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Black Triangles Causes and Management: A Review of Literature


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Open gingival embrasures often pose complex functional and esthetic problems. Management of open embrasures requires careful evaluation of the underlying causes. A team approach comprising of general dentist, an orthodontist, and a periodontist is critical. The authors reviewed a total of 51 articles including review of the literature using the terms ‘black triangle’; ‘open gingival embrasure’; ‘interdental papilla’ and interproximal contact area’. These articles provided information regarding etiology, diagnosis, and management of black triangles. There are several risk factors leading to the development of black triangles. These factors include periodontal disease, loss of height of the alveolar bone relative to the interproximal contact, length of embrasure area, root angulations, interproximal contact position, triangular-shaped crowns and aging. Treatment of black triangles often requires an interdisciplinary approach, involving of periodontal; orthodontic and restorative treatment. - See more at:
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British Journal of Applied Science & Technology
6(1): 1-7, 2015, Article no.BJAST.2015.061
ISSN: 2231-0843
SCIENCEDOMAIN international
Black Triangles Causes and Management: A Review
of Literature
B. K. Al-Zarea
, M. G. Sghaireen
, W. M. Alomari
, H. Bheran
and I. Taher
Faculty of Dentistry, Aljouf University, Sakaka-Aljouf, Saudi Arabia.
Department of Prosthetic Dentistry, Faculty of Dentistry, Aljouf University, Saka-Aljouf, Saudi Arabia.
Faculty of Dentistry, Jordan University of Science and Technology, Irbid, Jordan.
Department of Dentistry,
Ministry of Health, Aljouf, Saudi Arabia.
Faculty of Medicine, Aljouf University, Sakaka-aljouf, Saudi Arabia.
Authors’ contributions
This work was carried out in collaboration between all authors. Author BKA designed the study,
performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript and
managed literature searches. Authors MGS, WMA, HB, IT managed the analyses of the study and
literature searches. All authors read and approved the final manuscript.
Article Information
DOI: 10.9734/BJAST/2015/11287
(1) A.A. Hanafi-Bojd, Department of Medical Entomology & Vector Control, School of Public Health, Tehran University of
Medical Sciences, Iran.
Wetende Andrew, Department of Periodontology and Community dentistry, School of Dental Sciences, University of Nairobi,
Nairobi, Kenya.
Angelo Troedhan, Faculty of Dentistry, Health Science University Vientiane, Laos; Center for Facial Aesthetics Vienna,
Complete Peer review History:
Received 8
May 2014
Accepted 1
November 2014
Published 15
December 2014
Open gingival embrasures often pose complex functional and esthetic problems. Management of
open embrasures requires careful evaluation of the underlying causes. A team approach comprising
of general dentist, an orthodontist, and a periodontist is critical. The authors reviewed a total of 51
articles including review of the literature using the terms ‘black triangle’; ‘open gingival embrasure’;
‘interdental papilla’ and interproximal contact area’. These articles provided information regarding
etiology, diagnosis, and management of black triangles. There are several risk factors leading to the
development of black triangles. These factors include periodontal disease, loss of height of the
alveolar bone relative to the interproximal contact, length of embrasure area, root angulations,
interproximal contact position, triangular-shaped crowns and aging. Treatment of black triangles
often requires an interdisciplinary approach, involving of periodontal; orthodontic and restorative
Review Article
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
Keywords: Aesthetic; black triangles and interproximal contact areas.
The field of aesthetic dentistry is governed by
rules and values, and should be studied from
both subjective and objective point of view.
Perception varies between individuals and is
controlled by social background and personal
experience [1]. Aesthetics has been studied from
different perspectives.
Aesthetic has been studied from different
perspective to obtain an esthetically pleasing
smile; many components should be in harmony
and symmetry. These include gingival display;
lips contour and outline; and tooth shape; color;
size; and position [2]. Consequently, open
gingival embrasures or black triangles are
complex aesthetic and functional problems that
are noticeably unaesthetic and negatively affect
smile (Fig. 1). Open gingival embrasures “black
triangles” are defined as the embrasures cervical
to the interproximal contact that is not filled by
gingival tissues [3] (Fig. 1). Consequently, Open
gingival embrasures or black triangles are
complex aesthetic and functional problems.
Among these problems is that they are
noticeably unaesthetic which negatively affects
the smile, facilitate retention of food debris which
can negatively affect the health of the
periodontium [2]. Black triangles are present in
more than one third of all adults but are more
frequent in adult patients who suffer bone loss
[4]. Treatment plan should be discussed with
patients before starting dental treatment [3,5].
Fig. 1. Open gingival embrasures or black
Amongst the main objectives of restorative and
orthodontic treatment is preserving papilla and
avoiding black triangles in the esthetic zone. The
etiology of open embrasures is known to be
multifactorial. Etiological factors include aging,
periodontal disease, loss of height of the alveolar
bone relative to the interproximal contact,
length of embrasure area, root angulations,
interproximal contact position, and triangular-
shaped crowns. Its management varies
depending on the etiological factor, but is
favorably managed by a team work usually
including restorative, orthodontic and periodontic
treatment. In certain cases correction of these
open embrasures is not straightforward and may
increase both the complexity and duration of
treatment. Sometimes, the decision to close the
embrasures or not is difficult especially when the
open embrasures are small.
