Buccal space infection

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Here is a detailed overview of buccal space infection drawn from multiple surgical and emergency medicine textbooks.

Buccal Space Infection

Anatomy of the Buccal Space

The buccal space (also called the buccinator space) is located in the cheek, on the lateral side of the buccinator muscle - between the buccinator muscle medially and the skin of the cheek laterally. It is an ovoid space bounded:

Superiorly: Below the zygomatic arch
Inferiorly: Above the inferior border of the mandible
The space is filled with the buccal fat pad

Left Buccal Space Infection - schematic and clinical photograph

Fig. Left Buccal Space Infection: (A) Schematic showing tooth apex breaching above the buccinator. (B) Clinical photograph of left cheek swelling. - ROSEN's Emergency Medicine

Etiology and Source Teeth

Buccal space infection is odontogenic in origin. The space becomes involved in two scenarios depending on which arch is involved:

From maxillary teeth: Infection of maxillary molar teeth (all three maxillary molars can be responsible) breaks out superior to the attachment of the buccinator muscle, entering the buccal space from above.

From mandibular teeth: Mandibular molar periapical infection can also spread into the buccal space, in addition to the submandibular space.

Anterior mandibular teeth (incisors) tend to spread to the buccal/vestibular space or the sublingual space.
The buccal space can be involved by both maxillary and mandibular molar infections.
Cummings Otolaryngology Head and Neck Surgery, p. 203
ROSEN's Emergency Medicine, p. 863

Microbiology

Buccal space infections are typically polymicrobial, reflecting oropharyngeal flora. Common organisms include:

Mixed aerobic and anaerobic bacteria
Streptococcal and staphylococcal flora
Anaerobic gas-producing organisms including Bacteroides fragilis
Actinomyces can cause cervicofacial actinomycosis with characteristic draining sinus tracts
Beta-lactamase-producing organisms are found in up to 40% of isolates from odontogenic neck abscesses
ROSEN's Emergency Medicine, p. 864

Clinical Features

Buccal space infections present with:

Dramatic cheek swelling - the infection is visible externally as marked facial swelling of the cheek
Pain at the affected site
Fever and malaise
Trismus (difficulty opening the mouth) - may occur due to involvement near the masticator space
History of poor dentition or recent dental work in adults
In children, sinus or pharyngeal infection may precede it

The presentation can be dramatic in appearance given the external visibility of the cheek swelling, even though the infection itself may be more limited than it appears.

Cummings Otolaryngology, p. 203

Diagnosis

Clinical diagnosis based on history, examination, and dental assessment
CT scan with contrast is the imaging of choice when deep space involvement is suspected - it delineates the extent of infection, identifies abscess pockets, and guides surgical planning
CT also helps distinguish cellulitis from a drainable abscess

Treatment

Treatment follows three pillars: source control, surgical drainage, and antibiotics.

1. Remove the Source

Extract the offending tooth (or teeth) as the primary intervention to eliminate the source

2. Surgical Drainage

The buccal space is accessible transorally:

Incision of the buccal mucosa
Blunt spreading of the buccinator muscle parallel to the facial nerve (to avoid iatrogenic facial nerve injury)
After drainage and irrigation, a Penrose drain or gauze wick can be placed through the incision and secured with a silk suture if ongoing drainage is needed
The wound can be left open to close secondarily, or closed loosely with an interrupted absorbable suture
K.J. Lee's Essential Otolaryngology, p. 711
Cummings Otolaryngology, p. 203

3. Antibiotics

Expanded-spectrum penicillins are first-line: ampicillin-sulbactam, ticarcillin-clavulanic acid, or piperacillin-tazobactam
These cover beta-lactamase-producing organisms
Metronidazole may be added for anaerobic coverage
IV antibiotics are preferred initially for significant infections

Spread and Complications

The buccal space can communicate with adjacent spaces, and uncontrolled infection may spread:

To the masticator space (submasseteric, pterygomandibular spaces)
To the parapharyngeal space and further into the retropharyngeal space
Ultimately to the mediastinum (descending necrotizing mediastinitis) - a life-threatening complication

Maxillary molar infections that spread via the canine space (rather than buccal) risk cavernous sinus thrombosis via the ophthalmic veins - an important distinction.

When infection involves all three primary mandibular spaces (submandibular, sublingual, submental), this constitutes Ludwig's angina, a true surgical emergency.

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, p. 690
Roberts and Hedges' Clinical Procedures in Emergency Medicine, p. 1579

Summary Table

Feature	Detail
Location	Between buccinator muscle and skin of cheek
Source teeth	Maxillary and mandibular molars
Presentation	Dramatic cheek swelling, pain, fever, possible trismus
Microbiology	Polymicrobial (aerobes + anaerobes)
Key risk	Spread to masticator/parapharyngeal space
Drainage route	Transoral - buccal mucosa incision + blunt buccinator spread
Critical precaution	Blunt dissection parallel to facial nerve
Antibiotics	Ampicillin-sulbactam or extended-spectrum penicillin

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