marka residents

1. Fascial Spaces and Spread of
Odontogenic Infection
Dr. Sahar Aldisi

2. Fascia
Fascia : is defined as layers of fibrous connective
tissue underlying the skin and surrounding muscles
, bones , vessels , nerves and organs .

4. Fascia of the head and neck is divided into :
1-Superficial Fascia.
2-Deep Fascia.

6. 1-Superficial Fascia: attached intimately deep to the
skin (elastic).
Function : separation of skin from deeper structures
making the skin move independently (elastic).
Contents :
- Fat.
- Cutaneous vessels .
- Cutaneuos nerves.
-Lymph nodes.
-Platysma muscle (covering the anterior triangle )
(covered by superficial cervical fascia).
- The muscles of facial expression.

8. 2-Deep Fascia is divided into :
a-Deep fascia of the face and jaws.
b-Deep cervical fascia.

10. 2-Deep Fascia of the face and jaws: covering deeper
structures such as bones ,muscles ,vessels and nerves.
(Inelastic and dense fibrous tissue )
Layers of deep fascia of the face are divided into :
1-Temporal fascia : covering the Temporalis muscle and
structures superior to the zygomatic arch.
2- Massetric-parotid : covering the Masseter and
structures inferior to the zygomatic arch surrounding
the parotid gland.
3-Pterygoid fascia covering the medial surface of medial
pterygoid muscle .
(Those 3 layers are continuous with each other and with
the investing layer of deep cervical fascia )

11. b- deep cervical fascia
Layers of deep cervical fascia of the neck are
divided into
1- investing fascia (most external )
2-pretracheal fascia
3-prevertebral fascia
4-carotid sheath
5-buccopharyngeal fascia

13. 1- Investing layer of deep cervical fascia :
Surrounding the neck like a collar .
It splits around 2 muscles : Sternocleidomastoid and
Trapezius .
Anteriorly it is attached inferiorly to the hyoid bone.
Superiorly attached to the lower border of mandible
anteriorly
Laterally at the mastoid process
Posteriorly it is attached to the superior nuchal line
and external occipital protuberance

14. *Between the angle of the mandible and the tip of
mastoid process it splits to enclose the parotid .
The Superficial part blend with the massetric-parotid
until it reaches the zygomatic arch and the deep
part attaches with the stylomandibular ligament
until it reaches the base of the skull .
Inferiorly , the investing layer of deep cervical fascia is
attached to the spine and acromion of the scapula
and clavicle with the Trapezius and to the clavicle
and the manubrium of sternum with
Sternocleidomastoid .

15. The investing layer is continuous with the deep fascia
of the face.
The Investing layer of deep cervical fascia splits
around 2 salivary glands : parotid and
submandibular salivary glands
And 2 muscles : Sternocleidomastoid and Trapezius.

16. 2- Prevertebral fascia
Is firm and tough membrane that covers the
prevertebral muscle extending from the base of the
skull until it reaches t4 vertebra .
It covers muscles that form the floor of the posterior
triangle of the neck and all the cervical nerve roots .
In front of this fascia is retropharyngeal space.

17. 3-Pretracheal fascia
Thin fascia lying deep to the infrahyoid strap muscle
(sternothyroid , sternohyoid and omohyoid )
Its upward attachment is at the body of hyoid bone and oblique
line of thyroid cartilage .
It splits to enclose the thyroid cartilage and adheres to it at the
back of the isthmus 2,3,4 the ring of trachea .
Laterally it fuses with the front of carotid sheath on the deep
surface of sternocleidomastoid muscle . It also surrounds the
pharynx , esophagus , larynx and trachea .
Behind prevertebral fascia is the prevertebral space .

19. 4- Carotid sheath
Is situated deep to the investing fascia and
sternocleidomastoid muscle and at the base of the
neck –thorax.
Contents (internal carotid artery , common carotid
artery , internal jugular vein and the vagus nerve
(X).

20. Carotid sheath
Contains an areolar tissue surrounding the common carotid artery
and internal carotid artery and internal jugular vein and deep
cervical lymph nodes.
Thin layer surrounding the internal jugular vein to allow its dilation
during increase blood flow .
Attached to the base of the skull at the margins of the carotid canal
and jugular fossa and continued downward blending with the
aortic arch .
Anteriorly its lower part fuses with the fascia of the deep surface of
the sternocleidomastoid muscle
It blends with the pretracheal fascia laterally .
Behind the carotid sheath there is thin layer of loose areolar tissue
between it and prevertebral fascia .
Cervical sympathetic trunk lies in front of the prevertebral fascia.

