FACIAL SPACES OF PERIODONTAL INTEREST

Presented By

Dr. M. Shiva Shanker

Ist Year Post Graduate Student ,

Dept of Periodontics, Mamata Dental College.

CONTENTS

Introduction

Classification of spaces

Formation of spaces

Maxillofacial odontogenic infections

Individual spaces

Communications

Complications

Case report

conclusion

INTRODUCTION

Connective tissue - naturally forms a padding between and around the various structures in the neck, and also elsewhere in the body.

- tends to be somewhat more dense where it is arranged immediately about organs.

When the fascia and spaces of the head and neck of normal bodies are investigated, the looser Connective tissue intervening between organs is torn and pressed against these organs, there by exaggerating any fascial layer already present.

The interrelationships of these spaces have been regarded as special importance in the spread of infection.

Accurate knowledge of the anatomy of these spaces and prompt drainage of them when they become infected is necessary.

CLASSIFICATION

Fascia & spaces above the hyoid bone :

Superficial layer of fascia

Prevertebral

Buccopharyngeal

Space of the body of mandible

Sub-maxillary gland space.

Masticator space.

Space of parotid gland.

Retropharyngeal space

Lateral pharyngeal space.

Fascia & spaces below the hyoid bone :

Superficial layer of fascia

Pretracheal

Prevertebral

Carotid sheath

Retrovisceral space.

Danger space or space of Grodinsky and Holyoke.

CLASSIFICATION ….

Depending upon its relationship with Hyoid bone.

Infrahyoid spaces

` (Below the hyoid bone)

Pretracheal space

Retrovisceral space

Carotid space

Space 4 or danger space.

Suprahyoid spaces (above the hyoid bone)

This is further divided into 2 categories.

Blind or intrafascial spaces.

Space of the body of mandible.

Space of submaxillary gland.

Masticatory spaces.

Space of parotid gland.

Peripharyngeal spaces.

Retropharyngeal space.

Lateral pharyngeal space.

Submandibular space.

CLASSIFICATION ….

Depending upon the involvement

Primary spaces

Secondary spaces

FASCIA The fascia is divided into two major divisions

Superficial layer

Deep cervical fascia

Superficial fascia This arises from the vertebral spinous processes and the ligamentum

nuchae and completely encircles the neck to attach again to these.

It invests the platysma in the neck, the muscles of facial expression, and the epicranial muscles in the scalp.

Deep cervical fascia1. Anterior layer

Investing fascia (over the neck)

Parotideomassetric

Temporal

2. Middle layer

Sternohyoid-omohyoid division

Sternothyroid-thyrohyoid division

Visceral division

Buccopharyngeal

Pretracheal

retropharyngeal

Posterior layer

Alar division

Prevertebral division

The DCF of the neck is contiguous with the mediastenal structures in the thorax through the thoracic inlet. As it emerges from the neck superior to the hyoid bone.

Deep cervical fascia......

FASCIALSPACES

Space of Burns

Fascia anterior to strap muscles

between the two sternocleidomastoid

muscles

splits into two layers just above the sternum

Suprsternal space( SOB)

Pretracheal fascia.

The pretracheal fascia passes behind the infrahyoid or strap muscles, infront of the trachea and thyroid gland.

The pretracheal layer with the carotid sheath laterally and the prevertebral layer posteriorly, forms the visceral compartment containing the trachea, esophagus and associated structures.

