Factors associated with hematoma of the floor of the mouth after placement of dental implants
Article Outline
- Abstract
- 1. Introduction
- 2. Materials and methods
- 3. Results
- 4. Discussion
- 5. Conclusion
- References
- Copyright
Abstract
Purpose
The aim of this article is to determine factors associated with hematoma during placement of dental implants in the anterior mandible and to provide the dental practitioner with preventive measures to avoid such a life-threatening complication.
Methods
All available clinical case studies from (1986 to 2010) published in English or with English abstract were reviewed and analyzed.
Results
Nineteen studies have been identified and written in the literature. Most of the reported studies were case series and they showed that hematoma is a very rare complication, but general dental practitioners do not pay attention to the significance of the mandible anatomy in the anterior area and the possibility of perforation of the lingual cortex during placement of the dental implants in that position.
Conclusions
The use of dental CT in planning the implant treatment coupled with accurate determination of implant length in order to provide detailed data about the mandible anatomy are highly recommended to avoid the occurrence of hematoma in the floor of the mouth and the airway obstruction that may lead to death during placement of dental implants in the anterior mandible.
Keywords: Hematoma, Complication of dental implant, Mandible anterior area
1. Introduction
Placement of dental implants in the anterior mandible is a routine procedure and considered to be safe. The sublingual hematoma complication that can occur during placement of mandibular endosseous dental implants is potentially life-threatening (Kalpidis and Setayesh, 2004). The growing of knowledge of the causes of that complication is an important aspect of treatment planning. General practitioners and specialists do not pay attention to discuss this complication with patients before surgery. Upper airway obstruction, severe bleeding and formation of a hematoma in the floor of the mouth are the result of vascular trauma (Hofschneider et al., 1999). This vascular complication is attributed to unwanted perforations in the lingual cortical plate (Kalpidis and Setayesh, 2004, Hofschneider et al., 1999).
Formation of hemorrhage can easily spread in the loose tissues of the floor of the mouth, the sublingual area and the space between the lingual muscles. Swelling can occur rapidly and can cause acute airway obstruction, which may require intubation or an emergency tracheostomy (Kalpidis and Setayesh, 2004, Hofschneider et al., 1999, Krenkel et al., 1985). The mandible region from the lingual side, is a very important vascular area. It is supplied by the sublingual branch of the lingual artery which anastomoses with the submental artery, a branch of the facial artery, and the incisive arteries, branches of the inferior alveolar artery (Kalpidis and Setayesh, 2004, Hofschneider et al., 1999, Krenkel et al., 1985). This rich anastomosing blood supply plexus lies very close to the interforaminal lingual cortical plate of the mandible and severe hemorrhage from this region has been reported as a complication of implant placement and other surgical procedures (Kalpidis and Setayesh, 2004, Hofschneider et al., 1999, Dubois et al., 2010). Different anatomical studies reported that many unnamed accessory foramina are present in the mandible, especially on the lingual side (Hofschneider et al., 1999, McDonnel et al., 1994, Loukas et al., 2008). The anatomical description of the median, situated in the midline of the mandible (McDonnel et al., 1994) and lateral lingual foramina, situated between the canine and the premolar region (Kalpidis and Setayesh, 2004) and their linked canals contents is still a matter of debate. Different descriptions about canal content and different terminology to locate the mandible lingual foramen have been reported in the literature (Kalpidis and Setayesh, 2004, Hofschneider et al., 1999, Liang et al., 2006). The purpose of this review is to identify the sublingual hematoma complication that have been reported in conjunction with dental implant treatment in the mandible anterior area and provide data regarding its frequency.
2. Materials and methods
A literature search using MEDLINE, accessed via the National Library of Medicine PubMed interface (http://www.ncbi.nlm.nih.gov/pubmed), searching for articles relating to the floor of mouth hemorrhage and life-threatening airway obstruction during immediate dental implant placement in the anterior mandible written in English. The following search string was used: floor of mouth hemorrhage, implant placement in the anterior mandible, complication of dental implant. All the reported papers in the literature were reviewed (1986–2010). We also used the “Related Articles” feature of PubMed to identify further references of interest within the primary search. These references were obtained, and from their bibliographies, pertinent secondary references were also identified and acquired. The process was repeated until no further new articles could be identified. The abstracted literature was reviewed.
3. Results
Our search has identified 19 studies that were written in the literature. No randomized controlled trials have been identified in the literature to evaluate the incidence of that life threatening complication and to give a clear guideline to avoid that complication, therefore, all of these studies which reported that complication were case series (Table 1).
