Oral Lacerations

By admin On Oct 12, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Oral Lacerations

Brent H. Messick

Kevin E. Burroughs

Basics

Description

Soft tissue injury in the orofacial area
Typically results from a direct blow to the mouth resulting from a fall or impact by an opponent or object
Lacerations may be an indirect result of an individual biting the cheek or lip.

Epidemiology

Most common in contact sports not requiring face protection (basketball, hockey, soccer, baseball, wrestling)
Other at-risk sports include bicycling, in-line skating, and gymnastics.
Children are most susceptible between the ages of 7 and 11.

Incidence

As high as 1.06/100,000 athlete exposures (1)

Prevalence

1.4/10,000 athlete exposures in football and 18.3/10,000 in basketball; 58–75% of these injuries are soft tissue lacerations (2).

Risk Factors

Participation in collision or contact sports
Not using a mouth guard

Commonly Associated Conditions

Fracture of the mandible, dental arch, palate
Dental luxation or avulsion
Tooth fracture
Temporomandibular joint (TMJ) trauma
Vessel injury
Nerve transection
Salivary gland duct injury

Diagnosis

History

Determine where and how the injury was sustained. Common in sports, but also seen as result of fighting, assault, and abuse.
Determine areas of numbness or loss of muscle control to evaluate for nerve injury.
Determine last tetanus immunization, as wounds often are contaminated from the environment as well as from the oral cavity.
Sensitivity of teeth (assess for occult dental trauma)

Physical Exam

Significant hemorrhage due to the abundant blood supply in the face and maxillofacial areas
Visible defects with “through and through” lacerations (lacerations involving all layers: Mucosa, muscular, SC, and skin)
Patient distress
Head and neck examination for signs of neural injury
Palpate over TMJ joint to evaluate for subcondylar mandibular fracture
Test mobility of jaw
Evaluate laceration for length and depth as well as for affected structures, including nerves and vessels (transected nerves need to be referred for surgical repair)
Buccal lacerations need to be evaluated for parotid salivary flow from the Stenson's duct. Parotid orifice is located opposite the maxillary 1st molar. Saliva should flow from opening when parotid gland is palpated (disruptions of the duct should be referred for repair).
Evaluate for normal occlusion of the teeth. Dental examination should be performed to check for fractured, loose, or avulsed teeth.

Diagnostic Tests & Interpretation

Imaging

If there is a clinical suspicion of a fracture or foreign body such as a tooth fragment, appropriate studies should be ordered: Panorex for teeth, plain radiographs for foreign bodies or CT for facial fractures, etc.
Bone fixation/repair, if needed, should be performed before soft tissue closure.

Differential Diagnosis

Contusion
Abrasion
Dental trauma (luxation, avulsion, fracture)

Treatment

Most oral lacerations can be left to heal by secondary intention. Only those that are >1 cm, gapping at rest, or require hemostasis may need to be repaired.
Copious irrigation of the wound to remove foreign debris and wound contaminants
Clean with antiseptic scrub
Regional anesthesia via nerve block is preferred over local injection to minimize tissue distortion, making approximation easier (especially for the vermilion border).
Infraorbital nerve block numbs the upper lip.
Mental nerve block numbs the anterior lower lip and teeth.
Maxillary nerve 2nd division numbs the entire maxilla on the blocked side.
Interrupted stitches using 3–0 chromic or similar absorbable suture material
Inside-out and bottom-up technique; eliminating dead spaces helps prevent hematoma and subsequent infection
Muscular layer: 4–0 slow-absorbing suture; polyglactic suture breaks down more slowly than chromic suture, maintaining wound strength for ∼30 days.

P.419

Oral mucosa: 3–0 or 4–0 chromic or other absorbable suture material on a cutting needle
Small intraoral lacerations may be left to heal by secondary intention.
SC layer: 3–0 or 4–0 plain gut on a cutting needle
Skin: 4–0 to 6–0 nylon
Suture orbicularis oris 1st; see above suture suggestions
Loosely approximate the vermilion border (very important for cosmetic appearance) with a suture at the junction with the skin
Proceed in layers as above
Superficial lacerations <1 cm and not gaping at rest do not require sutures unless required for hemostasis.
Lacerations involving the muscular layer or labial margin require sutures.
Lacerations involving the tip may require sutures to prevent a “forked tongue.” Most can be left alone. Anterior tongue lacerations are rare and are often self-inflicted. Small ones can close, but large ones will require sutures. If the tongue heals “forked,” it can also be corrected later if necessary.
Repair in layers: 4–0 slow-resorbing polyglactic suture for the muscle and chromic suture for the mucosa
Typically “V” shaped
Small lacerations can be allowed to close by secondary intention.
Hemorrhage typically from disruption of the muscular layer may require a stitch to obtain hemostasis.
Large gaping lacerations can be repaired with 1 or 2 vertical sutures.

Additional Treatment

Additional Therapies

Tetanus immunization status
Prophylactic antibiotics for severe or grossly contaminated laceration (coverage for the oral flora includes amoxicillin, penicillin, clindamycin, or erythromycin)
If fracture is present, leave wound open until fixation is completed.

In-Patient Considerations

Initial Stabilization

Evaluate ABCs.
Control hemorrhage.
Protect the airway if compromised.

Ongoing Care

Follow-Up Recommendations

Laceration associated with fracture or involving nerves or salivary ducts should be referred for definitive care as soon as possible.
Refer dental trauma to a dentist or oral surgeon.
Patients receiving antibiotics should be rechecked in 48 hr to ensure improvement and antibiotic susceptibility.

References

1. Labella CR, Smith BW, Sigurdsson A. Effect of mouthguards on dental injuries and concussions in college basketball. Med Sci Sports Exerc. 2002;34:41–44.

2. Flanders RA, Bhat M. The incidence of orofacial injuries in sports: a pilot study in Illinois. J Am Dent Assoc. 1995;126:491–496.

Additional Reading

Echlin P, McKeag DB. Maxillofacial injuries in sport. Curr Sports Med Rep. 2004;3:25–32.

Echlin PS, Upshur RE, Peck DM, et al. Craniomaxillofacial injury in sport: a review of prevention research. Br J Sports Med. 2005;39:254–263.

Ranalli DN, Demas PN. Orofacial injuries from sport: preventive measures for sports medicine. Sports Med. 2002;32:409–418.

Ud-din, Zia and Aslam, Musarrat. Should minor tongue lacerations be sutured in children. Best Evidence Topics. 2007. Accessed 10/05/2009. http://www.bestbets.org/home/bets-introduction.php

Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc. 2006;137:1712–1720.

Codes

ICD9

873.60 Open wound of mouth, unspecified site, uncomplicated
873.61 Open wound of buccal mucosa, uncomplicated
873.62 Open wound of gum (alveolar process), uncomplicated