FACIAL SPACES OF PERIODONTAL
INTEREST

Presented By
Dr. M. Shiva Shanker
Ist Year Post Graduate Student ,
Dept of Periodon...


Introduction



Classification of spaces



Formation of spaces



Maxillofacial odontogenic infections



Individu...


Connective tissue - naturally forms a padding between and around the
various structures in the neck, and also elsewhere...
 Fascia

& spaces above the
hyoid bone :



Fascia & spaces below the hyoid
bone :



Superficial layer of fascia



P...


Depending upon its relationship with Hyoid bone.



Infrahyoid spaces

` (Below the hyoid bone)



Suprahyoid spaces ...
 Depending

 Primary

upon the involvement

spaces

 Secondary

spaces

CLASSIFICATION ….
FASCIA
 The

fascia is divided into two major divisions

 Superficial layer
 Deep

cervical fascia

 Superficial fasci...
Deep

cervical fascia

1. Anterior layer


Investing fascia (over the neck)



Parotideomassetric



Temporal

2. Midd...
Deep cervical fascia......



Posterior layer


Alar division



Prevertebral division

The DCF of the neck is contiguo...
FASCIAL
SPACES
Space of Burns
Fascia anterior to strap
muscles

between the two
sternocleidomastoid
muscles

splits into two layers just
...
 Pretracheal

fascia.



The pretracheal fascia passes behind the infrahyoid or strap muscles,
infront of the trachea an...
FORMATION OF SPACES
 Vestibular space:


Medial: mandible or maxilla and overlying periosteum



Lateral: vestibular mu...
SUB MANDIBULAR SPACE


Medial: mylohyoid, hyoglossus, styloglossus
muscles



Lateral: skin and platysma muscle



Supe...
SUB MENTAL SPACE

Mandible

Ant digastric
Inferior border of the mandible
Mylohyoid muscle

Hyoid bone
SUBLINGUAL SPACE

Floor of mouth mucosa
Mandible
Geniohyoid
Mylohyoid
Hyoid bone
BUCCAL SPACE

Zygomatic arch

Skin
Buccinator muscle and attachment to maxillary and
mandibular alveolus

Mandibular and S...
BUCCAL SPACE

Zygomatic major muscle

Depressor anguli oris
CANINE SPACE
Maxilla
Nasal bone
Levator labii superioris

Skin
Buccal space
LATERAL PHARYNGEAL SPACE

Sub lingual, sub mandibular spaces
Pterygomandibular raphae
Hyoid bone
Parotid capsule
Base of t...
RETROPHARYNGEAL SPACE

Lateral pharyngeal space

Base of the skull
Vertebrae C6-T4
MASSETRIC SPACE

Superficial part of masseter

Deep part of masseter

Mucosa of retromolar triangle of mandible
Parotidoma...
PTERYGOMANDIBULAR SPACE

Parotid gland & its fascia
Superior constrictor of pharynx
Mandibular ramus
Lateral pterygoid mus...
SUPERFICIAL TEMPORAL SPACE

Temporal fascia
Temporalis
DEEP TEMPORAL SPACE

Temporalis
Fascia of deep surface of temporalis
PREVERTEBRAL SPACE
 Medial: postural

neck muscles

 Lateral: postural

neck muscles

 Superior: base

of skull

 Infe...
INFRA TEMPORAL SPACE
 Medial: lateral pterygoid muscle
 Lateral: temporalis

and lateral pterygoid plate

tendon and cor...
MAXILLOFACIAL ODONTOGENIC INFECTIONS

Spread of infection
STAGES OF INFECTION
Characteristic
Duration
Pain

Inoculation
0-3 days
Mild-moderate

Cellulitis
3-7 days
Severe and gener...
MANAGEMENT OF SPACE INFECTIONS
Management of infections, mild or severe, always has five general goals:


Medical support...
INDIVIDUAL SPACES
Vestibular space
Etiology
Signs

and symptoms

Treatment and

applied aspects
CLINICAL PICTURE SHOWING VESTIBULAR
SPACE INFECTION
SUBMANDIBULAR SPACE

Facial vessels
Hypoglossal nerve
Submandibular gland
Marginal mandibular branch of VII