Table 1. Shows the description of the clinical case series that reported in the literature (1986–2010).
| Author name | Reason of bleeding | Onset of bleeding | Airway management |
|---|---|---|---|
| Krenkel and Holzner (1986) | Perforation of lingual plate, which was felt during osteotomy | After 4 h | Intubation |
| Mason et al. (1990) | Perforation of lingual plate, which was felt during osteotomy | After 4–5h | Intubation |
| Laboda (1990) | Not reported | Not reported | Intubation |
| Ten Bruggencate et al. (1993) | Perforation of lingual plate, which was felt during osteotomy | After 6h | Intubation |
| Ratschew et al. (1994) | Implant osteotomy preparation | During implantation | Intubation |
| Mordenfeld et al. (1997) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Intubation |
| Darriba and Medonca-Caridad (1997) | Surgical manipulations | During implantation | Tracheostomy |
| Panula and Oikarinen (1999) | Tear of lingual periostium | After 30min | Intubation |
| Givol et al. (2000) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Tracheostomy |
| Niamtu (2001) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Tracheostomy |
| Isaacson (2004) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Not reported |
| Boyes-Varley and Lownie (2002) | Perforation of lingual plate, which was felt during osteotomy | After 30min | Tracheostomy |
| Kalpidis and Konstantinidis (2005) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Not reported |
| Budihardja et al. (2006) | Perforation of lingual plate, which was felt during osteotomy | Not reported | Intubation |
| Woo et al. (2006) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Tracheostomy |
| Del Castillo-Pardo et al. (2008) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Intubation |
| Pigadas et al. (2009) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Intubation |
| Dubois et al. (2010) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Tracheostomy |
| Frenken et al. (2010) | Perforation of lingual plate, which was felt during osteotomy | During implantation | Administration of medication and intensive observation |
Krenkel and Holzner (1986) reported the formation of the threatening hemorrhage in the floor of the mouth due to a single tooth implant in the canine region. Mason et al. (1990) reported the potential of fatal hemorrhage arising from dental implant placement in the mandible. Anatomic considerations of the lingual artery and its divisions in the floor of the mouth should be identified. Laboda (1990) reported an unusual but dangerous complication of implant surgery. Minimal perforations of the lingual plate and inferior border of the mandible had been considered previously to be benign occurrences. Ten Bruggencate et al. (1993) have indicated that two cases of this life-threatening complication are reported. Ratschew et al. (1994) reported that the bleeding results are from the implant osteotomy preparation in the anterior mandible. Mordenfeld et al. (1997) described a life-threatening hemorrhage in the floor of a patient’s mouth during routine implant placement in the anterior mandible. Airway obstruction caused by hematoma development resulted in acute nasotracheal intubation and subsequent surgical intervention. Darriba and Medonca-Caridad (1997) reported hemorrhage in the floor of a patient’s mouth during implant placement in the anterior mandible. Panula and Oikarinen (1999) reported severe hemorrhage after implant surgery. The reported cause of the bleeding was tear of lingual periostium. Givol et al. (2000) described a case of emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region. They stressed that short implants (14mm or less) should be used in the mandibular canine region and that effective treatment of this complication is essential. Niamtu (2001) reported a case of near-fatal airway obstruction secondary to sublingual bleeding and hematoma is presented. Furthermore, the authors indicated that the floor of the mouth contains branches of the submental, sublingual and mylohyoid arteries that may lead to life-threatening complications. This caution obviously extends to any dentoalveolar surgical procedure that concerns the floor of the mouth such as tori removal, extractions, and iatrogenic dental injuries. Isaacson (2004) reported a 56-year-old man with severe caries underwent multiple mandibular tooth extractions and alveoloplasty and received endosseous implants. During the surgical procedure, the patient developed a large sublingual hematoma that required hospitalization. They recommended that practitioners who perform implant surgery in the anterior mandible should notify patients of the potential risk of sublingual hematoma formation, and be able to manage acute airway that may result from this complication. Boyes-Varley and Lownie (2002) described an extensive hematoma in the floor of the mouth, following placement of implant in the anterior mandibular region, which rapidly became life-threatening, requiring an emergency tracheostomy to establish a surgical airway. Kalpidis and Setayesh (2004) have mentioned that massive internal bleeding in the highly vascularized region of the floor of the mouth is the result of an arterial trauma induced by instrumentation, usually through a perforation of the lingual cortical plate. Depending on the clinical situation, hemorrhage may commence immediately or with some delay after the vascular insult. The progressively expanding lingual, sublingual, submandibular, and submental hematomas have the tendency of displacing the tongue and floor of the mouth to obstruct the airway. Budihardja et al. (2006) described a case of life-threatening hemorrhage in the floor of the mouth after second-stage surgery to place the healing abutment. The implants were forced to match with the prosthesis in a severely atrophic lower jaw, resulting in perforation of the lingual cortex and mucosa of the floor of the mouth. Woo et al. (2006) described a life-threatening complication that resulted from the placement of mandibular implants. Dubois et al. (2010) reported that an immediate and delayed case of massive bleeding in the floor of the mouth after implant placement. This highly vascularized region is vulnerable and bleeding can be induced easily by instrumentation, causing a vascular trauma, usually by perforation of lingual periostium. They indicated that in almost all cases the expanding hematoma formation starts during surgery. The effect of the vasoconstrictive agent in the local anesthetic combined with an injury of the lingual arterio-venous plexus can result in delayed swelling, causing respiratory distress through obstruction of the upper airways. Frenken et al. (2010) reported that a patient experienced severe bleeding in the floor of the mouth as a consequence of the placement of 2 implants in the resorbed anterior segment of the mandible. The resulting swelling of the floor of the mouth caused a life-threatening obstruction of the trachea. The patient was urgently transferred to a hospital. Treatment there consisted of the administration of medication and intensive observation. Del Castillo-Pardo et al. (2008) reported that a 53-year-old man developed a hematoma of the floor of the mouth following dental implant procedure, requiring admission to the hospital. Pigadas et al. (2009) presented the case of a patient who attended their unit with acute airway obstruction following osseo-integrated implant placement in the anterior mandible.
