Anatomie considerations in diagnosis
and treatment of odontogenic infections
Daniel M. Laskin,* D.D.S., M.S., Chicago
The propagation of acute dental infec­
tions is influenced by the relationship of
the teeth to the alveolar process and by
the arrangement of the muscles and
fasciae of the face and neck. These struc­
tures not only play an important role in
directing the spread of infections, but
also serve as relative barriers for their
localization in specific anatomic spaces.
A comprehension of the regional anat­
omy is, therefore, indispensable for proper
clinical diagnosis and treatment planning.
The advent of antibiotics has altered pro­
foundly the management of acute dental
infections by allowing earlier surgical in­
tervention. Such procedures as extraction
(assuming that endodontic treatment is
not indicated), prompt incision and drain­
age or both considerably shorten the clini­
cal course and concomitantly lessen the
chance for the development of further
complications. Early treatment, however,
depends on proper diagnosis. This can be
accomplished only if one understands the
physiologic and anatomic factors that in­
fluence the spread and ultimate localiza­
tion of dental infections.
F A C TO R S IN S PRE A D A N D
L O C A L IZ A T IO N OF IN F E C T IO N
Whether an infection will remain at the
apex of a tooth or progress through the
surrounding tissues primarily depends on
such factors as the virulence of the infect­
ing organisms and the resistance of the
patient. In a healthy person with normal
body defenses, the bacteria must have a
relatively high degree of invasiveness for
progression of the infection to occur. On
the other hand when the resistance is low,
as for example in a patient with uncon­
trolled diabetes, rapid bacterial multipli­
cation and spread can result even with
organisms of relatively low virulence.
Once the balance has shifted in favor
of bacterial invasion, the alveolar bone
represents the first locally limiting barrier.
A progressive periapical infection will
tend to spread in a relatively concentric
manner within the bone until it extends
through one of the cortical plates. The
site of perforation can, therefore, be pre­
dicted if one knows the relations of the
root apexes to the alveolar process, since
perforation usually will occur at the
closest bony wall.1,2 When the infection
has traveled through the bone and peri­
osteum, the anatomic arrangement of the
 LASKIN . . .V O LU M E 6?, SEPTEMBER 1964 • 55/309

Fig. I • A : D ia g ra m show ing relative p osition o f m axillary central incisor in alveolar process. Labial
co rtical plate is closest to tooth apex. B: V e stib u la r ab sce ss arisin g from righ t m axillary central incisor.
D e sp ite g re a t size, infection is still co n tain e d in trao rally b y muscle and fa scia l barriers. C : Palatal
a b sce ss arisin g from left m axillary lateral incisor. Palatal curve o f root apex makes this su rface closest

adjacent muscles and fasciae then will de­ A N A T O M IC R E L A T IO N S OF T E E T H

termine the subsequent pathway of spread
and the first possible site of localization.
It must be emphasized, however, that
these structures represent only relative
barriers and that, ultimately, the systemic
reaction of the patient still governs the
extent of spread.
Numerous fascial spaces in the head
and neck have been described.3'9 These
spaces, however, are not always the same
sites in which clinically one sees the lo­
calization of odontogenic infections. For
example, the oft-mentioned masticator
space seldom is involved completely in an
inflammatory process. Gaughran9 has
shown that this actually is because of
fascial subdivisions of the space which
make spread from one part to another
difficult. Moreover, in some areas of the
face where localization occurs, there are
no strong fascial sheets.1,10 Instead, mus­
cles and bony surfaces serve as the limit­
ing boundaries for these extra-alveolar
infections. Thus, from a clinical stand­
point, certain surgical spaces can be de­
scribed which are different from the
fascial spaces often used for convenience
in anatomical orientation. An under­
standing of this concept is important for
proper diagnosis and treatment.
OF M A X IL L A A N D M A N D IB LE
Maxillary Central and Lateral Incisors *
The apexes of the maxillary central in­
cisors generally lie closer to the labial
aspect of the alveolar process. Infections
from these teeth, therefore, exit through
the bone in this region (Fig. 1 ,A ). The
further spread then is influenced by the
orbicularis oris muscle and the dense sub­
cutaneous tissue at the base of the nose,
which tends to limit the infection to the
loose areolar tissues of the oral vestibule
(Fig. 1,B). A similar anatomic arrange­
ment holds true in about 50 per cent of
the infections involving the maxillary lat­
eral incisors. In the remaining ones, how­
ever, the root apexes are located closer to
the palatal alveolar process, and perfora­
tion and localization take place in that
region. The densely attached palatal mu­
cosa greatly limits the spread of such
infections (Fig. 1,C).
Maxillary Cuspid • Because of the posi­
tion o f the maxillary cuspid in the alve­
olar process, infections from this tooth
will also exit from the bone on the labial
aspect. The relation of the levator anguli
oris muscle then determines whether the
56/310 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N

