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Hi AH & NV: Interproximator is in italics throughout the article. Also, these phrases “two thirds” “one half” “one third” do not have a hyphen as per our style, so I changed that in the text. Refs returned from Amanda. THANKS! AJR 12/11/08

Correction of the “Black Triangle”: Restoratively Driven Papilla Regeneration W
David Clark, DDS

hen a clinician faces the difficult aesthetic challenge of the “black triangle” (more appropriately termed “loss of interdental papilla” or “reduced papilla height”), there are many available options. In this article we will first explore a cost effective, minimally traumatic, and predictable approach utilizing the Bioclear Diastema Closure Matrix. Then, we will then briefly review other traditional treatment modalities that are available to resolve this clinical dilemma. Although the focus of this article is papilla regeneration (Table 1), the featured case (Case 1) begins as a restorative treatment. This case (Figures 1 to 17) is selected to demonstrate an important principle: Any restorative procedure involving the interproximal area is a candidate for papilla regeneration.

Figure 1. Preoperative view highlights the failing silicate restorations, accompanied by a blunted papilla or “black triangle.”

Figure 2. Immediate postoperative view.

Because gingiva adapts to a wide range of shapes, clinicians today can create convenient interproximal shapes if the restorations are smooth and without a sharp-marginal ledge.
Figures 1 to 3 demonstrate preoperative, immediate postoperative, and 6-week postoperative views. The patient originally presented with failing silicate restorations on the mesial of the maxillary right lateral incisor and the distal of the right central incisor. This 86-year-old patient requested that only the one interproximal area be treated and that the right canine-lateral area could be restored at a later time. Local anesthetic was administered and a rubber dam was placed. Figure 4 demonstrates modern nonretentive composite preparations with “infinity edge” margins. A new matrix design (Figure 5), the diastema closure matrix (Bioclear Matrix System) allows a smooth (yet aggressive) cervical curvature facilitating direct composite architectures that are extremely conducive to papilla regeneration. This is due to 2 inherent features. The first feature is the

Figure 3. This 6-week follow-up photo demonstrates the favorable response of the papilla to restorative intervention.

Figure 4. Rubber dam placement is not mandatory, but is helpful. The preparations are not “beveled” per se; instead, the correct description is a “saucer” shape with an “infinity-edge” margin.

ability to forgo a traditional wedge and to use the papilla as a wedging force. A traditional wedge creates a flat cervical shape. Flat cervical shapes lack the static pressure needed to regenerate papillae (Figure 6). The second feature is a completely appropriate anatomic shape with exaggerated palatal, interproximal, and facial surfaces. This permits the clinician to simply remove the matrix after photopolymerization with little to no interproximal finishing. When the finish is extremely smooth and there is a lack of a gingival ledge, tissue health can be ideal, even with a very round embrasure form. This modern view of cervical curvature is in sharp contrast to the outdated notion that prosthetic and restorative embrasures should be flat. The case continues with both of the matrices in position (Figures 7 to 10) Total etch remains as the most robust method

