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Life-Threatening Hemorrhage after Placement of an Endosseous Implant: Report of Case
J!SO A \ C L I N I C A L
R E P O R T S
Life-threatening hemorrhage after placement of an endosseous implant: report of case G erald L ab oda, D D S
This article reports an unusual hut dangerous complication o f im plant surgery. M inim al perforations of the lingual plate and inferior border o f the mandible had been considered previously to be benign occurrences. This report demonstrates the importance o f man aging acute airway problems resulting from perforations.
h e p la c e m e n t o f e n d o ss e o u s i m p l a n t s h a s b e c o m e a w id e ly a c c e p te d , c o m m o n ly p e r f o r m e d p ro c e d u r e . T h e success o f th e tw o-stage c y lin d rical tita n iu m im p la n ts h a s c a u se d in c re a se d in te re s t in im p lan to lo g y . M any p ra c titio n e rs a re involved in th e su rg ical p la c e m e n t a n d r e s to r a tio n o f im p la n ts . However, m any believe th a t th e p la ce m e n t o f im p la n ts is a n u n c o m p lic a te d p r o c e d u re . T his re p o r t illustrates an u n e x p e c te d a n d life-th reaten in g co m p licatio n .
T
Report of case T h e p a tie n t was a 67-year-old e d e n tu lo u s w h ite m a le w h o h a d g r e a t d if fic u lty in re ta in in g his m a n d ib u la r d e n tu re . H e h a d a n a n t e r i o r m a n d i b u l a r a u g m e n t a ti o n w ith h y d r o x y l a p a t i t e 3 y e a r s e a r l i e r . A p p r o x i m a t e l y 3 m o n t h s a f t e r th e
a u g m e n t a ti o n , a p a la ta l m u c o s a l g ra f t v e s tib u lo p la s ty w as p e r f o r m e d . Yet, th e p a tie n t c o n tin u e d to have d ifficu lty with d e n tu r e re te n tio n . T h e p a tie n t h a d a sig n ific a n t m e d ic a l h is to ry th a t in c lu d e d th e rem o v al o f his g a llb la d d e r , a fe m o ra l p o p lite a l bypass, e x c is io n o f a n a o r t ic a n e u r y s m , a n d a h e rn io rrh a p h y . All th ese p ro c e d u re s h a d b e e n p e rf o rm e d w ith in th e p a st 5 years. H e w as c u r r e n t l y t a k i n g p r o p r a n o l o l h y d ro c h lo rid e (In d e ra l, W yeth-A yerst), a d iu re tic , p o tassium a n d o n e asp irin daily. A fter co n su lta tio n w ith th e p a tie n t a n d th e restorative d en tist, th e tre a tm e n t p lan was th e p la c e m e n t o f two-stage cylindrical tita n iu m im p la n ts (C ore-V ent, C ore-V ent C o rp ) in th e r ig h t a n d le ft m a n d ib u la r c a n i n e r e g i o n s . A n o v e r d e n t u r e w ith a p p r o p r ia te ' a tta c h m e n ts w o u ld b e c o n stru c te d a fter e x p o su re o f th e im plants. T h e p ro c e d u re was p e rfo rm e d w ith th e p a t i e n t u n d e r lo c a l a n e s t h e s ia s u p p l e m e n t e d w ith in tr a v e n o u s s e d a tio n a n d a p p ro p ria te m o n ito rin g by pulse oxim etry, e lec tro c a rd io g rap h y , a n d a u to m a tic pu lse a n d b lo o d p r e s s u r e m e a s u r e m e n ts . A n incision was m a d e ju s t b uccal to th e crest o f th e m a n d ib u la r rid g e fro m th e left to th e rig h t p re m o la r reg io n . M u co p erio steal flaps w ere d ev elo p e d , ex p o sin g th e crest o f th e r i d g e in th e le f t a n d r i g h t c a n in e regions. U sing th e a p p ro p ria te overlay o n a p a n o r a m ic ra d io g r a p h , a n o . 4 m o d i
