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Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
Space infection   /certified fixed orthodontic courses by Indian dental academy
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Space infection /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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  • 1. COMPARTMENTS OF THE HEAD AND NECK – SURGICAL ANATOMY & APPLIED ASPECTS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. “He who sees things grow from the beginning will have the finest view of them” www.indiandentalacademy.com
  • 3. Fascial Spaces “The facial spaces or compartments are regions of loose C.T. that fill the areas between facial layers”. The concept of fascial ‘spaces’ is based on anatomists knowledge that all ‘spaces’, exist only potentially, until fasciae are separated by pus, blood, drains or a surgeon’s finger. www.indiandentalacademy.com
  • 4. How did the concept of facial spaces arise? “If I have seen further, it is by standing on the shoulder of Gaints”. Issac Newton” • In the 1930s the classic anatomical studies of Grodinsky and Holyoke established the modern understanding of the fascial layers and the potential anatomical spaces through which infection can spread in head and neck. www.indiandentalacademy.com
  • 5. What is fascia and its functions? • It is a sheet or layer of more / less condensed connective tissue. • Fascial layers are like tissue paper surrounding each item of clothing within a garment box, which allows them to pass over each other without their becoming unfolded. www.indiandentalacademy.com
  • 6. Functions of the fascia • Acts as a musculovenous pump• Limits outward expansion of muscles as they contract. • Contraction of muscles compress the intramuscular veins (push the blood towards the heart). • Prevent penetrating objects eg knife & low velocity bullets from vital structures • They also afford the slipperiness that allows the structures in the neck to move & pass over one another esply during swallowing & turning the neck. • Determine the direction of spread of infection www.indiandentalacademy.com
  • 7. CLASSIFICATION FASCIAE IN THE NECK SUPERFICIAL (SCF) DEEP (DCF) www.indiandentalacademy.com
  • 8. Superficial fascia Superficial fascia is not a fascial sheet in the classic sense, but rather a fatty loose connective tissue in which are embedded the www.indiandentalacademy.com voluntary muscles of facial expression and the platysma muscle.
  • 9. Superficial fascia Skin + Superficial fascia + Platysma muscle Complex morphological unit Superficial musculoaponeurotic system (SMAS) Clinical considerations: 1. Surgeons consider SMAS most important component of rhytidectomy / face-lift surgery / plastic surgery of the face. 2. Necrotizing fascitis – Infection of this fascia causes necrosis of the tissues in the subcutaneous space leading to necrotizing www.indiandentalacademy.com fascitis.
  • 10. Deep fascia Superficial layer of deep fascia Middle layer of deep fascia www.indiandentalacademy.com Deep layer of deep fascia
  • 11. Superficial layer of deep cervical fascia www.indiandentalacademy.com
  • 12. Superficial layer of deep cervical fascia www.indiandentalacademy.com
  • 13. Middle layer of deep cervical fascia www.indiandentalacademy.com
  • 14. Buccopharyngeal fascia www.indiandentalacademy.com
  • 15. Deep layer of deep cervical fascia www.indiandentalacademy.com
  • 16. Deep layer of deep cervical fascia www.indiandentalacademy.com
  • 17. Schematic diagram showing the arrangement of deep neck spaces www.indiandentalacademy.com
  • 18. Schematic diagram showing the arrangement of deep neck spaces www.indiandentalacademy.com
  • 19. • • • The greatest clinical implication of cervical fascia is that it divides the neck into potential spaces that function as a unit but are anatomically separate. Hyoid bone is considered the most important structure limiting the spread of infection. For this reason infection are classified by dividing the potential spaces into 3 general divisions: 1. Space of entire neck. 2. Supra hyoid spaces. 3. Infra hyoid spaces. www.indiandentalacademy.com
  • 20. Classification of the spaces of Face & Neck I Spaces of the Face A. Maxillary spaces 1. Buccal space. 2. Canine space. B. Mental space. II Spaces of neck A. Spaces involving the entire length of the neck. 1. Superficial space 2. Deep neck spaces (all involve only the posterior side of the neck) a) b) c) d) Retropharyngeal space (Space 3). Danger space (Space 4) Prevertebral space (Space 5) Visceral vascular space (within carotid sheath). www.indiandentalacademy.com
  • 21. B. Suprahyoid spaces: 1) Mandibular space • • • • Submandibular space. Submental space. Sublingual space. Space of the body of the mandible. 2) Masticatory space. 3) Lateral pharyngeal space (Pharyngomaxillary, peripharyngeal / parapharyngeal). 4) Peritonsillar space. 5) Parotid space. C. Infrahyoid space (involves anterior side of the neck only). 1. Pretracheal space. www.indiandentalacademy.com
  • 22. Concepts about space infections • The spaces are not empty they contain various organs, nerves, blood vessels, salivary glands, lymph nodes and fat surrounded by loose fibrous connective tissue. • The spaces of head and neck are not perfectly enclosed they are pathways around the muscles through which infection can spread. www.indiandentalacademy.com
  • 23. Concepts about space infections • Infections within each space has its own diagnostic signs and tends to spread in an orderly, anatomic fashion from one space to another by continuous extension. • If the surgeon understands this process, he can anticipate the spread of infection into dangerous spaces and abort the process by timely incision and drainage. www.indiandentalacademy.com
  • 24. Pathways of spread of dental infection Pericoronitis of third molar area Spread of infection from erupted and infected third molar area www.indiandentalacademy.com
  • 25. Predisposing factors • Primary predisposing factors leading to deep infection of the neck were: 1. Local dental disease like dental caries or diseases of the gums. 2. Lowered body resistance due to result of conditions such as tuberculosis, diabetes mellitus, syphiles, scurvy. Primary signs & symptoms of these infections: - Cellulitis / phlegmons. - Localized pain. - Tenderness. - Redness. www.indiandentalacademy.com - Edema of the overlying tissue.
