INCISION AND DRAINAGE

PRESENTED BY:
SANDEEP KUMAR SENGUPTA (CRI)
DEPARTMENT OF ORAL AND MAXILLOFACIAL
SURGERY
SRMKDC & H
How is I & D helpful ?

Incision & drainage helps-

To get rid of toxic purulent material.
To decompress odematous tissues.
To allow better perfusion of blood, containing antibiotics & defensive elements.
To increase oxygenation of infected area.

Removal of the cause; such as infected tooth, a segment of necrotic bone, a

foreign body should be done at the time of I & D procedure.
INCISION AND DRAINAGE PROCEDURE

-PROCEDURE SITE
-ANAESTHESIA
-INCISION
-WOUND DISSECTION
-WOUND IRRIGATION
-PACKING AND DRESSING
 INDICATIONS OF I & D

- EVIDENT CLINICAL SIGNS OF INFECTION AND UNDERLYING

SUPPURATION.

- LUDWIG`S ANGINA

-FASCIAL SPACE INFECTIONS

-DENTAL ABSCESSES

- PERITONSILLAR ABSCESS
ARMAMENTATRIUM
- LISTER`S SINUS FORCEPS OR CURVED HAEMOSTAT

- NO 11 BP BLADE FOR EXTRAORAL INCISION

- NO 15 BP BLADE FOR INTRAORAL INCISION

- NO 3 BP HANDLE

- SALINE IRRIGATION

- SUCTION

- YEAT`S OR CORRUGATED DRAIN FOR LARGE SUPERFICIAL ABSCESS

- VACCUM DRAIN FOR DEEP ABSCESS

NO 11 BP BLADE
NO 15 BP BLADE
 SURGICAL DRAINS
E.g
QUICK RECAP OF ODONTOGENIC
INFECTIONS
 PRINCIPLES OF I& D

- FOLLOW SHORTEST AND DIRECT ROUTE TO ACCUMULATED EXUDATE,

PRESERVING THE INTEGRITY OF ANATOMICAL STRUCTURES AND CONSIDERING ESTHETIC
CRITERIA

- PLACE INCISION IN HEALTHY MUCOSA AND AVOID FLUCTUATION

- PERFORM STRICTLY MUCOSAL OR CUTANEOUS INCISION FOLLOWED BY BLUNT DISSECTION

USING HAEMOSTAT. DISSECTION MOVEMENTS ARE DONE PARALLEL TO THE VESSELS TILL ALL
LOCULI ARE BROKEN.

- SUTURE LATEX DRAIN INTO PLACE AND AVOID USING GAUZE AS IT MAY RETAIN INFECTION.

- CLEAN DRAINAGE SYSTEM WITH STERILE SOLUTION UNTIL ALL SECRETIONS ARE WITHDRAWN.
INTRAORAL ABSCESS

- VESTIBULAR ABSCESS IS DRAINED BY MAKING AN INCISION PARALLEL TO OCCLUSAL PLANE AT

THE MOST PROMINENT PART OF THE SWELLING, MEASURING ABOUT 1-2 CM.

- THE INCISION SHOULD ONLY INVOLVE THE MUCOSA AND BLUNT DISSECTION IS DONE TO DRAIN
THE ABSCESS.

- SALINE IRRIGATION IS DONE AND SUCTION IS APPLIED TILL ACTIVE BLEEDING CAN BE SEEN.

- CORRUGATED DRAIN MAY BE INSERTED IN CASE OF LARGE ABSCESS AND SUTURED .

EXAMPLES OF SPACE INFECTIONS

CANINE SPACE INFECTION BUCCAL SPACE INFECTION

INFRATEMPORAL INFECTION SUBMENTAL INFECTION

I & D IN RELATION TO FASCIAL SPACES

CANINE SPACE- THE APPROACH TO THIS AREA IS THROUGH THE MUCOSA OF BUCCAL VESTIBULE IN THE
REGION OF LATERAL INCISOR AND CANINE. A CURVED MOSQUITO FORCEPS IS INSERTED SUPERIOR TO THE
ATTACHMENT OF CANINUS MUCLE, AND THE INFRAORBITAL SPACE IS ENTERED. PUS IS EVACUATED AND A
DRAIN IS INSERTED AND IS SECURED TO ONE OF THE MARGINS WITH A SUTURE.

