Missing upper right central with bone resorption: thoughts?

CBCT for width, canine to canine implant supported bridge with grafting and an essix provisional or mini implant provisional. If you do a single implant asking for trouble. Get him to stop smoking, deal breaker on a risky case.

Advanced vertical bone loss, smoker, and periodontal disease in other sites....3 set ups for failure. If you let the patient dictate treatment then you are just doing this case for the money.

I agree. The smoking is a deal breaker. I don't feel you can simply just treat the anterior region. What is the treatment plan for the perio and posterior teeth. If he stops smoking and if you are settling on canine supported prosthesis for an interim treatment then prepare patient that these implants could be used for the basis of a hybrid when his posterior segments fail. Now might be the time to think implanted supported FU or hybrid with 4 implants.

Even the adjacent teeth have bone loss... even if the patient agrees for a bridge... even then it is a poor case for a bridge... for that matter poor for any type of prosthesis.Give him a 1 tooth flipper and leave him alone!

Clearly not an implant case at this stage. Resin bonded bridge declined? odd response from patient but consider referring your case for a second opinion to trusted colleague who can present his conventional options with some authority and return partient to you for the bonded unit - More hygienic than any flipper and better for patient in the longer term. Patient has some life changes to make - or not! up to him but this is not one to be led by patient demands. The more teeth you extract in order to solve the case I feel that it is a bigger hole you are digging.

You are the doctor. Take photos, make models and present the whole package to him after you figure out what the whole package is. This one may keep you up at night. Good luck.

Tell the patient he has to stop smoking. fat chance he will comply. Tell him it's your way or the highway. It's his problem and he owns it. Don't let a patient dictate treatment, don't let them paint you in a corner. A Maryland bridge is a perfect option. Looks like #3 is in trouble.