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Head, Neck, and Orofacial Infections

1st Edition

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Regret for the inconvenience: we are taking measures to prevent fraudulent form submissions by extractors and page crawlers. Received: May 20, Published: May 24, Citation: Hegab A. Management of oral and maxillofacial infection.


Oral and Maxillofacial Surgery for the Clinician pp Cite as. Dental infection has plagued humankind for as long as our civilization has been a fight against microorganisms by man dates back to ancient civilization.

The discovery of antibiotics is encouraging trends conquest of the microbial infections. Infection of the deep facial spaces of the head and neck still represents a major challenge in hospitals. Untreated infections may result in abscess formation that can spread through different levels in and between the facial spaces and result in life-threatening situations including mediastinitis, pericarditis, meningitis, septic shock, airway compromise, jugular vein thrombosis, and arterial erosion, Although the complications are rare, they are serious and life threatening.

The most critical point in the facial space infections is the understanding of the common and uncommon signs and symptoms, choice of antibiotics, definitive treatment and a thorough knowledge about the sequela if left unmanaged. There is considerable amount of change in the behavior of infections for the past one decade.

The severity of infection is far greater than before which may be due to increased co-morbid conditions, demanding swift action and aggressive treatment. Fascial spaces do not exist in a normal healthy individual. These are latent spaces created by distention of tissues secondary to infection from the dental pulp, periodontal tissues and bone, where the infection perforates the cortical plate and discharge into the surrounding spaces. The infections range from simple superficial periapical abscess to deep infections in the neck region; some resolving with little consequences and some lead to life-threatening conditions.

The infection started in any area is automatically limited by tough fascial layers. If the infection becomes massive, it breaks through a nearby fascial barrier into the next fascial space [ 1 ]. The fascial spaces in the Head and Neck are the potential spaces between the various fascia normally filled with loose connective tissue and bounded by the anatomical barriers usually of bone, muscle, or fascial layers [ 2 ].

Facial planes offer anatomic highways for infection to spread superficially to deep planes. Antibiotic availability in fascial spaces is limited due to poor vascularity. The spread of the infections could be either through tissues, blood, or lymphatics leading to fatal consequences like Airway obstruction, Meningitis, and Septicemia; however, various factors influence the spread of infection. In the Oral and Maxillofacial region, fascial spaces are almost always of relevance due to the spread of odontogenic infections.

As such, the spaces can be classified according to their relation to the upper and lower teeth, and whether infection may directly spread into the space called primary space, or must spread via a primary space to the secondary space [ 3 ]. Classification of spaces in odontogenic infections based on mode of involvement. Primary maxillary spaces. Primary mandibular space. Severity score for spaces [ 4 ]. The infections arising from the maxillary anterior teeth spread to Canine space, while the infection from molars spread to Buccal space, Infratemporal space, or cause palatal abscess.

Likewise, the infection from the mandibular anterior teeth spread to Submental space or cause gingival abscess. Infection from mandibular molars spread to the Sublingual space or the Submandibular space. While the infection from mandibular third molars spread to Submasseteric space, Pterygomandibular space and Lateral Pharyngeal space.

Improves the drainage, by opening the lymphatic and venous channels, which were blocked by the edema and congestion. To allow better perfusion of blood thereby improving the delivery of antibiotics and defensive elements to the required site. Stab incision with the help of 11 number blade is made at the most dependent area along the skin crease.

Sinus forceps is inserted through the incision and all the locules in the abscess are explored. Purulent discharge, toxic material, gases, and necrotic tissue drained through the incision. Corrugated rubber drain is inserted deep into the abscess cavity and secured to the edge of the incision and the drain is removed once there are no active exudates.

Removal of the source of the infection is mandatory apart from drainage. Supportive management is mandatory in the form of antibiotics, anti-inflammatory, and electrolytes. The reader is also advised to refer the chapter on general principles of management of facial infections Chap. Route of administration depends upon the general condition and severity of the infection. Para-enteral route is preferred when the infection is acute and severe or when the patient is nutritionally or medically compromised.

With evidence of slough, gas, crepitus, and foul smell, anaerobic infection may be suspected and appropriate antibiotics have to be given.

