SPACES OF
HEAD AND NECK
AND INFECTIONS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacadem...
CONTENTS
INTRODUCTION
DEFINITION
DEEP FASCIA
CLASSIFICATION
PATHWAYS OF SPREAD
SPACES
COMPLICATIONS
CONCLUSION
www.indiand...
INTRODUCTION


The infection in orofacial region does not
spread haphazardly through the loose
connective tissue, but ten...




Fascia:- It is defined as a broad sheet of
dense connective tissue whose function is to
separate structure that must...
Fascia is described under:1) Superficial fascia
2)Deep fascia
Superficial fascia:

-Similar to subcutaneous
tissue
-Enshe...


Deep fascia:- In the neck the deep fascia upon
dissection forms several more or less distinct layers.
They are:a) Super...
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Midline layer:- it is the part of the anterior layer of
deep fascia that passes behind the strap muscles.
 It is divided ...




These are not usually involved in oro-facial
infections.
Third division has clinical significance because
- below th...


The deep neck spaces –
1)retropharyngeal
2)lateral pharyngeal
3)pre tracheal spaces all lie on the
superficial side of ...
Posterior layer:- the posterior layer of the deep
cervical fascia has two divisions
1) the alar
2) the prevertebral
The al...








This fusion forms the bottom of the retropharyngeal space.
Infection of the retro-pharyngeal space may
rupture...
Carotid sheath:- Carotid sheath surrounding
IJV, CCA & vagus nerve is interposed
between the superficial and pretracheal l...




The posterior wall is formed by a lamina
given off medially by the superficial layer as
the lather reaches the level...


Spaces of the head and neck:Grodinsky and Holyoke in 1938, described these
potential spaces as follows:
1)Spaces 1- the...
Classification of fascial spaces:1. based on clinical significance:
a) Face – buccal, canine, maticatiory,
parotid.
b) Sup...
2. Based on mode of involvement
a) direct involvement
primary spaces (i) maxillary spaces.
(ii) mandibular spaces.
b) indi...
MICROBIOLOGY OF ODONTOGENIC INFECTIONS:Usually the bacteria which causes infections are a
part of the indigenous flora and...
Pathways of odontogenic infection:Invasion of dental pulp by bacteria
Inflammation, edema, lack of collateral supply
Avasc...
Fistula

Cellulitis

Bacteremia – septicemia

Acute, chronic
periapical infection

Intra oral soft tissue
abscess

Osteomy...
Difference between cellulitis and abscess

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The spread can vary based on:
1) number and virulence of organism
2) host resistence
3) Anatomy of the involved area
The m...
QUALITY refers to the number of micro organisms that initially
colonize the host.
The host factor defences consists of
a) ...
Radiological Examination


Conventional radiography:-Iopa
-OPG
- LateraL OBLIQUE VIEW

other Diagnostic Aids:
C.T. – Gold...


Canine space:
boundaries:
superiorly – quadratus labii superiories
inferiorly – orbicularies ori
deep – anterior surfac...
INFRA ORBITAL OR CANINE
SPACE

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

Source of infection:
- maxillary canine
- first premolar
c/f:- - swelling of cheek and upper lip
- obliteration of naso...
Differential diagnosis of upper face infections

Dacrocystitis with
minimal involvement
of nasolabial fold.

Odontogenic c...
Buccal space:Boundaries:
anteriorly – zygomatic major above & depressor anguli
oris below
posteriorly – anterior border of...
Source of infection:-

max. bicuspid
max. molars
mand. Molars
mand. Bicuspids

c/f:- obvious and dome shaped over the chee...
Buccal space

Clinical evaluation: Examination of the patient with the buccal space infection
demonstrate swelling confine...
Treatment of buccal space abscess:Intra oral: horizontal incision just above the
depth of vestibule. Hemostat advanced
thr...
Infratemporal space or retro zygomatic space
Boundaries:Anteriorly – infratemporal surface of maxilla
posteriorly – mandib...
INFRATEMPORAL SPACE

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Source of infection:max. molars
through infected needle
c/f:- swelling over the TMJ in front of the ear.
trismus.
intraora...


Treatment of infratemporal space abscess:Intra oral: Vertical incision is made just
lateral to the 3rd molar and medial...


