Abscess oral maxillo-presentation
- 1. SOUMAN BARUA 5 TY YEAR VICTOR B ABES UNIVERSITY, TI MISOARA. Buccal, Canine, Palatinal, Submental, Submandibular, Sublingual & other Superficial Abscesses
- 2. WHAT IS ABSCESS? CLINICAL DIAGNOSIS STAGES There are Four stages in progression of acute odontogenic infections: Stage 1: Odontogenic in origin. periapical or periodontal or peri-coronal infection. Patient may be asymptomatic. Stage 2: Still confined with in the alveolar bone. it is termed as periapical osteitis. Tooth is tender to percussion and frequently extruded from the socket. Patient complains of severe pain. Stage 3 Once the infection exits through the bone and the periosteum into the surrounding soft tissue ,an inflammatory oedema occurs A diffuse swelling develops extra-orally which is soft and duffy in consistency called Cellulitis. At this stage no pus formation occurs. Stage 4 : When suppuration does occur and the infection localises, the condition is termed as, Abscess. With increased pressure it may even perforate the soft tissues and pus discharge may be seen as sinus opening or fistulous tract.
- 3. DIFFERENCE BETWEEN CELLULITIS AND ABSCESS Characteristics Cellulitis Abscess Duration Pain Size Localization Palpation Appearance Skin Quality Surface temperature Loss of Function Tissue Fluid Seriousness Bacteria 3-7 Days Severe and Generalised Large Diffuse Hard exquisitely tender Reddened Thickened Hot Severe Serosanguineous Severe Mixed Over 5 days Moderate and Localised Small Circumscribed Fluctuant and tender Peripherally reddened Centrally undermined Moderately heated Moderately severe Pus Moderate Anaerobic
- 4. CLINICAL DIAGNOSIS METHODS • History taking • Observation • Palpation • Diagnostic Imaging of fascial and neck space o X-Ray o MRI o CT o Ultrasound • Biopsy (For neoplastic masses) • Differential Diagnosis of Head and Neck Abscess • Enlargement of lymph nodes • Benign Swellings of the Head and Neck • Developmental Cyst – ThyroglossalCyst • Developmental Cyst - Branchial Cyst • Developmental Cyst Sebaceous cyst • Dermoid cyst • Neoplastic Masses of the Head and Neck- benign or malignant • Lymphomas
- 5. CLASSIFICATION OF INFECTION ACCORDING TO TOPAZIAN: (Clinical Significance) 1. Face • Buccal • Canine • Masticatory o Massetric o Pterygoid o Zygomatico Temporal • Parotid 2. Suprahyoid • Sublingual • Submandibular • Submental • Lateral Pharyngeal (Pharyngo- maxillary) • Peritonsilar 3. Infrahyoid Anterovisceral 4. Spaces of total Neck • Retropharyngeal • Danger space • Spaces of Carotid Sheath
- 6. CLASSIFICATION OF INFECTION BY PETERSON: Based on mode of Involvement 1. Primary Maxillary Space • Buccal • Canine • Palatinal • Infratemporal 2. Primary Mandibular Space • Buccal • Sublingual • Submandibular • Submental 3. Secondary Facial Space • Massetric • Pterygomandibular • Superficial
- 7. Vestibular/Buccal Abscesses Etiology: The buccal space abscess may originate from infected root canals of posterior teeth of the maxilla and/or mandible. Boundaries- Superiorly: zygomatic arch. Inferior: inferior border of mandible. Laterally: skin & subcutaneous tissue. Medially: buccinator muscle ,buccopharyngeal fascia. Posteriorly: anterior edge of masseter muscle. Anteriorly: posterior border of zygomaticus major & depressor anguli oris. Contents- Buccal fat pad. Stenson’s duct. Facial artery.
