Complex odontogenic infections Yaser Baroud

Deep fascial space infections Fascial spaces : Are fascia-lined tissue compartments filled with loose, areolar connective tissue that can become inflamed when invaded by microorganisms. As a general rule, infection erodes through the thinnest adjacent bone and causes infection in the adjacent tissue.

In healthy persons, the deep fascial spaces are only potential spaces that do not exist. The loose areolar tissue within these spaces serves to cushion the muscles, vessels, nerves, glands, and other structures that it surrounds and to allow relative movement between these structures.

Buccal Palatal sublingual Submandibular

Severity of deep fascial infections Classified according to their likelihood of threatening the airway or other vital structures Low severity infections: Infections that are not likely to threaten the airway or vital structures. Vestibular Buccal Subperiosteal Space of the body of the mandible Infraorbital

Severity of deep fascial infections Moderate- severity infections: Hinder access to the airway by causing trismus or elevation of the tongue, which can make endotracheal intubation difficult. Perimandibular spaces Submandibular Sublingual Submental Masticator space Submasseteric Pterygomandibular Superficial temporal Deep temporal (includes infratemporal) Submassetric space

Severity of deep fascial infections High severity infection: Can directly compress or deviate the airway or damage vital organs such as the brain, heart, lungs, or skin. Deep neck spaces Lateral pharyngeal Retropharyngeal Pretracheal Danger space Mediastinum Intracranial infections Cavernous sinus thrombosis Brain abscess Necrotizing fasciitis

Infections arising from any tooth Maxillary or mandibular teeth can cause infections of the buccal, vestibular, or subcutaneous spaces. Buccal space is considered a portion of the subcutaneous space, which extends from head to toes.

Infections arising from the maxillary teeth Infection arising from lateral incisor and palatal roots of upper premolars and molars can erode through bone without perforating the periosteum. The potential subperiosteal space in the palate is the palatal space. The infraorbital space is a thin potential space between the levator anguli oris and the levator labii superioris muscles.

Infections arising from the maxillary teeth Infraorbital space becomes involved by infection from the canine (superior to the origin of the levator anguli oris and below the origin of the levator labii superioris muscle) or extension of infection from the buccal space. When this space is infected, swelling of the anterior face obliterates the nasolabial fold Spontaneous drainage of infections of this space commonly occurs near the medial or the lateral canthus of the eye

Infections arising from the maxillary teeth Buccal space: Bounded by the overlying skin of the face on the lateral aspect and the buccinator muscle on the medial aspect. May become infected from extensions of infection from maxillary teeth through the bone superior to the attachment of the buccinator on the alveolar process of the maxilla. Posterior maxillary teeth, most commonly molars, cause most buccal space infections

Infections arising from the maxillary teeth Buccal space: Results in swelling below the zygomatic arch and above the inferior border of the mandible. Infection may extend to the temporal, infraorbital spaces. The zygomatic arch and the inferior border of the mandible remain palpable in buccal space infections.

Buccal space infection (extensions) Buccal space infection that has followed the extensions of the buccal fat pad into the infraorbital, periorbital, and superficial temporal spaces.

Infections arising from the maxillary teeth Infratemporal space: Posterior to the maxilla. The space is bounded medially by the lateral pterygoid plate of the sphenoid bone and superiorly by the base of the skull. Laterally and superiorly, the infratemporal space is continuous with the deep temporal space ( Bottom portion) Contains branches of the internal maxillary artery and the pterygoid venous plexus

Infratemporal space: Emissary veins from the pterygoid plexus pass through foramina in the base of the skull to connect with the intracranial dural sinuses. Because the veins of the face and the orbit do not have valves, bloodborne infections may pass superiorly or inferiorly along their course, so infection may spread intracranially (cavernous sinus) The cause is usually an infection of the maxillary third molar.

Infections arising from the maxillary teeth Periapical or periodontal infections of posterior maxillary teeth may erode superiorly through the floor of the maxillary sinus. Maxillary sinus infection may extend to the ethmoid sinus or the orbital floor to cause secondary orbital or periorbital infections.

