Four-year follow-up of a polymethyl methacrylate-based bone cement graft for optimizing esthetics in maxillary anterior implants: a case report Erica Mirand De Torres, DDS, MSc, PhD ® Luis Fernando Naldi, DDS, MSc, PhD Karina De Oliveira Bernades, DDS, MSc ® Alexandre Leite Carvalho, DDS, MSc, PhO Tooth loss promotes bone and gingival tissue remodel- ing, thus breaking the harmony between the residual ridge and natural teeth. This is critical inthe anterior region ofthe mouth, and the integration of several dental specialties i often essential I rehabilitation with implants. This article descrives a multidisciptinary ‘2pproach to Implant-supported oral rehabilitation in the mmaxilary anterior region, presenting a new technique for optimizing esthetics in implants. A 19-year-old woman was missing her central and lateral incisors ‘and had 2 dental implants inthe lateral incisor sites. ‘The patient exhibited deficient thickness of the alveo lar edge, toss of lip support, and absence of ginaival architecture, and the implants were improperly placed. 'A mulkdiscipinary team created a correct emergence profile through a polymethy! methacrylate-based bone ‘cement graft along with connective tissue rafts. This technique may be a useful therapeutic adjunct in dental implantolagy, showing good predictability and regular healing procedures, Recelved: July 24,2015 Revised: November 16,2 Accepted: December 28, Key words: biocompatible materials, bone cement, dental implants, esthetics, polymethy! methacrylate 48 GENERAL DENTISTRY Juiy/august 2017 entistry hs been trying to find the perfect balance between pink (gingiva) and whit (teeth) architecture inthe rep-oduction of an esthetically pleasant smile. Maintaining harmony between the pink and white is extremely important in achieving an optimal esthetic restoration. In oral rehabilitations with implants, the morphology and appearance of peri-imptant soft tissue associated with an implant-supported restoration play imgortant roles in achieving an esthetically ‘optimal outcome? Reconstructing the interimplant papilla in the esthetic zone is one ofthe most diffcul, challenging, and unprediet cedures in implant therapy tour; and pink architecture, the surgeon must have knowledge of several grafting techniques, including bos and biomaterials. Te key to natural and pleasant smile is proper managemen: ofthe sot tissues around the implants.’ Soft tissue grafts area classic clinical procedure to optimize esthetics around implants* However, some petients cannot be restored to an esthetic appearance without the assistance of additional procedures. ‘When there is loss cf pink steucture, dental trestment can become more complex and involve a multidisciplinary approach. Many tines, the sof tissue deficiency is accompa- nied by a severe hard tissue defect, whose management should involve hard tissue replacement (HTR), HTR may involve guided bone regeneration, bone augmentation with autogenous bone, xenografts, allografts, synthetic bone substitute materials (alloplasts), or mixtures of these materials” Jn medicine, alloclasts based on polymethyl methacrylate (PMMA) have been widely used in HT, resulting in high stability and low complication rates. A PMMA-based graft is considered to be biocompatible, stable, inert, cost-effective, and safe? In3 studies, Naldiet al used PMIMA-based bone cement in the anterior maxillaas an auxiliary method to minimize the y adverse reactions, such as soft tissue inflammation and bone resorption in the recipient area, were not reported in the medium This case report describes a multidis. treatment with implant-supported oral rehabilitation in the ‘maxillary anterior region, demonstrating a new technique for achieving esthetic implants inthis region by reestablishment of| hard and soft tissue contours using PMMA bone cement grafts associated with contectve tissue grafts. , tissue, alloplast,Fig 1. Initial appearance ofthe patient's smile Fig2. Severe remodeling ofthe residual ridge, A. The prosthesis cannot contact the gingival tissues. 8B. Residual ridge before surgical procedures, Case report 19-year-old woman presented to & private dental clinic in Goiania, Bazi, dissatisfied with the esthetics of her smile. Het central incisors and lateral incisors were missing as a conse- ‘quence of dental trauma following fall suffered in childhood. ‘The patient reported having undergone autologous bone graft- ing surgery 6 months earliet. The graft was harvested from the retromolar region of the mandibular right ramus. In the same srgical session, she received conical dental implants, compris- ing an external hexagon of 3.75 mrn in diameter and a 4.1-mim platform, in the left lateral incisor and ight lateral incisor regions. The patient was using a provisional removable partial denture made of acrylic resin with 4 elements (Fg 1) Clinical examination revealed loss of lip support, alow smile line, and the absence of anterior guidance duting protrusive and lateral moverments. In what appeared to be an attempt to hide the absence of gingival architecture and deficient thickness of the