Fig. 2 • A : D ia g ra m show ing relation o f levato r an gu li oris ( L A O ) to a p ica l region o f m axillary

cu sp id. If infection perforates bone a b o v e a tta ch m e n t o f this muscle, it localizes beneath le v a to r labii
superioris (L L S ) in canine space. A c c e ss to skin is affo rde d throu gh the g a p (arrow ) between these
muscles. B: C lin ic a l ap p e a ra n ce o f the canine sp ace abscess. (D ia g ra m m odified from Sicher, Harry.
O r a l anatom y, ed. 3. St. Louis, C . V. M o s b y C o ., I960.)

infection will be localized within the oral
vestibule or whether it will progress ex-
traorally (Fig. 2,A ) . If the site of perfora­
tion is below the muscle attachment, an
intraoral swelling will occur. On the other
hand, if it is located above the attachment,
the infection will spread into the canine
space. This is the region between the an­
terior surface of the maxilla and the over-
lying levator muscles of the upper lip.
Although these muscular sheets tend to
impede further progression to some ex­
tent, the gap between the levator labii
superioris and the levator labii superioris
alaeque nasi generally affords an open­
ing through which the skin surface may
be reached near the inner com er of the
eye (Fig. 2,A) Clinically, a canine space
infection is characterized by a swelling
lateral to the nose which obliterates the
nasolabial fold (Fig. 2 ,B ).
Mandibular Central and Lateral Incisors
* Periapical infections from the lower
central and lateral incisors will reach the
surface on the labial aspect of the alveolar
process. In this region the relationship of
the mentalis muscles to the root apexes
determines the further course o f the in­
fection (Fig. 3,A ) . If the infection breaks
through the bone above the attachment
of the mentalis muscle, it will be limited
to the oral vestibule. If, on the other
hand, it occurs below this muscle, it then
is located extraorally. It may remain lo­
calized in the subcutaneous tissues o f the
chin (submentalis space),2 or spread be­
neath the chin into the submental space
(Fig. 3,B) .1 This space is bounded later­
ally by the anterior bellies of the digastric
muscles, superiorly by the mylohyoid
muscle and inferiorly by the skin, super­
ficial fascia, platysma muscle and deep
cervical fascia. Clinically, the swelling
will be limited to the point of the chin
and to the region immediately below it
(Fig. 3 ,B ).
Mandibular Cuspid • Because the muscle
attachments (depressor labii inferioris,
depressor anguli oris and platysma) in the
region o f the mandibular cuspid are lo­
cated well below the root apex, periapical
infections from this tooth will localize in
 LASKIN . . . VOLUME 69, SEPTEMBER 1964 • 57/311

Tongue

Mentalis m

Digastric m. M ylo h yoid m.

Fig. 3 • A : D ia g ra m o f relationship o f m a n d ib u la r incisors to alve olar process and m entalis muscle.

