Oral Surgery FOURTH GRADE/ 2020-2021

MANAGEMENT OF ODONTOGENIC INFECTIONS

Dr. NOOR SAHBAN

Fascial Space Infection

Fascial spaces are fascia-lined tissue compartments, filled with loose, areolar connective
tissue (serves to cushion the muscles, vessels, nerves, glands, and other structures that
it surrounds and to allow relative movement between these structures). They are
potential spaces that can become inflamed when invaded by microorganisms.
During an infection, this cushioning and lubricating tissue has the potential to become
greatly edematous in response to the exudation of tissue fluid and then to become
indurated when polymorphonuclear leukocytes, lymphocytes, and macrophages migrate
from the vascular space into the infected interstitial spaces. Ultimately, liquefactive
necrosis of white blood cells and this connective tissue leads to abscess formation, and
spontaneous or surgical drainage typically leads to resolution.
Based on the relationship between the point at which the infection erodes through
alveolar bone and surrounding muscle attachments, infections arising from any
maxillary or mandibular tooth can cause primary or secondary space infections.

Classification of Fascial Spaces:

Based on mode of involvement, facial spaces divided into:
Primary spaces (spread of infection directly from the oral cavity):
 Primary maxillary: Labial vestibular, Infratorbital (canine), Buccal,
Infratemporal.
 Primary mandibular: Buccal, Perimandibular (submental, sublingual,
and submandibular).
Secondary spaces (spread of infection from the primary spaces):
 Secondary maxillary: Periorbital and orbital spaces, Cavernous sinus.
 Secondary mandibular: Masticator spaces (submasseteric,
pterygomandibular, superficial & deep temporal), Deep cervical fascial
spaces (Lateral pharyngeal, Retropharyngeal, Parotid, Prevertebral).

Primary maxillary spaces

1. Labial vestibular space:
Location: Between the vestibular mucosa and the muscles of facial expression.
Etiology: Maxillary central and canine usually have their roots in close
approximation to the buccal cortex of the bone.
Connections: Canine and Buccal spaces.
Signs and symptoms: Vestibular fluctuation and swelling.
Surgical approach: Vestibular incision.
Oral Surgery FOURTH GRADE/ 2020-2021

(Labial vestibular space infection)

2. Infraorbital or Canine space:

Location: Between the levator anguli oris and the levator labii superioris
muscles.
Content: Angular artery and vein, infraorbital nerve
Etiology: Maxillary canine (The canine root is often sufficiently long to allow
erosion to occur through the alveolar bone that is superior to the origin of the
levator anguli oris and below the origin of the levator labii superioris muscle).
Connections: Vestibular and Buccal spaces.
Signs and symptoms: Edema spreads towards the medial canthus of the eye,
lower eyelid, and side of the nose as far as the corner of the mouth. There is also
obliteration of the nasolabial fold, and somewhat of the mucolabial fold.
spontaneous drainage of infections of this space commonly occurs near the
medial or the lateral canthus of the eye because the path of least resistance is to
either side of the levator labii superioris muscle, which attaches along the center
of the inferior orbital rim.
Surgical approach: Vestibular incision.

(Infraorbital or Canine space infection)

Oral Surgery FOURTH GRADE/ 2020-2021

3. Buccal space:
Location/ boundaries: The overlying skin of the face on the lateral aspect, the
buccinator muscle on the medial aspect, the zygomatic arch from the superior
aspect and the lower border of the mandible from the inferior aspect.
Content: Parotid duct, anterior facial artery and vein, transverse facial artery and
vein, buccal fat pad.
Etiology: Infection from maxillary teeth through the bone superior to the
attachment of the buccinator on the alveolar process of the maxilla. Posterior
maxillary teeth (most commonly molars and rarely premolars) cause most buccal
space infections.
Connections: Vestibular space, Infraorbital (canine) space, Periorbital space,
Superficial temporal space, Infratemporal space, Pterygomandibular space.
Signs and symptoms: Swelling below the zygomatic arch and above the inferior
border of the mandible.
Surgical approach: Access to the buccal space is usually intraoral (vestibular
incision) for three main reasons: the abscess fluctuates intraorally in the majority
of cases, avoid injuring the facial nerve, for esthetic reasons.
An extraoral incision (submandibular incision: approximately 1-2 cm below and
parallel to the inferior border of the mandible) is made when intraoral access
would not ensure adequate drainage, or when the pus is deep inside the space.

