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PRIMARY SPACES
OF SPACE INFECTION
BY MANMOY SAHA
(INTERN)
CONTENTS
 INTRODUCTION
 POTENTIAL SPACES
 PRIMARY MAXILLARY SPACES
 -CANINE SPACE
 -BUCCAL SPACE
 -INFRA TEMPORAL SP...
INTRODUCTION
 Infections of orofacial and neck regions
range from periapical abscess to superficial
and deep neck infecti...
PATHWAYS OF ODONTOGENIC INFECTIONS
 Invasion of dental pulp by bacteria
after decay of tooth
 -> Inflammation, edema, lack of
collateral blood supply
 -> ...
SPREAD OF OROFACIAL INFECTIONS
 ROUTES OF SPREAD
 By direct continuity through the tissues
 By lymphatics to the region...
MAXILLA
 Swelling or fistula in the posterior part of hard palate it is
related to palatal roots of molars
 Maxillary in...
MANDIBLE
 Infection of mandibular incisors and
cuspids shows bulging in labial sulcus
 If infection spreads from bone de...
CLASSIFICATION OF FASCIAL SPACES
 BASED ON THE MODE OF INVOLVEMENT:
 Direct involvement:-
 Primary maxillary spaces- ca...
 Pterygomandibular space
 Superficial temporal space
 Deep temporal space
 Lateral pharyngeal space
 Retropharyngeal ...
The teeth which frequently give rise to abscess
in
this area are maxillary canines, premolars and
sometimes mesiobuccal ro...
CANINE SPACE( INFRA-ORBITAL SPACE)
 Boundaries:-
 Anteriorly- orbicularis oris
 Posteriorly- buccinator
 Superiorly-le...
CLINICAL FEATURES:-
 Swelling of cheek and upper
lip
 Obliteration of nasolabial fold
 Drooping of the angle of
mouth
...
It is the potential space between buccinator & masseter
muscle
Maxillary & Mandibular premolars and molars area
involved.
...
 Boundaries:-
 Anteromedially- buccinator
muscle
 Posteromedially- masseter
overlying the anterior border
of ramus of m...
CLINICAL FEATURES:-
Gum boil is seen in the
vestibule
(when the pus
accumulates on oral side
of the muscle)
If the pus acc...
 It is also called “retrozygomatic space”
 The space is continuous with upper part of pterygomandibular space
anteriorly...
Involvement-
 Infections of the
infratemporal space occurs
from the infections of
buccal roots maxillary 2nd
and 3rd mola...
 Boundaries:-
 Laterally- ramus of mandible
and temporalis muscle
 Medially-medial pterygoid
plateand lateral pterygoid...
 CLINICAL FEATURES:-
 Extraoral- trismus
 Bulging of temporalis
muscle
 Marked swelling of the
face on the affected si...
 Infections originating from 6 anterior mandibular teeth
then perforate cortical plate below the origin of mentalis
muscl...
BOUNDARIES:-
 Lateral- lower border of mandible and anterior
bellies of digastric
 Superior:- mylohyoid muscle
 Inferio...
CLINICAL FEATURES:-
 Extraoral findings- distinct,
firm swelling in midline
beneath the chin
 Skin over the swelling is
...
 Spread: of infection-
 Posteriorly- to involve
submandibular space
 It may discharge on the face in
the submental regi...
 The space lies between the anterior and posterior bellies
of digastric muscle.
 Upper part lies beneath the inferior bo...
INVOLVEMENT
 Infections originating from
mandibular molars, pus
perforates the lingual cortical
plate of mandible passes
...
BOUNDARIES:-
 Anteromedially:- floor is
formed by mylohyoid
muscle
 Posteromedially:- floor is
formed by hyoglossus
musc...
 CLINICAL FEATURES:-
 Extra oral:- firm swelling in
the submandibular region,
below inferior border of
mandible
 Rednes...
