This document provides information on oral and maxillofacial infections, including their causes, stages of progression, clinical diagnosis, and directions of spread. It discusses various facial spaces where infections may spread, including the buccal, submandibular, sublingual, pterygomandibular, and masticatory spaces. It also describes Ludwig's angina, a serious infection that can spread bilaterally in the submandibular, sublingual, and submental spaces. Management of infections involves airway maintenance, antibiotics, surgical decompression, and addressing the underlying cause.

1. ORAL AND MAXILLOFACIAL
INFECTIONS
BHARATH REDDY .M

2. INTRODUCTION
Oral and maxillofacial infections are commonly
caused by teeth they are referred as
odontogenic infections.
The etiological agents may be bacteria viruses or
fungi.
The infection may spread directly from the tooth
or secondary infections of cyst or tumours or
infection of surgical wound or by contaminated
needles.

3. CLINICAL DIAGNOSIS
There are three stages in progression of acute
odontogenic infections
Stage 1
Most infections are odontogenic in origin.They may
be periapical or periodontal or pricoronal infection of
tooth.
Patient may be asymptomatic.
Stage 2
When the infection is 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 sever pain.

4. 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 extraorally 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, Absess .
With increased pressure it may even perforate the soft tissues
and pus discharge may be seen as sinus opening or fistulous trac
ROOTS OF SPREADS OF INFECTION
1.Spreads by direct continuity
2.Spreads by lymphatics to regional lymph nodes
3.spreads by blood stream

5. The infection causes formation of pus locally and pus
accumulation in :1. Tissue spaces
2. Between periosteam and bone
3. Spaces present between muscle layers

6. Difference bet’n cellulitis and abscess
Characteristic
Cellulitis
Duration
Pain
Size
Localization
Palpation
Appearance
Skin quality
Surface temp.
Loss of function
Tissue fluid
0 of seriousness
Bacteria
3-7days
severe and generalised
large
diffuse
hard exquisitely tender
reddened
thickened
Hot
severe
serosanguineous
severe
mixed
Abscess
Over 5 days
Moderate and localised
Small
Circumscribed
Fluctuant and tender
Peripherally reddened
Centrally undermined
Moderately heated
Moderately severe
Pus
Moderate
Anaerobic

7. DIRECTION OF SPREAD OF INFECTION
Infection from any tooth will spread along the path of least resistance.
It can perforate either the buccal cortical plate or lingual / palatal
cortical plate depending upon which is thinner.
1. Lower central and lateral incisor teeth
If the root of these teeth are extended above the attachment of mentalis
muscle, pus accumulates in the vestibule
If the roots extended below the attachment of mentalis muscle
pus accumulates within the connective tissue of the muscle and seen
as a extra oral swelling
2. Lower canine
Because the muscle attachment ( depressor labii inferioris , depressor
anguli oris,platysma ) located well below the root apex the
periapical infection from this tooth will localise in the oral vestibule
3. Mandibular premolars
Infection from premolars after penetrating buccal cortex results
in vestibular abscess

8. 4.
Mandibular first molar
If the root apices are above the oblique line of buccinator attachment
then it will cause localised infection within the oral vestibule
If the root apices are below the buccinator attachment it can give rise to
buccal space abscess on lingual aspect mylohyoid muscle is roughly
parallel
to the buccinator muscle . The apices of premolars and first molars is
always above this muscle which give rise to sublingual space infection
since there is loose connective tissue interspersed between the muscle
forming the boundary the infection may spread across the midline in the
opposite side called LUDWIG’S ANGINA
5.
Mandibular second molar
Perforation below the mylohyoid muscle can give rise to submandibular
space infection

9. 6. Mandibular third molar
Placed medial to the vertical plane of ramus .therefore its apex is
more closer to lingual than the buccal cortical plate
In mesio angularly or horizontaly positioned tooth the infection will
tend to spread beyond the posterior extend of the mylohyoid muscle
localizing in the pterygomandibular space
Pericoronitis can give rise to submassetric space infection
INFECTION FROM UPPER TEETH
1. The infection from C .I , L.I may be confined in the buccal vestibule
by orbicularis oris and dense subcutaneous tissue of base of the nose

10. Canine
The infection from this tooth will exit from the bone on the labial
aspect the levator anguli oris muscle than determines whether
the infection will be localised within the vestibule or infection
will spread in the canine space
Maxillary premolars
Muscle attachment of zygomaticus major,zygomaticus minor &
levator labii superioris will tend to localised the infection within
the oral vestibule or may give canine space infection .
Maxillary molars
Periapical infection from the upper molars usually perforate the
buccal cortex . The attachment of buccinator will determines that
the infection weather localised intraorally or spreads extra orally.

