Complex Odontogenic Infection (Oral & Maxillofacial Surgery - Dentistry)

Dr. Sarang Suresh

Hotchandani

COMPLEX ODONTOGENIC

INFECTION

Infection erodes thorough the thinnest adjacent bone and causes

infection in the adjacent tissue.

Infection from Tooth apex perforates below the muscle

attachment – vestibular abscess will occur. (most common

infection)

Infection from Tooth apex above the muscle attachment –

facial space will be infected.

DEEP FASCIAL SPACE INFECTION

DR. SARANG SURESH HOTCHANDANI 2

They are fascia lined tissue

compartments filled with loose,

areolar connective tissue.The loose areolar tissue within these spaces serves to

cushion muscles, nerves, vessels, glands & other

structures.

FASCIAL SPACE (DEFINITION)


PATHOPHYSIOLOGY OF

DEEP FASCIAL SPACE INFECTION


SPACES WITH ANY TOOTH SPACES WITH MAXILLARY

TEETH

SPACES WITH

MANDIBULAR TEETH

SPACES OF NECK

Vestibular Infra orbital Body of mandible Lateral pharyngeal

Buccal Buccal Perimandibular space Retropharyngeal

Subcutaneous Infratemporal Submandibular Pre tracheal

Para nasal sinus Sublingual Danger space

Cavernous sinus thrombosis Submental Prevertebral

Masticator space

Pterygomandibular

Superficial temporal

Deep temporal

ANATOMIC SPACES INVOLVED IN

ODONTOGENIC INFECTION


Severity Score Anatomic Space

Severity Score = 1

Little threat to airway or vital structures

Vestibular

Buccal

Sub periosteal

Space of body of mandible

Infra orbital

Severity Score = 2

Moderate severity – hindered access to airway by

causing trismus or elevation of tongue

Submandibular

Submental

Sublingual

Pterygomandibular

Sub masseteric

Superficial temporal

Deep temporal (or infratemporal)

Severity score = 3

High risk to airway & vital structures – directly

compress & deviate the airway

Lateral pharyngeal

Retropharyngeal

Pretracheal

Severity Score = 4

Extreme risk to airway & vital structures

Danger space (space 4)

Mediastinum

Intracranial infection

Cavernous sinus thrombosis

Necrotizing fasciitis – flesh eating bacterial infection

CLASSIFICATION OF DEEP FASCIAL SPACE

INFECTION BASED ON S E V E R I T Y


ANATOMY OF DEEP FASCIAL SPACES OF

HEAD & NECK


ANATOMY OF DEEP FASCIAL SPACES OF

HEAD & NECK


RELATIONS OF DEEP FASCIAL SPACE

INFECTIONS OF HEAD & NECK


RELATIONS OF DEEP FASCIAL SPACE

INFECTIONS OF HEAD & NECK


MAXILLARY TEETH

INFECTION


Palatal space (sub periosteal space) – maxillary

lateral, premolar & molar.

Infra – orbital space

Swelling of anterior face

Nasolabial fold obliterated

Spontaneous drainage of this space infection occurs near to

medial or lateral canthus of the eye.

INFECTIONS ARISING FROM MAXILLARY TEETH


Buccal Space

Swelling below zygomatic arch &

above the inferior border of

mandible.

Buccal space infection follows the

extension of the buccal fat pad into

the infraorbital, periorbital &

superficial temporal space.

Dimpled appearance over the

zygomatic arch.

Zygomatic arch and inferior border of

mandible remain palpable in buccal

space infection.


A, Buccal space lies between buccinator muscle and overlying skin

and superficial fascia. This potential space may become involved via

maxillary or mandibular molars (arrows).

B, Typical buccal space infection, extending from the level of the

zygomatic arch to the inferior border of the

mandible and from the oral commissure to the anterior border of the

masseter muscle. DR. SARANG SURESH HOTCHANDANI 13

It is the bottom portion of deep temporal space & lies posterior to maxilla.

