Beyond benign swelling: fascial plane spread of dental therapy-related subcutaneous emphysema to critical cranio-cervicothoracic compartments — Clinical predictors and a management algorithm

Iatrogenic subcutaneous emphysema (SE) is an uncommon but potentially life-threatening dental complication that can rapidly progress into deep cranio-cervicothoracic compartments. This retrospective cohort study systematically evaluated 74 consecutive patients treated at a tertiary referral center over an 11-year period to identify clinical predictors of deep fascial spread and develop a management algorithm. All patients underwent computed tomography (CT) to delineate the volumetric extent of air. Critical compartment involvement (CCI), including deep cervical, orbital, or mediastinal extension, was identified in 48.6% of cases. Multivariate logistic regression identified high-speed air-driven handpieces (OR 4.5, p = 0.002) and procedures involving posterior mandibular teeth (OR 2.8, p = 0.031) as independent predictors of CCI. Clinically, dysphagia served as a significant indicator of deeper fascial extension. While management was predominantly conservative with a mean hospital stay of 2.2 days, pneumomediastinum was confirmed in 16.2% of patients. Systematic CT imaging proved essential for detecting subclinical spread. These findings informed a practical risk-stratified management algorithm designed to enhance patient safety by providing clinicians with a structured framework for early risk recognition and optimized diagnostic and therapeutic pathways.