Immediate placement too close to buccal?

Make a small vertical incision as close as you can to the tooth mesial to the implant. The incision should be no more than 5mm in length and should be done away from the crest at the height of the bone the buccal bone defect of the implant. Using a Prichard elevator, create a full mucoperiosteal tunnel passing the defect at least 5mm. Graft with your choice of bone. Personally I favor Irradiated Cancellous Particles from Rocky Mountain Tissue Bank, my other choice will be Cancellous particles from Maxeuss or use any bone grafting material of your choice. Place one suture to close the incision and leave it alone.

It looks like it’s going to be fine. But I would suggest you leave it at least six months before you restore. You didn’t say how long this implant has been in place. If it has been in place long enough to osseointegrate, it could be very difficult to remove. Keep in mind that you still have a Healthy periosteum with a good blood supply to protect and regenerate this area. And if inThe future you detect a dehiscence, you can always graft that small area. But I doubt very much that this will not turn out to be an excellent result. I hope your relative appreciates your fine skills.

Remember that with a CBCT scan hardening can occur around implants in the sense it appears as if there is no bone but in reality the affect of the scatter that occurs around metal objects a thin but stable cortical plate may be miss interpreted as a dehiscence when it is very well intact... Questions are.. does the implant have optimal stability.. is there a true dehiscence presence.. what is the over lying tissue biotype...can you palpate threads.... see a black apparence of the threads....when was it placed... why only a 10mm implant when you had plenty of room for a 12mm one... and was the center of the implant placed below the opposing palatal cusp where the forces should be directed down the long axis of the implant for optimal support..are you going to place more implants distal to that one to support it? research shows optimally you should have 1.5-2mm of solid buckle bone and at least the same on the lingual/palatal. If there is primary stability upon exposure... restore at 4 months ... if there is a true bucal plate issue Dr. Mena has a great simple approach to rectify the problem....

Thanks for the post. I had almost EXACTLY the same situation a few years ago- implant for mother-in-law! Apically looked good and crestally looked OK but middle very dodgy from bone coverage point of view- in fact part of the implant seemed to be completely devoid of bone. I did exactly what Raul is proposing and all worked out very successfully. Develop a sub-periosteal pocket over the area of thinned bone and graft- I used Nu-Oss mixed with iPRF to make a 'plate' and slipped it in but of course you can use whatever is your preferred material but you've got to do something to stabilise it at the site though otherwise it'll just migrate.

Yes, facially graft with a tunnel but place an additional implant to the distal and splint to avoid an overload of the thin facial cortex. This minimizes the occlusal load. For a long term functional and esthetic outcome 2mm (1.8mm Spray et al) of facial bone is needed

"but you’ve got to do something to stabilise it at the site ".. Please expound on what you do to stabilize the tunnel placed graft.

A tunnel access (full thickness to expose the bone) is done placing particulate material and sliding a collagen barrier between the soft tissue and the graft. Close with a non-resorbable suture. More importantly splint the compromised implant with a distal implant.

To stabilize the graft... I always extend the tunnel pocket at least one tooth anterior and posterior to allow for an excess amount of grafting material to be placed... I slip an extended resorbable collagen membrane into the pocket prior to placing the graft... to secure the membrane I tack it down by making a 3mm incision over the area of where the tacks will go .... usually in the interproximal areas...and place a simple non resorbable suture to close the incision. I do aggressively rasp the cortical plate to initiate RAP....have never had a problem with incision line opening and re hydrate the allograft with PRP prior.

Thank you very much appreciate your answering.