11. Secondary sites of spread of odontogenic infection
Facial spaces:
These areas are either clefts ( potential spaces between facial
layers ) or compartment containing connective tissue & various
anatomic tooth structures they are not voids in the tissues .
They are not voids in the tissues
These are not present in healthy people but become filled during
infections
When filled with loose areolar tisses , it is called clefts

12. CLASSIFICATION ACCORDING TO
TOPAZIAN:
1.Face
buccal
canine
masticatory
parotid
2.Suprahyoid
3. Infrahyoid
massetric
pterygoid
zygomatico temporal
sublingual
submandibular
sub maxillary
sub mental
lateral pharyngeal (pharyngo maxillary )
peritonsillar
anterovisceral (pretracheal)
4. Spaces of total neck
retropharyngeal
danger space
spaces of carotid sheath

13. CLASSIFICATION BY PETERSON
PRIMARY MAXILLARY SPACES
canine
buccal
infratemporal
PRIMARY MANDIBULAR SPACES
submental
buccal
submandibular
sublingual
SECONDARY FACIAL SPACES
pterygomandibular
massetric
superficial

14. SPACES ASSOCIATED WITH THE UPPER JAW
1. CANINE SPACE -- potential space present on the anterior
surface
of the maxilla between bone and canine fossa
musculature
BOUNDARIES –
Superiorly - limited by levator anguli oris and levator labii superioris
Inferiorly - limited by orbicularis oris
Anteriorly - lateral wall of nose
Posteriorly - communicates with buccal space
INFECTION - spreads from long canine root or upper first
premolar root
CONTENTS - Infraorbital nerve
CLINICAL FEATURES –
Swelling of the affected side upper lip , cheek upto the medial
canthus
of eye
Obliteration of naso labial fold
Drooping of angle of the mouth

15. 2.SUBPERIOSTEAL ABSCESS OF PALATE –
Palate is covered by tightly adherent
mucoperiosteum
Pus tends to accumulate between the periosteum
and bone
CLINICAL FEATURES –
Circumscribed , fluctuant swelling confined to one
side of the palate
May not discharge spontaneously
Doesn’t cross the midline
INFECTION –
From upper lateral incisors
Palatal pocket in premolars and molars
Infection of palatal root of upper molar

16. 3. BUCCAL SPACE –
BOUNDARIES –
Medially - buccinator muscle and buccopharyngeal
fascia
Laterally - skin of cheek and subcutanous tissue
Anteriorly - posterior border of zygomaticus major
above and depressor anguli oris below
Posteriorly - anterior edge of masseter muscle
Superiorly - zygomatic arch
Inferiorly - lower border of mandible
CONTENTS –
buccal fat pad
parotid duct
facial artery
SPREAD OF INFECTION –
through maxillary and mandibular molars

19. 4.INFRA TEMPORAL SPACE
upper extremities of pterygomandibular space
BOUNDARIES-
Laterally- ramus of the mandible
temporalis muscle
temporal fascia
Medially- lateral pterygoid plate,inferior portion of lateral
ptrygoid muscle & lateral pharyngeal wall
Superiorlly-infra temporal surface of greater wing of sphenoid
bone
Inferiorlly- lower head of lateral pterygoid muscle
Anteriorlly-infra temporal surface of maxilla,posterior surface of
zygomatic bone
CONTENTS -
ORIGIN OF PTERYGOID MUSCLE
PTERYGOID VENOUS PLEXUS

