# Introduction chulte and Heimke initially described protocol for immediate implant placement about 30 years ago. 1 Following which Lazzara in 1989 reintroduced immediate implant placement into fresh extraction sockets. 2 Immediate implant placement may be defined as implant placement immediately following tooth extraction and as a part of the same surgical procedure, or as implant placement immediately following extraction of a tooth which must be combined in most patients with a bone grafting technique to eliminate periimplant bone defects. 3 Immediate implant placement for replacing missing anterior teeth has become undoubtedly a predictable treatment option, at the same time it is challenging both surgically and prosthetically. Further, a variety of classifications were proposed to facilitate placement of implants in freshly extracted sockets. One of the most common of all is that given by Elian et al 2007. This classification scheme was based on presence or absence of adequate hard and soft tissues and states: Class I (adequate facial and palatal hard and soft tissues), Class II (inadequate facial soft tissue but adequate facial and palatal hard tissue), Class III (Inadequate hard and soft tissue on facial aspect but adequate hard and soft tissue on palatal aspect). 4 Although appropriate decontamination along with debridement of the surrounding hard and soft tissues of the freshly extracted socket is essential for placement of dental implant, to further prevent spread of infection to peri-implant tissues. 5 In cases with active infection like pain, draining sinus, purulent discharge, swelling and/or mobility; a 6 day protocol is carried out. Initially the infected tooth is extracted atraumatically with periotomes followed by complete curettage irrigation using bone curette with irrigation connection. Repeated irrigation using 500mg infusion solution of Metronidazole. Following extraction, the root was trimmed to its half-length, cleaned using ultrasonic scaler and reinserted into the extraction socket with its clinical crown bonded facially to adjacent natural teeth. Subsequentially post 6 days, the root was removed and the VST protocol is advised. On the other hand, the cases that show no active infection, could be treated directly with VST. Araujo and Lindhe 2005 advocated use of combined ridge augmentation (contour augmentation with guided bone regeneration) for placement of dental implants in areas of inadequate hard and soft tissues. 6 Implants placed in presence of inadequate hard and soft tissues may result in gingival recession altering future implant prognosis. Inadequate hard tissues could be replaced with appropriate bone grafts while soft tissues could be enhanced with mucogingival surgeries like connective tissue grafts. The cases with narrow extraction socket orifice, a cortical membrane shield of 0.6mm thickness is advised. Before use it has to be trimmed, hydrated and then introduced from the socket orifice through the tunnel apically till the vestibular access incision where it is stabilized by placing membrane tacks or micro-screws. This prevents possible risk of interdental papilla recession. As a result, a novel method called VST was developed by Dr Abdelsalem Elaskary in 2019. [16][17][18] This clinical protocol could be used to treat a wide variety of fresh extraction sockets with alveolar defects (thin, deficient facial plate with active infection). It follows the protocol of restoring freshly extracted infected socket with simultaneous implant placement. This not only reduces the treatment time but also allows immediate rehabilitation of infected socket with predictable esthetic outcomes which is the need of the hour. ) were used for its aggressive thread design to provide an optimal primary stability, as well as to benefit from the platform switched to enhance the peri implant tissue thickness to its planned location 3 to 4 mm apical to the socket orifice with adequate primary stability, were installed using the 3D printed surgical guide (Surgical Guide Resin, Form 2, Formlabs). vii. A flexible cortical resorbable membrane (OsteoBiol® Lamina, Tecnoss®, Torino, Italy) of