A Digital, Top-Down Approach to Three Predictable Restorative Options
By Justin Chi, DDS, CDT, and Taylor Manalili, DDS
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Single-tooth replacement in the anterior zone remains one of the most demanding procedures in restorative dentistry. Aesthetic risk, soft-tissue stability, and restorative outcome are all highly dependent on a prosthetically driven treatment plan. Inadequate planning can result in compromised gingival architecture, structural failure, or aesthetic shortcomings that are difficult—if not impossible—to correct.
Whether replacing an anterior tooth with a fixed prosthesis or an implant-retained restoration, predictable outcomes rely on clear communication with the laboratory and a working understanding of multiple restorative pathways. This article presents 3 common clinical solutions for the anterior edentulous site—a Maryland bridge, a 3-unit fixed bridge, and an implant-retained crown highlighting 2 prosthetic implant workflows: cement-retained and screw-retained. Regardless of the technique selected, success begins with a digital, prosthetically driven approach to treatment planning.
Top-Down Treatment Planning
Predictable outcomes begin with a clear vision of the end goal. Understanding the desired contours of the restoration and selecting the appropriate material from the outset is key to proper treatment planning, site preparation, and ultimately, long-term success. A top-down approach uses that endpoint to guide both surgical and restorative execution.
The primary objective of replacing an anterior missing tooth is to restore function while preserving aesthetics. To achieve this, the ideal position, shape, and contours of the final restoration must be established before surgical planning begins—and certainly before preparing a tooth. A digital diagnostic wax-up serves as the foundation of this process, allowing the clinician to visualize the proposed outcome in 3D. Supplementing this with 2D or 3D facial images of the patient can help evaluate incisal edge position, gingival display, and overall aesthetic integration in the anterior zone. Visualizing the ideal result helps you determine whether additional therapies are needed to achieve it. This is not a new concept; however, the way we perform these wax-ups and communicate with our colleagues and patients to achieve the desired results is continually improving.
Digital advancements in how records are captured in the dental office, as well as the software on the laboratory side, have transformed modern top-down treatment planning. Intraoral scanning provides a comfortable experience for patients while also helping them visualize their current situation and discuss proposed treatment. CBCT has become an essential component of any potential implant treatment, affording detailed insight into bone quantity and quality as well as the precise location of critical anatomical structures. In more complex or aesthetically demanding cases, 2D or even 3D images can be combined to help communicate gingival display, the smile line, and key facial landmarks. When these datasets are combined in treatment planning software, we can visualize the final restoration and generate a digital wax-up that guides surgical and prosthetic decisions.
With these principles in mind, the following clinical cases illustrate how a top-down, digitally driven approach can be applied to common anterior tooth replacement scenarios. Each case highlights a distinct restorative solution tailored to the patient’s desires, specific anatomical limitations, aesthetic demands, and functional considerations.
Case 1: Maryland Bridge
A 32-year-old male patient presented with a 2-wing, resin-bonded Maryland bridge that had been in service for several years. Clinical evaluation revealed debonding of the lateral retainer wing, resulting in mobility of the restoration. Following removal, a single-wing Maryland bridge was selected as a long-term provisional due to contraindications for implant placement. The reason we did not choose a 2-wing replacement is that they may restrict independent tooth movement, increasing stress at the adhesive interface and the risk of debonding and secondary caries (Figure 1).
Figure 1. (a to c) Preoperative views of an existing Maryland bridge and retained canine.
Implant placement was not an immediate option due to the presence of a retained canine. Definitive implant therapy would have required a multidisciplinary approach, including surgical exposure and orthodontic repositioning of the canine—or its removal altogether.
Following review of the clinical findings and discussion of available treatment options, the patient elected to pursue a more conservative approach at this time. Options included rebonding the existing restoration or fabricating a replacement resin-bonded Maryland bridge utilizing a single-wing design. This approach, which is supported in the literature, has been shown to reduce debonding stresses and improve long-term predictability (Figure 2). An added advantage of this treatment option is that it allows for minimal to no preparation of the abutment tooth. Successful single-wing Maryland bridges require adequate enamel quality, sufficient bonding surface area, and favorable occlusion. The intraoral scan confirmed the presence of these conditions (Figure 3).
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Figure 2. (a and b) Two-wing vs single-wing design.
Figure 3. (a to c) Intraoral scan.
Digital design of the single-wing Maryland bridge was completed to optimize enamel coverage, retainer thickness, and occlusal clearance, while maintaining a conservative, no-prep approach (Figure 4). An Obsidian NOW lithium disilicate milling block (Glidewell Direct) was selected for aesthetics, strength, and same-day delivery. The Maryland bridge was designed and milled in-office. No preparation was required, and an enamel-bonded protocol was performed using a flowable composite resin (Figure 5).
Figure 4. Digital design of the single-wing Maryland bridge.
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Figure 5. (a and b) Obsidian NOW lithium disilicate milling block (Glidewell Direct).
