Pugliese2019 Black Triangles - Preventing Their Occurrence, Managing Them When Prevention Is Not Practical
Pugliese2019 Black Triangles - Preventing Their Occurrence, Managing Them When Prevention Is Not Practical
Pugliese2019 Black Triangles - Preventing Their Occurrence, Managing Them When Prevention Is Not Practical
The interdental papilla is very important for an aesthetic smile. Black trian-
gles are defined as the embrasures cervical to the interproximal contact that
are not filled by gingival tissue. These spaces are the most negatively ranked
gingival factor by laypeople. Management of black triangles requires high
quality diagnosis and a multidisciplinary approach must be considered man-
datory to achieve a successful clinical outcome. Much of what is applicable
is born from severely complicated periodontal regeneration and implant
therapy. This review covers the multifactorial etiology and the management
of black triangles. (Semin Orthod 2019; 25:175–186) © 2019 Elsevier Inc. All
rights reserved.
Figure 2. (A) Thin biotype. (B) Underlying thin bone with dehiscence or fenestration.
27% of the times. These findings indicate that contact is more incisally located, increasing the
the papilla will extend only a limited distance roots distance, the length of embrasure area and
from the alveolar crest to the interproximal con- the distance from the crest of the alveolar bone to
tact (Fig. 3). Wu et al.15 found similar results. A the interproximal contact point. Burke et al.16
distance of 5, 6, and 7 mm resulted in an open showed the association between tapered crowns
embrasure in 2, 44, and 73% of the cases respec- and black triangles presence. Kurth and Kokich5
tively. These observations indicate that papilla also showed that the mesial crown form of maxil-
was present in almost 100% of the cases if the dis- lary central incisors is significantly related to open
tance from the alveolar crest to the contact point gingival embrasures. The lower mean crown form
was 5 mm or less. When the distance was more ratio in patients with open gingival embrasures sug-
than 7 mm, most patients had an open gingival gests a slightly more divergent crown form in these
embrasure. Based on this evidence, orthodontists subjects. A pretreatment crown shape analysis
can mitigate the risk for black triangles by devel- which results in identifying triangular crown shape
oping treatment plans with the alveolar bone to alerts the risk for black triangles. Thin scalloped
contact point distance in mind. periodontium that can often be found around slen-
der triangular shaped crowns and is usually paired
with narrow keratinized tissue width can easily be
Crown shape
diagnosed. The overlying gingiva is thin and clear,
Divergent or triangular shaped crown forms are this allows the probe to be visible through it. Risks
associated with posttreatment black triangles. stemming from thin tissue can be mitigated
(Fig. 4) Due to this crown shape, the interproximal through gingival grafting.
178 Pugliese et al
Root angulation
Burke et al.16 concluded that orthodontic move-
ment of crowded anterior teeth can separate the
roots and stretch the interdental papilla, increas-
ing the presence of black triangles between inci-
sors after orthodontic treatment.
Figure 3. Radiographic bone crest to contact point. Kurth and Kokich,5 with even more details,
showed that root angulation of the maxillary cen-
Interproximal contact point tral incisors is related to black triangles. Mean
root angulation in normal gingival embrasures
The length of the interproximal contact is converges at 3.65°. When mesial crown form,
another factor related black triangles. On aver- alveolar bone interproximal contact, and inter-
age, the interproximal contact, in patients with proximal contact incisal edge variables are con-
black triangles, was shorter or located 1 mm stant, a 1° increase in root divergence increased
more incisally than in patients with normal gingi- the odds of an open gingival embrasure by
val embrasures. Since the incisal edge is a fixed 14 21%.
Periodontal approach
Orthodontic treatment
Periodontists develop novel flap design during
Burke16 affirmed that a black triangle is a fre- surgical periodontal disease treatment to pre-
quent sequela of aligning crowded maxillary cen- vent, ischemia, trauma and extreme tissue loss so
tral incisors. One third of orthodontic patients as to maintain natural gingival contours. Quickly
can be expected to have crowded central inci- emerging regenerative treatments drive these
sors. Two-fifths of those can be expected to have papilla preservation flaps.
a post-orthodontic black triangle.
