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Hemorrhaging After Implant Placement: Explanation?

posted in Dental Implant Complications, advice

« CTX Level: What Level is Risky? | Sinus Tract with Purulent Discharge : How Proceed? »

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Anon. asks:
I was recently assisting a colleague recently placing two immediate dental implants in the 12 and 14 area(UK). The 12 was restored by means of a 14mm implant and the 14 by a 11mm. The wound was closed and the patient was given post operative instructions. Soon after, while still at the surgery the patient had spontaneous, immediate bleeding from his right nostril. The bleeding was intense but ceased after about 5 min. I discussed this with the implantologist but was not entirely convinced by his explanation. Would you be so kind to comment on this? What could have been going on here?

19 Responses to “ Hemorrhaging After Implant Placement: Explanation? ”

• anon dr December 10th, 2007

  
  

  predumbably xrays were taken. ?CT scans. i would go back and check these thoroghly. sounds like an invasion of the nasal floor or sinus. i would recommend a review of the patient. were any post xrays taken? if you find something which you cant handle then refer appropriately.

• Alejandro Berg December 11th, 2007

  
  

  This is a usual sympthom of a sinus perforation with membrane tearing. Normally if patient does not have active or chronic sinus disease or infection and if it is under antibiotics this should not be a problem, control x rays and post op controls and those should stay there , normally they fully integrate, just take good care of the patient for the first 3 weeks to be on the safe side.
  good luck

• Barry Sporer DMD December 11th, 2007

  
  

  it’s a sinus perforation. just make sure you have proper antibiotic coverage (either augmentin 875mg bid for 10 days or a levapack may be more convenient). the implant should be ok.

• Jack Hirschfeld, DDS December 11th, 2007

  
  

  I agree with Anon. Brisk bright red blood exiting from the nose is highly suggestive of perforation of the nasal floor. Take a close look at the post-op x-ray of the lateral incisor site.

• Yazad December 13th, 2007

  
  

  The cause of this bleed could be either the sinus or the nasal floor being perforated.
  Chances are more towards the nasal floor cause even if the sinus membrane is perforated in 14 region there aren’t that many vessels in 14 region to provoke a brisk bleed.
  What helps is a CT or a conventional OMV 45 degrees view to see air fluid levels in the sinus.
  Hope this helps.

• Nicholas Toscano DDS MS December 13th, 2007

  
  

  The most likely cause for the bleeding out the nose is sinus perforation as a result of the implant placement. Without seeing any radiographs it’s hard to say which implant perforated the sinus. Sinus anatomy varies from patient to patient so one or both of the implants may have perforated the sinus. The bleeding into the nose is probably coming from middle meatus which is situated between the middle and inferior conchae.

  There may be a possiblity of a nasal floor perf but there are ways of examining both situations clinically and with imaging to determine cause of the bleeding.

  In my humble opinion, At this point I would make sure you do aggressive follow up on the patient. Cover the patient with the normal regimen of medications used for sinus surgery and make sure the patient is adhereing to sinus precautions. As well as follow some of the other tips by the doctors above.

  Good luck.

• Dr SS December 13th, 2007

  
  

  Hi anon
  what was the surgeons explanation you were not satisfied with?
  I cant think of any other cause other than sinus perforation
  By they way to add to our collegues above I would additionally reccommend that pt should avoid blowing their nose or sneezing for first few days
  This is standard instruction with sinus graft or sinus invasion
  Regards
  ss

• pete December 14th, 2007

  
  

  I think bleeding may be from greater palatine artery.

• berto December 18th, 2007

  
  

  GREATR PALATINE ARTERY???????????????

• prof.Dr.Dr.Hossam Barghash December 19th, 2007

  
  

  bleeding from the nose during implant surgery can happened as most of the colleague said is either from sinus penetration or nasal floor penetration, if it was from nasal perforation then the bleeding well happened during the drilling, but as you described it it happened after , this is explaine that it is most probably from the sinus because this well take time to fill the sinus first & then the blood well come later from the nose as you described. of course ther is membrane tearing , we call this implant (Implant under threat)which means even with the success of this implant , whenever this patient got sinusitis he/she well feel pain @ the site of the implant & very rare retrograde infection depending on the immune system of the person. of course this pateint has allways to take nasal dropeswhen ever starting to catch cold.hope he/she is not a smooker.

