Soft Tissue Injuries of the Oral and Maxillofacial Region/Suturing Skills

Designed to assist local facilities with Dental Readiness Training

Course Date: 11/07 Reviewed/Updated: 10/10 Expiration Date: 10/13

Official Disclaimer
The opinions expressed in this presentation are those of the author and do not necessarily reflect the official position of the US Air Force or the Department of Defense (DOD). Devices or materials appearing in this presentation are used as examples of currently available products/technologies and do not imply an endorsement by the author and/or the USAF/DOD.

Objectives
Provide general information on maxillofacial soft tissue injuries and anatomic considerations. Provide a general review of suture materials, wound closure and wound healing.

Soft Tissue Injuries of the Oral and Maxillofacial Region/Suturing Skills

Overview
Initial Examination Classification of Injury Special Regional Considerations Animal and Human Bites Tetanus Suture Materials Wound Healing/Repair Wound Closure Conclusions

Initial Examination
Establish airway and control hemorrhage Rule out C-Spine Injury Rule out facial bone fractures Reduce fractures before soft tissue repair Keep wounds moist during examination Direct inspection of persistent bleeding Copious irrigation with saline Direct pressure to control bleeding Prevent hematoma formation

Initial Examination
Wounds divided into two groups: clean and contaminated Contamination increases with time The solution to pollution is dilution High-pressure pulsating streams best Anesthetize wound before irrigation Remove foreign bodies Clean animal/human bites thoroughly Tetanus prophylaxis as needed

Classification of Injury
Contusion Abrasion Accidental Tattoo Retained Foreign Bodies Puncture Wounds Simple Laceration Avulsion (flap) Avulsion (complete)

Classification of Injury
Contusion
Bruising injury caused by blunt trauma (with or without hematoma) Cleansing and observation usually sufficient Some hematomas spontaneously resorb Other hematomas require surgical intervention Basis for cauliflower ear deformity
Hematoma

Antihelix

Tragus

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 2448 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 Dont 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!

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 nonabsorbable sutures (Nylon or Polypropylene) Rule out hematoma

Special Regional Considerations

Ear
Direct blow causes hematoma - Cauliflower ear Use 6-0 nonabsorbable 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

Langers Lines
Described by Langer in 1861 Punched holes in skin of cadavers Langers lines parallel to fiber bundles Usually indicate direction for incision Inconspicuous scars fall in wrinkle lines
Adapted from: Dorlands Illustrated Medical Dictionary, www.mercksource.com. Accessed Oct 2010.

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 & Prevention (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

are pathogens Use Augmentin (amoxicillin with clavulanic acid) Quinolones in Penicillinallergic patients

canis, multocida and septica

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 Penicillinallergic patients
Revis, DR. Human Bite Infections. Available at www.emedicine.com/med/topic1033.htm. Accessed Oct 2010.

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 Age of wound Configuration Mechanism of Injury Signs of Infection Devitalized tissue Contaminants (dirt, feces, soil, saliva) Tetanus Prone 6 hours + Stellate, evulsions Missile, crush, heat/cold Present Present Present Clean, minor wound Less than 6 hours Linear, abrasion Sharp surface (knife/glass) Absent Absent Absent

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

Tetanus

Center for Disease Control & Prevention (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 0s 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 suture strand Stainless steel 2 basic configurations: cutting and tapered
cutting and reverse cutting needles: 3 cutting surfaces X-cross needles: 4 cutting surfaces (plastic/cosmetic surgery)
Tapered

Reversed Cutting

Cutting

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

Side Cutting
(X-cross)

Needles
vs. Cutting Triangular shape with 3 cutting edges Apex located on concave surface of the needle Can cause flap tear Reverse Cutting Triangular shape with 3 cutting edges Apex located on the convex surface of the needle Less likely to result in flap tear

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 manufacturers code
1/4 circle 3/8 circle

1/2 circle

3/4 circle

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 beginning epithelialization Epithelialization into stratified 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: Clinicians 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: Clinicians Pocket Reference, 8th ed. Appleton & Lange 1997.

Wound Closure
Close in layers, avoid dead space Deep layers close with 3-0 to 4-0 absorbable sutures Skin repair with 5-0 to 6-0 Nylon or Polypropylene (Prolene) Slight eversion of wound edges

Epidermis
Dermis Muscle Submucosa Mucosal Epithelium
Adapted from: Contemporary Oral and Maxillofacial Surgery, Mosby 1988.

Wound Closure
Knot on the subcutaneous suture should be buried First pass through the lower portion of the dermal layer Pass suture superficial to opposite wound margin Emerge at same level as subcutaneous suture of the opposing margin, tie knot

Adapted from: Clinicians 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 Dont hesitate to remove or replace sutures Consider wound taping

900

2 mm

2 mm

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 surecall for help Solution to pollution is dilution!

 Dorlands Illustrated Medical Dictionary. Langers Lines. Available at

www.mercksource.com/pp/us/cns/cns_hl_dorlands_split.jsp?pg=/ppdocs/us/common/dorlands/dorland/five/000060422.htm

References

Accessed Oct 2010. 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;101:243254. Loar M. Risks of pet ownership: the family practitioners 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 Oct 2010. 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. Clinicians Pocket Reference, 8th ed. Stamford: Appleton & Lange, 1997:327-338. Kwon PH. Sutures and suturing technique. In: Kwon PH, Laskin DM, eds. Clinicians Manual of Oral and Maxillofacial Surgery, 2nd ed. Chicago, Quintessence, 1997:241-250.