Received: 1 November 2022 | Revised: 6 February 2023 | Accepted: 24 February 2023

DOI: 10.1002/cre2.728

ORIGINAL ARTICLE

Factors impacting the height of the interproximal papilla:

A cross‐sectional study

Hamdane Khaireddine1,2 | Tlili Mohamed1,2 | Rmida Arij1,2 | Khanfir Faten1,2 |

Ben Amor Faten1,2

1
Research Laboratory in Oral Health and Oral‐
facial Rehabilitation, Faculty of Dentistry of Abstract
Monastir, University of Monastir, Monastir,
Objectives: To determine the relationship between different parameters (age,
Tunisia
2
Outpatients Department of Monastir, Dental
periodontal phenotype, contact point height, and crown shape) and the height of the
University clinic of Monastir, Monastir, Tunisia interproximal papilla around the teeth of/in the maxillary anterior sector.
Material and Methods: A total of 45 subjects were involved in this study, with 315
Correspondence
Hamdane Khaireddine, Research Laboratory in interproximal papillae of the maxillary anterior sector. The interproximal papillae
Oral Health and Oral‐facial Rehabilitation, were clinically classified according to the Norland and Tarnow classification. The
Faculty of Dentistry of Monastir, University of
Monastir, LR12ES11, Monastir 5019, Tunisia. periodontal phenotype was assessed by periodontal probe transparency through
Email: Khaireddine.hamdane@gmail.com the marginal gingiva. The height of the papilla, the height of the contact points,

Funding information and the width/length ratio of the crown were also measured using the periodontal
None probe. The relationship between the variables was studied using Pearson's
correlation. Statistical significance was set at a value of p < .05.
Results: A positive correlation was found between age and the papilla score.
However, a negative correlation was noted between age and papilla height, with
statistically significant values. A negative correlation was found between the papilla
score and the rest of the studied clinical parameters. However, this correlation was
not found with regard to the height of the papilla with the same parameters, except
for the height of the contact points.
Conclusions: A statistically significant relationship was noted between the
appearance of the interproximal papillae and all the parameters studied.

KEYWORDS
crown shape, interproximal papilla, papilla height, periodontal phenotype

1 | INTRODUCTION a black triangle, creating functional problems during phonation and

biological problems due to the retention of bacterial plaque.
Dentists are currently faced with esthetic standards requiring a For modern dentistry respecting the esthetic imperatives, the
perfect balance between the pink of the gums and the white of the interproximal papilla should be taken into account during the various
teeth. An incomplete interproximal papilla leads to the appearance of restorative and surgical therapeutics. Fundamental knowledge of the

