Received: 25 November 2019 Revised: 11 April 2020 Accepted: 15 May 2020

DOI: 10.1111/jerd.12608

REVIEW ARTICLE

Minimally invasive procedures for deficient interdental

papillae: A review

Yiding Zhang1,2 | Guang Hong2 | Yifan Zhang1,3 | Keiichi Sasaki3 | Hongkun Wu1

1
State Key Laboratory of Oral Diseases,
National Clinical Research Center for Oral
Diseases, West China Hosepital of
Stomatology, Sichuan University, Chengdu,
Sichuan, P.R. China
2
Division for Globalization Initiative, Liaison
Center for Innovative Dentistry, Graduate
School of Dentistry, Tohoku University,
Sendai, Japan
3
Division of Advanced Prosthetic Dentistry,
Graduate School of Dentistry, Tohoku
University, Sendai, Japan
Correspondence
Hongkun Wu, State Key Laboratory of Oral
Diseases, National Clinical Research Center for
Oral Diseases, West China Hospital of
Stomatology, Sichuan University, 14 Third
Section of Renmin South Road, Chengdu,
Sichuan 610041, P.R. China.
Email: wuhkscu@126.com
Funding information
Sichuan Province Science Foundation for
Cadres Medical Care, Grant/Award Number:
ZH2017-901
Abstract
Objective: Deficient interdental papillae cause a series of problems, including food
impaction, phonetic difficulties, and esthetic concerns. The purpose of this article is
to provide valid clinical recommendations for clinicians to address these problems in
a predictable and less invasive way.
Overview: Numerous treatments are available for interdental papillae reconstruction,
but most of them involve surgery and yield unpredictable outcomes. Minimally inva-
sive treatments have the advantages of being effective, predictable, and involving
only slight injury as compared to surgical treatments. We included 66 studies
obtained after searching for relevant papers in PubMed and Web of Science. The eti-
ology and classification of deficient interdental papillae are explained and minimally
invasive procedures for deficient interdental papillae reconstruction are summarized.
Conclusions: Minimally invasive procedures are promising ways to reconstruct defi-
cient interdental papillae, and have the advantages of slight pain and rapid recovery.
It should be noticed that some of the minimally invasive treatments still require fur-
ther long-term observation to confirm their efficacy.
Clinical significance: Familiarity with etiology and classification of deficient interden-
tal papillae can help clinicians to choose the appropriate minimally invasive approach
as well as help with case collection to enhance esthetics status in patients with defi-
cient interdental papillae.

KEYWORDS

clinical application, esthetic improvement, gingival reconstruction, hyaluronic acid, interdental

papilla

1 | B A CKG R O U N D 3 mm is considered unattractive. Food impaction caused by defi-

Interdental papillae occupy the space between adjacent teeth and
form part of the gingivae.1 Deficient interdental papillae cause open
embrasures, which lead to various issues, such as esthetic problems,
phonetic problems, and food impaction. The appearance of the papil-
lae is an important issue in gingival esthetics. Esthetically, the ulti-
mate goal is to achieve a “white and pink”2,3 esthetic. “White” refers
to the adjacent teeth, and “pink” refers to the interproximal gingival
tissue. A survey by Naorungroj et al4 suggested that a black triangle
of 2 mm in size may be noticed by lay people, and a black triangle of
ciency in interdental papillae also induces dental plaque accumula-
tion. Food impaction not only causes discomfort, but also leads to
adverse oral conditions, such as bad breath, root caries, and gingivi-
tis. In addition, when interdental papillae are missing, the open
embrasure provides space for air or saliva, which is the main cause
of phonetic problems.
The concept of an “interdental papillae house” has been proposed
to describe the relationship between soft tissue and hard tissue sur-
rounding the interdental papillae. The concept likens the interproximal
space containing the interdental papillae to a house, which includes

J Esthet Restor Dent. 2020;1–9. wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals, Inc. 1

