SREE SANKARA DENTAL COLLEGE

ORAL MEDICINE SEMINAR

Presented By ; AHANA A. IV BDS PART I

FACIAL SPACES
Potential spaces situated between the planes of fascia. Natural pathways along which infection can spread.

HOW MANY SPACES ???

PRIMARY SPACES MAXILLARY SPACES  Canine Space  Buccal Space  Infratemporal space  Parotid Space

MANDIBULAR SPACES

 Space for Body of mandible  Submental space  Sublingual Space  Submandibular space  Pterygomandibular space

 SECONDARY SPACES Masseteric space Pterygomandibular space Superficial & Deep temporal space Lateral pterygoid space Retropharyngeal space Prevertebral space

CANINE SPACE
ANATOMY
LOCATION : B/w Anterior surface of maxilla & overlying levator labi superioris. BOUNDARIES Superiorly: Levator labi superioris Anteriorly : Orbicularis oris Posteriorly: Buccinator

SOURCE OF INFECTION
Maxillary Canine First Premolar

CLINICAL FEATURES
INTRAORAL LOCATION Labial sulcus Rarely , Palatal swelling

LOCATION OF SWELLING Lateral to nose Obliterate nasolabial fold Sometimes oedema of cheek & upper lip Severe cases infection extend to orbit

BUCCAL SPACE
ANATOMY
LOCATION : B/W Buccinator & Masseter muscle & lies superficial to Buccopharyngeal fascia.

BOUNDARIES Medially: Buccinator & Buccopharyngeal Laterally: Skin of cheek Anteriorly: Anterior border of Zygomatic bone & Depressor anguli oris Superiorly: Zygomatic arch Inferiorly: Mandible Posteriorly: Masseter &Pterygomandibular raphe

CONTENTS
Buccal pad of fat Stensons duct Anterior facial artery & vein Transverse Artery & vein

SOURCES OF INFECTION
Maxillary bicuspid Maxillary molars Mandibular molars Mandibular Bicuspids

CLINICAL FEATURES
LOCATION OF SWELLING lower border of mandible to level of Zygomatic arch SYMPTOM Facial swelling with Trismus SIGN Obvious, Dome Shaped

PAROTID SPACE

Enclosed by superficial layer of deep cervical fascia along with Parotid gland Extension of odontogenic infection is difficult.

CONTENTS
Parotid gland Extra glandular & intraglandular parotid lymph nodes External carotid artery Internal carotid artery Maxillary artery Superficial temporal artery

SOURCES OF INFECTION
Blood born Retrograde extension pharyngeal spacE

from lateral

CLINICAL FEATURES
LOCATION OF SWELLING Zygomatic arch to lower border of mandible Posteriorly extends upto retromandibular region Anteriorly ends at the end of anterior border of ramus

SIGNS


Evertion of ear lobule

SYMPTOMS  Pain which is referred to ear & accentuated on chewing

DIAGNOSIS : made by
Evertion of ear lobule No trismus Possible escape of pus from parotid duct on milking All signs of abscess

DIFFERENTIAL DIAGNOSIS
Submasseteric Space infection

INFRATEMPORAL SPACE
ANATOMY
LOCATION: LOCATION irregularly shaped space behind posterior surface of mandible

BOUNDARIES
Laterally: temporalis tendon, coronoid
process & ramus

Medially: Lateral plate of pterygoid process Posteriorly: Lateral pterygoid muscle, condyle &
temporalis

Anteriorly: Maxillary tuberosity Superiorly: Greater wing of sphenoid Inferiorly: communicates with
Pterygomandibular space

CONTENTS  Pterygoid plexus  Maxillary artery & vein  Mandibular division of trigeminal nerve

SOURCES OF INFECTION
 Maxillary molars  Local infiltration of maxillary nerve

CLINICAL FEATURES
LOCATION OF SWELLING *Extraorally over the sigmoid notch & TMJ area *Intraorally in tuberosity

SYMPTOMS Trismus Swelling of eyelids in case of involvement of post zygomatic fossa SIGNS Entire cheek swollen; if buccal space involved

SPACE FOR BODY OF MANDIBLE

ANATOMY
LOCATION: LOCATION formed as the external cervical fascia splits medially & laterally, at the inferior border of mandible & becomes continuous with alveolar mucoperiosteum.

CONTENTS Mandible anterior to ramus Various Mandibular attachments.

SOURCES OF INFECTION
Fracture or direct extension Dental caries Blood born

CLINICAL FEATURES
LOCATION OF SWELLING
Incisors, Canines & bicuspids Outer cortical plate involvement Inner cortical plate involvement Molars Perforation of infection above external oblique ridge: oblique swelling in the oral vestibules. Perforation below mylohyoid line: infection point in the skin

SUBMENTAL SPACE
ANATOMY LOCATION: LOCATION Midline b/w symphysis menti & hyoid bone BOUNDARIES:
Floor: Mylohyoid muscle Roof: Suprahyoid portion of investing layer of deep cervical fascia Lateral: Anterior belly of Digastric

SOURCE OF INFECTION
Mandibular anterior teeth

CLINICAL FEATURES
LOCATION OF SWELLING Chin SWELLING: SYMPTOMS: SYMPTOMS Dyspnoea, Dysphagia SIGNS: SIGNS -Grossly swollen cheek -Firm -Erythematous

SUBMANDIBULAR SPACE
ANATOMY
LOCATION: LOCATION Lateral to submental space BOUNDARIES: Laterally
Submandibular skin Superficial fascia Platysma Superficial layer of deep cervical fascia Lower border of mandible

Medially Mylohyoid Hyoglossus styloglossus Inferiorly Anterior & Posterior belly of digastric Posteriorly Hyoid bone

