Revista Áquila, n. 35, e35010, 2026
ISSN: 1414-8846 | E-ISSN 2317-6474
DOI:https://doi.org/10.61565/revista-aquila.i35.1074
Guided digital workflow integrating esthetic crown lengthening and immediate
implant placement in a patient with altered passive eruption: a case report1
Fluxo de trabalho digital guiado integrando aumento de coroa clínica estético e instalação
imediata de implante em paciente com erupção passiva alterada: relato de caso
Flujo de trabajo digital guiado integrando alargamiento de corona clínica estético y
colocación inmediata de implante en paciente con erupción pasiva alterada: reporte de caso
Débora Pereira Azevedo2
Bruna Soares Pereira3
Jessica de Figueiredo Lopes³
Alexandra Tavares Dias4
Eduardo José Veras Lourenço5
ABSTRACT
Background: Prosthetically driven surgical planning via a digital workflow independently increases the
predictability of esthetic clinical crown lengthening and immediate implant placement; however, reports
integrating both procedures into a single workflow guided by the future position of the gingival margin and
the cementoenamel junction remain scarce. Case Presentation: This report describes the combined and guided
use of these two surgical techniques in a 23-year-old female patient presenting with altered passive eruption
and a non-restorable external cervical resorption of the right maxillary central incisor. In a single surgical
session, esthetic clinical crown lengthening, and immediate implant placement with provisionalisation were
performed using a dual periodontal guide and a static surgical guide. Following osseointegration, a
subepithelial connective tissue graft was performed to optimise the peri-implant soft tissue contour. Results:
At the two-year follow-up, stability of the peri-implant hard and soft tissues and esthetic integration with the
3 Bachelor of Dentistry, Rio de Janeiro State University. Master of Dentistry, Rio de Janeiro State University.
Rio de Janeiro State University. E-mail: [email protected]. ORCID: 0000-0001-9758-2497.
3 Bachelor of Dentistry, Federal University Veiga de Almeida. Master of Dentistry, Rio de Janeiro State
0009-0002-9333-4925.
4 Bachelor of Dentistry, Gama Filho University. Master of Dentistry, Fluminense Federal University. PhD in
0000-0001-8175-6341.
5 Bachelor of Dentistry, Rio de Janeiro State University. Master of Periodontology, University of São Paulo.
0000-0002-7163-8138.
2 Bachelor of Dentistry, Centro Universitário Arthur Sá Earp Neto. Master of Oral Rehabilitation, Veiga de
Almeida University. E-mail: [email protected]. ORCID: 0009-0005-3384-209X.
1 The translation of the article is the sole responsibility of the authors. Translations of excerpts from works
written in another language, when rendered into English, are likewise the responsibility of the authors, unless
a different authorship is declared.
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adjacent teeth were observed, without any biological or prosthetic complications. Conclusion: Planning the
definitive gingival architecture prior to implant positioning, with both procedures guided in the anterior
maxilla, may contribute to predictable esthetic outcomes in challenging clinical situations.
Keywords: Crown lengthening. Immediate dental implant. Tooth eruption. Workflow.
RESUMO
Introdução: O planejamento cirúrgico protético por meio do fluxo de trabalho digital aumenta, de forma
independente, a previsibilidade do aumento de coroa clínica estético e da instalação imediata de implantes;
contudo, relatos que integrem ambos os procedimentos em um único fluxo orientado pela futura posição da
margem gengival e pela posição da junção cemento-esmalte permanecem escassos. Relato de caso: Este
relato descreve o uso combinado e guiado destas duas técnicas cirúrgicas em paciente do sexo feminino, 23
anos, com erupção passiva alterada e reabsorção cervical externa do incisivo central superior direito sem
condições de restauração. Em sessão única, realizaram-se o aumento de coroa clínica estético e a instalação
imediata de implante com coroa provisória, empregando um duplo guia periodontal e uma guia cirúrgica
estática. Após a osseointegração, um enxerto de tecido conjuntivo subepitelial otimizou o contorno dos
tecidos moles peri-implantares. Resultados: Aos dois anos, observaram-se estabilidade dos tecidos duros e
moles peri-implantares e integração estética com os dentes adjacentes, sem complicações biológicas ou
protéticas. Conclusão: Planejar a arquitetura gengival definitiva antes do posicionamento do implante, ambos
guiados na pré-maxila, pode contribuir para desfechos estéticos previsíveis em situações clínicas
desafiadoras.
