Welcome to the ITI Academy Learning Module "Simultaneous Contour Augmentation Using GBR" by Daniel Buser, Stephen Chen, and Vivianne Chappuis.

The single tooth replacement with an implant-supported crown is a frequent indication for implant therapy. In the anterior maxilla, not only does the prosthetic replacement need to re-establish function, it also needs to satisfy esthetic expectations. To achieve optimal esthetic outcomes, the implant prosthesis must mimic the adjacent natural teeth in color and shape. In addition, the peri-implant soft tissues on the facial aspect must appear similar to the gingivae of the adjacent teeth in volume, contour, color, and texture.

When a tooth is extracted, healing in the early stages is characterized by healing of the soft tissue over the socket and bone regeneration within the socket. At the same time, resorption of the bone walls of the socket takes place, predominantly on the facial side. This results in loss of facial volume and contour of the ridge and loss of facial soft tissue support. The effect of these changes may be seen in implants that have been placed without sufficient grafting on the facial aspect. In this clinical case of a maxillary left central incisor single-tooth implant prosthesis, the facial soft tissues appear to be thin and darker in color than that of the contralateral central incisor. The change in color and texture of the soft tissues surrounding the implant prosthesis has occurred because of the resorption of the alveolar bone from the facial aspect. This resorption has caused a concavity of the ridge in the critical cervical region of the prosthesis. This resorption and loss of facial contour of the alveolar ridge is clearly seen on the occlusal view of the implant.

For an optimal functional and esthetic outcome, it is therefore necessary to compensate for bone resorption by reconstructing the facial bone. Doing so creates support for the facial soft tissues and restores and maintains alveolar ridge contour. This module will describe the clinical technique of guided bone regeneration for simultaneous contour augmentation when dental implants are placed in esthetic sites in the early stages of healing after tooth extraction, in other words, in Type 2 early placement with soft tissue healing and Type 3 early placement with partial bone healing. Whilst GBR can be performed in conjunction with any implant placement protocol it is particularly indicated in connection with early implant placement. More information on early implant placement including its advantages can be found in the ITI Academy Learning Module "Timing of Implant Placement after Tooth Extraction".

After completing this ITI Academy Learning Module, you should be able to explain the rationale for contour augmentation using guided bone regeneration or GBR; list the materials used for contour augmentation in esthetic sites; describe the surgical steps and considerations that precede simultaneous augmentation; and describe the treatment concept and surgical steps for simultaneous contour augmentation.

Studies have shown that at the midfacial region of an implant prosthesis, there is a suprabony soft tissue zone of 3 to 4 mm, also referred to as the "biologic width." The crest of the bone in the midfacial region is critical in supporting the soft tissues. If the soft tissues are 4 mm or more in height due to either a deep implant placement or resorption of the facial bone, then the risk of facial soft tissue recession increases over time. It is therefore essential in esthetic areas to reconstruct the facial bone to maintain the biologic width.

Recently, there has been a growing interest in the relationship between the presence of facial bone on an implant and long-term stability of the facial soft tissues. In three recent studies on immediate implants, 35 to 55% of sites did not have a facial bone wall that could be detected using cone beam CT imaging despite bone grafting at the time of implant placement. These studies reported more soft tissue recession at sites without a detectable facial bone wall compared to sites where the facial bone wall could be seen. It should be noted that the facial bone wall needs to be at least 0.8 mm thick to be reliably detected on cone beam CT scans.

To summarize, the rationale for contour augmentation in esthetic areas is to reconstruct a thick bone wall over the facial aspect of an implant to maintain bony support for soft tissues, thereby preventing mucosal recession. This is accomplished by using a bone graft substitute that remains volumetrically stable over time. This rationale is demonstrated in this clinical case. Guided bone regeneration has been performed to repair the defect over the facial aspect of the implant. The site has been grafted, and the graft has been protected with a barrier membrane. The final implant prosthesis replacing the upper left central incisor is shown from the occlusal aspect to illustrate how the contour of the ridge has been reconstructed. The accompanying cone beam CT shows the presence of a thick reconstructed facial bone wall with the bone crest located coronal to the junction between the implant shoulder and abutment. The soft tissue margins are visible, showing that a biologic width of approximately 3 mm has been maintained.

