Hemorrhage Related to Implant Placementin the Anterior Mandible

Ji-Ho Jo, DDS,* Su-Gwan Kim, DDS, PhD,† and Ji-Su Oh, DDS, MSD‡

In edentulous patients, implantplacement in the anterior mandiblehas been performed commonly for

the stability and maintenance of com-plete dentures. In such cases, most im-plants are placed in the space betweenthe 2 mental foramens, and this areahas been relatively recognized to besafe for implant placement without se-rious complications. In addition, thesuperior and inferior cortical plates ofthis area provide advantages for thestability of implants.1

However, serious complicationsmay develop even with implant place-ment in the interforaminal area. Numerousstudies have reported on life-threateningcomplications caused by implants.2–7

Among them, hematoma in the sublin-gual space that develops duringimplant placement in the anterior man-dible is a rare but serious complicationthat may be fatal.2–5,8–10 Hemorrhage oc-curring during implant placement iscaused by the perforation of the lingualplate and the damage of the peripheralbranch of adjacent artery. This hemor-rhage spreads to the sublingual spaceand the loose tissues between lingualmuscles and may occur as immediate ordelayed hemorrhage. The edema that

develops at that time elevates the tongueand induces the obstruction of the upperairways, and an emergency airway man-agement may be required.

Several authors11–14 have studiedthe blood supply to the floor of mouth,the interforaminal area, and the mentumusing computed tomography (CT) andcadavers, and it has been reported thatthe blood vessels are the terminal branchof the sublingual artery and submentalartery that penetrate the lingual corticalplate of the anterior mandible.

The bleeding complication associ-ated with implant placement can occurat the maxilla and in the mandible.The risk of bleeding followed by aninjury of the branch of the maxillaryartery during sinus graft procedureswas reported by Lee15 and Flanagan.16

This study was conducted to ex-amine the hemorrhagic complicationsthat may develop during implantplacement in the anterior mandibleand to evaluate the risks. And themanagement following hemorrhagewill be reviewed.

MATERIALS AND METHODS

This study was a review of theliterature of hemorrhages associatedwith placement of implants. The liter-

ature was collected by an Internetsearch, and the keywords for thesearch were “implant,” “bleeding,”“complication,” and “hematoma.” Thestudies were not limited to those fromspecific journals, and the studies ofimplant complications publishedwithin the past 15 years were reviewedprimarily. In addition, studies ofplacement of implants in the maxillaand posterior mandible were excludedfrom this study.

RESULTSCauses of Hemorrhage—Anatomical Review

It is without a doubt that hemor-rhages are caused by the damage ofblood vessels. In addition, it is widelyaccepted that the sublingual artery,which is a branch of the lingual artery, isthe main supply artery to the floor ofmouth. It has been also revealed that thesubmental artery also plays an importantrole in the blood supply to the floor ofmouth.11,12,17 The terminal branches ofthese submental artery and the sublin-gual artery run toward the lingual side ofthe anterior mandible in parallel to thegenioglossus muscle, and anastomoseduring running (Fig. 1).6 The terminalbranch of the sublingual artery pene-

*Resident, Department of Oral & Maxillofacial Surgery, Schoolof Dentistry, Chosun University, Gwangju, Republic of Korea.†Professor and Chairman, Department of Oral & MaxillofacialSurgery, School of Dentistry, Chosun University, Gwangju,Republic of Korea.‡Fellow, Department of Oral & Maxillofacial Surgery, School ofDentistry, Chosun University, Gwangju, Republic of Korea.

Reprint requests and correspondence to: Su-GwanKim, DDS, PhD, Department of Oral andMaxillofacial Surgery, School of Dentistry, ChosunUniversity, 375, SeoSukDong, DongGu, GwangJuCity, South Korea 501-759, Phone: 82-62-220-3815,Fax: 82-62-228-7316, E-mail: sgckim@chosun.ac.kr

ISSN 1056-6163/11/02003-033Implant DentistryVolume 20 • Number 3Copyright © 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3182181c6b

