Implications, Prevention and Management of Subcutaneous Emphysema During tic Treatment

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    Endod Dent Traumatol 1995: 11: 109-114Printed in Denmark . All rights reserved Copyright Munksgaard 1995Endodontics &Dental Traiunatology

    ISSN 0109-2502

    Review ar t ic le

    Im p lica tion s , p reven tion and m anagem en to f s u b c u ta n e o u s e m p h y s e m a d u rin gendodon t i c t rea tmen tBattrum DE, Gutmann JL. Implications, prevention, an(dmanagement of subcutaneous emphysema during endodontictreatment. Endod Dent Traumatol 1995; 11: 109^114. Munksgaard, 1995.Abstract - Subcutaneous emphysema (SCE) is a possible compli-cation of both nonsurgical and surgical endodontic treatment. Areview of the literature pertinent to endodontic intervention andSCE is highlighted, while the causes of and recommendations forthe prevention of SCE are provided. A review of the pathwayswhereby compressed air may travel through potential spaces inthe head and neck is also illustrated in an attempt to identify thepossibility' of morbidity and even mortality should operator in-duced SCE occur in a patient.

    D. E. B a t t r u m , J . L . G u t m a n nG rad u a t e E n d o d o n t i c s , D ep a r tm en t o f Res t o r a t iv eSc iences , Bay lo r Co l lege o f Dent is t ry , Dal las ,Texas, USA

    Ke y w o r d s ; s u b c u ta n e o u s e m p h y s e m a ; n o n -s u r g i c a l an d s u r g i c a l en d o d o n t i c t r ea t men t ;a n a t o m i c p a t h w a y s .James L. Gutmann, Graduate Endodont ics ,Baylor College of De nt is t ry , 3302 Gaston Ave,Dallas, Texas 75246 USAAccepted October 27, 1994

    Subcutaneous emphysema (SCE) is defined as the ab-normal presence of air under pressure, along or be-tween fascial planes (1). Entrapment of compressed airusually occurs rapidly, often causing morbidity^ andeven death. T he most comm on dental etiology of SCEis the introduction of air via the highspeed handpieceduring restorative procedures or during the surgical re-section of impacted teeth (2). Specific endo dontic treat-ment procedures, however, have also been implicatedas etiologic factors in the occurrence of SCE. The pur-pose of this paper is 1) to provide a contemporary^ re-view of the literature pertaining to entrapment of airduring endodon tic treatm ent which resulted in SCE; 2)to detail the fascial planes w hich are apt to be involvedin SCE during endodontic procedures; and 3) to pro-vide clinical guidelines, based on sou nd scientific data ,to prevent SCE during endodontic procedures andmanage this complication should it occur.

    LiteratureTissue emphysema subsequent to extraction was re-

    tooth of a "bugler" who suffered emphysema whileplaying his bugle shortly after the extraction. Theswelling resolved within days of the extraction whenhe ceased playing the bugle (2). Since that report, ad-ditional cases pertaining to this occurrence with endo-dontic implications have been identified in the litera-ture (2-11). In all cases, the spread of tissue emphy-sema was rapid and extensive. The extension ofedema often crossed the midline and extended bothsuperiorly and inferiorly from the site of operation. Inmany of the cases the root canal had been irrigatedwith a syringe containing hydrogen peroxide.SCE., in conjunction with endodontic treatmentmay last several days to a few weeks, usually clearingin facial regions before neck regions (6, 9, 11, 12). Incases where the neck is involved, respiratory difficultymay develop (13). Should this occur, hospitalizationusually follows with preparations made for tracheot-omy and the potential for mediastinitis (8,13). In mostreported cases, antibiotics were prescribed and recov-ery was usually complete within six weeks. Death wasreported in one case, secondary to the use of com-

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    B a t t r u m & G u tm a n nto endodontically caused subcutaneous emphysema isevident, even if rarely reported. The accessible litera-ture provides approximately 30 cases which specifi-cally deal with endodontically induced SCE. Clinicalfeatures of SCE can be classified as to those occurr ingimmediately or those occurring over various timeperiods following treatment. Often seen is localizedswelling, discomfort, and crepitus, with soft tissueradiographs or CT scans displaying tissue distension.Later sequelae are widespread edema, erythema, py-rexia, and sometimes pain. In serious cases the size ofthe swelling may increase over one to two hours. Theoccurrence of trismus is site dependent and notusually a serious problem. Advanced cases may dem-onstrate stripping of muscle attachments, poor heal-ing of involved soft tissues and chronic pain. The ac-tual occurrence of death has been reported exper-imentally in dogs (14), in addition to the casementioned above (8).

