In this Slide anatomy of Odontogenic Infection is defined not Management.

1. Dr. Sarang Suresh
Hotchandani
COMPLEX ODONTOGENIC
INFECTION

2.  Infection erodes thorough the thinnest adjacent bone and causes
infection in the adjacent tissue.
 Infection from Tooth apex perforates below the muscle
attachment – vestibular abscess will occur. (most common
infection)
 Infection from Tooth apex above the muscle attachment –
facial space will be infected.
DEEP FASCIAL SPACE INFECTION
DR. SARANG SURESH HOTCHANDANI 2

3. They are fascia lined tissue
compartments filled with loose,
areolar connective tissue.
The loose areolar tissue within these spaces serves to
cushion muscles, nerves, vessels, glands & other
structures.
FASCIAL SPACE (DEFINITION)
DR. SARANG SURESH HOTCHANDANI 3

4. PATHOPHYSIOLOGY OF
DEEP FASCIAL SPACE INFECTION
DR. SARANG SURESH HOTCHANDANI 4

5. SPACES WITH ANY TOOTH SPACES WITH MAXILLARY
TEETH
SPACES WITH
MANDIBULAR TEETH
SPACES OF NECK
Vestibular Infra orbital Body of mandible Lateral pharyngeal
Buccal Buccal Perimandibular space Retropharyngeal
Subcutaneous Infratemporal Submandibular Pre tracheal
Para nasal sinus Sublingual Danger space
Cavernous sinus thrombosis Submental Prevertebral
Masticator space
Pterygomandibular
Superficial temporal
Deep temporal
ANATOMIC SPACES INVOLVED IN
ODONTOGENIC INFECTION
DR. SARANG SURESH HOTCHANDANI 5

6. Severity Score Anatomic Space
Severity Score = 1
Little threat to airway or vital structures
 Vestibular
 Buccal
 Sub periosteal
 Space of body of mandible
 Infra orbital
Severity Score = 2
Moderate severity – hindered access to airway by
causing trismus or elevation of tongue
 Submandibular
 Submental
 Sublingual
 Pterygomandibular
 Sub masseteric
 Superficial temporal
 Deep temporal (or infratemporal)
Severity score = 3
High risk to airway & vital structures – directly
compress & deviate the airway
 Lateral pharyngeal
 Retropharyngeal
 Pretracheal
Severity Score = 4
Extreme risk to airway & vital structures
 Danger space (space 4)
 Mediastinum
 Intracranial infection
 Cavernous sinus thrombosis
 Necrotizing fasciitis – flesh eating bacterial infection
CLASSIFICATION OF DEEP FASCIAL SPACE
INFECTION BASED ON S E V E R I T Y
DR. SARANG SURESH HOTCHANDANI 6

7. ANATOMY OF DEEP FASCIAL SPACES OF
HEAD & NECK
DR. SARANG SURESH HOTCHANDANI 7

8. ANATOMY OF DEEP FASCIAL SPACES OF
HEAD & NECK
DR. SARANG SURESH HOTCHANDANI 8

9. RELATIONS OF DEEP FASCIAL SPACE
INFECTIONS OF HEAD & NECK
DR. SARANG SURESH HOTCHANDANI 9

10. RELATIONS OF DEEP FASCIAL SPACE
INFECTIONS OF HEAD & NECK
DR. SARANG SURESH HOTCHANDANI 10

11. MAXILLARY TEETH
INFECTION
DR. SARANG SURESH HOTCHANDANI 11

12. Palatal space (sub periosteal space) – maxillary
lateral, premolar & molar.
Infra – orbital space
Swelling of anterior face
Nasolabial fold obliterated
Spontaneous drainage of this space infection occurs near to
medial or lateral canthus of the eye.
INFECTIONS ARISING FROM MAXILLARY TEETH
DR. SARANG SURESH HOTCHANDANI 12

13.  Buccal Space
 Swelling below zygomatic arch &
above the inferior border of
mandible.
 Buccal space infection follows the
extension of the buccal fat pad into
the infraorbital, periorbital &
superficial temporal space.
 Dimpled appearance over the
zygomatic arch.
 Zygomatic arch and inferior border of
mandible remain palpable in buccal
space infection.
INFECTIONS ARISING FROM MAXILLARY TEETH
A, Buccal space lies between buccinator muscle and overlying skin
and superficial fascia. This potential space may become involved via
maxillary or mandibular molars (arrows).
B, Typical buccal space infection, extending from the level of the
zygomatic arch to the inferior border of the
mandible and from the oral commissure to the anterior border of the
masseter muscle. DR. SARANG SURESH HOTCHANDANI 13