alveolar cidge the artificial teeth were protrusive and buc- cally positioned (Fig 2). ‘Analysis ofa cone beam computerized tomography image revealed the absence ofthe 4 maxillary incisors, the presence of 3 screws adhering to the bone graft in the anterior maxilla, alveolar bone loss inthe edentulous region, and intimacy between the implant in the region of the right lateral incisoe and the right canine. Due to the poor positioning and inappropriate inclination of the dental implants, a plan to remove them and place new ‘osseointegrated implants was considered. This procedure, however, would involve even more loss of bone tissue, resulting in esthetic complications. The patient was informed about all treatment options, materials to be used, associated limitations, and the risks and benefits ofthe procedures to which she would be subjected Treatment plan ‘A decision was made to preserve the implants. A PMMA-based. bone cement graft associated with soft tissue grafts was planned to improve support of the lip and to restore the thickness of the alveolar ridge. This would improve the emergence profile of the future all-ceramic fixed prosthesis. Surgical procedures ‘An incision was performed, and a full-thickness flap was cre- ated to expose the entire anterior maxilla to obtain access to the ssubnasal depression and anterior nasal spine, The implants were located, the cover plate was removed, and healing caps were placed. The fixation screws of the bone graft were removed, ‘The PMMA-based bone cement material (Aminofix 3, Groupe Lépine) was manipulated according to the manufacturer’ instructions, and a sufficient amount was adapted to the wwnuagsiorg/generaldentistry 49Four-year follow-up of a polymethyl methactylate-based bone cement graft for optimizing esthetics in maxillary anterior implants Fig. Residual ridge immediately after surgical procedures. subnasal depression. After polymerization, the PMMA-based bone cement was modeled into a better conformation to recon- stitute the residual ridge’ height and thickness, respecting the implant’ position, Two screws (Neodent) were used to fix the bone cement graft (Fig 3). These screws were not removed over time, as has been dane in other clinical applications. The screws ‘were important to keep the PMMA-based bone cement graft static, thus avoiding micromaverments that could lead to an inflammatory reaction and/or bone resorption.” Fot esthetic reasons, connective tissue grafts were made to increase the gingival volume. Palatal tissue from the premolat/ ‘molar region was removed bilaterally and transferred to the anterior maxilla over the PMMA-based bone cement graft (Fig 4). After the grafts were sutured, the patient was informed about the postoperative medications (amoxicilin, 500 mg, every 8 hours for 7 days; nimesulide, 100 mg, every 12 hours for 3 days) and instructed on oral hygiene and prevention of trauma in the surgical acea (Fig 5), There were no complications inthe postoperative period, "The sutures were removed 8 days later, and the patient was informed about the expected duration of soft tissue healing ‘After 30 days, an incision was made to expose the implants. ‘The healing caps were removed, and abutments were selected, abutments (Minipilar Conico 17, Neodent) were chosen to enable prosthetic correction of the implant positions, achiev. ing esthetic orientation in the mesiodistal and buccolingual planes. Periapical radiographs af the regions were performed 50 GENERAL DENTISTRY July/August 2017 Fig 6 Soft tissue appearance with formation of papllae after conditioning by the provisional restoration. Fig7, Prosthesis in place. Nate the natural appearance achieved. to verily a perfect fit atthe implant-abutment interface. The abutment caps were then positioned, and healing was allowed to take place for 15 days Prosthetic procedures {A provisional 4-tooth fixed prosthesis was placed on the preex- {sting implants, Qcelusal adjustments were performed, and the patient was instructed on the proper cleaning af the prosthesis. Tooth re-anatomization of the prosthesis was performed once a week for 4 weeks. The cervical outline of the crowns was refurbished to allow symmetric conditioning of the gingival tissue and induce the formation of papillae. Tissue conditioningFig 8, Smile a final delivery ofthe prosthesis. was achieved, and the development of gingival papillae between the implants an pontics was confiemed (Fig 6). At-home bleaching treatment was performed using a 22% carbamide per- oxide gl (Nite White ACB, Vigodent SA Industria e Comércio). “To allow the laboratory technician to fabricate a prosthesis ‘witha profile similar tothe emergence profil established bythe temporary prosthesis, a precise final impresian is necessary. To achieve this objective inthe present case, a customized transfer was performed, The provisional fixed prosthesis was removed fiom the mouth, and the analogs were screwed onto it and inter- connected with acrylic resin (Duraley, Plidental). This structure ‘was immersed in heavy slicon (Zetalabor,Zhermack) until the tniddle third of the prosthetic