In routine cases, connective tissue grafting may not be necessary for long-term stability of the facial soft tissues and a favorable esthetic outcome following contour augmentation at the time of early implant placement. In 2015 Chappuis and co-workers reported on a cone beam CT study looking at post-extraction single-tooth sites. They observed a spontaneous fivefold soft tissue thickening in post-extraction sites with thin bone walls within an 8-week healing period, which resulted in a thick facial mucosa. A thick and well-vascularized mucosal flap is advantageous as it may reduce the need for adjunctive connective tissue grafting in conjunction with Type 2 early implant placement. In contrast, in patients with a thick facial bone wall, the facial soft tissue thickness remained unchanged.

The hypothesis is that the rapidly resorbed thin facial bone wall facilitates the ingrowth of facial soft tissue due to the high proliferation rate of the soft tissue cells. The soft tissue cells therefore occupy the majority of the available space in the extraction socket defect and thus promote spontaneous thickening of the soft tissue. In contrast, a thick bone wall represents a barrier that allows the extraction alveolus to be a self-contained bony defect. This morphology favors the ingrowth of cells from the bony socket walls and surrounding bone marrow spaces, thus only allowing for crestal soft tissue ingrowth due to the minimal bone resorption on the facial aspect of the extraction socket.

Rationale for Contour Augmentation Using GBR, Key Learning Points: Studies show that there is more soft tissue recession at sites with no detectable facial bone. In esthetic areas it is essential to reconstruct stable, thick crestal bone on the facial aspect of an implant to support the soft tissues and to re-establish or maintain the biologic width. Long-term stability of the reconstructed area requires a bone substitute that has a low substitution rate providing long-term volumetric stability. In routine cases, connective tissue grafting may not be necessary for soft tissue stability because spontaneous facial soft tissue thickening in post-extraction sites with thin walls results in thick, well-vascularized flaps.

When contour augmentation is performed simultaneously with early implant placement in esthetic sites, long-term stability of the augmented area requires the combination of two grafting materials: autologous bone chips and a bone substitution material with a low substitution rate. The osteogenic potential of the autologous bone chips promotes and accelerates formation of new bone in the defect area and increases the amount of new bone built. The autologous bone chips should be harvested locally in the vicinity of the implantation site. Local harvesting of bone reduces donor site morbidity, is time efficient, and lowers overall treatment costs. The chips should then be applied in a way that covers the exposed implant surface and fills the bony defect over the facial aspect of the implant.

Autologous bone chips have outstanding osteogenic potential because they contain numerous non-collagenous proteins and growth factors that promote the formation of new bone, such as osteocalcin, calcitonin, osteopoetin, sialoproteins, bone morphogentic proteins, transforming growth factor beta, insulin-like growth factor, platelet-derived growth factor, and fibroblast growth factor. Furthermore, recent research suggests that the osteocytes control and regulate bone formation, and that the osteocytes contained in the bone chips seem to have a positive effect on the early stages of wound healing.

The particle size and thus the osteogenic potential of autologous bone grafts depend to a great extent on the harvesting technique used. Therefore, care must be taken not to impede their osteogenic potential through a non-ideal harvesting technique. A bone scraper should be used to obtain a favorable particle size. Miron and co-workers have shown that bone chips harvested with a bone scraper contain significantly higher numbers of live cells compared to bone chips harvested with other devices such as bone traps or piezosurgical instruments. Freshly harvested bone chips show paracrine properties in that they release a multitude of molecules, including growth factors and non-collagenous proteins. If the bone chips are stored in a sterile dish directly after harvesting, mixed with some blood collected from the harvesting site and the same amount of Ringer's solution and then left alone for 15 to 20 minutes, these growth factors and non-collagenous proteins are released into the surrounding liquid, thus creating a so-called "bone-conditioned medium" or BCM for short. Among other proteins, TGF-β1 and BMP-2, which accelerate the formation of new bone, are found in the BCM.

The second material used for contour augmentation is a bone substitute material with a low substitution rate such as xenogeneic deproteinized bovine bone mineral particles or DBBM. The bone substitute material is used to cover the autologous bone chips to optimize the bone volume and contour of the alveolar crest, resulting in a so-called two-layer composite graft. At the same time, the DBBM particles serve as a scaffold for bone ingrowth due to their osteoconductive properties. The particles also support the resorbable collagen membrane covering the augmentation site so that it does not collapse during the first weeks following the procedure. The crest should be overcontoured to optimize the volume and contour of the facial aspect of the alveolar crest. This step helps to achieve esthetic peri-implant tissues and facial ridge contour. Due to its low substitution rate, the bone substitute material stabilizes and thus maintains the augmented volume and contour over the long term.