heterologous origin, 0.6 mm in thickness was prepared by hydrating and trimming it. The main advantage of VST is that it is the only technique available till date that reduces post-extraction ridge resorption of surrounding hard tissues [7][8][9] as well as soft tissues. [10][11][12][13][14][15] VST technique is known to show promising results as the flexible labial shield made up of membrane undergoes slow resorption, until then helps maintain appropriate dimensions of extraction socket. Furthermore, the vestibular access incision aids in stabilization of the labial shield, further ensuring stability of the bone graft materials. Additionally, a sub-epithelial connective tissue graft allows formation of thicker gingival biotype around extraction socket which not only decreases chances of mucosal gingival recession but at the same time also enhances soft tissue profile around the implant. # Inclusion Criteria for VST Figure Legends # Studies Carried Out on VST Elaskary et al 2020 carried out a single-arm clinical study on 12 fresh extraction sockets which were divided into two groups: Group 1: those with intact facial plate of bone and Group 2: those with deficient plate of bone. Sockets divided under both the groups were treated with VST. Pre-operative and post-operative CBCT scans were taken. Pink esthetic score (PES) was recorded 6 months and 13 months following VST protocol. At 3 months, marked co-incidence of facial plate of group 2 sockets was seen with the sockets of group 1 while an increase of 0.20 ± 0.13mm in the group 2 at 13 months. On the other hand, the PES score at 6 months and 13 months was a total of 14 with 11.33 being for both the groups. The authors concluded that the VST protocol was a minimally invasive treatment and showed predictable results in cases of deficient facial bone plate and hence advocate use of this technique to treat such compromised sockets. 16 Elaskary et al 2021 conducted one-arm cohort study including 16 implants that aimed to assess radiographic, esthetic and periodontal outcomes 1 year post implant placement in cases of compromised sockets in esthetic zone using VST. In this study, implants were directly placed into type II sockets whereas cases with active infection were treated with a 6 day protocol of anti-microbial therapy. Total parameters assessed were bone height, labial plate thickness at 3 levels at baseline and after 1 year in addition to that PES was determined along with certain periodontal parameters like modified sulcus bleeding index and peri-implant probing depth 1 year post implant placement. The results showed significant increase of bone height and thickness of bone at the middle and crestal thirds with mean PES of 12.63 (1.71), mean modified sulcus bleeding index was 1.19 (0.40) and lastly mean peri-implant probing depth of 1.97 (0.46) mm. Thus, the authors concluded VST protocol along with the 6-day protocol of anti-microbial therapy protocol was successful for treating such compromised sockets and thus aided to minimize total treatment time and surgical interventions providing predictable esthetic outcomes for the patient. 17 Elaskary et al 2021 assessed regeneration of hard and soft tissues following immediate implant placement in compromised fresh extraction sockets using VST 2 years post-operatively. This study included 27 compromised fresh extraction sockets that were treated with VST followed by immediate implant placement. The defects within the sockets were filled with particulate bone grafts (75% autogenous bone chips harvested from local surgical site infused with 25% de-proteinized bovine bone mineral (DBBM) of equine origin fully enzyme de-antigenised). Thickness of labial bone plate along with bone height were assessed through CBCT scans 2 years post-operatively. A statistically significant difference was observed for increase in total bone height crestally, mid-facially, apically along with bone thickness. Although, the changes in PES and probing depth were not as significant as that compared to thickness of labial plate. Lastly the authors concluded, a combination therapy of immediate implant placement followed by VST helps to manage such compromised sockets and provide prosthetic rehabilitation at an early stage. 