SREE SANKARA DENTAL COLLEGE

ORAL MEDICINE SEMINAR

Presented By ;

AHANA A.

IV BDS PART I

FACIAL SPACESFACIAL SPACES

• Potential spaces situated between the planes of fascia.

• Natural pathways along which infection can spread.

HOW MANY SPACES ???

• PRIMARY SPACES

MAXILLARY SPACESMAXILLARY SPACES Canine Space Buccal Space Infratemporal space Parotid Space

MANDIBULAR SPACESMANDIBULAR SPACES

Space for Body of mandible Submental space Sublingual Space Submandibular space Pterygomandibular space

• SECONDARY SPACESMasseteric spacePterygomandibular spaceSuperficial & Deep temporal space

Lateral pterygoid spaceRetropharyngeal spacePrevertebral space

CANINE SPACECANINE SPACE

ANATOMY LOCATIONLOCATION : B/w Anterior surface of maxilla & overlying levator labi superioris. BOUNDARIES Superiorly: Levator labi superioris Anteriorly : Orbicularis oris Posteriorly: Buccinator

SOURCE OF INFECTION• Maxillary Canine• First Premolar

CLINICAL FEATURES

•INTRAORAL LOCATIONLabial sulcusRarely , Palatal swelling

• LOCATION OF SWELLINGLOCATION OF SWELLINGLateral to noseObliterate nasolabial foldSometimes oedema of cheek &

upper lipSevere cases infection extend to

orbit

BUCCAL SPACEBUCCAL SPACE

• ANATOMY

LOCATION LOCATION : B/W Buccinator & Masseter muscle & lies

superficial to Buccopharyngeal fascia.

• BOUNDARIESBOUNDARIES Medially: Buccinator & Buccopharyngeal Laterally: Skin of cheek Anteriorly: Anterior border of

Zygomatic bone & Depressor anguli oris Superiorly: Zygomatic arch Inferiorly: Mandible Posteriorly: Masseter

&Pterygomandibular raphe

CONTENTSCONTENTSBuccal pad of fatStenson’s ductAnterior facial artery & veinTransverse Artery & vein

SOURCES OF INFECTIONMaxillary bicuspidMaxillary molarsMandibular molarsMandibular Bicuspids

CLINICAL FEATURES

• LOCATION OF SWELLINGLOCATION OF SWELLING lower border of mandible to

level of Zygomatic arch• SYMPTOMSYMPTOM Facial swelling with Trismus• SIGN SIGN Obvious, Dome Shaped

PAROTID SPACEPAROTID SPACE

• Enclosed by superficial layer of deep cervical fascia along with Parotid gland

• Extension of odontogenic infection is difficult.

CONTENTSCONTENTS

• Parotid gland• Extra glandular & intraglandular

parotid lymph nodes• External carotid artery• Internal carotid artery• Maxillary artery• Superficial temporal artery

SOURCES OF INFECTION

• Blood born• Retrograde extension – from

lateral pharyngeal spacE

CLINICAL FEATURES

LOCATION OF SWELLINGLOCATION OF SWELLINGZygomatic arch to lower border of mandible

Posteriorly extends upto retromandibular region

Anteriorly ends at the end of anterior border of ramus

SIGNSSIGNS Evertion of ear lobule

SYMPTOMSSYMPTOMS Pain which is referred to ear & accentuated on chewing

DIAGNOSISDIAGNOSIS : made byEvertion of ear lobuleNo trismusPossible escape of pus from parotid

duct on milkingAll signs of abscess

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISSubmasseteric Space

infection

INFRATEMPORAL SPACEINFRATEMPORAL SPACE

ANATOMY

LOCATIONLOCATION: irregularly shaped space

behind posterior surface of mandible

BOUNDARIESBOUNDARIES

Laterally: temporalis tendon, coronoid

process & ramus

Medially: Lateral plate of pterygoid process

Posteriorly: Lateral pterygoid muscle, condyle &

temporalis

Anteriorly: Maxillary tuberosity

Superiorly: Greater wing of sphenoid

Inferiorly: communicates with

Pterygomandibular space

SOURCES OF INFECTION

CONTENTSCONTENTSPterygoid plexusMaxillary artery & veinMandibular division of trigeminal

nerve

Maxillary molarsLocal infiltration of maxillary nerve

CLINICAL FEATURES

LOCATION OF SWELLINGLOCATION OF SWELLING

*Extraorally over the sigmoid notch

& TMJ area

*Intraorally in tuberosity

SYMPTOMSSYMPTOMSTrismusSwelling of eyelids in case of involvement of post zygomatic fossa

SIGNSSIGNSEntire cheek swollen; if buccal space involved

SPACE FOR BODY OF SPACE FOR BODY OF MANDIBLEMANDIBLE

ANATOMY LOCATIONLOCATION: formed as the external

cervical fascia splits medially & laterally, at the inferior border of mandible & becomes continuous with alveolar mucoperiosteum.

