MANDIBULAR SPACE INFECTIONS &

COMPLICATIONS

Submitted by

Geetha R

Final Year BDS part II

KANNUR DENTAL COLLEGE

Department of Oral & Maxillofacial Surgery

CONTENTS

INTRODUCTION

Odontogenic infections are among the most frequently encountered infections affecting humans. In majority of cases, these infections are minor and resolve either by spontaneous drainage through the gingival tissues of the tooth or by extraction of the offending tooth.

Chronic sinus tracts from the apex of the tooth to the surface mucosa or skin are not uncommon in populations who receive little or no dental care.

A great deal of pain and suffering accompany establishment of these draining sinus tracts. Removal of the offending tooth almost always results in rapid resolution of the infection, even with antibiotic therapy. Unfortunately, these minor tooth-related infections occasionally become serious and life-threatening. Aggressive surgical and medical care is necessary to prevent disastrous results.

CLASSIFICATION

BASED ON MODE OF INVOLVEMENT

Primary Maxillary Space

Canine space

Buccal space

Infratemporal space

Primary Mandibular Space

Buccal space

Submental space

Submandibular space

Sublingual space

Secondary Facial Space

Massetric space

Pterygomandibular space

Superficial & deep temporal space

Lateral pharyngeal space

Retropharyngeal space

Prevertbral space

Parotid space

Direct involvement Indirect involvement

MANDIBULAR SPACES

Infection may erode from mandibular teeth into a variety

of spaces, in addition to the usual vestibular abscess.

The three primary spaces are the submental,

sublingual,and submandibular spaces; the three

secondary spaces are the pterygomandibular, masseteric,

and temporal spaces.

The primary spaces are those into which infection

spreads directly from the teeth and bone.

SUBMENTAL SPACE

Etiology

1. Infection from anterior mandibular teeth.

2. Spread of infections from lower lip, skin around

cheek, floor of mouth , tip of tongue & sublingual

tissues

SURGICAL ANATOMY

Boundaries

Deep or Lateral : Anterior belly of digastric

Superficial or medial : Investing layer of deep

cervical fascia

Superior : Mylohyoid muscle

Inferior : Investing layer of deep cervical fascia

Anterior : Inferior border of mandible

Posterior : Hyoid bone

Contents

Submental lymph nodes & anterior juglar vein

CLINICAL FEATURES

Extraoral findings

Distinct, firm swelling in midline, beneath the chin. Skin

overlying the swelling is board like and taut. Fluctuation

may be present.

Intraoral findings

The anterior teeth, are either non-vital, fractured or

carious. The offending tooth may exhibit tenderness to

percussion and may show mobility. The patient may

experience considerable discomfort on swallowing.

INCISION & DRAINAGE

Transverse incision placed in skin below symphysis

of mandible.Blunt dissection done with kelly’s

forceps or sinus forceps

SPREAD

Infection can extend

a) Posteriorly, to submandibular space

b) Dicharge of contents in submental region in face

SUBLINGUAL AND SUBMANDIBULAR SPACES

The sublingual and submandibular spaces exit on

the medial aspect of the mandible.They are usually

involved by lingual perforation of infection from the

mandibular molars. The factor determining whether

the infection is in the sublingual or submandibular

space is the relationship between the area of the

infection's perforation and the location of the

mylohyoid muscle's attachment .

SUBMANDIBULAR SPACE

If the apex of the tooth is inferior to the muscle (third

molar) , the submandibular space is involved.

Etiology

1.Infection of mandibular molars

2.Infection from submandibular salivary gland

3.Infection from submental space

4.Infection from sublingual space

5.Infection from tongue , floor of mouth & cheek.

SURGICAL ANATOMY

Anteromedially :mylohyoid muscle

Posteromedially: hyoglossus muscle

Superolaterally : medial surface of mandible

Anteroinferiorly : anterior belly of digastric

Posteroinferiorly : posterior belly of digastric,

stylohyoid & stylopharyngeus muscle

Superficial: platysma & skin

Deep : Mylohyoid ,hyoglossus & superior

constrictor

Contents : superficial lobe of submandibular

salivary gland & lymph nodes , facial artery & vein

CLINICAL FEATURES

Extraoral

(i) Firm swelling in submandibular region, below the

inferior border of mandible.

