Radiopaque bone lesion at future implant site: thoughts?

Tricky one. My first thoughts are that limited vascularity into this site will compromise any implant placed in it. Biopsy is the best option. You need to know exactly what this is.

Looks fairly innocuous . It could be a dystrophic calcification due to previous infection or inflammation . At worst it could be a osteomyelitis but sclerosing type . bone biopsy is not indicated as this will not change your management - i.e. Do nothing if you don't plan implants. Also it will be helpful to compare any previous radiographs . Refer to OS if in doubt .

Agree that lack of vascularity could compromise ability for implant to integrate. If patient insists on implants, would have detailed (and documented) discussion with patient about possible complication secondary to lesions.

Possibly condensing osteitis due to the pathology of the extracted teeth. Do the biopsy to confirm the benign nature of the radiopacities, do not put the patient or yourself at risk if in the off chance that it is something aggressive or malignant. As far as overheating, my initial drill is at 1000 rpm. The remaining drills are 75-200 rpm. There are so many advantages to the slow speed including great graft material and being able to feel the quality and density of the bone.

if you look at the panoramic view you can see other lesions apucal to anterior teeth and premolars, those teeth are sound with no infection. So I am not sure if the lesions are due to previous pathology

DDx: florid cemento-osseous dysplasia, ossifying fibroma, osteomas secondary to Gardner's syndrome, other metabolic bone disorders. Cemento-osseous dysplasia is most likely, although lack of bilateral presentation is unusual. From Neville & Damm's Oral and Maxillofacial Pathology, 4th Ed, p 600: "...surgical procedures (e.g., biopsy, elective tooth extraction) should be avoided... Dental implant placement in an area of cemento-osseous generally is not recommended." Osteosclerotic lesions tend to be hypo-vascular, and exhibit impaired wound healing, much like bone exposed to ionizing radiation or anti-resorptive agents (bisphosphonates, denosumab). Caution is appropriate.

This appears to be a simple enostosis. No need for a biopsy.

Multi-focal lesions like these? Not likely.

I would have to agree with Dr. Flanagan, this is not a problem I would be concerned about. If you are using proper technique burning bone is not a concern.