METHODICAL RECOMMENDATIONS FOR INDIVIDUAL WORK OF STUDENTS DURING PREPARATION TO PRACTICAL (SEMINAR) LESSON

Academic discipline surgical stomatology Module № 6 Topic of the lesson№9 Phlegmon of orbit. Phlegmons of zygomatic, parotid- masticatory areas. Phlegmons of temporal area, pterygo-palatine and infratemporal fossas. Peripharyngeal abscess. Phlegmon of oral floor, and neck, quinsy of Jansule-Ludwig. Complications and its prevention. Principles of treatment of inflammatory processes of maxillofacial area. Course V Faculty International (Stomatological)

Poltava 1. Relevance of the topic: At present the problem of abscesses is very crucial. Indeed, the lower the economic situation in the country, the higher is the problem of phlegmon. It is not timely dental treatment at the dentist sooner or later lead to the development of abscesses. These problems are equivalent for both urban and rural areas.

2. THE SPECIFIC AIMS:

2.1. To analyze and know the statistics, classification, characteristics of etiology and pathogenesis, clinical signs of inflammatory processes of the maxillofacial area; 2.2. To explain the methods of diagnosis of superficial and deep abscesses of maxillofacial area. 2.3. To submit to inspect a patient with superficial and deep odontogenic phlegmon of the maxillofacial area. 2.4. To classify deep odontogenic phlegmon of the maxillofacial area. 2.5. To explain the theoretical and clinical research on the problem of odontogenic abscesses maxillofacial. 2.6. To draw diagrams, graphs. 2.7. To make a plan of treatment of odontogenic phlegmon in maxillofacial area. 2.8. To make a plan for complex treatment of patients with odontogenic phlegmons of the maxillofacial area.

3. BASE KNOWLEDGE, ABILITIES, SKILLS, NECESSARY FOR STUDY of THEME (INTERDISCIPLINARY INTEGRATION) Names of the previous disciplines The received skills 1. Topographical Anatomy and Anatomic and topographic structure MFA, Operative Surgery anatomy of teeth. 2. Pharmacology Drugs used in the treatment of diseases of the teeth and . 3. Preventive dentistry Causes, prevention and treatment of diseases of the oral cavity and the relationship to the general health of the patient. 4. Interdiscipline integration The need of dental health dentists. 5. Physiopathology Stages of inflammation, pathogenesis formation of pus in the tissues.

4. TASKS FOR INDIVIDUAL WORK DURING PREPARATION TO LESSON. 4.1. List of basic terms, parameters, characteristic, which a student must master at preparation to lesson: Term Definition 1. Phlegmon This diffuse purulent inflammation. 2. Fluctuation This swing of fluid in inflammation. 3. Trismus This the muscle dysfunction in.

4.2. Theoretical questions to lesson: 1. Anatomy and topographic anatomy in maxillofacial surgery. 2. Spaces of the maxillofacial area. 3. The ways of infection in maxillafacial space. 4. Spread infection in maxillofacial area. Complications which may be. 5. The main rinciples of treatment of inflammatory processes in maxillofacial area.

4.3. Practical work (task) that is performed in class. 1. To be able to collect anamnesis from a dental patient. 2. To know how to write a medical card for dental patient. 3. To determine fluctuations by palpation. 4. To perform the anesthesia by Vishnevsky. 5. To be able to prescribe additional examination methods. 6. To be able to read x-rays foto of the head. 7. To be able to carry out a differential diagnosis. THE CONTENT OF THE TOPIC:

I. Phlegmons and abscesses located around the upper jaw. Superficial absceses and phlegmons Phlegmon and abscess of the suborbital area – occur more commonly from the lateral incisors, canines and premolars, when the infection spreads from the buccal area and lateral nasal sections.An infiltrate and of the eyelids and malar region appear early, the upper is immovable. Phlegmon and abscess of the buccal area – occur from premolars and molars, when the infection spreads from the suborbital, parotid-masticatory and infratemporal regions. If an infection focus is situated close to the skin, facial asymmetry prevails. If an inflammation focus is under the mucosal lining than changes from the side of the vestibule of the mouth dominate. Phlegmon of the temporal area– occurs in case of infection which spreads from infratemporal fossa, parotid-masticatory region, in dermal inflammation, temporal area wounds infectioning. The clinical symptoms depend on the depth of the inflammatory focus location. A contracture is observed. Opening of the superficial abscesses and phlegmons of the temporal area is performed through the external access in the lower section of the inflammation focus (under the malar arch). Phlegmon of the infratemporal and ala-palatine fossae – the source of occurrence are maxillary molars, it may be as a result of tuberal anesthesia, infection spread from the buccal, parotid-masticatory region, ala-maxillary space. Inadequacy between the local signs of the disease and a general reaction is characteristic of phlegmons. Painful infiltrate is defined in the posterior formix part of the mouth vestibule (between the maxillary cusp and coronary processof the mandible) which is deformed from the vestibular site. The contracture and a severe pain are observed that may irradiate to an eye. There is an operative intraoral access. An opening is performed higher the transitional fold of the upper vestibule of the mouth and penetrate directly into the inflammation focus along the bone surface behind the jaw cusp. II. Phlegmons and abscesses located around the mandible. III. Superficial abscesses and phlegmons Phlegmon and abscess of the mandibular area are often encountered in children that more commonly result from lower premolars and molars.Secondary lesion is seen as a consequence of the inflammatory process from the sublingual and mental area, a fossa behind the jaw, ala- maxillary and peripharyngeal spaces, submaxillary . A child complains of pain and swelling in the submandibular area. The general state is disturbed. Significant of soft tissues of the appropriate area, a minor contracture, chewing, swallowing, speech disturbance are identified. An operative access in inflammatory processes of this location is internal. Dissection of skin, subcutaneous fat, superficial fascia and subcutaneous muscle is performed in the submaxillary triangle, taking a step back 2 cm from the jaw angle and a lower root parallel to the latter. Deep abscesses and phlegmons Phelgmon of the mouth floor – more commonly results from 36, 46 teeth. Two and more cellular spaces located over and under maxillary-sublingual muscle are involved into the inflammatory process. A dense infiltrate is observed in the mouth floor area, inability of dental occlusion is also seen. Edema of the mouth floor of the is revealed. It is accompanied with essential intoxication, a patient’s general condition is severe. The operative access is external. An opening of the focus is performed in both submandibular area and in submental triangle. Alar-maxillary space abscess – develops in case of tissues infectioning during anesthesia. A child suffers from limited opening of the mouth and sore that becomes more intensive while chewing. A contracture develops; a sharp pain appears in swallowing. The internal signs of the inflammation are absent during a long period of time, concomitant lymphadenitis is observed. An infiltrate under the angle of the mandible occurs later. There is an extraoral access following the safe incisions line. Peripharyngeal space phlegmon and abscess –results from the palatine inflammation, infection spread from the alar-maxillary space, submaxillary and parotid-masticatory regions. A child complains of a significant pain in swallowing from one side. General intoxication signs are marked. Clinically there are unilateral quinsy, moderate contracture, and lymphadenitis. Later breathing disturbance, hoarseness, dysphagia are observed. Pharyngeal wall infiltrate, palatine tonsils, soft are defined. There is operative extraoral access in the submaxillary area.