18 II. # Conclusion The VST protocol has offered predictable hard and soft tissue regeneration with preserving original anatomy of the extraction socket and allows immediate implant placement in altered and infected socket. The 6day anti-microbial therapy protocol for cases showing active infection has shown promising results too in limited span of time. # Conflicts of Interests: None 1![Intra-Oral Pre-Operative 2. Pre-Operative CBCT viii. The membrane was then tucked through the vestibular access incision (Figure No: 8), till it reaches 1 mm apical to the socket orifice, and stabilized using two membrane tacs (AutoTac System Kit, Biohorizons Implant Systems, Birmingham, Alabama Inc, USA) to the sound apical bone. ix. The gap between the implant and the shield/the labial plate was then filled with particulate bone graft [autogenous bone chips harvested form local surgical site mixed with inorganic bovine bone mineral matrix (MinerOssX, Biohorizons, Birmingham, Al, USA)] (Figure No: 9). x. Finally, the vestibular incision was secured with 6/0 nylon sutures (Stoma, Storz am Mark GmbH, Emmingen-Liptingen Germany) (Figure No 10). xi. A temporary Peek abutment (Figure No: 11) Inc, USA) was trimmed to the socket orifice level and the gap was filled with composite resin (Filtek? Supreme Ultra Flowable Restorative, 3M Corporate Headquarters, MN, USA) to create a sealed chamber that protected the bone graft. xii. Post-operative follow-up advised 10 days after surgery (Figure No: 12). xiii. Final crowns (full anatomical zirconia, bruxzir, Glidewell, CA, USA) were cemented 2 months postimplant placement (Figure No: 13). xiv. Patient recalled again at 6 months for follow-up visit (Figure No: 14). 7. Implant Placement Through 3D Printed Surgical Guide 8. Insertion of Cortical Membrane from the Vestibular Access Incision Up Till Socket Orifice and Stabilized with Auto-Tacs 9. Placement of Particulate Bone Graft Filling the Bone Defect 13. Final Prosthesis at 2 Months 14. Follow-Up at 6 Months Post-Operative Phase Antibiotics like Ciprodiazole (Combination of Ciprofloxacin 500mg and Metronidazole 500mg) and Analgesics (any NSAID (non-steroidal anti-inflammatory drug) are prescribed for a 5 day course along with rinsing with Chlorhexidine mouthwash 0.12% twice a day for 1 week. Advantages of VST 1) Used in infected freshly extracted sockets (thin, lost and infected) 2) Treat multiple teeth at a time 3) Single surgical entry 4) Minimal or no facial gingival recession 5) Pre-prosthetic profiling not required 6) Minimal post-operative soft tissue trauma 7) Treatment time reduced to 8 weeks](image-2.png "1 .") No: 6) that was created using a periotome and amicro-periosteal elevator (Stoma, Storz am MarkGmbH, Emmingen-Liptingen Germany).vi. Implants, (tapered pro Biohorizons, Birmingham, Al,USA) (Figure No 74) Hammerhead periotome: Its shape adapts to thecurved sockets and prevents laceration ofsurrounding tissues, available in10mm size.5) Forklift vestibular retractor: This retractor allowscomplete visualization of the surgical site and alsoaids in appropriate placement of bone graftmaterials.6) Soft tissue graft holding forceps: This forceps allowsholding of soft tissue grafts against the surgical siteand also helps in optimal stabilization of graft at theorifice of the socket while suturing.7) Scalpel blade holder8) Cooley's atraumatic 0.8mm straight forceps9) De Wijs's Periosteal elevator: 5mm in size10) Kelly's toothed angled scissors:16mm in length11) Barraquer Micro-needle holder: straight in shapeand 0.8mm in dimensionsPre-Operative Procedures? Non-surgical periodontal therapy followed by rinsingwith 0.12% Chlorhexidine mouth-rinse for one week.