One Tooth to Replace, and It Had to Match the One Beside It Exactly

Quick answer: A single implant at the front is the most demanding procedure in routine implant dentistry — not because of the implant, which is straightforward, but because the gum around it has to match the tooth next door, and there is a natural tooth beside it for comparison.

The call

She had been quoted a timeline of three months by one clinic and nine by another, and wanted to know why.

Shifra, 34, from RBS Bet, had lost an upper central incisor to a vertical root fracture — a root-treated tooth that had finally split. The tooth had been extracted six weeks earlier elsewhere, and she had been given a temporary denture she disliked intensely.

Both timelines she had heard about are real, they suit different situations, and hers was the longer one.

What we found

The extraction site had healed at the gum level. On the CBCT scan, the bone told the story: the thin plate of bone on the lip side had largely resorbed, which is what happens routinely after a front tooth is removed without grafting.

The result was a ridge that had lost width and, critically, height on the cheek side — visible as a slight hollow above the gap.

Her neighbouring teeth were healthy. She had a high smile line, showing the full height of her teeth and several millimetres of gum when she smiled broadly. That is the finding that raises the difficulty considerably: with a low smile line, small imperfections at the gum margin are hidden by the lip. With a high smile line, everything shows.

Why front implants are hard. The implant itself is a straightforward procedure. The difficulty is entirely about the tissue:

• The gum margin must sit at the same height as the tooth on the other side. A millimetre of difference is visible.
• The papilla — the gum triangle between the teeth — must fill the space. Papillae depend on the bone height between the teeth, and once lost they are extremely difficult to rebuild. A dark triangle beside a front tooth is the commonest aesthetic failure.
• The bone on the lip side must be thick enough to support the gum. Thin bone resorbs and the gum recedes, exposing a grey metal margin years later.
• The emergence profile — the shape where the crown comes out of the gum — has to be sculpted, not just fitted.

Immediate placement at the time of extraction is the three-month timeline, and it is excellent in the right case: intact bone plate, thick gum, no infection. Hers had none of those, because the tooth had already been out for six weeks and the plate had gone.

What we did

Bone grafting first, to rebuild the lost width and height on the lip side. Four months of healing.

Implant placement at four months, positioned deliberately slightly towards the palate — the commonest error in front implants is placing them too far towards the lip, which guarantees gum recession later. Placed with a surgical guide made from a planned tooth position rather than freehand.

A connective tissue graft at the same appointment, to thicken the gum on the lip side. Thick tissue is what keeps the margin stable over decades.

Three months of integration, with the temporary denture, which she tolerated by then because there was an end date.

A provisional crown at seven months, and this is the step that separates an acceptable result from a good one. A temporary crown was made and its shape adjusted repeatedly over eight weeks, each adjustment gently guiding the gum into the profile of a natural incisor. The gum is trained, not simply covered.

A custom abutment and the final crown at nine months, made to a shape copied from the provisional — the technician received a model that recorded the gum profile that had been developed, rather than a generic impression.

Shade matching in daylight, at a morning appointment, with the tooth photographed alongside its neighbour and the technician sent the photographs.

The outcome

The gum margins are level. The papillae fill both spaces. Shifra's own family cannot identify which tooth it is.

Nine months from start to finish, of which perhaps four hours were surgery and the rest was healing and tissue shaping.

The three-month quotation was not wrong as a general statement. It was wrong for a site that had already lost its bone plate.

What to do if this happens to you

1. Ask about grafting at the time of extraction, before the tooth comes out. It prevents most of this.
2. Ask about your smile line. It determines how much precision the case requires.
3. Ask whether a provisional crown will be used to shape the gum. For front teeth it should be.
4. Expect nine to twelve months for a front implant in a healed site, less if placed immediately.
5. Ask where the implant will be positioned relative to the lip side. Palatal placement protects the margin.
6. Ask to see cases with high smile lines, not just close-up photographs of the crown.

Missing or failing front tooth? Talk to Ramat Beit Shemesh Urgent Dental Care before the extraction if possible. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh

This is a composite clinical story. It reflects a presentation we see regularly in Beit Shemesh and Ramat Beit Shemesh; the name and details are illustrative and are not those of a real patient.