TEETH INVOLVED IN FASCIAL INFECTIONS Invasive dental manipulation is known to cause bacteremia and generally considered high-risk procedures for the spread of infection in susceptible patients. Sato et al., has shown that the main origin of maxillofacial infections were odontogenic (79.31%), followed by trauma (10.7%), immunosuppression (1.6%), pathologies (1.6%), and other causes (8%). Seppänen et al., also reiterated that the most common dental procedures that precede odontogenic infection complications are: tooth extraction (60%), endodontic treatment (20%), dental implant surgery (8%), restorative treatment (8%) and dental plaque and calculus removal (4%). Lower third molars are more frequently involved in odontogenic infections when compared with other teeth. Flynn et al., presented in their prospective study with 37 consecutive hospitalized patients, a 68% prevalence rate of this group of teeth in association with odontogenic infections, followed by other lower posterior teeth (premolars, first and second molars), without anterior teeth involvement. Third molar removal is one of the most regular dentoalveolar surgical procedures. With an 80% prevalence of retained third molars in the adult population, appropriate treatment, and especially prophylactic third molar removal remains a key focus of interest in healthcare with both medical and economic dimensions. It is generally accepted that substantial risks may arise both from third molar removal, as well as from a “wait and see “policy. Microbiological involvement The severe infections of odontogenic origin frequently involve a complex polymicrobial mix of aerobes, facultative aerobes and strict anaerobes working together. Some species like Peptostreptococcus, Staphylococcus, Lactobacillus, Prevotella, Treponema, Fusobacterium, Veillonella, Actinomyces, Bacteroide ssp. and oral Streptococcus sp. are frequently associated with infections of odontogenic origin. Sakamoto et al., reported 17 different species collected from a single surgical site. Flynn et al., isolated 90 different strains of microorganisms in 37 patients, and of these, 17 were penicillin-resistant. Other species can be easily found at the infection sites, but generally, they reflect the indigenous microflora of the oral cavity. Routine culture and sensitivity testing for minor oral infections does not appear to be justified, however, when an infection involves anatomic spaces of moderate or greater severity, or when there is significant medical/immune compromise, the tests become important to the outcome.