(Buccal space infection)

Oral Surgery FOURTH GRADE/ 2020-2021

4. Infratemporal space:
Location/ boundaries: Lies posterior to the maxilla, bounded medially by the
lateral pterygoid plate of the sphenoid bone and superiorly by the base of the
skull. Laterally, the infratemporal space is continuous with the deep temporal
space.
Content: Branches of the internal maxillary artery and the pterygoid venous
plexus.
Etiology: The infratemporal space is rarely infected, but when it is, the cause is
usually an infection of the maxillary third molar. Also infection may spread from
the pterygomandibular space.
Connections: Deep temporal, Ptyregomandibular, Buccal and Orbital spaces.
Signs and symptoms: Trismus and pain during opening of the mouth with lateral
deviation towards the affected side, edema at the region anterior to the ear, which
extends above the zygomatic arch, as well as edema of the eyelids.
Surgical approach: Intraoral (vestibular incision) or Extraoral (The incision is
performed on the skin in a superior direction, and extends approximately 3 cm,
starting from the angle created by the junction of the frontal and temporal
processes of the zygomatic bone).

(Infratemporal space infection)

Oral Surgery FOURTH GRADE/ 2020-2021

Secondary maxillary spaces

1. Periorbital or Orbital cellulitis:
Periorbital cellulitis is an infection of the eyelid and the periorbital soft tissues;
orbital cellulitis is an infection of the eyeball and tissues around it. Rarely occurs
as the result of odontogenic infection.
The presentation is typical: redness and swelling of the eyelids and involvement
of the vascular and neural components of the orbit. This is a serious infection and
requires aggressive medical and surgical intervention from an oral-maxillofacial
surgeon and sometimes from other specialists.

(Periorbital cellulitis) (Orbital cellulitis)

2. Cavernous sinus thrombosis:

A serious, life-threatening infection that requires aggressive medical and surgical
care and has a high mortality even today. Intravascular inflammation caused by
the invading bacteria stimulates the clotting pathways, lead to the formation of
thrombus in the cavernous sinus and communicating branches. Cavernous sinus
thrombosis rarely occurs due to an infected tooth.
Spread of infection: Because the veins of the face and the orbit do not have
valves, blood-borne infections may pass superiorly or inferiorly along their
course reaching dangerous structures such as cavernous sinus.
The anterior route to the cavernous sinus:
Infections erode into superior or inferior ophthalmic vein through the
superior orbital fissure and extend directly into the cavernous sinus.
The posterior route to the cavernous sinus:
The emissary veins from the pterygoid plexus pass through foramina in the
base of the skull and reach the cavernous sinus.
Oral Surgery FOURTH GRADE/ 2020-2021

Content: the cranial nerves Oculomotor III, Trochlear IV, ophthalmic maxillary
branches of the trigeminal nerves V1, and Abducens VI, which, accompanied by
the horizontal segment of the internal carotid artery.
Symptoms of the eyes include periorbital swelling and redness, ptosis, proptosis,
chemosis, external opthaloplegia and decreased visual acuity. The symptoms start
in one eye then spread to the other eye within 24-48 hrs.
Other symptoms: fever, headache, seizures.
Complications: meningitis, sepsis

(Hematogenous spread of infection from the jaw to the cavernous sinus)

Primary mandibular spaces

1. Buccal space:
Location/ boundaries: The overlying skin of the face on the lateral aspect, the
buccinator muscle on the medial aspect, the zygomatic arch from the superior
aspect and the lower border of the mandible from the inferior aspect.
Content: Parotid duct, anterior facial artery and vein, transverse facial artery and
vein, buccal fat pad.
Etiology: Infection arising from a mandibular posterior tooth perforates the
buccal cortical bone and the periosteum inferior to the attachment of the
buccinator muscle.
Connections: Vestibular space, Infraorbital (canine) space, Periorbital space
Superficial temporal space, Infratemporal space, Pterygomandibular space.
Signs and symptoms: Swelling below the zygomatic arch and above the inferior
border of the mandible.
Surgical approach: intraoral and extraoral approaches (discussed with the
maxillary spaces).
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2. Perimandibular spaces: (submental, sublingual, and submandibular spaces):

a) Submental space:
Location: Laterally and on both sides by the anterior belly of the digastric
muscle, the mylohyoid muscle superiorly and the overlying fascia inferiorly.
Content: Anterior jugular vein and the submental lymph nodes.
Etiology: Isolated submental space infections are rare, caused by infections of
the mandibular incisors. Also, spread of infection from submandibular space,
which can easily pass around the anterior belly of the digastric muscle and enter
the submental space.
Connections: Submandibular space.
Signs and symptoms: Indurated and painful submental edema, which later may
fluctuate.
Surgical approach: Extraoral approach (incision on the skin, beneath the chin,
in a horizontal direction and parallel to the anterior border of the chin).