Palavras-chave: Aumento de coroa clínica. Carga imediata em implante dentário. Erupção dentária. Fluxo
de trabalho.
RESUMEN
Introducción: La planificación quirúrgica protésica a través del flujo de trabajo digital aumenta, de forma
independiente, la previsibilidad del alargamiento de corona clínica estético y de la colocación inmediata de
implantes; sin embargo, los informes que integren ambos procedimientos en un único flujo orientado por la
futura posición del margen gingival y por la posición de la unión amelocementaria siguen siendo escasos.
Presentación del Caso: Este informe describe el uso combinado y guiado de estas dos técnicas quirúrgicas en
una paciente de 23 años con erupción pasiva alterada y reabsorción cervical externa en el incisivo central
superior derecho, sin posibilidad de restauración. En una sola sesión quirúrgica, se realizaron el alargamiento
de corona clínica estético y la colocación inmediata del implante con corona provisional, empleando una guía
periodontal doble y una guía quirúrgica estática. Tras la osteointegración, un injerto de tejido conectivo
subepitelial optimizó el contorno de los tejidos blandos periimplantarios. Resultados: A los dos años de
seguimiento, se observó estabilidad de los tejidos duros y blandos periimplantarios y una integración estética
con los dientes adyacentes, sin complicaciones biológicas ni protésicas. Conclusión: Planificar la arquitectura
gingival definitiva antes del posicionamiento del implante, ambos procedimientos guiados en la premaxila,
puede contribuir a resultados estéticos predecibles en situaciones clínicas desafiantes.
Palabras clave: Alargamiento de la corona clínica. Carga inmediata en implante dental. Erupción dentaria.
Flujo de trabajo.
INTRODUCTION
Immediate implant placement and provisionalisation has been established as a
treatment option for the replacement of single anterior teeth in the aesthetic zone, offering
clinical and patient-centred advantages (Meijer et al., 2025; Puisys et al., 2022; Pitman et
al., 2022). These include a reduction in total treatment time, lower morbidity due to fewer
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surgical interventions, preservation of soft tissue architecture (Ickroth et al., 2024;
Seyssens et al., 2021), and high levels of patient satisfaction (Slagter et al., 2021).
Furthermore, randomised clinical trials (Cosyn et al., 2024; Puisys et al., 2022) and
systematic reviews have demonstrated survival rates comparable to early placement
protocols (Ickroth et al., 2024; Puisys et al., 2022).
Altered passive eruption (APE) is characterised by a gingival margin positioned
coronally to the cementoenamel junction (CEJ) (Goldman; Cohen, 1968). Consequently,
affected teeth present clinically short crowns despite having normal anatomical
dimensions, as part of the anatomical crown remains covered by gingival tissue
(Alpiste-Illueca, 2011).
The reported prevalence of APE among patients with excessive gingival display
(EGD) ranges from 12% to 35.8% (Volchansky; Cleaton-Jones, 1974; Nart et al., 2014;
Andijani; Tatakis, 2019; Amro et al., 2026). Although not considered a pathological
condition, APE can have a substantial aesthetic impact. Patients frequently report concerns
regarding the appearance of “small teeth” or a “childish smile” (Antoniazzi et al., 2017;
Mele et al., 2018). An accurate diagnosis is essential for determining the most appropriate
management. Clinical examination, including transgingival probing to identify the CEJ,
remains the gold standard for diagnosing APE (Mele et al., 2018), whilst cone-beam
computed tomography (CBCT) can serve as an adjunctive diagnostic tool to evaluate the
relationship between the gingival margin, the alveolar bone crest, and the CEJ (Januário;
Barriviera; Duarte, 2008; Beire et al., 2021; Kahn et al., 2024).
