Abscess and phlegmon in maxillofacial region odontogenic infections-
By Dr. Mahdi Faour
Infection in general
Types of infection
Etiology of orofacial infections
Predisposing factors for acute oral infections
Routes of spread of infection
Anatomical factors influencing the direction of spread
Definition: Infection is the pathological
state resulting from the invasion of the
body by pathogenic microorganisms.
The reaction of the tissues to the presence
of these microorganisms and the toxins
generated by them is INFLAMMATION.
Types of Infection
Bacterial Infection: not only one particular specie,
but due to a mixture of species which make up the
Fungal Infection: Actinomycosis
Viral Infection: Not recognized because they are
complicated early by secondary bacterial infection.
Parasitic infection: Very rare( ex. Lyshmoniasis)
Etiology of Infection
The majority of oral, facial, and neck infections are
odontogenic in origin.
Although they may be caused by infections from
Antrum (maxillary sinus)
Major salivary glands
Specific Infections of jaws (osteoradionecrosis,
Odontogenic Causes of Infections
1. Decay (caries) reaching the dental pulp= pulpitis, this in turn
spreads to supporting bone resulting in periapical abscess which
in turn may spread subperiosteally.
2. Periapical abscess may occur in seemingly intact but devitalized
teeth (trauma, cracks or decay under fillings).
3. Periodontal diseases
4. Erupting teeth (especially partially impacted lower third molars)
can result in inflammation and infection of the gum flap
preventing eruption (operculum) with swelling pus etc. around
the crown (pericoronitis).
5. Retained roots supragingival or subgingival.
Predisposing factors for acute
I. Endocrine disturbances
II. Nutritional deficiency (decreases resistance)
III. Chemical compounds used in dentistry (arsenic)
IV. Blood disorders (leukemia, anemia)
V. General diseases (syphilis, TB)
VI. Immunological diseases (AIDS)
Fractures of jaw
Pressure type of anesthesia
Improper use of surgical burs without cooling
Odontogenic infections are multimicrobial:
Gram (+) cocci, aerobic and anaerobic:
Streptococci and their anaerobic counterpart,
Staphylococci, and their anaerobic counterpart,
Gram (+) rods:
Lactobacillus, diphtheroids, Actinomyces
Gram (-) rods:
Fusobacterium, Bacteroids, Eikenella, Psuedomonas
Rate of spread of infection
Rate depends on:
Virulence of the invading microbes
Dosage or number of these microbes
Severity of infection=
(Virulence x Dose)/Resistance
Clinically odontogenic infections can be
distinguished in three periods:
Period of periapical of dento-alveolar abscess
(in which the initial lesion develops)
Period of extension to the adjacent bone and
Period of serious complications (embolism,
Routes of spread of infection
By direct continuity through the tissues
By the lymphatics, to the regional lymph nodes and
eventually to the blood stream. If infection becomes
established in lymph nodes, then secondary abscess
By the bloodstream. Local thrombophlebitis may rarely propagate along
the veins, entering the cranial cavity via emissary veins to produce cavernous
sinus thrombophlebitis. Septicemia, pyaemia, and bacteraemia can be
caused by bloodstream spread. (N.B. Facial veins are valveless)
Hematogenous spread of infection from jaw to cavernous sinus may occur
anteriorly via inferior or superior ophthalmic vein or posteriorly via emissary
veins from pterygoid plexus.
Anatomical factors influencing the
direction of spread within tissue
1.The site of the source of infection (maxilla or mandible
and even the particular segment of the jaw).
2.The point at which pus escapes from the bone and
discharges into the soft tissues (linguopalatally or
3.The natural barriers to the spread of pus in the tissues,
such as by layers of fascia or muscle or the jaw bones
Fascial spaces are fascia-lined areas that can be eroded
or distended by purulent exudate.
These areas are potential spaces that do not exist in
healthy people but become filled during infections.
As infection erodes through bone, it can express itself in a variety of places,
depending on thickness of overlying bone and relationship of muscle
attachments to site of perforation. This illustration notes six possible locations:
1-vestibular abscess, 2-buccal space, 3-palatal abscess, 4-sublingual space,
5-submandibular space, and 6-maxillary sinus.
Principles of Treatment of
Principles of Treatment of
1.Remove the cause.
3.Institute antibiotic therapy.
4.Supportive care, including proper rest and
Basic Principles of Local Treatment
Surgical treatment of abscess and phlegmon is based on
the pus drainage, and therefore in all cases the
following steps should be followed.
