primary spaces of space infection

1. PRIMARY SPACES
OF SPACE INFECTION
BY MANMOY SAHA
(INTERN)

2. CONTENTS
 INTRODUCTION
 POTENTIAL SPACES
 PRIMARY MAXILLARY SPACES
 -CANINE SPACE
 -BUCCAL SPACE
 -INFRA TEMPORAL SPACE
 PRIMARY MANDIBULAR SPACES
 -SUBMENTAL SPACE
 -BUCCAL SPACE
 -SUBMANDIBULAR SPACE
 -SUBLINGUAL SPACE

3. INTRODUCTION
 Infections of orofacial and neck regions
range from periapical abscess to superficial
and deep neck infections
 The infections spread by following the path
of least resistance through connective
tissue and fascial planes
 The infection spread to such an extent
,distant from the site of origin causing
considerable morbidity and occasional death

4. PATHWAYS OF ODONTOGENIC INFECTIONS

5.  Invasion of dental pulp by bacteria
after decay of tooth
 -> Inflammation, edema, lack of
collateral blood supply
 -> venous congestion or avascular
necrosis
 ->Reservoir for bacterial growth
 ->periodic egress of bacteria into
surrounding alveolar bone

6. SPREAD OF OROFACIAL INFECTIONS
 ROUTES OF SPREAD
 By direct continuity through the tissues
 By lymphatics to the regional lymph nodes and
eventually into blood stream
 Which may lead to secondary areas of cellulitis or
tissue space abscess
 By the blood stream
 If the infection remains confined to the peri-apical
areas, chronic periapical infections develop , which
leads to sufficient destructions of bone-> osteomyelitis

8. MAXILLA
 Swelling or fistula in the posterior part of hard palate it is
related to palatal roots of molars
 Maxillary incisor and cuspid roots lie closer to thin labial
plate of bone than to thicker palatal bone
 Infection from maxillary bicuspids may extend into
connective tissue of buccal vestibule spread superiorly
causing cellulitis of eyelids
 Infection from molars may exit from alveolar bone
buccally, palatally or posteriorly
 Superior spread -> infratemporal space, maxillary sinus
 Posteriorly->masticator and pharyngeal space

10. MANDIBLE
 Infection of mandibular incisors and
cuspids shows bulging in labial sulcus
 If infection spreads from bone deeper to
origin of mentalis muscle->submental
space
 Infection from mandibular 3rd molar involve
buccal vestibule, buccal space, masticator
space, parapharyngeal spaces

12. CLASSIFICATION OF FASCIAL SPACES
 BASED ON THE MODE OF INVOLVEMENT:
 Direct involvement:-
 Primary maxillary spaces- canine space,
 buccal space, infra temporal space
 Primary mandibular spaces- submental
space
 buccal space, submandibular space,
 sublingual space
 Indirect involvement-
 Secondary fascial spaces- masseteric

13.  Pterygomandibular space
 Superficial temporal space
 Deep temporal space
 Lateral pharyngeal space
 Retropharyngeal space
 Prevertebral space
 Parotid space
 Basedon clinical significance
 Face - Buccal , canine, masticatory, parotid
 Suprahyoid- sublingual, submandibular,
 pharyngomaxillary, peritonsillar
 Infrahyoid- anterovisceral(pre tracheal)
 Spaces of total neck: retropharyngeal , space of
carotid sheath

14. The teeth which frequently give rise to abscess
in
this area are maxillary canines, premolars and
sometimes mesiobuccal root of 1st molar

15. CANINE SPACE( INFRA-ORBITAL SPACE)
 Boundaries:-
 Anteriorly- orbicularis oris
 Posteriorly- buccinator
 Superiorly-levator labii
superioris, zygomaticus
minor
 Inferiorly- caninus muscle
 Medially- anterolateral
surface of maxilla

16. CLINICAL FEATURES:-
 Swelling of cheek and upper
lip
 Obliteration of nasolabial fold
 Drooping of the angle of
mouth
 edema of lower eyelid
 Redness and marked
tenderness of facial tissues
 Intraoral- offending tooth is
mobile and tender on
INCISION &
DRAINAGE:-
 A curved mosquito
forcep is inserted
superior to the
attachment of caninus
muscle & the infra-
orbital space is
entered
 Pus is evacuated and
a drain is inserted &
secured to one of the
margins with suture

18. It is the potential space between buccinator & masseter
muscle
Maxillary & Mandibular premolars and molars area
involved.
Location of the root tip to the level of origin of buccinator
muscle determines the spread of infection either intraorally

19.  Boundaries:-
 Anteromedially- buccinator
muscle
 Posteromedially- masseter
overlying the anterior border
of ramus of mandible
 Laterally- forward extension
of deep fascia from the
capsule of parotid gland &
platysma muscle
 Inferiorly- deep fascia to the
mandible & depressor anguli
oris
 Superiorly- zygomatic
process of maxilla &
zygomaticus major and
minor

