Dr. Giuseppe Bruno PitassiDr. Giuseppe Bruno PitassiDoctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987Doctor Medicine & Surgery – (State DMS) – Napoli (Italy) 1987Dental Surgeon – Napoli – (Italy) 1989Dental Surgeon – Napoli – (Italy) 1989Specialist Maxillofacial Surgery – Napoli – (Italy) 1992Specialist Maxillofacial Surgery – Napoli – (Italy) 1992Pg/Cert. Clinical Periodontology -Bari (Italy) 1999Pg/Cert. Clinical Periodontology -Bari (Italy) 1999

Acute infection of Acute infection of oral & para-oral oral & para-oral

tissuestissues((Peri-mandibular and maxillary abscesses & phlegmonsPeri-mandibular and maxillary abscesses & phlegmons))

Clinical definition

Group of infections originating mainly but not only from Group of infections originating mainly but not only from dental & periodontal structures caused by the invasion dental & periodontal structures caused by the invasion and proliferation of pathogenic microrganisms within the and proliferation of pathogenic microrganisms within the soft tissues of the oro-maxillofacial region.soft tissues of the oro-maxillofacial region.

They may likewise be defined as: They may likewise be defined as:

““Peri-mandibular & maxillary abscesses and phlegmonsPeri-mandibular & maxillary abscesses and phlegmons””

with reference to the tissues of the oral & maxillofacial with reference to the tissues of the oral & maxillofacial region that are usually affected by this pathology.region that are usually affected by this pathology.

(Valletta G.C. -1987)

Classification of oral & para-oral infections

Odontogenic 92~94%(Scmelzel & Schwenzer -1988)

-Periapical periodontitis

-Pericoronitis/tooth retention

-Marginal periodontitis

-Infected odontogenic cysts & granulomas

Non-odontogenic 6~8%(Lopez-Perez, Aguillar & Gimenez -2006)

-Infected fracture gaps

-Infected soft tissue wounds or tumours

-Inflammatory skin/mucous membrane disorders

-Adeno-Phlegmons

-Hematogenous or lymphogeneous spreading

-Peri-tonsillar abscesss

-Paranasal sinuses

-Infected retained root fragments

-Infections after tooth extractions

Beware of malignacy presenting as an infections

-Dry socket complications

EtiopathogenesisEtiopathogenesis

““Causes of Acute Infections of Oral and Para-Oral  TissuesCauses of Acute Infections of Oral and Para-Oral  Tissues””

MicrobiologyMicrobiology

The bacteria causing odontogenic infections are mostly from the endogenous normal flora (bacteria normally in the oral cavity of the normal person),when these bacteria gain access to the deeper underlying tissues as through a necrotic pulp or deep periodontal pocket, they cause odontogenic infections.

The oral cavity supports the most complex enviromental population of bacteria in the human body, between 300 to 500 different bacteria strains.

Etiopathogenesis

95%95% of “of “Acute Infections of Oral & Para-oral tissuesAcute Infections of Oral & Para-oral tissues” ” are due to a multi-microbial originare due to a multi-microbial origin

60%60% originate only by anaerobic bacteriaoriginate only by anaerobic bacteria

35%35%  have mixed flora composed  have mixed flora composed by a miscellany of by a miscellany of aerobic and anaerobic bacteria with a prevalence aerobic and anaerobic bacteria with a prevalence of anaerobic 4:1 of anaerobic 4:1

5%5%  originate only by aerobic bacteria  originate only by aerobic bacteria

(Montagna & Piras 2005)(Montagna & Piras 2005)

The bacteria strains involved in the pathogenesis of the Oro-facial infections depend also on the pathologies of origin.