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

Clin Exp Dent Res. 2023;9:449–454. wileyonlinelibrary.com/journal/cre2 | 449


450 | KHAIREDDINE
different factors influencing the presence of this papilla is therefore
necessary to respect its integrity.
Several authors have proposed different classification systems to
assess the degree of papillary height loss. In 1997, Jemt et al. created a
classification to evaluate the volume of interproximal papillae adjacent
to single implant‐supported prostheses. Their objective was to provide a
clinical assessment of the degree of recession and regeneration of the
papillae adjacent to the restoration compared to that of the adjacent
teeth. This index includes five different scores, ranging from total
absence of the papilla to papilla hypertrophy (Jemt, 1997).
The following year, Norland and Tarnow proposed to classify the
papillae into four classes based on three anatomical reference points:
the contact point, the interproximal cementoenamel junction, and the
facial cementoenamel junction. These authors excluded hypertrophic
papilla to focus on papillary recession (Nordland & Tarnow, 1998).
In 2004, Cardaropoli et al. introduced an index evaluating the
papillary height in relation to the contact point and the cementoe-
namel junction. It is the papillary presence index. This index allows
estimating the height of the interproximal papilla even in the case of
diastema. Follow‐up can therefore be undertaken during orthodontic
treatment (Cardaropoli et al., 2004).
Many factors influencing the presence of the interproximal
papilla have been studied. The distance between the base of the
contact point and the top of the bony ridge is the best‐known factor,
as it has been extensively documented by Tarnow et al. (1992) The
majority of the studies on this parameter concluded that when the
distance between the contact point and the bony ridge is less than or
equal to 5 mm, the interproximal papilla is present in almost all cases.
However, when the distance is greater than 7 mm, it is usually absent
(Cho et al., 2006; Choquet et al., 2001; A. P. Kolte et al., 2014; de
Lemos et al., 2013; Roccuzzo et al., 2018; Tarnow et al., 1992; Wu
et al., 2003).
The impact of the clinical parameters on the presence of the
interproximal papilla has been less studied in the literature compared
to that of the radiological parameters (Chang, 2007; Chen et al., 2009;
Chow et al., 2010; Fischer et al., 2014; Joshi et al., 2017; A. Kolte
et al., 2016). In a study including 96 subjects, Cho et al. investigated
the influence of different clinical parameters (crown shape, contact
point height, periodontal phenotype) on the presence of inter-
proximal papilla (Chow et al., 2010).
Kolt et al. studied the influence of both the crown shape and the
interproximal space on the presence of the papilla. They reported a
strong correlation between these two parameters (A. Kolte
et al., 2016).
Joshi et al. also studied the impact of certain clinical and
radiological parameters on papilla height. They concluded that the
appearance of the papilla is significantly associated with the tooth
shape, crestal bone height, gingival thickness, and gingival angle
(Joshi et al., 2017).
Given the lack of data on a possible relationship between certain
clinical parameters and interproximal papillae and given the impor-
tance of the presence of such parameters in terms of esthetics and
function, this study proposed to determine the relationship between
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ET AL.
these parameters (age, periodontal phenotype, contact point height,
crown shape) and interproximal papilla height in maxillary anterior
teeth. The null hypothesis is that the presence of interproximal
papilla is not directly impacted by age (1), periodontal phenotype (2),
contact point height (3), and dental crown shape (crown width/length
ratio) (4).
2 | M A T E R I A L S AN D M E T H O D S
The subjects examined for this study were recruited from the
outpatient department at the University Dental Clinic of Monastir,
Tunisia. The sample included patients, interns, dental residents, and
staff of the above‐mentioned clinic.
The subjects included were adults (over 18 years of age) in good
general health with intact anterior dentition (presence of teeth
14−24). They had no pathologies or medication influencing the
periodontium, periodontitis, or history of periodontitis. Subjects with
any of the following criteria were excluded from the study: gingival
hypertrophy, previous or undergoing orthodontic treatment, diaste-
mas, caries or proximal restorations, and signs of high attrition of the
incisal edges.
The interview and all clinical assessments were performed by
one calibrated examiner. For calibration before the study, the
examiner performed repeated measurements of five subjects.
The interproximal papillae were clinically classified according to
the Norland and Tarnow classification (Figure 1), with a score ranging
from 0 to 3:
– Score 0: The interproximal papilla occupies the entire embrasure
up to the most apical point of the contact point or surface.
– Score 1: The top of the papilla is located between the contact
point and the most coronal point of the interproximal enamel‐
cement junction (ECJ).
– Score 2: The apex of the papilla is located at or apical to the
interproximal ECJ but coronal to the most apical point of the
facial ECJ.
– Score 3: The papilla is located at the same level or apically to the
most apical point of the facial ECJ.
The periodontal phenotype was assessed by the transparency of
the periodontal probe (CPU 15 UNC; Hu‐Friedys) through the
marginal gingiva and was classified as thick periodontium or thin
periodontium (Malpartida‐Carrillo et al., 2021; De Rouck et al., 2009).
A score of 0 was assigned for the thin periodontal phenotype and a
score of 1 for the thick phenotype.
The height of the measured papilla represents the distance from
the apex of the papilla to the line joining the gingival zeniths of the
two adjacent teeth.
The width‐to‐length ratio of the teeth bordering the papilla was
measured by considering the length as the distance between the
incisal edge or cuspidian tip and the gingival zenith. For width, it was
measured at the incisal/middle third junction of the crown (Figure 2).