4. Discussion
The design of clinical implant studies in the mandible anterior area has not been standardized, the reporting of the incidence of the hematoma tends to vary among studies in the literature, consequently, there are only a small number of studies reporting that complications (Table 1). This variation makes it difficult to determine whether an unreported complication was not evaluated as part of the study data collection, never occurred, or may have occurred but was not reported. Perforating the lingual cortex of the anterior mandible invades the floor of the mouth, and creates opportunity to damage structures in the sublingual area. It is necessary for dental implant practitioners to investigate the anatomy and vascular supply of the mandible at the stage of pre-treatment plan. Most studies indicate that the submental and sublingual arteries may course intimately to the lingual cortical plate from the floor of the mouth (Krenkel et al., 1985, Dubois et al., 2010, McDonnel et al., 1994). Bavitz et al. (1994) reported that the submental artery is most often the arterial major source to supply blood to the floor of the mouth and lingual gingiva (60% of the lateral neck dissection in 74 dissected human adult cadavers had a large branch of the submental artery perforating the mylohyoid muscle. Thirty-three percentage of the dissections of the floor of the mouth revealed a small sublingual artery. In all of these cases, a large branch of the submental artery was found perforating the mylohyoid.
Hofschneider et al. (1999) reported that the injured vessels in the floor of the mouth are most likely branches of the sublingual artery and not the submental artery as suggested by Bavitz et al. (1994).
Bavitz et al., 1994, Hofschneider et al., 1999 indicated that the arterial major supply of the anterior mandible depends on the sublingual artery and submental artery as well.
Practitioners should assess the anatomy of the mandibular lingual foramen and its linked canals (mandibular lingual vascular canals), describing their frequency, diameter, and location. The use of X-ray imaging, is not a useful substitute as it may not visualize these canals (McDonnel et al., 1994), but dental CT has the advantage for pre-implantation assessment of jaw anatomy to visualize the position, diameter and course of the lingual vascular canals of the mandible. However, in the most reported cases in this study a drilling depth of 15mm has been used during implant placement procedures and the arterial damage was always induced also by perforation of the lingual cortical plate, in consideration of the very rich bloody supply plexus which is close to the lingual cortical plate, and not directly by the mandibular lingual vascular canals because of their short diameter (Scaravilli et al., 2009). In patients with atrophic edentulous mandible, the alveolar ridge resorption could be considered a risk factor for lingual cortical plate perforation by implant placement and other surgical procedures (Woo et al., 2006).
The primary procedures to control the bleeding in the dental office and the experience of the general practitioners are so limited. Bavitz et al. (1994) indicated that previous attempts to ligate the lingual artery for floor of mouth hemorrhage may be ineffective and that the sublingual or its parent facial artery should be ligated first. If this does not control the bleeding, then the lingual artery should be ligated. Arterial ligation procedures are complex operations and require the expertise of a surgeon skilled in head and neck surgery. External arterial ligation is only used in severe or uncontrollable cases. Successful exploration of the floor of the mouth with visualization and ligation of the offending vessel has been described (Laboda, 1990).
