Oral and Maxillofacial Infection

Oral and
Maxillofacial
Infection
Part I
By: Dr Chirag MA
2nd year PG
Dept of OMFS

Contents:
• Introduction
• Types of infection
• Aetiology of orofacial infections
• Microbiology
• Spread of orofacial infections
• Surgical anatomy of facial spaces of head & neck
• Complications
• Management
• Conclusion
• Reference
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INTRODUCTION
•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.

•In establishing the presence of an infection,
interaction occurs among 3 factors:
• The host
• Environment
• The organism
• In a state of homeostasis, a balance exists among these 3
factors; any imbalance leads to disease.
• Host defense mechanism are the major factor in
determining the outcome of an infection.

Rate of spread of
Infection
Rate depends on:
1. Virulence of the
invading microbes
2. Dosage or number of
these microbes
3. Host resistance
Severity of infection =
(Virulence x
Dose)/Resistance

Types of infections
 Bacterial infections: not only one particular species, but due
to a mixture of species which make up the oral flora.
 Fungal infections: mainly by Actinomycosis
 Viral infections: Not recognized because they are complicated
early by secondary to bacterial infection.
 Parasitic infections: very rare (ex. Leishmaniasis)

 Infections arising from
contaminated needle puncture
 Others include infected
antrum, salivary gland
afflictions etc. Secondary to
oral malignancies
Etiology of orofacial and neck infections
 Odontogenic – periapical abscess, periodontal abscess,
infected cyst, residual abscess, peri coronal abscess.
 Traumatic – from penetrating wounds of soft and hard
tissues.
 Implant surgery
 Reconstructive Surgery

Predisposing factors for acute oral infections
i. Endocrine disturbances
ii. Nutritional deficiency (decreased resistance)
iii. Chemical compounds used in dentistry (arsenic)
iv. Blood disorders (leukemia, anemia)
v. General diseases (syphilis, TB)
vi. Immunological diseases (AIDS)
vii. Trauma
i. Fracture of jaw
ii. Improper use of surgical burs without cooling

Microbiology
Odontogenic infections are multi-microbial:
• Gram (+) cocci, aerobic and anaerobic:
• Streptococci and their anerobic counterpart,
peptostrptococci.
• Staphylococci, and their anerobic counterpart,
peptococci.
• Gram (+) rods:
• Lactobacillus, Diphtheroids, Actinomyces
• Gram (-) rods:
• Fusobacterium, Bacteroids, Eikenella, pseudomonas
(occasional)

Aerobic 25%
• Gram (+) cocci: 85%
• Streptococcus spp. (90%)
• Staphylococcus spp. (6%)
• Eikenella spp. (2%)
• Streptococcus (group D) spp. (2%)
• Gram (-) cocci:(Neisseria spp.) 2%
• Gram (+) rods: (Cornybacterium spp.) 3%
• Gram (-) rods: (haemophilus spp.) 6%
• Miscellaneous 4%

Anerobic 75%
• Gram (+) cocci: 30%
• Streptococcus spp. (33%)
• Staphylococcus spp. (65%)
• Peptostrptococcus spp. (65%)
• Gram (-) cocci:(Veillonella spp.) 4%
• Gram (+) rods: 14%
• Eubacterium spp.
• Lactobacillus spp.
• Actinomyces spp.
• Clostredia spp.
• Gram (-) rods: 50%
• Bacteroides spp.
• Fusobacterium spp.
• Miscellaneous 6%

Principles For Choosing The Appropriate
Antibiotics
1. Identification of causative organism:
The typical odontogenic infection are caused by mixture
of aerobic and anaerobic organisms (approx. 70% caused by
mixed flora). Pure anaerobic infections are seen only in 25%
of infections.

Antibiotics
2. Determination of antibiotic sensitivity:
• Most odontogenic infections are caused by organisms
such as streptococci that do not vary much in their
antibiotic sensitivity patterns.
• Viridans streptococci that have been exposed to B-
lactams may become quite resistant in short time (2-
3days) and they can cause serious infection in some
patients.
• Penicillinase resistant penicillin should be used.

Antibiotics
3. Use of specific, narrow spectrum antibiotic
• Antibiotic of narrowest spectrum should be chosen.
• Opportunity for development of resistant strains is
presented each time when bacteria is exposed to
antibiotic.
• In case of narrow spectrum antibiotic fewer organisms
have the opportunity to become resistant.
• The use of narrow spectrum antibiotic also minimize risk
of development of superinfection.

Antibiotics
4. Use of least toxic antibiotic
• Antibiotic are used to kill bacteria, but some antibiotics
may also kill normal human cells thus they can be highly
toxic.
• For eg: bacteria that cause odontogenic infection are
sensitive to both penicillin and chloramphenicol but
chloramphenicol is more toxic than penicillin.