Coslet, Vanarsdall, and Weisgold (1977) classified APE into two types (Types 1 and
2) and two subtypes (Subtypes A and B), proposing treatment recommendations according
to each clinical presentation. The management of APE is exclusively surgical and aims to
expose the entire anatomical crown through clinical crown lengthening procedures.
Depending on the anatomical features of each case, treatment may involve gingivectomy
or an apically positioned flap, with or without osteotomy and osteoplasty, to re-establish
the supracrestal attachment and achieve a stable, aesthetic gingival architecture (Coslet;
Vanarsdall; Weisgold, 1977; Mele et al., 2018; Kahn et al., 2024).
The development of digital guides for immediate implant placement reflects the
convergence of several technological advancements over the past two decades, which have
transformed a technically demanding procedure into a more predictable and prosthetically
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driven approach. Digitally guided immediate placement evolved from the broader
development of computer-assisted implant surgery. The introduction of CBCT enabled the
three-dimensional visualisation of the alveolar bone and adjacent structures, whilst the
development of specific software allowed for the integration of CBCT data with surface
scans for virtual implant planning (Tatakis; Chien; Parashis, 2019). Initially, the objective
was to accurately transfer the virtual implant position to the surgical field via
individualised guides. Stereolithography, alongside photopolymerisation techniques,
enabled the production of guides from images and 3D designs. However, these early
applications were focused on healed ridges rather than immediate placement scenarios
(Tatakis; Chien; Parashis, 2019). A decisive breakthrough was the introduction of intraoral
scanners (IOS), which allowed for the direct digital capture of intraoral structures and the
generation of STL files that could be integrated with CBCT data (Ballesteros et al., 2025).
The digital workflow then evolved into two distinct approaches: static computer-assisted
surgery, utilising physical surgical guides equipped with metallic sleeves, and dynamic
navigation, featuring real-time optical tracking. For immediate placement, the static
approach initially gained prominence by providing stable drill guidance within the
challenging anatomy of fresh extraction sockets (Tomar et al., 2026; Chen et al., 2023;
Chandran et al., 2023).
Immediate implant placement presents particular challenges: limited visual control
without flap elevation, risk of buccal implant deflection during site preparation, and the
need for precise three-dimensional positioning to prevent future soft tissue recession
(Pitman et al., 2024; Nava et al., 2026). Systematic reviews have established that digitally
guided immediate placement achieves acceptable accuracy, with mean deviations of 0.74
mm coronally, 1.01 mm apically, 0.50 mm in depth, and 2.34° in angulation (Xing; Lin;
Lyu, 2025).
Unlike implant surgery, where digital guidance is already well established, digitally
guided clinical crown lengthening is a relatively recent application, emerging alongside the
widespread availability of accessible planning software and low-cost 3D printing
technologies. The first digitally guided crown lengthening technique was described by Liu
et al. (2018), who introduced a dual-guide approach providing independent references for
gingival resection and bone recontouring. Building upon this concept, Coachman et al.
(2023) described an advanced digital workflow for aesthetic crown lengthening aimed at
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improving diagnosis, surgical execution, and postoperative evaluation in the anterior
aesthetic zone. The protocol employed a 3D-printed dual periodontal surgical guide
featuring windows for each tooth, whose outer and inner margins served as references for
osteotomy and gingivectomy, respectively. These advancements established the
contemporary digital workflow for crown lengthening, encompassing intraoral scanning,
the integration of CBCT and surface scan datasets, virtual surgical planning via image
superimposition, and the fabrication of individualised surgical guides to accurately transfer
the virtual plan to the surgical field (Coachman et al., 2023). The first randomised clinical
trial to validate digital guides for aesthetic crown lengthening was published by Carrera et
al. (2023), demonstrating that the guided dual approach achieved clinical outcomes
comparable to conventional techniques, maintaining stable periodontal parameters
throughout the follow-up period.