Case 2: Three-Unit Bridge
This case highlights the use of 3-unit fixed bridges as a restorative solution in an edentulous scenario where implant therapy was not ideal. A 37-year-old female patient presented with congenitally missing lateral incisors and generalized crowding and expressed frustration with a long history of resin-bonded (Maryland-type) bridge failures, including repeated debonding and ongoing repairs. Preoperative images show the congenitally missing lateral incisors following orthodontic alignment (Figures 6a to 6d). A diagnostic wax-up was created from an intraoral scan and transferred intraorally as a mockup to evaluate aesthetics, phonetics, and function—and to confirm the proposed outcome (Figures 6e and 6f). The mockup also served as a reduction guide with areas of additive contour requiring minimal or no tooth reduction.
Figure 6. (a to d) Pre-op view of congenitally missing lateral incisors following orthodontic alignment. (e and f) Diagnostic wax-up.
Each case highlights a distinct restorative solution…
Due to limited space and inadequate bone volume, implant placement was ruled out as a viable treatment option. A definitive restorative plan was developed, consisting of two 3-unit BruxZir Esthetic bridges (Glidewell) replacing teeth Nos. 6 to 8 and 9 to 11. Using the mockup as a preparation guide, the abutment teeth were prepared for BruxZir Esthetic Zirconia (Glidewell), with preparations aligned to establish a common path of insertion within each bridge unit to facilitate proper seating of the final restorations. To further enhance smile aesthetics and improve overall harmony, BruxZir Esthetic veneers were also planned for teeth Nos. 4, 5, 12, and 13.
The preparations were scanned and imported into digital design software (fastdesign.io [Glidewell]). Provisional restorations were milled from BioTemps NOW Milling Blocks (Glidewell Direct) using an in-office milling unit (fastmill.io [Glidewell]), resulting in two 3-unit anterior bridges and 4 premolar veneers. Milling time was approximately 30 minutes per bridge and 5 minutes per veneer, with only minor polishing required prior to delivery (Figure 7).
Figure 7. (a and b) Mockup as a preparation guide and tooth preparation. (c) Scanned preparations. (d) Digital design software (fastdesign.io [Glidewell]). (e) Milled provisional restorations.
The final restorations replicated the contours of the approved provisionals with BruxZir Esthetic Zirconia, accurately reflecting the validated design (Figure 8). Digital design software enabled precise control of both gingival margins and overall contours, supporting development of a natural emergence profile from the edentulous ridge and seamless integration with the surrounding dentition.
Figure 8. (a to d) The final restoration.
Case 3: Implant-Retained Restoration (Choosing Screw vs Cement)
As is often the case in restorative dentistry, treatment planning relied on a combination of patient-reported history, clinical findings, and available diagnostic information. Dentistry frequently presents problem-solving situations in which ideal conditions or complete control are not always possible. After a comprehensive evaluation and discussion of available options, both patients expressed a desire for a fixed, long-term solution. A single-unit, implant-retained restoration was agreed upon as the treatment plan to restore function, aesthetics, and confidence in their smiles.
When replacing an anterior edentulous site, implant therapy offers an opportunity to recreate natural aesthetics and function with long-term predictability; however, the success of an anterior implant is determined long before the osteotomy is prepared. A top-down digital workflow—beginning with the desired restorative outcome and working backward to the ideal implant position—allows the clinician to control the emergence profile, screw access trajectory, soft-tissue support, and restorative design with far greater precision.
Case 3A: Screw-Retained Restoration
This 38-year-old female patient presented with a missing maxillary central incisor (tooth No. 8). She reported that at the time of extraction, socket grafting was performed to maintain alveolar bone. An interim removable partial denture was provided during the healing phase; however, the appliance was ill-fitting and lacked stability, resulting in dissatisfaction with both function and aesthetics (Figure 9). The digital wax-up was created first to confirm appropriate spacing and the ability to achieve ideal restorative contours. Visualizing the proposed final restoration is a critical component of the treatment planning phase, as it enables the clinician to determine whether additional procedures may be required before or in conjunction with implant placement (Figure 10). Implant positioning was planned with consideration of both available bony volume and anticipated soft tissue support. This prosthetically driven approach enables the fabrication of a custom component, improving accuracy and enhancing chairside efficiency (Figure 11).
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Figure 9. (a and b) Patient pre-op images.
Figure 10. (a to c) Digital wax-up.
Figure 11. (a to c) Implant planning phase, implant positioning.
Guided surgery was utilized to ensure implant placement followed the restorative treatment plan (Figure 12). A Glidewell HT Implant was selected for this case (Glidewell Direct). The implant’s tapered body and buttress thread design facilitate high primary stability, enabling immediate provisionalization. The provisional restoration was slightly modified chairside to support soft-tissue maturation and sculpt the emergence profile based on the final implant position.
Figure 12. (a to c) Guided implant placement.