ficatio n o f th e im p la n t was selected fo r th e le ft sid e, a n d n o . 3 m o d ific a tio n fo r th e r i g h t s id e . B a s e d o n t h e w id th o f th e alveolus, 4.5-m m d ia m e te r im p la n ts w ere ch o sen . W hile th e tre p h in e was u se d o n th e left s id e o f t h e m o u t h , t h e r e w as a s l ig h t d e c r e a s e in r e s i s t a n c e a n d p o s s ib ly a p e rfo ra tio n o f th e in fe rio r b o rd e r o n th e lin g u a l a s p e c t o f th e m a n d ib le . T h e tre p h in e was im m ed iately w ithdraw n. T h e p e n e tra tio n th ro u g h th e c o rtical p late was e stim a te d to b e n o m o re th a n 1 m m . Brisk b le e d in g fro m th e p re p a r e d im p la n t site was c o n tro lle d easily w ith g au ze packing. P re p a ra tio n was c o m p le te d o n th e rig h t s id e o f th e m a n d i b le , a n d th e im p la n t in s e rte d . T h e n th e gau ze p a c k in g o n th e le f t sid e w as re m o v e d a n d th e im p la n t p la c e d . B o th im p l a n t s w e re f i r m l y in p o s i t i o n w ith c o r r e c t a l v e o l a r c r e s t m a r g in a l a d a p ta tio n . T h e in c is io n w as clo sed w ith a ru n n in g lo ck ed 3-0 black silk su tu re. D u r i n g t h e c lo s e o f t h e i n c i s i o n , sw ellin g h a d o c c u r r e d in th e s u b m e n ta l s p a c e . T h e p a t i e n t w as s till s e d a t e d , a lth o u g h h e h a d g o o d lary n g eal reflexes. Ic e a n d p r e s s u r e w e re a p p l i e d to t h e su b m e n ta l space, b u t w ithin 2 m in u te s th e a r e a o f s w e llin g w as d r a m a t i c a l l y in c r e a s in g , th e flo o r o f th e m o u th w as b e g i n n i n g to r is e , a n d th e to n g u e w as b e c o m i n g e l e v a t e d . A n a c u t e a ir w a y JA DA , Vol. 121, N o v em b er 1990 ■ 599
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p r o b l e m w as i m m i n e n t a n d a n e n d o tr a c h e a l in t u b a ti o n u n d e r d ir e c t la r y n g o s c o p y w as p la c e d w ith a 6 .5 -m m o ra l e n d o t r a c h e a l t u b e . T h is w as d i f f i c u l t b e c a u s e t h e t o n g u e r o s e c lo s e to th e p a l a t e . T h e p a t i e n t ’s v it a l s ig n s w e re m o n ito r e d a t all tim e s w ith o u t d ev ia tio n fro m n o rm a l ranges. T h e in tra v e n o u s lin e was m a in ta in e d , an a m b u la n c e was called, a n d th e e m e r g e n c y r o o m o f th e lo c a l h o s p ita l was n o tifie d ; sim u lta n e o u sly , an o t o l a r y n g o l o g i s t w as c a l l e d to t h e e m e r g e n c y r o o m to h e l p m a n a g e th e p a tie n t’s airway. In th e e m e r g e n c y ro o m , d ir e c t la ry n g o s c o p y a g a in w as p e r f o r m e d a n d th e e n d o tra c h e a l tu b e was in p o sitio n b u t was r e p l a c e d w ith a l a r g e r 7 .5 -m m e n d o trach eal tube. A trach eo sto m y was c o n te m p la te d b u t th e e n d o tr a c h e a l in tu b a tio n was m a in ta in in g a n a d e q u a te airw ay a n d th e p a tie n t was re sp o n d in g . T h e re was obviously an actively b le ed in g v e s s e l c a u s i n g a h e m a t o m a in th e s u b m e n t a l s p a c e t h a t w o u ld r e q u i r e e m e r g e n t ligation. T h e re fo re , th e p a tie n t w as ta k e n to t h e o p e r a t i n g r o o m , p u t u n d e r g e n e r a l a n e s t h e s i a , a n d th e su b m en tal space was e x p lo re d th ro u g h an e x tr a o ra l a p p r o a c h . T h e h e m a to m a was ev acu ated a n d an actively b le e d in g a rte ry
600 ■ JADA, Vol. 121, N o v em b er 1990
w as n o te d im m e d ia te ly a d ja c e n t to th e lin g u al a sp ect o f th e in fe rio r b o rd e r o f th e le f t s id e o f t h e m a n d i b l e , w h ic h w as c la m p ed a n d ligated. T h e p a ti e n t to l e r a t e d th e p r o c e d u r e well a n d his recovery was u n ev en tfu l. T h e e n d o tra c h e a l tu b e was left in place fo r 36 h o u rs . T h e c o a g u la tio n s tu d ie s w e re all w ith in n o rm a l lim its, a n d th e p a tie n t was d isch arg ed 4 days later. A f te r 3 m o n t h s , t h e i m p l a n t s w e re u n c o v e re d a n d a su ccessfu l o v e rd e n tu re was c o n stru c te d .
