# Submental Abscess Following Peri-Implantitis: Case Report and Comprehensive Literature Review
## 2 Case Description  
A 77-year-old man (Caucasian) went to the emergency room of the Policlinico Umberto I with an evident swelling of the neck, which involved the right submental and submandibular region (Figure 1). The following day, he was admitted to the Otorhinolaryngology (ENT) Ordinary Hospitalization Department with an admission diagnosis, later confirmed, of a right submental and submandibular abscess of possible dental implant origin. In the immediate pathological anannesis, the patient reported that approximately 15 days before he had undergone surgery for the insertion of four dental implants (bone level) in the mandibular area, which was followed by the appearance of a painful swelling in the right submental and submandibular region. Following this, the patient took a pharmacological therapy with amoxicillin and acid clavulanic 1 g (Augmentin(r), GlaxoSmithKline, Brentford, UK) and Betametasone 1 mg (Bentelan(r), Alfasigma S.p.A, Bologna, Italy) for 6 days, but without having any benefits, and instead reported a worsening of the symptoms and difficulty in swallowing. From the remote pathological anannesis, arterial hypertension, hyperuricemia and hypercholesterolemia are highlighted and pharmacologically managed with Allopurinolo 300 mg (Zyloric(r), Teofarima S.r.l., Pavia, Italy), Telmisartan 80 mg (Micardis(r), Boehringer Ingelheim Italia S.p.A., Milan, Italy), Atorvastatinita 10 mg (Totalip(r), A. Menarini Manufacturing Logistics and Services S.r.l., I'Aquila, Italy). On extraoral objective examination, the swelling appeared warm, painful, mobile, of a tense-elastic consistency and with normotrophic surrounding skin. The intraoral objective examination confirmed the recent introduction of dental implants at the mandibular level and the presence of hyperemic surrounding soft tissues. The orthopantomography, performed four days before access to the emergency room, showed clear signs of inflammation and bone resorption in the mandibular arch, evidenced by osteolytic areas of radiolucency both around the recently inserted implants and around the only previously inserted implant that appeared to support alone the lower prosthesis (Figure 2). Figure 1: Extra-oral view of swelling of the neck (**A**) right view. (**B**) frontal view. (**C**) left view. Previous panoramic X-rays showed that the patient had already undergone previous failed attempts of implant rehabilitation. The panoramic X-ray, performed approximately nine months before hospitalization, showed that of the seven implants previously inserted three years earlier in the lower arch, only three remained and had also undergone a significant process of peri-implantitis and bone resorption (Figure 3). The development of cervical swelling would therefore appear to be related to the formation of a peri-implant infectious process in a region that had already been previously weakened in terms of both soft and hard tissues. In fact, the therapeutic rage would have allowed the infectious process to make its way through anatomical structures that were now compromised and to reach the spaces of the neck by gravity. An urgent CT scan of the head and neck area was requested and performed, before and after the administration of contrast medium. The report confirmed the presence of an abscess in the right submental and submandibular area, with a multi-chambered appearance, which infiltrated the mylo-hyoid, genioglossus muscles and the submandibular gland. The infectious process slightly compressed but did not exceed the hyoid bone, located at the third and fourth cervical  
Figure 3: Previous panoramic X-rays (**A**) panoramic X-ray three years earlier. (**B**) panoramic X-ray nine months earlier. Figure 2: Preoperative panoramic X-ray. vertebrae; the lack of involvement of the hyoid bone at the time of admission confirmed that the infection had not yet invaded the airways.