-Streptococcus mutans-Streptococcus sobrinus-Streptococcus milleri-Rods Gram- (aerobics   & anaerobics)

Necrotic Pulpitis &Periapical periodontitis

-Actinobacillus actinomycetemcomitans-Prevotella oralis (bacterioides)-Porphyromonas gingivalis-Fusobacterium nucleatum-Eikenella corrodens

Marginal Periodontitis/Periodontal abscess

-Streptococcus mutans oralis-Enterococcus fecalis-Bacterioides forsythus-Fusobacterium nucleatum-Porphyromonas gingivalis-Prevotella intermedia

Pericoronaritis

The bacteria anaerobics Gram+ as “Bacterioides & Fusobacteria” for their characteristics are associated with greater frequency to more severe oral & para-oral infections. Typically they produce malodorous suppurations and promote the spread of abscesses and phlegmons due to the production and secretion of exoenzymes as collagenase and fibrinolisine.

The bacteria involved in  the periapical abscesses, also change  in relation to the persistence time  of the infection. In the initial phase, about the first 3 days after the onset of the infection, Cocci aerobics Gram+ predominates, they are sensitive to Penicillins. In the late phase, on the contrary, as a result of the affected tissues necrosis and the shortage in oxygen concentration is evident a prevalence of “Cocci anaerobic Gram+”, sensitive to Metronidazole.

Odontogenic infections

Odontogenic infections have three major originsOdontogenic infections have three major origins::

1- Periapical ~70% 1- Periapical ~70% (Periapical periodontitis)(Periapical periodontitis) As result of pulpar necrosis and subsequental bacterial As result of pulpar necrosis and subsequental bacterial invasion into periapical tissues.invasion into periapical tissues.

2- Periodontal ~20% 2- Periodontal ~20% (Marginal periodontitis)(Marginal periodontitis) AAs a result of rapidly-growing bacterial within a s a result of rapidly-growing bacterial within a periodontal pocket which becomes deeper allowing periodontal pocket which becomes deeper allowing bacterial invasion of underlying tissues.bacterial invasion of underlying tissues. 3- Pericoronitis ~10%3- Pericoronitis ~10% Is a common problem in young adults (15~25 yrs.) it is an Is a common problem in young adults (15~25 yrs.) it is an inflammatory reaction of the “operculum”, this is the inflammatory reaction of the “operculum”, this is the dense, fibrous flap that covers about 50% of the biting dense, fibrous flap that covers about 50% of the biting surface usually of the lower wisdom tooth, when it is surface usually of the lower wisdom tooth, when it is partially or completely erupted. The infection occurs partially or completely erupted. The infection occurs when the third molar start erupting, at this moment the when the third molar start erupting, at this moment the operculum and tissue around the wisdom toperculum and tissue around the wisdom tooth becomes ooth becomes inflammed because bacteria invade the area. Poor oral inflammed because bacteria invade the area. Poor oral hygiene and mechanical masticatory trauma on nearby hygiene and mechanical masticatory trauma on nearby tissue can facilitate this inflammation. tissue can facilitate this inflammation.

Dento-alveolar abscessDento-alveolar abscess

“Primum movens” for the formation of an oro-facial infection is the penetration, the invasion and finally the proliferation of bacteria, commonly found into buccal cavity within the para-dental tissues through a lesion of the integrity and the impairement of the seal function of the dental and periodontal structures.

The pathogenic micro-organism gain access into the periapical tissues through any of the following routes:

1-Infected or necrotic pulp of a carious tooth, traumatized tooth, or after traumatic exposure and contamination of the pulp of a tooth during cavity preparation (iatrogenic).

2-Trough the crevice of a gingival wound located in a deeply infected pocket in periodontally diseaded tooth 3- Extension of infection from adjacent infected tooth.

4- As progression of infection from the peri-coronal tissue to the deep tissues of the mandible and maxilla.