- 8. CLINICAL EVALUATION: • It is characterized by swelling of the cheek, which extends from the zygomatic arch to the inferior border of the mandible, • from the anterior border of the ramus to the corner of the mouth. • The skin appears taut and red, with or without fluctuation of the abscess, which, if neglected, may result in spontaneous drainage. • Dumb bell shaped appearance due to lack of swelling over zygomatic arch. Buccal Abscesses
- 9. • swelling of the cheek • extends from the zygomatic arch to the inferior border of the mandible • from the anterior border of the ramus to the corner of the mouth • skin appears taut and red, with or without fluctuation of the abscess Differential Diagnosis: Repeated buccal space infection suspect Crohn’s Disease.
- 10. Access to the buccal space is usually intraoral for three main reasons: The abscess fluctuates intraorally in the majority of cases To avoid injuring the facial nerve For esthetic reasons The intraoral incision is made at the posterior region of the mouth, in an anteroposterior direction, and carefully to avoid injury of the parotid duct. A hemostat is then used to explore the space thoroughly. An extraoral incision is made when intraoral access would not ensure adequate drainage, or when the pus is deep inside the space. The incision is made approximately 2 cm below and parallel to the inferior border of the mandible. Broad spectrum gram positive + gram negative antibiotic treatment for 7-14 days. In case of granular growth, biopsy can be performed. 1. can progress to lymphangitis, more abscess formation, or sepsis. 2. Infection by additional species of bacteria (superinfection) may occur, complicating treatment. Infection can also spread to the layer of tissue enveloping muscles (fascia), causing a serious infection (necrotizing fasciitis). 3. Older individuals may develop a blood clot (thrombophlebitis) as a result of cellulitis in more superficial tissues. Treatment of Buccal Space Abscess COMPLICATIONS
- 11. Canine Fossa Abscess Anatomic Location: The canine fossa, is a small space between the levator labii superioris and the levator anguli oris muscles. Etiology: Infected root canals of canines of the maxilla or premolars are considered to be responsible for the development of abscesses of the canine fossa. Clinical Presentation: This is characterized by edema, localized in the infraorbital region, which spreads towards the medial canthus of the eye, lower eyelid, and side of the nose as far as the corner of the mouth. There is also obliteration of the nasolabial fold, and somewhat of the mucolabial fold. The edema at the infraorbital region is painful during palpation, and later on the skin becomes taut and shiny due to suppuration, while its color is reddish.
- 12. • edema, localized in the infraorbital region • spreads towards the medial canthus of the eye, lower eyelid, and side of the nose as far as the corner of the mouth 12 years old. He attended with a large facial swelling after an episode of trauma 3 weeks previously. He feels unwell and his right eye is closing. Example of Canine Fossa abscess The edema at the infraorbital region is painful during palpation, and later on the skin becomes taut and shiny due to suppuration, while its colour is reddish.
- 13. Treatment of Canine Fossa Abscess The incision for drainage is performed intraorally at the mucobuccal fold (parallel to the alveolar bone), in the canine region. A hemostat is then inserted, which is placed at the depth of the purulent accumulation until it comes into contact with bone. Finally, a rubber drain is placed, which is stabilized with a suture on the mucosa. Broad spectrum gram positive + gram negative antibiotic treatment for 7 - 14 days. COMPLICATION 1. inflammation of all tissues of the eye (panophthalmitis). 2. Infective endocarditis 3. streptococcal septic shock 4. Osteomyelitis
- 15. DIFFERENTIAL DIAGNOSIS OF UPPER FACE INFECTIONS Dacrocystitis with minimal involvement of nasolabial folds Odontogenic Cellulitis Maxillary sinusitis Or Tuberculous Sinusitis Tuberculous Sinusitis