Several studies have investigated the impact of
open gingival embrasures. Kokich et al. [5] found
that orthodontists considered a 2 mm open
gingival embrasure as noticeably less attractive
than an ideal smile with normal gingival
embrasure. Open gingival embrasures slightly
greater than 3 mm were considered less
attractive by both general dentists and the
general population. Cunliffe [6] found that
interdental "black triangles" were rated as the
third most disliked aesthetic problem below
caries and crown margins.
In this review, the authors highlighted the
important etiological factors that predispose to
the occurrence of the black triangles. In addition
to the common biological factors, dimensional
changes of papilla during orthodontic alignment,
the relevant consequences of periodontal
disease treatment and iatrogenic treatment
mishaps such as poor veneers and crowns are
factors have also been discussed as factors that
may lead to black triangles.
Prevalence and Patient Attitude
One third of adults have unaesthetic black
triangles [5]. Other studies found that black
triangles were found in 67% of the population
over 20 years of age compared with 18% in the
population under 20 years of age [3,7,8,9]. A
recent study of patient attitudes found patient
dissatisfaction with black triangles to rank quite
high among aesthetic defects, ranking third
following carious lesions and dark crown margins
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
2.1 Black Triangles and Periodontal
Tarnow’s study [4] has become a standard in
calculation of crestal bone to contact area
distance when predicting the stable papilla
height. His study, based on 288 patients, showed
that when the contact point was within 5.0 mm of
the crestal bone, the papilla was present in 100%
of samples. However, when the distance was 7.0
mm, the papilla was present in only 27% of
samples (Table 1) [4]. Moreover, pocket depths
greater than 3 mm will lead to increased plaque
retention, inflammation, and possibly gingival
recession [7]. Wu YJ also found that a distance
of 5, 6, and 7 mm resulted in an open embrasure
in 2, 44, and 73% of the cases respectively [10].
These observations indicates that papilla was
present in almost 100% of the cases if the
distance from the alveolar crest to the contact
point was 5 mm or less. When the distance was
more than 7 mm, most patients had an open
gingival embrasure. Another study by Zetuhas
reported similar results [7].
Table 1. Adopted from Tarnow et al. 1992 [4]
Bone-contact distance (mm)
% Full papilla
3 100
4 100
5 98
6 56
7 27
8 10
9 25
10 0
For those with periodontal diseases, it is the
bone loss that increases the distance between
the contact points and alveolar crest and
eventually creates open gingival embrasures.
Tarnow’s 5.0 mm rule might be skewed in a
favorable or unfavorable direction because there
are many factors that determine the presence of
black triangles such as the root angulations,
teeth shape, occlusion and previous trauma. For
square-shaped teeth with wide contact points,
the chances of 'black triangles' is minimal
compared with triangular teeth having narrow,
more incisally positioned contact points.
Furthermore, the degree of interproximal fill is
also dependent on the periodontal biotype. A
thick periodontal biotype encourages interdental
fill, while a thinner tissue type creates un-
aesthetic hollow gingival embrasures [8].
Interdental width seems to be critical in papilla
presence. An increased interdental space results
in wide papillae base that may be helpful in
increasing blood supply to the papilla tip.
However, too wide of an interdental distance can
be detrimental, stretching and blunting the tip of
the papillae and increasing the likelihood of the
black triangle [9]. An extreme form of this is the
absolute loss of papilla in periodontal disease
that has been associated with loss of the
interdental papilla because of alveolar bone loss.
Chronic periodontitis and tooth brush trauma are
other factors that may cause open embrasures.
If interproximal tooth brushing is causing gingival
recession, and loss of interdental papilla, it
should be discontinued until the tissue recover
[11,12]. Plaque accumulation and gingivitis are
probably higher in people with crowding, but host
susceptibility and other factors may also play a
contributory role in the occurrence of open
gingival embrasures, especially in patients who
have been previously treated for periodontal
disease [11]. Such patients need to increase
their efforts to enhance periodontal maintenance
and oral hygiene to avoid further bone loss and
recession. The interdental papilla is a small
fragile area with minor blood supply which seems
to be the major limiting factor in all surgical
reconstructive and augmentation techniques [10].
Most surgical techniques published involve
gingival grafting, but show only limited success
because of insufficient blood supply [10,11].
However, some case studies have reported
some degree of success with the combination of
sub-epithelial connective tissue grafts and
orthodontic therapy [13,14]. A large number of
techniques have been proposed to reconstruct
the interdental tissues including a pedicle flap
[15]; semilunar coronally repositioned flap
envelop type flap [18]
osseous and connective tissue grafts [19] and
microsurgery. However, pedicle flaps have
provided better results than free gingival grafts
as reported by WuYJ. [10]
2.2 Black Triangle and Orthodontic
Tooth morphology determines two aspects of
gingival undulations. Firstly, the basic tooth
forms: circular; square or triangular; determine
the degree of gingival scallop. Circular (oval) or
square teeth produce a shallower gingival
scallop, while triangular teeth form the opposite
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
as pronounced scallop. The latter predisposes to
the black triangles especially with a thin biotype
which has a propensity for recession [5].
Furthermore, root divergence of adjacent teeth
either occurs naturally or as a result of improper
orthodontic treatment [20], triangular-shaped
incisor crowns [21] long and narrow teeth [22]
are all etiological factors for black triangles.
Treatment should be designed to create
parallelism of the roots and a favorable position
of the proximal contact point of the crowns. In
cases where incisors are malposed or
overlapping they should be up-righted and
moved mesially to correct the inclination of the
roots. The mesial cementum enamel junctions of
each incisor will then be closer to each other’s
causing the stretched transeptal fibers to relax.