Masticatory space:
the masticatory spaces are:
1) submasseteric
2) pterygoid
3) temporal

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

Sub masseteric space:Boundaries:
Anteriorly – anterior border of masseter muscle and
buccinator.
Posteriorly – parotid ...
SUB MASSETERIC
SPACE

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c/f:- extra oral swelling confined to the
boundaries of masseteric muscle.
limitation of mouth opening
fluctuation is abse...
Pterygomadibular space:Boundaries:Laterally – medial surface of ramus of mandible
Medially – lateral surface medial pteryg...
c/f: Trismus
Dysphagia
Midline of the palate is displaced to uneffected side,
uvula is swollen.
Medial displacement of lat...
Temporal space:It is secondary to the initial involvement of
pterygopalatine & infra temporal space.
Temporal pouches are ...
Contents:Superficial - Superficial temporal
vessel
Auriculo temporal nerve
Deep – deep temporal arteries & veins.
c/f:- Tr...
Parotid Space


Superficial layer of deep
fascia






Dense septa from
capsule into gland
Direct communication to
par...
Treatment of parotid space abscess:A retromandibular incision through the skin and super
fascia extending from inferior as...
Peritonsillar Space









Medial—capsule of palatine
tonsil
Lateral—superior
pharyngeal constrictor
Superior—anteri...
Sub mandibular space:Boundaries:

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SUBMANDIBULAR SPACE

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Contents:- Superficial lobe of submandibular salivary
gland.
Submandibular lymphnode
facial artery
c/f:- moderate trismus
...
Treatment of submandibular space abscess:Two stab incision at the anterior and
posterior limit of the most dependent,
fluc...


Submental:-

Boundaries:
lateral: lower border of mandible and anterior belly of digastric
muscle.
Superiorly: mylohyoi...
SUBMENTAL SPACE

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Sublingual:It is a v- shaped trough lying to muscle of tongue.
Boundaries:

Treatment of sublingual space abscess:Incisio...
Prevertebral space:Boundaries:
superiorly: base of the skull
inferiorly: extends to the level of t7/t8
vertebra
anteriorly...
PALATAL SPACE

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Lateral pharyngeal space:Boundaries:


Contents: The styloid process divides this space into two
compartment which are no...
Pharyngomaxillary Space


Communicates
with several deep
neck spaces.






Parotid
Masticator
Peritonsillar
Submand...
Treatment of lateral pharyngeal space:
Intraoral:
Incision into the most prominent part of the soft plate
where fluctuatio...
Spaces of the body of the mandible:
This space is formed by the investing
fascia as it splits at its attachment to the bas...
Management of facial space infections:“THE MORE SEVERE THE INFECTION, THE
MORE AGGRESSIVE SHOULD BE THE
MANAGEMENT”
1) Adm...


PRINCIPLES OF INCISION AND DRAINAGE:1) Incisions are sited according to the location of pus.
2) Incision must be made o...
Who gets complications?



Older pts
Systemic dz
 Immunodeficient pts






HIV
Myelodysplasia

Cirrhosis
DM



...


Complications:
1. Ludwig's angina
2. Mediastinitis
3. Brain abscess
4. Cavernous sinus thrombosis
5. Meningitis

www.in...


Ludwig’s angina:-

Ludwig’s angina may be described as an overwhelming
generalized septic cellulitis of submandibular r...
Ludwig’s Angina

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

c/f:
Tissues are braway, indurated, flat-board like, non pitting
and non fluctuant.
Pt. has typical open mouthed appear...
Incision for surgical drainage of Ludwig’s Angina

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

Meningitis:-

most common neurological complication.
c/f:- Headache
Fever
Stiffness of neck
Vomiting
Kernig’s sign
Brud...


Brain abscess:-

Occurs from bacteraemia accompanying
odontogenic infections.
c/f:- Headache
Nausea
Vomiting
Hemiplagia...


