This document discusses various orofacial infections and the fascial spaces they can involve. It begins with infections of the upper lip that can cause vestibular abscesses pointing towards the apex of the lateral incisor. Infections of the canine fossa from maxillary canine or premolar teeth cause swelling of the cheek and upper lip, obliteration of the nasolabial fold, and drooping of the angle of the mouth. Palatal and buccal space infections are also discussed. Cavernous sinus thrombophlebitis, a serious complication, is noted to potentially result from head and face infections above the maxilla. Treatment involves antibiotics, anticoagulants, and surgical

1. OROFACIAL INFECTION
- CHAPTER TWO –
FASCIAL SPACE INFECTION
DR. HAYDAR MUNIR SALIH ALNAMER
BDS, PHD (BOARD CERTIFIED)

2. POTENTIAL PRIMARY SPACES RELATED TO
UPPER JAW: UPPER LIP
• THE ABSCESS IS FORMED ON THE ORAL SIDE OF
ORBICULARIS MUSCLE; AND THEREFORE, IS A
VESTIBULAR ABSCESS, AND TENDS TO POINT IN THE
VESTIBULE
• THE DIRECTION IS GUIDED BY THE ORIGIN OF
ORBICULARIS ORIS MUSCLE, WHICH IS BENEATH
ANTERIOR NASAL SPINE. THIS RESULTS IN POINTING OF
THE ABSCESS TOWARDS THE APEX OF LATERAL

3. ABSCESS OF
UPPER LIP

4. DIFFERENTIAL DIAGNOSIS OF SWELLINGS OF UPPER
LIP
1. TRAUMA TO UPPER LIP:
2. TRAUMA TO UPPER INCISOR:
3. HYPERSENSITIVITY REACTION
4. CYSTS: CYSTS OF JAWS
5. NEOPLASMS:

5. UPPER LIP HYPERSENSITIVITY REACTION

6. NASOLABIAL CYST

7. CANINE FOSSA INVOLVEMENT
• THE TEETH WHICH FREQUENTLY GIVE RISE TO
ABSCESS IN THE AREA ARE THE MAXILLARY
CANINES AND PREMOLARS AND SOMETIMES THE
MESIOBUCCAL ROOT OF FIRST MOLARS. THE
PERIAPICAL ABSCESS DISCHARGES BUCCALLY
SUPERIOR TO THE ORIGIN OF THE LEVATOR
ANGULI ORIS MUSCLE AND PUS ACCUMULATES IN
THE CANINE FOSSA.

8. CANINE FOSSA INVOLVEMENT

9. CANINE FOSSA INVOLVEMENT
CLINICAL FEATURES:
• SWELLING OF CHEEK AND UPPER
LIP (VESTIBULAR ABSCESS).
• OBLITERATION OF NASOLABIAL
FOLD (PUS ACCUMULATES IN
CANINE FOSSA).
• DROOPING OF ANGLE OF THE
MOUTH.
• INTRAORAL: THE OFFENDING

10. CANINE FOSSA INVOLVEMENT

11. PALATAL ABSCESS
• PERIODONTAL ABSCESSES FROM PALATAL POCKETS
AND APICAL ABSCESSES FROM THE PALATAL
ROOTS OF THE POSTERIOR TEETH ARE THE SOURCE
OF PALATAL INFECTION. OCCASIONALLY THE
LATERAL INCISOR IS THE FREQUENT CAUSE, AS THE
INFECTION CAN MIGRATE POSTERIORLY, AS FAR AS
THE SOFT PALATE OWING TO THE MORE PALATAL
ORIENTATION OF IT’S ROOTS.
• A WELL-DEFINED CIRCUMSCRIBED FLUCTUANT
SWELLING IS SEEN, WHICH IS CONFINED TO ONE

12. PALATAL ABSCESS
• AN ANTEROPOSTERIOR
INCISION IS MADE
THROUGH THE MUCOSA,
DOWN TO THE BONE,
KEEPING IN MIND THE
COURSE OF GREATER
PALATINE NERVE AND

13. BUCCAL SPACE INVOLVEMENT
• BUCCAL SPACE IS THE POTENTIAL
SPACE BETWEEN BUCCINATOR
AND MASSETER MUSCLE.
• TEETH COMMONLY INVOLVED:
MAXILLARY AND MANDIBULAR
PREMOLARS AND MOLARS. THE
LOCATION OF THE ROOT TIP TO
THE LEVEL OF ORIGIN OF
BUCCINATOR MUSCLE
DETERMINES THE SPREAD OF
INFECTION EITHER INTRAORALLY
INTO THE VESTIBULE OR DEEP

14. BUCCAL SPACE INVOLVEMENT
CLINICAL FEATURES:
WHEN PUS ACCUMULATES ON ORAL
SIDE OF THE MUSCLE ‘GUM BOIL’ IS
SEEN IN THE VESTIBULE. IF PUS
ACCUMULATES LATERAL TO THE
MUSCLE, PROMINENT EXTRAORAL
SWELLING IS SEEN EXTENDING FROM
LOWER BORDER OF MANDIBLE TO THE
INFRAORBITAL MARGIN AND FROM
THE ANTERIOR MARGIN OF MASSETER
MUSCLE TO THE CORNER OF MOUTH.

