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Continuing Dental Education

INJECTION MOLDING

Direct Restorative
Solutions for Black Triangles
Jihyon Kim, DDS
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ing in this publication are those of the author(s) and do not
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Injection Molding
Direct Restorative Solutions
for Black Triangles
Jihyon Kim, DDS
ABSTRACT
A variety of methods are used to
eliminate “black triangles” (open
gingival embrasures). Injection
molding with warmed composite
offers many advantages over
legacy methods. This article
will describe the injection
molding protocol for eliminating
black triangles. The protocol
includes biofilm removal, contact
management, anatomic matrices,
injection molding with warmed
composite, and simplified
polishing steps.
LEARNING OBJECTIVES
• Describe the injection molding
steps for eliminating black
triangles.
• Discuss the benefits of warmed
injection-molded composite
versus hand-placed composite
and other direct and indirect
restoration protocols.
• Describe polishing steps to
assure esthetics and longevity
of the composite materials.
3 CDEWORLD.COM | VOLUME 7 • NUMBER 164
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M
ultiple factors contribute to the formation of “black
triangles,” or open gingival embrasures. Periodontal
concerns contributing to black triangle formation in-
clude loss of interproximal bone height, which can occur with
age or with attachment loss from periodontal disease, surgery, or
trauma. Orthodontic considerations contributing to black triangles
are unfavorable root angulation, wide interradicular distance, or a
more tapered crown form.1 Black triangles are associated with the
changes in the interproximal papilla height between both anterior
and posterior teeth. This loss of the interproximal papilla not only
is an esthetic issue with some patients, but can also contribute to
food retention and be etiologic for periodontal disease.2,3
SOLUTIONS FOR BLACK TRIANGLES
Direct Restoration
Traditional solutions for black triangles include orthodontic re-
positioning, interproximal bone graft, soft-tissue graft, papilla
reconstruction, and injectibles, which require continued mainte-
nance with repeated treatment.4 A conventional direct restorative
method is the placement of hand-manipulated cold pink and/or
white composite resin. Although the additive treatment can be
conservative to tooth structure, the restoration contours can have
a higher incidence of seams, voids, or ledges, which can collect
more biofilm (Figure 1).5
Indirect Restoration
Indirect restorations may require removal of tooth structure to
address path of draw and path of insertion concerns. Sometimes
a large amount of tooth structure must be sacrificed, especially
on lower anteriors (Figure 2). With continued gingival recession,
black triangles may again open. Retreatment may necessitate
sacrifice of even more tooth structure. Also, the potential abra-
siveness of ceramic restorations may lead to unfavorable wear of
opposing natural dentition.6
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of pink tissue against white tooth are less visu-

ally distracting than the stark contrasts between
white teeth and black triangles (Figure 3).6

Case Preparation for Injection Molding

1 used for maxillary lateral incisors and mandibular
Fig 1. Black triangle treated with layered, hand-manipulated com-
posite. A large overhang can collect biofilm and cause tissue
inflammation.
INJECTION MOLDING
Injection molding with warmed composite is
a noninvasive, additive treatment that requires
no tooth structure removal. Anatomic Mylar
matrices in the difficult to polish subgingival
and interproximal areas create smooth contours
favorable for tissue adaptation and health. An
advantage of the Mylar finish is reduced biofilm
and stain accumulation, with any calculus eas-
ily removed. Injection molding creates broad
incisal gingival and buccolingual contacts that
can lend orthodontic stability. Longer contact
lengths may result. However, soft color contrasts
A black triangle gauge is used to assess appropriate
matrix size before isolation. Large incisor matri-
ces should be used for maxillary central incisors
and cuspids, and small incisor matrices should be
central and lateral incisors. After they are selected,
try-in of the matrices is recommended to confirm
appropriate selection. The goal is to minimize the
black triangle by at least 85% with the matrices
in place. Tissue blanching is a clue that further
tissue adaptation may occur with time (Figure 4).
Overconstriction of the papilla should be avoided
because it may be unesthetic and may cause in-
flammation. The use of a rubber dam for soft-tissue
isolation and retraction is ideal. Rubber dam place-
ment facilitates soft-tissue retraction and isolation
from saliva and crevicular fluid. A rubber dam
stamp will facilitate proper spacing of punches, but
the appropriate diameter punch should be selected
for the size of the root. After teeth are isolated and
dried, biofilm disclosing solution is applied once.5

3
Fig 2. Preoperative (left) and preparation photograph (right) showing volume of tooth structure removed for this indirect treatment of black
triangles. (Case courtesy of Dr. Charles Regalado) Fig 3. Injection molding, preoperative (left) and postoperative (right) images. The stark
contrast of black and white is more visually noticeable than the soft contrast of pink and white.

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4 5

6
Fig 4. Matrices should be tried in to confirm adequate lateral pressure for tissue adaptation and triangle closure. Fig 5. Dual-sided sander
used to cleanse and manage tension of contact. Fig 6. An asymmetrical black triangle calls for the practitioner to add more volume to one
tooth and less to another.