20. INFECTION-
FROM UPPER MOLARS
CONTAMINATED NEEDLE DURING PSA BLOCK
CLINICAL FEATURES-
SEVERE TRISMUS
BULDGING OF TEMPORALIS MUSCLE
THIS SITUATION IS DANGEROUS DUE TO THE COMMUNICATIO
PTERYGOID VENOUS PLEXUS WITH CAVERNOUS SINOUS THR
EMMISSORY VEINS.
SPACES ASSOCIATED WITH LOWER JAW
SUBMENTAL SPACE
–
- POTENTIAL SPACE PRESENT JUST BELOW THE
CHIN
REGION ON THE MEDIAL SURFACE OF THE MANDIBLE
BOUNDARIES
SUPERIORLY :– MYLOHYOID MUSCLE
INFERIORLY – INVESTING LAYER OF DEEP CERVICA
FASCIA,
PLETYSMA,SUPERFACIAL FACIA,SKIN
LATERALLY – LOWER BORDER OF THE MANDIBLE
ANTERIORLY BELLY OF DIAGESTRIC

21. CONTENTS:
-- SUBMENTAL LYMPH NODES
-- ADIPOSE TISSUE
INFECTION :
-- FROM LOWER ANTERIOR TEETH,LOWER LIP,SKIN OF THE CH
TIP OF THE TONGUE,ANTERIOR PART OF THE FLOOR OF THE MOUTH
SUBLINGUAL TISSUE
CLINICAL FEATURES:
FIRM CIRCUMSCRIBED SWELLING BENEATH THE TOUNGE
DISCOMFORT & DIFFICULTY IN SWALLOWING
SUB MANDIBULAR SPACE INFECTION
POTETIAL SPACE PRESENT ON THE MEDIAL SURFACE OF THE
POSTERIOR ASPECT OF THE MANDIBLE .
BOUNDRIES:
LATERALLY--- SKIN
--- SUPERFECIAL FASCIA
-- PLYTISMA
-- DEEP FASCIA

22. MEDIALLY :
-- MYLOHYOID MUSCLE
-- HYOGLOSSUS MUSCLE
-- STYLOGLOSSUS MUSCLE
INFERIORLY:
--ANTERIOR & POSTERIOR BELLY OF DIAGASTRIC
SUPERIORLY:
--MEDIAL ASPECT OF MYLOHYIOD
ANTERIORLY:
--MYLOHYIOD SPACE
POSTERIORLY:
--HYIOD BONE
CONTENTS:
--SUBMANDIBULAR SALIVARY GLAND & LYMPH NODE
--FACIAL ARTERY
--PROXIMAL PART OF WHARTON’S DUCT
--LINGUAL & HYPOGLOSSAL NERVE

25. INFECTION:
THE
-- INFECTED LOWER MOLAR APICES PRESENT BELOW THE
MYLOHYOID INSERTION
-- THE LOWER TEETH ,MAXILLARY SINUS,UPPER
MOLARS,C MIDDLE THIRD OF TONGUE & FLOOR OF
MOUTH DRAIN INTO SUBMANDIBULAR LYMPH NODE
CLINICAL FEATURES:
--SWELLING WHICH IS SOFT& BRAWNY EXTRA ORALLY
--ASSOCIATED WITH LOWER MOLAR INFECTION
SUBLINGUAL SPACE ::
--POTENTIAL SPACE PRESENT IN THE ANTERIOR PART OF THE
OF THE MOUTH
BOUNDARIES:
ANTERIORLY & LATERALLY- - MEDIAL SURFACE OF THE MIDL
MANDIBLE & BODY OF THE MAND
SUPERIORLY—SUBLINSGUAL MUCOSA,MYLOHYIOD
INFERIORLY– MYLOHYIOD MUSCLE
POSTERIORLY– HYIOD BONE
MEDIALLY– GENIOGLOSSUS,GENIOHYIOD,STYLOGLOSSUS MUS

26. ONLY LOOSE CONNECTIVE TISSUE SEPERATES RIGHT & LEFT
SUBLINGUAL SPACE
INFECTION MAY COME FROM LOWER ANTERIORS
LOWER PREMOLARS
LOWER FRIST MOLARS
CLINICAL FEATURES:
-- TONGUE IS RAISED
-- FIRM PAINFUL SWELLING IN THE ANTERIOR PART OF THE FLOOR
OF THE
MOUTH
-- SWELLING HAS SHINY GELETINOUS APPEARANCE
-- PAIN & DISCOMFORT ON SWELLING
-- ENLARGED SUBMENTAL & SUBMANDIBULAR LYMPH NODES

