Abstract
Placement of dental implants in the interforaminal region of the edentulous mandible is considered a safe and routine surgical procedure. Hemorrhage in the floor of the mouth has been reported as a rare, potentially life-threatening complication related to the placement of implants in this region. In this case report the authors present an immediate and a 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. In almost all cases the expanding hematoma formation starts during surgery. The effect of the vasoconstrictive agent in the local anesthesic combined with an injury of the lingual arterio-venous plexus can result in delayed swelling, causing respiratory distress through obstruction of the upper airways.
Implant placement in the anterior mandible is considered to be a safe and routine procedure. Upper airway obstruction secondary to massive hemorrhage in the floor of the mouth is a rare, but potentially life-threatening condition, which can occur as a result of this type of surgery. Severe bleeding and formation of a large hematoma in the floor of the mouth are the result of vascular trauma . This vascular complication can be caused by surgical damage to the lingual periostium, but in most cases it is attributed to unwanted perforations in the lingual cortical plate ( Fig. 1 ). The 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.
Case 1
A 76-year-old woman with an atrophic edentulous mandible was referred. During interforaminal implant placement under local anesthesia, performed by her dentist, bleeding in the floor of the mouth resulted in progressive swelling of her tongue. The dentist immediately called for medical support. The patient had no history of bleeding disorders and did not use any anticoagulant medication. 15 min later the patient presented in the hospital emergency room with mild breathing difficulty. The dentist maintained digital pressure on the lingual cortex. Intraoral examination showed excessive swelling of the tongue and floor of the mouth ( Fig. 2 ). The tongue protruded 6 cm out of the oral cavity. The whole area was extremely ecchymosed, with profuse bleeding from the floor of the mouth. The patient was immediately taken to the operating room, and her saturation level (>90%) was monitored. The patient was very calm and had good saturation. The anesthesiologist chose a fiber-optic intubation with the patient awake and a controlled tracheostomy. The bleeding area was packed with gauze and, because of the excessive swelling, no further action, other than securing the airway using a tracheostomy, was necessary.
The patient was monitored in the intensive care unit for 5 days. 10 days after implant surgery the tracheo-stoma was removed and the following day she was dismissed from the hospital.
Case 2
A 62-year-old man with an edentulous mandible was referred for placement of dental implants. The patient had no history of bleeding and did not take anticoagulant medication. Two implants were positioned in the interforaminal region and there were no problems during surgery. No lingual perforation was noticed. 7 hours after surgery, the patient contacted the on-call maxillofacial surgeon with respiratory distress and swelling of the floor of the mouth.
At presentation in the emergency room, his saturation dropped below 85%. Intraoral examination showed a protruding tongue, with an ecchymosed, elevated floor of the mouth ( Fig. 3 ). The patient was immediately transported to the operating room and after induction of the general anesthesia, no endotracheal tube could be placed and an acute total obstruction of the upper airway occurred. An emergency tracheostomy was performed, after which the hematoma was evacuated and a sublingual artery was ligated by an intraoral approach. The patient was monitored in the intensive care unit for 4 days and 2 days later the patient was discharged.
Case 2
A 62-year-old man with an edentulous mandible was referred for placement of dental implants. The patient had no history of bleeding and did not take anticoagulant medication. Two implants were positioned in the interforaminal region and there were no problems during surgery. No lingual perforation was noticed. 7 hours after surgery, the patient contacted the on-call maxillofacial surgeon with respiratory distress and swelling of the floor of the mouth.
At presentation in the emergency room, his saturation dropped below 85%. Intraoral examination showed a protruding tongue, with an ecchymosed, elevated floor of the mouth ( Fig. 3 ). The patient was immediately transported to the operating room and after induction of the general anesthesia, no endotracheal tube could be placed and an acute total obstruction of the upper airway occurred. An emergency tracheostomy was performed, after which the hematoma was evacuated and a sublingual artery was ligated by an intraoral approach. The patient was monitored in the intensive care unit for 4 days and 2 days later the patient was discharged.