Choice of empirical antibiotics also refer Chap. Martins JR et al. Antibiotics should be administered for the shortest duration possible duration and should act as an adjuvant for the primary surgical treatment in countering any regional or systemic co-morbidities.

Apart from antibiotics and anti-inflammatory drugs, administration of fluids and electrolytes is mandatory, as there is a loss of fluids due to infection and fever. In non-ambulatory patients, intravenous fluids are administered depending on their systemic status. Hydration of patient through IV route, maintain adequate nutritional status-high protein intake. A simple and superficial abscess can be drained comfortably under local anesthesia, while deep-seated, multi-loculated abcesses may not be amenable for treatment under local anesthesia and may be managed under procedural sedation provided the patient has adequate mouth-opening and patent airway.

The canine space, synonymous with Infraorbital space, is situated in the anterior surface of the maxilla at the infraorbital region above canine fossa. Skin infections of upper lip [ 7 ]. Drainage of the space infection either intraorally or percutaneously is done; intraoral incision and drainage are preferred as these will not produce a facial scar. Drainage is made by making an in-depth incision of the maxillary vestibule near canine fossa.

Sinus forceps is inserted superiorly, laterally, and medially for complete breakage of locules and drainage. Care is taken while using sinus forceps, so as to not damage the infraorbital nerve and its branches. Aggressive antibiotic therapy is mandatory to prevent the spread as it lies in the danger area of the face and also to prevent Cavernous sinus thrombosis from septic thrombi entering into angular vein.

The involved tooth is either removed or subjected to root canal treatment with multiple dressings. Patient is advised good hydration and rest. The buccal space occupies the portion of the subcutaneous space present between the fascial skin, buccinator muscle, and masseter muscle [ 8 ]. Source of infection—From maxillary premolar and molar teeth root apices above buccinator attachment. From mandibular premolar and molar teeth root apices below the buccinator attachment.

Anterior: Posterior border of zygomaticus major above and depressor anguli oris below. For mandibular buccal space infection, intraoral drainage may not achieve the desired result, hence extraoral drainage at the lower border of mandible is made taking care of the facial artery and marginal mandibular nerve. The involved tooth is either removed or subjected to root canal treatment as required. According to Igoumenakis D et al. Source of infection—From upper third molars and infection from other spaces.

Clinical image of the classical dumb bell swelling blue arrows. The isthmus of the swelling at the zygomatic arch is shown by the green arrow. Surgical drainage is carried out through an incision made above the zygomatic arch; sinus forceps is inserted through the skin incision and passed through the superficial fascia and the temporal fascia. This space lies between the temporalis muscle and the skull.

Slightly below the level of zygomatic arch; both the superficial and deep temporal spaces communicate with each other. If the trismus is not severe, intraoral incision is given in the buccal sulcus at the second and third molar region.

With the sinus forceps, the space is entered medial to coronoid process superiorly and the pus is drained. Corrugated rubber tube is placed and secured with a suture. In case of severe trismus, extraoral incision is made above the zygomatic arch at the junction of frontal and temporal process of zygoma, sinus forceps is inserted and directed inferiorly and medially to enter the space and drain the pus.

The disadvantage of this approach is that it cannot produce dependent drainage. The infection from any of the six anterior teeth in the mandible may perforate the labial bone inferior to the mentalis muscle attachment and the pus may present at the anterior and lower border of the mandible and below the mylohyoid muscle lingually [ 11 ]. Clinical picture showing spread of infection to the submental space and buccal space.

Lateral: Skin, superficial fascia, platysma, superficial layer of deep cervical fascia. Superior: Medial aspect of mandible and the attachment of mylohyoid muscle. Transcutaneous approach in the chin region is the most effective drainage; incision is made below the symphysis menti to produce dependent drainage.

Sinus forceps is inserted upward and backward to break the locules and the pus is drained. A corrugated rubber drain is inserted and secured with a suture. Intraoral approach is cumbersome as we need to pierce mentalis muscle to reach the submental space and also drainage against gravity is not possible. The space is V-shaped lying lateral to the muscles of the tongue and in the lingual aspect of the body of the mandible.

