Management of INBRIEF

•\ Suggests gingival black triangles are

gingival black triangles preventable in many situations and

PRACTICE
manageable in others.
• \Highlights that gingival black triangles
can be caused and also treated using
P. Ziahosseini,1 F. Hussain2 and B. J. Millar*3 restorative and orthodontic procedures.
• \Provides a range of treatment
options, most of which are applicable
VERIFIABLE CPD PAPER to general practice.

Gingival black triangles (GBTs) are generally considered to be aesthetically unacceptable, have a multifactorial aetiology
and a range of treatment options. This review covers the surgical and non-surgical management of GBTs. Surgical
methods address recontouring, preserving or reconstructing the soft tissue including the interdental papilla as well
as the alveolar bone. Non-surgical approaches include restorative techniques (including the use of
prostheses and gingival-coloured materials), orthodontic movement, tissue engineering and tissue
volumisers. This review covers the aetiology and management of GBTs, highlighting the importance of
considering the options currently available when treating a lost dental papilla. A lack of longitudinal studies
investigating the long-term outcomes of the options in management of GBTs presence is identified.

INTRODUCTION who underwent orthodontic treatment for to maintain a full papillae, a very wide
The interdental papilla is an important maxillary incisors crowding could expect interdental width increases the risk of the
component in an aesthetic smile1–4 and its presence of GBTs after treatment.2 presence of a GBT possibly due to stretching
loss may result in a gingival black triangle Management techniques to rectify GBTs the papilla.3 Tall12 and Heins and Wieder13
(GBT). These spaces can also cause have been inconsistent among clinicians. stated that a certain lateral bone distance
phonation problems as well create space for Limited blood supply to the papilla is always between the roots of two adjacent teeth
food and plaque accumulation.5 Kokich et al. an issue in the tissue’s reaction to any trauma maintains the integrity status of the inter-
demonstrated that patients and dentists found or intervention. Low blood supply to dental papilla. Tall suggested maintaining 3
black triangles greater than 3 mm less interdental papillae makes them very fragile mm inter-dental distance to facilitate the
attractive.6 A recent study assessing 80 and sensitive to recession, which makes foundation of papillae. Martegani et al.14
randomly selected patients’ perceptions of restoring the receded papillae unpredictable. 9– studied measurement of interproximal width
GBTs in terms of number of visible triangles 11
with periapical radiographs. Their statistical
and their severity and showed that patients AETIOLOGY OF THE analysis concluded that when inter-radicular
found presence of GBTs the third most PRESENCE OF GBTS distance is more than 2.4 mm the presence of
disliked aesthetic problems after caries and full papillae in maxillary anterior teeth
Studies are well documented that the becomes less likely. This is regardless of the
crown margins.7 A unilateral papillary height
aetiology of GBTs is multifactorial. 1–16 bone level distance to contact points. Closer
reduction of 2 mm was considered to be
Papillae dimension can be changed due to root approximation increases the likelihood
unattractive.
any of the following reasons: of full papillae, while if the interdental
Kurth and Kokich sampled 337 patients from
1.\ Inter-proximal space between teeth distance is more than 4 mm then the presence
4,500 records of two private orthodontic
2.\ The distance between inter-proximal of full papillae is not expected.3
practices to assess the prevalence of GBTs
contact position to bone crest
between maxillary central incisors after Chang15 categorised the embrasure
3.\ Gingiva biotype
orthodontic treatment. The study showed the morphology into four categories based on the
4.\ Patient’s age
prevalence of incomplete papillae between horizontal distance between the adjacent
5.\ Periodontal disease and loss of cemento-enamel junction (CEJs) (inter-
maxillary incisors is about one third of the
attachment, resulting in recession radicular space) and distance from the crest
population.8 Another study estimated that 15%
6.\ Diverging roots, which can follow of bone to contact point. His categories
of the general adolescent patients
orthodontic treatment confirmed that the interdental width had
7.\ Tooth morphology and abnormal crown more of an influence than height.
1 General dental practitioner and postgraduate student, and restoration shape. Chow et al.10 confirmed Chang’s findings
2Clinical Senior Lecturer, 3Professor, Consultant in
Restorative Dentistry, King’s College London INTER-PROXIMAL SPACE for central incisors that wider interdental
Dental Institute, Bessemer Road, London, SE5
BETWEEN TEETH space results in more papilla recession.
9RW *Correspondence to: Professor Brian J. Millar
Email: brian.millar@kcl.ac.uk; Tel: 020 7848 1235
However, the papillae between the maxillary
The size of inter-dental width is relevant to central and lateral incisors showed an
Refereed Paper the presence of GBTs. While a greater width opposite result where wider interdental
Accepted 3 July 2014 may enable improved blood supply to
DOI: 10.1038/sj.bdj.2014.1004 spaces were more likely to have full papilla.
©British Dental Journal 2014; 217: 559-563
papillae tip, which may be helpful Chen et al.16 contraindicated the results from

