Pain after Grafting in the Mandibular Second Molar: Any Experience with this?

Dr. L asks:
I have had the following clinical scenario happen three times during the past two years. In each instance the patient had a mandibular second molar extracted, the socket grafted with mineralized cancellous allograft, a membrane placed and four to five months time allowed to pass before placing the implant. At the time of implant placment the patient complained of pain upon drilling the osteotomy. Anesthesia was provided via buccal and lingual infiltration. I do not administer an inferior alveolar nerve block in the mandibular arch. During insertion of the implant, two of the patients complained of discomfort. Once placed, the pain subsided. In one of the three cases the patient had discomfort during the uncovering process when I inserted the healing collar. In this latter case the implant appears to be both clinically and radiographically integrated. In no other site in the mouth have I had this occur. Anyone have a similar experience in the mandibular second molar area or have insight as to what maybe causing these clinical symptoms?

15 Comments on Pain after Grafting in the Mandibular Second Molar: Any Experience with this?

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Why don't you administer the IA block?
mark harari
why this tooth and no other? well, maybe contamination during the graft because of the saliva ? anyway, in spite of good results in the other sites, I should try another graft material just for the experience.
Dr. J. D.
I had the same experience once. I ended up removing the implant although everything looked good clinically and radiographically. I figured I ran into a situation with aberrant accessory innervation and impinged upon neural tissue. It was very painful for the gentleman and he had immediate relief when the implant was removed. Que sera sera perhaps.
Dr. Herndon
Give the IA block. Many years ago it was assumed that if you did not give the IA block, you could tell when you were close to the IA nerve. With modern assessment, this is no longer necessary. Therefore, give the IA block and your problem is over. However I do remember this having been placing and restoring implants since 1982.
Dr. Mehdi Jafari
Sir, Any pain feeling during the process of exposing the implants and switching the cover screws to healing abutments, is always indicating that something is wrong with the perfection of integration process.Since the synthetic biomaterials have been used to graft the socket in the first place, a defective osseo-integration wouldn't be much beyond a reasonable doubt.
peter fairbairn
Cancellous allograft is not a "synthetic" or alloplast graft material .....was internal irrigation used ? Regards
I had a similar experience 10 years ago. At that time I had previously placed an HTR alloplast in the #30 exo site 6 months prior. I used only an infiltration injection at that time.Upon preparing the osteotomy she felt pain. I was able to complete the osteotomy with further anesthesia. I became wary of using HTR and avoided using it in implant situations. As it turned out the implant is functioning perfectly 10 years later. I suspect it may have something to do with using only an infiltration technique in grafted or even non grafted areas which may have dense areas or areas of reduced permeability. i would stick to the use of a block to avoid this.
I ask my question again.... especially in the mandible with dense cortical bone which decreases the permeability of anesthetic into the medullary bone, why would you not give the IA block?
Dr. Mehdi Jafari
Sir, You are absolutely right.As a scientific principle, we teach our undergraduate students that they are allowed to use infiltration anesthesia in mandible only when they have planned to anesthetize deciduous incisors and canine.For locally anesthetizing any mandibular permanent tooth or deciduous molars, nerve blocks are mandatory.
Dr.Bülent Zeytinoğlu
Dear Dr. L Working in the mandıbular molar or premolar region needs block of N.Alveolaris inf. İt is a must.Additionally block of N.Lingualis and N.Buccalis must be done.With the fear of damaging the alveolar nerve under regional block of this nerve is not an excuse.Before instalation of any kind of dental implant in any place of the or cavity CT scan measurements must be done to avoid any damage to any important anatomic structure and to prevent the patient from feeling pain.Good Luck.
dream dds
