Infraocclusion Following Implant-Supported Restoration in the Anterior Maxillary Region: An 8-Year Follow-Up Case Report

Infraocclusion Following Implant-Supported Restoration in the Anterior Maxillary Region: An 8-Year Follow-Up Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Infraocclusion Following Implant-Supported Restoration in the Anterior Maxillary Region: An 8-Year Follow-Up Case Report Jingshi Lei, Sainan Li, Piaopiao Qiu, Zhen Fan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7559280/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Infraocclusion following anterior maxillary implant restoration is a complication compromising long-term aesthetic and functional outcomes. Although previous reports have described infraocclusion, cases with significant dental arch discrepancies severely impacting occlusal function and aesthetics remain rare. Case presentation: This study reports a case of severe infraocclusion occurring eight years after implant placement in the left maxillary anterior region, analyzing jawbone remodeling patterns and peri-implant soft tissue changes to elucidate mechanisms and optimize therapeutic strategies. A patient presenting with progressive infraocclusion and gingival hyperplasia eight years post-restoration underwent comprehensive evaluation, including Cone Beam Computed Tomography(CBCT) imaging, 3D superimposition of pre- and post-treatment jawbone models (Mimics 21.0 software), and histopathological analysis of soft tissue biopsies. The comparative literature review was conducted to establish diagnostic criteria and evidence-based interventions. Conclusion Persistent vertical and mesiodistal jawbone remodeling contributed to implant infraocclusion, while soft tissue hyperplasia exacerbated aesthetic compromise. Multidisciplinary management integrating 3D-guided prosthetic adjustments and soft tissue recontouring demonstrated clinical efficacy. This case underscores the importance of long-term monitoring and adaptive treatment planning to address dynamic craniofacial changes in anterior maxillary implant rehabilitation. Esthetic zone Infraocclusion ​Implant restoration Gingival hyperplasia​ Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Background The anterior maxillary teeth play a crucial role in aesthetics, speech, and chewing function. Losing these teeth can significantly impair oral function and negatively affect a patient's physical and psychological well-being. As a result, implant-supported crowns and bridges have become popular and preferred solutions for replacing anterior teeth due to their reliable outcomes. 1 The long-term success of a dental implant relies on the stability of both the surrounding bone and soft tissue, as well as ongoing maxillofacial growth, which can influence the aesthetic relationship between implants and adjacent natural teeth. Natural teeth are surrounded by periodontal ligaments, which allow them to adapt to changes in jaw growth. In contrast, osseointegrated implants do not have this ability. As a result, there is an increased risk of infraocclusion, a condition in which the restorations gradually appear shorter than the adjacent teeth. Consequently, current protocols recommend delaying implant placement until maxillofacial growth is complete, which is typically around 18 years of age or older. 2 Research demonstrates that between 40% and 100% of adult patients exhibit measurable infraocclusion during long-term follow-up assessments, challenging the belief that adult maxillofacial growth is minimal. 3 This report presents a clinically significant case of infraocclusion involving an anterior maxillary implant-supported crown after 8 years of restoration. The case is also accompanied by localized gingival hyperplasia. To assess positional changes in the surrounding teeth, digital three-dimensional reconstruction was employed. Additionally, a literature review is included to summarize the incidence, clinical characteristics, and management strategies for this complication, offering evidence-based insights for clinical practice. Case presentation A 37-year-old female presented to the Department of Implantology, Shanghai Tongji Stomatological Hospital (Affiliated Stomatological Hospital of Tongji University) in June 2015 with a chief complaint of missing left anterior maxillary teeth for over a decade. Her medical history revealed extraction of retained deciduous teeth (21 and 22) over ten years prior, followed by removable partial denture rehabilitation. She sought implant-supported prostheses due to dissatisfaction with the existing restoration. The patient denied systemic diseases, long-term medication use, or habits such as smoking or alcohol consumption but reported a penicillin allergy. Clinical examination demonstrated symmetry with midline alignment of facial and dental arches, and no tenderness in the temporomandibular joint regions. The intraoral assessment revealed missing teeth 21 and 22, with a larger edentulous span on the left side compared to the contralateral dentition. A firm, non-tender gingival hyperplasia (20 × 8 mm) was observed on the labial aspect of the edentulous area, confined to the labial mucosa without lingual involvement. Normal overjet and overbite were noted, and oral hygiene was satisfactory. Cone-beam computed tomography (CBCT) revealed available bone dimensions of 21 mm in height and 7.4 mm in width of 21, and 18.25 mm in height and 5.13 mm in width of 22. Based on clinical and radiographic findings, the patient was diagnosed with partial edentulism (21, 22) and suspected gingival hyperplasia. The proposed treatment plan included implant-supported, fixed, or removable prosthetic options for 21 and 22, with a recommendation for two implants and simultaneous bone augmentation if implants were selected. Additionally, a periodontal consultation was advised to evaluate the gingival hyperplasia (Fig. 1 ). (A) Occlusal view of the edentulous area in the upper left anterior region; (B) Coronal view of the edentulous area in the upper left anterior region; (C) Panoramic radiograph demonstrating the absence of teeth 21 and 22; (D)CBCT of teeth 21 and 22 showing labial bone resorption. The available bone widths at 1 mm, 3 mm, and 5 mm below the alveolar crest for tooth 21 were 3.88 mm, 6.68 mm, and 5.36 mm, respectively; corresponding measurements for tooth 22 were 1.88 mm, 2.87 mm, and 6.14 mm; (E) CBCT axial view revealing significant labial concavities in the 21 and 22 regions. The patient declined immediate intervention for gingival hyperplasia. Following a comprehensive discussion of the implant treatment protocol and associated financial considerations, the patient proceeded with implant-supported restoration combined with simultaneous bone augmentation. The patient underwent implant surgery on September 14, 2015. After obtaining informed consent, the patient was placed in a supine position. The surgical area was disinfected and draped. ​Local infiltration anesthesia was administered in the 12–24 region. A ​linear incision with mesial and distal releasing incisions fully exposed the bone surface. ​Stepwise drilling was performed, and a 3.5×11 mm implant (Ankylos, Germany) was placed with ​primary stability of approximately 20 N·cm. ​Bone grafting was simultaneously performed by creating nutrient holes on the labial side and placing 