Sublingual Space Research Articles

Persistent Oral Infection Caused by an Iatrogenic Displacement of a Lower Third Molar Root to the Sublingual Space

ABSTRACTAim and objectiveDescribe a case of sublingual displacement of a root of the lower third molar, as well as highlight the importance of using appropriate complementary imaging tests and provide the clinician with information on how to prevent and treat this complication.BackgroundThe displacement of the lower third molar is an accidental event that can lead to serious complications, which is usually the cause of inadequate surgical technique.Case descriptionA 69-year-old man presented pain and trismus due to local infection 1 month after a tooth extraction. After a misdiagnosis of retained root and surgical exploration, a cone-beam computed tomography (CBCT) showed a displaced root into the sublingual tissues. A surgical procedure under local anesthesia was carried out to easily remove the displaced tooth root, which resulted in complete healing of soft tissues and disappearance of signs of local infection.ConclusionThe use of CBCT is essential for the identification and location of the dislocated tooth and the removal of the fragment, as it allows a three-dimensional assessment providing adequate surgical planning which resulted in complete remission of all symptoms.Clinical significanceFew reports have been published to describe this rare complication of dental extractions that support key points for proper management: (1) the use of three-dimensional imaging for proper evaluation and establishment of exact location; (2) careful surgical planning; (3) precise surgery. Successful tooth removal is the main goal of treatment, which usually results in control of associated signs and symptoms.How to cite this articleSousa NWA, de Moraes ATL, Guimarães DM,et al.Persistent Oral Infection Caused by an Iatrogenic Displacement of a Lower Third Molar Root to the Sublingual Space. J Contemp Dent 2019;9(3):155–158.

Chew on This: Emergency Imaging of the Oral Cavity and Salivary Glands—What the Clinician Really Needs to Know

Nontraumatic emergencies of the oral cavity, sublingual and submandibular spaces, and salivary glands are common and those requiring imaging will most often be infectious in nature.1,2 However, noninfectious pathologies such as sialolithiasis, autoimmune sialoadenitis, and soft tissue swelling due to angioedema or hemorrhage are also important conditions that radiologists must be familiar with in order to inform the clinician of critical imaging findings that can have a profound impact on patient outcomes. To understand these pathologies, familiarity with the anatomy of these spaces is essential.

Ludwig Angina after First Aid Treatment: Possible Etiologies and Prevention—Case Report

Ludwig angina is a life-threatening type of soft tissue cellulitis involving 3 compartments on the floor of the mouth including the submental, sublingual, and submandibular spaces bilaterally. Prevention, early recognition, and treatment of Ludwig angina are critical because this is a clinical diagnosis with unpredictable progression. This article describes a rare case of Ludwig angina that evolved from an odontogenic infection and the specific microbiology and clinical course and discusses possible etiologies and prevention.

Mylohyoid Variations and their Clinical Implications

The mylohyoid separates the sublingual and submandibular spaces and is, therefore, important with regard to the spread of infection and space occupying lesions. The mylohyoid may also be elevated in submental flap procedures. Therefore, mylohyoid variations are implicated in infection spread and are also important with regard to surgical planning. However, there have only been a few reported mylohyoid variations outside of mylohyoid boutonnieres. This report documents a case series of exotic mylohyoid variations including mylohyoid musculature that does not insert at the hyoid but rather inserts into the anterior digastric muscle belly, intermediate tendon of the digastric muscle, and geniohyoid. In each case, the mylohyoid is not a true mylohyoid because it does not insert into the hyoid. Understanding the potential for mylohyoid variation may improve clinical assessment, treatment, and prognosis in the suprahyoid region.Support or Funding InformationWV Research Challenge Fund [HEPC.dsr.17.06] and [HEPC.dsr.14.13]This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Ludwig's angina: Pediatric case report and literature review

Ludwig's angina (LA) is a serious, rapidly progressive cellulitis of the floor of the mouth which involves the submandibular, submaxillary, and sublingual spaces of the face; it is life-threatening if not recognized early and complications such as septicemia and asphyxia caused by expanding edema of soft tissues of the neck may occur. A literature review identified 35 pediatric cases of LA with a 14% mortality rate. It occurs predominantly in immunocompetent children with an odontogenic source of infection in a third and unknown source of infection in a third of cases. Many departments may have limited experience of the disease because of its rare occurrence. Hence, it is important to recognize LA in the earlier stages of the disease. We here present a case of huge LA in a 6-month-old male child with a very short history.

