Oro facial infections__oral_surgery_

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Oro facial infections__oral_surgery_

  1. 1. ORAL AND MAXILLOFACIAL INFECTIONS BHARATH REDDY .M
  2. 2. INTRODUCTION Oral and maxillofacial infections are commonly caused by teeth they are referred as odontogenic infections. The etiological agents may be bacteria viruses or fungi. The infection may spread directly from the tooth or secondary infections of cyst or tumours or infection of surgical wound or by contaminated needles.
  3. 3. CLINICAL DIAGNOSIS There are three stages in progression of acute odontogenic infections Stage 1 Most infections are odontogenic in origin.They may be periapical or periodontal or pricoronal infection of tooth. Patient may be asymptomatic. Stage 2 When the infection is still confined with in the alveolar bone it is termed as periapical osteitis.Tooth is tender to percussion and frequently extruded from the socket. Patient complains of sever pain.
  4. 4. Stage 3 Once the infection exits through the bone and the periosteum into the surrounding soft tissue ,an inflammatory oedema occurs A diffuse swelling develops extraorally which is soft and duffy in consistency called Cellulitis. At this stage no pus formation occurs Stage 4 When suppuration does occur and the infection localises,the condition is termed as, Absess . With increased pressure it may even perforate the soft tissues and pus discharge may be seen as sinus opening or fistulous trac ROOTS OF SPREADS OF INFECTION 1.Spreads by direct continuity 2.Spreads by lymphatics to regional lymph nodes 3.spreads by blood stream
  5. 5. The infection causes formation of pus locally and pus accumulation in :1. Tissue spaces 2. Between periosteam and bone 3. Spaces present between muscle layers
  6. 6. Difference bet’n cellulitis and abscess Characteristic Cellulitis Duration Pain Size Localization Palpation Appearance Skin quality Surface temp. Loss of function Tissue fluid 0 of seriousness Bacteria 3-7days severe and generalised large diffuse hard exquisitely tender reddened thickened Hot severe serosanguineous severe mixed Abscess Over 5 days Moderate and localised Small Circumscribed Fluctuant and tender Peripherally reddened Centrally undermined Moderately heated Moderately severe Pus Moderate Anaerobic
  7. 7. DIRECTION OF SPREAD OF INFECTION Infection from any tooth will spread along the path of least resistance. It can perforate either the buccal cortical plate or lingual / palatal cortical plate depending upon which is thinner. 1. Lower central and lateral incisor teeth If the root of these teeth are extended above the attachment of mentalis muscle, pus accumulates in the vestibule If the roots extended below the attachment of mentalis muscle pus accumulates within the connective tissue of the muscle and seen as a extra oral swelling 2. Lower canine Because the muscle attachment ( depressor labii inferioris , depressor anguli oris,platysma ) located well below the root apex the periapical infection from this tooth will localise in the oral vestibule 3. Mandibular premolars Infection from premolars after penetrating buccal cortex results in vestibular abscess
  8. 8. 4. Mandibular first molar If the root apices are above the oblique line of buccinator attachment then it will cause localised infection within the oral vestibule If the root apices are below the buccinator attachment it can give rise to buccal space abscess on lingual aspect mylohyoid muscle is roughly parallel to the buccinator muscle . The apices of premolars and first molars is always above this muscle which give rise to sublingual space infection since there is loose connective tissue interspersed between the muscle forming the boundary the infection may spread across the midline in the opposite side called LUDWIG’S ANGINA 5. Mandibular second molar Perforation below the mylohyoid muscle can give rise to submandibular space infection
  9. 9. 6. Mandibular third molar Placed medial to the vertical plane of ramus .therefore its apex is more closer to lingual than the buccal cortical plate In mesio angularly or horizontaly positioned tooth the infection will tend to spread beyond the posterior extend of the mylohyoid muscle localizing in the pterygomandibular space Pericoronitis can give rise to submassetric space infection INFECTION FROM UPPER TEETH 1. The infection from C .I , L.I may be confined in the buccal vestibule by orbicularis oris and dense subcutaneous tissue of base of the nose
  10. 10. Canine The infection from this tooth will exit from the bone on the labial aspect the levator anguli oris muscle than determines whether the infection will be localised within the vestibule or infection will spread in the canine space Maxillary premolars Muscle attachment of zygomaticus major,zygomaticus minor & levator labii superioris will tend to localised the infection within the oral vestibule or may give canine space infection . Maxillary molars Periapical infection from the upper molars usually perforate the buccal cortex . The attachment of buccinator will determines that the infection weather localised intraorally or spreads extra orally.