Antibiotics
5. Patient drug history
• Two items must be reviewed
• Previous allergic reaction
• Previous toxic reaction
Allergy rate to penicillin is approx. 5%

Antibiotics
6. Use of bactericidal rather than bacteriostatic antibiotic
• Advantages:
• Less reliance on the host resistance
• Killing of bacteria by the antibiotic itself
• Faster result
• Greater flexibility with dosage interval

Antibiotics
7. Cost of antibiotic
It is difficult to place a price tag on the health, but we should
also consider the cost of antibiotic.
8. Encourage patient compliance
Once daily administration – approx. 80%
Twice daily administration – approx. 69%
Four times a day – approx. 35%
Patient stops taking antibiotics when after acute symptoms
subsides.
Highest compliance is on drug that could be given once a
day and for 4-5days.

Antibiotics
9. Combination antibiotic therapy
In addition to treating infections, along with broad spectrum
antibiotics, combination drug therapy should also be
avoided when not specifically indicated.
Because it leads to depression of normal host flora and
increased opportunity for resistant bacteria to emerge.

Antimicrobial Susceptibility Test
Susceptibility testing is used to determine which antimicrobials
will inhibit the growth of the bacteria or fungi causing a specific
infection.
Importance of Susceptibility testing
• Helps to determine which drugs are likely to be most effective in
treating a person's infection.
• Aids in the evaluation of treatment services provided by
hospitals, clinics and national programs for control and
prevention of infectious diseases.
• Monitor for resistance patterns due to the mutations in bacterial
DNA.

Antimicrobial Susceptibility Test
• Minimum Inhibition Concentration (MIC)
The lowest concentration of antimicrobial agent that
inhibits bacterial growth/ multiplication
• Minimum Bactericidal Concentration (MBC)
The lowest concentration of antimicrobial agent that allows
less than 0.1%of the original inoculum to survive

AST methods
a. Disk diffusion method:
1. Kirby Bauer method
b. Minimum Inhibition Concentration (MIC)
1. Broth dilution method
c. E-test

Disk Diffusion method
Principle
• Dilution method - vary amount of antimicrobial substances
incorporated into liquid or solid media
• Paper disks impregnated with antimicrobial agent are placed on
agar medium uniformly seeded with the organism; plates are
incubated at 37°C for 16-18hrs.
• A concentration gradient of the antibiotic is formed by diffusion
from the disk and the growth of the test organism is inhibited at a
distance form the disk (that is related among other factor) to the
susceptibility of the organism.

Broth Dilution Method
Procedure

E-Test
• E-test is a laboratory test used to determine minimum inhibitory
concentration (MIC) and whether or not a specific strain of
bacterium or fungus is susceptible to the action of a specific
antibiotic
• Antibiotic was applied to one side
• Interpretive scale printed on another side
• The strip is placed on the surface of agar that has been
inoculated with a lawn of test bacteria
• MIC - The point (read from scale) where the zone of inhibition
intersect the strip

READING
Each zone size is interpreted according to the organism by
reference in the CLSI guidelines
RESISTANCE :resistant , to indicate that the bacteria can not be
inhibited by the antibiotics.
INTERMEDIATE : intermediate , to indicate that the bacteria
can be inhibited by the high dose of antibiotics.
SUSCEPTIBLE :susceptible, to indicate that the bacteria can be
inhibited by the normal dose of antibiotics

Clinically odontogenic infections can be distinguished in
three periods:
• Periods of Periapical or Dentoalveolar abscess (in which
the initial lesion develops)
• Period of extension to the adjacent bone and facial spaces
• Period of serious complications (embolism, septicemia,
pyremia)

Routes of spread of infection
Routes of spread – the route by which infection can spread
are
 By DIRECT CONTINUITY through the tissues

 By lymphatics to the regional lymph nodes and eventually into
the blood stream. If the infection becomes established in
lymph nodes, the secondary abscess may develop.

 By the BLOOD STREAM. Local thrombophlebitis may rarely
propagate along the veins, entering the cranial cavity via emissary
veins to produce cavernous sinus thrombophlebitis, septicemia and
bacteremia can be caused .
 Hematogenous spread of infectionfrom jaw to cavernous sinus
may occur anteriorly via inferior or superior ophthalmic vein or
posteriorly via emissary vein from pterygoid plexus.

a) SIGNS OF INFECTION
• The cardinal signs of
inflammation.
• Rubor or redness
• Tumour or swelling
• Calor or heat
• Dolor or pain
• Fever / pyrexia
• Head ache
• Lymphadenopathy
b) OTHERS LIKE
• Draining sinuses or fistulae
• Trismus
• Dysphagia
• Increased salivation
• Changes in phonation.
• Difficulty in breathing
• Bad breath
C /F of Orofacial Infections (Generalized)

FASCIA
•Fascia: It is defined as a broad sheet of dense
connective tissue whose function is to separate
structure that must pass over each other during
movement such as muscles and glands and serve as
a pathway for the course of vascular and neural
structure.
•Shapiro defined Facial Spaces as “Potential spaces
between the layers of the fascia”.