Discussion
The first patient developed an immediate swelling of the floor of the mouth, whereas the second patient showed a delayed hemorrhage. Immediate hemorrhaging has been described previously . Late hemorrhaging is seldom reported ( Table 1 ). An explanation for the delayed bleeding may be vasoconstriction caused by the local anesthesia, which can mask trauma of the lingual arterio-venous plexus. The initial hemostasis of the constricted artery, which should enable the formation of a blood clot, is lost later when the effect of the vasoconstriction is diminishing, causing delayed hemorrhage.
| Reference | Implant-site | Onset | Reason | Clinical signs | Airway M | Hematoma M | Hosp days |
|---|---|---|---|---|---|---|---|
| Krenkel & Holzer 1986 | #22 | after 4 hours | PRF (O) | elevation of the FOM | intubation | implant removal | 6 |
| SLIN hematoma | evacuation | ||||||
| Mason et al. 1990 | #27 L 18mm | after 4-5 hours | PRF(O) | elevation of the FOM | intubation | compression | 5 |
| SLIN, SMEN, SMAN hematoma | evacuation | ||||||
| respiratory distress | ligation (IO) | ||||||
| Laboda 1990 | #22 | elevation of the FOM | intubation | compression | 6 | ||
| SMEN hematoma | evacuation | ||||||
| ligation (EO) | |||||||
| ten Bruggenkate et al. 1993 | #22 or #27 | after 6 hours | PRF(O) | SMAN and SLIN hematoma | intubation | hemostatic agents | 8 |
| respiratory distress | evacuation | ||||||
| #28 | during implantation | IOP | elevation of the FOM | observation | compression | 1 | |
| lingual HEM | evacuation | ||||||
| Ratschew et al. 1994 | #27 L 15mm | during implantation | IOP | elevation of the FOM | intubation | compression | 11 |
| SLIN and LIN hematoma | |||||||
| respiratory distress | |||||||
| Mordenfeld et al. 1997 | #27 L 15mm | during implantation | PRF (S) | elevation of the FOM | intubation | evacuation | 4 |
| SMEN, SMAN, SLIN hematoma | ligation (EO) | ||||||
| Darriba &Medonca-Caridad 1997 | 4 IMP IF | during implantation | DSM | elevation of the FOM | tracheostomy | evacuation | 14 |
| inra oral bleeding, SLIN hematoma | ligation (IO) | ||||||
| complete airway obstruction | |||||||
| Panula & Oikarinen 1999 | 2 IMP IF | after 30 minutes | TLP | elevation of the FOM | intubation | compression | 7 |
| SLIN and LIN hematoma | surgical expl (IO) | ||||||
| respiatory distress | |||||||
| Givol et al. 2000 | #22 L 18mm | during implantation | PRF (R) | elevation of FOM | tracheostomy | evacuation | 11 |
| SLIN and SMEN HEM | ligation (IO) | ||||||
| respiratory distress | |||||||
| Niamtu 2001 | #22 | during implantation | PRF (O) | elevation of the FOM | tracheostomy | compression | 6 |
| SMEN and SLIN hematoma | hemostatic agents | ||||||
| acute respiratory distress | |||||||
| Boyes-Varley & Lownie 2002 | #23 L 15mm | after 30 minutes | PRF (R,S) | elevation of the FOM | tracheostomy | surgical expl (IO) | 7 |
| SMEN and SLIN hematoma | evacuation | ||||||
| acute respiratory distress | |||||||
| Isaacson 2004 | #27 L 15mm | during implantation | PRF(R) | elevation of the FOM | expectant | implant removal | 2 |
| sublingual HEM | evacuation | ||||||
| ligation (IO) | |||||||
| Kalpidis & Konstantinidis 2005 | #28 L 15mm | during implantation | PRF (O) | elevation of the FOM | expectant | compression | 3 |
| SLIN and LIN hematoma | |||||||
| Budihardja et al. 2006 | 4 IMP IF | PRF(R) | elevation of the FOM | intubation | evacuation | 4 | |
| intra-oral bleeding, SLIN hematoma | ligation (IO) | ||||||
| mild respiratory distress | |||||||
| Woo et al. 2006 | during implantation | PRF (O) | elevation of the FOM | tracheostomy | evacuation | 3 | |
| SLIN and LIN hematoma | ligation (IO) | ||||||
| Respiratory distress | |||||||
| Dubois et al. 2009 | # 27 | during implantation | PRF (O) | elevation of the FOM | tracheostomy | compression | 11 |
| SLIN and SMEN hematoma | |||||||
| respiratory distress | |||||||
| #27 L 12mm | after 6-7 hours | PRF(R) | elevation of the FOM | tracheostomy | compression | 8 | |
| SLIN hematoma | evacuation | ||||||
| complete airway obstruction | ligation (IO) |
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