Soft Tissue Injuries of the Oral and

Maxillofacial Region/Suturing Skills

Designed to assist local facilities with
Dental Readiness Training
Soft Tissue Injuries of the Oral and
Maxillofacial Region/Suturing Skills
 Overview

• Initial Examination • Tetanus

• Classification of • Suture Materials
Injury • Wound Healing/Repair
• Special Regional • Wound Closure
Considerations • Conclusions
• Animal and Human
Bites
 Initial Examination
• Establish airway and • Direct inspection of
control hemorrhage persistent bleeding
• Rule out C-Spine Injury • Copious irrigation
• Rule out facial bone with saline
fractures • Direct pressure to
• Reduce fractures control bleeding
before soft tissue • Prevent hematoma
repair formation
• Keep wounds moist
during examination
 Initial Examination
• Wounds divided into • Anesthetize wound
two groups: before irrigation
 clean and • Remove foreign
contaminated bodies
• Contamination • Clean animal/human
increases with time bites thoroughly
• “The solution to • Tetanus prophylaxis
pollution is dilution” as needed
• High-pressure
pulsating streams best
 Classification of Injury

• Contusion • Puncture Wounds

• Abrasion • Simple Laceration
• Accidental Tattoo • Avulsion (flap)
• Retained Foreign • Avulsion (complete)
Bodies
 Classification of Injury
• Contusion
Hematoma
 Bruising injury caused by
blunt trauma (with or without
hematoma)
 Cleansing and observation
usually sufficient
Antihelix
 Some hematomas Tragus
spontaneously resorb
 Other hematomas require
surgical intervention
 Basis for “cauliflower ear”
deformity
Antitragus
 Classification of Injury
• 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 causing
accidental tattoos
 Foreign bodies should
ideally be removed
 Bullets and missile
fragments are not sterile
 Bullets often retained
 Remove glass, wood, and
dental fragments
 Classification of Injury
• 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
 Classification of Injury

• Simple Laceration
 Most common form of
facial injury
 Repair underlying
structures first
 Remove foreign bodies
 Classification of Injury
• Avulsion - flap
(undermining laceration)
 One of the most disfiguring
injuries
 Minimal debridement
(preserve tissue)
 Remove beveled wound
margins
 Pressure dressings/drains
to prevent hematomas
 Classification of Injury
• Avulsion - complete
(loss of tissue)
 Direct primary closure
is 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 Never!
 Do not shave eyebrow
 Repair muscles to
prevent depression
 Rule out fractures
 Special Regional Considerations

• Eyelid
 Protects globe and
drying of cornea
 Ophthalmology consult
mandatory
 Can be intramarginal or
extramarginal
 Rule out muscle
impairment
 Extramarginal close
with 6-0 Nylon or
Polypropylene
 Special Regional Considerations

• Nose
 Soft tissue injuries
usually simple
 Reduce fractures first
 Align nasal structures
accurately
 Use 6-0 non-
absorbable sutures
(Nylon or
Polypropylene)
 Rule out hematoma
 Special Regional Considerations

• Ear
 Direct blow causes
hematoma
- “Cauliflower ear”
 Use 6-0 non-absorbable
sutures (Nylon or
Polypropylene)
 Complex lacerations
-refer
 Special Regional Considerations

• Cheek
 Common facial injury
 Superficial injuries are
relatively simple
 Deeper injuries may
involve parotid gland
and facial nerve
 Special Regional Considerations

• Lip
 Vermilion border
 Single 5-0 Nylon or
Polypropylene suture
to re-orient
 Close in layers
 Muscle layer-use
Dexon or Vicryl
 Skin - use 6-0 Nylon or
Polypropylene sutures
 Special Regional Considerations

• Oral Mucosa and

Tongue
 Inspect for pieces of
teeth and/or
restorations
 Irrigate thoroughly
and suture loosely
 Close in layers, use
Vicryl or Dexon in the
muscle layers
 Injuries to tongue or
floor of the mouth may
compromise airway
 Langer’s Lines
• Described by Langer
in 1861
• Punched holes in skin
of cadavers
• Langer’s lines parallel
to fiber bundles
• Usually indicate
direction 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 bites become
infected
• 20-50% of cat bites become
infected
• Puncture wound highest rate
of infection

Center for Disease Control (CDC), MMWR: July 2003.; Presutti RJ. Postgrad Med 1997; 101:243-254.; Loar M. The Veterinary Clinics of North
America: Small Animal Practice.1987:17-25.; Sinclair C, Zhou C. Public Health Rep 1995; 110: 64-67.
 Animal Bites
• Primary closure of bite
wounds
• Antibiotics for animal
bites over 12 hours old
and deep puncture
wounds
• S. aureus and Pasteurella
canis, multocida and septica
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 no
sign 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 Clostridium 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, abrasion
Mechanism of Injury Missile, crush, heat/cold Sharp surface (knife/glass)
Signs of Infection Present Absent
Devitalized tissue Present Absent
Contaminants (dirt, feces, Present Absent
soil, saliva)
Center for Disease Control (CDC), MMWR: December 2006.
Tetanus