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© 2014 Macmillan Publishers Limited. All rights reserved
 PRACTICE

Cho et al.10 and Martegani et al.14 finding that

height is more influential than width.
100
DISTANCE BETWEEN INTER-
PROXIMAL CONTACT POSITIONS
TO ALVEOLAR BONE CREST
90 Tarnow 1992

papilla
The distance between the bone crest (BC)
and the contact point (CP) is a frequently Wu et al 2003
discussed factor in aesthetics of natural teeth,
restorations and in implantology.17 Tarnow18
80 Cho et al 2006
examined 288 papillae in 30 patients and
gathered data from anterior, premolar and
molar papillae, based on periodontal 70 Chen et al 2010

complete
sounding. He concluded that if the distance 50
from BC to CP is 5 mm or less, presence of
full papillae is almost expectable (98%). 60
Figure 1 illustrates the relationship between
the BC-CP distance and the likelihood of the
of

presence of full papillae. Wu et al.9

40
reproduced Tarnow’s study on 200 sites in
ercentageP

30

20

10

0
1 2 3 4 5 6 7 8 9 10
Distance BC to CP (mm)
Fig. 1 The likely presence of a papilla for given distance in mm from bone crest to contact
point, a comparison of data from studies (Tarnow et al.,17 Wu et al.,9 Cho et al.3 and Chen et al.16)