2 ZHANG ET AL.
the contact area, cementoenamel junction (CEJ), tooth surface, and
area where the root and soft tissue converge above the alveolar bone
crest.5
The reconstruction of deficient interdental papillae is one of
the most difficult and least predictable problems to address. Vari-
ous treatments aim to reconstruct interdental papillae by surgical
or nonsurgical approaches. Surgical procedures aim to reconstruct
or preserve the gingival tissue by using a soft tissue flap or soft tis-
sue augmentation.6 However, because of the narrowness and lim-
ited blood supply of interdental papillae, predictable outcomes are
7
difficult to achieve by means of surgical procedures. Therefore,
surgical procedures are more suitable for deficient interdental
papillae that involve a bone defect or a large amount of soft tissue
loss.8 Nonsurgical procedures remodify the embrasure space to
ensure that the papillae are tissue filling. Minimally invasive
approaches include nonsurgical procedures and emerging proce-
dures that involve less trauma, for example, laser or injection
treatments.
These methods, such as restorative techniques, orthodontic
movement to reshape and decrease open embrasures, and reconstruc-
tion of interproximal gingival tissue, are increasingly used in the
clinic.9 This review article first describes the etiology and classification
of deficient interdental papillae and then discuss minimally invasive
procedures used to manage the dilemma of deficient interdental papil-
lae. The purpose of this review article is to summarize evidence to
establish a treatment method that can address the esthetic problems
of patients with deficient interdental papillae.
2 | METHODS
PubMed and Web of Science databases were searched for relevant
published studies using either the following keywords or, in case of
the PubMed database, medical subject headings: “interdental papillae”
and “black triangle”; “interdental papillae” and “surgery”; “interdental
papillae” and “Periodontitis”; “interdental papillae” and “hyaluronic
acid”; “interdental papillae” and “biotype”; “interdental papillae” and
“teeth”; “interdental papillae” and “gingiva”; “interdental papillae” and
“regeneration”; “interdental papillae” and “injection”; “interdental
papillae” and “reconstruction.” No limit was selected for the year of
publication. The searches comprised all articles published up to
October 2019. All articles were fully reviewed to identify useful infor-
mation. Only the articles published in English and with full text avail-
able were included.
3 | RESULTS AND DISCUSSION
Sixty-six studies were included in the present review of the etiology
of deficient interdental papillae, classification of deficient interdental
papillae, and minimally invasive procedures for reconstruction of defi-
cient interdental papillae.
3.1 | Classification of deficient interdental papillae
A convenient and widely accepted classification of deficient interden-
tal papillae is beneficial for studying this phenomenon and for stan-
dardizing clinical cases. Nordland and Tarnow10 classified interdental
papillae by considering the CEJ and the interdental contact point as
references. In this classification, complete interdental papillae were
classified as normal. For abnormal cases with an open gingival embra-
sure in the interproximal area, cases in which the tip of the papillae is
located between the contact point and the interproximal CEJ was
classified as class I. Cases in which the papillae are located apically to
the interproximal CEJ, but coronally to the facial CEJ, was classified as
class II, and cases in which the papillae were located apically to the
facial CEJ were classified as class III.
In consideration of the absence of an interdental contact point in
some cases, Cardaropoli et al11 made another system to assess inter-
dental papillary level. This classification considered the CEJ and adja-
cent teeth as references to measure the soft tissue level. A papillae
presence index (PPI) score of 1 implies that the interdental papillae
completely fill the interproximal space, while PPI 2 means that there is
open interproximal space, but the interproximal CEJ remains covered.
When the facial CEJ is exposed, PPI 1, and PPI 2 are scored as PPI 1r
and PPI 2r, respectively. PPI 3 implies that the interdental papillae are
located apically to the interproximal CEJ, and PPI 4 indicates a suffi-
ciently large amount of soft tissue recession, such that both the inter-
proximal and facial CEJs are visible.
3.2 | Etiology of deficient interdental papillae
3.2.1 | Distance from the bone crest to the base of
the contact area
The distance between the bone crest and the base of the contact area
(BC-CA) is considered to be the main contributor to the presence of
interdental papillae.12,13 A survey by Tarnow et al14 indicated that,
when the BC-CA distance was less than 5 mm, the papillae occupied
98% of the interproximal space, while when the distance was more
than 7 mm, the papillae represented no more than 27% of the space.
On the other hand, the influence of the BC-CA distance on the
interdental papillae increases with increasing age.15 Kolte et al16
found that, when the BC-CA distance was less than 4 mm, there was
an 87% chance of interdental papillae being present. In addition, when
the distance was 6 mm, this chance decreased to 41.1%. The likeli-
hood of interdental papillae being present decreased as the distance
increased. In addition, in some particular sites, the BC-CA distance
had a different influence on the presence of interdental papillae, and
the maxillary central papillae seemed less sensitive to the increase in
