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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