  11. 11. Secondary sites of spread of odontogenic infection Facial spaces: These areas are either clefts ( potential spaces between facial layers ) or compartment containing connective tissue & various anatomic tooth structures they are not voids in the tissues . They are not voids in the tissues These are not present in healthy people but become filled during infections When filled with loose areolar tisses , it is called clefts
  12. 12. CLASSIFICATION ACCORDING TO TOPAZIAN: 1.Face buccal canine masticatory parotid 2.Suprahyoid 3. Infrahyoid massetric pterygoid zygomatico temporal sublingual submandibular sub maxillary sub mental lateral pharyngeal (pharyngo maxillary ) peritonsillar anterovisceral (pretracheal) 4. Spaces of total neck retropharyngeal danger space spaces of carotid sheath
  13. 13. CLASSIFICATION BY PETERSON PRIMARY MAXILLARY SPACES canine buccal infratemporal PRIMARY MANDIBULAR SPACES submental buccal submandibular sublingual SECONDARY FACIAL SPACES pterygomandibular massetric superficial
  14. 14. SPACES ASSOCIATED WITH THE UPPER JAW 1. CANINE SPACE -- potential space present on the anterior surface of the maxilla between bone and canine fossa musculature BOUNDARIES – Superiorly - limited by levator anguli oris and levator labii superioris Inferiorly - limited by orbicularis oris Anteriorly - lateral wall of nose Posteriorly - communicates with buccal space INFECTION - spreads from long canine root or upper first premolar root CONTENTS - Infraorbital nerve CLINICAL FEATURES – Swelling of the affected side upper lip , cheek upto the medial canthus of eye Obliteration of naso labial fold Drooping of angle of the mouth
  15. 15. 2.SUBPERIOSTEAL ABSCESS OF PALATE – Palate is covered by tightly adherent mucoperiosteum Pus tends to accumulate between the periosteum and bone CLINICAL FEATURES – Circumscribed , fluctuant swelling confined to one side of the palate May not discharge spontaneously Doesn’t cross the midline INFECTION – From upper lateral incisors Palatal pocket in premolars and molars Infection of palatal root of upper molar
  16. 16. 3. BUCCAL SPACE – BOUNDARIES – Medially - buccinator muscle and buccopharyngeal fascia Laterally - skin of cheek and subcutanous tissue Anteriorly - posterior border of zygomaticus major above and depressor anguli oris below Posteriorly - anterior edge of masseter muscle Superiorly - zygomatic arch Inferiorly - lower border of mandible CONTENTS – buccal fat pad parotid duct facial artery SPREAD OF INFECTION – through maxillary and mandibular molars
  17. 17. 4.INFRA TEMPORAL SPACE upper extremities of pterygomandibular space BOUNDARIES- Laterally- ramus of the mandible temporalis muscle temporal fascia Medially- lateral pterygoid plate,inferior portion of lateral ptrygoid muscle & lateral pharyngeal wall Superiorlly-infra temporal surface of greater wing of sphenoid bone Inferiorlly- lower head of lateral pterygoid muscle Anteriorlly-infra temporal surface of maxilla,posterior surface of zygomatic bone CONTENTS - ORIGIN OF PTERYGOID MUSCLE PTERYGOID VENOUS PLEXUS