Cavernous sinus thrombosis:Involvement: external route
internal route
c/f:- Swelling of eye lids
Tenderness in the eye ...
CAVERNOUS SINUS THROMBOSIS

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Conclusion:Early recognition of orofacial infections and
prompt appropriate therapy is absolutely
essential. A through kn...
Thank you
Leader in continuing dental education
www.indiandentalacademy.com

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    1. 1. SPACES OF HEAD AND NECK AND INFECTIONS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. CONTENTS INTRODUCTION DEFINITION DEEP FASCIA CLASSIFICATION PATHWAYS OF SPREAD SPACES COMPLICATIONS CONCLUSION www.indiandentalacademy.com
    3. 3. INTRODUCTION  The infection in orofacial region does not spread haphazardly through the loose connective tissue, but tends to accumulate in these potential spaces around the head and neck. Many of these spaces communicate with each other. www.indiandentalacademy.com
    4. 4.   Fascia:- It is defined as a broad sheet of dense connective tissue whose function is to separate structure that must pass over each other during movement such as muscles & glands and serve as a pathway for the course of vascular &neural structure Definition:- Shapiro defined facial spaces as “potential spaces between the layers of the fascia”. These area are normally filled with loose connective tissue which readily breaks down when invaded by infection. www.indiandentalacademy.com
    5. 5. Fascia is described under:1) Superficial fascia 2)Deep fascia Superficial fascia: -Similar to subcutaneous tissue -Ensheathes platysma and muscles of facial expression www.indiandentalacademy.com
    6. 6.  Deep fascia:- In the neck the deep fascia upon dissection forms several more or less distinct layers. They are:a) Superficial or anterior or investing layer. b) Middle or pretracheal layer. c) Posterior or prevertebral layer. d) Carotid sheath. www.indiandentalacademy.com
    7. 7. www.indiandentalacademy.com
    8. 8. www.indiandentalacademy.com
    9. 9. Midline layer:- it is the part of the anterior layer of deep fascia that passes behind the strap muscles.  It is divided into 3 divisions: 1)sternohyoid – omohyoid 2)sternothyroid – thyrohyoid 3)visceral and buccopharyngeal The 1st two divisions surround the corresponding strap muscles of the neck between hyoid bone and clavicle. The primary surgical significance of these layers is they must be divided in the midline in a surgical approach to trachea or thyroid gland.  www.indiandentalacademy.com
    10. 10.   These are not usually involved in oro-facial infections. Third division has clinical significance because - below the hyoid bone the visceral layer surrounds the trachea oesophagus and thyroid gland. - above the hyoid bone the visceral fascia wraps around the lateral and posterior side of the pharynx, lying on the superficial side of pharyngeal constrictor muscle – known as buccopharyngeal fascia. www.indiandentalacademy.com
    11. 11.  The deep neck spaces – 1)retropharyngeal 2)lateral pharyngeal 3)pre tracheal spaces all lie on the superficial side of visceral division of the middle layer of the deep cervical fascia. www.indiandentalacademy.com
    12. 12. Posterior layer:- the posterior layer of the deep cervical fascia has two divisions 1) the alar 2) the prevertebral The alar fascia passes through the transverse process of the vertebrae on either side, posterior to the retropharyngeal fascia. In the vertical dimension the posterior layer extends from the base of the skull to diaphragm. The alar fascia fuses with retropharyngeal fascia at a variable level between 6th cervical and 4th vertebrae.  www.indiandentalacademy.com
    13. 13.     This fusion forms the bottom of the retropharyngeal space. Infection of the retro-pharyngeal space may rupture the alar fascia, thus entering the danger space , which is continuous with the posterior mediastinum. The prevertebral fascia surround the vertebra and the attached postural muscles of the neck & back Prevertebral fascia is usually not invaded by infection arising in maxillofacial regions. www.indiandentalacademy.com
    14. 14. Carotid sheath:- Carotid sheath surrounding IJV, CCA & vagus nerve is interposed between the superficial and pretracheal layer on the one hand and prevertebral layer on the other. Its anterolateral wall is infact the superior layer of fascia deep to sternocleidomastoid muscle and to a lesser extent, the pretracheal layer where the infrahyoid muscle overlap the great vessels.  www.indiandentalacademy.com