 An incision of about 1.5 to
2 cm length is made 2cm
below the lower border of
mandible
 Skin and subcutaneous
tissues a...
 Space is a “V” shaped trough lying lateral to muscles of
tongue including hyouglossus, genioglossus, geniohyoid
 Involv...
BOUNDARIES:-
 Inferiorly- mylohyoid muscle
 Laterally:- medial side of the
mandible above mylohyoid
muscle
 Medially:- ...
CLINICAL FEATURES:-
Extraorally: there is little or no
swelling.
The lymph nodes may be
tender & enlarged
Pain and discomf...
INCISION & DRAINAGE:-
 Inraorally:- incision is made
close to the lingual cortical
plate, lateral to sublingual
plica (wh...
MANAGEMENT OF OROFACIAL INFECTIONS
 Antibiotic therapy:-
 Use of penicillin G (2 to 4 million
units, IV 4 to 6 hrs)and
...
HILTON’S METHOD OF INCISION AND DRAINAGE
 Topical anesthesia:- achieved with the help of ethyl
chloride spray
 Stab inci...
 Abscess cavity is entered and forceps is opened in a direction
parallel to vital structures
 Pus flow along side of bea...
INVOLVEMENT OF MULTIPLE PRIMARY SPACES
 LUDWIG’S ANGINA
 It is a firm, massive, brawny cellulitis and acute, toxic stage...
TREATMENT OF LUDWIG’S ANGINA
 Early diagnosis
 Maintenance of the patient
airway
 Intense and prolonged
antibiotic ther...
THANK
YOU
Primary spaces of space infection
Primary spaces of space infection
Primary spaces of space infection
Primary spaces of space infection
Primary spaces of space infection
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Primary spaces of space infection

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Primary spaces of space infection

  1. 1. PRIMARY SPACES OF SPACE INFECTION BY MANMOY SAHA (INTERN)
  2. 2. CONTENTS  INTRODUCTION  POTENTIAL SPACES  PRIMARY MAXILLARY SPACES  -CANINE SPACE  -BUCCAL SPACE  -INFRA TEMPORAL SPACE  PRIMARY MANDIBULAR SPACES  -SUBMENTAL SPACE  -BUCCAL SPACE  -SUBMANDIBULAR SPACE  -SUBLINGUAL SPACE
  3. 3. INTRODUCTION  Infections of orofacial and neck regions range from periapical abscess to superficial and deep neck infections  The infections spread by following the path of least resistance through connective tissue and fascial planes  The infection spread to such an extent ,distant from the site of origin causing considerable morbidity and occasional death
  4. 4. PATHWAYS OF ODONTOGENIC INFECTIONS
  5. 5.  Invasion of dental pulp by bacteria after decay of tooth  -> Inflammation, edema, lack of collateral blood supply  -> venous congestion or avascular necrosis  ->Reservoir for bacterial growth  ->periodic egress of bacteria into surrounding alveolar bone
  6. 6. SPREAD OF OROFACIAL INFECTIONS  ROUTES OF SPREAD  By direct continuity through the tissues  By lymphatics to the regional lymph nodes and eventually into blood stream  Which may lead to secondary areas of cellulitis or tissue space abscess  By the blood stream  If the infection remains confined to the peri-apical areas, chronic periapical infections develop , which leads to sufficient destructions of bone-> osteomyelitis
  7. 7. MAXILLA  Swelling or fistula in the posterior part of hard palate it is related to palatal roots of molars  Maxillary incisor and cuspid roots lie closer to thin labial plate of bone than to thicker palatal bone  Infection from maxillary bicuspids may extend into connective tissue of buccal vestibule spread superiorly causing cellulitis of eyelids  Infection from molars may exit from alveolar bone buccally, palatally or posteriorly  Superior spread -> infratemporal space, maxillary sinus  Posteriorly->masticator and pharyngeal space
  8. 8. MANDIBLE  Infection of mandibular incisors and cuspids shows bulging in labial sulcus  If infection spreads from bone deeper to origin of mentalis muscle->submental space  Infection from mandibular 3rd molar involve buccal vestibule, buccal space, masticator space, parapharyngeal spaces