when bonding to large enamel areas, especially on uncut enamel (Figure 11).1 There is no need to stabilize the Bioclear matrices since they are designed to be self-stabilizing. Alternatively, a metal matrix can be utilized. However, it must first be hand burnished and annealed over an alcohol torch (not pictured). After placing the bonding agent, a small initial increment of flowable composite (Filtek Supreme Flowable restorative [3M ESPE]) is carefully injected in both teeth to fill this crucial cervical area (Figure 12; light-curing not shown in photos). Advanced magnification is of paramount importance for this step. Advanced magnification has become the standard for optimal soft-tissue response.2 A flowable composite (rather than a paste composite) is preferred for this first increment. A paste composite would be
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Backlit view of matrices with a drop of water used to lubricate their insertion. FEBRUARY 2009 • DENTISTRYTODAY. We have done microscopic study intraorally and on extracted teeth and discovered that an undisturbed interproximal Mylar finish stays mirror-smooth for years. Once the cervical “hips” (or undercuts) are established with the flowable composite (Figures 13 and 14). Backlit view of matrices. Steps 3. oral hygiene habits. Center. it holds its form because of various patented features. Tarnow’s study3 has become a standard in calculation of crestal bone to contact area distance when predicting the stable papilla height. the papilla was present in 100% of samples. even decades. the affected areas are re-prepared with “saucer preparations. the papilla is engaged. Although at first glance the teeth appear somewhat bulky in the gingival one third. CASE 2 Diastema Closure Combined With Papilla Regeneration Figures 19 to 21 demonstrate an interesting case that was treated previously to close a diastema. As the matrix slides into the sulcus. Bonding resin is placed followed with a small amount of flowable composite then followed with paste composite placement. cervical profile (roundness of clinical crown). or preferably no. (Figure 20) The aggressive cervical curvature transitions to a fairly flat shape in the incisal two thirds of the matrix. Sculpting and polishing. 8. and then light-cured. 7. and iatrogenic treatment mishaps. Traditional wedge in position. The regenerated papilla completes the space closure and the static tension of the gingiva against the interproximal tooth surfaces provides a youthful seal. This staged-wedging technique has been employed for some time by the masters in direct composite dentistry. 7. when the matrices are removed. even in an anesthetized patient. In addition to the distance from contact to interproximal crestal bone height. Patient discomfort is a common problem that occurs when traditional wedges are placed near the palate. Bioclear Diastema closure matrices are placed. “on top” of the gingiva.Clark:Clark 12/17/08 1:53 PM Page 49 49 AESTHETICS nearly impossible to place in this “claustrophobic” area without voids. Figure 10. previous trauma. Total etch technique is utilized. 5. 12. the teeth will spring back to establish a snug contact. The act of squeezing a water balloon (Figure 18) mimics the adaptable nature of interdental gingiva. interproximal finishing. showed that when the contact point was within 5. Flowable composite is injected into the cervical area. If defective restorations are present. Facial view of fully-seated Diastema Closure matrices. Teeth are aggressively cleaned with rubber cup and flour of pumice.0 mm of the crestal bone. interproximal areas that the dentist “polished” are often gouged. Because of ideal adaptation and since their precurved shape does not exit the sulcus. Note: For strict papilla regeneration. and stained. and the matrix in turn “squeezes” the papilla. When the distance was 7. If one reviews the literature regarding papilla loss. These lower central incisors were retreated using a new Bioclear DC-UFI (Diastema ClosureUniversal Flat Incisor) matrix. 22 papillae did not return to their original shape––a startling 69% attrition rate! Once a clinician becomes aware of the somewhat fragile yet flexible nature of the interdental papilla. That is because a “Mylarcomposite finish” has no oxygeninhibited layer.COM . The use of the Interproximator is preferred because the soft body of this unique stabilizer/separator will not elicit pain from the palatal gingiva. but it is not well publicized. Gingival edge of matrix is now 3 mm subgingival.0 (Figure 15) is placed to separate the teeth. Figure 6. The patient was extremely pleased with the result. occlusion. Figure 5. Final polish with new diamond impregnated polisher. Once the Interproximator and the matrices are removed. (Figure 21) The postoperative image (Figure 22) demonstrates the significant difference that a specific Diastema closure matrix can provide. and 8 are eliminated as the contact area of the affected teeth is already present. the smooth and extremely durable surface is visible. As is typical with traditional direct composite techniques that rely on Mylar strip matrices. a wedge or Interproximator (bioclearmatrix. Conversely. Figure 8. Table 1. In a classic study. Interproximal areas are aggressively sprayed with high pressure sodium bicarbonate. Paste composite (Filtek Supreme Plus [3M ESPE]) is then placed on top of the previously placed initial layer of cured flowable composite. A small dollop of flowable composite (or bonding resin) can be used before placing the paste to “butter” the restoration in order to avoid seams or voids. the contact may be open. there are other important components that will skew Tarnow’s 5 mm rule in a favorable or unfavorable direction. Many traditional diastema treatments achieve closure with composite (or porcelain) that reaches mesiodistally. the previous composites (Figure 19) did not have adequate cervical curvature to close the gingival one half of the embrasure much less provide a “scaffold” for papilla regeneration. The new goal of composite dentistry is to do little. rough. adult orthodontic treatment. “In the sulcus versus” versus “on the gingiva”: The key in this new technique for diastema closure is to provide aggressive cervical curvature that begins subgingivally. Although the Mylar matrix is very thin (75 µm). The papilla stabilizes the matrix. Once the matrix is removed. 6. There are many factors that determine papilla height. 2. Figure 9. The patient reported Figure 7.4 Of the 32 specimens. Tooth separation is then created with a wedge or Interproximator. Right: The outcome of traditional composite matrices techniques: a “black triangle” results. In reality. eliminating bacterial colonization and debris accumulation. Figures 16 and 17 demonstrate the advantage of anatomically shaped matrices. Otherwise. 11. 6. or as in this case. Bonding resin is placed but not light-cured. host factors. 10. based on 288 patients. these include: root proximity. which has an ideal shape for lower incisors. Palatal view showing anatomic features of the matrix. Light-curing all 3 components of Step 9 together. the papilla was present in only 27% of samples. Clinical Steps for Combined Papilla Regeneration and Diastema Closure. 1. 2 papillae (per patient) were surgically excised from 16 dental student participants. Left: Traditional flat Mylar matrix in position. the art of regeneration can become more commonplace. 9. His study. 4. bleeding is rare. High level magnification throughout the procedure is recommended. once the lower lip was allowed to drape normally against the teeth (not pictured). Bioclear Diastema Closure Matrix with aggressive cervical curvature that transitions rapidly to an anatomic root shape. in mid-tooth. and without disturbing the matrices. 3. the aesthetic result was ideal. just enough to compensate for the thickness of the Mylar.” Infinity edge margins are created with coarse and fine diamonds.