The same soft tissue will fill in the gingival
embrasure, which has been narrower [23].
Kurth et al. [20] noticed that a mean root
angulation of 3.65° in normal gingival
embrasures and an increase in root divergence
by increased the probability of occurrence of
an open gingival embrasure from 14 to 21%.
Bracket repositioning can be performed to
converge maxillary incisor roots to reduce or
eliminate the open gingival embrasures as
paralleling divergent roots decreases the severity
of a black triangle. During orthodontic treatment
bracket’s slots should be bonded perpendicular
with the long access of the tooth and not to the
incisal edge. If brackets placement is done based
on incisal edges, greater root divergence may
result causing an open gingival embrasure [10].
In case where the crowns are triangular,
interproximal reduction (IPR) of enamel between
the triangular crowns will broaden the contact
area and also move it gingivally leading to
reduced open gingival embrasures. Typically,
0.5-0.75 mm of enamel is removed with IPR for
correction of black triangles [10].
The severity of crowding does not influence the
incidence of open embrasures as they were
found to occur in a similar percentage in patients
with incisor crowding of less than 4 mm and
those with 4-8 mm of incisor crowding. It was
found that when the crowding was more than 8
mm, the occurrence of black triangles increased
by only 7% [20]. However, these results were not
statistically significant. It was also found that the
orthodontic treatment duration did not have any
significant effect on the occurrence of open
gingival embrasures [3].
2.3 Black Triangle and Restorative
Natural interproximal embrasures are
constructed with a wide range of cervical shapes
and varying root proximities. The gingival usually
adapts to a wide range of teeth cervical area
shapes. Clinicians can create convenient
interproximal shapes if the restorations are
smooth and without sharp margina ledge.
Composite, porcelain laminate veneers; pink
auto-cure and heat-cured acrylics, resins and
thermoplastic acrylics, as well as silicone-based
soft materials [24,25,26] are all treatment
modalities for closure of open gingival embrasure
space. Composite and porcelain laminate resin
can be extended into the gingival sulcus,
however, care must be taken not to impinge on
the interdental tissue or violate the biological
width [24].
Clark presented a feature case of management
of open gingival spaces that includes restorative
treatment followed by papilla regeneration [25].
He used flowable composite resin rather than
composite paste for the first increment since
paste composite would be nearly impossible to
place in such “claustrophobic” area without voids
and without disturbing the anatomically shaped
matrices (Figs. 2a and 2b). In an attempt to
reduce the interproximal space and improve
esthetics and phonetics Barzilay [26] used two
types of removable prosthesis; Molloplast B soft
lining material and clear acrylic facing (Fig. 3).
However, his type of prosthesis suffers from few
limitations. Retention may be difficult, and
because of the inherent porosity of the silicone-
based material, staining and plaque
accumulation may be a problem. Therefore, it
would be better if it is made of heat-curd acrylic
resin (Figs. 4a and 4b). Retention can be further
enhanced by providing implant supported
prosthesis when space is available.
Porcelain veneers are considered an excellent
choice to eliminate or reduce the black triangle.
Nevertheless, care must be taken when planning
for anterior crowns or veneers in order to
avoid occurrences of black triangles.
This complication can be avoided by proper
planning and pre-operative periapical X-rays to
carefully assess the level of the alveolar crest
bone. The interproximal contact area can be
extended apically to compensate for some bone
resorption, and the contact area should be
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
Fig. 2a. Before treatment
Fig. 2b. After treatment with flowable
Fig. 3. Molloplast B soft lining material and
clear acrylic facing
placed at a point within 5.0 mm of the crestal
bone as stated by Tarnow [4].
In a complete denture wearer, knowledge of the
ideal papilla location for optimal aesthetics
originated from classic literature on prosthetic
tooth selection and arrangement. Frush and
Fisher [27] attempted to establish guidelines for
proper papilla form to enhance denture
aesthetics. They described the ideal papilla
position and shape in relation to the interproximal
contact location and morphology; it was thought
that the papilla could enhance a youthful
appearance as a complimentary factor in age
2.4 Black Triangle and Implant
Close attention to both soft tissues and hard
tissues around teeth and implants before, during,
and after restorative procedures will greatly
increase the probability of successful outcomes
[28]. The presence of the dental papilla is critical
in achieving an esthetic single tooth dental
implant restoration. The vertical and horizontal
distances from the implant to the natural teeth,
and the distance from the restoration contact
point to the bone level of the natural teeth are
paramount criteria that could be utilized to predict
the presence or absence of the papilla. These
criteria are based on studies involved natural
teeth and implant restorations [4,29,30].
To preserve the interdental papilla and allow for
adequate oral hygiene, 1.5 - 2.0 mm of space is
needed between the implant and the tooth on
each side. Therefore, 7 mm of mesiodistal space
must be created between the adjacent teeth [31].
After the appropriate amount of coronal space
has been determined, it is necessary to evaluate
the inter-radicular spacing. The minimum inter-
radicular distance required is generally 5-7 mm
for a single implant placement.
Grunder [32] reported an excellent papilla results
for single tooth implant restoration even when the
distance from contact point to the implant bone
was 9 mm, whereas, Tarnow et al. [4] concluded
that all papilla were present in the natural teeth
when 5 mm or less was present from the contact
point to the crestal bone and less than 50% when
the distance was over 6mm. In another study by
Tarnow et al. [29] crestal bone loss was
evaluated in relation to horizontal inter-implant
distance. In this study it was reported that
increased crestal bone loss would occur if the
inter-implant distance was less than 3 mm. Their
findings lacked statistical analysis that examined
significance at an acceptable level of confidence.
