Grafting options in thin bone biotype in the aesthetic zone

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Posted on By Hamid Kazemi In Anterior/Esthetic

Patient status post 5 years of orthodontic treatment with missing #8. Thick soft tissue biotype, but extremely thin hard tissue biotype with significant bone atrophy on missing tooth site #8- horizontal and vertical. GBR or block graft are certainly options to restore bone- but very high risk of further bone loss on adjacent teeth with flap elevation. What would you do?

missing #8
PA #8

CBCT- #8
CBCT- #7

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Hi Hamid...
I would go with Versah drill for expansion & veneer graft with a mini flap. Plus PRF and CTG on uncover if necessary.


Thanks Jorge


Ryan; tough Case. Concerned about the lateral incisor long term prognosis as well. Although I dislike smaller flaps I would utilize broad based papilla sparing incisions and perform an onlay bone block from Ramus....still to me the Gold standard unless you wish to split it and use as Khoury Plates.....I would NOt use expansion drills or split this way (dense cortical bone does not do well with this in many cases and the risk of fracture is large. regards Mo


Tough indeed. Ernesto Lee's SMART is the only other non-invasive technique to graft without significant flap elevation and further compromise of periodontal apparatus of adjacent teeth. Onlay block graft as you describe will work well- minus potential vertical scan lines in the aesthetic zone- otherwise great. Thanks for the thoughts


Hello Hamid,
Like Dr Salama, I do not like smaller flaps with papilla sparing incisions, although this may be of benefit in this case. I however would manage with a crestal incision including papillae and two vertical incisions one tooth away. Ti-mesh to level of current IHB or slightly more coronal, and overlay with a rotated palatal pedicle.
Tunnel grafting also sounds like a good option here, however I do not have much experience with the technique.
Looking forward to your treatment here.



Ryan, have you performed the SMART technique yet?? Thanks Maurice


Hard tissue augmentation in VISTA approach would be an option here, but there are very few of us performing this kind of surgery. This case actually screams after this kind of treatment!
Alternatively: I agree with Jorge and ridge expansion utilizing Densah burs. There is a trabecular bone here - a bone cut and chisels to open the space, Densah site preparation, than veneer graft. Implant with healing abutment to enhance a vertical volume, PCTG to minimize coronal flap advancement and give a soft tissue volume and nice texture.
The patient has already brackets - have you thought about orthodontic extrusion of adjacent teeth to improve papillae?
Thank you for sharing, hopefully see you at XP Symposium in Florida?
Best regards


This is a classic class 5 ridge according to our new classification that we have just published in the Journal of Prosthetic dentistry. This is the biggest problem area to work with as you are outside the envelope in every way. To me there is only one way to go and that is block grafts with Khoury plates. I would not touch a Densah Bur here as the possibility of bone loss is high. Build your bone first and then go back later and use debrah to further develop the bone. Overbuild the ridge if possible and then place implants 4 months later. I dont believe any synthetic material would work as well. Anything without a strengthened non reservable membrane is a waste of time


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Nobel Biocare