Abscess oral maxillo-presentation

1. SOUMAN BARUA
5 TY YEAR
VICTOR B ABES UNIVERSITY, TI MISOARA.
Buccal, Canine, Palatinal, Submental,
Submandibular, Sublingual
&
other Superficial Abscesses

2. WHAT IS ABSCESS? CLINICAL DIAGNOSIS STAGES
There are Four stages in progression of acute odontogenic
infections:
Stage 1: Odontogenic in origin. periapical or periodontal or peri-coronal
infection. Patient may be asymptomatic.
Stage 2: Still confined with in the alveolar bone. it is termed as periapical
osteitis. Tooth is tender to percussion and frequently extruded from the
socket. Patient complains of severe pain.
Stage 3
Once the infection exits through the bone and the periosteum into the surrounding
soft tissue ,an inflammatory oedema occurs A diffuse swelling develops extra-orally
which is soft and duffy in consistency called Cellulitis. At this stage no pus
formation occurs.
Stage 4 : When suppuration does occur and the infection
localises, the condition is termed as, Abscess. With increased
pressure it may even perforate the soft tissues and pus discharge may be
seen as sinus opening or fistulous tract.

3. DIFFERENCE BETWEEN CELLULITIS AND ABSCESS
Characteristics Cellulitis Abscess
Duration
Pain
Size
Localization
Palpation
Appearance
Skin Quality
Surface temperature
Loss of Function
Tissue Fluid
Seriousness
Bacteria
3-7 Days
Severe and Generalised
Large
Diffuse
Hard exquisitely tender
Reddened
Thickened
Hot
Severe
Serosanguineous
Severe
Mixed
Over 5 days
Moderate and Localised
Small
Circumscribed
Fluctuant and tender
Peripherally reddened
Centrally undermined
Moderately heated
Moderately severe
Pus
Moderate
Anaerobic

4. CLINICAL DIAGNOSIS METHODS
• History taking
• Observation
• Palpation
• Diagnostic Imaging of fascial and neck space
o X-Ray
o MRI
o CT
o Ultrasound
• Biopsy (For neoplastic masses)
• Differential Diagnosis of Head and Neck Abscess
• Enlargement of lymph nodes
• Benign Swellings of the Head and Neck
• Developmental Cyst – ThyroglossalCyst
• Developmental Cyst - Branchial Cyst
• Developmental Cyst Sebaceous cyst
• Dermoid cyst
• Neoplastic Masses of the Head and Neck- benign or malignant
• Lymphomas

5. CLASSIFICATION OF INFECTION ACCORDING TO TOPAZIAN:
(Clinical Significance)
1. Face
• Buccal
• Canine
• Masticatory
o Massetric
o Pterygoid
o Zygomatico Temporal
• Parotid
2. Suprahyoid
• Sublingual
• Submandibular
• Submental
• Lateral Pharyngeal (Pharyngo-
maxillary)
• Peritonsilar
3. Infrahyoid Anterovisceral
4. Spaces of total Neck
• Retropharyngeal
• Danger space
• Spaces of Carotid Sheath

6. CLASSIFICATION OF INFECTION BY PETERSON:
Based on mode of Involvement
1. Primary Maxillary Space
• Buccal
• Canine
• Palatinal
• Infratemporal
2. Primary Mandibular Space
• Buccal
• Sublingual
• Submandibular
• Submental
3. Secondary Facial Space
• Massetric
• Pterygomandibular
• Superficial

7. Vestibular/Buccal Abscesses
Etiology:
The buccal space abscess may originate from
infected root canals of posterior teeth of the
maxilla and/or mandible.
Boundaries-
Superiorly: zygomatic arch.
Inferior: inferior border of mandible.
Laterally: skin & subcutaneous tissue.
Medially: buccinator muscle ,buccopharyngeal
fascia.
Posteriorly: anterior edge of masseter muscle.
Anteriorly: posterior border of zygomaticus
major & depressor
anguli oris.
Contents-
Buccal fat pad.
Stenson’s duct.
Facial artery.

