Maxillofacial Abscesses and Phlegmons

• Abscesses and phlegmons affect the maxillofacial region

Abscess

• It is a pus-filled pocket located under the skin tissue, but rarely in other tissues

Phlegmona

• This is an acute purulent inflammatory process located under the skin, muscle, and other tissues
• It spreads to other tissues and regions, unlike an abscess

Etiology of Infection

• Odontogenic sources are a cause
• Maxillary sinus infections can be a cause
• Issues with major salivary glands can cause
• Specific infections, such as osteomyelitis, can cause it

Predisposing Factors

• Blood diseases like leukemia and anemia
• Immunological diseases such as AIDS
• General diseases like syphilis and tuberculosis
• Trauma
• Bone fractures

Microbiology

• Odontogenic infections are polymicrobial
• Streptococci accounts for 90% of cases
• Staphylococci accounts for 6% of cases
• Gram-positive bacteria involved
• Gram-negative bacteria involved
• Aerobic bacteria are present
• Anaerobic bacteria are present

Spaces Involved in Odontogenic Infections

• Maxillary space
• Canine, buccal, and infra temporal spaces
• Mandibular spaces
• Submental space
• Buccal space
• Sublingual space
• Submandibular space

Odontogenic Infections

• Tooth decay reaches the pulp, leading to pulpitis and infection spreading to supporting bone
• This forms periapical abscesses that spreads to periapical area
• Periodontal diseases
• Decay under fillings or cracks
• Impacted wisdom teeth and pericoronaritis
• Retained roots

Clinical Signs

• Swelling
• Pain
• High temperature
• Trismus (masseter muscle)
• Asymmetry
• Purulent inflammation
• Lymph node reaction

Infraorbital Space

• Superior border: inferior margin of the orbit
• Inferior border: alveolar process
• Mesial border: margin of the piriform aperture
• Lateral border: zygomatic-maxilla suture

Cause

Odontogenic

• Maxillary canines
• Premolars

Non-Odontogenic

• Trauma
• Skin infection
• Hematoma

Clinical Signs (Infraorbital Area)

• Edema localized in the infraorbital area, spreading to the lower eyelid and side of the nose
• Pain
• Fluctuation during palpation
• Reddish color of the skin surface

Canine Fossa Abscess Treatment

• Incision for drainage is performed intraorally at the mucobuccal fold parallel to the alveolar bone in the canine region
• A hemostat is inserted at the depth of the purulent accumulation until contacting bone; the index finger of the non-dominant hand palpates the infraorbital margin
• A rubber drain is placed and stabilized with a suture on the mucosa

Buccal Space Borders

• Superior: inferior margin of zygomatic arch
• Inferior: inferior margin of mandible
• Anterior: corner of the mouth
• Posterior: anterior margin of masseter muscle
• Interior: buccinator muscle

Buccal Space Layers

• Skin
• Superficial fascia
• Buccinator muscle
• Buccal fat pad
• Submucous layer
• Mucous membrane

Buccal Space Infection

Odontogenic

• Often maxillary and mandibular posterior teeth

Nonodontogenic

• Adenophlegmon of facial lymph nodes

Secondary Spread

• Superiorly: pterygopalatine space
• Inferiorly: pterygomandibular space
• Buccal space lies between buccinator muscle and overlying skin and superficial fascia
• It is a potential space involved via maxillary or mandibular molars

Clinical Presentation of Buccal Abscess

• Swelling of the cheek extends from the zygomatic arch to the inferior border of the mandible, and from the anterior border of the ramus to the corner of the mouth
• The skin appears taut and red, with or without fluctuation of the abscess
• Intraoral bulging is possible

Buccal Space Abscess Treatment

• Access to the buccal space is usually intraoral for three main reasons:
  • Abscess fluctuates intraorally in majority of cases
  • Avoid injury to facial nerve
  • For esthetic reasons
• An intraoral incision is made at the posterior region of the mouth, in an anteroposterior direction, carefully to avoid injury of the parotid duct
• A hemostat is used to explore the space thoroughly
• An extraoral incision is made when intraoral access won't ensure adequate drainage, or pus is deep inside the space
• The incision is made approximately 2 cm below and parallel to the inferior border of the mandible

