Odontogenic Infection & Surgical Management

Odontogenic infection
&
Surgical management
Somchart Raocharernporn
Mahidol University
Scope
• Anatomical consideration in Maxillofacial
infection
• Pathogenesis
• Classification
• Clinical presentation
• Investigation
• Surgical management
• Summary
ANATOMY MICROORGANISM
(ENVIRONMENT)
INFECTION
HOST
(IMMUNE)
Fascia
• Fascia : broad sheet of
dense connective tissue
whose function to
- Separate structure
that pass during movement
- Serve as pathways
for the course of vascular
& neural structures
Fascial space infection
• Spread of infection
determined by
– Presence & pattern of
loose connective
– Path of least resistance
– Hydrostatic pressure
Fascia of head & neck
• Superficial fascia
• Deep cervical fascia
• A. Superficial layer
• B. Middle layer
• 1. Muscular division
• 2. Visceral division
• - Buccopharyngeal
• - Pretracheal
• - Retropharyngeal
Fascia of head & neck
• C. Posterior layer
• 1. Alar division
• 2. Prevertebral
Infection spreads
by 3 main routes
– Hematogenous
route
– Lymphogenous
route
– Direct continuity
Fascial
layers
• Superficial
cervical fascia
– Layer directly
beneath skin
– Contains
subcutaneous
adipose
tissue,muscle of
facial expression,
platysma
Fascial layers
– Surrounds muscles,glands,…
– Consists of 5 layers
Middle cervical fascia

Visceral
Alar
Investing
Prevertebral
fascia
fascia
layer
fascia
Deep cervical fascia
• Superficial layer
(investing layer,
splitting layer)
– Lies immediately
beneath superficial
cervical fascia
– Surround almost all
structures of neck
– Forming enclosed
compartment
• Superficial layer
– Boundaries :
Fascial layer split

to enclose trapezius,SCM
• Suprahyoid
portion :
– Antr component
– Postr component
• Infrahyoid portion :
– Attachs to sternum
and forms Space of
Burns
• Middle cervical
fascia
– Divided into outer
& inner parts
– Invests infrahyoid
muscle
• Middle cervical fascia
– Boundaries :
Lateral – attach to fascial
enclosure of carotid a.,Int.
Jugular v., vagus n.
Supr – hyoid bone
Infr – sternum & clavicle
Deep cervical fasica
• Visceral fascia
(buccopharyngeal fascia)
– Surrounds the trachea,
thyroid gland, esophagus
– Extends from base of
skull to the thorax
– b/w middle cervical fascia
& prevertebral fascia
• Visceral fascia
Buccopharyngeal Fascia
Prevertebral Fascia
• Alar fascia
– Lies b/w
visceral fascia
and
prevertebral
fascia
– Formation of
carotid fascia
• Alar fascia
– Supr : base of skull
– Infr : level of T1-T2
• Prevertebral fascia
– Covers vertebral
bodies, deep muscle of
postr region of neck
– Supr : base of skull
– Infr : coccyx
“Fascial space infection”
• In the normal state,spaces b/w layers of
fascia do not exist
• Infective process may be digested and
replaced within fascial layers
• Spread to one or more other spaces either
through destruction of intervening fascial
layers or through areas perforated by
blood vessels and nerves
NATURAL HISTORY OF PROGRESSION OF
ODONTOGENIC INFECTIONS
2 major origins :
1. Periapical origin
 Pulpal necrosis
2. Periodontal origin
– Deep periodontal pocket
– Pericoronitis
Location of the infection from
the specific tooth
1. The thickness of the

bone overlying the
apex of the tooth.
2. The relationship of
the site of
perforation of bone to
muscle attachments of
the maxilla and
mandible.
Pathogenesis
• Odontogenic origin
Infection pulp or periodontal tissue
- pulpitis
- periodontitis
- pericoronitis
apical region
First stage periapical osteitis

Pathogenesis
• First stage Periapical osteitis
1)wall off granuloma
dentoalveolar abscess
2)no wall off bone lamina dura

spongy bone
periosteum(periosteitis)
wall off subperiosteal abscess
Pathogenesis
Subperioteal abscess
Soft tissue
1)No muscle attachment (submucosal abscess)
(vestibular abscess)
2) Deep region muscle attachment
(fascial space infection)
Second stage no wall off cellulitis
(soft diffuse swelling)
Third stage wall off fascial space abscess
Infection in the pulp or periodontal tissue
Pulpitis, Periodontitis, Pericoronitis
PERIAPICAL or PERICORONAL INFECTION (periapical osteitis)
Periapical Radicular cyst Fistula Intraoral soft

granuloma tissue abscess
Deep fascial space
Cellulitis infection
Ascending Bacteremia
facial-cerebral Osteomyelitis
/septicemia
infection
PRINCIPLES OF INFECTION MANAGEMENT
1. Removal of cause
2. Incision and drainage
3. Appropriate antibiotic care
4. Supportive care
PRINCIPLES OF THERAPY OF ODONTOGENIC INFECTIONS
I : Determine the severity of the

infection.
– Complete history : chief complaint, onset,
duration, rapidity, previous treatment.
– Physical examination : vital signs, signs of
infection, characteristic of the swelling
(soft, doughy, indurated, fluctuant)
– Radiographic examination : intraoral or/and
extraoral film.
– Source of infection; specific tooth.
– Determine the cellulitis or abscess.
Signs and symptoms of infection :
• Pain and tenderness

