Dr. Giuseppe Bruno PitassiDr. Giuseppe Bruno PitassiDoctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987Doctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987Dental Surgeon – Napoli – (Italy) 1989Dental Surgeon – Napoli – (Italy) 1989Specialist Maxillofacial Surgery – Napoli – (Italy) 1992Specialist Maxillofacial Surgery – Napoli – (Italy) 1992Pg/Cert. Clinical Periodontology -Bari (Italy) 1999Pg/Cert. Clinical Periodontology -Bari (Italy) 1999Acute infection ofAcute infection oforal & para-oraloral & para-oraltissuestissues((Peri-mandibular and maxillary abscesses & phlegmonsPeri-mandibular and maxillary abscesses & phlegmons))
Group of infections originating mainly but not only fromGroup of infections originating mainly but not only fromdental & periodontal structures caused by the invasiondental & periodontal structures caused by the invasionand proliferation of pathogenic microrganisms within theand proliferation of pathogenic microrganisms within thesoft tissues of the oro-maxillofacial region.soft tissues of the oro-maxillofacial region.They may likewise be defined as:They may likewise be defined as:““Peri-mandibular & maxillary abscesses and phlegmonsPeri-mandibular & maxillary abscesses and phlegmons””with reference to the tissues of the oral & maxillofacialwith reference to the tissues of the oral & maxillofacialregion that are usually affected by this pathology.region that are usually affected by this pathology.(Valletta G.C. -1987)
Classification of oral & para-oral infectionsOdontogenic 92~94%(Scmelzel & Schwenzer -1988)-Periapical periodontitis-Pericoronitis/tooth retention-Marginal periodontitis-Infected odontogenic cysts & granulomasNon-odontogenic 6~8%(Lopez-Perez, Aguillar & Gimenez -2006)-Infected fracture gaps-Infected soft tissue wounds or tumours-Inflammatory skin/mucous membrane disorders-Adeno-Phlegmons-Hematogenous or lymphogeneous spreading-Peri-tonsillar abscesss-Paranasal sinuses-Infected retained root fragments-Infections after tooth extractionsBeware of malignacy presenting as an infections-Dry socket complications
EtiopathogenesisEtiopathogenesis““Causes of Acute Infections of Oral and Para-Oral TissuesCauses of Acute Infections of Oral and Para-Oral Tissues””
The bacteria causing odontogenic infections are mostlyfrom the endogenous normal flora (bacteria normally inthe oral cavity of the normal person),when these bacteriagain access to the deeper underlying tissues as through anecrotic pulp or deep periodontal pocket, they causeodontogenic infections.The oral cavity supports the most complex enviromentalpopulation of bacteria in the human body, between 300 to500 different bacteria strains.
Etiopathogenesis95%95% of “of “Acute Infections of Oral & Para-oral tissuesAcute Infections of Oral & Para-oral tissues””are due to a multi-microbial originare due to a multi-microbial origin60%60% originate only by anaerobic bacteriaoriginate only by anaerobic bacteria35%35% have mixed flora composed have mixed flora composed by a miscellany ofby a miscellany ofaerobic and anaerobic bacteria with a prevalenceaerobic and anaerobic bacteria with a prevalenceof anaerobic 4:1of anaerobic 4:15%5% originate only by aerobic bacteria originate only by aerobic bacteria(Montagna & Piras 2005)(Montagna & Piras 2005)
The bacteria strains involved in the pathogenesis of the Oro-facial infections depend also on the pathologies of origin.-Streptococcus mutans-Streptococcus sobrinus-Streptococcus milleri-Rods Gram- (aerobics & anaerobics)Necrotic Pulpitis &Periapical periodontitis-Actinobacillus actinomycetemcomitans-Prevotella oralis (bacterioides)-Porphyromonas gingivalis-Fusobacterium nucleatum-Eikenella corrodensMarginal Periodontitis/Periodontal abscess-Streptococcus mutans oralis-Enterococcus fecalis-Bacterioides forsythus-Fusobacterium nucleatum-Porphyromonas gingivalis-Prevotella intermediaPericoronaritis
The bacteria anaerobics Gram+ as “Bacterioides & Fusobacteria” fortheir characteristics are associated with greater frequency to moresevere oral & para-oral infections. Typically they producemalodorous suppurations and promote the spread of abscesses andphlegmons due to the production and secretion of exoenzymes ascollagenase and fibrinolisine.The bacteria involved in the periapical abscesses, also change inrelation to the persistence time of the infection. In the initialphase, about the first 3 days after the onset of the infection,Cocci aerobics Gram+ predominates, they are sensitive to Penicillins.In the late phase, on the contrary, as a result of the affectedtissues necrosis and the shortage in oxygen concentration is evidenta prevalence of “Cocci anaerobic Gram+”, sensitive to Metronidazole.