crown, leaving the incisal third ‘exposed, The temporary prosthesis was removed from the con wall, and transfers were connected to the analogs and bonded with Ducalay Bis-acryl resin (Protemp 4, 3M ESPE) was injected into the negative impression made in the slicon around the trans- fers. The set vas plced in the mouth, and te final impression ‘was obtained using polyvinyl siloxane (Express XT, 3M SPE). Photographs and @ model ofthe provisional prosthesis were taken and sent to the laboratory for fabrication ofthe all- ceramic final restoration. The final prosthesis (zirconia with ceramic coating) was fitted and screwed into place. Correct interarch placement in protrusive and lateral movernents was observed, ané the final restoration showed an appropriate emer- gence profil, symmetric ginglval contours, adequate papillae, and well-placed gingival zeniths (Fig 7). The bone cement graft enabled repositioning ofthe prosthetic teeth to contact the ingival tissues, The esthetic restoration made the smile appear more pleasant and natural (Fig 8). Follow-up ‘A follow-up examination 4 years later revealed a stable clinical appearance (Fig 9). Radiographic aspects also were satisfactory. ‘The patient ceported being very satisfied. Discussion ‘Many parameters play a role in achieving an ideal esthetic result with implants. Correct placement of the implants is 2 key Fig 9, Esthetics and function remain satisfactory 4 years after \raatment, factor Implants should be placed based on 3-dimensional con- siderations (mesiodistal, buccolingul, and apicocoronal posi- tions): However, when the planning of the implant position fails or there are ervars in the technique, itis still possible to achieve adequate restoration through prosthetic abutment selection. An angled abutment was selected in the current case. Angled abut ‘ments are indicated where there isa need to alter the insertion, direction of the prosthesis screws away from the axial ditection of the implant. However, one of the most challenging aspects of periodontal reconstructive surgery is to obtain predictable peri-implant papillae inthe esthetic zone.** Open gingival embrasures that form interproximal black spaces not only affect the esthetics (of a smile but also contribute to the retention of food debris, negatively impact phonetics, and may impair the health of perio- dontal tissues Certain parameters need to be considered in prosthetic rehabilitation—such as the vertical distance from the point of contact in the future prosthesis o the bone crest as well as the distance between adjacent implants—as they influence the level, cof the papilla." In the horizontal plane, a minimum distance of 3 mm between implants should be observed in order to preserve the bone crest and consequently the peri-implant papilla." ‘When placement of multiple implants in the esthetic zone is not feasible, cantilevering a pontic to the implant should be consid- ered! In the current case, no further implants were considered, and @ fixed prosthesis with pontics was preferred ‘Adequate thickness of solt tissue is required to enable sat- isfactory gingival conditioning. When the amount of bone is sufficient for cartect placement ofthe implant, but the bone crest is insufficient to achieve the appropriate amount of esthetic contouring, itis necessary to increase mucosal tissue thickness. ‘Managing and conserving the thickness of tissue by increasing the ridge can help achieve better esthetic soft tissue and papillae In the present case, the patient had already undergone an autogenous bone graft, and connective tissue grafts were required to increase the mucosal tissue thickness. However, soft tissue grafts may not be sulfcient to achieve short- and long-term esthetic success in the reconstruction of predictable wawagdera/aeneraldentstry 31Four-year follow-up ofa polymethyl methecrylate-based bone cement graft for optimizing esthetics in maxillary anterior implants papillae’ Long-term stability of augmented soft tissue volume around implants has not been documented Therefore, the authors theorized that PMMA could help to maintain the aug- ‘mented soft tissue volume over time. This was deemed possible ‘due to the long-term stability of PMMA grafts, which show no remodeling.** The 4-year follow-up results in this patient confirmed this assumption. A PMMA bone cement was used for HTR, elevating the soft tissue and connective tissue grafts to the height ofthe desired emergence profile, providing adequate tissue volume, enabling lip support, and helping inthe creation of interimplant papillae. ‘There isa great heterogeneity in bone augmentation stud- les regarding materials, techniques, observation periods, and evaluation methods, leading to limited information concerning the correlation between HTR and soft tissue stability” HTR could be accomplished with an autogenous bone graft, but the necessity of donor site and the continuous bone resorption associated with these grafts have been pointed out as disadvan- tages.” Alloplastic materials, such as titanium and hydroxy. apatite also could be used in HTR, but theit high cost and a lack of scientific evidence to support their superiority over PMMA.based materials guided the choices in the current case According to Marchac & Greensmith, the ideal alloplastic ‘material should have a low risk of infection and must be inert, highly biocompatible, cheap, easily available, easy to use, stable, and easy to remove? Studies with PMMA grafts have noted these properties "#2 ‘The biocompatibility of PMMA has been well acepted since the fist hip prosthesis made from PMMA was introduced in 1947." Today, PMMA is used in many medical specialties for various purposes.