Susan McMahon, DMD

Black triangles, also known as open gingival embrasures, are spaces or gaps of missing gum at the cervical embrasure above the contact point and are a common dental issue seen in approximately 30% of adults.

The main determinant of the interproximal papilla height is the underlying bone crest (ie, osseous peaks). Research shows that the distance from the base of the contact area to the crest of bone correlates with the presence or absence of the interproximal papilla. When the distance is less than 5 mm, the papilla fills the interproximal space nearly 100% of the time, but when the distance is 7 mm or greater, the interproximal space is completely filled in only approximately 25% of the time.

Appearance and self-esteem have long been intertwined, so as our social media and selfie use continues to grow, more people are seeking out cosmetic dentistry to enhance their appearance. Often, they’re seeking care for relatively small dental issues that are of big concern to them. Patients’ perceptions of interdental black triangles were rated as the third most disliked esthetic problem, below caries and crown margins.

Black triangles are very prevalent, and approximately 40% of adult orthodontic cases may result in them.

Black triangles may be caused by several conditions,

decreased interproximal bone height from periodontal disease, attachment loss, periodontal surgery, or trauma;

excessive embrasure space and deficient papilla form affected by root angulation, interradicular distance, crown form, and distance between alveolar bone and interproximal contact;

patients’ biologic width and inherent or thinning gingival biotype; and

other factors such as age, patient habits, and iatrogenic issues.

Depending on the size, position in the esthetic zone, and cause of the black triangle, several treatment options are available, including surgical, orthodontic, indirect, and direct.

Small Black Triangles

, direct restoration is the best and most conservative approach. Many clinicians find direct restoration in this area to be challenging, often resulting in restorations with ledges and voids that collect biofilm and stain. However, newer techniques including injection molding improve the results.

The following case demonstrates an easy technique that employs traditional sectional matrix bands, Aura Easy composite, and Aura Easyflow, both from SDI Limited. Aura Easy is a universal nanohybrid composite that combines a low-shrinkage resin system and a unique morphology of ultra-high density glass filler. It can withstand high compressive forces and still deliver amazing handling and polishing properties. Therefore, it can be utilized in anterior and posterior restorations without compromising strength or esthetics. AuraEasy comes in 4 shades that cover the spectrum of the Vita shade guide and blends beautifully with natural enamel.

The patient shown in Figure 1 did not like the black triangle between his central incisors. He complained that, “it always looks like I have something stuck in my teeth.” Prior to closure of the black triangle, the patient is whitened with Pola Rapid in-office whitening 

It is difficult to attain proper contour interproximally with traditional mylar strips or matrix bands. Using a small, sectional matrix band placed vertically gives the perfect contour and can be adapted for an undetectable margin with no overhang.

First, isolate the left central incisor, and etch the enamel (37% phosphoric acid). After rinsing and light drying, apply Zipbond Adhesive (SDI Limited), air thin, and cure 

. The matrix band is placed interproximally. It is apparent the contour of the band will allow for a well-adapted closure of the black triangle 

Apply Aura Easy shade AE1 and contour to the band. Use Aura Easyflow to fill on the lingual as necessary 

 shows the final results after finishing and polishing.

1. 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. doi:10.1902/jop.1992.63.12.995

2. Cunliffe J, Pretty I. Patients’ ranking of interdental “black triangles” against other common aesthetic problems. 

3. Kurth JR, Kokich VG. Open gingival embrasures after orthodontic treatment in adults: prevalence and etiology. 

. 2001;120(2):116-123. doi:10.1067/mod.2001.114831

4. Kim J, Clark DJ. Full mouth black triangle treament protocol. 

5. Tanaka OM, Furquim BD, Pascotto RC, Ribeiro GL, Bósio JA, Maruo H. The dilemma of the open gingival embrasure between maxillary central incisors. 

Articles

Creating restorations with Aura Easy composite can help close small black triangles with ease.

How To Use This Easy Technique For Closing Small Black Triangles

 is a new 3-viscosity, addition-curing, elastomeric impression material. It’s based on a new material, vinylsiloxanether.

	Vinylsiloxanether gives Identium properties and advantages of both polyether impression materials and A-silicone impression materials. Polyether materials exhibit dimensional stability and wettability. A-silicones exhibit high elastic recovery with flexibility for mouth removal and have a neutral or good taste. 

	One of the most challenging procedures clinicians face in dentistry is obtaining an ideal impression for fixed restorations. Making an accurate impression requires precise preparation of the margins, thorough management of the surrounding gingival tissues, a good understanding of impression material properties and the correct use of impression trays.

	A recent evaluation conducted by several commercial dental laboratories determined 86 percent of crown and bridge impressions contained at least one detectable error and 55 percent contained a critical error related to the finish line.

	A quality, reliable impression material is critical. Retaking impressions is both time- and material-consuming and an expense that should be minimized.

	When considering past errors that necessitated impression retakes, our reviewers ranked missed margins as the No. 1 reason. Bubbles/voids, tear errors and distortion errors followed missed margins. Also noted were fin/folds, contamination, lack of integration between tray and injected material, inadequate working time for multi-unit impressions and incorrect tray selection. Impression errors result in ill-fitting restorations followed by restoration failure (

	A majority of our reviewers rated Identium “better or much better” than their current impression material. The reviewers cited the viscosity of light body, tray seating resistance, syringing ease, working time around multiple units, tray loading and, most importantly, consistent readable margins as favorable.

