Fascial SpacesFascial Spaces

Presented by:- under the guidance of :-Dr Surbhi Dr C. AnandPg 1st year Dr Archana nagpalDept of OMR Dr Puneeta vohra Dr Sanjeev lallar Dr Mamta malik

Fascial SpacesFascial Spaces

These areas are either clefts ( potential These areas are either clefts ( potential

spaces between facial layers ) or spaces between facial layers ) or

compartment containing connective tissue.compartment containing connective tissue.

Fascial planes offer anatomic highways for Fascial planes offer anatomic highways for infection to spread from superficial to deep infection to spread from superficial to deep planes.planes.

Classification of Fascial SpacesClassification of Fascial Spaces Based on mode of involvement-Based on mode of involvement- Primary spaces.Primary spaces. Secondary spaces.Secondary spaces.

Primary maxillary- Primary maxillary- canine, buccal, infratemporal.canine, buccal, infratemporal.

Primary mandibular- Primary mandibular- submental, sublingual, buccal, submental, sublingual, buccal, submandibular.submandibular.

Secondary spaces- Secondary spaces- masseteric, pterygomandibular, masseteric, pterygomandibular, superficial & deep temporal, lateral pharyngeal, superficial & deep temporal, lateral pharyngeal, retropharyngeal, parotid, prevertebral.retropharyngeal, parotid, prevertebral.

Based on clinical significance-Based on clinical significance-

Face-Face- Buccal, canine, parotid, masticatory. Buccal, canine, parotid, masticatory.

Suprahyoid-Suprahyoid- Sublingual, submental, submandibular, Sublingual, submental, submandibular,

lateral pharyngeal, peritonsillar.lateral pharyngeal, peritonsillar.

Infrahyoid-Infrahyoid- Pretracheal. Pretracheal.

Spaces of total neck- Spaces of total neck- Retropharyngeal, space of Retropharyngeal, space of

carotid sheath.carotid sheath.

Buccal space

Sublingual

Submandibular

Canine SpaceCanine Space It is the region between anterior surface of maxilla and overlying It is the region between anterior surface of maxilla and overlying

levator muscles of upper lip.levator muscles of upper lip. Contains angular artery & vein, infraorbital nerve.Contains angular artery & vein, infraorbital nerve.

Etiology-Etiology-

Maxillary canine & 1Maxillary canine & 1stst premolar infection & sometimes premolar infection & sometimes mesiobuccal root of first molars.mesiobuccal root of first molars.

Boundaries-Boundaries- Superiorly: Superiorly: levator superioris alaque nasi and levator labii levator superioris alaque nasi and levator labii

superioris superioris Inferiorly: Inferiorly: caninus musclecaninus muscle Medially: Medially: anterolateral surface of maxillaanterolateral surface of maxilla Posteriorly: Posteriorly: buccinator mucsle.buccinator mucsle. Anteriorly: Anteriorly: orbicularis oris orbicularis oris

8

Clinical Features-Clinical Features- Swelling of cheek, lower eyelid & upper lip.Swelling of cheek, lower eyelid & upper lip. Drooping of angle of mouth.Drooping of angle of mouth. Nasolabial fold obliterated.Nasolabial fold obliterated. Odema of lower eyelidOdema of lower eyelid

Buccal SpaceBuccal SpaceBoundaries-Boundaries- Superiorly: Superiorly: zygomatic arch.zygomatic arch. Inferior: Inferior: inferior border of mandible.inferior border of mandible. Laterally: Laterally: skin & subcutaneous tissue.skin & subcutaneous tissue. Medially: Medially: buccinator muscle ,buccopharyngeal fascia.buccinator muscle ,buccopharyngeal fascia. Posteriorly: Posteriorly: anterior edge of masseter muscle.anterior edge of masseter muscle. Anteriorly: Anteriorly: posterior border of zygomaticus major & depressor posterior border of zygomaticus major & depressor

anguli oris.anguli oris.

Contents-Contents- Buccal fat pad.Buccal fat pad. Stenson’s duct.Stenson’s duct. Facial artery.Facial artery.

Etiology-Etiology- Infected mandibular & maxillary premolars & molars.Infected mandibular & maxillary premolars & molars.