22. 5-buccopharyngeal fascia . Lateral to the pharynx
continuous with the fascia covering the buccinator
and the superior constrictor muscle of the pharynx
till the pterygomandibular raphe .

24. Fascial Spaces

25. Fascial spaces
are potential spaces found between layers of fascia.
Facial spaces contain loose areolar connective
tissue making them potential spaces and not actual
spaces, unless infection in those spaces occur
leading to displacement of the loose connective
tissues .Also , during surgeries these spaces are
opened up .

26. Facial Spaces are divided into (according to their position) :
A-Spaces of the face and jaws
1-vestibular spaces
2-canine space
3-buccal space
4-parotid space
5-masticator space
6-submandibular space
7-sublingual space
8-Submental space
9-palatal space
B-spaces of the neck
1-parapharyngeal (lateral pharyngeal ) space
2-retropharyngeal space

27. Another classification of the facial spaces (according to direct spread of infection )
Primary spaces
are the spaces that directly adjacent to the origin of odontogenic infection :
1-vestibular spaces
2-canine space
3-buccal space
4-submandibular space
5-submental space
6-sublingual space
7-palatal space
8-Infratemporal space
Secondary spaces
Are spaces that become involved following spread of infection to primary spaces .
1-masticator tissue spaces
2-pharyngeal spaces
3-prevertebral space

28. Vestibular Space

33. 1-vestibular space of the maxilla ( the space of upper
jaw)
Found Medial to the buccinator muscle below the
muscle attachment along alveolar process of the
maxilla . Its lateral wall is the oral mucosa .
Communication : with maxillary teeth and
periodontium of maxillary teeth .
2-Vestibular space of the mandible between the
buccinator muscle and oral mucosa above the
attachment of buccinator muscle to the mandible
Communication :with mandibular teeth and their
periodontium .

34. Canine Space

40. 3 –Canine space (infraorbital space )
Located superior to the upper lip and lateral to the apex of the maxillary canine .
Between the skin and muscles of facial expression levator labi superioris and zygomaticus minor
and canine fossa .
-Boundaries : anteriorly : orbicularis oris muscle.
Posteriorly :levator anguli muscle
-Communicates with buccal space and cavernous sinus via venous communications .
-Contents
Infraorbital nerve
Angular artery and vein
-Source of infection is the Maxillary canine tooth .
Clinical features
1-loss of nasolabial fold
2-oedema of the lower eyelid
3-swelling of cheek upper lip
4-drooping of the corner of the mouth
5-sometimes spontaneous drainage from medial canthus of the eye .
-Surgical management
Incise high in the maxillary labial vestibule , Haemostat advanced through levator anguli muscle
and place a rubber drain and suture into the lower margin of vestibular incision.

41. Buccal Space.

46. Buccal space
Between buccopharygeal fascia of buccinator muscle and Masseter muscle.
-Boundaries :
Superiorly : the zygomatic arch
Inferior : the inferior border of the mandible
(That’s why both boundaries are palpable in buccal space infection)
Medially : buccopharyngeal fascia surrounding the buccinators muscle .
Laterally : covered by skin , superficial fascia , partially by the platysma (the inferior part) and the Massetric-Parotid
fascia .
Posteriorly : anterior border of the Masseter .
Anteriorly : orbicularis oris muscle .
- Contents :fat pad
Parotid duct
Anterior facial artery and vein
Transverse facial artery and vein
- Communication : canine space , pterygomandibular space
-Source of infection :maxillary and mandibular premolars and molars
-Clinical features
Dumb-bell –shaped swelling due to lack of swelling of zygomatic arch and inferior border of the mandible
-Surgical management
Intraoral incision :horizontal incision above the depth of vestibule (the most prominent bulge of buccal mucosa )
avoiding the injury to parotid duct .
Extraoral incision :cutaneous drainage inferior to point of fluctuation for dependant drainage.