	When rating performance by individual impression characteristics, our clinicians found Identium better than their current material when considering gingival margin quality, impression detail, voids and bubbles, depth of sulcus penetration, subgingival margin detail and ease of removing the impression (

	Identium is an excellent choice for implant impressions, multi-unit impressions, impressions where isolation is compromised and impressions with subgingival preps (

	The majority of Catapult reviewers agreed Identium has improved properties compared to their current impression material. Overwhelmingly (79 percent), our reviewers state they would use it in their practices.  
	Identium, the new vinylsiloxanether impression material, gives reliable and accurate restorative impressions. It’s a great choice for consistency and value. 

	1. Rau CT, Olafsson VG, Delgado AJ, Ritter AV, Donovan TE. The quality of fixed prosthodontic impressions: an assessment of crown and bridge impressions received at commercial laboratories. JADA. 2017;148(9):654-660.

Why Catapult Education reviewers gave Identium the Catapult Education Vote of Confidence.

Creating reliable and accurate restorative impressions

	A much more conservative approach is taking root in dentistry as technology and materials allow providers to save teeth and tissue. When faced with deep carious lesions and root lesions, we as clinicians should be changing our focus from endodontic treatment, post and cores, and deep-cut full coverage restorations to, if possible, achieving pulpal health and restoring more conservatively.  

	Catapult Education reviewers evaluated Biodentine

 made from the patented ABS technology. Active biosilicate, Septodont’s bioactive material, was primarily reviewed for its use in direct pulp caps and indirect pulp caps. Additional uses include repairing root perforations, pulpotomies, root resorption and deep caries bases. Catapult reviewers overwhelmingly reported positive feedback with Biodentine. Eighty-five percent said they would recommend Biodentine to a colleague.  

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	When dentin has been compromised, whether from decay, resorption or mechanical perforation, previous restorative options have been limited. Calcium hydroxide bases have long been used to stimulate dentin formation but their weak physical properties have been a drawback. Only 60 percent of our evaluators reported using Dycal or MTA. This begs the question of how teeth with deep carious lesions and root lesions are being treated. Are we opting for more aggressive procedures in lieu of pulp caps, root repairs or other resorption repairs? Endodontic treatment followed by posts, cores and crowns is an aggressive treatment option that can result in destruction of significant tooth structure. We find many endontically treated and crowned teeth are eventually lost and replaced with implants or other restorative means.   

	Biodentine by Septodont, a calcium silicate restorative dentin substitute, maintains pulpal vitality and stimulates formation of tertiary dentin. It can be used both on the crown portion of the tooth and on the roots. With its physical properties, compressive strength, elasticity and hardness, similarity to dentin, and reparative stimulation from calcium hydroxide ion release, Biodentine is an excellent choice for direct pulp capping, indirect pulp capping, pulpotomies, furcation repair and resorption repair. Biodentine’s bioactivity is what makes it a superior clinical choice over calcium hydroxide bases and glass ionomers.  

	Case: Indirect pulp cap on deep carious lesion

	The patient is 26-year-old female with several missing teeth and gross decay of several others.  She has neglected her dental care due to limited access and financial duress. The lower right second molar had previously been restored with amalgam. The amalgam had partially fractured out and there was a deep carious lesion with close proximity to the pulp (

). The tooth was asymptomatic. The pulp tested vital with traditional pulp testing. Because of the deep decay and proximity to the pulp, I previously would have considered endodontically treating this tooth and then restoring with a passive post and core followed with a full coverage crown.  

	Fig. 1                                                                                     Fig. 2

	The patient was anesthetized with an inferior alveolar block with 4% Septocaine(1:100,000epi). Isolation was obtained with a rubber dam. The remaining amalgam restoration was removed with a high-speed carbide bur. The deep distal caries were excavated completely with a #6 round carbide bur with low torque. A very thin layer of dentin was left remaining over the pulp (

). A traditional matrix band was placed. Biodentine was prepared, triturated and placed in a layer over the thin dentin (

). The Biodentine was allowed to set for its 12-minute set time.The preparation was then refined and cleaned.

	Fig. 3                                                                                      Fig. 4

	Next, 37% phosphoric acid was applied for 15 seconds as a total etch on the enamel, dentin and Biodentine. The etchant was then rinsed off.  Adhesive was applied, air thinned and cured. A low stress bulk fill flowable was placed and topped with a universal composite resin then finished and polished (

). Thus, this tooth has been restored and the pulp has been left intact and vital. The Biodentine layer, acting as a indirect pulp cap and dentin replacement, will presumably stimulate tertiary dentin formation and keep this pulp healthy. Considerable tooth structure has been saved and the long-term prognosis much improved. This makes me feel like a dental hero, saving this young patient’s tooth from endodontic and crown treatment.  

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	For use, the liquid component is added to the capsule. The capsule is then triturated for 30 seconds. The material, a malleable paste, is applied to the tooth with the supplied disposable small spatula. The set time is 12 minutes.  Some evaluators cited the mixing and handling as challenging. The set time may seem little time-consuming by today’s instantaneous standards, but the biostimulating activity with the associated clinical benefits of dentin stimulation and maintenance of pulpal vitality warrant the clinical time.  

	Overall, Catapult evaluators reported a short-term success rate of 95 percent with direct and indirect pulp caps. Pulpal health is maintained and reparative dentin is stimulated. More conservative restorations can be placed and more natural tooth structure can be maintained.  Biodentine earns the ‘Catapult Vote of Confidence.’

Why Catapult Education reviewers enjoyed using this bioactive dentin substitute from Septodont.