  9. 9. CLASSIFICATION OF FASCIAL SPACES  BASED ON THE MODE OF INVOLVEMENT:  Direct involvement:-  Primary maxillary spaces- canine space,  buccal space, infra temporal space  Primary mandibular spaces- submental space  buccal space, submandibular space,  sublingual space  Indirect involvement-  Secondary fascial spaces- masseteric
  10. 10.  Pterygomandibular space  Superficial temporal space  Deep temporal space  Lateral pharyngeal space  Retropharyngeal space  Prevertebral space  Parotid space  Basedon clinical significance  Face - Buccal , canine, masticatory, parotid  Suprahyoid- sublingual, submandibular,  pharyngomaxillary, peritonsillar  Infrahyoid- anterovisceral(pre tracheal)  Spaces of total neck: retropharyngeal , space of carotid sheath
  11. 11. The teeth which frequently give rise to abscess in this area are maxillary canines, premolars and sometimes mesiobuccal root of 1st molar
  12. 12. CANINE SPACE( INFRA-ORBITAL SPACE)  Boundaries:-  Anteriorly- orbicularis oris  Posteriorly- buccinator  Superiorly-levator labii superioris, zygomaticus minor  Inferiorly- caninus muscle  Medially- anterolateral surface of maxilla
  13. 13. CLINICAL FEATURES:-  Swelling of cheek and upper lip  Obliteration of nasolabial fold  Drooping of the angle of mouth  edema of lower eyelid  Redness and marked tenderness of facial tissues  Intraoral- offending tooth is mobile and tender on INCISION & DRAINAGE:-  A curved mosquito forcep is inserted superior to the attachment of caninus muscle & the infra- orbital space is entered  Pus is evacuated and a drain is inserted & secured to one of the margins with suture
  14. 14. It is the potential space between buccinator & masseter muscle Maxillary & Mandibular premolars and molars area involved. Location of the root tip to the level of origin of buccinator muscle determines the spread of infection either intraorally
  15. 15.  Boundaries:-  Anteromedially- buccinator muscle  Posteromedially- masseter overlying the anterior border of ramus of mandible  Laterally- forward extension of deep fascia from the capsule of parotid gland & platysma muscle  Inferiorly- deep fascia to the mandible & depressor anguli oris  Superiorly- zygomatic process of maxilla & zygomaticus major and minor
  16. 16. CLINICAL FEATURES:- Gum boil is seen in the vestibule (when the pus accumulates on oral side of the muscle) If the pus accumulates lateral to the muscle extraoral swelling is seen extending from lower border of mandible to the infra orbital margin and from anterior margin of masseter muscle to the corner of the mouth INCISION & DRAINAGE:-  Horizontal incision through the oral mucosa of the cheek in the premolar molar region  If the pus is lateral to the muscle then the muscle is penetrated with curved mosquito forceps to enter the buccal space  Drain is placed secured with suture
  17. 17.  It is also called “retrozygomatic space”  The space is continuous with upper part of pterygomandibular space anteriorly, it is separated from it by lateral pterygoid muscle posteriorly  The infratemporal fossa forms the upper extremity of pterygomandibular space
  18. 18. Involvement-  Infections of the infratemporal space occurs from the infections of buccal roots maxillary 2nd and 3rd molars  Local anesthesia injections with contaminated needles in the area of tuberosity  Spread from other spaces infection Spread of infection  Pus can extend upwards to involve the temporal space or inferiorly perforate the lateral pterygoid muscle to involve the pterygomandibular space  It can spread through pterygoid plexus of veins upwards into cavernous sinus  From infratemporal fossa to middle cranial fossa
  19. 19.  Boundaries:-  Laterally- ramus of mandible and temporalis muscle  Medially-medial pterygoid plateand lateral pterygoid muscle superiorly - infratemporal surface of greater wing of sphenoid  Inferiorly- lateral pterygoid muscle  Anteriorly- infratemporal surface of maxilla  Posteriorly -parotid gland
