Esthetic Considerations in Interdental Papilla:

Remediation and Regeneration jerd_307 18..28

ANITA ANGELA SHARMA, DMD, DHSc*

JAE HYUN PARK, DMD, MSD, MS, PhD†‡

ABSTRACT
This article reviews the etiology and treatment of open gingival embrasures or black triangles.
An open gingival embrasure or black triangle occurs as a result of a deficiency of papilla
beneath the contact point. The treatment of open embrasures may require restorative, ortho-
dontic and periodontal considerations depending on the underlying etiology. The authors
reviewed a total of 42 articles including review of literature, radiographic, cross-sectional, and
retrospective studies in Ovid search engine using the terms “open gingival embrasure,” “inter-
dental papilla,” and “black triangle.” The studies provided information regarding etiology,
diagnosis, and treatment of open embrasures. There are several risk factors leading to the
development of open gingival embrasures. These 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. Treatment
of open embrasures requires an interdisciplinary approach of orthodontic, periodontic, and
restorative treatment.

CLINICAL SIGNIFICANCE
Open gingival embrasures are complex esthetic and functional problems. An interdisciplinary
team approach with the general dentist, orthodontist, and periodontist is critical. Management
of open embrasures requires careful evaluation of the underlying etiology.
(J Esthet Restor Dent 22:18–30, 2010)

INTRODUCTION are a common occurrence. Black health of the periodontium.1

triangles occur in more than one- Understanding the underlying etiol-

P reserving papilla in the gingival

embrasure of the esthetic zone
is a key consideration in restorative
third of adults and therefore,
should be discussed with the
patient prior to initiating dental
ogy and customizing patient treat-
ment is essential to reducing the
frequency and severity of open gin-
and orthodontic treatment. Today, treatment.1,2 Not only are black gival embrasures. Gingival embra-
with an aging adult population triangles unesthetic, but they also sure is defined as the embrasure
with a history of periodontal contribute to retention of food cervical to the interproximal con-
disease, open gingival embrasures debris, and can adversely affect the tact.2 It is open if the embrasure

*Former postgraduate orthodontic resident, Postgraduate Orthodontic Program,

Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA
†
Associate professor and chair, Postgraduate Orthodontic Program,
Arizona School of Dentistry & Oral Health, A.T. Still University, Mesa, AZ, USA
‡
International scholar, the Graduate School of Dentistry, Kyung Hee University, Seoul, Korea
Anita Angela Sharma is now in private practice in Calgary, Canada

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18 DOI 10.1111/j.1708-8240.2009.00307.x VOLUME 22, NUMBER 1, 2010
 S H A R M A A N D PA R K

Figure 1. Open gingival embrasure between the maxillary Figure 2. Interdisciplinary approach to addressing black
central incisors is an esthetic problem. triangles. Restorative, periodontal, and orthodontic
treatment are all involved when treating black triangles.

could account for the higher

prevalence in adults.2

Esthetically, open gingival embra-

sures can affect a patient’s smile.
In one study,4 orthodontists rated a
2-mm open gingival embrasure as
noticeably less attractive than an
ideal smile with normal gingival
embrasure. Open gingival embra-
sures slightly greater than 3 mm
were considered less attractive by
both general dentists as well as the
general population. It is important
to note that open embrasures are
visible and do not go unnoticed.
Corrective action should be taken
Figure 3. Hierarchy of risk factors for black triangle. to minimize or prevent open
Increasing levels of the pyramid pose a greater risk for
black triangles. embrasures. Restorative, periodon-
tal, and orthodontic treatment
space is not completely filled by adolescent population and 41.9% planning can play a significant role
the gingiva (Figure 1). Open gingi- in adolescent patients who are in the closure of gingival embra-
val embrasures are more common treated for maxillary incisor sures (Figure 2).
in the adult population and occur crowding.3 Open gingival embra-
in 38% of the adult orthodontic sures are associated with periodon- The etiology of open gingival
patients.1 Open gingival embra- tal disease, periodontal surgery, embrasures is multifactorial. Poten-
sures occur in 15% of the general and orthognathic surgery, which tial causes include dimensional