Discussion A p o sto p erativ e ra d io g ra p h ic ex am in a tio n o f th is p a t i e n t s h o w e d w e ll- p o s itio n e d im p la n ts (F ig 1). T h e lin g u a l p la te j u s t above th e in fe rio r b o rd e r o f th e m a n d ib le ra th e r th a n th e in fe rio r b o r d e r itse lf was p ro b a b ly p e rf o ra te d . T h is is n o t u n c o m m o n in th e p la c e m e n t o f im p la n ts in th e a tro p h ic m an d ib le, a n d generally, is o f n o c o n se q u e n c e o r has n o serio u s sequelae. D r. J o h n K e n t n o t e d ( p e r s o n a l c o m m u n ic a tio n , J u ly 19 8 9 ) t h a t in th e p l a c e m e n t o f a ll ty p e s o f c y l i n d r i c a l im p la n ts in w hich it is d esirab le to en g ag e th e c o rtic a l p la te at th e in f e r io r b o r d e r level, it is n o t u n c o m m o n to p ro d u c e sm all
p e rf o ra tio n s w ith n o c o n s e q u e n c e a lo n g th e base, o r th e b u ccal o r lingual surfaces o f th e in fe rio r b o rd er. P e rfo ra tio n is often in te n tio n a l in sev e re a tr o p h ic rid g e s to g ain m ax im u m b o n e -im p lan t surface area re te n tio n . It se e m s th a t th e r e was a n a n o m a lo u s vessel im m ed iately ad ja c e n t to th e lingual p la t e a t t h e i n f e r i o r b o r d e r o f th e m a n d ib le in th e c a n in e re g io n . T h is was p ro b a b ly a b ra n c h o f th e lin g u a l artery , a lth o u g h it c o u ld also have b e e n a b ran ch o f th e fa c ia l a r te r y . In e i t h e r c a s e , an in n o c u o u s , m in im a l p e r f o r a ti o n o f th e li n g u a l p l a t e a t t h e i n f e r i o r b o r d e r re s u lte d in la c e ra tio n o f th is vessel w ith s u b s e q u e n t life -th re a te n in g h e m o rrh a g e . H a d th e su rg e o n a n d th e office p erso n n el n o t b e e n tr a in e d in th e m a n a g e m e n t o f a c u te airw ay e m erg en cies, this p a tie n t may n o t have survived.
Summary T h is a r tic le d e s c r ib e s a life -th re a te n in g h e m o r rh a g e se c o n d a ry to th e p la c e m e n t o f a n e n d o s s e o u s im p la n t. T h e p r o m p t m a n a g e m e n t o f th e e m e rg en cy saved this p a tie n t’s life. T h e p la c e m e n t o f en d o steal im p la n ts w ith p e n e tr a tio n o f th e d e e p e r an a to m ic stru c tu re s o f th e jaw s can create m o re se rio u s p ro b le m s. R eco g n izin g a n d m a n a g in g m ed ical em erg e n c ies o f all types m u s t b e a n i n t e g r a l p a r t o f th e b a c k g ro u n d a n d tr a in in g o f an y d e n tis t e n g a g in g in im p la n t surgery.
------------------- JADA -----------------D r. L a b o d a is in p r i v a t e p r a c t i c e , o r a l s u r g e r y , S o u th w e s t O r a l S u r g e r y A s s o c ia te s , S u m m e rlin M ed ic al P a rk , 5285 S u m m e rlin R o a d , S u ite 101, F o rt M yers, FL 33907-7699. A d d re ss re q u e s ts fo r re p rin ts to Dr. L a b o d a.
