Introduction

Rehabilitating missing anterior teeth with dental implants in the maxillary esthetic zone presents particular restorative challenges due to the high esthetic demands of this region. The esthetic zone is highly visible when a person smiles or speaks, and any imperfections can significantly affect a patient's appearance and self-confidence. Achieving a harmonious integration of the implant-supported restoration with the surrounding natural dentition is crucial for patient satisfaction. However, the variability in esthetic outcomes can be influenced by several factors, including the patient's biotype, the quality and quantity of the surrounding soft and hard tissues, and the skill and experience of the clinician³.

Immediate implant placement in the esthetic zone requires precise planning and execution to achieve optimal esthetic and functional results⁴. This approach often involves a multidisciplinary team, including restorative dentists, oral surgeons, and dental technicians, to ensure a comprehensive treatment plan tailored to the individual patient's needs. The use of advanced digital technology, such as computer-aided design & computer-aided manufacturing (CAD/CAM), and guided surgery, has disrupted the planning and placement of dental implants. These technologies enhance the accuracy of implant placement, allowing for a more predictable outcome and reducing the risk of complications⁵.

In the following case report, we present a fully guided immediate implant restoration in the esthetic zone, with a 6-year follow-up. This case highlights the importance of meticulous planning, the use of advanced technology for guided surgery, and the long-term stability of the esthetic and functional outcomes. The patient presented with a hopeless maxillary central incisor and strongly desired a rapid and esthetically appealing solution. Through detailed preoperative assessment and guided implant surgery, we achieved immediate implant placement and restoration, providing the patient with a seamless transition from a failing tooth to a functional and esthetically pleasing implant-supported restoration.

The 6-year follow-up period offers valuable data on the stability of the treatment, underscoring the importance of a correct diagnosis and treatment planning.

Initial situation

A 45-year-old woman, in good health (ASA I), a non-smoker, and with no medications or allergies, visited our clinic due to concerns about one of her central incisors. She reported, “I have a front tooth that has changed color and was told it needed to be extracted. I would like it to be restored quickly because it's the first thing you see when talking and smiling." She desired a minimally invasive esthetic solution for her upper right central incisor.

The extraoral examination showed a high smile line. The intraoral examination of tooth #11 revealed signs of external root resorption on the palatal surface (Fig. 1). The tooth appeared darker and slightly intruded compared to its contralateral tooth (Fig. 2), raising suspicion of ankylosis. The tooth was non-sensitive to percussion, and the CO2 test was negative. No signs of local infection, occlusal trauma, or periodontal inflammation were observed.

The CBCT scan confirmed the extent of the root resorption with no loss of alveolar height detected (Fig. 3).

Based on the SAC classification, the patient's surgical case was categorized as complex, and her prosthodontic case was evaluated as advanced (Fig. 4).

Treatment planning

Following an extensive discussion of the treatment options, immediate implant placement was selected, considering the favorable clinical conditions and the patient's desire. Tooth #11 was atraumatically extracted with the intention of preserving the residual alveolar bone. A temporary screw-retained crown was placed on the same day.

The treatment workflow included:

1. Digital planning to establish a prosthetically-driven implant position.
2. Atraumatic extraction of tooth #11.
3. Guided surgery for a Straumann® Bone Level Tapered 3.3 mm SLActive® 12 mm implant placement in a prosthetically driven position. 
4. Connective tissue graft on the buccal side. 
5. Temporary screw-retained crown delivery after surgery.
6. After healing, final screw-retained crown delivery. 

Surgical procedure

We initiated the evaluation of the tooth, noting the absence of dental plaque, bleeding on probing, or increased probing depth (Fig. 5). Local anesthesia with 4% articaine and 1:100,000 epinephrine was administered, and tooth #11 was extracted atraumatically.

The sterile surgical guide was verified and positioned for implant-site preparation following the extraction. The implant bed was prepared according to the manufacturer's guidelines (Fig. 6). The Straumann® depth gauge was utilized to confirm the complete preparation depth and the correct orientation of the implant axis (Fig. 7).

The Straumann® Bone Level Tapered 3.3 mm SLActive® 12 mm implant was inserted using the surgical guide with the aid of the handpiece in a clockwise direction at a speed of 15 rpm torqued to 35 Ncm (Fig. 8). Soft tissue augmentation was performed in the buccal zone with a connective tissue graft (Fig. 9).

A tension-free closure of the soft tissue was achieved, and a provisional abutment was placed (Fig. 10). A radiograph was taken to confirm the precise positioning of implant #11 in relation to teeth #21 and #12, as well as the placement of the abutment. Subsequently, the abutment was torqued to 35 Ncm using a torque wrench, followed by the placement of an immediate temporary crown (Fig. 11). Proximal contacts and occlusion were verified, and all occlusal contacts were adjusted to eliminate interference during lateral and excursive movements. The patient received instructions on care and hygiene.

The site demonstrated good healing at the time of suture removal ten days later and at subsequent follow-up appointments.

Prosthetic procedure

Four months after the implant had healed and osseointegration was confirmed, the temporary crown was removed. The gingiva was examined for healing, showing sufficient interdental papilla and buccal contours similar to those of the adjacent teeth (Figs. 12,13).

A digital impression was taken using a Virtuo Vivo™ IOS, and the final crown was placed, ensuring proper occlusion and esthetics. A radiographic intraoral examination confirmed the absence of any pathological findings (Fig. 14). Access holes were sealed with Teflon and composite restoration. The patient was highly satisfied with the treatment's esthetic and functional results. Oral hygiene instructions were given, and follow-up appointments were scheduled.

Clinical and radiographic evaluations were performed yearly. During these follow-up assessments, at two (Fig. 15) and six years (Figs. 16,17), the clinical examinations showed well-maintained gingival tissues and gingival margin around the implant. The prosthesis was deemed satisfactory in terms of esthetics, and patient satisfaction. At six years, the radiographic evaluation confirmed the preservation of peri-implant bone tissue (Fig. 19).

Treatment outcomes

The final outcome demonstrated exceptional health in both the hard and soft tissues. The gingival tissue surrounding the implants has remained stable with no recession six years following final crown placement. The patient expressed gratitude, stating, "I am very pleased with the treatment results, especially having had a provisional prosthesis from the outset. The new crown looks natural and blends perfectly with my other teeth—I love it."

Author’s testimonial

The key to successful implant therapy in the anterior esthetic zone is the optimal management of the relationship between hard and soft tissues. Implants that are adequately stabilized can be successfully loaded without occlusal contact at the time of implant placement. They can later be definitively loaded with occlusal contact, without compromising function or esthetics.