How to manage a lingual concavity perforation?

I was performing an osteotomy on a lower left second molar. The patient had very limited mouth opening so performing the osteotomy was difficult. I ended up perforating the lingual cortical plate. I placed the implant but didnt realize I had the lingual plate fenestration. There was good primary stability.No hematoma formation. Patient just feels sore. How would I manage this case? Access to graft the lingual concavity is quite challenging for this patient.

dffddsmsc comments:

Remove the implant and replace it with a shorter implant. This area is most likely in the submandibular space, which contains the submandibular artery. Additionally, the lack of apical bone support may result in a late failure. Dennis Flanagan DDS MSc

mccavity comments:

After informing patient fully of situation and options nearly all would prefer to wait for integration and restoration without further surgical intervention as long as symptoms improve (“just feels sore”) and no pathology / instability develops - I’ve seen text book cases fail miserably and “failures” succeed without intervention- so many factors to consider and ultimately the informed patient (although “challenging”) will guide treatment rationale.

oa244 comments:

Remove the implant, let it heal, fabricate a surgical guide with CT SCAN and replace the implant in the proper area with the proper size according to the surgical plan.

xp80 comments:

would the cortical bone heal with removal of implant. Secondly if the implant were to remain insitu, as its an apical perforation, would bone grow around the apical implant if the rest of the implant is osseointegrated?

drdangober comments:

If the implant is of average width (4-5 mm) then the likelihood of spontaneous bone healing is high after removing the implant. You can also slide a resorbable membrane under the flap to obstruct the perforation from the lingual tissue for reassurance.

drdangober comments:

How do you know you perforated the lingual plate? Do you have a post op CBCT?

xp80 comments:

I felt the bur drop a bit when i was getting to length

drdangober comments:

In that case, for next time I would suggest placing an implant of shorter length once you realize that. Perforations of that size will typically heal spontaneously. If you have a CBCT available, I would recommend taking a scan right after to just make sure you have a precise sense of the apex of the implant relative to the lingual perforation so that you can make a decision as to whether to take it and place a shorter implant or if you should just take it out and leave it out. Also, just because you felt the bur drop a little does not necessarily mean you perforated the lingual plate. Sometimes the bur can feel like it drops when going from more mineralized to more spongy bone. Whenever I suspect perforating the lingual plate, I place a probe into the "perforated" site and try to feel for it on the lingual tissue with my finger to confirm. Hope this helps a little. Great scenario to discuss on the forum.

richardhughesdds comments:

Do you probe using the first to last bur? I’ve had some perforations. They healed uneventfully.

xp80 comments:

havent probed but from now on I will for every case. did you have perforations on the anterior or posterior, and did you graft bone?