•These spaces are normally filled with loose
connective tissues and various anatomical structures
like veins, arteries, glands lymph nodes etc.
•Those spaces which are directly involved by
infection are known as primary fascial spaces.
•Infections can extend beyond these primary spaces
into additional fascial spaces, they are known as
secondary fascial spaces.

Superficial
fascia
Deep fascia
Anterior layer
Investing Fascia
Parotiodmasseteric
Temporal
Middle layer
Sternohyoid-Omohyoid division
Sternothyroid-Thyrohyoid division
Visceral division Buccopharyngeal
Pretracheal
Retropharyngeal
Posteriorlayer
Alar division
Prevertebral
division

Superficial Fascia
• Superficial cervical fascia is a thin layer of subcutaneous
connective tissue that lies between the dermis of the skin
and the deep cervical fascia.
• It contains the platysma, cutaneous nerves, blood, and
lymphatic vessels.
• It also contains a varying amount of fat, which is its
distinguishing characteristic.
• It is considered by some to be a part of the panniculus
adiposus, and not true fascia.

Deep Fascia
• Deep cervical fascia lies under cover of the platysma, and
invests the muscles of the neck; it also forms sheaths for the
carotid vessels, and for the structures situated in front of the
vertebral column. Its attachment to the hyoid bone prevents
the formation of a dewlap.
• The deep cervical fascia is often divided into:
1. Anterior layer
2. Middle layer
3. Deep layer

• The Anterior Layer encircles neck, envelopes the trapezius,
sternocleidomastoid, and muscles of facial expression. It also
contains the submandibular and parotid salivary gland as well as
the muscles of mastication.
• Fascia in anterior layer
a. Investing fascia
b. Parotideomasseteric
c. Retropharyngeal

The Investing Layer
completely surrounds the neck.
Attachments:
Superior: attaches to the
external occipital protuberance
and the superior nuchal line.
Inferior: attaches to the spine
and acromion of the scapula, the
clavicle, and the manubrium of
the sternum.
Anterior: attaches to the hyoid
bone.
Posterior: attaches along the
ligamentum nuchae.

• At the inferior border of mandible it fuses with Ramus of mandible.
Over the ascending ramus it splits encircling muscles of
mastication, forming masticator space.

• It attaches to
cranium,
terminating at the
superficial temporal
crest, forming
temporal fascia.
• It is further divided
into superficial and
deep temporal
fascia.

• The anterior layer splits at about 2cm above the manubrium of
the sternum to form supra sternal space of burns.

• The Middle Layer envelopes the strap muscles (sternohyoid,
sternothyroid, thyrohyoid, and omohyoid muscles).
• Middle layer can be divided into three divisions; the first two are
Sternohyoid-Omohyoid division and Sternothyroid-Thyrohyoid
division.
• Two divisions are not directly involved, as they do not lie on the
major routes that an orofacial infection may follow.

• Below the hyoid bone, visceral division surrounds trachea,
esophagus and thyroid gland. Above the hyoid bone, fascia wraps
around the posterior sides of pharynx, forms Buccopharyngeal
Fascia.

• Deep neck spaces i.e., Retropharyngeal, lateral pharyngeal and
Pretracheal spaces, all lie on the superficial side of the visceral
division.
• The Pretracheal fascia is a portion of the structure of the human
neck. It extends medially in front of the carotid vessels and assists
in forming the carotid sheath.
• This layer is fused on either side with the prevertebral fascia, and
with it completes the compartment containing the larynx and
trachea, the thyroid gland, and the pharynx and esophagus.

• The retropharyngeal space is,
bounded by the
buccopharyngeal fascia
anteriorly and the alar fascia
posteriorly.
• Because serious infections of
teeth can spread down this
space into the posterior
mediastinum, it is often
confused with the danger
space.

• The Deep Layer is the pre vertebral fascial layer and surrounds the
paraspinous muscles and cervical vertebrae.
• It has 2 divisions: Alar and Prevertebral
• Alar fascia passes through the transverse process of the vertebrae
on each side, posterior to retropharyngeal fascia. It extends from
base of skull to the diaphragm.
• The prevertebral fascia surrounds the vertebrae and the attached
postural muscles of the neck and back.
• The prevertebral fascia is usually not involved in the infection of
maxillofacial region.

• The Deep Layer is the pre vertebral fascial layer and surrounds the
paraspinous muscles and cervical vertebrae.
• It has 2 divisions: Alar and Prevertebral
• The Alar Fascia is a layer of fascia, sometimes described as part of
the prevertebral fascia.
• Alar fascia passes through the transverse process of the vertebrae
on each side, posterior to retropharyngeal fascia. It extends from
base of skull to the diaphragm.

