A stepwise approach to esthetic zone reconstruction: clinical case insights
A complex esthetic challenge was resolved through a digitally guided, minimally invasive workflow. This step- by-step case illustrates how integrated planning, precise surgery, and the use of premium, evidence-based solutions contribute to predictable outcomes and esthetic excellence in implant dentistry.
Initial condition
A 32-year-old male patient was referred to our practice presenting darkening of the upper left central incisor (tooth #21) and presence of a fistula in the same region. His medical history was unremarkable. Dental history revealed prior endodontic treatment and subsequent apicoectomy, both unsuccessful. Cone-beam computed tomography (CBCT) demonstrated a perforation of the buccal bone plate at the apex of tooth #21, a complication likely related to the previous surgical intervention.
The patient had a medium to high smile line and a harmonious free marginal gingival contour across all anterior maxillary teeth, though discolored tooth #21 and a poorly restored tooth #11 negatively impacted the overall smile esthetics.
A Tomographic section of tooth #21 showing perforation of buccal bone plate
B Frontal view where darkening of #21 and unsatisfactory restoration of #11 can be seen
Treatment planning
A patient-centered, minimally invasive approach was prioritized. Digital treatment planning was carried out using DTX Studio™, integrating CBCT and intraoral scans (IOS) to allow high-precision planning for implant positioning and prosthetic restoration. Software-based analysis demonstrated that following extraction of tooth #21, there would be sufficient bone to enable immediate implant placement. The implant selected was NobelReplace® CC TiUltra™, known for its tapered body design and primary stability which is essential for immediate provisionalization. To maintain the soft and hard tissue contours and optimize esthetics, guided bone regeneration (GBR) and a connective tissue graft were planned in conjunction with implant placement.
C Implant position planning
D Surgical guide generated by the DTX Studio™
E Printed guide
Surgical procedure
Under local anesthesia, tooth #21 was atraumatically extracted. Using a fully guided surgical protocol based on the DTX-generated guide, the implant was placed immediately into the extraction socket, following the pre-planned trajectory. An occlusal view confirmed correct 3D positioning.
Buccal bone deficiency was addressed with guided bone regeneration, using a mixture of xenograft and autogenous bone covered by a resorbable membrane. A connective tissue graft harvested from the maxillary tuberosity was then positioned on the buccal aspect to enhance soft tissue thickness and esthetics, followed by meticulous suturing.
F Tooth extraction
G Guided implant placement
H Occlusal view of the implant placed
I Guided bone regeneration for closing the bone defect
J Tissue graft removed from tuberosity
K Tissue graft positioned on the buccal side
Prosthetic procedure
To facilitate immediate provisionalization, the crown from the extracted tooth was repurposed and relined chairside. It was temporarily cemented over a temporary abutment attached to the implant. The provisional played a crucial role in maintaining gingival architecture and supporting the emergence profile during healing.
L–M Suture of the soft tissue graft
N Crown of the removed tooth was used as temporary
After a 6-month healing period, the site was reevaluated clinically and radiographically. Both soft and hard tissues demonstrated excellent stability, with preservation of the original contour.
O Clinical view 6 months post-op
P X-ray
Q Soft tissue contour
Digital impressions were taken using a scanbody, and the intraoral scan was processed for prosthetic design. In collaboration with a dental technician, the final restoration was crafted, including a ceramic veneer for tooth #11 and an implant-supported NobelProcera® crown for tooth #21.
R Elos Accurate Intra Oral Position Locator Conical Connection
S Scanbody in position for intraoral scanning
T Intraoral scan
U Laboratory work for the fabrication of a veneer on #11 and an implant-supported NobelProcera® crown on #21 [Dental laboratory technician: Cristiano Soares]
The NobelProcera® final restorations showed excellent integration with the surrounding dentition, including harmonized color, shape, and contour. A pleasing smile line and frontal view confirmed the success of the treatment. Comparison of follow- up images with the original digital treatment plan confirmed stability of the peri-implant tissues at two years post-treatment.
V Smile line
W Frontal view at final prosthetic delivery
X Cone-beam computed tomography before and at 2-year follow-up
Y Healthy soft tissue at 2-year follow-up
Concluding remarks
Digital planning has become an indispensable component of modern clinical workflows, offering substantial benefits to practitioners at all levels of experience. Platforms like DTX Studio™ enable comprehensive preoperative assessment of the surgical site, facilitate the creation of precise surgical guides, and support the optimal selection of prosthetic components, ultimately enhancing procedural accuracy and patient safety.
The design of Nobel Biocare implants, such as the NobelReplace® CC TiUltra™, provides excellent primary stability due to their high insertion torque. Combined with advanced surface technologies, these implants support stability of both hard and soft tissues while delivering superior esthetic outcomes. For us, it is essential that all these solutions and products are backed by well-documented scientific evidence. An evidence-based approach enhances clinical confidence, improves treatment predictability, and ultimately leads to better long-term outcomes and esthetic results for patients.1–7
This case illustrates how a challenging clinical scenario in a highly esthetic zone can be resolved through a single, digitally guided procedure, demonstrating the power of integrated planning, surgical precision, and prosthetic excellence in contemporary implant dentistry.
References
- Todescan FF, et al. Int J Periodontics Restorative Dent.2023;43(1):e27-e34.
- Roe P, et al. Int J Oral Maxillofac Implants. 2012;27(2):393-400.
- Levine RA, et al. Compend Contin Educ Dent. 2017;38(4):248-260.
- Kan JYK, et al. Periodontol 2000. 2018;77(1):197-212.
- Qin R, et al. Int J Oral Maxillofac Implants. 2023;38(3):422-434c.
- Wittneben JG, et al. Clin Oral Implants Res. 2023;34 Suppl 26:266-303. 7. Zuiderveld EG, et al. J Clin Periodontol. 2024 Apr;51(4):487-498.