45 randomly selected adults investigating inflammatory response.10 Therefore, flat biotype effect of periodontal biotype on the presence
maxillary anterior teeth with similar results. is considered more favourable to achieve of GBTs.23
Cho et al.3 measured the distance between papillae fullness than scalloped. Ahmed 22 stated Differences may be explained by the
contact heights to bone crest of 206 sites in that a pronounced scallop, especially with a thin methods for qualifying thick or thin
80 patients during a gingival flap procedure biotype, predisposes to presentation of GBTs periodontium as these are often subjective: a
in 2006. The slight variation in the results of more than other types. Chow et al.10 examined periodontal probe in the sulcus can be used to
this study may be due to the different papillae fullness in 672 sites in 96 adult differentiate between biotypes24 while others
recording procedure, direct observation patients, concluding that sites with complete concluded that trans-sulcular probing was
rather than by probing, or due to the papillae have thicker buccal-palatal tissues. 10 more accurate compared to visual
exclusion of subjects with inflammation, a However, in contrast a study on 333 papillae examinations.23
history of orthodontic treatment and found no
malposition teeth. Chen et al.16 also recorded PATIENT AGE
different results compared to Tarnow and Systemic health such as osteoporosis 25 as
Wu with reduced papillary presence for a well as age10,15,26 have been suggested as
given dimension. This study measured the generalised risk factors for presence of
distance from BC to CP radiographically in GBTs. Ageing results in thinning oral
102 interdental papillae, between maxillary epithelium and reduced keratinisation, which
anterior teeth in 30 patients. can result in reduced papillae height.
Van der Velden26 presented the changes in
GINGIVAL BIOTYPE the periodontal tissue due to ageing and
Siebert and Lindhe19 classified the biotype into concluded there is insufficient evidence for
‘thin and scalloped’ and ‘thick and flat’ physiological gingival or papillae apical
biotypes. Becker et al.20 classified biotype into migration during ageing. However, he
three groups: flat, scalloped and pronounced highlighted that periodontal tissue recession due
scalloped. Scalloped thin tissue is more likely to plaque, inflammation and trauma increases
to react to trauma or inflammation by recession with age and also suggested that periodontal
while flat-thick tissue reacts with deeper breakdown develops more rapidly due to a
periodontal pockets.21 Restricted blood supply slower rate of wound healing.
at the papillae tip can interrupt healing resulting Vandana & Savitha27 showed the
in unpredictable repair, whereas thicker tissues association of thinner tissue with ageing
respond more favourably due their increased using trans-gingival probing. They associated
vascularity, which cope better with the the thinning periodontium with the increasing
effects of traumatic habits and a diminishing demonstrated how the biological width TOOTH MORPHOLOGY
of the keratinised layer through ageing. A increases as a result of severe, generalised
Ahmed mentioned that although triangular
retrospective study on 60 subjects found that chronic periodontitis, leading to loss of
shaped teeth have divergent roots with
the incidence of GBTs between mandibular papillae.
thicker inter proximal bone, which result in
central incisors is higher in older patients.28
DIVERGING ROOTS AND POST- less bone loss compared to square-shaped
ORTHODONTIC TREATMENT teeth, the incidence of GBTs in square
PERIODONTAL DISEASE AND LOSS shaped teeth is less than triangular shaped
Burke et al.30 reviewed 500 orthodontics
OF ATTACHMENTS AND BONE teeth. This was considered to be due to a
records and highlighted that orthodontic
shorter inter-proximal distance from the
Marginal inflammation contributes to the movement of crowded anterior teeth can osseous crest to the free gingival margin in
loss of inter-dental papillae.19 Novak et al.29 separate the roots and stretch the inter-dental square-shaped teeth compared to triangular-
papilla, increasing the presence of GBTs shaped teeth.22
between incisors after orthodontic treatment. The design of the contact area in crowns,
The authors also raised concern regarding bridges and any type of restoration effects the
orthodontically moving roots very close to interdental area. Taeki5 emphasised proper
each other, jeopardising the interdental bone width and location of contact area in the
and interdental papilla due to lack of facial-lingual dimension. He emphasised that
embrasure space. This may be a risk with the the placement of the contact area is related to
increasing number of techniques that depend the marginal ridge contour and dictates the
on interdental tooth stripping for space occlusal facial and lingual embrasure form.
creation during alignment.

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 PRACTICE

\ Intact\ Slight\ Moderate\ Major

N&T\ normal\ Class 1\ Class 2\ Class 3
PIS\ 0\ 1\ 2\ 3
PPI\ 1\ 2\ 3\ 4
Fig. 2 A comparison of the indices in use (N&T - Nordland and Tarnow, 31 PIS - Nemcovsky,32 PPI - Cardarpoli et al.33)