CONTENTS
Etiology

Signs

and symptoms

Treatment and

aspects

applied
CLINICAL PICTURE OF SUBMANDIBULAR
SPACE
SUBMENTAL SPACE
Etiology



Signs

and symptoms

Treatment and

aspects
Spread of infection

applied
CLINICAL PICTURE OF A SUBMENTAL SPACE
SUBLINGUAL SPACE

Lingual nerves and vessels
Submandibular ganglion
Submandibular gland

CONTENTS
Etiology



Signs

and symptoms

Treatment and

aspects
Spread of infection

applied
CLINICAL PICTURE OF A SUBLINGUAL SPACE
BUCCAL SPACE

Parotid duct

Buccal branch of VII
Facial vessels
Buccal fat pad

CONTENTS
Etiology



Signs

and symptoms

Treatment and

aspects
Spread of infection

applied
CLINICAL PICTURE OF BUCCAL SPACE
CANINE SPACE

Infraorbital nerves and vessels
Levator anguli oris

CONTENTS
Etiology
Signs

and
symptoms

Treatment and

applied aspects
CLINICAL PICTURE OF A CANINE SPACE
LATERAL PHARYNGEAL SPACE
Etiology
Signs

and symptoms

Treatment and

aspects
B. Lateral
Pharyngeal
Space

applied
RETROPHARYNGEAL SPACE
Etiology
Signs

and symptoms

Treatment and

aspects

applied
PREVERTEBRAL SPACE


Etiology
Signs

and symptoms

Treatment and

aspects

applied
MASTICATOR SPACE

Etiology
Signs

and symptoms
MASSETRIC SPACE
Treatment and

applied aspects:

Spread of infection
CLINICAL PICTURE SHOWING
MASSETRIC SPACE
PTERYGOMANDIBULAR SPACE

Treatment and

aspects:
A. Pterygomandibular Space

applied
TEMPORAL SPACE
Treatment and

applied aspects:
INFRATEMPORAL SPACE
Etiology
Signs

and symptoms

Treatment and

aspects

applied
PRETRACHEAL SPACE
 The

pretracheal space is encased by the
middle layer of the DCF and contains the
thyroid gland, trach...
COMMUNICATIONS
COMPLICATIONS OF HEAD AND NECK INFECTIONS











Extension of infection from local to regional
spaces
Orbital...
Aminoglycosides
Gentamicin

IM/IV

Cephalosporins
Cefaclor
Cefadoxil
cephalexin

3mg/kg/day in equal doses 8 hourly

250-5...


For practical purposes, it makes little difference to the surgeon in an uninfected neck
whether a facial sheath is pres...
REFERENCES
1. Grays anatomy-Muscles and fascia of the head, 38th edition, (789-807)
2. Oral and Maxillofacial surgery, Fon...
THANK YOU………….
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Facial spaces of periodontal interest.

