Black triangles: Preventing their

occurrence, managing them when

prevention is not practical
Fernando Pugliese, Roger Hess, and Leena Palomo

The interdental papilla is very important for an aesthetic smile. Black trian-
gles are defined as the embrasures cervical to the interproximal contact that
are not filled by gingival tissue. These spaces are the most negatively ranked
gingival factor by laypeople. Management of black triangles requires high
quality diagnosis and a multidisciplinary approach must be considered man-
datory to achieve a successful clinical outcome. Much of what is applicable
is born from severely complicated periodontal regeneration and implant
therapy. This review covers the multifactorial etiology and the management
of black triangles. (Semin Orthod 2019; 25:175–186) © 2019 Elsevier Inc. All
rights reserved.

Introduction tissue esthetics during smile. The authors con-

cluded that black triangles were the most nega-
he interdental papilla is a key to anterior
T esthetics. In cases of periodontitis, when
supportive alveolar bone is lost, connective tis-
tively ranked gingival factor by laypeople.2
Another study assessed patients perceptions in
terms of number of visible triangles and their
sue and epithelial attachment are compro-
severity, and showed that patients found pres-
mised, papilla may be deficient. In adult
ence of this gingival embrasures the third most
patients, a growing segment of orthodontic
disliked aesthetic problems after caries and
practices, it is notable that the black trian-
crown margins.3 Black triangles slightly greater
gle problem is surfacing in dental implant cases
than 3 mm were considered less attractive by
(Fig. 1). Since supporting tissues are compro-
both general dentists and the general popula-
mised adjacent to the site of a missing tooth
tion. For orthodontists, however, 2 mm was
replaced with implant supported prosthesis, a
enough to be noticed.4
black triangle may result in the interproximal
The prevalence of posttreatment open gingi-
space, multidisciplinary strategies for preven-
val embrasures in an average adult orthodontic
tion and treatment are emerging. These spaces
population is about 38%.5 Other studies have
impact directly on the smiles aesthetics and
shown that 67% of people over 20 years old
function, interfering on the phonetics and
have black triangles comparing to only 18% of
facilitating food retention which can further
people under 200 s.6,7 These are important find-
negatively affect the periodontal health.1
ings specially with the increasing number of
A recent study was designed to determine the
adults looking for orthodontics treatment every
perceptions of laypeople to variations in soft
year.
But why is the black triangle problem so com-
Department of Orthodontics, Case Western Reserve University,
mon? In addition to the multifactorial etiology,
2124, Cornell Rd., Cleveland, OH 44106, USA; Private Practice of
Periodontics, Cleveland, OH, USA; Department of Periodontics, Case the fragility of the gingival papilla plays a signifi-
Western Reserve University, Cleveland OH, USA. cant role on the prevalence of the black triangle.
Acknowledgments Fig. 6 Dr. Fred Lurie and Dr Felix Gen. Vascular supply to the papilla is limited. Papilla is
Corresponding author at: Department of Orthodontics, Case nourished exclusively from the capillary vessels
Western Reserve University, 2124, Cornell Rd., Cleveland, OH
of the periodontal ligament and crestal bone
44106, USA. E-mail: fdp10@case.edu
which extend coronally. The papilla is the termi-
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 nal end point of the gingival microvasculature
https://doi.org/10.1053/j.sodo.2019.05.006 such that capillary loops run just inferior to the