- 16. Palatal Abscess Involvement: • from the maxillary lateral incisor or Palatal Roots of Posterior Teeth • although the lateral incisor is the commonest source of palatal abscess, most lateral incisor abscesses present labially. • Abscesses from palatal Pocket because of infection Boundaries: • Inferiorly: Bounded by cortical plates of hard palate • Superiorly: Overlying periosteum • Laterally: alveolar process of maxilla and teeth Clinical features: i) well defined circumscribed fluctuant swelling, confined to one side of palate ii) Tooth causing the abscess is tender on percussion. Differential diagnosis: • Extravasation cyst • Gumma • Pleomorphic adenoma • Carcinoma of maxillary antrum
- 17. Incision & Drainage. • incision- through the mucosa down to the bone. • care should be taken as to avoid cutting of greater palatine nerves & blood vessels. • A Slucular Incision can be done to avoid damage the greater Palatine Artery • Incision should be in AP direction to avoid injury to anterior palatine nerve • Treatment of offending tooth • Broad spectrum gram positive + gram negative antibiotic treatment for 7 -14 days. Treatment of Palatal Abscess
- 18. Odontogenic infections of maxillary posterior teeth Odontogenic infections involving the pterygomandibular space or infection from buccal space coursing along the masticatory fat pad. Anatomical boundaries: a. laterally: ramus of mandible, temporalis muscle and temporalis tendon b. Medially: lateral pterygoid plate c. Superiorly: infratemporal surface of the greater wing of sphenoid d. Inferiorly: lower head of lateral pterygoid muscle Contents: a. Origin of pterygoid muscles b. Pterygoid venous plexus c. Internal maxillary artery d. Mandibular nerve and its branches Infratemporal space infection Management: a. Intravenous antibiotics b. Incision in upper buccal sulcus in third molar region c. Use of sinus forceps along medial surface of coronoid and temporalis- upwards and backwards Signs and symptoms: a. Infected upper molar teeth b. Severe trismus is universal finding c. extraoral swelling over the sigmoid notch, intra oral swelling in the tuberosity area
- 19. Submandibular Abscess Submandibular space It is a potential space present on the medial surface of the posterior aspect of the mandible Anatomical boundaries: • Anteriorly – ant. belly of digastric muscle • Posteriorly - post. belly of digastric muscle, stylohyoid muscle, stylopharyngeus muscle • Superior – inf & medial surfaces of mandible • Inferior – digastric tendon • Superficial – platsyma muscle, investing fascia • Deep – mylohyoid, hypoglossus, sup constricting muscles • Laterally – bounded by skin, superficial fascia, platysma Contents: • Submandibular salivary gland • Lymph nodes • Facial artery • Lingual and hypoglossal nerves
- 21. Etiology- Infected mandibular 2nd & 3rd molars. From submental, sublingual spaces. Clinical Features- Indurated swelling in submandibular region. Usually bulges over lower border of mandible. Dysphagia Spread of Infection- Across midline to contralateral space. To contiguous pharyngeal spaces. Submandibular Abscess
- 22. DIFFERNTIAL DIAGNOSIS: • Nonmalignant swelling may be caused by mumps, sialadenitis, Sjögren syndrome, cysts and infections. • Submandibular lymphadenopathy may also result from infections of teeth, upper respiratory track, sinuses and tonsils or infections mononucleosis and cut scratch disease • The neoplastic growths in the submandibular area may include in most of the case tumors of the submandibular gland, the tail of the parotid gland, the Hodgkin's disease and non-Hodgkin's lymphomas Submandibular Abscess complications: • Ludwig’s Angina • a blocked airway • sepsis, which is a severe reaction to bacteria or other germs • septic shock, which is an infection that leads to dangerously low blood pressure
- 23. The mylohyoid muscle will determine whether infections that drain lingually Line of insertion of the mylohyoid muscle Lateral diagrammatic illustration showing the localization of infection above or below the mylohyoid muscle, depending on the position of the apices of the responsible tooth
- 24. Sublingual Abscess Sublingual Space Boundaries- Superiorly: mucosa of floor of mouth. Inferior: mylohyoid muscle. Posteriorly: body of hyoid bone. Anteriorly & laterally: inner aspect of mandibular body. Medially: geniohyoid,styloglossus,genioglossus muscle. Contents- Deep part of Submandibular gland. Wharton’s duct. Sublingual gland. Lingual & hypoglossal nerves. Terminal branches of lingual artery.