CLASSIFICATION OF GBTS inter-proximal embrasure to the same be effective when used in combination with
A classification system to identify and level as in the adjacent teeth with a surgical approaches. Kotchy & Lacky 34 have
describe the severity of papillae loss is useful complete harmony with the adjacent used preservation papilla flaps (MPPF and
during the patient examination, recording papillae. SPPF) in combination with EMP (enamel
patient records and facilitates monitoring of matrix protein).
papillary augmentation techniques. It also Cardarpoli et al.33 introduced a scoring
assists in communication about the aesthetic system as papillae presence index (PPI) Tissue engineering
concern but they are rarely used in practice. based on the visibility of the CEJ: With advanced capabilities in tissue
•\ PPI 1: The papilla is completely present engineering, this approach may be less
Nordland & Tarnow31 introduced a and at the same height of the adjacent invasive in rectifying the presence of GBTs.
classification for papillae loss with four tooth Gerus et al.35 performed a study including a
broad categories based on three identifiable •\ PPI 2: The papilla is not completely surgical approach in combination with the
anatomical landmarks: present but interproximal CEJ is not use of an injectable regenerative acellular
8.\ \The inter-dental contact points (IDCP) visible dermal matrix into insufficient papillae at the
9.\ \The facial apical extent of the •\ PPI 3: The papilla is not completely same time as the surgery on 12 patients,
cemento-enamel junction (CEJ) present and interproximal CEJ is visible mean age 55 years with 38 insufficient
10.\The interproximal coronal extent of the •\ PPI 4: The papilla is not completely papillae being treated. There was a reported
CEJ. present and CEJ is visible from buccal highly statistically significant improvement
and interproximal. in papilla restoration after 5 months.
Based on their classification, the papillae
was described as: Figure 2 shows a comparison of the indices. The injection of periodontal cells with
•\ Normal: The tip of papillae extends to pluripotential capabilities has been used, with
the apical of IDCP MANAGEMENT fibroblasts in particular to treat both oral and
•\ Class 1: The tip of the papillae presents Surgical approaches skin defects. One randomised, double blind,
between IDCP and the most coronal placebo-controlled study showed
extent of inter proximal CEJ Periodontal plastic surgery has a long history considerable improvement in regaining the
•\ Class 2: The tip of the papillae presents at in overcoming unsightly GBTs. However, the lost interdental papilla after injecting
or apical to the inter proximal CEJ but papillae’s poor blood supply is the main extracted fibroblasts harvested from the
coronal to the apical extent of the facial limiting factor in all augmentation and tuberosity.36
CEJ reconstruction surgical approaches. As it is
•\ Class 3: The tip of the papillae presents known that damaged inter-dental papilla are Tissue volumising
level with or apical to the facial CEJ. difficult and sometimes impossible to repair Hyaluronic acid (HA) is frequently used as a
or regenerate5,19 it is essential to preserve the soft tissue volumiser in facial tissue
Nemcovsky32 introduced a classification papilla and minimise trauma during any rejuvenation.37 Based on this, Becker et al.38
system as a papillae index score (PIS) based restorative procedure. evaluated the use of HA to reduce or
on a comparison with adjacent teeth: Seibert and Lindhe19 classified papillary eliminate GBTs adjacent to dental implants
•\ PIS 0: Presence of no papillae and no surgical techniques into: releasing, reflecting and teeth in the aesthetic zone. A total of 14
soft tissue curvature and stabilising the papillae. Over the years GBTs were treated by injecting HA gel 2-3
•\ PIS 1: Present papillae height is less half there have been a number of techniques mm apical to the tip of the papilla up to three
than the present papillae in adjacent teeth including different flap designs, the use of times at 3 weeks intervals. The results of this
within a convex curvature of the soft bone augmentation and membranes. More study were promising, even after 25 months
tissue recently modified papilla preservation flap and no relapse was apparent. An interesting
•\ PIS 2: Presence of at least half the papilla (MPPF) and simplified papilla preservation outcome was the high level of patient
that was not similar with the inter-dental flap (SPPF) in combination with enamel satisfaction as all subjects found the whole
papillae of the proximal teeth and there is matrix proteins (EMP) and acellular dermal procedure painless.
no complete harmony with the interdental matrix allografts have been used.34,35 EMPs
papillae of the proximal teeth increase protein production in human Reshaping and restoring tooth shape
periodontal ligament cells and have been The contour of a restoration is important and
•\ PIS 3: Papilla completely fills the reported to can affect the papillary space. For example

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 PRACTICE

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. Poor oral
hygiene and limitation in manual dexterity
are the primary contraindications to consider
in using this technique.
There are different methods to make this
inexpensive and easy to make prosthesis. The
important issue is the retention of the
Fig. 3 An example of pre and post-op diastema closure. Following tooth whitening a three- removable veneer into inter-proximal areas
layer direct composite build up closed the diastema, positioning the contact area that can be achieved by using the gaps as
5 mm from the alveolar crestal bone to encourage the papilla to fill the retention grooves or incorporating slotted
interproximal space, preventing a potential GBT (Miris, Coltene) attachments into the prosthesis. 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.40

