Radiolucency or just Over Drilling?

tough crowd you did perforate it will probably be more than ok if it is not too mesial or distal, very restorable pre-op scan and guide where necessary can never hurt

I sure hope so, the implant is still poorly placed, will integrate that way and be a long term issue since the forces will not be down the long axis and parallel with the cortical plates. Remember a natural tooth has two roots an implant is a single cylinder. The anatomical structure you entered is the lingual shelf, had you been in the middle of marrow space the cortical plate would not had been a problem and the drilling would have been in homogeneous bone and you would not have had to push so hard perforating the plate. Seeing more of these types of cases suddenly in the literature, wonder why?

What an interesting case thank you for being brave enough to share online. If it is two weeks and your patient is asymptomatic, I am sure he/she is fine and will heal. Did you see clinical signs of perforation? Bruising, ecchymosis etc? IT IS CRITICAL THAT ONE NOT MAKE AN OPINION OR A DIAGNOSIS FROM ONE ANGLE/VIEW ONE SLICE. The AXIAL VIEW would be more accurate to observe a perforation (interruption in the lingual cortical plate) not the coronal view you have or cross-sectional slice you have provided. As well as viewing the pre-op scan if possible. I THINK the people who have stated you have perforated are very brave as I would not feel comfortable making that statement without actually viewing the entire scan in all three planes viewing as well as knowing the resolution of the scan and what slice thickness your picture/image is above. The cortical plate is very thin but there is no perforation observed. There is still cortical bone directly apical on the buccal side directly inferior to the implant; if you did perforate it would have had to be with one of the initial drills smaller drills. Also your contrast is too high for viewing in this image. You can tell as your implant looks very white. As for ALARA a CBCT scan is equivalent to being outside for about 3 days in the sun. The radiation amount is piddle compared to a Medical Head CT scan about 180 days. The new machines scans are less than a some Pano machines. If you felt that it was clinically warranted it will not harm an adult patient whose cells are fully differentiated. I feel that you would have not taken this scan without a good reason. Good advice about always checking you osteotomy sites with a probe after each drill. There is very critical anatomy which could cause your patient to bleed out but it would have occurred on the same day. Remember the lingual artery comes directly of off the external carotid so hitting this would be a very bad day in surgery. (second branch of external carotid) If I was you and you had further concern I would send it to an Oral Maxillofacial Radiologist who can evaluate your before and after scan and tell you for sure if you perforated. There are services online were you can upload your scan. Some people actually lingualize there implants to engage the cortical plate. Another thing the term radioluceny is not for CBCT only 2D images this would be described as a low density area with or without lingual cortical plate thinning and/or perforation. Here from one slice appears thin. It is important that you understand this as this helps to better understand what you are observing. Low density could mean marrow space, so the shade of gray you are observing is critical. All the best, thanks for sharing.

Looks like a perf to me. Sometimes it is best to be honest. But the person who placed the implant should be able to feel the "give" in the bone when perforating although a consultant can be helpful, it is the operating surgeon in the moment, who makes the call. If they can't tell then something is amiss.

Had similar incident, was placing immediate implant several years ago into the #26 spot. Had sublingual hematoma, sent to ED asap and ended up with an emergency tracheotomy. This was early days of the CBCT. I sent for CBCT to check after the fact and the implant had perforated the lingual cortex by about 1.5 mm. Definitely to need to be careful when placing these implants, and observe close for any sign of problems before discharging from the office.

The best CBCT still needs to be clinically correlated there are many variables and artifacts in the technique and a radiographic interpretation is only as good as the clinical application. I would be careful giving this kind of advice since it is speculative.

You did that on purpose?

That's a perf, periapical radiolucencies don't look like that and typically spread laterally thru the marrow not thru dense cortical plate. Bicortical engagement is not necessary with an osteointrgrated implant it is not a Steinmann pin treating a fracture. Based on your comments there is trouble in the future if this path is followed.