  18. 18. INFECTION- FROM UPPER MOLARS CONTAMINATED NEEDLE DURING PSA BLOCK CLINICAL FEATURES- SEVERE TRISMUS BULDGING OF TEMPORALIS MUSCLE THIS SITUATION IS DANGEROUS DUE TO THE COMMUNICATIO PTERYGOID VENOUS PLEXUS WITH CAVERNOUS SINOUS THR EMMISSORY VEINS. SPACES ASSOCIATED WITH LOWER JAW SUBMENTAL SPACE – - POTENTIAL SPACE PRESENT JUST BELOW THE CHIN REGION ON THE MEDIAL SURFACE OF THE MANDIBLE BOUNDARIES SUPERIORLY :– MYLOHYOID MUSCLE INFERIORLY – INVESTING LAYER OF DEEP CERVICA FASCIA, PLETYSMA,SUPERFACIAL FACIA,SKIN LATERALLY – LOWER BORDER OF THE MANDIBLE ANTERIORLY BELLY OF DIAGESTRIC
  19. 19. CONTENTS: -- SUBMENTAL LYMPH NODES -- ADIPOSE TISSUE INFECTION : -- FROM LOWER ANTERIOR TEETH,LOWER LIP,SKIN OF THE CH TIP OF THE TONGUE,ANTERIOR PART OF THE FLOOR OF THE MOUTH SUBLINGUAL TISSUE CLINICAL FEATURES: FIRM CIRCUMSCRIBED SWELLING BENEATH THE TOUNGE DISCOMFORT & DIFFICULTY IN SWALLOWING SUB MANDIBULAR SPACE INFECTION POTETIAL SPACE PRESENT ON THE MEDIAL SURFACE OF THE POSTERIOR ASPECT OF THE MANDIBLE . BOUNDRIES: LATERALLY--- SKIN --- SUPERFECIAL FASCIA -- PLYTISMA -- DEEP FASCIA
  20. 20. MEDIALLY : -- MYLOHYOID MUSCLE -- HYOGLOSSUS MUSCLE -- STYLOGLOSSUS MUSCLE INFERIORLY: --ANTERIOR & POSTERIOR BELLY OF DIAGASTRIC SUPERIORLY: --MEDIAL ASPECT OF MYLOHYIOD ANTERIORLY: --MYLOHYIOD SPACE POSTERIORLY: --HYIOD BONE CONTENTS: --SUBMANDIBULAR SALIVARY GLAND & LYMPH NODE --FACIAL ARTERY --PROXIMAL PART OF WHARTON’S DUCT --LINGUAL & HYPOGLOSSAL NERVE
  21. 21. INFECTION: THE -- INFECTED LOWER MOLAR APICES PRESENT BELOW THE MYLOHYOID INSERTION -- THE LOWER TEETH ,MAXILLARY SINUS,UPPER MOLARS,C MIDDLE THIRD OF TONGUE & FLOOR OF MOUTH DRAIN INTO SUBMANDIBULAR LYMPH NODE CLINICAL FEATURES: --SWELLING WHICH IS SOFT& BRAWNY EXTRA ORALLY --ASSOCIATED WITH LOWER MOLAR INFECTION SUBLINGUAL SPACE :: --POTENTIAL SPACE PRESENT IN THE ANTERIOR PART OF THE OF THE MOUTH BOUNDARIES: ANTERIORLY & LATERALLY- - MEDIAL SURFACE OF THE MIDL MANDIBLE & BODY OF THE MAND SUPERIORLY—SUBLINSGUAL MUCOSA,MYLOHYIOD INFERIORLY– MYLOHYIOD MUSCLE POSTERIORLY– HYIOD BONE MEDIALLY– GENIOGLOSSUS,GENIOHYIOD,STYLOGLOSSUS MUS
  22. 22. ONLY LOOSE CONNECTIVE TISSUE SEPERATES RIGHT & LEFT SUBLINGUAL SPACE INFECTION MAY COME FROM LOWER ANTERIORS LOWER PREMOLARS LOWER FRIST MOLARS CLINICAL FEATURES: -- TONGUE IS RAISED -- FIRM PAINFUL SWELLING IN THE ANTERIOR PART OF THE FLOOR OF THE MOUTH -- SWELLING HAS SHINY GELETINOUS APPEARANCE -- PAIN & DISCOMFORT ON SWELLING -- ENLARGED SUBMENTAL & SUBMANDIBULAR LYMPH NODES
  23. 23. 6 Y LUDWIG’S ANGINA:: DEFINITION – IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY & OF THE SUBMENTALIS SPACE. -- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN ETIOLOGY: 1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION A LOWER THIRD MOLAR 2. TRAUMATIC INJURIES & INFECTED LESIONS 3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS MENIFEST AS LUDWIG’S ANGINA 4. CYSTS OR TUMORS IN THIRD MOLAR REGION PETHOLOGY: 1. INFECTION FROM LOWER THIRD MOLAR REACHES THE SUBMANDIBULAR SPACES 2. FROM HERE INFECTION SPREADS ALONG THE SUMANDIBULAR SALIVARY GLANDS ABOVE THE