When altered passive eruption is present in patients requiring anterior tooth
replacement, correcting the gingival architecture becomes an essential component of the
treatment plan. Failing to correct the altered gingival levels may compromise the symmetry
of peri-implant soft tissues and, ultimately, the aesthetic outcome, even when ideal implant
positioning is achieved.
Although guided digital workflows have been independently described for
immediate implant placement (Tomar et al., 2026; Chen et al., 2023; Chandran et al.,
2023) and aesthetic clinical crown lengthening, reports integrating both procedures into a
single prosthetically driven digital plan remain scarce (Rodeja-Vazquez et al., 2025). In
patients concurrently presenting with altered passive eruption and the need for immediate
implant replacement in the anterior aesthetic zone, digital integration may facilitate
comprehensive smile planning, enhance the transfer of the virtual design to the surgical
field, and increase the predictability of hard and soft tissue management. Therefore, the
aim of this case report is to describe a fully digital workflow that combines guided
aesthetic clinical crown lengthening for altered passive eruption with guided immediate
implant placement and provisionalisation in the aesthetic zone, highlighting the surgical
sequence, digital planning protocol, and short-term clinical outcomes.
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MATERIALS AND METHODS
A 23-year-old female patient, a dental student at Veiga de Almeida University,
presented to the integrated clinic complaining of sensitivity in tooth 11. Following clinical
examination, periapical radiography, and CBCT, an external cervical resorption (ECR) was
diagnosed and classified as 3-C-p according to Patel et al. (2018). Endodontic treatment,
conducted by an experienced endodontist, was initiated in an attempt to arrest the lesion's
progression; however, it was unsuccessful. Consequently, tooth extraction followed by
immediate implant placement and provisionalisation was indicated. Clinically, it was
observed that the maxillary anterior teeth appeared reduced in size, with a "childish"
appearance characteristic of Type 1 altered passive eruption (APE) with a wide band of
keratinised mucosa and attached gingiva, Subgroup B (Coslet et al., 1977). This was
corroborated by the tomographic slices, which showed the alveolar bone crest positioned at
the same level as the cementoenamel junction, indicating the need for osteotomy in
addition to gingivectomy. As the vertical positioning of the implant is directly related to
the location of the gingival margin, the possibility of performing immediate implant
placement concurrently with clinical crown lengthening was discussed with the patient.
The patient signed a free and informed consent form, expressly authorising the publication
of images in accordance with National Health Council (CNS) Resolution No. 466/2012,
complemented by Ministry of Health Resolution No. 510/2016. Furthermore, the study was
approved by the Research Ethics Committee of Veiga de Almeida University, Brazil
(CAAE 0069831800005291), and registered on the Brazilian Registry of Clinical Trials
(REBEC) platform (RBR-8t6c99).
Therefore, a fully digital workflow was adopted to allow for the simultaneous
planning of the aesthetic clinical crown lengthening and the immediate implant placement.
Digital impressions were obtained using an intraoral scanner and merged with the CBCT
data via image superimposition. Virtual planning was performed to establish the ideal
gingival architecture prior to defining the three-dimensional implant position using
Nemostudio software (Nemotec – SL, Madrid, Spain), according to the future prosthetic
emergence profile. Based on this planning, a dual periodontal guide and a static surgical
guide for the implant were designed and fabricated.
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The periodontal guide was designed according to the protocol proposed by
Coachman et al. (2023). The measurements obtained from the CBCT included the distance
from the CEJ to the gingival margin and from the CEJ to the alveolar bone crest. These
measurements were used to determine the planned gingival margin and the amount of bone
recontouring according to the patient's periodontal phenotype. Following the biological
parameters proposed by De Rouck et al. (2009), a distance of 3 mm was planned between
the future gingival margin and the alveolar bone crest for this thick-scalloped phenotype
(Type B) (Zhao et al., 2023). Consequently, the distance between the inner and outer
margins of the periodontal guide was designed to reproduce this relationship during
surgery.
Figure 1 – a) Initial intraoral and b) extraoral aspects. c) Tomographic image showing an invasive cervical
lesion and a failed endodontic treatment.