KHAIREDDINE ET AL.
F I G U R E 1 The different classes of papillae according to the classification of Norland and Tarnow. (a) Papilla between 11 and 21: Class 0; (b)
papilla between 11 and 21: Class 1; (c) papilla between 11 and 21: Class 2; (d) papilla between 41 and 31: Class 3.
FIGURE 2 Illustration of the different clinical measurements
performed.
Data were analyzed using the Statistical Package for Social
Science (IBM Corp. Released 2021; IBM SPSS Statistics for
Windows; Version 26.0.: IBM Corp.). The relationship between the
different parameters (age, periodontal phenotype, contact point
height, and crown shape) and PSs/heights (papilla scores and height)
was studied using Pearson's correlation. A negative value (negative
correlation) is indicated when a clinical variable increases and the
papillary height or papillary score decreases; however, a positive
value (positive correlation) indicates that the two variables vary
together in the same direction. Statistical significance was set at a
value of p < .05.
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| 451
T A B L E 1 Demographic characteristics and the mean height of
the interproximal papilla of the study population.
Age, mean ± SD (range), year 29.75 ± 6.79 (23−49)
Sex, n (%)
Male 21/45 (46)
Female 24/45 (54)
Papilla height, mean 3.3
Note: The height of the papilla is expressed in mm.
3 | RESULTS
Subject recruitment was performed between February and June
2022. The demographic characteristics are summarized in Table 1. A
total of 45 subjects were included in the study out of 82 examined
with a total of 315 interproximal papillae. They were from a Tunisian
population. The subjects' average age was 29.75 years (±6.79; range
23−49). They all had good oral hygiene, with no evidence of active
periodontal disease or history of periodontal disease. The frequencies
of the different interproximal PSs are summarized in Table 2. The
most frequent score according to the Norland and Tarnow
classification was score 0, with the papilla completely occupying
the interproximal space. No score higher than 2 was noted.
The distribution of recessions (score greater than or equal to 1)
according to location is summarized in Table 3. The highest
prevalence was noted at the inter‐incisal papilla.
Pearson's correlations between the interproximal papilla mea-
surements and the different clinical parameters are summarized
in Table 4.
 20574347, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/cre2.728 by Honduras HINARI REGIONAL, Wiley Online Library on [12/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
452 | KHAIREDDINE ET AL.

TABLE 2 Frequency of the different scores. assessed to study the impact of certain factors on their presence. A

Papilla score Score 0 Score 1 Score 2 Score 3 statistically positive relationship was found between inter‐incisal
papilla recession and age, and a statistically negative relationship was
Percentages 78.4 20.6 1 0
found between age and papilla height in all the study groups
Note: The different scores were assigned according to the classification of (Chang, 2007).
Norland and Tarnow.
In another study by Chow et al. investigating the impact of some
parameters on the interproximal papilla, 96 subjects were divided
T A B L E 3 Frequency of the different scores according to the into three age groups: <35 years (74 subjects), 35−49 years (11
location of the interproximal papilla. subjects), and >50 years (11 subjects). Regardless of the interproximal
Score 0 Score 1 Score 2 Score 3 site, the older group was found to have a higher incidence of papillary