In another study by Mark et al. [33] describing
the relationship between horizontal implant-tooth
distances and the presence of papilla,’ they
reported that the distance from the contact point
to the implant increased the chance of loss of
papilla significantly. They also found that there
was no difference between delayed or immediate
provisionalization and papilla scores.
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
In cases where two implants are placed adjacent
to each other, open gingival embrasures are
more pronounced [34]. Selective utilization of
implant with a smaller diameter at the implant-
abutment interface may be beneficial when
multiple implants are to be placed in the esthetic
zone so that a minimum of 3 mm of bone can be
retained between them at the implant-abutment
level [29].
Open gingival embrasures or black triangles
often pose complex aesthetic and functional
problems that are noticeably unaesthetic and
negatively affect the smile. A multidisciplinary
approach must be considered mandatory if a
successful clinical outcome is to be achieved. All
etiological factors and treatment alternative must
be discussed with the patient before starting the
Authors have declared that no competing
interests exist.
1. Rosenstiel SF. Dentists' preferences of
anterior tooth proportion-a web-based
study. J prosthodont. 2000;9(3):123-36.
2. Van der Geld P, Oosterveld P, Van Heck
G, Kuijpers-Jagtman AM. Smile
attractiveness. Self-perception and
influence on personality. Angle Orthod.
3. Ko-Kimura N, Kimura-Hayashi M,
Yamaguchi M, et al. Some factors
associated with open gingival embrasures
following orthodontic treatment. Aust
Orthod J. 2003;19(1):19-24.
4. 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 dental papilla.
J Periodontol. 1992;63(12):995-996.
5. Kokich VO Jr, Kiyak HA, Shapiro PA.
Comparing the perception of dentists and
lay people to altered dental esthetics. J
Esthet Dent. 1999;11(6):311-324.
6. Cunliffe J, pretty I. Patients' ranking
of interdental "black triangles" against
other common aesthetic problems. Eur J
Prosthodont Restor Dent. 2009;17(4):177-
7. Zetu L, Wang HL. Management of inter-
dental/inter-implant papilla. J Clin
Periodontol. 2005;32(7):831-839.
8. Ahmad I. Anterior dental
aesthetics: Gingival perspective.
Br Dent J.
9. Cho HS, Jang HS, Kim DK, Park JC, Kim
HJ, Choi SH, Kim CK, Kim BO. The effect
of interproximal distance between roots on
the existence of interdental papillae
according to the distance from the contact
point to the alveolar crest. J Periodontol.
10. Wu YJ, Tu YK, Huang SM, Chan CP. The
influence of the distance from the contact
point to the crest of bone on the presence
of the interproximal dental papilla. Chang
Gung Med J. 2003;26(11):822-828.
11. Prato GPP, Rotundo R, Cortellini P, Tinti
C, Azzi R. Interdental papilla management:
A review and classification of the
therapeutic approaches. Int J Periodontics
Restorative Dent. 2004;24(3):246-255.
12. Tanaka OM, Furquim BD, Pascotto RC, et
al. The dilemma of the open gingival
embrasure between maxillary central
incisors. J Contemp Dent Pract.
Fig. 4a. Patient with black triangles as a
result of periodontal disease
Fig. 4b. Same patient with a heat-cured
acrylic prosthesis masking the black triangle
Al-Zarea et al.; BJAST, 6(1): 1-7, 2015; Article no.BJAST.2015.061
13. Checchi L, Montevecchi M, Checchi V,
Bonetti GA. A modified papilla preservation
technique, 22 years later. Quintessence
Int. 2009;40(4):303-311.
14. Nemcovsky CE. Interproximal papilla
augmentation procedure: A novel surgical
approach and clinical evaluation of 10
consecutive procedures. Int J Periodontics
Restorative Dent. 2001;21(6):553-559.
15. Beagle JR. Surgical reconstruction of the
interdental papilla: Case report. Int J
Periodontics Restorative
Dent. 1992;12:145–51.
16. Han TJ, Takei HH. Progress in gingival
papilla reconstruction. Periodontol 2000.
17. Carnio J. Surgical reconstruction of
interdental papilla using an interposed
subepithelial connective tissue graft: A
case report. Int J Periodontics Restorative
Dent. 2004;24:31–37.
18. Azzi R, Etienne D, Carranza F. Surgical
reconstruction of the interdental papilla. Int
J Periodontics Restorative Dent.
19. Azzi R, Takei HH, Etienne D, Carranza FA.
Root coverage and papilla reconstruction
using autogenous osseous and connective
tissue grafts. Int J Periodontics Restorative
Dent. 2001;21:141–7
20. Kurth JR, Kokich VG. Open gingival
embrasures after orthodontic treatment in
adults: Prevalence and etiology. Am J
Orthod Dentofacial Orthop.
21. Turverson DL. Anterior interocclusal
relations. Part I. Am J Orthod.
22. Olsson M, Lindhe J. Periodontal
characteristics in individuals with varying
form of the upper central incisors. J Clin
Periodontol. 1991;18:78-82.
