BDS Seminar

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CONTENTS
 INTRODUCTION
 DEFINITION
 FASCIA OF HEAD AND NECK
 PATHOPHYSIOLOGY OF INFECTION
 PATHWAYS OF DENTAL INFECTION
 FOCI OF INFECTION
 CLASSIFICATION OF FASCIAL SPACES
 SURGICAL ANATOMY OF MANDIBULAR TEETH IN RELATION TO SPACES
 VESTIBULAR SPACE INFECTION
 SUBCUTANEOUS SPACE INFECTION
 BUCCAL SPACE INFECTION
 SUBLINGUAL SPACE INFECTION
 SUBMANDIBULAR SPACE INFECTION
 SUBMENTAL SPACE INFECTION
(NOTE: LUDWING’S ANGINA & PERITONSILLAR ABSCESS QUINSY)
 SUBMASSETRIC SPACE INFECTION
 PTERYGOMANDIBULAR SPACE INFECTION
 SUPERFICIAL TEMPORAL SPACE INFECTION
 DEEP TEMPORAL SPACE INFECTION
 PAROTID SPACE INFECTION
 LATERAL PHARYNGEAL SPACE INFECTION
 RETROPHARYNGEAL SPACE INFECTION
 DANGER SPACE INFECTION
 CAROTID SPACE INFECTION
 CONCLUSION
 REFERENCES

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INTRODUCTION
various anatomic studies established the modern understanding of the fascial layers and the
potential anatomical spaces through which infection can spread in the head and neck.
Tissue spaces, or fascial spaces are potential spaces situated between planes of fascia that
form natural pathways along which infection may become localized with actual abscess
formation.
Shapiro defined “ the fascial space as potential tissue space, since none are actually spaces
until pus has been formed.” These potential spaces are compartments that contain structures
such as salivary glands, fat or lymph nodes. Normally, these structures are surrounded by
loose connective tissues, which can be easily stripped back by finger pressure, either during
surgery in the patient, or by dissection in the cadaver to produce a cavity. Odontogenic
infections are the most common of all infections of the head and neck. These infections
range from periapical abscess to superficial & deep neck infections. The infections generally
spread by following the path of least resistance through connective tissue and along fascial
planes. In 1930 grodinsky & holyoke hypothesized that “the infections spread primarily by
hydrostatic pressure.”These hypothesis do explain the usual progress of abscess forming
infections in this region. The flow of infected fluids guided by the resistance of certain tissue
such as fasciae, muscle and bone. The attachment of muscles may determine the route that an
infection will take, channeling the infection into certain tissue spaces. The distribution and
the interrelations of the many potential tissue spaces in the facial and cervical regions must be
appreciated to understand the ease with which infection may spread throughout this area and
even into distant areas.
However current theory explains the mechanisms by which suppurative infections of the head
& neck can dissect from one anatomical space to another. Although most of these infections
can be managed successfully with minimal complications, with the use of antibiotics.
General factor including the spread of infection
A) patient resistance
B) bacterial quality and virulence
C) diabetic patient, rapid bacterial multiplication and spread of infection.
d) patient resistance depends on both humoral & cellular factors.

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humoral cellular factors
include polymorphonuclear immunoglobulins derived from
leukocytes, monocytes sensitized b-lymphocytes or
lymphocytes and tissue plasma cells.
macrophages
Local factors influencing the spread of infection
1. The alveolar bone represents the first locally limiting barrier to the spread of
periapical infection.
2. Further progress in infection extends through cortical plates.
3. The next local barrier is the periosteum.
4. Development of a subperiosteal abscess.
5. The next possible site of localization is the anatomic arrangement of the adjacent
muscles & fascia.
alveolar bone
periosteum
development of subperiosteal abscess
muscles & fascia
Spaces communicate with each other

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DEFINITION
Infections spread through natural pathways into potential tissue spaces situated between
different planes of fascia. Infections into the various tissue spaces are known as the space
infections, such infections in the mandibular jaw region through natural pathways into
potential mandibular tissue spaces are called mandibular space infection.”
The infection in orofacial region doesnot spread haphazardly through the loose connective
tissue, but tends to accumulates in these potential spaces around the head and neck. Once the
odontogenic infections reach the bone or mucosa or lymphnodes etc, they may either resolve
spontaneously or spread to the local or the distant sites. Various factors determing the spread
of oral infections to distant sites, i.e virulence of the microorganisms, immunity of the host,
anatomical site of the initial infection.
The infection from the tooth spreads to various fascial spaces adjacent to the jaw. Commonly
the infections from the mandibular molars spread to sublingual or submandibular space.
While as the infection to the buccal, submassetric spaces, pterygomadibular space or the
lateral pharyngeal space are from the mandibular anteriors either produce the gingival abscess
or a submental space abscess.