47. Parotid Space

52. Parotid Space
-Boundaries
Laterally : Skin , superficial fascia , Masstric-Parotid fascia.
Medially :Investing layer of deep cervical fascia
Posteriorly :sternocleidomastoid muscle
Anteriorly :posterior border of the ramus
-Communication
Lateral pharyngeal , submassetric and pterygomandibular spaces .
Contents :
Superficial and deep portion of parotid gland .
Facial nerve
External carotid artery
Retromandibular vein
Parotid lymph nodes
-Clinical features
Firm swelling (because pus is enclosed within this thick layer of deep cervical fascia )
Evertion of the ear lobule. Oozing of pus from duct .
No trismus
*Extension of odontogenic infections to this space is difficult since the fascial covering is firmly attached to the
gland
-Surgical Management
Intraoral :Through the buccinator muscle and advancing the of Haemostat superiorly .
Extraoral : inverted (L) incision 1-2 cm made at that hair line in the retromandibular area from the lower aspect of
ear lobule to the angle of the mandible .
Blunt dissection with Haemostat cautiously to avoid facial nerve injury by dissection parallel to the facial nerve

53. Masticator Space

55. Masticator Tissue Space :Space enclosed by deep
fascia of the face covering muscles of mastication
and the ramus of the mandible .
Masticator tissue spaces :
1.Submassetric Space
2.Pterygomandibular Space
3.Infratemporal Space
4.Temporal space

56. The 4 spaces of the masticator tissue space ,
communicate with each other and with
Submandibular and parapharyngeal space .
Trismus is a common clinical feature found in
the 4 spaces of masticator space infection. Also ,
pain and swollen tonsillar pillars .

57. Submassetric Space

63. 1.Submassetric space : between the ramus of the mandible and the Masseter muscle
-Boundaries
Anteriorly :buccal space ,parotid-massetric fascia
Posteriorly :parotid Gland and the investing layer of deep cervical fascia
Superiorly :zygomatic arch
Inferiorly :Inferior border of the mandible
Medially :Ramus of the mandible
Laterally : Masseter muscle
-Contents :
Massetric artery and vein
-Source of infection :
Mandibular 3rd molars .
-Clinical features :swelling of the angle of the mandible.
Obliteration of the mandibular sulcus posteriorly
Trismus and throbbing pain
Osteomyelitis due to relation of the massetric muscle which is responsible for
blood supply of ramus of the mandible supplied by the mandibular artery leading
to occurrence of ischemia in the bone denuded by the periosteum by abscess
leading to osteomyelitis and sequestrum formation .
A common clue for the diagnosis of submassetric space infection is the subperiosteal
new bone deposition beneath the periosteum .

64. Pterygomandibular Space

69. 2.Pterygomandibular Space : between the ramus and the medial pterygoid muscle laterally
Anteriorly : Buccal space , Parotid massetric fascia
Inferiorly :Inferior border of the mandible .
Superiorly : zygomatic arch and the inferior head of lateral pterygoid muscle .
Anteriorly : the muscle fibers of buccinators arising from pterygomandibular raphe and below it is the tendon of Temporalis muscle .
Posteriorly: Parotid Gland covered by investing layer of deep cervical fascia and parotid gland .
Laterally :medial surface of the Ramus of the mandible
Medially : lateral surface of medial pterygoid muscle
-Communication :Submandibular and parapharyngeal Spaces.
-Contents :
Inferior alveolar artery and vein
Mandibular division of trigeminal nerve .
-Source of infection:
Mandibular 3rd molars (especially with mesiongular or horizontal impaction )
Fracture of the angle of the mandible .
-Clinical features :
Swelling is not obvious extraorally
Intraorally :Swelling on the same side of the soft palate , tonsillar pillars, and deviation of the uvula to the other side .
Dysphagia
Fever
Lymphadenitis
-Surgical Management
Intraoral incision : vertical incision along the external oblique line of the mandible .
Blunt dissection and opening of the Haemostat when it reaches lateral aspect of the ramus beneath the Masseter muscle .
Extraoral approach : small incision beneath the angle of the mandible on the medial aspect of the ramus and pterygomandibur
raphe.
In cases of trismus , general anaesthesia is indicated or administration of mandibular nerve block by an extraoral approach .

