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Complex Odontogenic Infections

Complex Odontogenic Infections. Part 1. Topographical Anatomy. Connective Tissue. Types Areolar (or loose) connective tissue Dense connective tissue  Elastic tissue Reticular connective tissue  Adipose tissue . Fascia.

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Complex Odontogenic Infections

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  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 

  4. Fascia •  A sheet of connective tissue covering or binding together body structures • Types • Superficial Fascia • Deep Fascia

  5. Superficial Fascia • Muscles of facial expression • Continuous with superficial Cervical fascia http://media-2.web.britannica.com/eb-media/56/118356-004-EE793D60.jpg

  6. Deep Fascia- • Geography of Deep Fasica • Deep fascia of head and Neck

  7. Deep Fascia of Jaws • Muscles of Mastication • Temporal Fascia • Masseteric fascia • Parotidomasseteric fascia • Pterygoid fascia Continuous with Deep Fascia of Neck

  8. 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

  9. Clinical Correlation

  10. 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

  11. Spaces • Vestibular- • potential space between oral vestibular mucosa and muscles of facial expression

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

  13. Palatal • Anatomic considerations • Greater Palatine artery • Greater palatine nerve • Minor salivary glands

  14. 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

  15. 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 • (levatorlabiisuperioris attaches along the center of the inferior orbital rim)

  16. Buccal Space • Portion of subcutaneous space • Contents: Buccal fat pad, stensen’s 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

  17. 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.

  18. 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)

  19. 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 crohn’s disease

  20. 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

  21. 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

  22. 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.

  23. 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.

  24. 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

  25. 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

  26. 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

  27. Sublingual Space

  28. 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 wharton’s duct

  29. Sublingual Space- Treatment • Place incision intraorally parallel to the wharton’s duct bilaterally • If submandibualr space is involved then both spaces can be reached through an extra oral submandibular approach

  30. 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

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

  32. 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

  33. 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

  34. 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

  35. Submandibular space • Communication around posterior digastric leads to lateral pharyngeal; • Around anterior digastric leads to submental space

  36. 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

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

  38. Ludwig’s Angina • Late seventeenth century extraction of abscessed teeth was considered dangerous • 3’F’s 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

  39. 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

  40. 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

  41. Ludwig’s Angina • Secure airway • Prompt early aggressive I & D surgery • Antibiotic therapy

  42. Ludwig’s Angina-Treatment

  43. 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

  44. 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

  45. 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

  46. Masticator Space (Contd.) • Infections result in significant trismus • Differentiate from parotid swellings because submasseteric infections obscure earlobe from frontal view whereas parotid swellings elevateit.

  47. 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

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