Enamel

Dentine

Pulp

Cementum

Dental Structures

Root

Alveolar bone

Gingival

Periodontal ligament

Vascular-nervous bundle

Root apex & Apical foramen

PERIODONTAL

STRUCTURES

Support and damping structure

Two examples of marginal periodontitisprobably evolving in periodontal abscess

Two examples of Pericoronal infection/Pericoronaritisand retained 3th. wisdom/molars

Pa x-ray periapical abscess

Pa x-ray image of periodontal

abscess

OPG X-ray pericoronritis

abscess

Pathways of odontogenic infectionsBacteria from tooth deep decay

invade the pulp therein proliferate

Activation of host inflammatory reaction into pulpal tissue

Hypoxia if prolonged over time causes pulpal necrosis

Pulpal abscess formation

Vasodilatation and development of inflammatory exudate

Oedema increasing and intra-pulpal pressure rise

Extravasation of the abscess in the periapical tissues

Collapse of the intra-pulpal local microcirculation

Pulpal bacterial invasion

1) Intra-dental stage

Pulpal necrosis

2) Intra-dental stage

Collection of purulent fluid within periodontal apical space

Acute Apical Periodontitis

Liquefactive necrosis of the dental pulp

1) Extra-dental stage

Progression to medullary space infections and osteomielitis.

Sub-periosteal Dentoalveolar Abscess

2) Extra-dental stage

More commonly, such pus collections get fistulous tract through alveolar bone that may pass through oral mucosa and/or facial skin draining toward outside

Suppurative Apical Periodontitis “open”

1) Extra-osseous stage

Local symptoms. The severity of the pain depends on the stage of development of the inflammation In the initial phase the pain is dull and continuous and worsens during percussion of the responsible tooth or when it comes into contact with antagonist teeth.If the pain is very severe and pulsates, itmeans that the accumulation of pus is still within the bone or below the periosteum. There is a sense of elongation of the responsible tooth and slight mobility; the tooth feels extremely sensitive to touch, while difficulty in swallowing is also observed.

Periapical abscess

Sub-periosteal infiltration

Fistulous tract alveolar bone

Endosteal infiltration

Abscess

Cellulitis\Phlegmon

Once established infection may spread and this is governed by hosts and Pathogenes factors.Local anatomy is an important host factor and in this regard is possible to assert that “Infection may spread by one of three routes:

- By continuity through tissue spaces and planes

- By way of lymphatic sistem (Acute lymphangitis and lymphadenitis)

-By way of bloodstream circulation (Bacteriemia)As regards the infections affecting the oral and para-oral tissues is extremly important the routes of spread by continuity through tissues, spaces and planes.Taking into consideration that in this case the infection spreads flowing along routes of minor resistance and also that the progression of the infection is determined between the relationship of the muscle insertion to the bone and the point where infection perforate the bone

Some muscles of mastication involving the mandible that will Some muscles of mastication involving the mandible that will form plans and anatomical spaces in the face and upper neckform plans and anatomical spaces in the face and upper neck

Spaces involved in odontogenic infections

Primary maxillary spacesAbscess of base of the upper lipCanineBuccalInfratemporal

Primary mandibular spacesSubmentalBuccalSubmandibularSublingual

Secondary fascial spacesMassetericPterygomandibularSuperficial and deep temporalLateral pharyngealRetropharyngealPrevertebral

a

Infections of the base of the upper lip usually results from infected anterior teeth leading to swelling and protrusion of the upper lip, usually accompanied by obliteration the mucolabial fold.

N.B. the base of the upper lip is a dangerous region because it may lead to “CAVERNOUS SINUS THROMBOSIS”. Therefore, early diagnosis is essential to prevent this complications.

Abscess of base of the upper lip

Canine space abscess

The Canine space lies between the levator anguli oris and levator labii superioris muscles.

The source of infection of this space is usually from infected long canine roots (subsequently to erosion of labial plate superior to the origin of levator anguli oris muscle).

Clinically, infection of this space leads to swelling of the anterior face with obliteration of the nasolabial fold. Severe cases leads to edema of upper and lower eyelids and may close the eye.

