26 June 2024

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Critical Hemorrhage in the Floor of the Mouth During Implant Placement in the First Mandibular Premolar Position: A Case Report

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Although dental implantation is considered to be a safe surgical procedure, this report focuses on a critical hemorrhaging episode associated with implant placement in the first mandibular premolar position. Excessive bleeding and formation of massive lingual, sublingual, and submandibular hematomas were the result of arterial trauma that occurred during the osteotomy preparation. The vascular injury was induced through a perforation of the lingual mandibular cortex. Critical bleeding was conservatively controlled and the case was furtherhandled efficiently with an expectant airway management in a hospital environment. Similar case reports are reviewed in an attempt to draw attention to this rare but potentially life-endangering risk of implant dentistry. Common causes of severe hemorrhage in the floor of the mouth, anatomical considerations, bleeding control measures, and related airway issues are also discussed.

Upper airway embarrassment has been considered a rare but potentially life-threatening complication of severe internal lingual/sublingual hemorrhage. The enlarged tongue is displaced posteriorly, obliterates the oral airway, and encroaching upon the pharyngeal wall, sets the ground for a respiratory emergency. Dangerous upper airway obstruction, secondary to massive bleeding may result from malignant invasion, vascular malformation, hypertension, intraoral piercing, coagulation disorders, anti-thrombotic pharmacotherapy, maxillofacial trauma, and iatrogenic arterial insult.

Critical hemorrhagic episodes have been described in the literature following erosion of the suprahyoid, lingual, deep lingual, and sublingual arteries by squamous cell carcinoma of the tongue.1,2 Tongue lymphangiomas are vascular hamartomas of varying severity with a history of recurrent lingual enlargement and possible airway blockage after traumatic or infectious insult.3,4 Even though intracranial bleeding or epistaxis are typical manifestations of uncontrolled high blood pressure, a spontaneous severe lingual/paralingual hemorrhage and disastrous respiratory deterioration have been reported, secondary to extreme hypertension.5 Prolonged bleeding and considerable swelling are frequently encountered complications of tongue piercing related to the high vascularity of the region. Serious internal lingual hemorrhage resulting in upper airway embarrassment, has been reported as a life-threatening risk of tongue piercing.6

Congenital and acquired coagulopathies may be related to unique internal bleeding in the lingual/sublingual tissues and to subsequent respiratory embarrassment.3,7 Treatment of acute ischemic cerebrovascular episodes and myocardial infarctions with tissue plasminogen activator, aspirin, heparin, or streptokinase has occasionally induced lingual, sublingual, and submandibular hematomas with subsequent airway deterioration.8–10 In addition, chronic prophylactic administration of heparin and warfarin has also precipitated similar spontaneous and metatraumatic life-endangering incidents.11–13

Massive lingual/sublingual hemorrhage and following airway emergencies have been reported in gunshot wounds through the lower face,14 home accidents,15 and blunt trauma of the head caused by traffic collisions.16–18 Self-inflicted tongue biting during eclamptic,19 alcohol withdrawal,20 or convulsive21 seizures with consequent hemorrhage and airway obstruction have been sporadically published in the literature. In these exceptional cases, prolonged macroglossia may be sustained through impaired drainage caused by strangulation of the protruded tongue between the teeth.19,21

However, the majority of lingual/sublingual hemorrhagic incidents stem from iatrogenic manipulation. Vascular necrosis induced by radiation therapy for the treatment of tongue carcinomas may result in profuse hemorrhage and airway blockage.1 Cleft palate repairs,22 orthognathic mandibular osteotomies,23 periodontal surgery involving osteoplasty,24 mandibular vestibuloplasties,25,26 and biopsy24,27 or surgical excision of lesions from the floor of the mouth,13,28 have been occasionally complicated by dangerous restriction of the upper airway and hemorrhage in the floor of the mouth. Both simple and surgical exodontia has also been associated with similar life-threatening or even fatal episodes.24,28–31 Even infiltration of an anesthetic solution adjacent to the lingual periosteum and simple procedures in the dental practice involving the use of rotating burs have occasionally provoked brisk bleeding and respiratory problems.28,32

Sporadic incidents of potentially life-threatening airway embarrassment secondary to perilous hemorrhage in the floor of the mouth have also been encountered during or after implant surgery in the mandible.33–45 The purpose of this article is a) to present a case of implant placement in the position of the first mandibular premolar with formation of extensive intraoral hematomas; b) to review similar bibliographic reports; and c) to discuss the etiology and management of this grave complication. Moreover, it was within the objectives of this report to draw the attention of specialists and general practitioners involved in dental implantation to this unusual but hazardous risk of implant dentistry.

Author: Kalpidis, Christos D. DDS, DSc; Konstantinidis, Anthony B. DDS, MSc, PhD

Source: https://journals.lww.com/