upper teeth from the front

This is the fifth in a series of articles on managing open interdental spaces, diastemas, or black triangles using a convex restorative form. The previous articles in this series addressed preparation margin location, both gingival and interdental axial walls, provisional restorations, and laboratory communication. Part 5 will discuss the veneer restoration insertion and the management of the gingival tissue.

During the try-in appointment, assess the gingival health. If there is inflammation of the tissue, you may have an inaccurate portrait of the potential papilla height. Once the inflammation is resolved, the tissue may shrink, and a black triangle may reappear.

Before the provisional restoration is removed, measure the interproximal sulcus depth. It should be measure a normal 2.5 mm. If it is less, re-evaluate your provisional interproximal contours. Is the interproximal space closed with excess contour which is preventing the papilla from reaching its true potential height? In this case, during try-in of the veneer restorations you would expect to see a black triangle. If the gingival aspect of the interdental contact is 4.5 mm from the sulcus depth, you can bond the veneers in with the expectation that the papilla will creep into the space. If the contact is greater than 4.5 mm from the sulcus depth, ceramic will need to be added to make a longer contact.

The sequence of steps to follow must be efficiently accomplished because once the provisional is removed, the papilla will begin to change form and slump. First, remove the provisional with a micro-hemostat. The provisional may need to be sectioned if it is bonded securely. Second, clean the preparations with a microbrush. Third, try in individual restorations to check the marginal fit. Fourth, try in adjacent restoration checking the interproximal contact by confirming the same marginal fit, especially the adjacent interproximal. Fifth, while holding both veneers on the teeth, confirm the papilla fills in the gingival embrasure.

If there is a space, measure the sulcus depth. If it measures 4.5 mm, ceramic will need to be added to make a longer contact to touch the papilla. If the clinician does not have a ceramic furnace in the office, the restoration will need to be sent back to the laboratory. Be certain to take a photograph of the try-in so the technician can see the spaces. Also measure the distance from the margin to the contact so you can prescribe how much ceramic needs to be added. Re-evaluate your provisional contours before recementing/bonding on the teeth.

If blanching of the papilla occurs during veneer try-in, there is excess contour in the gingival third interproximally on the restorations. The restorations need to be recontoured with a fine diamond bur at 20,000 rpm or a medium polishing wheel at 8,000 rpm. The goal is to establish the appropriate contour to support the papilla, establishing a 4.5 mm sulcus so the interdental contact touches the tip of the papilla with minimal to no blanching.

After you confirm that the restorations have the proper contour to support the papilla, proceed with your normal protocol to bond the veneers. Inform the patient that a black triangle may be present after you complete all the clinical steps to insert the restorations, including gingival retraction and cleanup of excess resin cement. Reassure the patient the papilla will fill in the space.

The fundamental principle to closing open interdental spaces is to know before you begin treatment, how much if any the papilla will move incisally. Having an outcome-based preparation design concept will improve the predictability of the procedures you use. Establishing the correct contours to manage the papilla during provisionalization is an essential step in the process to have predictable outcomes. Critical information and communication are necessary with the dental technician for the restoration to be completed with biologically correct contours.

Following the concepts provided in this series of articles, highly predictable long-term outcomes to close interdental spaces are achievable.

Tooth preparations before gingival retraction. Note the blunted papillae.
Provisional restorations
Provisional restorations removal
Provisional removed. Note the shaped papillae.
Provisional removed. Note the shaped papillae.
Individual veneer try-in to check marginal fit.
Veneer try-in to check contact and papilla height relative to contact.
Veneer restorations.

Robert Winter, D.D.S., is a member of Spear Resident Faculty.