• Swelling : cellulitis or abscess
• Redness of the covering mucosa or skin
• Increased temperature
• Trismus : masticatory muscle involvement
• Fever : phagocytic activity
II : Evaluate the state of the patient’s

host defense mechanisms.
1. Host defense mechanisms
– Local defenses
• Intact anatomic barrier
• Indigenous bacteria
– Humoral defenses
• Immunoglobulins
• Complement
– Cellular defenses
• Phagocytes : granulocytes, monocytes
• Lymphocytes
2. Medical conditions that compromise host defenses.
– Uncontrolled metabolic diseases
• Uremia, alcoholism, malnutrition, severe diabetes
– Suppressing diseases
• Leukemia, lymphoma, malignant tumors
– Suppressing drugs
• Cancer chemotherapeutics agents, immunosuppressives
Laboratory investigation
1. Hematologic studies
1. WBC and differential count
PMN : 60-70% ; acute bacterial infection
Lymphocyte : 20-30% ; viral infection
Monocyte : 4-5% ; TB , typhoid
Eosinophil : 1% ; parasitic infection , allergy
Basophil : 0.5% ; leukemia
2. Hemocultures : severe infection, high fever,
septicaemia (H. influenza)
3. ESR (Erythrocyte sedimentation rate)
Man 0-15 mm/h
Woman 0-20 mm/h
Infection state 30-70 mm/h
2. Histopathologic examination
– Granulomatous infection : TB, Actinomycosis,
Syphilis, Fungus
3. Microbiological examination and testing

1. Gram stain : positive or negative, shape (cocci or
bacilli or spirochete), chain or cluster
2. Culture and sensitivity test : aerobe or anaerobe,
specific microorganism and antibiotic sensitivity
Indications for culture and antibiotic
sensitivity testing (C/S)
• Rapidly spreading infection
• Postoperative infection
• Nonresponsive infection
• Recurrent infection
• Compromised host defenses
• Osteomyelitis
• Suspected actinomycosis
III : Determine whether the patient should

be treated by a general practitioner or a
specialist.
Criteria for referral to a specialist
1. Rapidly progressive infection*

2. Difficulty in breathing*
3. Difficulty in swallowing*
4. Fascial space involvement
5. Elevated temperature (>101 F)
6. Severe jaw trismus (<10 mm)
7. Toxic appearance
8. Compromised host defenses
IV : Treat the infection surgically .

• Surgical drainage (primary method)
• Removal of the cause of the infection
• Obtaining a specimen of the pus for culture and
sensitivity test
Incision & drainage
• To get rid off toxic
purulent material
• Decompression
• Allowing better
perfusion of blood
• Increased
oxygenation
When employing incision and drainage
1. Incise in healthy skin and mucosa when
possible.
2. Place the incision in an esthetically

acceptable area.
3. Place the incision in a dependent position to

encourage drainage by gravity.
4. Dissect bluntly through deeper tissues and

explore all portions of the abscess cavity.
When employing incision and drainage
5. Stabilize the drain with sutures.
6. Consider use through-and-through drains in

extra-oral cases.
7. Do not leave drains in for an overly long

period of time; remove them when drainage
becomes minimal.
8. Clean wound margins daily under sterile

conditions to remove clots and debris.
Incise in healthy skin and mucosa
when possible.
Dissect bluntly through deeper tissues and
explore all portions of the abscess cavity.
Stabilize the drain with sutures.
V : Support the patient medically.

• Encouraged to drink a lot of water or juice.
• Take high-calorie nutritional supplements.
• Adequate parenteral fluid and electrolytes.
• Adequate analgesics.
• Encouraged physiotherapy : warm compression and
jaw exercise.
VI : Choose and prescribe the appropriate

antibiotic.
• Is antibiotic administration necessary?
• Use empiric therapy routinely.
• Use the narrowest spectrum antibiotic.
• Use the antibiotic with the lowest toxicity and
side effects.
• Use bactericidal antibiotic if possible.
• Be aware of the cost of antibiotics.
Indication for use of antibiotics
• Acute-onset infection
• Diffuse swelling
• Compromised host defenses
• Involvement of fascial spaces
• Severe pericoronitis
• Osteomyelitis
Situations in which use of antibiotics
is not necessary
• Chronic well-localized abscess
• Minor vestibular abscess
• Dry socket
• Root canal sterilization
• Mild pericoronitis
Effective orally administered antibiotics
useful for odontogenic infections
• Penicillin : Penicillin V, Amoxicillin,
• Amoxycillin + Clavulanic acid: Augmentin® Curam® Amoxiklav®
• Macrolides : Erythromycin, Roxithromycin (Rulid® Rocithin®),
Azithromycin (Zithromax®)
• Clindamycin (Dalacin-C®)
• Cephalosporin : Cephalexin (Keflex®, Ibilex®), Cefaclor
• Metronidazole (Flagyl®)
• Tetracycline
• Aminoglycosides : Gentamycin, Amikacin
• Quinolones : Ciprofloxacin (Ciprobay®)
VII : Administer the antibiotic properly.

• Proper dosage and interval.
• Duration of antibiotic therapy is 2-3 days
after the infection has resolved.
• Improvement by the 3rd day, reasonably
asymptomatic by the 5th day.
VIII : Evaluate the patient frequently.

• Follow up carefully to monitor
response to treatment and
complication.
• Check for recurrent infection :
– too early stopped taking the antibiotics
– too early removed the rubber drain
– too early sealed of the drainage site
Reason for treatment failure
1. Inadequate surgery
2. Depressed host defenses
3. Foreign body
4. Antibiotic problems
Patient noncompliance
Drug not reaching site
Drug dosage too low
Wrong bacterial diagnosis
Wrong antibiotic
Fascial spaces
• Fascia surround the muscle.
– Superficial layer: subcutaneous tissue
– Deep layer : superficial or anterior,
middle, posterior layer
• Divide, unite, blend and fuse to form various
compartments or spaces.
Fascial spaces
• Potential spaces exist when fasciae are
separated by pus, blood, drains or surgeon’s
finger.
• Muscle attachment at the facial bone.

