ORAL AND MAXILLOFACIAL

INFECTIONS
MANAGEMENT OF ODONTOGENIC
INFECTIONS

 eight steps :
 1. Determine the severity of infection.

 2. Evaluate host defenses.

 3. Decide on the setting of care.

 4. Treat surgically.

 5. Support medically.

 6. Choose and prescribe antibiotic therapy.

 7. Administer the antibiotic properly.

 8. Evaluate the patient frequently.

ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 In 1930s Grodinsky and Holyoke established the modern
understanding of fascial layers
 Infections spread primarily by HYDROSTATIC pressure
w/ the flow of infected fluid guided by the resistance of
certain tissues (fascia, muscles, bone)
 Established 5 spaces of the H + N region
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Space # 1: lies superficial to the superficial fascia – SubQ sp
 Space #2: group of spaces surrounding the strap muscles
 Superficial to the sternothyroid-thyrohyoid division of the middle
layer of the DCF
 Space # 3: potential anatomic space lying superficial to the
visceral division of the MDCF
 Contents: Pretracheal, Retropharyngeal, Lateral Pharyngeal sp
 Space #3a: contains the Carotid Sheath
 Space #4: potential spaces that lies btwn the alar and pre-
vertebral divisions of the PDCF
 “the danger space”
 Space #5: Prevertebral sp
 Space # 5a: enclosed by the prevertebral fascia – post. To the
transverse process of the vertebrae
 Surrounds the scelene and postural muscles
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Superficial
 Layer of dense CT that courses deep the SQ tissue
 Muscles of facial expression lie deep below the mouth and superficial
above
 Deep cervical fascia
 Anterior layer
 Investing
 Parotidomasseteric
 Temporal
 Middle
 Sternohyoid-omohyoid
 Sternothyroid-thyroid
 Visceral Division *
 Buccopharyngeal

 Pretracheal

 Retropharyngeal

 Posterior
 Alar
 Prevertebral
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Anterior layer – contains the investing,
Parotidomasseteric, Temporal
 Forms the superficial border of the submandibular space to
form the capsule
 At the ramus splits and surrounds the masseter and parotid
posteriorly
 Covers the superficial layer of the temporalis
 Above the zygomatic arch – divides ~ 2cm above and houses
the temporal fat pad
 2cm above the sternum divides and forms the suprasternal
space of burns
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Middle layer of the DCF
 Sternohyoid
 Sternothyroid-thyrohyoid
 Visceral***
 Important in deep neck spaces
 Contains the retropharyngeal, lateral

pharyngeal and pretracheal spaces]

…all lie superficial to the middle
layer
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Posterior
 Alar
 Passes through the transverse process of the vertebrae post to the
retropharyngeal fascia
 Extends from bases of skull to diaphragm

 Fuses w/ the retropharyngeal fascia at lvls btwn C6-T4 forming the

bottom of the RP space

 Infections may rupture this fascia and enter the danger space #4

 Prevertebral
 Surrounds the vertebra and attach postural muscles of the neck and
back
 Infection of the vertebrae may enter this space i.e. Osteomyelitis

related to TB
 Usually not caused by OMF infection
ORAL AND MAXILLOFACIAL INFECTION
– FASCIAL SPACES
 Carotid Sheath
 Origin at superior mediastinum
 Passes through pre-tracheal space in an upward and posterior
direction
 Above the hyoid lies @ the junction of the lateral and
Retropharyngeal spaces
 Light blue: Superficial
 Y: alar
 Purp: middle
 Red: Anterior
VESTIBULAR/PALATAL SPACE
 Simple!
 Localized swelling of vestibular or palatal space adjacent
to the tooth
 Possible spread into other adjacent spaces
 Peritonsilarsp
 Masticator Space
 Canine Space
 Buccal Space
 Pterygomandibular/masseteric space

