Focal osteo-cavitation in the posterior mandible is a condition that is not well known by clinicians. Inadvertent implant placement in such areas may result in nerve damage due to abrupt drill penetration and implant displacement in the medullary space. In the present case series, focal osteo-cavitation was managed with the following procedures: 1) undersized drilling, 2) gentle trabecular curettage, 3) bone substitute material grafting in the cavity, and 4) long healing period for osseointegration. In all cases, a sudden loss of drilling pressure immediately after passing through the thin cortical layer revealed focal osteo-cavitation. Following undersized drilling and gentle trabecular curettage, the bone substitute material was packed into the cavity with care not to press the inferior alveolar canal. Implant placement was subsequently performed. Despite a lack of primary implant stability in three of four cases, the implants were successfully osseointegrated after 6–9 months. Over the course of 5–24 years, all implants functioned well.

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