ORAL AND MAXILLOFACIAL ORAL AND MAXILLOFACIAL INFECTIONSINFECTIONS

BHARATH REDDY .MBHARATH REDDY .M

INTRODUCTIONINTRODUCTION Oral and maxillofacial infections are commonly Oral and maxillofacial infections are commonly

caused by teeth they are referred as caused by teeth they are referred as odontogenic infections.odontogenic infections.

The etiological agents may be bacteria viruses or The etiological agents may be bacteria viruses or fungi.fungi.

The infection may spread directly from the tooth The infection may spread directly from the tooth or secondary infections of cyst or tumours or or secondary infections of cyst or tumours or infection of surgical wound or by contaminated infection of surgical wound or by contaminated needles.needles.

CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

There are three stages in progression of acute There are three stages in progression of acute odontogenic infections odontogenic infections

Stage 1Stage 1 Most infections are odontogenic in origin.They may Most infections are odontogenic in origin.They may

be periapical or periodontal or pricoronal infection of be periapical or periodontal or pricoronal infection of tooth.tooth.

Patient may be asymptomatic.Patient may be asymptomatic.Stage 2Stage 2 When the infection is still confined with in the When the infection is still confined with in the

alveolar bone it is termed as periapical osteitis.Tooth is alveolar bone it is termed as periapical osteitis.Tooth is tender to percussion and frequently extruded from the tender to percussion and frequently extruded from the socket.socket.

Patient complains of sever pain.Patient complains of sever pain.

Stage 4 When suppuration does occur and the infection localises,the condition is termed as, Absess . With increased pressure it may even perforate the soft tissues and pus discharge may be seen as sinus opening or fistulous tract

Stage 3 Once the infection exits through the bone and the periosteum into the surrounding soft tissue ,an inflammatory oedema occurs . A diffuse swelling develops extraorally which is soft and duffy in consistency called Cellulitis. At this stage no pus formation occurs .

ROOTS OF SPREADS OF INFECTION 1.Spreads by direct continuity 2.Spreads by lymphatics to regional lymph nodes 3.spreads by blood stream

The infection causes formation of pus locally and pus accumulation in :- 1. Tissue spaces 2. Between periosteam and bone 3. Spaces present between muscle layers

Difference bet’n cellulitis and abscessDifference bet’n cellulitis and abscess

CharacteristicCharacteristic CellulitisCellulitisDuration 3-7daysDuration 3-7daysPain severe and generalisedPain severe and generalisedSize largeSize largeLocalization diffuseLocalization diffusePalpation hard exquisitely tenderPalpation hard exquisitely tenderAppearance reddenedAppearance reddenedSkin quality thickenedSkin quality thickenedSurface temp. HotSurface temp. HotLoss of function severeLoss of function severeTissue fluid serosanguineousTissue fluid serosanguineous00 of seriousness severe of seriousness severeBacteria mixedBacteria mixed

AbscessAbscessOver 5 daysOver 5 daysModerate and localisedModerate and localisedSmallSmallCircumscribedCircumscribedFluctuant and tender Fluctuant and tender Peripherally reddenedPeripherally reddenedCentrally underminedCentrally underminedModerately heatedModerately heatedModerately severe Moderately severe PusPusModerateModerateAnaerobicAnaerobic

DIRECTION OF SPREAD OF INFECTION

Infection from any tooth will spread along the path of least resistance.

It can perforate either the buccal cortical plate or lingual / palatal cortical plate depending upon which is thinner.

1.Lower central and lateral incisor teeth If the root of these teeth are extended above the attachment of

mentalis muscle, pus accumulates in the vestibule If the roots extended below the attachment of mentalis muscle pus accumulates within the connective tissue of the muscle and

seen as a extra oral swelling

2. Lower canine Because the muscle attachment ( depressor labii inferioris ,

depressor anguli oris,platysma ) located well below the root apex the periapical infection from this tooth will localise in the oral vestibule

3.Mandibular premolars Infection from premolars after penetrating buccal cortex results in vestibular abscess

