The patient started amoxicillin one day before surgery.

The procedure was performed under local anesthesia using articaine with epinephrine 1:100,000 on the facial aspect and articaine with epinephrine 1:200,000 on the palatal aspect.

Atraumatic tooth extraction represented a critical step of the immediate implant protocol.

The patient was informed preoperatively that preservation of the socket walls, particularly the facial plate, would determine whether immediate implant placement could proceed. In the event of facial bone plate fracture or significant socket damage during extraction, treatment would be converted to a delayed implant placement protocol.

To minimize mechanical stress on the alveolar walls, the existing ceramic crown was first removed.

The remaining root complex, including the intraradicular post, was then sectioned despite this being a single-rooted tooth. This allowed individual mobilization and removal of the root fragments while minimizing pressure against the facial and palatal socket walls.

A flapless approach was selected, avoiding elevation of a full-thickness mucoperiosteal flap and preserving the interproximal papillae.

Following extraction, the socket was carefully inspected.

All four socket walls remained intact, confirming favorable anatomy for proceeding with immediate implant placement.

A Straumann PURE Ceramic Implant, 4.0 × 12 mm, was selected.

The osteotomy was initiated with a 2.0-mm lance drill. The drill was initially introduced at approximately 45° toward the palatal socket wall, allowing engagement of the palatal bone while avoiding the facial plate.

Once palatal bone engagement had been achieved, the trajectory was progressively redirected into the planned prosthetically driven implant axis, oriented toward the cingulum region of the adjacent anterior dentition.

The same trajectory was subsequently reproduced with the 2.8-mm drill and finally with the 3.5-mm cylindrical drill.

This final preparation was particularly important because of the macrogeometry of the ceramic implant.

Unlike highly self-cutting or self-drilling tapered implant designs, the straight ceramic implant closely follows the geometry and trajectory of the prepared osteotomy. The final osteotomy therefore needed to accurately reproduce both the intended implant position and final preparation geometry.

Excessive insertion torque was deliberately avoided, and the osteotomy was prepared to permit controlled implant insertion.

The implant was ultimately positioned according to the prosthetic requirements of the future restoration.

The PURE Ceramic Implant used in this case presents a 1.8-mm polished ceramic transmucosal collar and therefore requires a different vertical positioning strategy from a conventional bone-level implant.

The intended vertical position was approximately 2 mm, accounting for the supracrestal polished collar and the desired restorative emergence profile.

Avoiding excessive apical positioning was particularly important because the coronal geometry of the tissue-level implant could otherwise interfere with the mesiodistal socket walls and compromise both implant insertion and the subsequent prosthetic emergence profile.

The implant achieved high primary mechanical stability, with a final insertion torque of approximately 60 Ncm.

Resonance frequency analysis using Osstell provided ISQ values ranging from 84 to 86.

These values were interpreted cautiously.

Most conventional clinical thresholds relating RFA measurements to implant stability and loading protocols have been established predominantly from titanium implant data. Material-specific prognostic thresholds for ceramic implants remain insufficiently validated.

Consequently, immediate provisionalization was not based on ISQ alone.

The decision incorporated insertion torque, socket integrity, three-dimensional implant position, available bone anchorage, occlusal conditions and the ability to completely eliminate functional loading of the provisional restoration.

Before grafting the facial jumping gap, the immediate provisional restoration was prepared.

A prefabricated polished PMMA temporary component from the Straumann system was connected to the implant and prepared intraorally in a manner comparable to the preparation of a provisional restoration on a natural tooth.

The facial ceramic shell of the patient's pre-existing crown was preserved and bonded to the PMMA temporary component.

The provisional restoration was subsequently removed and finalized extraorally, allowing appropriate contouring, finishing and polishing.

Importantly, the provisional restoration was completely prepared before placement of the xenogeneic graft.

Once the provisional restoration was ready for insertion, the facial jumping gap between the implant and the intact facial socket wall was grafted with small-particle Geistlich Bio-Oss.

The xenogeneic particles were carefully condensed to obtain stability within the gap.

The previously prepared provisional restoration was then immediately inserted, providing a prosthetic seal of the extraction socket and supporting the peri-implant soft-tissue architecture during early healing.

The emergence profile was designed according to the specific transmucosal geometry of the ceramic tissue-level implant.

No connective tissue graft was performed and no sutures were required.

Following grafting of the facial jumping gap, the immediate provisional restoration was inserted and tightened to 20 Ncm.

The screw-access channel was sealed with PTFE tape and composite resin.

Occlusion was carefully adjusted to ensure complete absence of contact in maximum intercuspation, lateral excursions and protrusive movements.

To provide additional clearance during protrusion, the provisional restoration was intentionally designed approximately 0.5 mm shorter than the corresponding definitive incisal reference.

The procedure was therefore completed without flap elevation, connective tissue grafting or suturing.

In this implant design, the coronal tulip-shaped ceramic portion already contributes to the emergence profile.

Consequently, the restorative transition differs substantially from that of a conventional deeply positioned bone-level implant.

The facial subcritical contour of the provisional restoration was designed with a relatively straight transition rather than an accentuated concavity, since part of this transition was already incorporated into the geometry of the implant itself.

Interproximally, a more concave contour was maintained to provide space for soft-tissue adaptation and maturation.

No conventional platform-switching concept was present, since this tissue-level implant was designed with a supracrestal polished ceramic collar.

The provisional component incorporates a metallic internal element; however, the metallic portion remains confined within the implant connection. The transmucosal component is polished PMMA, avoiding intended direct contact between the metallic component and the surrounding peri-implant hard or soft tissues.