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changes of papilla during ortho-

dontic alignment, loss of periodon-
tal attachment resulting in
recession, loss of height of the
alveolar bone relative to inter-
proximal contact, length of embra- A B C
sure area, root angulations,
Figure 4. Paralleling divergent roots will decrease a black
interproximal contact position, triangle. A, Divergent roots with open black triangle.
and triangular-shaped crowns B, Bracket positioning to follow long axis of the tooth and
(Figure 3).5 The interproximal correct black triangle. C, Converged roots with closed
black triangle after orthodontic treatment.
contact between the maxillary
central incisors is composed of the
actual tooth contact and soft tissue gingival embrasures converge at the papilla.7 The crowns of each
papilla. Open embrasures are 3.65° and an increase in root diver- incisor will move closer, causing
found to be age related. Studies2,6 gence by 1° raises the probability the stretched transeptal fibers to
have shown that patients over 20 of an open gingival embrasure relax and fill in the gingival
years of age are more susceptible from 14 to 21%. With orthodontic embrasure.8 This will reduce the
than people below 20 years of age. treatment, maxillary incisor roots probability and severity of
Open embrasures were found in could be paralleled to reduce or open embrasures.
67% of the population over 20 eliminate open gingival embrasures
years of age compared with 18% (Figure 4). Diverging roots can be Patients with triangular crown
in the population under 20 years caused by improper bracket place- morphology are more susceptible
of age.2 This is because of the thin- ment. In adults with worn incisal to open embrasure spaces
ning of oral epithelium, decrease in edges, the bracket slot must be per- (Figure 5A). The crowns of the
keratinization, and reduction in pendicular to the long axis of the central incisors can be much wider
papilla height as a result of aging. tooth and not parallel to the incisal incisally than cervically, resulting in
Age is a significant risk factor edges. It is important to review the an abnormal contact position.
leading to wide and long embra- periapical radiograph prior to Interproximal contact between
sure spaces in adults. Embrasure bracket placement, especially in central incisors is located at the
morphology also plays a role in patients with attrition.7 Bonding incisal 1 mm of the crown. Inter-
the occurrence of central papilla. based on incisal position will result proximal reduction (IPR) of
Black triangles occur increasingly in greater root divergence, contrib- enamel on triangular crowns will
in short narrow, long narrow, uting to an open gingival embra- convert a point contact to a
long wide, and short wide sure. Bonding the bracket so that broader contact area that will
embrasure morphologies.6 the slot is perpendicular to the reduce open gingival embrasures
long axis of the tooth will allow (Figure 5B,C). One method for cor-
O R T H O D O N T I C C O N S D E R AT I O N S roots to converge, and may require rection of the black triangle is the
Divergent roots have a strong asso- the worn distoincisal edges to be reduction of interproximal enamel
ciation with open gingival embra- restored. As roots become more with a reducing diamond strip to
sures. One study1 showed that parallel, the contact point will recontour the mesial surfaces of
mean root angulations in normal lengthen and move apically toward the central incisors (Figure 6).

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A B C
Figure 5. Triangular crowns can be reduced interproximally and the space closed to reduce open embrasures. A, Patient
with triangular crown morphology. Reducing black triangle by changing point contact (B) to a broader surface (C) by
interproximal reduction. Orthodontic space closure and soft tissue filling the gingival embrasure.

A B C

Figure 6. Reduction of black triangle with interproximal reduction. A, Point contact with black triangle present between
central incisors. B, Interproximal reduction with medium diamond strip. C, Posttreatment. Complete fill of soft tissue in
gingival embrasure by closing space and creating a broader contact that is closer to the alveolar crest.