Pathway of facial and cervical infections of odontogenic origins Fascial infections derived from mandibular odontogenic origins Infections originating in the facial planes of the head and neck spread downward along the cervical fascia, facilitated by gravity, breathing, and negative intrathoracic pressure. Knowledge of the facial spaces and fascial planes is essential for understanding the propagation, pathways, symptoms, and complications of cervical infections. Although the pattern of spread varies among patients, a relatively constant trend in the distribution of infection into the spaces seem to be evident. Some studies clearly demonstrated that the masticatory space is the most prevalent site for odontogenic infection spread. Taken together with the finding that the masticatory space encompasses the posterior mandibular body, ramus, and a part of the alveolar bones of the maxilla, this suggests that the masticatory space may be the initial site of spread of odontogenic infection. This contention was further supported by the finding that mandibular infection more frequently involved the masseter and medial pterygoid muscles (located in the lower compartment of the masticatory space where the mandible is included) than the temporalis and lateral pterygoid muscles (located in the upper compartment of the space where part of the maxilla is included). The spaces adjacent to the masticatory space are the parotid space posteriorly, the parapharyngeal space medially, and the submandibular and sublingual spaces inferiorly. The parapharyngeal space occupies the central position among the masticatory, parotid, and carotid vascular spaces. Therefore, infections in the parapharyngeal space may originate from any adjacent space. A fascia extends from the posterior superior margin of the to the base of the skull to separate the masticatory space from the parapharyngeal space. In this way, it is possible to believe that infection spreading from the masticatory space into the parapharyngeal space may pass via the medial pterygoid muscle. Yonetsu et al., found that 100% of patients with parapharyngeal space involvement also had the medial pterygoid muscle affected, and 79% of patients with infection in the medial pterygoid muscle area had concomitant involvement of the parapharyngeal space. However, in none of their cases spread from the submandibular into the pharyngeal spaces. The parotid space abuts the posterior masticatory space and is enveloped by a layer of the deep cervical fascia. Yonetsu et al., demonstrated that odontogenic infection may extend into the parotid space, via the masticatory space. The retropharyngeal space connects the skull base to the upper mediastinum and contains loose fatty tissue in its infrahyoid portion. Thus, the retropharyngeal space is considered to be important due to its proximity to the airway and because infections in this space may cause mediastinitis, bronchial erosion, and septicemia. The vertebral and vascular spaces are thought to be rarely involved by head and neck infection. The infection spread occurs when accumulated pus perforates bone at the weakest and thinnest part. In the mandible, the lingual aspect of the molar region represents the easiest way. If odontogenic infection perforates this portion of bone, it will spread into the sublingual or . As these spaces are partially separated by a thin sheet of mylohyoid muscle, infection in either space easily spreads into the other. It is generally believed that the midline enables free communication from either the sublingual or submandibular space. Delineating the maxillary spread pattern is quite difficult, because limited data is available regarding its infections. Nevertheless, it is plausible to consider that the observed difference in the spread profile between maxillary and mandibular infections may be due to differences in the distance between the original focal area in jaw bones and each of the spaces. For instance, maxillary infection was associated with temporalis muscle involvement more often than mandibular infection. Maxillary infection also spreads first to the masticatory space, but the temporalis and lateral pterygoid muscles are predominant targets for the infection. Involvement of the sublingual and submandibular spaces is rare. Otherwise, odontogenic infection arising in the mandible spreads first to the masticatory space. The masseter and medial pterygoid muscles in the masticatory space are most frequently involved. Thereafter, the infection spreads medially into the parapharyngeal space and posteriorly into the parotid space. Involvement of the sublingual and submandibular spaces seems to occur directly from the primary site of mandibular infection. There are complex pathways which allow infection to spread along the facial and neck structures. Thus, it is important for dental practitioners to know more about the possibility of a dental intervention to be a cause of severe infections.

The sequence of odontogenic infection spread that most commonly occurs is:

The masticatory space is the primary site of spread from mandibular infection. 2. The parotid and pharyngeal spaces are the secondary sites of spread from the masticatory space. 3. Mandibular infection spreads directly to the sublingual and submandibular spaces, and 4. Maxillary infection spreads to the deep facial and neck spaces in a different way from that of mandibular infection.

Fascial infections derived from maxillary odontogenic origins The pattern of maxillary infection spread differs from that of the mandible. Generally, the main maxillary spaces involved were found to be the buccal maxillary (19.05%) and canine (15.24%). According to Yonetsu et al., the temporalis muscle was involved in 100% of the patients with maxillary infection. The involvement of the temporalis muscle in mandibular infections occurred only in 26% of the patients. The downward spread into the sublingual and submandibular spaces from maxillary infections did not occur. The lateral pterygoid and masseter muscles were frequently involved (86%) as in the cases of mandibular infection. Other spaces were also involved, but less frequently. The was involved in 57% of the patients with maxillary infection.

Different locations of odontogenic infections. (A) Submandibular and sublingual region. (B) Submandibular region. (C) Cervical region. (D) Palate. (E) Orbital region. (F) Submandibular and buccal region.

Pericoronitis is an infection of the gingiva of a partially erupted tooth. The most frequent form of pericoronitis is caused by the partially erupted lower third molar, mainly due to the favorable niche that is created once the mucous cap covering the molar becomes retentive and deep enough to trap food particles and reduce the oxygen potential. These factors create the perfect microenvironment for the onset and subsequent development of a recurrent infectious, inflammatory condition caused by polymicrobial microorganisms, especially strict anaerobes. Third molar pericoronitis may appear in either of its two acute variations, namely serous and suppurative, as well as in its chronic form; when either of the two acute forms previously mentioned stays untreated. Periapical lesions/Intra-oral abscess The most significant clinical condition of all bacterial infections of periapical origin is the so-called acute apical periodontitis. It is usually the result of purulent pulpitis that spreads into the periapical space, therefore, it appears in the course of pulpal disease. In acute apical periodontitis there is an accumulation of pus inside the apical space of the tooth involved. This condition is commonly underestimated by dental practitioners in terms of its morbidity and mortality.

Clinical presentation of Ludwig’s angina.