14.  It is the bottom portion of deep temporal space & lies posterior to maxilla.
 Boundaries;
 Medial – lateral pterygoid plate of sphenoid bone
 Superior – base of skull
 Lateral & superiorly – continuous with deep temporal space
 Contents;
 Branches of internal maxillary artery
 Branches of pterygoid Venus plexus – emissary veins
 Infra temporal space is the origin of the posterior route by which infection
spread to cavernous sinus.
 It is rarely infected, if infection occurs; it is mostly from maxillary 3rd molar.
INFECTIONS ARISING FROM MAXILLARY TEETH
DR. SARANG SURESH HOTCHANDANI 14

15.  The masticator space is bounded by the
fascia overlying the masseter muscle,
medial pterygoid muscle, temporalis
muscle, and the skull.
 The superficial and deep temporal
spaces are separated from each other
by the temporalis muscle.
 The lateral pterygoid muscle divides the
Pterygomandibular space from the
infratemporal portion of the deep
temporal space, and
 the zygomatic arch divides the sub
masseteric space from the superficial
temporal space.
DR. SARANG SURESH HOTCHANDANI 15

16. • anteriorly via
the inferior or
superior
ophthalmic vein
or
• posteriorly via
emissary veins
from the
pterygoid
plexus.
HEMATOGENOUS
SPREAD OF
INFECTION FROM
THE JAW TO THE
CAVERNOUS
SINUS MAY
OCCUR
DR. SARANG SURESH HOTCHANDANI 16

17. Maxillary Sinus Infections
 20% case of maxillary sinusitis are odontogenic
 Odontogenic maxillary sinus infections may also spread superiorly through
ethmoid sinus or the orbital floor and cause secondary periorbital or orbital
infection.
 Clinical Features of Periorbital or Orbital Infections;
 Redness & swelling of eyelids
 Displacement of pupil
Cavernous Sinus Thrombosis
 Routes mentioned above.
 Most vulnerable structure in cavernous sinus thrombosis – abducens 6th
cranial nerve.
INFECTIONS ARISING FROM MAXILLARY TEETH
DR. SARANG SURESH HOTCHANDANI 17

18. MANDIBULAR TEETH
INFECTION
DR. SARANG SURESH HOTCHANDANI 18

19.  SUBMAXILLARY SPACES or PERIMANDIBULAR SPACE
 It is one large space made of;
 Submandibular
 Sublingual
 Submental space
 Sublingual & submandibular spaces are infected by lingual perforation of
mandibular molars & premolars
 If the perforation occurs above the mylohyoid muscle – sublingual space infection will
occur.
 If the perforation occurs below the mylohyoid muscle – submandibular space infection
will occur.
 Mostly infected by mandibular 3rd molar
INFECTIONS FROM MANDIBULAR TEETH
DR. SARANG SURESH HOTCHANDANI 19

20.  Sublingual Space;
 Little or no extra oral swelling in floor of mouth
 Mostly bilateral infection
 Elevated tongue.
INFECTION FROM MANDIBULAR TEETH
A, The sublingual space lies between
the oral mucosa and the mylohyoid
muscle. The space is primarily involved
by infection from mandibular premolars
and first molar.
B, Severe sublingual space abscess that
has elevated the tongue into the palate
such that only the ventral
surface of the tongue and floor of the
mouth are visible.
DR. SARANG SURESH HOTCHANDANI 20

21.  Submandibular space (figure
17 – 15)
 Swelling that look like an inverted
triangle
 Base - inferior border of mandible
 Sides – anterior & posterior bellies
of digastric muscle
 Apex – hyoid bone
INFECTION FROM MANDIBULAR TEETH
The submandibular space lies between the mylohyoid muscle and
anterior layer of the deep cervical fascia, just deep to the platysma
muscle, and includes the lingual and inferior surfaces of the mandible
below the mylohyoid muscle attachment.
DR. SARANG SURESH HOTCHANDANI 21

22. Typical
submandibular
space infection
demarcated by
both bellies of the
digastric muscle,
the inferior border
of the mandible,
and the hyoid
bone.
DR. SARANG SURESH HOTCHANDANI 22

23. Submental space
infection
appears as
discrete swelling
in central area of
submandibular
region.
DR. SARANG SURESH HOTCHANDANI 23

24. Bilateral involvement of Perimandibular spaces.
Rapidly spreading cellulitis that can obstruct
airway and
Spread posteriorly to deep fascial spaces of
neck
LUDWIG ANGINA
DR. SARANG SURESH HOTCHANDANI 24

