Orofacial Infections - Part-II PDF

Oral and Dental Surgery - II Orofacial Infections - Part-II Asst. Prof. Mustan Barış SİVRİ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Pathways of Orofacial Infection 2. Fascial Spaces 3. Spacies around the Maxilla Lear...

Oral and Dental Surgery - II Orofacial Infections - Part-II Asst. Prof. Mustan Barış SİVRİ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] Course Content 1. Pathways of Orofacial Infection 2. Fascial Spaces 3. Spacies around the Maxilla Learning Outcomes At the end of this course you will; ✓Explain the pathways of odontogenic infections. ✓Define fascial spaces ✓Know fascial spaces around the maxilla Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Pathways of Odontogenic Infection Pathways of Odontogenic Infection Odontogenic infections have two major origins: (a) Periodontal- due to bacterial inoculations into underlying tissues via deep periodontal pockets (b) Periapical-, more common, and occur subsequent to pulpal necrosis, reaching the periapical structures. Periapical Origin Pathways of Odontogenic Infection ❑ Once the periodontal or periapical tissues get inoculated with bacteria, the infection may spread equally in all directions but mostly follows the path of least resistance. ❑ It travels through the cancellous bone to reach the cortical plate. ❑ If the cortical plate is thin, infection easily perforates it to enter the surrounding soft tissue. ❑ At this stage, if an intervention such as an endodontic or periodontal procedure or dental extraction is done, the further spread may be arrested. ❑ Antimicrobials alone may not cure the condition as the focus of infection from necrotic pulp or periapical tissues still remains and may cause recurrence of the infection, if the therapy is stopped. ❑ When left untreated, the infection continues to spread depending principally on the thickness of bone and the type of muscle attachment. Buccinator muscle Buccinator muscle Vestibular Abscess Buccal Space Abscess ❑ Apart from these factors, the angulation of root apex is also important. For example, in periapical abscess with respect to maxillary lateral incisor, swelling is likely to occur on the hard palate rather than labial vestibule as its root apex is slightly palato-distally curved. What is 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. ❑An odontogenic infection follows the path of least resistance. ❑A periapical infection may perforate the nearest or the weakest cortex and travel along the soft tissue, initially as cellulitis and eventually resulting in abscess formation. ❑This abscess may drain spontaneously, extraorally or intraorally and may involve one or more anatomically potential spaces. When this happens, it is known as a space infection. What is Fascial Space? Fascial Space Infection 3. With any offending mandibular tooth ▪ Medullary space of mandibular body ▪ Submandibular ▪ Sublingual 1. With any tooth ▪ Submental ▪ Subcutaneous ▪ Masticator ▪ Vestibular ▪ Submasseteric ▪ Buccal ▪ Pterygomandibular 2. With any offending maxillary tooth ▪ Superficial temporal ▪ Buccal ▪ Maxillary along with other para nasal sinuses ▪ Deep temporal 4. Deep fascial spaces ▪ Infraorbital ▪ Lateral pharyngeal ▪ Infratemporal ▪ Retropharyngeal ▪ Temporal ▪ Pretracheal ▪ Danger (Alar space). ▪ Prevertebral Following are frequently affected anatomic spaces, Fascial Space Infection ❑Various Space Infections and Their Relative Severity: MILD—Vital structures and airway may be mildly threatened • Subperiosteal • Infraorbital • Buccal MODERATE—Airway may be compromised • Vestibular • Pterygomandibular • Osteomyelitis of the mandible • Superficial temporal HIGH—Vital structures or airway under direct threat • Lateral pharyngeal • Retropharyngeal • Danger space (Alar space) • Pretracheal • Cavernous sinus thrombosis • Intracranial infections (brain abscess) • Mediastinal • Prevertebral • Submandibular • Sublingual • Submental • Submasseteric • Infratemporal • Deep temporal • Masticator Fascial Space Infection Six possible locations are: ➢ the vestibular abscess (1), ➢ buccal space (2), ➢ palatal abscess (3), ➢ sublingual space (4), ➢ submandibular space (5), ➢ maxillary sinus (6). Space of the Head and Neck Space of the Head and Neck Space of the Head and Neck Space of the Head and Neck Spaces Around the Maxilla Canine Space/Infraorbital Space ❑ Source of Infection • From upper canine and premolars. • Skin infections of upper lip ❑ Contents • Angular artery and vein. • Infraorbital nerve. ❑ Clinical Features 1. Pain and tenderness. 