Outline

I- Definition of Head and Neck Fascial Space

II- Anatomical Factors Influencing Spread of Dental Infections

a. Alveolar Bone
b. Periosteum
c. Muscle attachment
d. Cervical Fascia

III- Classification of Fascial Spaces

a. Based on the Mode of Involvement
b. Based on Clinical Significance

IV- Potential Primary Spaces Related to Upper Jaw

a. Infraorbital Space
b. Buccal Space
c. Infratemporal Fossa Space

V- Potential Primary Spaces Related to Lower Jaw

a. Submental Space
b. Submandibular Space
c. Sublingual Space

VI- Secondary Potential Fascial Spaces

a. Temporal Space
b. Parotid Space
c. Submasseteric Space
d. Pterygomandibular Space
e. Lateral Pharyngeal Space
f. Retropharyngeal Space: Prevertebral Space
g. Peritonsillar Abscess
Definition of Head and Neck Fascial Space
 The fascial spaces in the Head and Neck are the potential spaces between the various
fascia normally filled with loose connective tissue and bounded by the anatomical
barriers usually of bone, muscle, or fascial layers.

 Facial planes offer anatomic highways for infection to spread superficially to deep
planes. Antibiotic availability in fascial spaces is limited due to poor vascularity.

Anatomical Factors Influencing Spread of Dental Infections

1- Alveolar Bone

 In the maxilla, the alveolar bone is weakest on the buccal side throughout.

 In the mandible, the alveolar bone is weakest in the lingual aspect posteriorly affecting
the molars, and on the buccal side more anteriorly involving the incisors and canines.

2- Periosteum

 This structure is better developed in mandible; and hence can delay further spread
leading to development of a sub-periosteal abscess.

3- Muscle attachment

 Maxillary teeth:
- Infection above muscle attachment; an extraoral swelling
- Infection below muscle attachment; an intraoral swelling

 Mandibular teeth:
- Infection below muscle attachment; an extra oral swelling.
- Infection above muscle attachment; an intra oral swelling.

4- Cervical Fascia

 Cervical fascia is a continuous layer of connective tissue consisting of the superficial,

middle, and deep layers.

 The layers’ envelope separates and supports structures forming fascial spaces which are
potential spaces along which infection may spread cellulitis or within it infection may
become localized.
Classification of Fascial Spaces

Based on the Mode of Involvement

I- Direct involvement (Primary spaces)

a. Maxillary spaces: canine, buccal, and infratemporal spaces.

b. Mandibular spaces. : submental, buccal, submandibular, and sublingual spaces.

II- Indirect involvement (Secondary spaces)

Masseteric, Pterygomandibular, Superficial and Deep temporal, Lateral pharyngeal,

Retropharyngeal, Prevertebral spaces, Parotid space.

Based on Clinical Significance

I- Face: canine, buccal, masticatory, parotid

II- Suprahyoid: sublingual, submandibular, submental, lateral pharyngeal,

peritonsillar

III- Infrahyoid: Anterovisceral (pretracheal)

IV- Spaces of total neck: retropharyngeal, danger space, space of carotid sheath.
 
Potential Primary Spaces Related to Upper Jaw
Infraorbital Space (Canine Space)
Involvement and Surgical anatomy

 Periapical abscess discharging buccally from an upper canine or premolar may lead to
pus accumulation in canine fossa, deep to muscles of facial expression moving upper lip.

 The periapical abscess discharges buccally superior to the origin of the caninus muscle
and pus accumulates in the canine fossa.

Canine with a short root:

- The pus from a periapical abscess will emerge and tends to point in upper buccal sulcus, as
buccinator muscle has no attachment to bone anterior to first molar.

Canine with a long root:

- The pus from periapical abscess will emerge above the origin of levator anguli oris and
escaping to the space between levator labii superioris and levator labii superioris alaque nasi.

The infection may:

- Spread anteriorly through the gap between angular and infraorbital heads of quadratus muscle
emerging under the skin, just below the inner corner of the eye.

- Escape posteriorly between the infraorbital head and zygomatic head of the quadratus muscle,
emerging under the skin, just below the outer corner of the eye.

Clinical features

Early phase:
 Inflammatory enlargement of the upper lip
 Drooping of the angle of the mouth.
 Obliteration of nasolabial fold.
 Periorbital oedema.

Late phase:
 Marked periorbital oedema, forcing the eyelid to close.
 Redness and marked tenderness of the facial tissues.

Chronic phase:
 Chronic fistula in the cleft area between the levator labii superioris alaque nasi, and
zygomaticus minor muscles near the medial canthus of the eye.
Buccal Space Involvement

 Buccal space is the potential space between buccinator and masseter muscle.

