Implant placement in the aesthetic zone presents significant clinical challenges, particularly in the presence of unfavourable spacing and deficient ridge conditions. Achieving predictable primary stability while preserving peri-implant soft tissue architecture is especially demanding in sites requiring bone regeneration and multidisciplinary intervention.

In such contexts, treatment success relies on a prosthetic-driven approach, combining surgical precision, soft tissue management and optimized implant design to ensure both functional and aesthetic outcomes. Managing regenerated low-density bone (D3–D4) remains a key difficulty, requiring adapted protocols to achieve stability and long-term predictability.

This case illustrates how a multidisciplinary and digitally guided workflow, using the Axiom® X3S implant system, can address these challenges and support predictable rehabilitation in a complex anterior indication.

A 52-year-old female patient, medically fit and a non-smoker, presented with a non-restorable fractured upper right lateral incisor (UR2) with retained root remnants.

The patient also exhibited a congenital absence of the upper left lateral incisor (UL2), associated with spacing discrepancies and mesial migration of adjacent teeth, leading to compromised anterior aesthetics and prosthetic conditions.

Clinical and radiographic evaluation revealed insufficient mesio-distal space and inadequate ridge volume, rendering immediate implant placement unsuitable and indicating the need for a staged multidisciplinary approach. UR2 was extracted, followed by clear aligner orthodontic treatment and subsequent guided bone and soft tissue regeneration to reconstruct the deficient residual ridge (Fig 1-2).

A fully guided digital workflow was selected, incorporating the complete Anthogyr surgical and restorative ecosystem.¹ The Axiom® X3S implant was chosen to enhance primary stability in low-density regenerated bone through its tapered macro-design and aggressive thread geometry, while preserving the same prosthetic trilobe connection as the Axiom® X3 system. Following implant placement, an anatomically shaped, scannable healing abutment, HealFit^® SH, was used to guide soft tissue maturation and support a simplified digital workflow, followed by seamless integration with the X-Base® Ti-base restorative solution.²˒³˒⁵

Together, these technologies streamlined the clinical workflow, minimised chair-time, preserved the maturing peri-implant tissues and enhanced communication between clinician and laboratory, improving overall predictability and patient experience.

A prosthetic-driven, staged multidisciplinary approach was planned to overcome anatomical constraints and achieve predictable stability in regenerated low-density bone. The strategy combined space optimisation and ridge reconstruction to enable prosthetically guided implant placement, followed by delayed implantation using an adapted protocol to maximise primary stability in D3–D4 bone. The rehabilitation was completed through a streamlined digital workflow designed to preserve peri-implant tissue architecture and ensure efficient, aesthetic integration.

Surgical management was performed in a staged approach to optimise site conditions prior to implantation. Following atraumatic extraction of the non-restorable UR2, initial healing was combined with orthodontic optimisation (ClearCorrect®). Guided bone regeneration (GBR) was subsequently carried out using a combination of xenograft (Cerabone plus®, Botiss) and autogenous bone, together with soft tissue augmentation using an acellular collagen matrix (Mucoderm®, Botiss) to reconstruct ridge volume and enhance buccal tissue thickness in the aesthetic zone (Fig 3-4).

After an 8‑month healing period, implant placement was performed using a fully guided, prosthetic-driven protocol. Digital planning (SMOP®) ensured precise three-dimensional positioning in accordance with restorative objectives. Site preparation followed an under-preparation protocol adapted to regenerated low-density (D3–D4) bone, aimed at maximising mechanical engagement (Fig 5).

The Axiom X3S® implant (Ø3.4 × 12 mm) was placed with high primary stability (>45 N·cm), supported by its tapered design and aggressive thread geometry, enabling controlled insertion and optimal anchorage in the grafted site. A transmucosal approach was subsequently adopted, with immediate placement of a HealFit^® SH anatomical healing abutment and simultaneous soft tissue optimisation to support emergence profile and peri-implant tissue maturation (Fig 6-10).

This surgical protocol enabled predictable implant placement in a regenerated low-density environment, while simplifying the workflow and establishing stable conditions for prosthetic rehabilitation.

Prosthetic rehabilitation was performed using a fully digital workflow, beginning with intraoral scanning carried out with the HealFit^® SH abutment maintained in situ, allowing accurate capture of the conditioned soft tissue profile without the need for abutment removal or additional scan bodies. A CAD/CAM screw-retained implant crown was fabricated on an X‑Base® titanium base, ensuring prosthetic stability and continuity with the Axiom X3S® system (Fig 11-13).

Final aesthetic rehabilitation also included two lithium disilicate (E.max®) veneers on UR1 and UR3, together with a three-unit E.max® bridge on the left side to close the residual spacing associated with the congenitally missing UL2. The conventional restorative treatment and the previous aligner treatment was completed by Dr Konstantinos Karatzioulas (Fig 14-16).

The combination of a scannable healing abutment and a fully digital workflow enabled preservation of peri-implant soft tissue architecture, reduced clinical steps, and improved communication between clinician and laboratory, contributing to a predictable and efficient restorative outcome.

Long-term supportive periodontal and peri-implant maintenance program with regular clinical and radiographic review and hygiene appointments.