Jennifer, a 27-year-old professional, was ready to stop living with a removable flipper and began her journey by self-referencing an orthodontist.

After years of feeling limited by a temporary tooth, she wanted a permanent solution and specifically wanted an implant.

Her orthodontist, who has worked closely with Dr. Lofthus for over 25 years, referred her to Dr. Lofthus for expert planning and treatment of an anterior implant case.

Initial Condition & Life Before Treatment

Jennifer was congenitally missing a maxillary lateral incisor and had been managing the space with a removable flipper for approximately 10 years. 

Over time, she became increasingly frustrated with the daily inconvenience of removing it, cleaning it, and worrying about how it looked or felt in social situations.

Although she had wanted an implant for years, she had repeatedly been told she “didn’t have enough space yet,” but she was ready to finally move forward and complete her smile with a permanent tooth.

When a tooth fails to develop, the surrounding bone doesn’t develop to its normal thickness either. This presents a significant challenge for implant placement, as adequate bone width is essential for long-term implant stability and esthetic emergence. 

Without sufficient ridge width, the implant cannot be positioned correctly, the surrounding soft tissue won’t drape naturally, and the final result often looks artificial rather than integrated.

First Appointment & Discovery

Jennifer was already in orthodontic treatment. Her orthodontist had created ideal spacing and felt the roots were in the correct position for an implant, and asked Dr. Lofthus to confirm everything from a surgical and bone-volume standpoint.

Pre-treatment frontal view showing spacing maintained with a removable prosthesis. The ridge deficiency is evident clinically, confirming CBCT findings of inadequate bone width for implant placement.

Dr. Lofthus performed a CBCT scan (3D imaging) to evaluate the ridge anatomy and determine whether implant placement was possible.

The scan revealed a common challenge in congenitally missing-tooth cases. Because the tooth never developed, the jawbone in that area never fully formed to normal thickness. Because the baby tooth had been missing for many years, the ridge had become too narrow and deficient for predictable implant placement.

In other words, the space was ready, but the bone was not.

Cone-beam computed tomography (CBCT) is essential in these cases because it reveals bone width, height, and density in three dimensions, information that cannot be accurately assessed from traditional 2D radiographs. 

This allows the surgeon to measure the exact ridge dimensions and plan the appropriate volume and positioning of bone augmentation needed to support an implant long-term.

Misunderstandings or Clinical Oversights

Jennifer’s case was special for three reasons.

1. It proved that “not enough bone” does not mean “no implant possible.”

Many patients are told that if the ridge is too narrow, an implant is not an option. In reality, modern ridge augmentation techniques can rebuild bone predictably, especially when carefully planned using 3D imaging.

A common misconception is that ridge deficiency automatically disqualifies a patient from implant treatment. The truth is that when performed by an experienced periodontist, ridge augmentation using autogenous bone (the patient’s own bone) offers excellent long-term success rates. 

Autogenous bone grafts integrate more predictably than synthetic materials because they contain living cells and growth factors that promote new bone formation. The mandibular ramus is an ideal donor site. It provides cortical bone that maintains volume well during healing, and the harvest site heals quickly with minimal post-operative discomfort.

2. The entire process happened while she was still in orthodontic treatment

A common misconception is that grafting and implant treatment must wait until braces are removed. In Jennifer’s case, orthodontics and implant planning worked together smoothly, helping maintain ideal tooth position and allowing a temporary tooth to be supported in a stable way during treatment.

Coordinating implant surgery with active orthodontics requires careful timing and communication. 

The advantage of this approach is that the orthodontist can maintain ideal spacing during the graft-healing and implant-integration phases, preventing adjacent teeth from drifting. The braces also provide a stable framework for temporization, allowing the patient to maintain esthetics throughout the entire process without relying on a removable prosthesis during healing.

Active orthodontic treatment establishes ideal spacing and root angulation of adjacent teeth. Coordination between orthodontist and periodontist ensures optimal three-dimensional positioning for future implant placement.

3. It was truly interdisciplinary care

This was a coordinated effort between:

• Her orthodontist (creating ideal spacing and root alignment)
• Dr. Lofthus (bone reconstruction and implant placement)
• Her general dentist (final restoration)

This type of collaboration is what makes high-level anterior implant results possible. 

Each specialist contributes their expertise at the appropriate stage, and treatment is sequenced to optimize both function and esthetics. 

Without this coordination, even technically successful implants can result in compromised esthetic outcomes due to poor positioning, inadequate tissue support, or timing issues that allow adjacent teeth to shift.

Treatment Plan & Approach

Dr. Lofthus reviewed Jennifer’s options in detail and explained that the gold standard for rebuilding ridge width in cases like hers is ridge augmentation.

Jennifer chose a predictable and biologically strong approach using her own bone:

Stage 1: Ridge Augmentation with a Mandibular Ramus Block Graft

A bone block was harvested from the mandibular ramus (lower jaw) and transplanted to the missing-tooth site. The graft was secured in place with a fixation screw to ensure stability during healing and integration.