Muscle attachment of
the skull and mandible
Muscle attachment of the medial side of
mandible and relationship to the root apex.
The fascia and muscle of the neck.
Vestibular space
• Boundary
– Superior : buccinator muscle attachment at zygomatic
process
– Inferior : oral mucosa at upper vestibule
– Medial : lateral cortex of the maxilla
– Lateral : buccinator muscle
• Signs and symptom
– Swelling and shallow labial or buccal vestibule.
– Swelling of the cheek and lip commissure.
• Spreading
– Buccal and canine spaces; superiorly.
– Cavernous sinus; via facial, angular, ophthalmic veins.
Buccal space
• Boundary
– Anteromedial : buccinator muscle
– Posteromedial : masseter muscle, anterior
border of the ascending ramus
– Lateral : skin, subcutaneous tissue, parotid
capsule
– Swelling of the cheek posterior to lip
commissure, anterior to the masseter muscle
or ascending ramus, inferior to the lower
border of the mandible
– No trismus in general.
Buccal space
• Spreading
– Pterygomandibular or submasseteric
space; posteriorly.
– Deep temporal space; superiomedially.
– Superficial temporal space;
superiolaterally.
– Lateralpharyngeal space; posteriorly.
Palatal abscess
• Infected upper teeth

(anterior teeth or
palatal root of the
posterior teeth)
through the cortex of
the palate
(subperiosteal
abscess)
• Swelling of the
palate.
Canine space
• Boundary
– Superior : levators muscle
– Anterior : orbicularis oris
– Posterior : buccinator muscle
• Spreading
– Cavernous sinus via facial vein, angular vein,
ophthalmic vein.
– Buccal space; posterolaterally.
– Periorbital area (preseptal space); superiorly.
Boundary of the canine space
Canine space abscess
Signs and symptoms

– Swelling of the canine
fossa, shallow nasolabial
fold.
– Swelling of the lower
eyelid and upper lip,
labial vestibule anterior
to the zygomatic buttress.
Canine space abscess
• Shallow vestibule of the anterior
teeth to canine region.
Incision for approaching
canine space.
Blunt dissection through the
canine space
Orbital infection
Anatomy of the orbit.
Orbital cellulitis
Preseptal cellulitis and canine space abscess
Orbital cellulitis and buccal space abscess
Perimandibular or subperiosteal space
• Boundary
– Between mandible and periosteum from symphysis
to anterior border of the masseter and medial
pterygoid muscle.
– Doughy swelling , tender at the mandible.
• Spreading
– Every spaces; through the periosteum.
Mental space
• Boundary
– Superior : mentalis
and inferior labialis
muscle
– Inferior : platysma
and chin prominence
– Swelling at the
labial vestibule and
chin prominence.
• Spreading
– Submental and
submandibular spaces.
Submental space
• Boundary
– Superior : mylohyoid muscle
– Inferior : platysma muscle
– Lateral and posterior : anterior belly of
digastric muccle
– Swelling at the lower border of the anterior
mandible, may be dysphagia ,but without
elevated tongue.
• Spreading
– Sublingual and submandibular spaces.
– Parapharyngeal space.
Boundary of the submental space.
Sublingual space
• Boundary
– Superior : oral mucosa at flloor of mouth
– Inferior : mylohyoid muscle
– Anterior and lateral : medial cortex of the
mandible
– Medial : hyoglossus, geniohyoid, genioglossus
muscles
• Signs and symptoms
– Swelling at the floor of mouth, elevated tongue
and dysphagia.
• Spreading
– Posterio-inferior : submandibular space
– Posterio-lateral : parapharyngeal space or
pterygomandibular space (rare)
The relationship of the sublingual space
to the adjacents.
Submandibular space
• Boundary (submandibular triangle)
– Superior : mylohyoid muscle
– Medial : hypoglossus , mylohyoid muscle
– Inferior : anterior and posterior belly of
digastric muscle
– Lateral : lower border of the mandible,
platysma muscle
– Swelling inferiorly to lower border of the
mandible.
– Limitation of mouth opening.
Submandibular space
• Spreading
– Sublingual space; through mylohyoid
muscle.
– Contra-lateral submandibular space
– Fascial plane of the neck; inferiorly.
– Parapharyngeal space or
pterygomandibular space; posteriorly.
– Deep temporal space; supero-posterior.
Boundary and the contents of the
submandibular space.
The relationship of the submandibular space
to the adjacents.
Ludwig’s angina
• Dr. Wilhelm Friedrich von Ludwig (1836)
• Angina = a sensation of choking and

suffocation
• Firm (brawny), acute, toxic cellulitis

of the submandibular and sublingual
spaces bilaterally and of the submental
space.
Ludwig’s angina
– High fever, look toxic with sign of airway
obstruction.
– Unable to lay down and trismus.
– Common cause of death are respiratory failure
and sepsis.
– Compromised patient is susceptible to be
attacked.
Boundary of the Ludwig’s angina.
Submasseteric space
• Boundary
– Lateral : masseter muscle
– Medial : lateral surface of ramus
– Severe trismus and throbbing pain.
– Mild swelling at masseter muscle.
• Spreading
– Superficial temporal space; superiorly
– Buccal space; antero-lateral
Pterygomandibular space
• Boundary
– Lateral : medial surface of the ramus
– Medial : lateral surface of medial pterygoid
muscle
– Superior : lateral pterygoid muscle
– Moderate to severe trismus
– Odynophagia
– Swelling of the pterygomandibular raphe
• Spreading
– Temporal space ; superiorly
– Parapharyngeal space ; anteromedially and
posteriorly
– Infratemporal space ; anteriorly
– Submandibular space ; anterior and inferior
The masticator space (coronal section)
The masticator space (axial section)
Spreading of the infection from the lower 3rd
molar to the masticator and
parapharyngeal space.
Parapharyngeal space
• Lateral pharyngeal • Retropharyngeal
space space
– Cone-shaped; base is at the – Between superior
base of skull, apex is at constrictor muscle and
carotid sheath. carotid sheath and
– Between medial pterygoid prevertebral fascia.
and superior constrictor
muscle.
– Inferior : hyoid bone and
deep cervical fascia.
Parapharyngeal space
• Severe odynophagia, limitation of mouth

