Aesthetic Solutions for Treating Black Triangles: Avoiding the Smile Killer
Nothing will ruin a beautiful smile design more than having black triangles post-cementation. To avoid this smile killer, it’s crucial that careful treatment planning factors are considered. Here are some aesthetic solutions for treating black triangles.
Considerations for Treating Black Triangles
Gingival aesthetics are often overlooked when planning a smile design, yet they can greatly impact your outcome. Identifying deficiencies in papilla symmetry is the first step. Varying gingival zeniths, blunted papillae, or existing restorations that are modifying tissue position and health are important in managing our patients’ expectations. Existing blunted papillae is the most difficult deficiency to correct. Soft tissue remodeling through laser contouring or crown lengthening can vastly improve your results.
Identifying the position of desired papilla compared to final incisal edge position determines if closing the black triangle will result in a “long contact” or aesthetic appearance. This requires numbing your patient and sounding bone. A good reference for this is information presented in a study by DP Tarnow.
By measuring the distance from the crest of bone to the planned contact point, Tarnow’s study found that when this measurement 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. When the distance was 7 mm or more, the papilla was present 27% of the time or less. The rule of thumb I use is 4mm so that I know we’re golden.
Aesthetically, the length of the tooth should be split between the papilla and the contact. The papilla will ideally fill 50% of the contact zone between the two maxillary central incisors. As you move more posterior, the papilla gets shorter and wider. If you can achieve this then you will achieve a natural looking result. It is important to develop ideal prep design to support the papillae filling the embrasure space.
Preparation Design is Key to Close Black Triangles
One of the challenges of closing black triangles or a gingival embrasure space with a veneer or all ceramic crown is not creating ledge interproximally with the preparation. The preparation must continue through the contact points of the teeth. This is called a “slice” preparation.
In addition to giving the technician adequate room to close the space without leaving a ledge, the preparation margin must be taken far enough subgingivally in the interproximal areas without violating the biologic attachment. The gingival margin of the preparation should mimic the ginigival profile. It should be higher interproximally than it is on the facial to avoid violating the biologic attachment.
To communicate the contact with the laboratory, sound bone interproximally to the preparation margin. Note the distance the margin is from the proximal bone, then tell the lab how many millimeters incisal to the margin the contact point should be created. This contact point should be made 4-4.5 mm from bone. Keep in mind that the papilla will fill to the highest point of bone, so it is important to sound both teeth in the proximal zone.
What is your favorite clinical technique to ensure gorgeous smile design or for treating black triangles? We’d love to hear from you in the comments!
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Very helpful..Thank you Dr Nosti!
Thank you Dr Olitsky.!:)