- 25. Etiology- • The abscess is rare. • Infected mandibular premolar & 1st molar. Clinical Features- • Swelling of floor of mouth. • Elevated tongue. • Pain & discomfort on swallowing. Sublingual Abscess Differential Diagnosis: • Malignant cyst formation and may need biopsy. • Immunodeficiency- systemic disease - Recurrent abscess associated with other lesions
- 26. Treatment of Sublingual Abscess Incision is placed at the base of the alveolar process in the lingual sulcus so that the sublingual gland, lingual nerve & submandibular duct are not injured A hemostat is inserted through the incision in an anterior & posterior direction & beneath the sublingual gland to evacuate the pus drug therapy symptomatic treatment rehabilitation treatment supportive treatment 1-3 months Complication • Sublingual abscess may cause sepsis • Oral cancer diagnosis • Sublingual and submandibular gland infection • Lingual nerve
- 27. • The incision for drainage is performed on the skin, approximately 1 cm beneath and parallel to the inferior border of the mandible. • During the incision, the course of the facial artery and vein (the incision should be made posterior to these) and the respective branch of the facial nerve should be taken into consideration. • A hemostat is inserted into the cavity of the abscess to explore the space and an attempt is made to communicate with the infected spaces. • Blunt dissection must be performed along the medial surface of the mandibular bone also, because pus is often located in this area as well. After drainage, a rubber drain is placed. • airway management and IV antibiotics. • Treatment of the effecting tooth. Submandibular space infection is a rapidly spreading, bilateral, indurated cellulitis occurring in the suprahyoid soft tissues, the floor of the mouth, and both sublingual and submaxillary spaces without abscess formation. Treatment of Submandibular Abscess
- 28. Submental Abscess Signs and symptoms: • Firm circumscribed swelling beneath the chin • Patient complains of discomfort and difficulty in swallowing. Submental space Potential space present just below the chin region on the medial surface of the mandible It is a midline structure bordered laterally by the anterior bellies of digastric muscle Infections begin in the anterior mandibular Teeth Secondarily Infected skin wounds or anterior mandibular fractures may also cause infections BORDERS: • Anterior – inf border of mandible • Posterior – hyoid bone • Superior – mylohyoid muscle • Inferior – investing layer of deep cerical fascia • Deep/Lateral - ant. bellies of digastric muscle Contents: • Submental lymphnodes • Anterior juglar veins • Adipose tissue
- 29. Management: • Incision is made bilaterally through the skin, subcutaneous tissue and platsyma muscle at the most inferior aspect of swelling • A hemostat is inserted through one incision and then exited through the second incision Submental Abscess • Local Anaesthesia is performed around the abscess • Peripheral infiltration anaesthesia of healthy tissues surrounding inflammation An incision on the skin is made beneath the chin, in a horizontal direction and parallel to the anterior border of the chin Transverse incision- symphysis of mandible- kelly’s forceps/sinus forceps-upward & backward direction - drained & sutured
- 30. Submental Abscess Insertion of a hemostat and exploration of the abscessed area Withdrawal of the hemostat from the cavity with open beaks, facilitating the evacuation of pus Rubber drain placed at the drainage site of the abscess COMPLICATIONS: • Sepsis • Septic shock • Osteo-necrosis DIFFERNTIAL DIAGNOSIS: • Neoplastic Masses – malignant or benign • benign masses can be serious if they impact nerves or exert pressure
- 31. Sub-masseteric Abscess Boundaries- Superiorly: zygomatic arch. Inferiorly: inferior border of mandible. Laterally: medial surface of masseter muscle. Medially: lateral surface of ramus of mandible. Posteriorly: parotid gland & its fascia. Anteriorly: buccal space & buccopharyngeal fascia. CONTENTS - • Masseteric artery and vein Neighboring spaces- • Buccal, pterygomandibular, superficial temporal, parotid space