A case of sublingual adenoid cystic carcinoma involving the mandible presenting as a “skip lesion”

Adenoid cystic carcinoma (ACC) is a slowly growing malignant neoplasm with a propensity for perineural invasion. Microscopic invasion of ACC often prevents its detection on computed tomography (CT) or magnetic resonance imaging (MRI). We herein report a rare case of sublingual ACC presenting as a "skip lesion" that rapidly infiltrated the mandible after tumor resection. A 64-year-old man presented to Okayama University Hospital with an 18-month history of swelling in the right floor of the mouth. Clinical examination displayed an ulcerated swollen mass in that region. An enhanced mass was detected in the right sublingual space on CT and MRI. Bone surface erosion was observed at the inferior border of the mandible, but continuity with the sublingual mass or mass around that lesion was not detected by imaging. Sublingual tumor resection and selective neck dissection were performed by the pull-through method. Histopathologically, the surgical margins were free of cancer cells, and the tumor was diagnosed as ACC. Continuity with the sublingual mass and mandibular bone was not detected intraoperatively. However, marked bone resorption was detected in the anterior mandible 3months after the operation. Biopsy was performed, and the findings indicated the same histological type of sublingual ACC. This case suggests that a malignant tumor close to the jaw bone requires the clinician to consider the possibility of bone invasion and to observe a wide region surrounding the tumor using imaging examination.

Causative Factors of Ludwig’s Angina

Introduction: Ludwig’s angina is a rapidly progressive, potentially fulminant cellulitis involving the sub-lingual, submental and sub-mandibular spaces. It typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars. Besides, poor nutritional status, lack of proper medical supports are still major predisposing factors in developing Ludwig’s angina in countries like Bangladesh.Aim: Our study aimed to observe the role of odontogenic infection in development of Ludwig’s Angina.Method: We carried out a cross sectional study among 26 patients with Ludwig’s angina admitted in the department of ENT and Head-neck surgery in SSMC &Mitford Hospital from January-December-2014.Results: In this study we found that males are predominantly affected than females (21 males and 5 females, ratio-4.2:1) with odontogenic infection (18, 69%) as source. We found historyof recent tooth extraction in 6 cases (23%) & organism was isolated from pus culture,Klebsiella in 10 cases (19.2%) out of 26 cases. We elicited underlying systemic disease mainly is Diabetes Mellitus in 9 cases (35%) that predisposes to Ludwig’s angina.\Conclusion: Our study suggests that prompt and thorough clinical evaluation and definitivecare will considerably improve patient condition and reduce morbidity and mortality.J Dhaka Medical College, Vol. 26, No.1, April, 2017, Page 3-7

Accidental displacement of mandibular third molar root into the sublingual space and delayed removal

AbstractOral surgeons rarely experience accidental displacement of a mandibular impacted third molar into adjacent anatomical spaces as a complication. As any displaced third molar or its root is commonly removed at the time of displacement or within several weeks of the extraction, delayed removal several years after initial extraction is extremely rare. We report here accidental displacement of a mandibular third molar root into the sublingual space and a 5‐year delay in its removal. A 42‐year‐old woman presented to our department with pain and swelling in the lingual aspect of the left mandible. Computed tomography revealed a 15 × 11 × 9 mm lesion, with a similar density to that of the surrounding bone and involving the lingual cortex of the left mandible. A yellowish‐white hard tissue lesion was protruding from the lingual mucosa of the left mandibular ramus. The patient had undergone removal of a left impacted mandibular third molar at a private dental clinic 5 years earlier and we diagnosed the lesion as a remnant third molar root. The patient had not been informed by her dentist of accidental displacement of the tooth into the sublingual space after crown removal. After complete alleviation of inflammation, the patient underwent intraoral removal of the root under general anaesthesia. After elevating the lingual mucoperiosteal flap from the mandibular ramus to the premolar region, the root was easily removed using an elevator and forceps. Her postoperative course was uneventful and there were no complications such as lingual nerve injury.