Sequence of drainage of odontogenic infection – case 1. Note that the most dependent part (under the swelling) must be incised not the thin most swollen part (to prevent scarring). Infection of sublingual, submental and submandibular spaces (Ludwig’s Angina) Ludwig’s angina is a rapidly spreading cellulitis that may produce upper airway obstruction, often leading to death. The most common source of Ludwig’s angina is an odontogenic infection, from one or more grossly decayed, infected teeth, and is usually as a result of a native oral mixed aerobic-anaerobic flora. The patient with Ludwig’s angina presents severe and obvious extra oral swellings including bilateral submandibular, submental, and sublingual spaces. Elevation and displacement of the tongue, trismus, drooling of saliva, airway obstruction, sore throat, dysphagia and/or dyspnea are commonly present. With extensive use of drainage and antibiotics, most facial infections have satisfactory outcome before they have a chance to progress to Ludwig’s angina. Cervical cellulitis is most commonly from odontogenic origin and despite modern antibiotic therapy, cases with an initial delay in diagnosis and treatment may still result in this life-threatening situation. Odontogenic infections are usually locally confined, self-limiting processes. However, under certain circumstances, like anatomical variations or suppression of the immune system of some patients, these infections may pass through the bony, muscular, and mucosal barriers and spread into contiguous and distant spaces, resulting in severe fulminating infections in the body cavities. When cervical cellulitis involves the parapharyngeal, retropharyngeal, and viscerovascular spaces, the purulent process has easy access to the mediastinum, pericardium, and thorax, thereby increasing mortality rates. Because of the fulminant nature of descending cervical cellulitis with mediastinal complications, prompt recognition followed by broad-spectrum antibiotic therapy, immediate surgical intervention, and intensive medical support are required. The second and third mandibular molars are the teeth most frequently implicated in the cause of odontogenic deep neck infections. Because their roots lie below the mylohyoid muscle, medial perforation of a periapical abscess has immediate access to the submandibular space. Then, a collection of pus in the neck spreads along the cervical fascial planes, resulting in complications. Descending Necrotizing Mediastinitis (DNM) Acute purulent mediastinitis occasionally develops as a complication of odontogenic infection, in which case it is denominated descending necrotizing mediastinitis. This is a serious infection involving the that fills the interpleural spaces and surrounds the median thoracic organs. It is one of the most dreaded and the most lethal form of mediastinitis, which occurs as a complication of oropharyngeal abscesses or as a complication of cervical trauma, with severe cervical infection spreading along the fascial planes into the mediastinum. As infection spreads along deep cervical fascial planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may concomitantly occur. The delay of diagnosis and late or incomplete drainage of the mediastinum are the main causes for high mortality rates associated with this condition. Even with the use of computed tomography scanning or magnetic resonance examination, aggressive drainage, and modern antibiotic treatment, the mortality rate of descending necrotizing mediastinitis remains high. Surgical management, particularly the optimal form of mediastinal drainage, remains controversial with support ranging from cervical drainage alone to cervical drainage and routine thoracotomy. Necrotizing fasciitis Abscesses of the peritonsillar region are among the most common deep abscesses of the head and neck. Although rare, complications resulting from this disease may be life threatening. One of the most dangerous complications is necrotizing fasciitis, which is a rare soft tissue infection characterized by progressive destruction of fascia and adipose tissue that may not involve the skin. Necrotizing fasciitis is characterized by its fulminating, devastating, and rapid-progressing course. Diabetes mellitus, burns and malnutrition are common predisposing factors. Initially, cervical necrotizing fasciitis is predominantly characterized by a “simple” infection in the upper aerodigestive tract like pharyngitis or even tonsillitis. Typically, the general condition gets worse within a very short period of time with cardiovascular decompensation due to a toxic shock-like condition. Cervical necrotizing fasciitis initially involves the superficial muscular system and superficial fascial planes of the head and neck or it may result from a deep soft tissue infection, such as odontogenic infections or even pharyngitis, which spreads along the deep fascial planes. If the disease is not recognized in time the infection can rapidly involve the great vessels or mediastinum, producing systemic toxicity and sepsis.The basis of successful treatment comprises aggressive surgical debridement and drainage of the involved necrotic fascia and tissue along with intensive broad-spectrum intravenous antibiotic coverage. Treatment of odontogenic infections includes diagnosis and management of the causative factor, drainage when necessary and, usually, prescription of appropriate antibiotics. It is imperative that the source of infection be addressed immediately. In addition, the patient’s medical status must be optimized. The patient’s fluid and nutrition status should also be addressed, as many patients with odontogenic infections have decreased oral intake due to pain and difficulty in chewing or swallowing. The clinician must be aware of the most likely causative organisms and prescribe the narrowest spectrum of antibiotics that will cover all possible offending organisms.

Sequence of drainage of odontogenic infection – case 2.

Phlegmons of orbital area (phlegmone regionis orbitalis) localized in fat eye socket. Clinic: proptosis of the eyeball and its limitations. This contributes to scar swelling and conjunctivitis (hemoz). Eyelids are swollen. Treatment. The skin incision when it is done in the lower-outer edge of the eye socket.

Phlegmons of the zygomatic area (phlegmone regionis zygomatici). On the bottom edge of the zygomatic bone, zygomatic arch in parallel, the incision through the skin approach to inflammation of this area. Thus, the main orient is the place of the greatest fluctuations, considering the topography of the branches of the facial nerve. Clinic. Complaints of pain is radiating to the temple and infraorbital area, possibly limited mouth opening.

Submasseterial abscess (phlegmone submasseterica) may occur in the tissue under masticatory muscles. Clinic. Nabryak lower division bilyavuhovo chewing area. The central part of this edema is visualized on carbon mandible. At the site of attachment of the masticatory muscles. Treatment. Lesion, length of 5-7 cm, which is bordering the angle of the mandible in the form of an arc, cut through soft tissue to bone. In the area of attachment of the masticatory muscles to the corner of the lower edge of the branches of the lower jaw it is partially cut and peeled through this muscle always keeping outer surface of the branches of the lower jaw, reach ulcer or pre defoliate muscle along the muscle fibers to the appearance of pus.