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 “0’s” in the number, the smaller the suture
 Microsurgery/repair: 9-0 or 10-0 suture
 Facial 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 and
duration
 Duration is 2-3 weeks
 Knot security greater than
plain gut
 Absorption by proteolytic
enzymes
 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 as
Dexon
 Strength loss after 16-20 days
 Absorbed by hydrolysis of
ester bond
 Braided suture like Dexon
 Non-absorbable Sutures
• Silk
 70% natural silk, silk
worm larvae
 Main advantage is
favorable handling
 Knot security is good
 Tissue response to silk is
severe
 Braided material,
potential for infection is
great
 Non-absorbable Sutures
• 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
 Non-absorbable Sutures
• Polypropylene (Prolene)
 Similar to Nylon, synthetic
monofilament polymers
 Breaking strength less than
Nylon
 Knot security and ease of
tying greater than Nylon
 Absorption is non-existent,
good for contaminated
wounds
 Non-absorbable Sutures
• 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 Tapered
suture strand
• Stainless steel, 2 basic
configurations; cutting and
tapered Cutting

• Cutting, reverse cutting

needles
Reversed Cutting

Adapted from: Contemporary Oral and Maxillofacial Surgery, Mosby 1988.

 Needles
• No universal needle labeling or
coding 1/4 circle 3/8 circle
• Straight to as much as 5/8ths
round in shape
• For minor wound care, the 3/8
and 1/2 circle needles are used 1/2 circle 3/4 circle
• Size corresponds with the
outline on package
• Described on package (cutting)
along with manufacturer’s code Curve-ended
straight Straight

Adapted from: Contemporary Oral and Maxillofacial Surgery, Mosby 1988.

 Wound Healing and Repair
Stages

• Inflammatory Phase

• Proliferative Phase

• Remodeling or Maturation Phase

 Wound Healing and Repair
Stages
• 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
 Wound Healing and Repair
Stages
• Inflammatory Phase
Clot formation and Epithelialization into stratified
beginning epithelialization squamous epithelium

Adapted from: General Dentistry, Jul-Aug 1998.

 Wound Healing and Repair
Stages
• Proliferative Phase
 late inflammatory stage macrophages release
factors initiating fibroblast migration
 fibroblast synthesize ground substance and
collagen
 haphazard collagen matrix / new vascularization
called granulation tissue; increased wound tensile
strength
 fibrin clot organization is complete
 Wound Healing and Repair
Stages
• Remodeling or Maturation Phase
 granulation tissue takes on normal tissue
appearance
 initial repair collagen fibers destroyed and
replaced with collagen fibers oriented to resist
tensile forces; similar to adjacent non-damaged
tissue
 vascular bed remodeled; reduced blood flow and
erythema
 wound tissue strengthens to a level 80 to 85% of
uninjured tissue
 Wound Healing and Repair
Stages

• Scar formation
Foreign material
Necrosis
Ischemia
Wound tension
 Wound Closure
• “There 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, Reconstructive Plastic Surgery)
• 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
• Basic Principles
 Less scarring by primary intention; open wound granulates and scars
- debride and close primarily
 Closure with minimal tension
 Handle tissue gently
 Use appropriate suture
 Close ASAP
 If delayed primary closure, give systemic antibiotics and place sterile
dressing
 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: Clinician’s Pocket Reference, 8th 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 edges
better with the vertical mattress

Adapted from: Clinician’s Pocket Reference, 8th ed. Appleton & Lange 1997.
 Wound Closure
• Close in layers, avoid
dead space
• Deep layers close with Epidermis
3-0 to 4-0 absorbable Dermis
sutures
• Skin repair with 5-0 to Muscle

6-0 Nylon or
Polypropylene Submucosa
Mucosal
(Prolene) Epithelium
• Slight eversion of
wound edges
Adapted from: Contemporary Oral and Maxillofacial Surgery, Mosby 1988.
 Wound Closure
• Knot on the
subcutaneous suture
should be buried
• First pass through the 1 2
lower portion of the
dermal layer
• Pass suture superficial to
opposite wound margin
• Emerge at same level as
subcutaneous suture of 4
3
the opposing margin, tie
knot

Adapted from: Clinician’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
900
angle
 2 mm from margin, 2 mm
apart
2 mm 2 mm
 Don’t hesitate to remove
or replace sutures
 Consider wound taping

Adapted from: Contemporary 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
Wound Closure
Wound Closure
Wound Closure
Wound Closure
Wound Closure
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 at
www.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 Veterinary Clinics of North America:
Small Animal Practice. 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. Human Bite Infections. 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. Contemporary Oral and Maxillofacial Surgery, 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 wound
care. In: Gomella LG, Haist SA, Billeter M, eds. Clinician’s Pocket
Reference, 8th ed. Stamford: Appleton & Lange, 1997:327-338.
• Kwon PH. Sutures and suturing technique. In: Kwon PH, Laskin DM,
eds. Clinician’s Manual of Oral and Maxillofacial Surgery, 2nd ed.
Chicago, Quintessence, 1997:241-250.