  1. 1. FACIAL SPACES OF PERIODONTAL INTEREST Presented By Dr. M. Shiva Shanker Ist Year Post Graduate Student , Dept of Periodontics, Mamata Dental College.
  2. 2.  Introduction  Classification of spaces  Formation of spaces  Maxillofacial odontogenic infections  Individual spaces  Communications  Complications  Case report  conclusion CONTENTS
  3. 3.  Connective tissue - naturally forms a padding between and around the various structures in the neck, and also elsewhere in the body. - tends to be somewhat more dense where it is arranged immediately about organs.  When the fascia and spaces of the head and neck of normal bodies are investigated, the looser Connective tissue intervening between organs is torn and pressed against these organs, there by exaggerating any fascial layer already present.  The interrelationships of these spaces have been regarded as special importance in the spread of infection.  Accurate knowledge of the anatomy of these spaces and prompt drainage of them when they become infected is necessary. INTRODUCTION
  4. 4.  Fascia & spaces above the hyoid bone :  Fascia & spaces below the hyoid bone :  Superficial layer of fascia  Prevertebral  Superficial layer of fascia  Buccopharyngeal  Pretracheal  Space of the body of mandible  Prevertebral  Sub-maxillary gland space.  Carotid sheath  Masticator space.  Retrovisceral space.  Space of parotid gland.   Retropharyngeal space Danger space or space of Grodinsky and Holyoke.  Lateral pharyngeal space. CLASSIFICATION
  5. 5.  Depending upon its relationship with Hyoid bone.  Infrahyoid spaces ` (Below the hyoid bone)  Suprahyoid spaces (above the hyoid bone)  This is further divided into 2 categories.  Blind or intrafascial spaces.  Pretracheal space  Retrovisceral space  Space of the body of mandible.  Carotid space  Space of submaxillary gland.  Space 4 or danger space.  Masticatory spaces.  Space of parotid gland.  Peripharyngeal spaces.  Retropharyngeal space.  Lateral pharyngeal space.  Submandibular space. CLASSIFICATION ….
  6. 6.  Depending  Primary upon the involvement spaces  Secondary spaces CLASSIFICATION ….
  7. 7. FASCIA  The fascia is divided into two major divisions  Superficial layer  Deep cervical fascia  Superficial fascia  This arises from the vertebral spinous processes and the ligamentum nuchae and completely encircles the neck to attach again to these.  It invests the platysma in the neck, the muscles of facial expression, and the epicranial muscles in the scalp.
  8. 8. Deep cervical fascia 1. Anterior layer  Investing fascia (over the neck)  Parotideomassetric  Temporal 2. Middle layer  Sternohyoid-omohyoid division  Sternothyroid-thyrohyoid division  Visceral division  Buccopharyngeal  Pretracheal  retropharyngeal
  9. 9. Deep cervical fascia......  Posterior layer  Alar division  Prevertebral division The DCF of the neck is contiguous with the mediastenal structures in the thorax through the thoracic inlet. As it emerges from the neck superior to the hyoid bone.
  10. 10. FASCIAL SPACES
  11. 11. Space of Burns Fascia anterior to strap muscles between the two sternocleidomastoid muscles splits into two layers just above the sternum Suprsternal space( SOB)
  12. 12.  Pretracheal fascia.  The pretracheal fascia passes behind the infrahyoid or strap muscles, infront of the trachea and thyroid gland.  The pretracheal layer with the carotid sheath laterally and the prevertebral layer posteriorly, forms the visceral compartment containing the trachea, esophagus and associated structures.
  13. 13. FORMATION OF SPACES  Vestibular space:  Medial: mandible or maxilla and overlying periosteum  Lateral: vestibular mucosa  Superior: buccinator muscle  Inferior: buccinator muscle  Anterior: intrinsic lip muscles  Posterior: lateral pharyngeal and massetric space
