Int. J. Oral Maxillofac. Surg.

2002; 31: 165169

doi:10.1054/ijom.2001.0190, available online at http://www.idealibrary.com on

Clinical paper:
Oral medicine
Y. Ariji1, M. Gotoh1, Y. Kimura2,
Odontogenic infection pathway M. Naitoh1, K. Kurita3, N. Natsume4,
E. Ariji1
1

to the submandibular space: Department of Oral and Maxillofacial

Radiology, Aichi-Gakuin University School of
Dentistry, Nagoya, Japan; 2Department of
Radiology and Cancer Biology, Nagasaki

imaging assessment University School of Dentistry, Nagasaki,

Japan; 2First Department of Oral and
Maxillofacial Surgery, Aichi-Gakuin University
School of Dentistry, Nagoya, Japan; 3Second
Department of Oral and Maxillofacial Surgery,
Y. Ariji, M. Gotoh, Y. Kimura, M. Naitoh, K. Kurita, N. Natsume, E. Ariji: Aichi-Gakuin University School of Dentistry,
Odontogenic infection pathway to the submandibular space: imaging assessment. Int. Nagoya, Japan
J. Oral Maxillofac. Surg. 2002; 31: 165169.  2002 International Association of
Oral and Maxillofacial Surgeons

Abstract. The aims of this study were to determine the pathways of odontogenic
infection spread into the submandibular space and their relationship to the clinical
symptoms. Computerized tomography (CT) and magnetic resonance (MR) images
of 33 patients with submandibular involvement were analyzed. The spread of
infection was evaluated by lateral asymmetry of the shape and density of the fascial
spaces and tissues, and by obliteration of the interfascial fat spaces. Imaging
findings were classified into three types: in 19 patients (57.6%), infection spread
through the mylohyoid muscle or sublingual space (type I). In five patients (15.2%),
infection spread through the bony structures of the mandible with periosteal
reaction or perforation of the cortical plate (type II) and was associated with
relatively mild symptoms. In four patients (12.1%), infection spread from the
masticatory space (type III). Seven of 11 patients with dysphagia or fever showed Key words: odontogenic infection;
submandibular involvement spreading into the parapharyngeal space. CT and MR submandibular space; tomography X-ray
imaging clearly demonstrated dierent pathways of the spread of odontogenic computed; magnetic resonance imaging.
infection into the submandibular space, which influenced the manifestation of
clinical symptoms. Accepted for publication 1 December 2001

Introduction
Understanding the anatomy of fascial
spaces is essential for the diagnosis and
treatment of infection, because the fascia
is an eective barrier to the spread
of infection1,10,13,19 (Fig. 1). Cross-
sectional imaging, such as computerized
tomography (CT) or magnetic resonance
imaging (MRI), has significantly con-
tributed to this evaluation and many
studies have reported on the spread of
maxillofacial infection1,5,6,8,12,19. Odon-
togenic infections occasionally spread
beyond the barriers of the fascial
spaces13, which are formed by the deep
cervical fascia of the suprahyoid region
of the neck10. Among several spaces, the
0901-5027/02/020165+05 $35.00/0
submandibular space is one of the first to
be involved by odontogenic infection
similar to the masticatory space1,12,15,19.
Involvement of the submandibular space
causes severe symptoms such as neck
rigidity, trismus, dysphagia, respiratory
distress, sialorrhea, and pyrexia2,14.
Moreover, the submandibular space is
regarded as a space through which
inflammation spreads to the parapha-
ryngeal space. If the infection spreads
into the parapharyngeal space, rapid
and critical airway obstruction may
occur4,14,17.
Although CT and MRI are useful for
depiction of the extent of odontogenic
infection1,5,6,19, the pathways of spread
 2002 International Association of Oral and Maxillofacial Surgeons
to the submandibular space have not
completely been elucidated. Infections
originating in the mandible often spread
to the submandibular space and several
possible pathways have been suggested:
+ Spreading directly beyond the
mylohyoid ridge of the mandible3,5
+ Spreading posteriorly from the
adjacent sublingual space10
+ Spreading from the inflammatory
periostitis of the mandible18
+ Spreading downward from the
masticatory space8.
The aim of this study was to investi-
gate the pathways of odontogenic infec-
tion spread into the submandibular
166 Ariji et al.

