Rationale: Sublingual hematoma is a potentially lethal complication following mandibular implant placement. Due to the scarce cases reported, the management is controversial. In this article, a case is discussed focusing on the different treatment options to establish an orientative guideline. Patient Concerns: A patient with sublingual hematoma following implant surgery was urgently referred. Despite no active bleeding, breathing difficulty due to oropharyngeal obstruction and oxygen saturation decrease were present. Diagnosis: Stable sublingual hematoma with respiratory distress, based on clinical findings and observation. Treatment: Under local anaesthesia, percutaneous tracheostomy without previous intubation was performed for airway preservation. No surgical approach for the hematoma was made. Outcomes: Uneventful recovery with spontaneous resolution of the hematoma in few days. Takeaway Lessons: Anatomic knowledge of this area and proper surgical planning are required to avoid this complication. Regarding management, airway preservation is mandatory. Surgical approach for the bleeding source will depend on hematoma progression.