CLASSIFICATION OF OROFACIAL INFECTION & FASCIAL SPACES INFECTION AISHAH, RUHAIZAN, ANIS, SYAFIQAH

Based on the organism causing the infection Based on the tissues affected Based on the route of entry Based on the deep fascial spaces of the head and neck infiltrated by the infection CLASSIFICATION

Based on the organism causing the infection Bacterial infections: The odontogenic infections encountered in orofacial region are mostly bacterial infections Nonodontogenic infections: (i) Tonsillar (ii) Nasal infections which are more common in children (iii) Furuncle of overlying skin Fungal infections: These infections have slow rate of spread. These are difficult to diagnose in early stages. Viral infections: The literature does not show sufficient reports about these conditions of odontogenic origin.

Based on the tissues affected Odontogenic infection Caries in the dentin > spread to the pulp > pulpitis > spread to the bone > PA abscess Traumatic root fracture/pathological exposure due to tooth wear Traumatic pulpal exposure including dental treatment Through PD membrane and accessory root canal Rarely by anachoresis i.e seeding of the organism directly into pulp via pulpal blood supply during bacterimia Trauma, cracks, decay under fillings Periodontal disease > PA & periodontal abscess Erupting teeth > operculitis & pericoronitis RR Non-odontogenic

Based on the route of entry Pulpal Periodontal Pericoronal Fracture Tumour Iatrogenic Opportunistic

Based on the clinical presentation Acute Abscess It is a circumscribed collection of pus in a pathological tissue space. Cellulitis spreading infection of loose connective tissues. It is a diffuse, erythematous, mucosal or cutaneous infection. It is characteristically the result of streptococci infection; and does not normally result in large accumulation of pus Fulminating infections involves the secondary spaces involving vital structures, along the pathway of least resistance Chronic Chronic fistulous tract or sinus formation Chronic osteomyelitis Cervicofacial actinomycosis

Based on the deep fascial spaces of the head and neck infiltrated by the infection

Other spaces mandible Primary Maxillary Spaces Canine Space Primary spaces Submental Space Submandibular space Sublingual space Buccal Space Secondary spaces submassenteric Space Pterygomandibular Space Temporal Space Primary Maxillary Spaces Canine Space Buccal Space Infratemporal space Other spaces Deep Neck Spaces Lateral Pharyngeal Space Retropharyngeal space Prevertebral space

PRIMARY MANDIBULAR SPACES

Submental space Causes Mandibular anterior teeth Contents Anterior jugular vein Lymph nodes Location Laterally: between the anterior bellies of the digastric muscle Deeply: by the mylohyoid muscle, and Superiorly: by the deep cervical fascia, the platysma muscle, the superficial cervical fascia and the skin Posteriorly: hyoid bone

Submandibular space Causes Mandibular molars Contents Submandibular gland Facial artery Lymph nodes Location Superior- mylohyoid muscle and inferior border of the mandible Anteriorly- anterior belly of the digastric muscle Posteriorly- posterior belly of the digastric muscle Inferiorly- hyoid bone Superficially- platysma muscle and superficial layer of the deep cervical fascia

Sublingual space Causes Mandibular premolars Mandibular molars Trauma Contents Sublingual glands Wharton’s duct Sublingual artery & nerve Lingual nerve Location Anterior – lingual surface of mandible Posterior – body of hyoid bone Medial – muscle of the tongue Lateral – lingual surface of mandible Superior- oral mucosa Inferior- mylohyoid muscle

BUCCAL SPACE Boundaries • Anteromedially: Buccinator muscle • Posteromedially: Masseter overlying the anterior border of ramus of mandible • Laterally: By forward extension of deep fascia from the capsule of parotid gland and by platysma muscle. • Inferiorly: Limited by the attachment of the deep fascia to the mandible and by depressor anguli oris. • Superiorly: The zygomatic process of the maxilla and the zygomaticus major and minor muscles. Contents Buccal pad of fat, Stenson‘s (parotid ) duct, anterior and transverse facial artery and vein Source of infection Maxillary and mandibular bicuspid Maxillary and mandibular molar

Mandibular Secondary spaces

Submasseteric space Causes Mandibular 3rd molars Contents Masseteric artery & vein Location Anterior – buccal space, parotidomasseteric fascia Posterior – parotid gland and its fascia Medial – ramus of the mandible Lateral – masseter muscle Superior- zygomatic arch Inferior- inferior border of mandible

Temporal space Causes Involvement is secondary to the initial involvement of pterygopalatine and infratemporal space. Components Superficial temporal space: located between temporal fascia and temporalis muscle Deep temporal space: located between the temporalis muscle and the temporal bone Continuous with the infratemporal space

Primary Maxillary Spaces

BUCCAL SPACE Boundaries • Anteromedially: Buccinator muscle • Posteromedially: Masseter overlying the anterior border of ramus of mandible • Laterally: By forward extension of deep fascia from the capsule of parotid gland and by platysma muscle. • Inferiorly: Limited by the attachment of the deep fascia to the mandible and by depressor anguli oris. • Superiorly: The zygomatic process of the maxilla and the zygomaticus major and minor muscles. Contents Buccal pad of fat, Stenson‘s (parotid ) duct, anterior and transverse facial artery and vein Source of infection Maxillary and mandibular bicuspid Maxillary and mandibular molar

CANINE SPACE Boundaries Superiorly: levator labii superioris alaque nasi, levator labii superioris, and zygomaticus minor muscles. • Inferiorly, caninus muscle • Anteriorly, orbicularis oris, • Posteriorly, buccinator muscle • Medially, anterolateral surface of maxilla. Contents Angular artery and vein Infraorbital nerve Source of infection -Maxillary canine -First upper premolar

INFRATEMPORAL SPACE Boundaries Anteriorly: Posterior pharyngeal wall Posteriorly: prevertebral fascia Superiorly: Base of skull Inferiorly: Mediastinum Medially: Common space, no wall Laterally: Communicates with the lateral pharyngeal space Content No major structure Source of infection Suppurative adenitis Dental infection diffusing through contiguous spaces Nasal and pharyngeal infections through pharyngeal trauma or foreign bodies

Other spaces

LATERAL PHARYNGEAL SPACE Boundaries Anteriorly: Superior and middle pharyngeal constrictor muscle Posteriorly: Carotid sheath, stylohyoid, Styloglossus and Stylopharyngeus Superiorly: base of skull Inferiorly: Hyoid bone Medially: superior pharyngeal constrictors Laterally: medial pterygoid muscle and capsule of parotid gland Content Carotid artery Internal jugular vein Vagus nerve Cervical sympathetic chain Likely source of infection Mandibular third molar Tonsilar infection Pharyngitis Parotitis

DEEP NECK SPACES Uncommon infection beyond the primary spaces of maxilla and mandible Possible sequelae: compromise upper airway and descending mediastinitis Pterygomandibular space infection spread posteriorly to the lateral pharyngeal space

PREVERTEBRAL SPACE Boundaries: Superiorly: skull base Space between alar and prevertebral layers Infection causes Mediastinitis

RETROPHARYNGEAL SPACE Boundaries Anteriorly: Posterior pharyngeal wall Posteriorly: prevertebral fascia Superiorly: Base of skull Inferiorly: Mediastinum Medially: Common space, no wall Laterally: Communicate with the lateral pharyngeal space Content No major structure Likely source of infection Suppurative adenitis Dental infection diffusing through contiguous spaces Nasal and pharyngeal infections through pharyngeal trauma of foreign bodies