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FASCIA OF THE HEAD AND NECK
A. Superficial fascia
B. Deep cervical fascia
i) superficial fascia
ii) deep cervical fascia
a) Anterior layer
i) Investing fascia cover the neck
ii) Parotideomassetric
iii) Temporal
b) Middle layer
i) Sternhyoid-omohyoid division
ii) Sternthyroid-thyrohyoid division
a. Buccopharyngeal
b. Pretracheal
c. Retropharyngeal
c) Posterior layer
i) Alar division
ii) Prevertebral division

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PATHOPHYSIOLOGY OF INFECTION:
THE INFLAMMATORY RESPONSE
Hyperemia caused by vasodilation of arteries & capillaries
& increased permeability of vesicles
Passage of exudates rich in plasma proteins, antibodies &
nutrients, & the escape of leucocytes into surrounding tissues
Release of a permeability factors, leukotoxin which allows
migration of polymorph nuclear leukocytes
precipitation of a network of fibrin from exudates tending to wall off
phagocytosis of bacteria, dead cells
Disposal by macrophages of necrotic debris

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PATHWAYS OF DENTAL INFECTION
fistula bacteremia septicemia
cellulitis acute-chronic deep fascial space
periapical infection infection
Intra oral soft osteomyelitis ascending facial-
Tissue abscess cerebral infection
Serious dental infections, spreading beyond the tooth socket, is more common due to the
pulpal infection than the periodontal infecteria after detion.
invasion of the dental pulp by bacteria after decay of a tooth
inflammation, oedema & lack of collateral blood supply
venous congestion or avascular necrosis (pulpal tissue death)
reservoir for bacterial growth (anaerobic)
Periodic egress of bacteria into surrounding alveolar bone
The periapical infection progress can vary according to the –
1.the number & virulence of the organism
2. Host resistance
3. Anatomy of the involved area
 Types of infections are:- a)acute & b)chronic
a) Acute stage – the infection spreading in the clinical situation i.e abscess, cellulitis,
fulminating infections.
b) Chronic stage – different forms of chronic stages are:-
- chronic fistulous tract or sinus formation
- chronic osteomyelitis
- cervicofacial actinomycosis

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FOCI OF INFECTION (FOCAL INFECTION)
 It has been observed since long time that infections from oral cavity can spread to
distant parts of the body & produce fresh lesions over there.
orofacial tissues escepially the teeth & the periodontium normally harbor
numerous microorganisms, which are otherwise non pathogenic as long as they are
within the oral cavity. However ,once these organisms spread to the distant organs of
the body, they behave as strickly pathogenic organisms and produce diseases.
Moreover, oral tissues are vulnerable to infections caused by various microorganisms
(eg,bacteria,virus&fungus), which produce a wide variety of lesions in the oral cavity.
Infections from these primary lesions may spread to the distinct organs to initate
secondary diseases.
Definition
Metastates of microorganisms or their toxins from a localized site of infection to any
distant part of the body with subsequent injury are called focal infections.
Mechanism of focal infection
Focal infections mostly occur by the following mechanisms.
 Spread of pathogenic microorganisms from their primary site of infection to
the distant part of body via the blood vessels or lymphatics.
 Spread of toxins liberated by the pathogenic microbes to distant organs either
via blood vessels to distant organs either via blood vessels or
lymphatics(erythrogenic toxins) liberated by beta hemolytic streptococci
produce diffuse, bright skin rashes in scarlet fever.
Various examples of oral foci of infections
 Periapical abscess (acute or chronic)
 Pericoronitis
 Infected periapical granuloma or cyst
 Periodontal abscess
 Infected dental pulp or root canals
 Infected root fragments of teeth
 Osteomylitis
 Syphilic chancre
 Infections in the maxillary sinus, nasal sinus, throat & tonsils etc.

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Classification of fascial spaces
Based on the mode of involvement
I.direct involvement
primary space:- (a) maxillary spaces
(b) mandibular spaces
Ii.indirect involvement
secondary spaces:-
Spaces involved in odontogenic infections:
A) primary maxillary spaces: canine, buccal & infratemporal spaces
B) primary mandibular spaces: submental, buccal, sub mandibular & sublingual spaces.
C) secondary fascial spaces: massetric, pterygmandibular, superficial & deep temporal,
lateral pharyngeal, retropharyngeal and prevertebral spaces, parotid space.
Based on clinical significance
(i) face- buccal, canine, masticatory, parotid
(ii) suprahyoid- sublingual, submandibular (sub-maxillary, submental),
pharyngomaxillary (lateral pharyngeal), pretonsillar.
(iii) infrahyoid- pretracheal
(iv) spaces of total neck- retropharyngeal, space of carotid sheath.
Fascial spaces of clinical significance
Face - buccal,canine,masticatory,parotid
Suprahyoid - sublingual
- submandibular(submaxillary, submental)
- pharyngomaxillary(lateral pharyngeal)
- peritonsillar
Infrahyoid - anterovisceral (pretracheal)
Spaces of total neck - retropharyngeal
- space of carotidsheath

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SURGICAL ANATOMY OF MANDIBULAR TEETH IN RELATION TO
SPACE
Mandibular central & lateral incisors-
Periapical infections from the lower central & lateral incisors will reach the surface on the
labial aspect of the alveolar process.in this region the relationship of the mentalis muscles to
the root apices determines the further cause of the infection. If the infection breaks through
the bone above attachment of the mentalis msucle, it will be limited to the oral vestibule. If
on, the other hand, penetration occurs below this muscle, the infection is then located
extraorally. It remains localized in the subcutaneous tissue of the chin or spread beneath the
chin into the submental spaces. The latter space is bounded laterally by the anterior bellies of
the digastric muscles, superiorly by the mylohyoid muscle & inferiorly by skin, platysma,
superficial fascia & deep cervical fascia. Clinically the swelling will be located limited to the
point of the chin & the region immediately below it.
Mandibular canine
Because the muscle attachments (depress or labil inferioris, depressor angulioris & platysma)
in the region of the mandibular canine are located wellbelow the root apex, periapical
infections from this tooth will localize in the oral vestibule after extending through the labial
cortical plate.
Mandibular premolar
Infection from mandibular premolars usually penetrate the buccal cortex. Further extension
then is governed by the same muscles that confine infections from the canine tooth. This
results in a vestibular abscess. Occasionally, however alingual cortical perforation may occur
& result in a sublingual abscess.
Mandibular first molar
Infections from the lower first molar also can give rise to a buccal space abscess if the
infection exists from the buccal aspect of the bone below the attachment of the buccinator
muscle. The oblique line of buccinator attachment on the mandible, however a lingual
cortical perforation may occur & result in a sublingual abscess.

