Facial spaces part II

Fascial spaces related to the mandible

Submental space

Perimandibular
Submandibular space spaces

Sublingual space

Masseteric space(masseter space/

pterygomandibular space)
Lower central
Submental space

Superior/mylohyoid mscle
Inferior/platysma muscle,
deep cervical fascia
Anterior/inferior border of
the mandible
Posterior/hyoid bone
Laterally/anterior belly of
digastric
Content
Communication
Premolar and molars
What are the factors regulate the direction of
spread of infection?!
Sublingual space
Superior/mucosa of the floor of the mouth
Inferior/mylohoid muscle
Anterolateral/medial surface of mandible
Posterior-medial/hyoglossus, genioglossus
Content
Lingual artery and vein
Lingual nerve
Sublingual salivary gland
Deep part of submandibular salivary gland
Clinical picture

Painful swelling
Elevate the floor of the
mouth
Dysphagia
Primary fascial space infection with minimal or no
external fascial swelling?
Submandibular space

Superior/mylohoid muscle
Inferior and lateral/skin,
patysma
Anterolateral/medial surface
of the mandible
Posterior/hoid bone,
poterior belly of digastric
Medially/anterior belly of
digastric
Submandibular space content
Submandibular gland, lymph node
Which teeth there roots are in direct connection
with submandibular space??
Submandibular space infection
Ludwig Angina
Ludwig Angina
Bilateral rapid spreading cellulitis affecting the
perimandibular spaces
(submandibular-sublingual and submental) that
can obstruct the air way, and spread posteriorly to the
deep fascial spaces of the head and neck.
Clinical picture
Sever swelling
Elevation and displacement of the tongue
Tens, hard indurated submandibular region.
Trismus
Difficulty in swallowing and breathing/anxiety.
How submandibular space infection reach the
deep neck fascial spaces??
Danger space
Routes of spread of infection from a lower 3rd
molar
Trismus + pain + no fascial swelling = ??

Pterygomandibular space infection

Management of odontogenic infection of
the head and neck
In General,,

Once there pus you should drain >> abscess

Antibiotic is first line of ttt when >> cellulitis

Treatment of odontogenic infection

• Stage of infection:

Periapical osteitis

Cellulitis

Abscess
Treatment

Medical
Antibiotic
Analgesic Surgical
C&S >> culture and sensitivity Removal of the tooth
test
I&D
Patient hydration
Increase of cellulitis >> No
external Hot packs (cause skin
suppuration)
Antibiotic principle of use
Identification of causative organism
(staph cocci/ abscess – streptococci
/ cellulitis).

Specific narrow spectrum antibiotic.

Least toxic.

Bactericidal rather than

bacteriostatic.

Patient drug history.

Pus drainage

Root canal

Extraction

I&D (intra-oral/extra-oral)
Principle of I&D

Knowledge of local anatomy.

Most dependent area (not in
the center it cause necrosis).
Wide incision
Esthetically accepted area
Avoid trauma to important
structure.
Incision!!
Anesthesia
Hilton technique
Causes of treatment failure

Inadequate surgical treatment

Depressed host deference

Antibiotic failure

Wrong bacteria

Wrong antibiotic

Drug not reaching

Stages in progression in acute dental
infection
Infection confined to alveolar bone.
Tooth extruded from the socket.
Painful to pitting to percussion.
Root canal/extraction.
Empirical antibiotic.
Analgesic.
Hot application.
Cellulitis
Swelling not sharply demarcated
No fluctuation
Antibiotic
Extraction/endodontic treatment.
Abscess

Distinctive swelling
Fluctuation
Pus discharge
Aspiration to confirm diagnosis
In canine space incision will be
inrta-oral >> labial vestibule
Infratemporal space incision
Submental incision
Submandibular drainage in Ludwig angina
Massteric space
Pterygomandibular space
Parotid space
Osteomyelitis
An inflammatory condition of bone, that begins as an
infection of medullary cavity and haversian systems of the
cortex and extends to involve the periosteym of the
affected area.
Acute, subacute, chronic.
• Predisposing:
Immune-compromised patients.
Condition alter vascularity-radiation (osteoradionecrosis).
Bisphosphonate induced osteonecrosis.

• Etiology:
Odontogenic infection
Trauma
Acute, strept. Haemolyticus
Chronic actinomycosis
Mandible>Maxilla

Mandible:
Depend on one blood vessel
Thick cortical plate

Maxilla:
Rich vascularity
Thin cortical plate
Radiology
Treatment
Sequestrectomy (removal of sequestrum)
Saucerization (removal of bony cavity)
Antibiotic.
Hyperbaric oxygen.