Orofacial inflamations History •“Ubi pus, ibi evacuo” •Pre-antibiotic period – mortality 10-40% •Discovery ATB decrease of incidence, morbidity and mortality •Lastly, the increase of resistance to antibiotics increases the incidence of maxillary inflammations • Pre-antibiotic era - mortality 10-40% The discovery of antibiotics fell incidence, severity, morbidity and mortality odontogenic infections Lastly, the increase in resistance to antibiotics increases the incidence of maxillary inflammations period Terminology •infection •odontogenous •periodontitis •periodontitis •abscess •phlegmona •intraoral incision (i. o. incision) •extraoral incision (e. o. incision) Etiopathogenesis orofacial inflamations •Routes of infection - per continuitatem - lymphatic pathways - blood vessels pathways Routes of infection per continuitatem lymphatic pathways blood vessels Etiopathogenesis orofacial inflamations (3 most common reasons) •1. devital tooth (70%) – acute exacerbation of chronic periodontitis •2. inflammation of alveolus after tooth extraction •3. dentitio difficilis • Etiopathogenesis orofacial inflamations 6-%20eo.jpg Etiopathogenesis orofacial inflamations po%20extr-8%20io.jpg Etiopathogenesis orofacial inflamations dent%20diff%20-8%20io.jpg Etiopathogenesis orofacial inflamations • 4. suppurating cyst 5. osteomyelitis of jaw bone 6. parodontosis 7. local anesthesia - or nerve-block anesthesia infiltration 8. fractures of the jaw bones 9. sialoadenitis 10. tonsillitis 11. purulent skin lesion 12. infectious diseases suppurating cyst 5th osteomyelitis of jaw bone 6th parodontosis 7th injection anesthesia - or nerve-block anesthesia infiltration 8th fractures of the jaw bones 9th sialoadenitis 10th tonsillitis 11th purulent skin lesion 12th infectious Diseases Odontogenous infection •Polymicrobial - a combination of aerobes, facultative anaerobes and strict anaerobes Streptococcus viridans Peptostreptococcus Prevotella Fusobacterium • streptococcus%20viridans.jpg Acute (apical) periodontitis, periodontitis acuta •In typical cases of acute apical periodontitis occurs in four phases: 1. Periodontal 2. Enoseal 3. Periosteal 4. Submucous • Clinical manifestations •Rubor- Erythema •Erythema of the inflamation area due to •vasodilatation •and hyperemia • rubor.jpg Clinical manifestations •Tumor- swelling •swelling caused by inflammatory edema and vasodilation tumor%202.jpg Clinical manifestations •Dolor- bolest • Inflammatory pain arises stimulation of peripheral nerve endings - acidic pH, cytokines •Calor- elevation of temperature locally we can palpate warmer area Clinical manifestations •Functio laesa - impaired function Inflamation can damage the function of the closer organs • • • •Trismus functio%20leasa.jpg Clinical manifestations •Systemic symtoms: • Fever • Increased sedimentation of erytrocytes Leukocytosis Increased levels of CRP Diagnosis •Clinical examination •Auxiliary examination methods: - panoramic radiograph (ortopantomogram-OPG) - Ultrasonography (ultrasound) - Computed tomography (computed tomography-CT): Diagnosis tureckova%20-58d.jpg neumann%20-8%20b.jpg Distribution of jaw inflamation •Spreading inflammation in the lower jaw arise following abscesses: •abscessus submentalis •abscessus perimandibularis •abscessus regionis parotideomassetericae •abscessus submandibularis •abscessus spatii pterygomandibularis et parapharyngei •abscessus linguae et regio sublingulais Distribution of jaw inflamation •Spreading inflammation in the upper jaw arise following abscesses: • •abscessus palatinus •abscessus perimaxillaris •abscessus retromaxillaris •abscessus orbitae Distribution of jaw inflamation •Spreading inflammation from both jaw arise following abscesses: • •abscessus fossae pterygopalatinae •abscessus fossae infratemporalis •abscessus fossae temporalis • Abscessus submentalis •Cause: The mandibular anterior teeth • •Spatium submentale: •Between surface of m. mylohyoideus and superficial neck fascia (lamina superficialis fasciae cervicalis) with m. platysma, lateraly