Orofacial infection and its mgt

It ranges from per-apical abscess to superficial and

deep neck infection
Abscess-is a circumscribed collection of pus in
pathological space
-due to staphylococci/often anaerobes
such as bacteriods.
Cellulitis-is a spreading infection of loose connective
tissue
- due to streptococci.
Charax abscess cellulitis
• Duration over 5 days 3-7 days
• Pain moderate/localized sever/generalized
• Size small large
• Localization circumscribed diffuse
• Palpation fluctuant and tender Hard and very tender
• Pus yes no
• Bacteria anaerobic Mixed
• Appearance Peripherally reddened reddened
• Surface temp moderately heated hot
 Etiology of orofacial infection

Odontogenic
• Majority of infection of orofacial region is due to this.
• It is an infection arising from
-diseases of the tooth pulp
-periodontal infections
-infected cyst
-remaining root fragment/residual abscess
-pericoronal infection
Traumatic
• Occasionally, trauma from penetrating wounds of soft and
hard tissues of the face
 Conti..

- infected antrum
- salivary gland affliction
- contaminated needle puncture
- implant surgery
- reconstructive surgery
- plastic surgery
 Odontogenic infection pathway
Dental Caries
‫׀‬
Invasion of pulp tissue
‫׀‬
Inflammation, edema & lack of blood supply
‫׀‬
Venus congestion/avascular necrosis of pulp
‫׀‬
Bacterial growth/anaerobic
|
Periodic progress of bacteria into surrounding alveolar bone

N.B: The progress varies according to the number of virulence factors of

the microorganism, host resistance and anatomy of the involved area
 Types of odontogenic infection
Acute stage
- peri-apical abscess
- peridontal abscess
- dento-alveolar abscess
- pericoronal abscess
Chronic stage
• chronic fistulous tract or sinus formation
- abscess neglected for a long time discharge intra-
orally and extra-orally
• OML
• Cervicofacial actinomycosis
 Microbiology
• The most common species of bacteria isolated
in odontogenic infections are anaerobic g+ve
cocci streptococcus milleri group
and peptostreptococcus.
• Anaerobic g-ve rods, such as bacteroides,
prevotella, fusobacterium, porphyromonas
also play an important role.
• Anaerobic g-ve cocci and anaerobic g+ve rods
have little effect.
 Odontogenic infection treatment

• Consists of supportive medical therapy like

-Hydration
if pt is dehydrated due to diminished liquid intake
and toxic nature of the infection it self.
-soft or liquid diet rich with ptn.
-analgesics
-antiseptic mouth wash
-Antibiotic therapy
-Surgical therapy (ID)
 Function of drainage
• to get rid of toxic purulent materials
• to decompress the edematous tissue
• to allow better perfusion of blood, containing
antibiotics and defensive elements

• to increase oxygenation of the infected area.

 Hilton’s method of incision and pus
drainage

-It is a method of opening an abscess with out

damaging vital structures like nerves, blood
vessels.
Steps:-
1.topical anesthesia-achieved with the help of ethyl
chloride spray
2. Stab incision-over the maximum fluctuation in the
most dependent area along the Skin creases. Use
number 11 surgical blade for skin incision
 Conti…
3. If pus is not encountered –further deepening of surgical site is
achieved by sinus forceps to avoid damage to nerves and blood
vessels.
4. closed forceps-pushed through deep fascia and towards pus
collection
5. Open the closed forceps in a direction parallel to vital structure.
6. Pus flows along sides of the beaks
7. Explore the entire cavity for additional loculi
8. Placement of drain (piece of glove) and secure external wound
margin with the help of suture
9. Drain left for at least 24 hrs.
10. Dressing
 Conti…
• Purpose of keeping the drain
-to allow the discharge of tissue fluid and from
the wound by keeping it patent
-for debridement of abscess cavity by irrigation
Spread of orofacial infection
Routes of spread
- By direct continuity through the tissue
- By lymphatic to the regional lymph nodes, and eventually
to the bloodstream
- Blood stream
• If the infection is confined to the periapical area it forms
periapical infection→sufficient bone destruction(medullary
cavity) →cancellous bone→cortical bone→periosteam.
• inflamation of cancellous bone →edema in bone marrow
space→failure of blood supply→ischeamia→bone becomes
necrotic →bacteria easily proliferate(anaerobic).
 Fascial spaces of the face
 Classified in to two:
1. Primary spaces
2. Secondary spaces

