MANAGEMENT OF PATIENT WITH AN

ABSCESS INVOLVING MASTICATOR

SPACES
PRESENTER: IGNAS SENKONDO DDS5
(2019-04-13464)
OUTLINE.

 Introduction

 Submasseteric space

 Pterygomandibular space

 Temporal space

 Medical management

 Refferences

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OBJECTIVES

 To identify different masticatory spaces.

 To identify various source of infection to the masticatory spaces.

 To identify clinical features of the masticatory spaces infections.

 To identify the different surgical management approach to masticatory spaces.

 To be aware of the medical management of facial space infection.

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 INTRODUCTION
Masticator spaces
The masticator space is created by dividing the investing fascia into superficial
and deep layers. The superficial layer runs along the lateral surface of the
masseter and lower half of the temporalis, while the deep layer passes along
the medial surface of the pterygoid muscles before attaching to the base of the
skull superiorly.
It comprises three facial spaces which are;
 Submasseteric space
 Pterigomandibular space
 Temporal space (Superficial and deep temporal space)

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 SUBMASSETERIC SPACE
Anatomical borders
Anterior- Anterior border of the masseter muscle
Posterior-Parotid gland
Medial-Lateral surface of the mandibular ramus
Lateral-Masseter muscle
Superior-Origin of the masseter at the inferior border of the zygomatic arch
Inferior-It extends up to the insertion of the masseter at the angle of the
mandible

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Source of infection
 Mandibular third molar infect ions are the most common source of infection as
the infection can extend Subperiosteally in the submasseteric space
(Linguoversion of third molars).
 Septic fractures at the angle of the mandible are also the cause of the
submasseteric space infection.
 Hematogenous spread of the infection can also lead to submasseteric
space infection in cases of septicemia.

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Clinical features
 Trismus due to spasm of masseter
muscle.
 Deep seated pain and tenderness over
the mandibular ramus.
 Swelling over the angle of mandible.
 General constitutional signs and
symptoms like fever, malaise, body ache,
etc. are present

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Surgical management
The surgical treatment comprises of incision and
drainage of the abscess. It can be done either
intraorally and extraorally as well
Intraoral approach
 In the intraoral procedure, an incision is placed
in the retromolar area along the anterior border
of the ramus and the dissection is done along
the lateral border of the ramus. An artery forcep
is introduced between the ramus and the
masseter muscle to drain the abscess. A guaze
drain is placed to facilitate the drainage of the
pus along it.
 Disadvantage of this method is there is no
gravity assisted drainage 02/08/2024 05:37 PM 10
Extraoral approach
 Extraoral procedure for abscess drainage involves placing a Risdon's
submandibular incision 1 cm below and behind the mandible's inferior border,
curving around the angle to avoid facial nerve damage and hide scars.
 Superficial abscesses are drained with a stab incision, while deep-seated
abscesses require layer-by-layer dissection, including incising and reflecting
masseter muscle fibers without damaging the facial artery.
 To achieve full drainage, a sinus forceps or gloved finger is used to break
loculi, a rubber dam drain is inserted, and, if bleeding occurs, iodoform or
glycerine-magsulf (MgSo4) tape gauze is packed in the abscess cavity for
hemostasis.

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 PTERYGOMANDIBULAR SPACE
Anatomical borders
Anterior- Pterygomandibular raphe
Posterior- Deep portion of parotid gland
Medial- Medial pterygoid muscle
Lateral- Medial aspect of ramus
Superior- Lateral pterygoid muscle
Inferior- Pterygomasseteric sling

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Contents
 Inferior alveolar nerve
 Inferior alveolar artery
 Lingual nerve
 Nerve to mylohyoid muscle

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Source of infection
 Due to contaminated needles/solution used while giving inferior alveolar nerve
block.
 Septic fractures of mandibular ramus.
 Infections from mandibular third molars. (Mesioangular, horizontal impacted
third molar)

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Clinical features
 Trismus due to involvement of medial
pterygoid muscle
 No obvious swelling extraorally
 Anterior bulging of the soft palate and
anterior tonsillar pillar
 Deviation of the uvula to the unaffected side
 Difficult in swallowing
 Pain at the retromolar region

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Spread
Superficial temporal, parotid spaces.