Odontogenic infections have three major originsOdontogenic infections have three major origins::1- Periapical ~70%1- Periapical ~70% (Periapical periodontitis)(Periapical periodontitis)As result of pulpar necrosis and subsequental bacterialAs result of pulpar necrosis and subsequental bacterialinvasion into periapical tissues.invasion into periapical tissues.2- Periodontal ~20%2- Periodontal ~20% (Marginal periodontitis)(Marginal periodontitis)AAs a result of rapidly-growing bacterial within as a result of rapidly-growing bacterial within aperiodontal pocket which becomes deeper allowingperiodontal pocket which becomes deeper allowingbacterial invasion of underlying tissues.bacterial invasion of underlying tissues.3- Pericoronitis ~10%3- Pericoronitis ~10%Is a common problem in young adults (15~25 yrs.) it is anIs a common problem in young adults (15~25 yrs.) it is aninflammatory reaction of the “operculum”, this is theinflammatory reaction of the “operculum”, this is thedense, fibrous flap that covers about 50% of the bitingdense, fibrous flap that covers about 50% of the bitingsurface usually of the lower wisdom tooth, when it issurface usually of the lower wisdom tooth, when it ispartially or completely erupted. The infection occurspartially or completely erupted. The infection occurswhen the third molar start erupting, at this moment thewhen the third molar start erupting, at this moment theoperculum and tissue around the wisdom toperculum and tissue around the wisdom tooth becomesooth becomesinflammed because bacteria invade the area. Poor oralinflammed because bacteria invade the area. Poor oralhygiene and mechanical masticatory trauma on nearbyhygiene and mechanical masticatory trauma on nearbytissue can facilitate this inflammation.tissue can facilitate this inflammation.
“Primum movens” for the formation of an oro-facialinfection is the penetration, the invasion and finally theproliferation of bacteria, commonly found into buccalcavity within the para-dental tissues through a lesion ofthe integrity and the impairement of the seal function ofthe dental and periodontal structures.The pathogenic micro-organism gain access into theperiapical tissues through any of the following routes:1-Infected or necrotic pulp of a carious tooth, traumatizedtooth, or after traumatic exposure and contaminationof the pulp of a tooth during cavity preparation(iatrogenic).2-Trough the crevice of a gingival wound located in a deeplyinfected pocket in periodontally diseaded tooth3- Extension of infection from adjacent infected tooth.4- As progression of infection from the peri-coronal tissueto the deep tissues of the mandible and maxilla.
RootAlveolar boneGingivalPeriodontal ligamentVascular-nervousbundleRoot apex &Apical foramenPERIODONTALSTRUCTURESSupport and damping structure
Two examples of marginal periodontitisprobably evolving in periodontal abscess
Two examples of Pericoronal infection/Pericoronaritisand retained 3th. wisdom/molars
Pa x-rayperiapicalabscessPa x-ray image ofperiodontalabscessOPG X-raypericoronritisabscess
Pathways of odontogenic infectionsBacteria from tooth deep decayinvade the pulp therein proliferateActivation of host inflammatoryreaction into pulpal tissueHypoxia if prolonged over timecauses pulpal necrosisPulpal abscess formationVasodilatation and developmentof inflammatory exudateOedema increasing and intra-pulpal pressure riseExtravasation of the abscess inthe periapical tissuesCollapse of the intra-pulpallocal microcirculation
Progression to medullary spaceinfections and osteomielitis.Sub-periosteal Dentoalveolar Abscess2) Extra-dental stage
More commonly, such pus collections get fistulous tractthrough alveolar bone that may pass through oralmucosa and/or facial skin draining toward outsideSuppurative Apical Periodontitis “open”1) Extra-osseous stage
Local symptoms.The severity of the pain depends on thestage of development of the inflammationIn the initial phase the pain is dull andcontinuous and worsens during percussionof the responsible tooth or when it comesinto contact with antagonist teeth.If the pain is very severe and pulsates, itmeans that the accumulation of pus is stillwithin the bone or below the periosteum.There is a sense of elongation of theresponsible tooth and slight mobility; thetooth feels extremely sensitive to touch,while difficulty in swallowing is alsoobserved.Periapical abscess
Once established infection may spread and this is governed by hosts andPathogenes factors.Local anatomy is an important host factor and in this regard is possible toassert that “Infection may spread by one of three routes:- By continuity through tissue spaces and planes- By way of lymphatic sistem (Acute lymphangitis and lymphadenitis)-By way of bloodstream circulation (Bacteriemia)As regards the infections affecting the oral and para-oral tissues isextremly important the routes of spread by continuity through tissues,spaces and planes.Taking into consideration that in this case the infection spreads flowingalong routes of minor resistance and also that the progression of theinfection is determined between the relationship of the muscle insertionto the bone and the point where infection perforate the bone