*"**" Although there have been reports of allergic reactions to PMMA, these are rare and usually are associated with an injectable PMMA that is mainly used as filler ‘material in facil wrinkles and furrows.” Overall, PMMA- ‘based bone cement is stable and inert material tha is well tol- erated without presenting biological or clinical side effects, such as foreign body reactions 4" In dentistry, PMMA has been used as a composite mixed ‘with a polyhydroxylethy! methacrylate (PHEMA) and calcium hydroxide synthetic bone graft as graft material in class If molar furcations.*" Some articles describe HTR therapy with synthetic bone alloplass for onlay facial augmentation and for filling extcaction sites in patients who had radiation therapy for cancer inthe head and neck tegions.*"* No complications, such as ‘ejection oF resorption of surrounding bone, have been reported Naldi etal introduced a new technique for the correction of gummy smile through esthetic crown lengthening and lip repositioning with implantation of a PMMA graft—Aminofix 3 the same material used in the current case." In cases in Which this material was used, no complications caused by infection, inflammation, or rejection of the implanted graft material were observed." No other study has described the use ofa PMMA-based bone cement graft to increase the thickness ofthe residual rldge for esthetic improvement. Nevertheless; similar to other reports using PMMA-based grafts for different clinical appi- cations, the 4-year follow-up of the patient in the present case showed no adverse effects 811887 52 GENERAL DENTISTRY Juiy/august 2017 It is worth noting that in the present clinical case, additional prosthetic procedutes were necessary to manage the soft tissue ‘contour in order to cbtain an esthetic gingival design. The pro- visional prosthesis isan important, yet often underemphasized, aspect of implant dentistry. Having a fixed provisional restora tion in place for atime provides suitable preloading to augment ‘osseointegration, promote proper peri-implant tissue contours, and create a correct emergence profile and interimplant papil- lee and thereby faciliates the fabrication ofthe final implant- supported crown." Increments of acrylic resin in the subgingival portion of the restoration can be used to achieve gingival conditioning by li pressure. Moreover, the emergence profile ofthe final prosthesis, should be carefully created, as shown in the current case, Ifthe profile is oo narrow, no contralateral pressure or support for the gingiva will exst,and the interdental papilla will diminish! After the final tissue contours and emergence profile are established forthe definitive restoration, an impression of the Lissue contours should be captured, communicated to the dental laboratory, and reproduced in the final restoration, Without a ‘customized transfer, he final impression would simply capture the incorrect circumferential emergence profile, thus compro- rising the final resul.* Conclusion In this case, a multiisciplinary approach was necessary to achieve a pleasant and esthetic result. A PMMA-based bone ‘cement graft was essential for success, as it promoted HTR to support soft tissue volume augmentation aver time, This result ‘was possible due to the high stability of the MMA-besed bone cement, which exhibits no remodeling and causes no ‘complications in the long term, The PMMA graft promoted lip repositioning and optimized the emergence profile of the implant-supported prosthesis. Additional prosthetic procedures ‘were important to manage the soft tissue contours, obtaining an esthetic gingival design. The results were stable a the 4-year follow-up, with comp ete patient satisfaction and the absence of ‘any undesirable side efects. The presented technique can be an important auxiliary procedure in oral implantology. Author information Dr Torres is an associate professor, Department of Oral Rehabilitation, School of Dentistry, Federal University of Goits, Goidnia, Brazil, where Dr Naldi is an associate professor, Department of Periodontology. Dr Bernades completed an MS¢ in health sciences, University of Braslia, Brazil, Dr Carvalho is a professor of periodontology and implantology, Brazilian Dental Association, Goids, Golinia, Brazil References 1 Mohan Simon? kur t,t Pi estas so town acheigeim, in Dnt Ase UI3EO23L. 2 Pak, Da vo, Weber titan egal. Opts penomenon of pet-maant sets, tspetesoloneticassane’ofrtvalicah angle primp snc. 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