Seminars in Orthodontics, Vol 25, No 2, 2019: pp 175 186 175

176 Pugliese et al
Figure 1. Black triangle. (A) smile. (B) Intraoral.
oral epithelium of the attached and free gingiva.
Classic studies show capillaries do not continue
into the interdental col area.8
Since reconstruction of the lost interdental
papilla is one of the most challenging and least
predictable problems we face, the main goal of
all dental procedures is to respect papillary integ-
rity minimizing its disappearance as far as possi-
ble. This therapy is favorably managed by a team
work usually including restorative, orthodontic
and periodontal care.
The purpose of this review is to highlight the
etiological factors that predispose the occur-
rence of black triangles and to discuss current
available procedures recommended for the
papilla preservation and reconstruction, around
natural teeth and implants.
Managing the risks of developing black
triangles
Aging
Aging changes the oral epithelium by thinning
the epithelium and diminishing keratinization,
which can result in reduced papillae height.9
Ko-Kimura et al.6 assessed the relation between
age and presence of black triangles after orthodon-
tic treatment and concluded that open gingival
embrasures were more frequently found in patients
over 20 years of age than in younger patients.
To explain this phenomenon, Chang10 mea-
sured the papillary height on standardized peri-
apical radiographs of maxillary central incisors
in 180 adults and found the interdental dis-
tance increased and papillary height decreased
with age.
Based on this evidence, orthodontic manage-
ment of older patients involves risk of papilla loss
and presence of black triangles; this risk cannot
be modified.
Periodontal biotype
Gingival Biotype can be classified as thin and
scalloped or thick and flat.11 Because of the
restricted blood supply, the thin biotype is
more friable and shows more risk of recession
following trauma as surgeries or inflammations
(Fig. 2).
Less than 1.5 mm gingival thickness is consid-
ered thin tissue biotype and often exists with
underlying thin bone with dehiscence or fenes-
tration (Fig. 2). On the other hand, the thick tis-
sue responds better to procedures, reacting with
no recessions but with deeper periodontal pock-
ets.12 Chow et al.13 found a positive association
between interproximal gingival thickness and
presence of gingival papilla presence in 96 adult
patients. Tissue thickness is most easily assessed
by placing a metal instrument, usually a peri-
odontal probe in the facial sulcus. Thickness can
also be assessed by transgingival probing, or
ultrasonic measurement, but since it may induce
discomfort it is usually performed under local
anesthesia.
Based on this evidence, biotype evaluation
prior to the start of orthodontic therapy may
identify patients at risk for black triangles. Such a
susceptible patient can be referred for intercep-
tive periodontal therapy.
Distance from the crest of alveolar bone to the
contact point
Increased distance from the crest of the alveolar
bone to the interproximal contact is significantly
related to presence of black triangles. According
to the classic study from Tarnow et al,14 when the
distance from the contact point to the alveolar
bone was less or equal to 5 mm, the papilla was
present in 98% of the times, while at 6 mm it
dropped to 56% and at 7 mm it was only present
 Black triangles: a review
Figure 2. (A) Thin biotype. (B) Underlying thin bone with dehiscence or fenestration.
27% of the times. These findings indicate that
the papilla will extend only a limited distance
from the alveolar crest to the interproximal con-
tact (Fig. 3). Wu et al.15 found similar results. A
distance of 5, 6, and 7 mm resulted in an open
embrasure in 2, 44, and 73% of the cases respec-
tively. These observations indicate that papilla
was present in almost 100% of the cases if the dis-
tance from the alveolar crest to the contact point
was 5 mm or less. When the distance was more
than 7 mm, most patients had an open gingival
embrasure. Based on this evidence, orthodontists
can mitigate the risk for black triangles by devel-
oping treatment plans with the alveolar bone to
contact point distance in mind.
Crown shape
Divergent or triangular shaped crown forms are
associated with posttreatment black triangles.
(Fig. 4) Due to this crown shape, the interproximal
177
contact is more incisally located, increasing the
roots distance, the length of embrasure area and
the distance from the crest of the alveolar bone to
the interproximal contact point. Burke et al.16
showed the association between tapered crowns
and black triangles presence. Kurth and Kokich5
also showed that the mesial crown form of maxil-
lary central incisors is significantly related to open
gingival embrasures. The lower mean crown form
ratio in patients with open gingival embrasures sug-
gests a slightly more divergent crown form in these
subjects. A pretreatment crown shape analysis
which results in identifying triangular crown shape
alerts the risk for black triangles. Thin scalloped
periodontium that can often be found around slen-
der triangular shaped crowns and is usually paired
with narrow keratinized tissue width can easily be
diagnosed. The overlying gingiva is thin and clear,
this allows the probe to be visible through it. Risks
stemming from thin tissue can be mitigated
through gingival grafting.
178
Figure 3. Radiographic bone crest to contact point.
Interproximal contact point
The length of the interproximal contact is
another factor related black triangles. On aver-
age, the interproximal contact, in patients with
black triangles, was shorter or located 1 mm
more incisally than in patients with normal gingi-
val embrasures. Since the incisal edge is a fixed
Figure 4. Triangular crown shape.
Pugliese et al
reference point, the mean difference in contact
position is probably due to a difference in length
of the interproximal contact.5
The length of the contact point presumably has
an effect on the distance from the contact to the
alveolar bone crest in that the longer the contact
point, the closer it is to the bone crest. In the case
of central incisors, this dimension is easily modi-
fied. However, in other anterior teeth, bilateral
symmetry of the contacts on the opposite side must
be kept in mind. Modified contact points involving
laterals, canines, and premolars require similar