PALATAL ABSCESS- AN ANTERO-POSTERIOR INCISION IS MADE THROUGH THE MUCOSA, DOWN TO THE BONE,
KEEPING IN MIND THE COURSE OF GREATER PALATINE NERVE AND VESSELS. A CURVED MOSQUITO FORCEPS
IS INSERTED AND THE PUS IS EVACUATED. A SMALL PIECE OF RUBBER DRAIN IS INSERTED INTO THE ABSCESS
CAVITY AND SECURED WITH SUTURE.

BUCCAL SPACE- IN THIS, HORIZONTAL INCISION THROUGH THE ORAL MUCOSA OF THE CHEEK IN THE
PREMOLAR, MOLAR REGION. IF THE PUS IS LATERLA TO THE MUSCLE THEN THE MUSCLE IS PENETRATED
WITH CURVED MOSQUITO FORCEPS TO ENTER THE BUCCAL SPACE. DRAIN IS PLACED AND SECURED WITH
SUTURE.
INFRAORBITAL SPACE-1. IN THIS, IF TRISMUS IS NOT MARKED, INTRAORAL INCISION IS GIVEN IN THE
BUCCAL VESTIBULE OPPOSITE TO THE 2ND AND 3RD MOLARS. THE SPACE IS ENTERD,AND DRAINED,AND A
SMALL PIECE OF CORRUGATED RUBBER DRAIN IS KEPT AND SECURED WITH A SUTURE.
2.IN SEVERE INTRACTABLE INFECTIONAN EXTRAORAL INCISION IS MADE AT THE UPPER AND POTERIOR
EDGE OF THE TEMPORALIS MUSCLE,WITHIN THE HAIRLINE. PUS IS EVACUATED, RUBBER DRAIN IS
INSERTED AND SECURED WITH SUTURE.

SUBMENTAL SPACE-A TRANSVERSE INCISION IS MADE IN THE SKIN BELOW THE SYMPHYSIS OF THE
MANDIBLE.BLUNT DISSECTION IS CARRIED OUT BY INSERTING A KELLYS FORCEPS THROUGH THE
INCISION, UPWARD AND BACKWARD. A SMALL PIECE OF RUBBER DRAIN IS INSERTED IN THE ABSCESS
CAVITY AND SECURED TO ONE OF THE MARGINS OF THE WOUND WITH A SUTURE.

SUBMANDIBULAR SPACE-A INCISION OF ABOUT 1.5 TO 2CM LENGTH IS MADE 2CM BELOW THE LOWER
BORDER OF MANDIBLE. A SINUS FORCEPS IS INSERTED THROUGH THE INCISION SUPERIORLY AND
POSTERIORLY ON THE LINGUAL SIDE OF THE MANDIBLE BELOW THE MYLOHYOID TO RELEASE PUS FROM
THE SUBMANDIBULAR SPACE. A CORRUGATED RUBBER DRAIN IS INSERTED AND SECURED WITH SUTURE.
SUBLINGUAL SPACE-INTRAORALLY AN INCISION IS MADE CLOSE TO THE LINGUAL CORTICAL PLATE,LATERAL TO THE
SUBLINGUAL PLICA AS THE IMPORTANT STRUCTURE AT THIS SITE THE SUBLINGUAL NERVE IS LESS LIKELY TO BE DAMAGED BY
THIS APPROACH. OTHER IMPORTANT STRUCTURE MEDIAL TO IT IS THE WHARTONS DUCT, SUBLINGUAL ARTERY AND VEINS AND
LINGUAL NERVE. THE SINUS FORCEPS IS THEN INSERTED AND PUS IS EVACUATED.
WHEN BOTH SUBLINGUAL AND SUBMENTAL SPACES CONTAIN PUS THEY CAN BE DRAIN VIA SKIN INCISION PLACED IN THE
SUBMENTAL REGION, PUSHING A CLOSED SINUS FORCEPS THROUGH THE MYLOHYOID MUSCLE.