    15. 15.   The posterior wall is formed by a lamina given off medially by the superficial layer as the lather reaches the level of the vessels: this lamina passes behind the vessels and nerve to form the posterior wall of the sheath and the medial wall of the sheath is then completed by fascia passing from anterolateral to the posterior wall between the contents of the sheath and the trachea and oesophagus. The sheath is attached medially to the prevertebral layer of fascia. The sympathetic trunk lies behind it. www.indiandentalacademy.com
    16. 16.  Spaces of the head and neck:Grodinsky and Holyoke in 1938, described these potential spaces as follows: 1)Spaces 1- the potential space superficial and deep to platysma muscle. 2)Spaces 2- the spaces behind the anterior layer of deep cervical fascia. 3)Spaces 3- pretracheal spaces lies anterior to trachea. 4)Spaces 3a- “lincoln’s highway” 5)Spaces 4- danger spaces is a potential spaces between the alar &prevertebral fascia. www.indiandentalacademy.com
    17. 17. Classification of fascial spaces:1. based on clinical significance: a) Face – buccal, canine, maticatiory, parotid. b) Suprahyoid – sublingual, submandibular, lateral pharyngeal, pretonsillar. c) Infrahyoid – pretracheal. d) Spaces of total neck – retropharyngeal, space of carotid sheath.  www.indiandentalacademy.com
    18. 18. 2. Based on mode of involvement a) direct involvement primary spaces (i) maxillary spaces. (ii) mandibular spaces. b) indirect involvement: secondary spaces. www.indiandentalacademy.com
    19. 19. MICROBIOLOGY OF ODONTOGENIC INFECTIONS:Usually the bacteria which causes infections are a part of the indigenous flora and odontogenic infections are no exception to this. 60% of all odontogenic infections are caused by aerobic and anaerobic bacteria. Only anaerobic make up about 35% and pure aerobes, 5% only. The commonly isolated organisms are  Aerobes : Anaerobes : Streptococci (70%) Staphylococci(6%) Peptococci (11%) Peptostreptococci (11%) Bacteroides (34%) Fusubacteria (13%) www.indiandentalacademy.com
    20. 20. Pathways of odontogenic infection:Invasion of dental pulp by bacteria Inflammation, edema, lack of collateral supply Avascular necrosis Reservoir of bacterial growth Spreading to the surrounding bone www.indiandentalacademy.com
    21. 21. Fistula Cellulitis Bacteremia – septicemia Acute, chronic periapical infection Intra oral soft tissue abscess Osteomylytis www.indiandentalacademy.com Deep facial space infection Ascending fascial cerebral infection
    22. 22. Difference between cellulitis and abscess www.indiandentalacademy.com
    23. 23. The spread can vary based on: 1) number and virulence of organism 2) host resistence 3) Anatomy of the involved area The microbial factors include VIRULENCE and QUALITY. Virulence refers to the inherent ability of a microbe to cause infection. It is the sum total of all microbial quality which are harmful to the host. To cause an infection the micro-organism should be able to: a) enter the host b) multiply with in the host c) at least temporarily, resist or not stimulate host defences d) cause damage to the host www.indiandentalacademy.com
    24. 24. QUALITY refers to the number of micro organisms that initially colonize the host. The host factor defences consists of a) Local defences b) Humoral component c) Cellular component LOCAL DEFENCES consists of:a) Epithelial lining b) Secretions and drainage systems c) Mucosal immune system d) Microbial flora interference HUMORAL COMPONENT consists of:a) Immuno globulins b) complement system CELLULAR COMPONENT consists of Polymorphs & Lymphocytes. www.indiandentalacademy.com
    25. 25. Radiological Examination  Conventional radiography:-Iopa -OPG - LateraL OBLIQUE VIEW other Diagnostic Aids: C.T. – Gold Standard in head and neck infections 1. Showing complete extent of inflammatory process. 2. Difference between myositis – facitis and abscess formation. 3. Demonstrates status of airway and involvement of lymph nodes 4. Abscess drainage and drain placement can be done by C.T. guidance. M.R.I fine needle aspiration www.indiandentalacademy.com
    26. 26.  Canine space: boundaries: superiorly – quadratus labii superiories inferiorly – orbicularies ori deep – anterior surface of maxilla medially – levator labii alaeque nasii laterally – zygomaticus major contents: - angular artery & vein - infra orbital nerve www.indiandentalacademy.com
    27. 27. INFRA ORBITAL OR CANINE SPACE www.indiandentalacademy.com
