SURGICAL ANATOMY OF

FASCIAL SPACES

GUIDED BY: PRESENTED BY:

DR GAGAN KHARE DR NASIM
CONTENTS

• DEFINITION • SUPERFICIAL TEMPORAL SPACE

• FASCIA OF HEAD AND NECK • LATERAL PHARYNGEAL SPACE
• CLASSIFICATION OF FASCIAL • RETROPHARYNGEAL SPACE
SPACES • PRETRACHEAL SPACE
• BUCCAL SPACE • CONCLUSION
• INFRAORBITAL SPACE
• SUBMANDIBULAR SPACE
• SUBMENTAL SPACE
• SUBLINGUAL SPACE
• PTERYGOMANDIBULAR SPACE
• SUBMASSETRIC SPACE
• INFRATEMPORAL SPACE
 FASCIAE OF HEAD AND NECK

• Fascia: broad sheets of dense connective tissue whose function is to

separate structures that must pass over each other during
movement, such as muscles and gland, and serve as pathways for the
course of vascular and neural structures.

SUPERFICIAL FASCIA DEEP CERVICAL

FASCIA
SUPERFICIAL FASCIA

• Layer of dense connective tissue that courses deep to the

subcutaneous tissue throughout the entire body.
• Subcutaneous space is defined as tissues lying superficial to
superficial fascia.
DEEP CERVICAL FASCIA

SUPERFICIAL FASCIA
 DEEP CERVICAL FASCIA
B. MIDDLE LAYER
1.Sternohyoid-omohyoid division
A. ANTERIOR LAYER
2.Sternothyroid-thyrohyoid
1. Investing layer
division
2. Parotideomasseteric
3.Visceral division
3.Temporal
a. Buccopharyngeal
b. Pretracheal
c.Retropharyngeal

C. POSTERIOR LAYER
a. Alar Division
b. Prevertebral division
ANTERIOR LAYER

• Superficial or investing layer

• Encircles the neck, splits to surround the SCM and trapezius muscles,
and attaches posteriorly to spinous process of the cervical vertebrae.
• Approaches inf border of mandible and fuses with horizontal ramus
of mandible, splitting to surround muscles of mastication.
• Here it is referred as PAROTIDEOMASSETRIC FASCIA covering the
masseter muscle and splits to surround parotid gland.
• After covering the zygomatic arch, rises superiorly towards
temporalis muscle to form TEMPORAL FASCIA.
• Splits at 2cm above the manubrium of sternum to form the
SUPRASTERNAL SPACE OF BURNS containing only areolar connective
tissue.
MIDDLE LAYER

• Middle layer divided into three divisions.

• The first two are sternohyoid-omohyoid and the
sternothyroid-thyrohyoid divisions.
• Surround the corresponding strap muscles of the neck
between the hyoid bone and the clavicle.
• They must be divided in the mid line in a surgical approach
to the trachea or thyroid gland.
• Not directly involved in head and neck infections because
they do not lie on the major routes that an orofacial
infection may follow to the mediastinum or chest wall.
• The third division of the middle layer is visceral division
which is clinically significant.
• Below the hyoid bone the visceral layer surrounds the
trachea oesophagus and thyroid gland.
• Above the hyoid bone the visceral fascia wraps around the
lateral and posterior side of the pharynx, lying on the
superficial side of pharyngeal constrictor muscle – known as
buccopharyngeal fascia.
POSTERIOR LAYER
• The posterior layer of the deep cervical fascia has two divisions:
1) the alar
2) the prevertebral
• The alar fascia passes through the transverse process of the vertebrae on
either side, posterior to the retropharyngeal fascia.
• The alar fascia fuses with retropharyngeal fascia at a variable level
between 6th cervical(C6) and 4th thoracic (T4)vertebrae.
• This fusion forms the bottom of retropharyngeal space.
• Infection of the retro-pharyngeal space may rupture the alar fascia, thus
entering the danger space , which is continuous with the posterior
mediastinum.
• The prevertebral fascia surround the vertebra and the attached postural
muscles of the neck & back.
• Prevertebral fascia is usually not invaded by infection arising in
maxillofacial regions.
CAROTID SHEATH

• Begins at origin of carotid artery.

