How Does Low Bone Density Affect Osteotomy?

After vacation, the nervous patient returns for #30, 31 implant placement.  After infiltration anesthesia, initial osteotomy goes on smoothly at the depth of 10 and 8 mm, respectively (Fig.1).  Depth gauge post 5x10 mm drilling shows that the distal osteotomy at #30 is 14 mm in spite of depth control (using drill stopper).  Damage the Inferior Alveolar Canal or Mental Loop?  Since hemorrhage is moderate, a 5x10 mm submerged implant is placed without discomfort from the patient (Fig.2); when the osteotomy at #31 is being enlarged with 2/2.7 mm pilot drill at 8 mm, the patient experiences severe pain without any obvious reason.  The infiltration anesthesia is increased with Articaine and Marcaine.  The depth of the osteotomy reduces at 6 mm.  The osteotomy and 5.9x6 mm implant placement is done in a slow and gentle manner (Fig.3,4).  The bone density mesioapical to the implant at #30 is low (Fig.3 dot line, Fig.5 (CBCT, ≤50 units) *)).  This may account for apparent increase in the osteotomy at #30.  The soft bone gives in to the depth gauge!

How to explain pain and discomfort of osteotomy and implant placement at #31 in spite of large clearance from the Inferior Alveolar Canal (Fig.3 red dashed line)?  Still the low bone density theory.  The low bone density (Fig.5 * at #31) makes it easy to transmit the heat and vibration associated with the osteotomy to the underlying nerve!

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Xin Wei, DDS, PhD, MS 1st edition 06/16/2016, last revision 06/16/2016