The mandibular ramus bone block technique involves harvesting a precisely sized section of cortical bone from the posterior lower jaw. This cortical bone is denser than the cancellous bone often used in other grafting techniques, which means it maintains its volume better during the remodeling phase. 

The block is contoured to match the deficient ridge anatomy and rigidly fixated with a titanium screw, which prevents micromovement during healing, a critical factor for successful graft incorporation.

The fixation screw serves two purposes: it stabilizes the graft during the initial healing phase, and it acts as a marker for future surgery, making it easier to locate the augmented site when the implant is placed months later.

Healing Phase: Approximately 6 Months

Jennifer healed uneventfully, and the graft matured into a much stronger, wider ridge capable of supporting an implant.

During this healing period, the bone graft undergoes a process called “creeping substitution,” where the patient’s own cells gradually replace the grafted bone with new, living bone tissue. 

This biological integration is why autogenous grafts have superior long-term success compared to synthetic materials. The final result is the patient’s own bone, fully vascularized and capable of supporting an implant indefinitely.

Stage 2: Implant Placement

After healing, the site was re-accessed, the fixation screw was removed, and the implant was placed into an ideal position for long-term stability and esthetics.

Implant positioning in the anterior maxilla requires extreme precision. The implant must be placed not only in the center of the available bone, but also in a position that allows the final crown to emerge naturally from the tissue, match the adjacent tooth contours, and support long-term papillae (the gum tissue between teeth). 

Even a millimeter of deviation can result in visible esthetic compromise.

Following six months of bone block graft integration, the implant was positioned in the augmented ridge with ideal three-dimensional placement for long-term esthetic and functional success.

Implant Integration: Approximately 4 Months

The implant was allowed to fully integrate with the bone before restoration.

Throughout this process, Jennifer remained in braces, which actually helped maintain precise spacing and allowed the orthodontist to support temporization during healing.

Case Progression & Key Milestones

• Consultation and CBCT planning confirmed an inadequate ridge width
• Bone block graft placed and fixated with a screw
• 6-month healing period with excellent graft integration
• The fixation screw was removed, and the implant was placed in the ideal position
• The implant healed in approximately 4 months
• Temporary tooth maintained during orthodontics
• Final crown delivered by her general dentist in under one year from graft surgery

The total treatment time from ridge augmentation to final crown delivery was approximately 10-11 months. While this may seem lengthy compared to immediate implant placement in ideal bone, this staged approach ensures the biological foundation is solid before loading the implant with a restoration. 

The result is an implant that can function for decades rather than one that may fail prematurely due to inadequate bone support.

Outcome

Jennifer healed beautifully at every stage. The ridge augmentation created the bone volume needed for implant placement, and the implant integrated predictably. There were no complications, and the final result was stable and healthy.

The final implant crown blended naturally with her neighboring teeth. The tooth looked proportionate, symmetrical, and realistic in the smile, with an emergence profile that appeared natural rather than artificial. 

Most importantly, the final result did not look like “an implant.” It looked like her own tooth had always been there.

For Jennifer, the biggest win was freedom. 

After living with a removable flipper for a decade, she finally had a tooth that felt secure, permanent, and effortless. She could smile, talk, and laugh without thinking about whether her temporary tooth was shifting, coming loose, or drawing attention. 

The result restored not only her smile, but also her confidence.

Patient Testimonial

“I wore a flipper for years and always felt like I was waiting for the day I could finally have a real tooth. I’m so happy I did this. The result looks completely natural.”

Final implant restoration demonstrating natural emergence profile, ideal tissue architecture, and symmetric integration with adjacent dentition. The result is indistinguishable from a natural tooth.

Clinical Notes for Referring Doctors

This case demonstrates the predictability of autogenous bone block grafting from the mandibular ramus for horizontal ridge augmentation in congenitally deficient sites. 

Key success factors included:

• Thorough 3D diagnostic planning to quantify the exact bone deficit and plan graft dimensions
• Rigid fixation of the bone block to prevent micromovement during the critical healing phase
• Adequate healing time (6 months) before implant placement to ensure complete graft maturation
• Interdisciplinary coordination with orthodontics to maintain ideal spacing and support temporization throughout treatment
• Precise implant positioning guided by the restored ridge anatomy and esthetic requirements

This approach is ideal for patients with congenitally missing teeth, post-extraction defects, or traumatic ridge loss where synthetic grafting materials alone would be insufficient. The biological superiority of autogenous bone ensures long-term volume maintenance and implant stability.

When to refer similar cases:

• Horizontal ridge deficiencies measuring less than 5mm width at the implant site
• Congenitally missing teeth with underdeveloped alveolar ridges
• Cases where esthetic demands are high (anterior zone)
• Young patients seeking permanent solutions to replace long-term temporaries
• Situations requiring coordination with orthodontics or restorative specialists

Dr. Lofthus has over 33 years of experience in complex bone reconstruction and anterior implant surgery. He welcomes referrals for cases requiring ridge augmentation, interdisciplinary treatment planning, and high-level esthetic implant outcomes.