• The prevertebral fascia
surrounds the vertebrae
and the attached postural
muscles of the neck and
back.
• The prevertebral fascia is
usually not involved in
the infection of
maxillofacial region.

• Controversy exists as to
which of the deep cervical
fascia contribute to
Carotid Sheath. Some
authors believe that carotid
sheath is formed by alar
division, whereas others
attribute formation of this
important structure to all
the 3 layers.

• Carotid sheath contains
Cervical sympathetic chain is
attached to the posterior
surface of sheath. Carotid,
jugular and Vagus have each
compartment within the
carotid sheath and Ansa
Cervicalis on the anterior
surface of sheath.

CLASSIFICATION
MODE OF
INVOLVEMENT
1º maxillary
spaces
1º mandibular
spaces
2º fascial
spaces
• Submental
• Submandibular
• Sublingual
• Buccal
• Massetric
• Pterygomandibular
• Sup. & deep temp.
• Lateral pharyngeal
• Retropharyngeal
• Prevertebral
• Parotid space
•Canine
• Buccal
• Infratemporal

CLINICAL SIGNIFICANCE
Face
Suprahyoid
Spaces
Infrahyoid
Spaces
Spaces Of
Total Neck
• Retropharyngeal
• Space of carotid
sheath.
• Pretracheal• Sublingual
• Submandibular
Sub maxillary
Sub mental
• Lateral pharyngeal
• Peritonsillar
• Buccal
• Canine
• Masticator
Masseter
Pterygoid
Temporal
• Parotid

SCOTT’S CLASSIFICATION
Floor of
mouth
Masticator
space
Paratracheal
space
• Deep pterygoid
space
• Parotid
compartment
• Paratonsillar
space
• Temporal
Superficial
Deep
• Submasseteric
• Superficial
pterygoid
space
• Sublingual space
• Submandibular
space
• Submental space

GRODINSKY & HYOLYOKE
Space I Space II Space III Space IV
III IIIA
Space superficial
& deep to platysma
Space behind anterior layer
of deep cervical fascia
Pretracheal
space Viscero- vascular
space
Danger space –
potential space
between alar &
prevertebral fascia

CANINE SPACE
Boundaries :
 Superiorly : Levator labii superioris alaeque nasi, levator
labii superioris and zygomaticus minor muscle.
 Inferiorly : Caninus muscle (levator angulion’s)
 Anteriorly : Orbicularis oris
 Posteriorly : Buccinator muscle
 Medially : Anterior surface of maxilla.
Source of infection :
• Odontogenic infections from Maxillary Canines,
Premolars and Sometimes Mesiobuccal Root of
Maxillary First Molars.
• Rarely from Nasal Infections

Clinical features :
 Swelling lateral to nose.
 Obliteration of nasolabial fold and drooping of angle of
mouth.
 Edema of lower eye lid.
 Intra orally the offending tooth is tender and mobile and
obliteration of the buccal sulcus also seen.
Spread of infection :
• To buccal space
Treatment :
 CST and appropriate antibiotic therapy.
 I & D, intra orally high in the labial vestibule apical to
the lateral incisor and canine, rubber drain placed

DANGER AREA OF FACE
• The deep connections of the facial vein
include the communication between the
supraorbital and superior ophthalmic
veins and another communication with
the pterygoid plexus through deep
facial vein which passes back wards
over the buccinator.
• The facial vein communicates with the
cavernous sinus through these
connections.
• Since these veins does not have valves,
infection from the face can spread in a
retrograde direction and causes
thrombosis of cavernous sinus.

BUCCAL SPACE
It is the potential space between the buccinator and the
masseter muscle.
Boundaries :
 Medially – buccinator muscle and buccopharyngeal
membrane.
 Laterally – Skin and sub cutaneous tissue.
 Anteriorly – Zygomaticus major above and depressor
anguli oris below.
 Superiorly – Zygomatic arch.
 Inferiorly – lower border of mandible.
 Posteriorly – pterygomandibular raphe and anterior edge of
masseter muscle.

Contents :
• Buccal pad of fat
• Parotid duct (Stenson’s duct)
• Facial artery
Periapical infections from maxillary and mandibular
molars and premolars.
• To Infraorbital space
• To Pterygomandibular space
• To Infratemporal space

Clinical features :
 If pus accumulates on the oral side of buccinator muscle,
swelling in the vestibule seen.
 If pus accumulates lateral to the muscle marked extraoral
swelling extending from lower border of mandible to infra
orbital margin and from anterior margin of masseter to the
corner of mouth.
 Fluctuance

Treatment :
• CST and appropriate antibiotic therapy
• I and D horizontal incision through the oral mucosa
along the premolar, molar region. If pus is lateral to
the buccinator, then the muscle is penetrated with a
curved mosquito forceps to enter the buccal space, pus
evacuated and drain is placed.
10-12-2019 Oral & Maxillofacial Spaces 72

Complications:
• An infection may continue its spread along the
pterygomandibular raphe and enter the lateral pharyngeal
space.
• Extension along the buccal fat pad, transverse facial vein
and pterygoid plexus allows infections to enter
infratemporal space.
• Buccal space infection that erode into the transverse facial
vein may follow the posterior route to the cavernous sinus,
causing cavernous sinus thrombosis.
• Buccal space is a portion of subcutaneous space, buccal
infection can spread through the subcutaneous space into
periorbital space.