4. Mandibular first molar If the root apices are above the oblique line of buccinator

attachment

then it will cause localised infection within the oral vestibule

If the root apices are below the buccinator attachment it can give

rise to

buccal space abscess on lingual aspect mylohyoid muscle is roughly

parallel

to the buccinator muscle . The apices of premolars and first molars

is

always above this muscle which give rise to sublingual space

infection

since there is loose connective tissue interspersed between the

muscle

forming the boundary the infection may spread across the midline in

the opposite side called LUDWIG’S ANGINA

5. Mandibular second molar Perforation below the mylohyoid muscle can give rise to

submandibular

space infection

6. Mandibular third molarPlaced medial to the vertical plane of ramus .therefore its apex is

more closer to lingual than the buccal cortical plate

In mesio angularly or horizontaly positioned tooth the infection will

tend to spread beyond the posterior extend of the mylohyoid muscle

localizing in the pterygomandibular space

Pericoronitis can give rise to submassetric space infection

INFECTION FROM UPPER TEETH

1. The infection from C .I , L.I may be confined in the buccal vestibule

by orbicularis oris and dense subcutaneous tissue of base of the nose

2. Canine The infection from this tooth will exit from the bone on the labial aspect the levator anguli oris muscle than determines whether the infection will be localised within the vestibule or infection will spread in the canine space 3. Maxillary premolars Muscle attachment of zygomaticus major,zygomaticus minor & levator labii superioris will tend to localised the infection within the oral vestibule or may give canine space infection. 4. Maxillary molars Periapical infection from the upper molars usually perforate the buccal cortex . The attachment of buccinator will determines that the infection weather localised intraorally or spreads extra orally.

Secondary sites of spread of odontogenic infection

Facial spaces: These areas are either clefts ( potential spaces between

facial layers ) or compartment containing connective tissue &

various anatomic tooth structures they are not voids in the

tissues .

They are not voids in the tissues

These are not present in healthy people but become filled

during infections

When filled with loose areolar tisses , it is called clefts

CLASSIFICATION ACCORDING TO TOPAZIAN: 1.Face buccal canine masticatory massetric pterygoid zygomatico temporal parotid

2.Suprahyoid sublingual submandibular sub maxillary sub mental lateral pharyngeal (pharyngo maxillary ) peritonsillar3. Infrahyoid anterovisceral (pretracheal)

4. Spaces of total neck retropharyngeal danger space spaces of carotid sheath

CLASSIFICATION BY PETERSON

PRIMARY MAXILLARY SPACES canine buccal infratemporal

PRIMARY MANDIBULAR SPACES submental buccal submandibular sublingualSECONDARY FACIAL SPACES massetric pterygomandibular superficial and deep

temporal lateral pharyngeal retropharyngeal prevertebral

SPACES ASSOCIATED WITH THE UPPER JAW 1. CANINE SPACE -- potential space present on the anterior surface of the maxilla between bone and canine fossa musculature

BOUNDARIES –Superiorly - limited by levator anguli oris and levator labii superioris Inferiorly - limited by orbicularis orisAnteriorly - lateral wall of nosePosteriorly - communicates with buccal space

INFECTION - spreads from long canine root or upper first premolar root CONTENTS - Infraorbital nerve CLINICAL FEATURES – Swelling of the affected side upper lip , cheek upto the medial canthus of eye Obliteration of naso labial fold Drooping of angle of the mouth Oedema of lower eyelid

2.SUBPERIOSTEAL ABSCESS OF PALATE – Palate is covered by tightly adherent

mucoperiosteum Pus tends to accumulate between the

periosteum and bone

CLINICAL FEATURES – Circumscribed , fluctuant swelling confined to

one side of the palate May not discharge spontaneously Doesn’t cross the midline

INFECTION – From upper lateral incisors Palatal pocket in premolars and molars Infection of palatal root of upper molar

3. BUCCAL SPACE – BOUNDARIES – Medially - buccinator muscle and buccopharyngeal fascia Laterally - skin of cheek and subcutanous tissue Anteriorly - posterior border of zygomaticus major above and depressor anguli oris below Posteriorly - anterior edge of masseter muscle Superiorly - zygomatic arch Inferiorly - lower border of mandible

CONTENTS – buccal fat pad parotid duct facial artery SPREAD OF INFECTION – through maxillary and mandibular molars