  20. 20.  CLINICAL FEATURES:-  Extraoral- trismus  Bulging of temporalis muscle  Marked swelling of the face on the affected side in front of the ear overlying area of tmj  Intra oral –swelling in tuberosity area with elevation of temp 104F  INCISION & DRAINAGE:-  Intraoral approach- incision is given in buccal vestibule opposite 2nd and 3rd molar exploration is carried out medial to coronoid process and temporalis muscle upwards backwards with sinus forcep ,space is entered and drained  Extra oral approach- incision is made at upper and posterior edge of temporalis muscle within hairline.  Sinus forcep directed upward medially  Pus is evacuated
  21. 21.  Infections originating from 6 anterior mandibular teeth then perforate cortical plate below the origin of mentalis muscle labially ,mylohyoid lingually  It can also affected from lower incisors , lower lip, skin overlying the chin, anterior part of floor of mouth,  tip of tongue and sublingual tissues
  22. 22. BOUNDARIES:-  Lateral- lower border of mandible and anterior bellies of digastric  Superior:- mylohyoid muscle  Inferior:- suprahyoid portion of the investing layer of deep cervical fascia
  23. 23. CLINICAL FEATURES:-  Extraoral findings- distinct, firm swelling in midline beneath the chin  Skin over the swelling is board like taut  Intraoral findings- the anterior teeth are either non-vital fractured or carious .  The offending tooth may exhibit tenderness to percussion may show mobility
  24. 24.  Spread: of infection-  Posteriorly- to involve submandibular space  It may discharge on the face in the submental region  INCISION & DRAINAGE:-  A transverse incision is made in the skin below the symphysis of the mandible.  Blunt dissection is carried out by inserting a kelly’s forcep through this incision ,upward ,backward  Then corrugated rubber drain is inserted in the abscess cavity and sutured
  25. 25.  The space lies between the anterior and posterior bellies of digastric muscle.  Upper part lies beneath the inferior border of mandible and lower part lies deep to the investing layer of deep cervical fascia
  26. 26. INVOLVEMENT  Infections originating from mandibular molars, pus perforates the lingual cortical plate of mandible passes directly into the submandibular space  Infection from submental space  Infection from posterior part of sublingual space  Infections from middle third of the tongue, posterior part of floor of mouth, maxilary teeth,
  27. 27. BOUNDARIES:-  Anteromedially:- floor is formed by mylohyoid muscle  Posteromedially:- floor is formed by hyoglossus muscle  superolaterally :- medial surface of mandible  Anterosuperiorly:- anterior belly of digastric  Posterosuperiorly:- posterior belly of digastric
  28. 28.  CLINICAL FEATURES:-  Extra oral:- firm swelling in the submandibular region, below inferior border of mandible  Redness of overlying skin  Intra oral:- teeth are sensitive to percussion  Teeth are mobile  Dysphagia  Moderate trismus  Spread: of infection-  There is no major anatomic barriers so infection can extend into submental space  There is no anatomical barrier so infection can spread easily across the midline involve submandibular space on other side  It communicates with sublingual space around posterior border of mylohyoid muscle  It can also spread into parapharyngeal space
  29. 29.  An incision of about 1.5 to 2 cm length is made 2cm below the lower border of mandible  Skin and subcutaneous tissues are incised  Sinus forcep is inserted through the incision superiorly and posteriorly on the lingual side of mandible below the mylohyoid to release pus from submandibular space INCISION & DRAINAGE:-