  14. 14. SUB MANDIBULAR SPACE  Medial: mylohyoid, hyoglossus, styloglossus muscles  Lateral: skin and platysma muscle  Superior: mandible, mylohyoid and masseter muscle Mandible Post digastric Stylohyoid muscle  Inferior: hyoid bone  Anterior: anterior digastric muscle, submental space  Posterior: posterior belly of digastric muscle and stylohyoid muscle Ant digastric Mylohyoid
  15. 15. SUB MENTAL SPACE Mandible Ant digastric Inferior border of the mandible Mylohyoid muscle Hyoid bone
  16. 16. SUBLINGUAL SPACE Floor of mouth mucosa Mandible Geniohyoid Mylohyoid Hyoid bone
  17. 17. BUCCAL SPACE Zygomatic arch Skin Buccinator muscle and attachment to maxillary and mandibular alveolus Mandibular and Sub Mandibular space
  18. 18. BUCCAL SPACE Zygomatic major muscle Depressor anguli oris
  19. 19. CANINE SPACE Maxilla Nasal bone Levator labii superioris Skin Buccal space
  20. 20. LATERAL PHARYNGEAL SPACE Sub lingual, sub mandibular spaces Pterygomandibular raphae Hyoid bone Parotid capsule Base of the skull
  21. 21. RETROPHARYNGEAL SPACE Lateral pharyngeal space Base of the skull Vertebrae C6-T4
  22. 22. MASSETRIC SPACE Superficial part of masseter Deep part of masseter Mucosa of retromolar triangle of mandible Parotidomassetric fascia
  23. 23. PTERYGOMANDIBULAR SPACE Parotid gland & its fascia Superior constrictor of pharynx Mandibular ramus Lateral pterygoid muscle Pterygomandibular raphae Buccinator
  24. 24. SUPERFICIAL TEMPORAL SPACE Temporal fascia Temporalis
  25. 25. DEEP TEMPORAL SPACE Temporalis Fascia of deep surface of temporalis
  26. 26. PREVERTEBRAL SPACE  Medial: postural neck muscles  Lateral: postural neck muscles  Superior: base of skull  Inferior: coccyx  Anterior: alar fascia and retropharyngeal space  Posterior: vertebral bodies
  27. 27. INFRA TEMPORAL SPACE  Medial: lateral pterygoid muscle  Lateral: temporalis and lateral pterygoid plate tendon and coronoid process  Superior:  Inferior:  Anterior: maxillary tuberosity  Posterior: lateral muscle, temporalis muscle, and condyle
  28. 28. MAXILLOFACIAL ODONTOGENIC INFECTIONS Spread of infection
  29. 29. STAGES OF INFECTION Characteristic Duration Pain Inoculation 0-3 days Mild-moderate Cellulitis 3-7 days Severe and generalized Size Location Palpation Small Diffuse Soft,doughy, mildly tender Large Diffuse Hard, exquisitely tender Abscess >5 days Moderate-severe localized Small Circumscribed Fluctuant, tender Appearance Normal color Reddened Peripherally reddened Skin quality Normal Thickened Centrally undermined and shiny Surface temperature Slightly heated Hot Moderately heated Loss of function Tissue fluid Minimal or none Edema Levels of malaise Severity Percutaneous bacteria Mild Mild Aerobic Severe Moderately severe Serosanguineous, flecks of Pus pus Severe Moderately severe Severe Moderately severe Mixed Anaerobic and
  30. 30. MANAGEMENT OF SPACE INFECTIONS Management of infections, mild or severe, always has five general goals:  Medical support of the patient  Administration of proper antibiotics  Surgical removal of the source of infection as early as possible  Surgical drainage of the infection  Constant reevaluation of the resolution of the infection.
  31. 31. INDIVIDUAL SPACES Vestibular space Etiology Signs and symptoms Treatment and applied aspects
  32. 32. CLINICAL PICTURE SHOWING VESTIBULAR SPACE INFECTION
  33. 33. SUBMANDIBULAR SPACE Facial vessels Hypoglossal nerve Submandibular gland Marginal mandibular branch of VII CONTENTS
  34. 34. Etiology Signs and symptoms Treatment and aspects applied
  35. 35. CLINICAL PICTURE OF SUBMANDIBULAR SPACE
  36. 36. SUBMENTAL SPACE Etiology  Signs and symptoms Treatment and aspects Spread of infection applied
  37. 37. CLINICAL PICTURE OF A SUBMENTAL SPACE
  38. 38. SUBLINGUAL SPACE Lingual nerves and vessels Submandibular ganglion Submandibular gland CONTENTS
  39. 39. Etiology  Signs and symptoms Treatment and aspects Spread of infection applied
  40. 40. CLINICAL PICTURE OF A SUBLINGUAL SPACE
