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Perforated the lingual cortical plate by around 3 mm: What can I expect?

Last Updated: Jan 14, 2014

During the installation of an implant in #20, 21 area [mandibular left second, first premolar; 35, 34] I perforated the lingual cortical plate by around 3 mm. I did not realize it then as there was no significant bleeding, and went ahead with torquing down the implant fixture into the osteotomy site and did not encounter any problems. I achieved about 50Ncm torque. I made an immediate open tray impression, and in the evening, while I was screwing the implant replicas on the impression post, I thought that the implant had too much a lingual inclination. I called the patient on the third day after installation and he reported that there was some sublingual hematoma, but nothing life threatening. I have scheduled the implant for removal tomorrow. Should I worry about bleeding or a hematoma now during untorquing? Should I go ahead with implant placement in an adjacent site? Should I reflect a large flap and then untorque, or untorque it through the flap after removing the healing abutment? Or should I leave it as it is?

6 Comments on Perforated the lingual cortical plate by around 3 mm: What can I expect?

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Robert J. Miller

1/14/2014

Sublingual bleeding is usually caused by the drill transecting the lingual plexus of vessels in the floor of the mouth. The fact that your implant now extends into the lingual space is secondary. It only comes into play farther down the road when tongue and mucosal movement rubs on the roughened apex causing a microtrauma mediated inflammatory process. But removing the implant by reverse torque, before integration, is the best and safest way to mitigate this problem. RJM

CRS

1/15/2014

I would get a CTScan and see where the implants are. Could be a perforation of the lingual periosteum vs a floor of the mouth issue. I would wait until the hematoma has resolved prior to removal.

Dennis Flanagan DDS MSc

1/15/2014

The sublingual artery can course very close to the medial mandible. I don't believe that a cursory touch from an implant drill can cause a perforation of this artery. However, persistent drilling may do exactly that. The area you are in may or may not be in the submandibular space, which a bleed here is life threatening, as you know. It may be better to ascertain the position of the apex of the implant with a CBCT as previously suggested and it may be better to not venture further lest an arterial encounter.

Bruce G Knecht

1/21/2014

If your placement is bad then change it. I have perforated the lingual plate and then redirected the implant with a new osteotomy. If you rub your finger on the lingual plate of that area you should feel the apex of the implant if you have a large perforation. Cat Scan will determine how bad. Best thing to do before you sink the implant is to probe the osteotomy with a blunt probe. I know BioHorizons has one and I think Nobel has one too. I would not freak out the patient by saying I perforated your bone, but just say: "I do not like the direction and I want to improve it so you get the best final result.

Dr. Mohammed A.R. Khan

1/21/2014

I would take the implant out, graft the area and go back later.

Dr. Omar Olalde

1/24/2014

If you don't have a good diagnose, then you can't do a treatment. Ask for a CTScan.That would be a very good discusion in this forum.

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