 Primary maxillary spaces:

– Canine space
– Buccal space
– Infratemporal space
 Conti..
 Primary mandibular spaces:
- Submental space
- Buccal space
- Sublingual space
- Submandibular spaces
 Conti..
• Secondary/potential fascial spaces:
- Retrophrygeal space
- Prevertebral space
- Parotid space
- Pretracheal space
Potential spaces
 Possible life threatening complications of orofacial infection

• Related to the lower jaw:

- Ludwig's angina
- Descending deep cellulitis→resulting in mediastinitis
• Related to the upper jaw:
- Intracranial complications like:
- Cavernous sinus thrombosis(CST)
- Brain abscess
- Osteomylitis of the skull
- Retrobulbar cellulitis→Blindness
 Ludwig’s angina

It’s the name given to:

• A massive
• Firm
• Brawny cellulitis
• Toxic stage
• Involving simultaneously and bilaterally the
submandibular, sublingual and submental
spaces.
 Conti..
• It was 1st described by Wilhelm friedreich von
Ludwig (1836).
• The word angina, derived from the Latin word
`angre’meaning suffocation or chocking sensation
• Ludwig-the person who described
• Interestingly Ludwig died of throat inflammation
• Ludwig’s angina has many terminologies:
- Strangulatories-b/c of the chocking effect.
- Angina malignae.
 Cont..
• Its unique identity is 3F:
-it was to be feared
-it rarely becomes fluctuant
-it was often fatal
 Etiologies of Ludwig‘s Angina
1. Odontogenic
2. Iatrogenic
– Use of contaminated needles for giving anesthesia
3. Trauma to orofacial region
4. Acute exacerbation of chronic osteomyelitis
5. Submandibular and sublingual sialadenitis
6. Infection of tonsils
– Purulent tonsillitis and impaction of foreign body
like fish bone.
 Clinical features
• Patient looks toxic, very ill and dehydrated.
• Pyrexia
• Anorexia
• Chills
• Malaise
• Dysphagia
• Impaired speech
 Conti..
• hoarseness of voice
• trismus -restricted mouth opening and
movement of jaw due to muscle spasm.
• tenderness
• airway obstruction
• raised RR
• Cyanosis-due to progressive hypoxia
• raised floor of mouth
 Spread
• E.g. Infection from submandibular region.
1. Tracts to submassetric space→pterygomandibular
space and more posteriorly parapharyngeal,
paratonsillar space→worsening airway compromise.

2. Dwnwards along and beneath the investing layer of

deep cervical fascia towards the clavicle
→mediastinitis.
 Conti..
• Mediastinum contains
-heart
-aortic arch, carotid and subclavian artery
-thoracic duct
-vagus,pherenic,splanchnic nerves
-superior and inferior venacava
-Trachea and esophagus
 Conti..
• The descending cervical cellulitis is dangerous
b/c it contains oral contents like air, saliva,
aerobic mo→which contribute to virulent
descending necrotizing mediastinitis(DNM).
• The DNM occurs due to the the polymicrobial
and gas producing nature of the infection.
 Conti..
Fate of ludwig’s angina:
• If untreated can be fatal with in 12-24 hrs.
• Death arising from:
– Asphyxia
– Septicemia
– Mediastinitis
 Principle of Rx.