    R e v i e w o f t h e a n a t o m y o f t h e f a s c i a l p i a n e sThe fascial planes are areas of tissue boundaries,which under nonpathological conditions, are only po-tential spaces. Liebgott (15) defines seven regions ofthe head and neck in addition to the mediastinumwhere fascial planes occur (Table 1). As well as pres-surized air, hemorrhage and infection are also poss-ible causes of encroachment of the potential spaces.The prudent clinician will be aware of these potentialcomplications during treatment and avoid causativefactors which may effect subcutaneous emphysemaduring nonsurgical or surgical endodontic pro-cedures.During nonsurgical endodontic procedures, aftercoronal access and canal patency have been obtained,visibility is often limited. The temptation to clear theworking site using an air syringe with compressed airis great. This action may, however, introduce highpressure air into the periradicular tissues, and in some

    Ta b le 1 . A na tom y o f Fa s c ia l p la ne s - po te n t ia l s p r e a d o f c om pr e s s e d a i rR e g i on Area of Potent ia l Spread ot Compressed Ai rSuper f ic ia l Cheek , lower l i p , i n f r a o r b i t a l r e g i onP a ro t i d A long pa r o t i d du c t , w i t h i n pa r o t i d g l a ndS ubm a nd i bu l a r S upe r f i c ia l s pa c e , s ub l ingu a l re g i on , pa r o t i d g l a nd , m a s s e te r

    reg ionS ub l ingu a l S ubm a nd i bu l a r , m a s s e te r i c , pa r a pha r y nge a l s pa c e s & u l t i -

    m a te l y a i r w a yTons i ll a r S ubm u c os a o f s o f t pa l a te , s ub m a nd i bu l a r, s ub l ing ua l r e g i onM a s t ic a to r P a ra pha r y nge a l s pa c e s , pa r o t id , s ub l ing ua l , s ub m a nd i bu l a r

    r e g io n s , c a v e r n o u s s i n u s v i a f o ra m e n o v a le , o r b i t v i a i n f ra -o r b i t a l f i s s u r e

    Parapharyngeal Carotid sheatfi & contents; diWculty s pe a k i ng , s w a f l ow / ng ,w i t h e v e n t ia l m e d i a s t i n i t is

    (A da p te d f r om L ie bg o t t B . T h e anatomical basis of dentistry. Toronto- Decker

    cases along fascial planes (4-7). Likewise, the forcremoval of debris with oxygenated irrigants, such hydrogen peroxide which may pass beyond the apicforamen, can also create the abnorm al presence of atrapped in the tissues. Subsequent air entrapment ccause minor tissue swelling, which is usually self-liming (7). However, it can also be absorbed into thcirculatory system and may cause embolism formtion in various parts of the body, including the cornary and cerebral circulation. The consequencesthis may be tragic (8).iV I e c h a n i s m f o r S C E m o r h i d i t yThe potential avenues of travel for compressed air ashown in Figs. 1 & 2 . Air which is introduced inor along fascial planes presents with three potentisequelae. Initially, it can remain in the space until is resorbed. This leads to the "ballooning" (emphsema) of tissue and the occurrence of crepitus alonthe overlying involved tissues, immediately after aentrapment (1). Secondarily, it can escape along thpath of introduction, such as a patent root canal, anbe released into room air, causing no damage (2). Fnally, it can enter a blood vessel in a large enougvolume to cause obstruction of coronary flow, resuling in cardiac air embolism, or to cause obstructioin cranial fiow, resulting in cerebral ischemia, (stroke

    F i g . ]. Sagittal view indicating possible routes of movement of eompressed air in the anterior region; n=nasal eavity; p=palate; ssuperficial fa.scial space; sl=sublingual space; s m e = submentaspace; v=vestibule. (By permission from CV Mosby-Year BookLiebgott B. Th e anatomical basis of dentistry. Toronto: Decker,

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    S u b c u t a n e o u s e m p h y s e m aN a s a l c a v i t y

    M a x i l l a r y s i n u s

    2. Coronal section through the molar re-

    s = maxillar\' sinus; p= pal ate; s = superficialcial space; s l = sublingua] space; srad= sub-

    . The anatomical basis of dentistry. Toronto :ecker, 1986; 461)

    B u c c i n a t o r m .