opening.
• Swelling at the angle of the mandible.
• Tonsil, pharyngeal wall and uvula may be
shifted to the opposite side.
Parapharyngeal space (coronal section)
Presentation/Origin
• Parapharyngeal Space
– Fever, chills, malaise
– Pain, dysphagia, trismus
– Medial bulge of lateral
pharyngeal wall
– Cause—infection of pharynx,
tonsil, adenoids, dentition,
parotid, mastoid, suppurative
lymphadenitis, extension from
other deep neck spaces
Superficial temporal space
• Boundary
– Between temporal fascia and temporalis
muscle.
– Inferior : zygomatic arch
– Pain at temporal region, above the zygomatic
arch; not remarkable swelling.
– Trismus.
• Spreading
– Pterygomandibular and submasseteric space;
inferiorly.
– Parapharyngeal space; posterioinferiorly.
Deep temporal space
• Boundary
– Between temporalis muscle and skull (temporal
bone).
– Inferior : lateral pterygoid muscle and
infratemporal space.
– As superficial temporal space.
• Spreading
– As superficial temporal space
Infratemporal space
• Boundary
– Inferior : inferior head of the lateral pterygoid muscle.
– Lateral : medial surface of the mandible and temporalis
muscle
– Medial : medial and lateral pterygoid muscle
– Severe trismus, tense and tender temporalis muscle.
• Spreading
– Deep temporal space; superiorly.
– Pterygomandibular space; inferiorly.
– Cavernous sinus via pterygoid venous plexus; cavernous
sinus thrombosis or brain abscess.
Boundary of the temporal space and
extraoral approach incision
Superficial temporal space abscess
Signs of deep neck infections
• Swelling below the inferior border of the mandible
Swelling of the floor of the mouth
• Difficulty swallowing
• Difficulty talking
• Pain while swallowing or pain out of proportion to
swelling
• Trismus out of proportion to swelling
Facial and cervical infections associated
with gas-producing bacteria
• Severe pain in the wound
• Toxemia
• Drowsiness, fever, tachycardia
• Intensely tender edematous wound
• Sweet- or foul-smelling discharge
• Dead muscle
• Gas formation with or without crepitus
• Overlying skin that that is gangrenous or
erythematous; occasionally with a coppery hue and
bullous formation.
Complication and Severe maxillofacial infections
• Necrotizing faciitis
– Streptococcal gangrene, gangrenous erysipelas
• Mediastinitis
– Descending infection from retropharyngeal space.
• Actinomycosis
• Meloidosis
– Pseudomonas psedomallii
– Normal flora in the soil, animal feces
– Southeast asia esp. Myanmar, Malaysia, Northeast and
Southern of Thailand.
Spreading of
the infection
down to the
mediastinum
Soft tissue of the retropharyngeal space in
the lateral neck X-ray. Normal is
6 mm. at C2 and 22 mm. at C6.
Osteomyelitis of the Jaws
• Inflammatory condition of bone involving
the medullary cavity, the haversian
system, and the adjacent cortex.
• Mandible > maxilla
Osteomyelitis of the Jaws
• Causes may be
– A traumatic episode
– Chronically inflamed carious tooth
– Infection in an adjacent anatomical
structure
– Metastatic septic focus releasing
septic thrombi
– Advanced chronic periodontitis
• Medically compromised patients with altered
resistance to infection because
– Neoplasia
– Drug therapy
– Tuberculosis
– Blood dyscrasia
– Syphillis
– Malnutrition
– Metabolic diseases ; osteopetrosis
Bone morphology
- cortical or
compact bone
- Medullary or
spongy bone
Classification of the osteomyelitis of the jaws
1. Acute suppurative osteomyelitis

2. Chronic suppurative osteomyelitis
3. Chronic sclerosing osteomyelitis
Diffuse
Focal
4. Chronic osteomyelitis with proliferative
periostitis (Garre’s chronic
nonsuppurative sclerosing osteomyelitis)
Acute suppurative osteomyelitis
History Pain; caries or periodontitis tooth;

recent tooth extraction; infection of
adjacent anatomic site; debilitating
disease; malaise
Clinical Diffuse swelling; pus discharge; acute or

chronic pulpitis; periodontal abscess;
fever; trismus
X-ray Negative or localized periapical

radiolucencies
Organisms isolated
• Streptococcus , Bacteroides, Lactobacillus,
Eubacterium, Klebsiella spp.
• S. aureus, Escherichia coli, Veillonella
parvula, Fusobacterium nucleatum,
Peptostreptococcus magnus
• Anaerobic bacteria
Line of treatment
• Careful clinical and radiographic evaluation to
establish undiagnosed foci of infection (teeth,
foreign bodies, dead or necrotic bone)
• Aggressive debridement, removal the cause, IV
antibiotic, prolonged oral antibiotic therapy
(depend on C/S)
• Clinical and radiographic follow-up: months or
year.
Chronic suppurative osteomyelitis
History Previous episode of odontogenic infection or
acute suppurative osteomyelitis; debilitating
disease; anesthesia or paresthesia;
chronic jaw pain; malaise is unlikely.
X-ray Patchy areas of radiolucency and radiopacity

