ISSN:

Printed version: 1806-7727

Electronic version: 1984-5685
RSBO. 2012 Oct-Dec;9(4):448-56

Literature Review Article

Papillary regeneration: anatomical aspects and

treatment approaches
Jaína Dias de Oliveira1
Carmen Mueller Storrer2
Andrea Maria Sousa3
Tertuliano Ricardo Lopes4
Juliana de Sousa Vieira5
Tatiana Miranda Deliberador6

Corresponding author:
Tatiana Miranda Deliberador
Mestrado Profissional em Odontologia Clínica, Universidade Positivo.
Rua Professor Pedro Viriato Parigot de Souza, n. 5.300 – Campo Comprido
CEP 81280-330 – Curitiba – PR – Brasil
E-mail: [email protected]
1
Graduate student of the Specialization Course in Periodontology, Positivo University – Curitiba – PR – Brazil.
2
Associate Professor, Positivo University – Curitiba – PR – Brazil.
3
MsC in Dentistry from the State University of Ponta Grossa – Ponta Grossa – PR – Brazil.
4
Associate Professor, Positivo University – Curitiba – PR – Brazil.
5
Graduate Student of the Master Course in Dentistry from the Positivo University – Curitiba – PR – Brazil.
6
Full Professor, Positivo University – Curitiba – PR – Brazil.

Received for publication: July 5, 2012. Accepted for publication: August 20, 2012.

Abstract
Keywords:
dental papilla; gingival;
regeneration. Introduction and objective: This paper aims to report a literature
review on the anatomy and morphology of the interproximal papilla
and present the options of both surgical and nonsurgical treatment
for the recovery of interdental papilla. Literature review: The loss
of the interdental papilla because of the interproximal bone loss
accounts for aesthetic, phonetic and functional problems of patients
with periodontal disease. The interproximal tissue reconstruction
has been reported in literature through both surgical procedures
with the use of subepithelial connective tissue graft, restorative
and orthodontic treatment. Conclusion: The etiology of gingival
black space is multifactorial, therefore, it is important to diagnose
properly the etiological factor to establish an appropriate treatment
planing. However, the treatment approaches are not predictable and
further studies are necessary to recommend the clinical practices
available to date.
 RSBO. 2012 Oct-Dec;9(4):448-56 – 449

Introduction the posterior region, it is wider and with a ridge-

shaped concave area so-called the col [10]. This
Currently a growing concern with beauty and crest, which determines the position and extent
physical appearance comes together with greater
of the contact point of the adjacent teeth, is non-
demands regarding to aesthetics in Dentistry. The
keratinized or parakeratinized and covered with
gingival esthetics is one of the most important
stratified squamous epithelium [16].
factors for success in a restorative treatment.
The contact point on the maxillary central
The absence of interdental papilla as a result
incisors is located at the incisal third of the labial
of the periodontal disease development or of
aspect, between the central incisors; the contact
the periodontal therapy used is a situation that
leads to aesthetic, phonetic and food impaction point on the maxillary lateral incisor is located in
problems. Papillary regeneration aims to fill the the middle of this teeth and between the lateral
black spaces that occur in interproximal surfaces, incisor and canine at the apical third [24]. This
one of the most complex cosmetic procedures to means that the most visible papilla, located on
be performed among periodontal surgeries. Black the upper central incisors, is filled with more
triangles (spaces because of the darkened aspect space than the others, and its lack causes major
of the oral cavity) occur in more than half of the aesthetic problems. It is therefore more difficult to
adults. Therefore, this issue should be discussed be reconstructed.
with the patient prior to the initiation of dental The classical study conducted by Tarnow et al.
treatment [32]. The black spaces are not aesthetic [37] correlated the presence or absence of interdental
and contribute for food retention as well as they papilla with the distance between the bone crest
may affect the periodontium health [22]. A correct and the contact point at 288 interproximal sites
diagnosis should be performed for either the in 30 patients. The presence of the papilla was
success or improvement of the treatment of papilla observed in almost 100% of the cases in which
loss, as their etiological factors must be eliminated the distance was less than or equal to 5 mm, in
before considering therapies for reconstruction. In 56% of cases in which the distance was 6 mm,
addition to act as a barrier to protect the periodontal and only 27% of cases in which the distance was
structures, the papilla plays a critical role in the 7 mm or more.
aesthetics. Therefore, it is very important to respect According to Fradeani [11], the distance between
the papillary integrity during the dental procedures the roots is another factor that can influence the
and minimize its disappearance [42]. presence or absence of interdental papilla. The
The aim of this paper is to report a literature author stated that the a inter-radicular distance
review on the morphological and anatomical smaller than 0.3 mm jeopardizes the presence
aspects of interproximal papilla and present the of the proximal bone and, therefore, it is usually
periodontal, restorative and orthodontic therapeutic accompanied by the lack of interdental papilla.
considerations about the recovery of interdental The gingival black space has been defined as
papilla. a distance from the cervical black space to the
interproximal contact [18]. A smile with gingival
black spaces affects the aesthetic of the patient.
Literature review Kokich [20] observed that the gingival space larger
than 3 mm is considered a visible aesthetically
Papillary anatomy and morphology
problem both for the dentists and the general
The interdental space is the physical space population.
present between two adjacent teeth, and its shape
and volume are determined by the morphology of Etiological factors for papilla absence
the teeth. The interdental papilla represents the
gingival tissue that fills this space and is formed by The etiolog y of the papilla absence of is
dense connective tissue covered by oral epithelium multifactorial (figure 1). The causes include changes
and may be influenced by the height of the alveolar in papilla during orthodontic alignment, loss of
bone, distance between the teeth and interdental periodontal ligament resulting in recession, loss of
contact point [32]. alveolar bone height in relation to the interproximal
In the area of the incisors, the interdental contact, length of the area of the niche, root angle,
papilla is narrow and has a pyramidal shape and positioning of the interproximal contact and
with its tip just below the point of contact. In triangle-shaped crowns.
 Oliveira et al.
450 – Papillary regeneration: anatomical aspects and treatment approaches