    B u c c a l v e s t i b u l eG e n i o g l o s s u s m .S u b l i n g u a l g l a n dG e n i o h y o i d m .A n t e r i o r b e l l y o fd i g a s t r i c m .

    M y l o h y o i d m .

    15). Either of these two latter sequelae may result inHydrogen peroxide has been implicated as well ascompressed air in the etiolog)' of SCE (2,5,6,9,10). It

    xygen is liberated from hydrogen peroxide on con-act with blood and tissue proteins (17,18), this gas-

    Bhat (10), reported a case in which hydrogen per-esult of faulty access and subsequent lateral perfor-tion of a maxillar}^ central incisor. In this case the

    Ka ufm an (9) reporte d on a maxillary^ first pre -olar which was instrumented beyond the apical37o hydrogen peroxide. T he onset of emphysema wasudden and painful, extending from the lower eye lido the lower lip, and laterally to the nose. In bothhese cases the apical foramen was compromised, an

    xide was forcefully extruded beyond the apex. A

    rogen peroxide, was presented by Walker (5).Kaufman et al. (12) presented a case of delayedemphysem a subsequent to hydrogen peroxide

    cruciating pain. The incision of a large intraoral ves-tibular swelling with crepitus, resulted in the releaseof a bloody, foaming liquid. There was an immediatecessation of pain.Hirschmann & W'alker (6) cited a case of endodon-tic treatment on a grossly carious maxillary right can-ine, where compressed air was used often during thecaries removal procedure. The patient experiencedan immediate swelling on the right side of the facewhich rapidly spread to the left side. The patient wasgiven penicillin and three days later the swelling haddisappeared. In a second case report, the sameauthors reported the loss of a fractured reamer outthe apex subsequent to forceful hydrogen peroxideirrigation which had been used in an attempt todislodge the broken instrument. This patientexperienced tissue emphysema which subsided overfive days. Me dication included a course of oral am pi-cillin. Subsequent extraction of the tooth showed thereamer had perforated the buccal plate.A similar problem was reported by F alamo in 1984(7), when compressed air was used to dry a root canalof a maxillary right central incisor. Within minutes,the left eyelid, cheek and upper lip were swollen.Antibiotics were prescribed and resolution occurredin six days. Interestingly, the right side was not in-volved, pointing out the possible movement of airalong fascial planes, crossing the midline.Wright and others (19) reported facial emphysemain a two year old during general anesthesia, whileundergoing a pulpectomy of a prim ary central incisor.Due to continual seepage from the canal, air from the

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    Ba t t ru m & G u t m a n ntracted due to the inability 'to stop seepage'. Althoughthe child was discharged the same day with antibioticscoverage, the patient was readmitted three days laterwith facial swelling. Intravenous cephlorexin was ad-ministered and again the patient was discharged.After 28 days, the patient was readmitted with fever,swelling on the affected side with persistent nasal dis-charge. The diagnosis of abscess of the infraorbitalarea anterior to the right maxilla was made. Undergeneral anesthesia, examination showed chronic ul-ceration and necrotic mucosa of the nasal vestibule,consistent with chemical burn. Culture and sensitivityshowed Staphloccocus aureus. It should be noted that ir-rigation of the anterior tooth had been performedwith sodium hypochlorite and formocresol, prior tothe use of compressed air, in an attempt to control thebleeding from the canal. The child eventually healedwithout adverse sequelae.

    A severe sequelae, pneumomediastinum, was re-ported by Lloyd (11) and Nahieli and Neder (8) sub-sequent to the use of compressed air and hydrogenperoxide, respectively. In the latter case, the patienthad undergone pulp extirpation of the mandibularright third molar, using 3% hydrogen peroxide as ir-rigant. Subcutaneous emphysema was noted withinminutes and the patient thereafter complained ofshortness of breath and pressure in the chest. Chestradiography showed air in the mediastinum. Treat-ment consisted of ampicillin for ten days and the em-physema subsided in two weeks.