suggesting bone destruction and sequestrum
formation.
Line of treatment
• Remove of all suspected causes.
• Sequestrectomy and saucerization : Wide

surgical debridement of dead bone, granulation
tissue, chronic exudate.
• Decortication : Removal of the buccal plate of

the mandible at the infection site.
Line of treatment
• Closed wound irrigation-suction : After intra-
oral saucerization or decortication (Neomycin
sulfate-polymyxin B sulfate solution)
• Antibiotic inpregnated bead : Acrylic resin +
high concentration antibiotic (Gentamycin or
tobramycin)
• Resection and immediate reconstruction
Decortication
Saucerization
Closed wound irrigation-suction
Chronic focal sclerosing osteomyelitis
(condensing osteitis)
History Previous history of odontalgia;
patients are younger than age 20.
Clinical Decreased sensation of the tooth
related to the radiopacity; no other
specific clinical findings.
X-ray A well circumscribed radiopaque mass
of sclerotic bone often related to a
tooth root; localized radiopacity in
an edentulous area of the jaw.
Chronic diffuse sclerosing osteomyelitis
• History Pain and local swelling often in
cyclic exacerbations; previous tooth
extractions; short term antibiotic
therapy
• Clinical Swelling along the inferior border of
the mandible; facial asymmetry;
trismus; normal teeth and gingiva;
infrequently lymphadenopathy or
mucosal and cutaneous fistula.
X-ray Varies considrably with the stage of
the disease and age of the patient.
• Osteolytic areas as well as zones of sclerotic
bone appearing early after the onset of
symptom.
• A local cortical bone deficit often at the
mandibular angle.
• Increased mandibular volume in superio-inferior
(children and young adults)
• Reduction in mandibular volume esp. angle
region (adults)
• Shortening of the tooth roots. Diff.diag. from
fibrous dysplasia.
Line of treatment
• Long term antibiotic (Penicillin) at least 3
months.
• Cortisone therapy ; late chronic stages after
antibiotics have failed, fails NSAIDs.
• Long term follow-up (several years)
• Avoid stretch exercises in the trismus patients.
• Decortication should be done if initial therapy
fails.
Chronic osteomyelitis with proliferative periostitis
(Garre’s chronic nonsuppurative sclerosing osteomyelitis)
History Young patients; asymptomatic; mandibular 1st