A tion was established from the patients Two radiologists interpreted each
clinical course. Surgical drainage was image. If any disagreements in interpret-
performed in five patients. In all ation existed, consensus was reached
patients, clinical signs and symptoms after discussion.
G S were diminished after antibiotic treat-
L
M G
M S ment. Patients who had primary siaload-
H
enitis of the submandibular gland or Results
M

P
SMS cervical lymphadenitis were excluded.
SMG P CT was performed on all patients in
S
the supine position with a Somatom
ART (Siemens AG, Erlangen,
Germany). Axial scans were obtained
CS
contiguously, with a section thickness of
3 mm and with the scan plane parallel to
the occlusal plane or inferior margin of
B the mandible. Of them, five patients sus-
piciously associated with abscess under-
went i.v. injection via rapid drip of
TM
100 ml of contrast medium (iopamidol,
LMP MS Iopamiron 300, Schering, Germany).
M
P MRI was performed on six patients
P
P S with a 1.0-T MAGNEX-100XP
M
(Shimadzu, Kyoto, Japan) and a head
MM
coil. The standard MR imaging
sequences were performed: spin-echo
SMG
SMS
T1-weighted images (500/1520 [rep-
etition time ms/echo time ms]);
T2-weighted images (5500/110 [rep-
Fig. 1. Anatomy of the fascial spaces in axial
(A) and coronal (B) images. SMS: sub- etition time ms/echo time ms]); short
mandibular space; SLS: sublingual space; PPS: inversion time inversion-recovery
parapharyngeal space; CS: carotid space; MS: (STIR) (2500-3800/22/90-110 [repetition
masticatory space. SMG: submandibular time ms/echo time ms/inversion time
gland; GGM: genioglossus muscle; MHM: ms]). Of them, one patient underwent
mylohyoid muscle; MM: masseter muscle; MR examination after a bolus injection
MPM: medial pterygoid muscle; LPM: lateral of gadolinium dimeglumine for detecting
pterygoid muscle; TM: temporal muscle. abscess formation. In general, the sec-
tion thickness was 5.0 mm with an inter-
space using CT and MRI, and to clarify section gap of 1.0 mm. The acquisition
the frequency of each pathway. We also matrix was 256256. The axial, coronal
investigated the correlation between and sagittal planes were used.
pathways and clinical symptoms. The spread of infection was evaluated
by lateral asymmetry of the shape and
density of the fascial spaces and tissues,
Material and methods
and by obliteration of the interfascial fat
CT and MR images of the maxillofacial spaces1,6,19. The inflammatory condition
and neck regions of 46 patients with of the periosteum was evaluated based
extended odontogenic infection treated on the periosteal new bone formation
between July 1996 and November 2000 and/or destruction of cortical
were reviewed. The diagnosis of infec- bone7,11,16.
No patient revealed retropharyngeal or
carotid space involvement. There was no
definite submandibular space involve-
ment in patients with infection originat-
ing in the maxilla.
Out of the 46 patients with odon-
togenic infection, 33 patients (26 men
and seven women) with extensions of
infection into the submandibular space
were enrolled for the following analysis.
All these patients had extensions from
mandibular infections; 16 followed peri-
coronitis or extraction of the mandibular
third molar, 14 originated in the lower
first or second molar, and three from
incisor or premolar teeth.
All patients demonstrated clinical
swelling of the submandibular region.
Spontaneous pain was present in 17
patients, trismus in 11, dysphagia or
dyspnoea in eight, and pyrexia in four.
The duration from onset of infection to
CT or MR examinations ranged from
1 day to 3.5 months.
Of these 33 patients with submandibu-
lar infection, none included involvement
of the lateral pterygoid and temporal
muscles. Only one patient showed
involvement in the parotid space and
two in the buccal space. The digastric
and platysmal muscles were involved in
20 (60.6%) and 25 (75.8%) patients,
respectively.
The findings were classified into three
types. The first type (type I) was charac-
terized as submandibular involvement
accompanied by enlargement of the
mylohyoid muscle. In this type, inflam-
mation was observed mainly on the lin-
gual side of the mandible without
changes in the masseter muscles. A total
of 19 patients (57.6%) were classified as

Table 1. Imaging features of the patients with submandibular involvement

Space and muscle involvements*
Types of
involvement Masticatory space Sublingual Parapharyngeal
(no. of patients) Bone change MM MPM space space MH DI PL
I (19) 0 0 4 14 10 19 15 11
II (5) 5 0 1 0 0 0 1 5
III (4) 0 4 3 0 1 3 2 4
I&II (3) 3 0 1 0 2 3 2 3
II&III (1) 1 1 1 0 0 0 0 1
Unclassified (1) 0 0 0 0 0 0 0 1
Total (33) 9 5 10 14 13 25 20 25

Arabic numbers show the number of patients with involvement on images.

*MM: masseter muscle; MPM: medial pterygoid muscle; MH: mylohyoid muscle; DI: digastric muscle; PL: platysma.