Involvement and Surgical anatomy

 Teeth commonly involved are the maxillary and mandibular premolars and molars.

 The location of the root tip to the level of origin of buccinator muscle determines the
spread of infection either intraorally into the vestibule or deep into the buccal space.

 Pericoronitis in lower third molar pus can travel forward along the channel formed by the
muscle attached to the sloping external oblique ridge and the body of the mandible. In
this case, pus pools intraorally opposite 1st or 2nd molars. If pus penetrates the muscle in
the retromolar area, then it is directed laterally into the buccal space.

Clinical features

 When pus accumulates on oral side of the muscle-‘Gum boil’ is seen in the vestibule.

 If pus accumulates lateral to the muscle, prominent extraoral swelling is seen extending
from lower border of mandible to the infraorbital margin and from the anterior margin of
masseter muscle to the corner of mouth. Sometimes oedema of the lower eyelid is seen.
Infratemporal Fossa Space
 It is also called ‘retrozygomatic space’ as it is partly situated behind the zygomatic bone.

 The space is continuous with upper part of pterygomandibular space anteriorly. However,
it is separated from it by lateral pterygoid muscle posteriorly. Thus, the infratemporal
fossa forms the upper extremity of pterygomandibular space.

Involvement and Surgical anatomy

 Infections of the infratemporal space arise from the infection of the buccal roots of
the maxillary second and third molars, particularly, from unerupted third molars

 Local anaesthesia injections with contaminated needles in the area of tuberosity

 Spread from the other spaces infection.

 Infection of infratemporal space should always be regarded as a serious event,

because of the proximity of pterygoid plexus of veins, from which infection can track
upwards to the cavernous sinus, Thus, rarely, it may involve central nervous system,
which is presented as headache, irritability, photophobia, vomiting, and drowsiness.

Clinical features

 Extraoral:
‐ Trismus
‐ Bulging of temporalis muscle
‐ Marked swelling of face on the affected side in front of the ear, overlying area of TMJ.
‐ The eye is often closed and is proptosed.

 Intraoral:
‐ Swelling in the tuberosity area.
Potential Primary Spaces Related to Lower Jaw

Submental Space
Involvement and Surgical anatomy

 It is involved most frequently by the infections originating from the six anterior
mandibular teeth; then perforate the cortical plate below the origin of mentalis muscle
labially; and mylohyoid lingually.

 The space can be secondarily involved due to infection of submental lymph nodes,
following lymphatic spread from lower incisors.

Clinical features

 Extraoral:
‐ The submental lymph nodes lie embedded in adipose tissue, and hence, submental
abscesses tend to remain well circumscribed.

‐ Distinct, firm swelling in midline, beneath the chin. Skin overlying the swelling is board
like and taut. Fluctuation may be present.

 Intraoral:
‐ The anterior teeth are either nonvital, fractured or carious. The offending tooth may
exhibit tenderness to percussion and may show mobility.

‐ The patient may experience considerable discomfort on swallowing.

Submandibular Space
 The space lies between the anterior and posterior bellies of the digastric muscles.

 The upper part lies beneath the inferior border of mandible and the lower part lies deep to
the investing layer of deep cervical fascia.

 Submandibular spaces are considered the anterior extensions of parapharyngeal space.

Involvement and Surgical anatomy

 It is involved most frequently by infections originating from the mandibular molars. The
pus perforates the lingual cortical plate of mandible, inferior to the attachment of
mylohyoid muscle, and passes directly into the submandibular space.

Clinical features

 Extraoral:
‐ Firm swelling in submandibular region, below the inferior border of mandible.
‐ Generalized constitutional symptoms,
‐ Some degree of tenderness
‐ Redness of overlying skin.

 Intraoral:
‐ Teeth are sensitive to percussion and mobile
‐ Dysphagia
‐ Moderate trismus.
Sublingual Space
This space is a V-shaped trough lying lateral to muscles of tongue, including hyoglossus,
genioglossus and geniohyoid.

Involvement and Surgical anatomy

 The teeth which frequently give rise to involvement of sublingual space are the
mandibular incisors, canines, premolars and sometimes first molars.

 The apices of these teeth are superior to the mylohyoid muscle.

 The infection perforates lingual plate below the level of the mucosa of the floor of the
mouth and passes into the sublingual space.

 It is a paired space; but the two sides communicate anteriorly. This space communicates
with submandibular space around the posterior border of mylohyoid muscle.