 When there is a palatal swelling always consider –

infection vs. neoplasia – ask about duration of swelling
(SUB)MASSETERIC SPACE
 Borders
 Anterior: Buccal Space
 Posterior: Parotid gland
 Superior: Zygomatic Arch
 Inferior: Inferior border of the mandible
 Superficial/Medial: Ascending ramus of the mandible
 Deep/Lateral: Masseter muscle
 Causes
 Lower 3rd molars, fracture angle of the mandible
 Contents:
 Masseteric artery and vein
 Neighboring sp:
 Buccal, Pterygomand., Superficial Temp, Parotid
 One of the 3 spaces of the Masticator space, commonly
associated with Trismus
CANINE/INFRAORBITAL SPACE
 Borders
 Superior- Quadratus Labii superioris
 Inferior- Oral mucosa
 Posterior- Buccal Sp.
 Anterior- Nasal Cartilages
 Lateral (Deep)- Levator anguli oris, Maxilla
 Medial (superficial) - Quadratus Labii superioris,
 Contents
 Angular artery and vein, infraorbital nerve
 Causes of infection
 Upper canine and pre-molars
 Can spread to cavernous sinus via angular vein (non-valves) 
leading to Cavernous Sinus Thrombosis
 **********
CANINE SPACE
 PICTURE
CAVERNOUS SINUS THROMBOSIS
CAVERNOUS SINUS THROMBOSIS
 CS
 Anteriorly bordered by the SOF and receives tributary from the ophthalmic vein
(from a combination of the superior and inferior ophthalmic veins)
 Posterior communication via the Pterygoid plexus
 Via the Posterior facial (retromandibular) and external jugular veins
 “Valveless veins” of the face and anterior skull base allow blood flow in either
direction
 An Ascending Thrombophlebitis can occur anteriorly or posteriorly
 CNs III, IV, V1, VI
 Dx: via clinical presentation and confirmed with CT w/ contrast
showing a filling void on the affected side of the cavernous sinus, CN
deficits
 Diplopia, visual disturbance
 vascular congestion in the periorbital/scleral/retinal veins
 Ptosis
 dilated pupils
 absent corneal reflex
 supraorbital sensory deficits
BUCCAL SPACE
 Borders
 Superior- Maxilla/infraorbital space
 Inferior- Mandible
 Posterior- Masseter and Pterygomandibular sp.
 Anterior- corner of mouth
 Lateral- subQ tissue and skin
 Medial- buccinator
 Contents
 Parotid Duct
 Anterior facial artery/vein
 Transverse facial artery
 Buccal fat pad
 Causes of infection
 Upper pre-molars/molars and lower pre-molars
 Neighboring spaces: Infratemporal, Pterygomand., Infratemporal
SUBLINGUAL SPACE-

 BORDERS:
 Superior- mucosa of the floor of the mouth
 Inferior- mylohyoid muscle
 Posterior- submandibular space and hyoid bone
 Anterior- lingual surface of the mandible
 Lateral- medial surface of the mandible
 Medial- muscles of the tongue

 CONTENTS:
 The sublingual space contains the sublingual gland, the Wharton’s duct, the
lingual nerve and the sublingual artery and vein.
 CAUSES OF INFECTION:
 Broken down and carious mandibular premolars and molars are the most
common etiological factor leading to infection of the sublingual space, direct
trauma to the sublingual space can also cause infection
 ****Commonly pt has pain on protrusion of tongue and possibly
Trismus
SUPERFICIAL TEMPORAL SPACE-

 BORDERS:
 Superior- superior temporal lines
 Inferior- zygomatic arch
 Lateral- superficial temporal fascia
 Medial- temporalis muscle
 Anterior- posterior surface of the lateral orbital rim
 Posterior- fusion of temporal fascia with pericranium
 CONTENTS:
 The superficial temporal space contains temporal fat pad and the
temporal branch of the facial nerve. 
 CAUSES OF INFECTION:
 The most likely causes of spread of infection to the superficial
temporal space are carious and broken down maxillary and
mandibular molars.
 ***Temporal tenderness, possible periorbital edema
DEEP TEMPORAL SPACE-