If we are to “do no harm” when doing elective diastema closures. Figure 21. An initial increment of flowable composite is placed and cured. Instead of a traditional wedge. Center: 2mm increment is placed and photopolymerized. the aesthetic diastema closure often results in significant compromises in the root/crown architecture. In addition. at least in the anterior sextant. The dental arches are then essen- Figure 20. combined with the negative effects of the interim prosthesis. Because gingiva adapts to a wide range of shapes. The reaction of the papilla during this process can be . Prosthetic Intervention: Porcelain laminate veneers. Figures 19.5-7 Figures 16 and 17. a soft silicone “Interproximator” is used: it does not elicit the typical discomfort found when a traditional wedge presses against the palatal tissue. a traditional wedge can be inserted to gain tooth separation in order to compensate for the Mylar thicknesses. The dreaded “black triangle” (or gingival diastema) can be a source of significant patient dissatisfaction and even possible litigation. Orthodontic re-treatment is expensive. At this point. clinicians today can create convenient interproximal shapes if the restorations are smooth and without a sharpmarginal ledge. the “unraveling” of incisors will result in a dramatic improvement in the aesDENTISTRYTODAY. Left: Initial increment of flowable is demonstrated on simulation model.” Immediate postoperative view is shown in Figure 21. Occasionally. One option that has been frequently undertaken in the past is to re-treat the case orthodontically. High magnification view of photo shown in Figure 13. The patient requested that the treatment be redone to eliminate the “black triangle. and also facilitate better health of the surrounding gingiva. requires multiple appointments. The new DC-UFI Bioclear matrix has a flatter incisal portion. Note the angle of flowable composite canula. The interdental papilla demonstrates a response very similar to the water balloon.) Gradually. Restoratively driven papilla regeneration should become a viable option for all restorative dentists.. making it an ideal choice for the mesial surfaces of maxillary incisors and for all interproximal surfaces of mandibular incisors. The downside of this method of treatment can be significant. Figure 15. Ethics and Diastema Closure Many aesthetic procedures that we routinely provide can actually improve the structural integrity of the tooth. or with a highspeed handpiece and diamond burs. the soft silicone “Interproximator” is used instead: it does not elicit the typical discomfort found when a traditional wedge presses against the palatal tissue. poised to begin injection.Clark:Clark 12/17/08 1:54 PM Page 50 50 AESTHETICS Xxxx. often fails to provide either of these secondary benefits. are a proven and successful solution. Diastema closure. Highly magnified views from facial and palatal views. Previous diastema closure is seen in Fig 19 with unacceptable contour in gingival half.COM • FEBRUARY 2009 thetics of tooth position. Figure 11. Traditional Treatment Modalities for Correction of Gingival Diastema (Black Triangle) Orthodontic Treatment or ReTreatment: Many adult orthodontic cases are undertaken to correct the problem of crowding. The loss of tooth enamel when the contact areas are stripped can be significant and is irreversible. Figure 14. tially “collapsed” to approximate the roots. infinity edge margins and the complete elimination of the black triangle. Figure 12. and actually felt smoother than her natural tooth surfaces. A finger can be lightly rested against the matrices during rinsing. this is often followed by increased caries activity.) Figure 18. DISCUSSION Natural interproximal embrasures are constructed with a wide range of cervical shapes and varying root proximities. Note the invisible. However. Consequently. When pressure is applied to certain areas of a water balloon. the interdental papillae are compressed. we must elevate our game.. the balloon simply swells elsewhere. Tables 2 and 3 highlight a magnification-based approach to the multiple factors that determine the gingival reaction to prosthetic and restorative intervention into the sulcus and pericrestal zones. It can also contribute to increased plaque retention with subsequent deterioration in periodontal health. and can come with potential compromise in tooth position and arch size. the act of tissue retraction. (Similar to the “water balloon effect” described earlier in the article. One will observe that a bulbous contour is far less detrimental than other often ignored and clinically unseen factors. (Note the untouched Mylar finish in the interproximal. Bridge abutments and exotic implant emergence profiles have aptly demonstrated this clinical reality. Sadly. will cause an untoward tissue response. can negatively impact the outcome. continued from page 3 important improvements: • Elimination of the dark space • Elimination of food impaction • The highly polished composite surface (Jazz composite polishers [SS White]) attracts less plaque than the previous large embrasure space. or full-coverage porcelain crowns. The affected teeth are aggressively stripped in the interproximal areas with lightning strips.2 Any discrepancy greater than 50 µm. Right: For educational purposes only: The matrix is removed and the ivorine tooth is partially extruded to demonstrate cervical shape and impeccable marginal integrity. time consuming. Often times. but with the unfortunate side effect of blunted papillae. Figure 13. however in this case (as in most cases) the matrices did not need to be braced during rinsing and drying steps. the papillae swell (or “creep”) incisally and engage the contact area. Gel-etch in use.