(ii) Generalized constitutional symptoms

(iii) Some degree of tenderness

(iv) Redness of overlying skin.

Intraoral

(i) Teeth are sensitive to percussion

(ii) Mobile

(iii) Dysphagia

(vi) Trismus.

INCISION & DRAINAGE

Incision of about 1.5 to 2 cm in length is made 2 cm

below lower border of mandible. Skin & subcutaneous

tissue are incised .A sinus forceps is inserted through

incision superiorly & posteriorly on lingual side to

mandible to drain pus. Rubber drain is placed & secured

with sutures.

SPREAD

Involve contralateral submandibular space

Involve submental space

Involve sublingual space

Involve parapharyngeal space

SUBLINGUAL SPACE

Submandibular and sublingual spaces surgically distinct, but

should be considered as surgical unit due to proximity and

frequent dual involvement in odontogenic infections.

Etiology

1. Infected premolar and 1st molar teeth frequently drain into this space due to their root apices existing superior to the mylohyoid muscle

SURGICAL ANATOMY

Boundaries

1. Inferiorly : Mylohyoid muscle

2. Laterally : Medial surface of mandible

3. Medially : Hyolglossus, genioglossus & geniohyoid

4. Posteriorly : Submandibular space

5. Laterally & inferiorly : Mylohyoid muscle & lingual side of mandible

Contents

Geniohyoid & genioglossus muscle , hyoglossusmuscle ,submandibular & sublingual salivary gland,

lingual & hypoglossal nerve.

CLINICAL FEATURES

Extraoral : There is little or no swelling. The lymph

nodes may be enlarged and tender. Pain and discomfort

on deglutition. Speech may be affected.

Intraoral : Firm, painful swelling seen in the floor of the

mouth on the affected side. The floor of the mouth is

raised. The tongue may be pushed superiorly.

INCISION AND DRAINAGE

Intraorally : an incision is made close to the ligual

cortical plate lateral to the sublingual plica, as the

important structure at this site is the sublingual nerve.

Extraorally : When both the submental and sublingual

spaces contain pus, they can be drained via a skin

incision placed in the submental region, pushing a closed

sinus forceps through the mylohyoid muscle.

SPREAD

Infection can spread to contralateral side

Infection can spread to submandibular,

pterygomandibular & parapharyngeal space

Infection can spread to submental or

submandibular lymph nodes

Infection spread through aperatures of perforating

arteries into submental space

SECONDARY SPACES

The three secondary spaces of the mandible are

posterior to the tooth-bearing portion of the

mandible in the angle-ramus area. They are called

secondary spaces because they become infected

by secondary spread of infection from other anterior

spaces. The primary spaces feeding them are the

buccal, sublingual, and submandibular spaces.

MASSETERIC

The masseteric space exists between the lateral

aspect of the mandible and the masseter muscle.

This space is involved most often by spread from

the buccal space or from soft tissue infection

around the third molar. When it is involved, the

posteroinferior portion of the face swells.

In addition to the swelling, the patient has mild to

moderate trismus caused by inflammation of the

masseter muscle.

ETIOLOGY

Infection of third molar

Infection from fracture of angle of mandible

SURGICAL ANATOMY

Boundaries

Anterior : Anterior border of masseter & buccinator

Posterior : Parotid gland

Superior : Zygomatic arch

Inferior : Inferior border of mandible

Medial : Lateral surface of ramus

Lateral : Medial surface of masseter

Contents

Massetric nerve , superficial temporal artery &

transverse facial artery

CLINICAL FEATURES

INCISION & DRAINAGE

PTERYGOMANDIBULAR SPACE

The pterygomandibular space lies between the

medial aspect of the mandible and the medial

pterygoid muscle.

Etiology

1.This space becomes involved from spread from the

sublingual and submandibular spaces and from soft

tissue infection around the third molar(pericoronitis)

2.Use of contaminated needle for inferior alveolar

nerve block

3.Infection can arise from maxillary third molar from

posterior superior alveolar nerve block injection

SURGICAL ANATOMY

Boundaries

Lateral : Ramus of mandible.

Medial : Medial pterygoid muscle.

Posterior : Parotid gland

Anterior : Pterygomandibular raphae.

Contents : Lingual nerve,

Mandibular nerve,

Inferior alveolar,

Mandibular artery.

Mylohyoid nerve and vessels.

Loose areolar connective tissue.

