Sublingual hemorrhage on implant placement: what happened?

It is very possible you penetrate one of the small arteries in the sublingual space. I think you were lucky, as severing the lingual artery is a medical emergency, which can even lead to death by asphyxiation. Be very careful with the flapless placement, and use one of your fingers on the lingual aspect of the mandible to feel if there is some bone penetration.

It sounds like your preoperative preparation was well done. However the danger of implant placement in the mandibular anterior region is grossly underestimated. I agree that flapless surgery of this area is likely not ideal. There is anastamoses of the sublingual and submental artery in this region and you are indeed lucky it was controlled. In the future I think a full thickness flap or guided surgical guide would be the best.

This only goes to confirm that surgical guides do have errors, and that flapless procedures in the anterior mandible can be fraught with pitfalls -- which is why I abandoned the flapless for that area entirely. I prefer to see the bone I'm going into, and have an excellent grasp of it's inclination. All the more so in a #21 where one is mere mm's away from the mental foramen.

It’s very dangerous and unfortunate situation. If God forbid happens again, sit your Pt straight and pull his tongue out. It will stop bleeding.

What happened is very clear. During your osteotomy, you damaged a blood vessel. That area (the mandibular symphysis, used to be considered somewhat safe to place implants, when in reality there are several vessels which can be damaged during the osteotomy if you perforate on the lingual. I co-authored an article precisely about that topic with Robert J. Miller, DDS that illustrates the risks and the anatomy of the area. You can view it here: http://www.joionline.org/doi/full/10.1563/AAID-JOI-D-10-00136 Good luck!

You did not mention if you did indeed proceed with implant placement. You also did not mention if you used an instrument to explore your osteotomy and determine if you had a lingual perforation. What was the mylohyoid undercut like? Was it quite prominent? If you had a guide I assume you had a scan. Yes? It is fortunate that the arterial tributary you nicked (severed?) tamponaded itself. Frankly I do not agree with the other posts concerning guided and flapless surgery. I started placing implants in 1982 before scans were invented and the only guide was something you made on a stone model by hand. I have placed somewhere between 7,000 and 8,000 implants. I rarely flap and I almost never use a guide for single placement. I ALWAYS place the index finger of my non-dominant hand against the lingual plate of the mandible and feel for the drill vibrating against the cortex. If I feel it I change my angulation accordingly. I also depress the floor of the mouth so that if I perforate the only thing I will cut is my own finger. It hasn't happened yet BTW! Cudos to you for noticing that the guide was inaccurate. I was in that same situation in an all on 4 (well 5 in this case) last week. The distal sites on the guide were way off and would have put me straight (actually angled) thru the IANs. I flapped, exposed the mental foramens, and did the posterior implants free hand. I noticed when I finished that it took less time to flap, place the implants, and suture than it seems to take when I'm fooling with a guide. Access is better and visualization is better. Not to mention that you sometimes have to smooth the alveolar crest and/or trim the soft tissue. So even though I do a lot of flapless surgery, flaps do have there place. Well, Im getting a little off topic. Thanks for posting.

Great experience from our flapless-surgeon colleague. I am wondering how you mange the anterior cases or resorbed sites that at least in half of the cases need simultaneous GBR. I am asking about immediate placements.

SORRY FOR THE MISSING ‘not’ Great experience from our flapless-surgeon colleague. I am wondering how you mange the anterior cases or resorbed sites that at least in half of the cases need simultaneous GBR. I am NOT asking about immediate placements.

The sublingual artery was damaged. The rich anastomosing causes a lot of bleeding. This is probably not life threatening. It is superior to the mylohyoid muscle and will not compromise the airway. Nonetheless, if the hematoma enlarges, the tongue can be pressed against the palate and close oral breathing while nasal breathing is open. The patient needs monitoring until the hematoma is deemed stable and not enlarging. Flanagan D JADA Implants and Arteries 2004 May 135(5): 566