Infection has extended beneath m entalis muscle into subm ental space. B: C lin ic a l a p p e a ra n c e of
p atie n t with subm en tal space abscess

the oral vestibule after extending through well confined by the palatal mucosa. In
the labial cortical plate (Fig. 4 ). infections perforating the buccal cortex,
the relationship of the root apexes to the
Maxillary and Mandibular Bicuspids • attachment of the buccinator muscle is
Infections from the maxillary bicuspids the factor which determines whether lo­
generally exit from the bone on the buc­ calization will be intraoral or extraoral.
cal aspect o f the alveolar process. O cca­ If the perforation is below the buccinator
sionally, however, a palatal abscess at the
first bicuspid may develop from infections
of the palatal root.
Since the muscle attachments in the
buccal region are situated considerably
above the root apexes of the upper bicus­
pids, infections from these teeth will tend
to localize within the oral vestibule (Fig.
4 ). Because of a similar anatomic ar­
rangement in the mandibular bicuspid
region, infections from these teeth also
generally form vestibular abscesses (Fig.
4 ).

Maxillary Molars • Periapical infections

from the upper molars usually perforate
the buccal aspect of the alveolar process.
Sometimes, however, a palatal abscess
may be encountered. These generally are
Fig. 4 • D ia g ra m o f o rigin s o f muscles o f fa c ia l
expression. N o te th a t those a d ja ce n t to m a n d ib u ­
lar cu sp id an d b icu spid s an d m axillary b icu spid s
are attach e d well b e y o n d a p ic a l re gio n s o f these
teeth. (M o d ifie d from Sicher, H a rry . O r a l a n a t­
omy, ed. 2. St. Louis, C . V. M o s b y C o ., 1952.)
58/312 • THE JO U R N A L O FT H E A M E R IC A N DENTAL A SSO C IA T IO N

BUCCINATOR M.

SKIN
ORAL MUCOSA

P L A T Y SM A M
DIG A ST R IC M.

BUCCAL SPACE ABSCESS [ ____

Fig. 5 • D ia g ra m m a tic representation an d clinical a p p e a ra n ce o f bu ccal sp a ce abscess. A lth o u g h

p e rio rb ital area is not involved directly, im p a ire d venous and lym ph atic d ra in a g e often results in
g re a t edem a o f this region

attachment, the swelling will be located
in the oral vestibule. In the reverse situa­
tion, however, the infection extends lat­
eral to the buccinator muscle forming a
buccal space abscess (Fig. 5 ).6 T h e buc­
cal space is bounded medially by the buc­
cinator muscle and its covering bucco­
pharyngeal fascia, laterally by the skin
and subcutaneous tissues, anteriorly by
the posterior border of the zygomaticus
major above and the depressor anguli oris
below and posteriorly by the anterior edge
of the masseter muscle. Superiorly the
space is bounded by the zygomatic arch
Fig. 6 • D ia g ra m illustrating relation o f roots o f
m a n d ib u la r b icu spid s and m olars to lin gual a t­
ta chm en t o f m yloh yoid muscle
and inferiorly by the lower border o f the
mandible.
Mandibular First Molar • Infections
from the lower first molar also can give
rise to a buccal space abscess if the infec­
tion exits from the buccal aspect of the
bone below the attachment of the buc­
cinator muscle (Fig. 5 ). The oblique line
of buccinator attachment on the man­
dible, however, generally results in the
root apexes being above the origin of
this muscle, thereby causing localization
within the oral vestibule.
On the lingual aspect of the mandible,
the attachment of the mylohyoid muscle
roughly parallels the oblique downward
and forward course of the buccinator
muscle (Fig. 6 ). The apexes of the bicus­
pids and first molar are almost always
above the attachment of this muscle.
Should lingual perforation of a dental
infection arise in such instances, swelling
will occur in the sublingual space (Fig.
7,A ) . This space is bounded inferiorly by
the mylohyoid muscle, laterally and an­
teriorly by the lingual aspect of the man­
dible, superiorly by the mucosa of the
oral cavity, posteriorly at the midline by
the body of the hyoid bone and medially
by the geniohyoid, genioglossus and stylo­
 LASKIN . . . VO LUM E 69, SEPTEMBER 1964 • 59/313