0.25 g of Bio-Oss bone powder (Geistlich, Switzerland), followed by covering with a 13×25 mm² Bio-Gide absorbable collagen membrane (Geistlich, Switzerland). The labial flap was released for tension-free closure, and a ​submerged suture was applied. Postoperative CBCT confirmed ​optimal implant positioning. Sutures were removed 14 days postoperatively, with ​soft tissue healing satisfactory and the healing cap remaining unexposed (Fig. 2 ). (A) Postoperative panoramic radiograph after implant placement; (B) Postoperative CBCT of tooth 21 demonstrating optimal implant positioning with retained labial bone graft material; (C) Postoperative CBCT of tooth 22 confirming proper implant placement and stable labial bone graft material; (D) Occlusal view at 14-day suture removal, showing well-healed surgical sites and non-exposed healing abutments; (E) Coronal view 14 days postoperatively, revealing intact soft tissue architecture. At the ​6-month postoperative follow-up, ​osseointegration of the implant was confirmed. A ​splinted crown restoration was subsequently performed. The patient opted for a ​zirconia abutment combined with an all-ceramic crown. After prosthesis delivery, the restoration achieved satisfactory functional and aesthetic outcomes. ​Periapical radiographs and CBCT confirmed proper seating of the prosthesis, stable marginal bone levels, and complete tightening of the abutment screw. The crown was ​resin-bonded to the abutment (Fig. 3 ). (A) CBCT demonstrates good osseointegration of the 21 implant with intact labial bone plate; (B) CBCT shows successful osseointegration of the 22 implant; (C) Intraoral coronal view after abutment placement; (D) Periapical radiograph confirms proper seating of the abutment following definitive crown delivery; (E) Intraoral coronal view after restoration, demonstrating midline alignment of the maxillary arch at the midline of tooth 41 crown, with incisal edge alignment between teeth 21 and 11. Four months after prosthesis delivery, the patient returned for evaluation. ​Clinical examination revealed stable peri-implant soft tissues without signs of gingival hyperplasia. ​CBCT demonstrated maintained marginal bone stability around the implant, with ​no pathological bone resorption observed (Fig. 4 ). (A) Coronal intraoral view demonstrating stable peri-implant soft tissues; (B) Occlusal intraoral view; (C) Coronal intraoral view showing stable soft tissue contour around the labial aspect of the implant with no significant changes compared to preoperative conditions; (D) CBCT image confirming stable marginal bone levels around the implant at site 21; (E) CBCT image confirming stable marginal bone levels around the implant at site 22. The patient returned on April 29, 2024, reporting a noticeable gap between the implant-supported prosthesis and adjacent teeth and significant incisal shortening of the restoration. Clinical examination revealed stable fixation of the 21 and 22 implant crowns with clear percussion sounds. Labial gingival hyperplasia persisted, characterized by ​firm, pink tissue. CBCT imaging demonstrated maintained peri-implant bone stability, with no evidence of marginal bone loss (Fig. 5 ). (A) Intraoral coronal view at 8-year follow-up showing significant infraocclusion of the implant restoration with noticeable gaps between the restoration and adjacent teeth; (B) Intraoral occlusal view demonstrating mesiodistal marginal gaps between the implant restoration and adjacent teeth; (C) Intraoral coronal view revealing an expanded area of peri-implant soft tissue hyperplasia on the labial aspect; (D) CBCT sagittal section confirming stable bone levels around the 21 implant; (E) CBCT sagittal section demonstrating maintained bone stability around the 22 implant. CBCT data analysis revealed significant skeletal changes between the 2016 post-restoration and 2024 follow-up periods. Given the osseointegrated nature of the implant, which maintains a fixed position relative to the jawbone, Mimics 21.0 software was employed to reconstruct and align the 2016 and 2024 skeletal models. After cropping artifact-prone regions and registering the datasets using the implant as a reference, vertical and mesiodistal positional discrepancies (0.36–0.56 mm) were observed: Tooth 11 exhibited labial, distal, and coronal displacement, while tooth 23 shifted distally, palatally, and apically (Fig. 6 ). (A) Superimposition of 2016 CBCT (red) and 2024 models (pink), with the implant-supported prosthesis model in purple; (B) Sagittal comparison of natural tooth 11, showing an incisal edge positional discrepancy of approximately 0.36 mm; (C) Axial comparison of tooth 11, revealing a mesial positional discrepancy of 0.54 mm; (D) Sagittal comparison of tooth 23, demonstrating incisal edge and labial positional discrepancies of 0.54 mm and 0.51 mm, respectively; (E) Axial comparison of tooth 23, showing a mesial positional discrepancy of 0.56 mm. Intraoral examination identified localized progression of peri-implant soft tissue hyperplasia compared to baseline. Histopathological analysis of a biopsy sample confirmed gingival hyperplasia with focal papillary proliferation. The virtual prosthetic simulation revealed increased edentulous span dimensions due to skeletal changes, prompting a revised treatment plan to replace the original two-unit restoration with a three-unit splinted crown to address the enlarged mesiodistal space (Fig. 7 ). (A) Coronal view of the intraoral condition post-crown removal; (B) Occlusal view post-crown removal, demonstrating stable peri-implant soft tissues; (C) Coronal view of the provisional restoration design, transitioning from two-unit to three-unit crown restoration due to increased mesiodistal space; (D) Occlusal view of the provisional crown restoration design. The patient declined the option for soft tissue recontouring but consented to placing a three-unit splinted crown. Following a three-month trial period with a provisional restoration, the patient reported satisfaction with the morphology and contour of the crown. Observations indicated favorable recontouring of the peri-implant soft tissues around the provisional restoration. A digital intraoral scan effectively captured the transmucosal emergence profile, facilitating the design of an optimal emergence contour. The abutment screw was tightened according to the manufacturer’s specified torque. Subsequently, Polytetrafluoroethylene (PTFE) tape was employed to isolate the screw channel, followed by the application of light-cured resin for sealing (Fig. 8 ). The patient conveyed high levels of satisfaction regarding both the functional and aesthetic outcomes, with no complications noted during the follow-up period. (A) Coronal view of the provisional restoration; (B) Occlusal view of the provisional restoration demonstrating occlusal table design; (C) Coronal view of the abutments after provisional restoration removal; (D) Intraoral evaluation of the implant emergence profile at the transmucosal zone; (E) Extraoral view of the definitive prosthesis; (F) Laboratory cast showing abutment positioning for definitive restoration; (G) Coronal view of the definitive prosthesis in occlusion; (H) Occlusal view of the definitive prosthesis with functional cusp-fossa relationships; (I) Periapical radiograph confirming precise seating of the definitive prosthesis. Discussion and conclusions Over the past 35 years, implant-supported prostheses have become widely adopted for partial and complete edentulism, with increasing attention to long-term complications. 