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Infections Arising from Mandibular Teeth

of the head and neck, Grodinsky and Holyoke identified the

Although many infections arising from mandibular teeth erode into

submaxillary

the vestibular space, they may also spread into other deep fascial

space as one large space that encompasses the three anatomic

spaces. Initially, such mandibular infections tend to enter the space

spaces referred to separately today as submandibular, sublingual, and

of the body of the mandible, the submandibular, sublingual, submental,

submental spaces.1-3 One may collectively refer to them as

or masticator spaces. From there, severe infections can spread

perimandibular

into the deep fascial spaces of the neck, and even extend into the

spaces. The sublingual and submandibular spaces have the medial

mediastinum to threaten the heart, lungs, and great vessels.

border of the mandible as their lateral boundary. These two spaces are

The space of the body of the mandible, like the palatal space, is

involved primarily by lingual perforation of infection from mandibular

a subperiosteal space. Thus, if an infection erodes through the buccal

molars, although they may be involved by premolars as well. The

cortical bone but does not perforate the periosteum, it can essentially

factor that determines whether the infection is submandibular or

peel the periosteal layer of soft tissue off the bony surface. Clinically,

sublingual

this results in a swelling that assumes the shape of the underlying

is the attachment of the mylohyoid muscle on the mylohyoid

mandible. It can appear as if the bone itself has been enlarged, as in

ridge of the medial aspect of the mandible (Fig. 17-13). If the infection

Figure 17-12.

erodes through the medial aspect of the mandible above this

If an infection arising from a mandibular posterior tooth perforates

line, the infection will be in the sublingual space. This is most

the buccal cortical bone and the periosteum inferior to the

commonly

attachment of the buccinator muscle, then the buccal space is

seen with premolars and the first molar. If the infection erodes

involved (see Fig. 17-6, A).

through the medial aspect of the mandible inferior to the mylohyoid

In their landmark work on the anatomy of the deep fascial spaces

line, the submandibular space will be involved. The mandibular third

molar is the tooth that most commonly involves the submandibular

The floor of the mouth contains the sublingual space,

space directly. The second molar may involve the sublingual or

submandibular space, and submental space, and

submandibular

there is ready communication across the midline

space, depending on the length of individual roots.

through to the opposite site. Due to this anatomy,

The sublingual space lies between the oral mucosa of the floor of

infection may readily spread from the sites initially

the mouth and the mylohyoid muscle (Fig. 17-14, A). The posterior

involved to most or all of the spaces in the floor of the

border of the sublingual space is open, and therefore, it freely

mouth. This condition is called Ludwigs angina,

communicates

named after the German physician, Wilhelm Frederick

with the submandibular space. Clinically, little or no extraoral

von Ludwig, who described the condition fully in

swelling is produced by an infection of the sublingual space, but

1836.96 Since most cases of Ludwigs angina are of

much intraoral swelling is seen in the floor of the mouth on the

dental origin, bacterial cultures may mirror the oral

infected side. The infection often becomes bilateral, and the tongue

flora. These infections usually involve viridans streptococci

becomes elevated (see Fig. 17-14, B).

and anaerobes.97

The submandibular space lies between the mylohyoid muscle

Ludwigs angina is characterized by a firm swelling

and the overlying superficial layer of the deep cervical fascia (Fig.

of the floor of the mouth with elevation of the

17-15). The posterior extent of the submandibular space communicates

tongue, a relatively spreading cellulitis with no tendency

with the deep fascial spaces of the neck. Infection of the

to form abscesses and involvement of bilateral


submandibular and sublingual spaces (Fig. 29.38).
The majority of infections begin in the submandibular

Ludwigs angina

space, often resulting from an infection of a mandibular

molar tooth, and then rapidly spread to involve

with high fever, tachycardia, and malaise often

the sublingual space, usually on a bilateral basis.

observed. As the swelling progresses, there is increasing

Although the initial symptoms are unilateral, they

encroachment upon the airway, resulting from

will progress to involve both sides. The submandibular

elevation of the tongue and extension to the lateral

and submental regions become tense, swollen,

pharyngeal space. It should be noted that progression

and tender. There is increasing neck rigidity, trismus,

from the onset of symptoms to respiratory obstruction

odynophagia (painful swallowing), and drooling.

often occurs within 1224 hours.

The floor of the mouth will become tense and indu-

The infection may spread to involve posterior

Fig. 29.36 Submental space infection caused by periapical abscess in

fascial spaces, in particular the lateral pharyngeal

the mandibular incisor.

space. Ludwigs angina has historically been associated

Fig. 29.37 Surgical drainage for submental abscess is usually

with a high mortality rate, primarily due to

performed through a cutaneous incision. A horizontal incision

inadequate diagnosis and management of airway

should be placed 13 cm below the lower border of the mandible

obstruction. Although the prognosis has improved,

rather than the top of the swelling (abscess) to exploit gravity to

Ludwigs angina remains a serious and life-threatening

encourage drainage.

disease.

Infections of the Oral and Maxillofacial Region 513

With regard to treatment, special attention must

rated with extensive mucosal swelling. Intense pain

be given to maintenance of the airway. Early and

is usually present, but fluctuance is unusual. The

vigorous incision and aggressive opening of all

tongue is pushed superiorly and its movements

involved spaces are recommended to provide decompression

become stiff. The patient can develop a toxic condition,

of the area involved. Drainage through generous

incision on the skin in the submandibular and

In addition to extraoral drainage, transoral

submental regions is required. Although the length

drainage should be undertaken if instruments can be

of the cutaneous incision may be variable, incision

inserted into the oral cavity.

generally crosses to the submandibular region bilaterally.