FORMATION OF SPACES

Vestibular space: Medial: mandible or maxilla and overlying periosteum

Lateral: vestibular mucosa

Superior: buccinator muscle

Inferior: buccinator muscle

Anterior: intrinsic lip muscles

Posterior: lateral pharyngeal and massetric space

SUB MANDIBULAR SPACE

Medial: mylohyoid, hyoglossus, styloglossus muscles

Lateral: skin and platysma muscle

Superior: mandible, mylohyoid and masseter muscle

Inferior: hyoid bone

Anterior: anterior digastric muscle, submental space

Posterior: posterior belly of digastric muscle and stylohyoid muscle

Mandible

Post digastric

Stylohyoid muscle

Ant digastric

Mylohyoid

SUB MENTAL SPACE

Mandible

Ant digastric

Inferior border of the mandible

Mylohyoid muscle

Hyoid bone

SUBLINGUAL SPACE

Floor of mouth mucosa

Mandible

Geniohyoid

Mylohyoid

Hyoid bone

BUCCAL SPACE

Zygomatic arch

Skin

Buccinator muscle and attachment to maxillary and mandibular alveolus

Mandibular and Sub Mandibular space

BUCCAL SPACE

Zygomatic major muscle

Depressor anguli oris

CANINE SPACE

Maxilla

Nasal bone

Levator labii superioris

Skin

Buccal space

LATERAL PHARYNGEAL SPACE

Sub lingual, sub mandibular spaces

Pterygomandibular raphae

Hyoid bone

Parotid capsule

Base of the skull

RETROPHARYNGEAL SPACE

Lateral pharyngeal space

Base of the skull

Vertebrae C6-T4

MASSETRIC SPACE

Superficial part of masseter

Deep part of masseter

Mucosa of retromolar triangle of mandible

Parotidomassetric fascia

PTERYGOMANDIBULAR SPACE

Parotid gland & its fasciaSuperior constrictor of pharynx

Mandibular ramusLateral pterygoid muscle

Pterygomandibular raphae

Buccinator

SUPERFICIAL TEMPORAL SPACE

Temporal fascia

Temporalis

DEEP TEMPORAL SPACE

Temporalis

Fascia of deep surface of temporalis

PREVERTEBRAL SPACE

Medial: postural neck muscles

Lateral: postural neck muscles

Superior: base of skull

Inferior: coccyx

Anterior: alar fascia and retropharyngeal space

Posterior: vertebral bodies

INFRA TEMPORAL SPACE

Medial: lateral pterygoid muscle and lateral pterygoid plate

Lateral: temporalis tendon and coronoid process

Superior: -

Inferior: -

Anterior: maxillary tuberosity

Posterior: lateral muscle, temporalis muscle, and condyle

MAXILLOFACIAL ODONTOGENIC INFECTIONS

Spread of infection

STAGES OF INFECTION

Characteristic Inoculation Cellulitis AbscessDuration 0-3 days 3-7 days >5 daysPain Mild-moderate Severe and generalized Moderate-severe and

localized

Size Small Large SmallLocation Diffuse Diffuse CircumscribedPalpation Soft,doughy, mildly tender Hard, exquisitely tender Fluctuant, tender

Appearance Normal color Reddened Peripherally reddened

Skin quality Normal Thickened Centrally undermined and shiny

Surface temperature Slightly heated Hot Moderately heated

Loss of function Minimal or none Severe Moderately severeTissue fluid Edema Serosanguineous, flecks of

pusPus

Levels of malaise Mild Severe Moderately severeSeverity Mild Severe Moderately severePercutaneous bacteria Aerobic Mixed Anaerobic

MANAGEMENT OF SPACE INFECTIONS

Management of infections, mild or severe, always has five general goals:

Medical support of the patient

Administration of proper antibiotics

Surgical removal of the source of infection as early as possible

Surgical drainage of the infection

Constant reevaluation of the resolution of the infection.