R E P O R T S
Life-threatening hemorrhage after placement of an endosseous implant: report of case G erald L ab oda, D D S
This article reports an unusual hut dangerous complication o f im plant surgery. M inim al perforations of the lingual plate and inferior border o f the mandible had been considered previously to be benign occurrences. This report demonstrates the importance o f man aging acute airway problems resulting from perforations.
h e p la c e m e n t o f e n d o ss e o u s i m p l a n t s h a s b e c o m e a w id e ly a c c e p te d , c o m m o n ly p e r f o r m e d p ro c e d u r e . T h e success o f th e tw o-stage c y lin d rical tita n iu m im p la n ts h a s c a u se d in c re a se d in te re s t in im p lan to lo g y . M any p ra c titio n e rs a re involved in th e su rg ical p la c e m e n t a n d r e s to r a tio n o f im p la n ts . However, m any believe th a t th e p la ce m e n t o f im p la n ts is a n u n c o m p lic a te d p r o c e d u re . T his re p o r t illustrates an u n e x p e c te d a n d life-th reaten in g co m p licatio n .
T
Report of case T h e p a tie n t was a 67-year-old e d e n tu lo u s w h ite m a le w h o h a d g r e a t d if fic u lty in re ta in in g his m a n d ib u la r d e n tu re . H e h a d a n a n t e r i o r m a n d i b u l a r a u g m e n t a ti o n w ith h y d r o x y l a p a t i t e 3 y e a r s e a r l i e r . A p p r o x i m a t e l y 3 m o n t h s a f t e r th e
a u g m e n t a ti o n , a p a la ta l m u c o s a l g ra f t v e s tib u lo p la s ty w as p e r f o r m e d . Yet, th e p a tie n t c o n tin u e d to have d ifficu lty with d e n tu r e re te n tio n . T h e p a tie n t h a d a sig n ific a n t m e d ic a l h is to ry th a t in c lu d e d th e rem o v al o f his g a llb la d d e r , a fe m o ra l p o p lite a l bypass, e x c is io n o f a n a o r t ic a n e u r y s m , a n d a h e rn io rrh a p h y . All th ese p ro c e d u re s h a d b e e n p e rf o rm e d w ith in th e p a st 5 years. H e w as c u r r e n t l y t a k i n g p r o p r a n o l o l h y d ro c h lo rid e (In d e ra l, W yeth-A yerst), a d iu re tic , p o tassium a n d o n e asp irin daily. A fter co n su lta tio n w ith th e p a tie n t a n d th e restorative d en tist, th e tre a tm e n t p lan was th e p la c e m e n t o f two-stage cylindrical tita n iu m im p la n ts (C ore-V ent, C ore-V ent C o rp ) in th e r ig h t a n d le ft m a n d ib u la r c a n i n e r e g i o n s . A n o v e r d e n t u r e w ith a p p r o p r ia te ' a tta c h m e n ts w o u ld b e c o n stru c te d a fter e x p o su re o f th e im plants. T h e p ro c e d u re was p e rfo rm e d w ith th e p a t i e n t u n d e r lo c a l a n e s t h e s ia s u p p l e m e n t e d w ith in tr a v e n o u s s e d a tio n a n d a p p ro p ria te m o n ito rin g by pulse oxim etry, e lec tro c a rd io g rap h y , a n d a u to m a tic pu lse a n d b lo o d p r e s s u r e m e a s u r e m e n ts . A n incision was m a d e ju s t b uccal to th e crest o f th e m a n d ib u la r rid g e fro m th e left to th e rig h t p re m o la r reg io n . M u co p erio steal flaps w ere d ev elo p e d , ex p o sin g th e crest o f th e r i d g e in th e le f t a n d r i g h t c a n in e regions. U sing th e a p p ro p ria te overlay o n a p a n o r a m ic ra d io g r a p h , a n o . 4 m o d i
