TRAUMATIC

INJURIES
Outline:

⚫ I. Soft Tissue Injuries

⚫ II. Dentoalveolar Injuries
⚫ III. Types of Wound Healing
⚫ I. Soft Tissue Injuries
1. Abrasion
2. Contusion
3. Laceration
⚫ 1. Abrasion

● superficial wound where the

epithelium of skin is removed or
destroyed because of friction.
On the face, may involve the tip of
the nose, lips, cheeks and chin in
patients who sustained
dentoalveolar trauma.
Primary Wound Care - Abrasions
● Treatment is nonsurgical.
▪ 1. Cleanse the wound from any foreign material
▪ 2. Use surgical scrub brush to remove dirt or any
foreign particle that lodged into the wound to
prevent a permanent traumatic tattoo. Local anes
may be used for pain.
▪ 3. Should be performed within the first day of
injury.
▪ 4. Use moist dressings & topical antibiotic to
protect the wound and aid healing.
⦿ Abrasion of lower lip - usually as a
result of shank of bur rotating on soft
tissue. The abrasion represents a
combination of friction and heat
damage. The wound should be kept
covered with antibiotic ointment until
an eschar forms which drops off by
itself once inflammation has subsided..
⚫ 2. Contusion

● Injury resulting from a forceful blow

to the skin and soft tissues with a
blunt object resulting to submucosal
bleeding but outer layer of skin
remains intact.
● Apply cold compress to help constrict
blood vessels and control hematoma
formation and swelling.
Primary Wound Care - Contusions

● From black & blue bruise may turn greenish

yellow during healing
Treatment:
▪ Require minimal care if there is no break on the
surface skin or mucosa
▪ Should be evaluated for possible deep
hematoma or other tissue injuries that may
indicate more severe morbidity.
▪ An expanding hematoma can damage overlying
skin and demands evacuation or ligation of the
bleeding vessel.
⚫ 3. Lacerations

● Injury where tissue is cut or torn

commonly caused by a sharp object
● Common lacerations in the oral cavity
from trauma involve the lips, floor of
the mouth, tongue, labial mucosa,
buccolabial vestibule and gingiva.
● Hard tissue injury should be managed
first before closing laceration.
Primary Wound Care -
Lacerations
● Treatment:
● After cleansing & debriding tissue
from any blood clot and foreign
material and irrigate, wound margins
are realigned with careful regard to
prevention of any further crush injury
to tissues.
● Sterile dressings are applied and
immobilization is recommended for
complex wounds.
 Primary Wound Care For
Lacerations
Tx procedure:
After anesthesia:
1) Cleansing mechanically with surgical
soap and brush to remove any
particulate matter.
▪ Pulsed irrigation with copious amount
of NSS is also effective.
2) Debridement to remove contused and
devitalized tissues and jagged margins
to enable linear closure of the wound.
▪ Only obvious devitalized tissue is
excised.
Primary Wound Care -
Lacerations
3) Hemostasis - established before suturing
▪ Active hemorrhage within the wound
might burst open the wound margins.
▪ If big blood vessel was severed, be sure
to clamp & ligate or cauterize it before
suturing.
▪ Most common blood vessel involved in lip
trauma - labial artery which runs
horizontally across the lip just beneath
the labial mucosa & frequently
encountered in vertical lip lacerations.
 Labial Artery

https://www.researchgate.net/publication/336383222_Translucent_and_Ultrasonographic_Studies_of_the_Inferior_Labial_
Artery_for_Improvement_of_Filler_Injection_Techniques
Superior Labial Artery

https://exploreplasticsurgery.com/case-study-upper-lip-labial-artery-aneurysm/
Inferior Labial Artery of
the Lower Lip

https://exploreplasticsurgery.com/case-study-upper-lip-labial-artery-aneurysm/
Primary Wound Care -
Lacerations
4) Closure of laceration
● small lacerations are best left open to heal

by secondary intention
● larger or long deep lacerations require

suturing
● For the lip, start suturing at the

mucocutaneous junction of the vermillion

border. Perfect alignment is important for
esthetics.
 Start suturing at the mucocutaneous
junction of the vermillion border of the lip
for a cosmetic finish
Hupp, James R., Ellis, Edward III and Tucker, Myron R. (2019) Contemporary Oral and Maxillofacial Surgery. 7th ed. p. 501
 Complete lip laceration is sutured in 3 layers:*
(1) Oral Mucosa (2) Muscle (3) Skin Surface