70. InfraTemporal Space

73. Infratemporal : the upper extremity of the pterygomandibular space behind the maxilla .
Boundaries :
Medially : lateral pterygoid plate .
Anteriorly : maxillary tuberosity
Laterally :medial surface of the mandible and the Temporalis muscle.
Superiorly :Infratemporal surface of the greater wing of sphenoid
Inferiorly : Lateral pterygoid muscle
Posteriorly :mandibular condyle
-Contents
Internal Maxillary artery
Pterygoid Plexus
Mandibular nerve
Source of infection : maxillary molars
Local infiltration of maxillary nerve
Mandibular nerve and its branches
Pterygoid plexus (which may cause cavernous sinus infection because the cavernous sinus emissary veins are in
contact with pterygoid plexus)
Cavernous sinus infection clinical features (headache , photophobia , irritability , vomiting and drowsiness)
-Clinical features :
Severe trismus and pain .
If the swelling is present over the tuberosity area then extraorally it can be seen over tempro-mandibular joint and
zygomatic arch.

74. Temporal Space

79. Temporal space
Divided into 2 spaces :
Superficial space
Deep space
Both spaces of temporal space is separated by the Temporalis muscle .
Superficial Temporal Space :
Boundaries
Laterally : Skin ,and Superficail fascia .
Medially :lateral surface of the Temporalis muscle
Superiorly: Superior Temporal line
Inferiorly :zygomatic arch
Deep temporal space :
Boundaries
Laterally : Medial surface of the Temporalis muscle
Medially : Temporal bone
Superiorly : Greater wing of sphenoid bone
-Contents :
Temporal fat pad
Temporal branch of facial nerve
-Clinical features :
Trismus
Dysphagia ,dyspnea, airway compromise , severe pain
Dumb-bell shaped swelling due to the inferior boundary of the zygomatic arch
Swelling is more obvious in the superficial temporal space infection because it's only restrained by fascia laterally .

80. Masticator Space Surgical
Management

81. Palatal Space

84. Palatal Space :
Infection of this space usually originates from maxillary teeth
whose roots lie close to it e.g. maxillary lateral incisors (causing
anterior palatal abscess) and palatal roots of molars (causing
posterior palatal abscess ).
This infection perforates the palatal alveolar bone and pus
accumulates beneath the palatal mucoperiosteum
Usually localization of infection and fluctuation is hard to
achieve due to the thick palatal mucoperiosteum that is firmly
attached to the underlying bone
-Surgical management
Intraoral incision done along the palatal mucoperiosteum down to
the bone .the incision is made at right angles of to the long axis of
the teeth carried out antro-posteriorly carefully avoid injury of the
palatal arteries that’s why the incision is done on the alveolar
mucosa rather the palatal mucosa .
.

85. Submandibular Space

94. Submandibular Space
Found between anterior and posterior bellies of digastrics.
It is located lateral and posterior to the submental space on each side of the jaw,
The cross section is triangular with the mylohyoid muscle superior-medially .
Boundaries :
Superiorly :mylohyoid muscle
Anteriorly Anterior belly of digastric muscle
Inferiorly :hyoid bone posteriorly .and Anteriorly skin , superficial fascia ,platysma , the investing layer of deep cervical fascia anteriorly (that’s why abscess in this region does
not normally drains through the skin .
Laterally :medial surface of the mandible below the mylohyoid line
Medially :mylohyoid , hyoglossus muscle
Posteriorly: posteriorly belly of digastric
-Content : Submandibular lymph nodes
Submandibular salivary gland
Facial artery and vein and submental branch
Nerve to mylohyoid
-Communications
Infratemporal Space
Submental Space
Sublingual space
Parapharyngeal space
-Source of infection :
Mandibular molars
Clinical features
Firm swelling of the inferior border of the mandible at point where the facial artery crosses
Obliteration of the angle of the mandible
Dysphagia due to restricted mouth openings
Extension of the swelling starts from the lower border of the mandible down till the level of hyoid bone in a shape of an inverted cone
Systemic signs of sepsis may be found
-Surgical Management
Extraoral incision :2 cm below and parallel to the lower border of the mandible through the skin, superficial fascia , platysma and investing layer of deep cervical fascia.
2 cm is left below the inferior border of the mandible to avoid injury to the marginal mandibular branch of facial nerve
Blunt dissection is done cautiously to avoid injury to the facial artery anterior to the facial vein and nerve.