Source: The authors (2026).
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Figure 2 – a) Apico-coronal implant position in relation to the existing gingival margin. b) Placement of the
dual periodontal guide, illustrating the new apico-coronal implant position based on the future gingival
margin level (pink line).
Source: The authors (2026).
Following local anaesthesia with 4% articaine containing 1:100,000 epinephrine
(DFL Indústria e Comércio S.A., Rio de Janeiro, RJ, Brazil), the dual periodontal guide
was positioned, and its passive seating was verified. The inner margin of the guide was
used to outline the new gingival margin, and an internal bevel gingivectomy was
performed using a 15C blade, followed by the refinement of the gingival contour with
Castroviejo micro-scissors. Subsequently, a full-thickness flap was elevated, exposing the
underlying alveolar bone. The outer margin of the guide served as a reference for the
osteotomy and osteoplasty necessary to establish the planned bone level, which were
performed using diamond burs. Throughout the procedure, the guide was repeatedly
repositioned to verify the accuracy of the soft and hard tissue recontouring. Completing the
periodontal phase prior to implant placement allowed the implant to be positioned
according to the definitive soft tissue architecture, rather than the preoperative gingival
margin.
Tooth 11 was then extracted with minimal trauma, and the implant surgical guide
was seated. Site preparation and placement followed the digitally planned
three-dimensional position. A 3.5 × 13 mm Helix Acqua GM implant (Neodent, Curitiba,
PR, Brazil) was placed, maintaining a minimum buccal gap of 2 mm, which was filled with
xenograft particles (Cerabone®, Straumann AG, Basel, Switzerland). A prefabricated
universal abutment was connected, and an immediate provisional restoration was
fabricated utilising the patient's natural clinical crown. Occlusal adjustment eliminated
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both centric and eccentric contacts, ensuring a non-functional immediate provisionalisation
protocol. Finally, the flap was repositioned without tension and sutured using 6-0 nylon
(Techsuture, Bauru, SP, Brazil) with simple interrupted and suspensory sutures to achieve
hermetic wound closure.
Figure 3 – a) Placement of the dual periodontal guide following local anaesthesia. b) Intraoral view after
gingivectomy guided by the dual periodontal guide. c) Round diamond bur (size 2) defining the maximum
extent of the vertical osteotomy.
Source: The authors (2026).
Figure 4 – a) Placement of the static implant surgical guide following extraction. b) Verification of the
guide's seating through the inspection window, illustrating intimate contact with the left central incisor. c)
Osteotomy preparation using the final drill in the sequence (3.5 mm diameter) with the aid of the reducer key.
d) Placement of the Neodent Helix Acqua GM implant (3.5 × 16.0 mm).
Source: The authors (2026).
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Figure 5 – a) Provisional restoration fabricated using the patient's natural tooth and relined with composite
resin. b) Intraoral view of the immediate provisional restoration in situ; the incisal edge was positioned
slightly apically to prevent any contact during centric and excursive movements, especially given the
patient's Class II malocclusion.
Source: The authors (2026).
RESULTS
Sutures were removed after seven days. Following a three-month healing period,
osseointegration progressed uneventfully, and the peri-implant tissues exhibited
satisfactory healing; however, a soft tissue volume deficiency was noted, yielding a Pink
Esthetic Score (PES) of 12 (Fürhauser et al., 2005). To improve aesthetics and the
long-term stability of the soft tissues, a subepithelial connective tissue graft (SCTG) was
proposed to enhance the buccal soft tissue contour and optimise the emergence profile
(Seyssens et al., 2021). Although the SCTG could have been performed simultaneously
with the implant placement, the reassessment was intentionally postponed to the 3-month
mark (Struys et al., 2025). This decision, consciously made and agreed upon with the
patient, aimed to prevent prolonging the initial surgical procedure, which had already
encompassed aesthetic clinical crown lengthening (including gingivectomy and
osteotomy), immediate implant placement, and provisionalisation in a single session. After
an additional three months of soft tissue maturation, a digital impression was taken at the
implant level. A customised zirconia abutment on a titanium base (Ti-base) was fabricated
to support an adhesively cemented lithium disilicate crown. At the two-year follow-up,
stable peri-implant hard and soft tissues were observed, alongside harmonious gingival
margins, preservation of the buccal contour, and satisfactory aesthetic integration with the
adjacent dentition. No biological or prosthetic complications were detected during this
period.