Implant placement in the eden-tulous anterior mandible is rela-tively considered a routine and safeprocedure. The interforaminal areais the usual area in the mandible forimplant placement for the supportand retention of a fixed partial den-ture or removable overdenture. Thisregion is also the usual donor site ofbone grafts. However, implant

placement, like any other surgicalprocedure, is not free of risks andcomplications. The purpose of thisreview article was to investigate therisk of a life threatening hemorrhagedue to arterial injury at implantplacement in the anterior mandible.(Implant Dent 2011;20:e33–e37)Key Words: hemorrhage, anteriormandible, implant, complication

IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e33

trates the lingual cortical bone andreaches the inside of the mandible insome cases. In studies of dried craniumand studies using CT scan, the perfo-rated arteries in the lingual plate of an-terior mandible was observed in 80%and 60%, respectively.18

If the lingual cortical bone is per-forated during implant placement, asshown in Fig. 1, the sublingual arterymay be injured, and although rare, itmay be a cause of life-threateninghemorrhage.6 In addition to an injuryin the sublingual artery, tearing of theperiosteum caused by the lift of peri-osteal flap may also be a cause ofsevere hemorrhage. Even when themandibular lingual cortical bone is notperforated, the sublingual artery run-ning within the bone may be injured,causing a hemorrhage. Once hemor-rhage occurs, blood may spread intothe connective tissues in the floor ofmouth and the sublingual space, whichmay lift the tongue and result in theobstruction of the upper airways. Thismay become an emergency situationrequiring endotracheal intubation oremergency tracheostomy. It has beenreported that the possibility of such ahemorrhage is increased in patientswho have been taking anticoagulantsfor a long time.19,20

Hemorrhage Management

When a blood vessel is injuredduring implant placement, first, thedentist should evaluate the airway.The endotracheal intubation or trache-

ostomy may be required in somecases. Once the airway is secured, thenext task is hemostasis. Hemorrhagecould be managed by the insertion ofgauzes,5,21 application of hemostaticagents,5,8 electric cauterization,9 or fin-ger compression methods.2,8,19 Arteryligation could be one of the methodsfor hemostasis. But, drain insertion forthe purpose of reducing the pressurecould prevent hemostasis.22 In a seri-ous hemorrhage, vascular angiographymay be of help to find the hemorrhagesite.23

DISCUSSION

This study confirms the potentialrisk of implant placement in theanterior mandible. In edentulous pa-tients in particular with severe re-sorption of the alveolar bone, thepossibility of injury due to lingualperforation of blood vessels wouldbe increased. It has been confirmedby several studies that injury of thelingual periosteum or the rupture ofthe sublingual artery during implantplacement may induce continuoushemorrhage, and the hemorrhagecould form a large hematoma in thefloor of mouth without particular re-sistance.20,22 In addition, such a he-matoma could be indurated at neckpalpation. For the spread pattern, theclinical characteristics are similar tothe infection pathway, and thespread is rapid, resulting in the ob-struction of the upper airway such as

Ludwig’s angina. For the treatmentof hemorrhage, endotracheal intuba-tion for securing the airway, trache-ostomy, hemostasis with hemostaticagents, arterial ligation, compres-sion, and other procedures wereperformed.1–5,8 –10

If implant placement in the an-terior mandible is planned, dentistsshould perform presurgical evalua-tion by CT, etc., to determine thepresence or absence of the lingualperforation artery and its location. Ithas already been established as oneof the most effective presurgical di-agnostic methods in dental implantplacement.24

Longoni et al18 have reported thatin studies of dried skulls and CT im-ages, at least 1 lingual perforation ar-tery was observed in 80% and 60%,respectively, and the number rangedfrom 1 to 4. In addition, the lingualperforation artery was observed in themedian area of the mandible in �51%of the entire dry skulls, and similarly,on CT images, the perforation arterywas observed in the median area ofmandible in �55%.

During placement of implant inthe anterior mandible, a serious hem-orrhage rarely occurs. But, when itdoes occur, surgeons should make ef-forts to secure the airway and performhemostasis immediately.

CONCLUSION

As shown in this study, numerousinvestigators have reported that place-ment of implant in the anterior man-dible are not as safe as we believe.During implant placement in the ante-rior mandible, especially in the me-dian area, special attention should bepaid on the lingual perforation branchof the sublingual artery, and for this, itis essential to conduct clinical exami-nation including CT.

Disclosure

The authors claim to have no fi-nancial interest, directly or indirectly,in any company or product mentionedin this article.

