Managing Mandibular Lingual Plate Perforation?

Graft, do not overpack the grafting material, you don't want to have grafting material extruding out of the osteotomy. Close and wait at least 3 month to do a reentry. Of course you could be a cowboy and try to redirect the osteotomy, but if you couldn't direct it properly the first time, I wouldn't try such a maneuver at this time. Play it Safe.

Graft, do not overpack the grafting material, you don't want to have grafting material extruding out of the osteotomy. Close and wait at least 3 month to do a reentry.

One has to be very careful in this region. In my maxillo-facial residency In Great Britain a patient was admitted with a lingual hematoma of such a size that the airway was impeded. A mandibular second molar had been extracted in the morning, there was later bleeding intra-orally. The dentist then paced a plug in the socket. That's when the hematoma started developing. The patient was anaesthetised but it was impossible to pass an airway, so a "blind" tracheotomy was performed and a tracheotomy tube placed. I always remember that when operating in this region. These days I always use a CBCT. If one is not available then the lingual region is always palpated to determine the extent of the mylohyoid ridge. A drill channel is always prepared with the channel paralleling the outer plate of bone. That's important because the mandibular bone in the molar region often skews to the lingual. With simple guides like this then this is a safe procedure, but I still have that case in the back of my mind. Good luck!

I have had several experiences with lingual perforations (all have turned out well) as well as provided expert testimony in cases where the issue was improperly handled. Dr. Hunt is offering wise words of caution and a technique for predictability in this area. It is imperative to have enough bone width to be able to follow the buccal bone trajectory. If you do not have this, please consider using a blade, or one of many bone expansion/augmentation techniques before just drilling your hole. A pre-operative CBCT is considered standard of care now. I would add, that the risk of extruding particulate material into the submandibular space is very high. Therefore, I would not ever take that risk by placing a particulate bone graft. It can migrate. The safest approach is to place an L-PRF plug in the osteotomy and membrane of L-PRF (for quick healing and inflammatory management), then re-entry to augment or use very short implants in 3-4 months. Also, 900mg-1200mg Clindamycin daily for 10+ days. Observe your patient closely with daily communication, as hospitalization could be likely and you must stay on top of this. Remember the side effects of this amount of Clindamycin.

Interesting that in my OMFS residency 30+ years ago we routinely placed titanium screws in the maxillary sinus for our osteotomies. When plating mandibular fractures we would place our gloved fingers in the lingual sulcus and wanted to feel the tip of the screw just penetrate. We had no problems. Are implants "different"?

Dr Hacker, Very well thought and complete posting. I also liked the idea of placing a blade implant in the area.

I like all the prior comments! I would consider using a collagen plug such as one of the new OsteoGen plugs to graft the defect. One then does not need to worry about any particulate in the space.

This happened to me 2 months ago, of course you are going to want primary closure here, so make sure you have released the mylohyoid musle with blunt finger pressure and wet gauze to have flexibility of your lingual flap. Take the broken piece of the plate and put it back in place like a puzzle piece. Take a titanium mesh (ti-mesh) membrane prep it buccal/ lingual to cover the area (rounded edges). Slide the lingual portion of your ti-mesh in first against the lingual flap and the piece you broke to hold the broken piece in place. Add bonegraft a top the broken piece and the ti mesh and down the lingual side of the jaw; this with (antibiotic) metronidazole 150mg if the patient isn't allergic. You should already have good bone flow from when you broke the plate. If you don't have good blow flow from the osteotomy create good blood flow to hydrate graft prior to grafting of course. Bend the ti-mesh over to the buccal part of jaw screw it down if you can, if you can' t screw it then suturing will hold it in the end; add a collagen membrane atop the ti-mesh membrane; undermine buccal flap; gain primary, place sutures. Wait 4-8mths to reopen :) have a bud on me...

corrections should state blood flow not bone/blow flow :)