contact point modifications on the other side so as
to maintain symmetry. This point opens the door
to multidisciplinary treatment and places the
orthodontist in a central management position.
Root angulation
Burke et al.16 concluded that orthodontic move-
ment of crowded anterior teeth can separate the
roots and stretch the interdental papilla, increas-
ing the presence of black triangles between inci-
sors after orthodontic treatment.
Kurth and Kokich,5 with even more details,
showed that root angulation of the maxillary cen-
tral incisors is related to black triangles. Mean
root angulation in normal gingival embrasures
converges at 3.65°. When mesial crown form,
alveolar bone interproximal contact, and inter-
proximal contact incisal edge variables are con-
stant, a 1° increase in root divergence increased
the odds of an open gingival embrasure by
14 21%.
 Black triangles: a review
Distance between roots
Cho et al.7 investigated the existence of interdental
papillae at certain distances from the contact point
to the alveolar crest, depending on the interproxi-
mal distance between roots. They found that the
number of papillae that filled the interproximal
space decreased with increasing interproximal dis-
tance between roots and became more promi-
nently decreasing with the increasing distance
from the contact point to the alveolar crest. Treat-
ment planning to decrease this distance mitigates
the risk of developing black triangles.
Morphology of embrasure area
The size of the gingival embrasure area is a signif-
icant determinant of black triangles. Patients
with open gingival embrasures have significantly
larger mean embrasure areas than patients with
normal gingival embrasures.5
Chang17 assessed standardized periapical
radiographs of the maxillary central incisors
from 330 adult patients to analyze the associa-
tion between embrasure morphology and
central papilla recession. The author concluded
that central papilla recession as a result of
ageing is most frequently associated with a wide
interdental width and long distance between
proximal cementoenamel junction and contact
point.
These findings allow the orthodontist to not
only identify patients whose age puts them at risk
for losing papilla, but also to vet the many meth-
ods to reduce the embrasure area.
Orthodontic treatment
Burke16 affirmed that a black triangle is a fre-
quent sequela of aligning crowded maxillary cen-
tral incisors. One third of orthodontic patients
can be expected to have crowded central inci-
sors. Two-fifths of those can be expected to have
a post-orthodontic black triangle.
An et al.18 found association between black
triangles and lingual movement of the inci-
sors, large antero-posterior overlap between
the two central incisors before treatment
in the maxilla. The authors still demonstrated
that a large amount of intrusion of the man-
dibular incisors can aggravate the severity of
open gingival embrasures.
179
Ikeda et al.19 found a positive correlation
between the duration of active orthodontic treat-
ment and open gingival embrasures.
Uribe et al.20 showed that more than two thirds
of the patients who had a mandibular incisor
extracted had a black triangle embrasure at the end
of treatment. And that the open gingival embra-
sures are noticeable by 52% those patients. The
magnitude of an open gingival embrasure is moder-
ately to very noticeable in 52% of these patients.
Agreeing with Uribe, Phyton et al.21 concluded
that black spaces after mandibular incisor extrac-
tion had negative repercussions with regard to
dental esthetics for the dentist, the dental student,
and the layperson. Although mandibular incisors
are less visible than maxillary, the presence of a
black triangle may still be considered unaccept-
able; it is worth risk assessment.
Understanding the pathways by which black
triangles can form empowers clinicians assess
risks for development and to hedge those risks
through treatment plans which avoid those risks.
Strategies to manage the black triangles
Eliminating the risks of developing black triangles is
not always possible; a multidisciplinary understand-
ing of management strategies is useful. Implement-
ing general principles of periodontal treatment can
be useful. Deficient papilla in implant treatment
generate new knowledge and treatment options
including extrusion, temporary crowns, and inject-
ables. Knowledge of these state-of-the art strategies
augments an orthodontist’s armamentarium.
Periodontal approach
Periodontists develop novel flap design during
surgical periodontal disease treatment to pre-
vent, ischemia, trauma and extreme tissue loss so
as to maintain natural gingival contours. Quickly
emerging regenerative treatments drive these
papilla preservation flaps.
Papilla preservation during periodontal
regeneration surgeries
Understanding the fragility and the limited vascular-
ity, periodontists select delicate flap designs during
periodontal treatment to avoid trauma to the inter-
proximal blood supply. Surgical techniques have
been developed to prevent the papilla trauma.
180 Pugliese et al
Aslan et al.22 presented a novel technique
applied to 12 patients with at least one isolated
deep intra-bony defect. The “entire papilla pres-
ervation” technique is a tunnel-like approach of
the defect associated inter-dental papilla. It pro-
vides access to the intra-bony defect by a beveled
vertical releasing incision positioned in the buc-
cal gingiva of the neighboring inter-dental space.
Following the elevation of a buccal flap, an inter-
dental tunnel was prepared undermining the
defect. Granulation tissue is removed, root surfa-
ces are debrided and bone substitutes and
enamel matrix derivate are applied. Microsurgi-
cal suture is used for optimal closure. As results,
the authors showed that early healing was
uneventful in all cases. After 1 year, there was sig-
nificant attachment gain of 6.83 mm. The results
were associated with a mean minimal increase in
gingival recession of 0.16 mm.
Rodríguez and Caffesse23 presented a mini-
mally invasive surgical approach for periodontal
regeneration of a severely compromised case.
The non-incised papillae surgical approach was
performed to improve regenerative parameters
in hopeless teeth. This surgical approach is spe-
cifically indicated as a periodontal reconstructive
procedure for interproximal intra-bony defects