CONTENTS
Superficial part of Submandibular salivary gland & lymph nodes Facial artery Whartons duct Lingual & hypoglossal nerve Facial vein

SOURCES OF INFECTION
Second & Third Molars

CLINICAL FEATURES
LOCATION: LOCATION Near angle of jaw SIGNS Brawny Edematous After some days swelling becomes soft & cystic

SUBLINGUAL SPACE ANATOMY

LOCATION: LOCATION Above mylohyoid BOUNDARIES: Superiorly mucous membrane of floor of mouth Anteriorly & laterally inner surface of body of mandible Medially geniohyoid, genioglossus, median raphe of tongue

Posteriorly Hyoid bone Inferiorly mylohyoid muscle

SOURCES OF INFECTION
Directly from perforation of lingual cortical plate From submandibular space

CLINICAL FEATURES
LOCATION: Floor of mouth, close to mandible
&spreads towards midline or beyond

SYMPTOMS
Elevation of tongue Dysphasia Dyspnoea

SIGNS
Brawny Erythematous Tender

SUBMASSETERIC SPACE
ANATOMY
BOUNDARIES Anteriorly: body of mandible Posteriorly: Parotid space Medially: Lateral pharyngeal space Superiorly: continuous with superficial & deep temporal pouches

CONTENTS - Masseteric artery & vein - Muscles of mastication

SOURCES OF INFECTION
- Mandibular 3rd molars

CLINICAL FEATURES
LOCATION - External: brawny induration over ramus & angle of mandible - Internal: Sublingual region & pharyngeal wall SYMPTOMS -Excruciating pain -Radiates to ear -Dysphagia -Trismus

TEMPORAL SPACE
ANATOMY
LOCATION: LOCATION Superficial & deep temporal BOUNDARIES Anteriorly- Maxillary tuberosity Posteriorly- Lateral pterygoid, condyle, temporalis Laterally- Lateral pterygoid plate, inferior belly of lateral pterygoid

CLINICAL FEATURES
LOCATION
Infection with superficial temporal space Swelling is limited below by zygomatic arch Laterally by outline of superficial temporal line Deep temporal abscess Produce less swelling Lies deep to temporalis muscle Less fluctuant

DUMBELL SHAPED APPEARANCE : with buccal space involvement SYMPTOMS Pain severe Trismus

PTERYGOMANDIBULAR SPACE
ANATOMY
LOCATION - Well defined - b/w ramus & pterygoid muscle CONTENTS - Fat - Inferior alveolar nerve - Maxillary artery

BOUNDARIES Lateral wall: Inner surface of ramus Medial wall: Medial pterygoid muscle Roof : Lateral pterygoid Posterior : Retromandibular space Anterior : Deep tendon of temporalis

CLINICAL FEATURES
LOCATION : No external evidence Intraorally anterior bulging of soft palate : Deviation of tongue to affected SIGNS side SYMPTOMS : Severe trismus & Dysphagia

LUDWIGS ANGINA

FIRST DESCRIPTION IN 1836 BY DR.VON LUDWIG

DEFINITION
ARCHER: ITS A BILATERAL, ACUTE, RAPIDLY SPREADING, SEPTIC, INFLAMMATORY, INDURATED, WOODEN HARD CELLULITIS OF FLOOR OF MOUTH

SIGNS AND SYMPTOMS

MASSIVE,FIRM,HARD BOARD LIKE,BRAWNY NON PITTING SWELLING OF NECK EXTENDING DOWN TO CLAVICLE OPEN MOUTH DRIBBLING OF SALIVA RAISED FLOOR OF MAOTH SHINY MUCOSA WHITE COLLAR APPEARANCE STIFF TONGUE TOUCHING PALATE DYSPHAGIA, DYSPNOEA EDEMA OF GLOTTIS

MOST IMPORTANT COMPLICATION OF SPACE INFECTIONS INCLUDES SUBMANDIBULAR, SUBMENTAL & SUBLINGUAL SPACES BILATERALLY.

AIR WAY OBSTRUCTION

MANAGEMENT OF FACIAL SPACE INFECTIONS

PROPER HISTORY TAKING , EXAMINATION & INVESTIGATION

MEDICAL TREATMENT
ANTIBIOTICS & ANALGESICS Penicillin Amoxicillin Ornidazole cephalosporin

SUPPORTIVE THERAPY
Adequate hydration Rich nutritional supplements Rx of pre existing disease

EXTRACTION
Extraction of offending tooth

INCISION & DRAINAGE

Surgical evacuation of pus is necessary for 2 reasons; To prevent further burrowing of purulent mass in an attempt to spontaneous evacuation & to avoid dreaded complications like erosion of major vessels

TECHNIQUE
Preparation of skin Aseptic manner prepared area is draped with sterile towels Local anesthesia Site of incision Most dependent part of abscess than the centre. - This provides dependent drainage & avoids puckering of skin & excessive scar contracture - Incision should be in cosmetically & functionally acceptable place

 Blunt dissection After initial sharp incision through mucosa

- Sinus forceps : gentle poking

& opening beaks of instrument till abscess cavity s reached

- Beaks of forceps should be

spread parallel to vital structures.

 Dissection - Extended to alveolar process overlying the roots of involved tooth i.e.; the source of infection.

 AN INFECTED TOOTH SHOULD ALWAS BE GIVEN DUE IMPORTANCE TO PREVENT THE ABOVE FURTHER COMPLICATIONS !!!!!!

REFERENCES
Text book of Oral medicine- ANIL GHOM Textbook of Oral Pathology Shaffers Textbook of oral surgery BALAJI Textbook of Anatomy CUNNIGHAM Google images