8. CLINICAL EVALUATION:
• It is characterized by swelling of the
cheek, which extends from the
zygomatic arch to the inferior
border of the mandible,
• from the anterior border of the
ramus to the corner of the mouth.
• The skin appears taut and red, with or
without fluctuation of the abscess,
which, if neglected, may result in
spontaneous drainage.
• Dumb bell shaped appearance due to
lack of swelling over zygomatic arch.
Buccal Abscesses

9. • swelling of the cheek
• extends from the zygomatic arch to the inferior border of the mandible
• from the anterior border of the ramus to the corner of the mouth
• skin appears taut and red, with or without fluctuation of the abscess
Differential Diagnosis:
Repeated buccal space infection suspect Crohn’s Disease.

10.  Access to the buccal space is usually intraoral for three main reasons:
 The abscess fluctuates intraorally in the majority of cases
 To avoid injuring the facial nerve
 For esthetic reasons
 The intraoral incision is made at the posterior region of the mouth, in an
anteroposterior direction, and carefully to avoid injury of the parotid duct.
 A hemostat is then used to explore the space thoroughly.
 An extraoral incision is made when intraoral access would not ensure adequate
drainage, or when the pus is deep inside the space.
 The incision is made approximately 2 cm below and parallel to the inferior border of
the mandible.
 Broad spectrum gram positive + gram negative antibiotic treatment for 7-14 days.
 In case of granular growth, biopsy can be performed.
1. can progress to lymphangitis, more abscess formation, or sepsis.
2. Infection by additional species of bacteria (superinfection) may occur,
complicating treatment. Infection can also spread to the layer of tissue
enveloping muscles (fascia), causing a serious infection (necrotizing fasciitis).
3. Older individuals may develop a blood clot (thrombophlebitis) as a result of
cellulitis in more superficial tissues.
Treatment of Buccal Space Abscess
COMPLICATIONS

11. Canine Fossa Abscess
 Anatomic Location: The canine fossa, is a
small space between the levator labii
superioris and the levator anguli oris muscles.
 Etiology: Infected root canals of canines of
the maxilla or premolars are considered to be
responsible for the development of abscesses
of the canine fossa.
 Clinical Presentation: This is characterized
by edema, localized in the infraorbital region,
which spreads towards the medial canthus of
the eye, lower eyelid, and side of the nose as
far as the corner of the mouth.
 There is also obliteration of the nasolabial
fold, and somewhat of the mucolabial fold.
The edema at the infraorbital region is painful
during palpation, and later on the skin
becomes taut and shiny due to suppuration,
while its color is reddish.

12. • edema, localized in the infraorbital region
• spreads towards the medial canthus of the eye,
lower eyelid, and side of the nose as far as the
corner of the mouth
12 years old. He attended with a large facial
swelling after an episode of trauma 3 weeks
previously. He feels unwell and his right eye is
closing. Example of Canine Fossa abscess
The edema at the infraorbital region is painful
during palpation, and later on the skin becomes
taut and shiny due to suppuration, while its colour
is reddish.

13. Treatment of Canine Fossa Abscess
 The incision for drainage is performed intraorally at the
mucobuccal fold (parallel to the alveolar bone), in the canine
region.
 A hemostat is then inserted, which is placed at the depth of the purulent
accumulation until it comes into contact with bone. Finally, a rubber drain
is placed, which is stabilized with a suture on the mucosa.
 Broad spectrum gram positive + gram negative antibiotic treatment for 7 -
14 days.
COMPLICATION
1. inflammation of all tissues of the eye (panophthalmitis).
2. Infective endocarditis
3. streptococcal septic shock
4. Osteomyelitis

15. DIFFERENTIAL DIAGNOSIS OF UPPER FACE INFECTIONS
Dacrocystitis with
minimal involvement of
nasolabial folds
Odontogenic Cellulitis
Maxillary
sinusitis
Or
Tuberculous
Sinusitis
Tuberculous Sinusitis

16. Palatal Abscess
Involvement:
• from the maxillary lateral incisor or
Palatal Roots of Posterior Teeth
• although the lateral incisor is the
commonest source of palatal abscess,
most lateral incisor abscesses present
labially.
• Abscesses from palatal Pocket because of
infection
Boundaries:
• Inferiorly: Bounded by cortical plates of
hard palate
• Superiorly: Overlying periosteum
• Laterally: alveolar process of maxilla and
teeth
Clinical features:
i) well defined circumscribed fluctuant
swelling, confined to one side of palate
ii) Tooth causing the abscess is tender on
percussion.
Differential diagnosis:
• Extravasation cyst
• Gumma
• Pleomorphic adenoma
• Carcinoma of maxillary antrum

