Читать книгу Management of Complications in Oral and Maxillofacial Surgery - Группа авторов - Страница 94

Major bleeding during dental implant placement is a rare complication, but can occur and may be life‐threatening. Failure to acknowledge the anatomical vascular variations in the maxilla and mandible can lead to iatrogenic vascular injury and major hemorrhage during implant placement. Many publications have reported that life‐threatening hemorrhage occurred most commonly when implants were placed in the anterior region of the mandible. Most patients experienced some degree of airway compromise necessitating intubation or the creation of a surgical airway (Figure 3.10). The bleeding is believed to be caused by lingual plate violation with the drill or implant with vascular injury to the terminal branches of the sublingual or submental artery (Figures 3.11 and 3.12) [30]. There may be tributaries of the terminal branches of the sublingual or submental arteries that enter the lingual aspect of the mandible through accessory lingual foramina in the lingual cortical bone (Figure 3.13). Also, there may be an arterial anastomosis between the sublingual and submental arteries that occurs 10% of the time. In a systematic review [30], all patients who suffered massive bleeding had received implants ≥15 mm in length. Another contributing factor to an increased frequency of bleeding is a significantly elevated systolic blood pressure at the time of vascular injury and hematoma formation leading to expansion of the hematoma. Treatment includes airway management and control of the hemorrhage, and an evaluation in an emergency department with probable, hospital admission. Basic measures to control bleeding such as immediate application of pressure on the site of suspected vascular injury, as well as blood pressure control, should be performed. Administering a local anesthetic solution with a vasoconstrictor can be useful as well. It has been suggested that arterial ligation may be technically difficult due to the engorgement of the tissues and the retraction of the offending vessel into the deeper tissues of the floor of the mouth, and should only be performed in cases of uncontrollable bleeding with no other available acute treatment options. If surgical intervention is deemed necessary, an extraoral approach for arterial ligation is preferred, but angiography with embolization remains the mainstay of therapy in a hospital imaging center (Algorithm 3.4). Medical management should involve the use of systemic antibiotics to prevent infection of the hematoma, and corticosteroids can help to reduce swelling and limit further airway compromise.

Fig. 3.10. Floor of mouth hematoma following anterior mandible implant placement.

Fig. 3.11. Implant violation of the lingual plate that may transect the sublingual or submental vessels leading to floor of mouth hemorrhage.

Fig. 3.12. CBCT view showing the violation of the lingual cortex by an implant.

Fig. 3.13. Lingual nutrient canal in the anterior mandible that may lead to floor of mouth bleeding from implant placement.