

































 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

Management of Black Triangle by composit restoration :  

A Clinical Case Report 

Rafalimino HN1,2, Rakotonirina FP1,3, Radafisolo MEF4, Soanasolo CM5,  
 Andrianjafinoro TH1,2, ,Ramaroson J1. 

 
1Sub-section of Conservative Odontology Endodontic  

at the Tropical Odonto-Stomatological Institute of Madagascar (IOSTM),  
University of Mahajanga 

 
² University Hospital Profesora Zafisaona Gabriel Androva Mahajanga Madagascar, 

 
3Oral Health Center, Ministry of Industrialization, Trade and Consumption 

Antananarivo, 
 

4Sub-section of Pediatric Dentistry,  
at the Tropical Odonto-Stomatological Institute of Madagascar (IOSTM),  

University of Mahajanga 
 

5Sub-section of Parodontology  
at the Tropical Odonto-Stomatological Institute of Madagascar (IOSTM),  

University of Mahajanga 
 

Corresponding author: Rafalimino Holy Nasandratra 
Sub-section of Conservative Odontology Endodontic at the Tropical Odonto-
Stomatological Institute of Madagascar (IOSTM), University of Mahajanga 

--------------------------------------------------------------------------- 

Abstract 

An adequate smile is dictated by the harmony and symmetry of the gingival 

biotype, lips outline, and dental crown shape. However, the loss of the interdental 

papilla leads to the appearance of a black triangle at the gingival base. This observation 

concerns a 55-year-old patient presenting multiple "black triangles" in the anterior-

superior area, causing aesthetic concerns. The use of a specific matrix, the application of 

the fifth-generation adhesive MR2 system, alongside enamel and dentin nano-hybrid 

composites, allowed us to limit the requested interproximal shapes, ensure effective 

composite bonding, mimic the state of natural teeth, and mask the black triangles for the 

patient. Considering ethics, the adhesive restorative technique will be the most cost-

effective therapeutic choice. In line with the therapeutic gradient, this minimally 

invasive technique should be the primary approach for cases involving "black triangles." 

Keywords : aesthetic, black triangle, dental composite, interproximal area, operative 

dentistry 

 

IJO JOURNALS

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 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

I.Introduction 

According to the Tarnow rule, disappearance of interdental papilla associated with a 

vertical distance bony crest - contact point exceeding 6 mm diagnoses the presence of a 

black triangle [1]. The base of black triangles located at gingival base. Also called open 

gingival embrasure, this gingival biotype defect promotes premature aging of the smile, 

causes functional discomfort, and undermines the periodontal health of the patient. 

Frequently found in multiple locations, this pathology represents a complex aesthetic 

and functional issue. Its etiology is multifactorial. Periodontal origine due to bone loss, 

orthodontic treatment complication, or related to the root morphology (divergence 

greater than 3.65°), related to crown morphology (triangular dental morphology) [2]. 

According to a study by Ko-Kimura et al. in 2018, cases of black triangles were 

observed in 66.7% of individuals over 20 years old [3]. Swasson KK in 2018, conducted 

a study about black triangle in Washington. They reported that 40% of orthodontically 

treatment induced black triangles [4]. This condition is also frequently diagnosed in 

individuals with triangular dental morphology. Where a more incisal contact point 

position is unfavorable for maintaining the interdental papilla [5]. Depending on the 

degree of involvement, Nordland and Tarnow classified them into four classes from I to 

III.  In normal case, interdental papilla fills the gingival embrasure. In Class I, the type 

of the interdental papilla is located between the contact point and the most coronal 

extent of the interproximal cemento-enamel junction (CEJ). In Class II, the crest of the 

papilla is at or apical to the interproximal (CEJ) but coronal to the facial CEJ. In Class 

III, the crest of the papilla is at or apical to the facial CEJ [1]. Management options is 

interdisciplinary. It includes non-surgical approaches, such as additive composite 

restoration, proximal enamel reduction, or prosthetic treatmen. While surgical options 

involve interproximal bone grafting or gingival grafting. The overall objective of this 

work was to present a case of a black triangle managed by a non-surgical technique of 

additive composite restoration. 

II.Observation 

This is a 55-year-old man who presented to the odonto-stomatology department of the 

University Hospital Profesora Zafisaona Gabriela Androva Mahajanga due to aesthetic 

concerns. The patient's request is based on improving the aesthetics of the anterior-

IJO JOURNALS

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 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

superior area. During the anamnesis, the patient did not show any general health 

problems. Endodontic treatment of a posterior tooth is on going. Upon extraoral 

examination, he displayed a gingival-type smile. In the intraoral examination, the 

patient's oral hygiene was average, and a triangular crown morphology was noted, with 

the presence of black triangles in the anterior-superior and inferior sectors. According to 

the Nordland and Tarnow’s classification, Class II of black triangle was diagnosed in the 

anterior-superior area involving teeth 11, 12, 13, 14, 21, 22, and 23.  

The etiology is due to the triangular morphology of the dental crown. The tip of the 

papilla is located at the enamel-cement junction, and the most apical point is situated at 

the labial surface. The vertical distance from the alveolar crest to the contact point of the 

black triangles was greater than 7.1 mm (Figure 1). 

The contact points are located close to the incisal base. Gingival recessions have been 

observed. The therapeutic challenge focused on closing the gingival embrasures while 

considering the maintenance of periodontal health. The distal and mesial contours, the 

anatomical widths of the teeth, and the accuracy of the verticality of the contact points 

were all highlighted. As a means of management, the patient consented to a minimally 

invasive approach through additive composite restoration. The technique involves the 

re-anatomization of the dental crowns. Pre-treatment, a photograph was taken, which 

will serve for the chromatic study of the color of the tooth to be restored and the shade 

of composites to be used, as well as delineating the additive restoration (Figure 1). 