BC-CA distance than were the lateral papillae. The central papillae
may still occupy most of the interproximal space until the BC-CA dis-
tance reaches 8 mm, while the lateral papillae could not fill the space
when the BC-CA distance exceeded 5 mm.17 Another logistic
ZHANG ET AL.
regression study confirmed this finding and showed that, when root
convergence occurs, when the incisal contact area and the crown
shape are the same, and when the distance between the alveolar crest
and the contact area increases to 1 mm, the likelihood of interdental
papillae being deficient increased to 78%-97%.18
3.2.2 | Interproximal contact area
The length and height of the interproximal contact area between
teeth determine the size of the interproximal space that accommo-
dates the interdental papillae. Kolte et al15 studied the proximal con-
tact area and the proportion of the proximal contact area of the
crown, and found that both of these were decreased from the maxil-
lary central incisor to the first molar on both sides. This study
suggested a close relationship between these factors and the pres-
ence of interdental papillae. The study by Chow et al19 also proved
that a larger interproximal contact area increased the possibility of a
complete interdental papilla.
However, the study by de Santana et al20 suggested that the
interproximal contact area has little influence on the presence of
interdental papillae. Therefore, more evidence is needed to verify the
relationship between the interproximal contact area and interdental
papillae.
3.2.3 | Interproximal root distance
As the root distance increased, the likelihood of the presence of the
interdental papillae decreased. A study by Kolte et al16 suggested that
the likelihood of interdental papillae existing was 78.5% when the
root distance was 0.5 to 1 mm, but decreased to 75.6% when the dis-
tance increased to 1 to 1.5 mm. When root distance became greater
than 1.5 mm, but was less than 2 mm, there was a 56.7% probability
of interdental papillae existing. The study also showed that root dis-
tance had a greater influence on the existence of interdental papillae
when the vertical distance from the alveolar crest to the base of the
contact area was 5 mm. Cho et al21 investigated 206 interdental papil-
lae in 80 patients and found that, when the root distance was 1 mm,
interdental papillae were present in 72.4% of the cases; however,
when the root distance was 3.5 mm, interdental papillae were present
in only 6.3% of the cases.
3.2.4 | Root angulation
The divergence of roots is another factor associated with interden-
tal papillae. A large divergence angle can stretch the transseptal
22
fiber, which promotes an interproximal open embrasure. Kurth
et al18 reported that the divergence angle is 3.65 for the normal
condition of interdental papillae, and that the chance of an open
embrasure increased to 14% to 21% for a 1 increase in the diver-
gence angle.
3
3.2.5 | Crown contour
The appearance of the maxillary central papillae is a frequent topic of
analysis and carries great weight in esthetic treatment plans. The
shape of teeth, particularly of the maxillary central incisor, influences
the presence of interdental papillae. On the basis of the ratio of the
tooth crown width and length, the shape of the central incisor is
divided into three types: triangle, square-tapered, and square. Among
these three shapes, the square shape has the largest interproximal
contact area, and the interproximal space is also the smallest, whereas
the triangle shape has the smallest interproximal contact area; there-
fore, triangular crowns require more gingival tissue to fill the inter-
proximal space.23 In addition, with a square-shape crown, a shorter
interdental papilla is more likely.
3.2.6 | Biotypes
Gingival thickness is a critical factor that influences the presence of
interdental papillae, and also affects interdental papilla reconstruction.
As it is supported by a larger area of keratinized tissue, thick alveolar
bone structure, and increased blood supply, thick gingival tissue has
better resistance than thin gingival tissue against external stimulation
24,25
or gingival inflammation. A thick biotype is defined as having a
gingival tissue thickness ≥2 mm, while a thin biotype is defined by a
gingival tissue thickness of <1.5 mm.26 Generally, a thick biotype is
usually associated with flatter and shorter interdental papillae and has
less opportunity to form an open embrasure. On the other hand, a
thin biotype is more likely to have a shorter interdental papillary
height and an open embrasure when the distance between the con-
tact area and the alveolar crest is increased.17,19,27 However, Barboza
de Lemos et al25 suggested that, when the distance between the alve-
olar bone and the contact point was 6 mm, interdental papillae were
more likely to exist among those with the thin biotype.
3.2.7 | Age
There was a positive relationship between the height of interdental
papillae and age. Chang28 showed that the oral epithelium is thinner
with increasing age, while bone volume, aging, and traumatic oral
hygiene were also the causes of interdental papillae deficiency.
3.2.8 | Orthodontic therapy
Orthodontic treatment could lead to deficient interdental papillae,
particularly in the case of overlapped teeth. Burke et al26 showed that
41.9% of maxillary central incisors had an open gingival embrasure
after orthodontic treatment. Furthermore, Jeong et al29 suggested
that, after dentition was regularly arranged, maxillary central interden-
tal papillae were 0.8 mm shorter, on average. This dilemma may be
due to the alveolar bone absorption caused by orthodontic treatment,
 4