molar or deciduous teeth with necrotic pulp.
Clinical Afebrile, bony hard swelling on the lateral
aspect of the mandible, normal mucosa.
X-ray Focal overgrowth on the lateral or lower
border of the mandible cortex; “Onion
skinning” or “Periosteal reaction”. Mixed
radiopaque-radiolucent areas in the
medullary areas.
Periosteal reaction at the lower
border of mandible : “onion skin”
appearance
Osteoradionecrosis (ORN)
• Post irradiation complication (more than 6000 rad)
• Necrotic bone or sequestrum at the surgical area.
• “3 H” ; Hypovascular, Hypocellular, Hypoxia
• Infection will develop when contaminate with the
normal flora.
Treatment
• Less debridement and prophylaxis antibiotic.
• Hyperbaric oxygen therapy
Pediatric infections
• Maxilla > mandible
• More aggressive than adults.
• Surgical treatment with growth and development
consideration.
Hyperbaric oxygen therapy (HBO)
• Increase in arterial and venous oxygen tension
• Oxygen enhances healing in osteomyelitis by a
direct bacteriostatic effect on microorganisms;
renders them susceptible to lower ATB
concentration.
• Enhances leukocyte bactericidal activity and
fibroblastic activity.
Hyperbaric oxygen therapy (HBO)
Indication
1. Chronic refractory suppurative osteomyelitis
2. Osteoradionecrosis (ORN)
3. Post radiation therapy
Further reading
• L.J. Peterson: Principles of Oral and Maxillofacial Surgery
vol.1
• L.J. Peterson, E. Ellis III, J.R.Hupp, M.R. Tucker:
Contemporary Oral and Maxillofacial Surgery
• R.G. Topazian, M.H. Goldberg: Oral and Maxillofacial
Infections
ั ยกรรมชอ
• งานศล ่ งปากและแมกซล ิ โลเฟเชย
ี ล กลุม
่ งานทันตกรรม
โรงพยาบาลหาดใหญ่: เอกสารประกอบการอบรม เรือ ื้ ทีม
่ งการติดเชอ ่ ส
ี าเหตุ
จากฟั น, 14-16 กุมภาพันธ์ พศ. 2539
• จีรพันธ์ พันธ์วฒ
ุ ก
ิ ร:การวินจ ื้ ทีม
ิ ฉั ยและการบาบัดการติดเชอ ่ ส
ี าเหตุจากฟั น
Classification
• Hohl et al (1983)
- Infection at dento-alvelolar area
- Infection at mandible and submandibular
region
- Infection at cheek and lateral of face
- Infection at mid face
- Infection at maxillary sinus
- Infection at pharyngeal area
Infection of dentoalveolar area
- Confined at the dento-alveolar process
- Gum boils formation
- Extration & curretage
Infection of
mandible,submandibular region
• Vestibule of the mandible
• Subperiosteal space of the mandible
• Mentalis space
• Submental space
• Sublingual space
• Submandibular space
• Ludwig’s angina
Vestibule of the mandible
(vestibular space abscess)
• Sign & symptoms
- swelling,shallow vestibule
- fluctuant or firm
in consistency
- tender
• Cause
- Periodontal abscess (not drain in
gingival sulcus) vestibule
- Periapical lesion
- confine in oral mucosa
& buccinator m.
-Buccal space through buccinator
m.
- I&D parallel to alveolar crest of vestibule
- Extraction of an infected tooth
Subperiosteal space
(Perimandibular space, space of body of
mandible )
• Potential space between periosteum and
body of mandible
• Extent from symphysis of mandible to
anterior border of masseter muscle,
medial pterygoid muscle
Subperiosteal space
• Sign & symptoms
- firm, swelling at body of mandible
- no increase redness in oral mucosa
- tender
Subperiosteal space
• Cause
- any lower teeth
- periosteitis
- post surgical infection
Subperiosteal space
- vestibule,sublingual,submental,buccal,
mentalis,submandibular
Subperiosteal space
•Surgical management
- horizontal intraoral I&D (buccal/ligual)
- blunt dissection to subperiostrum
Mentalis space
• Locate between anterior surface of
symphysis of mandible and periosteum
• Below mentalis muscle & depressor labii
inferioris muscle
• Superior to platysma
muscle
Mentalis space
• Sign & symptoms
- Swelling at chin
- Bulging & Fluctuant at lower anterior
vestibule
Mentalis space
• Cause
- Lower incisors
Mentalis space
- Submental submandibularis
Mentalis space
- Incision at vestibule paralle to alv. ridge
- blunt dissection ( mentalis m. bone at
periapical)
Submentalis space
• Locate between mylohyoid muscle and
platysma muscle
• Locate between anterior belly of digastric
muscle
• Communucate to
submand. space
posteriorly
• Content : Submental
lymph node
Submentalis space
• Sign & Symptoms
- Swelling at submental region
Submentalis space
• Cause
- Lower incisors
- Spread of infection from submand. space
,mental space
Submentalis space
- submandibular space parapharyngeal
space
- sublingual space
Submentalis space
- Extraoral submental incision paralle to
lower border of mandible
- Intraoral vestibule incision
not adequate
Sublingual space
• V- shape ,superior to mylohyoid m.
• Inferior to mucosa of floor of mouth
• 2 compartment (Lt ,Rt) by
hyoglossus,geniohyoid,genioglossus m.
• Communicate to
Submand. Space
posteriorly
Sublingual space
• Content :
- sublingual salivary gland,Wharton’s duct,
lingual nerve,hypoglossal nerve,lingual
artery
Sublingual space
• Sign & Symptoms
- No Extraoral swelling
- Firm swelling at floor of mouth
- Redness with tender
- Elevate of tongue
- Dysphagia
Sublingual space
• Cause
- Any lower teeth ,apex above mylohyoid
muscle
- Lower incisor to mesial root of 1st molar
Sublingual space
- Postero-lateral : Lateral pharyngeal
space (styloglossus m.)
- Postero-inferior :
Submandibular space
(mylohyoid m.)
Submental space
Sublingual space
- Intraloral incision at FOM closed to
mucogingival fold
Sublingual space
• Sugical management
- Extraoral : Submandibular approach
(Blunt dissection mylohyiod m. lingual )
Submandibular space
• Content
- Submandibular
salivary gland,
lymph
node, facial
artery,facial vein,
proximal part
of Wharton’s duct
,lingual nerve,
hypoglossal nerve
Submandibular space
• Sign & Symptoms
- Swelling at submandibular area
- Tenderness
- Fever
Submandibular space
• Cause
- lower 2nd ,3rd molar
(apex below mylohyoid muscle)
- Post extraction or surgical infection
(lower 3rd molar)
- pericoronitis
lower 3rd molar
Submandibular space
- Sublingual space
- Submental space
- Opposite submand.
- pterygomandibular
- parapharyngeal
- deep temporal space
Submandibular space
- horizontal incision
2 fingerblad from
inferior border of
mandible
Ludwig’s angina
• A firm ,acute,toxic cellulitis of the submand
, subligual spaces and submental space
Ludwig’s angina
• Sign & symptoms
-indurated bilat. submandibular,submental
swelling ,browny edema
-elevated of tongue
-trismus , dysphagia
-difficulty to breathing
airway obstruction
-toxic appearance,fever
-life-threatening condition
Ludwig’s angina
• Cause
- lower teeth
- post extraction
- submandibular gland sialadenitis
- compound mandibular fracture
- oral soft tissue laceration and puncture
wound of oral floor
Ludwig’s angina
- Parapharyngeal space
- Mediatinum though
neck fascial space
Ludwig’s angina
-maintenance of the airway
-intense and prolong antibiotic therapy
-extraction of the offending teeth
-incision and drain of
submental, submand.
, sublingual space
Infection of the cheek & lateral face
• Buccal vestibule of maxilla

• Buccal space
• Submasseteric space
• Deep temporal space
• Superficial temporal space
• Infratemporal space
• Parotid space
Buccal vestibule of maxilla
• Located between buccinator muscle & oral
mucosa
• Inferior to insertion of buccinator m.
• Below zygomatic process of maxilla
• Sign & symptoms
- swelling at vestibule
- tender
• Cause
-any of maxillary posterior teeth
-below insertion of buccinator muscle
-superior : buccal space
, infraorbital space
-via facial vein ,
angular vein ,and
ophthalmic vein
to cavernous sinus
Buccal space
• Locate between skin

& buccinator muscle
• Content : facial
artery,vein,buccal fat
pad ,stensen’s duct
Buccal space
• Sign & symptoms

- Swelling at buccal
area below
zygomatic arch
and above inferior
border of mandible
, posterior to
corner of mouth
may be malarise,fever,no trismus

Buccal space
• Cause
- upper and lower
posterior teeth
Buccal space
- Posterior :
Pterygomandibular
space,
submassteric
space,lateral
pharyngeal space
Buccal space
- superior-medially:
deep temporal
space
- superior-laterally :
superficial temporal
space
Buccal space
-extraoral approach :
horizontal skin incision
-intraoral approach :
vestibular incision
parallel to buccinator
muscle
Submasseteric space
• potential space
between
masseter muscle
and lateral
surface of
mandibular
ramus
Not true space

