the likelihood of
papillary loss after prosthetic treatment or orthodontic
treatment.
Other factors (e.g., root angulation of adjacent
teeth, crown shape, space between adjacent teeth, and
volume of the embrasure space) also affect whether
the interdental papilla is present or not. There is a
need for further study of interactions among these
factors.
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