• Above the hyoid bone, it lies at the junction of the lateral pharyngeal
and retropharyngeal spaces.
• Terminates at jugular foramen and carotid canal containing IJV,
carotid artery and vagus nerve.
FASCIAL SPACES

• The fascial spaces in head and neck are the potential spaces between
the various layers of fascia normally filled with loose connective
tissue and bounded by anatomical barriers usually of bone, muscle or
fascial layers.
• They are lined areas that can be eroded or distended by purulent
exudate.
• The fascial spaces are always of relevance due to the spread
of odontogenic infections.
• As such, the spaces can also be classified according to their relation
to the upper and lower teeth.
• Infection may directly spread into the space (primary space),
• or must spread via another space (secondary space)
 CLASSIFICATION
OF FASCIAL SPACES
Grodinsky and Holyoke (1938)

SPACE 1:
• Superficial to the superficial fascia and synonyms to
subcutaneous space.
SPACE 2:
• Spaces surrounding the cervical strap muscles.
SPACE 3:
• Between the visceral fascia and the sternothyroid-
thyrohyoid layer anteriorly, the carotid sheath laterally, and
the alar fascia posteriorly.
SPACE 3A:
• Lincoln’s highway
• Carotid sheath
• SPACE 4:
• Also known as danger space, lies between alar &
prevertebral fascia.
SPACE 4A:
• posterior triangle of neck
SPACE 5:
• prevertebral space.
SPACE 5A:
• fascia enclosed by prevertebral fascia
BASED ON MODE OF INVOLVEMENT

DIRECT INVOLVEMENT INDIRECT INVOLVEMENT

PRIMARY SPACES SECONDARY SPACES

MAXILLARY MANDIBULAR MASSETRIC

PTERYGOMANDIBULAR
CANINE SUBMENTAL SUPERFICIAL AND DEEP
BUCCAL BUCCAL TEMPORAL
INFRATEMPOR SUBMANDIBU LATERAL PHARYNGEAL
AL LAR RETROPHARYNGEAL
SUBLINGUAL PREVERTEBRAL
PAROTID
 BASED ON THE CLINICAL SIGNIFICANCE

FACE SUPRAHYOID INFRAHYOID SPACES OF TOTAL

NECK

Buccal Sublingual Anterovisceral Retropharyngeal

Canine Submandibular (pretracheal) Space of carotid
Masticatory (submaxillary/ sheath
Parotid submental)
Pharyngomaxillary
(lateral pharyngeal)
Peritonsillar
 BUCCAL SPACE
BOUNDARIES ANTERIOR : corner of mouth
POSTERIOR: massetor muscle ,
pterygomandibular space
SUPERIOR: maxilla, infraorbital space
INFERIOR: mandible, tissue and skin
SUPERFICIAL/MEDIAL: subcutaneous
DEEP/LATERAL: buccinator muscle

CONTENTS Parotid duct

Ant. Facial artery and vein
Transverse facial artery and vein
Buccal fat pad

NEIGHBORING SPACES Infraorbital

Pterygomandibular
infratemporal
CLINICAL FEATURES

• Maxillary and mandibular premolars and molars.

• ‘Gum boil’ is seen in the vestibule.
• Extraoral swelling is seen extending from lower border of mandible
to the infraorbital margin and from the anterior margin of masseter
muscle to the corner of mouth.
• Sometimes edema of the lower eyelid is seen.
TREATMENT:
• Incision and drainage: Horizontal incison through the oral mucosa of
the cheek in the premolar, molar region.
• If the pus is lateral to the muscle, then the muscle is penetrated with
curved mosquito forceps to enter the buccal space.
• Drain is placed and secured with suture.
INFRAORBITAL SPACE / CANINE SPACE
BOUNDARIES ANTERIOR : nasal cartilages
POSTERIOR: buccal space
SUPERIOR: quadratus labii superioris
muscle
INFERIOR: oral mucosa
SUPERFICIAL/MEDIAL: quadratus labii
superioris muscle
DEEP/LATERAL: levator anguli oris
muscle, maxilla

