COMPARTMENTS OF THE HEAD
AND NECK – SURGICAL
ANATOMY & APPLIED ASPECTS
INDIAN DENTAL ACADEMY
Leader in continuing dental e...
“He who sees things grow from
the beginning will have the
finest view of them”
www.indiandentalacademy.com
Fascial Spaces
“The facial spaces or compartments are regions
of loose C.T. that fill the areas between facial
layers”.
Th...
How did the concept of facial
spaces arise?
“If I have seen further, it is by standing on the
shoulder of Gaints”.
Issac N...
What is fascia and its functions?
• It is a sheet or layer of more / less
condensed connective tissue.
• Fascial layers ar...
Functions of the fascia
• Acts as a musculovenous pump• Limits outward expansion of muscles as they contract.
• Contractio...
CLASSIFICATION
FASCIAE IN THE NECK

SUPERFICIAL
(SCF)

DEEP
(DCF)

www.indiandentalacademy.com
Superficial fascia
Superficial fascia is not a fascial sheet in the classic sense, but
rather a fatty loose connective tis...
Superficial fascia
Skin
+
Superficial fascia
+
Platysma muscle

Complex
morphological
unit

Superficial
musculoaponeurotic...
Deep fascia
Superficial layer
of deep fascia

Middle layer of
deep fascia

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Deep layer of
deep...
Superficial layer of deep cervical fascia

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Superficial layer of deep cervical fascia

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Middle layer of deep cervical fascia

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Buccopharyngeal fascia

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Deep layer of deep cervical fascia

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Deep layer of deep cervical fascia

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Schematic diagram showing the arrangement
of deep neck spaces

www.indiandentalacademy.com
Schematic diagram showing the arrangement
of deep neck spaces

www.indiandentalacademy.com
•

•
•

The greatest clinical implication of cervical
fascia is that it divides the neck into potential
spaces that functi...
Classification of the spaces of Face & Neck
I Spaces of the Face
A.

Maxillary spaces
1. Buccal space.
2. Canine space.
B....
B. Suprahyoid spaces:
1) Mandibular space
•
•
•
•

Submandibular space.
Submental space.
Sublingual space.
Space of the bo...
Concepts about space infections
• The spaces are not empty they contain various
organs, nerves, blood vessels, salivary gl...
Concepts about space infections
• Infections within each space has its own
diagnostic signs and tends to spread in an
orde...
Pathways of spread of dental infection

Pericoronitis of third molar area

Spread of infection from erupted and
infected t...
Predisposing factors
•

Primary predisposing factors leading to deep
infection of the neck were:
1. Local dental disease l...
Relationship of point of bone perforation to
spread of infection

Infection enters soft tissue through
thinnest bone

www....
Stages of infections
•
•
•
•

Stage I – Inoculation
Stage II – Cellulitis
Stage III – Abscess
Stage IV – Resolution

www.i...
Surgical anatomy of deep facial
spaces of head and neck

www.indiandentalacademy.com
Buccal space

Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confine...
Canine space / Infraorbital space

• Clinical evaluation: Patient exhibits swelling lateral to the nose
obliterating the n...
Differential diagnosis of upper face
infections

Dacrocystitis with
minimal involvement
of nasolabial fold.

Odontogenic c...
Suprahyoid spaces
1) Mandibular space
•
•
•
•

Submandibular space.
Submental space.
Sublingual space.
Space of the body o...
Mandibular spaces
Submandibular space

Clinical Evaluation:
Infection mostly arises from 2nd or third molar.
Induration an...
Sublingual space

Clinical evaluation: Edema and induration of the floor of the mouth on the
affected side displacing tong...
Submental space

Boundary
Clinical evaluation
Management
Complications

www.indiandentalacademy.com
Ludwig’s Angina

Ludwig’s angina is a firm, acute, toxic cellulitis of the submandibular
and sublingual spaces bilaterally...
Ludwig’s Angina
•

The original description of the disease was given by Wilhelm
Friedrich von Ludwig.