Phlegmons of the parotid area (phlegmone regionis parotidei). Inflammation distributed foci in 48 and 38 teeth. Spreads by lymphogenous way from the upper molars section. Clinic. Complaints of pain in parotid-masticatory area, enhanced by obstructed mouth opening. Face is asymmetric, due to swelling of the tissues in parotid- masticatory area. Treatment. Stepping back into 1.5-2 cm outside of the angle of the mandible, cut the skin around it, from the subcutaneous tissue, fascia between the sternoclavicular-mastoid muscle and the posterior edge of the branches of the lower jaw. What not to damage the , deep penetrating blunt layering tissue.

Phlegmons of the infratemporal and pterygopalatine fossa (phlegmonae fossarum infratemporalis et pterygopalatini). Localization of abscesses projected inward from the infratemporal fossa. Within the upper arch of the mouth threshold, in the last two molars level of the upper jaw, cut mucosa to the bone. Then using raspatory or probe Kocher, hill along the upper jaw to penetrate inside the temporal fossa in the direction from front to back and up.

Phlegmons of temporal area (phlegmonae regionis temporalis). Phlegmons of this site may be the surface that lie between the skin and the temporal aponeurosis , middle - between the and aponeurosis , deep - under the temporal muscle; spills that apply to all of the above layers. At the forefront of the temporal muscle cut the skin, subcutaneous tissue, muscle aponeurosis, and when in need, provided finger gloves are under the temporal muscle and reveal an abscess. If detected diffuse cellulitis, it is advisable to make the semilunar incision in place of attachment of the temporal muscle and its aponeurosis (linea temporalis). In the presence of deep ulcers temporal areas incision made in the radial direction along the muscle fibers on the basis of the topography of the major arteries of the site. For more reliable outflow of pus often additional cuts are provided (counterpuncture).

Abscess and phlegmon of peripharyngeal space. Purulent process in peripharyngeal space can occur as a complication of acute or rarely chronic tonsillitis. Odontogenic source of infection of this space are large indigenous bottom teeth, sometimes of the upper jaw. Peripharyngeal space often amazed at the spread of infection of the submandibular triangle, hyoid, retromandibular area, as well as pterygopalatine mandibular space. Borders of peripharyngeal space: internal - muscular layer of the , exterior - medial pterygoid and deep pharyngeal part of the parotid gland; Front - interpterigoidea fascia and the inner surface of the medial pterigoideus muscles; back - fascial side shoots coming from prevertebral fascia to the muscular layer of the pharynx. Stilohioideus, stilopharyngeal, stiloglossus surrounding fascia and muscle peripharyngeal share space on the front and back departments. In anterior peripharyngeal space loose and adipose tissue, in its upper section adjacent pterygoid venous plexus. In the posterior part of the space are the internal carotid artery, internal jugular vein, IX, X, XI, XII , lymph nodes. Fiber located in peripharyngeal space communicates with fibers of palatal fossa sublingual areas submandibular triangle.

Abscess and phlegmon of the tongue. Purulent inflammatory diseases of the tongue may be odontogenic, stomatogenic, tonzillogenic nature. Odontogenic abscess or abscess in intermuscular intervals of the tongue occurs in the transition process from purulent lower front teeth. Abscesses of the back and body of the tongue develop as a result of single or repeated mucosal damage when biting, fish bone injury, dental instruments, sharp-edged teeth, dentures, etc., as well as stomatitis. In some cases, the inflammatory process in the tongue develops on the background of acute tonsillitis. Spread of the hyoid, rarely from the submental area, also leads to the development of purulent process. Tongue is a muscular organ. In the back and the body of the tongue muscle bundles are longitudinal, transverse and vertically bound direction. Between them there is a significant of connective tissue streaks. In the root of the tongue, there are other gaps slit located symmetrically outwards from several previous ones, which also has fiber layer. Inside they are limited genioglossal and outside - hyo-lingual muscles. In these intermuscular crevices of cellulitis are the right and left lingual arteries are little lymph nodes.

