Kweh Ting Jing1, Cheah Chia Wei2, Lim Ghee Seong2*
Abstract
The present clinical case report discusses about the use of gingival veneers as a prosthodontic solution for managing the interdental spaces or ‘black triangles’, which are gaps that appear due to loss of interproximal papillary height often following periodontal therapy. A 39-year-old patient presented with significant unsightly black triangles between her maxillary anterior teeth, adversely affecting her smile aesthetics. After thorough examination and patient consent obtained, custom-fabricated gingival veneers made from polyamide, a flexible thermoplastic resin, were used to mask these gaps. The gingival veneers provided immediate aesthetic improvement, restoring the natural appearance of the gingiva without surgical intervention. The patient’s satisfaction and quality of life improved significantly post-procedure. The present clinical case report highlights the importance of periodontal supportive care, the advantages of gingival veneers, including their non-invasive nature, reversibility, and high level of personalization, making them a viable option for patients with aesthetic concerns following periodontal therapy. The successful outcome of this case supports the broader application of gingival veneers in contemporary dental practice.
Introduction
Loss of interproximal papillary height, or what commonly referred as “black triangles”, is often a sequela of periodontal therapy after the diseased periodontal soft tissues return to a stable periodontal health. Black triangles posed a cosmetic challenge as it adversely affects the pink aesthetics. Nordland and Tarnow developed a classification system for loss of papillary height based on readily identifiable anatomical landmarks as reference [1]. These aids clinicians diagnose how much papillary tissue is lost and plan treatment accordingly. It offers guidance to clinicians on deciding which interventions would be most appropriate for improving the patient’s aesthetic, particularly considering that small openings exist beneath crowns. Management of gingival black triangles can range from a conservative non-surgical approach to surgical augmentation depending on the severity of tissues loss [2].Non-surgical approaches may include orthodontic adjustments, restorative procedures (e.g., resin composite masking), and/or gingival veneers that help hide these unsightly gaps thereby maintaining cosmetic balance in oral cavity without resorting to surgery. Orthodontic treatment can help in repositioning the teeth to reduce or eliminate the appearance of black triangles especially when there is mild to moderate papillary height loss related with them [2]. Restorative procedures such as composite resins masking can fill in the spaces immediately improving their aesthetics for now but not necessarily suitable for more advanced ones with quite considerable amount of tissue loss at this level [3]. While surgical augmentation techniques generally entail grafting procedures performed in order to restore lost interdental papillae [4]. However, these ways offer a long-lasting solution but are more traumatic, require longer healing periods and risk of infections. Whether or not, surgery is successful depends largely on the initial periodontal condition of the patient and his general oral health. Prosthodontic solutions in other hand such as gingival veneers can be promising alternatives to cases where non-surgical or surgical approaches are either not possible or have failed to produce the desired results. Custom-fabricated prosthetic devices known as gingival veneers are made to cover these black triangles in order to match up with natural gum tissues. These devices are prosthodontically fabricated using acrylic base material, which is colored and textured in harmony with patient’s own gum tissues so as to result into an aesthetically pleasing outcome [5].
This case report presents a prosthodontic approach for managing advanced gingival black triangles affecting multiple anterior teeth. The focus here was placed on achieving an aesthetic satisfying outcome through use of gingival veneers. In addition, this report will describe how clinical procedures were performed in fabricating and placing the veneers, which proves their effectiveness in restoring the balance of one’s smile’s aesthetic perspective.
Gingival veneers have several advantages over other treatment options. They do not require surgical intervention because they are minimally invasive techniques of rectifying this problem [2]. These procedures involve taking precise impressions, laboratory fabrication and clinical placement. Besides, gingival veneers provide high level personalization that allows for individualized approach towards meeting distinct aesthetic requirements by different patients at a time like no other method does [6]. Another thing is the usage of gingival veneers and it is a reversible solution. Gingival veneers can be removed or adjusted unlike surgical procedures which change periodontal tissues permanently. For such patients, the flexibility of this procedure allows for future consideration of other treatment options or in case aesthetic preferences change. Most patients are accepting to gingival veneers mainly due to their immediate cosmetic benefits and non-invasive nature [7]. Feedback from patients who have had gingival veneers often shows that they have become more confident and pleased with themselves after undergoing the procedure. This positive impact on the patient’s quality of life underscores the importance of addressing the aesthetic concerns associated with black triangles.