Based on the combination of the following factor

• Early diagnosis.
• Extraction of offending tooth.
• Maintaince of air way in case of respiratory
embarrassment/obstruction (nasoendotracheal
intubation & tracheostomy)
• Antibiotic Rx eg. PCN.is the 1st line antibiotics in
treating such infection (pencilline-G2-4million IU IV
every six hourly
• Hydration of pt.
 Intracranial complication
Infection of the:
• Head
• face and
• intraoral structures above the maxilla
particularly lead to this disease.
N.B -It is serious condition consisting of
formation of thrombus in cavernous sinus
 Conti..
• There are two roots by which infection from
orofacial area reach intra cranial cavity.
1. External route
• Infection from the face and lip is carried by:
– facial veins
– angular veins and
– nasofrontal veins (which is danger area of face) to
superior ophthalmic veins →which enters the CS
through the superior orbital fissure.
 Conti..
2. Internal route
• The dental infection is carried by the way of the
pterygiod plexus from the posterior maxillary region
→inferior orbital fissure →inferior ophthalmic vein
→to superior orbital fissure →CS (Cavernous sinus).

• Pterygoid plexus of veins →emissary veins→CS.

Dangerous triangle of face
 Conti..
• Why rapid complication and occasional death resulted
from infections by virulent organisms from the upper
part of the face?
• B/c:
1. The short distance from the facial regions to the sinuses
of the brain through superior draining Venus system.
2. Frequent anastamosis of these veins leading to direct
communication with sinuses.
3. Lack of protective valves in the facial vessels involved in
this complication
 treatment
• CAF 1gm IV /6hr
• heparinization (Heparin 20,000 IU in 1500ml
of 5% dextrose)-to prevent extension of
thrombosis.
• neuro surgical consultation
• Anticoagulant –to prevent thrombosis
Trauma to maxillofacial area
• Classified in to four:
1. Trauma to soft tissue
2. Trauma to teeth
3. Trauma to mandible
4. Trauma to middle 3rd of face.

• Basic principles of mgt of head and neck

injuries...
 Trauma to soft tissue

1. Abrasions:-caused by the frictional violence,

due to friction b/n an object and surface of
soft tissue.
• Has row bleeding area.
• Superficial/deep.
• Involves terminal nerve endings and it can be
quite painful.
• Most of the time heals by re-epithelization
with out scar formation.
 Conti..
Mgt:-thorough cleaning with profuse saline
irrigation and surgical soap
-removal of foreign and sticky materials to
prevent traumatic tattooing
-dressing for deep abrasions
-topical antibiotic ointment application
 Conti..
2. Contusion-is simply tissue disruption due to fall
against a hard or blunt object without break in soft
tissue resulting in subcutaneous/sub mucosal
hemorrhage leading to bluish or bruise.
• Submucosal/subcutaneous bleeding is self limiting.
• The discoloration is important for diagnosis and
search for an osseous trauma.

• Mgt:-application of ice pack will help to stop further

extra vacation of blood.
 Conti..
3. Laceration
• A tear in epithelial and sub epithelial tissue
due to vehicular accidents and etc….
• The underline vessels, muscles, nerves, and
bone may be injured.
• Usually highly contaminated.
 Conti..
Mgt-cleaning of wounds
-removal of foreign bodies
-debridement
-homeostasis
-Closure in layers- ms, dermis, epidermis, sub
mucosa, mucosa, skin
-Dressing-should be changed with in 24 hrs
-prevention of infection
-pain control
-follow up
 Conti..
Trauma to tooth
Types:
• Intrusion-entering of the tooth beyond its socket due to trauma.
• Extrusion-partial pulled out of tooth.
• Avulsion-totally comes out of its socket.
• Fracture of tooth:
- Enamel fr. - E + D fr.
- E + D +P fr. - Root fr.
• Common site:- upper front tooth.

• Treatment:- interdental wiring - extraction - restoration

- antibiotics and anti-pain - splinting - RCT
Trauma to the middle 3rd of the facial skeleton

• Middle 3rd of the facial skeleton is defined as

an area bounded:
– Superiorly by a line drawn across the skull from
zygomaticofrontal suture, across the frontonasal
and frontomaxillary sutures to the
zygomaticofrontalsuture of the opposite side, &
– Inferiorly the oclusal plane of the upper teeth.
 Conti..
• Middle 3rd of face is made up of considerable
number of bones which are fragile and
articulate in most complex fashion.
• So that fractures of this area are generally
comminuted.
• Bones constituting the middle 3rd of the
face….? 18 bones.
Classification of the middle 3rd fracture

• It is classified by Rene Lefort in to three:

Lefort-І (horizontal)
Lefort- ІІ (pyramidal) } depending on the direction of fracture
Lefort- ІІІ (transverse).

