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Soft Tissue Injuries of the Oral andMaxillofacial Region/Suturing Skills

Designed to assist local facilities withDental Readiness Training



Soft Tissue Injuries of the Oral and

Maxillofacial Region/Suturing Skills



Overview

Initial Examination

Classification of

Injury

Special Regional

Considerations

Animal and HumanBites

Tetanus

Suture Materials

Wound Healing/Repair

Wound Closure

Conclusions



Initial Examination

Wounds divided into

two groups:

clean andcontaminated

Contamination

increases with time

³The solution topollution is dilution´

High-pressure

pulsating streams

best

Anesthetize wound

before irrigation

Remove foreignbodies

Clean animal/human

bites thoroughly

Tetanus prophylaxisas needed



Classification of Injury

Contusion

Abrasion

Accidental Tattoo

Retained Foreign

Bodies

Puncture Wounds

Simple Laceration

Avulsion (flap)

Avulsion (complete)




Contusion Bruising injury caused by

blunt trauma (with or without

hematoma)

Cleansing and observation

usually sufficient

Some hematomas

spontaneously resorb

Other hematomas requiresurgical intervention

Basis for ³cauliflower ear´

deformity

Tragus

Antitragus

Antihelix

Hematoma




Abrasion

Results from deflecting type

trauma Like a burn from partial to

full thickness

Cleanse thoroughly with

mild non-irritating soap

Apply antibiotic ointment No scar unless approaches

third - degree



Classification of Injury Accidental Tattoo

(dermal imbedded particles)

Remove promptly from

abrasion to prevent tattoo

Fixation occurs within 24-48

hours

Scrub with stiff bristle

brush

Grease or oil removal with

ether or acetone



Classification of Injury Retained Foreign Bodies

Larger than bodies causingaccidental tattoos

Foreign bodies shouldideally be removed

Bullets and missilefragments are not sterile

Bullets often retained

Remove glass, wood, anddental fragments




Puncture Wounds

Not common on the face

Possible injury to deeper structures

Often swell due to

hematomas

Remove implanted

foreign bodies Sometimes excised for

best healing




Simple Laceration Most common form of

facial injury Repair underlying

structures first

Remove foreign bodies




Avulsion - complete

(loss of tissue)

Direct primary closureis preferable

Flap or skin graft may

be indicated

Don¶t let it heal by

secondary granulation



Special Regional Considerations

Forehead and Brow

Preservation of the

eyebrow Do not shave eyebrow

Repair muscles to

prevent depression

Rule out fractures

Never!




Eyelid Protects globe and

drying of cornea

Ophthalmology consultmandatory

Can be intramarginal or extramarginal

Rule out muscle

impairment Extramarginal close

with 6-0 Nylon or Polypropylene




Nose Soft tissue injuries

usually simple

Reduce fractures first

Align nasal structuresaccurately

Use 6-0 non-absorbablesutures (Nylon or

Polypropylene) Rule out hematoma




Ear

Direct blow causes

hematoma- ³Cauliflower ear´

Use 6-0 non-absorbable

sutures (Nylon or

Polypropylene)

Complex lacerations -refer




Cheek

Common facial injury

Superficial injuries arerelatively simple

Deeper injuries may

involve parotid gland

and facial nerve




Lip

Vermilion border

Single 5-0 Nylon or Polypropylene suture

to re-orient

Close in layers

Muscle layer-use

Dexon or V

icryl Skin - use 6-0 Nylon or

Polypropylene sutures




Oral Mucosa andTongue Inspect for pieces of

teeth and/or restorations

Irrigate thoroughly

and suture loosely

Close in layers, use

Vicryl or Dexon in themuscle layers

Injuries to tongue or floor of the mouth maycompromise airway



Langer¶s Lines Described by Langer

in 1861

Punched holes in skinof cadavers

Langer¶s lines parallel

to fiber bundles

Usually indicatedirection for incision

Inconspicuous scars

fall in wrinkle lines

Adapted from: Dorland¶s Illustrated Medical Dictionary,www.mercksource.com. Accessed July 2007.



Animal Bites Estimated 4.7 million dog

bites in 1994

368,245 treated in

hospital ERs in 2001 Peak incidence

ages 5-9

15-20% of dog bitesbecome infected

20-50% of cat bitesbecome infected

Puncture wound highestrate of infection

Center for Disease Control (CDC), MMWR: July 2003.; Presutti RJ. Postgrad Med 1997; 101:243-254.; Loar M. The Veterinary Clinics of NorthAmerica: Small Animal Practice.1987:17-25.; Sinclair C, Zhou C. Public Health Rep 1995; 110: 64-67.



Animal Bites Primary closure of bitewounds

Antibiotics for animal

bites over 12 hours old

and deep puncturewounds

S. aureus and Pasteurella

c anis, multoc ida and septi c a

are pathogens

Use Augmentin(amoxicillin with clavulanic

acid)

Clindamycin in

Penicillin-allergic patients



Human Bites

Exact incidence unknown

10-15% become infected

Irrigation and debridement are

mainstays of treatment

Less than 12 hours old and nosign of infection, suture

closed

Contaminated with oral flora

as well as with Staph, from the

skin of the victim Augmentin is antibiotic of

choice

Clindamycin in Penicillin-

allergic patients

Revis, DR. Human Bite Infections. Available at www.emedicine.com/med/topic1033.htm. Accessed July 2007.