The augmented site is then covered by a temporary, mechanical barrier in the form of a resorbable collagen membrane. The membrane serves as a barrier that excludes rapidly proliferating epithelial cells and connective tissue fibroblasts from the augmentation site, thus allowing new bone formation. It also keeps the particulate graft material from dislocating.

Ideally, a non-crosslinked resorbable collagen membrane should be used because this type of membrane offers several advantages. It is easy to handle and does not require any re-entry surgery. Furthermore, according to von Arx and Buser the risk of complications with these membranes is low in the case of a soft-tissue dehiscence. Applying two membrane layers, which is called the "double layer technique," increases the stability of the membrane.

Augmentation Materials, Key Learning Points: Autologous bone chips are harvested locally with a bone scraper and placed over the exposed implant surface; their osteogenic potential accelerates the formation of new bone. A bone substitute material with a low substitution rate such as deproteinized bovine bone mineral is applied over the autologous bone chips to optimize the ridge volume and facial contour of the alveolar crest. A non-crosslinked resorbable collagen membrane is applied over the augmentation site to keep the particles in place and to create a temporary barrier against the migration of connective tissue cells and fibroblasts into the augmented area.

The primary objective of implant therapy in the esthetic zone is to achieve a treatment outcome with long-term stability and optimal esthetics and function as well as high predictability and a low risk of complications. Guided bone regeneration for contour augmentation has been proven to achieve this objective. These clinical photographs document the successful esthetic and functional outcome in the maxillary left central incisor site at implant loading with the definitive prosthesis as well as the long-term stability of these outcomes at 3 and 5 years after loading. The treatment steps that precede the contour augmentation procedure will be described in the following slides.

The first step is to extract the tooth to be replaced with an implant in a low-trauma approach. Whenever possible, the extraction should be made without raising a flap to minimize trauma to the soft tissues and the underlying alveolar bone and to avoid scar formation. When compared to a full-thickness flap, flapless tooth extraction has been shown to reduce the amount of bone loss in the early healing phase of 4 to 8 weeks post-extraction. Therefore flapless extraction should always be considered in connection with an early implant loading protocol. This image shows the clinical situation before extraction of the maxillary right canine, which is to be replaced by an implant. A flapless extraction was performed, including thorough degranulation of the alveolus. A collagen plug was used to stabilize the coagulum. This image shows the healed extraction site at 8 weeks after the low-trauma extraction.

After the extraction site has healed for approximately 8 weeks, a full-thickness flap is prepared and raised in order to place the implant. The flap design should always be planned in advance and in a way that ensures optimal blood supply and wound closure. Generally, three different incision and flap designs can be applied for single-tooth gaps in the anterior maxilla. These are a trapezoidal flap design with papilla-sparing incisions, a trapezoidal flap design with sulcular incisions, and a triangular flap design with sulcular incisions. Today, a triangular flap is preferred over the trapezoidal flap designs.

Today, in the esthetic zone a triangular flap design is preferred over a trapezoidal flap design because it is recommended to make only one vertical incision. The vertical incision should be located outside the esthetic zone and distal to the canine or even the first premolar. A triangular flap design with one distal releasing incision provides sufficient access to the surgical site in single-tooth cases with increased vascularity when compared to a trapezoidal flap with two vertical releasing incisions.

Next, blood is collected from the surgical site with a sterile syringe and stored in a sterile dish. The autologous bone chips needed for the augmentation procedure are then harvested with a bone scraper. The chips can be taken from the nasal spine area or the facial bone surface near the canine fossa, as shown in the clinical image. The bone chips are placed in the sterile dish and soaked in the previously collected blood to create the bone-conditioned medium in which the DBBM particles will be soaked before they are applied at the augmentation site later on.

The next step is the preparation of the implant bed for a bone-level implant. Care must be taken to place the implant in the prosthetically driven, correct three-dimensional position. It is important that sufficient crest width is present at the planned implant site to allow for circumferential bone anchorage of the implant after bone healing. The defect morphology must also be such that it provides sufficient stability for the graft and the grafted site. The defect morphology must be such that it provides two bone walls to allow for the formation of bone and offers sufficient stability for the bone chips applied. Localized two-wall bony defects in which the exposed implant surface is within the bony envelope provide a favorable morphology for simultaneous augmentation with early implant placement. Regeneration of such defects is predictable and fast. One-wall bony defects are not suitable for simultaneous contour augmentation because they do not provide sufficient stability for the graft.