In brief, interproximal papillary height loss that results in black triangles represents one common esthetic challenge following periodontal therapy. Different treatment modalities are available; nevertheless, intervention should be predicated on severity of tissue loss and specific patient needs. The present case report described a prosthodontic approach to manage an advanced stage of gingival black triangles involving multiple anterior teeth to achieve an aesthetically satisfying outcome.
Case Report
A 39-year-old Chinese lady was referred to the Prosthetic Postgraduate Clinic for the management of spacings between her upper front teeth. The patient complained of unpleasant aesthetics due to the presence of gaps over her teeth. She suffered from periodontal disease and had mobile teeth since the year 2018. She started to receive periodontal treatment in the year 2019, where multiple non-surgical and surgical periodontal therapies were carried out. Open flap debridement and guided bone regeneration surgery was performed for the maxillary anterior dentition in September 2021, which resulted in the gaps after healing.
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-1-Extraoral-frontal-smile-view-1.png?resize=426%2C486&ssl=1)
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-2-Maxillary-arch-frontal-view-1.png?resize=876%2C384&ssl=1)
Patient had history of gestational diabetes during her past two pregnancies. She was not on any medication for this condition. Otherwise, she was fit and healthy. Extraoral smile view revealed excessive display of gaps between her maxillary anterior dentition (Figure 1). Upon intraoral examination, it was noted that there was presence of a black triangles in relation to the maxillary anterior teeth resulted from clinical attachment loss. Significant interpapillary loss was noted mainly from 12 – 22, where the tip of the papilla was apical to the facial cemento-enamel junction (Nordland and Tarnow class III) (Figure 2). Oral hygiene was good; gingiva was firm and pinkish with minimal bleeding upon probing. The periodontal condition was declared stable, and she was under supportive periodontal therapy prior to her referral to our clinic.
Our treatment aim is to restore the aesthetic appearance by closing the gaps. Gingival veneer prosthesis was proposed, and patient provided her informed consent to carry out the treatment. Maxillary and mandibular alginate impressions were taken to obtain the study models. A maxillary special tray with one-layer wax spacer was constructed in such a way that it could be inserted and removed via a labial direction. Secondary impression was taken using regular body polyvinylsiloxane (PVS) impression material after blocking the palatal embrasure of 12 – 22 with wax to prevent overflow of excess impression material. A working model was fabricated for the subsequent laboratory procedure.
![Figure 3 Wax up on working cast](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-3-Wax-up-on-working-cast.png?resize=598%2C439&ssl=1)
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-4-Processed-gingival-veneer.png?resize=619%2C337&ssl=1)
Gingival veneer wax up (Figure 3) was done and patient was recalled for try in. The fitting and aesthetic were checked and approved by the patient. Before processing, the wax up wax finalised by adding the stippling appearance, sealed to the working cast, and processed with flexible denture material (ThermoSens, Vertex Dental, Netherlands) (Figure 4).
At issue stage, the gingival veneer was inserted with satisfactory retention as the flexible denture material was able to engage some undercuts between the embrasure of 12 – 22. The aesthetics were restored as the black triangles were masked completely by the prosthesis (Figure 5 – 7). Prosthesis care instructions were provided, and patient was referred back to the Periodontal Postgraduate Clinic to resume her supportive periodontal therapy. Recall visits at 1-week, 1-month, and 1-year post-op revealed successful outcome as patient was adapting well to the prosthesis and claimed that her quality of life (QoL) had improved significantly.
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-5-Pre-op-post-op-prosthesis-insertion.png?resize=1024%2C282&ssl=1)
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-6-Gingival-veneer-insertion-intraoral-view.png?resize=580%2C327&ssl=1)
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Figure-7-Pre-op-post-op-extraoral-view.png?resize=913%2C510&ssl=1)
Discussion
Gingival veneers were introduced in the 1950s as removable prosthetic devices designed to replace missing hard and soft tissues, especially in the aesthetically crucial upper anterior region of the mouth [3]. Over the years, advancements in materials and techniques have made gingival veneers a reliable solution for addressing both functional and aesthetic concerns associated with tissue loss.