- 32. ETIOLOGY:- • Pericoronitis related to vertical or distoangular impaction of third molars • Fracture of angle of mandible Clinical features External facial swelling is moderate Tenderness over angle of mandible Limited mouth opening Pyrexia & malaise. Necrosis of muscle Sub-masseteric Abscess
- 33. Intraorally: Drainage is done through a vertical incision along the external oblique line of the mandible Starting at the level of the occlusal plane and extending downward & forward in the buccal sulcus to a point opposite the second molar A hemostat is inserted and passed posteriorly along the lateral aspect of the ramus to point beneath masseter muscle Beaks are opened Rubber drain is inserted & sutured Extraorally: • Incision is made behind the angle of the mandible (retromandibular incision) • Hemostat is inserted and passed along the lateral aspect of the ramus • Rubber drain is inserted Sub-masseteric Abscess
- 34. Pterygomandibular space Abscess Pterygomandibular Space Boundaries- • Superiorly: lower head of lateral pterygoid muscle. • Laterally: medial surface of ramus. • Medially: medial pterygoid muscle. • Posteriorly: deep part of parotid. • Anteriorly: pterygomandibular raphe. Contents- • Inferior alveolar neurovascular bundle. • Lingual & auriculotemporal nerves. • Mylohyoid nerve & vessels. Etiology- • Infected mandibular 3rd molars (mesioangular/horizontal) • Pericoronitis. • Infected needles or contaminated LA solution.
- 35. Clinical Features- • Absence of extra-oral swelling. • Severe trismus. • Difficulty in swallowing. • Anterior bulging of half of soft palate & tonsillar pillars with deviation of uvula to unaffected side.
- 36. PTERYGOMANDIBULAR SPACE PTERYGOID PLEXUS EMISSERY VEINS CAVERNOUS SINUS THROMBOSIS LATERAL PHARYNGEAL SPACE RETROPHARYNGEAL SPACE MEDIASTINUM CAROTID SHEATH DANGER SPACE 4 NOTE : DANGER SPACE 4 IS THE SPACE BETWEEN PREVERTIBRAL AND ALAR FASCIA Pterygomandibular space Abscess
- 37. TREATMENT: • Intraoral- vertical incision(1.5cm) made on anterior & medial aspect of - ramus of mandible - sinus forceps opened & closed & with drawn - Pus drained & sutured. • Extraoral- incision made at angle of mandible - sinus forceps - Pus drained & sutured Pterygomandibular Abscess
- 38. Two divisions: a. Superficial – It is between superficial temporal fascia and lateral aspect of temporalis muscle b. Deep – It is between the medial surface of the temporalis muscle and periosteum of temporal bone. Inferiorly the temporal space is limited to the attachments of the temporalis muscle and fascia. Inferiorly, it communicates with the pterygomandibular space Its contains loose connective tissue and vessels supplying the temporalis muscle Superficial Temporal space Abscess Signs and symptoms: • Swelling confined to the shape of the muscle extending from the lateral orbital rim, above the zygomatic arch, covering the lateral aspect of temporal bone. • swelling more prominent in a superficial temporal space infection. • severe trismus • The spread of odontogenic infections may sometimes involve the infratemporal space. The most likely causative tooth is the maxillary third molar (upper wisdom tooth).
- 39. Superficial Temporal space Abscess Clinical Appearance: • Note the lack of swelling over the zygomatic arch causing a dumbell shaped configuration • Marked Trismus • Swelling of face in front of ear, over TMJ, Behind zygomatic process • Eye is closed and proptosed Deep temporal abscess Produce less swelling Lies deep to temporalis muscle Less fluctuant
- 40. Management: Intra oral sicher’s incision along the anterior border of the ramus of the mandible Extra oral cutaneous incision slightly above the zygomatic arch made parallel to zygomatic arch followed by blunt dissection and placement of drain Superficial Temporal space Abscess
- 41. Parotid Space Infection Clinical Evaluation: • The symptoms of Parotitis include pain and induration over the involved gland • Purulent marked swelling of the angle of the jaw without associated trismus or pharyngeal swelling • Secretions may sometimes be expressed after massage from the parotid depth • Very Characteristic pitting edeme of the gland is pathognomic for parotid gland abscess.
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