Subcutaneous emphysema (SE) is a rare yet potentially serious complication that can occur during or after third molar (wisdom tooth) extraction.
It involves the inadvertent introduction of air into the subcutaneous tissues, leading to swelling, crepitus upon palpation, and in severe cases, extension into deeper fascial spaces, potentially resulting in pneumomediastinum or pneumothorax.
Etiology and Risk Factors
The primary cause of SE during dental procedures is the use of air-driven high-speed handpieces.
These instruments can force air into the soft tissues through mucosal defects or surgical flaps, especially when extracting mandibular third molars.
A retrospective study analyzing 10,779 third molar extractions reported an incidence of SE at 0.018%, with all cases associated with the use of air turbines.
Interestingly, SE can also occur without the use of air-driven instruments.
A case report documented SE following the extraction of a maxillary third molar using only manual instruments, suggesting that factors like bone fractures or sinus perforations can also facilitate air entry into soft tissues.
Clinical Presentation
Patients typically present with sudden facial swelling, often accompanied by a crackling sensation (crepitus) upon palpation.
In some cases, the air can track along fascial planes, leading to periorbital edema, neck swelling, or even chest discomfort if the mediastinum is involved.
Symptoms may develop immediately during the procedure or within a few hours postoperatively.
Diagnosis and Management
Diagnosis is primarily clinical, based on the characteristic signs and patient history. Imaging studies, such as plain radiographs or computed tomography (CT) scans, can help assess the extent of air spread and rule out complications like pneumomediastinum.
Management strategies include:
✔ Observation: Most cases are self-limiting and resolve within 7–10 days without intervention.
✔ Antibiotic Therapy: Prophylactic antibiotics are often prescribed to prevent secondary infections due to the potential introduction of oral flora into sterile spaces.
✔ Hospitalization: Indicated for extensive SE, involvement of deep neck spaces, or respiratory compromise.
✔ Surgical Intervention: Rarely required but may be necessary in cases with airway obstruction or abscess formation.
► LUDWIG'S ANGINA: Updated Overview on Symptoms, Causes, Treatment, Prognosis, Epidemiology, and Complications
Prevention
To minimize the risk of SE:
✔ Avoid using air-driven handpieces for surgical extractions, especially in the mandibular region.
✔ Ensure proper surgical techniques to prevent mucosal tears.
✔ Educate patients to avoid activities that increase intraoral pressure postoperatively, such as forceful nose blowing or playing wind instruments.
Conclusion
While subcutaneous emphysema is an uncommon complication of third molar surgery, awareness of its etiology, clinical presentation, and management is crucial for dental practitioners.
Prompt recognition and appropriate intervention can prevent progression to more severe conditions and ensure patient safety.
References
- Romeo U, Galanakis A, Lerario F, et al. Subcutaneous emphysema during third molar surgery: a case report. Braz Dent J. 2011;22(1):83-86.
- Soylu E, Asan CY, Kiliç E, Alkan A. An unusual complication after the extraction of a maxillary third molar: extensive subcutaneous emphysema. J Clin Anal Med. 2016;7(4):510-513.
- Ye LY, Wang LF, Gao JX. Pneumomediastinum and subcutaneous emphysema secondary to dental extraction: two case reports. World J Clin Cases. 2022;10(27):9904-9910.