ficatio n o f th e im p la n t was selected fo r th e le ft sid e, a n d n o . 3 m o d ific a tio n fo r th e r i g h t s id e . B a s e d o n t h e w id th o f th e alveolus, 4.5-m m d ia m e te r im p la n ts w ere ch o sen . W hile th e tre p h in e was u se d o n th e left s id e o f t h e m o u t h , t h e r e w as a s l ig h t d e c r e a s e in r e s i s t a n c e a n d p o s s ib ly a p e rfo ra tio n o f th e in fe rio r b o rd e r o n th e lin g u a l a s p e c t o f th e m a n d ib le . T h e tre p h in e was im m ed iately w ithdraw n. T h e p e n e tra tio n th ro u g h th e c o rtical p late was e stim a te d to b e n o m o re th a n 1 m m . Brisk b le e d in g fro m th e p re p a r e d im p la n t site was c o n tro lle d easily w ith g au ze packing. P re p a ra tio n was c o m p le te d o n th e rig h t s id e o f th e m a n d i b le , a n d th e im p la n t in s e rte d . T h e n th e gau ze p a c k in g o n th e le f t sid e w as re m o v e d a n d th e im p la n t p la c e d . B o th im p l a n t s w e re f i r m l y in p o s i t i o n w ith c o r r e c t a l v e o l a r c r e s t m a r g in a l a d a p ta tio n . T h e in c is io n w as clo sed w ith a ru n n in g lo ck ed 3-0 black silk su tu re. D u r i n g t h e c lo s e o f t h e i n c i s i o n , sw ellin g h a d o c c u r r e d in th e s u b m e n ta l s p a c e . T h e p a t i e n t w as s till s e d a t e d , a lth o u g h h e h a d g o o d lary n g eal reflexes. Ic e a n d p r e s s u r e w e re a p p l i e d to t h e su b m e n ta l space, b u t w ithin 2 m in u te s th e a r e a o f s w e llin g w as d r a m a t i c a l l y in c r e a s in g , th e flo o r o f th e m o u th w as b e g i n n i n g to r is e , a n d th e to n g u e w as b e c o m i n g e l e v a t e d . A n a c u t e a ir w a y JA DA , Vol. 121, N o v em b er 1990 ■ 599
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p r o b l e m w as i m m i n e n t a n d a n e n d o tr a c h e a l in t u b a ti o n u n d e r d ir e c t la r y n g o s c o p y w as p la c e d w ith a 6 .5 -m m o ra l e n d o t r a c h e a l t u b e . T h is w as d i f f i c u l t b e c a u s e t h e t o n g u e r o s e c lo s e to th e p a l a t e . T h e p a t i e n t ’s v it a l s ig n s w e re m o n ito r e d a t all tim e s w ith o u t d ev ia tio n fro m n o rm a l ranges. T h e in tra v e n o u s lin e was m a in ta in e d , an a m b u la n c e was called, a n d th e e m e r g e n c y r o o m o f th e lo c a l h o s p ita l was n o tifie d ; sim u lta n e o u sly , an o t o l a r y n g o l o g i s t w as c a l l e d to t h e e m e r g e n c y r o o m to h e l p m a n a g e th e p a tie n t’s airway. In th e e m e r g e n c y ro o m , d ir e c t la ry n g o s c o p y a g a in w as p e r f o r m e d a n d th e e n d o tra c h e a l tu b e was in p o sitio n b u t was r e p l a c e d w ith a l a r g e r 7 .5 -m m e n d o trach eal tube. A trach eo sto m y was c o n te m p la te d b u t th e e n d o tr a c h e a l in tu b a tio n was m a in ta in in g a n a d e q u a te airw ay a n d th e p a tie n t was re sp o n d in g . T h e re was obviously an actively b le ed in g v e s s e l c a u s i n g a h e m a t o m a in th e s u b m e n t a l s p a c e t h a t w o u ld r e q u i r e e m e r g e n t ligation. T h e re fo re , th e p a tie n t w as ta k e n to t h e o p e r a t i n g r o o m , p u t u n d e r g e n e r a l a n e s t h e s i a , a n d th e su b m en tal space was e x p lo re d th ro u g h an e x tr a o ra l a p p r o a c h . T h e h e m a to m a was ev acu ated a n d an actively b le e d in g a rte ry
600 ■ JADA, Vol. 121, N o v em b er 1990
w as n o te d im m e d ia te ly a d ja c e n t to th e lin g u al a sp ect o f th e in fe rio r b o rd e r o f th e le f t s id e o f t h e m a n d i b l e , w h ic h w as c la m p ed a n d ligated. T h e p a ti e n t to l e r a t e d th e p r o c e d u r e well a n d his recovery was u n ev en tfu l. T h e e n d o tra c h e a l tu b e was left in place fo r 36 h o u rs . T h e c o a g u la tio n s tu d ie s w e re all w ith in n o rm a l lim its, a n d th e p a tie n t was d isch arg ed 4 days later. A f te r 3 m o n t h s , t h e i m p l a n t s w e re u n c o v e re d a n d a su ccessfu l o v e rd e n tu re was c o n stru c te d .