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Mandibular first molar
Infections from the lower 1st molar also can rise to a buccalspace abscess if the infection exits
from the buccal aspect of the bone below the attachment of the buccinator muscle. The
oblique line of buccinator attachment on the mandible, however generally results in the root
apices being above origin of this muscles thereby causing localization of the infection within
the oral vestibule.
On the lingual aspect of the mandible the attachment of the mylohyoid muscle roughly
parallels the oblique downwards and forward courses of the buccinator muscle. The apices of
the premolars & the first molar are almost always above attachment of this muscle should
lingual perforation of a dental infection arise in such instances, swelling will occur in the
sublingual space. This space is bounded inferiorly by the mylohyoid muscles laterally &
anteriorly by the lingual aspect of the mandible, superiorly by the mucosa of the oral cavity,
posteriorly at the midline by the body of the hyoid bone & medially by the geniohyoid,
genioglossus & styloglossus muscles. Because there is loose connective tissue interspersed
between the latter muscles, as well as between the intrinsic muscles of the tongue, infections
of the sublingual space usually spread across the midline to the opposite side, as well as into
the body of the tongue. Such sublingual infections have been erroneously called ludwing's
angina because they generally are associated with swelling & elevation of the tongue & with
varying degrees of respiration difficulty. It is possible, however for a sublingual space
abscess to develop into the ludwing's angina since this space communications with the
parapharyngeal space at the posterior border of the mylohyoid muscle lateral to the hyoid
bone.
Mandibular second molar
Because of the position of the mandibular second molar in the alveolar process, there is a
50% possibility of either buccal or lingual perforation from a periapical infection. Likewise
there is anequal chance for the root apices to be either above or below the attachment of the
buccinator or mylohyoid. Thus there are 4 possible sites of localization for infections arising
from this tooth. On the buccal aspect the abscess will form either in the vestibule in buccal
space, depending on the relationship of the buccinator muscle on the lingual surface, exit of
infection above mylohyoid muscle will result in a sublingual abscess. Perforation below the
mylohyoid muscle produces an infection of the submandibular space. With the rare
exception of the mandibular 1st molar only the second & third molars. Can give rise to a
submandibular space infections. Such infections enter the neck directly because they are

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located below mylohyoid muscle, which forms floor of the oral cavity. Deep neck infections
arising from all other teeth are secondary to spread from communicating spaces in the faces
and oral cavity.
The sub mandibular space is bounded laterally by the skin, superficial fascia, platysma &
superficial layer of deep cervical fascia.
Medially the mylohyoid, hyoglossus & styloglossus muscles bound the space. Inferiorly, the
space is bordered by anterior and posterior bellies of the digastric muscle, superiorly the
space is limited by medial aspect of the mandible & attachment of the mylohyoid muscle.
Clinically there should be no difficulty in differentiating submandibular space infections from
those in the buccal space.
Whereas the buccal space abscess is a relatively ovoid swelling beginning at lower border of
mandible & extending upto level of zygomatic arch. Abscess is triangular begins at lower
border of mandible & extends to level of hyoid bone.
Mandibular third molar
The mandibular 3rd molar generally positioned medial to vertical plane of ramus, apex is
much closer to lingual than to buccal cortical plate.
In this region the attachment of mylohyoid muscles near the alveolar margin & its posterior
border is behind the tooth. Because of this relationship, infections from vertically positioned
3rd molars will extend below mylohyoid muscle & localize in submandibular space with
mesio angularly or horizontally positioned teeth. However, the infection will tend to spread
beyond the posterior extent of the mylohyoid muscle, localizing in pterygo mandibular space.
This region as the name implies, is bounded laterally by the medial ramus of mandible &
medially by lateral assessment of medial pterygoid muscle. It is space into which needle is
passed in performing an inferior alveolar nerve block injection. Posteriorly, this space
communicates with lateral pharyngeal space. An infection of 3 molar also can pass directly
into parapahryngeal space by extension medial to medial pterygoid muscle.
A patient with a submandibular space abscesses will show no external evidence of swelling.
Intra oral examination, however reveals an anterior bulging of half the soft palate & anterior
tonsillar pillar with deviation of uvula to unaffected side.
The patient will have severe trismus & difficulty in swallowing. Despite the limitation in
opening, deep ression of tongue with a tongue blade usually permits inspection of soft palate
and pharyngeal wall otherwise an anaesthetic may be needed to permit the mouth to be
opened for an adequate examination. The pterygo mandibular space absceses most be
distinguished from peritonsillar abscess.

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With the latter thereis less trismus & no dental involvement.
Occasionally an infection from a third molar can involve the submassetric space, usually this
is the result of pericoronitis, but it can arise from a periapical infection when lingvo version
of the tooth or extreme curvature of the roof brings apex closer to buccal surface.
The submassetric space is banded laterally by masseter muscle & medially by lateral surface
of mandibular ramus. The anterior boundary is facial extension of parotid ectomassetric
fascia & posterior boundary is parotid fascia & retro mandibular portion of parotidgland.
Superiorly the space extends to level of zygomatic arch & communicates with the
infratemporal space.
Clinically, a submassetric space infection is characterized by deep-seated severe throbbing
pain & tenderness over the mandibular ramus associated with severe trismus. The swelling is
mainly over angle of mandible, but may extend to level of zygomatic arch. A submassetric
space infection can be distingted from a buccal. Space infection by the fact that its anterior
bandary ends at nterior border of masseter muscle, whereas the posterior border of buccal
space swelling ends at that point.

