Tackling black triangles on a self-conscious patient

patient case study Here Balraj Sohal shows how he tackles black triangles on a self-conscious patient.

A 43-year-old patient attended for consultation. She expressed her concern about the large spaces developing between her teeth as well as the staining and decay present. She always felt self-conscious of those large gaps. Her interest turned to how we could help.

The patient’s medical history is unremarkable, and she is a non-smoker.

Her extraoral structures and intraoral soft tissues were healthy. Periodontal assessment revealed she had stabilised periodontal disease, BPE scores of 100/101.

Clinical and radiographic assessment identified caries on the distal of the upper left central incisor, mesial and distal of the upper left lateral incisor, mesial and palatal of the upper left canine.

Considering our patient required restorations of the carious lesions, we advised her whilst doing the fillings we could simultaneously also provide a solution to her chief complaint and offer a solution to close the black triangles between the teeth.

She was very interested in this. So, we opted to use the anterior bioclear matrix system (Clark matrix system).


  • Caries: UL1D UL2M+D UL3M+P
  • Black triangles: UL1 UL2 UL3
  • Treatment plan: composite restorations on UL1D UL2M+D UL3M+P.

Step one

Pre-operative view of the carious lesions present on the distal of the upper left central incisor, mesial and distal of the upper left lateral incisor, mesial and palatal of the upper left canine.

Rubber dam isolation alongside floss ligatures to gain maximum isolation and retraction of the soft tissues. Prior to isolation a shade of the teeth was taken. I identified Shade A3 Venus body as the best match for the natural dentition.

Figure 1

Step two

Caries removal using a round diamond bur.

The cavity margins were bevelled using a white stone and ultrasonic scaler tip followed by micro-abrasion using 27-micron silica particles to allow a clean substrate ready for bonding.

Note the UL3 distal cavity – the UL3 buccal enamel was preserved, as the caries was accessed palatally to ensure we preserved as much tooth structure as possible.

Figure 2

Step three

The restorations were filled using shade A3 Venus composite.

I opted to use single shade due to the small size of the cavity lesions. Bioclear matrices were placed between each cavity.

A small increment of Venus A3 flowable composite was placed (uncured) into the cavity, followed by an increment of packable composite – this enabled good adaptation of the composite as the flowable acted as a carrier ensuring the composite filled each portion of the cavity, reducing the chances of any voids/defect.

Figure 3

Step four

The immediate post op; I removed the rubber dam. The gingivae are slightly traumatised from the force applied due to the floss ligatures.

Particular care was taken to refine the palatal aspect of the restorations to ensure the restorations conformed to the existing occlusal scheme as well as ensuring they felt smooth and comfortable to the patient’s tongue.

Figure 4

Step five

The patient returned for a one-week review to assess the restorations and enable us to do final refinements and final polishing.

She expressed her delight at the restorations and was incredibly happy at the outcome.

After assessing the restorations under magnification, I felt there was very little to refine, so we opted to leave the restorations as they are.

At the one week-review it is clear to see the very healthy gingival tissues – the inflammation from the rubber dam and floss ligatures has subsided but more importantly the restorations are placed to a high standard and very respecting of the gingival tissues.

Figure 5


On reflection the outcome for this case had a nice outcome. The patient and dentist were both satisfied with the end result.

For future cases I would photograph and document each individual step to improve case documentation. For instance a photograph of the different matrices in place would be of use to the reader. It will aid with further understanding of how the case was carried out.

This article first appeared in Young Dentist magazine. You can read the latest issue here.

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