Some muscles of mastication involving the mandible that willSome muscles of mastication involving the mandible that willform plans and anatomical spaces in the face and upper neckform plans and anatomical spaces in the face and upper neck
Spaces involved inodontogenic infectionsPrimary maxillary spacesAbscess of base of the upper lipCanineBuccalInfratemporalPrimary mandibular spacesSubmentalBuccalSubmandibularSublingualSecondary fascial spacesMassetericPterygomandibularSuperficial and deep temporalLateral pharyngealRetropharyngealPrevertebral
aInfections of the base of the upper lip usually results from infectedanterior teeth leading to swelling and protrusion of the upper lip, usuallyaccompanied by obliteration the mucolabial fold.N.B. the base of the upper lip is a dangerous region because it may leadto “CAVERNOUS SINUS THROMBOSIS”. Therefore, early diagnosis isessential to prevent this complications.Abscess of base of the upper lip
Canine space abscessThe Canine space lies between the levator anguli oris and levator labiisuperioris muscles.The source of infection of this space is usually from infected longcanine roots (subsequently to erosion of labial plate superior to theorigin of levator anguli oris muscle).Clinically, infection of this space leads to swelling of the anterior facewith obliteration of the nasolabial fold. Severe cases leads to edema ofupper and lower eyelids and may close the eye.
Buccal space abscessThe buccal space is bounded by theoverlying skin of the face on thelateral aspect and the buccinatormuscle medially.The buccal space becomes involvedfrom maxillary molar teeth wheninfection erodes through the bonesuperior to the attachment of thebuccinator muscle.The buccal space may also becomeinfected from the infected mandibularmolar
Buccal space abscessSigns and symptomsExtraoral swelling of the cheek area between the zygomaticarch and inferior border of the mandibleThe swelling protrudes into the mouth with severe throbbingpain.
Infratemporal space abscessAnatomic Location: The space inwhich this abscess develops is thesuperior extension of thepterygomandibular space. Laterally,this space is bounded by the ramus ofthe mandible and the temporalismuscle,while medially, it is bounded bythe medial and lateral pterygoidmuscles. The Infratemporal space israrely infected but when it is, thecause is usually an infection of themaxillary third molar.Infection of this space may result dueto infected infiltration anesthesia ofmaxillary nerve.
Infratemporal space abscessSigns and symptomsTrismus and pain duringopening of the mouthwith lateral deviationtowards the affectedside, edema at the regionanterior to the ear whichextends above thezygomatic arch, as well asedema of the eyelids areobserved
Submental space abscessThis space is bounded superiorly by themylohyoid muscle, laterally and on both sidesby the anterior belly of the digastric muscle,inferiorly by the superficial layer of the deepcervical fascia that is above the hyoid bone,and finally, by the platysma muscle andoverlying skin. This space contains the anteriorjugular vein and the submental lymph nodeSubmental space is primarily infected by mandibular incisors,which are long to allow the infection to erode through the labialplate apical to attachment of mentalis muscle.Other origin for infection of that space is symphyseal fracture.
Signs and symptomsFirm swelling under the chin in thesubmental areaDiscomfort on swallowingThe abscess may extendposterioly to the submandibularspace, and also may extendposteriorly to the submandibularspace and also may extend tosubmental space of the other side.
Mandibular molar teethinfection erode through thelingo-cortical bone, morefrequent than anterior teeth.1st Mandibular molar will drainbuccally or lingually.2nd Mandibular molar canperforate either buccally orlingually but usually lingually.3rd Mandibular molar infectionalmost always erode throughthe linguo-cortical plate.Spread of infection frommandibular molars
The mylohyoid muscle will determinewhether infections that drainlinguallygo intoIf above the mylohyoid musclethe ,infection localizes sublingually,if below the attach, of the muscle,the infection localizes instead intosubmandibular space.SublingualspaceSubmandibularspace
Lateral diagrammatic illustration showingthe localization of infection above or belowthe mylohyoid muscle, depending on theposition of the apices of the responsibletoothLine of insertion of the mylohyoid muscleLine of insertion of the mylohyoid muscle
Sublingual space abscessSublingual space liesbetween:-Oral mucosa from above.-Mylohyoid muscle below-Lingual surface of themandible laterally
Sub-mandibular space abscessSubmandibular space is boundedlaterally by the inferior borderof the body of the mandible,medially by the anterior belly ofthe digastric muscle, posteriorlyby the stylohyoid ligament andthe posterior belly of thedigastric muscle, superiorly bythe mylohyoid and hyoglossusmuscles, and inferiorly by thesuperficial layer of the deepcervical fascia. This spacecontains the submandibularsalivary gland and thesubmandibular lymph nodes.
