Single tooth replacement in a thin biotype: A staged implant and digital prosthetic approach

Clinical situation

A 38-year-old healthy male was referred by his general dentist for evaluation of chronic discomfort at the maxillary right central incisor (#8). The tooth had a long restorative history beginning with trauma in childhood, followed by a large bonded composite, later replaced with a crown, root canal therapy, and a second crown for esthetic improvement. The patient referred to it as “the tooth that always has a problem.” Clinical examination revealed a deep, narrow facial probing depth with abscess formation—findings highly suggestive of a vertical root fracture.

Treatment planning and surgical procedure

An exploratory surgical procedure was proposed to confirm the suspected vertical root fracture. Given the patient’s thin gingival biotype, triangular tooth morphology, wide interdental embrasures, and high smile line, preserving soft tissue architecture was a top priority. If the tooth proved to be non-restorable, a staged surgical approach would be implemented to optimize healing and esthetic outcomes. A NobelActive NP implant was planned with an angulated screw channel (ASC) abutment, accommodating the proclined alveolar ridge that would complicate conventional screw retained restoration.

Exploratory flap surgery confirmed a long vertical facial root fracture. The tooth was extracted, and alveolar ridge preservation was performed using bone grafting. Implant placement and immediate provisionalization were carried out during a second surgery. This staged approach allowed enhanced spatial and soft tissue control. A modified flap design was employed during implant placement to support gingival architecture and minimize surgical trauma. Large scale hard and soft tissue augmentation was intentionally avoided to maintain biologic integrity and achieve a natural esthetic blend with adjacent teeth.

Prosthetic procedure and treatment outcomes

After four months of healing with the provisional, the definitive restoration was completed using a model less, two appointment digital workflow. An intraoral scan captured both the implant position and the tissue contours developed by the provisional. The final prosthesis was a NobelProcera® Full-contour Zirconia Implant Crown (FCZ) crown on a Nobel Biocare angulated screw channel (ASC) abutment, designed with DTX Lab (Nobel Biocare).

Key to success

Meeting the patient’s high esthetic expectations required clear communication of both goals and limitations. The success of this case rested on procedural simplicity, favoring biological compatibility over aggressive surgical intervention. The angulated screw channel (ASC) abutment enabled an ideal implant position while honoring a prosthetically driven design, achieving what is often challenging with conventional screw retained restorations. It also allowed flexible screw channel positioning, optimizing both ceramic strength and clinical access. 

The patient, a heavy bruxer with a history of restoration fractures and root failure, benefited from a high strength NobelProcera® Zirconia FCZ crown with minimal or no cutback. The liquid ceramic surface treatment achieved acceptable esthetics while maintaining a simplified and efficient prosthetic workflow.