In addition to the basic clinical examination setup in odonto-stomatology, the technical 

setup for the additive restoration was prepared in advance. A bonding system, 

specifically a fifth-generation MR2 adhesive system, was utilized (Figure 2). For the 

matrix system, a matrix with integrated curvature was employed (Figure 3). For 

finalizing the restoration, the finishing of the transition lines was achieved using a 

yellow-ring turbine bur (Figure 5). Polishing was performed using polishing discs with 

a diameter of 14 mm, in medium, fine, and superfine grits. The chosen operative 

protocol includes an etching step with 37% phosphoric acid, followed by rinsing and 

drying, application of the fifth-generation adhesive system, then photopolymerization, 

adjustment of the matrix system (gingival groove) (Figure4), combined composites 

placement according to the C-factor, and finishing and polishing of the restoration. 

IJO JOURNALS

Volume 08 | Issue 03 | March 2025 |         https://ijojournals.com/index.php/hsn/index 18



 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Patient's pre-restorative 
dental condition 

(Buccal view) 
In A: Black triangle [Rafalimino] 

 

Figure 2: Technical platform used 
In A: Etching 

In B: Adhesive system 
In C: Composites [Rafalimino] 

 

Figure 3: Finishing accessories 
A: Stamping system 

B: Polishing system [Rafalimino] 
 

Figure 4: Adjustment of the 
matrix system [Rafalimino] 

 

Figure 5: Finishing the restoration 

[Rafalimino] 

 

Figure 6: Polishing step 

[Rafalimino] 

 

Figure 7: Initial case status of Black 

triangle [Rafalimino] 

 

Figure 8: Post-therapeutic state 

[Rafalimino] 

 

IJO JOURNALS

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 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

III.Discussion 

As a result, the additive composite management technique for the black triangles was 

non-aggressive to the hard dental tissues compared to indirect techniques, and our 

results corroborate those of authors such as : Swason KK and coll, who stated that it is 

the most conservative technique for this case [4]. Al-Khayatt AS and coll, said that resin 

composite restoration is a minimally invasive and less costly treatment option relative to 

a fixed option [6]. Composite restoration has a long-term survival rate and aesthetic 

benefit with the advantage of a straightforward maintenance visit such as minor repair 

or polishing of a chipped composite. According to Clark D, the same matrix used and its 

manipulation technique procured predictable and positively anatomical results [7]. 

Clarck DJ noted that the composites used, specifically the combination of flowable 

composites with condensable composites, created the perfect viscosity to fill the 

interproximal spaces [8]. 

Conclusion  

According to the results, the aesthetic efficiency of the additive restorative technique 

using composite has been observed, and the stability and compatibility of the composite 

material associated with the matrix system ensure effective filling. Hence, the 

importance of prioritizing this therapeutic choice. 

Conflicts of interests 

We, the authors of this manuscript, declare no conflicts of interest regarding the 

publication of this article.  

Patient consent  

The patient has given full permission for the publication other use of his clinical case 

and photographs. 

References  

1. Tarnow, D. P., Magner, A., & Fletcher, P. (1992). The significance of the distance 

from the crest of bone to the contact point in the relationship of interproximal 

papilla to the teeth. Journal of Periodontology, 63(12), 996-99. 

2. Clarck DJ. Treatment of the dreaded black triangle: a case report and an 

introduction to injection moulded composite dentistry. International dentistry. 

African Edition. Whashintong. 2022; 18-4. 

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 IJO - INTERNATIONAL JOURNAL OF HEALTH SCIENCES AND NURSING  
 ( ISSN: 2814-2098 )                                                                                    Rafalimino Holy Nasandratra 

1
*  

https://ijojournals.com/                                                     Volume 08 || Issue 03 || March, 2025 || 

“ Management of Black Triangle by composit restoration : A Clinical Case Report." 

 

 

3. Ko-Kimura N, Kimura-Hayashi M, Yamaguchi M, Ikeda D, Meguro D,  Kanekawa 
M et all. Some factors associated with open gingival embrasures following 
orthodontic treatment. Australian orthodontic Journal.2003 : 19-4. 

4. Swason KK. Predictable, Conservative Closure of Black Triangles. A simple 
technique to treat this increasingly prevalent issue with confidence.Inside Dentistry. 
Whashintong. 2018; 32-6 

5. Sorel O, Brezulier D. Traiter ou prévenir la perte des papilles inter-dentaires. 

Orthod Fr 2018; 89:235–45 

6. Al-Khayatt AS, Ray-Chaudhuri A, Poyser NJ, et al. Direct composite restorations 

for the worn mandibular anterior dentition : a 7-year follow-up of a prospective 

randomised controlled split-mouth clinical trial. J Oral Rehabil 2013 ;40(05) :389–

401 

7. Clarck D. Treating the “Black Triangle” with Direct Composite – a Microscopic 

Perspective.Microscope dentistry. 2010 :76-80. 

8. Clark DJ. Restoratively driven papilla regeneration; a microscopic perspective. 

Canadian Journal of Rest Dent and Prosthodontics 2008 ; Aug :40-46. 

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https://pubmed.ncbi.nlm.nih.gov/?term=Kanekawa+M&cauthor_id=12790352
https://orthodfr.edpsciences.org/articles/orthodfr/abs/2018/03/orthodfr180022/orthodfr180022.html

