Congenital agenesis of the maxillary lateral incisors represents one of the most frequent dental anomalies encountered in clinical practice, with significant implications for both function and esthetics, particularly when it occurs bilaterally in the anterior esthetic zone. While orthodontic space closure or prosthetic rehabilitation with resin-bonded bridges remain valid alternatives in specific cases, implant-supported restoration is often considered the gold standard, offering a biomechanically independent solution that preserves the integrity of adjacent teeth.
However, the placement of osseointegrated implants in young patients is not without controversy. Unlike natural teeth, which continue to erupt passively throughout life in response to ongoing craniofacial growth, an osseointegrated implant behaves as an ankylosed structure: once integrated, it no longer follows the vertical and sagittal changes of the alveolar process. In a growing patient, this translates into a progressive risk of infra-occlusion, with the implant crown appearing to “sink” relative to the adjacent natural dentition as the surrounding bone and teeth continue to erupt and remodel. This phenomenon can compromise both the esthetic outcome and the long-term functional stability of the restoration, and is the primary reason why implant placement is traditionally deferred until skeletal maturity is reached.
This limitation, however, can be effectively bypassed in patients who, despite their young chronological age, have already achieved complete somatic and craniofacial development. In such cases, growth-related structural changes are no longer a clinically relevant variable, and the risk of future infra-occlusion is substantially eliminated, or better it will has the same behavior it could have in an adult patient. Identifying this window—where biological maturity precedes chronological expectations—is therefore a critical diagnostic step, allowing clinicians to proceed with immediate loading implant therapy safely, without exposing the patient to the long-term complications typically associated with early implant placement.
Fig.1
The patient came to our office asking for the replacement of the two lateral incisors missing. After a visit and hearing the patient request, it was decided to replace them with two immediate loaded implants.
The patient was 24 years old, but despite is young age he was judged he has already achieved complete somatic and craniofacial development, and the risk of future infra-occlusion is substantially reduced.
Fig.2
At the end of orthodontic treatment, the space obtained is perfect for two prosthetic crowns supported by implants.
Fig.3
The case is ideal because a part from the correct mesio-distal distance between the canines and the central incisors, the patient has an ideal soft tissue conformation. The papillae are competent, there is a big amount of keratinized gingiva, and also the soft tissue thickness is also abundant.
Fig.4
A digital plan was made to be sure to insert the implant in the right position avoiding to stay too close to the adjacent roots or worst to cause injury to them with the drill.
Fig.5
Into the surgical planning software is possible to control if in the correct implant position there is a sufficient amount of bone or a GBR is necessary.
Fig.6
Before starting with the surgery it is mandatory to try in the static surgical guide, to be sure that it fits correctly on the supporting teeth, so that the drilling will be correct.
Fig.7
The surgical guide has two identical sleeves with a diameter of 1,5 mm to be used as guide just for the first drill.
Fig.8
At the end of the osteotomy drilling it was inserted a real narrow implant (2,8 mm diameter) and a flap was raised to prepare a bed for a connective tissue graft.
The implant has a very narrow diameter and to make it possible to be a two peaces implant the restorative connection is not screw retained but is a pure conometric connection.
Fig.9
After the implant insertion a provisional abutment with a conometric connection was connected, and then a provisional restoration was relined and finished.
Fig.10
The provisional restoration with the characteristic concave profile that is typically used with the immediate implant insertion with immediate restoration and connective tissue graft.
To be noted that there is not any thread because the connection with the implant is pure conometrical.
Fig.11
As the implant was inserted and the provisional crown relined, a connective tissue was grafted inside the envelope by the use of a sling suture to traction and then to stabilize it inside.
Fig.12
The provisional crown with the concave profile just connected. It is clear that thanks to the concavity no ischemia is present, and the soft tissue graft doesn’t receive any compression, and it is absolutely free to gently heal and grow.
Fig.13
Following the same procedure also the second implant was inserted.
Fig.14
Once the implant was inserted, the distance between it and the provisional crown was checked, to be sure to have more or less 4 mm of distance between the implant head and the crown emergence profile.
The provisional crown has two wings that allow its correct positioning avoiding every rotation or angulation.
Fig.15
After the implant insertion, exactly in the same way as in picture #9, a provisional abutment with a conometric connection was connected, and then a provisional restoration was relined and finished.
Fig.16
In the same way, at the end of the prosthetic phase, a connective tissue harvested from the palate was grafted inside the envelope by the use of a sling suture to traction and then to stabilize it inside the tunnel.
Fig.17
The provisional restoration with the characteristic concave profile that is used with the immediate implant insertion with immediate restoration and connective tissue graft, in this case with a conometric connection.
Fig.18
The two provisional crowns at the end of the surgery treatment.
Fig.19
Ten days later, initial healing can be seen and the soft tissues have begun to arrange themselves around the profile of the provisional restorations.
Fig.20
From this view it is evident how the connective tissue graft has increased the thickness of the soft tissues.
Fig.21
At 8 months from the surgery a traditional impression was taken using repositioning transfer.
Fig.22
The soft tissues at one year are still maturing around the two crowns, but the papillae have almost completely filled their space.
Fig.23
At two years the soft tissues have matured and arranged themselves around the crowns with a very natural effect.
On the mesial papilla on tooth #12 a small incision is visible, probably a scar residue caused by the suture.
Fig.24
At three years the soft tissues are completely matured and their appearance is very beautiful and natural.
Fig.25
After 8 years the tissues are stable and despite the young age of the patient no problems of infra-occlusion of the implant restorations caused by late facial growth and continuos dentoalveolar eruption have been observed.
Fig.26
Even the x-rays at 8-year demonstrate the stability of the bone tissues around the implants and their correct insertion thanks also to the use of a surgical stent to insert the implants in a very small space.
Conclusions
Congenitally missing lateral incisors present a unique restorative challenge, especially in young, growing patients where continuous dento-alveolar eruption and residual craniofacial remodeling can compromise long-term implant esthetics. In this case, immediate loading of two implant-supported crowns was combined with a concave transmucosal emergence profile and connective tissue grafting to optimize peri-implant soft tissue volume and stability — key factors in minimizing the visual impact of future infraocclusion. While no implant is entirely immune to the effects of ongoing growth, a soft-tissue-driven, biologically informed approach helps safeguard esthetic outcomes over time. Careful patient selection, attention to facial growth pattern and smile line, and a soft tissue-focused surgical protocol remain essential pillars for predictable, long-lasting results in agenesis cases.
Bibliography
- Valente NA, D’Amato S, Farella M.: Late facial growth and continuous dentoalveolar eruption: Implications for optimal dental implant placement. Periodontology 2000. 2025;00:1-22.
- R Saito H, Chu S, Reynolds M, Tarnow D: “Provisional Restorations Used in Immediate Implant Placement Provide a Platform to Promote Peri-implant Soft Tissue Healing: A Pilot Study “ Int J Period Rest Dent 2016;36:47-52.
- Redemagni M, Cremonesi S, Garlini G, Maiorana C: “Soft Tissue Stability with Immediate Implants and Concave Abutments.” Eur J Esthet Dent 2009;4:226-235