    Most recently, Pynn et al. (20) reported a suddenswelling subsequent to the perforation of a maxillaryleft lateral incisor during endodontic treatment. Theswelling extended from the left orbit to the submandi-bular and subclavicular areas and crossed the midlinein the submental area. Again, marked crepitus wasnoted. Complete resolution occurred subsequent toantibiotic treatment and the passage of six weekstime.A review of the literature has failed to disclose anyreported cases of SCE during surgical endodonticprocedures. However, there are reports in the oralsurgical literature regarding SCE in which the highspeed handpiece was used to section teeth prior toextraction (21, 22), following trauma (23), or sub-sequent to temporomandibular joint surgery (24). Itfollows that caution should be exercised when expos-ing tissue during surgical procedures in order to avoidthe introduction of compressed air along fascialplanes.

    Alternatives to the standard air driven highspeedhandpiece exist for endodontic surgical entry. Belli-zi & Loushine (25) recom men d the high-torque surgi-cal drill that relies on an electric motor driven systeminstead of compressed air. This apparatus avoids the

    reduction sealed-head hand pieces pressurized by aor nitrogen have also been recommended to preveSCE, as long as they are used with copious watelavage (26).Another alternative to minimize or negate SCduring surgical procedures would be to use ultrasonpreparation as an alternative to handpiece prepartion of teeth during root-end preparation. This approach has been recommended as a viable alternativto preparation with a compressed air hand piecProblems of visualizing the surgical site in the absencof compressed air from the hand held syringe can beliminated with the judicious use of vasoconstrictoprior to the procedure and copious rinsing with salinduring the surgical entrv- (27,28).Dis c u s s io nCl in i ca l gu ide l i nes f o r p reven t i on , i den t i f i ca t i on andm a n a g e m e n tDuring endodontic treatment the actions which macontribute to the occurrence of SCE var^- consideably. The prime area of air entry into anatomicaspaces appears to be the root canal space. Howeveair movement through soft tissue lacerations, such afrom the rubber dam clamp, or during surgical procedures cannot be overlooked, although the latter hanot been reported.The most prominent clinical feature of SCE rapid swelling of the face and sometimes the necThe affected area becomes puffy and in almost evercase crepitus may be elicited on palpation (2). Pain variable and is usually of short duration. Sometimeonly a slight discomfort or sensation of fullness is felIf the neck is involved there is generally some dicomfort with difficulty in swallowing.Differential diagnosis of SCE should be made froman allergic reaction, hematoma, and angioneurotiedema. The former is far more severe than SCE, witthe skin manifestations preceding serious cardiorespiatory manifestations. Hematoma formation is rapiand often without initial discoloration. Althougsponginess may be present, crepitus is absent. In angioneurotic edema, circumscribed areas of edemsometimes preceded by a burning sensation, may appear on the skin or mucous membrane. The possbility of necrotizing faciitis, in w hich b acterial gas production is possible, should also be considered (23).

    While cases reported of endodontically-inducesubcutaneous emphysema resolved, the morbidity waremarkable. In an experimental canine model, Rickes & Joshi (13) reported the death of 4 of 7 dogs subsequent to the administration of compressed air intpatent root canals. Autopsy revealed air in the righventricle, large thoracic vessels and coronary vessel

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    S u b c u t a n e o u s e m p h y s e mTa b le 2 . P re v e n t io n o f s u b c u ta n e o u s e m p h y s e m a d u r i n g e n d o d o n t ic p r o -cedures (1-3, 5-7, 9 , 10, 25)1 . A lw a y s u s e a ru b b e r d a m2 . L o o s e l y p l ac e i r r i g a t i o n n eed l es i n t o t h e r o o t c an a l3 . D e li v e r c o n t en t s o f t h e i r r i ta t i n g s y r i n g e g en t ly4 . A v o i d t h e u s e o f h y d r o g e n p e r o x i d e w h i l e i r r i g a t i n g r o o t w i t h o p e n a p i c e s5 . A v o i d t h e u s e o f h y d r o g e n p e r o x i d e i n h i g h l y h e m o r r h a g i c p u l p c a n a l s6 . U se h i g h -s p e e d a s p i r a t io n o r p a p e r p o i n t s t o d r y f l u id s f r o m t h e r o o t c a n a l7. A v o id d i r e c t in g c o m p r e s s e d a i r i n to t h e e n d o d o n t ic a c c e s s o p e n i n g d u r i n gt r e a t m e n t8 . C o n s id e r u s i n g " v e n t e d " h i g h s p e e d h a n d p i e c e s o r m o t o r iz e d s u r g i c a lh a n d p i e c e s d u r i n g s u r g i c a l o s s e o u s e n t r y a n d r o o t - e n d r e s e c t i o n9 . Us e s o n i c o r u l t r as o n i c d e v i c es f o r s u rg i c a l r o o t - en d p rep a ra t io n s