Great comments. I have never been a fan of infiltrating for lower molar implants. I have had this pain issue you describe in the second molar area; maybe an accessory n. from IAN, could it be from buccal or lingual n. also or are these just soft tissue. So, my case was 15 y/a and CTs were not used much although were available. I placed a second and first molar implant. The pain was "after" the procedure. It was off and on for months. I asked oral surgeons and sent out an appeal on message boards. I paid for a CT to clear myself of placing an implant into the mylo hyoid fossa. Luckily the implant was in bone. The patient was not patient. Her husband was very angry. They threatened law suit. 15 y/a the plan was to evaluate the implant integration by reverse torque to 50 ncm, which I did with no pain caused. The patient came to office one day, took record copies and I never heard from them again. Maybe off your point but similar issue. I graft with allograft as you described, this would not cause pain. I think it is a nerve branch issue- for example, there is a lateral IAN branch to the buccal bone where harvest is made for bone blocks, this branch becomes very superficial and is a major issue with possible paresthesia cases. Hope this helps. Sincerely Leoanrd
Pieter Boshoff
It often happens ,especially in the mandibular molar areas, that the patient experiences bizarre pains when placing the implant. (you have either administered a IAblock or just infiltrated and as a clinician you are satisfied that you can proceed with implantation but the patient complains of discomfort every time you commence drilling)It sometimes happens that the site remains painfull for a prolonged time after the first stage--it may then settle down and integrate OR it may fester out and have to be removed. The area will then heal and very often, you will be able to replace the implant in the very same position and,this time,without any bizarre anaesthesia,post-op pain and/or loss of the second implant. In my opinion you have INADVERTENTLY been placing the implant in an area of necrotic bone. These areas are sometimes easily missed (40-50%bone loss needs to occur before it is radiologically evident)--J.American Dent.Assoc 1961 62:152 The cases that eventually get better were cavitations that were unwittingly treated and you were lucky. The painful implants that were prematurely lost were placed inCavitation or NICO lesions and by their removal the cavitation area was unwittingly treated.The subsequent implant that was uneventful after its placement and healing was placed now in healed bone. I am always suspicious of an area that gives bizarre anaesthesia and I am doubly suspicious when the quantity and quality of the bone between the flutes of my osteotomy drill is minimal. I normally abort the procedure, curettage the bone and pack it with a bone regen. material. I place the implant 2-3months later un eventfully. Good luck.
Dr Sanjay Jamdade
Of the speculations expressed above Dr Pieter Boshoff's explanation appeals more to me. Necrotic pockets of bone or residual infection occurs more often than we think. Why were the offending teeth extracted? Did they have periapical/periradicular pathologies?
M. Maningky
There is no reason that drilling into a pocket of necrotic bone is more painfull then into vital bone. If I do a sequestrectomie because of osteonecrosis there is no pain until you reach vital bone. The problem with the lower second molar region is the anatomy of the mandible. This is the part of the mandible where the cortical plates especially on the buccal side are the thickest. So if you only use infiltration the patient will feel pain and discomfort as you are basicly drilling without anaesthetics because the anaesthesia can't get to where you are drilling! If you place an implant in the lower jaw always make sure you keep a healthy margin from the IA nerve and give the patient a block. Placing the implant so close to the nerve that you have to trust on a pain respons by the patient to keep you from damaging the nerve is a really tight rope.
Dr. Gerald Rudick
Dr L. mentions that the patient (s) had pain following the installation of implants in the lower second molar areas that had been previously grafted. He does not mention the circumstances why the natural teeth were extracted in the first place.There exists the possibility that granulomatous tissue remained in the sockets while they were grafted. This type of tissue is destructive, and contains very sensitive neurovascular elements....hence the sensitivity....dollars to donuts that ultimately these implants will fail. When there is pain associated with installing and tightening healing collars, granulomatous tissue is does not generally disappear....and the implant(s) may fail. I agree with Dr. L, that it is generally not necessary to give a mandibular block when placing implants into the lower second molar area, buccal lingual and crestal infiltrations are enough....if there is sensitivity caused by a stray nerve that has been uncovered, rinsing the osteotomy with the anaesthetic solution will usually take the pain away; if not, when the depth is checked with a guide pin, and it is safe, there is no harm in giving an inferior alveolar nerve block. Dr. Gerald Rudick Montreal, Canada