(Figure No: 1)? Pre-operative CBCT (Cone beam computedtomography) scan to determine anatomy of thesurgical site. (Figure No: 2)? Computer guided scans that aid in preparation ofguide for guided implant placement.Surgical Protocol for Vestibular Socket Therapyi. Atraumatic tooth extraction (Figure No: 3) wascarried out using periotomes (Stoma, Storzam Mark) under local anesthesia (ARTINIBSA 4%1:100,000, Inibsa Dental S.L.U.) and a postextraction CBCT was taken inorder to evaluate labialbone plate (Figure No: 4).ii. Following which, the socket was thoroughly curettedand debrided and repeatedly irrigated with 100 mLExclusion Criteria for VSTof anti-anaerobic infusion solution of 500 mg? Current smokersmetronidazole (Minapharm Pharmaceuticals).? Patients with debilitating systemic diseaseiii. The socket was curetted and rinsed with saline, and? Patients who have undergone any sort ofthe VST protocol was implemented :radiotherapy and chemotherapy in past 2 years.iv. A 1-cm long vestibular access incision (Figure No :5) was made using a 15c blade (Stoma, Storz amMark GmbH, Emmingen-Liptingen Germany), 6-8mm apical to the mucogingival junction of theinvolved tooth.v. The socket orifice and the vestibular access incisionwere connected via a subperiosteal tunnel (Figure? Pregnant and Lactating females Vestibular Socket Therapy Instrument Kit Comprises of 1) Vestibular elevator: Used to carefully elevate periosteum with perforating and leaving behind any residual tissue, available in 4mm or 8mm varieties. 2) Membrane holding forceps: * The Tubinger immediate implant WSchulte GHeimke Quintessenz 27 1976 * Immediate Implant Placement Into Extraction Socket Sites: Surgical And Restorative Advantages RJLazzara 1989 9 * Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late? Periodontol DBuser VChappuis UCBelser SChen 2000. 2017 73 * A simplified socket classification and repair technique. Practical Procedures and Aesthetic Dentistry NElian SCho SFroum RBSmith DPTarnow 2007 Mar 1 19 99 * Postextraction implant in sites with endodontic infection as an alternative to endodontic retreatment: a review of literature SCorbella STaschieri ITsesis DelFabbro M 10.1563/AAID-JOI-D-11-00229 J Oral Implantol 39 3 2013 Google Scholar * Dimensional ridge alterations following tooth extraction. An experimental study in the dog MGAraújo JLindhe J Clin Periodontol 32 2005 * Alveolar socket healing: what can we learn? Periodontal MGAraùjo COSilva MMisawa FSukekava 2000. 2015 68 * Immediate implant placement: Surgical techniques for prevention and management of complications AlSabbagh MKutkut A Dent Clin Am 59 2015 * Dimensional ridge alterations following tooth extraction. An experimental study in the dog MGAraùjo JLindhe J Clin Periodontol 32 2005 * Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study LSchropp AWenzel LKostopoulos TKarring Int J Perio Rest Dent 23 2003 * Double-blind randomized controlled trial study on post-extraction immediately restored implants using the switching platform concept: soft tissue response. Preliminary report LCanullo GIurlaro GIannello Clin Oral Implants Res 20 2009 * A prospective randomized clinical study of changes in soft tissue position following immediate and delayed implant placement CJVan Kesteren JSchoolfield JWest TOates Int J Oral Maxillofac Implants 25 2010 * A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year NPLang LPun KYLau KYLi MWong Clin Oral Implants Res 23 2012 * Single-tooth replacement by immediate implant and connective tissue graft: A 1-9-year clinical evaluation AEBianchi FSanfilippo Clin Oral Implants Res 15 2004 * The Effect of Subepithelial Connective Tissue Graft Placement on Esthetic Outcomes Following Immediate Implant Placement: Systematic Review CLee CTao JStoupel J. Periodontol 87 2016 * A Novel Method for Immediate Implant Placement in Defective Fresh Extraction Sites ATElaskary YYGaweesh MAMaebed SCCho ElTantawi M International Journal of Oral & Maxillofacial Implants 35 4 2020 Jul 1 * Vestibular Socket Therapy: A Novel Approach for Implant Placement in Defective Fresh Extraction Sockets with or Without Active Socket Infection (One-Arm Cohort Study) ThElaskary AGaweesh YY ElTantawi MMaebed MA International Journal of Oral & Maxillofacial Implants 36 1 2021 Jan 1 * Vestibular socket therapy with immediate implant placement for managing compromised fresh extraction sockets: A prospective single-arm clinical study AElaskary MMeabed IARadi International Journal of Oral Implantology