REFERENCES

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Fig. 1. The anatomical features of the sublingual and submental arteries in the sublingualregion. The arrow indicates the perforation of the lingual artery that can cause fatal bleedingcomplications during the placement of implants.

e34 IMPLANT PLACEMENT IN THE ANTERIOR MANDIBLE • JO ET AL

LJ, Ellis E III, Hupp JR, et al, eds. Contem-porary Oral and Maxillofacial Surgery. 3rded. St. Louis, MO: Mosby; 1998:308-309.

2. Mason ME, Triplett RG, Alfonso WF.Life-threatening hemorrhage from place-ment of a dental implant. J Oral MaxillofacSurg. 1990;48:201-204.

3. Budihardja AS, Pytlik C, HaarmannS, et al. Hemorrhage in the floor of themouth after second-stage surgery: Casereport. Implant Dent. 2006;15:148-152.

4. Givol N, Chaushu G, Halamish-Shani T, et al. Emergency tracheostomyfollowing life-threatening hemorrhage inthe floor of the mouth during immediateimplant placement in the mandibular ca-nine region. J Periodontol. 2000;71:1893-1895.

5. ten Bruggenkate CM, Krekeler G,Kraaijenhagen HA, et al. Hemorrhage ofthe floor of the mouth resulting from lingualperforation during implant placement: Aclinical report. Int J Oral Maxillofac Im-plants. 1993;8:329-334.

6. Kalpidis CD, Setayesh RM. Hemor-rhaging associated with endosseous im-plant placement in the anterior mandible: Areview of the literature. J Periodontol.2004;75:631-645.

7. Kalpidis CD, Konstantinidis AB. Crit-ical hemorrhage in the floor of the mouthduring implant placement in the first man-dibular premolar position: A case report.Implant Dent. 2005;14:117-124.

8. Boyes-Varley JG, Lownie JF.Haematoma of the floor of the mouth fol-lowing implant placement. SADJ. 2002;57:64-65.

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Profuse bleeding and life-threatening air-way obstruction after placement of man-dibular dental implants. J Oral MaxillofacSurg. 1997;55:1328-1330.

10. Panula K, Oikarinen K. Severehemorrhage after implant surgery. OralSurg Oral Med Oral Pathol Oral RadiolEndod. 1999;87:2.

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12. Bavitz JB, Harn SD, Homze EJ. Ar-terial supply to the floor of the mouth andlingual gingiva. Oral Surg Oral Med OralPathol. 1994;77:232-235.

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14. Gahleitner A, Hofschneider U, Tep-per G, et al. Lingual vascular canals of themandible: Evaluation with dental CT. Radi-ology. 2001;220:186-189.

15. Lee CY. Brisk, prolonged pulsa-tile hemorrhage during the sinus graftprocedure: a case report with discussionon intra-operative hemostatic manage-ment. Implant Dent. 2010;19:189-195.

16. Flanagan D. Arterial supply ofmaxillary sinus and potential for bleedingcomplication during lateral approach si-nus elevation. Implant Dent. 2005;14:336-339.

17. Martin D, Pascal JF, Baudet J, etal. The submental island flap: A new donorsite. Anatomy and clinical applications as afree or pedicled flap. Plast Reconstr Surg.1993;92:867-873.

18. Longoni S, Sartori M, Braun M, etal. Lingual vascular canals of the mandible:The risk of bleeding complications duringimplant procedures. Implant Dent. 2007;16:131-138.

19. Rosenbaum L, Thurman P, KrantzSB. Upper airway obstruction as a compli-cation of oral anticoagulation therapy. Re-port of three cases. Arch Intern Med. 1979;139:1151-1153.

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Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Ji-Ho Jo, DDS, Su-Gwan Kim, DDS, PhD,Ji-Su Oh, DDS, MSDBlutungskomplikationen bei Implantatsetzung im vorderenUnterkiefer

ZUSAMMENFASSUNG: Die Einpflanzung von Implan-taten im zahnlosen vorderen Unterkiefer wird als relativerRoutineeingriff mit großer Sicherheit angesehen. Die In-terforaminalregion ist der Bereich, in dem normalerweiseim Unterkiefer eine Transplantierung durchgefuhrt wird,um damit eine feste Teilprothese oder herausnehmbareProthese zu stutzen und zu halten. Auch wird in diesemBereich normalerweise die Entnahme von Spendergewebedurchgefuhrt, falls eine Transplantierung vorgenommen

werden soll. Jedoch ist eine Implantierung wie jeder an-dere chirurgische Eingriff nicht ohne Risiken und mogli-che Komplikationen. Der vorliegende Uberblicksartikelzielte darauf ab, das Risiko einer lebensbedrohlichen Blu-tung aufgrund Arterienverletzung bei Implantierung imvorderen Unterkiefer zu untersuchen.