(Submental space infection)

b) Sublingual space:
Location: Between the oral mucosa of the floor of the mouth superiorly and the
mylohyoid muscle inferiorly. Anteriorly and laterally by the inner surface of the
body of the mandible and medially by the midline genioglossus/geniohyoid
muscle complex. The posterior border of the sublingual space is open, and
therefore, it freely communicates with the submandibular space.
Content: Submandibular duct (Wharton’s duct), the sublingual gland, the
sublingual and lingual nerve, terminal branches of the lingual artery, and part of
the submandibular gland.
Etiology: The factor that determines whether the infection is submandibular or
sublingual is the attachment of the mylohyoid muscle on the mylohyoid ridge of
the medial aspect of the mandible.
Oral Surgery FOURTH GRADE/ 2020-2021

If the infection erodes through the medial aspect of the mandible above this line,
the infection will be in the sublingual space. This is most commonly seen with
premolars and the first molar.
If the infection erodes through the medial aspect of the mandible inferior to the
mylohyoid line, the submandibular space will be involved. The mandibular third
molar is the tooth that most commonly involves the submandibular space directly.
The second molar may involve the sublingual or submandibular space, depending
on the length of individual roots.
Connections: Submandibular and Lateral Pharyngeal spaces.
Signs and symptoms: Swelling of the mucosa of the floor of the mouth, resulting
in elevation of the tongue towards the palate and laterally (little or no extraoral)
swelling. The mandibular lingual sulcus is obliterated and the mucosa presents a
bluish tinge. The patient speaks with difficulty, because of the edema, and
movements of the tongue are painful.
Surgical approach: Intraoral approach (incision is lateral and along Wharton’s
duct and the lingual nerve) or extraoral approach (submandibular incision:
approximately 1-2 cm below and parallel to the inferior border of the mandible).

(Sublingual space infection- above the attachment of mylohyoid muscle)

c) Submandibular space:
Location: Lies between the mylohyoid muscle and the overlying superficial layer
of the deep cervical fascia. Bounded laterally by the inferior border of the body
of the mandible, medially by the anterior belly of the digastric muscle, posteriorly
by the stylohyoid ligament and the posterior belly of the digastric muscle. The
posterior extent of the submandibular space communicates with the deep fascial
spaces of the neck.
Content: Facial artery and vein, the submandibular salivary gland and the
submandibular lymph nodes.
Etiology: Infection of this space may originate from the mandibular third molars
(and second molar if their apices lies beneath the attachment of the mylohyoid
Oral Surgery FOURTH GRADE/ 2020-2021

muscle). It may also be the result of spread of infection from the sublingual or
submental spaces.
Connections: Submental, Sublingual, Lateral pharyngeal and Buccal spaces.
Signs and symptoms: Moderate swelling at the submandibular area, which
spreads, creating greater edema that is indurated and redness of the overlying
skin. In addition, the angle of the mandible is obliterated, while pain during
palpation and moderate trismus due to involvement of the medial pterygoid
muscle are observed as well.
Surgical approach: Extraoral approach (submandibular incision: approximately
1-2 cm below and parallel to the inferior border of the mandible).

(Submandibular space infection -below the attachment of mylohyoid muscle-)

 Ludwig’s angina:
When the perimandibular spaces (submandibular, sublingual, and submental) are
bilaterally involved in an infection, it is known as Ludwig’s angina. The most
common cause of Ludwig’s angina is an odontogenic infection.
This infection is a rapidly spreading cellulitis that can obstruct the airway and
commonly spreads posteriorly to the deep fascial spaces of the neck.
Severe swelling is almost always seen, with elevation and displacement of the
tongue, and a tense, hard, bilateral induration of the submandibular region superior
to the hyoid bone. The patient usually has trismus, drooling, and difficulty
swallowing and sometimes breathing. The patient often experiences severe anxiety
over the inability to swallow and maintain an airway.
This infection may progress with alarming speed and, thus, may produce upper
airway obstruction that often leads to death. Management with a protocol of initially
securing the airway and then performing early and aggressive I&D procedures.
Antibiotic therapy plays only a supportive role in the management of severe
odontogenic infections.
 Oral Surgery FOURTH GRADE/ 2020-2021