23. Burke S, Burch JG, Tetz JA. Incidence and
size of pretreatment overlap and post
treatment gingival embrasure space
between maxillary central incisors. Am J
Orthod Dentofacial Orthop. 1994;105:511.
24. Sharma AA, Park JH.
Esthetic considerations in interdental
papilla: Remediation and regeneration. J
Esthet Restor Dent. 2010;22(1):18-28.
25. Clark D. Correction of the "black
triangle": Restoratively driven papilla regen
Todays FDA. 2010;22(2):52-57
26. Barzilay I, Irene T. Gingival prostheses--a
reviewJ Can Dent Assoc. 2003;69(2):74-8.
27. Frush JP, Fisher RD. The dynesthetic
interpretation of the dentogenic concept. J
Prosthet Dent. 1958;8(4):558-581.
28. Goldberg PV, Higginbottom FL, Wilson TG.
Periodontal considerations in restorative
and implant therapy. Periodontol 2000.
29. Tarnow DP, Cho SC, Wallace SS. The
effect of inter-implant distance on the
height of inter-implant bone crest. J
Periodontol. 2000;71:546.
30. Choquet V, Hermans M, Adriaenssens P,
et al. Clinical and radiographic evaluation
of the papilla level adjacent to single tooth
dental implants. A retrospective study in
the maxillary anterior region. J Periodontol.
31. Zuccati G. Implant therapy in cases of
agenesis. J Clin Orthod. 1993;27(7):369-
32. Grunder U. Stability of the mucosal
topography around single tooth implants
and adjacent teeth: 1-Year results. Int J
Periodont Restor Dent. 2000;20:11.
33. Mark R. Ryser, Michael S. Block, Donald
E. Mercante. Correlation of papilla to
crestal bone levels around single tooth
Implants in Immediate or Delayed Crown
Protocols. J Oral Maxillofac Surg.
34. Pradeep AR, Karthikeyan BV. Peri-implant
papilla reconstruction: Realities and
limitations. J Periodontol. 2006;77(3):534-
© 2015 Al-Zarea et al.; This is an Open Access article distributed under the terms of the Creative Commons Attribution License
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Peer-review history:
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... A recent study of patients' attitude found that there is patient's dissatisfaction with the black triangles in which these imperfections rank quite high among aesthetic defects. Their level is the third followed carious lesions and dark crown margins [2]. Open gingival embrasures or black triangles form complex aesthetic and functional problems. ...
... Numerous non-surgical and surgical treatments for soft tissue abnormalities and interproximal spaces have been proposed. Regarding nonsurgical treatments, they include repeated papillae curettage, restorative intervention, orthodontic treatment, and prosthetic treatment [2]. As a guide for the formation of an interdental papilla, a resin composite can be inserted near the gingival sulcus [4]. ...
... Score (1) represent the absence of plaque and inflammation. Score (2) where there was little plaque without gingival inflammation. Score (3) was obtained when the plaque accumulation was at an acceptable level and gingival bleeding was acceptable the restoration took score (3). ...
Full-text available
Background: Open gingival embrasures form complex aesthetic and functional problems. This clinical trial assessed the bioclear matrix using injection molding technique against conventional celluloid matrix technique in management of black triangle. Methods: A total of 26 participants were randomly divided into two groups (13 participants each) according to the technique used. In group (A) celluloid conventional matrix method was used, while in group (B) bioclear matrix with injection molding technique was used. The different outcomes (Esthetic evaluation, marginal integrity and patient satisfaction) were evaluated following the FDI criteria by two blinded examiners. The evaluation was done at (T0) (immediate after restoration); (T6) after 6 months; and (T12) after 12 months. Statistical analysis was done as categorical and ordinal data were presented as frequency and percentage values. Categorical data were compared using fisher's exact test. Intergroup comparisons for ordinal data were analyzed utilizing the Mann-Whitney U test, while intragroup comparisons were analyzed using Friedman's test followed by the Nemenyi post hoc test. The significance level was set at p ≤ 0.05 within all tests. Results: Regarding radiographic marginal integrity and marginal adaptation, the bioclear matrix group revealed superior results when compared to celluloid matrix group with a significant difference between both groups at all intervals (p < 0.05); however no significant difference was detected at different intervals. While for proximal anatomical form and esthetic anatomical form, as well as phonetics and food impaction, all cases in both groups were successful with no statistical significant difference between groups. For the periodontal response, there was no significant difference between groups. However, there was a significant difference between scores measured at different intervals, with T0 being significantly different from other intervals (p < 0.001). Marginal staining revealed that there was no significant difference between groups. While, a significant difference between scores measured at different intervals. Conclusions: The restorative management of the black triangle with both protocols was able to deliver superior aesthetic and good marginal adaptation; suitable biological properties; with adequate survival time. Both techniques were almost equally successful, however they are depending on the operator skills. Trial registration: The clinical trial was registered in the ( www. Clinicaltrials: gov/ ) database in 23/07/2020; with the unique identification number NCT04482790.
... We also found that age was not significantly associated with papilla recession. On the other hand, previous studies described that an increased age is associated with papilla recession [4,28]. This discrepancy may be the result of the size of the study population in this study. ...
