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Complex Odontogenic Infections Part 1. Topographical Anatomy.

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Presentation on theme: "Complex Odontogenic Infections Part 1. Topographical Anatomy."— Presentation transcript:

1 Complex Odontogenic Infections Part 1

2 Topographical Anatomy

3 Connective Tissue – Types Areolar (or loose) connective tissue Dense connective tissue Elastic tissue Reticular connective tissue Adipose tissue


5 Fascia A sheet of connective tissue covering or binding together body structures Types – Superficial Fascia – Deep Fascia

6 Superficial Fascia Muscles of facial expression Continuous with superficial Cervical fascia

7 Deep Fascia- Geography of Deep Fasica Deep fascia of head and Neck

8 Deep Fascia of Jaws Muscles of Mastication – Temporal Fascia – Masseteric fascia – Parotidomasseteric fascia – Pterygoid fascia Continuous with Deep Fascia of Neck

9 What are fascial spaces? Fascia lined tissue compartments filled with loose, areolar connective tissue that can be inflamed when invaded with microorganisms. – Potential spaces – Loose areolar tissue within these spaces serve as cushion to adjacent muscles, vessels, nerves, glands – Allows movement

10 Clinical Correlation

11 Spaces of the Jaws Deep Facial Spaces associated with any tooth – Vestibular – Subcutaneous – Buccal Deep Facial Spaces associated with Maxillary teeth – Palatal – Infraorbital – Canine – Periorbital – Orbital – Cavernous Sinus Deep Facial Spaces associated with Mandibular teeth – Space of the body of the mandible – Sublingual – Submandibular – Submental – Masticator – Submasseteric – Pterygomandibular – Superficial Temporal – Deep Temporal – Parotid


13 Spaces Vestibular- – potential space between oral vestibular mucosa and muscles of facial expression

14 Palatal Space Infected by lateral incisors and palatal roots Subperiosteal space of the palate C/F : Very painful swelling – (rich innervation of the periosteum)

15 Palatal Anatomic considerations Greater Palatine artery Greater palatine nerve Minor salivary glands

16 Infraorbital Space/ Canine space Thin potential space between levator anguli Oris and levator labii superioris muscles. Source of Infection : – Infections from Maxillary canines and bicuspids – Extension from buccal space – Skin infection from nose and upper lip

17 Infraorbital Space/ Canine space Signs and Symptoms Cheek Swelling and Redness Obliteration of the nasolabial fold Edema of upper and lower eye lid Tenderness and severe pain secondary to infra orbital nerve edema and inflammation Abscess drains through the medial or lateral canthus of the eye (levator labii superioris attaches along the center of the inferior orbital rim)

18 Buccal Space Portion of subcutaneous space Contents: Buccal fat pad, stensens duct, facial artery Borders – Anterior-Corner of the mouth – Posterior-Masseter muscle – Superior – Maxilla – Inferior –Mandible – Superficial -subcutaneous tissue – Deep-Buccinator muscle Source of Infection – Infection from the upper and lower premolars and molars

19 Buccal Space Signs and symptoms – Cheek swelling (Below Zygomatic arch and above inf.border of Mandible) – Redness anterior to the masseter muscle – Can spread through subcutaneous tissues into the periorbital space – and past the inferior border of the mandible to the subcutaneous tissues lying superficial to the submandibular space.

20 Buccal-space – Posteriorly communicates with the submasseteric space Other communications – Pterygomandibular space – Infratemporal space (via pterygoid plexus) – Lateral pharyngeal space (via pterygomandibular raphe) – Superficial Temporal space (via buccal fat pad) – Subcutaneous spaces (superficial to submandibular space)

21 Incision and Drainage Drained percutaneously when fluctuance occurs Drainage should be performed inferior to the point of fluctuance Recurrent Buccal space infections can occur as a complication of crohns disease

22 Cavernous Sinus Thrombosis CS are bilateral venous drainage channels for the contents of the middle cranial fossa(esp. – Pitutary gland) Anatomy: – Anteriorly-Bound by Sup.Orbital fissure – Receives a tributory Inf.Opthalmic vein – (orbital infections pass thru CS) – Drained by sup and Inf Opthalmic veins – Posteriorly-Trigeminal ganglion

23 Cavernous Sinus Thrombosis Maxillary OI erode the Infra Orbital vein in the infra orbital space or the Inf Opthalmic vein via the sinuses – Follow Common Opthalmic vein through the superior ophthalmic fissure Extends to Cavernous Sinus – Resulting inflammation caused by invading bacteria » Stimulates the clotting pathways » CS thrombosis

24 Cavernous Sinus Thrombosis C/F: – Congestion of retinal veins of eye of unaffected side – Papilledema, retinal hemorrhages, and decreased visual acuity and blindness may occur from venous congestion within the retina. – Fever, tachycardia, sepsis may be present. – Headache with nuchal rigidity may occur.

25 Cavernous Sinus Thrombosis C/F: Congestion of retinal veins of eye of unaffected side Papilledema, retinal hemorrhages, and decreased visual acuity and blindness may occur from venous congestion within the retina. Fever, tachycardia, sepsis may be present. Headache with nuchal rigidity may occur.

