Complex Odontogenic Infections

Part 1

Topographical Anatomy

Connective Tissue

– Types• Areolar (or loose)

connective tissue• Dense connective tissue • Elastic tissue• Reticular connective

tissue • Adipose tissue

Fascia

• A sheet of connective tissue covering or binding together body structures

• Types– Superficial Fascia– Deep Fascia

Superficial Fascia

• Muscles of facial expression• Continuous with superficial Cervical fascia

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Deep Fascia-

• Geography of Deep Fasica• Deep fascia of head and Neck

Deep Fascia of Jaws

• Muscles of Mastication– Temporal Fascia– Masseteric fascia– Parotidomasseteric fascia

– Pterygoid fascia

Continuous with Deep Fascia of Neck

What are fascial spaces?

• Fascia lined tissue compartments filled with loose, areolar connective tissue that can be inflamed when invaded with microorganisms. – Potential spaces– Loose areolar tissue within these spaces serve as

cushion to adjacent muscles, vessels, nerves, glands

– Allows movement

Clinical Correlation

Spaces of the Jaws• Deep Facial Spaces

associated with any tooth– Vestibular– Subcutaneous– Buccal

• Deep Facial Spaces associated with Maxillary teeth– Palatal– Infraorbital– Canine– Periorbital– Orbital– Cavernous Sinus

• Deep Facial Spaces associated with Mandibular teeth– Space of the body of the

mandible– Sublingual– Submandibular– Submental– Masticator– Submasseteric– Pterygomandibular– Superficial Temporal– Deep Temporal– Parotid

Spaces

• Vestibular-– potential space between oral

vestibular mucosa and muscles of facial expression

Palatal Space

• Infected by lateral incisors and palatal roots• Subperiosteal space of the palate• C/F : Very painful swelling

– (rich innervation of the periosteum)

Palatal

• Anatomic considerations

• Greater Palatine artery

• Greater palatine nerve

• Minor salivary glands

Infraorbital Space/ Canine space

• Thin potential space between levator anguli Oris and levator labii superioris muscles.

• Source of Infection : – Infections from Maxillary

canines and bicuspids– Extension from buccal space– Skin infection from nose and

upper lip

Infraorbital Space/ Canine space

Signs and SymptomsCheek Swelling and RednessObliteration of the nasolabial foldEdema of upper and lower eye lidTenderness and severe pain secondary to infra orbital

nerve edema and inflammationAbscess drains through the medial or lateral canthus

of the eye (levator labii superioris

attaches along the center of the inferior orbital rim)

Buccal Space

• Portion of subcutaneous space• Contents: Buccal fat pad, stensen’s

duct, facial artery• Borders

– Anterior-Corner of the mouth – Posterior-Masseter muscle– Superior – Maxilla– Inferior –Mandible– Superficial -subcutaneous tissue– Deep-Buccinator muscle

• Source of Infection– Infection from the upper and

lower premolars and molars

Buccal Space• Signs and symptoms

– Cheek swelling (Below Zygomatic arch and above inf.border of Mandible)

– Redness anterior to the masseter muscle

– Can spread through subcutaneous tissues into the periorbital space

– and past the inferior border of the mandible to the subcutaneous tissues lying superficial to the submandibular space.

Buccal-space– Posteriorly communicates with the submasseteric

space• Other communications

– Pterygomandibular space– Infratemporal space (via pterygoid plexus)– Lateral pharyngeal space (via pterygomandibular

raphe)– Superficial Temporal space (via buccal fat pad)– Subcutaneous spaces (superficial to submandibular

space)

Incision and Drainage

• Drained percutaneously when fluctuance occurs

• Drainage should be performed inferior to the point of fluctuance

• Recurrent Buccal space infections can occur as a complication of crohn’s disease

Cavernous Sinus Thrombosis

• CS are bilateral venous drainage channels for the contents of the middle cranial fossa(esp. – Pitutary gland)

• Anatomy:– Anteriorly-Bound by Sup.Orbital fissure– Receives a tributory Inf.Opthalmic vein– (orbital infections pass thru’ CS)– Drained by sup and Inf Opthalmic veins– Posteriorly-Trigeminal ganglion

Cavernous Sinus Thrombosis

• Maxillary OI erode the Infra Orbital vein in the infra orbital space or the Inf Opthalmic vein via the sinuses

– Follow Common Opthalmic vein through the superior ophthalmic fissure

• Extends to Cavernous Sinus

– Resulting inflammation caused by invading bacteria

» Stimulates the clotting pathways» CS thrombosis

Cavernous Sinus Thrombosis

• C/F: – Congestion of retinal veins of eye of unaffected

side– Papilledema, retinal hemorrhages, and decreased

visual acuity and blindness may occur from venous congestion within the retina.

– Fever, tachycardia, sepsis may be present. – Headache with nuchal rigidity may occur.

Cavernous Sinus Thrombosis

• C/F: Congestion of retinal veins of eye of unaffected side

• Papilledema, retinal hemorrhages, and decreased visual acuity and blindness may occur from venous congestion within the retina.

• Fever, tachycardia, sepsis may be present. • Headache with nuchal rigidity may occur.

Cavernous Sinus Thrombosis (C/F)

Pupil may be dilated and sluggishly reactive. Infection can spread to contralateral cavernous sinus

within 24–48 hr of initial presentation. Cranial nerve most commonly affected is Abducens (VI)Classic presentations are abrupt onset of

unilateral periorbital edema, headache, photophobia,Proptosis

Sublingual space

Defined superiorly by FOM mucosa and inferiorly by mylohyoidAnterior/lateral-

mandibleMedially-tongue and

genioglossusPosterior-superior,

posterior, and medial portion of the submandibular space

Sublingual Space

• Sublingual space communicates with submandibular space around the posterior border of the mylohyoid.