INDIVIDUAL SPACES

Vestibular space Etiology Signs and symptoms Treatment and applied aspects

CLINICAL PICTURE SHOWING VESTIBULAR SPACE INFECTION

SUBMANDIBULAR SPACE

Facial vesselsHypoglossal nerve

Submandibular gland

Marginal mandibular branch of VII

CONTENTS

Signs and symptoms

Etiology

Treatment and applied aspects

CLINICAL PICTURE OF SUBMANDIBULAR SPACE

SUBMENTAL SPACE

Spread of infection

Signs and symptoms

Etiology

Treatment and applied aspects

CLINICAL PICTURE OF A SUBMENTAL SPACE

SUBLINGUAL SPACE

Lingual nerves and vessels

Submandibular ganglion

Submandibular gland

CONTENTS

Spread of infection

Signs and symptoms

Etiology

Treatment and applied aspects

CLINICAL PICTURE OF A SUBLINGUAL SPACE

BUCCAL SPACE

Parotid duct

Buccal branch of VII

Facial vessels

Buccal fat pad

CONTENTS

Spread of infection

Signs and symptoms

Etiology

Treatment and applied aspects

CLINICAL PICTURE OF BUCCAL SPACE

CANINE SPACE

Levator anguli oris

Infraorbital nerves and vessels

CONTENTS

Etiology Signs and

symptoms Treatment and

applied aspects

CLINICAL PICTURE OF A CANINE SPACE

LATERAL PHARYNGEAL SPACE

Etiology Signs and symptoms Treatment and applied

aspects

B. Lateral Pharyngeal Space

RETROPHARYNGEAL SPACE

Signs and symptoms

Etiology

Treatment and applied aspects

PREVERTEBRAL SPACE

Signs and symptoms

Etiology

Treatment and applied aspects

MASTICATOR SPACE

Etiology Signs and symptoms

MASSETRIC SPACE

Treatment and applied aspects:

Spread of infection

CLINICAL PICTURE SHOWING MASSETRIC SPACE

PTERYGOMANDIBULAR SPACE

Treatment and applied aspects:

A. Pterygo-mandibular Space

TEMPORAL SPACE Treatment and applied aspects:

INFRATEMPORAL SPACE

Etiology Signs and symptoms Treatment and applied

aspects

PRETRACHEAL SPACE

The pretracheal space is encased by the middle layer of the DCF and contains the thyroid gland, trachea, and esophagus.

Infections in this space usually result from thyroiditis or perforation of the anterior cervical esophagus.

This space is rarely involved as a result of odontogenic infection

COMMUNICATIONS

COMPLICATIONS OF HEAD AND NECK INFECTIONS

Extension of infection from local to regional spaces

Orbital complications (blindness, ophthalmoplegia)

Jugular vein thrombosis

Septicemia

Metastatic abscesses

Airway compromise

Aspiration

Carotid artery rupture

Mediastinitis

Osteomyelitis

Cutaneous fistula

Cranial nerve deficits

Cavernous sinus thrombosis

Necrotizing fasciitis

Maxillary sinusitis, oroantral fistula

Septic shock

ANTIBIOTIC ADMINISTRATION REGIMEN FOR ORAL INFECTIONS

Aminoglycosides Gentamicin

IM/IV 3mg/kg/day in equal doses 8 hourly

CephalosporinsCefaclor Cefadoxilcephalexin

250-500 mg 8 hourly500mg-1g 12-24 hrs250-500mg 6hrs

PenicillinsAmoxicillin Cloxacyclin

1g initially than 250-500mg 6hrs250-500mg 6hrly

MacrolidesErythromycinAzithromycin

250-500mg 6hrly10mg/kg upto 500mg initially followed by 5mg/kg upto 250 mg qd- 5 days

TetracyclinsDoxcycline

oxytetracycline

100mg q 24hrs or 50mg q 12 hrs250mg q 24 hrs

Clindamycin 150mg q 6hrs

Metronidazole 500mg q 6hrs

Vancomycin IV 1g infused over 1hr before procedure

CONCLUSION

For practical purposes, it makes little difference to the surgeon in an uninfected neck

whether a facial sheath is present or not. Of some practical importance however are the

relationships of the loose connective tissue areas, the fascial spaces, of the head and neck,

both because of the structures that transverse or abut against them, and because they may

become infected. The interrelationships of these spaces have been regarded as special

importance in the spread of infections and many surgeons have urged accurate knowledge

of the anatomy of these spaces and a prompt drainage of them when they become infected

REFERENCES

1. Grays anatomy-Muscles and fascia of the head, 38th edition, (789-807)

2. Oral and Maxillofacial surgery, Fonseca, vol-5 (77-118)

3. Oral and Maxillofacial surgery, Laskin, Vol-2 (219-252)

4. Oral and Maxillofacial infections, Topazian, 4th edition (158-214)

5. Atlas of minor oral surgery, Hary dym (154)

6. Text book of Clinical periodontology, Newman, Takei, Carranza, 10th edition

7. Anatomical considerations in periodontal surgery, journal of periodontology 1971, vol 42, number 10.

8. Two cases of masticator space abscess initially diagnosed as TMJD, Clarke, Kobe J. Med. Sci., Vol. 54, No. 3, pp. E163-E168, 2008

THANK YOU………….