Gingival Veneer: A Prosthetic Solution for Black Triangles

Kweh Ting Jing¹, Cheah Chia Wei², Lim Ghee Seong^2*

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. 

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. 

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. 

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.

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 

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