  41. 41. BUCCAL SPACE Parotid duct Buccal branch of VII Facial vessels Buccal fat pad CONTENTS
  42. 42. Etiology  Signs and symptoms Treatment and aspects Spread of infection applied
  43. 43. CLINICAL PICTURE OF BUCCAL SPACE
  44. 44. CANINE SPACE Infraorbital nerves and vessels Levator anguli oris CONTENTS
  45. 45. Etiology Signs and symptoms Treatment and applied aspects
  46. 46. CLINICAL PICTURE OF A CANINE SPACE
  47. 47. LATERAL PHARYNGEAL SPACE Etiology Signs and symptoms Treatment and aspects B. Lateral Pharyngeal Space applied
  48. 48. RETROPHARYNGEAL SPACE Etiology Signs and symptoms Treatment and aspects applied
  49. 49. PREVERTEBRAL SPACE  Etiology Signs and symptoms Treatment and aspects applied
  50. 50. MASTICATOR SPACE Etiology Signs and symptoms
  51. 51. MASSETRIC SPACE Treatment and applied aspects: Spread of infection
  52. 52. CLINICAL PICTURE SHOWING MASSETRIC SPACE
  53. 53. PTERYGOMANDIBULAR SPACE Treatment and aspects: A. Pterygomandibular Space applied
  54. 54. TEMPORAL SPACE Treatment and applied aspects:
  55. 55. INFRATEMPORAL SPACE Etiology Signs and symptoms Treatment and aspects applied
  56. 56. PRETRACHEAL SPACE  The pretracheal space is encased by the middle layer of the DCF and contains the thyroid gland, trachea, and esophagus.  Infections in this space usually result from thyroiditis or perforation of the anterior cervical esophagus.  This space is rarely involved as a result of odontogenic infection
  57. 57. COMMUNICATIONS
  58. 58. COMPLICATIONS OF HEAD AND NECK INFECTIONS          Extension of infection from local to regional spaces Orbital complications (blindness, ophthalmoplegia) Jugular vein thrombosis Septicemia Metastatic abscesses Airway compromise Aspiration Carotid artery rupture Mediastinitis        Osteomyelitis Cutaneous fistula Cranial nerve deficits Cavernous sinus thrombosis Necrotizing fasciitis Maxillary sinusitis, oroantral fistula Septic shock
  59. 59. Aminoglycosides Gentamicin IM/IV Cephalosporins Cefaclor Cefadoxil cephalexin 3mg/kg/day in equal doses 8 hourly 250-500 mg 8 hourly 500mg-1g 12-24 hrs 250-500mg 6hrs Penicillins Amoxicillin Cloxacyclin 1g initially than 250-500mg 6hrs 250-500mg 6hrly Macrolides Erythromycin Azithromycin 250-500mg 6hrly 10mg/kg upto 500mg initially followed by 5mg/kg upto 250 mg qd- 5 days Tetracyclins Doxcycline 100mg q 24hrs or 50mg q 12 hrs 250mg q 24 hrs ANTIBIOTIC ADMINISTRATION REGIMEN oxytetracycline Clindamycin 150mg q 6hrs FOR ORAL INFECTIONS Metronidazole Vancomycin 500mg q 6hrs IV 1g infused over 1hr before procedure
  60. 60.  For practical purposes, it makes little difference to the surgeon in an uninfected neck whether a facial sheath is present or not. Of some practical importance however are the relationships of the loose connective tissue areas, the fascial spaces, of the head and neck, both because of the structures that transverse or abut against them, and because they may become infected. The interrelationships of these spaces have been regarded as special importance in the spread of infections and many surgeons have urged accurate knowledge of the anatomy of these spaces and a prompt drainage of them when they become infected CONCLUSION
  61. 61. REFERENCES 1. Grays anatomy-Muscles and fascia of the head, 38th edition, (789-807) 2. Oral and Maxillofacial surgery, Fonseca, vol-5 (77-118) 3. Oral and Maxillofacial surgery, Laskin, Vol-2 (219-252) 4. Oral and Maxillofacial infections, Topazian, 4th edition (158-214) 5. Atlas of minor oral surgery, Hary dym (154) 6. Text book of Clinical periodontology, Newman, Takei, Carranza, 10th edition 7. Anatomical considerations in periodontal periodontology 1971, vol 42, number 10. surgery, journal of 8. Two cases of masticator space abscess initially diagnosed as TMJD, Clarke, Kobe J. Med. Sci., Vol. 54, No. 3, pp. E163-E168, 2008
  62. 62. THANK YOU………….
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