Throughout my career, I’ve had three watershed moments when it comes to my continuing education in direct composite dentistry. The first was during a course by Dr. Dennis Hartlieb, and the second from Dr. Jason Smithson, whom I had learned about through Dentaltown. These clinicians demonstrated techniques and results with composite that I initially had thought were unattainable. The third moment came in 2006, when I met Dr. David Clark during his course at the Big Apple Dental Meeting, where I first learned about the Bioclear method. Clark demonstrated a minimally invasive and predictable way to close black triangles and restore deep Class III restorations. Up to this point, I had attempted to restore these types of restorations via flat Mylar, often leaving a bloody mess and less than optimal results.
Besides realizing this new method of dentistry would improve my entire approach to composite dentistry, I also understood that it spoke to many things that my patients were already asking for: They don’t want to remove tooth structure, they do want to keep their costs down, and they do want results that are strong and look good. And if they can’t get that from you, they’ll get it somewhere else! That’s why it’s important to keep learning about new materials and new techniques. The following case explores my own use of a new composite and a new(er) technique for closing black triangles.
Turning black triangles pink
The dark spaces between patients’ teeth can make the teeth look old or give the feeling that the teeth are diseased in some way. Many patients have an adverse reaction to this look and don’t even realize it will happen to them, especially as a result of orthodontic treatment. So, what are the options? A veneer just blocks the space—it doesn’t regenerate a papilla and doesn’t go between the teeth like a composite can. We don’t want to just block the space, anyway; we want to create a pink triangle and regenerate the papillae at the same time. We’re talking almost 100% additive dentistry, which really separates this technique from veneers and crowns.
A 35-year-old patient presented in good overall health. His chief complaint was the appearance of black triangles between his lower teeth after receiving orthodontic treatment (Figs. 1–2). He wanted them gone. After consulting with his usual dentist, he was told they could use veneers or crowns to close the black triangles. (Keep in mind there was no decay on the teeth.) Thankfully, the patient didn’t like the idea of cutting away healthy tooth structure, so he did what so many patients do nowadays: search for other options online. This is how he found our clinic.
The consultation appointment included taking photographs, and we treatment-planned the Bioclear method to close the black triangles, to which the patient agreed.
Because there was no removal of tooth structure, we applied a topical anesthetic. Typically, local anesthetic is not needed for black-triangle resolutions. I applied a rubber dam to isolate the teeth and to further retract the papilla (Fig. 3). This gave us better access to the interproximal tooth structure. Note: The rubber dam has to be applied first, because when using a slurry polisher or air abrasion, it’s possible to cause gingival bleeding. The dam protects the gingiva and provides an isolated environment. Once this was completed, we used a slurry polisher (Bioclear Blaster) to remove any biofilm and make sure we were bonding to tooth structure and avoiding future composite staining.
After this cleaning, we used a Bioclear black triangle gauge to determine the size of our matrices for the injection-molding process. There is a real advantage in using anatomical matrices vs. Mylar strips, so make sure you are choosing matrices carefully. This stems from the matrices’ gingival curvature. This curvature allows for an early and aggressive transition from gingival to incisal, which will reposition contact points closer to the gingiva, thereby increasing the ability to resolve black triangles. Additionally, the curvature will help provide a better seal at the gingival area and smooth emergence profiles.
Once the matrices were selected, we started with the central incisors. Each tooth was filled by scrubbing in the adhesive (Scotchbond Universal, 3M Oral Care), then utilizing injection molding with warmed bulk-fill flowable (Filtek Bulk Fill Flowable, 3M Oral Care) and warmed universal composite (Filtek Universal, 3M Oral Care). Care is taken to ensure that the matrices are fully filled, and no visible bubbles or voids are observed. This process was then repeated for teeth #22–27 (Fig. 4). Once all teeth are completed, excess composite from the buccal and lingual surfaces were removed. It should be noted that if applied properly, the interproximal areas need not be addressed as they should be smooth, rounded and void-free.
As a final step, we finished and polished using a combination of discs (Sof-Lex, 3M Oral Care, and Rockstar Polish, Bioclear). The teeth were then checked to make sure there were no overhangs (Fig. 5). The entire procedure, from rubber dam placement to final polish, was completed in less than two hours.
Lower anterior black triangles present their own challenges because of the small area we need to get into with our composite. Thankfully modern dental techniques and products have adapted to make this an enjoyable procedure—have you adapted?
Fig. 1: Preoperative smile view.
Fig. 2: Preoperative retracted view.
Fig. 3: Rubber dam application.
Fig. 4: Lower anteriors are a very small area, so the thin tip of Filtek Universal really helps to facilitate the placement of the composite in the area.
Fig. 5: Final result.