An et al.18 found association between black
Papilla preservation during periodontal
triangles and lingual movement of the inci-
regeneration surgeries
sors, large antero-posterior overlap between
the two central incisors before treatment Understanding the fragility and the limited vascular-
in the maxilla. The authors still demonstrated ity, periodontists select delicate flap designs during
that a large amount of intrusion of the man- periodontal treatment to avoid trauma to the inter-
dibular incisors can aggravate the severity of proximal blood supply. Surgical techniques have
open gingival embrasures. been developed to prevent the papilla trauma.
180 Pugliese et al
Aslan et al.22 presented a novel technique incision was made on the buccal mucosa, as far
applied to 12 patients with at least one isolated as possible from the interdental papillae and
deep intra-bony defect. The “entire papilla pres- marginal keratinized tissues. The soft tissue was
ervation” technique is a tunnel-like approach of reflected apico-coronally, by a full-thickness flap,
the defect associated inter-dental papilla. It pro- exposing the coronal limit of the intra-bony com-
vides access to the intra-bony defect by a beveled ponent of the defect. Unlike historic flap eleva-
vertical releasing incision positioned in the buc- tion, excessive bone exposure was avoided to
cal gingiva of the neighboring inter-dental space. maintain the capillary integrity involved in nour-
Following the elevation of a buccal flap, an inter- ishing the delicate interproximal tissues. As an
dental tunnel was prepared undermining the outcome, marginal soft tissues shrinkage is
defect. Granulation tissue is removed, root surfa- avoided.
ces are debrided and bone substitutes and
enamel matrix derivate are applied. Microsurgi-
cal suture is used for optimal closure. As results, Papilla reconstruction with tissue grafting
the authors showed that early healing was influenced by growth factors
uneventful in all cases. After 1 year, there was sig- Treating recession defects has driven periodon-
nificant attachment gain of 6.83 mm. The results tal practice innovations including grafting tech-
were associated with a mean minimal increase in niques, and tissue engineering. Due to crown
gingival recession of 0.16 mm. shape and thin biotype, missing papilla occurs
Rodríguez and Caffesse23 presented a mini- with severe recession; so innovations born from
mally invasive surgical approach for periodontal treating recession defects are of particular use
regeneration of a severely compromised case. here (Fig. 5). Stimulating cells to regenerate
The non-incised papillae surgical approach was using growth factors, hormones, extracellular
performed to improve regenerative parameters matrix, cell occluding barriers have improved
in hopeless teeth. This surgical approach is spe- regenerative predictability. Such innovations tis-
cifically indicated as a periodontal reconstructive sue engineering such as acellular dermal matrix,
procedure for interproximal intra-bony defects enamel matrix derivative and even patient
with the requirement of the extension to the buc- derived products such as platelet rich plasma
cal aspect of the tooth. It is a preservation papil- enhance outcomes, often through cell signaling,
lae technique, where the interdental papillae and involving improved angiogenesis. Geisinger
and the marginal tissues surrounding the defect et al. reviewed the outcomes of using growth fac-
must not be altered. Only one apical horizontal tors to treat severe recession sites. Emerging
evidence drove her to couple the gold standard are used to shape the soft tissue. Urban et al.28
recession treatment, subepithelial connective tis- showed that tissue healing around an immediate
sue graft with acellular dermal matrix and temporary abutment helps in proper tissue con-
enamel matrix derivative for successful surgical touring. The authors presented a case report with
treatment of severe recession in the maxillary poor prognosis that was treated by a combination
molars and elimination of black triangle. Per- of soft tissue grafting and a prosthetic approach. It
haps because of the variety of tissue engineering was used a customized abutment with a subtle sub-
products, the power of currently available meta- marginal convex contour that confines the space
analytic evidence is weak but increasing.24 available for the papilla. The subgingival abutment
It is a note of optimism to recognize the trajec- contour allowed to shape and enhance papilla ref-
tory of platelet-derived growth factor. Over the ormation and its maintenance for 10 years. Chal-
last two decades it has been well characterized, lenging implant cases have strengthened team
marketed and successfully improved regenera- based management of black triangles. Periodont-
tive outcomes.25 With tissue engineering devel- ists therefore are a strong ally to help orthodontists
oping at this rate, procedures and products to predict black triangles, by bone sounding, and
enhance predictable papilla treatment should be manage them when unavoidable.
anticipated.