Various materials can be used to construct gingival veneers, including acrylic resins, composite resins, porcelains, and silicone-based soft materials. Each material has its benefits and drawbacks, influencing the choice based on clinical requirements and patient preferences. Acrylic and composite resins are popular due to their ease of manipulation, ability to match tooth color, and cost-effectiveness. Porcelain offers superior aesthetics with its natural translucency and color stability but is more brittle and expensive. Silicone-based materials, being soft and flexible, provide comfort but may lack long-term durability [8].
In the present case, a polyamide gingival veneer, a type of thermoplastic flexible acrylic resin, was selected for its high flexural strength and flexibility. Polyamide’s properties make it suitable for engaging undercuts in embrasure regions, ensuring secure retention without discomfort [9].
The prosthodontic management demonstrated in this case effectively complemented periodontal therapy. Following periodontal treatment, while the patient may achieve stable periodontal health, the resulting black triangles due to interproximal papilla loss can be aesthetically challenging [1]. Gingival veneers offer a solution by masking these black triangles, thereby restoring the natural gingival appearance and enhancing the overall aesthetics of the smile.
The integration of gingival veneers into the treatment plan not only addresses aesthetic concerns but also contributes to the functional aspects of dental health. In this case, the high flexural strength of the polyamide material used provided additional splinting support to the periodontally compromised teeth. This support helps distribute occlusal forces more evenly across the dental arch, potentially reducing the risk of further periodontal damage or tooth mobility.
Patient acceptance and satisfaction with the gingival veneer were high, highlighting the importance of addressing aesthetic concerns in dental treatment. The immediate improvement in appearance following the placement of the gingival veneer positively impacted the patient’s self-esteem and overall quality of life, demonstrating the significant role of aesthetic dentistry in enhancing patient outcomes beyond functional restoration.
Gingival veneers also offer practical advantages in terms of ease of use and maintenance. Being removable, patients can clean both the veneer and the underlying gingiva effectively. This removability also allows for adjustments without invasive procedures, providing flexibility and adaptability in managing the patient’s ongoing dental health [7].
The successful outcome of the present case supports the broader application of gingival veneers as a treatment modality for managing black triangles resulting from periodontal therapy. With careful material selection and precise fabrication, gingival veneers can provide a durable, aesthetically pleasing, and functionally supportive solution. This approach is particularly beneficial for patients who are not candidates for surgical augmentation due to health, financial, or personal reasons.
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Conclusion
Gingival veneers represent a valuable prosthodontic solution for addressing the aesthetic and functional challenges posed by black triangles. The use of polyamide in this case provided a robust, flexible, and aesthetically pleasing outcome, highlighting the material’s suitability for such applications. By complementing periodontal therapy, gingival veneers not only enhance aesthetic appearance but also contribute to overall dental stability and health. This case underscores the potential of gingival veneers to improve patient satisfaction and quality of life, reaffirming their place in contemporary dental practice.
References
1. Nordland, W.P. and D.P. Tarnow, A classification system for loss of papillary height. J Periodontol, 1998. 69(10): p. 1124-6.
2. Ziahosseini, P., F. Hussain, and B.J. Millar, Management of gingival black triangles. Br Dent J, 2014. 217(10): p. 559-63.
3. Yusof, H.M. and N.A.A. Hayei, Restorative Treatment Considerations for Black Triangle: A Case Series. European Journal of General Dentistry 2023. 12(01): p. 61-66.
4. AlAhmari, F., Reconstruction of lost interdental papilla: a review of nonsurgical approaches. Journal of Dental and Medical Sciences 2018. 17: p. 59-65.
5. Ramanujam, C. and S. Rengasamy, Gingival veneer: A prosthetic solution for the esthetically challenging black triangles: A case series. Indian Journal of Multidisciplinary Dentistry 2015. 5(1): p. 23.
6. Nayar, S. and N.W. Craik, Achieving predictable gingival stippling in labial flanges of gingival veneers and complete dentures. Journal of Prosthetic Dentistry, 2007. 97(2): p. 118.