Orbital and periobital infections present as redness and swelling of the eyelids and involvement of the vascular and neural components of the orbit (serious infection).

Infections arising from mandibular teeth

Space of the body of mandible Infection erodes through the buccal cortical bone but does not perforate the periosteum, it can essentially peel the periosteal layer of soft tissue off the bony surface. It can appear as if the bone itself has been enlarged.

Buccal space infection If an infection arising from a mandibular posterior tooth perforates the buccal cortical bone and the periosteum inferior to the attachment of the buccinator muscle, then the buccal space is involved.

Perimandibular spaces Sublingual space Submandibular space Submental space Sublingual and submandibular spaces are involved primarily by lingual perforation of infection from mandibular molars, although they may be involved by premolars as well. Attachment of mylohyoid muscle determines the space to be infected either sublingual (premolars & first molars) or submandibular ( third molars).

Sublingual space lies between the oral mucosa of the floor of the mouth and the mylohyoid muscle. The posterior border of the sublingual space is open, it freely communicates with the submandibular space. Clinically, little or no extraoral swelling is produced by an infection of the sublingual space, but much intraoral swelling is seen in the floor of the mouth on the infected side. The infection often becomes bilateral, and the tongue becomes elevated

Submandibular space lies between the mylohyoid muscle and the overlying superficial layer of the deep cervical fascia and platysma muscle. The posterior extent of the submandibular space communicates with the deep fascial spaces of the neck.

Submandibular space Infection causes swelling that can look like an inverted triangle, with the base at the inferior border of the mandible, the sides determined by the anterior and posterior bellies of the digastric muscle, and the apex at the hyoid bone.

Submental space lies between the anterior bellies of the right and left digastric muscles and between the mylohyoid muscle and the overlying fascia. Infections is rare , caused by infections of the mandibular incisors, or as a result of the spread of a submandibular space infection.

Submental space infection

1790-1865 قل للطبيب تخطفته يد الردى******* من يا طبيب بطبه أرداكَ

Ludwig’s angina When the perimandibular spaces (submandibular, sublingual, and submental) are bilaterally involved in an infection, it is known as Ludwig’s angina. This infection is a rapidly spreading cellulitis that can obstruct the airway and commonly spreads posteriorly to the deep fascial spaces of the neck. Patient usually has sever indurated swelling with tongue elevation, has trismus, drooling, and difficulty swallowing and sometimes breathing.

Ludwig’s angina May lead to upper airway obstruction that often leads to death. The most common cause is odontogenic infection. Managed by securing the airways, aggressive surgical management, and antibiotics.

Masticator space Composed of four compartments: The masticator space is formed by the splitting of the investing layer of the deep cervical fascia, to surround the muscles of mastication. Composed of four compartments: Submassetric space (between the masster m. and the lateral surface of the ramus) Pterygomandibular space ( between the medial pterygoid m. and the medial surface of the ramus) Superficial temporal space (between the temporalis fascia and temporalis muscle) Deep temporal space (between temporalis muscle and the skull)

Submassteric space Involved by infection most commonly as the result of spread from the buccal space or from soft tissue infection around the mandibular third molar (pericoronitis), or trauma (mandibular angle fracture). Patient has trismus due to masster muscle inflammation

Pterygomandibular space Infection spread primarily from the third molar, or infected needle track after mandibular block. Patient has trismus without significant facial swelling. Swelling of the anterior tonsillar pillar and deviation of the uvula toward the opposite side.

Pterygomandibular space Infection may cause deviation of the upper airway.

Sperficial and deep temporal spaces The superficial and deep temporal spaces rarely become infected and usually only in severe infections. When these spaces are involved, the swelling that occurs is evident in the temporal region, superior to the zygomatic arch and posterior to the lateral orbital rim. The tight attachment of the anterior layer of the deep cervical fascia to the zygomatic arch prevents swelling there.

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