95. Sublingual Space

101. Sublingual space
Boundaries
Superiorly :oral mucosa of the floor of the mouth
Inferiorly : mylohyoid muscle
Medially: the tongue and its intrinsic muscle
Laterally :medial surface of the mandible above mylohyoid line
Anteriorly :lingual surface of the mandible
Posteriorly :Body of the hyoid bone
Contents :
Sublingual salivary gland and duct
Duct of the submandibular salivary gland
Lingual nerve and artery
Deep portion of submandibular salivary gland
Communications
Submental space
Submandibular space
Source of infection
Mandibular premolar and molars
Trauma
Clinical features :
No visible features extraorally
Painful swelling of the floor of the mouth on the affected side thereby raising the tongue and deflecting it to the opposite side and decreasing its mobility
Dysphagia and Dyspnea
Salivary glands become more prominent
Systemic signs of Sepsis
Surgical management
Intraoral incision of the base of the alveolar process of the lingual sulcus or 1.5 cm away from the lingual cortical plate taking care not to injure sublingual gland or lingual
nerve
Haemostat inserted in an anterior-posterior direction beneath the sublingual gland .

102. Submental Space

104. Submental Space
Midline space between symphysis and hyoid bone
Boundaries
Anteriorly :lingual surface of the Mandible
Posteriorly :Hyoid bone
Inferiorly :skin, superficial cervical fascia , platysma , investing layer of deep cervical fascia
Superiorly :mylohyoid muscle covered by investing fascia
Medially : midline space
Laterally :2 diverging anterior bellies of digastrics
-Contents:
Submental lymph nodes
Anterior jugular vein
-Communication
Submandibular space
Sublingual space
-Source of infection
Mandibular anterior teeth
-Clinical features :
Hard midline swelling under the chin
Dysphagia
Signs of sepsis
-Surgical management
Extraoral incision through skin , superficial cervical fascia , platysma , investing layer of deep cervical fascia at the
most inferior aspect of the swelling for a more dependant drainage .

105. Pharyngeal Space

111. Pharyngeal Space
Is divided into 1. Peripharyngeal space (around the
pharynx)
a.parapharyngeal space(laterally)
b.retropharyngeal space (posteriorly)
-Both spaces are considered (Danger Spaces )
2.intrapharyngeal space (within the pharynx)

112. Lateral pharyngeal space (parapharyngeal )
A cone shaped space with its base is at the base of the skull superiorly and its apex is at the greater horn of the hyoid bone
Borders:
Anteriorly: Superior and middle constrictor of the pharynx and the pterygomandibular raphe and communicating anteriorly with the pterygomandibular space
Medially: Superior constrictor of the pharynx
Laterally : medial pterygoid muscle and pterygoid fascia and parotid capsule
Superiorly :Base of the skull
Inferiorly :Hyoid bone
Also it communicate along the carotid sheath with the superior mediastinum .
Posteriorly :carotid sheath and prevertebral fascia .
-Contents :
Carotid artery
Internal jugular vein
Vagus nerve
Cervical sympathetic chain
Source of infection
Mandibular 3rd molar
Tonsillar infections
Pharyngitis and parotitis
-Clinical features
Severe Pain on the affected side of throat
Displacement of the tonsil , tonsillar pillars and uvula to the medial side
The four cardinal signs of pharyngeal abscess : 1.trismus
2.Induration Swelling of the angle of the jaw leading to ability to palpate the angle of the mandible
3.Fever
4. Pharyngeal bulging
Dysphagia
Inability to palpate angle of the mandible
Tension of the sternocleidomastoid muscle due to rotation of the neck away from the side of swelling
-Complication :septic jugular vein thrombophlebitis
Cavernous sinus thrombosis , meningitis and brain abscess
-Surgical Management :
Intraoral incision is done in the retromolar triangle lateral and parallel to the pterygomandibular space extending between the ramus and the posterior and medial aspect of the medial pterygoid muscle where blunt
dissection is performed
Intraoral incision are contraindicated if there has been hemorrhage no matter how minimal it is .
Extraoral incision :
2cm along the anterior border of sternocleidomastoid muscle
Combined approach (intraoral and extraoral)
Lateral mucosal incision and curved Haemostat is passed lateral to the superior constrictor muscle and medial to medial pterygoid and the tip of the Haemostat is palpated extraorally (anterior to the
sternocleidomastoid ) and a cutaneous incision is made over the tip .
This approach provides direct access into lateral pharyngeal space and aids in placement of a correct extraoral incision in a swollen face .

