OROFACIAL SOFT TISSUE INJURY AND WOUND HEALING

Dr. A.S.M. ARIFUL ISLAM

ASSISTANT PROFESSOR & HEAD
ORAL AND MAXILLOFACIAL SURGERY DEPARTMENT
UPDATE DENTAL COLLEGE AND HOSPITAL.
 ATLS GUIDELINE

ADVANCED TRAUMA LIFE SUPPORT PROTOCOL:

A=airway maintenance
B=breathing and ventilation
C=circulation with bleeding control
D=disability/neurologic assessment
E=exposure and environmental control
 Soft tissue injuries

The types of soft tissue injuries the dentist may see in practice vary considerably.
However, it is fair to assume that given the current availability of other health care
providers, the dentist will probably not be involved in the management of severe soft
tissue injuries around the face. (contemporary)
Thorough wound cleaning, gentle tissue handling and meticulous repair will
result into excellent healing of facial injury. Facial lacerations should be
repaired at the earliest time as soon as patient’s general condition allows. Early
wound repair lessens edema and prevents the formation of granulation tissue
infection. This will lead towards minimum scar formation. Preferably the facial
wounds should be repaired within 6-8 hours. Because of excellent blood supply
to the facial region, if necessary, safe primary repair can be done even after 1
or 2 days. (nelima)
TYPES OF SOFT TISSUE INJURY AND MANAGEMENT
1) ABRASION
An abrasion is a wound caused by friction between an object and the surface of
soft tissue. It is presented as raw bleeding areas. The wound is superficial and it
denudes the epidermis, occasionally involves deeper layers. Abrasion involves the
terminal nerve endings of many nerve fibers and it can be quite painful.Commonly seen
as scraps and re-epithelization occurs without scarring. While deep abrasions may
require skin grafting. Abrasions may be contaminated depending on the surroundings.
Foreign matter embedding contributes to traumatic
tattooing of the skin, foreign body reaction or
fibrosis and infection, with delayed wound healing.

Management :

a) Superficial abrasions can be covered with

topical antibiotic application and left open.
• b)Thorough cleaning with profuse saline
irrigation, removal of foreign material and
gentle scrubbing with the soft brush to
remove sticky material can be don’t to prevent
tattooing. Use of surgical soap is required to be
done prior to dressing.
C)Topical application of antibiotic ointment with
compression dressing promotes good healing.
 2) CONTUSION:

Contusion is caused by a blow or fall against a hard or blunt object .blood extravasates
in the subcutaneous or submucous tissue leading to bluish area or bruise. Subcutaneous
bleeding is self-limiting. Discoloration of the skin or mucosa causes ecchymosis. Areas of
ecchymosis which becomes evident in 48 hours will be seen as bluish black and these
fade away with change in variety of colors as blue, green, yellow, etc. Important for
diagnosis and search for an osseous trauma/fracture is mandatory.

Application of ice pack will help to stop further extravasation of blood.

 3) LACERATION :

Lacerated wounds are most frequent type of soft tissue injuries. Here tearing of mucosal
tissue or skin is seen due to vehicular accidents, low velocity missiles, or bomb splinters.
The margins are contused and lacerated in deep wounds, the muscles are also lacerated
and devitalized. There may be associated injury to the underlying vessels, nerves and
bone. These wounds are usually highly contaminated with dust, mud, greasy material,
etc.
Contusion injury
Laceration injury
TREATMENT OF LACERATED WOUNDS :
1. Cleaning of wound.
2. Removal of foreign bodies.
3. Debridement.
4. Hemostasis.
5. Closure in layers(muscle, dermis, epidermis, and submucosa and mucosal closure)-
primary closure.
6. Dressing.
7. Prevention of infection.
8. Pain control.
9. Follow up.
 4) HEMATOMAS:

Hematomas are localized collection of blood in the subcutaneous or intramuscular or

submucosal space. It may be deeply seated or superficial. Contusions and hematomas
may be associated with fracture or rupture of a vessel or vessels. Careful examination
may be repeated and x-ray examination is essential for proper diagnosis and treatment.