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Management
 An extraoral submandibular approach is normally employed. Bluntly dissection
is made 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
 Jaw exercises postoperatively to prevent trismus

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 TEMPORAL SPACE

It comprises of two spaces the superficial temporal space and deep temporal
space

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Superficial Temporal space
 The space lies between the temporal fascia and temporalis muscle
 Source of infection- From upper third molars and infection from other spaces

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Anatomical borders
Anterior- Posterior surface of lateral orbital rim.
Posterior- Fusion of temporal fascia with pericranium.
Medial- Temporalis muscle.
Lateral- Superficial temporal fascia.
Superior- Superior temporal lines.
Inferior- Zygomatic arch.

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Contents
 Temporal fat pad
 Temporal branch of facial nerve

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Clinical features
 Pain and tenderness at the temporal
region
 Swelling is present above and below
zygomatic arch leading to classical “Dumb
bell” shaped appearance
 Trismus may be present

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Management
Surgical drainage is carried out through
an incision made above the zygomatic
arch; sinus forceps is inserted through
the skin incision and passed through the
superficial fascia and the temporal fascia.

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Deep temporal space
This space lies between the temporalis muscle and the scull, and slightly below
the level of zygomatic arch, both the superficial and temporal spaces
communicate with each other.
Source of infection- Upper third molar and spread from other spaces

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Anatomical borders
 Medial- Medial pterygoid plate and lower part of infratemporal fossa.
 Lateral- Medial surface of the temporalis muscle.
 Superior- Attachment of temporal fascia to the cranium.
 Inferior- Lateral pterygoid muscle.
Contents
 Branches of internal maxillary artery.
 Mandibular division of trigeminal nerve.

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Clinical features
 Pain.
 Swelling at the infratemporal region and lateral aspect of the eye.
 Obliteration of the buccal sulcus at tuberosity area.
 Trismus due to proximity of masticatory muscle.
 Infection may extend to the infratemporal and pterygo-mandibular region.

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Management
 If the trismus is not severe, intraoral incision is given in the buccal sulcus at
the second and third molar region. With the sinus forceps, the space is
entered medial to coronoid process superiorly and pus is drained. Rubber tube
is placed and secured with a suture.
 In case of severe trismus, extraoral incision is made above the zygomatic arch
at the junction of frontal and temporal process of zygoma, sinus forceps is
inserted and directed inferiorly and medially to enter the space and drain the
pus

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 MEDICAL MANAGEMENT
 Preferred Antibiotics for Odontogenic Infections; Penicillin or cephalosporin
(beta-lactam group) antibiotics are typically prescribed. Gram-positive oral
microorganisms, common in odontogenic infections, respond well to
penicillin.
 Adjusting Doses in Severe Cases; Higher antibiotic doses are
recommended for severe infections or compromised immune patients.
 Cloxacillin as a Complementary Antibiotic; Cloxacillin can be added to
ampicillin or amoxicillin to enhance effectiveness, especially against beta-
lactamase-producing organisms.

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 CONT…
 Aminoglycosides for Mixed Infections; Aminoglycosides like gentamycin
and amicacin may be used in mixed infections for broader gram-negative
coverage. However, their value is limited in odontogenic infections, where
gram-negative organisms are uncommon.
 Metronidazole for Anaerobic Infections; Metronidazole is recommended
when evidence of anaerobic infection is present (slough, crepitus, gas,
foul-smelling pus). Anaerobic infections thrive in specific environments,
such as hypoperfused cavities or devitalized tissue.
 Note: Definitive antibiotic therapy should follow culture and sensitivity
tests, and specific dressing (glycerine and magsulf) is used in the diffuse
and acute stage.

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REFERENCES
 Textbook of Oral and Maxillofacial Surgery by Rajiv M Borle 2014

 Rajasekhar Gaddipati Fascial Space infections

 Standring S, Editor Gray anatomy; The anatomical basis of clinical practice

 A Concise Textbook of Oral & Maxillofacial Surgery by Sumit Sanghai 2009

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