glossus muscles. Since there is loose con­

nective tissue interspersed between these
latter muscles, as well as between the in­
trinsic muscles of the tongue, infections
o f the sublingual space usually spread
across the midline to the opposite side
as well as into the body of the tongue
(Fig. 7,B). Such sublingual infections
have been erroneously called “ Ludwig’s
angina” because they generally are asso­
ciated with swelling and elevation of the
tongue and with varying degrees of res­ S U B L IN G U A L SPACE ABSCESS
piratory difficulty. It is possible, however,
for a sublingual space abscess to develop A
into a true Ludwig’s angina (descending
cellulitis of the neck) since this space
communicates with the parapharyngeal
space at the posterior border of the mylo­
hyoid muscle lateral to the hyoid bone.

Mandibular Second Molar • Because of

the position of the mandibular second
molar in the alveolar process, there is a
50 per cent possibility of either buccal or
lingual perforation from a periapical in­
fection. Likewise, there is an equal chance
for the root apexes to be either above or
below the buccinator or mylohyoid mus­
cles. Thus, there are four possible sites of
localization for infections arising from
this tooth. On the buccal aspect, the
abscess will form either in the vestibule
or in the buccal space, depending on the
relationship of the buccinator muscle
(Fig. 5 ). On the lingual surface, exit of
the infection above the mylohyoid muscle
will result in a sublingual abscess (Fig.
7 ). Perforation below the mylohyoid
muscle produces an infection of the sub­
mandibular space (Fig. 8 ). With the rare
exception of the mandibular first molar,
only the second and third molars can give
rise to submandibular space infections.
Such infections enter the neck directly
since they are located below the mylohy­
oid muscle which forms the floor of the
oral cavity. Deep neck infections arising
from all other teeth are secondary to
spread from communicating spaces in the
face and oral cavity.
The submandibular space (Fig. 8) is
bounded laterally by the skin, superficial
Fig. 7 • A : D ia g ra m sho w ing d e ve lo p m e n t o f
su b lin gu al sp a ce absce ss from m a n d ib u la r first
molar. B: C lin ic a l a p p e a ra n c e o f p atie n t with
su b lin gu al sp a ce abscess. S p re a d o f infection
thro u gh loose co n n e ctive tissue in flo o r o f m outh
often results in bilate ral sw elling an d elevation
o f to n g u e
fascia, platysma muscle and the superfi­
cial layer of the deep cervical fascia.
Medially, the mylohyoid, hyoglossus and
styloglossus muscles bound the space. In-
feriorly, the space is bordered by the an­
terior and posterior bellies of the digastric
muscle; superiorly, the space is limited
by the medial aspect of the mandible
and the attachment of the mylohyoid
muscle.
Clinically, there should be no difficulty
in differentiating submandibular space
infections from those in the buccal space.
Whereas the buccal space abscess is a
relatively ovoid swelling beginning at the
lower border of the mandible and extend­
ing upward to the level of the zygomatic
60/314 • T H E J O U R N A L O F T H E A M E R IC A N DENTAL A SSO C IA T IO N

SUBM ANDIBULAR SPACE ABSCESS

Fig. 8 • D ia g ra m m a tic an d clinical a p p e a ra n c e o f su b m a n d ib u la r sp a ce abscess. A lth o u g h infection

has reached co n sid e rab le size, a n ato m ic barriers as well as the p h y sio lo gic response o f p a tie n t have
served to m aintain localization

arch (Fig. 5 ), the submandibular space
abscess is triangularly shaped, begins at
the lower border of the mandible and
extends to the level of the hyoid bone
(Fig. 8 ).
Mandibular Third Molar • The mandib­
ular third molar generally is positioned
medial to the vertical plane of the ramus;
therefore, its apexes are much closer to
the lingual cortical plate. In this region
the attachment of the mylohyoid muscle
is near the alveolar margin, and its pos­
terior border is located just behind the
tooth. Because of this relationship, infec­
tions from vertically positioned third
molars will extend below the mylohyoid
muscle and localize in the submandibular
space (Fig. 8 ). With mesioangularly or
horizontally positioned teeth, however,
the infections will tend to spread beyond
the posterior extent of the mylohyoid

