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CASE STUDY 9 Fig. 1: The scarred vestibulum results from the multiple prior operations elsewhere. Fig. 3: At the time of the initial examination the neighboring teeth were vital, clinically stable and free of inflammation. Apart from the tissue deficit, the X-ray showed no irregularities. Fig. 2: The occlusal view shows the substantial loss of hard and soft tissue in region 21 and 22. considered unfavorable. In order to address this problem, several years ago Khoury and coworkers [7] described a new “shell technique”. Here the aim is to combine the excellent vitality of an iliac crest graft with the high resorption stability of a mandibular angle graft. For this purpose, a corticocancellous bone chip is harvested from the mandibular angle from which a thin, purely cortical “shell” is obtained. This is fixated with micro osteosynthesis screws, so that the outline of the area to be augmented is defined. The region augmented is then filled with the remaining bone component, which is particulated. This ensures rapid and safe bony fusion with outstanding vitality of the augmentation material, while the cortical shell protects the augmentation material from excessive resorption during the healing phase. The following article shows how a patient case with a complex hard and soft tissue problem was resolved predictably and with long-term stability in a multi-stage procedure. Case history and finding The 36-year-old female patient presented with the request for implantological rehabilitation of an interdental gap in region 21-22. She was a non-smoker, there was nothing of note in her case history. Concerning the special anamnesis, the patient stated that her teeth 21, 22 had been treated with root fillings following a front tooth trauma in her childhood. Over the years, recurrent problems had arisen with pain, swelling and fistulization. As a result, several surgical treatments of the teeth had been conducted elsewhere, which only ever led to relief of symptoms for a limited period. Finally the teeth were extracted elsewhere and an interim prosthesis was placed. At the time the patient presented to us for the first time, the intraoral finding showed a considerable loss of hard and soft tissue with a scarred vestibulum due to the multiple prior operations. (Figs. 1 and 2) .The neighboring teeth had composite restorations and were vital, clinically stable and free of inflammation. The further intraoral and X-ray findings were inconspicuous (Fig. 3) . Planning Even complex cases are less daunting if a precise evaluation of the overall situation is initially performed. A detailed analysis was presented by Dawson et al. [4] with the SAC (straight forward – advanced – complex) classification. He divided the risk and the anticipated treatment se- verity into general, esthetic, surgical and restorative influencing factors and presents an overall evaluation based on these criteria. Accordingly, the following questions were raised before commenc- ing therapy: How is the anticipated hard and soft tissue availability in the region of the planned implants? What number of implants and position is expedient? Especially against the backdrop of multi- ple prior operations, what is the healing potential with regard to perfusion, scar- ring in the soft tissue etc.? How is the gingiva type to be evaluated? Where is the patient's laugh line?