Boundaries; Medial – lateral pterygoid plate of sphenoid bone

Superior – base of skull

Lateral & superiorly – continuous with deep temporal space

Contents; Branches of internal maxillary artery

Branches of pterygoid Venus plexus – emissary veins

Infra temporal space is the origin of the posterior route by which infection spread to cavernous sinus.

It is rarely infected, if infection occurs; it is mostly from maxillary 3 rd molar.



The masticator space is bounded by the fascia overlying the masseter muscle, medial pterygoid muscle, temporalis muscle, and the skull.

The superficial and deep temporal spaces are separated from each other by the temporalis muscle.

The lateral pterygoid muscle divides the Pterygomandibular space from the infratemporal portion of the deep temporal space, and

the zygomatic arch divides the sub masseteric space from the superficial temporal space.


• anteriorly via

the inferior or

superior

ophthalmic vein

or

• posteriorly via

emissary veins

from the

pterygoid

plexus.

HEMATOGENOUS

SPREAD OF

INFECTION FROM

THE JAW TO THE

CAVERNOUS

SINUS MAY

OCCUR


Maxillary Sinus Infections 20% case of maxillary sinusitis are odontogenic

Odontogenic maxillary sinus infections may also spread superiorly through ethmoid sinus or the orbital floor and cause secondary periorbital or orbital infection.

Clinical Features of Periorbital or Orbital Infections; Redness & swelling of eyelids

Displacement of pupil

Cavernous Sinus Thrombosis Routes mentioned above.

Most vulnerable structure in cavernous sinus thrombosis – abducens 6th

cranial nerve.



MANDIBULAR TEETH

INFECTION


SUBMAXILLARY SPACES or PERIMANDIBULAR SPACE

It is one large space made of;

Submandibular

Sublingual

Submental space

Sublingual & submandibular spaces are infected by lingual perforation of mandibular molars & premolars

If the perforation occurs above the mylohyoid muscle – sublingual space infection will occur.

If the perforation occurs below the mylohyoid muscle – submandibular space infection will occur. Mostly infected by mandibular 3 rd molar

INFECTIONS FROM MANDIBULAR TEETH


Sublingual Space;

Little or no extra oral swelling in floor of mouth

Mostly bilateral infection

Elevated tongue.

INFECTION FROM MANDIBULAR TEETH

A, The sublingual space lies between

the oral mucosa and the mylohyoid

muscle. The space is primarily involved

by infection from mandibular premolars

and first molar.

B, Severe sublingual space abscess that

has elevated the tongue into the palate

such that only the ventral

surface of the tongue and floor of the

mouth are visible.DR. SARANG SURESH HOTCHANDANI 20

Submandibular space (figure

17 – 15)

Swelling that look like an inverted

triangle

Base - inferior border of mandible

Sides – anterior & posterior bellies

of digastric muscle

Apex – hyoid bone

INFECTION FROM MANDIBULAR TEETH

The submandibular space lies between the mylohyoid muscle and

anterior layer of the deep cervical fascia, just deep to the platysma

muscle, and includes the lingual and inferior surfaces of the mandible

below the mylohyoid muscle attachment.DR. SARANG SURESH HOTCHANDANI 21

Typical

submandibular

space infection

demarcated by

both bel l ies of the

digastric muscle,

the inferior border

of the mandible,

and the hyoid

bone.


Submental space

infection

appears as

discrete swell ing

in central area of

submandibular

region.


Bilateral involvement of Perimandibular spaces.

Rapidly spreading cellulitis that can obstruct

airway and

Spread posteriorly to deep fascial spaces of

neck

LUDWIG ANGINA


Sever swelling

Elevation & displacement of tongue

Tense, hard, bilateral induration of submandibular region superior to

hyoid bone.

Trismus, drooling, difficulty swallowing & breathing.

