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Oral Surgery

Lecture Outline
Dr.A.Sabagh

Orofacial Infection Lec#4


• Submental space infection:
• Submandibular space infection:
Anatomic continuation of the submental space creating a bilateral right & left submandibular spaces.

 Surgical anatomy:
- Lies below the myelohyoid muscle which separate it from the oral cavity & located
below & medially to the posterior part of the inner aspect of the mandible.
- Bordered posteriorly by:
Hypglossous muscle
Posterior belly of digastric muscle
Medial pterygoid muscle

 Contents:
- Submandibular salivary glands. "It has a tongue-like projection that extend into the
sublingual space".
- Submandibular lymph nodes.

 Clinical picture:
- Diffuse, enlarged , indurated browny edema (Cellulitis).
- No elevation of lobe of ear (elevated in case of parotid swelling)

 Spread of infection: (according to)


(I)
1- The position of the myelohyoid ridge
The myelohyoid ridge runs obliquely, higher posteriorly than anteriorly
In the lower posterior aspect, the apices of teeth related to the area below the myelohyoid ridge will
spread infection into the submandibular space.
2- Level of the apices of the lower arch (Direct penetration of the lingual plate).
(II) Secondary to involvement of submandibular lymph nodes.

Sublingual space, superior to mylohyoid muscle. The submandibular space is


inferior to the mylohyoid muscle

Spread of process superiorly and posteriorly elevates floor of mouth and tongue. In
anterior spread, the myoid bone limits spread inferiorly, causing a "bull neck"
appearance.
 Signs & symptoms
- Usual systemic signs & symptoms.
- Massive browny swelling along the lower border of the mandible extending posteriorly
to the angle.
- Moderate mandibular limitation.
- The swelling is board-like, tender, indurated, inflammatory red & hot.
 The moderate limitation of the mandible arise from the involvement of the medial
pterygoid muscle which extend posteriorly in the space not within the infection.
 The difficulty with swallowing arise from the large surface area of myelohyoid muscle
that is involved.

 Treatment: Extra-oral Incision & Drainage


The incision should be done at the deepest area of infection to help the drainage rapidly &
completely with the aid of gravity.
Incision in the stage of pitted on edema or localized swelling...
This incision should be:
1- Anatomically should be away from any important anatomical structures (mandibular
branch of facial nerve).
2- At minimally scanning or disfiguring area "Cosmotic consideration" e.g along s skin
crisis
So, the incision should be done along the medical surface of the dentist finger, I finger breadth (1.5-
2cm) below the inferior border of the mandible @ the skin rest position. The incision should pass
through the (skin, superficial fascia, platysma, deep fascia) layer by layer with blunt dissection.
Further more, a blunt instrument should be inserted within the infected space to completely damage
any septi & partition to ensure complete drainage of pus.
The ideal blunt instrument is an index finger.
Finally, the space should be filled with gauze by a mosquito forceps & left there for 24 hours. This
drain will allow pus evacuation from un-reached areas & the newly formed pus.
This drainage should be left in place to keep the incision line patent until the entire induration is
relieved.
Finally, dressing is placed externally to allow healing.

• Sublingual space infection:


 Surgical anatomy:
It's a V-shaped space located lateral to the tongue bilaterally.

 Bounded by:
The mucosa of the floor of the mouth  roof
The origin of the myelohyoid muscle  floor
The lingual aspect of the mandible  laterally
The hyoglossous, genioglossous& geniohyoid muscles  medially

 Spread of infection:
Apical or periodontal infection related to the incisors, canine & premolars.

 Signs & symptoms:


- Firm, painful swelling on the affected side sublingually causing tongue deflection
medially & superiorly.
- Shiny sublingual mucosa & of a gelatinous appearance.
- Pain & discomfort during swallowing.
- No extra-oral manifestation because myelohyoid muscle, & the mandibular bone resist
the spread.

 Treatment:
Intra-oral incision & drainage
The incision should run postero-anteriorly, lateral to the tongue & sublingual plica.

• Buccal space infection:


 Anatomy:
Anteromedially  buccinator muscle.
Posteromedially  masseter & lateral surface of anterior part of the ramus.
Above  Zygomatic process
Below Attachment of deep fascia to the mandible
Laterally  Platysma muscle & skin

 Contents:
Buccal pad of fat.

 Etiology:
Dento-alveolar abscess of posterior teeth:
- If abscess outside the buccinator muscle  buccal space infection.
- If abscess inside the buccinator muscle  vestibular abscess
Extra-oral manifestation is seen in case of buccinator muscle infection.
Intra-oral manifestation is seen in case of vestibular space infection.

 Signs & symptoms/treatment:


Localized extra-oral swelling in the cheek area:
Causing buffness when compared to the outer side + Difficulty in mouth opening.

Intraoral horizontal incision low down inside the cheek most likely related to the mucobuccal fold.
The direction should be posterior-anterior to prevent damage of salivary gland ducts.
The incision should be followed by blunt dissection of the buccinator muscle sheet.
 Theoretically, the buccal space infection can occur as a result of upper & lower posterior
teeth infection. However, Lower teeth infection is more likely to cause sublingual or
submandibular infection due to the thick buccal plate of bone compared to the upper.
Vestibular infection:
S&S: Intra-oral localized swelling
Tx: Intra-oral horizontal incision (in the same location of linea alba)
Palatal abscess (subperiosteal abscess):
Occasionally involvement of the palatal roots of upper teeth may lead to palatal abscess beneath the
mucosa & periosteum.
Tx: Posterior-anterior incision through the mucosa & the periosteum. We should take care of the
greater palatine bundle.
• Submasseteric space infection:
 Anatomy:
Bounded by masseter muscle laterally
The lateral aspect of the mandible ramus medially
The parotid gland is found posteriorly

 Spread of infection:
Lower 3rd molar area
Pericoronitis or periapical infection.

 Signs & symptoms:


- No extra-oral swelling is seen however, the inflammatory edema spreading into the
masseter muscle can cause moderate extra-oral swelling & slight disfiguring.
- Tender in palpitation.
- Complete limitation to mouth opening due to the contractive spasm of the masseter
muscle.
- Usual systemic signs & symptoms.
- Patient has severe pain upon complete closure into occlusion due to the contraction &
approximation of the masseter muscle to the lateral border of the mandibular ramus.

 Treatment:
- Intraoral incision along the anterior border of the ramus staring from the condylar
process & ending lateral to the ramus.
- In case of severe mandibular lock, even under G.A, extra-oral incision along the
mandibular angle inferiorly can be done.
- In both cases, elimination of the main cause is essential..
Allah Bless You
Muchas Gracias
Strawberry

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