11−21 60% 40% 0% 0% recession compared to the younger group (Chow et al., 2010).
Similar to periodontal disease, aging is not directly related to the
11−12 66% 26% 7% 0%
loss of attachment at the interproximal papillae. However, the
12−13 73% 27% 0% 0% accumulation of certain factors over time can lead to recessions at
13−14 95% 5% 0% 0% this level. Age, therefore, increases the risk of recession.
It was found that a negative correlation exists between the rest
21−22 73% 27% 0% 0%
of the clinical parameters studied (contact point height, periodontal
22−23 80% 20% 0% 0%
phenotype, and width/height ratio of mesial and distal dental crowns)
23−24 100% 0% 0% 0% and the appearance of the interproximal papilla. The three null
Note: The different scores were assigned according to the classification of hypotheses were therefore rejected.
Norland and Tarnow. These results are in agreement with those reported in the
literature.
In 2009, Chen et al. analyzed the impact of certain factors on the
T A B L E 4 Pearson's correlation between interproximal papilla complete presence of interproximal papillae in a study including 102
measurements and different clinical parameters. interproximal sites at the anterosuperior sectors. They concluded
W/H that the thickness of the keratinized tissue is the main factor
Age HCP PP Mesial Distal affecting the height of the interproximal papilla (Chen et al., 2009).
PS 0.324*** −0.291*** −0.196*** −0.276*** −0.434*** In the previously cited study conducted by Chow et al., the authors
HP −0.163** −0.142** 0.39 −0.064 −0.119 concluded that papilla appearance is significantly associated with the
subject's age, tooth shape, interproximal contact length, alveolar bone
Note: “*“ indicates statistical significance: *p ≈ .05; **p < .05; ***p < .001.
height, and interproximal gingival thickness (Chow et al., 2010).
Abbreviations: HCP, height of contact points; HP, height of the papilla;
PP, periodontal phenotype; PS, papilla score; W/H, width/height of the In a more recent study by Joshi et al., 150 interproximal papillae in 30
crown. patients were evaluated using clinical and study models to investigate the
correlation with certain factors. The appearance of interproximal papillae
was reported to be significantly associated with tooth shape, alveolar
A positive correlation was found between age and papilla score bone height, and gingival thickness (Joshi et al., 2017).
and a negative correlation between age and papilla height, with However, some of these parameters (periodontal phenotype and
statistically significant values (p < .5). With age, the papilla score dental crown width/length ratio) are only significantly correlated with
increased and the papilla height decreased. PSs and not with papilla height. The fact that a thicker periodontal
A negative correlation with statistically significant values was phenotype is not correlated with higher papillary height seems to be
found between the papilla score and the rest of the clinical quite consistent. This type of periodontium has less scalloped gingiva
parameters studied (contact point height, periodontal phenotype, with shorter papillae, which counterbalances the lower prevalence of
and width/height ratio of mesial and distal dental crowns). However, attachment loss at this level. Similarly, for the width/length ratio of
this correlation was not found for the height of the papilla with the dental crowns, a square‐shaped crown is associated with a lower
same parameters, except for the height of the contact points. interproximal papilla compared to an oval‐shaped crown (Figure 3).
In addition to the parameters already mentioned, a positive
correlation between the height of the interproximal papilla and the
4 | DISC US SION gingival angle is reported in the literature. This angle is formed by
the intersection of the two lines joining the most coronal points of
In the present study, a correlation was noted between papilla the interproximal papillae to the gingival zenith. This angle is used
appearance and age. The first null hypothesis was therefore rejected. with the papillae height to assess the gingival contour (Joshi
These results are in agreement with those found in the literature. et al., 2017). A positive correlation is also reported between papilla
In a study by Chang et al., 330 inter‐incisor papillae were visually height and interdental width (Chen et al., 2009; A. Kolte et al., 2016).