28. 6
Y
LUDWIG’S ANGINA::
DEFINITION – IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE
SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY
& OF THE SUBMENTALIS SPACE.
-- FRIST DISCRIBED BY WILHELM FREDREICH VON LUIDWIG IN
ETIOLOGY:
1. PERIAPICAL,PERICORONAL OR PERIODONTAL INFECTION
A LOWER THIRD MOLAR
2. TRAUMATIC INJURIES & INFECTED LESIONS
3. INFECTIVE CONDITIONS SUCH AS OSTEOMYELITIS
MENIFEST AS LUDWIG’S ANGINA
4. CYSTS OR TUMORS IN THIRD MOLAR REGION
PETHOLOGY:
1. INFECTION FROM LOWER THIRD MOLAR REACHES
THE SUBMANDIBULAR SPACES
2. FROM HERE INFECTION SPREADS ALONG THE
SUMANDIBULAR SALIVARY GLANDS ABOVE THE

29. FROM ONE SIDE OF THE SUBLINGUAL SPCE IT MOVES ACROSS THE
GENIOGLOSSUS MUSCLE AND REACHES THE SUBLINGUAL SPACES
ON OTHER
SIDE IT THEN CROSS ONCE THE MYLOHYIOD MUSCLE & REACH THE
OPPOSITE SIDE SUBMANDIBULAR SPACE.
SUBMENTAL SPACE GET INVOLVED VIA LYMPHATICS
SINCE IT IS CELLULITIS IT SPREADS RAPIDLY ALONG THE FACIAL
AND
TISSUE PLANES
IT SPREADS IN THE TONGUE POSTERIORLY ALONG THE COURSE OF
SUBLINGUAL ARTERY IN THE CLEFT BETWEEN THE GENIOGLOSSUS
AND GENIOHYOID MUSCLE PRODUCING OEDEMA OF LARYNGEAL
INLET
FROM SUBMANDIBULAR SPACE IT CAN PASS ALONG THE INVESTING
LAYER OF DEEP CERVICAL FASCIA ALONG THE ANTERIOR ASPECT
OF THE NECK TO THE CLAVICLE AND THE MEDIASTINUM

31. CLINICAL FEATURES SYSTEMIC FEATURES- PYREXIA , DEHYDRATION , DYSPHAGIA ,
DYSPNOEA , HOARSENESS OF VOICE AND STRIDOR
EXTRA ORAL FEATURES – HARD TO FIRM BROWNY INDURATED
SWELLING
SKIN OVER THE SWELLING APPEARS ERYTHMATOUS
AND STRETCHED
SWELLING IS TENDER WITH LOCAL RISE IN
TEMPERATURE
Difficulty in closing the mouth and drooling of saliva
Respiratory distress
INTRA ORAL FEATURES –
Trismus , floor of the mouth is raised , tongue raised upwards ,
increased salivation

32. MANAGEMENT -
1.Airway maintainence- Intubation is contraindicated
perforation may lead to aspiration of pus
Tracheostomy and Cricothyroidectomy is advisable
2. Parentral antibiotics - Penicillin antibiotic of choice
Amoxycillin + Cloxacillin
Metronidazole in anaerobic infection
3.Surgical decompression – performed under L.A
Decompression improves vascularity and potentiates the
action of antibiotics
Bilateral submandibular incision with a midline submental
incision pus should be drained
A drain is inserted and loose dressing is placed
4.Hydration of the patient –
It is necessary to put the pt on i.v. fluids
5. Removal of cause The offending tooth is removed

33. COMPLICATIONS –
Death due to airway compromise
septicemia
aspiration of pus
mediastinitis
carotid blow out
Masticatory space –
Potential space present around the muscle of mastication
a) SUBMASSETRIC SPACE
Present between the three layers of masseter muscles

34. BOUNDARIES –
Superiorly - zygomatic arch
Lateraly - masseter muscle
Medially - lateral aspect of the mandibular ramus
Inferiorly - attachment of masseter onto the lower border of the
mandible
INFECTION can spread from lower third molar
CLINICAL FEATURES –
external facial swelling confined to masseter muscle
complete trismus
acutely tender