Upper airway obstruction

LUDWIG ANGINA CLINICAL FEATURES


Compartments of masticators space;

Sub masseteric space

Pterygo mandibular space

Superficial temporal space

Deep temporal space

MASTICATOR SPACE


b/w the masseter muscle & lateral surface of ascending ramus

Infected by;

buccal space infection

pericoronitis

mandibular angle fracture

Clinically

moderate to severe trismus due to inflammation of masseter muscle.

Obscured ear lobe due to swelling b/w the masseter muscle & lateral surface of

ascending ramus

SUB MASSETERIC SPACE


b/w medial pterygoid muscle & medial surface of ascending ramus.

It is the site into which LA is given in IAN block.

Clinically

Trismus without swelling is diagnostic of Pterygomandibular space infection

Swelling and erythema of anterior tonsillar pillar on the affected side.

Deviation of uvula on opposite side of infection.

On CT examination, fluid collection detected b/w medial pterygoid muscle and the

mandible.

Airway is compressed & deviated

PTERYGO MANDIBULAR SPACE


Rarely infected

Clinical Features;

Swelling in temporal region, superior to

zygomatic arch and posterior to lateral orbital

rim

Hourglass shape in frontal view.

SUPERFICIAL & DEEP TEMPORAL INFECTION


The lateral pharyngeal space is located between the medial

pterygoid muscle laterally and the superior pharyngeal constrictor

medially.

The retropharyngeal and danger spaces lie between the pharyngeal

constrictor muscles and the prevertebral fascia.

The retropharyngeal space lies between the superior constrictor muscle and the

alar fascia.

The danger space lies between the alar layer and the prevertebral fascia.

DEEP CERVICAL FASCIAL SPACE INFECTION


Infection usually comes from

Pterygomandibular, submandibular, sublingual

space.

Is made of two compartments;

Anterior compartment – loose C.T

Posterior compartment – carotid sheath, cranial

nerves (9th, 10th, 12th)

LATERAL PHARYNGEAL SPACE INFECTION


Trismus – inflammation of medial pterygoid muscle

Lateral swelling of neck – b/w angle of mandible & S.C.M

Bulge toward midline – swelling of lateral pharyngeal wall

Difficulty swallowing, high temperature.

swelling of the anterior tonsillar pil lar and blunting of the palate -vulvar fold.

Thrombosis of internal jugular vein

Erosion of carotid sheath

Airway is deviated to opposite side of infection.

LATERAL PHARYNGEAL SPACE INFECTION

(CLINICAL FEATURES)


The retropharyngeal and the alar fasc ia fuse at a var iable levelbetween the C6 and T4 vertebrae, which forms a pouch at the infer iorextent of the retropharyngeal space.

I f infect ion passes through the alar fasc ia to the danger space, thePostero-superior mediast inum wi l l most l ike ly soon become involved.

The infer ior boundary of the danger space is the diaphragm, whichputs the ent i re mediast inum at r isk .

This space conta ins only loose C.T and lymph nodes, so i t providesl i t t le barr ier to spread of infect ion from one latera l pharyngeal space tothe other to encirc le the airway.

The infect ion can rupture the alar fasc ia poster ior ly to enter the dangerspace

Prevertebral infect ions are usual ly caused by osteomyel i t is ofver tebrae.

RETRO PHARYNGEAL SPACE


This infection causes skin vesicle and then

a dusky purple discoloration of overlying

skin due to ischemia.

Later frank necrosis and undermining of

skin occur which require surgical

debridement of large areas of skin.

NECROTIZING FASCIITIS –

FLESH EATING BACTERIAL INFECTION


Email: [email protected]

THE END

References

JAMES R. HUPP, E. E. (n.d.). CONTEMPORARY ORAL AND MAXILLOFACIAL

SURGERY (6 ed.). ELSEVIER.


Health & Medicine

Complex Odontogenic Infection (Oral & Maxillofacial Surgery - Dentistry)