CONTENTS Infraorbital nerve

Angular artery and vein

NEIGHBORING SPACES Buccal

CLINICAL FEATURES

• Maxillary canines
• Swelling of cheek and upper lip (vestibular abscess).
• Obliteration of nasolabial fold (pus accumulates in canine fossa).
• Drooping of angle of the mouth.
• Edema of lower eyelid; it indicates pointing of abscess below medial
corner.
• Inflammatory enlargement of the upper lip, and the angle of the mouth
is seen to droop.
• Periorbital edema
• Redness and marked tenderness of the facial tissues.
• The offending tooth is mobile and is tender to percussion.
SUBMANDIBULAR SPACE
BOUNDARIES ANTERIOR : ant. belly of digastric
muscle
POSTERIOR: post. belly of digastric
muscle, stylohyoid, stylopharyngeus
SUPERIOR: inf. and med. surfaces of
mandible
INFERIOR: digastric tendon
SUPERFICIAL/MEDIAL: platysma muscle
investing fascia
DEEP/LATERAL: mylohyoid muscle,
hyoglossus, sup constrictor muscles

CONTENTS Submandibular gland

Facial artery and vein
Lymph nodes

NEIGHBORING SPACES Sublingual

Submental
CLINICAL FEATURES

• Mandibular molars
• Firm swelling in submandibular region, below the inferior border of
mandible.
• Generalized constitutional symptoms.
• Some degree of tenderness.
• Redness of overlying skin.
• Intraoral:
(i) Teeth are sensitive to percussion.
(ii) Teeth are mobile,
(iii) Dysphagia, and
(iv) Moderate trismus.
SUBMENTAL SPACE
BOUNDARIES ANTERIOR : inf border of mandible
POSTERIOR: hyoid bone
SUPERIOR: mylohyoid muscle
INFERIOR: investing fascia
SUPERFICIAL/MEDIAL: investing fascia
DEEP/LATERAL: ant bellies of digstric
muscle

CONTENTS
Anterior jugular vein
Lymph nodes

NEIGHBORING SPACES Submandibular(on either side)

CLINICAL FEATURES

• Six anterior mandibular teeth.

• Distinct, firm swelling in midline, beneath the chin.
• Skin overlying the swelling is board like and taut.
• Fluctuation may be present.
• The anterior teeth, are either nonvital, fractured or carious.
• The offending tooth may exhibit tenderness to percussion and may
show mobility.
• The patient may experience considerable discomfort on swallowing.
SUBLINGUAL SPACE
BOUNDARIES ANTERIOR : lingual surface of mandible
POSTERIOR: submandibular space
SUPERIOR: oral mucosa
INFERIOR: mylohyoid muscle
SUPERFICIAL/MEDIAL: muscles of
tongue
DEEP/LATERAL: lingual surface of
mandible

CONTENTS Sublingual glands

Wharton’s duct
Lingual nerve
Sublingual artery and vein

NEIGHBORING SPACES Submandibular

Lateral pharyngeal
Visceral (tracheal and esophagus)
CLINICAL FEATURES

• Mandibular incisors, canines, premolars and sometimes first molars.

• There is little or no swelling.
• The lymph nodes may be enlarged and tender.
• Pain and discomfort on deglutition.
• Speech may be affected.
• Firm, painful swelling seen in the floor of the mouth on the affected
side.
• The floor of the mouth is raised.
• The tongue may be pushed superiorly.
• This will bring about airway obstruction.
• The ability to protrude the tongue beyond the vermillion border of
upper lip is affected.
 PTERYGOMANDIBULAR SPACE
BOUNDARIES ANTERIOR : buccal space
POSTERIOR: parotid gland
SUPERIOR: lateral pterygoid muscle
INFERIOR: inf border of mandible
SUPERFICIAL/MEDIAL: medial
pterygoid muscle
DEEP/LATERAL: ascending ramus of
mandible

CONTENTS Mandibular division of trigeminal nerve

Inferior alveolar artery and vein

NEIGHBORING SPACES Buccal

Lateral pharyngeal
Submassentric
Deep temporal
Parotid
Peritonsillar
CLINICAL FEATURES

• Pericoronitis related to the mandibular third molar.

