The International Journal of Periodontics & Restorative Dentistry

COPYRIGHT © 2004 BY QUINTESSENCE PUBLISHING CO, INC.

PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM
WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 489

The Papilla Presence Index (PPI):

A New System to Assess Interproximal
Papillary Levels

Daniele Cardaropoli, DDS* The presence or absence of the

Stefania Re, MD, DDS* interdental papilla is a topic of great
Giuseppe Corrente, MD, DDS* concern. In cases of papilla absence
with opening of so-called “black tri-
The present article describes a classification system used to assess the interdental angles” or “black spaces,” both
papillary height on natural teeth; the index can also be used in cases of lack of esthetic and functional problems can
contact points and presence of diastemata. This system is particularly useful to develop. Often, the loss of the
define the loss of the interdental papilla because of periodontal disease and papilla is a consequence of peri-
papilla reconstruction after periodontal treatment, particularly if tooth reposition- odontal disease because of gingival
ing is involved. The index, based on esthetic evaluations, measures interproximal inflammation, attachment loss, and
soft tissue height in relation to the CEJ, adjacent teeth, and the point corre-
interproximal bone height resorp-
sponding to the ideal contact point. The four index scores are useful for an easy
tion. Missing papillae can also result
clinical assessment with respect to patient esthetics. (Int J Periodontics
from periodontal surgical therapy,
Restorative Dent 2004;24:488–492.)
as the soft tissues usually contract
during the healing period.
Consequently, soft tissue aug-
mentation techniques have been
developed to restore lost papil-
lae,1–4 but unfortunately no long-
term studies reporting papilla
reconstruction as a predictable pro-
cedure are available. From a bio-
logic point of view, the presence or
absence of the papilla primarily
depends on the distance between
the interdental contact point and
the interproximal crest of bone.5,6
From an anatomic point of view,
*Private Practice, Turin, Italy.
periodontal disease can produce
Correspondence to: Dr Daniele Cardaropoli, c.so Sicilia 51, 10133 Turin, bone resorption, with formation of
Italy. Fax: + 39 011 6611719. e-mail: dacardar@tin.it horizontal defects plus suprabony

Volume 24, Number 5, 2004

COPYRIGHT
COPYRIGHT ©© 2004
2004 BY
BY QUINTESSENCE
QUINTESSENCE PUBLISHING
PUBLISHING CO,
CO, INC.
INC.
PRINTING
PRINTING OF
OF THIS
THIS DOCUMENT
DOCUMENT ISIS RESTRICTED
RESTRICTED TO
TO PERSONAL
PERSONAL USE
USE ONLY.
NO
NO PART
PART OF
OF THIS
THIS ARTICLE
ARTICLE MAY
MAY BE
BE REPRODUCED
REPRODUCED OROR TRANSMITTED
TRANSMITTED ININ ANY FORM
WITHOUT
WITHOUT WRITTEN
WRITTEN PERMISSION
PERMISSION FROM
FROM THE
THE PUBLISHER.
PUBLISHER.
490
pockets, or with the formation of
vertical defects plus infrabony pock-
ets. Both patterns of bone resorp-
tion can lead to a lengthening of
the distance from the bone crest to
the contact point. Moreover, severe
chronic periodontitis is often asso-
ciated with tooth migration and
spaces opening. The formation of a
pathologic diastema, without the
presence of a normal contact point,
creates the presupposing situation
for an apical shift of the papilla.
The development of new
approaches to obtain papilla regen-
eration, such as surgical or nonsur-
gical periodontal techniques and
combined orthodontic-periodontic
treatments,7 should benefit from a
presence index to facilitate commu-
nication between clinicians and stan-
dardize clinical procedures.
Papilla Presence Index
(PPI)
The classification system presented
here is based on the positional rela-
tionship among the papilla, cemen-
toenamel junction (CEJ), and adja-
cent teeth.
• Papilla Presence Index score 1
(PPI 1) is reported when the
papilla is completely present and
coronally extends to the contact
point to completely fill the inter-
proximal embrasure. This papilla
is at the same level as the adja-
cent papillae (Fig 1).
• Papilla Presence Index score 2
(PPI 2) describes a papilla that is
no longer completely present
The International Journal of Periodontics & Restorative Dentistry
COPYRIGHT
COPYRIGHT ©© 2004
2004 BY
BY QUINTESSENCE
PRINTING
PRINTING OF
OF THIS
THIS DOCUMENT
DOCUMENT ISIS RESTRICTED
NO
NO PART
PART OF
OF THIS
THIS ARTICLE
ARTICLE MAY
MAY BE
WITHOUT
WITHOUT WRITTEN
WRITTEN PERMISSION
and lies apical to the contact PPI scores can be adapted to denti-
point. This papilla is not at the tions presenting diastemata (Figs 5
same level as the adjacent papil- to 8), and the classification model
lae, and the embrasure is no may become useful to compare
longer completely filled, but the modifications of papillary levels
interproximal CEJ (iCEJ) is still between baseline and end of treat-
not visible (Fig 2). ment, eg, after orthodontic realign-
• Both PPI 1 and PPI 2 scores can ment.
be complicated by the presence The proposed classification
of buccal gingival recession, clas- index allows for an easy measure-
sified as PPI 1r and PPI 2r. ment of papillary height in all clinical
• Papilla Presence Index score 3 situations and allows comparisons
(PPI 3) refers to the situation in between baseline and posttreat-
which the papilla is moved more ment levels. This index is useful to
apical and the iCEJ becomes vis- allow an easily readable assessment
ible. This situation is compatible of papilla modifications and may
with a great amount of interden- improve communications between
tal soft tissue recession (Fig 3). clinicians.
• Papilla Presence Index score 4
(PPI 4) describes when the papilla
lies apical to both the iCEJ and
buccal CEJ (bCEJ). Interproximal
soft tissue recession is present
together with buccal gingival
recession, and patient esthetics is
dramatically compromised (Fig
4).
This kind of classification, used
for measurements made in a stan-
dard clinical situation with teeth
alignment, can also be used for mea-
surements made on dentitions
showing flaring of the anterior teeth,
spaces opening, and presence of
diastemata. In these situations, be-
cause of the lack of an anatomic
interdental contact point, an ideal
contact point should be assessed on
the interproximal surface and used
as a reference. Moreover, the papil-
lary level should be compared to
that of the adjacent teeth. In this
way, the four previously described
QUINTESSENCE PUBLISHING
PUBLISHING CO,
CO, INC.
INC.
RESTRICTED TO
TO PERSONAL
PERSONAL USE
USE ONLY.
BE REPRODUCED
REPRODUCED OROR TRANSMITTED
TRANSMITTED ININ ANY FORM
PERMISSION FROM
FROM THE
THE PUBLISHER.
PUBLISHER.
 491

