CTG vs. GBR to correct facial concavity

147 Rating(s).

Posted on By Brad Fulkerson In Esthetic Therapy (General)

I wanted to post this case I will be doing shortly to hear different opinions on how you all would treat it.
This is my assistants sister. She had the implant placed about 12 years ago for replacement of a congenitally missing lateral incisor. Over time the buccal plate and tissue has resorbed (or may never have been present) resulting in a concavity (and shadow) which she has become more self conscious of recently. CBCT shows a thin remaining buccal plate.
My initial thought was a GBR / veneer graft With a mixture of allograft / xenograft for slower resorption and PRF. With a possible secondary CTG if indicated.
-I have also considered alloderm. Thoughts?
-Vista vs conventional flap?
I am Interested to hear some discussion on a problem we all see. And again, this is my assistants sister...so pressure is on!
Thanks all,

Facial view #10
CBCT cross section

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Dear Colleague Brad: In my humble opinion, these cases should be studied with great attention. In the CBCT, we can see enough bone in the buccal plate. The concavity on the area are genetic. A CTG may be sufficient to increase volume and increase vascularity. On the other hand, if the implant had lost bone in the buccal face and is not contaminated by bacteria, a bone sounding could help the diagnosis ... the GBR does not consider it an alternative treatment, because the bone graft will not be integrated into the implant , so a CTG is the best option. The preferred approach is Tunnelization, VISTA or other boarding technique.
Best Regards
Alberto Miselli


Could not agree more with Alberto. A CTG is for me the ideal solution. I have done many times with a sulcular pocket approach but here I don´t recomend it. I would prefer a lateral approach like VISTA or a horizontal incision on apical area and a retrograde pocket to leave the area without any scar.
Good luck and


Brad; Great post and common dilemma. I agree with the above #Xperts. If the implant crown and abutment can be temproarily removed, I prefer to work vertically thru the sulcus witha tunnel approach, if not then a VISTA here. warmest regards and thanks for sharing. Dr. S


In agreement with previous comments-I would insert CTG through VISTA approach.
Best regards


Hello Brad, great to see your post. I agree with the other experts, and I would definitely go without a conventional flap. I have had some cases like this before and the tunnel with intrasulcular approach has work very well.
Good luck!
Best regards


Incredible post!!!


Magnetic Mallet