Mask the black triangle with filler
Single tooth implant
Since surgical procedures are not yet predictable in
Experience with implants has taught important les- all cases, and since restorative dentistry involves
sons about the chances of papilla loss. Tarnow cost, minimally invasive injection strategies have
et al.14 set out to preserve implant papilla, and real- been suggested to treat black triangles. Cell injec-
ized that is critical to keep the distance from the tions involve harvesting cells and involve difficulty
contact point to bone crest at 5 mm or less. How- of collection. Fibroblast injections using cultured
ever, the distance of adjacent natural tooth to the fibroblasts have shown initial safety and efficacy.29
alveolar crests is most critical than the height of Hyaluronic acid has been suggested as an easily
the implant contact to the bone. Because of that, obtainable injectable solution. The evidence
to reduce the risk the encouraged interproximal remains mixed, however pilot data and animal
bone sounding on the adjacent teeth should be studies show promise.30 A significant problem
before implant placement.26 That same bone remains that injectables are temporary. Cost effec-
sounding can be strategically employed in non- tiveness studies comparing restorative outcomes to
implant cases to assess the bone crest to contact long term injectables are needed to identify the
point distance. Once that has been completed, the better long term expenditure.31
shape of the contact point can be strategically
designed. On the other hand, extrusion of a tooth
Restorative approach
will allow the bone to extrude with the tooth,
resulting in a decrease in that distance, and an The restorative approach gives several strategies to
increase of soft tissue.27 reduce the appearance of black triangles when
More importantly, these extrusion cases started development cannot be avoided.32 Restorative den-
important conversations between periodontists, tistry can change crown shape. This could be per-
restorative doctors and orthodontists. Clinicians formed by direct or indirect restorations, such as
placing implants are often challenged with limited composite or ceramic veneers. Bonded segmental
bone in the site of a future implant. Specifically, in proximal restorations, whether direct or laboratory
cases where grafting these deficient areas is not fea- fabricated, can be added to selected aspects of a
sible either due to systemic contraindications or tooth utilizing the acid-etch technique with no
poor prognosis of native vertical bone morphology micromechanical preparation. When properly exe-
the implant team seek orthodontists to extrude the cuted the prosthetic supplements guide and support
tooth and the bone along with it (Fig. 6). In these newly regenerated papillae in deficient interproxi-
cases, with no chance of having a full papilla, every- mal aspects. Involving a restorative dentist also allows
thing, even the temporary is part of the strategy to for controlling other risks for papilla loss associated
minimize the black triangle. Temporary crowns with the relationship between crown and embrasure
182 Pugliese et al
Figure 6. Severely complicated periodontal and implant therapy cases leave no option to prevent black triangles.
These cases provide strategic management examples for orthodontists managing far less complex situations in
non-implant cases.
(A) Extrusion to develop bone for implant site.
(B) Post extrusion for implant site development in severely resorbed ridge.
(C) Implant placed after extrusion.
(D) Temporary crown to shape soft tissue.
(E) Implant crown final radiograph.
(F) Final.
(G) Final smile.