4 Current research primarily focuses on peri-implantitis 5 , occlusal overload 6 , and marginal bone resorption 7 , while the relationship between implants and adult continuous craniofacial growth remains poorly understood. Lifelong maxillofacial changes are attributed to multifactorial mechanisms. 8 Maxillary growth is closely linked to cranial structure, gender, and facial type, while mandibular growth correlates with overall physical development. 9 , 10 Generally, females experience peak craniofacial growth between ages 9–14, and males between 11–17, with transverse development completing first, followed by sagittal and vertical planes. 11 Unlike natural teeth, osseointegrated implants lack periodontal ligaments and are directly anchored to bone, preventing continuous eruption or passive adaptation to skeletal growth—a key reason for avoiding implants in adolescents. 12 , 13 Nevertheless, craniofacial changes persist into adulthood, potentially leading to biological and aesthetic complications that compromise long-term implant outcomes. 14 This phenomenon, termed infraocclusion, occurs when ongoing jaw growth causes a vertical discrepancy between implants and adjacent teeth. 15 Research on infraocclusion reveals vertical discrepancies in 40%–100% of implant patients. In anterior regions, the average discrepancy is 0.1 mm in the first year, 0.4 mm in the fifth year, and 0.5 mm in the eighth year, while premolar regions show an average of 0.2 mm. 16 Beyond vertical changes, adjacent natural teeth often exhibit labiolingual inclination. Proximal contact loss between implants and natural teeth, another long-term complication of persistent craniofacial growth, occurs in 34%–65% of patients within 3–8 months post-restoration. 17 While some studies suggest a higher incidence in females, others report no significant gender difference. 18 In this case, the patient’s adjacent tooth discrepancies (0.36–0.56 mm) align with the reported data. Notably, 14–20 years post-implantation, most patients remain satisfied with anterior implant aesthetics, with only 18.2% seeking corrective interventions—predominantly females (22.2%). 19 This may reflect greater aesthetic awareness among female patients, who are more likely to detect dental changes and seek treatment. In this case, the patient—a 38-year-old female at implantation—developed significant infraocclusion and proximal gaps after 8 years due to ongoing eruption of natural teeth and jaw growth, leading to compromised aesthetics and a strong desire for corrective intervention. Current clinical consensus suggests regular annual follow-up remains the primary management strategy for malocclusion-induced dental misalignment post-implant restoration. When complications such as food impaction or interdental spacing arise, clinicians often choose to replace the implant crown and perform adjacent tooth restorations to reestablish proper contacts. In this case, the patient ultimately underwent prosthetic revision, transitioning from two-unit to three-unit splinted crowns to close interdental gaps and restore proper anterior overjet and overbite relationships. (Fig. 7 ). Notably, significant labial soft tissue hyperplasia was observed in the edentulous zone. For clinicians, this poses a critical challenge to pink-and-white esthetics in the anterior region, distinct from but equally urgent as infraocclusion. However, the patient persistently declined soft tissue contouring. This decision may relate to her medium smile line, minimizing perceived aesthetic impact. While current literature lacks evidence directly linking maxillofacial growth to gingival hyperplasia, studies confirm that autologous soft tissue grafts (e.g., connective tissue grafts, CTG, free gingival grafts, FGF) demonstrate sustained increases in thickness and width over time. 20 Whether this soft tissue expansion relates to skeletal growth or gingival phenotype requires further investigation. This case highlights infraocclusion 8 years after anterior maxillary implant restoration, emphasizing the long-term impact of ongoing alveolar growth on esthetic outcomes. Clinicians should consider infraocclusion, especially in young female patients, during long-term prosthetic planning. Furthermore, future protocols should incorporate dynamic interactions between bone and soft tissue into risk assessments and patient counseling. Abbreviations Full name abbreviations Cone Beam Computed Tomography CBCT Polytetrafluoroethylene PTFE connective tissue grafts CTG free gingival grafts FGF Declarations Ethics approval and consent to participate This study was approved by the ​​Ethics Committee of the Affiliated Stomatology Hospital of Tongji University​​ (Approval No. 2023-DW-13) and conducted in accordance with the ​​Ethical Review Measures for Biomedical Research Involving Humans and the ​​Declaration of Helsinki​​. Written informed consent was obtained from the patient for participation of this case report and accompanying images. Clinical trial number: not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and accompanying images. Competing interests The authors declare that they have no competing interests Funding This work was financially supported by the National Key Research and Development Program of China (Grant No. 2021YFC2400400) and the National Natural Science Foundation of China (Grant No. 81400485). Jingshi Lei acknowledges the funding support from Shanghai Municipal Science and Technology Innovation Action Plan (Qimingxing Cultivation Program - Yangfan Special Project) (Grant No. 23YF1450600), Medical New Technology Research and Translational Seed Program (General Project) of the Shanghai Municipal Health Commission (Grant No. 2024ZZ2069). Author Contribution Jingshi Lei: Conceptualization, investigation, supervision, resources, original draft. Sainan Li: Methodology, software, data curation, formal analysis. Piaopiao Qiu: methodology, software, data curation, review and editing. Zhen Fan: Conceptualization, methodology, data curation, project administration, review and editing. Data Availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. References Gerritsen AE, Allen PF, Witter DJ, et al. Tooth loss and oral health-related quality of life: a systematic review and meta-analysis. Health Qual Life Outcomes. 2010;8:126. 10.1186/1477-7525-8-126 . Papaspyridakos P, Chen C-J, Singh M, et al. Success criteria in implant dentistry: a systematic review. J Dent Res. 2012;91:242–8. 10.1177/0022034511431252 . Bernard JP, Schatz JP, Christou P, et al. Long-term vertical changes of the anterior maxillary teeth adjacent to single implants in young and mature adults. A retrospective study. J Clin Periodontol. 2004;31:1024–8. 10.1111/j.1600-051X.2004.00574.x . Howe M-S, Keys W, Richards D. Long-term (10-year) dental implant survival: A systematic review and sensitivity meta-analysis. J Dent. 2019;84. 10.1016/j.jdent.2019.03.008 . Fransson C, Tomasi C, Pikner SS, et al. Severity and pattern of peri-implantitis-associated bone loss. J Clin Periodontol. 2010;37:442–8. 10.1111/j.1600-051X.2010.01537.x . Kim Y, Oh T-J, Misch CE, Wang H-L. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Clin Oral Implants Res. 2005;16:26–35. 10.1111/j.1600-0501.2004.01067.x . Oh T-J, Yoon J, Misch CE, Wang H-L. The causes of early implant bone loss: myth or science? J Periodontol. 2002;73:322–33. 10.1902/jop.2002.73.3.322 . Oesterle LJ, Cronin RJ. Adult growth, aging, and the single-tooth implant. Int J Oral Maxillofac Implants. 2000;15:252–60. Akgül AA, Toygar TU. Natural craniofacial changes in the third decade of life: a longitudinal study. Am J Orthod Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. 2002;122:512–22. 10.1067/mod.2002.128861 . Klinge A, Becktor K, Lindh C, Becktor JP. Craniofacial height in relation to cross-sectional maxillary and mandibular morphology. Prog Orthod. 2017;18:32. 10.1186/s40510-017-0187-8 . Heij DGO, Opdebeeck H, van Steenberghe D, et al. Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement. Int J Oral Maxillofac Implants. 2006;21:867–78. Odman J, Gröndahl K, Lekholm U, Thilander B. The effect of osseointegrated implants on the dento-alveolar development. A clinical and radiographic study in growing pigs. Eur J Orthod. 1991;13:279–86. 10.1093/ejo/13.4.279 . Mankani N, Chowdhary R, Patil BA, et al. Osseointegrated dental implants in growing children: a literature review. J Oral Implantol. 2014;40:627–31. 10.1563/AAID-JOI-D-11-00186 . Daftary F, Mahallati R, Bahat O, Sullivan RM. Lifelong craniofacial growth and the implications for osseointegrated implants. Int J Oral Maxillofac Implants. 2013;28:163–9. 10.11607/jomi.2827 . Cocchetto R, Pradies G, Celletti R, Canullo L. Continuous craniofacial growth in adult patients treated with dental implants in the anterior maxilla. Clin Implant Dent Relat Res. 2019;21:627–34. 10.1111/cid.12790 . Chang M, Wennström JL. Longitudinal changes in tooth/single-implant relationship and bone topography: an 8-year retrospective analysis. Clin Implant Dent Relat Res. 2012;14:388–94. 10.1111/j.1708-8208.2010.00272.x . Wei H, Tomotake Y, Nagao K, Ichikawa T. Implant prostheses and adjacent tooth migration: preliminary retrospective survey using 3-dimensional occlusal analysis. Int J Prosthodont. 2008;21:302–4. Winitsky N, Naimi-Akbar A, Nedelcu R, et al. 3‐D tooth movement adjacent to single anterior implants and esthetic outcome. A 14‐ to 20‐year follow‐up study. Clin Oral Implants Res. 2021;32:1328–40. 10.1111/clr.13833 . Alsulaimani FF, Batwa W. Incisors’ proportions in smile esthetics. J Orthod Sci. 2013;2:109–12. 10.4103/2278-0203.119685 . Barootchi S, Tavelli L, Zucchelli G, et al. Gingival phenotype modification therapies on natural teeth: A network meta-analysis. J Periodontol. 2020;91:1386–99. 10.1002/JPER.19-0715 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7559280","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":524243627,"identity":"1311cb06-ae68-4a3b-becc-ed148bd0b55b","order_by":0,"name":"Jingshi Lei","email":"","orcid":"","institution":"Shanghai Engineering Research Center of Tooth Restoration and Regeneration \u0026 Tongji Research Institute of Stomatology \u0026 Department of 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07:16:33","extension":"xml","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":60081,"visible":true,"origin":"","legend":"","description":"","filename":"e744802af6964d4bb7f139a0e02d140e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/fe599860a56e73466887ec38.xml"},{"id":93011116,"identity":"4fc3882d-2e25-4930-b039-83d85ebefb0e","added_by":"auto","created_at":"2025-10-08 07:16:33","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66604,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/c0ad1b739a8a565043298d7b.html"},{"id":93011097,"identity":"2a9d9ede-5077-4ee4-aa20-26a276d1f2c6","added_by":"auto","created_at":"2025-10-08 07:16:33","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":240001,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative intraoral and radiographic findings.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Occlusal view of the edentulous area in the upper left anterior region; (B) Coronal view of the edentulous area in the upper left anterior region; (C) Panoramic radiograph demonstrating the absence of teeth 21 and 22; (D)CBCT of teeth 21 and 22 showing labial bone resorption. The available bone widths at 1 mm, 3 mm, and 5 mm below the alveolar crest for tooth 21 were 3.88 mm, 6.68 mm, and 5.36 mm, respectively; corresponding measurements for tooth 22 were 1.88 mm, 2.87 mm, and 6.14 mm; (E) CBCT axial view revealing significant labial concavities in the 21 and 22 regions.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/c1f744444350eac10b508ffe.jpeg"},{"id":93011106,"identity":"981a70e9-d02a-4b22-badb-2fe117dbd9b7","added_by":"auto","created_at":"2025-10-08 07:16:33","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":215298,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePostoperative radiographic and intraoral findings.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Postoperative panoramic radiograph after implant placement; (B) Postoperative CBCT of tooth 21 demonstrating optimal implant positioning with retained labial bone graft material; (C) Postoperative CBCT of tooth 22 confirming proper implant placement and stable labial bone graft material; (D) Occlusal view at 14-day suture removal, showing well-healed surgical sites and non-exposed healing abutments; (E) Coronal view 14 days postoperatively, revealing intact soft tissue architecture.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/dc45a15bd2cd7d731e028569.jpeg"},{"id":93013903,"identity":"57ae799f-6caa-4a66-a896-e4c0e82d9857","added_by":"auto","created_at":"2025-10-08 07:32:33","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":234565,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographic and intraoral evaluation at 6 months postoperatively.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) CBCT demonstrates good osseointegration of the 21 implant with intact labial bone plate; (B) CBCT shows successful osseointegration of the 22 implant; (C) Intraoral coronal view after abutment placement; (D) Periapical radiograph confirms proper seating of the abutment following definitive crown delivery; (E) Intraoral coronal view after restoration, demonstrating midline alignment of the maxillary arch at the midline of tooth 41 crown, with incisal edge alignment between teeth 21 and 11.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/06948ab734161e511bcca0e0.jpeg"},{"id":93013261,"identity":"d211285d-0196-4382-9ec4-47e56b170660","added_by":"auto","created_at":"2025-10-08 07:24:33","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":206861,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographic and intraoral evaluation at 4-month follow-up.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Coronal intraoral view demonstrating stable peri-implant soft tissues; (B) Occlusal intraoral view; (C) Coronal intraoral view showing stable soft tissue contour around the labial aspect of the implant with no significant changes compared to preoperative conditions; (D) CBCT image confirming stable marginal bone levels around the implant at site 21; (E) CBCT image confirming stable marginal bone levels around the implant at site 22.