CLINICAL FEATURES

Severe degree of limitation of mouth opening.

Tenderness over the area of swollen soft tissues medial to

anterior border of ramus.

Dysphagia is present.

Medial displacemnet of lateral wall of the pharynx.

Redness and edema of the area around the third molar.

Midline of the palate is displaced to the unaffected side.

Uvula is swollen.

Difficulty in breathing.

INCISION & DRAINAGE

Intraoral : A vertical incision, approximately 1.5 cm in length, is made on the anterior and medial aspect of the ramus of mandible. A sinus forceps in inserted in the abscess cavity, opened and closed & withdrawn. The pus is evacuated, a rubber drain is introduced and is secured in position with a suture.

Extraoral : An incision is taken in the skin below the angle of the mandible. A sinus forceps is inserted towards the medial side of the ramus in an upward and backward direction. Pus is evacuated and the drain inserted from an intraoral approach and sutured in position.

MASTICATOR SPACES

Masseteric, pterygomandibular, and temporal spaces

spaces are collectively known as the masticator space,

since they are bounded by the muscles of mastication:

masseter, medial pterygoid, and temporalis.

The three individual spaces communicate freely with one

another and are simultaneously involved

.If all three of the primary mandibular spaces become involved with the infection, the infection is known as Ludwig's angina. Ludwig's angina, described in 1936, was a relatively common occurrence until the antibiotic era. It is a rapid, bilaterally spreading, gangrenous cellulitis of the submandibular, sublingual, and submental spaces. It usually spreads posteriorly to the secondary spaces as well. It produces gross swelling, elevation and displacement of the tongue, and tense, brawny induration of the submandibular region superior to the hyoid bone. There is usually little or no fluctuance (Finch et al, 1980; Patterson et al, 1982). The patient experiences severe trismus, drooling of saliva, tachypnea, and dyspnea. Impending compromise of the airway produces marked anxiety. The cellulitis can progress with alarming speed, producing an upper airway obstruction that may lead to death. The usual cause of Ludwig's angina is an odontogenicinfection, usually from the mandibular second or third molar. The microbes involved are usually Streptococcus, oral anaerobes, or both.

CERVICAL (DEEP NECK) SPACES

CERVICAL (DEEP NECK) SPACES

Extension of odontogenic infection beyond the mandibularspaces is an unusual event.

When it does occur, spread to the cervical or deep neck spaces from the submandibular, sublingual, or pterygomandibularspaces may have serious, life-threatening sequelae. These sequelae may result of complications, such as upper airway obstruction or mediastinitis.

Odontogenic infections cause as much as 30% of all deep neck infections (Virolainen et al, 1979).

The deep neck spaces have a variety of names and descriptions.Three are relatively consistent through the literature: the lateral pharyngeal space, the retropharyngeal space, and the prevertebral space, or danger space No, 4.

The layers of deep cervical fascia form and bind these three spaces.

LATERAL PHARYNGEAL SPACE

The lateral pharyngeal space is classically described as having the shape of an inverted pyramid or funnel.

Etiology

Infection from third molars

Tonsillar infection in neighbouring spaces

Surgical Anatomy

Superior : Skull base at the sphenoid bone

Inferior : Hyoid bone.

Lateral : Medial pterygoid muscle

Medial : Superior & middle pharyngeal constrictor muscle

Anterior : Pterygomandibular raphe

Posterior : Carotid sheath & scalena fascia

Contents : Carotid artery , Internal juglar vein, Vagusnerve, Cervical sympathetic chain

LATERAL PHARYNGEAL SPACE

Around the boundary is pterygomandibular raphe, it

communicates with the spaces of the mandible.

Posteromedially it extends to and is bounded by the

prevertebral fascia and communicates freely with the

retropharyngeal space.

The styloid process and associated muscles and fascia

divide the lateral pharyngeal space into an anterior

compartment, which contains muscles, and a posterior

compartment, which contains the carotid sheath and

cranial nerves

CLINICAL FEATURES

Severe trismus

Lateral swelling of the neck

Bulging of the lateral pharyngeal wall

Rapid progression of infection in this space is common

Posterior compartment involvement can result in thrombosis of the internal jugular vein, erosion of the carotid artery or its branches, and interference with cranial nerves IX to XII

INCISION & DRAINAGE

Extraoral approach

An incision is made along the anterior border of sternocleidomastoid muscle, extending from below the angle of the mandible, to the middle third of submandibular gland.

