Journal of Oral Implantology June 2014 - (Page 341)
LETTER TO THE EDITOR
Dear Editor,
I read with great interest ''Hemorrhage secondary
to implant surgery'' by Drs Sakka and Krenkel.1 Some
important considerations were not discussed in the
article, and there seems to be some confusion about
anatomic spaces.
The floor of the mouth anatomy has basically 3
spaces of concern to implant dentists: submandibular, submental, and sublingual. The submandibular
space contains the submental artery, as discussed in
the article, and a hemorrhage from this artery is
indeed life threatening.2 A patient with a violated
submental artery would need early airway maintenance to prevent a later forced entry or tracheotomy.
A complex dissection done to locate a hemorrhaging
submental artery for ligation may be inappropriate.
Ligation at the origin of the submental artery near
the angle of the mandible as it leaves the facial
artery, relatively remote from the bleeding site, may
be the best course of action. However, because of
the multiple anastomoses that generally occur here,
the bleeding may not substantially subside, so the
patient would require immediate hospitalization.
The authors list several considerations. The third
consideration cautions against lingual cortical perforations. Although this is appropriate, apparently
the authors missed information in their reference
23, in which Isaacson reported a case where arterial
bleeding was encountered during implant surgery
in the anterior mandible.3,4 After a lingual aspect
dissection, the osteotomy was found to be completely intraosseous. The sublingual artery was
sectioned intraosseously by the drill. It then recoiled
into the floor of the mouth and formed a
hematoma. The authors of the case report apparently did not dissect the lingual aspect of the
mandible to determine if the osteotomy was indeed
extracortical. Their osteotomy may have been
completely intraosseous, so the true cause of the
hemorrhage will never be known. If the osteotomies
perforated the lingual cortex then they would need
to be redirected so as not to have the implants
perforate the cortex when placed. The authors
DOI: 10.1563/AAID-JOI-D-13-00290
apparently do not know if their implants are
inappropriately positioned. It is understandable that
the authors did not desire to remove the periosteum of the distracted bone, thus compromising the
vascular supply that may induce resorption. However, ascertaining the position of the implants may
be an important consideration. Perhaps a cone
beam computerized tomogram would have been
appropriate or a discussion about probing the
lingual aspect to detect a perforating osteotomy.
In their fifth consideration, the authors may have
confused the submandibular space with the sublingual space. The sublingual artery generally courses
and enters the symphysis superior to the mylohyoid
and genioglossus muscles that form a substantial
separation from the submandibular and submental
spaces.5 Thus, a hemorrhage of the sublingual
artery at the anterior mandible would not compromise the airway and would not be life threatening,
although not to be minimized because the patient
would need to be monitored. However, referral to
specialized care or hospitalization would not be
indicated. Nevertheless, if the surgeon is uncertain
as to the source of the hemorrhage then an
immediate referral or hospitalization would be
necessary. A hemorrhage in the sublingual space
would not require hospitalization. The sublingual
space communicates with the submandibular space
at the posterior free borders of the mylohyoid
muscle but a sublingual hematoma would need to
be massive and long-standing to create an airway
compromise. The sublingual artery may not be
capable of creating such a massive hematoma. The
submental and submandibular spaces communicate directly, and a hematoma in the submental
space would directly involve the submandibular
space, potentially compromising the airway.
In severely atrophic mandibles, the sublingual
artery generally deteriorates and is not found. The
major blood supply to the anterior mandible is from
the facial artery via the periosteum. The authors'
case was an osseous distraction in an atrophic
mandible. The report did not indicate whether there
was indeed a reformed arterial supply or if the
vascular supply was periosteal. The hemorrhage the
Journal of Oral Implantology
341
Table of Contents for the Digital Edition of Journal of Oral Implantology June 2014
Controlled Early Inflammation and Bone Healing—Potential New Treatments
Zygomatic Implants: The Impact of Zygoma Bone Support on Biomechanics
A Comparative Study on Microgap of Premade Abutments and Abutments Cast in Base Metal Alloys
Topical Simvastatin Improves the Pro-Angiogenic and Pro-Osteogenic Properties of Bioglass Putty in the Rat Calvaria Critical-Size Model
Assessment of the Correlation Between Insertion Torque and Resonance Frequency Analysis of Implants Placed in Bone Tissue of Different Densities
Benefits of Rehabilitation With Implants in Masticatory Function: Is Patient Perception of Change in Accordance With the Real Improvement?
A Method for Fabrication of Implant-Supported Fixed Partial Dentures
Safe Sinus Lift: Use of Acrylic Stone Trimmer to Avoid Sinus Lining Perforation
The Effects of Sinus Membrane Pathology on Bone Augmentation and Procedural Outcome Using Minimal Invasive Antral Membrane Balloon Elevation
Cellular Responses to Metal Ions Released From Implants
A Two-Stage Surgical Approach to the Treatment of Severe Peri-Implant Defect: A 30-Month Clinical Follow-Up Report
Eight-Year Follow-Up of a Fixed-Detachable Maxillary Prosthesis Utilizing an Attachment System: Clinical Protocol for Individuals With Skeletal Class III Malocclusions
Active Implant Peri-Apical Lesion: A Case Report Treated Via Guided Bone Regeneration With a 5-year Clinical and Radiographic Follow-up
Flapless Implant Placement: A Case Report
Active Implant Periapical Lesions Leading to Implant Failure: Two Case Reports
A Review of Platelet Derived Growth Factor Playing Pivotal Role in Bone Regeneration
LETTER TO THE EDITOR
REVIEW OF CURRENT LITERATURE
Journal of Oral Implantology June 2014
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