35. b) Pterygomandibular space –
BOUNDARIES Medially –
medial pterygoid muscle
Laterally medial surface of the ramus of the mandible
Superiorly – lateral pterygoid
Posteriorly – deep lobe of the parotid gland
Inferiorly attachment of the medial pterygoid to the mandib
Anteriorly – pteygomandibular raphe
CONTENTS –
Inferior alveolar nerve and vessels
Lingual nerve
Loose areolar tissue
INFECTION FROM LOWER THIRD MOLAR
CLINICAL FEATURES –
Trismus
Intra oral swelling in the medial aspect of the ramus of the mandible

36. c). Temporal Space
Divided into  Superficial temporal space
 Deep temporal space
Superficial temporal space is between superficial temporal fascia
& lateral aspect of temporalis muscle
Deep temporal space is present between the medial surface of
the temporalis muscle & the periosteum of the temporal bone
Contents:
- vessels supplying the temporalis muscle
Clinical features:
- swelling confined to the shape of the muscle extending from
the lateral orbital rim, above the zygomatic arch, covering of
the lateral aspect

37. d). Lateral
pharyngeal space 
Synonyms  Parapharnygeal space
 Pharyngomaxillary space
Boundaries potential cone shaped space
 base is uppermost at the base of the skull
 apex is at the hyoid bone
Clinical features
- Pain on swallowing
- Trismus
- Tonsils & lateral pharyngeal wall are pushed to the midline
- No extra oral swelling
- It may lead to thrombophlebitis of internal jugular vein or
may cause carotid blowout

38. Peri tonsillar abscess:
Infection in connective tissue bed of the faucial tonsil
And can also be from the infection of the third molar
Clinical features
Acute pain in throat on the affected side which radiates to the ear
Dysphagia
Trismus
Awkward speech described as hot potato speech
Foul breath
Bulge in the soft palate on the affected site
SPACES IN THE NECK
Retropharyngeal Danger space and prevertebral spaces all lie between
deep cervical Fascia that surrounds the pharynx and oesophagus and
vertebral spine with its muscle attachments posteriorly

39. Principles of management of odontogenic
infections
Determine the severity of
infection
Evaluate host defense
Decide on the setting of care
Treat surgically
Support medically
Choose and prescribe antibiotic
therapy
Administer the antibiotic properly
Evaluate the patient frequently
1.Determine the severty of infection
A careful history and thorough physical examination to determine
the anatomic location, rate of progression and the potential for
airway compromise of a given infection.

40. 2.Evaluate host defenses
Immune system compromise:
diabetes,steroid therapy,organ transplant,malignancy
chemotherapy,chronic renal disease,malnutrition,
alcoholism,end –stage AIDS
Systemic reserve
The host response to severe infection can place a sever
physiologic load on the body.fever can increase fluid losses
and calori requirements.
A prolonged fever may cause dehydration , which can therefor
decrease cardiovascular resevers and deplete glycogen stores
shifting the body metabolism to a catabolic state.

41. 3. Decide on the setting of care
Indications for hospital care
temp.>101 F
dehydration,infection in moderate to severe anatomic spaces
threat to airway or vital structures
need for genral anesthesia
need for in patient controll of systemic disease
4.Treat surgically
Airway security
Surgical drainage:drainage of pus and removal of cause
An intra oral incision should be made through the mucous
membrane , parallel to the surface of alveolar bone

42. Hilton s method of incision and drainage
Method of incision and drainage esp. in head and neck rigion .
Technique:
1.Anesthesia is achieved by regional blocking or by topical
anesthesia by ethylchloride spray .
2.Ethylchoride is sprayed on the most flectuant part until
frosting occurs.
3.The incision is made through skin , superficial fascia ,muscle,
deep fascia parallel to the main nerves & vessels in closed
proximity to that area.
4.A sinus forceps is inserted through the incision towards the
area of pus collection .the forceps is closed when it is entered
into the tissues. Once it is inside ,it is gently opened up in a
direction parallel to the important structures .
5.The pus collected in that area flows along the beaks of the
sinus forceps.
6. The drain is secured to the skin by sutures .a loose dressing
is placed on the wound