  • 26. Relationship of point of bone perforation to spread of infection Infection enters soft tissue through thinnest bone www.indiandentalacademy.com In respect to buccinator muscle
  • 27. Stages of infections • • • • Stage I – Inoculation Stage II – Cellulitis Stage III – Abscess Stage IV – Resolution www.indiandentalacademy.com
  • 28. Surgical anatomy of deep facial spaces of head and neck www.indiandentalacademy.com
  • 29. Buccal space Clinical evaluation: Examination of the patient with the buccal space infection demonstrate swelling confined to the cheek with abscess forming beneath the buccal mucosa and bulging into the mouth. www.indiandentalacademy.com
  • 30. Canine space / Infraorbital space • Clinical evaluation: Patient exhibits swelling lateral to the nose obliterating the nasolabial fold, grouping at the corner of the mouth and swelling of the upper lip, edema occurs in the www.indiandentalacademy.com upper and lower lid that may close the eye.
  • 31. Differential diagnosis of upper face infections Dacrocystitis with minimal involvement of nasolabial fold. Odontogenic cellulitis. The nasolabial fold is effaced. www.indiandentalacademy.com
  • 32. Suprahyoid spaces 1) Mandibular space • • • • Submandibular space. Submental space. Sublingual space. Space of the body of the mandible. www.indiandentalacademy.com
  • 33. Mandibular spaces Submandibular space Clinical Evaluation: Infection mostly arises from 2nd or third molar. Induration and erythema in the submandibular area obliterating the mandibular line and extending to the level of hyoid bone. www.indiandentalacademy.com No trismus.
  • 34. Sublingual space Clinical evaluation: Edema and induration of the floor of the mouth on the affected side displacing tongue medially and superiorly. Hot potato voice. Elevation of tongue to palate causing airway compromise. Prevents patient from extending tongue beyond the vermilion border of upper lip. www.indiandentalacademy.com
  • 35. Submental space Boundary Clinical evaluation Management Complications www.indiandentalacademy.com
  • 36. Ludwig’s Angina Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular and sublingual spaces bilaterally and of the submental space. Three ‘fs’ of Ludwig’s Angina -feared -rarely fluctuant www.indiandentalacademy.com -often fatal
  • 37. Ludwig’s Angina • The original description of the disease was given by Wilhelm Friedrich von Ludwig. • Ludwig’s original description he emphasized that the angina 1. Is characterized by rapidly spreading gangrenous cellulitis. 2. Originates in the region of submandibular gland but never involves one single space and 3. Arises from extension by continuity and not by lymphatics and 4. Produces gangrene with serosanguinous, putrid infiltration but very little or no frank pus. www.indiandentalacademy.com
  • 38. Ludwig’s Angina Clinical evaluation: - It is characteristically aggressive and rapidly spreading. - Patient will appear toxic with elevation of WBC count, fever, chills. - Airway compromise occurring quickly and with little fore warning. - Drooling, dysphagia, mouth pain and neck stiffness are not uncommon. - Physical examination. - Anteriorly protruding tongue, induration and erythema of the floor of the mouth and indentation of the tongue by the teeth. - A woody induration in the suprahyoid region of neck. - Trismus is usually absent. www.indiandentalacademy.com
  • 39. Management of Ludwig’s Angina • • • • Hospitalization. Airway control – tracheostomy. Early I.v. antibiotics. External surgical exploration with division of mylohyoid muscle and drainage. • Blind or nasotracheal intubation is unsafe. • Drainage: ‘Classic’ horizontal incision midway between chin and hyoid bone is no longer advocated. • Bilateral through and through drainage of submandibular space with simultaneous exploration of submental and sublingual space is recommended. www.indiandentalacademy.com
  • 40. Incision for surgical drainage of Ludwig’s Angina X www.indiandentalacademy.com
  • 41. Deep neck infections • All involve only posterior side of neck. a)Retropharyngeal space (space 3, posterior visceral space). b)Danger space (space 4). c)Prevertebral space (space 5). d)Visceral vascular space (within the carotid sheath) www.indiandentalacademy.com
  • 42. Principles for Rx of the deep neck spaces • 1. 2. 3. 4. 5. Benjamin J. Gans, in his Atlas of oral surgery, articulated these principles: Drain all significant deep space infections. Do not wait for fluctuance. Fluctuance is a late sign. Determine incision placement, incisions designed to avoid important anatomical structures, provide dependent drainage and leave cosmetically acceptable scar. Institute definitive treatment as soon as possible, Offending tooth to be removed. www.indiandentalacademy.com Check for systemic disease.