Black triangles: a review 183
Figure 6. Continued
space such as the relationship between the embra- contact incisal edge variables are constant, a 1°
sure size and contact shape and size. Similarly, when increase in root divergence increased the odds of
risks for papilla loss apply to laterals, canines and pre- an open gingival embrasure by 14 21%.5 Ortho-
molars, restorative approach is needed to maintain dontic treatment can be performed to converge
bilateral symmetry. The importance of restorative maxillary incisor roots to reduce or eliminate open
quality cannot be overstated. Restorations which are gingival embrasures.
over contoured, improperly finished or inappro- The bracket slots must be perpendicular to
propriately convex intercrevicular areas can be bac- the long axis of the tooth and not parallel to the
terial plaque biofilm traps and will have adverse incisal edges during bracket placement, espe-
effects on periodontal tissues. Over time, not only cially in adults with grinded incisal edges. It is
papilla, but adjacent gingiva will be adversely important to evaluate the panoramic radiogra-
effected. Restorative treatment requires maintaining phy prior to bracket placement. If brackets are
natural crown proportions, gingival harmony. Addi- placed based on incisal edges, greater root diver-
tionally, care is needed during restoration prepara- gence may cause an open gingival embrasure.
tion not violate the biological width, to avoid food Bonding brackets with slots perpendicular to the
impaction and periodontal inflammation.33 long axis of the teeth will allow roots to converge,
and may require the incisal edges to be restored
or contoured. As roots become more parallel,
Orthodontic approach the contact point will be larger and move apically
Root angulation of the maxillary central incisors is toward the papilla, thus reducing black triangles.
related to open gingival embrasures. Mean root The cervical portion of the crowns of each inci-
angulation in normal gingival embrasures con- sor will move closer, relaxing the papilla (Fig. 7).
verges at 3.65°. When mesial crown form, alveolar Clinicians also should expect a moderate num-
bone interproximal contact, and interproximal ber of adult patients to have divergent crown shape,
184 Pugliese et al
making them more susceptible to black triangles.5 of the two adjacent teeth, keeping the right root
The triangular crown shape results in a more inci- angulation. It will increase the interproximal con-
sally interproximal contact, increasing the roots dis- tact point length with its consequent cervical move,
tance, the length of embrasure area and the decreasing the distance from the crest of the alveo-
distance from the crest of the alveolar bone to the lar bone (Figs. 8 and 9).
interproximal contact point. Accurate diagnosis of Pre-existing anterior crowding seems to be
divergent crown shape is essential so that the appro- related to the presence of black triangles after
priate interproximal contact stripping may be per- orthodontic treatment. Even with no direct associa-
formed. This reduction of interproximal enamel tion, Burke et al.16 affirmed that a black triangle is
(IPR) with the use of diamond strip or discs, is one a frequent sequela of aligning crowded maxillary
effective alternative to reduce the length of black central incisors (Fig. 10). And because of that, it is
triangles. Typically, 0.5 0.75 mm of enamel is very important to inform patients that they may be
removed with IPR.5 Orthodontic closure of the predisposed to have a black triangle following the
space should be attained with a bodily movement incisors level and alignment (Fig. 11).
Figure 8. IPR changing the crowns shape, lengthening interproximal contact with consequent reduction of the
interproximal embrasure area, after incisors bodily mesial movement.
Black triangles: a review 185
Figure 9. (A) Before. (B) After. Black triangle reduction by 0.5 mm IPR and central incisors mesial movement.
Figure 10. Black triangle appearance after crowding correction between teeth 24 and 25. (A) Before. (B) After.
Figure 11. Virtual setup showing the treatment prediction and black triangles appearance after crowding align-
ment. (A) Before. (B) After.
having to manage them. The etiology of black tri- 17. Chang LC. The association between embrasure morphology
angles is multifactorial, but research suggests dis- and central papilla recession. J Clin Periodontol. 2007;34
tance between the alveolar crest and interproximal (5):432–436.
18. An SS, Choi YJ, Kim JY, et al. Risk factors associated with
contact point appear to be the most significant fac- open gingival embrasures after orthodontic treatment.
tor contributing to occurrence. Angle Orthod. 2018;88(3):267–274.
19. Ikeda T, Yamaguchi M, Meguro D, et al. Prediction and
cause of open gingival embrasure spaces btween the man-
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