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/d49c407a5fdc909c10af1b73.jpeg"},{"id":93013263,"identity":"6980e943-808f-4b6e-a1e5-b41a2b2db19f","added_by":"auto","created_at":"2025-10-08 07:24:33","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":209030,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographic and intraoral evaluation at 8-year follow-up.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Intraoral coronal view at 8-year follow-up showing significant infraocclusion of the implant restoration with noticeable gaps between the restoration and adjacent teeth; (B) Intraoral occlusal view demonstrating mesiodistal marginal gaps between the implant restoration and adjacent teeth; (C) Intraoral coronal view revealing an expanded area of peri-implant soft tissue hyperplasia on the labial aspect; (D) CBCT sagittal section confirming stable bone levels around the 21 implant; (E) CBCT sagittal section demonstrating maintained bone stability around the 22 implant.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/44b36783f9a05c24be9c6e25.jpeg"},{"id":93011107,"identity":"508a2636-4c53-49da-bb12-763eecc51abb","added_by":"auto","created_at":"2025-10-08 07:16:33","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":164700,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThree-dimensional reconstruction comparing skeletal changes between 2016 (red) and 2024 (pink).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Superimposition of 2016 CBCT (red) and 2024 models (pink), with the implant-supported prosthesis model in purple; (B) Sagittal comparison of natural tooth 11, showing an incisal edge positional discrepancy of approximately 0.36 mm; (C) Axial comparison of tooth 11, revealing a mesial positional discrepancy of 0.54 mm; (D) Sagittal comparison of tooth 23, demonstrating incisal edge and labial positional discrepancies of 0.54 mm and 0.51 mm, respectively; (E) Axial comparison of tooth 23, showing a mesial positional discrepancy of 0.56 mm.\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/4028d93f1bcd4fe822435113.jpeg"},{"id":93013262,"identity":"cb512926-c729-412f-96b4-5c13be72f696","added_by":"auto","created_at":"2025-10-08 07:24:33","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":215905,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical status post-crown removal and provisional restoration design at 8-year follow-up.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Coronal view of the intraoral condition post-crown removal; (B) Occlusal view post-crown removal, demonstrating stable peri-implant soft tissues; (C) Coronal view of the provisional restoration design, transitioning from two-unit to three-unit crown restoration due to increased mesiodistal space; (D) Occlusal view of the provisional crown restoration design.\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/e19174978368e48f19aa9d93.jpeg"},{"id":93013265,"identity":"fb1f9b04-89b3-4c35-9fd2-4a6d8b817757","added_by":"auto","created_at":"2025-10-08 07:24:33","extension":"jpeg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":227094,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoral outcomes of provisional restoration and definitive prosthesis.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(A) Coronal view of the provisional restoration; (B) Occlusal view of the provisional restoration demonstrating occlusal table design; (C) Coronal view of the abutments after provisional restoration removal; (D) Intraoral evaluation of the implant emergence profile at the transmucosal zone; (E) Extraoral view of the definitive prosthesis; (F) Laboratory cast showing abutment positioning for definitive restoration; (G) Coronal view of the definitive prosthesis in occlusion; (H) Occlusal view of the definitive prosthesis with functional cusp-fossa relationships; (I) Periapical radiograph confirming precise seating of the definitive prosthesis.\u003c/p\u003e","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/093f722560bd83fdb540ec00.jpeg"},{"id":95526164,"identity":"762ab6c8-0736-468e-a31f-cbea9b3dcece","added_by":"auto","created_at":"2025-11-10 10:06:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2357743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7559280/v1/7b1412cd-0770-490a-a94e-a934dedadc54.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Infraocclusion Following Implant-Supported Restoration in the Anterior Maxillary Region: An 8-Year Follow-Up Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eThe anterior maxillary teeth play a crucial role in aesthetics, speech, and chewing function. Losing these teeth can significantly impair oral function and negatively affect a patient's physical and psychological well-being. As a result, implant-supported crowns and bridges have become popular and preferred solutions for replacing anterior teeth due to their reliable outcomes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The long-term success of a dental implant relies on the stability of both the surrounding bone and soft tissue, as well as ongoing maxillofacial growth, which can influence the aesthetic relationship between implants and adjacent natural teeth. Natural teeth are surrounded by periodontal ligaments, which allow them to adapt to changes in jaw growth. In contrast, osseointegrated implants do not have this ability. As a result, there is an increased risk of infraocclusion, a condition in which the restorations gradually appear shorter than the adjacent teeth. Consequently, current protocols recommend delaying implant placement until maxillofacial growth is complete, which is typically around 18 years of age or older.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eResearch demonstrates that between 40% and 100% of adult patients exhibit measurable infraocclusion during long-term follow-up assessments, challenging the belief that adult maxillofacial growth is minimal.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This report presents a clinically significant case of infraocclusion involving an anterior maxillary implant-supported crown after 8 years of restoration. The case is also accompanied by localized gingival hyperplasia. To assess positional changes in the surrounding teeth, digital three-dimensional reconstruction was employed. Additionally, a literature review is included to summarize the incidence, clinical characteristics, and management strategies for this complication, offering evidence-based insights for clinical practice.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 37-year-old female presented to the Department of Implantology, Shanghai Tongji Stomatological Hospital (Affiliated Stomatological Hospital of Tongji University) in June 2015 with a chief complaint of missing left anterior maxillary teeth for over a decade. Her medical history revealed extraction of retained deciduous teeth (21 and 22) over ten years prior, followed by removable partial denture rehabilitation. She sought implant-supported prostheses due to dissatisfaction with the existing restoration. The patient denied systemic diseases, long-term medication use, or habits such as smoking or alcohol consumption but reported a penicillin allergy.