17. Incision & Drainage.
• incision- through the mucosa
down to the bone.
• care should be taken as to avoid
cutting of greater palatine nerves &
blood vessels.
• A Slucular Incision can be done to
avoid damage the greater Palatine
Artery
• Incision should be in AP direction
to avoid injury to anterior palatine
nerve
• Treatment of offending tooth
• Broad spectrum gram positive +
gram negative antibiotic treatment
for 7 -14 days.
Treatment of Palatal Abscess

18.  Odontogenic infections of maxillary
posterior teeth
 Odontogenic infections involving the
pterygomandibular space or infection
from buccal space coursing along the
masticatory fat pad.
Anatomical boundaries:
a. laterally: ramus of mandible, temporalis
muscle and temporalis tendon
b. Medially: lateral pterygoid plate
c. Superiorly: infratemporal surface of the
greater wing of sphenoid
d. Inferiorly: lower head of lateral pterygoid
muscle
 Contents:
a. Origin of pterygoid muscles
b. Pterygoid venous plexus
c. Internal maxillary artery
d. Mandibular nerve and its branches
Infratemporal space infection
 Management:
a. Intravenous antibiotics
b. Incision in upper buccal sulcus in
third molar region
c. Use of sinus forceps along medial
surface of coronoid and temporalis-
upwards and backwards
 Signs and symptoms:
a. Infected upper molar teeth
b. Severe trismus is universal finding
c. extraoral swelling over the sigmoid
notch, intra
oral swelling in the tuberosity area

19. Submandibular Abscess
Submandibular space
 It is a potential space present on the medial
surface of the posterior aspect of the
mandible
 Anatomical boundaries:
• Anteriorly – ant. belly of digastric muscle
• Posteriorly - post. belly of digastric muscle,
stylohyoid muscle, stylopharyngeus muscle
• Superior – inf & medial surfaces of mandible
• Inferior – digastric tendon
• Superficial – platsyma muscle, investing fascia
• Deep – mylohyoid, hypoglossus, sup
constricting muscles
• Laterally – bounded by skin, superficial fascia,
platysma
 Contents:
• Submandibular salivary gland
• Lymph nodes
• Facial artery
• Lingual and hypoglossal nerves

20. Submandibular Abscess

21. Etiology-
 Infected mandibular 2nd & 3rd molars.
 From submental, sublingual spaces.
Clinical Features-
 Indurated swelling in submandibular region.
 Usually bulges over lower border of mandible.
 Dysphagia
Spread of Infection-
 Across midline to contralateral space.
 To contiguous pharyngeal spaces.
Submandibular Abscess

22. DIFFERNTIAL DIAGNOSIS:
• Nonmalignant swelling may be caused
by mumps, sialadenitis, Sjögren
syndrome, cysts and infections.
• Submandibular lymphadenopathy
may also result from infections of
teeth, upper respiratory track, sinuses
and tonsils or infections
mononucleosis and cut scratch
disease
• The neoplastic growths in the
submandibular area may include in
most of the case tumors of the
submandibular gland, the tail of the
parotid gland, the Hodgkin's disease
and non-Hodgkin's lymphomas
Submandibular Abscess
complications:
• Ludwig’s Angina
• a blocked airway
• sepsis, which is a severe
reaction to bacteria or other
germs
• septic shock, which is an
infection that leads to
dangerously low blood pressure

23. The mylohyoid muscle will determine
whether infections that drain lingually
Line of insertion of
the mylohyoid
muscle
Lateral diagrammatic
illustration showing the
localization of infection
above or below the
mylohyoid muscle,
depending on the
position of the apices of
the responsible tooth

24. Sublingual Abscess
Sublingual Space
Boundaries-
 Superiorly: mucosa of floor of mouth.
 Inferior: mylohyoid muscle.
 Posteriorly: body of hyoid bone.
 Anteriorly & laterally: inner aspect of mandibular
body.
 Medially: geniohyoid,styloglossus,genioglossus
muscle.
Contents-
 Deep part of Submandibular gland.
 Wharton’s duct.
 Sublingual gland.
 Lingual & hypoglossal nerves.
 Terminal branches of lingual artery.