  • 43. Retropharyngeal space Retropharyngeal space is the potential space sandwiched between alar and prevertebral layers of deep layer of the deep investing fascia. Extension Base of the skull Mediastinum Most dangerous of all types of deep neck infections Two compartments: Suprahyoid Sagittal section of retropharyngeal space Infrahyoid www.indiandentalacademy.com 1. Only fat 1. Lymph nodes and fat.
  • 44. Diagnosis of the soft tissue radiograph for retropharyngeal space infection Step I: • Look at the prevertebral or retropharyngeal soft tissue shadow. • In the area of 2nd and 3rd CV, RP soft tissue shadow should be less than 7mm wide. • In the area of 6 cervical vertebra soft tissue shadow is behind the trachea and includes the thickness of esophagus making it approx. Children – 14mm wide adults – 22mm wide www.indiandentalacademy.com
  • 45. Step II. The second feature that should be looked for in this radiograph is the presence of gas. Anaerobic bacteria will produce gas that can be seen as emphysema in the soft tissues of the neck Areas of Emphysema in the submandibular and lateral www.indiandentalacademy.com pharyngeal space region
  • 46. Clinical Evaluation • Children less than 4 yrs commonly affected. • In adults it manifests as cold abscess. • Sore throat, dysphagia, odynophagia, difficulty handling secretions. • Hot potato voice. Early signs: Late signs •Refusal to take food. •Neck tilts towards involved side. •Cervical lymphadenopathy. •Hyperextended complete inability to flex the neck. •Slight neck rigidity. •Noisy breathing due to laryngeal edema. •Respiratory embarssment may occur if abscess not ruptured or drained. www.indiandentalacademy.com
  • 47. Complications of space infection Frontal view of the patient with right cavernous sinus thrombosis • Venous congestion of the fundus of the left eye. • the same patient two weeks later. Clinically One eye experiences early involvement than the other. www.indiandentalacademy.com Cranial nerve most likely to be involved is abducens.
  • 48. Diagnosis of cavernous sinus thrombosis • Eagleton’s six features. – Known site of infection. – Evidence of blood stream infection. – Early sign of venous obstruction in retina, conjunctiva or eyelids. – Paresis of III, IV, VI cranial nerves resulting from inflammatory edema. – Abscess forms and neighboring tissues and – Evidence of meningeal irritation. www.indiandentalacademy.com
  • 49. Surgical incisions used to approach deep neck infections www.indiandentalacademy.com
  • 50. Diagnostic Imaging of Fascial & Neck Spaces Plain film. CT. MRI www.indiandentalacademy.com Ultrasound
  • 51. Principles of incision and drainage • Incise in healthy skin and mucosa when possible. • Incision placed at the site of maximum fluctuance results in a puckered, unesthetic scar. • Place the incision in an esthetically acceptable area. • When possible place the incision in a dependent position to encourage drainage by gravity. • Dissect bluntly with closed surgical clamp or finger, through deeper tissues. • Place a drain and stabilize it with sutures. www.indiandentalacademy.com
  • 52. Principles of incision and drainage • Consider use of through and through drains in bilateral submandibular space infections. • Do not leave drains in place for an overly extended period. • Remove them when drainage becomes minimal. • Clean wound margins daily under sterile conditions to remove clots and debris. • Another approach to drainage is the use of computed tomographic (CT) guided catheter. www.indiandentalacademy.com
  • 53. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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