SOURCES OF INFECTION

CONTENTSCONTENTSMandible anterior to ramusVarious Mandibular attachments.

•Fracture or direct extension•Dental caries•Blood born

CLINICAL FEATURES

LOCATION OF SWELLINGLOCATION OF SWELLING Incisors, Canines & bicuspids

•Outer cortical plate involvement

•Inner cortical plate involvement Molars

•Perforation of infection above external oblique ridge: oblique swelling in the oral vestibules.

•Perforation below mylohyoid line: infection point in the skin

SUBMENTAL SPACE

ANATOMY LOCATIONLOCATION: Midline b/w

symphysis menti & hyoid bone BOUNDARIESBOUNDARIES:

Floor: Mylohyoid muscle Roof: Suprahyoid portion of

investing layer of deep cervical fascia Lateral: Anterior belly of

Digastric

SOURCE OF INFECTION

• Mandibular anterior teeth

CLINICAL FEATURES LOCATION OF SWELLINGLOCATION OF SWELLING: Chin

SYMPTOMSSYMPTOMS: Dyspnoea, Dysphagia SIGNSSIGNS: -Grossly swollen cheek -Firm -Erythematous

SUBMANDIBULAR SPACEANATOMY LOCATIONLOCATION: Lateral to submental

space

BOUNDARIES:BOUNDARIES: Laterally

»Submandibular skin»Superficial fascia»Platysma»Superficial layer of deep cervical

fascia»Lower border of mandible

Medially–Mylohyoid–Hyoglossus–styloglossus

Inferiorly–Anterior & Posterior belly of digastric

Posteriorly–Hyoid bone

CONTENTSCONTENTS

• Superficial part of Submandibular salivary gland & lymph nodes

• Facial artery• Wharton’s duct• Lingual & hypoglossal nerve• Facial vein

SOURCES OF INFECTION

• Second & Third Molars

CLINICAL FEATURES

LOCATIONLOCATION: Near angle of jaw

SIGNSSIGNS–Brawny–Edematous–After some days swelling becomes soft & cystic

SUBLINGUAL SPACE

ANATOMY LOCATIONLOCATION: Above mylohyoid BOUNDARIES: Superiorly – mucous membrane

of floor of mouth Anteriorly & laterally – inner

surface of body of mandible Medially – geniohyoid,

genioglossus, median raphe of tongue

SOURCES OF INFECTION

Posteriorly – Hyoid bone Inferiorly – mylohyoid muscle

• Directly from perforation of lingual cortical plate

• From submandibular space

CLINICAL FEATURESLOCATION: Floor of mouth, close to

mandible &spreads towards midline or beyond

SYMPTOMSSYMPTOMS–Elevation of tongue–Dysphasia–Dyspnoea

SIGNSSIGNS–Brawny–Erythematous–Tender

SUBMASSETERIC SPACE

ANATOMY BOUNDARIESBOUNDARIES Anteriorly: body of mandible Posteriorly: Parotid space Medially: Lateral pharyngeal

space Superiorly: continuous with

superficial & deep temporal pouches

SOURCES OF INFECTIONSOURCES OF INFECTION

CONTENTSCONTENTS - Masseteric artery & vein - Muscles of mastication

- Mandibular 3rd molars

CLINICAL FEATURESLOCATIONLOCATION - External: brawny induration over

ramus & angle of mandible - Internal: Sublingual region &

pharyngeal wallSYMPTOMS SYMPTOMS -Excruciating pain -Radiates to ear -Dysphagia -Trismus