TABLE 1 The factors that contributed to deficient interdental papillae in each study

Periodontal
Study, year Measurement methods Age Measurement area status Influencing factors
Kolte et al, Radiograph and digital caliper Group 1:21-40 years Maxillary anterior teeth Periodontally ICA, age, BC-CP, ICA/CL
201815 Group 2:41-60 years healthy
Joshi et al, 20171 Periodontal probe, UNC-15 probe, study >18 years of age Maxillary incisors and canine Periodontally BC-CP, gingival thickness, crown contour,
model, digital caliper healthy gingival angle
de Santana, Periodontal probe Mean age: Maxillary anterior teeth Periodontally Negative result: contact point is irrelevant
201720 20.8 years healthy to interdental papillae
Ahmed et al, Digital caliper, periodontal probe, study From 18 to 60 years Maxillary anterior dentition with contact Periodontally Gingival biotype
201727 model point healthy
Chander et al, Digital caliper, From 25 to 30 year No record Periodontally Negative result: gingival zenith and the tip
201664 healthy of the interdental papillae has no
proportional ratio
Nichani et al, Periodontal probe, digital photograph From 20 to 25 years Maxillary central teeth Periodontally Crown contour
201623 healthy
Tanwar et al, Periodontal probe(invasive), UNC-15 probe, No record Teeth with normal contact points and need Chronic BC-BP, IRD, facial cementoenamel junction
201613 interproximal ruler periodontal surgical treatment periodontitis
Kinsel et al, No record No record No record No record Crown contour
201537
Malhotra et al, Periodontal probe Mean age: 35 years Maxillary anterior teeth Periodontally Gingival biotype, CL
201465 healthy
Kolte et al, Periodontal probe, digital caliper Mean age: 79 anterior, 52 premolar, and 128 M areas Periodontally BC-CP, IRD
201416 38.2 years healthy
Bindushree et al, Periapical radiographs, digital photograph From 34 to 50 years Maxillary central incisors Periodontally BC-CP, age, BC to facial CEJ, BC to the
201430 healthy proximal CEJ, IRD
Kim et al, 201312 Periapical radiographs, periodontal probe, Mean age: 25.36 Maxillary central incisors Periodontally BC-CP, tooth contour, CP to CEJ, CEJ to
digital caliper ± 7.58 years healthy BC, CA, embrasure space
de Lemos et al, Periodontal probe Mean age: 36 Maxillary central incisors and the papillae Periodontally Gingival biotype
201325 ± 11.14 years between canines and premolars healthy
Montevecchi Periodontal probe, periapical radiographs Mean age: 48 Papillae between maxillary central incisors Periodontally Age, BC-CP, tooth contour
et al, 201117 ± 14 years and lateral incisors healthy
Chow et al, UNC-15 periodontal probe，ultrasonic Mean age: 31.1 Maxillary first premolars, canines and Periodontally Age, tooth contour, ICA, BC-CP,
201019 measuring device, periapical radiographs， ± 11.5 years incisors healthy interproximal gingival thickness
digital caliper
Martegani et al, Periapical radiographs, periodontal probe No record Maxillary central incisors and lateral incisors Periodontally BC-CP, IRD
200766 healthy
Chang et al, Periapical radiographs Mean age: Maxillary central incisors Periodontally Age, BC-CP, IRD
201428 40.8 years healthy