Canine space abscess

Buccal space abscess

The buccal space is bounded by the overlying skin of the face on the lateral aspect and the buccinator muscle medially.The buccal space becomes involved from maxillary molar teeth when infection erodes through the bone superior to the attachment of the buccinator muscle.The buccal space may also become infected from the infected mandibular molar

Buccal space abscess

Buccal space abscess

Signs and symptoms

Extraoral swelling of the cheek area between the zygomatic arch and inferior border of the mandible

The swelling protrudes into the mouth with severe throbbing pain.

Infratemporal space abscess

Anatomic Location: The space in which this abscess develops is the superior extension of the pterygomandibular space. Laterally, this space is bounded by the ramus of the mandible and the temporalis muscle,while medially, it is bounded by the medial and lateral pterygoid muscles. The Infratemporal space is rarely infected but when it is, the cause is usually an infection of the maxillary third molar.

Infection of this space may result due to infected infiltration anesthesia of maxillary nerve.

Infratemporal space abscess

Signs and symptoms Trismus and pain during opening of the mouth with lateral deviation towards the affected side, edema at the region anterior to the ear which extends above the zygomatic arch, as well as edema of the eyelids are observed

Submental space abscess

This space is bounded superiorly by the mylohyoid muscle, laterally and on both sides by the anterior belly of the digastric muscle, inferiorly by the superficial layer of the deep cervical fascia that is above the hyoid bone, and finally, by the platysma muscle and overlying skin. This space contains the anterior jugular vein and the submental lymph node

Submental space is primarily infected by mandibular incisors, which are long to allow the infection to erode through the labial plate apical to attachment of mentalis muscle.

Other origin for infection of that space is symphyseal fracture.

Signs and symptoms

Firm swelling under the chin in the submental area

Discomfort on swallowing

The abscess may extend posterioly to the submandibular space, and also may extend posteriorly to the submandibular space and also may extend to submental space of the other side.

Mandibular molar teeth infection erode through the lingo-cortical bone, more frequent than anterior teeth.

1st Mandibular molar will drain buccally or lingually.

2nd Mandibular molar can perforate either buccally or lingually but usually lingually.

3rd Mandibular molar infection almost always erode through the linguo-cortical plate.

Spread of infection from mandibular molars

The mylohyoid muscle will determine whether infections that drain lingually

go into

If above the mylohyoid muscle the ,infection localizes sublingually, if below the attach, of the muscle, the infection localizes instead into submandibular space.

Sublingualspace

Submandibularspace

Lateral diagrammatic illustration showing the localization of infection above or belowthe mylohyoid muscle, depending on the position of the apices of the responsible tooth

Line of insertion of the mylohyoid muscleLine of insertion of the mylohyoid muscle

Sublingual space abscess

Sublingual space lies between:

-Oral mucosa from above.

-Mylohyoid muscle below

-Lingual surface of the mandible laterally

Sub-mandibular space abscess

Submandibular space is bounded laterally by the inferior border of the body of the mandible, medially by the anterior belly of the digastric muscle, posteriorly by the stylohyoid ligament and the posterior belly of the digastric muscle, superiorly by the mylohyoid and hyoglossus muscles, and inferiorly by the superficial layer of the deep cervical fascia. This space contains the submandibular salivary gland and the submandibular lymph nodes.

Sub-mandibular space abscess

Signs and symptoms The infection presents as moderate swelling at theSub-mandibular area, which spreads, creating greater edema that is indurated with redness of the overlying skin. Also, the angle of the mandible is obliterated. There is pain during palpation and moderate trismus due to involvement of the medial pterygoid muscle are.

Ludwig's angina

When there is bilateral involvement of the submandibular /submental & sublingual space, the infection is termed Ludwig's angina

Ludwig's angina

Sign and Symptoms It is a rapidly fulminating massive brawny hard cellulitis affecting the submandibular, submental & sublingual spaces bilaterally.