Clinical Features-Clinical Features- Obliteration of nasolabial fold.Obliteration of nasolabial fold. Angle of mouth shifted to opposite side.Angle of mouth shifted to opposite side. Swelling in cheek extending to corner of mouth.Swelling in cheek extending to corner of mouth. Buccal space associated with temporal space – Buccal space associated with temporal space – Dumb bell Dumb bell

shapedshaped appearance due to lack of swelling over zygomatic appearance due to lack of swelling over zygomatic arch.arch.

Buccal Space InfectionBuccal Space Infection

Infratemporal SpaceInfratemporal SpaceBoundaries-Boundaries- Superiorly: Superiorly: infratemporal surface of infratemporal surface of

greater wing of sphenoid.greater wing of sphenoid. Inferiorly: Inferiorly: lateral pterygoid muscle.lateral pterygoid muscle. Laterally: Laterally: temporalis tendon & temporalis tendon &

coronoid process.coronoid process. Medially: Medially: lateral pterygoid plate & lateral pterygoid plate &

lateral pharyngeal wall.lateral pharyngeal wall. Posteriorly: Posteriorly: condyle & lateral condyle & lateral

pterygoid muscles.pterygoid muscles. Anteriorly: Anteriorly: infratemporal surface of infratemporal surface of

maxilla & posterior surface of maxilla & posterior surface of zygomatic bone.zygomatic bone.

Contents-Contents- Pterygoid plexus of veins.Pterygoid plexus of veins. Internal maxillary artery.Internal maxillary artery. Mandibular nerve & its branches.Mandibular nerve & its branches.

Etiology-Etiology- Infected maxillary 3Infected maxillary 3rdrd molars. molars. Infected needles or contaminated LA solution.Infected needles or contaminated LA solution.

Clinical Features-Clinical Features- Extra-oral swelling over sigmoid notch area.Extra-oral swelling over sigmoid notch area. Intra-oral swelling in tuberosity area.Intra-oral swelling in tuberosity area. Trismus.Trismus.

Spread of Infection-Spread of Infection- To temporal space.To temporal space. Cavernous sinus thrombosis- Cavernous sinus thrombosis- infection spreads via pterygoid plexus infection spreads via pterygoid plexus

of veins.of veins.

Submental SpaceSubmental SpaceBoundaries-Boundaries- Roof: Roof: mylohyoid muscle.mylohyoid muscle. Inferior: Inferior: deep cervical fascia, platysma, superficial fascia & skin.deep cervical fascia, platysma, superficial fascia & skin. Laterally:Laterally: anterior belly of digastric. anterior belly of digastric. Posteriorly:Posteriorly: submandibular space. submandibular space.

Contents-Contents- Lymph nodes, anterior jugular vein.Lymph nodes, anterior jugular vein.

Etiology-Etiology- Infected mandibular incisors.Infected mandibular incisors. Anterior extension of submandibular space.Anterior extension of submandibular space.

Clinical Features-Clinical Features-• Chin appears glossy & swollen.Chin appears glossy & swollen.• Pain & discomfort on swallowing.Pain & discomfort on swallowing.

Sublingual SpaceSublingual SpaceBoundaries-Boundaries- Superiorly:Superiorly: mucosa of floor of mouth. mucosa of floor of mouth. Inferior:Inferior: mylohyoid muscle. mylohyoid muscle. Posteriorly:Posteriorly: body of hyoid bone. body of hyoid bone. Anteriorly & laterally: Anteriorly & laterally: inner aspect of mandibular body.inner aspect of mandibular body. Medially: Medially: geniohyoid,styloglossus,genioglossus muscle.geniohyoid,styloglossus,genioglossus muscle.

Contents-Contents- Deep part of Submandibular gland.Deep part of Submandibular gland. Wharton’s duct.Wharton’s duct. Sublingual gland.Sublingual gland. Lingual & hypoglossal nerves.Lingual & hypoglossal nerves. Terminal branches of lingual artery.Terminal branches of lingual artery.

Etiology-Etiology- Infected mandibular premolar & 1Infected mandibular premolar & 1stst molar. molar.

Clinical Features-Clinical Features- Swelling of floor of mouth.Swelling of floor of mouth. Elevated tongue.Elevated tongue. Pain & discomfort on swallowing.Pain & discomfort on swallowing.