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VESTIBULAR SPACE INFECTION
The vestibular space is the potential space between the oral vestibular mucosa & the nearby
muscles of facial expression. The term dentoalveolar abscess describes an infection between
the alveolar process and the alveolar mucosa on the facial wall of the alveolar process.
Boundaries : posteriorly : the local muscle of facial expression is the buccinator.
Anteriorly : the instrinsic muscles of either lip, such as the orbicularis oris, quadratus labii
superioris, mentalis or risorius, limit the vestibular space. The vestibular space is filled with
submucosal and areolar connective tissue is crossed by the long buccal and mental nerves. It
communicates, between gaps in the muscle of facial expression, with the buccal and
subcutaneous spaces.
Clinical features
A) vestibular swellings may elevate the overlying facial structures, distorting the
externally visible features. Spontaneous drainage often occurs through the oral
mucosa.
B) the swelling over the alveolar process extends into the labial vestibular with pointing
of the infection of the oral mucosa.

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SUBCUTANEOUS SPACE INFECTION
In the head & neck the sub cutaneous space occupies the potential space between the
superficial fascia, along with the muscles of facial expression & the skin. Infection in almost
any deep fascial space may point through the subcutaneous space to the skin.
Necrotizing fascitis, a rapidly spreading infection, causes necrosis of the tissues in the
subcutaneous space by thrombosis of vessels that supply the superficial muscles & skin.
Boundaries - in neck necrotizing fascitis may follow the platysma muscle inferiorly, to its
terminus on the anterior chest wall. Necrotizing fascitis may also affect the deeper fascial
spaces, resulting in a particularly aggressive spread through these spaces to deeper structures,
as in descending necrotizing media stinitis.

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BUCCAL SPACE INFECTION
The buccal space occupies the portion of the sub cutanaeous space between the facial skin
and the buccinator muscle.
Boundaries of buccal space infection
Anteriorly : corner of mouth
Posterior : masseter space
pterygomandibular space
Superior : infraorbital space
Inferior : mandible
Superficial or medial : subcutaneous tissue & skin
Deep or lateral : buccinator muscle
Contents of buccal space infection
A) parotid's duct
B) anterior facial artery & vein
C) transverse facial artery & vein
D) buccal fat pad
Teeth commonly involved
Upper premolar, upper molars, lower premolars.

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Clinical features
1) pus accumalates an oral side of muscle 'gum-boil' is seen in the vestibule.
2) buccal abscess originating from periapical infection.
3) swelling may be intra oral & extra oral, it depend on the muscle attachment of root
apices above & below.
4) massive swelling, erythema, early skin necrosis.
5) marked cheek swelling, which helps in diagnosis.
Differential diagnosis
1) cellulitis - caused by h influenzae seen in infants & children under 3 years of age.
usually, there is high fever, for at least 24 hours.
2) erysipelas - there is rapid onset, dark red swelling & associated otitis media frequently
present.
3) crohn's disease (recurrent buccal space abscess) - it is a segmental transmural
intestinal disease.
the granulomatous lesions & ulcerations can progress to the buccal space abscess.
Communications of buccal space infection
Direct - communication with maxillary & mandibular space.
Indirect
A) submassetric space - if infection tracks backwards & penetrates the parotid omassetric
fascia.
B) in continuation with pterygo mandibular space.
C) superficial temporal space.
D) to infratemporal space along the fascia accompanying the stenson's duct.
E) superficial temporal space.
F) lateral pharyngeal space.
G) carotid sinus.
Management of buccal space infection
1) incision & drainage
2) supportive care

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1) Incision & drainage - Incision is made vertically rather than horizontally. If the intra
oral route is used, the horizontal incision should be placed just above the depth of the
vestibule.
the incision for extra oral drainage of a buccal space abscess are placed below the
lower border of the mandible using no.1 scalpel blade.
if pus is lateral to the muscle then the muscle is penetrated with curved mosquito
forceps to enter the buccal space. Drain is placed and secured with suture.
2) Supportive care includes :
Those modalities which aid the patient's own body defenses in combating the infection.
It consists of the administration of antibiotics, hydration of the patient, an analgesic for pain,
bedrest, the application of heat in the form of moist packs/mouth rinses, & opening the tooth
for drainage.

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SUBLINGUAL SPACE INFECTION
This space is a v shaped trough lying lateral to muscles of tongue, including hyoglossus,
genioglossus, geniohyoid.
Boundaries of sublingual space infection
Anteriorly : lingual surface of mandible
Posteriorly : submandibular space
Superior : oral mucosa
Inferior : mylohyoid muscle
Superficial or medial : muscles of tongue
Deep or lateral : lingual surface of mandible
Contents
 Sublingual glands
 Wharton's ducts
 Lingual nerve
 Sublingual artery & vein
Teeth commonly involved :
 Lower premolars
 Lower molars
 Direct trauma
Clinical features
 It appears as browny, firm erythematous, tender swelling on the floor of mouth.
 Swelling may be intra oral & extra oral.
Extra oral : pain & discomfort on deglutition.
Intra oral : the floor of the mouth raised. Tongue may be pushed superiorly.
Communication of sublingual space infection
I) infection always crosses the midlines & can affect the space on the opposite side.
Ii) infection from the postero inferior part of the space can spread around the
submandibular space & again can be spread posteriorly.