anterior bellies of mm. digastrici. •Contains infrequent adipose tissue with submental lymphonodes • Abscessus submentalis 1 2 Abscessus submentalis •Clinical symptoms: •swelling, warm skin erytema, palaption • painfulness • painful mouth opening •Incision: e.o. incize vertical in the midline Abscessus perimandibularis •Cause: infected root of the tooth of the lower jaw - the spread to the outer surface of the mandible • Clinical symptoms : swelling not over the edge of the mandible, extending to the face (without swelling of eyelid). • - induration, palaption painfulness • • Incision: i.o. or e.o. incision below the point of greatest convexity, possibly a combination of both Abscessus submandibularis •Cause: molars of the lower jaw, the spread from the surrounding area and lymphatic vessels • •Spatium submandibulare: •Cranial: medial wall of mandible under mylohyoid linea and mylohyoideus m. •Caudal and lateral: lamina superficialis fasciae cervicalis •Frontal: anterior belly of digastric m. (adjacent with submentale space) •Distal: exact border is missing, open to parapharyngeum and retropharyngeum sp. •Medial: sublingual space •Lateral: pterygomandibular space and parotid gland • •Contains: submandibular gland, submandibular lymphatic node, a. and v. facialis, n. lingvalis, n. hypoglossus Abscessus submandibularis Abscessus submandibularis • Clinical symptoms : •Painful mouth opening and swallowing. •Induration, collateral edema, the edge of the mandible cannot palpate •Soft swelling around + lymphonoditis - LN enlarged •Warm skin erytema •Intraoraly erytema, swollen, elevate of vestibule and sublingual mucosa •Trismus, high fever • • Incision: e.o. incision under the edge of the mandible Abscessus submandibularis C:\WINDOWS\Application Data\OLYMPUS\Camedia Master 4\Album\MAC\Záněty\PC280330.JPG Abscessus regionis parotideomassetericae •Cause: infected lower molars, dentitio difficilis • Abscessus regionis parotideomassetericae •Clinical symptoms : edema of parotediomaseteric space, skin taut, painful mouth opening •Trismus. •Incision: e.o. incision under angle of mandible • Abscessus spatii pterygomandibularis et parapharyngei •Cause: -mandibular bloc -dentitio difficilis -after extraction of wisdom teeth -Suppurating hematoma after local anaest. administration -spread of infection from submandibular space Abscessus spatii pterygomandibularis et parapharyngei od8_dospm(1).jpg Abscessus spatii pterygomandibularis et parapharyngei •Clinical symptoms : -begins muscle contracture -difficult i.o. examination -i.o. - edema, erytema of soft palate and palate arch. -tonsil pushed to the midline. -painful mouth opening -retromandibular swelling -spread of inflamation to parafaryngeal space Abscessus spatii pterygomandibularis et parapharyngei •Cave: inflammation of the parapharyngeal space can quickly spread to surrounding areas: • •- Retrofaryngeal space: between the spine and throat, as well as between the spine and the esophagus into the posterior mediastinum •- Anterior mediastinum: along the internal carotid artery and internal jugular vein •- Fossa infratemporalis a pterygopalatina •- Parotid gland • Abscessus spatii pterygomandibularis et parapharyngei •Incision: •- ptergomandibular space: i.o. incision above the anterior edge of the mandibular ramus • e.o. under body of mandible •- parafaryngeal space: e.o. under angle of mandible, along the sternocleidomastiod m., the revision of the cervical area Abscessus spatii pterygomandibularis et parapharyngei Rozborka krku.jpg Rozborka krku II.jpg Abscessus sublingulais •Cause: infected distal teeth of mandible (roots lie above the inserion of mylohyoid m.) • •Clinical symptoms : edema of mouth floor, mucosal erytema, deviation of tongue, submandibular and submental edema Abscessus sublingulais SM absces coronarsirenisl.jpg • Abscessus sublingulais • •Incision: e.o. incision under edge of mandible • •in case of smaller absces – i.o. incision on medial wall of mandible ( cave: lingual nerve) Abscessus linguae •Phlegmonous