25.  Sever swelling
 Elevation & displacement of tongue
 Tense, hard, bilateral induration of submandibular region superior to
hyoid bone.
 Trismus, drooling, difficulty swallowing & breathing.
 Upper airway obstruction
LUDWIG ANGINA CLINICAL FEATURES
DR. SARANG SURESH HOTCHANDANI 25

26. Compartments of masticators space;
Sub masseteric space
Pterygo mandibular space
Superficial temporal space
Deep temporal space
MASTICATOR SPACE
DR. SARANG SURESH HOTCHANDANI 26

27.  b/w the masseter muscle & lateral surface of ascending ramus
 Infected by;
 buccal space infection
 pericoronitis
 mandibular angle fracture
 Clinically
 moderate to severe trismus due to inflammation of masseter muscle.
 Obscured ear lobe due to swelling b/w the masseter muscle & lateral surface of
ascending ramus
SUB MASSETERIC SPACE
DR. SARANG SURESH HOTCHANDANI 27

28.  b/w medial pterygoid muscle & medial surface of ascending ramus.
 It is the site into which LA is given in IAN block.
 Clinically
 Trismus without swelling is diagnostic of Pterygomandibular space infection
 Swelling and erythema of anterior tonsillar pillar on the affected side.
 Deviation of uvula on opposite side of infection.
 On CT examination, fluid collection detected b/w medial pterygoid muscle and the
mandible.
 Airway is compressed & deviated
PTERYGO MANDIBULAR SPACE
DR. SARANG SURESH HOTCHANDANI 28

29. Rarely infected
Clinical Features;
Swelling in temporal region, superior to
zygomatic arch and posterior to lateral orbital
rim
Hourglass shape in frontal view.
SUPERFICIAL & DEEP TEMPORAL INFECTION
DR. SARANG SURESH HOTCHANDANI 29

30.  The lateral pharyngeal space is located between the medial
pterygoid muscle laterally and the superior pharyngeal constrictor
medially.
 The retropharyngeal and danger spaces lie between the pharyngeal
constrictor muscles and the prevertebral fascia.
 The retropharyngeal space lies between the superior constrictor muscle and the
alar fascia.
 The danger space lies between the alar layer and the prevertebral fascia.
DEEP CERVICAL FASCIAL SPACE INFECTION
DR. SARANG SURESH HOTCHANDANI 30

31. Infection usually comes from
Pterygomandibular, submandibular, sublingual
space.
Is made of two compartments;
Anterior compartment – loose C.T
Posterior compartment – carotid sheath, cranial
nerves (9th, 10th, 12th)
LATERAL PHARYNGEAL SPACE INFECTION
DR. SARANG SURESH HOTCHANDANI 31

32.  Trismus – inflammation of medial pterygoid muscle
 Lateral swelling of neck – b/w angle of mandible & S.C.M
 Bulge toward midline – swelling of lateral pharyngeal wall
 Difficulty swallowing, high temperature.
 swelling of the anterior tonsillar pillar and blunting of the palate-vulvar fold.
 Thrombosis of internal jugular vein
 Erosion of carotid sheath
 Airway is deviated to opposite side of infection.
LATERAL PHARYNGEAL SPACE INFECTION
(CLINICAL FEATURES)
DR. SARANG SURESH HOTCHANDANI 32

33.  The retropharyngeal and the alar fascia fuse at a variable level
between the C6 and T4 vertebrae, which forms a pouch at the inferior
extent of the retropharyngeal space.
 If infection passes through the alar fascia to the danger space, the
Postero-superior mediastinum will most likely soon become involved.
 The inferior boundary of the danger space is the diaphragm, which
puts the entire mediastinum at risk.
 This space contains only loose C.T and lymph nodes, so it provides
little barrier to spread of infection from one lateral pharyngeal space to
the other to encircle the airway.
 The infection can rupture the alar fascia posteriorly to enter the danger
space
 Prevertebral infections are usually caused by osteomyelitis of
vertebrae.
RETRO PHARYNGEAL SPACE
DR. SARANG SURESH HOTCHANDANI 33

34. This infection causes skin vesicle and then
a dusky purple discoloration of overlying
skin due to ischemia.
Later frank necrosis and undermining of
skin occur which require surgical
debridement of large areas of skin.
NECROTIZING FASCIITIS –
FLESH EATING BACTERIAL INFECTION
DR. SARANG SURESH HOTCHANDANI 34

35. Email: hotchandaniss@hotmail.com
THE END
References
JAMES R. HUPP, E. E. (n.d.). CONTEMPORARY ORAL AND MAXILLOFACIAL
SURGERY (6 ed.). ELSEVIER.
DR. SARANG SURESH HOTCHANDANI 35