Orthodontic movement
Orthodontic movement has several
applications in reducing the GBTs. Closing
Fig. 4 Gingival reproduction on an implant Fig. 5 Darker shade ceramic used on crowns the interdental contacts by conventional
retained prosthesis using gingival coloured to aesthetically close a large GBT (Courtesy of orthodontic movement with or without inter-
composite resin (Gradia Gum GC) Dr Chris Ho, Sydney)
dental stripping reduces the BC-CP distance.
However the length of treatment, the need for
appliances and cost are limiting factors.
Salama and Salama41 suggested that
paralleling closed roots with orthodontic
movements may be beneficial in supporting
the inter-dental papillae. Burke et al.2
recommend bringing the roots closer by
mesial torquing movement to rectify
presence of GBTs. In conjunction with
orthodontic treatment, proximal enamel can
be recontoured to change the contact area to a
Fig. 6 A gingival acrylic veneer used to close multiple
broader surface along with relocating the
large GBTs (Courtesy of Dr Matthew Garrett, KCHT)
contact more apically.
Based on the data illustrated in Figure 1 the
a convex crown can affect the biologic and from the alveolar crestal bone to encourage less distance there is between the inter-proximal
morphologic features of the interdental the papilla to fill the interproximal space and contact and the bone crest, the less likely will be
gingiva and the scalloped outline of the eliminate a potential GBT following the presence of a GBT. Extrusive and intrusive
gingival margins. Restorations can often be diastema closure. tooth movement can maintain the alveolar bone
designed to have broad contact areas level and reduce GBTs.42
Using pink restorative
positioned correctly in relation to the bone Cardaropoli et al.33 presented a study
crest to eliminate a GBT. Bichacho 39 stated materials to mask the GBTs evaluating a combined approach of
that when the involved teeth are intact, there Composite resin is available in pink shades orthodontic-periodontal treatment to
is no logical reason for macro-mechanical for gingival reproduction (Fig. 4). It can be reconstruct the inter-dental papillae between
intervention to close the GBTs, presenting used on restorations to replace missing soft upper central incisors, demonstrating that the
cases using direct and laboratory fabricated tissue. It is considered to be more realistic soft tissues adapted to the new emergence
restorations showed the importance of the than pink porcelain in similar situations. profiles during intrusion of the teeth as the
cervical contouring concept in six different Although pink porcelain can mask the loss of inter-proximal spaces were reduced.
aesthetic cases. inter-dental papilla, the shades and optical
Modifying the GBTs by direct adhesive properties are limited and it is often better to CONCLUSION
restoration is a non-invasive, viable and use darker tooth shades instead (Fig. 5). This review highlights the aetiology and
affordable option. Figure 3 shows an example management of GBTs adjacent to natural
of pre- and post-op diastema closure. Tooth teeth. GBTs are caused by lack of presence
whitening was carried out to minimse the Gingival veneer of the inter-dental papillae, which is
visibility of the white spots followed by Removable acrylic or silicone can be used as multifactorial including the position of the
composite recontouring to close the diastema, a gingival veneer to mask GBTs (Fig. 6). alveolar crest and the teeth. Orthodontics can
positioning the contact area 5 mm This removable prosthesis can also be used both cause and be used to treat GBTs.