Fig. 2. Patient No. 8 had swelling and slight
tenderness in the submental region. The infec-
tion followed extraction of the left mandibu-
lar second molar and continued for 2 months.
Axial CT image (A) shows swelling of the left
mylohyoid muscle (arrow). Coronal STIR
MR image (B) shows high signal intensity in
the socket after the extraction of tooth
(arrow). The enlargement and increment of
signal intensity in the mylohyoid muscle
(arrowheads) and the submandibular space
are also observed.
having this type. Of these, 14 patients
showed sublingual space involvement.
The mandibular infections were con-
sidered to have spread downward
to involve the submandibular space
through the mylohyoid muscle (Fig. 2)
or sublingual space (Fig. 3). Two
patients with infection from incisors or
premolars were classified as having this
type.
Five patients (15.1%) were classified
as having the second type (type II).
The submandibular involvement was
accompanied by mandibular bony
changes without involvement of the sub-
lingual space or mylohyoid muscle. Of
these, four patients had a periosteal reac-
tion and all five patients had disruption
of the cortical bone of the mandible.
Bone changes were observed in four of
five type II patients in the lingual side
and only one in the buccal side. In this
type, the infection is thought to spread
along the periosteum or directly into the
Odontogenic infection in submandibular space
Fig. 3. Patient No. 2 complained of swelling
and pain in the submandibular region for 19
days. The source of infection was a mandibu-
lar premolar. Axial CT (A) shows lateral
asymmetry in the sublingual and sub-
mandibular spaces. Coronal STIR MR (B)
image clearly shows increments of signal
intensity in the sublingual space (arrow). This
high-intensity area continues to the sub-
mandibular space (arrowheads).
submandibular space through the
mandibular bone (Fig. 4).
In the third type (type III), inflamma-
tory findings were observed mainly in
the masticatory space, especially in the
masseter muscle. Four patients (12.1%)
were classified as having this type and all
had changes in the masseter muscle with-
out sublingual space involvement (Fig.
5). The mandibular infection would
spread initially into the masticatory
space and subsequently extend down-
ward to the submandibular space.
Four patients showed combinations of
these types. Three patients showed type I
and type II characteristics and one
patient showed type II and type III
characteristics. All four of these patients
had the buccal bone changes. The
remaining patient could not be classified
because the changes were observed only
in the submandibular space and the
platysma.
167
Fig. 4. Patient No. 24 showed an infection
following pericoronitis of the mandibular
third molar for 2 months. Axial CT image (A)
shows periosteal reaction parallel to the lin-
gual cortical plate of the posterior mandible
(arrow). Axial STIR MR images (B) show a
high signal short line (arrow) at the area cor-
responding to the periosteal reaction on CT.
Coronal MR image (C) shows a high-intensity
line continuing from the mandibular
trabecula to the submandibular space through
the disrupted cortical plate (arrow). No en-
largement is visible in the mylohyoid muscle.
A total of 13 patients had involvement
both in the parapharyngeal and sub-
mandibular spaces (Fig. 6). Of these,
seven patients showed no changes in the
medial pterygoid muscle. This finding
suggested that infection spread through
the submandibular space to the parapha-
ryngeal space. Regarding the type of
involvement, parapharyngeal space in-
volvement was shown in 10 (52.6%) of
19 type I patients, while no patients had
168 Ariji et al.
Fig. 5. Patient No. 27 complained of trismus
and submandibular swelling with pain and
redness for 12 days. The source of infection
was considered to be the mandibular second
molar region. Axial CT image shows the
enlarged medial pterygoid muscle (arrow) and
increments of density in the submandibular
space together with thickening of the platys-
mal muscle (arrowheads).
Fig. 6. Patient No. 12 complained of trismus,
dysphagia and dyspnoea with marked swell-
ing of the submandibular region. Axial CT
image shows severe asymmetry with disloca-
tion of the airway. The parapharyngeal space
(*) is involved together with the sublingual
and submandibular spaces.
this involvement in type II and only one
patient in type III.
The clinical symptoms were compared
among the three types of imaging fea-
tures. Out of 19 patients with type I, six
patients (31.6%) had trismus and six
patients (31.6%) showed dysphagia or
fever. Out of five patients with type II,
none demonstrated trismus and only one
showed signs of fever. Out of four
patients with type III, three patients
(75.0%) had trismus and two patients
(50.0%) had dysphagia.
Discussion
The submandibular space is considered
to be important in odontogenic infec-
tion, because infection in this space is
Fig. 7. Schematic drawing of the three types
of pathways: type I (A), type II (B) and type
III (C).
often accompanied by changes in other
surgical spaces3,19. The findings of the
present study support these previous
observations. In this study, 75.8% of
patients with infection of the sub-
mandibular space showed involvement
in multiple spaces.
The i.v. contrast enhancement on CT
and MR imaging have been usually
applied to deep facial and neck infec-
tions to detect abscess formation. It
should be applied to CT examination
for more accurate diagnosis1, although
special sequence MR images, such as
short inversion time inversion-recovery
(STIR) imaging, are able to clearly dem-
onstrate the abnormal findings including
abscess without enhancement5.
On the basis of the present findings, the
pathways to the submandibular space
were classified into three types (Fig. 7).
The pathway through the mylohyoid
muscle or sublingual space (type I) was
observed most frequently in 19 of 33
patients (57.6%) with submandibular
space involvement. Odontogenic infec-
tions, such as periodontal abscess, perfor-
ate bone in its thinnest and weakest part.
In the mandible, this is the lingual aspect
of the posterior molar region13. Infection
spreads to the lingual side of the mandible
and involves the mylohyoid muscle,
which separates the submandibular space
from the sublingual space in its anterior
part10. Therefore, infection spreads to
both of the sublingual and submandibular
spaces through the mylohyoid muscle.
Since there is no fascia separating these
spaces at the posterior margin of the my-
lohyoid muscle, the submandibular space
freely communicates with the sublingual
space10 and infection of one space readily
spreads to involve the other space10,12,19.
Infection originating in the anterior teeth
would initially extend to the sublingual
space and subsequently spread directly or
through the mylohyoid muscle into the
submandibular space12. In the present
study, the sublingual space was frequently
involved, even in infections originating in
the molar regions. These findings confirm
that infection spreads easily between these
spaces.
In type II patients, apparent bony
pathology and submandibular space
involvement were observed without
involvement in the sublingual space and
the mylohyoid muscle. This type would
include two possible pathways. First,
infections such as periapical lesions
spread in the mandible and perforate the
cortical plate at the lower part of the
mandible, opening a fistula directly to
the submandibular space. In this type,
the location of the submandibular fistula
is occasionally away from the causal
tooth. Another pathway is the perios-
teum, with its involvement well demon-
strated on MR images7,16. Infection
spreads downward along the periosteum
of the mandible to involve the sub-
mandibular space. Infection spreading
along the lingual periosteum is often
accompanied by enlargement of the
mylohyoid muscle. This finding could
not be classified as being characteristic of
type I or type II. Three patients showed
this appearance (type I & II). An expla-
nation is proposed for the dierence in
the pathways according to the length of
the causal teeth. Infection caused by
teeth with short roots above the mylo-
hyoid ridge tended first to involve the
sublingual space or mylohyoid muscle
representing type I, while that from
teeth with long roots beyond the mylo-
hyoid ridge directly involved the sub-
mandibular space, forming type II12,19.