*Note: Suture from inside out

Hupp, James R., Ellis, Edward III and Tucker, Myron R. (2019) Contemporary Oral and Maxillofacial Surgery. 7th ed. p. 501
 1. Oral Mucosa is sutured with black silk sutures.
2. Orbicularis oris muscle should be sutured with
absorbable - chromic catgut.
3. Skin surface should be sutured with 5-0 or 6-0 nylon
suture, to leave small marks.
Hupp, James R., Ellis, Edward III and Tucker, Myron R. (2019) Contemporary Oral and Maxillofacial Surgery. 7th ed. p. 501
Primary Wound Care For
Lacerations
Postoperative care:
1. Cover skin sutures with antibiotic
ointment.
2. Prescribe amoxicillin 500mg q 8 h for 7
days.
3. Give anti-tetanus toxoid shot within
first 24 hours from injury.
4. Careful cleaning of wound.
Primary Wound Care For
Lacerations
Postoperative care:
5. Diet should be liquid or soft or as
tolerated.
6. Facial skin sutures are removed in 4 to 6
days after surgery. Avoid retaining the
sutures too long to minimize scar
formation.
⚫ II. Dentoalveolar
Injuries
• Classification of
Dentoalveolar Injuries
1.Crown Craze or Crack
• Crack or incomplete fracture of enamel without loss of
tooth structure
2.Horizontal or Vertical Crown Fracture
• Confined to enamel
• Enamel and dentin involved
• Enamel, dentin, and exposed pulp involved
• Horizontal or vertical
• Oblique (involving the mesio- or distoincisal angle)
3.Crown-Root Fracture
• No pulp involvement
4.Horizontal Root Fracture
• Involving apical third
• Involving middle third
• Involving cervical third
• Horizontal or vertical
5.Sensitivity (ex.Concussion)
• Injury to tooth-supporting structure, resulting
in sensitivity to touch or percussion but without
mobility or displacement of the tooth
6.Mobility (ex.Subluxation or Looseness)
• Injury to tooth-supporting structure, resulting
in tooth mobility but without tooth
displacement
7.Tooth Displacement
• a.Intrusion (displacement of tooth into its
socket—usually associated with
compression fracture of socket)
• b.Extrusion (partial displacement of tooth out
of its socket—possibly no
concomitant fracture of alveolar bone)
• c.Labial displacement (alveolar wall fractures
probable)
• d.Lingual displacement (alveolar wall fractures
probable)
• e.Lateral displacement (displacement of tooth
in mesial or distal direction,
usually into a missing tooth space—alveolar wall
fractures probable)
8.Avulsion
• Complete displacement of tooth from its
socket (may be associated with alveolar wall
fractures)
9.Alveolar Process Fracture
• Fracture of alveolar bone in the presence or
absence of a tooth or teeth
(Data from Sanders B, Brady FA, Johnson R. Injuries. In: Sanders B, ed.
Pediatric Oral and Maxillofacial Surgery. St Louis: Mosby; 1979).
Management:

The goal in the treatment of dentoalveolar

injuries is reestablishing normal form and
function of the masticatory apparatus.
Depending on severity of tooth injury:
● 1.if crown is cracked without pulp
involvement, restore crown
● 2.if tooth is luxated, immobilize by splinting
or use braided ortho wire cemented on
etched crown.
Management
● 3.if pulp is devitalized, perform RCT.
● - if mature tooth is displaced 1mm in any
direction, assume pulp degeneration to occur
● 4. if tooth is avulsed, replant tooth within
20-30 minutes after injury for better chance
of restoring periodontal attachment.
● - after stabilizing mature tooth for 2 weeks,
do RCT.
Management

● 5. if avulsed tooth has open apex, pulp vitality

may be restored and RCT not necessary
● - survival of pulp on tooth with open apex is
possible if replanted within 2 hours after
injury.
● - with open apex, splinting is longer, 3-4 wks,
to promote revascularization of pulp.
● - if pulp vitality of open apex root is not
restored, perform apexification.
Stabilization Periods for
Dentoalveolar Injuries
Injury Duration of
Immobilization
Mobile tooth 7–10 days
Tooth displacement 2–3 weeks
Root fracture 2–4 months
Replanted tooth (mature) 7–10 days
Replanted tooth (immature) 3–4 weeks
⚫ Avulsion

● Injury where a section of tissue is

torn off, either partially or totally.
➢ soft tissue avulsion
➢ soft tissue avulsion with bone
fracture
➢ tooth avulsion
Primary Wound Care - Partial
Avulsion
● 1. Partial avulsion – tiss is elevated
but remains attached to the body.
● In the case where the torn tissue is
still well-vascularized and viable,
the tissue is gently cleansed and
irrigated and the flap is reattached
to its anatomical position.
Primary Wound Care - Total
Avulsion
● 2. Total avulsion – tissue is completely
torn from the body with no point of
attachment.
● – If the torn tissue is non-viable, it is
often excised and the wound closed
using a skin graft or local flap.
● - Where avulsed tissue has been
preserved, chance of reattaching is
better thru microvascular surgery.
Tooth Avulsion