Abbreviations: BC, bone crest; BC-CP, distance from bone crest to contact point; CA, contact area; CEJ, cementoenamel junction; CL, crown length; ICA, interproximal contact area; IRD, interproximal root
distance.
ZHANG ET AL.
ZHANG ET AL.
an inappropriate bracket position, or an increase in the length of the
tooth crown.18
In fact, deficient interdental papillae are caused by multiple fac-
tors, as illustrated by numerous studies. The factors that contributed
to the deficient interdental papillae in each study cited above are sum-
marized in Table 1.
3.3 | Measurement
Because of the complex anatomic structure around interdental papil-
lae, the methods used for precisely measuring papillary height have
often been discussed. Some studies measured the BC-CA distance by
positioning the periodontal probe along the axis of the tooth to the
25
base of the interproximal contact area under anesthesia, while the
gingival thickness has been measured by a UNC 15 probe.1 A hard tis-
sue marker, such as the BC-CA distance and the root distance, can be
measured by radiological examination, and the interdental height can
be measured directly using a Vernier caliper, or indirectly by analyzing
a digital photograph or dental model.15,30,31
Kolte et al32 reported that soft tissue could be accurately mea-
sured on X-ray dental film after marking the tip of an interdental
33
papilla using radiopaque material. Kniha et al tested five types of
radiopaque materials to identify which was the best to mark the inter-
dental papillae. The results showed that a mixture of zinc oxide, euge-
nol cement, and tungsten powder was the most reliable material for a
soft tissue marker. As the measurement methods mentioned above
may be affected by personal factors, intraoral scanning, which is a
reproducible and reliable way to record soft tissue, has recently been
used to solved this problem.34-36 The 3D image could record fixed
and dry soft tissue precisely and could thus be applied to record
changes in interdental papillae.
3.4 | Minimally invasive procedures for interdental
papillae reconstruction
Many studies have focused on finding a minimally invasive and pre-
dictable way to rebuild the esthetic zone. Based on the anatomy of
the interdental papillae, these methods largely focus on reshaping the
interproximal contact area, reducing the BC-CA distance, or increasing
the soft tissue volume.
Reshaping the interproximal contact area aims to make the inter-
proximal space smaller to eliminate deficient interdental papillae.
Composite resin is commonly used to rebuild the interproximal con-
tact area.31 Notably, the shape of the filled resin should be smooth,
without any overhangs, because this may damage the periodontal
tissue.
The tooth contour can also be reshaped by performing crown res-
toration. Kinsel et al37 reported that the black triangle can be mini-
mized by improving the tooth contour. In addition, the interdental
papillae can also be regenerated when the BC-CA distance is
5
decreased during crown restoration. Papalexiou et al38 used an animal
model to verify that the interdental papillae refilled the interproximal
space when the BC-CA distance was controlled to 5 mm by crown
restoration. Yin et al3 adjusted the BC-CA distance through crown
lengthening surgery under the guidance of a three-dimensional print-
ing template and restored the contact area by computer-aided
design/computer-aided manufacturing crowns according to the
Tarnow principle.14 Seven months later, the interdental papillae filled
the open embrasure.
Orthodontic treatment has both advantages and disadvantages
for deficient interdental papillae. As mentioned above, orthodontic
treatment could cause deficient interdental papillae. On the other
hand, deficient interdental papillae can also be reconstructed by
orthodontic treatment: orthodontic treatment can reduce the inter-
proximal space and shorten the root distance by realigning teeth.
When the angle of the adjacent roots is decreased by realigning or
rotating the roots, the transseptal fiber is loosened and fills the open
embrasure, pushing the interdental papillae in the incisal direction.39
If the outcome of orthodontic treatment is unsatisfactory, defi-
cient interdental papillae could also be reconstructed by interproximal
enamel reduction, since interproximal enamel stripping could increase
the interproximal contact area and reshape tooth contour.22 However,
and notably, not every case is suitable for orthodontics. Periodontal
disease usually causes a relatively large open embrasure. If a tooth
must be moved a long distance to close the embrasure through ortho-
dontic treatment, the possibility of alveolar bone resorption increases.
Therefore, combination therapy is better in cases with a large open
embrasure.40
Lasers have been widely used as a painless and minimally invasive
therapy in periodontal tissue regeneration, periodontitis, and peri-
odontal surgery, etc.41 The principle of photobiomodulation (PBM)
therapy involves modulating cell function by using a low-level laser or
light-emitting diodes on biological tissues.42 The mechanism of action
of PBM involves the effect of a low-level laser on mesenchymal stem
cells (MSCs).43 Hemolasertherapy (HLT) is a type of hemotherapy
developed by McGuire et al to regenerate deficient interdental papil-
lae by stimulating gingival blood flow and promoting blood clot forma-
tion in open embrasures.44 After using PBM to stimulate cell
proliferation and differentiation in the blood clot, soft tissue filled the
open embrasure perfectly within the first 14 days of therapy.45
McGuire et al44 proposed that PBM may promote the accumulation
and survival of stem cells that are released from the blood clot. Their
report investigated three cases in whom HLT was used to reconstruct
deficient interdental papillae, with 4 to 5 years' follow-up. The results
suggested that HLT had positive effects.
Hyaluronic acid (HA) is a glycosaminoglycan located in extracellu-
lar tissue in the human body. HA has been widely used as a filler for
facial wrinkles and local depressions. Non-crosslinked and crosslinked
HA have also been used to treat periodontitis and gingival recession,
as well as for periodontal tissue regeneration, depending on the spe-
cific HA properties.46-48 Because the construction and surface of
crosslinked HA allow cell adhesion and proliferation, HA is also used
 6