There are preventative measures to be considered before placing implants in an atrophic mandible. One simple method is to palpate the lingual surface to determine the possibility of perforation potential. In addition, palpation of the lingual surface of the mandible during the preparation while gently advancing the bur would be helpful. A lingual subperiosteal flap will ensure direct observation and protection of the lingual structures for those patients in whom perforation is a concern. It is recommended to use computed tomographs or tomograms that show the mandibular anatomy in a sagittal plane. Such procedure would be preferable in the pre-assessment of the dental implants particularly in the mandible anterior area.
5. Conclusion
Although implant placement in the edentulous anterior mandible is a common procedure, it is not without a risk. Clinicians should inform patients of that potential complication, and surgeons should be well educated and trained to apply the primary emergency procedures in the treatment of sublingual hematoma. Clinicians should assess the mandible anatomy for the patient to determine if he or she is a good candidate for implants, as well as determine the correct implant length. Early recognition and treatment of the sublingual hematoma should result in a favorable prognosis for the patient.
References
- . Arterial supply to the floor of the mouth and lingual gingivae. Oral Surg. Oral Med. Oral Pathol. 1994;77:232–235
- . Haematoma of the floor of the mouth following implant placement. SADJ. 2002;57:64–65
- . Hemorrhage in the floor of the mouth after second-stage surgery: case report. Implant Dent. 2006;148–152
- . Profuse bleeding and life-threatening airway obstruction after placement of mandibular dental implants. J. Oral Maxillofac. Surg. 1997;55:1328–1330
- . Hematoma of the floor of the mouth and airway obstruction during mandibular dental implant placement: a case report. Oral Maxillofac. Surg. 2008;12(4):223–226
- . Excessive bleeding in the floor of the mouth after endosseous implant placement: a report of two cases. Int. J. Oral Maxillofac. Surg. 2010;39(4):412–415
- . Haematoma of the floor of the mouth following implant surgery. Ned. Tijdschr. Tandheelkd. 2010;117(1):17–21
- . Emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region. J. Periodontol. 2000;71:1893–1895
- . Assessment of the blood supply to the mental region for reduction of bleeding complications during implant surgery in the interforaminal region. Int. J. Oral Maxillofac. Implants. 1999;14:379–383
- . Sublingual hematoma formation during immediate placement of mandibular endosseous implants. J. Am. Dent. Assoc. 2004;135:168–172
- . Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of literature. J. Periodontol. 2004;75:631–645
- . Critical hemorrhage in the floor of the mouth during implant placement in the first mandibular premolar position: a case report. Implant Dent. 2005;117–124
- . Lingual bone perforation as causal factor in a threatening hemorrhage of the mouth floor due to a single tooth implant in the canine region. Quintessenz. 1986;37:1003–1008
- . Hematoma of the mouth floor following oral surgery and its anatomical characteristic. Dtsch. Z. Mund. Kiefer Gesichtschir. 1985;9:448–451
- . Life-threatening hemorrhage after placement of an endosseous implant: report of case. J. Am. Dent. Assoc. 1990;121:599–600
- . An assessment on spiral CT scan of the superior and inferior genial spinal foramina and canals. Surg. Radiol. Anat. 2006;28:98–104
- . Anatomical variation in arterial supply of the mandible with special regard to implant placement. Int. J. Oral Maxillofac. Surg. 2008;37:367–371
- . Life-threatening hemorrhage from placement of a dental implant. J. Oral Maxillofac. Surg. 1990;48:201–204
- . The mandibular lingual foramen: a consistent arterial foramen in the middle of the mandible. J. Anat. 1994;184:363–369
- . Hemorrhage in the floor of the mouth during implant placement in the edentulous mandible: a case report. Int. J. Oral Maxillofac. Implants. 1997;12:558–561
- . Near-fatal airway obstruction after routine implant placement. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2001;92:597–600
- . Letters to the editor: severe hemorrhage after implant surgery. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1999;87:2
- . Massive sublingual haematoma following osseo-integrated implant placement in the anterior mandible. Br. Dent. J. 2009;206(2):67–68
- . Life threatening hemorrhage during placement of dental implants in the mandible. A case report (in German). Dtsch Zahnartztl Z. 1994;49:65–67
- . Mandibular lingual vascular canals (MLVC): evaluation on dental CTs of a case series. Eur J Radiol. 2009;(Epub ahead of print)
- . Hemorrhage of the floor of the mouth resulting from lingual perforation during implant placement: a clinical report. Int. J. Oral Maxillofac. Implants. 1993;8:329–334
- . Floor of mouth haemorrhage and life threatening airway obstruction during immediate implant placement in the anterior mandible. Int. J. Oral Maxillofac. Surg. 2006;35:961–964
PII: S1013-9052(11)00075-7
doi:10.1016/j.sdentj.2011.11.003
© 2011 Published by Elsevier Inc.