    28. 28.  Source of infection: - maxillary canine - first premolar c/f:- - swelling of cheek and upper lip - obliteration of nasolabial fold - odema of lower eye lid Treatment of canine space abscess:Incise high in the maxillary labial vestibule. Hemostat advanced through levator anguli oris muscle. www.indiandentalacademy.com
    29. 29. Differential diagnosis of upper face infections Dacrocystitis with minimal involvement of nasolabial fold. Odontogenic cellulitis. The nasolabial fold is affected. www.indiandentalacademy.com
    30. 30. Buccal space:Boundaries: anteriorly – zygomatic major above & depressor anguli oris below posteriorly – anterior border of masseter superiorly – zygomatic arch inferiorly – inferior border of mandible medially – buccinator laterally – skin & subcutaneous tissue Contents:parotid duct anterior fascial artery & vein transverse fascial artery & vein buccal fat pad  www.indiandentalacademy.com
    31. 31. Source of infection:- max. bicuspid max. molars mand. Molars mand. Bicuspids c/f:- obvious and dome shaped over the cheek from the zygomatic arch to the lower border of the mandible. Spread:- pterygomandibular space infratemporal space submasseteric space www.indiandentalacademy.com
    32. 32. 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
    33. 33. Treatment of buccal space abscess:Intra oral: horizontal incision just above the depth of vestibule. Hemostat advanced through the buccinator. Extra oral: when fluctuance occurs ,it should be drained percutaneously. Cutaneous drainage should be performed inferior to point of fluctuance. www.indiandentalacademy.com
    34. 34. Infratemporal space or retro zygomatic space Boundaries:Anteriorly – infratemporal surface of maxilla posteriorly – mandibular condyle superiorly – infra temporal crest of sphenoid inferiorly – lateral pterygoid medially – temporal tendon, coronoid process laterally – lateral pterygoid plate Contents:- pterygoid plexus internal maxillary artery & vein mandibular nerve  www.indiandentalacademy.com
    35. 35. INFRATEMPORAL SPACE www.indiandentalacademy.com
    36. 36. Source of infection:max. molars through infected needle c/f:- swelling over the TMJ in front of the ear. trismus. intraoral swelling over the tuberosity area. Spread:- extended upwards to involve temporal space. inferiorly – pterygomandibular space. upwards into cavernous sinus. www.indiandentalacademy.com
    37. 37.  Treatment of infratemporal space abscess:Intra oral: Vertical incision is made just lateral to the 3rd molar and medial to upper extent of ramus. Extra oral: horizontal incision parallel to the junction of frontal & temporal processes of zygoma (JUGAL POINT). www.indiandentalacademy.com
    38. 38.  Masticatory space: the masticatory spaces are: 1) submasseteric 2) pterygoid 3) temporal www.indiandentalacademy.com
    39. 39.  Sub masseteric space:Boundaries: Anteriorly – anterior border of masseter muscle and buccinator. Posteriorly – parotid gland, posterior part of masseter Inferiorly – lower border of mandible Medially – lateral surface of ramus of mandible Laterally – medial surface of the masseter muscle Contents:- masseteric nerve superficial temporal artery transverse facial artery www.indiandentalacademy.com
    40. 40. SUB MASSETERIC SPACE www.indiandentalacademy.com
    41. 41. c/f:- extra oral swelling confined to the boundaries of masseteric muscle. limitation of mouth opening fluctuation is absent pyrexia & malaise Treatment of submasseteric space abscess:Intra oral: vertical incision along the external oblique ridge. Extra oral: incision made below and parallel to angle of mandible. www.indiandentalacademy.com
    42. 42. Pterygomadibular space:Boundaries:Laterally – medial surface of ramus of mandible Medially – lateral surface medial pterygoid plate Posteriorly – deeper portion of parotid gland Anteriorly – pterygomandibular raphe Superiorly – lateral pterygoid muscle Contents:-Lingual nerve Mandibular nerve Inferior alveolar artery Mylohyoid nerve & vessel  www.indiandentalacademy.com
    43. 43. c/f: Trismus Dysphagia Midline of the palate is displaced to uneffected side, uvula is swollen. Medial displacement of lateral wall of pharynx. Spread: Infra temporal fossa Buccal space Lateral & pterygoid space Submandibular space Treatment of pterygomandibular space abscess: Intra oral: Incision along or medial to pterygomandibular raphae. Extra oral: Incision is made 1 inch below and parallel to angle of mandible. www.indiandentalacademy.com
    44. 44. Temporal space:It is secondary to the initial involvement of pterygopalatine & infra temporal space. Temporal pouches are facial spaces in relation to the temporalis muscle. They are two :(i) Superficial temporal space (ii) Deep temporal space  www.indiandentalacademy.com