Typically, 0.5 to 0.75 mm of the contrast, moving a tooth labially incisor may be placed palatally or
enamel is removed with IPR.9 IPR will cause the tissue to thin and labially, relative to the other incisor
and space closure will lengthen move apically.10 Therefore, patients (Figure 7). Interestingly, maxillary
the contact point and move the with a Class II Division 2 maloc- incisor imbrication and rotation
contact gingivally. clusion would be more prone to have a controversial association
open gingival embrasure spaces with open gingival embrasure
Gingival embrasures are affected than Class II Division 1 with flared spaces.1,3,10 Orthodontists are rec-
by the direction of tooth move- incisors. Labial movement of pala- ommended to inform patients with
ment and by the labiolingual thick- tally placed and imbricated teeth imbricated maxillary incisors that
ness of the supporting bone and may also be predisposed to they may be predisposed to an
soft tissue, following orthodontic gingival recession following open gingival embrasure following
treatment. During lingual tooth orthodontic treatment. orthodontic treatment.
movement, the gingival tissue will
thicken and move occlusally on the Imbricated incisors are arranged in Severity of crowding plays only a
facial aspect of the tooth. In an overlapping manner so that one minimal role in open embrasures.

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A B

C D

Figure 7. Imbricated incisors have been associated with black triangles. A, Mesially rotated-out overlapping maxillary
incisors initially. B, Orthodontic movement will require lingual movement of the mesial of the maxillary central incisors
and, therefore, has a lower probability of black triangles. C, Mesial rotated-in overlapping maxillary incisors initially.
D, Orthodontic movement will require labial movement of the mesial of the central incisors that has been linked to
black triangles.

Ko-Kimura et al.2 found that open The volume of soft tissue in the additional orthodontic and/or
embrasures occurred in a similar gingival embrasure will depend on restorative treatment.
percentage of patients with incisor existing tissue, bone levels, and the
crowding of less than 4 mm and severity of the diastema. Closing a P E R I O D O N TA L C O N S I D E R AT I O N S

those with 4 to 8 mm of incisor diastema orthodontically will com- Periodontal disease has been asso-
crowding. When crowding was press the soft tissue to come ciated with loss of the interdental
more than 8 mm, the occurrence together and fill in the embrasure papilla because of alveolar bone
of open gingival embrasures area (Figure 8). Minor diastema loss. Although the occurrence of
increased by 7%. However, closure during the retention phase plaque and gingivitis is probably
these results were considered can be simplified with a removable higher in people with crowding,
insignificant. In addition, duration orthodontic appliance (Figure 9). host susceptibility and other
of orthodontic treatment However, large diastema factors may also play a role in
had no effect on open closure may result in an open open embrasures, especially in
gingival embrasures. gingival embrasure requiring patients who have been previously

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Esthetic Considerations in Interdental Papilla: Remediation and Regeneration

B C
Figure 8. Diastema closure and regeneration of papilla. A, Pretreament with diastema. B, Orthodontic closure of space.
C, Formation of papilla to fill gingival embrasure.

A B C

Figure 9. Limited orthodontic treatment to close a diastema. A, Pretreatment with diastema. B, Modified maxillary
Hawley retainer with extended arms. Elastics (3/8⬙, 3.5 oz; 3M Unitek, Monrovia, CA, USA) are worn across the teeth
from right arm to left arm of the retainer. C, Posttreatment after 4 weeks of treatment.

treated for periodontal disease. A distance of 5 mm from the than 3 mm will lead to increased
Increased periodontal maintenance alveolar crest to contact point is plaque retention, inflammation,
and oral hygiene is very important considered periodontally healthy.11 and recession.11 In periodontal
to prevent bone loss and recession. However, pocket depths greater disease, it is the loss of bone that

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A B
Figure 10. A, The distance of alveolar crest to contact point (white) is critical in determining the presence of an open
embrasure. A distance greater than 5 mm is associated with black triangle. B, Summary of several studies measuring the
distance from alveolar crest to contact point. Increasing distance will increase the frequency of an open embrasure.