Anteriorly communicates with submental space and posteriorly communicates with the submandibular space at the edge of the mylohyoid muscle [ 12 ]. Periapical infection from mandibular teeth is situated above mylohyoid muscle. Sinus forceps or a thin mosquito forceps is inserted and the pus is drained.

If an extraoral approach is planned, then incision is placed at the submandibular region, taking care of the facial artery and marginal mandibular nerve; a sinus forceps is inserted piercing the mylohyoid muscle to drain the pus and a corrugated rubber drain is inserted and secured with a suture, as this approach provides gravity-dependent drainage.

The submandibular space is present at the inferior border of the mandible between the anterior and posterior bellies of digastric muscles [ 13 ]. Infection from the periapical region of molar teeth below mylohyoid muscle. Laterally: Skin, superficial fascia, platysma, and superficial layer of deep cervical fascia. Superiorly: Medial aspect of mandible and the attachment of mylohyoid muscle.

Swelling is situated at the submandibular region, inferior to the lower of the mandible. Masticator space is formed by splitting of the investing fascia into superficial and deep layers.

The superficial layer lies along the lateral surface of the masseter and lower half of the temporalis. Deep layer passes along the medial surface of the pterygoid muscles before attaching to the base of the skull superiorly.

Submasseteric space. Pterygomandibular space. Temporal space. Infratemporal space. Masseter consists of three layers which are firmly attached anteriorly and loose posteriorly.

Head, Neck, and Orofacial Infections

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward SOR by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination.

Use best practices in effectively treating infections of the head, neck, and orofacial complex! Head, Neck, and Orofacial Infections: An Interdisciplinary Approach is the only resource on the market with in-depth guidelines to the diagnosis and management of pathology due to severe infections. No longer do you have to search through journal articles and websites, as this comprehensive, full-color reference covers both cutting-edge and time-tested approaches to recognizing and handling infections. From well-known OMS educator James Hupp and oral surgeon Elie Ferneini, and with chapters written by expert contributors, this book is ideal for use in the classroom, as preparation for the NBDE and specialty exams, and as a clinical resource for patient care. Odontogenic Infections of the Fascial Spaces chapter focuses on the etiology, clinical manifestations, anatomic considerations, and treatment of odontogenic infections. Nasal and Para-Nasal Sinus Infections chapter discusses the pathophysiology and management of nasal and paranasal sinus infections. Microbiologic Considerations with Dental Implants chapter reviews the issues associated with the prevention of infection with surgical implant placement, including the factors that are known to cause infection, the putative bacteria involved and means to control infection once it occurs.

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1st Edition

Boynton and others published Odontogenic Infections of the Fascial Spaces Find, read and cite all the research you. The present case report describes a child with fascial space infection of oral and maxillofacial region who was treated by incision and drainage in. If you continue browsing the site, you agree to the use of cookies on this website.

New to Thieme E-Books & E-Journals

Oral and Maxillofacial Surgery for the Clinician pp Cite as. Dental infection has plagued humankind for as long as our civilization has been a fight against microorganisms by man dates back to ancient civilization. The discovery of antibiotics is encouraging trends conquest of the microbial infections. Infection of the deep facial spaces of the head and neck still represents a major challenge in hospitals.

Odontogenic infection is one of the common infectious diseases in oral and maxillofacial head and neck regions. Clinically, if early odontogenic infections such as acute periapical periodontitis, alveolar abscess, and pericoronitis of wisdom teeth are not treated timely, effectively and correctly, the infected tissue may spread up to the skull and brain, down to the thoracic cavity, abdominal cavity and other areas through the natural potential fascial space in the oral and maxillofacial head and neck. Severe multi-space infections are formed and can eventually lead to life-threatening complications LTCs , such as intracranial infection, pleural effusion, empyema, sepsis and even death.

Fascial Space Infections


  • Guesporagre 20.04.2021 at 14:00

    PDF | It is my unpublished work on the fascial spaces in head and neck and one Oral Maxillofacial Surgery journal, the editor of the latter.

  • Pomeroy S. 21.04.2021 at 01:24

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  • Elizabeth H. 26.04.2021 at 21:28

    David W. Eisele, M.D., Section Editor. Head and neck fascia and compartments: No space for spaces. Alice K. Guidera, BSc, MBChB,1* Patrick.


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