This decision tree illustrates the decision-making process for contour augmentation. Simultaneous contour augmentation can only be performed in a predictable manner where a favorable crest width is present that allows for correct three-dimensional, restoration-driven implant placement, along with a favorable defect morphology, which means a localized two-wall bony defect around the implant.

Implant placement in the correct three-dimensional position follows the concept of the "comfort" and "danger" zones established at the 3rd ITI Consensus Conference by Buser and coworkers in 2004. Mesiodistally, an interproximal distance of at least 1 to 1.5 millimeters must be ensured between the neck of the implant and the periodontal attachment of the neighboring teeth. The orofacial position of the implant shoulder should be located 1.5 to 2 millimeters palatal to the point of emergence of the future implant crown. In the coronoapical dimension the implant shoulder is positioned approximately 3 millimeters below the future mucosal margin. The correct implant angulation is also of utmost importance for the correct three-dimensional implant position. The implant axis should be located approximately 1 millimeter palatal to the future incisal edge, thus allowing for trans-occlusal screw retention of the prosthesis, with the screw emerging in the cingulum area.

After implant placement in the correct three-dimensional position, a healing cap is placed on the implant. Note the two-wall anatomy of the bony defect around the implant.

Preceding Surgical Considerations and Steps, Key Learning Points: The tooth to be replaced should be extracted with a low-trauma technique that avoids flap elevation if possible. Tooth extraction is followed by a healing period of 4 to 8 weeks. The preferred flap design for contour augmentation is a triangular flap with sulcular incisions and one vertical incision distal to the canine or first premolar. Autologous bone chips are harvested from the nasal spine or canine fossa and soaked in blood. The implant bed is prepared and the implant inserted in the prosthetically driven, correct three-dimensional position. Simultaneous contour augmentation can be utilized in two-wall bony defects in which the exposed implant surface is inside the bony envelope, offering successful outcomes with high predictability.

The surgical treatment concept behind guided bone regeneration for contour augmentation comprises four central elements. The first is the use of autologous bone chips to cover the exposed portion of the implant surface. This is followed by the application of an over-contoured layer of a hydroxyapatite-based bone substitution material with a low substitution rate on top of the autologous bone chips for facial contour augmentation. The low substitution rate of hydroxyapatite-based materials ensures stability of the augmented area over time. Third, the augmented site is covered with a non-crosslinked, resorbable collagen membrane applied in a double layer. The fourth central element is primary wound closure of the mucoperiosteal flap to ensure protection of the applied biomaterials and undisturbed healing of the augmented implantation site.

Subsequent to implant placement, the exposed implant surface is covered with the previously harvested, blood-soaked autologous bone chips. Care must be taken to apply the bone chips up to the rim of the healing cap. This results in a favorable future position of the marginal bone, that is, a facial bone wall with the bone crest located coronally to the junction between the implant shoulder and the abutment. Small bur holes can be drilled into the cortical bone surface if necessary before the bone chips are applied to open the marrow cavity and thus evoke slight bleeding.

The layer of autologous bone chips is then covered with a layer of bone substitute material with a low substitution rate such as deproteinized bovine bone mineral particles or DBBM. Soaking the DBBM particles in BCM – bone-conditioned medium - before application not only facilitates their handling and application but also allows for the blood's proteins and growth factors to be absorbed by the particles, a process that results in biologically activated DBBM particles. Care must be taken to apply enough material to overcontour the alveolar ridge. This ensures the reconstruction of a thick, long-term stable facial bone wall. Applying DBBM particles to the rim of the healing cap will ensure that the facial bone crest extends coronally to the junction between the implant shoulder and the abutment.

The augmented site is now covered with a non-crosslinked collagen membrane applied in a double layer. Application of the membrane in two layers increases the thickness and thus improves the stability of the membrane. In routine cases membrane fixation, for example with tacks, is not necessary.

The final step is primary wound closure. A releasing incision of the periosteum is made where necessary for tension-free primary wound closure. Primary wound closure is very important to ensure protected, uneventful healing of the augmented site. Care must be taken not to apply any pressure to the augmented site during wound closure to prevent dislocation of the augmentation material and thus a flattening of the augmented area. Interrupted single sutures with 5-0 non-resorbable monofilament suture material are used for the closure of the wound.