• Infections from sublingual space can pass through this gap and directly enter the lateral pharyngeal space

Sublingual Space

Sublingual Space-Clinical features

• Brawny, erythematous, tender swelling, FOM

• Begins close to mandible and extends to the midline

• Elevation of the tongue (late cases)

• DD:– Cellulitis– Sialolith of wharton’s duct

Sublingual Space- Treatment

• Place incision intraorally parallel to the wharton’s duct bilaterally

• If submandibualr space is involved then both spaces can be reached through an extra oral submandibular approach

Submental Space

• Potential space in the chin

• Infected either by Mandibular incisors or indirectly by the SM space

• Submental-midline; bordered laterally by anterior digastrics– Superficial border-anterior

layer of Deep Cervical Fascia, platysma, sup.fascia, skin

– Contents: Filled with areolar CT, submental lymph nodes and anterior jugular veins

Clinical Features-Submental Space

• Chin appears grossly swollen

• Firm , erythematous swelling

• Chronic infection drains as a fistula from the submental region

Submental space -treatment

Drainage-Achieved by percutaneous approach

Horizontal incision in the most inferior portion of the chin

Use natural skin creaseCosmetically acceptable scar

Intra oral drainage Through the mentalis muscle through labial vestibule

Submandibular-Boundaries

• Anterior/Posterior Borders-ant/post digastrics• Posterior boundary also includes stylohyoid

muscle and middle/superior pharyngeal constrictors.

• Superior border-inferior border and lingual surface of mandible below mylohyoid line.

• Medial border-mylohyoid muscle which extends from mylohyoid line to the hyoid

Submandibular• Communication to sublingual space around posterior border

of mylohyoid (following path of submandibular gland and duct)

• Contents – Gland/duct– Facial artery – Facial vein– lymph

Submandibular space

• Communication around posterior digastric leads to lateral pharyngeal;

• Around anterior digastric leads to submental space

Submandibular space

• Separated from overlying sublingual space by mylohyoid muscle

• Cause of infection : Mandibular second and third molars– Root apices of these

teeth lie inferior to mylohyoid line of the muscle attachment

Submandibular Space• Diagnosis: Brawny or

soft swelling, correlate with offending tooth

• May commonly cross the midline into the contralateral space

• Treatment

Ludwig’s Angina

– Late seventeenth century extraction of abscessed teeth was considered dangerous

– 3’F’s became evident: It was to be feared, it rarely became fluctuant, and it often was fatal

(Topazian et al)

• Definition:– Firm, acute, Toxic cellulitis of

submandibular, and sublingual spaces bilaterally and of the submental space

Clinical features as described by Wilhelm Friedrich von Ludwig.. In the late seventeenth century..

• Erysepalous angina• Temperature swings• Discomfort while swallowing• Develops on both sides

Clinical features

• Severe swelling• Elevation and displacement of tongue• Tense hard bilateral induration of submandibular

region, superior to hyoid bone• Trismus• Drooling of Saliva• Inability to swallow• Infection progresses at an alarming speed to cause

airway obstruction-Often leads to death

Ludwig’s Angina

• Secure airway• Prompt early aggressive

I & D surgery• Antibiotic therapy

Ludwig’s Angina-Treatment

Masticator Space

• Space is enclosed by the splitting of the anterior fascia around the muscles of mastication.

• Infections affect discrete portions of the space– Submasseteric– Pterygomandibular– Superficial temporal– Deep temporal

Masticator Space (Contd.)• Submasseteric

– Lies between parotideomasseteric fascia and lateral surface of ascending ramus

– Communicates with pterygomandibular space via the sigmoid notch

– Openly communicates with the superficial temporal space deep to ZM arch

Masticator Space (Contd.)

• Source of Infection:– Molars esp.Third molars

• Signs and Symptoms– Swelling of the face– Severe trismus– Dysphagia– Swelling of the retromolar triangle area

Masticator Space (Contd.)

• Infections result in significant trismus

• Differentiate from parotid swellings because submasseteric infections obscure earlobe from frontal view whereas parotid swellings elevate it.

Masticator Space (Contd.)Pterygomandibular space-infections correlate with

pericoronitis, needle tractsBorders

Lateral-ascending ramusMedial-medial pterygoidInferior-pterygomasseteric slingSuperior-lateral pterygoidPosterior-parotidAnterior-pterygomandibular raphe

Commonly communicates with lateral pharyngeal by passing around the anterior border of the medial pterygoid

Temporal Spaces

• Divided into superficial and deep temporal

• Clinical features – Severe Pain– Jaw deviates to the affected

side– TRISMUS– Swelling of the temporal area– Tenderness over the condyle

Temporal Spaces• Infra temporal space• Lies posterior to maxilla• Bottom portion of the

deep temporal space• Source of Infection-

Maxillary third molars

Temporal Spaces-Infra temporal space

• Contents– -Internal maxillary artery– Pterygoid venous plexus– Emissary veins pass from the pterygoid plexus

through base of skull to connect with intracranial dural sinuses

– Origin of the posterior route by which infection spread to Cavernous sinus

Masticator Space • Temporal spaces

– Superficial-communicates with buccal space via buccal/temporal fat pad

– Communicates inferiorly with the submasseteric space– Deep

• Lateral-temporalis muscle• Medial-squamous temporal bone• Inferior-lateral pterygoid• Anterior-posterior wall of max sinus and orbit• Infratemporal space lies inferior to the infratemporal crest of the sphenoid

bone– Contents found in infratemporal portion: maxillary artery and V3

Temporal Space Infection