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Objectives To evaluate the influence of miniscrew-assisted rapid palatal expansion (MARPE) on the interdental papilla height of maxillary central incisors. Materials and methods Patients who completed MARPE treatment at the Radboud University Medical Center between 2018 and 2021 were included in this retrospective study. The papilla height between the maxillary central incisors was evaluated on frontal intraoral photographs taken before expansion (T0) and 1.5 years after MARPE treatment (T1) using the Jemt classification. The difference in Jemt score at T0 and T1 was the primary outcome variable. In addition, gender, age, Angle classification, MARPE duration, midpalatal suture maturation stage, maximal central diastema (MCD) immediately after expansion, crown width to length ratio (W/L), pretreatment overlap of maxillary central incisors, and the distance between the approximal contact point of the central incisors and the bone crest (CP-B) were also record. Results Twenty-two patients were included (2 men, 20 women, mean age 27.3 ± 8.8 years) and 4 patients (18%) showed a significant reduction in the Jemt score following MARPE (p = 0.04), indicating papilla recession. Interdental papilla recession was significantly associated with the increase of CP-B (p = 0.02), smaller W/L (p < 0.01), overlapping of maxillary central incisors (p < 0.01), and smaller MCD immediately after expansion (p = 0.02). Conclusions One and a half years after MARPE, 18% of patients exhibited mild recession of papilla height of the maxillary central incisors. Overlapping and smaller W/L of maxillary central incisors were prognostic factors for interdental papilla recession. Clinical relevance Clinicians have to be aware of and inform the patients about the occurrence of papilla recession following MARPE.
... [4] Gingival grafting procedures are often selected; however, the success rate is low due to the gingival tissue minimal blood supply. [6] The use of hyaluronic acid (HA) has been claimed to be an effective treatment for OGE. Mansouri et al. described that HA gel injections used to reconstruct the interdental papilla showed more than 50% of development in the samples. ...
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Background: The aim of this research was to assess the effectiveness of eggshell-membrane (ESM)-containing hyaluronic acid (HA) in the treatment of open gingival embrasure (OGE) following orthodontic tooth movement (OTM). Materials and methods: This study is an in vivo quasi experimental research. A total of 24 Cavia cobaya were equally divided into two groups, treatment (10% HA injection) and control (phosphate-buffered saline [PBS]). A separator was inserted between mandibular incisors to induce an OGE. A volume of 20 μl of either PBS (n = 12) or ESM extract (n = 12) was locally injected within the interdental papilla. Decapitation of animals was made on day 1, 4, and 7 postinjection. The staining was done using hemotoxylin and eosin to observe angiogenesis and Mallory to observe the collagen density. Fourier-transform infrared spectroscopy (FTIR) and thin-layer chromatography (TLC) analysis were performed to detect the amount of HA available in ESM. The results were then compared with independent t-tests and the Mann-Whitney test. The level of statistical significance was set at 0.05. Results: The FTIR and TLC analysis showed that HA was successfully identified in the ESM samples. Local injection of 10% HA induced an increase of angiogenesis compared to the control group on day 1 and 4 postinjection (P < 0.05). Significant differences (P < 0.05) were also noted in the collagen density and the growth of interdental papilla on day 4 and 7 postinjection. Conclusion: ESM has the potential effect of regenerating the interdental papilla construction after OTM by increasing the collagen fiber density and inducing angiogenesis.
... These spaces are also known as "black triangles." [6] Black triangles are a common cause of patient's misery who then tends to complain about hesitation while smiling due to the gaps. These can also lead to problems of phonetics or also cause food lodgment. ...
... This previous procedure has a side effect on the interdental papillae in maxillary anterior teeth which is black triangles. Black triangles in the current case categorized as class I, where the tip of interdental papilla is placed between interdental contact point of CEJ at interproximal surface [36] Black triangles are a multifactorial, may cause by recession, reduced alveolar bone height associated with interproximal contact [37]. These previous causes are present in the current case, leading to formation of these black triangles. ...
... A etiologia dos triângulos negros gengivais é multifatorial (Henriques, 2006;Ziahosseini, Hussain and Millar, 2014;Al-Zarea et al., 2015), sendo inúmeros os fatores, inatos ou adquiridos, que podem contribuir para esta condição: defeitos congénitos, trauma, lesões iatrogénicas, morfologia dentária anómala, grande distância interproximal entre dentes adjacentes, grande distância entre o ponto de contacto interdentário e a crista óssea, biótipo gengival, inserção anómala de freios, idade, raízes divergentes, doença periodontal, profundidade das bolsas periodontais dos dentes adjacentes, presença de restaurações proximais desbordantes, tratamento ortodôntico, entre outros. (Tarnow, Magner and Fletcher, 1992;Bichacho, 1998 ...
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A papila ou gengiva interdentária quando íntegra constitui um importante atributo na arquitetura do sorriso tendo também funções fisiológicas e anatómicas. O incompleto preenchimento da ameia cervical pela papila dá origem aos chamados triângulos negros gengivais. Estes, podem causar problemas fonéticos e estéticos além de propiciar a acumulação de resíduos alimentares e placa bacteriana na zona.(Ziahosseini, Hussain and Millar, 2014). A gestão da papila interdentária é um tema de elevada preocupação para os clínicos, não só devido à sua importância estética, como também pelo seu papel na manutenção da saúde dentária e periodontal, (Al-Zarea et al., 2015) uma vez que a área interdentária é uma zona especialmente suscetível no desenvolvimento de lesões cárie e periodontite (Fig.1).(Singh et al., 2013; Ziahosseini, Hussain and Millar, 2014; Al-Zarea et al., 2015; Yu et al., 2015) A complexa anatomia da zona associada ao fraco aporte sanguíneo torna a correção deste problema difícil e pouco previsível (Ziahosseini, Hussain and Millar, 2014). Deste modo, o domínio e compreensão das principais variáveis que afetam a integridade e morfologia da gengiva interdentária é essencial. É inquestionável que esta temática constitui um dos maiores desafios da atualidade para os médicos dentistas.(Ziahosseini, Hussain and Millar, 2014; Al-Zarea et al., 2015) Procedeu-se a uma pesquisa de artigos relevantes nas bases de dados primárias Medline (PubMed) e Cochrane tendo sido selecionados artigos publicados em língua inglesa e portuguesa. Foram utilizadas as seguintes palavras-chave: black triangles; open embrasures; interdental papilla; etiology; therapeutic approaches para completar esta pesquisa foi realizado um cruzamento manual de referências dos artigos elegíveis para identificar estudos adicionais relevantes.