4.INFRA TEMPORAL SPACE upper extremities of pterygomandibular space BOUNDARIES- Laterally- ramus of the mandible temporalis muscle temporal fascia Medially- lateral pterygoid plate,inferior portion of lateral ptrygoid muscle & lateral pharyngeal wall Superiorlly-infra temporal surface of greater wing of sphenoid bone Inferiorlly- lower head of lateral pterygoid muscle Anteriorlly-infra temporal surface of maxilla,posterior surface of zygomatic bone CONTENTS- ORIGIN OF PTERYGOID MUSCLE PTERYGOID VENOUS PLEXUS

INFECTION- FROM UPPER MOLARS CONTAMINATED NEEDLE DURING PSA BLOCK CLINICAL FEATURES- SEVERE TRISMUS BULDGING OF TEMPORALIS MUSCLE THIS SITUATION IS DANGEROUS DUE TO THE COMMUNICATION OF PTERYGOID VENOUS PLEXUS WITH CAVERNOUS SINOUS THROUGH EMMISSORY VEINS.

SPACES ASSOCIATED WITH LOWER JAW –SUBMENTAL SPACE - POTENTIAL SPACE PRESENT JUST BELOW THE CHIN REGION ON THE MEDIAL SURFACE OF THE MANDIBLE BOUNDARIES SUPERIORLY :– MYLOHYOID MUSCLE INFERIORLY – INVESTING LAYER OF DEEP CERVICA FASCIA, PLETYSMA,SUPERFACIAL FACIA,SKIN LATERALLY – LOWER BORDER OF THE MANDIBLE ANTERIORLY BELLY OF DIAGESTRIC MUSCLE

CONTENTS: -- SUBMENTAL LYMPH NODES -- ADIPOSE TISSUEINFECTION : -- FROM LOWER ANTERIOR TEETH,LOWER LIP,SKIN OF THE CHIN , TIP OF THE TONGUE,ANTERIOR PART OF THE FLOOR OF THE MOUTH & SUBLINGUAL TISSUE CLINICAL FEATURES: FIRM CIRCUMSCRIBED SWELLING BENEATH THE TOUNGE DISCOMFORT & DIFFICULTY IN SWALLOWING

SUB MANDIBULAR SPACE INFECTION POTETIAL SPACE PRESENT ON THE MEDIAL SURFACE OF THE POSTERIOR ASPECT OF THE MANDIBLE.

BOUNDRIES: LATERALLY--- SKIN --- SUPERFECIAL FASCIA -- PLYTISMA -- DEEP FASCIA

MEDIALLY : -- MYLOHYOID MUSCLE -- HYOGLOSSUS MUSCLE -- STYLOGLOSSUS MUSCLE INFERIORLY: --ANTERIOR & POSTERIOR BELLY OF DIAGASTRIC

SUPERIORLY: --MEDIAL ASPECT OF MYLOHYIODANTERIORLY: --MYLOHYIOD SPACEPOSTERIORLY: --HYIOD BONE

CONTENTS: --SUBMANDIBULAR SALIVARY GLAND & LYMPH NODE --FACIAL ARTERY --PROXIMAL PART OF WHARTON’S DUCT --LINGUAL & HYPOGLOSSAL NERVE

INFECTION: -- INFECTED LOWER MOLAR APICES PRESENT BELOW THE MYLOHYOID INSERTION -- THE LOWER TEETH ,MAXILLARY SINUS,UPPER MOLARS,C MIDDLE THIRD OF TONGUE & FLOOR OF THE MOUTH DRAIN INTO SUBMANDIBULAR LYMPH NODE

CLINICAL FEATURES: --SWELLING WHICH IS SOFT& BRAWNY EXTRA ORALLY --ASSOCIATED WITH LOWER MOLAR INFECTION SUBLINGUAL SPACE ::

--POTENTIAL SPACE PRESENT IN THE ANTERIOR PART OF THE FLOOR OF THE MOUTH

BOUNDARIES: ANTERIORLY & LATERALLY-- MEDIAL SURFACE OF THE MIDLINE MANDIBLE & BODY OF THE MANDIBLE SUPERIORLY—SUBLINSGUAL MUCOSA,MYLOHYIOD INFERIORLY– MYLOHYIOD MUSCLE POSTERIORLY– HYIOD BONE MEDIALLY– GENIOGLOSSUS,GENIOHYIOD,STYLOGLOSSUS MUSCLE