• Lefort during his experimental studies on cadaver head, he

discovered that the complex fracture patterns could be
broadly subdivided in to three.
Anatomy of face
 Conti..
Lefort-І: Horizontal, low level, sub-zygomatic
fracture.
• Complete dentoalveolar separation.
• Floating fracture b/c it is held only by means of
soft tissue.
• Occulusal disharmony can be seen, open bite,
cross bite.
• Most of the time bilateral and involves lower
3rd of the nasal septum.
 Conti..
• Clinical feature
– Slight swelling with the upper lip swelling
– Ecchymosis in the labial and buccal vestibule
– Bilateral epistaxis
– Mobility of the upper dentoalveolar portion of the
jaw
– Disturbed occlusion
– Pain while speaking and moving jaw
 Conti..
Lefort- ІІ: Pyramidal.
• Usually extends from glabella to the alveolar
margin results pyramidal shape.
• The fracture line runs below the frontonasal
suture down on either side, crossing the
frontal process of the maxilla and passes
anteriorly across the lacrimal bones & passes
downward, forward and laterally and reach
zygomatico-maxillary suture.
 Conti..
Clinical feature
– There is gross edema.
– Presence of bilateral circum orbital edema (black
eye).
– Depressed nasal bridge.
– Lefort-I symptom.
 Conti..
Lefort- ІІІ
• Transverse (supra-zygomatic fracture).
• High level.
• Craniofacial separation.
• The line commences near the frontonasal
suture, causes dislocation of the nasal bones
and disruption of cribriform plate of the
ethimoid bone with tearing of dura mater and
consequent CSF rhinorrhoea.
 Conti..
Clinical features
– Complete mobility of middle 3rd of the face.
– CSF rhinorrhea.
– Clinical features of lefort I and II.
 Mandibular fracture
• Commonest sites:
– Condylar fracture
– Angle fracture
– Body
– Symphysis
– Ramus
– Dento-alveolar
– Coronoid
 Conti..
Principle of management:
• clear airway
• stabilize with barrel bandage to prevent
airway obstruction especially in gross
mandibular fr.
• treat shock
• stop hemorrhage
• prevent infection
 Conti..
Aim of treatment
-reduction of displacement and immobilization by
-interdental wiring
-antibiotics
-Intra-ossous
-splinting
-arch bar fixation
-prevention of infection
-extraction of carious tooth in fracture line
 Conti..
Complications:
• Delayed union- due to:
– Infection
– Teeth in fracture line
– Poor immobilization
– Wide separation of fragments &
– Foreign bodies in fracture line.
• Non union.
 Conti..
• Basic principles of treatment of the fracture:
– Reduction
– Fixation } for re-establishment of form,
function and occlusion with minimum morbidity
– Immobilization
 Conti..
A. Reduction
• Restoration of the fractured fragments to their orginal
anatomical position.
• It can be:
– Closed reduction
– Open reduction
1. Closed reduction:
– Alignment without visualization of the fracture line.
– It can be also-reduction by manipulation or
– Reduction by traction.
• Here occlusion of the tooth is the guiding factor b/c it is non
surgical procedure.
 Conti..
Reduction by manipulation-(for fresh fractures):
• When fractured segments are adequately
mobile without much impaction and the
patient comes for treatment immediately after
trauma. (Here disimpaction forceps is useful).
• It can be done under LA or GA depending on
the need of pt.
• Finally barrel bandage.
 Conti..
Reduction by traction:
– I/O traction method
– E/O traction method
• I/O traction method-prefabricated arch bars
are attached to maxillary and mandibular
dentoalveolar by means of interdental wiring
(MMF)/IMF.
 Conti..
E/O method
• anchorage is taken usually from intact skull of
the pt.and different types of head gears are
used for various attachments, coming down
over the face and connected to the arch bars by
elastics and wires.
2. Open reduction
• Surgical intervention by visual identification of
fractured fragments.
 Conti..
B.Fixation
-preventing displacement of fractured fragment
-Eg.external skeletal fixation with pop skeletal
cap
C.Immoblization
- stabilization of the reduced fragments in to
their normal anatomical position, until clinical
bony union takes place.
 Conti..
• Immobilization period will depend on the
type of fracture and the bone involved.
– For maxilla-3 to 4 weeks.
– For mandible-4 to 6 weeks} the fibroblasts and
osteoblasts produce so much fibrous matrix to
form callus.
– For condylar fracture-2 to 3 weeks-for prevention
of ankylosis.
 TMJ disorder
TMJ:- is called cranio-mandibular joint.
• B/c its articulation consists of:
– Mandibular fossa/glenoid fossa.
– Articular eminence or tubercle.
– The condyle of the mandible.
The TMJ is limited
• Anteriorly- tubercle /articular eminence
• Posteriorly- post glenoid tubercle
 Conti..
• Blood supply
– External carotid artery.
• Nerve supply
– 3rd division of 5th cranial nerve (Auricullo temporal nerve).