2. Swelling in the anterior cheek region. 3. Obliteration of Nasolabial folds. 4. Edema of lower eyelid and upper lip. 5. Obliteration of labial vestibule. Canine Space/Infraorbital Space ❑ Boundaries • Anterior—Elevator muscles of upper lip (Orbicularis oris). • Posterior—Anterior surface of Maxilla. • Medial—Levator Labii Alaeque nasi. • Lateral—Zygomaticus major. Canine Space/Infraorbital Space Canine Space/Infraorbital Space ❑ Management ✓ Drainage of the space infection either intraorally or percutaneously is done; intraoral incision and drainage are preferred as these will not produce a facial scar. ✓ Drainage is made by making an in-depth incision of the maxillary vestibule near canine fossa. ✓ Sinus forceps is inserted superiorly, laterally, and medially for complete breakage of locules and drainage. ✓ Care is taken while using sinus forceps, so as to not damage the infraorbital nerve and its branches. ✓ Aggressive antibiotic therapy is mandatory to prevent the spread as it lies in the danger area of the face and also to prevent Cavernous sinus thrombosis from septic thrombi entering into angular vein. ✓ The involved tooth is either removed or subjected to root canal treatment with multiple dressings. ✓ Patient is advised good hydration and rest. Buccal Space ❑Source of infection • From maxillary premolar and molar teeth root apices above buccinator attachment. • From mandibular premolar and molar teeth root apices below the buccinator attachment. ❑Contents • Buccal pad of fat. • Stenson’s duct. • Facial artery. Buccal Space ❑Clinical Features 1. Pain and tenderness. 2. Diffuse swelling on the side of the cheek. 3. Obliteration of buccal vestibule. 4. Swelling of upper/lower lip ❑Boundaries • Medial: Buccinator muscle, buccopharyngeal fascia, and mucosa. • Lateral: Skin of cheek and subcutaneous tissue. • Anterior: Posterior border of zygomaticus major above and depressor anguli oris below. • Posterior: Edge of masseter muscle. • Superior: Zygomatic arch. • Inferior: Lower border of mandible. Buccal Space ❑ Management Temporal Pouches 1.Superficial Temporal Space 2.Deep Temporal Space Superficial Temporal Space ❑ Source of infection • From upper third molars and • Infection from other spaces ❑ Boundaries • Superior—superior temporal lines • Inferior—zygomatic arch • Lateral—superficial temporal fascia • Medial—temporalis muscle • Anterior—posterior surface of lateral orbital rim • Posterior—fusion of temporal fascia with pericranium ❑ Contents • Temporal fat pad. • Temporal branch of Facial nerve. ❑ Clinical Features 1. Pain and tenderness at the temporal region. 2. Swelling is present above and below zygomatic arch, leading to classical “Dumb bell” shaped appearance 3. Trismus may be present ❑ 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. Superficial Temporal Space Deep Temporal Space ❑ Source of infection • Upper third molar and • Spread from other spaces. ❑ Boundaries • Superior—Attachment of temporal fascia to the cranium. • Inferior—Lateral pterygoid muscle. • Medial—Medial pterygoid plate and lower part of infratemporal fossa. • Lateral—Medial surface of the temporalis muscle. ❑ Contents • Branches of Internal maxillary artery. • Mandibular division of trigeminal nerve. ❑ Clinical Features 1. Pain. 2. Swelling at the infratemporal region and lateral aspect of the eye. 3. Obliteration of buccal sulcus at tuberosity area. 4. Trismus due to proximity of masticatory muscles. 5. Infection may extend to the infratemporal and pterygomandibular region. Deep Temporal Space ❑ 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 the pus is drained. Corrugated 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. THANK YOU..