113. Retropharyngeal Space
(Danger Space )

117. Retropharyngeal space
Midline space lying posterior to the pharynx and anterior to the prevertebral fascia extending upward to the base of the skull inferior to the retrovisceral space
(Danger space )
Borders
Anteriorly :Posterior pharyngeal wall
Posteriorly :prevertebral fascia
Superiorly : Base of the skull
Inferiorly :Mediastinum
Medially :common midline space
Laterally :lateral pharyngeal space
-Source of infection
Suppurative adenitis
Dental infection diffusing through adjacent spaces
Nasal or pharyngeal infections
-Clinical features :
Pain
Fever
Stiffness of the neck
Drooling and dysphagia
Supraglottic edema causing airway obstruction
Aspiration pneumonia
Acute mediastinitis leading to empyema and pericardial effusion
-Surgical management
Drainage will not be dependant
Intraoral incision : vertical incision lateral to the midline of pharyngeal walls
Intraoral is more dependant
Extraoral incision :
Along the anterior border of Sternocleidomastoid muscle and inferior to the hyoid and the muscle . Carotid sheath and the sternocleidomastoid is retracted labially .
Blunt dissection is done between the carotid sheath and the
Inferior constrictor .

118. Prevertebral Fascia

121. The prevertebral space
Boundaries
Anteriorly :prevertebral fascia
Laterally :attachment of the prevertebral fascia to the
transverse processes of the vertebra
Posteriorly : anterior longitudinal ligament , the vertebral
bodies and musculature .
It extends through the entire length of the vertebral
column.

122. Spread of Odontogenic Infections.

123. Routes of odontogenic infection:
1-Direct continuity through bone (direct spread) of
infection through bone and soft tissue spaces
(above or below) muscles and facial attachments to
reach potential surgical spaces and their
communications.
2-Haematogenous spread (by vascular system)
3-Lymphatic spread
4-spread to paranasal sinuses

125. Infection initially spreads in the spongiosa with
jaw bone until it reach and perforates the nearest
and thinnest cortical plate , once outside the bone
further spread will occur following the path of least
resistance such as loose connective tissue .The
inflammatory exudates will be guided by layer of
dense fascia or muscles and will not penetrate them
.

126. Factors influencing direction and destination of direct
spread of infection
1-Position of teeth in the alveolar bone and thickness
of related cortical plates of bone.
2-Adjacent Muscles attachment relations
3-Attachments of layers of deep fascia where
infection also spreads along but does not penetrate
these layers.
4- Proximity of anatomical structures and potential
spaces

128. 1.Position of teeth in the alveolar bone and thickness of related
cortical plates of bone.
The bone is first locally limiting barrier to further spread of a
periapical infection. The thin cortex surrounding the
periapical abscess will be penetrated before the thicker one.
Direct spread within bone is affected by:
a-the roots length
b-proximity to buccal, lingual or palatal cortical plates
c- Thickness of cortical plate in different parts of jaws
d-relation to certain anatomical structures such as the floor of
the nose and maxillary sinus.
e –anatomic structure
F-stage of development

130. Maxilla
The incisors, canines, buccal roots of the premolar and molars are covered
(labially by a thin layer of cortical bone) a thin layer of cancellous bone
.Therefore, infection will tend to readily perforate the labial or buccal plates.
Lateral incisors in some orthodontic cases are inclined labially , thereby the
roots will be directed palatally so infection will be palatally related .
Palatal roots of first and second molars are related to the palatal cortical plate .
Incisors are related to the nasal cavity floor
Premolar and molar are related to the floor of the maxillary sinus
Canine is in the neutral position between the two cavity .

132. Mandible :
In incisor , canine area both inner and outer cortical
plates are thin and increasing as we go distally in
thickness.
Premolar and first molar are closer in relation to the
buccal cortical plate.
2nd and 3rd molars are related to the lingual cortical
plates due to medial shift of the alveolar process in
relation to the body of the mandible and external
oblique ridge (thick outer cortical plate)

133. 2-Adjacent Muscles attachment relations
E.g. . Mylohyoid , buccinators and constrictor muscle
of the pharynx
Infection spreads along muscles and does penetrate
them , thereby muscles guide infection along its
fibers.