Clinical features

 Extraoral:
‐ There is little or no swelling.
‐ The lymph nodes may be enlarged and tender.
‐ Pain and discomfort on deglutition.
‐ Speech may be affected.

 Intraoral:
‐ Firm, painful swelling seen in the floor of the mouth on the affected side.
‐ The floor of the mouth is raised.
‐ The tongue may be pushed superiorly. This will bring about airway obstruction.
‐ The ability to protrude the tongue beyond the vermillion border of upper lip is affected.
Secondary Potential Fascial Spaces

Temporal Space
Involvement and Surgical anatomy

 Involvement of the temporal space occurs secondary to the initial involvement of

pterygopalatine and infratemporal space.
 Temporal pouches are fascial spaces in relation to the temporalis muscle.
 They are two: Superficial and Deep temporal space.
 The superficial temporal pouch lies between the temporal fascia and temporalis muscle.
 The deep temporal pouch lies deep to the temporalis muscle and the skull.
 Below the level of zygomatic arch, superficial and deep temporal pouches communicate
directly with the infratemporal and pterygopalatine fossa.

Clinical features
 Pain
 Trismus
 Swelling over temporal region may be present
Parotid Space
Involvement and Surgical anatomy

 Infections are either blood borne or retrograde infections through the Stenson’s duct.

 The gland is strongly attached to the parotid fascia, and there is very little intervening
loose connective tissue. This makes extension of odontogenic infections into the parotid
space usually very difficult.

 The gland is contiguous to submasseteric, pterygomandibular and lateral pharyngeal

spaces; and on rare occasions the parotid space can be involved by an odontogenic
infection from one of these spaces.

Clinical features

 Severe pain which may be referred to the ear; and is accentuated by eating. Because of
the pain associated with eating, these patients do not consume adequate fluids, and hence,
these patients may get severely dehydrated.

 Presence of swelling over the masseter muscle, extending from the level of zygomatic
arch to lower border of mandible. Anteriorly, it ends at the anterior border of ramus of the
mandible, and posteriorly, it extends into the retromandibular region. Earlobe seems to be
everted or lifted up.

 There is escape of pus from the Stenson‘s duct when the gland is milked.

 
Submasseteric Space
 Masseter consists of three layers fused anteriorly but can be easily separated posteriorly.

 There is potential space in the substance of the muscle between middle and deep heads,
while the bony insertion is firm above and below, the intermediate fibers have a loose
attachment and can relatively easily separate from bone by pus accumulation.

 When the pus accumulates between the ramus of the mandible and the masseter muscle,
it produces a submasseteric space abscess.

Involvement and Surgical anatomy

 Infection usually originates from the lower third molars; either resulting from:
‐ Pericoronitis related to vertical and distoangular third molars.
‐ Periapical abscess spreading subperiosteally in a distal direction.

 The presence of buccinator attachment probably discourages backward extension of

pericoronal infection, where third molar crown is anterior to this muscle barrier.

 The extension of abscess inferiorly is limited by the firm attachment of masseter to lower
border of ramus of mandible.

 The forward spread beyond the anterior border of ramus is restricted by the anterior tail
of the tendon of temporalis, which is inserted into the anterior border of the ramus.

Clinical features

 External facial swelling is confined to the outline of the masseter muscle; the swelling is
seen extending from the lower border of the mandible to the zygomatic arch, anteriorly to
the anterior border of masseter; and posteriorly to the posterior border of the mandible.

 There is tenderness over the angle of the mandible.

 There is almost complete limitation of mouth opening.

 Fluctuation cannot be elicited because the muscle lies between the pus and the surface.

 The ramus is more dependent upon blood supply from the overlying muscle than the
body of the mandible, which is supplied by inferior alveolar artery. As a result, ischemic
changes may take place in that part of bone denuded by periosteum by a submasseteric
abscess so that a low-grade osteomyelitis of lateral cortical plate may occur.

 Often submasseteric infection leads to subperiosteal new bone deposition beneath the
periosteum. Necrosis of the muscle can also occur.
Pterygomandibular Space
Involvement and Surgical anatomy

 The situation most frequently responsible for involvement of this space, is the
pericoronitis related to the mandibular third molar.

 Infection can also be produced by a contaminated needle used for IAN block.

 Infection, at times, can originate from a maxillary third molar, following a posterior
superior alveolar nerve block injection.

Clinical features

 Severe degree of limitation of mouth opening.