 BORDERS:
 Lateral- temporalis muscle
 Medial- squamous temporal bone, skull base
 Inferior- lateral pterygoid muscle
 Superior and Posterior- attachment of the temporalis muscle to the
cranium at the temporal crest
 Anterior- posterior wall of the maxillary sinus and the posterior
surface of the orbit
 CONTENTS:
 The deep temporal space contains the pterygoid plexus, the internal
maxillary artery and vein and the mandibular division of the
trigeminal nerve 
 CAUSES OF INFECTION:
 The deep temporal space is most commonly involved when
infection spreads from infected and necrotic maxillary molars.
INFRATEMPORAL SPACE-

 BORDERS:
 Medial- Lateral pterygoid plate
 Superior- base of the skull
 Lateral- continuous with the deep temporal space

 CONTENTS:
 The infratemporal space is continuous with the deep temporal space
and contains the pterygoid plexus, the internal maxillary artery and
vein and the mandibular division of the trigeminal nerve.

 CAUSES OF INFECTION:
 The most likely cause of spread of infection to this space is a
infected maxillary third molar.
 ***One of the 3 spaces of the masticator space –
pain/swelling on maxillary tuberosity
SPACE OF THE BODY OF THE MANDIBLE
 Potential cleavage plane between the fascia and the bone.
 Limited anteriorly by superfical investing fascia and the attachment
of the anterior belly of the digastric
 Limited posteriorly by investing fascia and the attachment of the
medial pterygoid to the jaw
 Inferiorly closed by the continuity of the fascial layers
 Superiorly closed by the attachment of fascial layers to the inferior
border of the body of the mandible.
 Formed by the attachment of the superficial layer of fascia to both
the outer and inner surfaces of the body of the mandible
 attachment to the outer surface is at the lower border of the mandible
 attachment to the inner surface can be elevated from the mandible up to
the origin of the mylohyoid muscle
 Clinical: An infection here may remain localized or may spread
to the masticator space.
PTERYGOMANDIBULAR SPACE

 Borders:
 Lateral-Mandibular Ramus
 Medial-Medial Pterygoid
 Anterior-Pterygomandibular Raphe
 Posterior-Parotid Gland
 Superior-Lateral Pterygoid
 Inferior-Pterygomasseteric Sling

 CONTENTS
 Mandibular division of trigeminal nerve(lingual, IAN, mylohyoid, and
auriculotemporal)
 IAN neurovascular bundle
 
 Infection
 Spread is typically from sublingual and submandibular spaces with little
or no swelling but significant trismus
 ***One of the 3 sp of the masticator spaces, TRISMUS!!
SUBMANDIBULAR SPACE

 Borders:
 Lateral-mandible
 Medial and Posterior-Digastric muscles
 Superior-Mylohyoid
 Inferior-Superficial Fascia, platysma, and skin
 Anterior-Anterior belly of digastric

 CONTENTS
 Submandibular gland, Facial artery and vein, and lymph nodes

 CAUSES OF INFECTION:
 Perforation of lingual cortex of mandible typically in the 3rd molar
region, but can arise from 2nd molar. Communicates posteriorly with
pterygomandibular space.
LUDWIGS ANGINA
 Condition exhibiting bilateral swelling of the submental, sublingual, and
submandibular spaces.
 Characterized by extreme hardness of the floor of the mouth, "brawny",
"indurated" swelling (no give or fluctuation due to pus formation) of the neck
centering about the floor of the mouth and by the ensuing elevation of the
mucosa of the mouth and tongue. Interstitial spaces are filled with fluid.
 The infection here may eventually extend to the lateral pharyngeal space and
then may enter the retropharyngeal space and even descend to the mediastinum.
 Death from Ludwig's angina occurs as a result of suffocation due to edema of
the mouth, tongue, and the glottis, from mediastinitis due to spread, or from
septicemia or pneumonia
 Problem with the patient opening the mouth: Trismus
 Extraction of a lower molar tooth and subsequent infection precedes Ludwig's
angina in a majority of cases.
 The roots of the second and third molar teeth reach downward to the level of the
attachment of the mylohyoid muscle, and usually below it, while most of those
of the first molar teeth, and usually all of those anterior to this, are located above
this level
LUDWIG’S ANGINA
LATERAL PHARYNGEAL SPACE