Figure 1 – Etiology pyramid of the gingival black space

Source: Sharma and Park [32]

The periodontal disease has been associated the cases. An increase of 1 mm in the distance
with loss of interdental papilla due to the loss of between the alveolar bone and the interproximal
alveolar bone [42]. Additionally to the periodontal contact increases the probability of a gingival black
disease, other factors such as the host susceptibility, space from 78% to 97%. As a rule, the distance
are involved in gingival black space. The distance of between 5 and 6 mm is the most critical and it
5 mm from the alveolar crest to the contact point determines the presence or lack of space in the
is considered periodontally healthy [42]. However gingival embrasure [41].
pockets with probing depth greater than 3 mm Currently, the study of Chen et al. [8] demonstrated
will lead to an increasing of plaque retention, that the presence of papilla is significantly related
inflammation and recession [42]. In the periodontal to the distance from the contact point to the bone
disease, the alveolar bone loss increases the distance crest, that is, the smaller this distance, the smaller
between the contact point and the alveolar crest the distance between two adjacent teeth; the lower
resulting in a space black. the area of the gingival niche, the more likely is
In the study of Wu et al. [41] it was demonstrated the presence of interdental papilla. The authors
that the distance of 5, 6 and 7 mm resulted in a reported that the interdental papilla is more present
gingival black space of 2.44% and 73% of the cases, in rectangular-shaped teeth. According to these
respectively. This indicates that if the alveolar same authors [8], the loss of bone height may be
crest distance to the contact point is equal to or the crucial factor in the loss of interdental papilla.
less than 5 mm, the papilla will be present in However, it is unclear whether the position change
almost 100% of cases. If the distance is greater of the contact point to reduce the distance between
than 7 mm, there will be papilla in most cases. the contact point and the bone crest would help the
At 6 mm, the papilla is present in about half of recovering of the interdental papilla [8].
 RSBO. 2012 Oct-Dec;9(4):448-56 – 451

The brushing trauma can also causes gingival based on three anatomic points: the interdental
black spaces. If the loss of papilla height is caused contact point, the most coronal point of the enamel-
by trauma during brushing, the aggressively cleaning cementum junction (ECJ) at the interproximal
of the interproximal tissue should be interrupted surface and the most apical point of the ECJ at
so that the tissue could be recovered [35]. the labial surface. Four classes were identified
The presence of gingival black spaces can (figure 2):
also be related to age. The studies of Ko-Kimura • Normal: the interdental papilla fills the niche
et al. [18] showed that patients over 20 years-old up to the apical extension of the interdental
are more likely to gingival black space than those contact point;
under 20 years-old. Gingival spaces were found • Class I: the tip of the interdental papilla is
in 67% of the population over 20 years-old; in placed between the interdental contact point
the population under 20 years-old, the percentage and the most coronal point of the ECJ at the
reached 18%. This is because of the thinning of interproximal surface;
the oral epithelium, decreasing of the keratinization • Class II: the tip of the papilla is placed between
and a reduction in the height of the papilla as the the most coronal point of the ECJ at the
result of age. interproximal surface and the most apical point
of ECJ at the labial surface;
Classification of the interdental papilla loss • Class III: the tip of the interdental papilla is
The interdental papilla loss was classified by at the ECJ or it is apically to the most apical
Nordland and Tarnow [26]. This classification is point of ECJ at the labial surface.