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 PRACTICE

The presence of a GBT can have a negative 13.\ Heins P J, Wieder S M. A histologic study of the biologic width in severe, generalized,
the width and nature of inter-radicular chronic periodontitis: implications for therapy. J
impact on dental aesthetics as well as impact spaces in human adult pre-molars and Periodontol 2008; 79: 1864–1869.
on the health of the gingiva and phonation. molars. J Dent Res 1986; 65: 948–951. 30.\ Burke S, Burch J, Tetz J. Incidence and size
Recognising the early signs of papilla loss 14.\ Martegani P, Silvestri M, Mascarello F et al. of pretreatment overlap and post-treatment
Morphometric study of the interproximal unit in the gingival embrasure space between maxillary
and its monitoring by the dental practitioner esthetic region to correlate anatomic variables central incisors. Am J Orthod Dentofacial
and the application of preventive measures affecting the aspect of soft tissue embrasure Orthop 1994; 105: 506–511.
space. J Periodontal 2007; 12: 2260–2265. 31.\ Nordland W P, Tarnow DP. A classification
can be part of the good clinical practice. 15.\ Chang L C. The association between embrasure system for loss of papillary height. J
Management should be considered with morphology and central papilla recession. J Clin Periodontol 1998; 69: 1124–1126.
every proximal restoration and can include Periodontol 2007; 34: 432–436. 32.\ Nemcovsky C. Interproximal papilla
16.\ Chen M C, Liao Y F, Chan C P, Ku Y C, Pan W L, augmentation procedure: A novel surgical
non-invasive tooth recontouring. Novel Tu Y K. Factors influencing the presence of approach and clinical evaluation of 10
approaches including the use of HA need interproximal dental papillae between maxillary consecutive procedures. Int J Periodontics
anterior teeth. J Periodontol 2010; 81: 318–324. Restorative Dent 2001; 21: 553–559.
further investigation.
17.\ Palmer R M, Farkondeh N, Palmer P J, Wilson 33.\ Cardaropoli D, Stefania Re, Corrente G. The
R F. Astra Tech single-tooth implants: an audit papilla index (PPI): A new system to assess
1.\ Takei H, Yamada H, Hau T. Maxillary anterior of patient satisfaction and soft tissue form. J interproximal papillary levels. Int J Periodontics
aesthetics. Preservation of the inter-dental Clin Periodontol 2007; 34: 633–638. Restorative Dent 2004; 24: 488–492.
papillae. Dent Clin North Am 1989; 33: 263–273. 18.\ Tarnow D P, Magner A W, Fletcher P. The 34.\ Kotschy P, Laky M. Reconstruction of supracrestal
2.\ Burke S, Burch J, Tetz J. Incidence and size of effect of the distance from the contact point alveolar bone lost as a result of severe chronic
pretreatment overlap and post-treatment gingival to the crest of bone on the presence or periodontitis. Five year outcome: case report.
embrasure space between maxillary central incisors. absence of the interproximal dental papilla. Int J Periodontics Restorative Dent 2006; 26:
Am J Orthod Dentofacial Orthop 1994; 105: 506–511. J Periodontol 1992; 63: 995–996. 424–431.
3.\ Cho H S, Jang H S, Kim D K et al. The effect of 19.\ Seibert J, Lindhe J. Esthetics and periodontal 35.\ Gerus N, Romanos A, Vassilopoulos P, Reddy
inter-proximal distance between roots on the therapy: textbook of clinical periodontology. M. Dermal graft for use in inter-proximal papilla
existence of interdental papillae according to the 2nd ed. Copenhagen: Munksgaard, 1989. regeneration. Int J Periodontics Restorative
distance from the contact point to the alveolar crest. 20.\ Becker W, Ochsenbein C, Tibbetts L, Becker B E. Dent 2012; 32: 49–58.
J Periodontol 2006; 77: 1651–1657. Alveolar bone anatomic profiles as measured 36.\ McGuire K, Scheyer E T. A randomized, double-
from dry skulls. Clinical ramifications. J Clin blind, placebo-controlled study to determine the
4.\ Gonzalez M, Almeida A, Greghi S, Mondelli J,
Periodontol 1997: 24: 727–731. safety and efficacy of cultured and expanded