Ftarotid Carotid sheath

gland '■
’ j I Parapharyngeal
space
Medial.
pterygoid'

Pharynx

kSup.
constrictor

Buccinator m: Tongue

Fig. 9 • A : D ia g ra m m a tic illustration o f sp re a d o f infection into p te ry g o m a n d ib u la r sp a ce from

m e sioan gu la rly im p acte d m a n d ib u la r third molar. N o te proxim ity o f p a ra p h a ry n ge a l space. B: C lin ic a l
a p p e a ra n c e o f p atie n t with p te ry g o m a n d ib u la r sp a ce abscess. Su ch patients ge n e ra lly have difficulty
in sw allow ing and c o n sid e rab le trismus. O p e n in g in this p a tie n t was achieved by use o f extraoral block
o f third division o f trige m in al nerve to relieve pain
 lA S K IN . . .V O LU M E 69, SEPTEMBER 1964 • 61/315

Table • Sites of localization of acute dental infections

Relation of muscle
Involved teeth Usual exit attachment to root Site of
from bone apexes localization

Upper central Labial Above O ral vestibule

incisor

Upper lateral Labial Above O ral vestibule

incisor Palatal Palate

Above O ral vestibule

Upper cuspid Labial
Below Canine space

Buccal Above O ral vestibule

Upper bicuspids
Palatal Palate

Buccai Above O ral vestibule

Upper molars Below Buccal space
Palatal Palate

Above Submental space

Lower incisors Labial
Below O ral vestibule

Lower cuspid Labial Below O ral vestibule

Lower bicuspids Buccal Below O ral vestibule

Buccal Below O ral vestibule

Lower first Above Buccal space
molar Lingual Below Sublingual space

Buccal Below O ral vestibule

Lower second Above Buccal space
molar Lingual Below Sublingual space
Above Submandibular space

Submandibular or
Lower third pterygomandibular
molar Lingua! Above space

From section on oral surgery by D. M. Laskin and H. B. Adilman. In Levy, S. (ed.). Dentist's handbook of office
and hospital procedures. Chicago, Yearbook Medical Publishers, 1963.

muscle localizing in the pterygomandibu­
lar space (Fig. 9,A) .8 This region, as the
name implies, is bounded laterally by the
medial surface of the ramus of the man­
dible and medially by the lateral aspect
of the medial pterygoid muscle. It is the
space into which the needle is passed in
performing an inferior alveolar nerve
block injection. Posteriorly, this space
communicates with the parapharyngeal
space. An infection from a third molar
can also pass directly into the parapha­
ryngeal space by extension medial to the
medial pterygoid muscle. A patient with
a pterygomandibular space abscess will
show no external evidence of swelling.
Intraoral examination, however, reveals
an anterior bulging of half of the soft
palate and anterior tonsillar pillar, with
deviation of the uvula to the unaffected
side (Fig. 9,B).
D IS C U S S IO N
The probable sites of localization of peri­
apical infections arising from the various
teeth have been summarized in the table.
Such information is of diagnostic as well
as academic interest since, when one can
see the swollen region, one can predict
with great accuracy the tooth or teeth
likely to be involved in the infectious
process. With the possible exception of
the vestibular abscesses, however, the re­
gions described represent only the first
possible site of localization of infections
62/314 • T H E JO U R N A L O FT H E A M E R IC A N DENTAL A SSO C IA T IO N