Abscesses of the back, body, deep part of the tongue and tongue phlegmon. Abscess of back and body of the tongue are localized to the right or left half of it in the center of the tongue, in the middle section back of the tongue. Patients complain of pain in tongue, extending to the ear. Tongue movements are limited and painful, it is difficult, swallowing painful. Externally there are no changes, during palpation there are painful enlarged lymph nodes in the submental or anterior one of the submandibular triangle. Opening of the mouth is free. Marked thickening of the first half due to infiltration of the side of its department, dense, sharply painful coated bright red mucosa. In some patients, inflammatory edema extends to the lower surface of the tongue and sublingual area. Among diffuse infiltrate thicker tongue can mark a pain in the later stages - hearth softening and fluctuation. Sometimes there is a spontaneous breakthrough ulcer, after which the inflammation subsides. In some patients, the process may spread to the other half of the tongue. Abscess of the tongue develops in connective tissue puffs between paired muscles of the tongue over mylohyoid muscle. Relatively less abscess happens in intermuscular interval, located somewhat laterally from the midline, in a circle passing here lingual artery. Patients with abscess tongue base note sharp pains in the , the inability to swallow. Abscess of the tongue develops in connective tissue layer between the first paired muscles over mylohyoid muscle. Relatively less abscess happens in intermuscular interval, located somewhat laterally from the midline, in a circle passing here lingual artery. Patients with abscess of the tongue base note sharp pains in the tongue, the inability to swallow. Phlegmon of the tongue body is characterized by the proliferation of inflammatory effects on cellular tissue layer between the muscles of the tongue, down - to the seam mylohyoid muscle and up - to weave the tongue muscles. Patients seen better informed sore tongue, smack in the ear, sharply painful swallowing, slurred speech, shortness of breath often. Inflammatory swelling of the submental triangle extends to the anterior submandibular triangles. Regional lymph nodes are enlarged, painful, brazed together. In the depths of the submental area palpated spilled painful infiltration. Limited mouth opening, marked inflammatory contracture of the masticatory muscles. Tongue is significantly increased, his movements are limited and sharply painful. Often enlarged tongue does not fit in the mouth, and projecting forward, for the dentition, to the sides and protrudes upward, forcing patients to keep his mouth half open. Tongue coated whitish bloom, from the mouth an unpleasant putrid smell. Swallowing abundant viscous saliva dramatically hindered Neno, sometimes impossible. In some cases, due to the proliferation and swelling on podgortannik arytenoid-epiglottic folds appear difficulty breathing, hoarseness. Surgery for an abscess of the back and the body tongue is carried out a longitudinal incision along the edge or back of the tongue through a portion of softening or soreness. After dissection of the mucosa by blunt pass between bundles of muscle and empty the abscess. Abscess or phlegmon of the tongue reveal a cut of up to 4 cm in the submental triangle on the midline. Parting the edges of the wound, sectioned along the seam mylohyoid muscle. If pus in this section is not, blunt penetrate up between mentohyoid and genioglossal muscles or more lateral and posterior - between chin- lingual and sublingual, lingual muscles, which show accumulation of exudate. Aesthetic reasons spend arcuate incision anterior to the hyoid bone and parallel to the edge of the mandible. Cut through the skin, subcutaneous tissue, both anterior belly of the digastric and the seam mylohyoid muscle, and then bluntly penetrate the intermuscular spaces of the tongue. Purulent inflammation of the tongue can propagate from the back and the body tongue in its other divisions in the sublingual region, on the fabric floor of the mouth, in the pterygopalatine - mandibular and peripharyngeal space, down to the neck. Simultaneous destruction of the tongue, peripharyngeal spaces and floor of the mouth can lead to stenosis of the airways and asphyxia, which makes serious prognosis to patients' lives.

Phlegmon of the mouth floor. Phlegmon of the floor of the mouth is a common disease purulent when different combinations affected sublingual, submandibular region, submental triangle. Phlegmon of the floor of the mouth may develop as a result of infection in some cases of the hyoid or both of these areas, in others - from the submandibular, submental triangle, base of the tongue. The boundaries of the mouth floor: top - , lower - the skin right and left submandibular and under chin triangles back - root of the tongue and the muscles that attach to the styloid process; front - the inner surface of the body of the mandible. Floor of the mouth has two floors: the top, above the mylohyoid muscle, and the lower, being under it. Cellulitis at the bottom of the oral cavity of patients complain of intense pain, inability to swallow, limitation of mouth opening, obstructed breathing and speech. Puffy face. Determining spilled infiltration in both submandibular and submental triangles. Depending on the involvement in Pterygopalatine mandibular spaces limited mouth opening, however, the mouth half open. Tongue increased in size due to infiltration, raised toward the palate, often dry and covered with a dirty-brown patina. Swallowing painful, patients cannot swallow saliva and it follows from the half-open mouth. Tongue movements cause sharp pain. Sublingual folds infiltrated, bulging, sometimes above the crowns of the teeth. Depending on the different combinations over the affected area and submandibular - hyoid muscles, external incisions performed by the skin in the submental and submandibular triangles. Also effectively cut these areas collar skin incision followed by crossing fibers mylohyoid muscle. Sometimes external incisions combined with cuts in the actual mouth - through the mucosa of the alveolar process of the mandible, on sublingual folds. Cellulitis at the bottom of the oral cavity can be observed spread process Pterygopalatine - mandibular and peripharyngeal space for other front and lateral neck involving the neurovascular sheath, mediastinum. Note peculiar abscesses within the mouth floor, which participate in the development of anaerobic microbes, including Clostr. perfringens, Act. hystolyticus, Act. aedematicus, Clostr. septicum, etc. Progressive course with the development of gangrenous or putrid, gangrenous tissue inflammation and subsequent necrosis usually denoted as angina Zhansul-Ludwig. When Ludwig angina affects all tissues related to the bottom of the oral cavity and pterygopalatine - mandibular and peripharyngeal space. There is a trend to the further spread of the process to other adjacent areas including the front and side of the neck. Besides complaints characteristic abscesses floor of the mouth, usually celebrate choking, intoxication symptoms: fever, insomnia, agitation, delirium often. Characteristically forced position the patient sitting, reclining head tilted forward, which he avoids moving. The patient's face pale with an earthy shade and often jaundiced color. Dense and diffuse painful infiltration, located in both submandibular, submental areas spread up to the parotid and area, down to the neck. The skin over the infiltration brazed in the early days of the disease in color is not changed. Later it becomes tinged with red, sometimes it visible bluish- purple spots or blisters. On palpation infiltrate dense areas, not defined fluctuations is possible, but often marked crepitus. Patient's mouth half open, it implies thick viscous saliva. Simultaneously, limited and sharply painful mouth opening. When chewing and conversation difficult, slurred speech. Sublingual mucosa folds sharply raised, bulging of the shaft, which is above the crown of the tooth. On the mucosal surface is seen fibrinous plaque. Tongue is raised to the palate, lined, putrid odor from the mouth. When surgery is widely reveal outer sections affected cellular spaces: submandibular, submental triangle, sublingual region, the gap between genioglossal muscles of the tongue, as well as involved in the process and peripharyngeal Pterygopalatine - mandibular space. The most effective is collar or arcuate incision below the edge of the lower jaw and wide opening of the affected areas by dissection mylohyoid muscle. At autopsy and characteristic changes in the tissues: tissue located here has a gray- green, dark brown to black in color, no pus, body tissues stands muddy bloody or brownish-gray fetid liquid, sometimes with gas bubbles. Cellulose, necrotic muscle, grayish stinking mass. After surgery, a favorable course of the disease is characterized by fever, improvement of the general condition of the patient. Of surgical wounds begins pus, necrotic tissue are rejected if they were not removed during the operation, and gradually appear granulation. Further wound healing usually occurs without complications. In other cases - with rotten - necrotizing cellulitis inflammation tend to progression. Often develop mediastinitis, but can be bullish spread of infection. Inflammatory disease may be complicated by sepsis, in which patients with life- threatening septic shock and acute respiratory failure. Prognosis: at the bottom of the mouth cellulitis, particularly putrid - necrotic, with complications, serious life patients.

