24-Oct-19

Surgical Management

Surgical treatment may range from simply

Odontogenic infection - 4 opening tooth & extirpation of pulp to
complex incision & drainage.

Incision & Drainage

Surgical Management
Primary goal in surgical management is
to remove cause of infection.
Secondary goal is to provide drainage of
accumulated pus & necrotic debris.
Extraction provides both removal of cause of
infection and drainage of pus & debris.
Incision & drainage helps-
To get rid of toxic purulent material.
To decompress odematous tissues.
To allow better perfusion of blood, containing antibiotics &
defensive elements.
To increase oxygenation of infected area.
Removal of the cause; such as infected tooth, a segment of
necrotic bone, a foreign body should be done at the time of
I & D procedure.

Hilton’s method of I & D

1. Asepsis and Topical anesthesia
2. Stab incision given through skin & s/c tissue.
3. If pus is not encountered, further deepening of surgical
site done with sinus forceps.
4. Abscess cavity is entered and forceps opened in
direction parallel to vital structures.
5. Explore the entire cavity for additional loculi.
6. Cavity irrigated with saline & antiseptic solutions.
7. Placement of drain.
8. Dressing.

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Incisions and drainage Medical & Supportive Therapy

 Administration of antibiotics.
 Hydration of patient by I/V route.
 Soft or liquid diet rich of high proteins.
 Analgesics & NSAIDs.
 Antiseptic mouthwashes.
 Complete bed rest.

Causes of Treatment Failure

Learning outcome
• Inadequate surgery
•Describe the anatomical spaces that
can be involved in maxillofacial
• Depressed host defenses
infections and their inter relationships
• Foreign body

•Describe the generic treatment of

• Antibiotic problems
• Patient noncompliance
• Drug not reaching site maxillofacial infections
• Drug dosage too low
• Wrong bacterial diagnosis
• Wrong antibiotic
•Individual space infection

Space infection Space infection

• Abscess vs Cellulitis
• Infection vs Abscess
• Dentoalveolar abscess vs Periodontal abscess
• Cellulitis vs Ludwig’s angina
•How to read? • Submandibular abscess vs Sublingual abscess

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Cellulitis Cellulitis vs. Abscess

• If an abscess is not able to establish drainage through the
surface of the skin or into the oral cavity. it may spread
diffusely through fascial planes of the soft tissue. This acute
and edematous spread of an acute inflammatory process is
termed cellulitis .
• Although numerous patterns of cellulitis can be seen from
the spread of dental infections. two especially dangerous
forms warrant further discussion:
• (I) Ludwig's angina and
• (2) cavernous sinus thrombosis.
• Cellulitis is a diffuse infection of the soft tissues with no localized area of
pus amenable to drainage.
• Indurated (i.e., warm, red, and swollen) and painful.
• An abscess is a localized collection of pus, often with a component of
surrounding cellulitis (with the above signs).
• One sign of an abscess is an area of fluctuance
• Another sign is that an abscess often seems to “point;” that is, the skin
starts to thin from the pressure of the fluid underneath.
• The distinction between cellulitis and abscess is important. The main
treatment for an abscess is incision and drainage (cutting into the abscess
and widely opening the abscess cavity). Cellulitis does not warrant this
intervention.

Cellulitis vs. Abscess

Individual Space Infection

Cellulitis
• Soft tissue infection without pus
• Indurated and painful
• Usually Antibiotics needed
Abscess
• Localized collection of pus
• Fluctuance and painful  Anatomy/surgical boundary
• Need I&D  Etiology/which tooth likely to involve
 Clinical feature
 Treatment

Individual space infection/Abscess

• Buccal space
• Sublingual abscess Buccal space infection/abscess
• Submandibular abscess
• Ludwig’s angina

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Buccal Space
Buccal Space Infection
Contents-
Boundaries- Buccal fat pad.
Superiorly: zygomatic arch. Stenson’s duct.
Facial artery.
Inferior: inferior border of mandible.
Laterally: skin & subcutaneous tissue.
 Anatomy/surgical boundary Medially: buccinator muscle ,buccopharyngeal fascia.
 Etiology/which tooth likely to involve Posteriorly: anterior edge of masseter muscle.
 Clinical feature Anteriorly: posterior border of zygomaticus major &
 Treatment depressor anguli oris.

Buccal Space Buccal Space

Etiology-
Infected mandibular & maxillary premolars & molars.

Clinical Features-
• The skin appears taut and red, with or without fluctuation
of the abscess
• Obliteration of nasolabial fold.
• Angle of mouth shifted to opposite side.
• Swelling in cheek extending to corner of mouth.

Buccal space infection

• Treatment
• Incision and drainage if fluctuation present due to
formation and accumulation of abscess. Incision is usually Sublingual abscesses
intraoral.
• Collection of pus for C/S examination
• Removal or treatment of the offending tooth.
• Appropriate antibiotic therapy.
• Follow up

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Sublingual abscesses Sublingual abscesses

• Etiology.
• There are two sublingual spaces above the mylohyoid • Mandibular anterior teeth,
premolars and the first molar,
muscle, to the right and left of the midline. whose apices are found above the
• These spaces are divided by dense fascia. attachment of the mylohyoid
muscle.
• Abscesses formed in these spaces are known as sublingual
abscesses. • Infection from other contiguous
spaces with which it communicates
(submandibular, submental, lateral
pharyngeal).