Variation of the mylohyoid: implications for Ludwig angina, cervical contouring, and digastric muscle transfer

The mylohyoid (MH) musculature separates the sublingual and submandibular spaces and is, therefore, important with regard to the spread of infection and space occupying lesions. Moreover, the MH may be elevated and included in the myocutaneous submental island flap or sutured in conjunction with the platysmas and the anterior bellies of the digastric muscles (ABDMs) to add stability to submental muscular medialization procedures. Therefore, variation in the anatomy of the MH musculature must be considered in the management of the spread of infection and space occupying lesions as well as in surgical planning. This report reviews mylohyoid variations and documents a unique case in which several suprahyoid muscular variations occurred concurrently. The variations included isolated anterior bellies of the mylohyoid inserting into the geniohyoid thereby forming mylo-geniohyoid muscles as well as isolated posterior bellies of the mylohyoid inserting into the ABDM and the intermediate tendon of the digastric muscle thereby forming mylo-digastric muscles. Surgeons operating in the suprahyoid region should be aware of potential anatomical variation of the mylohyoid to develop contingency plans.

Analyses of anatomical relationship between mandibular third molar roots and variations in lingual undercut of mandible using cone-beam computed tomography

Background/purposeAnatomical features of the lingual undercut region is a potential factor that might increase the risk of displacement of a tooth or fragment. The aim of this study was to report the normal anatomical relationship of impacted lower third molar roots to the lingual cortex and soft tissues of mandible and anatomical variations of lingual balcony in the impacted third molar region. Materials and methodsOne hundred impacted third molars (54 males, 46 females) from 65 (31 men, 34 women) patients were evaluated for this study using cone-beam computed tomography. Three measurements [bone thickness, angle (Ang) 1 and Ang 2] were recorded on the coronal section slices of cone-beam computed tomography images; in these images, the impacted third molar root was closest to the lingual soft tissues. ResultsThe average distance between the tooth root and the lingual outer cortical bone layer (bone thickness) was 1.03 mm. The averages of Ang 1 and Ang 2 were 140.61° and 153.44°. Ang 1 and Ang 2 of female patients were larger than those of male patients. ConclusionThe narrow angulation of the lingual balcony region and the relationship between roots and lingual soft tissues should be noted to avoid undesirable complication of displacement of a tooth or fragment into sublingual, submandibular, and pterygomandibular spaces. There was no relation in the floor of the mouth between the position of the impacted third molar roots and different lingual undercut angulation variations.

The myloglossus in a human cadaver study: common or uncommon anatomical structure?

Additional extrinsic muscles of the tongue are reported in literature and one of them is the myloglossus muscle (MGM). Since MGM is nowadays considered as anatomical variant, the aim of this study is to clarify some open questions by evaluating and describing the myloglossal anatomy (including both MGM and its ligamentous counterpart) during human cadaver dissections. Twenty-one regions (including masticator space, sublingual space and adjacent areas) were dissected and the presence and appearance of myloglossus were considered, together with its proximal and distal insertions, vascularisation and innervation. The myloglossus was present in 61.9% of cases with muscular, ligamentous or mixed appearance and either bony or muscular insertion. Facial artery provided myloglossal vascularisation in the 84.62% and lingual artery in the 15.38%; innervation was granted by the trigeminal system (buccal nerve and mylohyoid nerve), sometimes (46.15%) with hypoglossal component. These data suggest us to not consider myloglossus as a rare anatomical variant.