Once osseointegration was confirmed and the peri-implant tissues had stabilized, the definitive impression was made. The provisional restoration had been used to shape the emergence profile, promoting gingival margin stability and papilla formation. Because the provisional closely mimicked the contours of the planned definitive restoration, it served as a guide for transferring the established soft-tissue architecture to the final prosthesis (Figure 13).
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Figure 13. (a and b) Restorative phase, impression.
Material selection for a single maxillary central incisor can be challenging, even in the most skilled hands. In this case, the contralateral central incisor exhibited pronounced characterization, including incisal and interproximal translucency and well-defined developmental lobes. These aesthetic features were replicated using BruxZir Fusion (Glidewell), which provided the depth, translucency, and internal characterization necessary to achieve a natural and harmonious match (Figure 14).
Figure 14. (a to c) Restorative material selection.
Case 3B: Cement-Retained Restoration
A 30-year-old female patient presented post-orthodontic therapy following multiple staged soft- and hard-tissue augmentation procedures. The patient declined further orthodontic treatment (including clear aligners) and requested implant placement contingent on adequate existing bony contours (Figure 15).
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Figure 15. (a and b) Patient pre-op presentation.
Digital planning began with a diagnostic wax-up to establish ideal tooth position, incisal edge location, and restorative contours. Implant positioning represented a balance between available bone anatomy and the proposed restorative design, with the wax-up helping define aesthetic and functional limitations. In this case, the ideal long axis of the implant positioned a screw-access channel directly through the incisal edge of the definitive restoration; therefore, a cement-retained approach was selected to preserve aesthetics while maintaining a prosthetically driven implant position (Figure 16).
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Figure 16. (a and b) Digital planning and implant positioning.
Guided implant placement was performed in accordance with the restorative treatment plan while respecting anatomic limitations. A screw-retained provisional restoration was fabricated to eliminate the use of cement in a fresh surgical field and to allow for easy removal and modification if needed. The provisional was used to guide peri-implant soft-tissue maturation, with tissue contours monitored over a 3- to 4-month healing period to achieve gingival symmetry and support papilla formation (Figure 17).
Figure 17. (a to d) Guided implant placement.
As demonstrated in the digital treatment plan, implant angulation precluded a screw-retained design, necessitating selection of a cement-retained restoration. A hybrid custom abutment (Ti-base with a 3Y zirconia coping) was fabricated to optimize the emergence profile, provide adequate support for the definitive crown, and allow for ideal positioning of the restorative margin to help limit potential cement-related complications. The final BruxZir Esthetic crown was cemented over the hybrid abutment, resulting in favorable peri-implant tissue support and optimal aesthetics without a visible screw-access channel. This case highlights the value of digital planning in identifying restorative constraints and selecting an appropriate prosthetic design prior to implant placement (Figure 18).
Figure 18. (a to c) Restorative phase and final restoration.
Conclusion
Cases 3A and 3B illustrate how digital planning guided not only implant placement, but also the restorative strategy. By integrating CBCT data, intraoral scans, and a digital wax-up, we were able to determine before surgery whether each case would be best restored with a screw-retained crown (Figures 9 to 14) or a cement-retained crown (Figures 15 to 18) based on the anticipated implant trajectory relative to the incisal edge position.
Single-tooth replacement in the anterior zone requires a careful balance of aesthetics, function, and biologic stability. As illustrated in these clinical cases, predictable outcomes are achieved when treatment begins with a clear restorative vision and a digitally driven, top-down approach. By defining the final restoration first—and allowing that endpoint to guide both restorative and surgical decisions—clinicians can anticipate limitations, communicate more effectively with the laboratory, and select the most appropriate treatment modality. In an era of increasingly sophisticated digital tools, success in anterior tooth replacement is less about the restoration chosen and more about how thoughtfully it is planned.
About the Authors
Dr. Chi is director of clinical technologies at Glidewell. He joined Glidewell in 2015 as a clinical research associate after earning his DDS from the Herman Ostrow School of Dentistry at University of Southern California, Los Angeles. He previously received a BS in dental laboratory technology from the LSU School of Dentistry in New Orleans and earned his CDT in crown and bridge in 2007. Drawing from both laboratory and clinical experience, Dr. Chi focuses on digital workflows, restorative materials, and advancing efficient, predictable dentistry. He can be reached at [email protected].
Dr. Manalili is director of clinical prosthodontics at Glidewell. At Glidewell she works in the onsite dental clinic where she helps to enhance laboratory protocols, conducts clinical research, and performs advanced restorative work, including implant placement, chairside restorations, and full-mouth rehabilitations. She received a BS degree in chemical engineering from Northeastern University and a DDS degree from Stony Brook University, where she also obtained an advanced education certificate in prosthodontics. Dr. Manalili is a Fellow of the Resnik Implant Institute and is a Diplomate of the International Congress of Oral Implantologists. She joined the Resnik International Implant Institute as a prosthodontic faculty member and has more than 10 years of teaching experience in diverse educational settings. She can be reached at [email protected].
Disclosure: Drs. Chi and Manalili are employees of Glidewell.