Submandibular SpaceSubmandibular SpaceBoundaries-Boundaries- Superiorly: Superiorly: mylohyoid muscle, inferior border of mandible.mylohyoid muscle, inferior border of mandible. Inferior: Inferior: anterior & posterior belly of digastric.anterior & posterior belly of digastric. Laterally: Laterally: deep cervical fascia, platysma, superficial fascia & skin.deep cervical fascia, platysma, superficial fascia & skin. Medially: Medially: hyoglossus,styloglossus,mylohyoid muscle.hyoglossus,styloglossus,mylohyoid muscle. Posteriorly: Posteriorly: to hyoid bone.to hyoid bone. Anteriorly: Anteriorly: submental space.submental space.

Contents-Contents- Submandibular salivary gland.Submandibular salivary gland. Proximal portion of Wharton’s duct.Proximal portion of Wharton’s duct. Lingual & hypoglossal nerves.Lingual & hypoglossal nerves. Branches of facial artery- palatine,tonsillar,glandular,submental.Branches of facial artery- palatine,tonsillar,glandular,submental.

Etiology- Infected mandibular 2nd & 3rd molars. From submental,sublingual spaces.

Clinical Features-• Indurated swelling in submandibular region.• Usually bulges over lower border of mandible.

Spread of Infection- Across midline to contralateral space. To contiguous pharyngeal spaces.

Submandibular Space Infection Submandibular Space Infection

Pterygomandibular SpacePterygomandibular SpaceBoundaries-Boundaries- Superiorly: Superiorly: lower head of lateral pterygoid muscle.lower head of lateral pterygoid muscle. Laterally: Laterally: medial surface of ramus.medial surface of ramus. Medially: Medially: medial pterygoid muscle.medial pterygoid muscle. Posteriorly: Posteriorly: deep part of parotid.deep part of parotid. Anteriorly: Anteriorly: pterygomandibular raphe.pterygomandibular raphe.

Contents-Contents- Inferior alveolar neurovascular bundle.Inferior alveolar neurovascular bundle. Lingual & auriculotemporal nerves.Lingual & auriculotemporal nerves. Mylohyoid nerve & vessels.Mylohyoid nerve & vessels.

Etiology-Etiology- Infected mandibular 3Infected mandibular 3rdrd molars(mesioangular/horizontal) molars(mesioangular/horizontal) Pericoronitis.Pericoronitis. Infected needles or contaminated LA solution.Infected needles or contaminated LA solution.

Clinical Features-Clinical Features- Absence of extra-oral swelling.Absence of extra-oral swelling. Severe trismus.Severe trismus. Difficulty in swallowing.Difficulty in swallowing. Anterior bulging of half of soft palate & tonsillar pillars with Anterior bulging of half of soft palate & tonsillar pillars with

deviation of uvula to unaffected side.deviation of uvula to unaffected side.

Spread of Infection-Spread of Infection- Superiorly to infratemporal space.Superiorly to infratemporal space. Medially to lateral pharyngeal space.Medially to lateral pharyngeal space. To submandibular space.To submandibular space.

Masseteric SpaceMasseteric Space

Boundaries-Boundaries- Superiorly: Superiorly: zygomatic arch.zygomatic arch. Inferiorly: Inferiorly: inferior border of mandible.inferior border of mandible. Laterally: Laterally: masseter muscle.masseter muscle. Medially: Medially: ramus of mandible.ramus of mandible. Posteriorly: Posteriorly: parotid gland & its fascia.parotid gland & its fascia. Anteriorly: Anteriorly: buccal space & buccopharyngeal fascia.buccal space & buccopharyngeal fascia.

Contents-Contents- Masseteric artery & vein.Masseteric artery & vein.

Etiology-Etiology- Mandibular 3Mandibular 3rdrd molars(pericoronitis). molars(pericoronitis).

Clinical Features-

Swelling limited to masseter muscle. Severe trismus & throbbing pain.

Temporal SpacesTemporal Spaces Superficial temporal-Superficial temporal- Laterally: temporalis fascia.Laterally: temporalis fascia. Medially: temporalis muscle.Medially: temporalis muscle. Deep temporal-Deep temporal- Laterally: temporalis muscle.Laterally: temporalis muscle. Medially: temporal bone & greater wing of sphenoid.Medially: temporal bone & greater wing of sphenoid.