• Severe degree of limitation of mouth opening.
• Tenderness present near medial to anterior border of ramus of the
mandible.
• Dysphagia is present.
• Medial displacement of the lateral wall of the pharynx, redness and
edema of the area around the third molar.
• Midline of the palate is displaced to the unaffected side and the
uvula is swollen.
• Difficulty in breathing.
SUBMASSETRIC SPACE
BOUNDARIES ANTERIOR : buccal space
POSTERIOR: parotid gland
SUPERIOR: zygomatic arch
INFERIOR: inf border of mandible
SUPERFICIAL/MEDIAL: ascending ramus
of mandible
DEEP/LATERAL: massetor muscle

CONTENTS Massetric artery and vein

NEIGHBORING SPACES Buccal

Pterygomandibular
Superficial temporal
Parotid
CLINICAL FEATURES

• Mandibular third molars

• External facial swelling is moderate in size; seen extending from the
lower border of the mandible to the zygomatic arch; and anteriorly to
the anterior border of masseter; and posteriorly to the posterior
border of the mandible.
• Tenderness over the angle of the mandible.
• Limitation of mouth opening.
• Pyrexia and malaise.
• Low-grade osteomyelitis of lateral cortical plate may occur with
sequestrum formation.
• Necrosis of the muscle can also occur.
 LATERAL PHARYNGEAL SPACE
BOUNDARIES ANTERIOR : sup and middle pharyngeal
constrictor muscles
POSTERIOR: carotid sheath and scalene
facsia
SUPERIOR: skull base
INFERIOR: hyoid bone
SUPERFICIAL/MEDIAL: pharyngeal
constrictors and retropharyngeal space
DEEP/LATERAL: medial pterygoid
muscle

CONTENTS Carotid artery

Internal jugular vein
Vagus nerve
Cervical sympathetic chain

NEIGHBORING SPACES Submandibular

Sublingual
Peritonsillar
Pterygomandibular
Retropharyngeal
CLINICAL FEATURES

• Mandibular third molar.

• Generalized septicemia and respiratory embarrassment due to
edema of the larynx.
• General constitutional symptoms in the form of malaise and pyrexia
are present.
• Brawny induration of the face, above the angle of the mandible.
• The anterior part of the lateral pharyngeal wall may be swollen; that
pushes the soft palate and the palatine tonsil towards the midline.
• Trismus
• Dysphagia
• Septicemia
 RETROPHARYNGEAL SPACE
BOUNDARIES ANTERIOR : sup and middle pharyngeal
constrictor muscles
POSTERIOR: alar fascia
SUPERIOR: skull base
INFERIOR: fusion of alar and
prevertebral fascia at C6-T4
DEEP/LATERAL: carotid sheath and
lateral pharyngeal space

Clinical features
• Acute infection of the throat.
• Painful deglutition,
• Dyspnea and
• Dysphagia
• Unilateral cervical adenitis
 PRETRACHEAL SPACE

BOUNDARIES ANTERIOR : sternothyroid-thyrohyoid

fascia
POSTERIOR: retropharyngeal space
SUPERIOR: thyroid cartilage
INFERIOR: superior mediastinum
SUPERFICIAL/MEDIAL: sternothyroid-
thyrohyoid fascia
DEEP/LATERAL: visceral fascia over
trachea and thyroid gland
INFRATEMPORAL/DEEP TEMPORAL SPACE

CONTENTS Pterygoid plexus

Internal maxillary artery and vein
V3
Skull base foramina

NEIGHBORING SPACES Buccal

Superficial temporal
Inferior petrosal sinus
CLINICAL FEATURES

• Infection of the buccal roots of the maxillary second and third

molars, particularly, from unerupted third molars.
• Trismus: marked limitation of oral opening.
• Bulging of temporalis muscle.
• Marked swelling of the face on the affected side in front of the ear,
overlying the area of the temporomandibular joint, behind the
zygomatic process.
• The eye is often closed and is proptosed.
• Swelling in the tuberosity area.
• Elevation of temperature up to 104ºF.
 SUPERFICIAL TEMPORAL SPACE

CONTENTS Temporal fat pad

Temporal branch of facial nerve

NEIGHBORING SPACES Buccal

Deep temporal
CONCLUSION

• Early recognition of orofacial infections and prompt appropriate

therapy is absolutely essential.
• A thorough knowledge of surgical anatomy of various spaces of head
and neck is necessary to predict pathways of spread of odontogenic
infection and drain the spaces adequately.
• Otherwise the infection may spread to such an extent causing
considerable morbidity and occasional death.
REFERENCES

• Oral and Maxillofacial Infections 4th edition Topazian

• Oral and maxillofacial surgery vol 2 by Daniel M.Laskin
• Killey and kay’s outline of oral surgery
• Gray’s anatomy
• Peterson’s Principles of Oral and maxillofacial surgery 2nd Edition