Introduction

In this case report, we present a young male patient referred for the extraction of tooth #11 due to a horizontal root fracture. The patient, concerned with the functional and esthetic impact of losing his front tooth, requested a durable and fixed solution. Clinical and radiographic examinations confirmed the need for extraction and showed sufficient bone support for immediate implant placement. Given the patient’s high smile line and gingival recessions in adjacent teeth, a precise treatment plan was necessary to achieve optimal functional and esthetic outcomes.

Leveraging a fully digital workflow within our practice, we chose to collaborate with the Smile in a Box™ team for assistance. This allowed us to streamline the surgical and prosthetic phases, outsourcing the production of the surgical guides and temporary implant prostheses. Additionally, we maintained full control over the surgical planning using coDiagnostiX® software, ensuring a personalized approach tailored to the patient's unique needs.

This report highlights the use of Smile in a Box™ for immediate extraction and implant placement in the esthetic zone, showcasing the benefits of precision, predictability, and efficiency in digital dentistry. Through this integrated approach, the patient received an immediate functional and esthetic restoration, resulting in high satisfaction and outstanding clinical outcomes.

Initial situation

A young male patient arrived for a consultation, referred by his endodontist for the extraction of tooth #11, which presented a horizontal root fracture. The patient had already been informed that he was going to lose the front tooth and desired a durable, fixed, functional, and esthetic solution.

The patient’s medical history revealed no significant findings, and intraoral examination showed good oral hygiene. Tooth #11 exhibited discoloration and grade II mobility; no bleeding on probing was noticed. A high smile line and a healthy amount of keratinized tissue surrounding tooth #11 were observed. The patient also presented marked recessions in the adjacent teeth. Radiographic examination showed sufficient mesiodistal width and an adequate distance from adjacent teeth.

Based on clinical and radiological assessments, the horizontal root fracture was confirmed (Figs. 1,2).

Treatment planning

After a thorough discussion of the treatment options with the patient, immediate implant placement was decided. Atraumatic extraction with immediate loading provisionalization was performed on the same day (Figs. 3-5).

The treatment workflow included:

1. Digital planning using coDiagnostiX® (Fig. 3).
2. Atraumatic extraction of the hopeless tooth #11.
3. Production of surgical guide for drilling protocol with Smile in a Box™.
4. Immediate implant placement of Straumann® BLX Implant, ∅ 3.75 mm SLActive® 12 mm. Roxolid®.
5. Installation of a PEEK temporary abutment for the provisional crown.
6. Bone augmentation around implant #11.
7. Immediate provisionalization of implant #11 and mucogingival surgery.
8. Final prosthetic rehabilitation with a screw-retained crown on implant #11.

Surgical procedure

Aseptic protocols were meticulously followed, and local anesthesia was administered using 2% lidocaine with 1:100,000 epinephrine. Tooth #11 was extracted atraumatically without the need for a flap, followed by carefully alveolar curettage and irrigation with saline to remove all debris left, while ensuring the preservation of alveolar wall integrity (Fig. 4). The surgical guide, previously designed with Smile in a Box™, was then verified for accurate fit and to allow for guided immediate implantation (Fig. 5).

Preparation of the surgical bed began with the osteotomy for implant #11 with the Ø 2.2 mm pilot drill, following the manufacturer's recommended drilling protocol. A Straumann® BLX Implant, ∅ 3.75 mm SLActive® 12 mm. Roxolid® was then inserted following the same orientation as the milling, using a handpiece in a clockwise direction at 15 rpm insertion speed, with a final torque of 35 Ncm. Primary stability was achieved in the final position.

Prosthetic procedure

Even in a completely guided solution, computer-assisted surgery does not provide absolute precision regarding the final positioning of the implant in immediate implantation situations. The presence of the extraction socket, the variations in bone density encountered, and the geometry of the alveolar walls often lead to systematic deviations of the implant. Finalizing the provisional prosthesis prior to the surgical procedure, while applicable to a healed site, becomes highly unpredictable at an extraction site. Therefore, we recommend utilizing a provisional shell with wings, fabricated from PMMA and based on virtual planning obtained through CAD/CAM. This approach offers several advantages, including adaptability to any deviations from the implant plan, while ensuring a simple, reliable, and reproducible method to achieve an optimal emergence profile.

The provisional restoration was checked intraorally for proper seating, stability, and adaptation, utilizing a Variobase RB ∅ 3.8 mm with an abutment height of 3.5 mm and a gingival height of 2.5 mm. The wings enable perfect positioning in three-dimensional space (Figs. 6,7).

A sterile compress and a sheet of rubber dam were placed around the provisional abutment to isolate the area and facilitate bonding with a composite resin in a dry environment. The screw access channel of the temporary cylinder was packed with PTFE (Figs. 8,9).

The provisional shell was secured to the abutment in the mouth, and the entire assembly was unscrewed for adjustment outside the patient's mouth. Resin was applied and polymerized into the correct anatomic position, paying careful attention to the anatomical details of the peri-implant critical areas. The ideal emergence profile was defined as follows: concave on the buccal side and straight in the proximal areas. The temporary abutment was polished on an implant analog to ensure compatibility with the oral situation while avoiding contact with the lower incisors (Figs. 10-15).

A healing abutment was placed to facilitate filling using the 'dual zone' technique with a particulate xenogenic material. The provisional restoration was then positioned on the implants, and the screw was tightened (Fig. 16). All occlusal contacts in maximum intercuspation (MIP) and during excursions were relieved, and hygiene instructions were provided. Follow-up visits for the patient were scheduled.

After four months, the healing was satisfactory, and it was decided to perform a mucogingival surgery to correct the recessions (Fig. 17).

Perioperative view showing the different connective tissue grafts placed on the gingiva before being positioned to outline the augmentation sites (Fig. 18). It was decided to overcorrect the implant site for tooth #11.

The grafts sutured in place (Fig. 19). View at the end of the procedure (Fig. 20).

Final view after four years follow-up (Figs. 21,22).

Treatment outcomes

The treatment outcomes showed successful healing and integration of the implant, improving the function and esthetics. The use of Smile in a Box™ facilitated accurate treatment planning and customization of the provisional restoration, contributing to improved patient comfort and satisfaction. Follow-up assessments showed the stability of the implant and integrity of the surrounding tissues, setting the stage for the final restoration.

Author’s testimonial

Equipped with a complete digital workflow that allows us to offer fully integrated treatment within our practice, we have chosen to rely on the Smile in a Box™ teams for technical assistance throughout the execution of our clinical cases. This helps us offload time-consuming steps and take advantage of the precision and reproducibility offered by centralized production for our surgical guides and temporary implant prostheses.