Etiology-Etiology- From infratemporal or pterygomandibular space.From infratemporal or pterygomandibular space.

Clinical Features-Clinical Features- Superficial temporal- Superficial temporal- swelling limited by outline of temporalis swelling limited by outline of temporalis

fascia. Trismus. Severe pain.fascia. Trismus. Severe pain. Deep temporal- Deep temporal- less swelling, difficult to diagnose. Trismus.less swelling, difficult to diagnose. Trismus.

Temporal Space Temporal Space InfectionInfection

Lateral Pharyngeal SpaceLateral Pharyngeal Space

Boundaries-Boundaries- Shape of an Shape of an inverted cone or pyramidinverted cone or pyramid, the base is at sphenoid , the base is at sphenoid

bone and the apex at hyoid bone. bone and the apex at hyoid bone. Anteriorly: Anteriorly: pterygomandibular raphe. pterygomandibular raphe. Posteriorly: Posteriorly: extends to prevertebral fascia.extends to prevertebral fascia. Laterally: Laterally: fascia covering medial pterygoid muscle, parotid & fascia covering medial pterygoid muscle, parotid &

mandible.mandible. Medially: Medially: buccopharyngeal fascia on lateral surface of buccopharyngeal fascia on lateral surface of

superior constrictor muscle.superior constrictor muscle. Styloid process divides the space into Styloid process divides the space into anterior muscular anterior muscular and and

posterior vascular posterior vascular compartment.compartment.

Contents- Anterior compartment: fat, muscle, lymph nodes and connective tissue. Posterior compartment: carotid sheath(carotid artery,internal

jugular vein,vagus nerve), cranial nerves IX through XII.

Etiology- Infected mandibular 3rd molars. Tonsillar infections. Pharyngitis. Parotitis.

Spread of Infection- To retropharyngeal space. To peritonsillar space.

Clinical Features-Clinical Features- Anterior compartment:Anterior compartment:

Trismus.Trismus.

Induration & swelling at angle of jaw.Induration & swelling at angle of jaw.

Fever.Fever.

Pharyngeal bulging.Pharyngeal bulging. Posterior compartment:Posterior compartment:

Posterior tonsillar pillar deviation.Posterior tonsillar pillar deviation.

Neurological involvement.Neurological involvement.

Thrombosis of internal jugular vein.Thrombosis of internal jugular vein.

Erosion of carotid vessels may occur.Erosion of carotid vessels may occur.

Retropharyngeal SpaceRetropharyngeal Space

Posteromedial to lateral pharyngeal space and anterior to the Posteromedial to lateral pharyngeal space and anterior to the prevertebral space .prevertebral space .

Boundaries-Boundaries- Anterior: Anterior: posterior pharyngeal wall. posterior pharyngeal wall. Posterior: Posterior: prevertebral fascia. prevertebral fascia. Superior: Superior: skull base.skull base. Inferior: Inferior: mediastinum.mediastinum. Laterally: Laterally: lateral pharyngeal space.lateral pharyngeal space.

Etiology-Etiology- Nasal & pharygeal infections.Nasal & pharygeal infections. Spread from odontogenic infections.Spread from odontogenic infections.

Clinical Features-Clinical Features- Stiffness of neck.Stiffness of neck. Dysponea.Dysponea. Dysphagia.Dysphagia. Bulging of posterior pharyngeal wall.Bulging of posterior pharyngeal wall.

Complications-Complications- Airway obstruction.Airway obstruction. Aspiration pneumonia.Aspiration pneumonia. Acute mediastinitis.Acute mediastinitis. Can spread to Danger space.Can spread to Danger space.

Prevertebral SpacePrevertebral Space

Potential space between two layers of prevertebral Potential space between two layers of prevertebral

fascia (fascia (alar and prevertebral layersalar and prevertebral layers). ).

Extends from skull base superiorly to the diaphragm Extends from skull base superiorly to the diaphragm

inferiorly. inferiorly.

MediastinitisMediastinitis is concern with prevertebral space is concern with prevertebral space

infections similarly to retropharyngeal space infections similarly to retropharyngeal space

infections.infections.

ObjectivesObjectives

Understand the microbiology of odontogenic Understand the microbiology of odontogenic infections.infections.

Understand the signs symptoms and findings Understand the signs symptoms and findings in patients with odontogenic infections.in patients with odontogenic infections.