SCHLUSSELWORTER: Blutung, vorderer Unterkiefer, Im-plantat, Komplikation

SPANISH / ESPAÑOLAUTOR(ES): Ji-Ho Jo, DDS, Su-Gwan Kim, DDS, PhD,Ji-Su Oh, DDS, MSDComplicacion de sangrado relacionada con la colocaciondel implante en la mandíbula anterior

IMPLANT DENTISTRY / VOLUME 20, NUMBER 3 2011 e35

ABSTRACTO: La colocacion del implante en la mandíbula an-terior sin dientes se considera un procedimiento relativamente se-guro y rutinario. La region interforaminal es el lugar usual de lamandíbula donde se coloca el implante para ofrecer el apoyo yretencion de una dentadura parcial fija o sobredentadura removible.Esta region tambien es el lugar usual de donacion para los injertosde hueso. Sin embargo, la colocacion del implante, como cualquierotro procedimiento quirurgico, no esta libre de riesgos y complica-ciones. El proposito de este trabajo es investigar el riesgo de unahemorragia que ponga en peligro la vida debido a una lesion arterialen la colocacion del implante en la mandíbula anterior.

PALABRAS CLAVES: hemorragia, mandíbula anterior, im-plante, complicacion

PORTUGUESE / PORTUGUÊSAUTOR(ES): Ji-Ho Jo, Cirurgiao-Dentista, Su-Gwan Kim,Cirurgiao-Dentista, PhD, Ji-Su Oh, Cirurgiao-Dentista,Mestre em OdontologiaComplicacao de Sangramento Relacionada a Colocacao deImplante na Mandíbula Anterior

RESUMO: A colocacao de implante na mandíbula anteriordesdentada e considerada um procedimento relativamente roti-neiro e seguro. A area interforaminal e a area usual na mandíbulapara colocacao de implante para o suporte e retencao de umadentadura parcial fixa ou sobredentadura removível. Essa regiaotambem e a area doadora usual de enxertos osseos. Contudo, acolocacao de implante, como qualquer outro procedimentocirurgico, nao e isenta de riscos e complicacoes. O propositodeste artigo de revisao era investigar o risco de uma hemorragiaameacadora da vida devido a lesao arterial na colocacao deimplante na mandíbula anterior.

PALAVRAS-CHAVE: hemorragia, mandíbula anterior, im-plante, complicacao

RUSSIAN /������: Ji-Ho Jo, ������ ���������� �����������, Su-Gwan Kim, ������ ���������� �����������, ������ ���������, Ji-Su Oh, ���������������� �����������, ������ ���������������� � ������� �����������

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TURKISH / TURKCEYAZARLAR: Ji-Ho Jo, DDS, Su-Gwan Kim, DDS, PhD,Ji-Su Oh, DDS, MSDAnterior Alt Cenede Implant Yerlestirme ile Baglantılı Ka-nama Komplikasyonu

OZET: Dissiz anterior alt cenede implant yerlestirme, rutinve guvenli bir islem olarak kabul edilir. Sabit bir kısmiprotezin ya da hareketli bir dis ustu protezin desteklenmesi vetutturulması icin implant yerlestirmede genellikle interforam-inal alan kullanılır. Bu bolge aynı zamanda genelde kemikgreftleri icin kullanılan donor yeridir. Ancak, baska herhangibir cerrahi islemi icin soz konusu oldugu gibi, implantyerlestirme risksiz ve komplikasyonsuz bir islem degildir. Buinceleme yazısının amacı, anterior alt cenede arteryelyaralanma nedeniyle yasamı tehdit eden kanama riskiniarastırmaktı.

ANAHTAR KELIMELER: kanama, anterior alt cene, im-plant, komplikasyon

e36 IMPLANT PLACEMENT IN THE ANTERIOR MANDIBLE • JO ET AL

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