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Iii) the sublingual space is separated from the submental space by mylohyoid muscle,
which forms a complete diaphragn in the floor of mouth.
Iv) the infection can spread to lateral pharyngeal & visceral (trachea & oesophagus)
spaces.
Treatment of sublingual space infection
These spaces are incised intraorally at the base of the alveolar process in the lingual sulcus,
so that sublingual gland, lingual nerve & submandibular duct are not injured.
A haemostat is inserted through the incision in an anterior & posterior direction & beneath
the sublingual gland to evacuate the pus.
A rubber drain is placed & sutured to the alveolar mucosa to avoid displacement by
movement of the tongue.
Frequently the sublingual spaces swollen bilaterally because of extension of the infection
across the midline.

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SUBMANDIBULAR SPACE INFECTION
The space lies between the anterior and posterior bellies of the digastric muscles. The upper
part lies beneath the inferior border of mandible & the lower part lies deep to the investing
layer of deep cervical fascia. The submandibular spaces are considered to be the anterior
extensions of parapharyngeal space.
Boundaries or borders of sub mandibular space infection
Anteriorly : anterior belly of digastric muscles
Posteriorly : posterior belly of digastric muscles
Superior : inferior & medial surfaces of mandible
Inferior : digastric tendon
Superficial or medial : platysma muscle, investing fascia
Deep or lateral : my lohyoid, hypoglossus, superior
Constricting muscles
Contents
 Submandibular glands
 Facial artery & vein
 Lymph nodes
Teeth commonly involved : lower molars
Clinical features : swelling appears extra oral swelling will be fever along with
constitutional symptoms like fever, tenderness, redness.
Intra oral swelling : tender on percussion will be positive, teeth are mobile, dysphagia,
moderate trismus.
Communication or spread :
A) there are no major anatomic barriers between the 2 submandibular & submental
spaces.
B) hence infection can extend into the submental space.
C) the sub mandibulr space communicates with sublingual space.
D) the infection can spread to lateral pharyngeal & buccal spaces.
E) the infection can spread extend easily across the midline & involve the submandibular
space on the contra lateral side.

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Diagnosis - of submandibular space infection is made by finding the intra oral swelling.
1) tender on percussion positive.
2) anterior teeth - non vital fractured, carious tooth, mobile teeth.
Spread - to sub mandibular space (on either side).
Treatment - it is performed by making transverse incision in the skin below the symphysis
of the mandible.
The incisions for draining a submental space abscess are made bilaterally through skin,
subcutaneous tissue & platysma muscle at the inferior aspect of the swelling.
A haemostat is inserted through one incision into the abscess cavity & then excised through
the second incision. A rubber drain is placed and a dressing applied.

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SUBMENTAL SPACE INFECTION
A potential fascial space exists in the chin and occasionally becomes infected, either directly
from a mandibular incisor or indirectly from the submandibular space.
Boundaries anterior : inferior border of mandible
Posterior : hyoid bone
Superior : mylohyoid bone
Inferior : investing fascia
Superficial : investing fascia
Deep : anterior bellies of digastric muscles
Contents : anterior jugular vein, lymph nodes
Teeth commonly involved : lower anteriors, fracture of symphysis
Clinical features
1. Chin appears grossly swollen & quite firm & erythematous.
2. Extra oral swelling : firm swelling in midline below the chin typical swelling of the
spaces either brawny or softy & correlating it with the presence of a diseased
mandibular molar.
Differential diagnosis : include acute sialadenitis, sublingual trauma or foreign body &
submandibular lymphadenitis.
Management - of submandibular space infection includes surgical drainage, antibiotics &
definitive care of the primary dental infection.
Incision is preformed through the skin below & parallel to the mandible.
Deep abscess loculations should be entered with a small closed clamp, probing in all
directions while attempting to avoid damage to sub mandibular gland, facial artery & lingual
nerve.
Ludwig's angina
It is the infection of submandibular space which lies between the mucous membrane & floor of
mouth & tongue & superficial layer of deep cervical fascia.
It is divided into 2 compartments.

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- sublingual i.e. above the myolhyid.
- submandibular & submental below the mylohyoid muscle.
2 compartments are continuous around the posterior border of mylohyoid muscle.
Etiology:-
1. 80% cases (dental infection) roots of premolar often lies above attachment of
mylohyoid & causes sublingual space infection. Molar tooth extends the mylohyoid
line & causes submandibular space.
2. Submandibular sialadenitis
3. Injury to oral mucosa
Clinical features:
A) it is characterized by swelling combined with inflammatory oedema.
B) there will be puttred halitosis.
C) there will be marked difficulty in swallowing. When infection is localized to
sublingual space structures in floor of mouth & tongue seems to be pushed up.
D) infection spreads to submandibular & submental infection
E) consistency will be woody hard along with widespread cellulites.
F) tongue apparently protrudes upwards & backward & causing obstructino to airways &
laryngeal edema occurs.
Treatment
Systemic antibiotics, incision and drainage may be done intraorally (sublin gual space)
extraorally in case of submental & submandibular space involved.
- transverse incision if extends from angle of mandible.
- tracheostomy may be required.
Complications
Spread of infection to parapharyngeal & retropharyngeal space.
There will be airway obstruction.
Peritonsillar abscess (quinsy)
It is a localized infection in the connective tissue bed between the tonsil & the
Superior constrictor muscle, between the anterior & posterior pillars of fauces.
Involvement
(i) infection from the depth of the tonsillar crypt or supra tonsillar fossa.