Opening the abcess
2. Opening the abscess
3.Taking of smear to
determine the bacteria
4.Drainage of abscess
Drainage of abscessDrainage of abscess
Superior: inferior margin of the orbit
Inferior: alveolar process of maxilla
Mesial: margin of periform aperture
Lateral: zygomatic-maxillary suture
Canine Fossa Infection
Odontogenic origin: maxillary canines and premolars
Infection can be superficial (due to dermatologic
infections) or can be deep (between muscles and
bone-odontogenic infection), and the infections
quickly spreads from superficial to deep and vice
Clinical Presentation (canine Fossa)
Edema, localized in the infraorbital region, which
spreads towards the 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 and
there is fluctuation during palpation, and later on the
skin becomes taut and shiny due to suppuration, while
its color is reddish(fig)
Glassy oedematous swelling of eye region of
canine fossa abscess
Extraoral swelling at the
infraorbital region and nasolabial
fold with red shiny skin
Canine space infection
in patient's right side
resulted from infected
canine tooth. The
swelling of nasolabial
and infraorbital areas is
Treatment of Canine Fossa Abscess
1.The incision for drainage is performed intraorally at
the mucobuccal fold (parallel to the alveolar bone), in
the canine region.
2. A hemostat is then inserted, which is placed at the
depth of the purulent accumulation until it comes into
contact with bone, while the index finger of the
nondominant hand palpates the infraorbital margin.
3. Finally, a rubber drain is placed, which is stabilized
with a suture on the mucosa.
Superior: inferior margin of zygomatic arch
Inferior: Inferior margin of mandible
Anterior: Corner of the mouth
Posterior: anterior margin of Masseter muscle
Interior: Buccinator muscle
Buccal Pad of fats
Buccal Space Infection
Odontogenic: (most frequently)maxillary and
mandibular posterior teeth.
Nonodontogenic: adenophlegmon of facial lymph
Secondary spread of infection:
Superiorly: pterygopalatine space
Inferiorly: pterygomandibular space
Buccal space lies between
buccinator muscle and
overlying skin and
superficial fascia. This
potential space may
become involved via
maxillary or mandibular
Clinical Presentation of Buccal Abscess
Swelling of the cheek, which extends from the zygomatic
arch as far as the inferior border of the mandible, and
from the anterior border of the ramus to the corner of the
The skin appears taut and red, with or without fluctuation
of the abscess.
There can be intraoral bulging.
This buccal space infection
was result of maxillary molar.
Typical swelling of the cheek
is demonstrated, which does
not extend beyond inferior
border of mandible.
Obvious swelling of the right cheek.
Side view. Fluctuant mass extending
toward the buccal side of the gum end
to the gingival-buccal reflection
---Gingiva with swelling and erythema.
Treatment of Buccal Space Abscess
Access to the buccal space is usually intraoral for three main
1. Because the abscess fluctuates intraorally in the majority of cases.
2. To avoid injuring the facial nerve.
3. For esthetic reasons.
The intraoral incision is made at the posterior region of the
mouth, in an anteroposterior direction and very carefully in
order 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.
Lateral: anterior bellies of the right and left Digastric muscles
Anterior: internal border of corpus of mandible
Posterior: Hyoid bone
Roof: Mylohoid muscle
Lower margin: Skin and Platysma muscle
Submental Space Infection
Odontogenic: from frontal teeth of the mandible
Nonodontogenic: adenophlegmon or trauma
Secondary spread: from submandibular or
Clinical Presentation of submental Abscess
Edema in submental region which can spread to
Palpation is painful and fluctuation is present
Hyperemia of skin
Functional disturbances in protrusion of the jaw
Dysphagia or discomfort while swallowing can be
Clinical photograph showing
severe extraoral swelling at the
Submental space infection appears as discrete swelling in central
area of sub-mandibular region.
Submental space abscess,
secondary to dental disease
Treatment of submental Abscess
1. Local anesthesia is performed around the abscess
Peripheral infiltration anesthesia of healthy
tissues surrounding inflammation
Mature submental abscess ready for
incision and drainage.
2. An incision on the skin is made beneath the chin, in
a horizontal direction and parallel to the anterior
border of the chin.
Diagrammatic illustration (a) and clinical photograph (b) showing the incision for
drainage of the abscess.