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The interdental papilla is of utmost importance in smile aesthetics. Missing interdental tissue often raises an aesthetic concern; however, the issue is more than just an aesthetic complication. This study reviews the most commonly seen cases and methods to minimize the aesthetic complications caused by missing interdental tissue. The technique that will be discussed is from nonsurgical techniques, including composite restoration, indirect restorations, and gingival veneer. This article is clinically relevant in educating clinicians on various methods to restore and improve the optics that arise from a missing interdental papilla.
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Keywords: Nothing will ruin a beautiful smile more than having dark spaces between teeth. The search for improved dentofacial aesthetics persists in modern society. As we age and many other factors, sometimes unwelcome dark spaces appear between our teeth .Besides adding an older appearance to our simile, these dark spaces may also collect food debris and plaque. Also known as dental black triangles figure-1) the clinical terminology is gingival embrasures-they can be the result of bone loss , recession of the gum line, or movement of the teeth. Some people have naturally occurring gaps between their teeth called Diastema. Though not always unhealthy, gaps between the teeth are sometimes the source of embarrassment or low self-esteem, especially fo the young population. Black triangle disease, interdental papilla, pink aesthetics, white aesthetics, derma fillers
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Objective The present study was a randomized controlled clinical trial with the aim of evaluating the increase in papillary height and reduction in black triangle height obtained by the novel papillary augmentation access with either connective tissue graft (CTG) or platelet-rich fibrin (PRF) as matrix from baseline to 6 months. Materials and Methods A total number of 20 sites with Nordland and Tarnow's Class I, I-II and II interdental papillary loss were recruited into the study. The sites were randomly allocated with 10 sites per group into either: Group A (control group) or Group B (test group) which utilizes the same technique with CTG or PRF as matrix, respectively. The clinical parameters such as PPD (probing pocket depth) and CAL (clinical attachment level) at the surgical site, plaque score (FMPS), bleeding scores (FMBS), interdental papillary height (PH) and black triangle height (BTH), along with visual analog score by dentist (VAS-D) and by patient (VAS-P) were evaluated at baseline and at 6 months. Results In both CTG and PRF groups, all the primary and secondary outcome variables such as PH, BTH, VAS-D and VAS-P showed statistically significant improvement from baseline to 6 months (p ≤0.05) within the group. On comparison at 6 months, there were no differences in the papillary height between the groups. However, the BTH has significantly reduced in the CTG group than the PRF group. Similarly, the VAS-D significantly improved in the CTG group than the PRF group (p = 0.010) at 6 months. Conclusion The study demonstrates that the proposed papillary augmentation access with CTG and PRF was successful in managing the unaesthetic interdental papillary loss, with CTG showing better results in terms of reduction of black triangle than PRF. Abstract Keywords ► black triangle ► connective tissue graft ► interdental papilla ► papillary loss ► papilla reconstruction ► platelet rich fibrin
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Objective: To determine differences in how orthodontic patients perceive the aesthetics relating to the use of Essix and Hawley retainers. Material and Methods: Photographs of a female patient using an Essix retainer and a Hawley retainer, respectively, were assessed by 70 orthodontic patients aged between 21 and 55 years. All participants were provided with the same images of the two retainer types being worn and were asked to grade the aesthetics of each retainer using a visual analog scale. The significance of differences in orthodontic patient perceptions of aesthetics in the use of Essix and Hawley Retainers in the young adult and adult age groups were tested using the Mann-Whitney test with assumed significance p
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The contour of the interdental tissues, as well as the color and texture of the keratinized tissues, are essential elements of anterior esthetics. Tissue loss in the interproximal regions, with related esthetic concerns, phonetic difficulties, and food impaction, can occur for a variety of reasons, including treatment of periodontal diseases. In periodontal surgical procedures, the soft tissues require elevation and resection to gain access to the root surfaces and osseous supporting structures. Compromised esthetics in the anterior region of the mouth could be a serious consequence of periodontal surgical procedures. Several articles have been devoted to flap designs and surgical techniques to maintain full papillary form and preserve the soft tissues during surgical access. Unfortunately, very little evidence of long-term results is available. The aims of the present article are to report a 22-year follow-up case of surgical interdental papilla preservation, discuss the anatomic variables that conditioned the outcome, and review and compare existing surgical techniques for maintaining the interproximal soft tissues.