TABLE 2 Reports on injection of HA to reconstruct deficient interdental papillae

Study, Adverse
year Cases Treated sites HA Injected method Therapeutic effect reaction Duration
Becker 11 patients, average age: 14 treated sites: 4 teeth and Restylane Less than 0.2 mL of HA was 3 implant sites and 1 site None 6-25 months
et al, 55.8 years (range: 10 implants in the injected 2–3 mm coronal adjacent to a tooth reported
201055 25-75 years) maxillary anterior region to the papillary tip. improved 100%,7 sites
improved 94% to 97%, 3
sites improved 76 to 88%,
and 1 site adjacent to
S. Sadat 11 patients, average age: 21 treated sites in the Restylane Less than 0.2 mL of HA was At 6 months, 43% of sites None 6 months
et al, 37.5 years (range: maxillary anterior region injected 2-3 mm coronal showed 50% or more reported
201356 20-75 years) to the papillary tip. improvement.
Awartani 9 patients, average age of 17 treated sites (13 Cross-linked HA gel 0.2 mL of HA was injected At 4 months, 13 sites had Pain or 4-6 months
et al, 36.4 years (rang: maxillary, 4 mandibular) directly into the base of ≥50%reduction in the discomfort
201657 22-55 years) the papilla. black triangle area; at
6 months, 8 and 3 sites
had complete interdental
papillae.
Bertl 21 patients, average age: 21 treated sites between Hyadent Barrier Gel (1 mL of 3 injection sites: in the No differences between the Swelling and 6 months
et al, 30 ± 6.4 years natural teeth, 21 treated the gel contains 16 mg of mucosa immediately test and control groups burning
201660 Test group: n = 11 sites between implants cross-linked Na- above the mucogingival sensation
Control group: n = 10 hyaluronate and 2 mg of junction (0.18 mL),
Na-hyaluronate) attached gingiva/mucosa
immediately below the
base of the deficient
papilla (0.12 mL), and
2-3 mm apically to the tip
of the deficient papilla
(0.06 mL).
Lee et al, 10 patients, average age 43 treated sites in the TEOSYAL PureSense Global 0.01 mL was injected 14 sites improved from 39 None 6 months
201658 32 years maxillary anterior region Action 2-3 mm coronal to the to 96% reported
papillary tip.
Tanwar 1 patient, 24 years old Deficient interdental papillae 0.2% HA Less than 0.2 mL of HA was Deficient interdental papillae None 3 months
et al, in the maxillary anterior injected 2-3 mm coronal were significantly reported
201659 region to the papillary tip. improved

Abbreviation: HA, hyaluronic acid.