\u003c/p\u003e\u003cp\u003eClinical examination demonstrated symmetry with midline alignment of facial and dental arches, and no tenderness in the temporomandibular joint regions. The intraoral assessment revealed missing teeth 21 and 22, with a larger edentulous span on the left side compared to the contralateral dentition. A firm, non-tender gingival hyperplasia (20 \u0026times; 8 mm) was observed on the labial aspect of the edentulous area, confined to the labial mucosa without lingual involvement. Normal overjet and overbite were noted, and oral hygiene was satisfactory. Cone-beam computed tomography (CBCT) revealed available bone dimensions of 21 mm in height and 7.4 mm in width of 21, and 18.25 mm in height and 5.13 mm in width of 22. Based on clinical and radiographic findings, the patient was diagnosed with partial edentulism (21, 22) and suspected gingival hyperplasia. The proposed treatment plan included implant-supported, fixed, or removable prosthetic options for 21 and 22, with a recommendation for two implants and simultaneous bone augmentation if implants were selected. Additionally, a periodontal consultation was advised to evaluate the gingival hyperplasia (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Occlusal view of the edentulous area in the upper left anterior region; (B) Coronal view of the edentulous area in the upper left anterior region; (C) Panoramic radiograph demonstrating the absence of teeth 21 and 22; (D)CBCT of teeth 21 and 22 showing labial bone resorption. The available bone widths at 1 mm, 3 mm, and 5 mm below the alveolar crest for tooth 21 were 3.88 mm, 6.68 mm, and 5.36 mm, respectively; corresponding measurements for tooth 22 were 1.88 mm, 2.87 mm, and 6.14 mm; (E) CBCT axial view revealing significant labial concavities in the 21 and 22 regions.\u003c/p\u003e\u003cp\u003eThe patient declined immediate intervention for gingival hyperplasia. Following a comprehensive discussion of the implant treatment protocol and associated financial considerations, the patient proceeded with implant-supported restoration combined with simultaneous bone augmentation.\u003c/p\u003e\u003cp\u003eThe patient underwent implant surgery on September 14, 2015. After obtaining informed consent, the patient was placed in a supine position. The surgical area was disinfected and draped. ​Local infiltration anesthesia was administered in the 12\u0026ndash;24 region. A ​linear incision with mesial and distal releasing incisions fully exposed the bone surface. ​Stepwise drilling was performed, and a 3.5\u0026times;11 mm implant (Ankylos, Germany) was placed with ​primary stability of approximately 20 N\u0026middot;cm. ​Bone grafting was simultaneously performed by creating nutrient holes on the labial side and placing 0.25 g of Bio-Oss bone powder (Geistlich, Switzerland), followed by covering with a 13\u0026times;25 mm\u0026sup2; Bio-Gide absorbable collagen membrane (Geistlich, Switzerland). The labial flap was released for tension-free closure, and a ​submerged suture was applied. Postoperative CBCT confirmed ​optimal implant positioning. Sutures were removed 14 days postoperatively, with ​soft tissue healing satisfactory and the healing cap remaining unexposed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Postoperative panoramic radiograph after implant placement; (B) Postoperative CBCT of tooth 21 demonstrating optimal implant positioning with retained labial bone graft material; (C) Postoperative CBCT of tooth 22 confirming proper implant placement and stable labial bone graft material; (D) Occlusal view at 14-day suture removal, showing well-healed surgical sites and non-exposed healing abutments; (E) Coronal view 14 days postoperatively, revealing intact soft tissue architecture.\u003c/p\u003e\u003cp\u003eAt the ​6-month postoperative follow-up, ​osseointegration of the implant was confirmed. A ​splinted crown restoration was subsequently performed. The patient opted for a ​zirconia abutment combined with an all-ceramic crown. After prosthesis delivery, the restoration achieved satisfactory functional and aesthetic outcomes. ​Periapical radiographs and CBCT confirmed proper seating of the prosthesis, stable marginal bone levels, and complete tightening of the abutment screw. The crown was ​resin-bonded to the abutment (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) CBCT demonstrates good osseointegration of the 21 implant with intact labial bone plate; (B) CBCT shows successful osseointegration of the 22 implant; (C) Intraoral coronal view after abutment placement; (D) Periapical radiograph confirms proper seating of the abutment following definitive crown delivery; (E) Intraoral coronal view after restoration, demonstrating midline alignment of the maxillary arch at the midline of tooth 41 crown, with incisal edge alignment between teeth 21 and 11.\u003c/p\u003e\u003cp\u003eFour months after prosthesis delivery, the patient returned for evaluation. ​Clinical examination revealed stable peri-implant soft tissues without signs of gingival hyperplasia. ​CBCT demonstrated maintained marginal bone stability around the implant, with ​no pathological bone resorption observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Coronal intraoral view demonstrating stable peri-implant soft tissues; (B) Occlusal intraoral view; (C) Coronal intraoral view showing stable soft tissue contour around the labial aspect of the implant with no significant changes compared to preoperative conditions; (D) CBCT image confirming stable marginal bone levels around the implant at site 21; (E) CBCT image confirming stable marginal bone levels around the implant at site 22.\u003c/p\u003e\u003cp\u003eThe patient returned on April 29, 2024, reporting a noticeable gap between the implant-supported prosthesis and adjacent teeth and significant incisal shortening of the restoration. Clinical examination revealed stable fixation of the 21 and 22 implant crowns with clear percussion sounds. Labial gingival hyperplasia persisted, characterized by ​firm, pink tissue. CBCT imaging demonstrated maintained peri-implant bone stability, with no evidence of marginal bone loss (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Intraoral coronal view at 8-year follow-up showing significant infraocclusion of the implant restoration with noticeable gaps between the restoration and adjacent teeth; (B) Intraoral occlusal view demonstrating mesiodistal marginal gaps between the implant restoration and adjacent teeth; (C) Intraoral coronal view revealing an expanded area of peri-implant soft tissue hyperplasia on the labial aspect; (D) CBCT sagittal section confirming stable bone levels around the 21 implant; (E) CBCT sagittal section demonstrating maintained bone stability around the 22 implant.\u003c/p\u003e\u003cp\u003eCBCT data analysis revealed significant skeletal changes between the 2016 post-restoration and 2024 follow-up periods. Given the osseointegrated nature of the implant, which maintains a fixed position relative to the jawbone, Mimics 21.0 software was employed to reconstruct and align the 2016 and 2024 skeletal models. After cropping artifact-prone regions and registering the datasets using the implant as a reference, vertical and mesiodistal positional discrepancies (0.36\u0026ndash;0.56 mm) were observed: Tooth 11 exhibited labial, distal, and coronal displacement, while tooth 23 shifted distally, palatally, and apically (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Superimposition of 2016 CBCT (red) and 2024 models (pink), with the implant-supported prosthesis model in purple; (B) Sagittal comparison of natural tooth 11, showing an incisal edge positional discrepancy of approximately 0.36 mm; (C) Axial comparison of tooth 11, revealing a mesial positional discrepancy of 0.54 mm; (D) Sagittal comparison of tooth 23, demonstrating incisal edge and labial positional discrepancies of 0.54 mm and 0.51 mm, respectively; (E) Axial comparison of tooth 23, showing a mesial positional discrepancy of 0.56 mm.