    45. 45. Contents:Superficial - Superficial temporal vessel Auriculo temporal nerve Deep – deep temporal arteries & veins. c/f:- Trismus Swelling with in the outline of temporalis Treatment of temporalis space abscess:Intra oral: Vertical incision is made just lateral to the 3 rd molar and medial to upper extent of ramus. Extra oral: horizontal incision parallel to the junction of frontal & temporal processes of zygoma (JUGAL POINT). www.indiandentalacademy.com
    46. 46. Parotid Space  Superficial layer of deep fascia    Dense septa from capsule into gland Direct communication to parapharyngeal space Contains     External carotid artery Posterior facial vein Facial nerve Lymph nodes www.indiandentalacademy.com
    47. 47. Treatment of parotid space abscess:A retromandibular incision through the skin and super fascia extending from inferior aspect of ear lobule to angle of mandible. Curved incision at the angle of the mandible. www.indiandentalacademy.com
    48. 48. Peritonsillar Space     Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar www.indiandentalacademy.com
    49. 49. Sub mandibular space:Boundaries: www.indiandentalacademy.com
    50. 50. SUBMANDIBULAR SPACE www.indiandentalacademy.com
    51. 51. Contents:- Superficial lobe of submandibular salivary gland. Submandibular lymphnode facial artery c/f:- moderate trismus dysphagia mobility of teeth sensitivity to percussion Spread:- submental submandibular space on contralateral side sublingual parapharyngeal space www.indiandentalacademy.com
    52. 52. Treatment of submandibular space abscess:Two stab incision at the anterior and posterior limit of the most dependent, fluctuant portion of the swelling, placed in the shadow of the mandible. www.indiandentalacademy.com
    53. 53.  Submental:- Boundaries: lateral: lower border of mandible and anterior belly of digastric muscle. Superiorly: mylohyoid muscle Inferiorly: deep fascia, platysma and skin Contents: Submental lymphnodes – anterior jugular vein c/f:- distinct ,firm swelling in midline, beneath the chin, skin overlying the fluctuation may be present Treatment of submental space abscess:Two horizontal incisions placed at the most dependant fluctuant portion of the swelling followed by placement through & through rubber dam www.indiandentalacademy.com
    54. 54. SUBMENTAL SPACE www.indiandentalacademy.com
    55. 55. Sublingual:It is a v- shaped trough lying to muscle of tongue. Boundaries: Treatment of sublingual space abscess:Incision is placed intraorally at the base of the alveolar process in the lingual sulcus. It pus is not obtained the periosteum opp to the offending tooth must be incised Sublingual abscess when accompanied by submandibular abscess may be drained through a submandibular incision with hemostat passing through mylohyoid muscle www.indiandentalacademy.com
    56. 56. Prevertebral space:Boundaries: superiorly: base of the skull inferiorly: extends to the level of t7/t8 vertebra anteriorly: alar fascia posteriorly: prevertebral fascia laterally: carotid sheath Infections from this space have an unimpeded progress toward the mediastinum.  www.indiandentalacademy.com
    57. 57. PALATAL SPACE www.indiandentalacademy.com
    58. 58. Lateral pharyngeal space:Boundaries:  Contents: The styloid process divides this space into two compartment which are not completely seperated www.indiandentalacademy.com
    59. 59. Pharyngomaxillary Space  Communicates with several deep neck spaces.      Parotid Masticator Peritonsillar Submandibular Retropharyngeal www.indiandentalacademy.com
    60. 60. Treatment of lateral pharyngeal space: Intraoral: Incision into the most prominent part of the soft plate where fluctuation is maxilla. Another incision is similar to one used for pterygomandibular space but after the incision, hemostat is advanced posteriorly and medial to the medial pterygoid. Extraoral: Incision is placed 1cm below and behind the angle of mandible. Incision is made another 1cm inferiorly to angle of mandible. preparations for tracheostamy must be at hand because edema of larynx may arise with suddeness  www.indiandentalacademy.com
    61. 61. Spaces of the body of the mandible: This space is formed by the investing fascia as it splits at its attachment to the base of the mandible to become continuous with the periosteum bordering the buccal lingual aspects of the body of the mandible. This space is continuous posteriorly with the masticatory space. Contents: body of the mandible. inferior alveolar nerve, artery & vein dento periodontal apparatus  www.indiandentalacademy.com