Submasseteric space
• Sign & symptoms
- Trismus
(moderate to
severe)
- deep seated
throbbing pain
- tender at
masseter muscle
Submasseteric space
• Cause
-lower molar teeth
esp. third molar
-contaminated
needle
-spread from
adjacent space
esp. buccal space
Submasseteric space
- Superior :
superficial space
- Antero-lateral :
buccal space
- Sigmoid
notch:pterygomandi
bular space
Submasseteric space
incision at inferior
border of mandible
vertical incision
lateral to
pterygomandibular
raphe
Deep & superficial temporal space
• Superficial
temporal space :
between temporal
fascia and
temporalis muscle
• Deep temporal
space : between
temporalis muscle
and underlying
bony skull
• Sign & symptoms

- Swelling at temporal region
above zygomatic arch
- pain, tender
- trismus
• Cause
Spread infection
from Upper & lower
molar via
pterygomandibular,
submasseteric
space
- inferior:
pterygomandibular,
submasseteric
space
- postero-inferior :
parapharyngeal
space
incision superior and
parallel to zygomatic
arch
incision at buccal
vestibule of posterior
teeth
Infratemporal space
• Content
- maxillary artery,pterygoid venious plexus
- mandibular branch of CN V,chorda
tympani
Infratemporal space
• Sign & symptoms
- Swelling at temporal area
- Trismus
• Cause
- upper third molar
- contaminate of tuberosity nerve block
- Maxillary sinusitis
Infratemporal space
- superior : deep temporal space
- inferior : pterygomandibular space,
parapharyngeal space
- pterygoid venous plexus to cavernous
sinus
Infratemporal space
- Intraoral : incision at vestibule of upper
posterior teeth
- Extraoral :
- incision submandibular area
- superior,horizontal to zygomatic arch
Parotid space
• Spilt of investing layer
• Parotidomasseteric fascia
• Posterior : stylomandibular ligament
(devide parotid from subamand.)
• Contact to lateral pharyngeal space
Parotid space
• Principle contents
-parotid gland
-facial nerve
-lymph node
-external carotid
artery
-posterior facial
vein(retromand vein)
Parotid space
• Sign & symptoms
- Swelling of the parotid at angle of the
mandible
- pain,tender
- no trismus
- purulent secretion from parotid duct
Parotid space
• Cause
- usually not odontogenic origin
- spread from nearly fascial space
- Parotitis
- Viral infection : Mump
- Otitis media
Parotid space
- Superficial : fistular tract at skin
- Medial : Parapharyngeal space
- Superior : Deep temporal space
Parotid space
- small abscess :
retromandibular or
submandibular
incision
- Large abscess :
parotidectomy incision
Infection of midface
• Palatal subperiosteal area
• Infraorbital area / Canine space
• Periorbital area
• Base of the upper lip
Palatal subperiosteal area
(Palatal abscess)
• Not truly fascial
space infection
• Palatal abscess
confined
subperiosteum
• Sign & symptoms
- Swelling ,fluctuant ,
at one side of palate
- Redness , tender
• Cause
- Maxillary incisor
(lateral incisor,1st
premolar )
- Incision paralle to greater palatine artery
Infraorbital area(Canine space)
• Between levator anguli
oris
• Superior to insertion of
levator labii superioris
alaeque nasi,levator
superioris,zygomaticus
major,zygomaticus
minor
• Sign & symptoms
- Swelling at infraorbital
area
- Shallow of nasolabial
fold
- Shallow of upper
vestibule
• Cause
- Upper teeth (canine,premolar,1st molar)
- to cavernous sinus via facial vein ,
angular vein , and ophthalmic vein
-posterior and lateral : buccal space
-superior : periorbital area
• Surgical
management
- Vestibular
incision paralle to
alveolar ridge
Periorbital area
• Associate with orbital septum
pre-septal : Periorbital cellulitis
post-septal : Orbital cellulitis
Orbital abscess
Subperiosteal abscess
Cavernous sinus
thrombosis
Normal Preseptal Cellulitis Orbital Cellulitis
Subperiosteal Abscess Orbital Abscess Cavernous Sinus