Contact sanders are used to clean the contacts
and optimize the contact tension before matrix
insertion. A safe-sided sander is used primarily
to remove any calculus and debris before rubber
dam placement to avoid possible tearing. Next, a
single-sided light sander is used to optimize the
contact tension and remove any stain or biofilm
from the contact before matrix placement and
injection molding. If needed, a double-sided
heavy sander may be used to more aggressively
manage the tension of the contacts (Figure 5).
Tooth preparation entails contact optimization
and removal of all biofilm. After the contacts
are cleaned, all remaining biofilm should be
removed with the blaster and aluminum trihy-
droxide powder with high pressure air and water.
Acid etch will remove the inorganic, not organic,
component of biofilm. Aluminum trihydroxide,
which is softer than aluminum oxide, will safely
remove biofilm without microetching ceramic
restorations or removing the finish off mirrors.5
When a black triangle is being treated, both the
shape and the size should be assessed (Figure 6).
For a symmetrical black triangle, two matrices of
the same size should be chosen to evenly distribute
the black triangle between two teeth and avoid
creation of a cant. An asymmetrical black triangle
calls for mixing matrices so the practitioner can
selectively add more volume to one tooth and less
to another to maintain a vertical line (Figure 7).
When selecting matrices, large incisor matrices
should be used for maxillary central incisors and
cuspids, while small incisor matrices for maxillary
lateral incisors and mandibular central and lateral
incisors.4 The selected matrices should then be in-
serted and checked for full seating and alignment.
The incisal edge of the matrices is a visual clue
as to whether those matrices are seated equally.

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7 8
Fig 7. Matrices of different sizes are used to adequately close a black triangle while maintaining a vertical line between the central and
lateral incisor. Fig 8. 8-year follow-up showing the possible integrity and color stability of injection-molded restorations. (Case courtesy
Dr. David Clark)
Injection Molding With Warmed Composite
It is estimated that about 14% of dentists cur-
rently heat composite, and the number is grow-
ing.1 The advantages of warmed composite for
injection molding are many. Heating of the
composite results in decreased viscosity, which
is better for injection molding.
Performing injection molding with dual-
viscosity composites allows creation of a mono-
lithic composite form around the tooth that can
be easily shaped back to create a restoration with
good long-term stability, stain resistance, and
esthetics. The composites have shown mono-
lithic uniform color stability without staining
or ditching, with smooth subgingival contours.
Figure 8 shows a restoration in which the quality
9 curing with a full 20 seconds each on the facial,
Fig. 9. Bioclear HeatSync.
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has been maintained after 8 years. The compos-
ite is warmed by inserting the composite guns,
flowable syringes, or composite capsules into
the heating device (Figure 9). An example of a
composite warmer is shown in Figure 9, which
shows the Bioclear HeatSync composite warmer.
The process begins with acid-etching the en-
tire tooth for 20 seconds, followed by rinsing and
drying. If immediate dentin sealing is needed, an
adhesive dentin bonding agent should be applied
and cured in accordance with the manufacturer’s
instructions for use (IFU) before injection mold-
ing. The curing light used had an irradiance of
1,470 mW/cm2.7
The injection molding steps begin with wet-
ting the entire tooth with adhesive (eg, 3M™
Scotchbond™ Universal Adhesive, Kuraray
ClearFil™ Universal Bond, or BISCO All-Bond
Universal®), and then it is air thinned but not
cured. Next, heated flowable composite (eg,
3M Filtek™ Supreme Ultra Flowable, Kuraray
ClearFil Majesty™ Flow, or Ivoclar Vivadent
Heliomolar® Flow) is deliberately applied to
the entire tooth to flow into constricted spaces.
Warmed universal composite (eg, 3M Filtek
Universal Restorative, Ivoclar Vivadent IPS
Empress® Direct, or Coltene Miris®2) is then in-
jected into the pool of uncured flowable. Curing
should be performed according to the compos-
ite’s IFU (in the case in this article, three-point
incisal, and lingual was performed). After the
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composite is fully cured, an explorer should be
used to peel away each matrix, ensuring each
is fully released below the contact. A hemo-
stat should be used to remove the matrices as
needed. Initial amputation is done while cut-
ting dry with a coarse flame diamond bur. The
incisal excess should be amputated to about a
half millimeter of the final incisal edge and
facial contour. An egg-shaped carbide bur is
used to trim the lingual excess, which can later
be finished with a brownie. A second round of
three-point curing should be done to ensure full
depth of cure.8
Final shaping is performed with a large, coarse
disc (eg, 3M Sof-Lex™ XT, Shofu Disk HC,
or Clinician’s Choice Finishing and Polishing
Discs). The disc serves as a multifaceted tool.
With continued use, the abrasiveness declines
and the disc becomes more supple. The disking
should be performed dry. The clinician should
start with a fresh disc to trim the incisal edge to
the final length. The same disc is used to bring
in the incisal facial half of the tooth. Next, the
same disc is used to blend the gingival half with
the incisal half. Then, finally, the palatal line
angles are refined.
Polishing starts with refining the surface
texture using a prepolish with multiple grits
of pumice (an aluminum oxide mix). A gener-
ous scoop should be used with a white rubber
prophylaxis (prophy) cup. The prepolish should
be massaged into the surface of the tooth at me-
dium speed and medium pressure. Final glossy
polish is achieved with a diamond-impregnat-
ed polisher (eg, Komet One Step Composite
Polishing Cup, SS White Jazz® Polishing Cup,
or Bioclear RS Polishing Cup).
The advantages of a smooth Mylar finished
composite are reduced biofilm attraction,
7 CDEWORLD.COM | VOLUME 7 • NUMBER 164
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increased stain resistance, and good color stability.
These restorations will not have the microsurface
texture that might accumulate stain and biofilm.
CONCLUSION
Injection molding for elimination of black
triangles offers significant advantages over
traditional direct and indirect restorative solu-
tions. These benefits include reduced biofilm
accumulation, increased stain resistance, and
increased abrasion resistance. The treatment
is conservative, and the technique can be rap-
idly mastered. The result is superior esthetics
and longevity of the restoration with no tooth
structure removal.
REFERENCES
1. 3M market research, January 2018. https://multimedia.3m.
com/mws/media/1739682O/3m-filtek-dental-restoratives.
pdf. Accessed April 15, 2020.
2. Chen MC, Liao YF, Chan CP, et al. Factors influencing
the presence of interproximal dental papillae between max-
illary anterior teeth. J Periodontol. 2010;81(2):318-324.
3. Singh VP, Uppoor AS, Nayak DG, Shah D. Black trian-
gle dilemma and its management in esthetic dentistry. Dent
Res J (Isfahan). 2013;10(3):296-301.
4. Kim, Jihyon. (2019, October 2). Direct Restorative Solu-
tions to treat “Black Triangles. Viva Learning.
5. Øilo M, Bakken V. Biofilm and dental biomaterials. Ma-
terials (Basel). 2015;8(6):2887-2900.
6. Cunliffe J, Pretty I. Patients’ ranking of interdental “black
triangles” against other common aesthetic problems. Eur J
Prosthodont Restor Dent. 2009;17(4):177-181.
7. 3M. 2017. 3M™ Elipar™ DeepCure-S LED Curing Light
Brochure. St. Paul, MN.
8. Sherawat S, Tewari S, Duhan J, et al. Effect of rotary cut-
ting instruments on the resin-tooth interfacial ultra structure:
an in vivo study. J Clin Exp Dent. 2014;6(5):e467-e473.
JUNE 2020
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Direct Restorative Solutions for Black Triangles