26 Cavernous Sinus Thrombosis (C/F) Pupil may be dilated and sluggishly reactive. Infection can spread to contralateral cavernous sinus within 24–48 hr of initial presentation. Cranial nerve most commonly affected is Abducens (VI) Classic presentations are abrupt onset of unilateral periorbital edema, headache, photophobia, Proptosis

27 Sublingual space Defined superiorly by FOM mucosa and inferiorly by mylohyoid Anterior/lateral- mandible Medially-tongue and genioglossus Posterior-superior, posterior, and medial portion of the submandibular space

28 Sublingual Space Sublingual space communicates with submandibular space around the posterior border of the mylohyoid. Infections from sublingual space can pass through this gap and directly enter the lateral pharyngeal space

29 Sublingual Space

30 Sublingual Space-Clinical features Brawny, erythematous, tender swelling, FOM Begins close to mandible and extends to the midline Elevation of the tongue (late cases) DD: – Cellulitis – Sialolith of whartons duct

31 Sublingual Space- Treatment Place incision intraorally parallel to the whartons duct bilaterally If submandibualr space is involved then both spaces can be reached through an extra oral submandibular approach

32 Submental Space Potential space in the chin Infected either by Mandibular incisors or indirectly by the SM space Submental-midline; bordered laterally by anterior digastrics – Superficial border-anterior layer of Deep Cervical Fascia, platysma, sup.fascia, skin – Contents: Filled with areolar CT, submental lymph nodes and anterior jugular veins


34 Clinical Features-Submental Space Chin appears grossly swollen Firm, erythematous swelling Chronic infection drains as a fistula from the submental region

35 Submental space -treatment Drainage-Achieved by percutaneous approach Horizontal incision in the most inferior portion of the chin Use natural skin crease Cosmetically acceptable scar Intra oral drainage Through the mentalis muscle through labial vestibule

36 Submandibular-Boundaries Anterior/Posterior Borders-ant/post digastrics Posterior boundary also includes stylohyoid muscle and middle/superior pharyngeal constrictors. Superior border-inferior border and lingual surface of mandible below mylohyoid line. Medial border-mylohyoid muscle which extends from mylohyoid line to the hyoid

37 Submandibular Communication to sublingual space around posterior border of mylohyoid (following path of submandibular gland and duct) Contents – Gland/duct – Facial artery – Facial vein – lymph

38 Submandibular space Communication around posterior digastric leads to lateral pharyngeal; Around anterior digastric leads to submental space

39 Submandibular space Separated from overlying sublingual space by mylohyoid muscle Cause of infection : Mandibular second and third molars – Root apices of these teeth lie inferior to mylohyoid line of the muscle attachment

40 Submandibular Space Diagnosis: Brawny or soft swelling, correlate with offending tooth May commonly cross the midline into the contralateral space Treatment

41 Ludwigs Angina – Late seventeenth century extraction of abscessed teeth was considered dangerous – 3Fs became evident: It was to be feared, it rarely became fluctuant, and it often was fatal (Topazian et al) Definition: – Firm, acute, Toxic cellulitis of submandibular, and sublingual spaces bilaterally and of the submental space

42 Clinical features as described by Wilhelm Friedrich von Ludwig.. In the late seventeenth century.. Erysepalous angina Temperature swings Discomfort while swallowing Develops on both sides

43 Clinical features Severe swelling Elevation and displacement of tongue Tense hard bilateral induration of submandibular region, superior to hyoid bone Trismus Drooling of Saliva Inability to swallow Infection progresses at an alarming speed to cause airway obstruction-Often leads to death

44 Ludwigs Angina Secure airway Prompt early aggressive I & D surgery Antibiotic therapy

45 Ludwigs Angina-Treatment

46 Masticator Space Space is enclosed by the splitting of the anterior fascia around the muscles of mastication. Infections affect discrete portions of the space – Submasseteric – Pterygomandibular – Superficial temporal – Deep temporal

47 Masticator Space (Contd.) Submasseteric – Lies between parotideomasseteric fascia and lateral surface of ascending ramus – Communicates with pterygomandibular space via the sigmoid notch – Openly communicates with the superficial temporal space deep to ZM arch

48 Masticator Space (Contd.) Source of Infection: – Molars esp.Third molars Signs and Symptoms – Swelling of the face – Severe trismus – Dysphagia – Swelling of the retromolar triangle area

49 Masticator Space (Contd.) Infections result in significant trismus Differentiate from parotid swellings because submasseteric infections obscure earlobe from frontal view whereas parotid swellings elevate it.

50 Masticator Space (Contd.) Pterygomandibular space-infections correlate with pericoronitis, needle tracts Borders Lateral-ascending ramus Medial-medial pterygoid Inferior-pterygomasseteric sling Superior-lateral pterygoid Posterior-parotid Anterior-pterygomandibular raphe Commonly communicates with lateral pharyngeal by passing around the anterior border of the medial pterygoid

51 Temporal Spaces Divided into superficial and deep temporal Clinical features – Severe Pain – Jaw deviates to the affected side – TRISMUS – Swelling of the temporal area – Tenderness over the condyle

52 Temporal Spaces Infra temporal space Lies posterior to maxilla Bottom portion of the deep temporal space Source of Infection- Maxillary third molars

53 Temporal Spaces-Infra temporal space Contents – -Internal maxillary artery – Pterygoid venous plexus – Emissary veins pass from the pterygoid plexus through base of skull to connect with intracranial dural sinuses – Origin of the posterior route by which infection spread to Cavernous sinus

54 Masticator Space Temporal spaces – Superficial-communicates with buccal space via buccal/temporal fat pad – Communicates inferiorly with the submasseteric space – Deep Lateral-temporalis muscle Medial-squamous temporal bone Inferior-lateral pterygoid Anterior-posterior wall of max sinus and orbit Infratemporal space lies inferior to the infratemporal crest of the sphenoid bone – Contents found in infratemporal portion: maxillary artery and V3

55 Temporal Space Infection

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