understands the relationship between re­

gional anatomy and the localization of
dental infections, but also treatment is
facilitated greatly. It is immediately ob­
vious that the intraoral or extraoral
spread of an infection depends entirely
on anatomic considerations and cannot
be influenced by heat or cold therapy.
It is also evident that fluctuation is not
entirely accurate as a sign of localization.
In a vestibular abscess, pus formation and
its perception may result almost simul­
taneously from the thinness of the over-
lying mucosa. In an extraoral space infec­
tion, however, fluctuation represents a
late stage of localization. T o carry out the
premise of early treatment, incision and
drainage of extraoral abscesses must be
performed before the amount of tissue
Fig. 10 • Infection in vo lvin g su bm an d ib ular, b u c ­
cal, p te ry g o m a n d ib u la r and p retem po ral spaces
destruction and suppuration is sufficient
(so -calle d "p a n -fa c ia l" a b sc e ss). Patient, who to be detected by palpation. If the clinical
had d iabetes, fa ile d to m aintain insulin therapy course of the infection and the anatomic
a fte r extraction o f m axillary righ t third molar,
and d ia b e te s b e ca m e uncontrolled. This illustrates boundaries of the space are understood,
interrelationship between a n ato m ic an d p h ysio ­ this can be accomplished readily. By
lo g ic fa c to rs in regulation o f infectious processes
prompt treatment, the site of evacuation
can be determined cosmetically; the pa­
tient is saved discomfort, and the possibil­
that have progressed beyond the bone. ity of further complications is reduced
Most of the spaces of the head and greatly.
neck communicate either directly or indi­
rectly with each other. Therefore, when
the general factors of patient resistance
and bacterial virulence favor extension of *Professor and associate head, department of oral
and maxillofacial surgery, College of Dentistry, and
the infection, spread from one region to clinical professor of surgery, department of surgery,
College of Medicine, University of Illinois, Chicago.
another can occur (Fig. 10). Thus, for 1. Sicher, H. Oral anatomy, ed. 3. St. Louis, C. V.
example, a buccal space infection can Mosby Co., I960, p. 397-414; 461-479.
2. Tiecke, R. W.; Stuteville, O. H., andCalandra,
extend upward along the course of the J. C. Pathologic physiology of oral disease. St. Louis,
C. V. Mosby Co., 1959, p. 422-440.
masticatory fat pad to invade the pretem­ 3. Coller, F. A., and Yglesias, L. Infections of lip and
poral space. It may also pass between the face. Surg. Gynec. & Obst. 60:227 Feb. (no. 2A) 1935.
4. Grodinsky, M., and Holyoke, E. A. Fasciae and
anterior border of the masseter muscle fascial spaces of head, neck and adjacent regions. Am.
and the buccinator muscle to enter the J. Anat. 63:367 Nov. 1938.
5. Dingman, R. O. Management of acute infections
pterygomandibular space (Fig. 9,A ) . A of face and ¡aws. Am. J. Orthodont. & Oral Surg.
25:780 Aug. 1939.
submandibular space infection can spread
6. Kostrubala, J. G. Potential anatomical spaces in
into the parapharyngeal space through face. Am. J. Surg. 68:28 April 1945.
the gap between the styloglossus and the 7. Shapiro, H. H.; Sleeper, E. L., and Guralnick,
W. C. Spread of infection of dental origin. Oral Surg.,
stylohyoid muscles. Ultimately, most of Oral Med. & Oral Path. 3:1407 Nov. 1950.
8. Frankel, Z. Submandibular and parapharyngeal
these dental infections can descend into spaces; their topography and importance in oral sur­
the deeper aspects of the neck. With gery. Oral Surg., Oral Med. & Oral Path. 2:1131 Sept.
1949; 2:1270 Oct. 1949.
proper therapy, however, such extension 9. Gaughran, G. R. Fasciae of the masticator space.
Anat. Rec. 129:383 Dec. 1957.
is the exception rather than the rule. 10. Braus, H. Anatomie des Menschen, vol. I, ed. 2.
Not only is diagnosis simplified if one Berlin, Germany, Julius Springer, 1929, p. 748.