with the requirement of the extension to the buc-
cal aspect of the tooth. It is a preservation papil-
lae technique, where the interdental papillae
and the marginal tissues surrounding the defect
must not be altered. Only one apical horizontal
Figure 5. Recession defect accompanies black triangle.
incision was made on the buccal mucosa, as far
as possible from the interdental papillae and
marginal keratinized tissues. The soft tissue was
reflected apico-coronally, by a full-thickness flap,
exposing the coronal limit of the intra-bony com-
ponent of the defect. Unlike historic flap eleva-
tion, excessive bone exposure was avoided to
maintain the capillary integrity involved in nour-
ishing the delicate interproximal tissues. As an
outcome, marginal soft tissues shrinkage is
avoided.
Papilla reconstruction with tissue grafting
influenced by growth factors
Treating recession defects has driven periodon-
tal practice innovations including grafting tech-
niques, and tissue engineering. Due to crown
shape and thin biotype, missing papilla occurs
with severe recession; so innovations born from
treating recession defects are of particular use
here (Fig. 5). Stimulating cells to regenerate
using growth factors, hormones, extracellular
matrix, cell occluding barriers have improved
regenerative predictability. Such innovations tis-
sue engineering such as acellular dermal matrix,
enamel matrix derivative and even patient
derived products such as platelet rich plasma
enhance outcomes, often through cell signaling,
and involving improved angiogenesis. Geisinger
et al. reviewed the outcomes of using growth fac-
tors to treat severe recession sites. Emerging
 Black triangles: a review
evidence drove her to couple the gold standard
recession treatment, subepithelial connective tis-
sue graft with acellular dermal matrix and
enamel matrix derivative for successful surgical
treatment of severe recession in the maxillary
molars and elimination of black triangle. Per-
haps because of the variety of tissue engineering
products, the power of currently available meta-
analytic evidence is weak but increasing.24
It is a note of optimism to recognize the trajec-
tory of platelet-derived growth factor. Over the
last two decades it has been well characterized,
marketed and successfully improved regenera-
tive outcomes.25 With tissue engineering devel-
oping at this rate, procedures and products to
enhance predictable papilla treatment should be
anticipated.
Single tooth implant
Experience with implants has taught important les-
sons about the chances of papilla loss. Tarnow
et al.14 set out to preserve implant papilla, and real-
ized that is critical to keep the distance from the
contact point to bone crest at 5 mm or less. How-
ever, the distance of adjacent natural tooth to the
alveolar crests is most critical than the height of
the implant contact to the bone. Because of that,
to reduce the risk the encouraged interproximal
bone sounding on the adjacent teeth should be
before implant placement.26 That same bone
sounding can be strategically employed in non-
implant cases to assess the bone crest to contact
point distance. Once that has been completed, the
shape of the contact point can be strategically
designed. On the other hand, extrusion of a tooth
will allow the bone to extrude with the tooth,
resulting in a decrease in that distance, and an
increase of soft tissue.27
More importantly, these extrusion cases started
important conversations between periodontists,
restorative doctors and orthodontists. Clinicians
placing implants are often challenged with limited
bone in the site of a future implant. Specifically, in
cases where grafting these deficient areas is not fea-
sible either due to systemic contraindications or
poor prognosis of native vertical bone morphology
the implant team seek orthodontists to extrude the
tooth and the bone along with it (Fig. 6). In these
cases, with no chance of having a full papilla, every-
thing, even the temporary is part of the strategy to
minimize the black triangle. Temporary crowns
181
are used to shape the soft tissue. Urban et al.28
showed that tissue healing around an immediate
temporary abutment helps in proper tissue con-
touring. The authors presented a case report with
poor prognosis that was treated by a combination
of soft tissue grafting and a prosthetic approach. It
was used a customized abutment with a subtle sub-
marginal convex contour that confines the space
available for the papilla. The subgingival abutment
contour allowed to shape and enhance papilla ref-
ormation and its maintenance for 10 years. Chal-
lenging implant cases have strengthened team
based management of black triangles. Periodont-
ists therefore are a strong ally to help orthodontists
predict black triangles, by bone sounding, and
manage them when unavoidable.
Mask the black triangle with filler
Since surgical procedures are not yet predictable in
all cases, and since restorative dentistry involves
cost, minimally invasive injection strategies have
been suggested to treat black triangles. Cell injec-
tions involve harvesting cells and involve difficulty
of collection. Fibroblast injections using cultured
fibroblasts have shown initial safety and efficacy.29
Hyaluronic acid has been suggested as an easily
obtainable injectable solution. The evidence
remains mixed, however pilot data and animal
studies show promise.30 A significant problem
remains that injectables are temporary. Cost effec-
tiveness studies comparing restorative outcomes to
long term injectables are needed to identify the
better long term expenditure.31
Restorative approach
The restorative approach gives several strategies to
reduce the appearance of black triangles when
development cannot be avoided.32 Restorative den-
tistry can change crown shape. This could be per-
formed by direct or indirect restorations, such as
composite or ceramic veneers. Bonded segmental
proximal restorations, whether direct or laboratory
fabricated, can be added to selected aspects of a
tooth utilizing the acid-etch technique with no
micromechanical preparation. When properly exe-
cuted the prosthetic supplements guide and support
newly regenerated papillae in deficient interproxi-
mal aspects. Involving a restorative dentist also allows
for controlling other risks for papilla loss associated
with the relationship between crown and embrasure
182 Pugliese et al