Most hematomas are reabsorbed. Persistent hematomas may require incision

and drainage. It cannot be aspirated as blood is partly clotted. Antibiotic coverage should
be given to prevent hematoma from getting infected.
Hematoma in face
5) INCISED WOUND:
Incised wounds are caused by sharp-cutting objects such as knife, dagger, glass piece,
tin edge, etc. These are clear cut, gapping, bleeding wounds with minimum
contamination. Deep wounds can bring about damage to the vital organs leading
towards major complications. The wound should be taken care as early as possible. The
wound is cleaned, explored and the bleeding is arrested. The wound is closed by
primary intention.
6) Penetrating and punctured wounds:
Punctured wounds are caused by pointed objects like a knife, bullet, bomb splinter, etc.
these wounds are highly deceptive as externally they may appear small, but may be deep
penetrating endangering vital organs. Careful clinical examination, x-ray examination and
other special investigation may be required.
Incised wound in face Punctured wound
7) CRUSHED WOUNDS:
Crushed wound is caused by road accidents, or a machinery accidents. Crushing of the
parts with lacerated skin, devitalization or crushing of the musculature is seen. Damage
to blood vessels and nerves with associated profuse bleeding is also observed. The
bone/bones are shattered. The wound is highly contaminated. There can be loss of
soft/hard tissue.
8) GUNSHOT INJURIES:
Gunshot injuries are in reality penetrating wounds, but are classified separately,
because of the extensiveness of the wounds and the special problems which arise
during their management. They are subclassified as : (1) penetrating wounds, when
the missile is retained in the wound, (2) perforating wounds, when the missile
produces another wound of exit, (3) avulsive wounds, when large portion of the soft
tissue or osseous structures are destroyed.
Crushed wound
Gunshot injury
 SUPPORTIVE THERAPY:

DRAINS:

Superficial wounds do not require drainage. Deeper wounds, particularly, those involving
oral cavity, require insertion of penrose or rubber drain. Drains may be placed between
the sutures or through dependent stab incision. Drains should be removed after 2-3
days.
DRESSINGS:

Sofra-tulle or antibiotic ointment along with dry gauze dressing should be

changed in 48 hours. Large wounds need pressure dressing. Sutures can be
removed on 5-7th day.

PREVENTION OF INFECTION:

Strict adherence to sterile technique, wound closure by eliminating all dead

spaces and adequate support antibiotic therapy and follow-up is necessary.
 PROPHYLAXIS AGAINST TETANUS:

Whenever there is an inclusion of dirt and debris in the wound, protection against
infection by the clostridium tetani organism must be provided. In a person who has been
immunized with pervious inoculation with the tetanus toxoid, a ‘booster’ dose of 1ml of
tetanus toxoid should be given as soon as possible. Passive immunity can be produced
by administrating 1500 units of tetanus antitoxin at weekly intervals, until three doses
have been given.
WOUND HEALING :
An important aspect of any surgical procedure is the preparation of the wound for
healing. Tissue injuries can be caused by either pathologic conditions or by traumatic
events. The dental surgeon has some control over pathologic tissue damage such as the
likelihood of a wound infection. However, the surgeon can favorably or unfavorably alter
the amount and severity of traumatically induced tissue injury and therefore can
contribute to promoting or impeding wound healing.
EPITHELIALIZATION:
Injured epithelium has a genetically programmed regenerative ability that allows it to
reestablish its integrity through proliferation, migration and a process known as contact
inhibition. In general, a free edge of epithelium continues to migrate until it comes into
contact with another free edge of epithelium.
 STAGES OF WOUND HEALING :

Regardless of the cause of nonepithelial tissue injury, a stereotypic process is initiated

