Research regarding bone density assessment using cone beam computed tomography (CBCT) in low bone density regions is sparse. This in vitro study aimed to evaluate the predictability of CBCT for low bone density regions and its correlations with primary implant stability when placing tapered design implants with a stepped osteotomy. Eighteen porcine mandibular condyles were used as simulated low bone density regions. Hounsfield units (HU), obtained via multislice computed tomography, and gray values (GVs), obtained via CBCT, were measured 3 times at 1-month intervals. The maximum implant insertion torque (MIT) and implant stability quotient (ISQ) were recorded as the taper design implants were placed using a stepped osteotomy. Hounsfield units and GV were measured as 335.05–803.07 and 389.98–906.40, respectively. For repeated measurements of HU and GV, the intraclass correlation coefficients were 0.989 and 0.980; the corresponding value for mean HU and GV was 0.768. Bland-Altman plots showed a mean difference between HU and GV of −78.15. Pearson correlation coefficients revealed a strong correlation between HU and GV (r = 0.91, P < .01). The mean ± SD values for MIT and ISQ were 36.44 ± 6.64 Ncm and 80.85 ± 2.03, respectively, but no statistically significant correlations were found with GV and HU. Within the study’s limitations, GV showed similar bone density estimation compared with HU in soft bones. Tapered implant placement with a stepped osteotomy achieved stable primary implant stability in soft bones. However, these in vitro results need to be approved in further clinical studies.

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