Sub-mandibular space abscessSigns and symptomsThe infection presents as moderate swelling at theSub-mandibular area, which spreads, creating greateredema that is indurated with redness of the overlyingskin. Also, the angle of the mandible is obliterated.There is pain during palpation and moderate trismus dueto involvement of the medial pterygoid muscle are.
Ludwigs anginaWhen there is bilateral involvement ofthe submandibular /submental &sublingual space, the infection is termedLudwigs angina
Ludwigs anginaSign and SymptomsIt is a rapidly fulminatingmassive brawny hard cellulitisaffecting the submandibular,submental & sublingual spacesbilaterally.There is almost always severeswelling with elevation andanterior displacement of thetongue. The patient usuallyhas trismus, drooling of saliva,with difficulty in swallowingand breathing.This infection may progressrapidly producing upperairway obstruction oftenleads to death.
The submasseteric space abscessThe submasseteric space is located on the lateral surface ofthe mandibular ramus, between the deep and superfacialfibers of the masseter muscle.Posteriorly it is bounded by the parotid gland, and anteriorlyit is bounded by the mucosa of the retromolar area.Infection of this space usually originate from the infectionaround the crown of the mandibular third molars(pericoronitis),
Signs and symptomsIt is characterized by a firmedema that is painful to pressurein the region of the massetermuscle, which extends from theposterior border of the ramus ofthe mandible as far as theanterior border of the massetermuscle. Also, severe trismus andan inability to palpate the angleof the mandible are observedIntraorally, there is edemapresent at the retromolar areaand at the anterior border ofthe ramus.The sub-masseteric space abscess
Pterygomandibular space abscessThis space is bounded laterallyby the medial surface of theramus of the mandible, mediallyby the medial pterygoid muscle,superiorly by the lateralpterygoid muscle, anteriorly bythe pterygomandibular raphe,and posteriorly by the parotidgland
Etiology- Infections of molar teethespecially third molar.- Septic inferior alveolar nerveblock with contaminated needleor anesthetic solution.- Spread of infection from theinfratemporal space- Compound fracture of the angleof the mandible.Pterygomandibular space abscess
Signs and symptomsSevere trismus and slightextraoral edema beneath theangle of the mandible areobserved.Intra-orally, edema of thesoft palate of the affectedside is present, and there isdisplacement of the uvula andlateral pharyngeal wall, whilethere is difficulty inswallowing.Pterygomandibular space abscess
The lateral pharingeal spaceAnatomic Location. conical shaped, with the base facing theskull while the apex reashes the hyoid bone. It is lateral tothe lateral wall of the pharynx and medial to the medialpterygoid muscle .Etiology. Infections of this space originate in the region ofthe third molar and are the result of spread of infectionfrom the submandibular and pterygomandibular spaces.Sign and symptoms: Extraoral edema at the lateral region ofthe neck that may spread as far as the tragus of the ear,displacement of the pharyngeal wall, tonsil and uvula towardsthe midline, pain that radiates to the ear, trismus, difficultyin swallowing, significantly elevated temperature, andgenerally malaise are noted
Retropharingeal space abscessAnatomic Location. The retropharyngeal space is locatedposterior to the soft tissue of the posterior wall of thepharynx and is bounded anteriorly by the superiorpharyngeal constrictor muscle and the associated fascia,posteriorly by the prevertebral fascia, superiorly by thebase of the skull, and inferiorly by the posteriormediastinum .Etiology. Infections of this space originate by spread ofthe infection from the lateral pharyngeal space, which isclose by.
Sign and symptoms:The same symptoms as those present in the lateralpharyngeal abscess appear clinically, with even greaterdifficulty in swallowing due to edema at the posterior wall ofthe pharynx. If it is not treated in time, there is a risk of:Obstruction of the upper respiratory tract, due todisplacement of the posterior wall of the pharynx anteriorly.Rupture of the abscess and aspiration of pus into the lungs.Spread of infection into the mediastinum.Retropharingeal space abscess
Principles of surgical therapyPrinciples of surgical therapy