Dental implant insertion is considered a safe and reliable surgical procedure and severe complications are seldom reported. However, we present a case of a 52-year-old patient who attended our Department of Oral and Maxillofacial Surgery, Johannes Gutenberg University Medical Center, Mainz, with spreading hematoma in the floor of the mouth and acute airway obstruction after insertion of a dental implant in the anterior mandible. The hematoma was removed and submentally drained by a silicon drainage. However, the progressive swelling of the tongue and the floor of the mouth necessitated a temporary tracheotomy for three days. The review of the literature summarizes guidelines for prevention and management of this life-threatening complication.
A 52-year-old otherwise healthy woman was referred to the outpatients department of the clinic for oral and maxillofacial surgery, Johannes Gutenberg University Medical Center, Mainz, around 7.30 p.m. as emergency consultation. Two hours before the incident her dentist had performed in his private praxis immediate interforaminal implant insertion (regions 32 and 42) and guided bone regeneration after extraction of teeth 32 and 42. On clinical inspection the patient presented a dysphagia with compromised speech and swallowing. The tongue was elevated up to the hard palate by a spreading hematoma at the floor of the mouth (Figure
Elevated floor of the mouth with protruding tongue.
Cone beam tomography of the implant in region 32.
Patient postoperative with tracheotomy and extraoral drainage in the chin region.
Postoperative orthopantogram.
Dental implants are set worldwide with numbers in the millions, thus resembling basically a safe therapeutic option with a thorough planning and a careful operation technique as prerequisite [
Case reports about vital life-threatening bleeding after implant insertion published in the years 2000–2015.
Study | Age | Region | Treatment |
---|---|---|---|
Givol et al., 2000 [ |
63 | Anterior mandible | Surgery, tracheotomy |
Niamtu, 2001 [ |
64 | Anterior mandible | Tamponade, compression, and tracheotomy |
Weibrich et al., 2002 [ |
60 | Posterior mandible | Surgery |
Boyes-Varley and Lownie, 2002 [ |
50 | Anterior mandible | Surgery, tracheotomy |
Isaacson, 2004 [ |
56 | Anterior mandible | Surgery |
Kalpidis and Konstantinidis, 2005 [ |
43 | Posterior mandible | Tamponade, compression |
Budihardja et al., 2006 [ |
80 | Anterior mandible | Tracheotomy |
Woo et al., 2006 [ |
47 | Anterior mandible | Surgery, tracheotomy |
de Vera et al., 2008 [ |
53 | Anterior mandible | Surgery |
Ferneini et al., 2009 [ |
77 | Posterior mandible | Observation |
Pigadas et al., 2009 [ |
71 | Anterior mandible | Surgery, tracheotomy |
Dubois et al., 2010 [ |
76 and 62 | Anterior mandible | Case 1: surgery, tracheotomy; |
Hong and Mun, 2011 [ |
54 | Posterior maxilla | Surgery |
Felisati et al., 2012 [ |
62 | Anterior mandible | Surgery, tracheotomy |
Lee et al., 2012 [ |
69 | Anterior mandible | Surgery |
Hwang et al., 2013 [ |
53 | Anterior mandible | Surgery |
Sakka and Krenkel, 2013 [ |
66 | Anterior mandible | Surgery |
The bleeding may lead to a rapid progressive and severe swelling of the floor of the mouth with affection of the deep spaces, rapid airway obstruction, and dyspnoea as life-threatening consequence. Patients with an episode of severe bleeding may present with visible loss of blood via the oral cavity, swelling, and protrusion of the tongue and floor of the mouth. As a consequence, it comes to deficiency in swallowing, problems when speaking, and increasing dyspnoea. As first therapeutic option one may perform bidigital compression; also the insertion of tamponades or application of hemostatic agents (e.g., tranexam gel) is helpful. The patient should be calmed down to reduce hypertension in the state of anxiety. In addition, oxygen may be supplied via the nose to lessen dyspnoea stress. A rapid transport to the nearest clinic should always be made, since a suspicion of bleeding in the floor of the mouth justifies the transfer of the patient to a specialist clinic [
In conclusion, the risk of severe bleedings in the anterior mandible should be kept in mind. For prevention of this serious complication a detailed diagnosis and planning of surgery should be done. Risk patients (e.g., patients with anticoagulant medication or high blood pressure) should be identified in advance; the indications should be carefully reviewed and specific surgical precautions should be applied. In case of lingual perforation during implant insertion in the anterior region, the operation should be stopped or placement of a shorter implant should be considered. In unclear cases an X-ray computed tomography could be performed postoperatively. These patients should receive a prolonged follow-up and detailed information about precautions.
The authors declare that they have no conflict of interests related to this case report.