INFRA TEMPORAL SPACE
Boundaries :
• Medially : Lateral pterygoid plate and lateral pterygoid
muscle.
• Laterally : Tendon of temporalis muscle and ramus.
Superiorly : Infra temporal surface of greater wing of
sphenoid and zygomatic arch.
• Anteriorly : Infra temporal surface of maxilla and posterior
surface of zygomatic arch.
• Posterolaterally : Mandibular condyle, temporalis, lateral
pterygoid muscle, and medial aspect of parotid capsule.

Contents :
• Pterygoid plexus
• Internal maxillary artery
• Mandibular, mylohyoid, lingual, buccinator & chorda
tympanic nerves.
• Lateral pterygoid muscle.
Infections from maxillary 2nd & 3rd molars.
Infections from pterygomandibular and buccal spaces.
L.A injections with contaminated needles in the area of
tuberosity.
• To pterygomandibular space
• To buccal space
• Can cause cavernous sinus thrombosis

Clinical features :
Extraoral :
• Trismus
• Marked swelling in front of
the ear.
• Swelling of eyelid and
Proptosis.
• Optic neuritis in severe
cases.
Intraoral :
• Swelling in the tuberosity
area.
• Swelling of the lateral
portion of soft palate.

Treatment :
• CST and appropriate antibiotic therapy
• I and D
Intraoral:
• incision in the Buccal vestibule opposite to 2nd and 3rd
molars, pus drained and rubber drain placed.
Extra oral approach :
• In severe cases Incision: Upper and Posterior edge of
Temporalis Muscle within the hair line and pus drained.
Rubber drain is inserted.
• Trismus persists - Active physiotherapy with jaw
exercises can improve the condition.
• In cases of failure to improve mouth opening then,
• Temporalis myotomy
• Excision of coronoid process.

Complications :
• Infection can spread to temporal space superiorly and
pterygomandibular space inferiorly.
• Because of the proximity of pterygoid plexus of veins,
from which infection can track upwards to cavernous
sinus via deep facial veins or emissary veins resulting
in cavernous sinus thrombosis.

SUBMENTAL SPACE
Boundaries :
• Laterally – By anterior belies of digastric muscle and
lower border of mandible.
• Superiorly – By mylohyoid muscle.
• Inferiorly – Skin, Superficial fascia, platysma, deep
cervical fascia.
Contents :
• Anterior jugular vein
• Submental lymph nodes
• Source of infection :
• Mand anterior teeth

Clinical features :
• E/O: – Distinct firm swelling in midline beneath the chin.
Fluctuation seen.
• I/O: - The offending tooth may exhibit tenderness to
percussion and mobility.
• Discomfort on swallowing.
Treatment :
• CST for appropriate antibiotic therapy.
• I & D by making a Horizontal incision in the skin below
symphysis of mandible pus evacuated and rubber drain
placed.

SUBLINGUAL SPACE
Boundaries :
• Superiorly – mucosa of the floor of oral cavity.
• Inferiorly – by mylohyoid muscle.
• Laterally and Anteriorly – by lingual aspect of
mandible above mylohyoid muscle.
• Medially – By geniohyoid, genioglossus and
styloglossus muscles.
• Posteriorly – by body of hyoid bone.
Contents :
• Sublingual gland
• Deep portion of submandibular gland and duct.
• Lingual and hypoglossal nerves
• Terminal branches of lingual artery.

Infection from lower incisors, canines, premolars & sometimes 1st
molars if lingual cortical plate is perforated.
Infection from tongue.
To submandibular space
Clinical features :
• E/O: Little or no swelling
lymph nodes may enlarged and tender
Pain and discomfort on deglutination.
• I/O: Swelling on the floor of mouth
Floor of mouth is raised and tongue pushed superiorly.
• Dysphagia
• Airway obstruction

Treatment :
• CST
• I and D
• I/O : An incision made close to the lingual cortical plate
avoiding the Wharton’s duct, sub lingual artery and
veins and the lingual nerve.
• E/O: When both Submental and sublingual spaces contain
pus they can be drained via skin incision placed in the
Submental region pushing a closed sinus forceps
through the mylohyoid muscle.