 Tenderness over the area of swollen soft tissues medial to anterior border of ramus
 Dysphagia is present.
 Medial displacement of the lateral wall of the pharynx.
 Redness, and oedema of the area around the third molar.
 Midline of the palate is displaced to the unaffected side and the uvula is swollen.
 Difficulty in breathing.
Lateral Pharyngeal Space
 It is a potential cone shaped space or cleft with its base uppermost at the base of skull and
its apex at the greater horn of the hyoid bone.

 The space is divided by the styloid process into anterior and posterior compartments.

 Infection is extremely serious owing to the intimate relationship with the carotid sheath.

Involvement and Surgical anatomy

 It is involved from an abscess extending backwards from mandibular third molar area.

 Backward spread from sublingual, submandibular, pterygomandibular space infections.

 Lateral spread from tonsillar abscess.

 Boundary walls of the space do not permit easy communication with the adjacent spaces.

 There is a weak zone in the posterior part of the fascia around the submandibular salivary
gland, medial to stylomandibular ligament, and rupture of a submandibular abscess into
the parapharyngeal space at this point may result in respiratory embarrassment.

Clinical features

a. Anterior compartment:

 Extraoral:
‐ Brawny induration of the face, above the angle of the mandible.

 Intraoral:
‐ The anterior part of the lateral pharyngeal wall may be swollen; that pushes the soft
palate and the palatine tonsil towards the midline.
‐ Marked trismus.
‐ Severe pain due to pus collection between the medial pterygoid and superior constrictor.

b. Posterior compartment:

‐ The clinical picture is dominated by septicemia.

‐ Little or no trismus.
‐ Slight pain.
‐ External swelling: subtle swelling in lateral neck, just above the hyoid bone, between
posterior belly of digastric and sternocleidomastoid muscle externally.
‐ Internal swelling: involves the lateral wall of pharynx behind the palatopharyngeal arch.
Retropharyngeal Space: Prevertebral Space

 It is also called as prevertebral space, which is a potential space present in the midline
between the pharyngobasilar fascia and prevertebral fascia.

 This space is continuous with retropharyngeal space into the posterior mediastinum.

Involvement and Surgical anatomy

 The space is involved by an extension of infection from the lateral pharyngeal space.

 There are no midline attachments in the retropharyngeal space; thereby, permitting

unimpeded inferior extension of inflammatory and neoplastic processes into
mediastinum.
 

Clinical features

 There is usually a preceding or concurrent acute infection of the throat. Patient will
complain of painful deglutition, and if the swelling is marked obstructive symptoms such
as snoring, choking or even dyspnea and stertorous breathing may occur.

 A unilateral cervical adenitis on the affected side is always seen.

Peritonsillar Abscess (Quinsy)
 It is a localized infection in the connective tissue bed between the tonsil and the superior
constrictor muscle, between the anterior and posterior pillars of fauces.

Involvement and Surgical anatomy

 Infection coming from the depth of the tonsillar crypt or supratonsillar fossa.

 As a complication of acute pericoronal abscess in which case the abscess points near the
lower pole of the tonsil.

Clinical features

 Patient looks ill, anoxic, and dehydrated.

 Pain on one side of the throat radiating to the ear.
 Dysphagia
 Speech is difficult with a characteristic “Hot Potato Voice”.
 Drooling of saliva.
 Coated tongue with marked foetor oris.
 When the abscess is fully developed; a large tense swelling of anterior pillar of fauces,
and a bulge in the soft palate on the affected side, which in extreme cases reaches the
midline; and pushes the uvula until it impinges against the opposite tonsil.
 Edema may eventually affect the base of the tongue, epiglottis, and aryepiglottic fold. In
3-5 days, the mass becomes fluctuant and ruptures by pointing usually through the
anterior tonsillar pillar.

 
References
 Textbook of Oral and Maxillofacial Surgery, Neelima Anil Malik -
Jaypee Brothers (2008), Section Eleven: Orofacial and Neck Infections
Pages 594 to 623.

 Gaddipati R. (2021) Fascial Space Infections. In: Bonanthaya K.,

Panneerselvam E., Manuel S., Kumar V.V., Rai A. (eds) Oral and
Maxillofacial Surgery for the Clinician. Springer, Singapore.
https://doi.org/10.1007/978-981-15-1346-6_21

 Flaviana Soares Rocha, Jonas Dantas Batista, Cláudia Jordão Silva,

Roberto Bernardino Júnior and Luis Henrique Araújo Raposo (April
22nd 2015). Considerations for the Spread of Odontogenic Infections
— Diagnosis and Treatment, A Textbook of Advanced Oral and
Maxillofacial Surgery Volume 2, Mohammad Hosein Kalantar
Motamedi, IntechOpen, DOI: 10.5772/59161.