135. Maxillary anterior region : infection will be directed
towards the labial sulcus due to the form of muscle
strips with the intervening superficial fascia where
infection will track those slits of muscle towards labial
sulcus .
Premolar and molar area the attached of the buccinators
will guide the spread of infection. If the apices of roots
are below the attachment , infection will spread to the
buccal sulcus . While in case of higher position of the
root apices in relation to the attachment of buccinators
 facial cellulitis.
The long root of the canine may direct infection to
infraorbital region causing infraorbital cellulitis .

137. Mandible
Mandibular anterior region  labial sulcus (vestibule )
 Skin of the lower border
of the mandible.
Premolar and 1st molar root apices lying above
buccinators  buccal sulcus .
2nd and 3rd molars
If apices are above mylohyoid muscle  sublingual Space
If apices are below the mylohyoid attachments 
Submandibular Space.

138. 3.Attachments of layers of deep fascia where
infection also spreads along but does not penetrate
these layers.
4. Proximity of anatomical structures and potential
spaces

139. Ludwig’s Angina

141. First described by Ludwig in 1836.
•Infection of 5 spaces; submental, and bilateral submandibular and
sublingual spaces.
•brauny edema of the spaces.
•paucity of pus .
•Edema of neck, floor of mouth & epiglottis.
•Dyspnea, loss of airway.
•Spread to involve masticator, pharyngeal space
Dysphonia
–“Hot potato” voice
–Odynophagia
–Drooling
–Tongue swelling
–Pain in floor of mouth
–Restricted neck movement
–Unilateral sore throat

142. Concern for asphyxiation
•If no respiratory difficulties
–Maintain in sitting position
–Continuous monitoring
–Must be prepared to intubate
–Airway complications must be anticipated as concurring supraglottic edema, trismus may
interfere with securing the airway
•If signs of impending respiratory compromise
•Fiberoptic nasal intubation is preferred route
–The ability to displace the soft tissues of the pharynx anterior to the line of vision on direct
laryngoscopy depends on the compliance of the submandibular tissue
–Ludwig's angina can decrease the compliance of the tissue so severely that the airway
structures cannot be visualized
•Ludwig's can distort the anatomy to such a degree that there is soft tissue displacement of the
trachea
•Antibiotics
•Uncertain value of steroids
•Reasons for surgery
–Unresponsive to medical therapy
–Patient in whom suppurative infections develop
–Presence of crepitus, fluctuance and soft tissue gas

143. 2-Haematogenous spread (by vascular system)
Through general circulation leading to bacteremia
, septicemia and pyaemia due to infected emboli
that may develop into metastatic infection or
emboli abscess elsewhere in the body . E.g.
Infective Endocarditis
Spread to cavernous sinus caused by
thrombophlebitis of the vein due to valve-less facial
veins making the infection able to travel against the
normal pattern , favored by septic thrombosis .
Infection reaching cavernous sinus may lead to
thrombosis or brain abscess
Death is common .

144. 3-Lymphatic spread : through the lymphatic vessels to regional
lymph nodes reaching eventually to the general circulation .
Submandibular nodes are the primary nodes for all teeth and
associated tissue except 3rd molars (which drains to the
superior deep cervical nodes and mandibular incisors to
submental nodes then drains to superior deep cervical nodes
emptying to inferior deep cervical nodes or directly into the
jugular trunk then to the vascular system making the spread
accessible to other tissues , structure and organs .
Lymphadenopathy
Lymph nodes infection characterized by lymph nodes
hypertrophy and change in consistency making it palpable

147. 4-spread to paranasal sinuses
Most commonly infection of the maxillary sinus
(maxillary sinusitis ) resulting from spread of
infection from periapical abscess of maxillary
premolars and molars perforating the sinus floor to
involve sinus mucosa .
Infection of paranasal sinuses may also spread to
other sinuses or the nasal cavity and may also
spread further to reach cranial cavity and brain .

148. References
-Oral Anatomy , Embryology and Histology .BKB
Berkovitz, Graham Rex Holland , B.J Moxham .
Mosby, 4th edition 2009.
-Illustrated Anatomy of the Head and Neck
.Margaret J. Fehrenbach, Susan W. Herring.
Elsevier, 4th edition 2012.
-The Anatomical Basis of Dentistry .Bernard
Leibgott , 3rd edition
-Last’s Anatomy ,Regional and Applied .Chummy
S. Sinnatamby . Elsevier 12th edition 2011.
-Textbook of Oral Maxillofacial Surgery .
S.M.Balaji. Elsevier India 2009.