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Figure 6 – a) Aesthetic and functional reassessment at 3 months, revealing a buccal soft tissue volume
deficiency (PES = 12). b) Surgical placement of a subepithelial connective tissue graft to address the contour
defect. c) Following a further 3-month healing period, try-in of the zirconia framework to promote
peri-implant tissue biocompatibility. d) Cementation of the definitive, characterised lithium disilicate crown.
.Source: The authors (2026).
Figure 7 – a) Intraoral and b) extraoral views at the 2-year follow-up following the initial surgery
Source: The authors (2026).
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Table 1 - Chronology and timeline of clinical, surgical, and prosthetic stages.
Moment /
Time
Clinical Stage
Procedures and Therapeutic Decisions
Outcome / Parameter
Evaluated
Baseline (T
initial)
Diagnosis and
Conservative
Attempt
Complaint of sensitivity in tooth 11.
Tomographic diagnosis of External Cervical
Resorption (ECR Class 3-C-p) and Altered
Passive Eruption (APE). Coslet Classification
Type 1B. Attempted endodontic treatment
(unsuccessful).
Confirmation of
non-restorable tooth 11;
indication for extraction
and peri-implant
rehabilitation integrated
with clinical crown
lengthening.
Preoperativ
e Phase
Digital
Planning and
Prototyping
Intraoral scanning (STL files) and CBCT with
lip retraction (DICOM). Merging and
planning in NemoStudio software. Definition
of the new gingival margin and bone crest (3
mm rule). 3D printing of the dual periodontal
guide and the static implant surgical guide.
Procurement of
individualised surgical
guides for precise
sequential execution in a
single session.
Day of
Surgery
(T0)
Integrated
Surgical
Intervention in
a Single
Session
Local anaesthesia and positioning of the dual
periodontal guide. Internal bevel
gingivectomy and full-thickness flap with
guided osteotomy/osteoplasty. Atraumatic
extraction of tooth 11. Guided placement of
Helix GM implant (3.5 × 13 mm) with palatal
and apical anchorage. Filling of the buccal
gap with Cerabone®. Fabrication of a
non-functional immediate provisional
restoration (natural crown). 6-0 nylon sutures.
Aesthetic crown
lengthening of the
anterior teeth and
three-dimensional
implant positioning
guided by the definitive
gingival architecture.
7 to 14 days
Immediate
Postoperative
Period
Monitoring of initial tissue healing. Suture
removal at 7 days.
Initial healing without
infectious complications
or suture dehiscence.
3 months
Secondary
Peri-implant
Plastic Phase
Clinical evaluation of osseointegration and
soft tissue maturation. Execution of a
subepithelial connective tissue graft (SCTG)
from the palate using a tunnelling/envelope
technique on the buccal aspect of tooth 11.
Gain in peri-implant soft
tissue volume and
thickness to optimise the
emergence profile.
6 months
Definitive
Prosthetic
Rehabilitation
Digital impression/scanning at the implant
level following 3 months of SCTG
maturation. Fabrication and placement of a
customised zirconia abutment on a Ti-base
and a cemented lithium disilicate crown.
Establishment of the
definitive prosthetic
contour in harmony with
the re-established
gingival margin.
2 years
(Tfinal)
Longitudinal
Follow-up
Clinical periodontal and peri-implant
evaluation (probing, keratinised mucosa,
pink/white aesthetics). Periapical/tomographic
radiographic control evaluation.
Dimensional stability of
hard and soft tissues,
absence of biological or
prosthetic
complications, and
harmonious aesthetic
integration.
Source: The authors (2026).
