MANAGEMENT OF THE INFECTIONS OF THE

MASTICATORY SPACES

‫ بدون المصادر‬1932 ‫عدد الكلمات‬

 Mx of infections of
Masticatory spaces

Orofacial infections are the most frequent cause that patients proceed to the dentist specialist; the infections
are essentially due to dental caries, with periapical pathology demonstrating clinically as pain and swelling.
The periapical lesions including the root apex may spread to, and exceeding, the maxillary bone or
mandible, then expanding to the nearby and distant soft tissues. Overall, odontogenic infections are
controlled adequately with caries restriction, endodontic treatment, scaling and root planning, and or tooth
removal. If the infection continues outside of the alveolus and basal bone of the jaws into the neighboring
soft tissues, the most judicious management is immediate surgical incision and drainage to limit significant
morbidity and airway compromise. Furthermore, if the infection spreads outside or distal to the vestibule, it
is usually best controlled by an oral and maxillofacial surgeon.

Infections that spread to the deep fascial spaces of the neck could result in significant edema, dysphagia,
dysphonia, systemic symptoms, disability to control secretions, and in the most difficult cases, airway
compromise. These critical or urgent clinical situations require immediate care and Management.

When the bacteria from the infected tooth gain entry into the periapical tissues and the immune system is
incapable of suppressing the invasion, the patient eventually shows signs and symptoms of an acute apical
abscess, which can develop to cellulitis. Clinically, the patient has swelling and feels mild to severe pain.
The swelling may be confined to the vestibule or continue into a fascial space. Depending on the association
of the apices of the tooth with the muscular attachments. The patient may additionally have systemic
manifestations, such as lymphadenopathy, fever, headache, chills, and nausea. The tooth may or may not
exhibit a radiographic sign of an enlarged periodontal ligament space, Because the response to the infection
may occur fast. Mostly, the tooth evokes a positive response to percussion, and the periapical area is tender
to palpation.

Management may include incision for drainage, root canal therapy, or extraction to eliminate the source of
the infection. Antibiotic treatment is indicated in patients with compromised host defense, the occurrence of
systemic symptoms, or involvement of a fascial space. Odontogenic infections of a Fascial space are
infections that have grown into the fascial spaces from a tooth periapical area.

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 Mx of infections of
Masticatory spaces
MASTICATORY SPACES

The masticator spaces are affected frequently from odontogenic infections and formed by the splitting of the
anterior layer of the deep cervical fascia. This superficial layer of the deep cervical fascia invests all of the
muscles of mastication.
This fascia splits at the inferior border of the mandible to pass laterally over the masseter muscle and
medially over the medial pterygoid muscle, it ends at the junction of the pterygoid plates and sphenoid bone.

The masticator space MLDCF, Middle layer, deep cervical fascia;

SLDCF, superficial layer, deep cervical fascia
includes:
- Masseteric (or submasseteric) space
- Pterygomandibular space
- Temporal spaces
o Superficial temporal space
o Deep temporal space
These spaces function as “subspaces” of the masticator
space, but they can all become involved rapidly once
one compartment is affected.
• The pterygomandibular space of the masticator
space is associated in 78% of cases.
• The most common offending tooth in masticator
space infections is the mandibular third molar due to
pericoronitis.
• The most common direct route of spread of infection from the mandibular third molars is to the
pterygomandibular space.
• The pterygomandibular and submasseteric spaces are involved first when a posterior mandibular molar
(e.g., periapical infection or pericoronitis) is the offending source.
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 Mx of infections of
Masticatory spaces

Masseteric (or submasseteric) space

The submasseteric space is surrounded by the lateral surface of the ramus of the mandible and the medial
surface of the masseter muscle. The origin of the infection is usually an impacted third molar, in which the
purulent exudate breaks within the lingual cortical plate, and the apices of the teeth that lie adjacent to or
within the space. An extra usual cause of submasseteric
space infections is an infected mandibular angle fracture.

Radiographic evidence of a submasseteric space infection

may involve a diffuse expansion of the masseter muscle due
to swelling. The main clinical finding in masticator space
involvement is trismus due to inflammation of the muscles of
mastication.

Extraoral swelling over the area occupied by masseter muscles,

which is over ascending ramus and angle of the mandible. The
infection of this space is characterized by trismus because of the
involvement of the muscles of mastication.

An approximately 4cm incision is made under and behind the

angle of ascending ramus. Dissection is made through the skin,
superficial fascia, and platysma muscles. The artery forceps should
be inserted and remain in contact with the outer aspect of
ascending ramus. The incision can be used to approach two spaces
(masseteric and pterygoid mandibular). Masseteric space can also
be drained throughout an intraoral incision or a combined The patient exhibited swelling of the
mandibular angle area. The impacted
intraoral-extraoral approach. third left, mandibular molar was thought
to be the cause of infection

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1.After incising the vestibular mucosa along the
anterior border of the master muscle, a hemostat
was introduced through the intraoral wound and
directed backwards. While the instrument was in
contact with the lateral surface of the ramus, the
masseter muscle was detached from the ramus as
much as possible.
3. The drain was attached to the hemostat, and
the hemostat was withdrawn. After checking the
position of the drain intraorally, the intraoral
incised wound was closed with an absorbable
suture.
Mx of infections of
Masticatory spaces
2. After detachment of the masseter muscle from
the ramus, a 1.0 cm horizontal incision was
marked 2.0 cm below the lower border of the
mandibular angle. The tip of the hemostat was
pushed toward the incision, lifting up on the
incision marking. After incising only, the elevated
skin, the tip of the hemostat was pushed through
the incised skin
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 Mx of infections of
Masticatory spaces
Pterygomandibular space

The pterygomandibular space is formed by the lateral surface of the medial pterygoid muscle medially and
the medial surface of the ascending ramus of the mandible
laterally. The superior extent of the space is the lateral
pterygoid muscle. Its inferior border is the inferior border of
the mandible. The parotid gland posteriorly and the
pterygomandibu lar raphe and the superior constrictor
muscle anteriorly. The pterygoid space contains the
inferior alveolar nerve, artery and vein, the
lingual nerve and the nerve to the mylohyoid muscle.