A healing time of approximately 8 weeks should be allowed before re-opening of the augmented site. A minimally invasive re-opening approach such as a punch incision around the healing cap should be chosen whenever possible, followed by loading of the implant with a provisional crown to initiate the peri-implant contouring process.

This digital animation video will present the Concept of Early Implant Placement with simultaneous Contour Augmentation that was developed in the late 1990's at the University of Bern, Switzerland. The surgical technique has been fine-tuned over the first 10 years of clinical application and is now routinely applied in daily practice. This 37-year-old female presented with a lateral incisor, which had to be extracted. The clinical situation represents an advanced difficulty level according to the SAC Classification of the ITI. The periapical radiograph shows the external root resorption at the lateral incisor. The extension of the root resorption is clearly visible in the CBCT. The coronal cut shows the bone lesion distally to the root and a sufficient crest width of more than 7 mm. The extraction is initiated with an intra-sulcular incision using a micro-blade. The gingival margin is carefully mobilized with a fine periosteal elevator. The extraction is carefully done with a rotational movement. The socket is debrided to remove the granulation tissue. Then, a collagen plug is applied for the stabilization of the coagulum. The socket is left to heal by secondary granulation. The removed tooth shows the area with the external resorption. During the 8 weeks of socket healing, keratinized mucosa spontaneously forms over the socket. Initially, there is a slight invagination of the mucosa at the crest. Then, a gradual flattening is observed on the mid-facial aspect of the extraction socket. However, the ridge contour does not change at the adjacent teeth within a 4- to 8-week healing period. This frontal view shows the resorption of the thin facial wall triggered by bundle bone resorption. This causes a crater-like defect in the middle of the socket. The sagittal view shows the facial bone resorption and the ingrowth of soft tissues into the alveolus leading to a spontaneous thickening of the soft tissues. This is biologically driven and is a clear clinical advantage for the future implant surgery. The coronal view shows the resorption of the facial bone wall and the spontaneous soft tissue thickening. Simultaneously, a flattening of the soft tissue contour takes place in the middle of the socket. 8 weeks post extraction, implant surgery is initiated with a sulcular incision at the adjacent central incisor and extended in the edentulous area in a slightly palatal position. The blade is inserted deep into the remaining socket along the inner palatal wall. The incision is continued through the sulcus of the adjacent lateral incisor, combined with a papilla base incision and a vertical releasing incision at the first premolar. The result is a triangular flap, which offers excellent vascularity and eliminates the risk of a vertical scar within the esthetic frame. The mucoperiosteal flap is now carefully elevated with a fine tissue elevator. In the extraction site, the soft tissue within the former extraction socket is mobilized as part of the buccal flap. This provides a thick soft tissue biotype in the future implant site. The surgical site is exposed and irrigated with sterile saline. The palatal flap is elevated as well to expose the palatal wall of the bone defect. A retraction suture is now applied to keep the flap off the surgical site during implant surgery. For the next step, blood is harvested with a syringe and stored in a sterile dish. Now, autogenous bone chips are locally harvested within the same flap from the cortical bone surface. This can be done with a flat chisel at the nasal spine, or with a sharp bone scraper from the bone surface towards to nasal fossa. The resulting bone chips are 1.5 to 2 mm in size, and they are stored in the blood. As shown by several pre-clinical in-vitro studies, these bone grafts release numerous proteins and growth factors into the blood, and is termed Bone Conditioned Medium. The surgery continues with the examination of the local anatomy by using first a periodontal probe. The crest width is then analyzed with a caliper, which should measure at least 6 mm oro-facially. Implant bed preparation is initiated with a no. 2 round bur preparing into the apical bone structure. This is followed with the first spiral drill of 2.2 mm diameter using a drill speed of 800 rpm. Bone preparation is done with copious cooling using chilled sterile saline. The depth gauge is inserted to check the sink depth and the implant axis. It is obvious that the axis must be carefully corrected to a slightly more inclined axis. This is done with the second spiral drill using a reduced drilling speed of 500 rpm. The preparation depth is chosen at 14 mm. The second depth gauge now confirms a correct implant axis. The final preparation is done with a profile drill removing some bone at the inner surface at palatal bone wall. The implant is inserted with a speed of 15 rpm without irrigation. The implant shoulder should always be located subcrestally in relation to the palatal wall. Depending on the local anatomy, a healing cap of 2 mm is inserted. The frontal view shows the correct position in corono-apical direction, having the implant shoulder roughly 3 mm apical to the mucosal margin of the future implant crown. The occlusal view shows that the implant shoulder is positioned about 1 mm towards the palate. The exposed implant shoulder is inside the bone resulting in a 2-wall defect on the facial aspect. At the next step, an incision of the periosteum is done to mobilize the flap for tension-free wound closure. Small bore holes are applied in the cortical bone surface to open the marrow cavity and allow some bleeding on the facial aspect. The blood in the sterile dish is diluted with some sterile saline to increase the volume of the Bone Conditioned Medium. The medium is used to moisten the bovine bone filler which has a low substitution rate. The Bone conditioned medium contains a lot of proteins and growth factors, which are absorbed by the bone filler particles. Bone augmentation is initiated with the application of the autologous bone chips. The first layer of bone chips is applied to the rim of the healing cap and completely fills the facial bone defect. The second layer of bovine bone particles is used to over-contour the local ridge anatomy. The surgical technique is called Contour Augmentation using the two synergistic bone fillers of autologous bone chips and bovine bone particles. A critical step for a GBR procedure is the utilization of a barrier membrane. A collagen membrane is cut into two pieces, a larger and a smaller one, and trimmed to shape. Collagen membranes offer several advantages for the clinician. One is that they are easy to apply when soaked with blood. When moistened with bone conditioned medium, the membrane becomes soft and adhesive. It can be easily adapted to the local bone anatomy. The second membrane strip improves the membrane thickness in the defect area and improves the stability of the membrane. The sagittal and coronal views show the various steps of contour augmentation: The bone chips fill the bone defect and will stimulate new bone formation. The bovine bone particles provide the contour augmentation and long-term stability, since they have a low-substitution rate. The collagen membrane provides a barrier function to avoid the ingrowth of soft tissue cells. The surgery is completed with a tension-free primary wound closure using interrupted single sutures with 5-0 non-resorbable, monofilament suture material. Several sutures are applied to achieve a close adaptation of the wound margins. This is followed by insertion of the provisional prosthesis which has been shortened in the edentulous area to avoid direct tissue contact. A pressure dressing is applied to the upper lip to minimize the post-surgical swelling in the first 2 days of healing. 8 weeks later, a reopening procedure is done with a punch incision using a 12b blade. The healing cap is removed with a screw driver and replaced by a longer one. Following a few days of soft tissue healing, the provisional crown is inserted to initiate the soft tissue conditioning. The sagittal view shows the seating of the provisional crown. The facial bone wall is fully regenerated. The implant shoulder is located subcrestally not only on the palatal, but also on the buccal aspect. The treatment is completed with the final, all ceramic crown, which is screw retained to provide optimal precision between the implant and the crown interface.