SUBMANDIBULAR SPACE
This space lies between anterior and posterior bellies of
digastric muscle.
Boundaries :
• Laterally - skin, superficial fascia, platysma, superficial
layer of deep fascia and lower border of mandible.
• Medially – mylohyoid, hyoglossus and styloglossus
muscles.
• Inferior – anterior and posterior bellies of digastric.
• Superiorly – medial aspect of mandible and attachment of
mylohyoid muscle.
• Floor – mylohyoid and hyoglossus muscles.
• Posteroinferior – stylohyoid and posterior belly of
diagnostic.
• Anteroinferior – anterior belly of digastric muscle.

Contents :
• Submandibular gland and duct.
• Facial artery, mylohyoid nerve and vessels.
• Submandibular lymph nodes
• Lingual and hypoglossal nerves.
• Infections from mandibular 2nd and 3rd molars. The pus
perforates the lingual cortical plate of mandible inferior to
the attachment of mylohyoid and passes directly into the
submandibular space.
• From sublingual and submental spaces.
• Contaminated needles while giving inferior alveolar block
To buccal space
To lateral pharyngeal space

Clinical features :
Extra oral :
• Swelling below lower border of mandible.
• Dyspnea,
• Signs of inflammation
• Tender on palpation
Intra oral :
• Teeth involved are mobile and tender
• Moderate trismus, Dysphagia
Treatment :
• CST & antibiotic therapy.
• I & D an incision of about 1.5 – 2 cm length is made 2
cm below the lower border of mandible in the skin
creases, pus evacuated and rubber drain is inserted.

LUDWIG’S ANGINA
It’s the name given to a massive, firm, cellulites / induration,
and acute, toxic stage, involving simultaneously, the
submandibular, sublingual and submental spaces
bilaterally.
It was first described by Wilhelm Friedreich Von Ludwig in
1836.
The condition had established its unique identity, in general
medical personnel with 3 FS as it was to be
• Feared it rarely become
• Fluctuant and it was often
• Fatal

Etiology :
Odontogenic : (90%) mandibular second and third molars
• Acute dentoalveolar abscess
• Acute periodontal abscess
• Pericoronal abscess
• Infected mandibular cyst.
Iatrogenic :
• like use of contaminated needle for LA.
• Traumatic injuries
• Mandibular fractures.
• Osteomyelitis
• Submandibular and sublingual sialadenitis
• Secondary infections of oral malignancies
• Miscellaneous Infections in tonsils or pharynx
• Foreign bodies such as fish bone etc.
10-12-2019 90
Microbiology :
Excess of microorganism has been implicated as the
causative agents.
They include :
• Streptococci
• Staphylococci
• Gram negative microorganisms such as E coli and
pseudomonas
• Anaerobics including bacteriodes
• Anaerobic streptococci
• Fusosphirochaetes

Clinical features :
a. General examination :
General : patient looks toxic, very ill and dehydrated.
pyrexia, anorexia, chills and malaise. Dysphagia
b. Regional examination :
Extra oral :
• Firm hard brawny (board like, woody hard) swelling in the
bilateral / submandibular and submental regions which
soon extends down the anterior part of the neck to the
clavicles, swelling is non pitting minimally or no fluctuant
associated with severe tenderness and with ill defined borders
with induration.
• Typically mouth remains open due to edema of sublingual
tissues
• Airway obstruction Respiratory rate raised, breathing being
shallow with accessory muscles of respiration being used.10-12-2019 Oral & Maxillofacial Spaces 91

Intra orally :
• The swelling develops rapidly distends and raises the floor
of mouth , woody edema of the floor of mouth tongue.
• Tongue may be raised.
• Increased salivation, stiffness of tongue and dysphagia.
• Backward spread of infection leads to edema of glottis
resulting in respiratory obstruction. Stridor being the
alarming sign of this fatal extension needing emergency
intervention to keep airway patent.
• There is reduced control of muscles and jaw posture, saliva
is excessive and saliva may be even seen drooling.

Fate of Ludwig's angina :
• If untreated, can be fatal within 12-24hrs, death
arising from asphyxia.
The other causes of death include
• Septicaemia / septic stock
• Mediastinitis
• Aspiration pneumonia

Treatment :
It should be taken as a life threatening emergency situation. It
is best treated by aggressive intervention.
The treatment is based on the combination of these factors.
• Early diagnosis
• Maintenance of patent airway /Tracheostomy
• Intense and prolonged antibiotic therapy.
• Extraction of offending tooth.
• Surgical drainage or decompression of fascia spaces.
• Bilateral submandibular incisions and if required a midline
submental incision 1cm below the inferior border of
mandible are sufficient to drain the involved spaces.

THE SECONDARY FASCIAL SPACES
• Massetric space
• Pterygomandibular space
• Superficial and deep temporal spaces
• Lateral pharyngeal space
• Retropharyngeal space
• Prevertebral space
• Parotid space
• Pterygopalatine space
• Space of body of mandible.