ONLY LOOSE CONNECTIVE TISSUE SEPERATES RIGHT & LEFT SUBLINGUAL SPACE

INFECTION MAY COME FROM LOWER ANTERIORS LOWER PREMOLARS LOWER FRIST MOLARS

CLINICAL FEATURES:-- TONGUE IS RAISED -- FIRM PAINFUL SWELLING IN THE ANTERIOR PART OF THE FLOOR OF THE MOUTH-- SWELLING HAS SHINY GELETINOUS APPEARANCE -- PAIN & DISCOMFORT ON SWELLING -- ENLARGED SUBMENTAL & SUBMANDIBULAR LYMPH NODES

LUDWIG’S ANGINA::

DEFINITION– IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY & OF THE SUBMENTALIS SPACE.

-- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN 1836 ETIOLOGY: 1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION OF A LOWER THIRD MOLAR 2. TRAUMATIC INJURIES & INFECTED LESIONS 3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS MAY MENIFEST AS LUDWIG’S ANGINA 4. CYSTS OR TUMORS IN THIRD MOLAR REGION PETHOLOGY: 1. INFECTION FROM LOWER THIRD MOLAR REACHES THE SUBMANDIBULAR SPACES 2. FROM HERE INFECTION SPREADS ALONG THE SUMANDIBULAR SALIVARY GLANDS ABOVE THE MYLOHYIOD MUSCLE. TO REACH THE SUBLINGUAL SPACE

FROM ONE SIDE OF THE SUBLINGUAL SPCE IT MOVES ACROSS THE GENIOGLOSSUS MUSCLE AND REACHES THE SUBLINGUAL SPACES ON OTHERSIDE IT THEN CROSS ONCE THE MYLOHYIOD MUSCLE & REACH THE OPPOSITE SIDE SUBMANDIBULAR SPACE.

SUBMENTAL SPACE GET INVOLVED VIA LYMPHATICSSINCE IT IS CELLULITIS IT SPREADS RAPIDLY ALONG THE FACIAL AND TISSUE PLANES

IT SPREADS IN THE TONGUE POSTERIORLY ALONG THE COURSE OF SUBLINGUAL ARTERY IN THE CLEFT BETWEEN THE GENIOGLOSSUS AND GENIOHYOID MUSCLE PRODUCING OEDEMA OF LARYNGEAL INLET

FROM SUBMANDIBULAR SPACE IT CAN PASS ALONG THE INVESTING LAYER OF DEEP CERVICAL FASCIA ALONG THE ANTERIOR ASPECT OF THE NECK TO THE CLAVICLE AND THE MEDIASTINUM

CLINICAL FEATURES - SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA , DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR

EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED SWELLING SKIN OVER THE SWELLING APPEARS ERYTHMATOUS AND STRETCHED SWELLING IS TENDER WITH LOCAL RISE IN TEMPERATURE

Difficulty in closing the mouth and drooling of salivaRespiratory distress

INTRA ORAL FEATURES – Trismus , floor of the mouth is raised , tongue raised upwards , increased salivation

MANAGEMENT - 1.Airway maintainence- Intubation is contraindicated perforation may lead to aspiration of pus Tracheostomy and Cricothyroidectomy is advisable

2. Parentral antibiotics - Penicillin antibiotic of choice Amoxycillin + Cloxacillin Metronidazole in anaerobic infection 3.Surgical decompression – performed under L.A Decompression improves vascularity and potentiates the action of antibiotics Bilateral submandibular incision with a midline submental incision pus should be drained A drain is inserted and loose dressing is placed

4.Hydration of the patient – It is necessary to put the pt on i.v. fluids 5. Removal of cause - The offending tooth is removed

COMPLICATIONS – Death due to airway compromise septicemia aspiration of pus mediastinitis carotid blow out

Masticatory space –

Potential space present around the muscle of mastication a) SUBMASSETRIC SPACE

Present between the three layers of masseter muscles

BOUNDARIES – Superiorly - zygomatic arch Lateraly - masseter muscle Medially - lateral aspect of the mandibular ramus Inferiorly - attachment of masseter onto the lower border of the mandible

