Pt is a very healthy 86 yr old female . She may live to 100!

She wants teeth to chew with . Does not like PDU/ PDL .

Root form fixture placed  Aug 15, 2016 , using lab constructed Surgical Guide. .

Fixture at 17 placed recently.

I observe at buccal of 15- thin biotype.  At the time of implant placement , I performed atraumatic extraction of 15, evaluated buccal bone , and noted it was intact fully apical to coronal . Using the Guide , implant was placed subcrestally immediately.

Now - I am able to see thru the thin gingiva  the shadow / color of the fixture at the buccal. . No inflammation . No syptoms .

See the CBCT of implant . It looks to me like it is lacking/ absent of bone  at buccal .  And the position does not appear the same as indicated on Guide planning ( enclosed) .  I suspect it may have shifted during placement ??  Position certainly could be more palatal .

So what must I do to fix this ?

 1. Flap, inspect , place GBR -- this will be onlay graft , and likely  fail , especially with thin biotype . Tissues are very delicate and be difficult to handle . 

2. Remove implant , perform socket preservation graft  ; close and wait 4 mo.

3. Remove implant , place a new fixture more palatally. Certainly threads will be exposed ;  graft would be within bony envelope, so  better chance of success . Placing the implant in proper position, however  will be a challenge..  And bone density is on soft side .

Any suggestions would be welcome .

Thanx .

M. Basie

OOps , I think I included an unnecessary image.