The pus is then drained in the same way as in the other
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
Superior: Mylohoid muscle
External: inferior border of the body of mandible
Anterior: Anterior belly of Digastric muscle
Posterior: Posterior belly of Digastric muscle
Submandibular salivary glands
Submandibular lymph nodes
Anterior facial vein
Submandibular Space Infection
Odontogenic: mandibular molars and premolars
Adenophlegmon of submandibular lymph nodes
Purulent process of submandibular salivary glands
Secondary spread: submental (most frequently) or
The infection presents as moderate swelling at the
submandibular area, which spreads, creating greater
edema that is indurated and redness of the overlying
Angle of the mandible is obliterated
Pain during palpation
Moderate trismus due to involvement of the medial
Clinical photograph showing severe
swelling at the left posterior area of
indurated swelling of
Abscesses of the submandibular neck space are common
in children. The treatment is incision and drainage.
Cultures are obtained and the appropriate antibiotic is
Treatment of Submandibular Abscess
1.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.
2. 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 .
3.After drainage, a rubber drain is placed.
Stabilization of a rubber
drain at the site of incision
photograph 10 days later
The submandibular abscess was incised and drained. It
contained thick, greenish pus. A drain was left in the
Submandibular abscess in an adult with diabetes
Superior: mucous membrane of floor of mouth
Inferior: Mylohoid muscle
Posterior: muscles of the tongue and hyoid bone
Lateral and anterior: inner surface of body of mandible
Medially: Lingual septum
Submandibular duct(Wharton’s duct)
Sublingual and lingual nerve
Terminal branches of lingual artery
Part of submandibular gland
Can be divided into:
Proper sublingual space
(right & left)
Sublingual Space Infection
Odontogenic: mandibular anterior teeth,
premolars, and 1st molars whose apices are found above
the attachment of the Mylohoid muscle.
Nonodontogenic: Sublingual glands infection
Secondary spread from:
Submental by ascending way through
fibers of Mylohoid muscle
Firm, painful swelling of mucosa of floor of the
mouth, resulting in elevation of the tongue towards
the palate and backwards
Pain and difficulty swallowing (Dysphagia)
Movement of the tongue is painful
Mandibular-lingual sulcus is obliterated and mucosa
presents a bluish tinge
Moderate or no external swelling
The patient speaks with difficulty, because of the
edema, and movements of the tongue are painful.
B- This isolated sublingual space infection
produced unilateral swelling of floor of
between oral mucosa and
Swelling of the mucosa of the
mouth floor and characteristic
elevation of the tongue towards
the opposite side
Abscess in the sublingual space
due to infection of Wharton's duct
sublingual abscess to
Treatment of Sublingual Abscess
1.The incision for drainage is performed intraorally,
laterally, and along Wharton’s duct and the lingual
2.In order to locate the pus, a hemostat is used to
explore the space inferiorly, in an anteroposterior
direction and beneath the gland.
3.After drainage is complete, a rubber drain is placed.
External : anterior margin of ramus of mandible
Internal: external surface of lateral pterygoid muscle
Superior: medial pterygoid muscle
Posterior: partially by parotid gland and styloglossus muscle
Anterior: Buccinator muscle
mandibular neurovascular bundle
part of the buccal fat pad
Pterygomandibular Space Infection
3rd molar pericoronitis
Apical infection of molars
Septic mandibular Nerve block----
Fracture of the jaw
lateral pharyngeal spaces.
Clinical Presentation of
Severe trismus and slight extraoral edema beneath the
angle of the mandible are observed
Tenderness and pain on deep palpation over medial
aspect of ramus
edema of the soft palate of the affected side is present
displacement of the uvula and lateral pharyngeal wall
There is difficulty in swallowing.
Treatment of Pterygomandibular
1.The incision for drainage is
performed on the mucosa
of the oral cavity and, more
specifically, along the
mesial temporal crest. The
incision must be 1.5 cm
long and 3–4 mm deep.
2.A curved hemostat is then inserted, which proceeds
posteriorly and laterally until it comes into contact
with the medial surface of the ramus.
3.The abscess is drained, permitting the evacuation of
pus along the shaft of the instrument.
Cellulitis: initial stage of infection
Diffuse, reddened, soft or hard
swelling that is tender to
Inflammatory response not yet
forming a true abscess.
Microorganisms have just
begun to overcome host
defenses and spread beyond
True abscess formation
As inflammatory response
matures, may develop a
focal accumulation of pus.
May have spontaneous
drainage intraorally or