Implant Placed Too Close to Defect

Low bone density is confirmed during osteotomy at #14 (6 months post socket preservation).  Underprep is adopted: after use of 3.5x10 mm drill instead of 4.5x10 mm one, a 4x10 and 4.5x10 mm dummy implant are placed for bone condensation.  When a 5x10 mm definitive implant is placed, it is unable to be placed to the depth.  After use of 4.0x10 mm, the final implant reaches depth ~ 1 mm more than planned.  But there appears no bone palatal to the implant clinically.  Small-field CT is taken.  In fact there is crestal bone palatal to the implant, but in small amount and in low bone density (Fig.1,2).  The implant should have been designed to be placed more buccal (Fig.3 arrow).  The implant also looks to be placed too close the root of the tooth #13, probably related to the rotation of #13 (Fig.4).  Unfortunately the patient does not agree to have limited orthodontics.  After palatal bone graft, GEM Cap is used to close the access with periodontal glue (Fig.5).  Spacer/periodontal dressing should have been used.  The wound heals 8 months postop, but 2-3 palatal threads are exposed with uncover.  After 6 mm profile drill and placement of a 6x4 mm healing abutment, allograft is placed palatal (Fig.6).  Upper Molar Immediate Implant, Trajectory II Shield Next Case of Buccal Defect  SP Xin Wei, DDS, PhD, MS 1st edition 11/19/2019, last revision 09/19/2020