\u003c/p\u003e\u003cp\u003eIntraoral examination identified localized progression of peri-implant soft tissue hyperplasia compared to baseline. Histopathological analysis of a biopsy sample confirmed gingival hyperplasia with focal papillary proliferation. The virtual prosthetic simulation revealed increased edentulous span dimensions due to skeletal changes, prompting a revised treatment plan to replace the original two-unit restoration with a three-unit splinted crown to address the enlarged mesiodistal space (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Coronal view of the intraoral condition post-crown removal; (B) Occlusal view post-crown removal, demonstrating stable peri-implant soft tissues; (C) Coronal view of the provisional restoration design, transitioning from two-unit to three-unit crown restoration due to increased mesiodistal space; (D) Occlusal view of the provisional crown restoration design.\u003c/p\u003e\u003cp\u003eThe patient declined the option for soft tissue recontouring but consented to placing a three-unit splinted crown. Following a three-month trial period with a provisional restoration, the patient reported satisfaction with the morphology and contour of the crown. Observations indicated favorable recontouring of the peri-implant soft tissues around the provisional restoration. A digital intraoral scan effectively captured the transmucosal emergence profile, facilitating the design of an optimal emergence contour. The abutment screw was tightened according to the manufacturer\u0026rsquo;s specified torque. Subsequently, Polytetrafluoroethylene (PTFE) tape was employed to isolate the screw channel, followed by the application of light-cured resin for sealing (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). The patient conveyed high levels of satisfaction regarding both the functional and aesthetic outcomes, with no complications noted during the follow-up period.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e(A) Coronal view of the provisional restoration; (B) Occlusal view of the provisional restoration demonstrating occlusal table design; (C) Coronal view of the abutments after provisional restoration removal; (D) Intraoral evaluation of the implant emergence profile at the transmucosal zone; (E) Extraoral view of the definitive prosthesis; (F) Laboratory cast showing abutment positioning for definitive restoration; (G) Coronal view of the definitive prosthesis in occlusion; (H) Occlusal view of the definitive prosthesis with functional cusp-fossa relationships; (I) Periapical radiograph confirming precise seating of the definitive prosthesis.\u003c/p\u003e"},{"header":"Discussion and conclusions","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003eOver the past 35 years, implant-supported prostheses have become widely adopted for partial and complete edentulism, with increasing attention to long-term complications.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Current research primarily focuses on peri-implantitis\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, occlusal overload\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, and marginal bone resorption\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, while the relationship between implants and adult continuous craniofacial growth remains poorly understood.\u003c/p\u003e\u003cp\u003eLifelong maxillofacial changes are attributed to multifactorial mechanisms.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Maxillary growth is closely linked to cranial structure, gender, and facial type, while mandibular growth correlates with overall physical development.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Generally, females experience peak craniofacial growth between ages 9\u0026ndash;14, and males between 11\u0026ndash;17, with transverse development completing first, followed by sagittal and vertical planes.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Unlike natural teeth, osseointegrated implants lack periodontal ligaments and are directly anchored to bone, preventing continuous eruption or passive adaptation to skeletal growth\u0026mdash;a key reason for avoiding implants in adolescents.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Nevertheless, craniofacial changes persist into adulthood, potentially leading to biological and aesthetic complications that compromise long-term implant outcomes.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e This phenomenon, termed infraocclusion, occurs when ongoing jaw growth causes a vertical discrepancy between implants and adjacent teeth.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eResearch on infraocclusion reveals vertical discrepancies in 40%\u0026ndash;100% of implant patients. In anterior regions, the average discrepancy is 0.1 mm in the first year, 0.4 mm in the fifth year, and 0.5 mm in the eighth year, while premolar regions show an average of 0.2 mm.\u003csup\u003e16\u003c/sup\u003e Beyond vertical changes, adjacent natural teeth often exhibit labiolingual inclination. Proximal contact loss between implants and natural teeth, another long-term complication of persistent craniofacial growth, occurs in 34%\u0026ndash;65% of patients within 3\u0026ndash;8 months post-restoration.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e While some studies suggest a higher incidence in females, others report no significant gender difference.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e In this case, the patient\u0026rsquo;s adjacent tooth discrepancies (0.36\u0026ndash;0.56 mm) align with the reported data.\u003c/p\u003e\u003cp\u003eNotably, 14\u0026ndash;20 years post-implantation, most patients remain satisfied with anterior implant aesthetics, with only 18.2% seeking corrective interventions\u0026mdash;predominantly females (22.2%).\u003csup\u003e19\u003c/sup\u003e This may reflect greater aesthetic awareness among female patients, who are more likely to detect dental changes and seek treatment. In this case, the patient\u0026mdash;a 38-year-old female at implantation\u0026mdash;developed significant infraocclusion and proximal gaps after 8 years due to ongoing eruption of natural teeth and jaw growth, leading to compromised aesthetics and a strong desire for corrective intervention.