Excessive bleeding in the floor of the mouth after endosseus implant placement: a report of two cases

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.

Fig. 1
Example of lingual strip (case 2) with clinical optimal implant position.

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.

Fig. 2
Elevated, ecchymosed floor of the mouth in case 1.

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.

Fig. 3
Elevated, ecchymosed floor of the mouth with protruding tongue in case 2.

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.

Fig. 3
Elevated, ecchymosed floor of the mouth with protruding tongue in case 2.

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.

Table 1
Case reports associated with massive hemorrhage after implant placement in the anterior mandible.
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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Feb 8, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Excessive bleeding in the floor of the mouth after endosseus implant placement: a report of two cases
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