PRIMARY SPACES

OF SPACE INFECTION

BY MANMOY SAHA
(INTERN)
 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
 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
PATHWAYS OF ODONTOGENIC INFECTIONS
 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
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
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

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
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

 Pterygomandibular space
 Superficial temporal space
 Deep temporal space
 Lateral pharyngeal space
 Retropharyngeal space
 Prevertebral space
 Parotid space
 Based on 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
The teeth which frequently give rise to abscess
in
this area are maxillary canines, premolars and
sometimes mesiobuccal root of 1st molar
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
CLINICAL FEATURES:- INCISION &
DRAINAGE:-
 Swelling of cheek and upper
lip  A curved mosquito
forcep is inserted
 Obliteration of nasolabial fold superior to the
attachment of caninus
 Drooping of the angle of muscle & the infra-
mouth orbital space is
entered
 edema of lower eyelid

 Pus is evacuated and

 Redness and marked
tenderness of facial tissues a drain is inserted &
secured to one of the
 Intraoral- offending tooth is
margins with suture
mobile and tender on
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
 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
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
 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
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
 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

 CLINICAL FEATURES:-  INCISION & DRAINAGE:-

 Extraoral- trismus  Intraoral approach- incision

is given in buccal vestibule
 Bulging of temporalis opposite 2nd and 3rd molar
muscle exploration is carried out
medial to coronoid process
and temporalis muscle
 Marked swelling of the upwards backwards with
face on the affected side in sinus forcep ,space is
front of the ear overlying entered and drained
area of tmj
 Extra oral approach-
 Intra oral –swelling in incision is made at upper
tuberosity area with and posterior edge of
elevation of temp 104F temporalis muscle within
hairline.
 Sinus forcep directed
upward medially
 Pus is evacuated
 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
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
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
 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
 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
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,
 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
 CLINICAL FEATURES:-  Spread: of infection-

 Extra oral:- firm swelling in  There is no major anatomic

the submandibular region, barriers so infection can
below inferior border of extend into submental space
mandible
 There is no anatomical barrier
 Redness of overlying skin so infection can spread easily
across the midline involve
submandibular space on other
 Intra oral:- teeth are sensitive side
to percussion
 It communicates with
 Teeth are mobile sublingual space around
posterior border of mylohyoid
 Dysphagia muscle

 Moderate trismus  It can also spread into

parapharyngeal space
INCISION &
DRAINAGE:-
 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
 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
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
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
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
 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
 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
 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
 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
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
THANK
YOU