Black triangle Management Journal Presentation

P. Ziahosseini, F. Hussain and
B. J. Millar
MANAGEMENT OF
GINGIVAL BLACK
TRIANGLES
21st NOVEMBER 2014

AIM
This review covers the surgical and non-surgical management of
Gingival black triangles (GBTs).
This review also covers the aetiology and management of GBTs,
highlighting the importance of considering the options currently
available when treating a lost dental papilla.

INTRODUCTION
The interdental papilla is an important component in an
aesthetic smile and its loss may result in a gingival black
triangle (GBT).
These spaces can also cause phonation problems as well
create space for food and plaque accumulation.
A unilateral papillary height reduction of 2 mm was
considered to be unattractive. Kokich et al, demonstrated
that patients and dentists found black triangles greater
than 3 mm less attractive.
Limited blood supply to the papilla is always an issue in
the tissue’s reaction to any trauma or intervention. Low
blood supply to interdental papillae makes them very
fragile and sensitive to recession, which makes restoring
the receded papillae unpredictable.

AETIOLOGY OF GBT’S
It is multifactorial. Papillae dimension can be changed due
to any of the following reasons:
1. Inter-proximal space between teeth
2. The distance between inter-proximal contact position to
bone crest
3. Gingival biotype
4. Patient’s age
5. Periodontal disease and loss of attachment, resulting in
recession
6. Diverging roots, which can follow orthodontic
treatment
7. Tooth morphology and abnormal crown and restoration
shape.

INTER-PROXIMAL SPACE BETWEENTEETH

DISTANCEBETWEENINTER-PROXIMAL
CONTACTPOSITIONS TO ALVEOLAR BONE
CREST

GINGIVAL BIOTYPE
Siebert and Lindhe classified the biotype into ‘thin and
scalloped’ and ‘thick and flat’ biotypes.
Becker et al. classified biotype into three groups: flat,
scalloped and pronounced scalloped.
Flat biotype is considered more favourable to achieve
papillae fullness than scalloped.
Restricted blood supply at the papillae tip can interrupt
healing resulting in unpredictable repair, whereas thicker
tissues respond more favourably due their increased
vascularity, which cope better with the inflammatory
response.

Differences may be explained by the methods for
qualifying thick or thin periodontium as these are often
subjective: a periodontal probe in the sulcus can be used
to differentiate between biotypes while others concluded
that trans-sulcular probing was more accurate compared to
visual examinations.

PATIENT AGE
Systemic health such as osteoporosis as well as age have
been suggested as generalised risk factors for presence of
GBTs. Ageing results in thinning oral epithelium and
reduced keratinisation, which can result in reduced
papillae height. This is mainly due to a slower rate of
wound healing.

PERIODONTAL DISEASE AND
LOSS OF ATTACHMENTS AND
BONE
Marginal inflammation contributes to the loss of inter-
dental papillae.
Novak et al, demonstrated how the biological width
increases as a result of severe, generalised chronic
periodontitis, leading to loss of papillae.

DIVERGING ROOTS AND POST-
ORTHODONTICTREATMENT
Orthodontic movement of crowded anterior teeth can
separate the roots and stretch the inter-dental papilla,
increasing the presence of GBTs between incisors after
orthodontic treatment.

TOOTH MORPHOLOGY
The incidence of GBTs in square shaped teeth is less than
triangular shaped teeth. Although triangular shaped teeth
have divergent roots with thicker inter proximal bone,
which result in less bone loss compared to square-shaped
teeth.
This was considered to be due to a shorter inter-proximal
distance from the osseous crest to the free gingival margin
in square-shaped teeth compared to triangular-shaped
teeth.

CLASSIFICATION OF GBTS
Nordland & Tarnow introduced a classification for
papillae loss based on three identifiable anatomical
landmarks:
•The inter-dental contact points (IDCP)
•The facial apical extent of the cemento-enamel junction
(CEJ)
•The interproximal coronal extent of the CEJ

Based on these, the papillae loss was described as:
•Normal: The tip of papillae extends to the apical of IDCP.
•Class 1: The tip of the papillae presents between IDCP
and the most coronal extent of inter proximal CEJ.
•Class 2: The tip of the papillae presents at or apical to the
inter proximal CEJ but coronal to the apical extent of the
facial CEJ.
•Class 3: The tip of the papillae presents level with or
apical to the facial CEJ.

