Because of the rich vascularity of the soft tissues of the mouth, impact injuries often lead to dramatic hemorrhages that send patients to the emergency department with relatively trivial lacerations. Blunt trauma to the face can cause secondary lacerations of the lips, frenulum, buccal mucosa, gingiva, and tongue. Active bleeding has usually stopped by the time a patient with a minor laceration has reached the emergency department.
What to do:
Provide appropriate tetanus prophylaxis and check for associated injuries such as loose teeth, mandibular or facial fractures .
When only small lacerations are present and only minimal gaping of the wound occurs, reassurance and simple aftercare is all that is required. Let the patient know the wound will become somewhat uncomfortable and covered with pus over the next 48 hours and tell him to rinse with lukewarm water or half strength hydrogen peroxide after meals and every one to two hours while awake for one week.
If there is continued bleeding, the wound edges gape significantly or there is a flap or deformity when the underlying musculature contracts, the wound should be anesthetized using lidocaine with epinephrine, cleansed thoroughly with saline and loosely approximated using a 4-0 or 5-0 absorbable suture. Consider using conscious sedation when suturing children who cannot cooperate. A traction stitch or special rubber-tipped clamp can be very helpful when attempting to suture the tongue of a small child or intoxicated adult. The same aftercare as above applies.
When the exterior surface of the lip is lacerated, any separation of the underlying musculature must be repaired with buried absorbable sutures. To avoid an unsightly scar when the lip heals, precise skin approximation is very important. One must first approximate the vermilion border, making this the key suture. Fine non-absorbable suture material (e.g., 6-0 nylon or Prolene) is most appropriate for the skin surfaces of the lip while a fine absorbable suture (e.g., 6-0 Dexon or Vicryl) is quite acceptable on the mucosa and vermilion.
For deep lacerations of the mucosa or lip, or any sutured laceration in the mouth, prescribe prophylactic penicillin (penicillin VK 500mg tid x 3-4 days) to prevent deep tissue infections (erythromycin may be substituted in penicillin-allergic individuals). Recommend acetaminophen for pain.
Have patients return in 48 hours for a wound re-evaluation.
Recommend cool liquids and soft foods beginning four hours after the repair.
What not to do:
Do not bother to repair a simple laceration or avulsion of the frenulum of the upper lip. It will heal quite nicely on its own.
Do not use non-absorbable suture material on the tongue, gingiva or buccal mucosa. There is no advantage and suture removal on a small child will be an unpleasant struggle at best.
Discussion
Imprecise repair of the vermilion border will lead to a “step-off” or puckering that is unsightly and difficult to repair later on. Fortunately, the tongue and oral mucosa usually heals with few complicating infections and there is a low risk of subsequent tissue necrosis.