increases the distance between papilla was missing in most of the cleaning should be discontinued
contact point and alveolar cases. At 6 mm, papilla was until the tissue can recover.14
crest, resulting in an open present in half of the cases.7 Other Currently, there are no predictable
gingival embrasure. studies7,13 have shown similar surgical procedures to augment
results (Figure 10B). Adult patients papilla.15–21 Surgical papillary
The distance from the base of the with open gingival embrasures reconstruction may result in con-
contact point to the alveolar crest have increased alveolar bone– traction and necrosis of the grafted
in central incisors is a strong indi- interproximal contact distance of tissue. The unpredictability is
cator of open embrasures 5.5 mm or more.1 A 1-mm increase because of tissue fragility and low
(Figure 10A). A classic study by in distance between the alveolar blood supply to interdental papilla.7
Tarnow et al.12 found an associa- bone and interproximal contact However, case studies22,23 have
tion between black triangles and increases the probability of an demonstrated some success with
the distance of the contact point to open gingival embrasure by 78 to subepithelial connective tissue
the alveolar crest of the bone. 97%. As a rule, a distance between grafts and orthodontic therapy.
Another study observed that a dis- 5 and 6 mm from contact point to Flap pedicles have shown better
tance of 5, 6, and 7 mm resulted in alveolar crest is most critical and results than free gingival grafts.7
an open embrasure in 2, 44, and determines the presence or absence For surgical success, it is important
73% of the cases, respectively.7 of an open gingival embrasure.7 that there is the presence of a thick
These observations indicate that, if biotype gingiva and there is no loss
the distance from the alveolar crest Chronic periodontitis and tooth- of insertion at the periodontal
to contact point was 5 mm or less, brush trauma may also cause open attachment.14 Patients with a thin
papilla was present in almost embrasures. If the loss of papillary biotype of gingiva are more
100% of the cases. However, when height is because of trauma during susceptible to recession and there-
the distance was more than 7 mm, tooth brushing, interproximal fore, to open gingival embrasures.

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Patients with thin periodontium are

Connector
shown to have long narrow upper
Contact
central incisors, whereas patients
50% 40% 30%
with a thick biotype have short and
wide central incisors.24 In addition,
the thick periodontal biotype has a
thick osseous structure with flat
morphology and a thick gingival
tissue with short wide papilla. In Figure 11. Connectors and interproximal contact.
Connectors (red) are where teeth appear to meet. Contact
contrast, the thin biotype is charac- (blue) between teeth is where they actually meet.
terized by a scalloped appearance Appropriate ratio for a connector between maxillary
with long interdental papilla.25 central incisors is 50% of central incisor height, ratio
between central–lateral connector is 40% of central incisor
Typically, the thick biotype has a height, and ratio between lateral–canine connector is 30%
better vascular supply and biologi- of central incisor height.
cal tissue memory that helps the
tissue to rebound, whereas the thin interdental tissue or harbor plaque. height will have longer connectors.
biotype usually results in perma- Typically, maxillary central incisors Also, embrasures are smaller
nent recession.20 Interdental gingi- have an 80% width : height ratio, between the central incisors and
val recession may occur, causing which is considered ideal. Restor- increases progressively toward the
reduced height and thickness of the ative treatment alone to reduce a posterior. To hide severe tissue
free gingiva, with a resulting long large space may result in diver- defects, application of pink-colored
clinical crown. This recession is gence of this ratio, resulting in an porcelain or a removable appliance
precipitated by plaque and tooth- unsatisfactory treatment outcome. is recommended.12 A comprehen-
brush trauma. Nontraumatic A combination of orthodontic sive understanding of anterior
plaque control is recommended and restorative treatment may esthetics is critical in
for patients susceptible to be required. determining the
black triangles.10 appropriate treatment.27–31
Restorative treatment requires
R E S T O R AT I V E C O N S I D E R AT I O N S maintaining an appropriate ratio of Single tooth implants have a sig-
There are several considerations in crown height between connector nificant chance of papilla loss
planning restorative treatment for and central incisor. The connector because of increasing distance from
large open embrasures. Mesiocervi- is where teeth appear to contact, the contact point to the alveolar
cal restorations or veneers will the contact point is where the teeth crest.32–37 To preserve implant
reduce the appearance of open actually connect. The connector of papilla, it is important to keep the
embrasures by altering the crown maxillary anterior teeth has a pro- distance from the contact point to
form. The composite resin can be portional relationship to the height bone level at 5 mm or less. The
inserted into the gingival sulcus to of the central incisors (Figure 11). distance of adjacent natural tooth
guide the shape of the interdental The ratio of connector to tooth to the alveolar crests is most
papilla, much like a provisional height for the central, lateral, and critical, whereas the height of the
crown for an implant. Care must canine is 50, 40, and 30%, respec- implant contact to the bone is less
be taken not to impinge on the tively.26 Teeth with greater crown important.32 Choquet et al.33