Review the various pathways of spread with Review the various pathways of spread with odontogenic infections.odontogenic infections.

Understand the medical and surgical Understand the medical and surgical management of odontogenic infections.management of odontogenic infections.

MICROBIOLOGY OF MICROBIOLOGY OF ODONTOGENIC INFECTIONS ODONTOGENIC INFECTIONS

Usually caused by endogenous bacteria.Usually caused by endogenous bacteria. Most odontogenic infections due to mixed flora.Most odontogenic infections due to mixed flora. StreptococcusStreptococcus species(alpha hemolytic) are species(alpha hemolytic) are

usually the etiologic organisms if aerobic bacteria usually the etiologic organisms if aerobic bacteria present.present.

Anaerobes- prevotella, bacteroids, fusobacterium Anaerobes- prevotella, bacteroids, fusobacterium also involved.also involved.

Factors affecting Spread of InfectionFactors affecting Spread of Infection General factors-General factors-1.1. Microbial factors-Microbial factors-

Level of virulence.Level of virulence.

No. of organisms introduced.No. of organisms introduced.

2.2. Host factors-Host factors-

General state of health.General state of health.

Integrity of surface defence.Integrity of surface defence.

Level of immunity.Level of immunity.

Capacity for inflammatory & immune response.Capacity for inflammatory & immune response.

Impact of medical intervention.Impact of medical intervention.

3.3. Combination of both factors.Combination of both factors.

Routes of SpreadRoutes of Spread

Direct spread-Direct spread-a)a) Spread into superficial soft tissues as-Spread into superficial soft tissues as-

Abscess-Abscess- pathological thick walled cavity filled with pus. pathological thick walled cavity filled with pus.

Cellulitis-Cellulitis- diffuse subcutaneous/submucous inflammation of diffuse subcutaneous/submucous inflammation of soft tissues. Tends to spread along fascial planes.soft tissues. Tends to spread along fascial planes.

b)b) Spread into adjacent fascial spaces.Spread into adjacent fascial spaces.

c)c) Into deep medullary spaces of bone- osteomyelitisInto deep medullary spaces of bone- osteomyelitis

Indirect spread-Indirect spread-a)a) Lymphatic routes to regional nodes.Lymphatic routes to regional nodes.

b)b) Hematogenous route to other organs such as brainHematogenous route to other organs such as brain..

Pathway of Odontogenic InfectionPathway of Odontogenic Infection

Acute-chronic periapical infection

Intraoral soft tissue abscess

Cellulitis

Deep fascial space infection

Bacteremia- septicemia

Sinus or Fistula

Ascending fascial cerebral infection

Medullary spaces of bone-osteomyelitis

Sites of Localization of Dental InfectionSites of Localization of Dental Infection

Involved teeth

Usual exit from bone

Relation of muscle to root apices

Site of localization

Upper central incisor

Labial Above Oral vestibule

Upper lateral incisor

Labial Palatal

Above Oral vestibulePalate

Upper canine

Labial Above Below

Oral vestibule Canine space

Upper premolars

Buccal Palatal

Above Oral vestibulePalate

Upper molars

Buccal

Palatal

AboveBelow

Oral vestibuleBuccal spacePalate

Involved teeth

Usual exit from bone

Relation of muscle to root apices

Site of localization

Lower incisors

Labial AboveBelow

Submental spaceOral vestibule

Lower canine Labial Below Oral vestibule

Lower premolars

Buccal Below Oral vestibule

Lower 1st molar

Buccal

Lingual

Below AboveBelow

Oral vestibuleBuccal spaceSublingual space

Lower 2nd molar

Buccal

Lingual

Below AboveBelow Above

Oral vestibuleBuccal spaceSublingual spaceSubmandibular space

Lower 3rd molar

Lingual Above Submandibular or pterygomandibular space

Clinical FeaturesClinical Features

Rubor- (rednessRubor- (redness) cutaneous surface involved due to vasodilatation ) cutaneous surface involved due to vasodilatation

effect of inflammation.effect of inflammation.

Tumor-(swellingTumor-(swelling) due to the accumulation of pus or fluid exudate.) due to the accumulation of pus or fluid exudate.

Calor-(heatCalor-(heat) is the result of increased blood flow to the area due to ) is the result of increased blood flow to the area due to

the vasodilatation. the vasodilatation.