Figure 6. Severely complicated periodontal and implant therapy cases leave no option to prevent black triangles.
These cases provide strategic management examples for orthodontists managing far less complex situations in
non-implant cases.
(A) Extrusion to develop bone for implant site.
(B) Post extrusion for implant site development in severely resorbed ridge.
(C) Implant placed after extrusion.
(D) Temporary crown to shape soft tissue.
(E) Implant crown final radiograph.
(F) Final.
(G) Final smile.
 Black triangles: a review
Figure 6. Continued
space such as the relationship between the embra-
sure size and contact shape and size. Similarly, when
risks for papilla loss apply to laterals, canines and pre-
molars, restorative approach is needed to maintain
bilateral symmetry. The importance of restorative
quality cannot be overstated. Restorations which are
over contoured, improperly finished or inappro-
propriately convex intercrevicular areas can be bac-
terial plaque biofilm traps and will have adverse
effects on periodontal tissues. Over time, not only
papilla, but adjacent gingiva will be adversely
effected. Restorative treatment requires maintaining
natural crown proportions, gingival harmony. Addi-
tionally, care is needed during restoration prepara-
tion not violate the biological width, to avoid food
impaction and periodontal inflammation.33
Orthodontic approach
Root angulation of the maxillary central incisors is
related to open gingival embrasures. Mean root
angulation in normal gingival embrasures con-
verges at 3.65°. When mesial crown form, alveolar
bone interproximal contact, and interproximal
183
contact incisal edge variables are constant, a 1°
increase in root divergence increased the odds of
an open gingival embrasure by 14 21%.5 Ortho-
dontic treatment can be performed to converge
maxillary incisor roots to reduce or eliminate open
gingival embrasures.
The bracket slots must be perpendicular to
the long axis of the tooth and not parallel to the
incisal edges during bracket placement, espe-
cially in adults with grinded incisal edges. It is
important to evaluate the panoramic radiogra-
phy prior to bracket placement. If brackets are
placed based on incisal edges, greater root diver-
gence may cause an open gingival embrasure.
Bonding brackets with slots perpendicular to the
long axis of the teeth will allow roots to converge,
and may require the incisal edges to be restored
or contoured. As roots become more parallel,
the contact point will be larger and move apically
toward the papilla, thus reducing black triangles.
The cervical portion of the crowns of each inci-
sor will move closer, relaxing the papilla (Fig. 7).
Clinicians also should expect a moderate num-
ber of adult patients to have divergent crown shape,
184 Pugliese et al

