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10 CASE STUDY How high are the patient's individual es- thetic expectations? The analysis in the case under investigation revealed: • a relatively thin, high scalloped gingiva type • considerable hard and soft tissue deficit • compromised perfusion and difficult soft tissue management due to the presence of scarring of the vestibulum • a gap between the central and lateral incisors (esthetically the most difficult implantological situation in the entire jaw) For this reason, according to the SAC classification, this case has to be allocated to the most difficult: type C. On the basis of this analysis, the following procedure was chosen: 1. Autologous augmentation with a cor- ticocancellous bone chip from the man- dibular angle using a shell technique de- scribed by Khoury and coworkers [7], at the same time a subepithelial connective tissue graft from the palate to improve the soft tissue situation 2. After a healing time of three months, the insertion of two CAMLOG ® SCREW- LINE implants and possibly further soft tissues augmentation to obtain sufficient volume for prosthetic shaping of the soft tissue 3. Exposure of the implant after three months 4. After a healing time of four weeks, commencement of the prosthetic phase with a long-term temporary for succes- sive shaping of the soft tissue 5. After a soft tissue shaping and matu- ration phase lasting six months in total, transfer of the situation achieved to the final prosthetic Pre-prosthetic phase The shell technique introduced by Khoury [7] was used to augment the defect in the anterior alveolar process. After form- ing a mucoperiosteal flap without re- course to releasing incisions in the visible region and removal of all granulation tissue, the alveolar process was shown to be almost fully destroyed in the trans- versal direction. In addition, a defect tun- neled palatinal apical (Figs. 4 and 5) was apparent in region 22 was most likely to be interpreted as a residual cyst. A corti- cocancellous chip was taken for augmen- tation from the right mandibular angle. Using a diamond cutting disc and cool- ing with physiological saline solution, this was cut into a purely cortical shell with a thickness of around 2 millimeters and a spongy remainder. The cortical shell was fixated with two osteosynthesis screws. The remaining space was filled out fully in three dimensions with the particulate, spongy remainder of the augmentation material (Figs. 6 and 7) . Augmenta- tion of the soft tissue with a subepithe- lial connective tissue graft from the pal- ate followed, and then the tension-free, multi-layer suture. A conscious decision was made not to use bone replacement material or a membrane, so only purely autologous augmentation technique was applied. Fig. 4: On exposure, the almost fully destroyed alveolar process is apparent. Fig. 10: The implant axes in the occlusal view. Fig. 5: A defect tunneled palatinal apical in region 22 was interpreted as a residual cyst. Fig. 11: As a result of the connective tissue graft, the soft tissue had sufficient volume and stable keratinized gingiva. Fig. 6: A corticocancellous bone chip from the right mandibular angle was split and fixated using two micro osteosynthesis screws. Fig. 12: After opening, firstly “bottlenecks” and after a week cylindrical healing caps were inserted for shaping the soft tissue.