  30. 30.  Space is a “V” shaped trough lying lateral to muscles of tongue including hyouglossus, genioglossus, geniohyoid  Involvement:- mandibular incisors, canines, premolars , sometimes molars  It is a paired space but the 2 sides communicates anteriorly, with submandibular space around the posterior border of mylohyoid muscle
  31. 31. BOUNDARIES:-  Inferiorly- mylohyoid muscle  Laterally:- medial side of the mandible above mylohyoid muscle  Medially:- hyoglossus, genioglossus & geniohyoid muscles  Posteriorly:- hyoid bone  Laterally and inferiorly:- mylohyoid muscle and lingual side of mandible
  32. 32. CLINICAL FEATURES:- Extraorally: there is little or no swelling. The lymph nodes may be tender & enlarged Pain and discomfort on deglutition Intraorally: firm, painful swelling seen in the floor of the mouth Floor of the mouth is raised Tongue pushed superiorly will cause airway obstruction Spread: of infection-  Infection crosses the midline and effect the space on the opposite  Infection from posterior inferior part of the space spread into submandibular space-> pterygomandibular and parapharyngeal space Infection spread via lymphatics to the submandibular or submental lymph node
  33. 33. INCISION & DRAINAGE:-  Inraorally:- incision is made close to the lingual cortical plate, lateral to sublingual plica (whartons duct, sublingual artery,veins & lingual nerve)  Sinus forceps is then inserted and openeed to evacuate the pus  Extraorally:- when both submental and sublingual space contains pus they can be drained by placing incision in submental region
  34. 34. MANAGEMENT OF OROFACIAL INFECTIONS  Antibiotic therapy:-  Use of penicillin G (2 to 4 million units, IV 4 to 6 hrs)and  metronidazole(400 mg 8 hourly orally or IV)  Oral clindamycin  Amoxicillin-clavulanic acid(augmentin)  1st and 2nd generation cephalosporins are useful in orofacial infections  In compromised patients- clindamycin alone 300 to 600 mg 8 hourly IV)  Or in combination with gentamycin ( 80 mg IM) can be given  SURGICAL THERAPY  Hilton’s method of incision and drainage  The method of opening an abscess ensures that no blood vessels or nerve is damaged  Incision helps to get rid of toxic purulent material  To allow better perfusion of blood containing antibiotic and defensive elements  To increase oxygenation of infected area
  35. 35. HILTON’S METHOD OF INCISION AND DRAINAGE  Topical anesthesia:- achieved with the help of ethyl chloride spray  Stab incision:- it is made over the point of maximum fluctuation in the most dependent area through skin and subcutaneous tissue  Deepening of surgical site is achieved with sinus forceps  Closed forceps are pushed through deep fascia move towards the pus collection
  36. 36.  Abscess cavity is entered and forceps is opened in a direction parallel to vital structures  Pus flow along side of beaks  Explore the entire cavity for additional loculi  Placement of drain:- A corrugated rubber drain is inserted into depth of abscess cavity & external part secured with suture  Drain is left for 24 hrs  Dressing:- applied over the site of incision taken extraorally without pressure
  37. 37. INVOLVEMENT OF MULTIPLE PRIMARY SPACES  LUDWIG’S ANGINA  It is a firm, massive, brawny cellulitis and acute, toxic stage involving simultaneously submandibular, sublingual, submental space bilaterally  It means “suffocation or choking sensation”  Clinical features:-  There is pyrexia, anorexia , chills, malaise  Severe muscle spasm may lead to trismus with restricted mouth opening and also jaw movements  Tongue movements may be reduced  Air obstruction  Fatal death may occur in untreated case of Ludwig’s angina within 10 to 24 hours due to asphyxia
  38. 38. TREATMENT OF LUDWIG’S ANGINA  Early diagnosis  Maintenance of the patient airway  Intense and prolonged antibiotic therapy  Extraction of offending teeth  Surgical drainage or decompression of fascial spaces
  39. 39. THANK YOU

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