(Ludwig’s angina)

Secondary mandibular spaces

1. The masticator space:
It is formed by the splitting the superficial layer of the deep cervical fascia to surround
the muscles of mastication. Within this space, four compartments that exist. These four
compartments clinically behave as separate spaces because, in most cases, only one
compartment of the masticator space becomes infected. However, in severe or
longstanding masticator space infections can involve all four compartments. These
compartments referred to as separate spaces. They are:

a) Submasseteric space:
Location: Between the masseter muscle laterally and the lateral surface of the
ascending ramus of the mandible medially. The zygomatic arch superiorly and
the lower border of the mandible inferiorly.
Content: Masseteric artery and vein.
Etiology: Infection most commonly as the result of spread from the buccal space
or from soft tissue infection around the mandibular third molar (pericoronitis).
Occasionally, an infected mandibular angle fracture causes a submasseteric space
infection.
Connections: Buccal space, parotid space and the rest of the masticator space.
Signs and symptoms: The masseter muscle becomes inflamed and swollen. The
patient also has moderate to severe trismus (due to the involvement of the
masseter muscle).
Surgical approach: Intraoral approach (incision begins at the coronoid process
and runs along the anterior border of the ramus towards the mucobuccal fold as
far as the second molar).
Oral Surgery FOURTH GRADE/ 2020-2021

Submasseteric space

b) Pterygomandibular space:
It is the space into which local anesthetic solution is injected during inferior
alveolar nerve block.
Location: Between the medial pterygoid muscle medially and the medial surface
of the ascending ramus laterally.
Content: Mandibular division of trigeminal nerve, Inferior alveolar artery and
vein.
Etiology: The mandibular third molar is the most commonly associated tooth.
Also may caused by needle track infection from inferior alveolar nerve block.
Connections: Buccal, Lateral pharyngeal, Submasseteric, Deep temporal,
Parotid, and Peritonsillar spaces.
Signs and symptoms: Little or no facial swelling is observed; however, the
patient almost always has significant trismus. Therefore, trismus without swelling
is a valuable diagnostic clue for pterygomandibular space infection.
Surgical approach: Intraoral approach (vertical incision, lateral and parallel to
the pterygomandibular raphe) or extraoral submandibular approach.

(Pterygomandibular space infection)

Oral Surgery FOURTH GRADE/ 2020-2021

c) Superficial temporal space:

Location: Bounded laterally by the temporal fascia and medially by the
temporalis muscle.
Content: Temporal fat pad, Temporal branch of facial nerve.
Etiology: Rarely become infected and usually only in severe infections due to
spread of infection from the infratemporal space, with which it communicates.
Connections: Buccal and Deep temporal spaces.
Signs and symptoms: Swelling over the temporal region, superior to the
zygomatic arch and posterior to the lateral orbital rim.
Surgical approach: Extraoral approach (incision made horizontally, at the
margin of the scalp hair and approximately 3 cm above the zygomatic arch).

d) Deep temporal space:

Location: Between the medial surface of the temporalis muscle and the temporal
bone.
Content: Mandibular division of trigeminal nerve, Skull base foramina.
Etiology: Rarely become infected and usually only in severe infections due to
spread of infection from the infratemporal space, with which it communicates.
Connections: Infratemporal space, Superficial temporal space, Inferior petrosal
sinus.
Signs and symptoms: Swelling over the temporal region, superior to the
zygomatic arch and posterior to the lateral orbital rim.
Surgical approach: Extraoral approach (incision made horizontally, at the
margin of the scalp hair and approximately 3 cm above the zygomatic arch).

(Superficial and Deep Temporal spaces boundaries)

 Oral Surgery FOURTH GRADE/ 2020-2021

2. Deep cervical fascial spaces:

Extension of odontogenic infections beyond the spaces described above is an
uncommon occurrence. However, when it does happen, involvement of the deep
cervical spaces may have serious life threatening sequelae. Infection of the deep fascial
spaces of the neck can compress, deviate, or completely obstruct the airway, invade vital
structures such as the major vessels, and allow extension of the infection into the
mediastinum and the vital structures it contains. These spaces are:

a) Lateral pharyngeal space:

Location: Extends from the base of the skull at the sphenoid bone superiorly to
the hyoid bone inferiorly. The space is bounded laterally by the medial pterygoid
muscle and the ramus of the mandible and medially by the superior pharyngeal
constrictor muscle and bounded anteriorly by the pterygomandibular raphe and
extends posteriorly to the prevertebral fascia.
Content: The styloid process and associated muscles and fascia divide the lateral
pharyngeal space into an anterior compartment, which contains primarily loose
connective tissue, and a posterior compartment, which contains the carotid sheath
and cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal).
Etiology: Lower third molars, Tonsils, Infection in neighboring spaces.
Connections: Pterygomandibular, Submandibular, Sublingual, Peritonsillar, and
Retropharyngeal spaces.
Signs and symptoms: Trismus (as the result of inflammation of the medial
pterygoid muscle), lateral swelling of the neck (especially between the angle of
the mandible and the sternocleidomastoid muscle), swelling of the lateral
pharyngeal wall causing it to bulge toward the midline, difficulty swallowing and
fever.
Complications: When the lateral pharyngeal space is involved, the odontogenic
infection is severe, may be progressing at a rapid rate, and has a direct effect on
the contents of the space, especially those of the posterior compartment. These
problems include thrombosis of the internal jugular vein, erosion of the carotid
artery or its branches, and interference with cranial nerves IX, X, and XII. Other
serious complication may arises if the infection progresses from the lateral
pharyngeal space to the retropharyngeal space or beyond.
Surgical approach: Extraoral approach (submandibular incision), intraoral
approach (incision in the lateral pharangyal wall)

b) Retropharyngeal space:
Location: Lies behind the soft tissue of the posterior aspect of the pharynx. It is
bounded anteriorly by the pharyngeal constrictor muscles and the retropharyngeal
fascia, posteriorly by the alar fascia, superiorly by the base of the skull and ends
inferiorly by the fusion of alar and prevertebral fascia (between the sixth cervical
(C6) and fourth thoracic (T4) vertebrae).
Oral Surgery FOURTH GRADE/ 2020-2021

Content: Loose connective tissue and lymph nodes.

Etiology: Spread of infection from lateral pharyngeal space.
Connections: Lateral pharyngeal space, mediastinum.
Signs and symptoms:The same symptoms as those present in the lateral
pharyngeal space appear clinically, with even greater difficulty in swallowing
though, due to edema at the posterior wall of the pharynx.
Complication: Obstruction of the upper respiratory tract (due to displacement of
the posterior wall of the pharynx anteriorly), rupture of the abscess and aspiration
of pus into the lungs with asphyxiation and spread of infection into the
mediastinum.
Surgical approach: Drainage through the lateral pharyngeal space.

(Lateral pharyngeal and Retropharyngeal spaces infection)

Oral Surgery FOURTH GRADE/ 2020-2021

c) Parotid Space: ‫لالطالع‬

Location: Bound by the superficial layer of deep cervical fascia. The space
extends from the external auditory canal to the angle of the mandible. It is located
lateral to the carotid and parapharyngeal spaces and posterior to the masticator
space.
Content: Parotid gland and its duct, the external carotid artery, the superficial
temporal and facial artery, the retromandibular vein, the auriculotemporal nerve,
and the facial nerve.
Etiology: spread of infection from lateral pharyngeal, parotitis, and sialadenitis.
Connections: Lateral pharyngeal, Pterygomandibular, Submasseteric space.
Signs and symptoms: Edema of the retromandibular and parotid region, trismus
and difficulty in swallowing and pain mainly during chewing, which radiates to
the ear and temporal region. In certain cases, there is redness of the skin and
subcutaneous fluctuation. Also, a purulent exudatemay be noted from the papilla
of the parotid duct after pressure is applied.
Surgical approach: Extraoral approach (broad incision posterior to the angle of
the mandible).

(Parotid Space infection)

d) Prevertebral space: ‫لالطالع‬

It is rarely involved in odontogenic infections because the prevertebral fascia
fuses with the periosteum of the vertebral bodies
Location: This is a potential space and extends from the skull base to the coccyx.
It is located anterior to the vertebral bodies, behind the prevertebral fascial layer
of the deep layer of deep cervical fascia. Laterally it is limited by the fusion of
the prevertebral fascia with the transverse processes of the vertebral bodies.
Etiology: Infection may be caused by osteomyelitis of the vertebrae, trauma, or
may originate from the cervical or thoracic spine.
Signs and symptoms: The diagnosis is difficult to make. Patients may present
with neck and/or back pain, just fever and/or neurologic dysfunction ranging from
nerve root pain to paralysis. MRI is the imaging modality of choice to assess
epidural or spinal cord involvement.