    Tab le 3 . Man ag e m en t o f s u b c u t ean e o u s em p h y s em a ( 1 , 6 , 7 , 19 , 2 3, 2 7, 29 )1 . D i s c o n t i n u e r o o t c a n a l t r e a t m e n t2 . R e a s s u r e t h e p a t i e n t3 . A t tem p t t o as c e r t a in t h e c au s e o f th e ac c i d en t ; eg . , p e r f o ra t io n o f th e ap ex

    o r r o o t w a l l, in d u c t io n o f c o m p r e s s e d a i r in t o t h e t is s u e s f r o m t h eh i g h s p e e d h a n d p i e c e d u r i n g s u r g e r y , i n tr o d u c t io n o f H 20 2a n d s o fo r t h .

    4 . I f s o l u t i o n s s u c h as H2O2 o r NaOGI a re i m p l ic a t e d , g en t ly i r ri g a t e t h e a reaw i t h w a t e r ( d i s t i l l ed i f av a i l ab l e ) t h ro u g h t h e p o r t a l o f en t r y

    5 . If t h e p a t i en t r ep o r t s p a i n , ad m i n i s t e r l o c a l an es t h e t ic s i n t h e ap p ro p r i a t ea rea( s )

    6 . I f t h e s w e l l in g ap p ea rs u n re l a ted t o S CE, c o n s i d e r an a l l e rg i c r eac t i o n o ra n g i o e d e m a a n d tr e a t a c c o r d in g l y

    7 . Co n s i d e r p re s c r i b i n g an t i b i o t i c s , s u c h as p en i c i ll in f o r 5 d ay s , s in c e t h ei n t ro d u c t i o n o f a i r m a y in c l u d e m i c ro o r g a n i s m s

    8 . C o n s id e r p res c r i b i n g an a l g es i c s s in c e p a i n d u e to d i s t en t i o n w i l l o c c u r an dt h a t m a y t a k e s e v e r a l d a y s t o s u b s i d e

    9. I f d i ff ic u l t y b r e a t h in g o r s w a l lo w i n g o c c u r s a n d d o e s n o t s e e m t o b e d u et o an x ie t y ( ie . , n o t qu i c k ly r es o l v ed ) , c o n s i d e r p ro m p t m ed i c a l i n v es t ig a t io n

    On e of the significant findings when com paring thereports of SCE in the literature is the unpredictabilityof t h e morbidity magnitude. Most practitioners at onetime or another may find they have used smallamounts of compressed air at the orifice of a toothwith a patent canal without inducing SCE. Therefore,it would appear that the occurrence of SCE is dueto the combination of several factors; 1) proceduralaccidents causing perforation of the apex or root of atooth allowing passage of air to the potential spaces;2) inadvertent irrigation of subcutaneous tissues withoxygen producing irrigants (H2O2) under pressure; 3)use of highspeed handpieces without exhaust protec-tion to prevent compressed air from being deliveredto the surgical site; and 4) prolonged or excessive useof hand-held air syringes for clearing surgical sites forimproved visibility.The most effective treatment, however, is the pre-vention of SCE during nonsurgical root canal treat-m ent by; 1) avoiding the use of com pressed air oncethe root canal has been opened; 2) using paper pointsto dry canals; and, 3) ensuring, if hydrogen peroxideis used, that it is retained within the canals (Table 2).

    syringe during irrigation; 2) using specific surgichighspeed handpieces, which direct the high pressurexhau st aw ay from the surgical site; or 3) using a slospeed, electrically-driven, or sealed-head air pressuized handpieces to remove bone, cementum and dentin when necessary. Additionally, the use of ultrasonior sonic instruments for root-end cavity preparatiomay also decrease the likelihood of inducing SC(Table 2).Although the occurrence of SCE is alarming, thcondition is generally not dangerous, and the air iabsorbed in the course of three or four days withouactive treatment. Should SCE occur, there are somreported treatment options, however, none have beescientifically tested (Table 3). In most cases antibioticsuch as penicillin, were prescribed, presumab ly on thassumption that if air has traveled into tissue spacethen microorganisms may follow suit. This complcation and the need for antibiotics have been chalenged as to its validity^ in some of the earlier report( 2 ) , while other authors claim an incidence of infection and mediastinitis, and the need for prophylactiantibiotic coverage (8,19,26). Likewise, the reporteuse of penicillin or erythromycin in these cases mabe based on empirical speculation, as the nature othe organisms present and their position in the tissuemay warrant the use of antibiotics such as metronidazole or clindamycin.