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The aim of this report is to present the etiology, diagnosis, and treatment planning strategy in the presence of an open gingival embrasure between the maxillary central incisors. The open gingival embrasure or "black triangle" is a visible triangular space in the cervical region of the maxillary incisors. It appears when the gingival papilla does not completely fill in the interdental space. The space may occur due to: (1) disease or surgery with periodontal attachment loss resulting in gingival recession; (2) severely malaligned maxillary incisors; (3) divergent roots; or (4) triangular-shaped crowns associated with or without periodontal problems and alveolar bone resorptions. The post-treatment prevalence in adult orthodontic patients is estimated to be around 40% compromising the esthetic result. Several methods of managing patients with open gingival embrasure exist, but the interdisciplinary aspects of treatment must be emphasized to achieve the best possible result. The orthodontist can play a significant role in helping to manage these cases. Various treatment strategies are available to treat cases of an undesirable black triangle and are dependent on the etiology of the condition.
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This study was designed to determine whether the distance from the base of the contact area to the crest of bone could be correlated with the presence or absence of the interproximal papilla in humans. A total of 288 sites in 30 patients were examined. If a space was visible apical to the contact point, then the papilla was deemed missing; if tissue filled the embrasure space, the papilla was considered to be present. The results showed that when the measurement from the contact point to the crest of bone was 5 mm or less, the papilla was present almost 100% of the time. When the distance was 6 mm, the papilla was present 56% of the time, and when the distance was 7 mm or more, the papilla was present 27% of the time or less.
Purpose: This study was designed to determine the perceptions of lay people and dental professionals with respect to minor variations in anterior tooth size and alignment and their relation to the surrounding soft tissues. Materials and Methods: Smiling photographs were intentionally altered with one of eight common anterior esthetic discrepancies in varying degrees of deviation, including variations in crown length, crown width, incisor crown angulation, midline, open gingival embrasure, gingival margin, incisal plane, and gingiva-to-lip distance. Forty images were randomized in a questionnaire and rated according to attractiveness by three groups: orthodontists, general dentists, and lay people; 300 questionnaires were distributed. Results: The response rate was 88.2% for orthodontists, 51.8% for general dentists, and 60.6% for lay people. The results demonstrated threshold levels of noticeable difference between the varying levels of discrepancy. A maxillary midline deviation of 4 mm was necessary before orthodontists rated it significantly less esthetic than the others. However, general dentists and lay people were unable to detect even a 4-mm midline deviation. All three groups were able to distinguish a 2-mm discrepancy in incisor crown angulation. An incisal plane cant of 1 mm as well as a 3-mm narrowing in maxillary lateral incisor crown width were required by orthodontists and general dentists to be rated significantly less esthetic. Lay people were unable to detect an incisal plane asymmetry until it was 3 mm, or a lateral incisor narrowing until it reached 4 mm. Threshold levels for open gingival embrasure and gingiva-to-lip distance were both at 2 mm for the orthodontic group. Open gingival embrasure became detectable by the general dentists and lay people at 3 mm, whereas gingiva-to-lip distance was classified by these groups as noticeably unattractive at 4 mm.
Abstract It has been suggested that the variation in the morphology of the human periodontium may be related to the shape and form of the teeth. Furthermore, the severity of symptoms of periodontal disease have been proposed to differ among these various morphologic entities or “biotypes”. The aim of the present study was (i) to identify individuals with markedly different crown forms and (ii) to determine probing pocket depth, probing attachment level and amount of gingival recession that had occurred at different teeth and tooth surfaces in such individuals. Clinical photographs of the maxillary incisor tooth region of 113 subjects who had been recruited for a long-term study on periodontal disease were available. The length (CL) and width (CW) of the crowns were determined and the CW/CL ratio was calculated for each tooth. 10% in each tail, 11 subjects in each group, were arbitrarily chosen as having either a long-narrow (N) or a short-wide (W) form of the central incisors. The probing pocket depth, probing attachment level and gingival recession data available from all subjects and subjects in groups W and N were compared and analyzed using the Student t-test and multiple regression analysis. The result from the analyses demonstrated that: (1) subjects with a long-narrow form of the upper central incisors had experienced more recession of the gingival margin at buccal surfaces than subjects who had a short-wide tooth form; (2) there was a significant influence of the CW/CL-ratio on the probing attachment level (p<0.05) and the amount of gingival recession (p<0.01) on buccal tooth surfaces. The observations reported tend to confirm the hypothesis that subjects with long, narrow teeth have a comparatively thin periodontium, and may be more susceptible to gingival recession than subjects who belong to a thick periodontal “biotype”.
The purpose of this study is to assess patients' aesthetic perceptions of interdental "black triangles", both in terms of the number of triangles visible and their severity; and to ascertain how patients rank the presence of "black triangles" against other aesthetic problems. It is based on a questionnaire of 80 randomly selected individuals who were asked to rate the aesthetics of digitally-manipulated images. Patients'perceptions of interdental "black triangles" were compared with their perceptions of other 'non-aesthetic' features. Interdental "black triangles" were rated as the third most disliked aesthetic problem below caries and crown margins. This study demonstrates the importance of interdental "black triangles" to patients, and therefore, as they can occur during prosthetic treatment, must be discussed with patients prior to commencing therapy.
Historically, periodontal treatment has been aimed more at the preservation and restoration of health to the periodontium than at the esthetic outcome of treatment. However, recent advances have enhanced the periodontist's ability to address esthetic concerns. To date, treatment of lost or collapsed interdental papilla has been largely unsuccessful. A case report is presented to demonstrate a technique by which a collapsed interdental papilla can be surgically reconstructed. The technique combines principles of Abram's roll technique for ridge augmentation with Evian's papilla preservation technique.