Sublingual abscesses Sublingual abscesses

• Boundaries-
Contents-
• Superiorly: mucosa of floor of
mouth. Deep part of Submandibular gland.
• Inferior: mylohyoid muscle. Wharton’s duct.
• Posteriorly: body of hyoid bone. Sublingual gland.
• Anteriorly & laterally: inner aspect Lingual & hypoglossal nerves.
of mandibular body.
Terminal branches of lingual artery.
• Medially: Geniohyoid, styloglossus,
genioglossus muscle.

Sublingual abscesses Sublingual abscesses

Clinical Features-
• Swelling of floor of mouth.
• Obliteration of the lingual sulcus
• Elevation of the tongue towards the palate and laterally
• Pain & discomfort on swallowing.
• The patient speaks with difficulty, because of the edema,
and movements of the tongue are painful.

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Sublingual abscesses

• Treatment
• Incision and drainage.
• Collection of pus for C/S examination Submandibular abscesses
• Removal or treatment of the offending tooth.
• Appropriate antibiotic therapy.
• Follow up

Submandibular space infection/abscess Submandibular space infection/abscess

Boundaries-
Superiorly: Mylohyoid muscle, inferior border of mandible.
Inferior: anterior & posterior belly of digastric.
Laterally: deep cervical fascia, platysma, superficial fascia & skin.
Medially: Hyoglossus, Styloglossus, Mylohyoid muscle.
Posteriorly: to hyoid bone.
Anteriorly: Submental space.
Surgical boundary

Submandibular space infection/abscess Submandibular space infection/abscess

Etiology-
Contents-  Infected mandibular 2nd & 3rd molars.
Submandibular salivary gland.  From submental, sublingual spaces.
Proximal portion of Wharton’s duct.
Clinical Features-
Lingual & hypoglossal nerves.
• Indurated swelling in submandibular region.
Branches of facial artery- palatine,tonsillar,glandular,submental. • Usually bulges over lower border of mandible.

Spread of Infection-
 Across midline to contralateral space.
 To contiguous spaces. (Sublingual, Submental, Pharyngeal spaces)

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Spread of Infection- Submandibular abscesses

• Treatment
• Incision and drainage.
• Collection of pus for C/S examination
• Removal or treatment of the offending tooth.
• Appropriate antibiotic therapy.
• Follow up

Submandibular abscesses Submandibular abscesses

Submental abscess

Boundaries-
Submental abscess Roof: mylohyoid muscle.
Inferior: deep cervical fascia, platysma, superficial fascia & skin.
Laterally: anterior belly of digastric.
Posteriorly: submandibular space.

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Submental abscess Submental abscess

Contents-
Lymph nodes, anterior jugular vein.
Etiology-
Infected mandibular incisors.
Anterior extension of submandibular space.
Clinical Features-
• Chin appears glossy & swollen.
• Pain & discomfort on swallowing.

Submental abscesses
• Treatment
• Incision and drainage.
• Collection of pus for C/S examination Pterygomandibular space
• Removal or treatment of the offending tooth.
• Appropriate antibiotic therapy.
• Follow up

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Etiology-
Infected mandibular 3rd Pterygomandibular space
molars(mesioangular/horizontal)
Pericoronitis.
Infected needles or contaminated LA solution. Spread of Infection-
Clinical Features- Superiorly to infratemporal space.
Absence of extra-oral swelling. Medially to lateral pharyngeal space.
Severe trismus.
To submandibular space.
Difficulty in swallowing.
Anterior bulging of half of soft palate & tonsillar
pillars with deviation of uvula to unaffected side.

Ludwig’s Angina
• Frist described by Wilhelm Frederic von Ludwig in 1836

• Ludwig’s angina is a grave acute cellulitis and is

Ludwig’s Angina characterized by bilateral involvement of the submandibular
and sublingual spaces, as well as the submental space .

• In the past this condition was fatal.

• Today adequate surgical treatment and antibiotic therapy have

almost eliminated fatal episodes.

Ludwig’s Angina Ludwig’s Angina

• The most frequent cause of the disease is periapical or

periodontal infection of mandibular teeth, especially of
those whose apices are found beneath the mylohyoid
muscle.

• Pericoronal infection of the lower third molar

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Clinical features Local Features

systemic features- • Extra oral features –
• Hard to firm brawny indurated swelling
Pyrexia , • Skin over the swelling appears erythematous and stretched
Dehydration ,
Dysphagia , • Swelling is tender with local rise in Temperature
Dyspnea ,
Hoarseness of voice and stridor, • Intra oral features –
Respiratory distress • Trismus , floor of the mouth is raised , tongue raised upwards ,
• Difficulty in closing the mouth and drooling of saliva

Management of Ludwig’s Angina

Ludwig’s angina surgical decompression

• Airway maintenance-
• Parenteral antibiotics
• Surgical decompression
• Hydration of the patient
• Removal of cause
• Follow up

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