that, if able to proceed unimpeded, works to restore tissue integrity. This process is
called wound healing. The process has been divided into basic stages that, although not
mutually exclusive, take place in this sequence. These three basic stages are
(1)inflammatory, (2) fibroblastic (3) remodeling.
1) INFLMMATOROY STAGE: The inflammatory stage begins the moment
tissue injury occurs and in the absence of factors that prolong inflammation, lasts 3 to 5
days. It has two phases: vascular and cellular. The vascular events set in motion during
inflammation begin with an initial vasoconstriction of disrupted vessels as a result of
normal vascular tone. The vasoconstriction slows blood flow into the area of injury,
promoting blood coagulation. Within minutes, histamine and prostaglandins E1 and E2,
elaborated by white blood cells, cause vasodilation and open small spaces between
endothelial cells, which allows plasma to leak and leukocytes to migrate into interstitial
tissues. Fibrin from the transudated plasma- aided by obstructed lymphatics
accumulates in the area of injury, functioning to dilute contaminants. This fluid collection
is called edema.
The cellular phase of inflammation is triggered by the activation of serum complement by
tissue trauma. Complement-split products, particularly C3a and C5a, act as chemotactic
factors and cause polymorphonuclear leukocytes (neutrophils) to stick to the side of
blood vessels (margination) and then migrate through the vessel walls (diapedesis).
Once in contact with foreign materials (e.g, bacteria), the neutrophils release the
contents of their lysosomes(degranulation). The lysosomal enzymes(consisting primarily
of proteases) work to destroy bacteria and other foreign materials and to digest necrotic
tissue.
Clearance of debris is also aided by monocytes, such as macrophages, which
phagocytes foreign and necrotic materials. With time, lymphocytes accumulate at the
site of tissue injury. The lymphocytes are in the B or T groups: B lymphocytes are able
to recognize antigenic material, produce antibodies that assist the remainder of the
immune system in identifying foreign materials, and interact with complement to lyse
foreign cells. T lymphocytes are divided into three principal subgroups: (1) helper T
cells, which stimulates B cell proliferation and differentiation, (2) suppressor T cells,
which work to regulate the function of helper T cells, (3) cytotoxic(killer) T cells which
lyse cells bearing foreign antigens.
 2) FIBROBLASTIC STAGE

The strands of fibrin, which are derived from blood coagulation, crisscross wound to form a
latticework on which fibroblasts can begin laying down ground substance and
tropocollagen. this is the fibroplastic stage of wound repair. The ground substance consists
of several mucopolysaccharides, which act to cement collagen fibers together. The
fibroblasts transform local and circulating pluripotential mesenchymal cells that begin
tropocollagen production on the third or fourth day after tissue injury. Fibroblasts also
secrete fibronectin, a protein that performs several functions. Fibronectin helps stabilize
fibrin, assists in recognizing foreign material that should be removed by immune system,
act as a chemotactic factor for fibroblasts, and helps to guide macrophages along fibrin
strands for eventual phagocytosis of fibrin by macrophages.
 3) REMODELING STAGE:

The final stage of wound repair, which continues indefinitely, is known as the remodeling
stage. During this stage many of the previous randomly laid collagen fibers are destroyed
as they are replaced by new collagen fibers, which are oriented to better resist tensile
forces on the wound. In addition, wound strength increases slowly but not with the same
magnitude of increase seen during the fibroplastic stage. Wound strength never reaches
more than 80% to 85% of the strength of uninjured tissue. Because of the collagen fibers
more efficient orientation, fewer of them are necessary, the excess is removed, which
allows the scar to soften. As wound metabolism lessens, vascularity is decreased, which
diminishes wound erythema. Elastin found in normal skin and ligaments is not replaced
during wound healing, so injuries in those tissues cause a loss of flexibility along the
scarred area.
A final process, which begins near the end of the fibroplasia and continues during early
portion of remodeling, is wound contraction. In most cases wound contraction plays a
beneficial role in wound repair, although the exact mechanism that contracts a wound is
still unclear. During wound contraction the edges of a wound migrate toward each other.
In a wound in which the edge are not or will not be placed in apposition, wound
contraction diminishes the size of the wound. However contraction can cause problems,
such as those seen in victims of third degree burns of skin, who develop deformity and
debilitating contractions if wounds are not covered with skin grafts and aggressive

physical therapy is not performed.

Another example of detrimental contraction is seen in individuals suffering sharply
curved lacerations, who frequently are left with amount of tissue on the concave side
of the scar because of wound contraction, even when the edges are well readapted.

contraction can be lessened by placement of a layer of epithelium between the free

edges of a wound. Surgeons use this phenomenon when they place skin grafts on the
bared periosteum during a vestibuloplasty or on full thickness burn wounds.
STAGES OF WOUND HEALING:-
 FACTORS THAT MODIFY WOUND HEALING OR
LEADING TOWARDS FAILURE :
1) Too tight suturing without adequate drainage, may lead toward wound breakdown.
2) Inadequate pressure dressing- collection of hematoma.
3) Foreign material.
4) Oral contamination of wound, with inadequate closure on the oral mucosal side.
5) Necrotic tissue.
6) Secondary hemorrhage.
7) Ischemia.
8) Inadequate antibiotic therapy.
9) Improper asepsis.
10) Secondary rough handling of the wound.
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