25. Etiology-
• The abscess is rare.
• Infected mandibular premolar & 1st molar.
Clinical Features-
• Swelling of floor of mouth.
• Elevated tongue.
• Pain & discomfort on swallowing.
Sublingual Abscess
Differential Diagnosis:
• Malignant cyst formation and
may need biopsy.
• Immunodeficiency- systemic
disease - Recurrent abscess
associated with other lesions

26. Treatment of Sublingual Abscess
 Incision is placed at the base of the
alveolar process in the lingual sulcus so
that the sublingual gland, lingual nerve &
submandibular duct are not injured
 A hemostat is inserted through the incision
in an anterior & posterior direction &
beneath the sublingual gland to evacuate
the pus
 drug therapy symptomatic treatment
rehabilitation treatment supportive
treatment 1-3 months
Complication
• Sublingual abscess may cause sepsis
• Oral cancer diagnosis
• Sublingual and submandibular gland infection
• Lingual nerve

27. • The incision for drainage is performed
on the skin, approximately 1 cm beneath
and parallel to the inferior border of the
mandible.
• During the incision, the course of the
facial artery and vein (the incision
should be made posterior to these) and
the respective branch of the facial
nerve should be taken into
consideration.
• A hemostat is inserted into the cavity of
the abscess to explore the space and an
attempt is made to communicate with the
infected spaces.
• Blunt dissection must be performed
along the medial surface of the
mandibular bone also, because pus is
often located in this area as well. After
drainage, a rubber drain is placed.
• airway management and IV antibiotics.
• Treatment of the effecting tooth.
Submandibular space infection is a
rapidly spreading, bilateral,
indurated cellulitis occurring in the
suprahyoid soft tissues, the floor of the
mouth, and both sublingual and
submaxillary spaces without abscess
formation.
Treatment of Submandibular Abscess

28. Submental Abscess
Signs and symptoms:
• Firm circumscribed swelling
beneath the chin
• Patient complains of
discomfort and difficulty in
swallowing.
Submental space
 Potential space present just below the chin
region on the medial surface of the mandible
 It is a midline structure bordered laterally by
the anterior bellies of digastric muscle
 Infections begin in the anterior mandibular
Teeth
 Secondarily Infected skin wounds or anterior
mandibular fractures may also cause
infections
BORDERS:
• Anterior – inf border of mandible
• Posterior – hyoid bone
• Superior – mylohyoid muscle
• Inferior – investing layer of deep cerical fascia
• Deep/Lateral - ant. bellies of digastric muscle
Contents:
• Submental lymphnodes
• Anterior juglar veins
• Adipose tissue

29. Management:
• Incision is made bilaterally through the skin, subcutaneous tissue and
platsyma muscle at the most inferior aspect of swelling
• A hemostat is inserted through one incision and then exited through the
second incision
Submental Abscess
• Local Anaesthesia is
performed around the
abscess
• Peripheral infiltration
anaesthesia of healthy
tissues surrounding
inflammation
An incision on the skin is made beneath the chin, in a
horizontal direction and parallel to the anterior border
of the chin
Transverse incision- symphysis of mandible- kelly’s
forceps/sinus forceps-upward & backward direction -
drained & sutured

30. Submental Abscess
Insertion of a hemostat and
exploration of the
abscessed area
Withdrawal of the hemostat
from the cavity with open
beaks, facilitating the
evacuation of pus
Rubber drain placed at the
drainage site of the
abscess
COMPLICATIONS:
• Sepsis
• Septic shock
• Osteo-necrosis
DIFFERNTIAL DIAGNOSIS:
• Neoplastic Masses – malignant or benign
• benign masses can be serious if they impact nerves
or exert pressure

31. Sub-masseteric Abscess
Boundaries-
Superiorly: zygomatic arch.
Inferiorly: inferior border of
mandible.
Laterally: medial surface of
masseter muscle.
Medially: lateral surface of
ramus of mandible.
Posteriorly: parotid gland & its
fascia.
Anteriorly: buccal space &
buccopharyngeal fascia.
CONTENTS -
• Masseteric artery and vein
Neighboring spaces-
• Buccal, pterygomandibular,
superficial temporal, parotid space

