SOFT TISSUE INJURIES
Injuries to the soft tissue of the oral cavity are almost always the result of the surgeon’s lack of adequate attention to the delicate nature of the mucosa and the use of excessive and uncontrolled force. The surgeon must continue to pay careful attention to the soft tissue while working primarily on the bone and tooth structure (Box 11-1).
The most common soft tissue injury is the tearing pf the mucosal flap during surgical extraction of a tooth. This is usually-the result of an inadequately sized envelope flap, which is retracted beyond the tissue’s ability to stretch
(Fig. 11-1). This results in a tearing, usually at one end of the incision. Prevention of this complication is twofold: (1) create adequately sized flaps to prevent excess tension. On the flap, and (2, use small amounts of retraction for,.ce on the flap. Ifa tear does occur in the flap, the flap should
be carefully repositioned once the surgery is complete. In most patients, careful suturing of the tear results in adequate but delayed healing. If the tear is especially jagged, the surgeon may consider excising the edges of the jorn flap to create a smooth flap margin for closure. This latter step should be performed with caution, because excision of excessive amounts of tissue leads to closure of the wound under tension and probable wound dehiscence. . If the area’ of surgery is near the apex of a tooth, an increased incidence of envelope-flap tearing exists as a result of excessive retractional forces. In this situation a release incision to create a three-cornered flap should be used to gain access to the bone
The second soft tissue injury that occurs with some frequency is inadvertent puncturing of the soft tissue. Instruments, such ‘as a straight elevator or periosteal ele-· vator, may slip from the surgical field and puncture or tear into adjacent soft tissue. ‘. Once again, this injury is the result of using unoon- .trolled force instead of finesse and is best prevented by the use of controlled force, with special attention given to the supporting fingers or support from the opposite hand in anticipation of slippage. If the instrument slips from the tooth or bone, the fingers thus catch the hand before injury occurs (Fig. 11-2). When a puncture wound does occur, the treatment is aimed primarily at preventing infection and allowing healing to occur, usually by secondary intention. If the wound bleeds excessively, it
should be controlled by direct pressure on the soft tissue. Once hemostasis is achieved, the wound is usually left open and not sutured, so that if a small infection were to occur, there would be an adequate pathway for drainage.
Abrasions or burns of the lips and corners ,of the mouth are usually the result of the rotating shank of the bur rubbing on the soft tissue (Fig. 11~3). When the surgeon is focused on the cutting end of the bur, the assistant should be aware of the location of the shank of the bur in relation to the cheeks and lips. If such an abrasion does develop, the dentist should advise the patient to keep it covered with Vaseline or an antibiotic ointment. It is important that the patient keeps the ointment only on the abraded area and not spread onto intact skin, because it is quite likely to result in a rash. These abrasions usually take 5 to 10 days to heal. The patient should keep the area moist .with the ointment during the entire healing period to prevent eschar formation .scarring, and delayed healing, as well as to keep the area reasonably comfortable.