A 23-year-old female patient reported to the Department of Prosthodontics after completing orthodontic treatment for the replacement of a missing maxillary left lateral incisor (tooth number 22) Figure 1 . For the rehabilitation of the missing tooth, both fixed and removable prosthetic options were discussed with the patient. However, she preferred a fixed solution. Three fixed options were suggested: a Maryland bridge, a fixed partial denture (FPD), and a dental implant. The patient consented to implant therapy, and a treatment plan was formulated for implant placement and rehabilitation at the site of the missing lateral incisor in the second quadrant.

A comprehensive preoperative assessment was carried out, including diagnostic casts and radiographic evaluation. Cone-beam computed tomography (CBCT) revealed inadequate bone volume at the planned implant site Figure 2 . To enhance bone density and improve implant stability, an osseodensification procedure using a Densah^® bur was planned. The patient had no significant medical history, and her primary concern was aesthetics. The surgical procedure was performed under aseptic conditions. Local infiltration anesthesia with 2% lignocaine was administered on both the buccal and palatal aspects of the implant site.

Figure 2

A midcrestal incision was made, and a full-thickness mucoperiosteal flap was raised to expose the underlying bone Figure 3 (A). Pilot drilling was performed, and the angulation was verified with adjacent teeth using an intraoral periapical (IOPA) radiograph. Osseodensification was carried out using Densah® burs to achieve adequate bone condensation and width around the implant site. Following final drilling, a 3.75 × 11.5 mm implant (Adin Dental Implant Systems Ltd., Israel) was placed Figure 3 3B, C Simple interrupted sutures were placed to achieve primary closure Figure 33D. Postoperative instructions were given, and antibiotics were prescribed for five days. The patient was recalled after one week for suture removal.

Figure 3

Four months later, she returned for evaluation. Osseointegration was confirmed radiographically using an IOPA radiograph, and a Stage II procedure was performed with placement of a gingival former Figure 4 4A. An implant-level open-tray impression technique was used, followed by verification of the impression using a jig. A customized abutment was fabricated using a castable plastic sleeve abutment (cast-to) to correct the implant angulation. A cement-retained porcelain-fused-to-metal (PFM) crown was fabricated and cemented onto the customized abutment Figure 4 B–D.                        

Figure 4

The patient expressed satisfaction with the final outcome, which provided both functional and aesthetic rehabilitation. Regular follow-up visits were scheduled to monitor implant health and peri-implant soft tissue status.

The precise placement of a dental implant is essential to achieve both functional efficiency and aesthetic harmony. Comprehensive treatment planning and accurate diagnosis are critical steps in ensuring long-term success. Prosthodontists often face significant challenges when placing implants in the anterior region, where aesthetic demands are particularly high 5. Several factors influence implant positioning, including the use of surgical stents, radiographic evaluation, soft tissue anatomy, abutment selection and prosthesis design. The present case involved a patient who had previously undergone orthodontic treatment. A pertinent consideration in such cases is whether orthodontic tooth movement affects the bone architecture and soft tissue levels in the edentulous region. A study on animal models demonstrated that orthodontic tooth movement within surgically induced periodontal bone defects promotes improved bone healing and increased bone apposition 2. The findings indicated that orthodontic movement may limit epithelial downgrowth and reduce pocket depth in surgically altered bone. Furthermore, it can induce coronal gingival displacement and vertical bone apposition, even in edentulous areas adjacent to the moved teeth. Consequently, the gingival margin may remain level with adjacent teeth, reducing the need for additional soft tissue augmentation procedures 7. In the present case, the implant was positioned slightly buccally relative to the adjacent teeth, resulting in aesthetic concerns. In such situations, prosthodontists can use prefabricated or customized angled abutments (cast-to abutments) to improve implant alignment, function, and aesthetics. These components help compensate for malpositioned implants and enhance the final prosthetic outcome 1, 3. To overcome aesthetic discrepancies, treatment options may include the use of crowns with artificial gingiva, angled abutments, customized porcelain coatings, or secondary grafting procedures. Misalignment of maxillary anterior implants poses an additional challenge in maintaining the natural mucogingival architecture, thereby increasing the complexity of aesthetic restoration 4. Ideally, the implant body should align perpendicularly to the curves of Wilson and Spee to distribute occlusal forces along its long axis. Proper axial alignment minimizes biomechanical complications such as abutment fracture and screw loosening. However, anatomical variations, including maxillary bone concavities and lingual surface irregularities, may necessitate angulated implant placement 6. When the implant angulation exceeds 25°, customized abutments are often required to achieve functional and aesthetic success. Despite advances in computer-aided design and manufacturing (CAD/CAM) technology, cast abutments remain a practical and cost-effective alternative. When the implant angulation exceeds 30° or inter-occlusal space is limited, cast abutments can be used. These are available in two types: cast-to and castable abutments. Cast-to abutments provide a more precise fit at the implant–abutment interface, whereas castable abutments are relatively less accurate due to casting distortions. Both serve as viable prosthetic solutions for managing implant angulation while maintaining long-term function 8, 9. In the present case, a cast-to abutment was used to correct the implant misalignment and ensure an accurate connection. The limitations of the present report include the absence of long-term follow-up and evaluation of soft tissue parameters. The successful restoration of implant-supported prostheses depends on accurate diagnosis, precise surgical placement, and appropriate prosthetic management. In cases of malpositioned implants, customized cast-to abutments provide an effective solution for aesthetic and functional rehabilitation. However, long-term clinical studies are required to assess the survival and stability of customized abutments in anterior implant restorations.

Precise planning and prosthetic customization are essential for successful anterior implant rehabilitation. In cases of suboptimal implant angulation, customized cast-to abutments offer a reliable and cost-effective solution to correct alignment discrepancies, underscoring the importance of individualized and multidisciplinary management for predictable aesthetic outcomes.

Funding: NilConflict of Interest: None