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Oral Surgery

Which handpieces are appropriate to use in bone removal and tooth sectioning during exodontia to minimize the risk of air embolism?

This question was submitted by a general dentist: Which handpieces are appropriate to use in bone removal and tooth sectioning during exodontia to minimize the risk of air embolism?

Dr. Suham Alexander, Oasis Discussions Editor, and Dr. George Sandor, Oral maxillofacial surgeon, provided this initial quick response

Subcutaneous air emphysema is a rare but dramatic complication which occurs following surgery in medical or dental procedures. Such dental procedures include: root canal treatment, dental restorations and extraction of mandibular and maxillary teeth. Most commonly, the surgical extraction of mandibular wisdom teeth is associated with this condition.


The condition arises from the use of an air-driven high-speed dental handpiece where air is vented forward towards the bur. This causes air to be forced under pressure into subcutaneous tissues when a flap is reflected or the gingival attachment to the alveolus is compromised. Air then enters the lamina propria or dermis and possibly to various fascia planes.

Treatment varies depending on the severity of the emphysema from reassurance to the patient (minor localized air emphysema) to hospitalization in cases where air enters fascia spaces, causing respiratory distress.


  • Avoid the use of air-driven high-speed dental handpieces for surgical extraction and osseous surgery.
  • Use of specific surgical handpieces which are electric (do not run with air) or nitrogen-driven handpieces which exhaust the gases to the rear.


  1. Mather AJ, Stoykewych AA, Curran JB. Cerviofacial and Mediastinal Emphysema Complicating a Dental Procedure. J Can Dent Assoc. 2006;72(6): 565-8.
  2. Penarrocha M, Ata-Ali J, Carrillo C, Penarrocha M. Subcutaneous emphysema resulting from surgical extraction without elevation of a mucoperiosteal skin flap. J Clin Exp Dent. 2011;3(3):e265-7.
  3. Reznick JB. Avoiding a very preventable surgical complication. DentalTown. August 2010; p. 52-54.
  4. Sekine J, Irie A, Dotsu H, Inokuchi T. Bilateral pneumothorax with extensive subcutaneous emphysema manifested during third molar surgery. Int J Oral Maxillofac Surg. 2000;29:355-7.


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  1. David ROSE March 20, 2014

    I was under the impression that air driven handpieces that don’t exhaust drive air out the front (such as the Impactair )are acceptable.

    1. JCDA Oasis March 20, 2014

      On Behalf of Dr. Suham Alexander, Oasis Discussions Editor:
      Yes, this is correct. ImpactAir is an example of a handpiece that exhausts air to the rear as well as the Sabra 45 or 105. Other companies make similar handpieces, such as Kavo.

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