Pain During Implant Placement: Reasons?

Was it an already healed and bone filled site? Or an immediate?

Perhaps the patient didn't have profound anesthesia to begin with ( or lost it due to catabolism ) and the osteotomy drill was simply approximating nerve innovated tissue/s. No perforations, no excessive bleeding, no paresthesia, good positioning and angulation.........no worries !!!

Yes. There can be a branch off the mylohyoid nerve that can enter into the lingual part of the mandible which needs to be numbed on the lingual aspect of the mandible. My thoughts are, if no perf, enough time for block, and not near ia nerve, is that the patient was "waiting" to feel something. Nervous. I had a patient that after I gave an ia block and an infiltration to do mini implants for an overdenture, he almost lost his mind "thinking" he felt a 4mm length pilot hole. He was given more than enough time to go numb but he watched too many "implants gone bad" on youtube. That's why I always do my own guides and take a low dose post op cbct to show everyone, even myself, that we placed where we wanted to within bone. Just follow up with patient and see how their doing...best of luck doc.

In some patients the mandibular 1st molar is served also by the mylohyoid nerve on the lingual and this patient may have had that innervation. This is a branch off the IAN before it enters the foramen and a block may not affect that branch. Application of 1/4 of anesthetic into the floor of the mouth at the 1st molar close to the ridge will zap that branch

Could it be granulomatous remnants from prior periodontal or apical inflammation before the tooth was extracted?

Radiographs? Could be nerve impingement. Agree with mylohyoid inervation comments.

I think you will be fine. I agree with all the comments above in regards to mylohyoid innervation and possibility of small amount of inflammatory tissue remaining. I have had that happen several times. I have had definite profound anesthesia. Once I added more directly into the osteotomy all pain went away. Also could be large marrow space which could also have some accessory innervation. I will always take a post CBCT to verify for everyone. All have been fine post op. You will be fine.

Hard to make a judgment without pre and post op radiographs

Also, a lot of practitioners may not know that in a small percentage of patients there can be accessory sensory innervation of the lingual mandible from the cervical spine, hence the need for deposition of anesthetic in the lingual vestibule in these patients. When a tooth is present in the area, these are the kind that typically need a PDL injection to augment the inferior alveolar block.

Thanks for all the input guys. Saw the pt today for post op. He is doing fine, no pain. He didn't even take a pain Med.

Most of time is the remaining soft tissue in previous extraction site cause the pain during surgery, just give local infiltration will take care of that pain. Ideally local infiltration is enough for implant placement. No need of nerve block, in that way you could have safe guard from patient felling if your drill too close nerve. Your post op show patient condition is safe. Don't worry.

I find good results from buccal infiltration of articaine 1:1000000 plus another half cartridge on the junction of teh floor of the mouth with the lingual wall of bone: I stopped giving blocks ages ago for most restorative stuff, endo etc...you will be happily surprised by how little the lingual shot irritates patients, and how effective the procedure is. Lip will numb up reasonably well on 6 and 7, more so on 4s and forward...