Tetanus

Potent exotoxin from C lostridium tetani 90 cases reported annually

Maintenance necessary for toxoid

Tetanus prophylaxis based on condition of

wound/patient history Tetanus can follow negligible wounds

Clinical Feature Tetanus Prone Clean, minor wound

Age of wound 6 hours + Less than 6 hours

Configuration Stellate, evulsions Linear, abrasionMechanism of Injury Missile, crush, heat/cold Sharp surface (knife/glass)

Signs of Infection Present Absent

Devitalized tissue Present Absent

Contaminants (dirt, feces,

soil, saliva)

Present Absent

Center for Disease Control (CDC), MMWR: December 2006.



Suture Materials

Monofilament or multifilament strands

Absorbable or non-absorbable

Absorbable loses strength in tissue and

degrades within 60 days

Non-absorbable greater than 60 days



Suture Materials Size: Refers to the diameter of the suture

The more ³0¶s´ in the number, the smaller the suture

Microsurgery/repair: 9-0 or 10-0 sutureFacial skin closure: 5-0 or 6-0 suture

Trunk or extremities: 4-0 or 5-0 suture

Scalp: 3-0 suture

Muscle, deep skin, intraoral mucosa: 3-0 or 4-0 suture



Absorbable Sutures Plain Gut

Derived from submucosa of

sheep intestines

Not a true monofilament

Less than 10 day life span in

tissue

Must be kept moist and

rinsed (packaged in alcohol)

100 times the bacterial

adhesion than that of Nylon

or Polypropylene



Absorbable Sutures

Chromic Gut

Plain gut tanned with

chromium salts

Improved strength andduration

Duration is 2-3 weeks

Knot security greater than

plain gut

Absorption by proteolyticenzymes



Absorbable Sutures

Dexon (polyglycolic or PGA)

Monofilament which is braided

Un-coated Dexon S and coated

Dexon Plus More durable than gut sutures

Absorbed by hydrolysis of ester

bond

Sutures lost orally is 16-20 days



Absorbable Sutures Vicryl

Copolymer of glycolic and

lactic acid in a 9:1 ratio;

Polyglactin 910

Nearly identical properties asDexon

Strength loss after 16-20 days

Absorbed by hydrolysis of

ester bond

Braided suture like Dexon



Non-absorbable Sutures

Silk70% natural silk, silk

worm larvae

Main advantage isfavorable handling

Knot security is good

Tissue response to silk issevere

Braided material,potential for infection isgreat




Nylon

Synthetic polyamide polymer

Available in monofilament or

multifilament

Poor knot security

Among the best for

minimizing infection

Face: 5-0 or 6-0 Nylon

Scalp: 3-0 Nylon




Polypropylene (Prolene)

Similar to Nylon, synthetic

monofilament polymers

Breaking strength less thanNylon

Knot security and ease of

tying greater than Nylon

Absorption is non-existent,

good for contaminatedwounds




Dacron (Mersilene)

Polyester braided suture

May be coated with Teflon to

improve handling

Strongest non-metallic suture

High coefficient of friction

No absorption occurs



Needles

Most swaged onto the

suture strand

Stainless steel, 2 basic

configurations; cutting and

tapered

Cutting, reverse cutting

needles

Tapered

Cutting

Reversed Cutting

Adapted from: C ontemporary Oral and Maxillofacial Surgery, Mosby 1988.



Needles

No universal needle labeling or

coding

Straight to as much as 5/8ths

round in shape

For minor wound care, the 3/8

and 1/2 circle needles are used

Size corresponds with the

outline on package

Described on package (cutting)along with manufacturer¶s code

1/4 circle

1/2 circle

3/8 circle

3/4 circle

Curve-ended

straight Straight




Wound Healing and Repair

Stages

Inflammatory Phase

Proliferative Phase

Remodeling or Maturation Phase



Inflammatory Phase

vasoconstriction facilitates clot formation

histamine/prostaglandin release; vasodilation

edema/erythema due to plasma/leukocyte

infiltration of interstitial tissue

complement release: PMNs, macrophages,

lymphocyte migration

bacteria and debris removed from injury site


Stages



Inflammatory Phase

Clot formation and

beginning epithelialization

Epithelialization into stratified

squamous epithelium


Stages

Adapted from: General Dentistry, Jul-Aug 1998.