INFECTION can spread from lower third molar

CLINICAL FEATURES – external facial swelling confined to masseter muscle complete trismus acutely tender

b) Pterygomandibular space – BOUNDARIES - Medially – medial pterygoid muscle Laterally - medial surface of the ramus of the mandible Superiorly – lateral pterygoid Posteriorly – deep lobe of the parotid gland Inferiorly - attachment of the medial pterygoid to the mandible Anteriorly – pteygomandibular raphe CONTENTS – Inferior alveolar nerve and vessels Lingual nerve Loose areolar tissue INFECTION FROM LOWER THIRD MOLAR CLINICAL FEATURES – Trismus Intra oral swelling in the medial aspect of the ramus of the mandible

c). Temporal Space Divided into Superficial temporal space Deep temporal space Superficial temporal space is between superficial temporal fascia & lateral aspect of temporalis muscle Deep temporal space is present between the medial surface of the temporalis muscle & the periosteum of the temporal bone Contents: - vessels supplying the temporalis muscle

Clinical features: - swelling confined to the shape of the muscle extending from the lateral orbital rim, above the zygomatic arch, covering of the lateral aspect

d).Lateral pharyngeal space

Synonyms Parapharnygeal space Pharyngomaxillary space

Boundaries potential cone shaped space base is uppermost at the base of the skull apex is at the hyoid bone Clinical features - Pain on swallowing - Trismus - Tonsils & lateral pharyngeal wall are pushed to the midline - No extra oral swelling - It may lead to thrombophlebitis of internal jugular vein or may cause carotid blowout

Peri tonsillar abscess: Infection in connective tissue bed of the faucial tonsil And can also be from the infection of the third molarClinical featuresAcute pain in throat on the affected side which radiates to the earDysphagia TrismusAwkward speech described as hot potato speechFoul breathBulge in the soft palate on the affected site

SPACES IN THE NECKRetropharyngeal Danger space and prevertebral spaces all lie between deep cervical Fascia that surrounds the pharynx and oesophagus and vertebral spine with its muscle attachments posteriorly

Principles of management of odontogenic infectionsDetermine the severity of

infection

Evaluate host defense

Decide on the setting of care

Treat surgically

Support medically

Choose and prescribe antibiotic

therapy

Administer the antibiotic

properly

Evaluate the patient frequently1.Determine the severty of infection A careful history and thorough physical examination to determine the anatomic location, rate of progression and the potential for airway compromise of a given infection.

2.Evaluate host defenses

Immune system compromise:

diabetes,steroid therapy,organ transplant,malignancy

chemotherapy,chronic renal disease,malnutrition,

alcoholism,end –stage AIDS

Systemic reserve The host response to severe infection can place a sever physiologic load on the body.fever can increase fluid losses and calori requirements.

A prolonged fever may cause dehydration , which can therefore decrease cardiovascular resevers and deplete glycogen stores shifting the body metabolism to a catabolic state.

3. Decide on the setting of care Indications for hospital care temp.>101 F dehydration,infection in moderate to severe anatomic spaces threat to airway or vital structures need for genral anesthesia need for in patient controll of systemic disease

4.Treat surgicallyAirway security Surgical drainage:drainage of pus and removal of cause An intra oral incision should be made through the mucous membrane , parallel to the surface of alveolar bone

Hilton s method of incision and drainage Method of incision and drainage esp. in head and neck rigion. Technique: 1.Anesthesia is achieved by regional blocking or by topical anesthesia by ethylchloride spray. 2.Ethylchoride is sprayed on the most flectuant part until frosting occurs. 3.The incision is made through skin , superficial fascia ,muscle, deep fascia parallel to the main nerves & vessels in closed proximity to that area. 4.A sinus forceps is inserted through the incision towards the area of pus collection .the forceps is closed when it is entered into the tissues. Once it is inside ,it is gently opened up in a direction parallel to the important structures . 5.The pus collected in that area flows along the beaks of the sinus forceps. 6. The drain is secured to the skin by sutures .a loose dressing is placed on the wound