Thrombosis
Periorbital area
• Sign & symptoms
- Varies of severity
- Swelling of upp & low
eyelids
- in severe case :
ophthalmoplegia, loss of
visual aquity , proptosis,
chemosis
Periorbital area
• Cause
- Most common
Paranasal sinusitis
- URI
- Maxillary teeth
- via anterior facial,
angular,opthalmic
vein to cavernous sinus
Periorbital area
- Extraoral area of abscess
- associate site (canine,sinus)
Base of the upper lip
• Sign & symptoms
- pain with swelling at upper lip
-elevation of alar base and nasal tip
-shallow of upp. labial vestibule
• Cause
- maxillary incisor
- infraorbital/canine space
- via anterior facial,angular,opthalmic
vein to cavernous sinus
- incision upp. anterior vestibule at
base of upp. lip
Infection of pharyngeal area
• Pterygomandibular space
• Parapharyngeal space
- lateral pharyngeal space
- retropharygeal space
• Peritonsillar abscess
• Locate between
medial surface of the
ramus and lateral
surface of medial
pterygoid muscle
• Content
- inferior alveolar nerve
and vessels
- lingual nerve
- mylohyoid nerve
- chorda tympani
nerve
• Cause
- pericoronitis of lower 3rd molar
teeth
-post extraction or surgical
removal of lower third molar teeth
-contaminate from IAN block
• Sign & symptoms
- no facial swelling
- redness with
swelling from
pterygomandibular
raphe to lateral
pharynx
- uvula deviate to
opposite site
- trismus
- superior :deep temporal
,infratemporal space
- postero-medial : lateral
pharyngeal space
- antero-lateral :
buccal,submasseteric space
- antero-inferior :
submandibular space
- intraoral : incision
lateral to
pterygomandibualr
raphe
- extraoral:
Submandibular incision
Lateral pharyngeal space
-superior : base of skull
at sphenoid bone
-inferior : hyoid bone
-anterior :
pterygomandibular
raphe
-posteromedial :
prevertebral fascia
-lateral : medial
pterygoid muscle ,
parotid gland
• Sign & symptoms
-pain on swallowing
-some limitation of
mouth opening
-dyspnea
-lateral swelling of
neck
• Sign & symptoms
-difficult to flexing
and turning the
neck
-swelling of tonsil
and lateral
pharyngeal wall ,
displace of uvula
and soft palate
• Cause
-pericoronitis of lower third molar
-post extraction or surgical removal of
lower third molar
-peritonsillitis
-parotitid
-otitis media
-mastoiditis
-retropharyngeal
space
-temporal space
-extend into
mediastinum along
carotid sheath or
through danger space
-retropharyngeal
space
-temporal space
-extend into
mediastinum along
carotid sheath or
through danger
space
-retropharyngeal
space
-temporal space
-extend into
mediastinum along
carotid sheath or
through danger space
• Surgical
management
-extraoral approach
: horizontal incision
between angle of
mandible and
sternocleidomastoid
muscle , superior to
hyoid bone
• Surgical
management
-extraoral approach
: horizontal incision
between angle of
mandible and
sternocleidomastoid
hyoid bone
-intraoral approach : muccosal incision ,
lateral to pterygomandibular raphe
Retropharyngeal space
• potential space
located posterior
to superior
constrictor
muscle and is
anterior to
carotid sheath
and prevertebral
fascia
• Sign & symptoms
- dyspnea
-dysphagia
-nuchal rigidity
-fever
-esophageal regurgitation
-bulging of posterior pharyngeal wall
• Cause
-lower third molar
-result from nasal and pharyngeal infection
in children
• Pattern of spread
-mediastinum
-prevertebral space
cutaneous horizontal
incision between angle
of mandible and
sternocleidomastoid
hyoid bone
muccosal incision ,
lateral to
pterygomandibular
raphe
Peritonsilar space
• Locate between oropharynx mucosa &
superior constrictor muscle
• Non odontogenic origin
• Confuse to pterygomandibular, lateral
pharyngeal space
Most common deep neck infection

Peritonsilar space
• Sign & symptoms
-severe sore
throat
-dysphagia
- swelling at
anterior tonsillar
pillar,soft palate
- uvula swelling ,
deviate to opposite
site
Trismus
Peritonsilar space
- lateral pharyngeal space
- pterygomandibular space
- deep temporal space
Peritonsilar space
- incision and drain
-curvilinear incision at
tonsillar pillar
-tonsillectomy
References
• Hohl TH , Whitacre RJ , Hoolely JR , Williams
BL.A self-instructional guide : diagnosis and
treatment of odontogenic infection.Seattle :
Stoma Press,1983 : 56-94.
• Randal A.Otto.The Neck,Chapter 7 : Deep
Neck Infections, P137-171.
• Topazian and Goldberg. Oral and
maxillofacial Infections, 4th Ed.
• จิรพันธ์ พันธ์ วุฒิกร . การวินิจฉัย และ การบาบัดการติดเชื้อสาเหตุจากฟัน ,
2542
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Odontogenic infection

Middle cervical fascia

Fascial layer split

1. The thickness of the

First stage periapical osteitis

2)no wall off bone lamina dura

Pulpitis, Periodontitis, Pericoronitis

PERIAPICAL or PERICORONAL INFECTION (periapical osteitis)

Periapical Radicular cyst Fistula Intraoral soft

I : Determine the severity of the

• Pain and tenderness

II : Evaluate the state of the patient’s

3. Microbiological examination and testing

III : Determine whether the patient should

1. Rapidly progressive infection*

IV : Treat the infection surgically .

2. Place the incision in an esthetically

3. Place the incision in a dependent position to

4. Dissect bluntly through deeper tissues and

5. Stabilize the drain with sutures.

6. Consider use through-and-through drains in

7. Do not leave drains in for an overly long

8. Clean wound margins daily under sterile

V : Support the patient medically.

VI : Choose and prescribe the appropriate

VII : Administer the antibiotic properly.

VIII : Evaluate the patient frequently.

– Superficial layer: subcutaneous tissue

– Deep layer : superficial or anterior,

middle, posterior layer

• Divide, unite, blend and fuse to form various

separated by pus, blood, drains or surgeon’s

• Muscle attachment at the facial bone.

• Infected upper teeth

Signs and symptoms

• Dr. Wilhelm Friedrich von Ludwig (1836)

• Angina = a sensation of choking and

• Firm (brawny), acute, toxic cellulitis

• Severe odynophagia, limitation of mouth

1. Acute suppurative osteomyelitis

History Pain; caries or periodontitis tooth;

Clinical Diffuse swelling; pus discharge; acute or

X-ray Negative or localized periapical

X-ray Patchy areas of radiolucency and radiopacity

• Sequestrectomy and saucerization : Wide

• Decortication : Removal of the buccal plate of

History Young patients; asymptomatic; mandibular 1st

• Buccal vestibule of maxilla

• Locate between skin

• Sign & symptoms

may be malarise,fever,no trismus

Not true space

• Sign & symptoms

Subperiosteal Abscess Orbital Abscess Cavernous Sinus

Most common deep neck infection

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