20. CLINICAL FEATURES:-
Gum boil is seen in the
vestibule
(when the pus
accumulates on oral side
of the muscle)
If the pus accumulates
lateral to the muscle
extraoral swelling is seen
extending from lower
border of mandible to the
infra orbital margin
and from anterior margin of
masseter muscle to the
corner of the mouth
INCISION & DRAINAGE:-
 Horizontal incision
through the oral mucosa
of the cheek in the
premolar molar region
 If the pus is lateral to the
muscle then the muscle is
penetrated with curved
mosquito forceps to enter
the buccal space
 Drain is placed secured
with suture

21.  It is also called “retrozygomatic space”
 The space is continuous with upper part of pterygomandibular space
anteriorly, it is separated from it by lateral pterygoid muscle
posteriorly
 The infratemporal fossa forms the upper extremity of
pterygomandibular space

22. Involvement-
 Infections of the
infratemporal space occurs
from the infections of
buccal roots maxillary 2nd
and 3rd molars
 Local anesthesia injections
with contaminated needles
in the area of tuberosity
 Spread from other spaces
infection
Spread of infection
 Pus can extend upwards
to involve the temporal
space or inferiorly
perforate the lateral
pterygoid muscle to
involve the
pterygomandibular space
 It can spread through
pterygoid plexus of veins
upwards into cavernous
sinus
 From infratemporal fossa
to middle cranial fossa

23.  Boundaries:-
 Laterally- ramus of mandible
and temporalis muscle
 Medially-medial pterygoid
plateand lateral pterygoid
muscle
superiorly - infratemporal
surface of greater wing of sphenoid
 Inferiorly- lateral pterygoid
muscle
 Anteriorly- infratemporal surface
of maxilla
 Posteriorly -parotid gland

24.  CLINICAL FEATURES:-
 Extraoral- trismus
 Bulging of temporalis
muscle
 Marked swelling of the
face on the affected side in
front of the ear overlying
area of tmj
 Intra oral –swelling in
tuberosity area with
elevation of temp 104F
 INCISION & DRAINAGE:-
 Intraoral approach- incision
is given in buccal vestibule
opposite 2nd and 3rd molar
exploration is carried out
medial to coronoid process
and temporalis muscle
upwards backwards with
sinus forcep ,space is
entered and drained
 Extra oral approach-
incision is made at upper
and posterior edge of
temporalis muscle within
hairline.
 Sinus forcep directed
upward medially
 Pus is evacuated

26.  Infections originating from 6 anterior mandibular teeth
then perforate cortical plate below the origin of mentalis
muscle labially ,mylohyoid lingually
 It can also affected from lower incisors , lower lip, skin
overlying the chin, anterior part of floor of mouth,
 tip of tongue and sublingual tissues

27. BOUNDARIES:-
 Lateral- lower border of mandible and anterior
bellies of digastric
 Superior:- mylohyoid muscle
 Inferior:- suprahyoid portion of the investing layer of
deep cervical fascia

28. CLINICAL FEATURES:-
 Extraoral findings- distinct,
firm swelling in midline
beneath the chin
 Skin over the swelling is
board like taut
 Intraoral findings- the
anterior teeth are either
non-vital fractured or
carious .
 The offending tooth may
exhibit tenderness to
percussion may show
mobility

29.  Spread: of infection-
 Posteriorly- to involve
submandibular space
 It may discharge on the face in
the submental region
 INCISION & DRAINAGE:-
 A transverse incision is made in
the skin below the symphysis of
the mandible.
 Blunt dissection is carried out by
inserting a kelly’s forcep through
this incision ,upward ,backward
 Then corrugated rubber drain is
inserted in the abscess cavity
and sutured

30.  The space lies between the anterior and posterior bellies
of digastric muscle.
 Upper part lies beneath the inferior border of mandible and
lower part lies deep to the investing layer of deep cervical
fascia

31. INVOLVEMENT
 Infections originating from
mandibular molars, pus
perforates the lingual cortical
plate of mandible passes
directly into the submandibular
space
 Infection from submental space
 Infection from posterior part of
sublingual space
 Infections from middle third of
the tongue, posterior part of
floor of mouth, maxilary teeth,

32. BOUNDARIES:-
 Anteromedially:- floor is
formed by mylohyoid
muscle
 Posteromedially:- floor is
formed by hyoglossus
muscle
 superolaterally :- medial
surface of mandible
 Anterosuperiorly:- anterior
belly of digastric
 Posterosuperiorly:-
posterior belly of digastric