32. ETIOLOGY:-
• Pericoronitis related to vertical or distoangular impaction of third molars
• Fracture of angle of mandible
Clinical features
External facial swelling is moderate
Tenderness over angle of mandible
Limited mouth opening
Pyrexia & malaise.
Necrosis of muscle
Sub-masseteric Abscess

33. Intraorally:
Drainage is done through a vertical
incision along the external oblique line of
the mandible
Starting at the level of the occlusal plane
and extending downward & forward in the
buccal sulcus to a point opposite the second
molar
A hemostat is inserted and passed
posteriorly along the lateral aspect of the
ramus to point beneath masseter muscle
Beaks are opened
Rubber drain is inserted & sutured
Extraorally:
• Incision is made behind the angle of the
mandible (retromandibular incision)
• Hemostat is inserted and passed along the
lateral aspect of the ramus
• Rubber drain is inserted
Sub-masseteric Abscess

34. Pterygomandibular space Abscess
Pterygomandibular Space
Boundaries-
• Superiorly: lower head of lateral pterygoid muscle.
• Laterally: medial surface of ramus.
• Medially: medial pterygoid muscle.
• Posteriorly: deep part of parotid.
• Anteriorly: pterygomandibular raphe.
Contents-
• Inferior alveolar neurovascular bundle.
• Lingual & auriculotemporal nerves.
• Mylohyoid nerve & vessels.
Etiology-
• Infected mandibular 3rd molars
(mesioangular/horizontal)
• Pericoronitis.
• Infected needles or contaminated LA
solution.

35. Clinical Features-
• Absence of extra-oral swelling.
• Severe trismus.
• Difficulty in swallowing.
• Anterior bulging of half of soft palate
& tonsillar pillars with deviation of
uvula to unaffected side.

36. PTERYGOMANDIBULAR SPACE
PTERYGOID PLEXUS
EMISSERY VEINS
CAVERNOUS SINUS
THROMBOSIS
LATERAL PHARYNGEAL SPACE
RETROPHARYNGEAL SPACE
MEDIASTINUM
CAROTID SHEATH
DANGER SPACE 4
NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN
PREVERTIBRAL AND ALAR FASCIA
Pterygomandibular space Abscess

37. TREATMENT:
• Intraoral- vertical incision(1.5cm) made on anterior & medial aspect of
- ramus of mandible - sinus forceps opened & closed & with drawn - Pus drained &
sutured.
• Extraoral- incision made at angle of mandible - sinus forceps - Pus drained &
sutured
Pterygomandibular Abscess

38. Two divisions:
a. Superficial – It is between superficial temporal fascia and lateral aspect of
temporalis muscle
b. Deep – It is between the medial surface of the temporalis muscle and
periosteum of temporal bone.
Inferiorly the temporal space is limited to the attachments of the temporalis
muscle and fascia.
Inferiorly, it communicates with the pterygomandibular space
Its contains loose connective tissue and vessels supplying the temporalis muscle
Superficial Temporal space Abscess
Signs and symptoms:
• Swelling confined to the shape of the muscle extending from the lateral
orbital rim, above the zygomatic arch, covering the lateral aspect of
temporal bone.
• swelling more prominent in a superficial temporal space infection.
• severe trismus
• The spread of odontogenic infections may sometimes involve the
infratemporal space. The most likely causative tooth is the maxillary third
molar (upper wisdom tooth).

39. Superficial Temporal space Abscess
Clinical Appearance:
• Note the lack of swelling over the
zygomatic arch causing a dumbell shaped
configuration
• Marked Trismus
• Swelling of face in front of ear, over TMJ,
Behind zygomatic process
• Eye is closed and proptosed
Deep temporal abscess
Produce less swelling
Lies deep to temporalis muscle
Less fluctuant

40. Management:
Intra oral sicher’s incision along the anterior border of the ramus of
the mandible
Extra oral cutaneous incision slightly above the zygomatic arch made
parallel to zygomatic arch followed by blunt dissection and placement
of drain
Superficial Temporal space Abscess

41. Parotid Space Infection
Clinical Evaluation:
• The symptoms of Parotitis
include pain and induration
over the involved gland
• Purulent marked swelling of
the angle of the jaw without
associated trismus or
pharyngeal swelling
• Secretions may sometimes be
expressed after massage from
the parotid depth
• Very Characteristic pitting
edeme of the gland is
pathognomic for parotid gland
abscess.

42. THANK YOU