KHAIREDDINE ET AL.
F I G U R E 3 Different periodontal phenotypes and coronal morphologies: the photograph on the right represents a thin phenotype with an
oval crown and that on the left represents a thick periodontal phenotype with a square coronal shape. We notice the whitening of the
gingiva following the insertion of the periodontal probe in the thick periodontal phenotype.
The results of this work showed that the interproximal papilla is an
anatomical structure, which, under certain constraints and under the
influence of certain factors, can lose its height and give the appearance of
an unsightly black triangle which can be badly experienced by the patient.
These results are consistent with some findings reported in the literature
and are inconsistent with others with regard to the influence of certain
factors on the papilla. However, to date, no systematic review or meta‐
analysis has been conducted to discuss this topic and confirm the
influence of these factors. This research could therefore contribute to the
elaboration of a study with a higher level of scientific evidence. In
addition, the significant correlation found in this work between the
appearance of the papilla and some predisposing factors (periodontal
phenotype, shape of the crown, and height of the contact points) allows
us to better understand, to manipulate these parameters for preventive
purposes, or to manage the loss of interproximal attachments. Indeed,
mucogingival surgery can be performed to thicken the keratinized tissues
in case of a thin periodontal phenotype. Prosthetic design and restorative
dentistry can modify the shape of the crown and the height of the
contact points to obtain an environment favorable to the stability or
regeneration of the interproximal papilla.
In the subjects examined in the present study, the papillae with a
score of 2 or 3 were almost absent (1% of the papillae for score 2 and
0% for score 3), which can be explained by the strict exclusion criteria
applied in this study (Table 2). These criteria included the presence of
active periodontal disease or a history of periodontal disease, which
is the primary cause of loss of attachment in interproximal papillae.
The results of this study also showed that inter‐incisal papillae
had the highest prevalence of recessions, with 40% of the papillae
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| 453
affected by recessions (Table 3). This can be explained by the
presence of a maxillary labial frenulum at this level, which can present
a low insertion favoring plaque accumulation and loss of attachment.
The present study presents some limitations. The method applied
to measure distances (height of papillae, height of contact points, and
crown width/height ratio) may be imprecise due to the limited
graduations of the periodontal probes. In addition, the measurements
were not taken from flat surfaces. They were taken from three‐
dimensional structures with convexities and concavities, which may
have distorted the reading of the results on the periodontal probe.
Similarly, the method used to evaluate the thickness of the
keratinized gingiva is another limitation despite its simplicity and ease
of reproducibility. Indeed, the reported results are thin or thick
periodontium. Other methods, such as ultrasound, have been used in
the literature to measure soft tissue thickness (Müller et al., 2000).
Future studies should therefore include standardized, simple, and
reproducible measurement methods with a larger study population. The
latter should include several ethnicities to assess and take into account
interethnic differences in the interpretation of the results. Studies with a
higher level of scientific evidence (systematic reviews and meta‐analyses)
should therefore be conducted to confirm or contradict these results.
5 | CONCLUSION
In the present study, a statistically significant relationship between
the appearance of interproximal papillae and various parameters (age,
periodontal phenotype, height of contact points, and shape of the

454 | KHAIREDDINE
crown) was found. Understanding these different factors is essential
to prevent and manage tissue loss in the papillae to obtain optimal
esthetic results from the various therapies performed.
A U T H O R C O N TR I B U T I O N S
Dr Hamdane Khaireddine and Pr Ben Amor Faten conceived of the
presented idea. Dr Hamdane Khaireddine, Dr Tlili Mohamed, and
Doctor Rmida Arij developed the analytic methods. Dr Khanfir Faten
and Pr Ben Amor Faten verified the analytic methods. Dr Khaireddine
Hamdane has carried out the interview and all clinical assessments.
Dr Tlili Mohamed took the photographs. All authors discussed the
results and contributed to the final manuscript.
A C KN O W L E D G M E N T S
The authors would like to thank Prof. Boukattaya Samir, English language
professor at the Faculty of Dental Medicine of Monastir for checking and
correcting English and all of the study participants, including the
outpatient staff and patients who volunteered their time for this work.
CO NFL I CT OF INTERES T S T ATEME NT
The authors declare no conflict of interest.
D A TA A V A I L A B I L I T Y S T A T E M E N T
Data that support the findings of this study are available on request
from the corresponding author. The data are not publicly available
due to privacy.
ORCID
Hamdane Khaireddine http://orcid.org/0000-0002-5178-3266
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How to cite this article: Khaireddine, H., Mohamed, T., Arij, R.,
Faten, K., & Faten, B. A. (2023). Factors impacting the height
of the interproximal papilla: A cross‐sectional study. Clinical
and Experimental Dental Research, 9, 449–454.
https://doi.org/10.1002/cre2.728