33.  CLINICAL FEATURES:-
 Extra oral:- firm swelling in
the submandibular region,
below inferior border of
mandible
 Redness of overlying skin
 Intra oral:- teeth are sensitive
to percussion
 Teeth are mobile
 Dysphagia
 Moderate trismus
 Spread: of infection-
 There is no major anatomic
barriers so infection can
extend into submental space
 There is no anatomical barrier
so infection can spread easily
across the midline involve
submandibular space on other
side
 It communicates with
sublingual space around
posterior border of mylohyoid
muscle
 It can also spread into
parapharyngeal space

34.  An incision of about 1.5 to
2 cm length is made 2cm
below the lower border of
mandible
 Skin and subcutaneous
tissues are incised
 Sinus forcep is inserted
through the incision
superiorly and posteriorly
on the lingual side of
mandible below the
mylohyoid to release pus
from submandibular space
INCISION &
DRAINAGE:-

35.  Space is a “V” shaped trough lying lateral to muscles of
tongue including hyouglossus, genioglossus, geniohyoid
 Involvement:- mandibular incisors, canines, premolars
, sometimes molars
 It is a paired space but the 2 sides communicates
anteriorly, with submandibular space around the
posterior border of mylohyoid muscle

36. BOUNDARIES:-
 Inferiorly- mylohyoid muscle
 Laterally:- medial side of the
mandible above mylohyoid
muscle
 Medially:- hyoglossus,
genioglossus & geniohyoid
muscles
 Posteriorly:- hyoid bone
 Laterally and inferiorly:-
mylohyoid muscle and lingual
side of mandible

37. CLINICAL FEATURES:-
Extraorally: there is little or no
swelling.
The lymph nodes may be
tender & enlarged
Pain and discomfort on
deglutition
Intraorally: firm, painful swelling
seen in the floor of the mouth
Floor of the mouth is raised
Tongue pushed superiorly will
cause airway obstruction
Spread: of infection-
 Infection crosses the
midline and effect the space
on the opposite
 Infection from posterior
inferior part of the space
spread into submandibular
space-> pterygomandibular
and parapharyngeal space
Infection spread via
lymphatics to the
submandibular or submental
lymph node

38. INCISION & DRAINAGE:-
 Inraorally:- incision is made
close to the lingual cortical
plate, lateral to sublingual
plica (whartons duct,
sublingual artery,veins &
lingual nerve)
 Sinus forceps is then
inserted and openeed to
evacuate the pus
 Extraorally:- when both
submental and sublingual
space contains pus they
can be drained by placing
incision in submental region

39. MANAGEMENT OF OROFACIAL INFECTIONS
 Antibiotic therapy:-
 Use of penicillin G (2 to 4 million
units, IV 4 to 6 hrs)and
 metronidazole(400 mg 8 hourly
orally or IV)
 Oral clindamycin
 Amoxicillin-clavulanic
acid(augmentin)
 1st and 2nd generation cephalosporins
are useful in orofacial infections
 In compromised patients-
clindamycin alone 300 to 600 mg 8
hourly IV)
 Or in combination with gentamycin
( 80 mg IM) can be given
 SURGICAL THERAPY
 Hilton’s method of incision and
drainage
 The method of opening an abscess
ensures that no blood vessels or
nerve is damaged
 Incision helps to get rid of toxic
purulent material
 To allow better perfusion of blood
containing antibiotic and defensive
elements
 To increase oxygenation of infected
area

40. HILTON’S METHOD OF INCISION AND DRAINAGE
 Topical anesthesia:- achieved with the help of ethyl
chloride spray
 Stab incision:- it is made over the point of maximum
fluctuation in the most dependent area through skin
and subcutaneous tissue
 Deepening of surgical site is achieved with sinus
forceps
 Closed forceps are pushed through deep fascia
move towards the pus collection

41.  Abscess cavity is entered and forceps is opened in a direction
parallel to vital structures
 Pus flow along side of beaks
 Explore the entire cavity for
additional loculi
 Placement of drain:- A corrugated
rubber drain is inserted into depth
of abscess cavity & external part
secured with suture
 Drain is left for 24 hrs
 Dressing:- applied over the site of incision taken extraorally
without pressure

42. INVOLVEMENT OF MULTIPLE PRIMARY SPACES
 LUDWIG’S ANGINA
 It is a firm, massive, brawny cellulitis and acute, toxic stage involving
simultaneously submandibular, sublingual, submental space bilaterally
 It means “suffocation or choking sensation”
 Clinical features:-
 There is pyrexia, anorexia , chills, malaise
 Severe muscle spasm may lead to trismus
with restricted mouth opening and also jaw
movements
 Tongue movements may be reduced
 Air obstruction
 Fatal death may occur in untreated case of Ludwig’s angina within 10 to
24 hours due to asphyxia

43. TREATMENT OF LUDWIG’S ANGINA
 Early diagnosis
 Maintenance of the patient
airway
 Intense and prolonged
antibiotic therapy
 Extraction of offending teeth
 Surgical drainage or
decompression of fascial
spaces

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