Pharyngitis in the Wake of an Invasive Dental Procedure

An 82-year-old man presented to the emergency department with the chief complaints of sore throat and difficulty swallowing of 2 days' duration. The history of his present illness was notable for a dental procedure performed 72 hours prior to arrival. Upon evaluation, the patient was resting comfortably, tolerating his secretions, and speaking in a clear tone. His vital signs were significant for fever, tachycardia, and tachypnea. An examination revealed stomatodynia, elevation of the sublingual space, and submandibular edema (Figure 1, Figure 2); the lungs were clear to auscultation bilaterally. Figure 2Medical photography demonstrating submandibular edema. View Large Image Figure Viewer Download Hi-res image

Clinico-Pathological Profile of Deep Neck Space Infection: A Prospective Study.

Deep neck space infections (DNI) has been a common and serious disease, involving several spaces created by planes of greater and lesser resistance between the fascial layers of the neck. Infection of deep neck space has been dangerous due to its potential ease of spread from one space to other space, associated sepsis and upper airway obstruction. This prospective study was done in 45 patients of DNI over a period of 1year. Patients with age of 1month to 80years of both the sexes were included. Patient's particular, clinical presentation and associated co-morbid conditions, physical examination, routine laboratory investigations and radiological investigations were analyzed. Patients were treated, response to the treatment was assessed and follow-up was done. In present study, DNI was more commonly seen in rural population (67%) with a male predominance (69%). Mean age of presentation was 34.4years. Odontogenic infection (64.11%) was the commonest etiological factor and diabetes mellitus (26.66%) was the commonest co-morbid condition. Most common presenting symptom was neck pain and neck swelling (91.1%) and submandibular space (66.6%) was the most commonly involved space followed by sublingual space (44.6%). Both medical and surgical treatment was needed in most of the cases (77.77%). 77.7% cases showed complete regression, 15.5% showed partial regression and they lost to follow-up, 4.4% expired and 2.2% showed progressive deterioration. DNI is a common and life-threatening disease. Early diagnosis and management is necessary for complete cure and to prevent complications associated with DNIs.

Topographical relationship between positions of lingual foramina and attachment of mylohyoid muscle in mental region.

Lingual foramina can be observed between the lingual aspects of the mandible in humans. A sublingual artery is thought to exist in sublingual space and a submental artery in submaxillary space, which pierce the mandible through lingual foramina. During surgery for oral implant placement between apices of the mental foramen, it is important to determine the existence and positioning of lingual foramina. The purpose of this study was to investigate the positions of lingual foramina in relation to the mylohyoid muscle and vertical position of the mylohyoid line using cone-beam computed tomography (CBCT) images. We examined 20 formalin-perfused cadavers. The mylohyoid muscle was dissected and marked with a silicone tube, then CBCT images were obtained to evaluate the relationship of that muscle with lingual foramina. We observed 37 lingual foramina in the 20 cadavers. As for vertical positioning, 16 lingual foramina were found in sublingual space, while in horizontal positioning, 6 were found in the anterior region of sublingual space. The ratio of vertical distance from the inferior margin to the mylohyoid line and mental spine was lower in the anterior region as compared to the posterior region. In this study, lingual foramina were found to commonly exist in sublingual space above the mylohyoid muscle and pierce the mesial side. For evaluation of the vertical position of the mylohyoid line, it is better to use the stable mental spine rather than the alveolar process.

Paralingual and sublingual space invasion in magnetic resonance imaging of squamous cell carcinoma of anterior two-thirds of tongue: Is there a prognostic significance? A prospective evaluation.