• TMJ movement:
– Depression
– Elevation/Jaw closure
– Protrusion
– Retrusion
– Lateral movements.
 Conti..
• Dislocation:-is excursion of the condylar head
beyond articular eminence due to extrinsic
/iatrogenic or intrinsic/self induced forces
• Intrinsic force:
-excessive yawing
-vomiting
-singing loudlly
-blowing wind instruments
-loughing loudly
-oppening mouth too wide for eating….etc
 Conti..
Extrinsic forces:-
• Injudicious use of mouth gag during general
anesthesia
• Excessive pressure on the mandible during
extraction
• The most common type of dislocation is
anterior dislocation and it may be unilateral
or bilateral.
 Conti..
Characteristics of unilateral dislocation
• difficulty in mastication and swallowing
• difficulty in speaking
• deviation of the chin towards the contra lateral
side
• lateral cross bite and open bite on contra lateral
side
• affected condyle cannot be palpable and felt in
front of the tragus of the ear
 Conti..
Bilateral dislocation
• sever pain
• Inability to close mouth
• Tense masticatory muscles
• Protruding chin
• Open bite
• excessive salivation
• A hollow in front of the tragus
• restricted mov’t of mandible
 Conti..
management
• the major problem of reduction of dislocation is
muscle spasm
• therefore, initially attention should be given to
reduce tension, anxiety and muscle spasm by:-
reassuring pt.
• Sedation and muscle relaxation, propofol
• pressure and massage to the area and finally
manipulation
 Conti..
• Depending on the amount of associated
muscle spasm, pain experienced by the pt.
and pt. cooperation, it can be reduced by
three methods:
– manipulation without any form of anesthesia
– manipulation with local anesthesia – injection of
local anesthesia in the glenoid fossa
– manipulation under general anesthesia
 Procedure of manipulation

Steps
1.the pt shd be given assurance-relax
2.few anesthetic sol drop may be injected in the glenoid
fossa
3.the operator has to stand in front of the pt and has to
grasp the mandible with both hands
-here the thumb of the operator shd be covered with
gauze to prevent injury during manipulation
4.the thumb are placed on the occlusal surface of the
lower molars and finger tips are placed below the chin.
 Conti..
5.exert full body pressure and give down ward
pressure on the posterior teeth to depress the
jaw and at the same time finger tips are
placed below the chin to elevate it by giving
upward pressure and then backward pressure
is given to push the entire mandible
posteriorly→ original place/reduced
6.immobilization:-mouth is closed and pt. is
asked to keep the oral opening restricted.
 Conti..
• It is carried out by giving barrel bandage to the
pt. for 10-14 days and pt. is kept on semisolid
diet → to allow rest to the joint.
• The pt is warned to avoid excessive opening of
mouth and support the chin while yawing in
future.