MASSETRIC SPACE
Situated between the masseter muscle and the lateral surface of the
ramus of the mandible.
Boundaries :
• Anterior : anterior border of masseter and buccinator
• Posterior : parotid gland and posterior part of masseter
• Inferior : attachment of masseter to the lower border of
mandible
• Medial : lateral surface of ramus of mandible
• Lateral : medial surface of masseter muscle

Contents :
• Masseter nerve
• Superficial temporal artery
• Transverse facial artery
• lower thirds molars, either resulting from pericoronitis related
to vertical and distoangular 3rd molars.
• If a periapical abscess spreads subperiosteally in a distal
direction.
Clinical features :
• External facial swelling, moderate in size and confined to the
outline of masseter muscle.
• Severe trismus and tenderness over the ramus of the mandible.
• Pyrexia and malaise seen.

Treatment :
• CST & antibiotic therapy
• Incision and drainage
• Intra oral approach : incision made vertically over the
lower part of anterior border of ramus of mandible, deep to
the bone. A sinus forceps is passed along the lateral surface
of the ramus downwards and backwards and pus evacuated
and drain placed.
• Extra oral approach : When the mouth cannot be opened
an incision is placed in the skin behind the angle of
mandible to open the abscess by Hilton’s method, and pus
evaluated and drain placed.

PTERYGOMANDIBULAR SPACE
Boundaries :
• Anteriorly : buccopharyngeal fascia and pterygomandibular
raphe.
• Posteriorly : by deep part of parotid gland
• Inferiorly : medial surface of ramus of mandible
• Medially : lateral aspect of medial pterygoid
• Laterally : inferior head of lateral pterygoid muscle
Contents :
• Inferior alveolar nerve and vessels
• Mylohyoid nerve and vessels
• Lingual nerve
• Loose areolar connective tissue

• Infections mesioangularly or horizontally positioned
mandibular and third molars including pericoronitis can
spread beyond the posterior extend of mylohyoid
muscle.
• Contaminated needle used for an inferior alveolar nerve
block.
• To parotid space, buccal space, infra temporal fossa.
• To lateral pharyngeal space and then to retropharyngeal
space.
• Can also spread anteroinferiorly to involve the
submandibular space.

Clinical features :
• Severe trismus
• Dysphagia
• Difficulty in breathing
• Medial displacement of the lateral wall of the
pharynx
• Midline of soft palate is displaced to the unaffected
side and uvula is swollen.
• The pterygomandibular space abscess should be
distinguished from peritonsillar abscess where there
is no trismus and no dental involvement.

Treatment :
I and D
Intraorally
A vertical incision 1.5 cm in length made on the
anterior and medial aspect of ramus of mandible, sinus
forceps inserted, pus evacuated and rubber drain placed.
Extra orally
An incision made in the skin below the angle of
mandible and sinus forceps inserted medial to the ramus
in an upward and backward direction, pus evacuated and
rubber drain inserted.

TEMPORAL SPACE
The temporal fascial spaces are in relation to the temporalis
muscle.
They are 2 in number
i. Superficial temporal space
ii. Deep temporal space
Boundaries :
Superficial temporal space
• Medially – by temporalis muscle
• Laterally – by temporal fascia
Deep temporal space
• Medially – temporal bone and greater using of
sphenoid bone
• Laterally – medial surface of the temporalis muscle

Secondary to extension of infection from infratemporal
space, massetric space and pterygopalatine space.
Clinical features :
• Severe pain and trismus seen
• Swelling over the temporal region.
• When there is an associated buccal space abscess, the
swelling has a characterize ‘dumbbell’ shape due to lack
of swelling over the zygomatic arch.
• Deep temporal space abscess produces less swelling and
difficult to diagnose. But there is considerable pain
trismus. Because of its depth it is difficult to elicit
fluctuation.

Treatment:
• Extra Oral: Incision and drainage: extra oral incision
in the temporal region, well above the hair line, 450 to
the zygomatic arch. The hemostat is inserted above
and below the temporalis muscle, pus evacuated and
drain placed.
• Intra Oral: A vertical incision is made just medial to
the upper extent of the anterior border of the ramus.
If the hemostat is passed superiorly along the lateral
aspect of the coronoid process it will enter the
superficial temporal space and if the hemostat is
passed superiorly along the medial aspect through the
infratemporal fossa, it will enter the deep temporal
space. Pus evacuated and drain secured

PHARYNGEAL SPACES
They are: 1) Lateral pharyngeal
2) Retropharyngeal space
These spaces form a ring around pharynx and together
form a pathway for spread of orofacial infections in neck
and mediastinum.
Lateral pharyngeal space (Para pharyngeal)
It is a potential cone shaped space or cleft lying lateral to
pharynx, medial to masticator, submandibular and
parotid spaces, with its base upper most at the base of
skull and its apex at the greater horn of hyoid bone.
The space is divided into two by the styloid process as
Anterior And Posterior compartments.