ZHANG ET AL.
ZHANG ET AL.
as a biodegradable and biocompatible scaffold, with high biological
activity, in bioengineering.49-54 Since Becker et al55 reported the use
of HA injection to reconstruct a deficient interdental papilla between
single teeth and between a single implant and a natural tooth in 2010,
other case reports have continued to described the effect of HA ther-
apy on interdental papilla reconstruction (Table 2). In most of these
cases,55-59 HA was injected in one site that was 2 to 3 mm apical to
the tip of the interdental papilla, except for the cases that were
reported by Bertl et al.60 In their study, HA injection was conducted
at three sites: 2 to 3 mm apical to the tip of interdental papillae, at the
base of the interdental papillae, and in the nonattached mucosa. The
results of Becker et al55 indicated that the outcome could be
maintained for a range of 6 to 25 months. However, HA injection has
disadvantages: several injections must be performed to increase the
61
volume of deficient interdental papillae. Bertl et al reported two
cases of adverse reactions with swelling and a burning sensation in
the lip after HA injection. These symptoms may have been caused by
HA absorbing water over time and compressing the vessels surround-
ing the filler. In addition, the adverse reaction may have been due to
injection of HA into the nonattached mucosa, immediately beyond
the mucogingival junction.
Since HA or cell injection could not be used to address deficient
interdental papilla cases satisfactorily, Yamada et al62 used a combina-
tion injection that mixed MSCs, platelet-rich plasma (PRP), and HA. As
PRP contains many growth factors, it has been used for periodontal
regeneration for many years. The results showed that for up to
5 years, the interdental papillae maintained a good shape in the inter-
proximal space. In addition, Okabe et al63 utilized HA as a scaffold and
PRP as an activator of MSCs proliferation and differentiation. As a
result, MSCs were shown to have potential to produce type I collagen,
which was the main protein in gingival tissue. Thus, this tissue-
engineering method not only increased the volume of the deficient
interdental papillae, but also promoted soft tissue regeneration, pro-
viding a basis that could support the interdental papillae in the
long term.
4 | C O N CL U S I O N S
Due to the anatomic structure surrounding interdental papillae, it is
difficult to identify one method that can satisfy all requirements in all
cases. Every treatment has advantages and disadvantages. The mini-
mally invasive procedures yield more predictable outcomes and are
more time-effective than surgical procedures. However, the minimally
invasive procedures are sometimes controversial, because they cannot
treat a large area of soft tissue deficiency. This review may assist clini-
cians in identifying the causes of deficient interdental papillae and
thus provide guidance for an appropriate way to resolve the issue, to
improve esthetics.
ACKNOWLEDGEMEN TS
The present study was supported by the Sichuan Province Science
Foundation for Cadres Medical Care, China (grant no. ZH2017-901).
7
CONFLIC T OF INT ER E ST
The authors declare that they have no competing interests. There are
no financial completing interests as we have not received any grants.
The authors alone are responsible for the content and writing of the
paper.
AUTHOR CONTRIBU TIONS
All authors made substantial contributions to the present study. Z. Y.
D. and H. G. contributed to conception and design, acquisition of data,
analysis and interpretation of data, and writing the manuscript. H. G.
also contributed to final approval of manuscript. Z. Y. F. were involved
in data analysis and writing and editing the manuscript. S. K. and
W. H. K. contributed to study design and revised the manuscript
before submission. All authors read and approved the final
manuscript.
DAT A AC CE SSI BILIT Y
All the articles included in the present narrative review are available in
the PubMed.
OR CID
Yiding Zhang https://orcid.org/0000-0002-6999-2007
RE FE RE NCE S
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12. Kim JH, Cho YJ, Lee JY, Kim SJ, Choi JI. An analysis on the factors
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8 ZHANG ET AL.
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18. Kurth JR, Kokich VG. Open gingival embrasures after orthodontic
treatment in adults: prevalence and etiology. Am J Orthod Dentofacial