Contour Augmentation Using GBR: Surgical Steps, Key Learning Points: To achieve an optimal esthetic and functional outcome with long-term stability, high predictability, and a low risk of complications the treatment concept comprises four steps: Coverage of the exposed implant surface with the harvested, blood-soaked autologous bone chips. Coverage of the autologous bone chips with an over-contoured layer of a bone filler with a low substitution rate mixed with BCM and applied up to the rim of the healing cap. Coverage of the augmentation material with two layers of a non-crosslinked collagen membrane. Tension-free primary wound closure to protect the augmentation materials.

Simultaneous Contour Augmentation Using GBR, Module Summary: Guided bone regeneration for contour augmentation with early implant placement in esthetic sites is a technique to reconstruct a long-term stable thick crestal bone on the facial aspect of an implant to support the soft tissues and to re-establish or maintain the biologic width to achieve a highly predictable long-term volumetrically stable, optimally esthetic and functional treatment outcome. The implant is placed in the prosthetically driven, correct three-dimensional position at 8 weeks after tooth extraction according to an early placement protocol, and the augmentation of the localized, two-wall bony defect around the implant is performed simultaneously, in other words directly after implant placement. The augmentation materials used are autologous bone chips, a bone substitution material with a low substitution rate, and a collagen membrane. Care must be taken to apply enough augmentation material to overcontour the alveolar ridge to ensure the reconstruction of a thick, long-term stable facial bone wall. Tension-free primary wound closure is key to protecting the biomaterials applied. A healing time of approximately 8 weeks should be allowed before crown installation.