Managing Mandibular Lingual Plate Perforation?

I was wondering if you all could comment on how you manage a mandibular lingual plate perforation during osteotomy preparation. I know that avoidance is the best method, but assuming you find a perforation would you graft and close or place some graft and try to re-orient the osteotomy and place a shorter implant. Does the position of the perforation i.e above or below the mylohyoid play a role as well as the degree of bleeding from the site?

9 thoughts on “Managing Mandibular Lingual Plate Perforation?

  1. Raul R Mena says:

    Graft, do not overpack the grafting material, you don’t want to have grafting material extruding out of the osteotomy.
    Close and wait at least 3 month to do a reentry.
    Of course you could be a cowboy and try to redirect the osteotomy, but if you couldn’t direct it properly the first time, I wouldn’t try such a maneuver at this time.
    Play it Safe.

  2. peter hunt says:

    One has to be very careful in this region. In my maxillo-facial residency In Great Britain a patient was admitted with a lingual hematoma of such a size that the airway was impeded. A mandibular second molar had been extracted in the morning, there was later bleeding intra-orally. The dentist then paced a plug in the socket. That’s when the hematoma started developing.

    The patient was anaesthetised but it was impossible to pass an airway, so a “blind” tracheotomy was performed and a tracheotomy tube placed.

    I always remember that when operating in this region. These days I always use a CBCT. If one is not available then the lingual region is always palpated to determine the extent of the mylohyoid ridge. A drill channel is always prepared with the channel paralleling the outer plate of bone. That’s important because the mandibular bone in the molar region often skews to the lingual. With simple guides like this then this is a safe procedure, but I still have that case in the back of my mind. Good luck!

  3. Timothy Hacker DDS, FAAID, D-ABOI/ID says:

    I have had several experiences with lingual perforations (all have turned out well) as well as provided expert testimony in cases where the issue was improperly handled. Dr. Hunt is offering wise words of caution and a technique for predictability in this area.
    It is imperative to have enough bone width to be able to follow the buccal bone trajectory. If you do not have this, please consider using a blade, or one of many bone expansion/augmentation techniques before just drilling your hole. A pre-operative CBCT is considered standard of care now.
    I would add, that the risk of extruding particulate material into the submandibular space is very high. Therefore, I would not ever take that risk by placing a particulate bone graft. It can migrate. The safest approach is to place an L-PRF plug in the osteotomy and membrane of L-PRF (for quick healing and inflammatory management), then re-entry to augment or use very short implants in 3-4 months. Also, 900mg-1200mg Clindamycin daily for 10+ days. Observe your patient closely with daily communication, as hospitalization could be likely and you must stay on top of this. Remember the side effects of this amount of Clindamycin.

  4. Michael Rowe says:

    Interesting that in my OMFS residency 30+ years ago we routinely placed titanium screws in the maxillary sinus for our osteotomies. When plating mandibular fractures we would place our gloved fingers in the lingual sulcus and wanted to feel the tip of the screw just penetrate. We had no problems. Are implants “different”?

  5. Elijah Arrington III D.M.D. says:

    This happened to me 2 months ago, of course you are going to want primary closure here, so make sure you have released the mylohyoid musle with blunt finger pressure and wet gauze to have flexibility of your lingual flap. Take the broken piece of the plate and put it back in place like a puzzle piece. Take a titanium mesh (ti-mesh) membrane prep it buccal/ lingual to cover the area (rounded edges). Slide the lingual portion of your ti-mesh in first against the lingual flap and the piece you broke to hold the broken piece in place. Add bonegraft a top the broken piece and the ti mesh and down the lingual side of the jaw; this with (antibiotic) metronidazole 150mg if the patient isn’t allergic. You should already have good bone flow from when you broke the plate. If you don’t have good blow flow from the osteotomy create good blood flow to hydrate graft prior to grafting of course. Bend the ti-mesh over to the buccal part of jaw screw it down if you can, if you can’ t screw it then suturing will hold it in the end; add a collagen membrane atop the ti-mesh membrane; undermine buccal flap; gain primary, place sutures. Wait 4-8mths to reopen 🙂 have a bud on me…

Leave a Comment:

Comment Guidelines: Be Yourself. Be Respectful. Add Value. For more details, read our comment guidelines. Though we require an email to comment, we will NEVER publish your email.
Required fields are marked *

Posted in Clinical Questions, Surgical.
Bookmark Managing Mandibular Lingual Plate Perforation?

Videos to Watch:

Suturing in Guided Bone Regeneration

This video provides clinical tips for suturing techniques in Guided Bone Regeneration. In Guided Bone[...]

Watch Now!
Socket grafting with Collagen Dressing and Bond Apatite

This video demonstrates socket grafting with just bond apatite and a collagen wound dressing.[...]

Watch Now!
Dental Implant for Lower Right Second Molar

This video shows implant placement on the lower right second molar.[...]

Watch Now!
Saving a Bridge with Periodontal Therapy

This video shows a case involving a 48-year-old male who was referred for periodontal treatment[...]

Watch Now!
Immediate Loading Full Arch

This video shows a case of Immediate loading of a full arch with simultaneous guided[...]

Watch Now!
Apically Repositioned Flap Technique Around Implants

The apically positioned flap is a commonly used surgical approach, that may help the long[...]

Watch Now!
Digitally Planned Bone Augmentation and Immediate Implantation

This video shows a case using the Ring technique to provide bone augmentation along with[...]

Watch Now!
AnyRidge Implants: Replacement of Upper Left Molars

This video shows the replacement of maxillary upper left molars with Megagen AnyRidge Implants.[...]

1 Comment

Watch Now!
Guided Implant Surgery & Immediate Temporisation

This video demonstrates the placement of a missing pre-molar using computer-guided surgery and immediate temporization.[...]

1 Comment

Watch Now!
Implantoplasty to Treat Peri-implantitis

This video shows the use of the Implantoplasty technique to treat peri-implantits. Granulation tissue and[...]


Watch Now!
Placement of Implant Using EZ Devices

This video demonstrates the placement of a dental implant in the upper jaw using the[...]

Watch Now!
BonePen: Improve Positioning of Implants

A short video demonstrating close up the use of the BonePen Kit, a set of[...]

Watch Now!