15. INCISION AND DRAINAGE:
HORIZONTAL INCISION
THROUGH THE ORAL
MUCOSA OF THE CHEEK
IN THE PREMOLAR,
MOLAR REGION. IF THE
PUS IS LATERAL TO THE
MUSCLE, THEN THE
MUSCLE IS PENETRATED
WITH CURVED MOSQUITO
FORCEPS TO ENTER THE
BUCCAL SPACE. DRAIN IS
PLACED AND SECURED
WITH SUTURE.

16. INFRATEMPORAL FOSSA SPACE
• THE INFRATEMPORAL FOSSA FORMS THE UPPER
EXTREMITY OF PTERYGOMANDIBULAR SPACE.
• INVOLVEMENT:
(i) INFECTIONS OF THE INFRATEMPORAL SPACE ARISE
FROM THE INFECTION OF THE BUCCAL ROOTS OF THE
MAXILLARY SECOND AND THIRD MOLARS,
PARTICULARLY, FROM UN ERUPTED THIRD MOLARS,
AND
(ii) LOCAL ANESTHESIA INJECTIONS WITH CONTAMINATED
NEEDLES IN THE AREA OF TUBEROSITY,
(iii)SPREAD FROM THE OTHER SPACES INFECTION.

17. INFRATEMPORAL FOSSA SPACE: BOUNDARIES
• LATERALLY, BY RAMUS OF
MANDIBLE, TEMPORALIS
MUSCLE
• MEDIALLY, MEDIAL PTERYGOID
PLATE, LATERAL PTERYGOID
MUSCLE,
• SUPERIORLY BY
INFRATEMPORAL SURFACE OF
GREATER WING OF SPHENOID
• INFERIORLY, LATERAL
PTERYGOID MUSCLE, WHICH

18. INFRATEMPORAL FOSSA SPACE: CLINICAL
FEATURES
(i) TRISMUS: MARKED LIMITATION OF
ORAL OPENING,
(ii) (II) BULGING OF TEMPORALIS
MUSCLE,
(iii) (III) MARKED SWELLING OF THE
FACE ON THE AFFECTED SIDE IN
FRONT OF THE EAR, OVERLYING
THE AREA OF THE
TEMPOROMANDIBULAR JOINT,
BEHIND THE ZYGOMATIC
PROCESS.

19. INFRATEMPORAL FOSSA SPACE: INCISION
AND DRAINAGE

20. POTENTIAL PRIMARY SPACES RELATED TO LOWER
JAW
SUBMENTAL SPACE
• IT IS INVOLVED MOST FREQUENTLY BY THE INFECTIONS
ORIGINATING FROM THE SIX ANTERIOR MANDIBULAR
TEETH; THEN PERFORATE THE CORTICAL PLATE BELOW
THE ORIGIN OF MENTALIS MUSCLE LABIALLY; AND
MYLOHYOID LINGUALLY
• THE SPACE CAN BE SECONDARILY INVOLVED DUE TO
INFECTION OF SUBMENTAL LYMPH NODES

21. SUBMENTAL SPACE: BOUNDARIES
Lateral: Lower border of
mandible, and anterior bellies
of digastric muscle.
Superior: Mylohyoid muscle.
Inferior: Suprahyoid portion of
the investing layer of deep
cervical fascia,

22. SUBMENTAL SPACE: CLINICAL FEATURES
• DISTINCT, FIRM SWELLING IN
MIDLINE, BENEATH THE
CHIN. SKIN OVERLYING THE
SWELLING IS BOARD LIKE
AND TAUT. FLUCTUATION
MAY BE PRESENT.
• THE OFFENDING TOOTH
MAY EXHIBIT TENDERNESS
TO PERCUSSION AND MAY
SHOW MOBILITY

23. SUBMENTAL SPACE: DRAINAGE

24. SUBMANDIBULAR SPACE INFECTION
• THE SPACE LIES BETWEEN THE ANTERIOR AND
POSTERIOR BELLIES OF THE DIGASTRIC MUSCLES.
THE UPPER PART LIES BENEATH THE INFERIOR
BORDER OF MANDIBLE AND THE LOWER PART LIES
DEEP TO THE INVESTING LAYER OF DEEP CERVICAL
FASCIA. THE SUBMANDIBULAR SPACES ARE
CONSIDERED TO BE THE ANTERIOR EXTENSIONS
OF PARAPHARYNGEAL SPACE