Jihyon Kim, DDS

1. Compared to other treatment modalities for black 6. The injection molding steps begin with:
triangles, injection molding is: A. wetting the entire tooth with adhesive.
A. a newer method that patients are requesting because they have B. injecting warmed universal composite.
seen advertising about it. C. peeling away each matrix.
B. a method that results in smoother subgingival and interproximal D. none of the above
areas, but may require tooth structure removal.
C. s imilar to other treatment modalities, but requires less time with 7. How should curing be performed after the entire tooth
the patient for the practitioner. has been injection molded?
D. a non-invasive, additive treatment that does not require tooth A. 40 seconds on the facial, 30 seconds on the incisal, 20
structure removal. seconds on the lingual
B. 20 seconds on the facial, 30 seconds on the incisal, 40
2. Which sanders should be used to clean contacts before seconds on the lingual
matrix insertion? C. 40 seconds on the facial, 20 seconds on the incisal, 20
A. Whichever sander the practitioner is most comfortable with seconds on the lingual
is the best. D. according to the composite’s IFU
B. A double-sided sander offers the flexibility for any sanding
necessary.
8. What type of disc should be used for final shaping?
C. Use a safe-sided sander, a single-sided sander, and a
A. large, coarse
double-sided sander.
B. small, coarse
D. Use a safe-sided sander and a double-sided sander, but a
C. large, soft, fine
single-sided is not necessary for this procedure.
D. large, hard, fine
3. What will safely remove biofilm without microetching
ceramic restorations? 9. How should the prepolish be applied?
A. aluminum oxide A. Use a small amount, massaging in with a bristle brush.
B. aluminum trihydroxide B. Use a generous scoop with a white rubber cup, massaging into
C. aluminum sulfate the surface of the tooth with slow speed and light pressure.
D. aluminum chloride C. Use a generous scoop with a white rubber cup, massaging into
the surface of the tooth at medium speed and medium pressure.
4. For a symmetrical black triangle, what should be used to D. Use a small amount, massaging into the surface of the
avoid creation of a cant? tooth at high speed and medium pressure.
A. self-tightening matrices
B. large and small incisor matrices 10. The advantages of a smooth Mylar finished composite are:
C. two matrices of the same size A. reduced biofilm attraction.
D. none of the above B. increased stain resistance.
C. good color stability.
5. Heating of the composite results in what feature that is D. all of the above
better for injection molding?
A. decreased viscosity
B. improved translucency
C. enhanced bioactivity
D. increased stackability

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