Exposure of implant threads during placement: what next?

Could have wedged the implant I would suggest using the neo fixture remover to remove and redrill at placement. This is an esthetic area and if that much implant is above the crest it may not heal can't tell without an X-ray. Or your grafting may work in a tenting fashion. Time will tell. Since this is iatrogenic I would have removed it, 50 Ncm is a lot of torque it might be wedged. Good luck.

I am unclear, you couldn´t seat the implant all the way in and 2mm are over the bone level or it was fully seated but had a vestibular exposure of 2mm?. If fisrt scenario... not good, it is unlikely that you will get a good esthetic result in the end so I would go back in and remove it and place a shorter one or drill deeper and get an implant all the way in. If second Scenario, I wouldnt worry, if you did a good GBR you should be fine. Rehab oriented implathology, specially in the anterior zones is harder than it looks( I call it DENTAL CONTACT SPORT) but most of the time can be rewarding so do what you would if it was your wife or daugther, allways stay calm and never ever cut corners best of luck

If the last drill width is not all the way to the proper depth, attempting to over torque the implant into the bone will cause it to bind along the walls of the osteotomy. In dense bone sometimes a partial tapping is necessary to prevent all that force to fully seat the implant. I like to use my implant drill to start seating the implant with 15-20ncm of controlled torque then finish seating it with my 25-30ncm torque wrench by hand. If you're using 50ncm in th anterior maxilla it is probably binding and can't go deeper. I like Alejandro's advice.

If the implant is properly aligned and cannot be removed, you may be able to place an abutment and prep apically and subgingival onto the implant. This way you can treat it prosthetically as a tooth. I have done this myself with not problems. I believe Carl Misch discusses this in his first text.

I agree with Alejandro, If the implant is not fully seated you may end up with an aesthetic disaster and this will be much harder to correct once integrated. If the implant only has 2mm exposed on the buccal surface then grafting as you have with the appropriate grafting material (following decortication of the bone immediately surrounding the area) will usually render a great result. The success will also largely depend on implant used and the bone material/barrier used. Hope that helps.

50Ncm is not that excessive for an insertion torque, 3i go upto +70Ncm. It might be that there just was not enough buccal wall bony thickness at the neck of the implant and thats the issue. Inform the patient now that further treatment with possible replacement may be needed and why you think that so at least you have an "informed patient". if the patuient then says "take it out" then do that but for your own security you can document that the patient was fully informed. If you start doing loads of procedures the patient will twig there is a problem.

On my comment, the qualifier is IF the angulation is not an issue. If the angulation is an issue, then remove the implant and place a shorter implant. The esthetic zone is serious business. Sometimes fixed bridges are a superior option.