Dolor-(or pain) Dolor-(or pain) results from pressure on sensory nerve endings from results from pressure on sensory nerve endings from

tisssue distention caused by edema or infection. tisssue distention caused by edema or infection.

Functiolaesa-(loss of function) Functiolaesa-(loss of function) problems with function.problems with function.

Lymphadenopathy-Lymphadenopathy- nodes enlarged,soft & tender in acute nodes enlarged,soft & tender in acute

infection. Firm & enlarged in chronic.infection. Firm & enlarged in chronic.

Halitosis. Halitosis.

Fever & headache. Repeated chills.Fever & headache. Repeated chills.

Presence of draining sinuses/fistulae.Presence of draining sinuses/fistulae.

Increased salivation.Increased salivation.

Trismus.Trismus.

Difficulty in swallowing. Difficulty in swallowing.

Changes in phonation.Changes in phonation.

Difficulty in breathing.Difficulty in breathing.

Investigations Investigations Routine laboratory investigations.Routine laboratory investigations. Special laboratory investigations.Special laboratory investigations. Radiological examination- Radiological examination- helpful in locating offending teeth or helpful in locating offending teeth or

other underlying cause.other underlying cause. IOPAIOPA OPGOPG Lateral oblique view mandible.Lateral oblique view mandible. A-P & Lateral view of neck for soft tissues A-P & Lateral view of neck for soft tissues can be useful in can be useful in

detecting retropharyngeal space infection.detecting retropharyngeal space infection. Ultrasound of swelling. Ultrasound of swelling. CT scan, MRI help in diagnosing extension of infection beyond CT scan, MRI help in diagnosing extension of infection beyond

maxillofacial region.maxillofacial region.

Management of Odontogenic InfectionsManagement of Odontogenic Infections

Goals of management of odontogenic infection:Goals of management of odontogenic infection:

1.1. Airway protection.Airway protection.

2.2. Surgical drainage.Surgical drainage.

3.3. Identification of etiologic bacteria.Identification of etiologic bacteria.

4.4. Selection of appropriate antibiotic therapy.Selection of appropriate antibiotic therapy.

5.5. Medical & supportive therapy.Medical & supportive therapy.

Selection of Antibiotic therapySelection of Antibiotic therapy

Parenteral penicillin.Parenteral penicillin.

Metronidazole Metronidazole in combination with penicillin can be used in combination with penicillin can be used

in severe infections. in severe infections.

Clindamycin for penicillin-allergic patients.Clindamycin for penicillin-allergic patients.

Cephalosporins (1Cephalosporins (1stst & 2 & 2ndnd generation cephalosporins). generation cephalosporins).

Antibiotics do not substitute for incision and drainage in Antibiotics do not substitute for incision and drainage in

cases of significant odontogenic infections.cases of significant odontogenic infections.

Causes for clinical failure include inadequate drainage or Causes for clinical failure include inadequate drainage or

antibiotic resistance.antibiotic resistance.

Surgical ManagementSurgical Management Surgical treatment may range from simply opening Surgical treatment may range from simply opening

tooth & extirpation of pulp to complex incision & tooth & extirpation of pulp to complex incision & drainage.drainage.

Primary goal Primary goal in surgical management is to remove in surgical management is to remove cause of infection.cause of infection.

Secondary goal Secondary goal is to provide drainage of accumulated is to provide drainage of accumulated pus & necrotic debris.pus & necrotic debris.

Extraction provides both removal of cause of infection Extraction provides both removal of cause of infection and drainage of pus & debris.and drainage of pus & debris.

Incision & DrainageIncision & Drainage

Incision & drainage helps-Incision & drainage helps- To get rid of toxic purulent material.To get rid of toxic purulent material. To decompress odematous tissues.To decompress odematous tissues. To allow better perfusion of blood, containing antibiotics & To allow better perfusion of blood, containing antibiotics &

defensive elements.defensive elements. To increase oxygenation of infected area.To increase oxygenation of infected area.

Removal of the cause; such as infected tooth, a segment of Removal of the cause; such as infected tooth, a segment of

necrotic bone, a foreign body should be done at the time of necrotic bone, a foreign body should be done at the time of

I & D procedureI & D procedure..