The fascia behind the gland is incised and a curved hemostat is inserted and carefully directed medially behind the mandible, as well as superiorly and slightly posteriorly until the abscess cavity is reached.

A rubber drain is inserted and secured to skin with suture

INCISION & DRAINAGE

Intraoral appraoch

A vertical incision is placed over the pterygomandibular raphe.

A sinus forcep or curved hemostat is passed through the pterygomandibular raphae along the medial surface of the mandible, medial to the medial pterygoid and just lateral to the superior constrictor is then divided posteriorly

SPREAD

Infection can spread upwards through foramina

such as f. ovale, f.lacerum & juglar foramen

resulting in brain abscess, meningitis or sinus

thrombosis

Infection can spread downward into carotid sheath

towards mediastinum ; a pathway Mosher called

the “Lincoln’s highway” of neck

RETROPHARYNGEAL SPACE

The retropharyngeal space lies posteromedial to

the lateral pharyngeal space.

SURGICAL ANATOMY

Anterior : Superior pharyngeal muscle and its

investing fascia

Posterior : Alar layer of prevertebral fascia

Superior : Skull base at pharyngeal tubercle

Inferior : Fusion of alar & prevertebral fascia at C6

to T1.This level is at the posterosuperior

mediastinum.

Lateral : Carotid sheath & Lateral pharyngeal space

CLINICAL FEATURES

When the retropharyngeal space becomes involved

condition is always fatal.

Clinical signs and symptoms are those of a severe

infection.

Trismus is severe in essentially all patients at this

stage.

Evaluation of the retropharyngeal space is

performed with the greatest sucess by a lateral

radiograph of the neck

Involvement of the retropharyngeal space may also

include the prevertebral space

INCISION & DRAINAGE

Suprahyoid portion : The space is approached through the

lateral pharyngeal space, hence the dissection is the same,

until the lateral pharyngeal space is further explored by blunt

finger dissection. the dissection is continued until the surgeon

is able to palpate the contralateral transverse processes of the

vertebrae, the endotracheal tube from its posterior aspect, and

if necessary the opposite carotid artery.

Infrahyoid portion : If the space is involved below the hyoid

bone, then the posterior end of the low submandibular incision

described above is extended inferiorly along the anterior

border of sternocleidomastoid muscle. As the dissection

passes deep to anterior layer of deep cervical fascia, the

sternocleidomastoid muscle is retracted posterolaterally to

expose the carotid sheath.

PREVERTEBRAL SPACE

A potential space between the two layers of prevertebral

fascia, the alar and prevertebral layers.

It extends from the skull base inferiorly to the

diaphragm.

The space is also known as the danger space No. 4 (Grodinsky and Holyoke, 1938).

Mediastinitis is concern with prevertebral space

infections similarly to retropharyngeal space infections

COMPLICATIONS

First, the upper airway is in danger of obstruction as a

result of anterior displacement of the posterior pharyngeal

wall into the oropharynx. Narrowing of the upper airway

as the retropharyngeal space swells.

Second, when the retropharyngeal spaces are filled with

pus, a danger exists of spontaneous rupture of the

abscess, resulting in aspiration, pneumonia, and

asphyxiation. Rupture may also be caused by attempts at

insertion of an endotracheal tube to secure the airway.

Third, once the infection has gained access to the

retropharyngeal spaces, the posterosuperior mediastinum

or the entire posterior mediastinum may become infected

also.

LUDWIG’S ANGINA

DEFINITION

Ludwig's angina is a bacterial infection of the floor of the

mouth.

ALTERNATE NAMES

PATHOLOGY

MICROBIOLOGY

ETIOLOGY

Ludwig's angina is a type of cellulitis that involves

inflammation of the tissues of the floor of the mouth,

under the tongue. It often occurs after an infection of the

roots of the teeth (such as tooth abscess) or a mouth

injury.

This condition is uncommon in children.

ETIOLOGY

CLINICAL FEATURES

Swelling of the tissues occurs rapidly and may block the airway or prevent swallowing of saliva.