Boundaries :
• Medially : superior pharyngeal constrictor (lateral wall of
pharynx)
• Laterally : by ascending medial pterygoid muscle and
medial surface of deep lobe of parotid gland.
• Anteriorly : pterygomandibular raphe.
• Posteriorly : bounded by styloid muscles, upper part of
carotid sheath, prevertebral fascia.
• Superiorly : base of skull, petrous portion of temporal bone
with foramen, lacerum and jugular foramen.
• Inferiorly : level of hyoid bone limited by the attachment of
capsule of submandibular gland and posterior belly of
digastric.

Contents :
• Lymph nodes of deep cervical group.
• Ascending pharyngeal artery and fascial artery
• Loose areolar connective tissue and fat.
• Carotid sheath (ICA, IJV and vagus nerve)
• Glossopharyngeal, spinal accessory and hypoglossal
nerves and cervical sympathetic trunk.
• No lymph nodes are present in posterior compartment.
• Infection from mandibular third molars and occasionally
from maxillary third molars.
• Lateral spread from tonsil (palatine)
• Infection from parotid gland.
• sublingual, submandibular and pterygomandibular space.

Extra oral:
An incision is made along the anterior border of
sternocleidomastoid muscle, extending from below the
angle of mandible to the middle third of submandibular
gland. The fascia behind the gland is incised and a
curved hemostat is inserted and carefully directed
medially behind the mandible, as well as superiorly and
slightly posteriorly until the abscess cavity is reached
and pus evaluated and drain inserted.

Intra oral:
Usually this approach is avoided because in the presence of
erosion of internal carotid, artery, massive hemorrhage results
which is fatal.
A vertical incision is placed over the pterygomandibular
raphe. A sinus forceps or curved hemostat is passed through the
pterygomandibular raphe along the medial surface of ramus,
medial to medial pterygoid and just lateral to the superior
constrictor into the lateral pharyngeal space, pus evaluated and
drain inserted.
Complications :
• Respiratory paralysis – acute edema of pharynx
• Thrombosis of internal jugular vein.
• Erosion of internal carotid artery.
• Mediastinitis
• Cavernous sinus thrombosis
• Meningitis and brain abscess

PAROTID SPACE
It is formed by splitting of anterior layer of deep cervical fascia. In
this region it is also called as parotideomasseteric fascia
Boundaries :
• Superior margin: external auditory canal; apex of the mastoid
process
• Inferior margin: inferior mandibular margin (although the
parotid tail can extend further inferiorly below the angle of the
mandible)
• Anterior margin: masticator space

Contents :
• parotid glands
• parotid lymph nodes
• facial nerve (CN VII)
• external carotid artery
• retromandibular vein
• Ascent of bacterial infection.
• Spread of infection from the auditory canal via the cartlaginous
fissures of Santorini or the bony foramen of Huschke.
Clinical features :
• Parotid enlargement.
• Pitting edema over the parotid area.
• Parotid massage expresses pus into the oral cavity via the
Stenson’s duct,opposite the upper 2nd molar.

Treatment :
Incision and drainage
• Extra oral approach :
• A retromandibular incision through the skin and super
fascia extending from inferior aspect of ear lobe angle
of mandible.
• Curved incision made at the angle of mandible (Blair
incision).

PALATAL SPACE
• Infection that begins in the lateral incisor or the palatal
roots of upper posterior teeth tend to cause infections of the
palatal space.
• It is the subperiosteal space of the palate, and infections in
this region will be very painful because of the rich
innervation of the periosteum.
• Because the palatal periosteum is bound tightly to the
underlying bone, abscess in this region are localized.
• Spontaneous drainage is uncommon, usually occurs
through the sulcus of the infected tooth.

SPACE OF THE BODY OF MANDIBLE
• Infection that perforate the bony cortical plate, but not the
overlying periosteum, commonly originate in mandibular
premolar and molar.
• It is the subperiosteal space of the mandible.
• Borders of the space of body of mandible are the periosteal
envelope and the cortical surface of the bone.
• The mandible itself appears enlarged in a patient with an
infection of the space.

CONCLUSION
• Early recognition of orofacial infections and prompt
appropriate therapy is absolutely essential.
• A through knowledge of anatomy of face and neck is
necessary to predict pathways of spread of infection
and drain the spaces adequately.
• Otherwise the infection spread to such an extent
causing considerable morbidity and occasional death..

REFERENCE
i. Surgical Pathology – Fonseca
ii. Oral And Maxillofacial Infections – Topazian
iii. Principles Of Oral And Maxillofacial Surgery – Peterson
iv. Textbook Of Oral Surgery – Daniel Laskin
v. Surgical Approaches to the facial skeleton – Edward Elli
vi. Clinics Of North America – Space Infection

Oral and Maxillofacial Infection

Oral and Maxillofacial Infection

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