\u003c/p\u003e\u003cp\u003eCurrent clinical consensus suggests regular annual follow-up remains the primary management strategy for malocclusion-induced dental misalignment post-implant restoration. When complications such as food impaction or interdental spacing arise, clinicians often choose to replace the implant crown and perform adjacent tooth restorations to reestablish proper contacts. In this case, the patient ultimately underwent prosthetic revision, transitioning from two-unit to three-unit splinted crowns to close interdental gaps and restore proper anterior overjet and overbite relationships. (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNotably, significant labial soft tissue hyperplasia was observed in the edentulous zone. For clinicians, this poses a critical challenge to pink-and-white esthetics in the anterior region, distinct from but equally urgent as infraocclusion. However, the patient persistently declined soft tissue contouring. This decision may relate to her medium smile line, minimizing perceived aesthetic impact. While current literature lacks evidence directly linking maxillofacial growth to gingival hyperplasia, studies confirm that autologous soft tissue grafts (e.g., connective tissue grafts, CTG, free gingival grafts, FGF) demonstrate sustained increases in thickness and width over time.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Whether this soft tissue expansion relates to skeletal growth or gingival phenotype requires further investigation.\u003c/p\u003e\u003cp\u003eThis case highlights infraocclusion 8 years after anterior maxillary implant restoration, emphasizing the long-term impact of ongoing alveolar growth on esthetic outcomes. Clinicians should consider infraocclusion, especially in young female patients, during long-term prosthetic planning. Furthermore, future protocols should incorporate dynamic interactions between bone and soft tissue into risk assessments and patient counseling.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFull name\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eabbreviations\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCone Beam Computed Tomography\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCBCT\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePolytetrafluoroethylene\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePTFE\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003econnective tissue grafts\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCTG\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003efree gingival grafts\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFGF\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThis study was approved by the ​​Ethics Committee of the Affiliated Stomatology Hospital of Tongji University​​ (Approval No. 2023-DW-13) and conducted in accordance with the ​​Ethical Review Measures for Biomedical Research Involving Humans and the ​​Declaration of Helsinki​​. Written informed consent was obtained from the patient for participation of this case report and accompanying images. Clinical trial number: not applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was financially supported by the National Key Research and Development Program of China (Grant No. 2021YFC2400400) and the National Natural Science Foundation of China (Grant No. 81400485). Jingshi Lei acknowledges the funding support from Shanghai Municipal Science and Technology Innovation Action Plan (Qimingxing Cultivation Program - Yangfan Special Project) (Grant No. 23YF1450600), Medical New Technology Research and Translational Seed Program (General Project) of the Shanghai Municipal Health Commission (Grant No. 2024ZZ2069).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJingshi Lei: Conceptualization, investigation, supervision, resources, original draft. Sainan Li: Methodology, software, data curation, formal analysis. Piaopiao Qiu: methodology, software, data curation, review and editing. Zhen Fan: Conceptualization, methodology, data curation, project administration, review and editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGerritsen AE, Allen PF, Witter DJ, et al. Tooth loss and oral health-related quality of life: a systematic review and meta-analysis. Health Qual Life Outcomes. 2010;8:126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1477-7525-8-126\u003c/span\u003e\u003cspan address=\"10.1186/1477-7525-8-126\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapaspyridakos P, Chen C-J, Singh M, et al. Success criteria in implant dentistry: a systematic review. 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Clin Oral Implants Res. 2021;32:1328\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/clr.13833\u003c/span\u003e\u003cspan address=\"10.1111/clr.13833\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlsulaimani FF, Batwa W. Incisors\u0026rsquo; proportions in smile esthetics. J Orthod Sci. 2013;2:109\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2278-0203.119685\u003c/span\u003e\u003cspan address=\"10.4103/2278-0203.119685\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBarootchi S, Tavelli L, Zucchelli G, et al. Gingival phenotype modification therapies on natural teeth: A network meta-analysis. J Periodontol. 2020;91:1386\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/JPER.19-0715\u003c/span\u003e\u003cspan address=\"10.1002/JPER.19-0715\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esthetic zone, Infraocclusion, ​Implant restoration, Gingival hyperplasia​, Case report","lastPublishedDoi":"10.21203/rs.3.rs-7559280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7559280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eInfraocclusion following anterior maxillary implant restoration is a complication compromising long-term aesthetic and functional outcomes. Although previous reports have described infraocclusion, cases with significant dental arch discrepancies severely impacting occlusal function and aesthetics remain rare.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eThis study reports a case of severe infraocclusion occurring eight years after implant placement in the left maxillary anterior region, analyzing jawbone remodeling patterns and peri-implant soft tissue changes to elucidate mechanisms and optimize therapeutic strategies. A patient presenting with progressive infraocclusion and gingival hyperplasia eight years post-restoration underwent comprehensive evaluation, including Cone Beam Computed Tomography(CBCT) imaging, 3D superimposition of pre- and post-treatment jawbone models (Mimics 21.0 software), and histopathological analysis of soft tissue biopsies. The comparative literature review was conducted to establish diagnostic criteria and evidence-based interventions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePersistent vertical and mesiodistal jawbone remodeling contributed to implant infraocclusion, while soft tissue hyperplasia exacerbated aesthetic compromise. Multidisciplinary management integrating 3D-guided prosthetic adjustments and soft tissue recontouring demonstrated clinical efficacy. This case underscores the importance of long-term monitoring and adaptive treatment planning to address dynamic craniofacial changes in anterior maxillary implant rehabilitation.\u003c/p\u003e","manuscriptTitle":"Infraocclusion Following Implant-Supported Restoration in the Anterior Maxillary Region: An 8-Year Follow-Up Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 07:16:28","doi":"10.21203/rs.3.rs-7559280/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"04c757d0-6842-4b92-937d-32cb6df559f1","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-07T10:54:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 07:16:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7559280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7559280","identity":"rs-7559280","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}