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A B C

Figure 12. Extrusion of the maxillary right lateral incisor to maximize bone and soft tissue prior to implant placement.
A, Mobility and devitalized maxillary right lateral incisor as a result of trauma was the treatment planned for extraction
and implant. B, A thermoformable plier can create buttons on the buccal of a clear aligner tray to provide attachments
for elastics. C, A button is bonded to the maxillary right lateral incisor for extrusion. The patient is instructed to wear
an elastic from the mandibular clear aligner to the maxillary lateral incisor. The patient returns every 2 weeks for
incisal reduction of the lateral to allow further extrusion.

showed the presence of papilla at Jemt38 found that the volume of implants is found subcrestally
100 and 50% level in healthy teeth soft tissue around anterior single instead of supracrestally, as is the
when the distance from the alveo- tooth implants can be expected to case in natural teeth.29 Ideally,
lar crest to the contact point of undergo soft tissue shrinkage on maxillary anterior implants should
single implant in the maxillary the buccal; however, there is an be 4 mm apical to the alveolar
anterior was at 5 and 6 mm, increase in soft tissue volume in crestal bone. Furthermore, to
respectively.28 Above 7 mm, a sig- 80% of cases after 1.5 years. Simi- prevent bone loss and subsequent
nificant increase in black triangles larly, Grunder et al.39 demonstrated papilla loss, it is important that the
was observed.24 Some clinicians a 0.375-mm increase in soft tissue distance between two adjacent
believe that tissue healing around volume after 1 year, although implants exceeds 3 mm.32 This
an immediate provisional abutment 0.6 mm of soft tissue shrinkage allows the interproximal bone to
helps in proper tissue contouring. occurred on the buccal side of the be maintained above the implant
Ryser et al.32 has demonstrated that implant crown. In order to com- shoulder. In the anterior region,
there is no difference in papilla loss pensate for the buccal soft tissue it is difficult to obtain this ideal
if an implant has immediate provi- shrinkage, the implant clinical mesio-distal distance. One method
sionalization. Extrusion of a tooth crown length should be 0.5 to for compensating the loss of inter-
prior to implant placement will 0.75 mm shorter at the time of proximal bone is to augment the
allow the bone to extrude with the crown insertion. buccal bone in the papillary
tooth, resulting in an increase of area.41,42 However, a distance
soft tissue. Tooth extrusion can be Black triangles are even more greater than 3 mm will not ensure
performed with intermaxillary elas- pronounced when two adjacent a complete papilla. There are
tics and a clear removable appli- implants are placed. This soft several considerations that may not
ance (Figure 12).36 However, tissue deficiency of 1 to 2 mm allow papilla regeneration but may
previous tissue loss prior to arises from the biological width help prevent additional interproxi-
implant placement will usually around an implant being apical to mal bone loss. Placing two adja-
result in an open embrasure the platform for the abutment.40 As cent implants in an esthetic zone
following final restoration. a result, the biological width of should be avoided to prevent bone

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CONCLUSION
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DISCLOSURE
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