Nemcovsky introduced a classification system as papillae
index score (PIS) based on a comparison with adjacent
teeth:
•PIS 1: Presence of no papillae and no soft tissue
curvature
•PIS 2: Present papillae height is less half than the present
papillae in adjacent teeth within a convex curvature of the
soft tissue
•PIS 3: Presence of at least half the papilla that was not
similar with the inter-dental papillae of the proximal teeth
and there is no complete harmony with the interdental
papillae of the proximal teeth
•PIS 4: Papilla completely fills the inter-proximal
embrasure to the same level as in the adjacent teeth with a
complete harmony with the adjacent papillae.

MANAGEMENT
Surgical approaches
Seibert & Lindhe classified papillary surgical techniques
into: releasing, reflecting and stabilising the papillae.
More recently Kotchy & Lacky introduced modified
papilla preservation flap (MPPF) and simplified papilla
preservation flap (SPPF) in combination with enamel
matrix proteins (EMP) increase protein production in
human periodontal ligament cells and acellular
dermal matrix allografts have also been used.

Tissueengineering
This approach may be less invasive in rectifying the
presence of GBTs.
Gerus et al. performed a study including a surgical
approach in combination with the use of an injectable
regenerative acellular dermal matrix into insufficient
papillae at the same time as the surgery. The report was
highly statistically significant, improvement in papilla
restoration was seen after 5 months.

The injection of periodontal cells with pluripotential
capabilities has been used, with fibroblasts in particular to
treat both oral and skin defects.
One randomised, double blind, placebo-controlled study
showed considerable improvement in regaining the lost
interdental papilla after injecting extracted fibroblasts
harvested from the tuberosity.

Tissuevolumising
Hyaluronic acid (HA) is frequently used as a soft tissue
volumiser in facial tissue rejuvenation.
Based on this, Becker et al. evaluated the use of HA to
reduce or eliminate GBTs adjacent to dental implants and
teeth in the aesthetic zone.
There was high level of patient satisfaction as all subjects
found the whole procedure painless.

Reshaping and restoring
tooth shape
The contour of a restoration is important and can affect
the papillary space.
A convex crown can affect the biologic and morphologic
features of the interdental gingiva and the scalloped
outline of the gingival margins.
Modifying the GBTs by direct adhesive restoration is a
non-invasive, viable and affordable option.

Using pink restorative
materials to mask the GBTs
Composite resin is available in pink shades for gingival
reproduction.
It can be used on restorations to replace missing soft
tissue. It is considered to be more realistic than pink
porcelain in similar situations.
Although pink porcelain can mask the loss of inter-dental
papilla, the shades and optical properties are limited and it
is often better to use darker tooth shades instead.

Gingival reproduction on an implant retained prosthesis
using gingival coloured composite resin
(Gradia Gum GC)
Darker shade ceramic used on crowns to aesthetically
close a large GBT (Courtesy of Dr Chris Ho, Sydney)

Gingival veneer
Removable acrylic or silicone can be used as a gingival
veneer to mask GBTs.
This removable prosthesis can also be used to cover the
exposed root surfaces due to advanced bone loss
especially in patients with a high smile line and to prevent
food impaction and phonetic disability.
The retention of the removable veneer into inter-proximal
areas that can be achieved by using the gaps as retention
grooves or incorporating slotted attachments into the
prosthesis.

Poor oral hygiene and limitation in manual dexterity are
the primary contraindications.
Different terminology is used to describe these appliances:
flange prosthesis, gingival veneer prosthesis, removable
gingival veneer, acrylic gingival veneer, acrylic
periodontal veneer, removable gingival extension and
gingival mask.

Orthodontic movement
Closing the interdental contacts by conventional
orthodontic movement with or without inter-dental
stripping reduces the BC-CP distance.
Salama H and Salama M suggested that paralleling
closed roots with orthodontic movements may be
beneficial in supporting the inter-dental papillae.

Burke et al. recommend bringing the roots closer by
mesial torquing movement to rectify presence of GBTs.
Along with orthodontic treatment, proximal enamel can
be recontoured to change the contact area to a broader
surface along with relocating the contact more apically.
Extrusive and intrusive tooth movement can maintain
the alveolar bone level and reduce GBTs.

CONCLUSION
GBTs are caused by lack of presence of the inter-dental
papillae, which is multifactorial including the position of
the alveolar crest and the teeth.
Management can be done by invasive and non invasive
techniques. Repeated curettage to stimulate the regrowth
of interdental papillae in necrotizing ulcerative gingivitis
was advocated by Shapiro et al.
Surgical management along with PRF shows better results
and its now used in injectable form with same properties
as i-PRF in tissue regeneration.

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