Fig 1 (left) Papilla Presence Index score 1

(PPI 1): Papilla is completely present.

Fig 2 (right) Papilla Presence Index

score 2 (PPI 2): Papilla is no longer com-
pletely present, but interproximal CEJ is
not visible.

Fig 3 (left) Papilla Presence Index score 3

(PPI 3): Papilla is no longer completely pre-
sent, and interproximal CEJ is visible.

Fig 4 (right) Papilla Presence Index

score 4 (PPI 4): Papilla is no longer com-
pletely present, and both interproximal
and buccal CEJs are visible.

Volume 24, Number 5, 2004

COPYRIGHT
COPYRIGHT ©© 2004
2004 BY
BY QUINTESSENCE
QUINTESSENCE PUBLISHING
PUBLISHING CO,
CO, INC.
INC.
PRINTING
PRINTING OF
OF THIS
THIS DOCUMENT
DOCUMENT ISIS RESTRICTED
RESTRICTED TO
TO PERSONAL
PERSONAL USE
USE ONLY.
NO
NO PART
PART OF
OF THIS
THIS ARTICLE
ARTICLE MAY
MAY BE
BE REPRODUCED
REPRODUCED OROR TRANSMITTED
TRANSMITTED ININ ANY FORM
WITHOUT
WITHOUT WRITTEN
WRITTEN PERMISSION
PERMISSION FROM
FROM THE
THE PUBLISHER.
PUBLISHER.
492

Fig 5 (left) Papilla Presence Index score 1

(PPI 1) with presence of interdental
diastema.

Fig 6 (right) Papilla Presence Index

score 2 (PPI 2) with presence of interdental
diastema.

Fig 7 (left) Papilla Presence Index score 3

(PPI 3) with presence of interdental
diastema.

Fig 8 (right) Papilla Presence Index

score 4 (PPI 4) with presence of interdental
diastema.

References
1. Shapiro A. Regeneration of interdental
papillae using periodic curettage. Int J
Periodontics Restorative Dent 1985;5(5):
27–33.
2. Beagle JR. Surgical reconstruction of the
interdental papilla. Case report. Int J
Periodontics Restorative Dent 1992;12:
145–151.
3. Han TJ, Takei HH. Progress in gingival
papilla reconstruction. Periodontol 2000
1996;11:65–68.
4. Azzi R, Etienne D, Carranza F. Surgical
reconstruction of the interdental papilla.
Int J Periodontics Restorative Dent
1998;18:467–474.
5. Tarnow DP, Magner AW, Fletcher P. The
effect of the distance from the contact
point to the crest of bone on the presence
or absence of the interproximal papilla. J
Periodontol 1992;63:995–996.
6. Nordland WP, Tarnow DP. A classification
system for loss of papillary height. J
Periodontol 1998;69:1124–1126.
7. Re S, Corrente G, Abundo R, Cardaropoli
D. The use of orthodontic intrusive move-
ment to reduce infrabony pockets in adult
periodontal patients: A case report. Int J
Periodontics Restorative Dent 2002;22:
365–371.

The International Journal of Periodontics & Restorative Dentistry

COPYRIGHT
COPYRIGHT ©© 2004
2004 BY
BY QUINTESSENCE
QUINTESSENCE PUBLISHING
PUBLISHING CO,
CO, INC.
INC.
PRINTING
PRINTING OF
OF THIS
THIS DOCUMENT
DOCUMENT ISIS RESTRICTED
RESTRICTED TO
TO PERSONAL
PERSONAL USE
USE ONLY.
NO
NO PART
PART OF
OF THIS
THIS ARTICLE
ARTICLE MAY
MAY BE
BE REPRODUCED
REPRODUCED OROR TRANSMITTED
TRANSMITTED ININ ANY FORM
WITHOUT
WITHOUT WRITTEN
WRITTEN PERMISSION
PERMISSION FROM
FROM THE
THE PUBLISHER.
PUBLISHER.