Recommended Guidelines of the American

Association of Endodontist
Treatment:
▪ I. Management at Site of Injury
1. Replant immediately, if possible. If
contaminated, rinse with water before
replanting.
2. When immediate replantation is not possible,
place tooth in the best transport medium
available.
 Tooth Avulsion

⚫ Transport Media:
1. Hank's Balanced Salt Solution (H.B.S.S.)
2. Milk
3. Saline
4. Saliva (buccal vestibule)
⚫ If none of the above is readily available, use
water.
⚫ (Recommended Guidelines of the American Association of
Endodontist)
Recommended Guidelines of the American
Association of Endodontist

● II. Management of Osseous structures

● Bony fractures resulting in mobility usually
require longer splinting periods (2-8 weeks).
● Home care during period of splinting should
include::
○ No biting on splinted teeth
○ Soft diet
○ Maintenance of good oral hygiene
○
Recommended Guidelines of the American
Association of Endodontist

▪ III. Adjunctive Drug Therapy

Considerations
▪ 1. Systemic antibiotics
▪ 2. Referral to physician for tetanus
consultation within 24 hours
▪ 3. Chlorhexidine rinses
▪ 4. Analgesics
Recommended Guidelines of the American
Association of Endodontist

▪ Tooth with open apex and >1 hour

extraoral dry time (poor
prognosis):
Thoroughly clean and fill the canal
with calcium hydroxide.
Recall the patient in 6 - 8 weeks.
Consider alternative treatment
options.
 Fracture

⚫ break in the continuity of bone

⚫ Goal of treatment for
dentoalveolar injury with jaw
fracture is maximal rehabilitation
with rapid bone healing and return
of normal masticatory function and
the least discomfort during healing
process.
● Types of Fractures

I. Greenstick
● an incomplete fracture of flexible
bone where one side is bent and the
other side is intact. Typically
occurring in children
● Types of Fractures

II. Simple
● a complete transection of the bone
with minimal fragmentation without
exposure to the external
environment.
● Types of Fractures

III. Compound
● communicates with the external
environment.
● In the case of mandibular fractures,
communication may occur through the
oral cavity or the skin of the face,
especially fractures caused by
vehicular accidents.
● Types of Fractures
IV. Comminuted
● bone is shattered into fragments, or
there are secondary fractures along
the main fracture lines
Management of Jaw Fractures

Management:
1. Closed reduction external fixation
2. Open reduction internal fixation
(orif)
Management of Jaw Fractures
Closed reduction external fixation
● Displacement of fracture is reduced
by manual manipulation and the
bony fragments are fixed by any of
the following methods:
1) skeletal pin fixation
2) splint
3) splint with circumferential wiring
Management of Jaw Fractures
External fixation:
4) intermaxillary fixation - Risdon
wiring, Stout’s multiple loop wiring,
Ivy loop wiring or Gilmer’s wiring
Management of Jaw Fractures

2. Open reduction internal fixation

1) direct interosseous wiring
2) use of mini plates and screws
3) use of implants & screws with
bone graft
⚫Types of Wound Healing
TYPES OF WOUND HEALING

▪ PRIMARY INTENTION
▪ SECONDARY INTENTION
▪ TERTIARY INTENTION
Primary Wound Healing
▪ Healing by first intention or primary closure,
when wound edges are coaptated directly
next to each another.
▪ Describes a wound closed by approximation
of wound margins or by placement of a graft
or flap, or wounds created and closed in the
operating room.
▪ Best choice for clean, fresh wounds in
well-vascularized areas.
 Primary Wound Healing
▪ Indications include recent (<24h old), clean
wounds where viable tissue is tension-free and
approximation and eversion of skin edges is
achievable.
▪ Wound is treated within 24 h following injury,
prior to development of granulation tissue.
▪ Little tissue loss
▪ Most surgical wounds heal by first intention
healing
Primary Intention Healing