There is almost always severe swelling with elevation and anterior displacement of the tongue. The patient usually has trismus, drooling of saliva, with difficulty in swallowing and breathing.This infection may progress rapidly producing upper airway obstruction often leads to death.

The submasseteric space abscess

The submasseteric space is located on the lateral surface of the mandibular ramus, between the deep and superfacial fibers of the masseter muscle.

Posteriorly it is bounded by the parotid gland, and anteriorly it is bounded by the mucosa of the retromolar area.

Infection of this space usually originate from the infection around the crown of the mandibular third molars (pericoronitis),

Signs and symptomsIt is characterized by a firm edema that is painful to pressure in the region of the masseter muscle, which extends from the posterior border of the ramus of the mandible as far as the anterior border of the masseter muscle. Also, severe trismus and an inability to palpate the angle

of the mandible are observed Intraorally, there is edema present at the retromolar area and at the anterior border of the ramus.

The sub-masseteric space abscess

Pterygomandibular space abscess

This space is bounded laterally by the medial surface of the ramus of the mandible, medially by the medial pterygoid muscle, superiorly by the lateral pterygoid muscle, anteriorly by the pterygomandibular raphe, and posteriorly by the parotid gland

Etiology

- Infections of molar teeth especially third molar.

- Septic inferior alveolar nerve block with contaminated needle or anesthetic solution.

- Spread of infection from the infratemporal space

- Compound fracture of the angle of the mandible.

Pterygomandibular space abscess

\

Signs and symptoms

Severe trismus and slight extraoral edema beneath the angle of the mandible are observed. Intra-orally, edema of the soft palate of the affected side is present, and there is displacement of the uvula and lateral pharyngeal wall, while there is difficulty in swallowing.

Pterygomandibular space abscess

The lateral pharingeal space

Anatomic Location. conical shaped, with the base facing the skull while the apex reashes the hyoid bone. It is lateral to the lateral wall of the pharynx and medial to the medial pterygoid muscle .

Etiology. Infections of this space originate in the region of the third molar and are the result of spread of infection from the submandibular and pterygomandibular spaces.

Sign and symptoms: Extraoral edema at the lateral region of the neck that may spread as far as the tragus of the ear, displacement of the pharyngeal wall, tonsil and uvula towards the midline, pain that radiates to the ear, trismus, difficulty in swallowing, significantly elevated temperature, and generally malaise are noted

Retropharingeal space abscess

Anatomic Location. The retropharyngeal space is located posterior to the soft tissue of the posterior wall of the pharynx and is bounded anteriorly by the superior pharyngeal constrictor muscle and the associated fascia, posteriorly by the prevertebral fascia, superiorly by the base of the skull, and inferiorly by the posterior mediastinum .

Etiology. Infections of this space originate by spread of the infection from the lateral pharyngeal space, which is close by.

Sign and symptoms:

The same symptoms as those present in the lateral pharyngeal abscess appear clinically, with even greater difficulty in swallowing due to edema at the posterior wall of the pharynx. If it is not treated in time, there is a risk of:

Obstruction of the upper respiratory tract, due to displacement of the posterior wall of the pharynx anteriorly.

Rupture of the abscess and aspiration of pus into the lungs.

Spread of infection into the mediastinum.

Retropharingeal space abscess

Principles of surgical therapyPrinciples of surgical therapy

Incision and drainage of upper lip abscess

Incision and drainage of canine space abscess

Incision and drainage of infratemporal abscess

Incision at the depth of the vestibularfold for incision and drainage of an infratemporal abscess

Incision and drainage of canine space abscess

Incision and drainage of submental space abscess

Incision and drainage for the sub-mental abscess

Incision and drainage of the sub-mandibular space abscess

Incision and drainage of pterygo-mandibular space abscess

Incision and drainage for case of Ludwig's angina

Tank you For your attention

Napoli (Italy)