This image depicts a high magnification view at the 2-week follow up. 1986. The reader is strongly cautioned that to attempt this elective procedure without using magnification and appropriate materials may not be in the patient’s best interest. Fletcher and lifetimedentistry.94:109-114. Once again. Scand J Dent Res. Anatomically ideal interproximal composite shapes can serve as a predictable scaffold to regain this valuable gingival architecture. Compend Contin Educ Dent. Residual cement and calculus apical to finish lines 2. Microroughness and porosities of porcelain or composite 4. and dental operatory design. including the Endo-Restorative Casting.29:208-215. Gingival and alveolar bone reaction to marginal fit of subgingival crown margins. injection-molded-composite-filling technique is new. He has developed numerous innovations in the fields of micro dental instrumentation. 5. He is a course director at the Newport Coast Oral Facial Institute in Newport Beach. A rationale for comparison of plaque-retaining properties of crown systems. 1.! References 1. The potential also exists for papilla health to become compromised. Magnification Based Protocol for Margin Evaluation of Porcelain or Composite. Previous attempts at both diastema closure and papilla regeneration using direct composites often ended with significant compromise in periodontal health. CONCLUSION Until now. Slowly. 4. and an associate member of the American Association of Endodontists. Parameters to be Combined with Factors from Table 1 to Maximize the Total Potential for Tissue Health. A 1986 graduate of the University of Washington School of Dentistry.63:995-996.53:181-192. 2008. Dennis Shanelec. Larsen IB. Sorensen JA. Microsurgical Papilla Regeneration Procedures: Masters of periodontal microsurgery (Drs. Calif. Morphology of the interdental papillae. This extremely rounded.62:264-269. Unsightly cyanotic and engorged tissues can be the end result. De Vree HM. 1965. 3. microprosthodontics. Sub Short Under-Contoured Emergence Profile Plus Long Rounded Emergence Profile Table 3. and Adrianna McGregor. Clark DJ. Figure 22. Table 2. technics and their biologic reactions. microperiodontics.96:116-126. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Wash. Clark is proud to join with Clinical Research Associates in the “Update Series” lectures and also to participate in the important research at their world class facility in Oral Health. an international association formed to advance the science and practice of microendodontics. there were very few dedicated tools or techniques for restoratively-driven papilla regeneration. retrain their hands and minds. Disclosure: Dr. He lectures and gives hands-on seminars internationally on a variety of topics related to microscope-enhanced dentistry. J Periodontol. 2006. Sorensen SE. nontreatment or referral would then Dr. In a worst case scenario. he can be reached at drclark@microscopedentistry. Hilgert LA. technological advancements allow us to perform techniques that were previously unthinkable. 1992. or even worsens. Optimizing gingival esthetics: a microscopic perspective. unpredictable. the “black triangle” remains. He is also developing new techniques and materials to better restore endodontically treated teeth. However. De Boever AL. J Prosthet Dent. He is co-director of Precision Aesthetics Northwest in Tacoma. et al. 2. J Periodontol.36:455-460. Magner AW. Periodontal aspects of cementation: materials. Dr. 1998. 7.COM . Adhesive procedures in daily practice: essential aspects. Rev Belge Med Dent. which are the hallmarks of optimal tissue health. Tarnow DP. ie) have demonstrated very acceptable outcomes from utilizing this exotic procedure. Note the excellent color and texture of the papilla. 1989. Kim J. Root roughness from errant bur movements 3.Clark:Clark 12/17/08 1:54 PM Page 51 51 AESTHETICS be recommended. imaging. Utah. Microleakage continued on page XX FEBRUARY 2009 • DENTISTRYTODAY. 6. and accept this clinical evolution in restorative dentistry. Peter Nordland. Jorgensen KD. the profession will change their thought patterns. this incredibly “nuanced” procedure is really beyond the scope of most general and periodontal specialty practices. Lopes GC. Clark founded the Academy of Microscope Enhanced Dentistry. The interdental papilla serves as both an aesthetic and functional asset. Clark has a financial interest in the patented Bioclear matrix system. De Boever JA. Araujo E. Holmes CH. and microdentistry.

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