Chapter 3

Intraoral Soft Tissue Injuries

Aim

To provide insight into the treatment of soft tissue injuries.

Outcome

After studying this chapter the reader should know what injuries can be treated in practice and which require referral to a secondary treatment centre.

Aetiology

Soft tissue injuries may occur to the lips, fraenum, mucosa, palate, tongue, floor of mouth, gingiva, or skin either alone or in addition to dental injuries. Such injuries can be caused by objects, toys or teeth, and are usually accompanied by acute bleeding and considerable distress for both parents and child. Children can fall with foreign bodies in the mouth including lollipop sticks, pens, pencils and other objects. In addition, a fall to the ground can clamp the teeth together, causing quite severe lacerations to the tongue or cheeks, which tend to be flabby in children and easily trapped between teeth. A sliding fall on to the face can pull the lips back from the attached gingiva, tearing the fraenal attachments. Sometimes there is shredding of the attached gingiva on the upper jaw or degloving the anterior part of the mandible, both above or below the muco-gingival junction. Each of these different injuries will be described in turn.

Diagnosis

To establish an accurate diagnosis of the extent of any soft tissue injury, it is important to control bleeding in the first instance. This will in turn remove much of the distress of all concerned. Often the injury is much less severe than is first thought and, when cleaned up, may be found to be relatively superficial. When a child is crying, mucosal and tongue injuries often gape and look quite severe. When the child is calmed and the tissues are at rest the apposition of cut edges is often favourable and healing can be remarkably quick. In children under five years old, surgical repair under local anaesthetic is seldom practical. If a general anaesthetic is considered to be necessary to carry out a repair the child must be adequately fasted. Fortuitously, this delay and the reexamination, which is then possible, often reveals a more favourable situation and that the repair under anaesthesia is not needed. This is particularly the case in puncture injuries of the soft palate or fauces. Many tongue lacerations will also heal very well without surgical intervention.

All the soft tissues of the mouth should be examined systematically following an injury:

• Lips: cuts, bruises, contusions, foreign bodies (dirt and tooth fragments), vermilion border injuries

• Fraenum – tears and lacerations

• Mucosa – bites, tears and contusions

• Palate, soft palate and fauces – bruising and penetrating wounds

• Tongue – bites and lacerations

• Floor of mouth – bruises, lacerations and penetrating wounds

• Gingiva – crushing, shredding and tears

• Skin – bruises, contusions and lacerations.

Treatment

Haemostasis is easily achieved in most cases by simple pressure with a damp saline swab. Children protect their mouth after an injury by holding their mouth open and refusing to swallow. This causes accumulation of copious amounts of saliva mixed with fresh blood. The combination makes an unsightly and alarming picture. When the mouth is cleared and the injuries are cleaned, the situation always looks much better. A calm and confident approach with minimal fuss reassures both child and parents. Keeping steady pressure with the swab for several minutes usually results in a cessation of crying and bleeding.

Specific Injuries

Lips

• Lower lip between upper and lower teeth – through and through. In this injury the intraoral wound seldom requires sutures and heals without a scar if the edges are in reasonable apposition at rest. The external skin wound should be held in apposition using an adhesive suture or if this is inadequate then by interrupted 4.0 monofilament sutures (Fig 3-1).

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