• Wound closure is performed with

sutures, staples, or adhesive at the time
of initial evaluation
• Examples: well repaired lacerations,
well reduce bone fractures, healing
after flap surgery.
Primary Intention Healing
▪ Wound is treated with irrigation and
débridement and tissue margins are
approximated using simple methods or with
sutures, grafts or flaps.
▪ Often the fastest and most cosmetically
pleasing method of healing (minimal scarring)
▪ Final appearance of scar depends on:
1. initial injury
2. amount of contamination and ischemia
3. method and accuracy of wound closure
Healing by Secondary
Intention
▪ Secondary wound healing or spontaneous
healing
▪ Describes a wound left open and allowed to
close by epithelialization and contraction.
▪ Commonly used in the management of
contaminated or infected wounds.
▪ Or if wound is left open to heal without
surgical intervention.
Healing by Secondary
Intention
▪ Surgeon may pack the wound with a gauze
or use a drainage system
▪ The wound is allowed to granulate.
▪ Granulation results in a broader scar.
▪ Unlike primary wounds, approximation of
wound margins occurs via reepithelialization
and wound contraction by myofibroblasts.
 Secondary Intention:
▪ Healing process can also be slow due to presence of
drainage from infection.
▪ Complications include late wound contracture and
hypertrophic scarring.
▪ Wound care must be performed daily to encourage
wound debris removal to allow for granulation tissue
formation.
▪ Examples: gingivectomy, gingivoplasty, tooth
extraction sockets, poorly reduced fractures.
Healing by Tertiary Intention
⚫ Tertiary wound healing or delayed primary
closure, typically 4 - 5 days before closure.
⚫ The wound is initially cleaned, debrided and
observed.
⚫ The wound is purposely left open and
subsequent repair of a wound initially left
open or not previously treated is later done .
⚫ Examples: healing of wounds by use of tissue
grafts.
 Tertiary Intention (Delayed
Primary Closure)
⚫ Useful for managing wounds that are too
heavily contaminated for primary closure
but appear clean and well vascularized after
4-5 days of open observation.
- Over this time, the inflammatory process
has reduced the bacterial concentration of
the wound to allow safe closure.
Tertiary Intention (Delayed
Primary Closure)
⚫ Indicated for infected or unhealthy wounds
with high bacterial content, wounds with a
long time lapse since injury, or wounds with a
severe crush component with significant
tissue devitalization.
⚫ Wound edges are approximated within 4-5
days and tensile strength develops as with
primary closure.
CLASSIFICATION
OF WOUNDS
According to degree of contamination
Classification of wounds

⚫ Clean
⚫ Clean contaminated
⚫ Contaminated
⚫ Dirty
 Classification of Wounds

1. Clean wound
⚫ Uninfected with no inflammation
⚫ Wounds in which no viscus (viceral organ)
has been entered & no septic area has
been encountered
⚫ Wounds managed without any break in
the aseptic technique.
Clean Wound

⚫ Management:
1. Closed by primary intention
Examples: Ex lap, mastectomy,
neck dissection, thyroid, vascular,
hernia, splenectomy
Infection rate for clean wound:
< 3%
 2. Clean Contaminated Wound

▪ Type of wound where the operation enters a

non-infected area but may encounter
bacteria.
▪ Respiratory, GI, GU tracts may be entered,
but contamination is controlled
▪ Careful control should result in minimal
spillage of organisms.
 Clean Contaminated
▪ No unusual contamination
▪ Ex: cholecystectomy, SBR, Whipple,
liver txp, gastric surgery, bronch,
colon surgery
 Clean Contaminated
▪ No unusual contamination
Tooth extraction
Infection rate for clean
contaminated surgery is < 10%.
3. Contaminated Wound

▪ Open, fresh, accidental wounds

▪ There is gross spillage of organisms, e.g.,
from GI tract
▪ Acute nonpurulent inflammation
▪ Surgery in the oral cavity with major
break in sterile technique.
Contaminated Wound
▪ Where there is an open wound exposed
for < 4 hours (e.g. following major
trauma).
▪ In this type of wound, sepsis > 30%.
▪ Ex: Inflamed appy, bile spillage in
cholecystectomy, diverticulitis, rectal
surgery, penetrating wounds
4. Dirty Wound
▪ Old traumatic wounds
▪ Devitalized tissue
▪ Where microorganisms present
before procedure
▪ An operation through an infected
area that has been exposed for over
4 hours.
Dirty Wound
⚫ Ex: Infected wounds such as abscess
I&D, perforated bowel, peritonitis,
positive cultures pre-op and
traumatic wound
⚫ Compound fractures of the jaw with
soil contamination
References:

Hupp, James R., Ellis, Edward III and Tucker, Myron R. (2019) Contemporary Oral and Maxillofacial
Surgery. 7th ed

https://www.researchgate.net/publication/336383222_Translucent_and_Ultrasonographic_Studies_of_the_Inferior_Labial_
Artery_for_Improvement_of_Filler_Injection_Techniques

https://exploreplasticsurgery.com/case-study-upper-lip-labial-artery-aneurysm/