Soft Tissue Trauma

Repair of associated injuries of gingival, lip, mucosal, and facial soft tissues should occur after stabilization of hard tissue in the oral cavity. Otherwise, intricate repairs may be damaged and torn during the manipulation required to reduce, reimplant, and stabilize subluxed or avulsed teeth or associated bony fractures.

Oral lacerations can involve any of the soft tissues of the mouth. Large intraoral lacerations (>1 cm) are susceptible to ulceration and secondary infection and tend to heal in a fibrotic mass. Intraoral lacerations should be inspected carefully for foreign material, including tooth fragments, and irrigated well with sterile normal saline. Retained foreign bodies serve as a nidus for infection and can result in need for later surgical removal and poor aesthetic outcome. Crushed and nonviable tissue should be debrided. Close approximation of the wound edges rather than a tissue seal is desired to allow drainage. Resorbable suture material such as 4-0 chromic is generally used. Black silk (4-0) is easier to use but requires removal in 7 to 10 days. When resorbable sutures are used, care should be taken to place the sutures so that the knots are buried. Prophylactic antibiotics generally are not indicated except with the most extensive lacerations. Forty-eight-hour follow-up is necessary to monitor healing.

Lacerations of the lips and tongue require special consideration. Care should be taken in wound-edge approximation of lacerations on the dorsum of the tongue because reepithelialization across the wound edge is important. If the edges are not well approximated, the epithelia will migrate downward and will result in an epithelial cleft and a bifid appearance. This is both a cosmetic and a functional problem requiring revision. Small tongue lacerations in children, where the edges remain approximated, need not be sutured. Bleeding can be controlled with pressure using gauzes or moistened tea bags (see below). Extensive tongue lacerations in children require conscious sedation and may be best referred for repair.

Lip lacerations are a potential cosmetic problem, so careful closure is essential. In lacerations involving the vermilion border, alignment of the border is important and should be completed first. The portion of the laceration extraoral to the wet-dry line of the lip and involving the skin of the face should be closed with 6-0 nylon monofilament or Prolene. The intraoral portion of the laceration is repaired in the same manner as any oral laceration. Because of the musculature of the lips, any deep laceration requires closure of the deep layers using a 4-0 resorbable suture material such as Polyvicryl to decrease the likelihood of the wound edges opening on removal of the suture. With any laceration involving the face or other aesthetic areas, sutures should be removed as early as possible, generally in 5 days, so as to decrease scarring from the suture material. Careful daily cleansing of the wound with dilute hydrogen peroxide and application of a triple-antibiotic ointment makes suture removal easier and improves the aesthetic results.

Controversy concerning closure of through-and-through lip laceration exists. Some advocate leaving the intraoral portion of the laceration open; however, it is my recommendation that mucosal lacerations larger than 1 cm be repaired. Generally, the intraoral component should be repaired first, and then, from an extraoral approach, the laceration should be cleansed and irrigated aggressively. A deep layer of sutures may be necessary in large lacerations. The skin then should be closed aesthetically. Prophylactic antibiotics such as penicillin VK or erythromycin 250 mg PO qid for about 5 days, are indicated.

Laceration of the maxillary labial frenulum, unless unusually large, does not require repair. These lacerations can be very painful, so adequate analgesia must be prescribed. Because of the vascularity of adjacent tissue, lacerations to the lingual frenulum usually do need to be repaired. Resorbable suture such as 4.0 chromic is appropriate.

Other soft tissue injuries commonly occur. Intraoral contusions and ecchymoses are prevalent with facial trauma. Ecchymoses and petechial hemorrhages to the soft palate, uvula, and pharynx from direct trauma or from the negative pressure created from suction are frequently associated with fellatio. Treatment is mainly palliative, with reassurance to the patient and NSAIDs for discomfort.

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