Interdental papilla deficiency resulting in the formation of "black triangles" is a frequent esthetic and functional problem in dentistry. These open gingival embrasures occur due to several factors including periodontal attachment loss, traumatic oral hygiene practices, tooth morphology, orthodontic treatment, and aging. In addition to compromising dental esthetics, black triangles may lead to food impaction, phonetic problems, and patient dissatisfaction with their smile.
Several therapeutic approaches have been proposed for the management of interdental papillary loss. These approaches can generally be classified into surgical and nonsurgical techniques. Surgical methods aim to reconstruct the lost papillary tissue through soft tissue grafting procedures such as the tube grafting technique. These procedures attempt to biologically restore the interdental papilla but may involve surgical morbidity and require advanced clinical skills.
Nonsurgical approaches have recently gained interest as minimally invasive alternatives. One such approach involves the use of injectable fillers such as hyaluronic acid to augment the volume of the interdental papilla. Hyaluronic acid is widely used in aesthetic medicine due to its biocompatibility and ability to promote tissue hydration and volumization. Another nonsurgical strategy is the restorative modification of tooth contours using the injection molding composite technique, which alters the shape of the proximal tooth surfaces to reduce the appearance of the gingival embrasure.
Despite the availability of these different treatment options, there is limited evidence directly comparing surgical and nonsurgical approaches for the management of interdental black triangles. Therefore, the present study aims to evaluate the efficacy of these treatment modalities in a randomized clinical trial design.
Thirty patients presenting with interdental papilla deficiency will be recruited from the outpatient clinic of the Faculty of Dentistry at King Salman International University. Eligible participants will be adults aged 18 to 50 years with Nordland and Tarnow Class I or II papillary loss and adequate interdental bone support (≤5 mm distance from the contact point to the alveolar crest). Participants with systemic diseases affecting wound healing, active periodontal disease, periapical pathology, pregnancy or lactation, parafunctional habits, or smoking history will be excluded.
After baseline assessment, participants will be randomly allocated into three equal groups:
Group I: Surgical reconstruction of the interdental papilla using the tube grafting technique.
Group II: Papillary augmentation using hyaluronic acid injection.
Group III: Restorative treatment using the injection molding composite technique.
Baseline clinical examination will include plaque index, bleeding index, probing pocket depth, and clinical attachment level. Standardized intraoral photographs will be obtained using a digital camera under controlled conditions. Image analysis software will be used to measure the surface area and height of the black triangle.
Follow-up assessments will be conducted at 3 months and 6 months after treatment. At each follow-up visit, clinical periodontal parameters and photographic measurements will be repeated. Patient satisfaction with the esthetic outcome will be evaluated using a Visual Analog Scale.
The primary outcomes of this study are the changes in black triangle surface area and height over time. Secondary outcomes include periodontal clinical parameters and patient-reported esthetic satisfaction. The results of this randomized clinical trial are expected to provide clinically relevant evidence regarding the effectiveness and stability of surgical and nonsurgical techniques for the management of interdental black triangles, contributing to evidence-based decision-making in esthetic dental practice.