Submental Space Borders

• Lateral: anterior bellies of the right and left digastric muscles
• Anterior: internal border of corpus of mandible
• Posterior: hyoid bone
• Roof: mylohyoid muscle
• Lower margin: skin and platysma muscle

Submental Space Infection

Odontogenic

• Frontal teeth of the mandible

Nonodontogenic

• Adenophlegmon or trauma

Secondary Spread

• Submandibular or sublingual spaces

Clinical Presentation of Submental Abscess

• Edema in the submental region can spread to submandibular space
• Palpation is painful with fluctuation
• Hyperemia of skin
• Functional disturbances in protrusion of the jaw
• Dysphagia or discomfort while swallowing can be present
• Rubber drain placed at the drainage site of the abscess

Submandibular Space Borders

• Superior: mylohyoid muscle
• Inferior: skin
• External: inferior border of body of mandible
• Anterior: anterior belly of digastric muscle
• Posterior: posterior belly of digastric muscle

Submandibular Space Contents

• Submandibular salivary glands
• Submandibular lymph nodes
• Facial artery
• Anterior facial vein

Submandibular Space Infection

Odontogenic

• Mandibular molars and premolars

Nonodontogenic

• Adenophlegmon of submandibular lymph nodes
• Purulent process of submandibular salivary glands

Secondary Spread

• Submental (most frequently) or sublingual

Clinical Presentation

• The infection presents as moderate swelling at the submandibular area, which spreads, creating greater edema that is indurated and redness of the overlying skin
• Angle of the mandible is obliterated
• Pain during palpation
• Moderate trismus is present due to involvement of the medial pterygoid muscle
• A hemostat may be inserted into the cavity of the abscess to explore the space, attempt to communicate with infected spaces.

Sublingual Space Borders

• Superior: mucous membrane of floor of mouth
• Inferior: mylohyoid muscle
• Posterior: muscles of the tongue and hyoid bone
• Lateral and anterior: inner surface of body of mandible
• Medially: lingual septum

Sublingual Space Infection

Odontogenic

• Mandibular anterior teeth, premolars, and 1st molars whose apices are found above attachment of the mylohyoid muscle

Nonodontogenic

• Sublingual glands infection

Secondary Spread From

• Submandibular
• Submental by ascending way through fibers of mylohyoid muscle
• Lateral pharyngeal

Clinical Presentation

• Firm, painful swelling of mucosa of floor of the mouth, resulting in elevation of the tongue towards the palate and backwards
• Pain and difficulty swallowing (dysphagia)
• Movement of the tongue is painful
• Mandibular-lingual sulcus is obliterated and mucosa presents a bluish tinge
• Moderate or no external swelling
• Speaking is difficult due to edema, movements of tongue are painful
• A rubber drain is placed

Maxillary Sinusitis Introduction

• Maxillary sinusitis is an infection or inflammation of the maxillary sinus
• Odontogenic maxillary sinusitis usually manifests unilaterally and its pathophysiology, microbiology and management are different from those of non-odontogenic sinusitis
• Maxillary premolar and molar teeth have closest proximity to antral floor, infection of these teeth is the most common cause
• Multiplication of bacteria invading from the focus of a dental infection results in odontogenic maxillary sinusitis

Additional Etiology

• Dental or alveolar trauma
• Odontogenic cysts
• Maxillary osteomyelitis
• Iatrogenic or accidental displacement of foreign bodies during routine dental treatment or dentoalveolar surgical procedures
• Other surgical complications that result in sinus exposure

Acute Signs and Symptoms

• Dull or intense pressure-like pain
• Erythema
• Swelling of the cheek and anterior maxilla
• Pressure or fullness in the vicinity of the maxillary sinus
• Headache
• Malaise
• Fever
• Oral malodor
• Mucopurulent rhinorrhea
• Nasal congestion or obstruction
• Drainage of foul-smelling mucopurulent materials into the nasal cavity and nasopharynx (postnasal drip)