Moreno T. Interdental papillary house; a new concept
and guide for clinicians. Int J Periodontics
21.\ Kao R T, Fagan M C, Conte G J. Thick vs. autologous fibroblast injections for the treatment of
thin gingival biotypes: A key determinant in interdental papillary insufficiency associated with
Restorative Dent 2011; 31: 6: e87–e93.
treatment planning for dental implants. J the priming procedure. J Periodontol 2007;
5.\ Takei H. The interdental space. Dent Clin
Calif Dent Assoc 2008; 36: 193–198. 78: 4–17.
North Am 1980; 24: 169–176.
22.\ Ahmed I. Anterior dental aesthetics: gingival 37.\ Rohrich Rod J, Ghavami A, Crosby M A. The role of
6.\ Kokich V, Kiyak A, Shapiro P. Comparing the perspective. Br Dent J 2005; 199: 195–202. hyaluronic acid fillers (restylane) in facial cosmetic
perception of dentists and lay people to altered 23.\ Rafiee R M, Melamed S, Chao J. Predicting surgery: review and technical consideration. Plast
dental aesthetics. J Esthet Dent 2005; 1: 311–324. black triangles. part ii interdental width. J West Reconstr Surg 2007; 120: 41S–54S.
7.\ Cunliffe J, Pretty I. Patient’s ranking of Soc Periodontol Periodontal 2012; 60: 3–5. 38.\ Becker W, Gabitov I, Stepanov M, Kois J, Smidt A,
interdental “black triangles” against other 24.\ Kan J Y, Rungcharassaeng K, Morimoto T, Lozada Becker B. Minimally invasive treatment for papillae
common aesthetic problems. Eur J J. Facial gingival tissue stability after connective deficiencies in the aesthetic zone: a pilot study.
Prosthodont Restor Dent 2009; 17: 177–181. tissue graft with single immediate tooth Clin Implant Dent Relat Res 2010; 12: 1–8.
8.\ Kurt J, Kokich V G. Open gingival embrasures after replacement in the esthetic zone: Consecutive case 39.\ Bichacho N. Papilla regeneration by noninvasive
orthodontic treatment in adults: prevalence and report. J Oral Maxillofac Surg 2009; 67: 40–48. prosthodontic treatment: segmental proximal
aetiology. Am J Orthod Dentofacial Orthop 2001; 25.\ Shum I, Leung P C, Kwok A et al. restorations. Pract Periodontics Aesthet Dent 1998;
120: 116–123. Periodontal conditions in elderly men with 10: 75, 77–78.
9.\ Wu Y J, Tu Y K, Huang S M, Chang C P. The influence and without osteoporosis or osteopenia. J 40.\ Alani A, Maglad A, Nohl F. The prosthetic management
of the distance from the contact point to the crest of Periodontol 2010; 81: 1396–1402. of gingival aesthetics. Br Dent J 2011;
bone on the presence of the interproximal dental 26.\ Van der Velden U. Effect of age on the periodontium. 210: 63–69.
papilla. Chang Gung Med J 2003; 26: 822–828. J Clin Periodontol 1984; 11: 281–294. 41.\ Salama, H, Salama M. The role of orthodontic
10.\ Chow Y C, Eber R M, Tsao Y P, Shotwell J L, Wang H 27.\ Vanadana K L, Savitha B. Thickness of gingival in extrusive remodelling in the enhancement of soft
L. Factors associated with the appearance of gingival association with age, gender and dental arch and hard tissue profiles before implant placement:
papillae. J Clin Periodontol 2010; 37: 719–727. location. J Clin Periodontol 2005; 32: 828–830. a systematic approach to the management of
11.\ Sharma A A, Park J H. Esthetic considerations in 28.\ Ikeda T, Yamaguchi M, Meguro D, Kasai K. Prediction extraction site defects. Int J Periodontics
interdental papilla: remediation and regeneration. and causes of open gingival embrasure spaces between Restorative Dent 1993; 13: 312–333.
J Esthetic Restor Dent 2010; 22: 18–28. the mandibular central incisors following orthodontic 42.\ Thailander B. Infrabony pockets and reduced
12.\ Tal H. Relationship between the interproximal treatment. Aust Orthod J 2004; 20: 87–92. alveolar bone height in relation to orthodontic
distance of roots and the prevalence of bony 29.\ Novak M J, Albather H M, Close J M. Redefining therapy. Semin Orthod 1996; 2: 55–61.
pockets. J Periodontol 1984; 55: 604–607.

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