Figure 2 – Classification of the interdental papilla loss

Source: Nordland and Tarnow [26]

Treatment approaches restoring it completely. If the loss of papilla is caused

by periodontal disease with interproximal bone
Some methods may be used in an attempt to
resorption, usually a complete reconstruction is not
achieve the reconstruction of interdental papilla,
achieved. Surgical and non-surgical considerations
including manipulating soft tissue [2], increasing
are proposed in the periodontal literature to provide
of the hard tissue [5] and the restorative and
a satisfactory reconstruction of the interdental
orthodontic treatment [24].
papilla.
Techniques of soft tissue manipulation Non-surgical considerations
If the loss of papilla is related to only soft In cases of the interdental papilla damage
tissue loss, reconstruction techniques are capable of performed by traumatic brushing, the interdental
 Oliveira et al.
452 – Papillary regeneration: anatomical aspects and treatment approaches

hygiene should be modified. The re-epithelialization area of the tuberosity. The graft is trimmed to the
of traumatic injuries can completely restore the ideal size and shape and placed under the flap to
papilla [1]. provide more volume in the papillary region. The
labial and palatal flaps are sutured together and
Surgical considerations subepithelial graft lies beneath them.
Currently there is no predictable surgical In 1999, Azzi et al. [3] described another
procedure to retrieve the interdental papilla [29]. technique to achieve root coverage and papilla
Reconstructive surgery can result in contraction reconstruction of a recession. In this case, the
of papillary necrosis and of the grafted tissue due incision is performed near to the mucogingival
to the fragility of the tissue and low blood supply junction, preserving the integrity of the cervical
in the region [41]. region, again involving the connective tissue
Among the surgical techniques, it may be used graft removed from the ma xillary tuberosity.
pedicle flaps, free gingival and connective tissue The connective tissue and the flap displacement
graft [23, 31]. Some case reports have demonstrated allowed the simultaneous treatment of the gingival
success with subepithelial connective tissue graft recession and loss of interproximal papilla. In
and orthodontic therapy [7, 25]. According to Wu et 2001, to increase the volume of the interdental
al. [41], the flap surgery has shown better results tissue additional to the f lap described in the
than the free gingival graft. Grupe et al. [14] stated aforementioned study, Azzi et al. [4] associated
that the techniques with pedicle flaps showed better an autogenous bone graft from the region of the
results than free gingival graft techniques, because maxillary tuberosity with a connective graft tissue
the blood supply is provided by the base of the from the region of the palate.
pedicle. In 1996, Han and Takei [15] described In the study published by Pellegrine et al.
a technique in which the interdental papilla was [28], it was presented a case in which there is
moved and placed coronally and a connective a reconstruction of the interdental papilla by
tissue graft was placed below the papilla. This modifying the technique of interdental papilla
technique is based on a model previously described preservation presented by Takei et al. [34] associated
by Tarnow [36]. A half-moon shaped incision was with the subepithelial connective graft. In this case,
made parallely to the labial free gingival margin it was shown the possibility of folding the graft to
and the flap dissected was coronally positioned to obtain a larger increase in the volume; procedure
cover an exposed root. In their modification for used in surgery for alveolar ridge thickness
reconstruction of the papilla, they recommended augmentation with possible applications in the field
the execution of the semilunar incision in the of papillary reconstruction [15].
interdental region to allow the restoration of the
lost interproximal papilla by placing a connective
Techniques of hard tissue augmentation
tissue graft below the deficient area. According to the
authors, this procedure must be repeated a second This type of procedure is not commonly used
or third time after two or three months of healing. because, although the guided bone regeneration or
This technique [15] was applied in a patient with bone grafts are used to increase the height of the
an implant onto the area of the maxillary central alveolar bone, these procedures are limited in the
incisor. The mesial and distal papillas were absent. interdental area [5].
After the placing of a provisional prosthesis, there
was a small improvement in the interdental region. Restorative treatment
The semilunar and intrasulcular incision was
executed to release the connective tissue of the root Concerning to the restorative treatment, one
surface and the papilla was coronally placed. The of the options is to change the position of the
subepithelial connective tissue graft was removed point of contact with ceramic veneer or crown.
from the palate and placed in the space created by Further, it is possible to add pink porcelain onto
the displacement. The gain of interdental tissue was the restoration to mask the loss of interdental
observed after the wound healing and also after the papilla [42]. Moreover, mesial-cervical restorations
period of healing of three and four months. or laminates will reduce the appearance of gingival
In 1998, Azzi et al. [2] reported a papilla by altering the shape of the crown. The composite
reconstruction using subepithelial graft associated can be inserted near the gingival sulcus to guide
with a partial thickness flap. The partial flap is the format of the interdental papilla [32].
raised in the labial and palatal graft to allow the Another method of correcting the black space
placement of the conjunctive graft removed from the is the interproximal enamel reduction, made with
 RSBO. 2012 Oct-Dec;9(4):448-56 – 453

a diamond strip to reshape the mesial surface of

the maxillary central incisor. Approximately 0.5 to
0.75 mm of enamel is removed by interproximal
reduction [19], which will increase the contact
point and move it gingivally. The interproximal
enamel reduction in teeth with triangular crowns
will change the point of contact for a larger area,
reducing the gingival embrasure [32].

