Esthetic Anterior Implant Replacement With Thin Buccal Bone and Smoking
A 38-year-old woman lost maxillary incisors 12, 11, and 21 in a bicycle accident 6 months ago. She has a high smile line with 4 mm of gingival display and wants a fixed, esthetic replacement. CBCT shows buccal bone width 3.5 mm at 11 and 4 mm at 21, vertical bone height 12 mm, and a nasopalatine canal 6 mm from the crest. Interarch space is 8 mm. The opposing dentition is natural, with no parafunction. She smokes 8 cigarettes daily and has controlled hypothyroidism. The gingival biotype is thin, and the adjacent teeth have no restorations. She asks for “teeth that look exactly like the others” and is willing to undergo grafting. She has a temporary acrylic partial denture that she finds bulky.
1. Outline the surgical and prosthetic sequence for replacing 12, 11, and 21. Justify immediate versus delayed implant placement and whether to graft.
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I would use a delayed, staged or simultaneous grafting approach, not immediate placement. The site is already 6 months healed, but buccal bone width is only 3.5–4 mm, which is inadequate for ideal implant placement with a buccal plate. Immediate placement is more predictable when there is an intact socket wall and no infection; here the thin buccal bone and esthetic risk make it less favorable.
Sequence:
- CBCT-based planning and a surgical guide; assess the nasopalatine canal and choose implant positions that allow screw retention and ideal emergence.
- Raise a flap and place implants with primary stability if possible. If width is insufficient, perform simultaneous guided bone regeneration with a particulate graft and membrane, or stage grafting first if primary stability cannot be achieved.
- Allow 4–6 months of healing, then uncover and place custom healing abutments or provisional restorations to develop the emergence profile.
- Final impressions, trial smile, and definitive restorations.
Smoking is a major modifier: I would ask her to stop at least 2 weeks before and 8 weeks after surgery. The high smile line and thin biotype mean that grafting is not optional cosmetic extras; it is part of the risk management.
2. Select screw-retained versus cement-retained restorations and describe how you would manage the emergence profile and papilla.
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I would prefer screw-retained restorations for retrievability and to avoid residual cement, which is a particular concern in the esthetic zone. The limitation is angulation; if the screw access would exit the facial surface, I would use an angulated screw channel or a custom zirconia abutment with a screw-retained crown. Cement-retained restorations are acceptable if angulation is unfavorable, but I would use a custom abutment and ensure all cement is removed.
Emergence profile management:
- use a provisional restoration or custom healing abutment to create a convex, cleanable contour;
- avoid overcontouring the facial aspect, which increases recession risk;
- support the papilla with the provisional and verify that the interproximal space is not compressed;
- if the vertical distance from the implant platform to the interproximal contact is greater than about 5 mm, complete papilla fill may be unrealistic, and pink ceramic may be needed.
The patient should understand that “exactly like the others” is a goal, not a guarantee, especially with three adjacent implants and a thin biotype.
3. Assess the risks of midfacial recession and implant failure in this patient, and what you would tell her during consent.
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Her risk of midfacial recession is high: thin biotype, high smile line with 4 mm of gingival display, multiple adjacent implants, and a history of trauma with buccal bone deficiency. Adjacent implants also compromise papilla support because there is no tooth root between them. Smoking further increases the risk of soft-tissue recession and implant failure.
During consent I would explain:
- grafting may be needed and may still not fully restore the original ridge contour;
- the final gingival margin may be apical to the adjacent teeth, and pink ceramic or a soft-tissue graft may be required;
- smoking increases failure and recession risk; cessation is strongly advised;
- the temporary partial denture should not compress the healing tissues;
- long-term maintenance and possible additional grafting should be anticipated.
Her controlled hypothyroidism is not a major contraindication, but I would confirm that it is stable. I would not promise a perfect esthetic result, and I would document the discussion.