Sublingual emphysema following alveoloplasty: A case report
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67 year old female presented for extraction of teeth numbered 32, 33, 42, and 43, alveoloplasty and placement of two implants for an overdenture. Under local anesthesia, a full thickness flap was raised on the buccal and lingual aspect, extending from the distal of 33 to the distal of 43. The teeth were extracted uneventfully, and bone reduction to provide adequate restorative space for the overdenture was performed with a surgical air driven high speed surgical hand piece. During the drilling process, slight swelling was noted in the floor of the mouth on the left side. This was attributed to pressure and trauma from flap retraction as the patient was asymptomatic during the procedure. Implant drilling was continued uneventfully according to protocol, and two Straumann BLT implants 4.1 mm × 12 mm were placed in the region of 33 and 43. No dehiscences or fenestrations were created during osteotomy preparation, and adequate bone volume was present surrounding the implants.

Upon completion of the procedure, blood pressure was 132/86 mm Hg. A prescription for amoxicillin 500 mg, three times daily for seven days, and chlorhexidine mouthwash twice daily was given. Since she was already taking tramadol and meloxicam for arthritis related pain, no additional analgesics were prescribed. The patient reported the next day for denture insertion with the chief complaint of severe pain and swelling beneath her tongue on the left side. Her temperature was 98.5°F, and her blood pressure was 145/80 mm Hg. She said the pain began during the afternoon of the procedure immediately “after the numbness went away.” She also reported, “It feels like my tongue is sitting on something.” After physical examination, a marked edema of the left floor of the mouth was noted. The edema was present at the lateral incisor/canine region and extended from the original intra surgical location into the floor of the mouth.

The edema was pronounced enough that it caused the lingual mucosa to cover the left alveolar ridge. A pathological consult was done, and a differential diagnosis of emphysema or mucocele was made. Upon palpation, crepitus was felt. Under local anesthesia, a 5 mm superficial incision in the central portion of edematous area was made. There was no discharge of mucous from the incision, but the swelling reduced after light pressure was applied and air bubbles were seen in the heme surrounding the incision line. As the patient was taking antibiotics and using antiseptic mouthwash, she was dismissed and instructed to report the next day. The next day the swelling was further reduced, the incision line appeared to be healing uneventfully by primary intention, and the patient denied any discomfort or pain. She was advised to complete the course of antibiotics and rinse with chlorhexidine. At the 2 week follow up, uneventful wound closure was observed.