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DISCUSSION
This case report describes a digitally integrated workflow that combines guided
aesthetic clinical crown lengthening and guided immediate implant placement into a single
prosthetically driven treatment concept. Rather than treating both procedures as
independent interventions, digital planning allowed the definitive gingival architecture to
be established prior to implant positioning, ensuring that the implant was placed according
to the planned prosthetic and periodontal outcome. The central aspect of this workflow was
that the virtual correction of the gingival architecture preceded the implant planning. As
the depth and bucco-lingual position of the implant directly influence the peri-implant soft
tissue profile, planning the implant according to the definitive gingival margin, rather than
the preoperative anatomy, can contribute to greater aesthetic predictability.
An additional justification for this sequence relates to the diagnosis of altered
passive eruption. In the present case, APE was identified during the comprehensive clinical
and tomographic examination, although it was not the patient's primary complaint. Had the
implant been planned solely based on the preoperative gingival margin, without
recognising the APE, it would likely have been positioned more coronally, since immediate
implants are typically placed approximately 3 to 4 mm apically to the existing gingival
margin to allow for a proper emergence profile. Subsequent correction of the gingival
levels via clinical crown lengthening would have exposed the implant-supported
restoration and compromised the peri-implant aesthetic relationship, potentially hindering
the harmonious correction of the adjacent teeth. Therefore, establishing the definitive
gingival architecture prior to implant planning was essential to ensure that the implant
position corresponded to the intended final aesthetic outcome, rather than the preoperative
soft tissue anatomy (Rodeja-Vazquez et al., 2025). In this workflow, the definitive gingival
margin became the reference for implant positioning, rather than the implant positioning
dictating the final gingival architecture.
Although digital guidance for aesthetic clinical crown lengthening was introduced
only recently, the protocol proposed by Coachman et al. (2023), and subsequently
validated in the randomised clinical trial by Carrera et al. (2023), has demonstrated that
guided surgery accurately reproduces the planned gingival and bone contours. The present
case broadens the application of this concept by integrating the periodontal guide into the
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immediate implant placement planning, yielding a high PES/WES (Pink Esthetic
Score/White Esthetic Score) (Belser et al., 2009) at the 2-year evaluation.
Soft tissue augmentation was intentionally delayed until the provisionalisation
phase. Although a connective tissue graft (SCTG) can be performed simultaneously with
immediate implant placement, its staggering reduced the duration of the initial surgery
whilst still allowing for soft tissue enhancement prior to the delivery of the definitive
restoration. This sequence, planned in agreement with the patient, permitted the refinement
of the emergence profile following the initial tissue maturation. An alternative would be
the use of a collagen matrix during the initial surgical procedure, avoiding a second
intervention and donor site morbidity. Although collagen matrices have emerged as a less
invasive alternative (Jepsen et al., 2026; Eeckhout et al., 2023) and demonstrate favourable
clinical outcomes, current evidence generally supports the autogenous SCTG as the most
predictable approach for achieving greater soft tissue thickness and long-term volumetric
stability around implants, particularly in the aesthetic zone. Thus, considering the aesthetic
demands of the anterior maxilla and the patient's young age, the SCTG was deemed the
most predictable option to optimise the final contour of the peri-implant soft tissues.
As a single case report, the present study does not allow for conclusions regarding
the superiority of this workflow over conventional approaches. Nonetheless, it illustrates
the clinical applicability of integrating two digitally guided procedures into a prosthetically
driven treatment sequence. Prospective clinical studies are necessary to evaluate the
accuracy, efficiency, aesthetic outcomes, and long-term stability of this integrated digital
workflow.
CONCLUSION
This case report demonstrates that the digital integration of guided aesthetic clinical
crown lengthening with guided immediate implant placement is clinically feasible and can
facilitate the prosthetically driven treatment of patients presenting with altered passive
eruption and the need for immediate implant replacement in the aesthetic zone. Although
further studies are required, this workflow may represent a useful strategy for enhancing
interdisciplinary planning and achieving predictable aesthetic outcomes.
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DOI:https://doi.org/10.61565/revista-aquila.i35.1074
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