Magnetic resonance imaging (MRI) in tumors of anterior two-thirds of tongue has a significant role in assessing different tumor parameters, and in prognosticating. This prospective study conducted in a tertiary cancer care center, focused on patients with squamous cell carcinoma of anterior two-thirds of tongue. The significance of invasion of paralingual and sublingual spaces in relation to the pathological grade of these tumors, and its predictive value in pathological nodal involvement were analyzed. All consecutive patients with the required inclusion criteria were accrued. Imaging was done with 3 Tesla MRI and invasion of sublingual and paralingual spaces were accurately assessed. Data elucidated were tabulated and analysed using IBM SPSS version 20.0. Chi-square test, nonparametric correlation using Spearman's Rho correlation, and two-independent sample test using Mann-Whitney's U-test were used to arrive at correlations between the imaging and histopathological parameters. Sixty-three patients were analyzed. Mean age was 52.3 ± 11.45 years. 74.6% were males. MRI showed sublingual space invasion in 47.6%. 18/28 with and 11/33 without invasion had node positivity. Paralingual space involvement was observed in 31.7% of patients. Thirteen of these and 16/43 with no involvement had positive cervical nodes. No statistically significant correlation was observed. This prospective study did not establish any statistically sound correlation, and robust data are lacking to support newer parameters such as sublingual space and paralingual space as probable predictors of cervical nodal involvement, and for prognostication.

Ultrasound of Neck Masses in Pediatrics

US plays an important role in the evaluation of palpable neck masses in pediatric patients. The superficially located structures are easily examined and exquisitely displayed by US using a high-frequency linear array transducer. In most of the cases, US can differentiate cystic from solid lesions. For the cystic lesions, the imaging diagnosis is based on location. The midline or paramedian location of cystic neck masses in pediatrics mostly are thyroglossal duct cyst and dermoid/epidermoid when locating between hyoid bone and thyroid gland, ranula or plunging ranula when locating in sublingual or submandibular spaces, and dermoid/epidermoid again when locating at suprasternal notch. Epiglottic cyst can also be detected in its typical location when there is no intervening air. The laterally-located cystic lesions are branchial cleft cyst, venolymphatic malformation, and phlebectasia of the jugular vein. Lymphatic malformation has its typical location in posterior triangle of the neck. Contents within cystic neck masses in many cases are not echo-free and may appear as pseudo-solid lesions on US. For the solid neck masses in pediatrics, US usually can tell whether it is an enlarged lymph node or not. Like in adult, US may depict the suspicious lymph node for biopsy. The imaging diagnosis of the solid neck masses other than enlarged lymph nodes in many cases are nonspecific and need histological diagnosis. However, there are some typical solid lesions that the diagnosis could be provided, e.g., fibromatosis colli, infantile hemangioma, ectopic thymus, and ectopic thyroid.

Prevention of neurological injuries during mandibular third molar surgery: technical notes.

Surgery to the mandibular third molar is common, and injuries to the inferior alveolar nerve and the lingual nerve are well-recognized complications of this procedure. The aim of these technical notes is to describe operative measures for reducing neurological complications during mandibular third molar surgery. The following procedure should be used to prevent damage to the inferior alveolar nerve: a well-designed mucoperiosteal flap, to obtain appropriate access to the surgical area; a conservative ostectomy on the distal and distal-lingual side; tooth sectioning, to facilitate its removal by decreasing the retention zones; tooth dislocation in the path of withdrawal imposed by the curvature of the root apex; and careful socket debridement, when the roots of the extracted tooth are in intimate contact with the mandibular canal. To prevent injury to the lingual nerve, it is important (I) to assess the integrity of the mandibular inner cortex and exclude the presence of fenestration, which could cause the dislocation of the tooth or its fragment into the sublingual or submandibular space; (II) to avoid inappropriate or excessive dislocation proceedings, in order to prevent lingual cortex fracture; (III) to perform horizontal mesial-distal crown sectioning of the lingually inclined tooth; (IV) to protect the lingual flap with a retractor showing the cortical ridge; and (V) to pass the suture not too apically and from the inner side in a buccal-lingual direction in the retromolar area.

Demographic and clinical characteristics of patients presenting with Cervico-Facial Cellulitis at the University of Calabar Teaching Hospital, Nigeria.

