Implant placement in anterior mandible with slight swelling: thoughts?

You have done the correct thing by getting a scan done . You may have merely entered a vascular area associated with the incisive branch at this level . But prevention is always best so scan before to check anatomy if in doubt then check pilot bur for angle and always check with you finger on the lingual plate when drilling down especially with the final drill to feel for any vibrations. You can also tell if the drilling feels different ( a wobble feeling ) then perforation is possible. Regards Peter

Based on your clininical description the lingual plate was perforated and the patient was very lucky. I don't understand the rationale for prescribing prednisone for hemmorhage control. The patient was lucky that the airway was not compromised. You may have hit a vein or muscle, an arterial bleed most likely would have ended in the ER. One question did keep the patient there for 5 hours?

CRS You are 100 % Right. There was either a perforation of the lingual plate or the lower border of the mandible. This patient airway could had been compromised and death could have occurred. It has already happened before. It is very important in a case like this to keep the patient under close supervision. Full knowledge of the anatomical landmarks and the procedures on how to control hemorrhage is extremely important. That is one of the main subjects covered in our 3 day hands on Cadaver Course. Note I am not promoting our course at all. My point is if you are going to walk through the jungle make sure that you know were the booby traps are or stay out of the jungle. Prednisone is of no use in this instance, Raul

from memory I think (in the UK) we have had a recorded fatality forma lingual perforation compromising the airway. That patient had undergone the procedure under GA. If that does happen then is the adivce to control the swelling with pressure or incise the FOM to allow bleeding then find the bleeding point and deal with it (Oral surgeon advice would be great as can happen to anyone).

Agree with CRS , most likely perforated the lingual plate and the area is very vascular. There are also anatomical variants and lingual arteries (sublingual), veins can run through the lingual cortical plate into the anterior mandibular region. Airway compromise due to these bleeds can be life threatening and the patient is lucky that you stopped the swelling in the floor of the mouth. techniques to help stop the bleeding can include pulling out the tongue (lingual artery bleeds), pressure along the inferior inner area of the body of the mandible at the antegonial notch to stop facial artery bleeds, or pressure at C4 transverse process to slow external carotid flow can all help with reducing the bleed, but it sounds like you managed to get it under control. Think this is also a good reminder for us to have emerg kits with oropharyngeal airway devices close at hand.

You either perforated the lingual at the inferior of the mandible or hit the artery that is at the genial tubericles on the lingual and enter the mandible at that point. See this article

thanks everyone for there comments. it really helps to here from such an experienced members. the patient is doing fine post 10 days. very slight swelling in floor of mouth.( feels like a clot confined to right side of floor of mouth anterior region ) no pain . will be posting the details as and when pt arrives with CBCT. also the profuse bleeding started only when the osteotomy length was increased from 11.5 to 13.5 mm. before that it was not bleeding. on RVG view of the osteotomy site prep , there was a some radiolucent area approx 2 x 2 mm at the apical end . it seems like a small bundle of vessels and nerve. ridge was resorbed. and finally 11.5 mm length implant was placed.

Where is the scan?

The anterior mandible has different regions with different surgical issues, so please be specific as to the exact site of the occurrence. (ie mental foramen, mental nerve, midline, adjacent to midline) This will help posters to identify your problem and better provide advice/solutions. Did you have a scan prior to surgery? That is when you would get the benefits of this technology-> - to investigate the anatomy (lots of rude surprises to be found, such as penetrating arterial vessels from the lingual or other anastamosing arteries, or unusual angulations of the lingual bony contour etc). - to prepare accurate surgical guides so that you drill only where planned (in safety). Scanning post-surgery will not reveal much (the metal causes areas of beam hardening and of photon starvation in the image, so the diagnostic definition needed is not there). And "... the horse has bolted...". If you perforated the lower border of the mandible, you would not get the bleed in the floor of the mouth - your bleed was at the level of the mylohyoid - indicating lingual plate perforation or striking a lingual perforating vessel (easily identifiable on a pre-op scan). Not sure of the wisdom of placing a shorter implant especially if you were using tapered implants and had already prepared the osteotomy - you would have had to place it deeper to get primary stability, and the apical part would still have penetrated the area where the bleed originated (albeit it would have formed a good 'plug' ! ). Agree with other posters that prednisone has no role in haemostasis. It could have a role in moderating an allergic response, but you certainly didn't have that. It could have the effect of reducing the infection-resistance - especially if bacteria gained hold within the sublingual mass of clotted blood, so I would never advocate that. Finally, congratulations for (mostly) appropriate response to your patient's medical emergency - highlights the need for adequate training. Your patient was developing a Ludwig's angina which can close the airway as the bleeding SLOWLY raises the floor of the mouth and the tongue.

This case is a good example why the DDS must take the proper course for implant placement and not just a commercial course to sell their implant system.