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(ii) as a complication of acute pericoronal abscess in which case the abscess points near the
lower pole of the tonsil.
A) patient looks ill anoxic & dehydrated.
B) pain on one side of the throat radiating to the ear.
C) dysphasia
D) limitation of mouth may not be pronounced.
E) speech is difficult, especially in bilateral cases & a peculiar muffled ‘hot potato in
mouth voice’ is characteristic.
(vi) drooling of saliva
(vii) when the abscess is fully developed, a large tense swelling of anterior pillar of fauces,
& a bulge in the soft plates n the affected side, which in extreme cases reaches the
midline & pushes uvula downwards & forwards, until is impinges against the opposite
tonsil.
(viii) coated tongue with marked foetor oris.

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Incision & drainage
Can be achieved by using a guarded knife & sinus forceps which are inserted into most
prominent part of the soft palate where the fluctuation is the maximal.
Spread
Oedema may eventually affect the base of the tongue, epiglottis & aryepiglottic fold. In 3-5
days durations the mass becomes fluctuant & ruptures by pointing usually through anterior
faucial pillar.

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SUBMASSETRIC SPACE INFECTION
Masseter consists of 3 layers, which are fused anteriorly but can be easily separated
posteriorly. There is potential space in the substance of the muscle between the middle & the
deep heads, while the bony insertion is firm above & below, the intermediate fibers have only
a loose attachment.
When the pus accumalates between the ramus of the mandible & masseter muscle, it
produces a submassetric space abscess.
Boundaries anterior : buccal space
Posterior : parotid gland
Superior : zygomatic arch
Inferior : inferior border of mandible
Superficial : ascending ramus of mandible
Deep : masseter muscle
Contents : masseteric artery & vein
Teeth or area involved : lower 3rd molars, fracture of angle of mandible
Clinical features
Infections in this space typically cause inflammation & edema of the overlying masseter
muscle.
The inflammatory process results in significant trismus the hallmark of this condition.
External facial swelling is moderate in size.
Tenderness over angle of mandible.
Pyrexia & malaise.
Differential diagnosis : these swellings must be differentiated from parotid swellings
because submassetric swellings. Obscure the ear lobe, while parotid swellings elevate it.
Communication or spread :
1) buccal
2) pterygo mandibular
3) superficial temporal
4) parotid

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Management of submassetric space abscess
A) intraoral approach : an incision is made vertically over the lower part of the anterior
border of the ramus of the mandible deep to the bone.
a sinus forceps are passed along the lateral surface of ramus downwards & backwards
& pus is drained.
the drain is inserted & secured with a suture.
the abscess is usually situated below level of incision.
B) extra oral approach : when the mouth cannot be opened an incisions placed in the
skin behind the angle of mandible to open abscess by hilton's method. A rubber drain
is inserted & secured in position with a suture. Dressing is applied.

29. 29
PTERYGO MANDIBULAR SPACE INFECTION
In a recent prospective study of severe odontogenic infection the pterygomandibular space
was the most frequently affected anatomical compartment; abscess or cellulites was present
in the pterygomandibular space.
Infection of the pterygomandibular space correlated highly with pericoronitis of the
mandibular 3rd molar.
Boundaries anterior : buccal space
Posterior : parotid gland
Superior : lateral pterygoid muscle
Inferior : inferior border of mandible
Superficial : medial pterygoid muscle
Deep : ascending ramus of mandible
Contents : mandibular division of trigeminal nerve.
inferior alveolar artery & vein.
Teeth commonly involved : lower 3rd molars.
Fracture of angle of mandible.
Clinical features
1) it do not cause much swelling of face over the submandibular region.
2) tenderness may be elicited over the area of soft tissues.
3) dysphagia present.
4) redness & oedema around the 3rd molar area.
5) trismus, caused by edema and inflammation of the medial pterygoid muscle, hinders the
view of the swollen anterior tonsillar pillar and deviation of the uvula to the opposite
side that are characteristics of infection in this space.

30. 30
Spread :
1) buccal
2) lateral pharyngeal
3) submassetric
4) deep temporal
5) parotid
Management
The abscess usually tends to point at the anterior border of the ramus of mandible & drainage
can be easily done by intraoral route.
A) intra oral : a vertical incision, approximately 1.5 cm in length, is made on the ramus
of mandible. A sinus forceps is inserted in the abscess cavity, opened & closed &
withdrawn. The pus is evacuated, a rubber drain is introduced & is secured in position
with a suture.
B) extra oral : an incision is taken in the skin below the angle of the mandible. A sinus
forceps is inserted towards the medial side of the ramus in an upward & backward
direction. Pus is evacuated & the drain is inserted from an intra oral approach &
sutured in position.

31. 31
SUPERFICIAL TEMPORAL SPACE INFECTION
The superficial temporal space lies below the temporal fascia, which is the continuation of
parotideomassetric fascia & the temporalis muscle.
The temporal fascia arises from the zygomatic arch to terminate at the superficial temporal
crest of the temporal bone.
Boundaries :
Anterior : posterior surface of the lateral orbital rim.
Posterior : is fusion of temporal fascia with the percranium at the posterior edge of the
temporalis muscle.
Inferior : zygomatic arch & areolar connective tissue.
Contents : temporal fat pad, temporal branch of facial nerve.
Teeth or areas commonly involved :
Upper molars
Lower molars
Spaces or communication : buccal deep temporal.
Management
Temporal space abscess can be drained intraorally through the same incision used for entrance.
The temporal space can be drained extra orally through same incision used for infra temporal
space abscesses. As the hemostat is passed medially, it first enters the superficial temporal
space.