    62. 62. Management of facial space infections:“THE MORE SEVERE THE INFECTION, THE MORE AGGRESSIVE SHOULD BE THE MANAGEMENT” 1) Administration of appropriate antibiotics in appropriate doses through the appropriate route. 2) Surgical removal of source of infection as early as possible. 3) Surgical incision and drainage. 4) Constant evaluation and supportive therapy till infection resolves.  www.indiandentalacademy.com
    63. 63.  PRINCIPLES OF INCISION AND DRAINAGE:1) Incisions are sited according to the location of pus. 2) Incision must be made over the most dependent of a fluctuant area or over the most direct route to the pus. 3) Resist the temptation to incise over the thinnest point of an abscess. This area would be ischaemic and incision can lead to necrosis and unsightly scaring. 4) Incision must be large enough to permit egress of pus and adequate drainage. The esthetic problem associated with large incision in cervico facial areas may be overcome by two stab incisions with a through and through drainage between them. 5) The location of incision on the skin is also guided by the direction of the langer’s lines and placement in esthetically acceptable area such as with the shadow of mandible. www.indiandentalacademy.com
    64. 64. Who gets complications?   Older pts Systemic dz  Immunodeficient pts     HIV Myelodysplasia Cirrhosis DM      Most common systemic Mbio – Klebsiella pneum. (56%) 33% with complications Higher mortality rate Prolonged hospital stay  20 days vs. 10 days www.indiandentalacademy.com
    65. 65.  Complications: 1. Ludwig's angina 2. Mediastinitis 3. Brain abscess 4. Cavernous sinus thrombosis 5. Meningitis www.indiandentalacademy.com
    66. 66.  Ludwig’s angina:- Ludwig’s angina may be described as an overwhelming generalized septic cellulitis of submandibular region with bilateral involvement of the submental, sublingual and submandibular spaces. The three “F”s evident are feared, rarely fluctuant and often fatal. Source of infection: 1. Dental infection has been reported as the causative factor in 90% of cases. 2. Submandibular gland siladinitis, compound fracture of mandible, puncture wound of oral floor, oral soft tissue lacerations etc… It is usually an extension of infection caused by streptococci, staphylococci, gram –ve enteric organisms and anaerobic including bactoroides and streptococci. www.indiandentalacademy.com
    67. 67. Ludwig’s Angina www.indiandentalacademy.com
    68. 68.  c/f: Tissues are braway, indurated, flat-board like, non pitting and non fluctuant. Pt. has typical open mouthed appearance with protrusion of tongue and elevation of floor of the mouth. Tissue may become gangrenous and when cut may a peculiar lifeless appearance. Dysphagia, dyspnea may develop. chills, fever, drooling at saliva may be present. Sharp limitation between involved and uninvolved tissue. Complication: Immediate danger is edema of glottis with asphyxation. Septicemia Mediastinitis www.indiandentalacademy.com
    69. 69. Incision for surgical drainage of Ludwig’s Angina www.indiandentalacademy.com
    70. 70.  Meningitis:- most common neurological complication. c/f:- Headache Fever Stiffness of neck Vomiting Kernig’s sign Brudzinski’s sign Treatment:- combination of chloramphenicol and penicillin-G. Maintainence of hydration and electrolyte balance. www.indiandentalacademy.com
    71. 71.  Brain abscess:- Occurs from bacteraemia accompanying odontogenic infections. c/f:- Headache Nausea Vomiting Hemiplagia Convulsions Abducens palsy Treatment:- Antibiotics, steroids and mannitol www.indiandentalacademy.com
    72. 72.  Cavernous sinus thrombosis:Involvement: external route internal route c/f:- Swelling of eye lids Tenderness in the eye to pressure Conjuctival edema Exophthalmos Kernig’s sign Brudzinski’s sign Cranial nerve involvement Retinal haemorrhage Photo phobia Treatment:- Antibiotic therapy, heparinization, mannitol, anticoagulants and surgical drainage. www.indiandentalacademy.com
    73. 73. CAVERNOUS SINUS THROMBOSIS www.indiandentalacademy.com
    74. 74. Conclusion:Early recognition of orofacial infections and prompt appropriate therapy is absolutely essential. A through knowledge of anatomy of face and neck is necessary to predict pathways of spread of infection and drain the spaces adequately. Otherwise the infection spread to such an extent causing considerable morbidity and occasional death. www.indiandentalacademy.com
    75. 75. Thank you Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

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