Proliferative Phase

late inflammatory stage macrophages release

factors initiating fibroblast migration

fibroblast synthesize ground substance andcollagen

haphazard collagen matrix / new vascularization

called granulation tissue; increased wound tensile

strength

fibrin clot organization is complete


Stages




Stages

Remodeling or Maturation Phasegranulation tissue takes on normal tissue

appearance

initial repair collagen fibers destroyed andreplaced with collagen fibers oriented to resisttensile forces; similar to adjacent non-damagedtissue

vascular bed remodeled; reduced blood flow and

erythemawound tissue strengthens to a level 80 to 85% of

uninjured tissue




Stages

Scar formation

Foreign material

Necrosis

Ischemia

Wound tension



Wound Closure

³There exists the strange belief that a plastic

surgeon can make an incision and leave no visible

scar and that he can in fact do away with previously

existing scars´ (Converse, R ec onstru c tive Plasti c S urgery )

Stabilize first, then treat soft tissue wounds

Clean wounds can be closed primarily 48 hours after

injury

Treat fractures before soft tissue closure

may access fracture through wound



Wound Closure

Simple interrupted

Advantages:

- common, apply rapidly

-can get good eversion of wound edges

Disadvantages:

- eversion of edges takes practice to master

- does not relieve tension from wound edges

- time consuming



Wound Closure

Vertical Mattress

Advantages:

- unsurpassed to provide

eversion of wound edges

-relieves tension from

the skin edges

Disadvantages:

- takes time to apply

- produces more cross-marks

- caution must be taken not to

place sutures too tight

Adapted from: C linician¶s Pocket Reference, 8 th ed. Appleton & Lange 1997.



Wound Closure

Horizontal mattress

Advantages:

- reinforces the subcutaneous

tissue- relieves tension from the skin

edges better

- can be applied quickly

Disadvantages:

-apposition of wound edgesbetter with the vertical mattress

Adapted from: C linician¶s Pocket Reference, 8 th ed. Appleton & Lange 1997.



Wound Closure

Close in layers, avoiddead space

Deep layers close with3-0 to 4-0 absorbablesutures

Skin repair with 5-0 to6-0 Nylon or

Polypropylene(Prolene)

Slight eversion of wound edges

Epidermis

Dermis

Muscle

Submucosa

Mucosal

Epithelium




Wound Closure

Knot on thesubcutaneous sutureshould be buried

First pass through thelower portion of thedermal layer

Pass suture superficialto opposite wound

margin Emerge at same levelas subcutaneous sutureof the opposing margin,tie knot

1

43

2

Adapted from: C linician¶s Manual of Oral and Maxillofacial Surgery 2nd ed. Quintessence 1997.



Wound Closure To approximate tissue

accurately:

Place test suture

Long laceration place

middle suture first

Enter tissue at 90

degree angle

2 mm from margin, 2

mm apart

Don¶t hesitate toremove or replace

sutures

Consider wound taping

2 mm2 mm

900

Adapted from:C

ontemporary Oral and Maxillofacial Surgery, Mosby 1988.



Wound Closure

After wound closure:

Dressings may be

applied for 48-72 hours

Antibacterial ointment

may be applied

Remove skin sutures

after 4-6 days

Scar will mature in 8-12

months



Wound Closure



Conclusions

Thorough initial examination

Remember type of injury and special regional

considerations

Complete debridement and irrigation Think about tetanus-prone wounds

Possible infection with animal and human bites

Use the appropriate suture

Proper suturing and management of the wound

Let the patient know that they will scar



Conclusions

Always think C-spine injury first

If you are not sure«call for help

Solution to pollution is dilution!



References

Dorland¶s Illustrated Medical Dictionary.Langer¶s

Lines

.Available atwww.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSz.

Accessed July 2007.

CDC. Nonfatal dog bite-related injuries treated in hospital emergency

departments-Unites States, 2001. MMWR 2003;52(26);605-610.

Presutti RJ. Bite wounds. Early treatment and prophylaxis against

infectious complications. Postgrad Med 1997;101:243-254.

Loar M. Risks of pet ownership: the family practitioner¶s viewpoint. In

august J, Loar A, eds. The V eterinary C lini c s of N ort h Ameri c a: S mall

Animal Prac ti c e. Philadelphia: W.B. Saunders Co.:1987:17-25.

Sinclair C, Zhou C. Descriptive epidemiology of animal bites in

Indiana, 1990-92: a rationale for intervention. Public Health Rep 1995;

110:64-67.



References Revis, DR. H uman Bite I nfec tions. Available at

www.emedicine.com/med/topic1033.htm. Accessed July 2007. CDC. Preventing Tetanus, Diphtheria, and Pertussis Among Adults:

Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine. MMWR 2006;55 (No. RR-17).

Hupp JR . Principles of surgery. In: Peterson LJ, Ellis E, Hupp JR,Tucker MR, eds. C ontemporary O ral and M axillofac ial S urgery, St.

Louis: Mosby:1988:13-26. Certosimo FJ, Nicoll BK, Nelson RR, Wolfgang M. Wound healing and

repair; a review of the art and science. Gen Dent 1998; 46(4):362-369.

Gomella LG, Haist SA, Billeter M. Suturing techniques and woundcare. In: Gomella LG, Haist SA, Billeter M, eds. C lini c ian¶s Pock et R eferenc e, 8th ed. Stamford: Appleton & Lange, 1997:327-338.

Kwon PH. Sutures and suturing technique. In: Kwon PH, Laskin DM,eds. C lini c ian¶s M anual of O ral and M axillofac ial S urgery , 2nd ed.Chicago, Quintessence, 1997:241-250.

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