•

Ludwig’s origina...
Ludwig’s Angina

Clinical evaluation:
- It is characteristically aggressive and rapidly spreading.
- Patient will appear t...
Management of Ludwig’s Angina
•
•
•
•

Hospitalization.
Airway control – tracheostomy.
Early I.v. antibiotics.
External su...
Incision for surgical drainage of Ludwig’s Angina

X

www.indiandentalacademy.com
Deep neck infections
• All involve only posterior side of neck.
a)Retropharyngeal space (space 3, posterior
visceral space...
Principles for Rx of the deep neck spaces
•
1.
2.
3.

4.
5.

Benjamin J. Gans, in his Atlas of oral

surgery, articulated ...
Retropharyngeal space
Retropharyngeal space is the potential space sandwiched between alar
and prevertebral layers of deep...
Diagnosis of the soft tissue radiograph
for retropharyngeal space infection
Step I:
• Look at the prevertebral or
retropha...
Step II.
The second feature that
should be looked for in
this radiograph is the
presence of gas.
Anaerobic bacteria will
p...
Clinical Evaluation
• Children less than 4 yrs commonly affected.
• In adults it manifests as cold abscess.
• Sore throat,...
Complications of space infection
Frontal view of the patient with right cavernous sinus
thrombosis

• Venous congestion of...
Diagnosis of cavernous sinus
thrombosis
• Eagleton’s six features.
– Known site of infection.
– Evidence of blood stream
i...
Surgical incisions used to approach deep neck
infections

www.indiandentalacademy.com
Diagnostic Imaging of Fascial & Neck
Spaces
Plain film.

CT.

MRI

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Ultrasound
Principles of incision and drainage
• Incise in healthy skin and mucosa when possible.
• Incision placed at the site of ma...
Principles of incision and drainage
• Consider use of through and through drains in
bilateral submandibular space infectio...
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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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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Space infection /certified fixed orthodontic courses by Indian dental academy

  1. 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. 2. “He who sees things grow from the beginning will have the finest view of them” www.indiandentalacademy.com
  3. 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. 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. 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. 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. 7. CLASSIFICATION FASCIAE IN THE NECK SUPERFICIAL (SCF) DEEP (DCF) www.indiandentalacademy.com
  8. 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. 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. 10. Deep fascia Superficial layer of deep fascia Middle layer of deep fascia www.indiandentalacademy.com Deep layer of deep fascia
  11. 11. Superficial layer of deep cervical fascia www.indiandentalacademy.com
  12. 12. Superficial layer of deep cervical fascia www.indiandentalacademy.com
  13. 13. Middle layer of deep cervical fascia www.indiandentalacademy.com
  14. 14. Buccopharyngeal fascia www.indiandentalacademy.com
  15. 15. Deep layer of deep cervical fascia www.indiandentalacademy.com
  16. 16. Deep layer of deep cervical fascia www.indiandentalacademy.com
  17. 17. Schematic diagram showing the arrangement of deep neck spaces www.indiandentalacademy.com
  18. 18. Schematic diagram showing the arrangement of deep neck spaces www.indiandentalacademy.com
  19. 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. 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. 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. 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. 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. 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. 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. 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. 27. Stages of infections • • • • Stage I – Inoculation Stage II – Cellulitis Stage III – Abscess Stage IV – Resolution www.indiandentalacademy.com
  28. 28. Surgical anatomy of deep facial spaces of head and neck www.indiandentalacademy.com
  29. 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. 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. 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. 32. Suprahyoid spaces 1) Mandibular space • • • • Submandibular space. Submental space. Sublingual space. Space of the body of the mandible. www.indiandentalacademy.com
  33. 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. 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. 35. Submental space Boundary Clinical evaluation Management Complications www.indiandentalacademy.com
  36. 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. 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. 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. 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. 40. Incision for surgical drainage of Ludwig’s Angina X www.indiandentalacademy.com
  41. 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. 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. 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. 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. 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. 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. 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. 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. 49. Surgical incisions used to approach deep neck infections www.indiandentalacademy.com
  50. 50. Diagnostic Imaging of Fascial & Neck Spaces Plain film. CT. MRI www.indiandentalacademy.com Ultrasound
  51. 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. 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. 53. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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