    R e f e r e n c e s1. KuLLAA-MiKKONEN A, MiKKONEN M. Subcutaneous air emphysema - a rare condition. Br J Oral Surg 1982; 20 : 2 0 0 -2 . SHOVELTON S . Surgical emphysema as a complication of dentoperations. Br Dent J 1957; 102: 125-9 .3 . M A G N I N J . Palpable edema after insufflation of air into the roocanal of an upper central incisor: report of case. R e i : Mens SuiOdont 1958; ^5.-437.4 . PE,\RSON SL. A case of surgical emphysema. Br Dent J 195105: 9 2 - 3 .5 . WALKER JEG. Emphysema of soft tissues complicating endodontic treatment using hydrogen peroxide: a case report. B rOral Surg 1975; /! 98-9.'6. HiRscHM.\.\N P., WALKER R. Facial emphysema during endodontic treatment - two case reports. Int Endod J 1983; 16 : 13

    2 .7 . FALOMO O . Surgical emphysema following root canal therapOral Surg Oral Med Oral Pathol 1984; 58 : 101-2.8. NAHIELI O , NEDER A. Iatrogenic pneumomediastunum aftendodontic therapy. Oral Surg Oral M e d Oral Path 1991; 77.-9.9. KAUFMAN A. Facial emphysema caused by hydrogen peroxidirrigation: report of case. J Endod 1981; 7 : 4 7 0 - 2 .

    1 0 . BH A T K . Tissue emphysema caused by hydrogen peroxide. OSurg Oral Med Oral Pathol 1974; 38 : 304 8.1 1 . LLO^T) R E . Surgical emphysema as a complication in endodontics. BrDentJ 1975; 138: 393-4.1 2 . KAUFMAN E, EEVINER E, G ALILI D , GARFUNKEL A. Subcutaneous air emphysem a a rare condition. J Oral Med 1984; 347-50.

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    B a t t r u m & G u tm a n n1 4 . RiCKLES N, JosHi B. Death from air embolism during root ca-

    nal therapy. J ^ m Dent Assoc 1963; 67: 397-404.1 5 . L I E B G O T T B. The anatomical basis of dentistry. To ro n to : Decker,

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    London: Qjaintessence, 1988; 197.1 9 . WRIGHT K, DERKSON G, RIDING K. Tissue-space emphysema,tissue necrosis, and infection following use of compressed airduring therapy: case report. Pediat Dent 1991; 13: 110-13.

    2 0 . PYNN B, AMATO D, WALKER D. Subcutaneous emphysema fol-lowing dental treatment: a report of two cases and review ofthe literature. J C a n Dent Assoc 192; 58: 496-9.

    2 1 . LEROY N B , BREGMAN AH. Subcutaneous emphysema. J AmDent Assoc 1968; 76: 798-9.

    2 2 . ARAGON S, DOLWICK F, BUGKLEY S. Pneumediastinum and

    subcutaneous cervical emphysema during third molar extration under general anesthesia. J Oral Maxillofac Surg 1986;141-4.

    2 3 . DEMAS PN, BRAUN TS. Infection associated with orbital subctaneous emphysema. J Oral Maxillofac Surg 1991; 49: 1239

    2 4 . GHUONG R, BOLAND TJ, PIPER MA. Pneumomediastinum asubcutaneous emphysema associated with temporomandibujoint surgery. Oral Surg Oral Med Oral Pathol 1992; 7 4 : 2 - 6 .

    2 5 . BELLIZZI R, LOUSHINE R. A clinical atlas o f endodontic surgerycago: Qintessence, 1991; 17.2 6 . .\RENS D. Surgical endodontics. In: Cohen S, Burns R, ePathivqvs of th e pulp. St. Louis: Mosby, 1991; 587.

    2 7 . GUTMANN JL, HARRISON JW. Surgical endodontics. BoBlackwell, 1991; 189.

    2 8 . GL^TMANN JL. Parameters of achieving quality anesthesia ahemostasis in surgical endodontics. Anesth Pain Control D1 9 9 3 ; 2.-223 6.

    2 9 . FEINSTONE T. Infected subcutaneous emphysema: report ofcase. J Am Dent Assoc 1971;

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