25. SUBMANDIBULAR TRIANGLE ANATOMY

26. SUBMANDIBULAR SPACE INFECTION :
INVOLVEMENT
(I) IT IS INVOLVED MOST FREQUENTLY BY INFECTIONS
ORIGINATING FROM THE MANDIBULAR MOLARS. THE PUS
PERFORATES THE LINGUAL CORTICAL PLATE OF MANDIBLE,
INFERIOR TO THE ATTACHMENT OF MYLOHYOID MUSCLE, AND
PASSES DIRECTLY INTO THE SUBMANDIBULAR SPACE.
(II) THE INFECTION FROM THE SUBMANDIBULAR SALIVARY GLAND
MAY PASS VIA LYMPHATICS TO THE SUBMANDIBULAR LYMPH
NODES.
(III) IT IS ALSO INVOLVED, AS AN EXTENSION OF INFECTION FROM

27. SUBMANDIBULAR SPACE INFECTION :
INVOLVEMENT
(IV) IT IS ALSO INVOLVED BY AN INFECTION
ORIGINATING FROM THE POSTERIOR PART OF
SUBLINGUAL SPACE.
(V) IT IS ALSO INVOLVED FROM INFECTION ORIGINATING
FROM MIDDLE THIRD OF THE TONGUE, POSTERIOR PART
OF THE FLOOR OF THE MOUTH, MAXILLARY TEETH,
CHEEK, MAXILLARY SINUS AND PALATE.

28. SUBMANDIBULAR SPACE INFECTION

29. SUBMANDIBULAR ABSCESS: CLINICAL
FEATURES
(I) FIRM SWELLING IN
SUBMANDIBULAR REGION,
BELOW THE INFERIOR
BORDER OF MANDIBLE. (II)
GENERALIZED
CONSTITUTIONAL
SYMPTOMS, (III) SOME
DEGREE OF TENDERNESS, (IV)
REDNESS OF OVERLYING

30. SUBMANDIBULAR SPACE INFECTION:
TREATMENT
AN INCISION OF ABOUT 1.5 TO 2
CM LENGTH IS MADE 2 CM
BELOW THE LOWER BORDER OF
MANDIBLE, IN THE SKIN CREASES.
SKIN AND SUBCUTANEOUS
TISSUES ARE INCISED. A SINUS
FORCEPS IS INSERTED THROUGH
THE INCISION SUPERIORLY AND
POSTERIORLY ON THE LINGUAL
SIDE OF THE MANDIBLE BELOW
THE MYLOHYOID TO RELEASE PUS

31. SUBLINGUAL SPACE INFECTION
• THIS SPACE IS A V-SHAPED TROUGH LYING LATERAL TO
MUSCLES OF TONGUE, INCLUDING HYOGLOSSUS,
GENIOGLOSSUS AND GENIOHYOID.
• THE TEETH WHICH FREQUENTLY GIVE RISE TO
INVOLVEMENT OF SUBLINGUAL SPACE ARE THE
MANDIBULAR INCISORS, CANINES, PREMOLARS AND
SOMETIMES FIRST MOLARS. THE APICES OF THESE TEETH
ARE SUPERIOR TO THE MYLOHYOID MUSCLE.
• IT IS A PAIRED SPACE; BUT THE TWO SIDES COMMUNICATE

32. SUBLINGUAL SPACE INFECTION

33. SUBLINGUAL SPACE INFECTION
Firm, painful swelling seen in the
floor of the mouth on the affected
side. The floor of the mouth is
raised. The tongue may be pushed
superiorly. This will bring about
airway obstruction. The ability to
protrude the tongue beyond the
vermillion border of upper lip is
affected

34. LUDWIG'S ANGINA
• WILHELM FREDERICK VON
LUDWIG 1836
• ANGINA : CHOCKING AND
SUFFOCATION

35. LUDWIG'S ANGINA
• THIS ACUTE CELLULITIS INFECTION IS DESCRIBED AS INVOLVING THE TISSUES OF
THE FLOOR OF THE MOUTH ON BOTH SIDES. THE INFECTION IS DENTAL IN
ORIGIN IN ABOUT 90% OF CASES THE TEETH MOST COMMONLY IMPLICATED ARE
THE SECOND AND THIRD MANDIBULAR MOLARS.