7. Venugopal, S., M. Garnett, and G.S. Lim, Gingival Veneers. Dental Update, 2020. 47(3): p. 218-230.
8. Gopakumar, A. and B. Sood, Conservative management of gingival recession: The gingival veneer. Journal of Esthetic and Restorative Dentistry 2012. 24(6): p. 385-393.
9. Vojdani, M. and R. Giti, Polyamide as a Denture Base Material: A Literature Review. J Dent (Shiraz), 2015. 16(1 Suppl): p. 1-9.
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Kweh Ting Jing
BDS (IMU), MFDS RCS (Edinburgh), MClinDent (Prosthetic Dentistry) (Malaya)
Lecturer, Division of Restorative Dentistry, School of Dentistry, IMU University, Kuala Lumpur, Malaysia.
Dr Kweh Ting Jing obtained his Bachelor of Dental Surgery (BDS) from the IMU University in the year 2015. He then served as a dental officer under the Minister of Health Malaysia and obtained his Membership of the Faculty of Dental Surgery (MFDS) of The Royal College of Surgeons of Edinburgh in 2018. He secured a scholarship scheme from his alma mater in 2019 to further his study specialising in prosthetic dentistry in the University of Malaya. He completed the program and obtained his Master of Clinical Dentistry (MClinDent) in the year 2023. He is currently a lecturer in the School of Dentistry of IMU University and has several manuscripts published under his name.
![](https://i0.wp.com/dentalresourceasia.com/wp-content/uploads/2024/07/Cheah-Chia-Wei.png?resize=204%2C267&ssl=1)
Cheah Chia Wei graduated from the University of Malaya with a Bachelor of Dental Surgery. She then worked as a dental officer in the Ministry of Health, before joining the Faculty of Dentistry. There, she underwent specialist training in Periodontology and became a lecturer, teaching general dentists and specialists in Periodontology. She has a PhD related to oral microbial profiling using 16S rRNA gene sequencing in relation to the inflammatory status of rheumatoid arthritis subjects with periodontitis. Currently, Cheah Chia Wei is the discipline coordinator and clinical coordinator for the Periodontology Unit, postgraduate coordinator for Master of Oral Sciences (Periodontology) program, and also heads the Clinical Craniofacial Dental Research Group in the Faculty of Dentistry, Universiti Malaya. She is also the treasurer for The Malaysian Society of Oral Microbiologists and Oral Immunologists. Her research interests include extraction socket ridge preservation, periodontal/bone regenerative material for implantology, and oral microbiology influencing periodontal health and systemic health. She has published her work in peer-reviewed journals and has presented it both locally and abroad. Cheah Chia Wei also serves as a reviewer for peer-reviewed journals in her area of expertise.
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Associate Professor Dr. Lim Ghee Seong graduated with a Bachelor of Dental Surgery from University of Malaya, Kuala Lumpur in 2008. He then pursued his Master in Clinical Dentistry, specializing in Restorative Dentistry at Newcastle University, Newcastle Upon Tyne, United Kingdom, where he graduated with distinction. He has also been awarded the International Training Fellowship (Prosthodontics) from the Royal College of Surgeons (England). His passion for teaching then led him to join the Faculty of Dentistry, University of Malaya and he has since become a valuable lecturer and clinical specialist in prosthodontics in the Department of Restorative Dentistry. He is currently the program coordinator for Master of Oral Sciences in Restorative Dentistry, he was the year coordinator for removable prosthodontic undergraduate year 5, head of the undergraduate module on occlusion and one of the multidisciplinary team for the TMD clinic. He has previous membership in the British Society for Restorative Dentistry, assistant secretary for the Malaysian Association of Aesthetic Dentistry, currently a lifetime member and vice president of the Malaysian Association for Prosthodontics. Currently, he is also the examiner for the Restorative Specialty Membership Examinations, Royal College of Surgeons, England. He has authored and co-authored handful of both local and international journal articles. His research interest is in clinical removable prosthodontics, regenerative dentistry, dental material and temporomandibular joint disorder (TMD).
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