• osurg December 19th, 2007

  
  

  Right you are Jack. I would also put my money on the floor of the nose being the site of perforation. The amount of bleeding is consistant with that Dx. I like most surgeons have ben in the sinus more time than I would like to admit. At no time did I have any brisk bleding. More often than not the patient would report a mild nose bleed the next day or so. Sudden bleeding would indicate the nasal floor. As suggested films or even a nasal speculum might answer the question.You might even see a small elevation just by looking in the nose.BTW you might want to review the treatment of acute nose bleeds so that you don’t get into trouble if this should hapen again.

• GWK, DMD, MMSc December 22nd, 2007

  
  

  This might be an obvious question, but was there any history of nosebleeds in this patient prior to the procedure? There is a low incidence of spontaneous nosebleeds both venous and arterial in the general population.

• Dr. Jim Cope December 24th, 2007

  
  

  “Brisk bleeding” may actually have been slight bleeding the accumulated in the sinus and poured out when the patient was no longer reclined.
  I saw this occur on a teenage patient on whom I had removed tooth #3 due to invasive resorption, The surgery resulted in a 5mm oral-antral opening. The extraction site bled into the sinus while I sutured the site closed. When he sat up and the assistant took him to the Panorex machine a large volume of blood came out of his right nostril…alarming but not as bad as it seems. “Sinus Precautions” (antibiotics, decongestant, and avoiding pressure buildup in the nose) with “tincture of time” resulted in good healing without defect. Your implant case will likely heal well.
  Jim

• Gary D. Kitzis DMD January 2nd, 2008

  
  

  In view of the statement that you are from the UNITED KINGDOM, I believe that the bleeding from the right nostril after placing implants in the RIGHT LATERAL INCISOR (FDI site 12) rather than the RIGHT SECOND PREMOLAR (FDI site 14). There was probably a soft tissue tear of the nasal floor when drilling the 14mm implant site at FDI site #12. That’s called site one-two–NOT twelve in the FDI numbering system. The implant at site 14 (one-four) may have been the culprit, but in view of the rapidity of the bleeding and thefact that it stopped fairly quickly and uneventfully, the lateral incisor site was the most likely cause.

  In the US system, tooth # 12 and 14 are ON THE LEFT. The bleeding was on the RIGHT.

  In Europe they use the FDI numbering system, not 1-32 like the US. The FDI system is similar to the Palmer where teeth are numbered 1-8 from incisor to molar with the addition of a quadrant number. Quadrant 1 is UR, 2 is UL, 3 is LL, 4 is LR.

• anon OMS January 8th, 2008

  
  

  “In view of the statement that you are from the UNITED KINGDOM, I believe that the bleeding from the right nostril after placing implants in the RIGHT LATERAL INCISOR (FDI site 12) rather than the RIGHT SECOND PREMOLAR (FDI site 14).”

  excellent pick up! (These Kitzis guys are always annoyingly sharp - one was my instuctor in dental school - & we did not get along AT ALL! - but you gotta give props where they’re due!)

• Gary D. Kitzis DMD January 21st, 2008

  
  

  Whoa! I just re-read my post, and the FDI site 14 is the right FIRST premolar, not the second. The FDI second premolar is site 15. Sorry about that! I stand by everything else I wrote.

• Rose November 26th, 2009

  
  

  A year ago I had an implant nbr 14. I have had sinus pain on that side the whole year. It’s making me crazy. Because of the pain I did not go back for the abutment and crown. Should I have it removed. Will the trauma of that cause more problems and more pain.
  The implant perforated the sinus cavity by about 2 to 4 mm…about 1/4 to 1/3 of the implant can be seen on the x-ray protruding into the cavity.

• Richard Hughes, DDS, FAAID, FAAIP, DABOI November 27th, 2009

  
  

  Rose, You may have a sinus infection that may or may not be related to the implants. It has been shown that bone will grow up to 4 to 5 mm. up an implant that has penetrated the sinus and without any complications.

• vancouver November 28th, 2009

  
  

  i placed implants in the nasal penetrating nasal sinus; patient healed well we are now ready to restore (initial implant placement was may 2009); however patient still feels tender when touching left nostril area rating it a 2 on a scale of 1 - 10.

  Radiographically area looks great, bone seems nice and dense all around implants; torque test at stage two surgery shows excellent implant stability and ready to reastore.

  Periodontal tissue looks great, buccal bone feels good. Probablem seems to be with firm palpation over nostril when patient feels discomfort.

  Any ideas roughly?

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