36. LUDWIG'S ANGINA
• THE CLINICAL FEATURES ARE THOSE OF SYSTEMIC
TOXICITY, WITH A BOARD LIKE SWELLING ACROSS THE
UPPER NECK FROM ANGLE TO ANGLE WITHIN THE
SUPRAHYOID REGION AND SWELLING WITHIN THE FLOOR
OF THE MOUTH, WHICH RAISES THE POSITION OF THE
TONGUE. THE SKIN IS RED AND INFLAMED; PITTING
EDEMA MAY BE PRESENT
• THE MORTALITY WAS ABOUT 75%; WITH AGGRESSIVE
EARLY TREATMENT WITH SURGICAL DECOMPRESSION

37. LUDWIG'S ANGINA

38. MASTICATORY SPACES
(I) PTERYGOMANDIBULAR,
(II) SUBMASSETERIC,
(III) TEMPORAL—SUPERFICIAL
TEMPORAL, AND
(IV) DEEP TEMPORAL OR
SUBTEMPORAL SPACES
• MASTICATORY SPACES ARE
DIVIDED INTO TWO BY THE RAMUS
OF MANDIBLE:
I. LATERAL COMPARTMENT

39. SUBMASSETERIC SPACE
• MASSETER CONSISTS OF THREE LAYERS, WHICH ARE
FUSED ANTERIORLY, BUT CAN BE EASILY SEPARATED
POSTERIORLY. THERE IS POTENTIAL SPACE IN THE
SUBSTANCE OF THE MUSCLE BETWEEN THE MIDDLE AND
THE DEEP HEADS, WHILE THE BONY INSERTION IS FIRM
ABOVE AND BELOW, THE INTERMEDIATE FIBERS HAVE
ONLY A LOOSE ATTACHMENT

40. SUBMASSETERIC SPACE: ANATOMY

41. SUBMASSETERIC SPACE: INVOLVEMENT
• INFECTION USUALLY
ORIGINATES FROM THE
LOWER THIRD MOLARS
• THE PRESENCE OF
BUCCINATOR ATTACHMENT
PROBABLY DISCOURAGES
BACKWARD EXTENSION OF
PERICORONAL INFECTION,
WHERE THIRD MOLAR CROWN

42. SUBMASSETERIC SPACE: CLINICAL FEATURES
External facial swelling is
moderate in size; and is
confined to the outline of the
masseter muscle
There is almost complete
limitation of mouth
opening. Fluctuation may
be absent;

43. SUBMASSETERIC SPACE INFECTION DRAINAGE

44. PTERYGOMANDIBULAR SPACE INFECTION
• DO NOT CAUSE MUCH
SWELLING OF FACE OVER THE
SUBMANDIBULAR REGION.
• THERE IS SEVERE DEGREE OF
LIMITATION OF MOUTH
OPENING.
• DYSPHAGIA IS PRESENT.
• MEDIAL DISPLACEMENT OF THE
LATERAL WALL OF THE
PHARYNX,

45. PTERYGOMANDIBULAR SPACE INFECTION

46. CAVERNOUS SINUS THROMBOPHLEBITIS
IT IS A SERIOUS CONDITION CONSISTING OF
FORMATION OF THROMBUS IN THE CAVERNOUS
SINUS OR ITS COMMUNICATING BRANCHES.
INFECTION OF HEAD, FACE AND INTRAORAL
STRUCTURES ABOVE THE MAXILLA, PARTICULARLY,
LEAD TO THIS DISEASE.

47. CAVERNOUS SINUS THROMBOPHLEBITIS

48. CAVERNOUS SINUS THROMBOPHLEBITIS:
INTERNAL SYSTEM

49. CAVERNOUS SINUS THROMBOPHLEBITIS:
DANGER AREA OF THE FACE

50. CAVERNOUS SINUS
THROMBOPHLEBITIS:
1. SWELLING OF THE FACE,
WITH EDEMATOUS
INVOLVEMENT OF THE
EYELIDS. PAIN IN THE EYE
AND TENDERNESS TO
PRESSURE
2. MARKED EDEMA AND
CONGESTION OF EYELIDS

51. CAVERNOUS SINUS
THROMBOPHLEBITIS:
4. PULSATING EXOPHTHALMOS
5. PTOSIS AND DILATION OF
PUPIL, EXOPHTHALMUS,
PHOTOPHOBIA WITH PROFUSE
LACRIMATION AND PAIN IN
THE DISTRIBUTION OF THE
OPHTHALMIC DIVISION OF
THE 5TH NERVE
6. RETINAL HEMORRHAGES

52. CAVERNOUS SINUS THROMBOPHLEBITIS:
TREATMENT
i) ANTIBIOTIC THERAPY:
ii) HEPARINIZATION, TO PREVENT EXTENSION OF THROMBOSIS,
iii) NEUROSURGICAL CONSULTATION.
(IV) MANNITOL: IT REDUCES EDEMA,
(V) ANTICOAGULANTS: IT PREVENTS VENOUS THROMBOSIS.
(V) SURGICAL DRAINAGE.