TEMPORAL SPACE

ANATOMY LOCATIONLOCATION: Superficial & deep

temporal BOUNDARIESBOUNDARIES Anteriorly- Maxillary tuberosity Posteriorly- Lateral pterygoid,

condyle, temporalis Laterally- Lateral pterygoid plate,

inferior belly of lateral pterygoid

CLINICAL FEATURES

LOCATIONLOCATION • Infection with superficial temporal space

–Swelling is limited below by zygomatic arch

–Laterally by outline of superficial temporal line

• Deep temporal abscess–Produce less swelling–Lies deep to temporalis muscle–Less fluctuant

DUMBELL SHAPED APPEARANCEDUMBELL SHAPED APPEARANCE : with buccal space involvement

SYMPTOMSSYMPTOMSPain severeTrismus

PTERYGOMANDIBULAR SPACE

ANATOMY LOCATIONLOCATION - Well defined - b/w ramus & pterygoid

muscle CONTENTSCONTENTS - Fat - Inferior alveolar nerve - Maxillary artery

BOUNDARIESBOUNDARIES

Lateral wall: Inner surface of ramusMedial wall: Medial pterygoid muscleRoof : Lateral pterygoid Posterior : Retromandibular spaceAnterior : Deep tendon of

temporalis

CLINICAL FEATURES

LOCATIONLOCATION : No external evidence Intraorally anterior

bulging of soft palate

SIGNSSIGNS : Deviation of tongue to affected side

SYMPTOMSSYMPTOMS : Severe trismus & Dysphagia

LUDWIG’S ANGINA

•FIRST DESCRIPTION IN 1836 BY DR.VON LUDWIG

DEFINITION

ARCHER: IT’S A BILATERAL, ACUTE, RAPIDLY SPREADING, SEPTIC, INFLAMMATORY, INDURATED, WOODEN HARD CELLULITIS OF FLOOR OF MOUTH

SIGNS AND SYMPTOMS

•MASSIVE,FIRM,HARD BOARD LIKE,BRAWNY NON PITTING SWELLING OF NECK EXTENDING DOWN TO CLAVICLE•OPEN MOUTH•DRIBBLING OF SALIVA•RAISED FLOOR OF MAOTH•SHINY MUCOSA•WHITE COLLAR APPEARANCE•STIFF TONGUE TOUCHING PALATE•DYSPHAGIA, DYSPNOEA•EDEMA OF GLOTTIS

• MOST IMPORTANT COMPLICATION OF SPACE INFECTIONS

• INCLUDES SUBMANDIBULAR, SUBMENTAL & SUBLINGUAL SPACES BILATERALLY.

•AIR WAY OBSTRUCTIONAIR WAY OBSTRUCTION

MANAGEMENT OF MANAGEMENT OF FACIAL SPACE FACIAL SPACE INFECTIONSINFECTIONS

PROPER HISTORY TAKING , EXAMINATION & INVESTIGATION

MEDICAL TREATMENT

• ANTIBIOTICS & ANALGESICS»Penicillin»Amoxicillin»Ornidazole»cephalosporin

SUPPORTIVE THERAPY

• Adequate hydration• Rich nutritional supplements• Rx of pre existing disease

EXTRACTION

•Extraction of offending tooth

INCISION & DRAINAGE

• Surgical evacuation of pus is necessary for 2 reasons; To prevent further burrowing of purulent mass in an attempt to spontaneous evacuation & to avoid dreaded complications like erosion of major vessels

TECHNIQUETECHNIQUE• Preparation of skinPreparation of skin – Aseptic manner

prepared area is draped with sterile towels• Local anesthesiaLocal anesthesia• Site of incisionSite of incision – Most dependent part of

abscess than the centre. - This provides dependent

drainage & avoids puckering of skin & excessive scar contracture

- Incision should be in cosmetically & functionally acceptable place

• Blunt dissectionBlunt dissection – After initial sharp

incision through mucosa

- Sinus forceps : gentle poking & opening beaks of instrument till abscess cavity s reached

- Beaks of forceps should be spread parallel to vital structures.

• DissectionDissection - Extended to alveolar

process overlying the roots of involved tooth i.e.; the source of infection.

• AN INFECTED TOOTH SHOULD ALWAS BE GIVEN DUE IMPORTANCE TO PREVENT THE ABOVE FURTHER COMPLICATIONS !!!!!!

REFERENCES

• Text book of Oral medicine- ANIL GHOM

• Textbook of Oral Pathology – Shaffers

• Textbook of oral surgery –BALAJI• Textbook of Anatomy –

CUNNIGHAM• Google images