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19. Chow YC, Eber RM, Tsao YP, Shotwell JL, Wang HL. Factors associ-
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37:719-727.
20. de Santana RB, de Miranda JLC, de Santana CMM. The relationship
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21. Cho HS, Jang HS, Kim DK, et al. The effects of interproximal distance
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the distance from the contact point to the alveolar crest.
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22. Sharma AA, Park JH. Esthetic considerations in interdental papillae:
remediation and regeneration. J Esthet Restor Dent. 2010;22:18-28.
23. Nichani AS, Ahmed AZ, Ranganath V. The shape of the maxillary cen-
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24. Abraham S, Deepak KT, Ambili R, Preeja C, Archana V. Gingival bio-
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25. de Lemos AB, Kahn S, Rodrigues WJ, Barceleiro MO. Influence of
periodontal biotype on the presence of interdental papillae. Gen Dent.
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26. Burke S, Burch JG, Tetz JA. Incidence and size of pretreatment over-
lap and posttreatment gingival embrasure space between maxillary
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27. Ahmed AJ, Nichani AS, Venugopal R. An evaluation of the effect of
periodontal biotype on inter-dental papillae proportions, distances
between facial and palatal papillae in the maxillary anterior dentition.
J Prosthodont. 2018;27:517-522.
28. Chang LC. The association between embrasure morphology and cen-
tral papillae recession: a noninvasive assessment method. Chang Gung
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29. Jeong JS, Lee SY, Chang M. Alterations of papillae dimensions after
orthodontic closure of the maxillary midline diastema: a retrospective
longitudinal study. J Periodontal Implant Sci. 2016;46:197-206.
30. Bindushree AR, Ranganath V, Nichani AS. Evaluation of the associa-
tion between embrasure morphology and central papillae recession
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31. Carnio J, Carnio AT. Papillae reconstruction: interdisciplinary consid-
eration for clinical success. J Esthet Restor Dent. 2018;30:484-491.
32. Kolte RA, Kolte AP, Ghodpage PS. Non-invasive and surgical mea-
surement of length of soft tissue from the tip of interdental papillae
to the alveolar crest. Saudi Dent J. 2013;25:153-157.
33. Kniha K, Mohlhenrich SC, Peters F, et al. Comparison of non-invasive
radiographic measurements of soft tissue in the interdental space: a
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34. Deferm JT, Schreurs R, Baan F, et al. Validation of 3D documentation
of palatal soft tissue shape, color, and irregularity with intraoral scan-
ning. Clin Oral Investig. 2018;22:1303-1309.
35. Lee SP, Kim TI, Kim HK, Shon WJ, Park YS. Discriminant analysis for
the thin periodontal biotype based on the data acquired from three-
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36. Strebel J, Ender A, Paque F, et al. In vivo validation of a three-
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37. Kinsel RP, Pope BI, Capoferri D. A review of the positive influence of
crown contours on soft-tissue esthetics. Compend Contin Ed Dent.
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38. Papalexiou V, Novaes AB Jr, Macedo GO, Luczyszyn SM, Muglia VA.
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39. Kokich VG. Excellence in finishing: modifications for the perio-
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40. Inocencio F, Sandhu HS. Interdental papillae reconstruction combin-
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41. Mizutani K, Aoki A, Coluzzi D, et al. Lasers in minimally invasive peri-
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42. Marques MM, Diniz IM, de Cara SP, et al. Photobiomodulation of
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43. Ginani F, Soares DM, Barreto MP, Barboza CA. Effect of low-level
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44. McGuire MK, Scheyer ET. A randomized, double-blind, placebo-
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46. Takeda K, Sakai N, Shiba H, et al. Characteristics of high-molecular-
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How to cite this article: Zhang Y, Hong G, Zhang Y, Sasaki K,
Wu H. Minimally invasive procedures for deficient interdental
papillae: A review. J Esthet Restor Dent. 2020;1–9. https://doi.
org/10.1111/jerd.12608