inflammation or abscess •Rare occurrence – bite, foreign body trauma, suppurative cysts floor of mouth, gangrenous teeth • •Phlegmonous glossitis – rapid development, large tongue and mouth floor edema – can cause breathing difficulties • Abscessus linguae DSCN0390 Therapy: vertical incision in the midline between the edge of the mandible and the hyoid bone, revises the base language and sublingual and submandibular scape Abscessus palatinus •Cause: small incisor, palatal root of the first premolar, the palatal roots of maxillary molars. •Clinical symptoms: mucous swelling on palate, border of abscess are clear, palpation is painfull, fluctuations. •Incision: i.o. incision near midline in anteriodistal direction - avoid risk of injury a major palatine artery Abscessus palatinus DSCN0386 DSCN0387 Abscessus perimaxillaris • •Cause: any tooth of the upper jaw. • •Location: space bounded of masseter m. and lower edge of orbit and - regio buccalis. • It may come down to the perimandibular space. Abscessus perimaxillaris coronarHCtvar.jpg Abscessus perimaxillaris •Clinical symptoms: Collateral edema may affect the whole face, upper and lower eyelid. It does not spread over the zygomatic arch and the lower edge of the mandible •Incision: i.o. or e.o. incision below the point of greatest convexity, possibly a combination of both. • Abscessus retromaxillaris •Cause: -suppurating cysts of jaws -inflammation of the maxillary sinus -suppurative hematoma after injury of the pterygoid plexus Abscessus retromaxillaris •Clinical symptoms: • fever, pain, trismus. Later, he develops a swelling under the arcus zygomaticus and soon over it. The arc exactly divides swollen face (cave: an important clinical sign). • •Incision: i.o. incision in the vestibule behind crista infrazygomatica Abscessus orbitae •Cause: teeth of upper jaw •Spreading – periosteal pus penetrates to the rim of the orbit, where it causes either an abscess lower eyelid, or continue to the orbit –Venous way - infection penetrates through v. angularis to the ophthalmic veins –Intraosseal spread- upper incisors and canines, ostitis –Transfer of infection into the orbit from the maxil. sinus or etmoid Abscessus orbitae 5 Abscessus orbitae • • •Therapy – extraoral incision near the infraorbital rim. Abscessus fossae infratemporalis •Pterygopalatinal, infratemporal and temporal are separated anatomically inaccurately bounded, are associated with parapharyngeal space •Cause: parapharyngeal space infection, inflammation in maxila, transfer of infection via the pterygoid plexus • Abscessus fossae infratemporalis •Clinical symptoms - edema of the zygomatic arch and in the temporal region, tough infiltrate temporal area and the zygomatic arch, eyelid edema, conjunctival chemosis, proptosis of the globe. Abscessus fossae infratemporalis Obrázek2 Abscessus fossae infratemporalis •Therapy – according to the origin and extent of inflammation, with inflammation of the lower jaw is reviewed parapharyngeal space of the cut of angle of the jaw. Abscesses caused by infection of the cost of the maxilla opening of intraoral cut in the fornix, hence penetrate a tuber, from external cut above and below the zygomatic bridge Abscessus fossae infratemporalis Obrázek5 Obrázek3 Surgical therapy anestezie.jpg Surgical therapy incize2.jpg drenaz2 .jpg Surgical therapy io incize (2).jpg Surgical therapy DSC_0193.jpg Surgical therapy eo incize (2).jpg Surgical therapy facialis.jpg Surgical therapy DSC_0170.jpg Surgical therapy DSC_0171.jpg Surgical therapy DSC_0172.jpg Surgical therapy DSC_0173.jpg Surgical therapy 030.jpg Medical therapy •Peniciliny (V - Penicilin v dávce 750mg p.o á 6hod, či 500mg p.o á 4hod) •Aminopenicilin (Ospamox 500 - 1000mg p.o á 8hod) •Amoxicilin with clavulanate acid (Augmentin 625 - 1000mg p.o á 8hod) •When alergy to beta-laktams ATB can use: •Klindamycin (Dalacin C 300mg p.o á 6 až 8 hod) •Less suitable choice for outpatient treatment are makrolids (Rovamycine 500-1000mg p.o á 8-12hod, or Roxithromycine 150mg p.o á 8-12hod)