Treatment

• Initial treatment: antibiotic therapy, like Penicillin, clindamycin, and metronidazole
• Increase drug dose and intravenous administration of antibiotic, especially for moderate to severe cases
• Drainage of the area helps to reduce pain intensity, prevents disease progression, and encourages resolution

Chronic Odontogenic Maxillary Sinusitis

• Results from prolonged low-grade inflammation in antral mucosa following acute phase or recurrence of acute sinusitis
• The antral mucosa is thickened with edema, infiltration of leukocytes and fibers, sometimes accompanied by the creation of polyps

Chronic Local Signs and Symptoms

• Generally subtle but malodor
• Persistent pus discharge, with or without postnasal drip
• Toothache during chewing
• Increased tooth mobility
• Migraine
• Dull headache

Chronic Treatment

• Initial Treatment: Antibiotic therapy and surgery
• Elimination of dental source by tooth extraction, apicoectomy, endodontic therapy, and removal of any involved foreign body

Surgical Steps for Treatment

• If the dental root or foreign body is displaced from extraction socket, the socket may be enlarged buccally after elevation of mucoperiosteal flaps to expose the maxilla above the socket
• A mucoperiosteal flap is made around the canine-premolar recess
• After the flap is reflected, a new small oroantral opening is created in the bone, 1cm above the root apices of the first premolar
• Saline solution is injected into the antral cavity to flood sinus through the expanded socket or the opening

People at Risk with Actinomycosis

• Having a dental disease or recent dental surgery
• Aspiration
• Having bowel surgery
• Swallowing fragments of chicken or other bones
• Women who have had an intrauterine contraceptive device(IUD) in place for many years

Types of Actinomycosis

• Skin
• Under the skin
• Mucosal
• Submucosal
• Odontogenic
• Muscle
• Lymph node
• Periosteum
• Jaw bone
• Tongue, salivary gland

Actinomycosis Clinical Signs

• Swelling of the mucous membrane of the mouth
• Inflammation of the mucous membranes of the mouth
• The formation of ulcers; some time later a fistula with pus forms
• Pulmonary actinomycosis causes chest pain and purulent sputum
• Colon actinomycosis causes pain, vomiting, diarrhea or constipation, weight loss

Actinomycosis Diagnosis

• In the earlier stage, this bacterial infection is difficult to diagnose
• Culture of the tissue or fluid shows Actinomyces species
• Examination of drained fluid under a microscope shows "sulfur granules" in the fluid

Actinomycosis Treatment

• Treatment classically begins with IV penicillin for 2-6 weeks, followed by oral therapy with penicillin or amoxicillin for 6-12 months
• If allergic to penicillin, may use tetracycline, erythromycin, minocycline and clindamycin

Tuberculosis of Oral Cavity and Maxillofacial Area

• Tuberculosis is a specific infection and chronic granulomatous disease
• Causative agent is Tuberculosis Mycobacterium
• Primarily affects the lungs (pulmonary TB)
• Spreads via airborne transmission

Tuberculosis Dissemination

• Dissemination in the oral cavity and maxillofacial area is lymphatic or hematogenous
• Can spread from an active infected area, air system, or skin and mucosa
• Active when the immune system becomes weak

Tuberculosis Clinical Types

• Primary TB: involves oral/nasal mucosa, facial, and neck lymph nodes
• Nodes are solid then transform to consistence of bone or cartilage
• There are a chain of chains of lymph nodes across the sternocleidomastoid muscle
• Ulcer in oral cavity
• May form abscess and fistulas on skin

Secondary Types

• More common
• Tongue is affected in most cases
• Causes chronic ulceration and swellings
• Mandibular swelling with intra bony involvement
• Forms granuloma or tuberculoma, which is painful
• Tuberculous osteomyelitis usually occurs in lated stage and prognosis is poor

Treatment

• Complex
• Surgery: extractions, fistulas, and osteomyelitis
• Drugs: rifampicin and amikacin