32. 32
DEEP TEMPORAL SPACE INFECTION
Boundaries : lateral : border of the deep temporal space is the temporalis muscle.
Medial border is the squamous temporal bone & skull base, formed mainly by sphenoid bone.
The infratemporal space is the portion of the deep temporal space that lies inferior to
infratemporal crest of the sphenoid bone.
Inferior border - superior surface of the lateral pterygoid muscle.
Superior : posterior border is formed by the attachment of the temporalis muscle to the
cranium at the temporal crest.
Anterior : border of the temporal space is composed of the posterior wall of the maxillary
sinus, the pterygomaxillary fissure & the posterior surface of the orbit including the inferior
orbital fissure.
Contents : pterygoid plexus
Interior maxillary artery & vein
Mandibular division of trigeminal nerve
Skull base foramina
Teeth or areas involved : upper molars
Management of deep temporal space infection
An abscess of the infratemporal fossa is usually incised intra orally. A vertical incision is
made just medial to the upper extent of the anterior border of the mandibular ramus & the
hemostat is passed superiorly along the medial aspect of coronoid process into the
infratemporal region. By using blunt dissection, damage to lingual nerve is avoided.
When patient has severe trismus, it may not be possible to approach the infra temporal region
intra orally.
In such situations a small horizontal incision, parallel to zygomatic branch of facial nerve, is
made posterior to junction of frontal & temporal process of zygoma.
The extra oral approach has the disadvantage of not producing dependent drainage & should be
used when intra oral access is not possible.

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PAROTID SPACE INFECTION
Boundaries : the parotid space is formed by spliting of anterior (investing) layer of the deep
cervical fascia to form the capsule of the parotid gland. In the region the fascia is called the
parotideo massetric fascia.
Inferiorly : stylomandibular ligaments which separates parotid space from the mandibular
space.
Contents :
A) parotid gland
B) facial nerve
C) external carotid artery
D) posterior facial lymphatic's &
E) posterior facial vein (retro mandibular) vein.
Clinical features
1) severe pain which may be referred to the ear & is accentuated by eating. Because of
the pain associated with eating, these patients do not consume adequate fluids & hence,
these patients may get dehydrated.
2) presence of swelling over the masseter muscle, extending from the level of zygomatic
arch to lower border of mandible. Anteriorly, it ends at the anterior border of ramus of
mandible & posteriorly, it extends into retro mandibular region. Earlobe seems to be
exerted.
3) there is escape of pus from the stenson's duct when the gland is milked.
Spread or communication
Communication between parotid space & submandibular space exist via anterior branches of
posterior facial vein. Infection can spread to sub massetric, pterygo mandibular & lateral
pharyngeal spaces.
Management of parotid space infection
The drainage requires an external approach. A retro mandibular incision is used, because the
pus is usually not in a single pool, but is located in numerous loculations within glandular
parenchyma & exploration of a wider area is often necessary to evaluate all the sites involved.
An incision is placed in skin behind posterior border of mandible extending from the level of
inferior aspect of the lobule of ear to just above mandible. A sinus forcep is inserted & with
blunt dissection the parotid fascia is reached. A rubber drain is inserted & secured to skin with
a suture.

34. 34
LATERAL PHARYNGEAL SPACE INFECTION
It is a potential cone shaped space or cleft with its base upper most at the base of skull & its
apex at the greater horn of the hyoid bone. The space is divided into 2 by the styloid process,
as anterior & posterior compartments. Infection of this space is extremely serious owing to the
intimate relationship with the carotid sheath.
Boundaries anterior : superior & middle pharyngeal constrictor muscles.
Posterior : carotid sheath & scalene fascia
Superior : skull base
Inferior : hyoid bone
Superficial : pharyngeal constrictors, retropharyngeal space
Deep : medial pterygoid muscle
Contents : carotid artery
Internal jugular vein
Vagus nerve
Cervical symphathetic vein
Teeth or areas involved : lower 3rd molars, tonsils, infection in neighbouring spaces.
Clinical features of lateral pharyngeal space infection
A) infections of the lateral pharyngeal space may result from pharyngitis, tonsillitis,
parotitis, otitis, mastoiditis, & dental infection.
B) if the anterior compartment becomes infected, the patient exhibits, pain, fever, chills,
medial bulging of the lateral pharyngeal wall with deviation of the palatal uvula, from
midline, dysphagla, swelling below the angle of the mandible & usually trismus.
C) infection of the posterior compartment is noted for absence of trismus & visible
swelling, but respiratory obstruction, septic thromboses of the internal jugular vein, &
carotidartery hemorrhage may occur in patients at a late stage of infection.
Diagnosis of these infection can be done by ct scan & may reveal confluence with other deep
space infections.
Spread or communications :
A) pterygo mandibular space
B) submandibular space

35. 35
C) sublingual space
D) peritonsillar
E) retro pharyngeal

36. 36
Management of lateral pharyngeal infection
The lateral pharyngeal space can be approached by an intra oral vertical incision similar to that
used for enter into the pterygo mandibular space. However instead of passing the haemostat
directly posteriorly between the medial aspect of the ramus & the lateral surface of the medial
pterygoid muscle, it is passed in a postero medial direction along the deep surface of the
muscle into the lateral pharyngeal space. When it is difficult for the patient to open the mouth
because of trismus, even when general anesthetic is used, or when there is concern about the
possible aspiration of pus, an extra oral incision & drainage can be performed. The incision is
made anterior & inferior to the angle of mandible & the hemostat is passed superiorly &
medially along the deep surface of medial pterygoid muscle into the lateral pharyngeal space.