 Borders:
 Posterior to pterygomandibular space
 Superior-Base of skull
 Inferior-Hyoid bone
 Lateral-Medial Pterygoid
 Medial-Superior constrictor
 Anterior-Pterygomandibular Raphe
 Extends posteromedially to prevertebral fascia

 Divided into 2 compartments by the styloid process

 Anterior-primarily muscles
 Posterior-Contains carotid sheath and cranial nerves IX through XII

 CONTENTS
 Carotid, Internal jugular vein, Vagus nerve, and Cervical Sympathetic chain
 
 Infection spreads from pterygomandibular space and can cause trismus, lateral swelling of
the neck, and swelling of the lateral pharyngeal wall toward midline. May also cause
erosion of the carotid, thrombosis of the internal jugular and interference with CN IX
through XII.
RETROPHARYNGEAL SPACE
 Area of loose connective tissue lying posterior to the pharynx and anterior to the alar layer
of the prevertebral fascia
 Largest interfascial space in the neck which permits movement of the pharynx,
esophagus, larynx, and trachea during swallowing
 Borders
 Anterior: Superior and middle Pharyngeal Constrictor Muscles
 Posterior: Alar Fascia
 Superior: Skull Base
 Inferior: Fusion of the Alar and prevertebral Fascia at C6 – T4
 Superficial/Medial:
 Deep/lateral: Carotid Sheath and lateral pharyngeal space

 Passes downward and is continuous with the (Retro)Visceral (retroesophageal) space

(which begins below the pharynx) and opens inferiorly into the posterior mediastinum
 Closed superiorly by the base of the skull, superficial layer of fascia of the masticator
space, submandibular space and laterally by the carotid sheath
 Contents
 retropharyngeal lymph nodes which drain the adenoids, nasal cavities, nasopharynx, and posterior
ethmoid sinuses
RETROPHARYNGEAL SPACE
 Clinical importance
 Key to an understanding downward spread of infections of the head and
neck: Commonly regarded as a route through which infections of the
mouth and throat reach the mediastinum. It can break through the
posterior wall of the space through the alar fascia, and can enter Danger
Space 4, between the two lamellae of the prevertebral layer of fascia
(extends from the base of the skull to the level of the diaphragm).
 Fatal hemorrhage could potentially result from an extension of a
retropharyngeal abscess to the deep vessels of the neck
 Majority of cases arising from the internal carotid artery rather than
from the jugular vein: the vein is more often occluded by the infectious
process than it is eroded to the point of hemorrhage.
 A sudden enlargement of a retropharyngeal mass may indicate erosion
of a large vessel and that in such a case aspiration of the mass before its
incision may prevent fatal hemorrhage
PRETRACHEAL SPACE
 Borders
 Ant: Sternothyroid-thyrohyoid fascia
 Post: Restropharyngeal Space
 Sup: Thyroid Cartilage
 Inf: Superior Mediastinum
 Superficial/medial: sternothyroid-thyrohyoid fascia
 Deep/lateral: Visceral fascia over trachea and thyroid gland
OTHER SPACES
 Prevertebral
 Potential pocket existing between the "prevertebral" fascia and the
vertebral bodies.
 Danger Space 4
 An area of delicate loose connective tissue that lies between the alar
and prevertebral fascia Extends from the base of the skull to the
mediastinum
 Infection can communicate from posterior wall of the oropharynx and
oral cavity to the thorax by traveling from the Retropharyngeal Space,
and passing downward to the Retrovisceral space (which begins below
the pharynx). It can then pierce thru the weak alar fascia - into Danger
Space #4
 "Dangerous" because an infection can easily travel to the thoracic cage
and mediastinum, i.e., mediastinitis. Abscess in the mediastinum could
go anteriorly to the pericardial area and could affect the manubrium,
sternum, etc..
MICROBIO
 Oral cavity has dense, diverse microbiota consisting of
protozoa, yeast, virus and > 20 genera of bacteria
 Composed primarily of aerobic and anaerobic GP cocci
and anaerobic GN rods
 Most odontogenic infections are caused by mixed
aerobic/anaerobic organisms (~ 60%)