Background/Objective: The study is aimed at evaluating the demographic and clinical characteristics of patients who presented with infections involving the cervico-facial region in a Nigerian tertiary hospital Patients and Methods: All patients that were managed for cervico-facial infections, over a 4-year period, at the Oral and Maxillofacial Unit of the University of Calabar Teaching Hospital, Calabar, Nigeria were retrospectively studied. The information obtained were the demographics, duration of symptoms, month of the year, source of infection, fascia space(s) involved, whether managed on in or out-patient basis, duration of hospital stay where applicable, treatment done, complications and treatment outcome. The information was analyzed using the statistical package for social sciences (SPSS version 13, Illinois, Chicago). P<0.05 was considered significant. Results: A total of 36 cases comprising 19 males and 17 females were seen, giving a male-to-female ratio of 1.2:1. The ages ranged from 2 -73 years, mean 40.6 ±17.12 years. Patients aged 21 and above were mostly affected and the most commonly affected age was the 51-60 years (n=9; 25%) age group. This was followed by the 21-30 years and the 31-40 years age brackets each equally represented by 7 (19.4%) cases. Distribution of cases was bimodal, with the first peak at January and February and second peak at June. This monthly distribution was significant (Fisher’s Exact test: ×2= 29.487; P=0.001). The buccal space was the most commonly affected accounting for 14 (38.9%), and this was followed by bilateral sublingual, submandibular and submental spaces (Ludwig’sangina) with observed frequency of 6 (16.7%). The source of infection was mainly of dental origin (n=34; 94.4% with non-odontogenic sources accounting for only 2 (5.6%) cases. Those of odontogenic origin was mainly due to infections involving lower molars (n=17; 50%). The length of hospital stay ranged from 2-21 days, mean (SD), 7.8 (4.9) days. Two out of the 36 patients died, giving a mortality of 5.6%. Involvement of distant sites outside the cervico-facial region (OR=1.67; P=0.016), time interval between onset and presentation to the Oral and Maxillofacial Unit (OR=1.33; P=0.044), as well as age of patients (OR=3.00; P=0.005) were found to significantly contribute to survival of patients. Conclusion: Buccal space was most commonly involved site which is different from most previous reports from Nigeria. Late presentation to the Oral and Maxillofacial Surgeon, advanced age and distant spread were the contributory factors to poor prognosis.

Ludwig’s Angina: Emergency Treatment

ABSTRACT Ludwig’s angina is a form of severe diffuse cellulitis that presents an acute onset and spreads rapidly, bilaterally affecting the submandibular, sublingual, and submental spaces resulting in a state of emergency. Early diagnosis and immediate treatment planning could be a life-saving procedure. Here, we report a case of Ludwig’s angina successfully treated by surgical decompression under antibiotic coverage. How to cite this article Kamala KA, Sankethguddad S, Sujith SG. Ludwig’s Angina: Emergency Treatment. J Health Sci Res 2017;8(1):46-48.

Acute subcutaneous laterocervical emphysema and pneumomediastinum secondary to inferior third molar extraction

Subcutaneous laterocervical emphysema and pneumomediastinum are often due to head and neck surgery, but these are uncommon complications of dental procedures. The use of high-speed air-turbine headpieces during dental extractions is sometimes associated with this complication, making simple the spread of air under sublingual, submandibular, retropharyngeal, and parapharyngeal spaces, routes of communication to the mediastinum. Due to its rarity, it is not simple to recognize, often confused with other complications after oral surgery, such as allergic reaction, hematoma, and infections. We present a case of subcutaneous laterocervical emphysema and pneumomediastinum after inferior impacted third molar tooth extraction, self-limiting with a conservative therapy. We need to focus on this case because it is often misdiagnosed by physicians in emergency department as an allergic reaction. We also underline the importance of an empiric antibiotic therapy to prevent spreading of oral microorganism causing severe mediastinitis and sepsis. To avoid these complications, high-speed air-turbine headpieces should be used only when it is essential.