Figure 7. Root angulation correction showing the interproximal embrasure decrease.

making them more susceptible to black triangles.5
The triangular crown shape results in a more inci-
sally interproximal contact, increasing the roots dis-
tance, the length of embrasure area and the
distance from the crest of the alveolar bone to the
interproximal contact point. Accurate diagnosis of
divergent crown shape is essential so that the appro-
priate interproximal contact stripping may be per-
formed. This reduction of interproximal enamel
(IPR) with the use of diamond strip or discs, is one
effective alternative to reduce the length of black
triangles. Typically, 0.5 0.75 mm of enamel is
removed with IPR.5 Orthodontic closure of the
space should be attained with a bodily movement
of the two adjacent teeth, keeping the right root
angulation. It will increase the interproximal con-
tact point length with its consequent cervical move,
decreasing the distance from the crest of the alveo-
lar bone (Figs. 8 and 9).
Pre-existing anterior crowding seems to be
related to the presence of black triangles after
orthodontic treatment. Even with no direct associa-
tion, Burke et al.16 affirmed that a black triangle is
a frequent sequela of aligning crowded maxillary
central incisors (Fig. 10). And because of that, it is
very important to inform patients that they may be
predisposed to have a black triangle following the
incisors level and alignment (Fig. 11).

Figure 8. IPR changing the crowns shape, lengthening interproximal contact with consequent reduction of the
interproximal embrasure area, after incisors bodily mesial movement.
 Black triangles: a review 185

Figure 9. (A) Before. (B) After. Black triangle reduction by 0.5 mm IPR and central incisors mesial movement.

Figure 10. Black triangle appearance after crowding correction between teeth 24 and 25. (A) Before. (B) After.

Figure 11. Virtual setup showing the treatment prediction and black triangles appearance after crowding align-
ment. (A) Before. (B) After.

Very strong correlation between lower incisor Conclusion

extraction and black triangle appearance was
found.20 Because of the greater exposure of the
lower incisors in adult patients during the speech
and smile, the black triangles have a very nega-
tive repercussion on dental esthetics for layper-
son. Pithon et al.21 advised that the option for
central incisor extraction should always be dis-
carded when there are other treatment option
available.
Black triangles impact directly on the smiles aes-
thetics and function. Multidisciplinary teamwork
allows the management of black triangles. Ortho-
dontics, periodontics and restorative dentistry all
have strategic interventions when combined in syn-
ergy, are effective for management when their
presence is unavoidable. Avoiding black triangles
by reducing the risks for their occurrence prevents
186 Pugliese et al
having to manage them. The etiology of black tri-
angles is multifactorial, but research suggests dis-
tance between the alveolar crest and interproximal
contact point appear to be the most significant fac-
tor contributing to occurrence.
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