  24. 24. FROM ONE SIDE OF THE SUBLINGUAL SPCE IT MOVES ACROSS THE GENIOGLOSSUS MUSCLE AND REACHES THE SUBLINGUAL SPACES ON OTHER SIDE IT THEN CROSS ONCE THE MYLOHYIOD MUSCLE & REACH THE OPPOSITE SIDE SUBMANDIBULAR SPACE. SUBMENTAL SPACE GET INVOLVED VIA LYMPHATICS SINCE IT IS CELLULITIS IT SPREADS RAPIDLY ALONG THE FACIAL AND TISSUE PLANES IT SPREADS IN THE TONGUE POSTERIORLY ALONG THE COURSE OF SUBLINGUAL ARTERY IN THE CLEFT BETWEEN THE GENIOGLOSSUS AND GENIOHYOID MUSCLE PRODUCING OEDEMA OF LARYNGEAL INLET FROM SUBMANDIBULAR SPACE IT CAN PASS ALONG THE INVESTING LAYER OF DEEP CERVICAL FASCIA ALONG THE ANTERIOR ASPECT OF THE NECK TO THE CLAVICLE AND THE MEDIASTINUM
  25. 25. CLINICAL FEATURES SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA , DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED SWELLING SKIN OVER THE SWELLING APPEARS ERYTHMATOUS AND STRETCHED SWELLING IS TENDER WITH LOCAL RISE IN TEMPERATURE Difficulty in closing the mouth and drooling of saliva Respiratory distress INTRA ORAL FEATURES – Trismus , floor of the mouth is raised , tongue raised upwards , increased salivation
  26. 26. MANAGEMENT - 1.Airway maintainence- Intubation is contraindicated perforation may lead to aspiration of pus Tracheostomy and Cricothyroidectomy is advisable 2. Parentral antibiotics - Penicillin antibiotic of choice Amoxycillin + Cloxacillin Metronidazole in anaerobic infection 3.Surgical decompression – performed under L.A Decompression improves vascularity and potentiates the action of antibiotics Bilateral submandibular incision with a midline submental incision pus should be drained A drain is inserted and loose dressing is placed 4.Hydration of the patient – It is necessary to put the pt on i.v. fluids 5. Removal of cause The offending tooth is removed
  27. 27. COMPLICATIONS – Death due to airway compromise septicemia aspiration of pus mediastinitis carotid blow out Masticatory space – Potential space present around the muscle of mastication a) SUBMASSETRIC SPACE Present between the three layers of masseter muscles
  28. 28. BOUNDARIES – Superiorly - zygomatic arch Lateraly - masseter muscle Medially - lateral aspect of the mandibular ramus Inferiorly - attachment of masseter onto the lower border of the mandible INFECTION can spread from lower third molar CLINICAL FEATURES – external facial swelling confined to masseter muscle complete trismus acutely tender
  29. 29. b) Pterygomandibular space – BOUNDARIES Medially – medial pterygoid muscle Laterally medial surface of the ramus of the mandible Superiorly – lateral pterygoid Posteriorly – deep lobe of the parotid gland Inferiorly attachment of the medial pterygoid to the mandib Anteriorly – pteygomandibular raphe CONTENTS – Inferior alveolar nerve and vessels Lingual nerve Loose areolar tissue INFECTION FROM LOWER THIRD MOLAR CLINICAL FEATURES – Trismus Intra oral swelling in the medial aspect of the ramus of the mandible
  30. 30. c). Temporal Space Divided into  Superficial temporal space  Deep temporal space Superficial temporal space is between superficial temporal fascia & lateral aspect of temporalis muscle Deep temporal space is present between the medial surface of the temporalis muscle & the periosteum of the temporal bone Contents: - vessels supplying the temporalis muscle Clinical features: - swelling confined to the shape of the muscle extending from the lateral orbital rim, above the zygomatic arch, covering of the lateral aspect