The infection is usually caused by the mandibular second

or third molars or adjacent soft tissue inflammation, in
which the purulent exudate drains directly into the space.
Also, contaminated inferior alveolar nerve injections can
cause infection of the space.
Nevertheless, these infections can spread quickly to the
other segments of the masticator space, and also to the
Left Pterygoid space abscess
lateral pharyngeal space.
Minimal extraoral facial swelling will be present if only
an isolated pterygomandibular space is involved.
A critical clinical feature is a trismus due to the
involvement of the medial pterygoid muscle.
Surgical approaches to the pterygoid space
An extraoral submandibular approach is normally
employed. Dissect bluntly through the pterygomasseteric
sling up to the pterygoid space, remaining medial to the
ramus and lateral to the medial pterygoid muscle. An intraoral
approach is done via a vertical incision, lateral and parallel to the
pterygomandibular raphe.
Blunt dissection is then used to reach the pterygoid space by
dissecting along the medial surface of the ramus. A combined
approach with through-and-through drains can also be employed.

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 Mx of infections of
Masticatory spaces
Radiographically the medial pterygoid muscle may be enlarged due to inflammation. In the case of abscess
formation, a fluid collection may be seen between the medial pterygoid muscle and the medial surface of the
ramus of the mandible. The intraoral examination is typically very difficult to perform due to marked
trismus, but it may reveal erythema and edema of the anterior tonsillar pillar region and, occasionally,
deviation of the uvula to the unaffected side, especially when the infection begins to extend into the lateral
pharyngeal space. The airway may be compromised, which contributes further to the severity and urgency.

The temporal spaces

The temporal space is divided into two compartments by the

temporalis muscle.
- The deep temporal space is formed by the lateral surface of the
skull and the medial surface of the temporalis and calvarium.
The infratemporal space is inferior part of the deep temporal
space and lies between the lateral pterygoid muscle and
infratemporal crest of the sphenoid bone. The pterygomandibular
and deep temporal spaces are separated by the lateral pterygoid
muscle.
- The superficial temporal space is formed by the temporalis
muscle and its overlying fascia. The submasseteric and
superficial temporal spaces are separated by the zygomatic arch.

The deep or superficial temporal spaces are involved indirectly if an

infection spreads superiorly from the inferior pterygomandibular or
submasseteric spaces, respectively. Only the most severe infections
will extend to the superficial and deep temporal spaces, because
infections usually spread in a gravity-dependent manner. Clinical
manifestations will be pain and edema, with fluctuance in
advanced temporal space infections. Because of the dense
attachment of the deep cervical fascia to the zygomatic arch the
swelling is not usually seen caudal to the zygomatic arch.
Actually, the involvement of both the temporal and
submasseteric spaces produces an hourglass-appearing swelling
due to the lack of the swelling just inferior to the zygomatic
arch.
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 Mx of infections of
Masticatory spaces
Sources of infection include maxillary molar infection or post-extraction sepsis; maxillary sinusitis,
maxillary sinus fractures; temporomandibular arthroscopy and sepsis following injections into the
temporomandibular joint.

Surgical approaches to temporal space

External approach. The incision for drainage is performed
horizontally, at the margin of the scalp hair and approximately 3 cm
above the zygomatic arch taking care not to injure the frontal and
temporal branches of the facial nerve which run across the superficial
temporal fat pad, deep to the orbicularis oculi muscle, just lateral to the
orbital rim. It then continues carefully between the two layers of the
temporal fascia as far as the temporalis muscle. A curved hemostat is
used to drain the abscess. The deep compartment is drained by
advancing the haemostat through the temporalis muscle into the space External approach to the
between the temporalis muscle and temporal and sphenoid bone. superficial and deep
compartments of the temporal
space
Intra-oral approach. The temporalis muscle attaches to the
coronoid process of the Mandible. The key anatomical landmark
for intraoral drainage is the ascending mandibular ramus. To drain
the superficial compartment, make a stab incision in the mucosa
lateral to the ascending ramus and advance a haemostat lateral to
the coronoid process into the abscess. To drain the deep
compartment, make a stab incision in the mucosa medial to the
ascending ramus and advance a haemostat medial to the coronoid
process into the abscess. A combined approach can also be used.
Intraoral drainage: Red arrow:
medial to coronoid process to reach
deep
compartment; Blue arrow: lateral to
coronoid process to reach superficial
compartment

Infratemporal abscess. a Diagrammatic illustration showing the

spread of the abscess into the infratemporal space. b Clinical
photograph of an infratemporal abscess. Swelling of the region of the
right zygomatic arch and edema of eyelids. c Incision at the depth of
the vestibular fold for incision and drainage of an infratemporal 7
abscess
 Mx of infections of
Masticatory spaces

Summary

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 Mx of infections of
Masticatory spaces

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