Implant surgery has become a mainstay of modern dental practice, yet severe haemorrhage remains a rare but potentially life-threatening complication, particularly when anatomical challenges or underlying bleeding disorders complicate treatment.
Hidden hazards
Minor post-operative bleeding is to be expected following oral surgery; however, more significant vascular injury requires urgent intervention in order to avoid serious consequences for patient safety. One of the most well-documented causes is perforation of the lingual cortical plate during implant placement.[i] The proximity of the sublingual and submental arteries, particularly in the severely resorbed mandible, increases the risk of arterial laceration and subsequent haemorrhage.[ii] Development of a floor-of-mouth haematoma may result in displacement of the tongue and progressive airway compromise, necessitating hospitalisation and airway management.
Medical matters
In addition to surgical considerations, clinicians must identify patient factors that may impair haemostasis. Inherited bleeding disorders such as Von Willebrand disease and haemophilia, alongside anticoagulant-induced and antiplatelet-induced bleeding disorders, may increase the likelihood of peri-operative and post-operative bleeding. Clinicians should of course be mindful of medications including aspirin, clopidogrel and warfarin, which are widely prescribed for cardiovascular disease and stroke patients, and may increase bleeding risk. This information can easily be gathered from a detailed medical history and by consulting with the patient’s wider medical team.
Haemophilia is an inherited bleeding disorder characterised by deficiencies in specific clotting factors, resulting in impaired haemostasis and an increased risk of prolonged bleeding following surgical procedures. Treatment of these patients requires multidisciplinary management involving the implant surgical team and haematology department.[iii] Pre-operatively these patients usually require clotting factor replacement therapy and the use of antifibrinolytic agents to support clot formation throughout the surgical and post-operative period.
The importance of post-operative management should not be overlooked. The literature consistently supports the provision of clear post-operative instructions aimed at protecting early clot stability, minimising the risk of secondary bleeding, as well as reassuring patients on what to do should complications arise at home.[iv]
Surgical safeguards
Comprehensive assessment, particularly through the use of 3D imaging such as cone beam computed tomography (CBCT) is invaluable in medically complex cases. Studies have repeatedly demonstrated that there is an increased risk of lingual plate perforation where anatomical variation has not been fully appreciated. Careful evaluation of bone morphology, lingual undercuts and adjacent vascular structures is therefore essential prior to treatment.[v],[vi]
Guided surgery can offer an additional degree of precision in selected cases by improving surgical accuracy and reducing the chance of inadvertently perforating the cortical plate. Case studies have reported successful ridge preservation and flapless implant rehabilitation in patients with mild haemophilia A following peri-operative administration of recombinant factor VIII and tranexamic acid. This demonstrates that regenerative implant procedures can be undertaken safely when managed through a multidisciplinary haematology led protocol.[vii]
Local anaesthetic selection also warrants consideration. Current guidance generally recommends adequate clotting factor cover prior to administration of regional anaesthetics, particularly inferior alveolar nerve blocks, due to the potential risk of deep tissue haemorrhage and haematoma formation. Infiltrations are preferred where clinically appropriate, although reports of serious complications remain limited.[viii] Surgical protocols generally aim to minimise tissue trauma, with flapless surgery, short implants and local haemostatic measures potentially offering advantages in some cases.[ix],[x] Resorbable sutures, collagen sponges, oxidised cellulose and tranexamic acid are often indicated to support bleeding control.
Achieving haemostasis – controlling complications
Despite meticulous planning, significant haemorrhagic complications can still occur. Development of a floor-of-mouth haematoma following arterial trauma represents a true surgical emergency due to the potential for tongue displacement, which may compromise the patient’s airway.ii Immediate management focuses on haemostatic measures such as direct pressure, suturing and the use of haemostatic agents like tranexamic acid. Rapidly expanding haematomas require the airway to be protected by intubating the patient and necessitate urgent hospital admission. In the most severe cases, surgical exploration and vessel ligation may be required to achieve definitive haemostasis. Clinicians need to be familiar with emergency management protocols and have clear referral pathways in place when necessary.
Preventative pathways
Recognising the limits of one’s training and experience is an important aspect of safe implant practice. Patients presenting with complex anatomy, significant medical comorbidities, inherited bleeding disorders or a history of previous surgical complications are likely to benefit from specialist assessment and treatment. Successful treatment of these cases relies on significant surgical expertise, experience and confidence to be able to manage unexpected surgical events.
Professor Cemal Ucer and the team at the Ucer Clinic provide comprehensive implant assessment and treatment for medically and surgically complex patients. Combining advanced diagnostic technologies with extensive clinical experience, the team supports both referring clinicians and patients through every stage of care.
Although significant haemorrhagic events associated with implant treatment are uncommon, the potential consequences should not be underestimated. In these complex cases, the difference between a successful procedure and a surgical emergency lies entirely in the planning.
Author: Professor Cemal Ucer, BDS, MSc, PhD, Oral Surgeon, ITI Fellow
Please contact Professor Ucer at ucer@icedental.institute or Mel Hay at mel@mdic.co
01612 371842
[i] Mardinger O, Manor Y, Mijiritsky E, Hirshberg A. Lingual perimandibular vessels associated with life-threatening bleeding: an anatomic study. International Journal of Oral and Maxillofacial Implants. 2007 Jan 1;22(1):127.
[ii] Sfondrini D, Marelli S, Patriarca R, Scribante A, Preda L, Savioli G, Novelli G, Bardazzi A. Floor of the mouth hemorrhage following dental implant placement or Guided Bone Regeneration (GBR) in the atrophic interforaminal mandible. Case Reports in Dentistry. 2024;2024(1):8413875.
[iii] Kumar M, Badagabettu S, Pai KM, Nayak BS. Dental management of people with congenital hemophilia: An integrative review of case reports and case series from a global scenario. Special Care in Dentistry. 2025 Jan;45(1):e13099.
[iv] Bacci C, Schiazzano C, Zanon E, Stellini E, Sbricoli L. Bleeding disorders and dental implants: review and clinical indications. Journal of Clinical Medicine. 2023 Jul 18;12(14):4757.
[v] Sun Y, Hu S, Xie Z, Zhou Y. Relevant factors of posterior mandible lingual plate perforation during immediate implant placement: a virtual implant placement study using CBCT. BMC Oral Health. 2023 Feb 6;23(1):76.
[vi] Chan HL, Benavides E, Yeh CY, Fu JH, Rudek IE, Wang HL. Risk assessment of lingual plate perforation in posterior mandibular region: a virtual implant placement study using cone‐beam computed tomography. Journal of periodontology. 2011 Jan;82(1):129-35.
[vii] Bacci C, Cerrato A, Zanette G, Pasca S, Zanon E. Regenerative surgery with dental implant rehabilitation in a haemophiliac patient. TH Open. 2021 Jan;5(01):e104-6.
[viii] Römer P, Heimes D, Pabst A, Becker P, Thiem DG, Kämmerer PW. Bleeding disorders in implant dentistry: a narrative review and a treatment guide. International Journal of Implant Dentistry. 2022 Apr 16;8(1):20.
[ix] Balaguer-Martí JC, Peñarrocha-Oltra D, Balaguer-Martínez J, Peñarrocha-Diago M. Immediate bleeding complications in dental implants: a systematic review. Medicina oral, patologia oral y cirugia bucal. 2014 Dec 5;20(2):e231.
[x] Benetello F, Zanon E, Sbricoli L, Bacci C. Flapless dental implant surgery in bleeding disorders. International Journal of Translational Medicine. 2024 Jun 11;4(2):342-53.