  31. 31. d). Lateral pharyngeal space  Synonyms  Parapharnygeal space  Pharyngomaxillary space Boundaries potential cone shaped space  base is uppermost at the base of the skull  apex is at the hyoid bone Clinical features - Pain on swallowing - Trismus - Tonsils & lateral pharyngeal wall are pushed to the midline - No extra oral swelling - It may lead to thrombophlebitis of internal jugular vein or may cause carotid blowout
  32. 32. Peri tonsillar abscess: Infection in connective tissue bed of the faucial tonsil And can also be from the infection of the third molar Clinical features Acute pain in throat on the affected side which radiates to the ear Dysphagia Trismus Awkward speech described as hot potato speech Foul breath Bulge in the soft palate on the affected site SPACES IN THE NECK Retropharyngeal Danger space and prevertebral spaces all lie between deep cervical Fascia that surrounds the pharynx and oesophagus and vertebral spine with its muscle attachments posteriorly
  33. 33. Principles of management of odontogenic infections Determine the severity of infection Evaluate host defense Decide on the setting of care Treat surgically Support medically Choose and prescribe antibiotic therapy Administer the antibiotic properly Evaluate the patient frequently 1.Determine the severty of infection A careful history and thorough physical examination to determine the anatomic location, rate of progression and the potential for airway compromise of a given infection.
  34. 34. 2.Evaluate host defenses Immune system compromise: diabetes,steroid therapy,organ transplant,malignancy chemotherapy,chronic renal disease,malnutrition, alcoholism,end –stage AIDS Systemic reserve The host response to severe infection can place a sever physiologic load on the body.fever can increase fluid losses and calori requirements. A prolonged fever may cause dehydration , which can therefor decrease cardiovascular resevers and deplete glycogen stores shifting the body metabolism to a catabolic state.
  35. 35. 3. Decide on the setting of care Indications for hospital care temp.>101 F dehydration,infection in moderate to severe anatomic spaces threat to airway or vital structures need for genral anesthesia need for in patient controll of systemic disease 4.Treat surgically Airway security Surgical drainage:drainage of pus and removal of cause An intra oral incision should be made through the mucous membrane , parallel to the surface of alveolar bone
  36. 36. Hilton s method of incision and drainage Method of incision and drainage esp. in head and neck rigion . Technique: 1.Anesthesia is achieved by regional blocking or by topical anesthesia by ethylchloride spray . 2.Ethylchoride is sprayed on the most flectuant part until frosting occurs. 3.The incision is made through skin , superficial fascia ,muscle, deep fascia parallel to the main nerves & vessels in closed proximity to that area. 4.A sinus forceps is inserted through the incision towards the area of pus collection .the forceps is closed when it is entered into the tissues. Once it is inside ,it is gently opened up in a direction parallel to the important structures . 5.The pus collected in that area flows along the beaks of the sinus forceps. 6. The drain is secured to the skin by sutures .a loose dressing is placed on the wound

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