Conclusions A simple tooth infection, especially in diabetics, immunocompromised, or debilitated patients should not be underestimated in its ability to cause severe infections. Furthermore, even non-invasive dental manipulations may also precipitate systemic spread. Facial and cervical infections are potentially lethal complications. However, with good knowledge of the anatomic pathways of the infection, early diagnosis, attention to airway maintenance, aggressive intravenous antibiotic therapy, surgical intervention and careful postoperative management, the infectious process should have a satisfactory outcome. The practitioner must be alert to the particularities of infections from odontogenic origin, as well as to the facial and cervical spaces anatomy, because these structures are crucial for the patient’s life and play important roles during the execution of treatment procedures.

6. MATERIALS FOR SELF-CONTROL: A. Questions for self-control: 1. Borders of submandibular and pterygoid-mandibular spaces. 2. Anatomic parts of the neck.

B. Tasks for self-control: 1. Task The patient, 28 years old, applied on the 3rd day after tooth extraction 1.6. At the injection site, I noticed a mild, mildly painful swelling with a bluish tinge. Complains of pain behind the upper jaw, which radiates to the temple, eyes, half of the head. Objectively: the body temperature is 37.8 C. The face is asymmetric due to edema of the soft tissues of the right buccal, zygomatic, lower part of the temporal region. Contracture is observed. There is 1.6 blood clot in the socket of the extracted tooth in the oral cavity. Along the transitional fold on the right at level 1.8, the mucous membrane is hyperemic, edematous, sharply painful on palpation. What is your diagnosis? Answer options: A. Acute periostitis of the right upper jaw from the tooth 1.6. B. Post-injection phlegmon of the right zygomatic region. C. Post-injection phlegmon of the right infratemporal fossa. D. Odontogenic phlegmon of the right temporal region from the tooth 1.6. E. Odontogenic phlegmon of the right infratemporal fossa from tooth 16. Correct answer: C. Post-injection phlegmon of the right infratemporal fossa. Solution algorithm: To establish a preliminary diagnosis, it is necessary to pay attention to the data: contracture, in the socket of the extracted tooth 1.6 a blood clot; along the transitional fold on the right at level 1.8, the mucous membrane is hyperemic, edematous, sharply painful on palpation. The preliminary diagnosis is post-injection phlegmon of the right infratemporal fossa.

Task 2. Patient B., 65 years old, applied to the Maxillofacial department with complaints of edema in the area of the mandibular angle, pain and heaviness when swallowing, limited opening of the mouth. From the anamnesis it is known that a tooth ache 4.8 a week ago. Clinically: edema and hyperemia of soft tissues along the pterygoid mandibular fold, half of the and protrusion of the lateral pharyngeal wall, the palatine uvula is deflected to the side. What is the clinical diagnosis? Answer options: A. Phlegmon parapharyngeal space. B. Phlegmon of the pterygoid mandibular space. C. Abscess of the root of the tongue. D. Phlegmon behind the mandibul. E. Phlegmon of the submandibular region. Correct answer: A. Phlegmon parapharyngeal space. Solution algorithm: To establish a clinical diagnosis, attention should be paid to the patient's complaints: edema in the area of the mandibular angle, pain and heaviness when swallowing, limited opening of the mouth. Objective examination data: edema and hyperemia of soft tissues along the pterygoid mandibular space- fold, half of the soft palate and protrusion of the lateral pharyngeal wall, the palatine uvula is deflected to the side, which allow choosing the correct answer A.

Task 3. A patient with phlegmon of the tongue root was hospitalized in the department of maxillofacial surgery. What is the prompt access to the opening of the phlegmon of the tongue root? Answer options: A. Intraoral incision. B. Slit like collar (the form) C. Midline incision. D. Submandibular incision. E. Incision bordering the corner of the mandible. Correct answer: C. Midline incision. Solution algorithm: Based on the principles of surgical anatomy, with phlegmon of the tongue, a median incision is shown.