Hilton’s method of I & DHilton’s method of I & D

1.1. Topical anesthesia achieved with spray or infiltration.Topical anesthesia achieved with spray or infiltration.

2.2. Stab incision given through skin & s/c tissue.Stab incision given through skin & s/c tissue.

3.3. If pus is not encountered, further deepening of surgical site If pus is not encountered, further deepening of surgical site done with sinus forceps.done with sinus forceps.

4.4. Abscess cavity is entered and forceps opened in direction Abscess cavity is entered and forceps opened in direction parallel to vital structures.parallel to vital structures.

5.5. Explore the entire cavity for additional loculi.Explore the entire cavity for additional loculi.

6.6. Cavity irrigated with saline & antiseptic solutions.Cavity irrigated with saline & antiseptic solutions.

7.7. Placement of drain.Placement of drain.

8.8. Dressing.Dressing.

Drainage of Fascial SpacesDrainage of Fascial Spaces

CanineCanine, , Sublingual Sublingual and and Vestibular Vestibular abscesses are drained abscesses are drained

intraorally.intraorally.

MassetericMasseteric, , PterygomandibularPterygomandibular, , BuccalBuccal and and Lateral Lateral

Pharyngeal space Pharyngeal space abscesses can be drained with combination abscesses can be drained with combination

of intraoral and extraoral drainage.of intraoral and extraoral drainage.

TemporalTemporal, , SubmandibularSubmandibular, , SubmentalSubmental, , Retropharyngeal Retropharyngeal and and

Parotid space Parotid space abscesses may mandate extraoral incision and abscesses may mandate extraoral incision and

drainage. drainage.

Medical & Supportive TherapyMedical & Supportive Therapy

Administration of antibiotics.Administration of antibiotics.

Hydration of patient by I/V route.Hydration of patient by I/V route.

Soft or liquid diet rich of high proteins.Soft or liquid diet rich of high proteins.

Analgesics & NSAIDs.Analgesics & NSAIDs.

Antiseptic mouthwashes.Antiseptic mouthwashes.

Complete bed rest.Complete bed rest.

LUDWIG’S ANGINA::

DEFINITION– IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY & OF THE SUBMENTALIS SPACE.

-- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN 1836 ETIOLOGY: 1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION OF A LOWER THIRD MOLAR 2. TRAUMATIC INJURIES & INFECTED LESIONS 3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS MAY MENIFEST AS LUDWIG’S ANGINA 4. CYSTS OR TUMORS IN THIRD MOLAR REGION PATHOLOGY: 1. INFECTION FROM LOWER THIRD MOLAR REACHES THE SUBMANDIBULAR SPACES 2. FROM HERE INFECTION SPREADS ALONG THE SUMANDIBULAR SALIVARY GLANDS ABOVE THE MYLOHYIOD MUSCLE TO REACH THE SUBLINGUAL SPACE

CLINICAL FEATURES - SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA , DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR

EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED SWELLING SKIN OVER THE SWELLING APPEARS ERYTHMATOUS AND STRETCHED

SWELLING IS TENDER WITH LOCAL RISE IN TEMPERATURE

Difficulty in closing the mouth and drooling of salivaRespiratory distress

INTRA ORAL FEATURES – Trismus , floor of the mouth is raised , tongue raised upwards , increased salivation

MANAGEMENT - 1.Airway maintainence- Tracheostomy and Cricothyroidectomy

is advisable

2. Parentral antibiotics - Penicillin antibiotic of choice Amoxycillin + Cloxacillin Metronidazole in anaerobic infection 3.Surgical decompression – performed under L.A Decompression improves vascularity and potentiates the action of antibiotics. Bilateral submandibular incision with a midline submental incision pus

should be drained

4.Hydration of the patient – It is necessary to put the pt on i.v. fluids 5. Removal of cause - The offending tooth is removed

COMPLICATIONS – • Death due to airway compromise• septicemia• mediastinitis• carotid blow out

References References

Textbook of oral & maxillofacial Textbook of oral & maxillofacial surgery : Neelima Malik.surgery : Neelima Malik.

Oral & maxillofacial Infections : Oral & maxillofacial Infections : TopazianTopazian

Textbook of oral & maxillofacial Textbook of oral & maxillofacial surgery : Laskinsurgery : Laskin

THANK YOU!!!!THANK YOU!!!!