37. 37
RETROPHARYNGEAL SPACE INFECTIONS
The esophagus & trachea are enclosed by the middle layer of deep cervical fascia. A thick
strand of connective tissue extends laterally from the oesophagus to the carotid sheath thus
creating an anterior neck compartment known as the pretracheal (previsceral space) & a
posterior or (retro pharyngeal) or (retro visceral space).
Boundaries of retropharyngeal space infection
Anteriorly : superior & middle pharyngeal constrictor muscle
Posterior : alar fascia
Superior : skull base
Inferior : fascia of alar & prevertebral fasciae at c6-t4
Deep : carotid sheath & lateral pharyngeal space
Clinical presentation
A) it may result from nasal & pharyngeal infections in children, dental infection through
contagious spaces, eosophageal trauma or foreign bodies & tuberculosis.
B) infection also may reach this space through the lymphatics to involve the
retropharyngeal lymph nodes.
C) dysphagia, dyspnoea, nuchal rigidity, esophageal regurgitation & fever characteristics
infections of the retropharyngeal space.
D) if the pharynx can be visualized, a bulging of the posterior wall may be observed & is
usually more prominent unilaterally because of the adherence of the medium raphe of
the prevertebral fascia.
Involvement : the space involved by an extension of infection from the lateral pharyngeal
space.
Diagnosis : can be made by lateral soft tissue radiographs of the neck & by widening of the
retropharyngeal space, well beyond the 3-6 mm width in normal adults at the second vertebra
(>14 mm) in children ct scan can also be used.
Management of retropharyngeal space infection
It may not need to be drain independently when independent drainage is necessary, it can be
done intraorally through vertical incision in the mucosa of the pharyngeal wall lateral to the

38. 38
midline. The abscess is opened by blunt dissection with a hemostat. The patient should be in a
trendelenburg position to avoid aspiration of the pus.
When there is rupture of abscess, during placement of an endotracheal tuber a tracheotomy
should be done prophylactically & the abscess drained extra orally. An incision is made along
the anterior border of the sternocleidomastoid muscle inferior to the hyoid bone, & the muscle
& carotid sheath are retracted laterally. Deep dissection between the carotid sheath & the
inferior constrictor muscle of the hypopharynx opens the retropharyngeal space for drainage.

39. 39
DANGER SPACE
The deep fascial space known as the danger space is aptly named because of its communication
with the mediastinum. The danger space extends from the base of skull. Superiorly, to the
diaphragm, inferiorly, its lateral extent is at the fusion of the alar & prevertebral fasciae at the
transverse processes of the cervical & thoracic vertebrae. The only content of the danger space
in the cervical region is areolar connective tissue. However, in the chest the danger space is
continuous with the posterior mediastinum, which contains the vena cava, aorta, thoracic duct,
trachea & oesophagus.
Clinically : therefore infections that pass through the danger space into the mediastinum can
erode into or compress major vessels, lower airway & upper digestive tract.

40. 40
CAROTID SHEATH
Carotid sheath is a fascial condensation surrounding the internal jugular vein, the vagus nerve,
the common & internal carotid arteries.
It extends from the jugular foramen & carotid canal in the occipital bone to the mediastinum,
where it divides to surround the major vessels that contribute to its contents.
The cervical symphathetic chain attaches to the posterior surface of the carotid sheath.
Clinically :
A) infections that have eroded into the carotid sheath may cause disruption of any of the
structure associated with it, including
a) expanding hematoma in the neck
b) bleeding episodes 'herald bleeds'.
c) variations in heart rate or speech function, or septic emboli.
B) involvement of the cervical symphathetic chain may cause "horner's syndrome on the
affected side, which is characterized by miosis (pupillary constrictions), ptosis
(dropping of the lid caused by inactivation of miller's muscle) & anhidrosis (decreased
sweating of the affected side of head neck & upper extremity).
C) chills, septicaemia, fever is present.
Management of carotid sheath space abscess
An abscess of the carotid sheath is approached through an incision made along the middle third
of the anterior border of the sternocleidomastoid muscle. The muscle is retracted posteriorly,
exposing the carotid sheath, which is carefully opened through a vertical incision.
If thrombosis of the internal jugular vein is noted, the vessel should be ligated above & below
the limits of involvement to prevent further spread of the infection.

41. 41
CONCLUSION
The incidence and severity of odontogenic infections have diminished since the advent of
antibiotic therapy. However, significant morbidity & mortality of these infections continue.
Dentists & physicians constantly must be alert the potential seriousness of these infections,
which should never be dismissed as simple dental abscesses. Odontogenic infection therapy-
dental, medical, or surgical, outpatient or inpatient- is based on the severity & anatomical
location of the infection, the patient’s general health status his or her response to therapy, & the
assumed or laboratory- determined pathogenic micro flora of the infection. Small superficial
odontogenic infections differ greatly from deep space infection despite their common origins.
Deep space infections must be recognized promptly & treated as an emergency. Underlying
medical problems must be controlled, a patent airway established, contemporary diagnostic
imaging done & deep drainage performed.
Repeat diagnostic & therapeutic measures may be necessary until the end point- absence of
clinical, radiographic & laboratory signs of infection have been reached.

42. 42
REFERENCES
 Oral and maxillofacial surgery
 Danial m. Laskin (volume two)
 Oral and maxillo facial infections
 Topazian
 Goldberg
 Hupp
 Textbook of oral and maxillofacial surgery
 Neelima anil malik

 General principles of oral surgery
 S.m. balaji
 text book of oral pathology
 Shafer (7th edition)