Discussion A p o sto p erativ e ra d io g ra p h ic ex am in a tio n o f th is p a t i e n t s h o w e d w e ll- p o s itio n e d im p la n ts (F ig 1). T h e lin g u a l p la te j u s t above th e in fe rio r b o rd e r o f th e m a n d ib le ra th e r th a n th e in fe rio r b o r d e r itse lf was p ro b a b ly p e rf o ra te d . T h is is n o t u n c o m m o n in th e p la c e m e n t o f im p la n ts in th e a tro p h ic m an d ib le, a n d generally, is o f n o c o n se q u e n c e o r has n o serio u s sequelae. D r. J o h n K e n t n o t e d ( p e r s o n a l c o m m u n ic a tio n , J u ly 19 8 9 ) t h a t in th e p l a c e m e n t o f a ll ty p e s o f c y l i n d r i c a l im p la n ts in w hich it is d esirab le to en g ag e th e c o rtic a l p la te at th e in f e r io r b o r d e r level, it is n o t u n c o m m o n to p ro d u c e sm all
p e rf o ra tio n s w ith n o c o n s e q u e n c e a lo n g th e base, o r th e b u ccal o r lingual surfaces o f th e in fe rio r b o rd er. P e rfo ra tio n is often in te n tio n a l in sev e re a tr o p h ic rid g e s to g ain m ax im u m b o n e -im p lan t surface area re te n tio n . It se e m s th a t th e r e was a n a n o m a lo u s vessel im m ed iately ad ja c e n t to th e lingual p la t e a t t h e i n f e r i o r b o r d e r o f th e m a n d ib le in th e c a n in e re g io n . T h is was p ro b a b ly a b ra n c h o f th e lin g u a l artery , a lth o u g h it c o u ld also have b e e n a b ran ch o f th e fa c ia l a r te r y . In e i t h e r c a s e , an in n o c u o u s , m in im a l p e r f o r a ti o n o f th e li n g u a l p l a t e a t t h e i n f e r i o r b o r d e r re s u lte d in la c e ra tio n o f th is vessel w ith s u b s e q u e n t life -th re a te n in g h e m o rrh a g e . H a d th e su rg e o n a n d th e office p erso n n el n o t b e e n tr a in e d in th e m a n a g e m e n t o f a c u te airw ay e m erg en cies, this p a tie n t may n o t have survived.
Summary T h is a r tic le d e s c r ib e s a life -th re a te n in g h e m o r rh a g e se c o n d a ry to th e p la c e m e n t o f a n e n d o s s e o u s im p la n t. T h e p r o m p t m a n a g e m e n t o f th e e m e rg en cy saved this p a tie n t’s life. T h e p la c e m e n t o f en d o steal im p la n ts w ith p e n e tr a tio n o f th e d e e p e r an a to m ic stru c tu re s o f th e jaw s can create m o re se rio u s p ro b le m s. R eco g n izin g a n d m a n a g in g m ed ical em erg e n c ies o f all types m u s t b e a n i n t e g r a l p a r t o f th e b a c k g ro u n d a n d tr a in in g o f an y d e n tis t e n g a g in g in im p la n t surgery.
------------------- JADA -----------------D r. L a b o d a is in p r i v a t e p r a c t i c e , o r a l s u r g e r y , S o u th w e s t O r a l S u r g e r y A s s o c ia te s , S u m m e rlin M ed ic al P a rk , 5285 S u m m e rlin R o a d , S u ite 101, F o rt M yers, FL 33907-7699. A d d re ss re q u e s ts fo r re p rin ts to Dr. L a b o d a.