TEMPORAL SPACE EXTRA ORAL INCISION I THE TEMPORAL REGION, WELL ABOVE THE HAIRLINE, 45 DEGREE TO THE
ZYGOMATIC ARCH. THE HAEMOSTAT IS INSERTED BELOW AND ABOVE THE TEMPORALIS MUSCLE.

PAROTID SPACE- THE DRAIN REQUIRES AN EXTERNAL APPROACH. A RETRO-MANDIBULAR INCISION IS USED BECAUSE THE PUS
IS NOT USUALLY IN A SINGLE POOL. AN INCISION IS PLACED IN THE SKIN BEHIND THE POSTERIOR BORDER OF THE MANDIBLE
EXTENDING FROM THE LEVEL OF THE INFERIOR ASPECT OF THE LOBULE OF THE EAR TO JUST ABOVE THE MANDIBLE. A SINUS
FORCEPS IS INSERTED AND WITH A BLUNT DISSECTION, THE PAROTID FASCIA IS REACHED. A RUBBER DRAIN IS INSERTED AND A
SUTURE IS PLACED.

SUBMASSETRIC SPACE- AN INTRAORAL INCISION IS MADE VERTICALLY OVER THE LOWER PART OF ANTERIOR BORDER OF
RAMUS OF MANDIBLE DEEP TO THE BONE. A SINUS FORCEP IS INSERTED IN THE LATERAL SURFACE OF THE RAMUS DOWNWARDS
AND BACKWARDS AND THE PUS IS DRAINED AND SECURED WITH SUTURE.
EXTRAORAL APPROACH- WHEN THE MOUTH CANNOT BE OPENED, AN INCISION IS PLACED OVER THE SKIN BEHIND THE ANGLE
OF THE MANDIBLE TO OPEN THE ABSCESS BY HILTON`S METHOD. A RUBBER DRAIN IS INSERTED AND SECURED WITH SUTURE
PTERYGOMANDIBULAR SPACE- INTRAORAL VERTICAL INCISION, APPROXIMATELY 1.5CM IN LENGTH, IS MADE ON THE ANTERIOR AND
MEDIAL ASPECT OF THE RAMUS OF MANDIBLE. A SINUS FORCEPS IS INSERTED IN THE CAVITY, OPENED AND CLOSED AND WITHDRAWN. THE
PUS IS EVACUATED, A RUBBER DRAIN IS INTRODUCED AND IS SECURED IN POSITION WITH A SUTURE.
EXTRA ORAL APPROACH- AN INCISION IS TAKEN IN THE SKIN BELOW THE ANGLE OF THE MANDIBLE. A SINUS FORCEPS IS INSERTED
TOWARDS THE MEDIAL SIDE OF THE RAMUS IN AN UPWARD AND BACKWARD DIRECTION. PUS IS EVACUATED AND THE DRAIN IS INSERTED
FROM AN INTRAORAL APPROACH AND SUTURED IN POSITION.

PERITONSILLAR ABSCESS- IT CAN BE ACHIEVED BY USING A GUARDED KNIFE AND SINUS FORCEPS, WHICH ARE INSERTED INTO THE MOST
PROMINENT PART OF THE SOFT PALATE, WHERE THE FLUCTUATION IS THE MAXIMAL.

LUDWIG`S ANGINA DEFINITION IT IS A FIRM, ACUTE,TOXIC CELLULITIS OF THE

SUBMANDIBULAR,SUBLINGUAL SPACES BILATERLLY
& OF THE SUBMENTALIS SPACE.

BILATERAL SUBMANDIBULAR INCISIONS AND IF REQUIRED, A MIDLINE SUBMENTAL INCISION 1 CM BELOW THE INFERIOR BORDER OF THE
MANDIBLE IS SUFFICIENT TO DRILL THE INVOLVED SPACES.
LUDWIG`S ANGINA MANAGEMENT
 REFERENCES

- ORAL AND MAXILLOFACIAL INFECTIONS BY TOPAZIAN

-TEXTBOOK OF ORAL SURGERY BY NEELIMA MALICK

- TEXTBOOK OF ORAL SURGERY BY LASKIN