Orthodontic treatment
The orthodontic treatment to put the contact
point more apically can be executed attempting to
reduce the black triangle (figure 3). Further, the
alveolar bone height and papilla can be induced
by orthodontic extrusion [17].
Divergent roots are associated with the gingival
black spaces. With the orthodontic treatment, the
maxillary central incisors can follow the axial long
axis of the tooth and correct the black space. As
the roots become more parallel, the contact point
will stretch and move towards the apex of the
papilla [41].

Figure 4 – Diastema closing and papilla regeneration.

A: Teeth prior to the orthodontic treatment showing
diastema. B: Orthodontic closure with papilla formation
filling the space
Source: Sharma and Park [32]

Loss of interproximal papilla in the treatment

with dental implants
Figure 3 – A: Divergent roots showing the black space. B: Single implants have a significant chance of
Orthodontic bracket positioning to follow the long axis losing papilla due to the increase of the distance
of the teeth and correct the black space. C: Convergent from the contact point to the alveolar crest. To
roots after the orthodontic treatment presenting the preserve the papilla in the implant, it is important
filling of the space with the papilla
to keep the distance from the point of contact to
Source: Sharma and Park [32] the bone level of 5 mm or less. The distance from
the adjacent natural tooth to the alveolar crest is
more critical than that from the height of the contact
As the crowns of each incisor approach, the point of the implant to the bone [9].
stretched transeptal fibers relax and fill the gingival Black spaces are even more pronounced when
embrasure [19], reducing their probability and two adjacent implants are placed. This deficiency
severity. When a diastema occurs because of the in the soft tissue of 1 to 2 mm arises from the
periodontal disease, its orthodontic closure can be biological space around the implant abutment
performed after the resolution of inflammation. In apically to the abutment platform [38]. As a result,
such cases, the reconstruction of the interdental the biologic space of the implant is located below
papilla is not the main goal of the treatment planing. rather than above the bone crest, as in the case of
natural teeth. Ideally, maxillary anterior implants
The volume of soft tissue in the interproximal
should be at 4 mm apically to the alveolar bone
space will depend on the amount of existing tissue, crest. Furthermore, to prevent bone loss and thereby
bone levels and severity of the diastema. The the papilla loss, it is important that the distance
diastema closure through orthodontic treatment between the two implants is of 3 mm [30]. This
will compress the soft tissue and thus fill the gap allows that the interproximal bone be held above
[32] (figure 4). the implant platform. In the anterior region, it is
 Oliveira et al.
454 – Papillary regeneration: anatomical aspects and treatment approaches

difficult to obtain this ideal mesial-distal distance. and surgical treatment, through the use of prosthesis
A method for compensating the interproximal bone for conditioning the gingival tissue. In addition,
loss is the increase of the palatal bone in the papilla the orthodontic treatment is successful with the
area [13]. However, a distance of ≥ 3 mm will not orthodontic extrusion to obtain the increase of the
ensure the presence of interproximal papilla. alveolar bone height [17], through the alignment
There are several considerations that do not of the roots following the long axis of the teeth
allow the papilla regeneration, but they help in [41] and the diastema closure [32]. On the other
preventing the interproximal bone loss and in hand, the manipulation techniques of hard tissue
the aesthetic achievement. One of the options for are not yet viable.
the treatment of the loss of two teeth that will Although there are surgical and non-surgical
be replaced by implants in an aesthetic area, it techniques for reconstruction of interdental papilla,
is to install just one implant and to construct a there are no treatments to achieve predictable
cantilevered prosthesis associated with soft tissue success.
graft and interproximal bone augmentation [39].

Conclusion
Discussion The etiology of the gingival black space is
The presence of interdental papilla is of multifactorial and it is important to diagnose
extremely important in the esthetic gingival factor properly the etiologic factor for establishing an
in this patient's smile. The loss of interdental appropriate treatment planing. However, the
papilla is caused by the loss of interproximal treatment approaches are not predictable and
bone, resulting from the periodontal disease further studies are needed to recommend the
advancement or history of the therapy used (surgical clinical practices available to date.
or nonsurgical). However, such factors as trauma
brushing, diastema and presence of divergent roots
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