Task 4. A 35-year-old patient was hospitalized with complaints of sharp pains in the tongue, difficulty in speaking, inability to swallow, and chew food. Slight swelling of the upper neck. Three days ago I injured my tongue in the back third with a fish bone. Bone removed the ENT and sent him home. The pain increased. There was a feeling of increasing the volume of the tongue. The second time I turned to ENT. The patient was referred to the department of maxillary surgery. Objectively: the mouth is half- open, saliva flows out. Edema of the posterior submental region and the right upper anterior neck. With deep palpation, a sharply painful infiltration over the hyoid bone is determined. The tongue is enlarged in size, swollen, coated with a gray bloom. Movements of the tongue forward are sharply painful. A sharp pain is determined when pressing on the tongue from top to bottom, especially in the posterior third. The mucous membrane of the jaw-lingual grooves on both sides and the sublingual region is swollen and swollen. On palpation in the area of the root of the tongue, a significant, sharply painful inflammatory infiltrate is determined. X-ray examination revealed no pathological changes in the bone tissue. 1. Establish a diagnosis. 2. Make a treatment plan. 3. What measures should be taken to eliminate complications in the early postoperative period. Solution algorithm: 1. Diagnosis: phlegmon of the tongue root. 2. Treatment plan: opening of phlegmon, general and local anti-inflammatory, symptomatic and general strengthening therapy. 3. Before the operation of opening the phlegmon, it is advisable for the patient to impose a tracheostomy in order to avoid the development of stenotic asphyxia due to significant edema in the early postoperative period.

Task 5. A 38-year-old patient is being treated at the clinic for a week with a diagnosis of phlegmon of the floor of the mouth. During the first 3 days after treatment, the patient's condition improved slightly. Then the patient's condition began to deteriorate again. The inflammatory process spread to the anterior-lateral surface of the neck. At the moment, the patient's condition is serious. The skin and visible mucous membranes are pale, sallow. There are many abscesses on the skin of the body. The patient is in a coma. On palpation, significant pain in the liver and right hip joint is determined. Heart sounds are muffled. 1. Establish a diagnosis. 2. What information is missing to clarify the diagnosis? 3. Make a treatment plan. Solution algorithm: 1. It can be assumed that the patient develops odontogenic sepsis. This is evidenced by a sharp deterioration in the patient's condition against the background of therapy, which was carried out, the spread of the process to neighboring cellular spaces. The generalization of the process is evidenced by the presence of abscesses on the skin, pain on palpation of the liver and the right hip joint, which indicate the development of metastatic purulent foci in them. 2. There is a lack of information characterizing the symptoms of intoxication of the patient: fever, blood counts, urine, blood pressure, pulse. There is no information on the results of peripheral blood cultures for microflora. 3. a) transfer of the patient to the intensive care unit; b) revision of the disclosed cellular spaces, if necessary - before disclosure; c) consultation of a general surgeon; e) carrying out massive pharmacotherapy aimed at destroying the infectious agent, correcting general disorders in the body, supporting and restoring vital functions.

LITERATURE. Basic literature: 1. Oral and maxillofacial surgery: textbook / Ed. by prof. V. Malanchuk / part one. – Vinnytsia: Nova Knyha Publishers, 2011. – 424 p. 2. Avetikov D.S. Using of modern methods of diagnostics in the practice of oral surgery: Text-book / Avetikov D.S, Skikevych M.G., Lokes K.P., Bojchenko O.M.-Poltava-2018 -122p. 3. S.I. Danylchenko Operative surgery and topographical anatomy: Text-book/ S.I. Danylchenko, E.N. Pronina, D.S.Avetikov .- Poltava-2011-239p. 4. Tkachenko P.I. Propaedeutics of surgical stomatology and inflammatory diseases of maxillofacial region / P.I. Tkachenko, A.I. Pan’kevich, K.Yu. Rezvina. – Poltava. – ASMI, 2001. – 283 p.

Additional: 1. Liudmila Krautsevich, Oleg Khorow, Clinical aspects, diagnosis and treatment of the phlegmons of maxillofacial area and deep neck infections, Otolaryngologia Polska, Volume 62, Issue 5, 2008, Pages 545-548, https://doi.org/10.1016/S0030- 6657(08)70311-1 2. Daniel Taub, Andrew Yampolsky, Robert Diecidue, Lionel Gold, Controversies in the Management of Oral and Maxillofacial Infections, Oral and Maxillofacial Surgery Clinics of North America, Volume 29, Issue 4, 2017, Pages 465-473, https://doi.org/10.1016/j.coms.2017.06.004 3. Arvind Babu Rajendra Santosh, Doryck Boyd, Kumaraswamy Kikeri Laxminarayana, Clinical Outline of Oral Diseases, Dental Clinics of North America, Volume 64, Issue 1, 2020, Pages 1-10 https://doi.org/10.1016/j.cden.2019.08.001 4. Richard A. Brodsky, Hans-David R. Hartwig Maxillofacial Swelling and Infections, Clinical Pediatric Emergency Medicine, Volume 11, Issue 2, 2010, Pages 95-102, https://doi.org/10.1016/j.cpem.2010.04.002

Web source:

[http://www.ncbi.nlm.nin.gov./Pub.Med/], 2016 [www.umj.com.ua], 2014 [http://www.ncbi.nlm.nin.gov./Pub.Med/], 2016 [www.umj.com.ua], 2014 [http://www.ncbi.nlm.nin.gov./Pub.Med/], 2016

Methodological recommendations were prepared by Associate Professor Skikevych M.G.