Symptoms include:

Breathing difficulty

Confusion or other mental changes

Fever

Neck pain

Neck swelling

Redness of the neck

Weakness, fatigue, excessive tiredness

Additional symptoms that may be associated with this disease:

Drooling

Earache

SWELLING IN SUBMANDIBULAR AREA

EXAMINATION & INVESTIGATION

An examination of the neck and head shows redness and

swelling of the upper neck, under the chin. The swelling

may reach to the floor of the mouth. The tongue may be

swollen or out of place.

A CT scan of the neck may be recommended.

Culture of fluid from the tissues may show bacteria

MANAGEMENT

If the swelling blocks the airway, emergency medical help is needed to maintain an open airway. This may involve placing a breathing tube through the mouth or nose and into the lungs, or surgery called a tracheostomy that creates an opening through the neck into the windpipe.

Antibiotics, usually penicillin or a penicillin-like medication, are given to fight the infection. They are usually given through a vein until symptoms go away. Antibiotics taken by mouth may be continued until tests show that the bacteria have gone away.

Dental treatment may be needed for tooth infections that cause Ludwig's angina.

Surgery may be needed to drain fluids that are causing the swelling.

PROGNOSIS

Ludwig's angina can be life threatening. However, it can

be cured with proper protection of the airways and

appropriate antibiotics

CAVERNOUS SINUS THROMBOSIS

Is the formation of a blood clot within the cavernous

sinus, a cavity at the base of the brain which drains

deoxygenated blood from the brain back to the heart.

The cause is usually from a spreading infection in the

sinuses, ears, or teeth.

Staphylococcus aureus and Streptococcus are often the

associated bacteria.

Cavernous sinus thrombosis causes decrease or loss of

vision, drooping or bulging eyes, headaches, and

paralysis of the cranial nerves which course through the

cavernous sinus.

This infection is life-threatening and requires immediate

treatment, which usually includes antibiotics and

sometimes surgical drainage

ETIOLOGY

CST most commonly results from contiguous spread of

infection from the sinuses (sphenoid, ethmoid, or frontal)

or middle third of the face.

Less common primary sites of infection include dental

abscess, nares, tonsils, soft palate, middle ear, or orbit

(orbital cellulitis).

The highly anastomotic and valveless venous system of

the paranasal sinuses allows retrograde spread of

infection to the cavernous sinus via the superior and

inferior ophthalmic veins.

Staphylococcus aureus is the most common infectious

microbe, found in 50% to 60% of the cases.

Streptococcus is the second leading cause.

Gram-negative rods and anaerobes may also lead to

cavernous sinus thrombosis.

Rarely, Aspergillus fumigatus and mucormycosis cause

CST.

CLINICAL FEATURES

The clinical presentation of CST can be varied.

Both acute, fulminant disease and indolent, subacute

presentations have been reported in the literature.

The most common signs of CST are related to

anatomical structures affected within the cavernous

sinus, notably cranial nerves III-VI, as well as symptoms

resulting from impaired venous drainage from the orbit

and eye.

Classic presentations are abrupt onset of unilateral

periorbital edema, headache, photophobia, and bulging

of the eye (proptosis).

Other common signs and symptoms include:

Ptosis, Chemosis, Cranial nerve palsies (III, IV, V, VI).

Sixth nerve palsy is the most common. Sensory deficits

of the ophthalmic and maxillary branch of the fifth nerve

are common.

Periorbital sensory loss and impaired corneal reflex may

be noted. 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.

Pupil may be dilated and sluggishly reactive.

Infection can spread to contralateral cavernous

sinus within 24–48 hr of initial presentation

DIAGNOSIS

The diagnosis of cavernous sinus thrombosis is made

clinically, with imaging studies to confirm the clinical

impression. Proptosis, ptosis, chemosis, and cranial

nerve palsy beginning in one eye and progressing to the

other eye establish the diagnosis.

DIFFERENTIAL DIAGNOSIS

Orbital cellulitis

Internal carotid artery aneurysm

CVA

Migraine headache

Allergic blepharitis

Thyroid exophthalmos

Brain tumor

Meningits

Mucormycosis

Trauma

CONCLUSION

Most odontogenic infections are caused by anaerobes

Identify possible complications of odontogenicinfections

Antibiotics may not sufficient and incision and drainage of these abscesses may be necessary for resolution

Extracting the causative tooth facilitates the resolution of the infection

Textbook of oral surgery by Neelima Malik.

Textbook of oral surgery by Peterson ,2 nd edition.