Orofacial Infections-Part-3.pdf

Oral and Dental Surgery - II Orofacial Infections - Part-III Asst. Prof. Ezgi YÜCEER ÇETİNER 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 Mandib...

Oral and Dental Surgery - II Orofacial Infections - Part-III Asst. Prof. Ezgi YÜCEER ÇETİNER 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 Mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Learning Outcomes At the end of this course you will; Explain the pathways of odontogenic infections. Define fascial spaces Know fascial spaces around the mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Resource • Hupp, J. R., Tucker, M. R., & Ellis, E. (2019). Contemporary Oral and maxillofacial surgery. 7th Ed., Elsevier. Chapter 16 Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Spaces Around the Mandible Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Perimandibular Spaces  Perimandibular spaces, as described by Grodinsky and Holyoke, include the submandibular, sublingual, and submental spaces.  These perimandibular spaces become involved when infections originating from the premolars and molars perforate the lingual cortex of the mandible.  If the infection perforates the mandible cephalad to the attachment of the mylohyoid muscle, the infection will enter the sublingual space.  If the infection perforates the lingual cortex inferior to the attachment of the mylohyoid muscle to the mandible, then it will enter the submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space • The submental space is affected often by infections originating from the mandibular incisor teeth. • However, commonly the submental space becomes involved as an extension of submandibular space infections. • This is due to the fact that the only anterior barrier of the submandibular space is the anterior belly of the digastric muscle, which is not a true barrier between the submandibular and submental spaces. • Furthermore, infections from one submandibular space may pass through the submental space to then involve the contralateral submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space Source of Infection • Infection from lower anterior teeth • Infected symphyseal or parasymphyseal fractures • Suppuration of submental lymph nodes Contents • Submental lymph nodes • Anterior jugular vein Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Boundaries • Lateral: Skin, superficial fascia, platysma, superficial layer of deep cervical fascia. • Medial: Mylohyoid, hyoglossus, and styloglossus. • Inferior: Anterior and posterior belly of digastric muscles. • Posterior: Hyoid bone. • Superior: Medial aspect of mandible and the attachment of mylohyoid muscle. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Clinical Features 1. Pain and tenderness in the chin region 2. Firm swelling at the chin 3. Difficulty in swallowing 4. Tenderness of lower anterior teeth Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submental Space  Management  Transcutaneous approach in the chin region is the most effective drainage; incision is made below the symphysis menti to produce dependent drainage.  Sinus forceps is inserted upward and backward to break the locules and the pus is drained.  A corrugated rubber drain is inserted and secured with a suture.  Intraoral approach is cumbersome as we need to pierce mentalis muscle to reach the submental space and also drainage against gravity is not possible. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space • The sublingual space is a perimandibular space that is commonly the first deep fascial space involved in mandibular odontogenic infections. • The boundaries include the floor of the mouth submucosa and the mylohyoid muscle. • It is unusual to observe an isolated sublingual space infection without a synchronous submandibular space infection. • This is due to the fact that the sublingual space has no posterior boundary and freely communicates with the submandibular space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space • However, unlike a submandibular space abscess, in an isolated sublingual space abscess, by definition there should be no noticeable extraoral swelling because the infection is limited to a location that is cephalad to the mylohyoid muscle. • Clinical findings of isolated sublingual space involvement include tongue and floor of mouth elevation, with difficulty with speech or swallowing, especially in later stage infections or in bilateral sublingual space infections. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Source of infection • Periapical infection from mandibular teeth is situated above mylohyoid muscle. • Infection from sublingual gland. Contents • Lingual nerve and hypoglossal nerve. • Deep part submandibular gland and duct. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Clinical Features 1. Pain and discomfort during deglutition. 2. Due to edema, there is elevation and protrusion of the tongue. 3. In case of laryngeal edema, there may be breathlessness. 4. Speech may be affected. 5. Enlarged and tender submandibular nodes. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space Boundaries • • • • • Orofacial Infections Part-III 10.11.2023 Anterior: Lingual aspect of mandible. Posterior: The body of hyoid bone. Superior: Mucosa of oral cavity. Inferior: Mylohyoid muscle. Medial:Geniohyoid,genioglossus,and styloglossus muscle. Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Sublingual Space  Management • An intraoral incision is made close to lingual cortical plate, near premolar region taking care of lingual nerve and the Wharton’s duct. Sinus forceps or a thin mosquito forceps is inserted and the pus is drained. • If an extraoral approach is planned, then incision is placed at the submandibular region, taking care of the facial artery and marginal mandibular nerve; a sinus forceps is inserted piercing the mylohyoid muscle to drain the pus and a corrugated rubber drain is inserted and secured with a suture, as this approach provides gravitydependent drainage. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space • The submandibular space, as opposed to the sublingual space, almost always manifests with the clinical finding of visible extraoral swelling. • This edema results because, by definition, a submandibular space infection occurs caudal to the mylohyoid muscle, and therefore the SLDF and platysma muscle are the only barriers between the abscess cavity and the skin. • Clinically it is the SLDF that is surgically entered during an incision and drainage procedure and produces the release of purulence when present. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space • As with the sublingual space, there is no posterior boundary of the submandibular space, and it communicates freely with the deeper fascial spaces of the neck (e.g., pterygomandibular and lateral pharyngeal spaces) that may result in significant morbidity when involved. • The submandibular space is triangular in configuration, formed by the inferior border of the mandible and the anterior and posterior bellies of the digastric muscles. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Source of infection • Infection from the periapical region of molar teeth below mylohyoid muscle. • Septic fractures of the mandible body region. • Infections from submandibular salivary gland. • Infections from submental and sublingual. • Infection from other space.  Contents • Submandibular salivary gland. • Submandibular nodes. • Facial artery and vein. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Boundaries • Laterally: Skin, superficial fascia, platysma, and superficial layer of deep cervical fascia. • Medially: Mylohyoid, hyoglossus, and styloglossus. • Inferiorly: Anterior and posterior belly of digastric muscles. • Posteriorly: Hyoid bone. • Superiorly: Medial aspect of mandible and the attachment of mylohyoid muscle. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Clinical Features 1. Pain and tenderness. 2. Swelling is situated at the submandibular region, inferior to the lower of the mandible. 3. Swelling is firm to soft in consistency. 4. Submandibular nodes are palpable and tender. 5. Intraoral—the involved teeth are sensitive. 6. Mild trismus may be noticed. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space  Management It is managed through an extraoral approach; incision is placed at the submandibular region in the most dependent area to facilitate gravitational drainage, taking care of the facial artery and marginal mandibular nerve; a sinus forceps is inserted superiorly, medially, and laterally piercing through the superficial fascia. A drain is inserted and secured with a suture to facilitate dependent drainage. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submandibular Space Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina  Involvement of sublingual, submandibular, and submental spaces is known as Ludwig angina.  This is a term often used inappropriately by clinicians for any perimandibular space infection; but when it does exist, it has clinical significance because the airway may be compromised.  When a cellulitis or abscess involves all three of these spaces (actually, five spaces: two submandibular spaces, two sublingual spaces, and one submental space), the airway should be the primary consideration and be secured promptly (e.g., tracheal intubation of tracheostomy). Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina  The clinical findings in Ludwig angına include firm induration of the skin in the submental and submandibular regions extraorally and elevation of the floor of the mouth and tongue intraorally (sublingual space) and possibly fluctuant swellings (abscess cavities) bilaterally from the inferior border of the mandible to the hyoid bone.  The inferior border of the mandible is often not palpable due to significant firm swelling.  Other clinical findings include dysphagia, dysphonia, trismus, floor of mouth, tongue elevation (causing inability to visualize and evaluate the posterior oropharynx), cervical immobility, globus sensation (feeling of a lump in throat) in the late stages, inability to handle oral secretions, head held in a forward “sniffing” position, a “hot potato” voice, and increased work of breathing due to upper airway obstruction.  In the early and mid-1900s, Ludwig angina was associated with high morbidity and mortality, and it was determined that securing the airway as early as possible, with early surgical intervention in the form of incision and drainage, significantly reduced patient morbidity. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Ludwig’s Angina Masticator Space The masticator spaces comprise the following four spaces: • Submasseteric space. • Pterygomandibular space. • Temporal space. • Infratemporal space. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space  Source of infection • Infection from buccally placed lower third molar. • Septic foci from infected angle fracture. • Infection from other space.  Boundaries • Anterior: Facial extension of parotidomasseteric fascia. • Posterior: Parotid fascia and deep portion of parotid gland. • Superiorly: Level of zygomatic arch. • Lateral: Medial surface of the Masseter muscle. • Medial: Lateral surface of the ramus.. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space Clinical Features 1. Pain and tenderness at angle mandible. 2. Moderate size swelling at the angle region. 3. Firm consistency swelling. 4. Severe trismus. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Submasseteric Space  Management • The drainage of the infection is done through two approaches. In intraoral approach, incision is placed at the retromolar area along the anterior border of the ramus of mandible. The sinus forceps is inserted through the incision laterally between the mandibular ramus and the masseter muscle to explore the submasseteric space. The disadvantage of intraoral technique is that incision and drainage is not gravity dependent. • In extraoral approach, the incision is placed on the skin at the angle and inferior border of the mandible; sinus forceps is inserted directing superiorly piercing the subcutaneous tissue and masseter muscle. Abscess drained corrugated rubber tube is placed and secured with a suture. Precautions are taken not to damage the marginal mandibular nerve. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Source of infection • From lower third molar. • Contaminated needle used during inferior alveolar nerve block. • Septic fractures of the mandibular angle. • Infection from other spaces (Superficial temporal) .  Contents • Inferior Alveolar nerve and artery. • Lingual Nerve. • Long Buccal Nerve. • Nerve to Mylohyoid. Orofacial Infections Part-III  Boundaries • Lateral: Medial surface of mandible. • Medial: Lateral aspect of medial pterygoid muscle. • Anterior: Pterygomandibular raphe. • Posterior: Deep part of parotid gland. • Superior: Lateral pterygoid muscle and infratemporal surface of greater wing of sphenoid bone. 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Clinical Features 1. Pain at the retromolar region. 2. Dysphagia. 3. Trismus. 4. No obvious swelling extraorally. 5. Swelling near anterior tonsillar pillar. 6. Deviation of Uvula. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space  Management • Generally, incision and drainage are done through intraoral approach; however, in case of severe trismus, extraoral approach may be indicated. Drainage is done either under general anesthesia or by giving mandibular nerve block. Intraoral Approach • A vertical incision of 1.5 cm is made at the anterior and medial aspect of the mandible, sinus forceps is inserted into the abscess cavity, and pus is evacuated. Corrugated rubber drain is inserted and sutured to the margins of the incision to prevent dislodgement. Extraoral Approach • In case of severe trismus, this approach is advised, an incision of 1.5 cm is made on the skin, toward the inner aspect of the angle region. Sinus forceps is inserted toward the medial aspect of the mandible directing superiorly close to the bone. Pus is evacuated and rubber drain is inserted and sutured to the margins of the incision. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner Pterygomandibular Space Management Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner THANK YOU.. Orofacial Infections Part-III 10.11.2023 Oral and Dental Surgery-II © Asst. Prof. Ezgi Yüceer Çetiner