Successful Management of Ludwig's Angina due to Dental Impla
Dental implant surgery is a common procedure in oral and maxillofacial surgery practices. Extensive training, skill, and experience allow this procedure to be performed with an atraumatic approach, but like any surgical technique, it is subject to accidents and complications. This is an unusual clinical case of an accidental displacement of an implant into the submandibular space that progressed to Ludwig's angina, and it has not yet been described in the literature.

A 47-year-old man underwent oral surgery in a private dental clinic for dental implant in the posterior region of the mandible. According to the surgeon's and patient's history, the implant was placed at the region of the first lower right molar, but fenestration of the lingual cortical plate required simultaneous bone regeneration by using lyophilized bovine bone grafts and collagen membrane. The implant primary stability was checked with a torque wrench used at a force of 32 N·cm, and the healing cap was placed. There was no postoperative complication during the period of bone repair.
After 120 days, during the healing cap removal, the implant was accidentally displaced into the submandibular space. Although the lingual access was performed through intrasulcular flap in the same session, the implant was not localized. Therefore, the intraoral access was closed and the patient medicated with amoxicillin , nimesulide, and dipyrone sodium. The patient was instructed to undergo a computed tomography (CT) scan of the mandible for reassessment and removal of the implant.

Panoramic radiographic and CT scan examinations showed displacement of the dental implant into the submandibular space and fracture of the mandibular lingual cortical bone adjacent to the region of tooth #36 . The patient was advised to return within 48 hours, but he did it only after seven days complaining of pain, swelling in the face, fever, and difficulty swallowing. After an initial evaluation, the patient was referred urgently

On physical examination, the patient presented consistent swelling in the submental region. In the submandibular and sublingual spaces, there was presence of painful symptomatology on local palpation bilaterally, trismus, mouth opening of approximately 20 mm, dysphonia, pain on cervical palpation, and intraoral purulent drainage, also affecting the floor of the mouth. In view of the clinical symptoms, laboratory tests and hospitalization were requested. Laboratory tests confirmed the infection, and Ludwig's angina was diagnosed.

After lingual flap retraction at the region of implant placement, detachment of the mucoperiosteum was performed for exploration of the area, but the dental implant was not found. Due to the failure of the intraoperative procedure, it was decided to use the surgical arch for radiographic shots in profile. At this time, it was verified that the implant had shifted to the submandibular space. Following the treatment, extraoral access was performed in the submandibular area by using hemostatic forceps and radioscopic technique, thus allowing the dental implant to be clamped and removed after removal, a Penrose drain was inserted into the bilateral submandibular region and the patient remained hospitalized for 72-hour follow-up, receiving ceftriaxone, clindamycin, dexamethasone, tenoxicam, and sodium dipyrone . The Penrose drain was removed after 48 hours.

The patient's postoperative recovery was uneventful, with regression of signs and symptoms, and he was discharged from the hospital with clindamycin prescription. After 7 days, the patient returned for reassessment. Clinical and radiographic examinations were performed, and the patient presented neither signs of infection nor limitation of mouth opening and pain complaintsIn conclusion, the displacement of dental implants into the submandibular space evolving into Ludwig's angina is a rare complication in implant dentistry. Early intervention to maintain airways preserved, including drainage and removal of the dental implant, is mandatory in the treatment. In this case report, the radioscopic equipment has proved to be efficient for removal of the dental implant.

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Dr. T●●●●z H●●●●●●i and 3 others like this4 shares
D●●●●i G●●●e
D●●●●i G●●●e Dentistry
What if the patient had returned back with 48hours? Will there be such complications?
Mar 23, 2020Like
Dr. s●●●●p s●●●●●●●●●a
Dr. s●●●●p s●●●●●●●●●a Oral and Maxillofacial Surgery
Such patients need to be in a close follow up. foreign body cases needs regular follow up. moreover there could have been other complication too...
Mar 24, 2020Like2