Four patients showed involvement
mainly in the masticatory space and
revealed swelling of the masseter muscle
together with submandibular space
involvement. Odontogenic infection
would initially extend to the masticatory
space and then spread downwards into
the submandibular space directly from
the masseter or medial pterygoid muscle
through the investing layer of the deep
cervical fascia. Since this fascia is rela-
tively thick and is an eective barrier
against the spread of infection, the inci-
dence of the submandibular involvement
is not so high in patients whose infection
was observed mainly in the masticatory
space1. The present findings support pre-
vious observations, because this type
(type III) was observed only in four of 33
patients (12.1%). Controversially, some
previous studies reported that the
masticatory space infection was often
accompanied with submandibular
involvement8,19. In these studies, the
majority of the involvement in both
spaces might be a result of simultaneous
two-directional spread from an original
focus rather than subsequent spread to
the submandibular space from the mas-
ticatory space. This discrepancy is prob-
ably due to dierences in the stages of
progression of infection or in examina-
tion time. However, it is known that
infection spreads into the parapharyn-
geal space from the medial pterygoid
muscle through the same fascia1,8. As
shown in Fig. 7, imaging features con-
firmed the existence of this pathway.
One patient revealed a combined
appearance of types II and III. Although
the exact cause of this appearance was
not clear, there are two possible explana-
tions based on previous findings. Mas-
seter or medial pterygoid cellulitis might
cause periosteal new bone formation18,
or infection in the mandible might per-
forate the cortical plate and invade the
masticatory space12.
Among various signs and symptoms
observed in patients with infection of the
submandibular space2,14, we focussed on
trismus, dysphagia and fever in this
study. Type II patients had no or rare
involvement of the parapharyngeal and
masticatory spaces, resulting in relatively
mild symptoms without trismus and dys-
phagia. As reported previously, trismus
is a significant symptom in the great ma-
jority of patients with masticatory space
involvement1,8. The present findings are
compatible with these previous observa-
tions. Of five patients with involvement
in the masseter muscle, four had trismus.
Dysphagia often occurred when infec-
Odontogenic infection in submandibular space 169
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