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Wound healing Regeneration & repair Healing by primary intention & secondary intention Healing in fractures Healing of extraction socket & its complications Factors influencing wound healing Methods of control of hemorrhage
Prevention Management Prosthetic considerations
What is a "WOUND"..?? -- its any injury to the tissues or the organs caused by a cut, stab or tear, usually going deeper than the outer skin. what is "HEALING"...??
--Is the body's response, to injury, to restore normal structure and function.
e.Therefore. .e. by: 1) replacement of the injured or dead cells by the new cells of the same kind. WOUND HEALING. i. is the body's ability to repair the injured tissues. Fibrosis. 2) replacement by the connective tissue. i. Regeneration.
REGENERATION: --Healing takes place by proliferation of the parenchymal cells and usually results in complete restoration of the original tissues. --cell proliferation can be stimulated by cell injury. leaving no residual trace of the previous injury. cell death and mechanical deformation of the tissues .
depending upon their capacity to divide cells of the body are divided into 3 main groups: 1) LABILE CELLS (continuously dividing cells) 2) STABLE CELLS (quiescent cells) 3) PERMANENT CELLS (non-dividing cells) .
REGENERATION: G0. G2 PHASE . S. G1.
granulation tissue formation: 2. called the.repair begins early in inflammation. Granulation tissue. Fibrosis. it occurs in two main steps as follows: 1.REPAIR: -. fibroblasts and vascular endothelial cells begin proliferating by 3-5 days to form a very specialized tissue that is the hallmark of the healing process. -.e. contraction of wounds: .its the replacement of the injured tissues by the fibrous tissue formation i.
phase of inflammation 2. phase of clearance 3. phase of ingrowth of granulation tissue -.fibrosis .Granulation tissue formation 1.angiogenesis -.
Contraction of wounds: (a) dehydration (b) contraction of the collagen (c) discovery of the myofibroblasts .
Scar formation Fibroblast migration & proliferation ECM deposition & Scar formation Tissue remodeling (metalloprotenases) .
incisions in the gingiva itself heal without scars.The oral cavity has many structurally different tissues that likely heal in different ways.** WHY NO SCAR FORMATION IN THE ORAL CAVITY? -. In addition. whereas harvesting gingival grafts from the palate produces no visible sign of scarring. . Periodontists and oral surgeons are well aware that incisions in the buccal mucosa result in scars.
including distinct fibroblast phenotype.-. .Various reasons have been suggested for minimal scarring in the oral cavity. and topical use of artificial saliva has been suggested as a treatment for skin burn wounds. the presence of bacteria that stimulate wound healing and the moist environment and growth factors present in saliva.This effect of saliva is attributed mainly to its relatively high concentration of epidermal growth factor (EGF).
Wound Healing: Inflammation Epithelialization Granulation Contraction Remodeling .
uninfected. Netrophils… Inc.Healing by Primary Intention: Healing of clean. mitotic activity of basal cells Cells meet in midline below scab . Continuity Within 24 hrs. surgical incisions Focal disruptions of basement memb.
keratinisation .Day 3 : Neutrophils replaced by macrophages Invasion of granulation tissue Vertically oriented collagen fibers Thick epithelial covering Day 5 : Neovascularisation – peak Abundant collagen fibers Differentiation .
By end of 1st month: Scar devoid of inflammatory cells Dermal appendages lost permanently Tensile strength inc. edema. … .During 2nd week: Continued collagen accumulation & fibroblast proliferation Vascularity. leukocyte infiltration decrease Collagen inc.
abcess or large wounds Healing from below upwards & margins inwards Slow & leads to scar formation .Healing by Secondary Intention: More extensive wounds – infarcts. Ulcers. inflamm.
Initial hemorrhage: Wound filled with blood & fibrin clot Inflammatory phase: Acute inflamm cells. then macrophages Epithelial changes: Proliferation from both margins Surface not covered till granulation tissue starts filling wound space Scab cast off .
granular & fragile but – pale Wound contraction: Not seen in primary healing Due to myofibroblasts 1/3 – ¼ the original size .Granulation tissue: Main bulk Fibroblasts & neovascularisation Deep red.
Healing by secondary intention .
Sutured wounds – 70% of unwounded skin 1 week- 10% 4 week- inc 3 month- 70-80% No further increase
Infection Pigmentation Implantation Deficient scar Hypertropied scar & Keloid Excessive contraction Neoplasia Incisional hernia
Factors influencing healing
A) LOCAL FACTORS
1) infections 2) poor blood supply 3) foreign bodies 4) movement 5) exposure to the ionising radiations 6) UV-Light
B) SYSTEMIC FACTORS 1) Age 2) Nutrition 3) systemic infection 4) administration of the glucocorticoids 5) uncontrolled diabetics 6) haematological disorders .
HEALING IN THE SPECIALISED TISSUES: FRACTURE HEALING Healing of the fracture by callus formation However the basic events in the healing of any type of fractures is similar and resemble healing of the skin wound to some extent. .
-. .*** PRIMARY UNION OF FRACTURES: -.in these cases the bony union takes place with formation of the medullary callus without the periosteal callus formation.it occurs in few special conditions when the ends of the fracture are approximated and is done by the application of the compression clamps.
ingrowth of the granulation tissue -. -.though its a continuous process its described under following headings: 1) PROCALLUS FORMATION: -.its a more common process of fracture healing.Haematoma -.Callus composed of the woven bone and the cartilage .Local inflammatory response -.*** SECONDARY UNION OF THE FRACTURES: -.
-.The woven bone is cleared away by the incoming osteoclasts and the calcified cartilage disintegrates.the procallus acts as a scafolding over which osseous callus composed of lamellar bone is formed. -.in their place newly formed blood vessels and the osteoblasts invade. laying down the osteoid which is calcified and the lamellar bone is formed by developing the Haversian system around the blood vessels.2) OSSEOUS CALLUS FORMATION: -. .
-.External callus is cleared away. both the osteoblastic and the osteoclastic activity takes place.during the formation of the lamellar bone.Intermediate callus gives place to the compact bone. thus remodelling the united bone ends. which are sometimes indistinguishable from the normal bone. -. . -.Internal callus develops the bone marrow cavity in it.3) REMODELLING: -.
Healing of extraction socket .
Healing Of Extraction Socket Immediate Reaction : Blood fills the socket & coagulates Torn blood vessels – sealed off Vasodilation & engorgement Leukocytes around the clot First Week Wound : Fibroblast proliferation Clot acts as scaffold Mild mitotic activity Clot organization. no osteoid formation .
Second Week Wound : Clot organization progresses Remnants of PDL – degeneration Epithelial Proliferation Socket margins – osteoclastic activity Third Week Wound : Clot totally organized Osteoid bone formation Rounded crest Complete epithelisation of surface Fourth Week Wound : Continuous remodeling & deposition Crest below adjacent tooth Radiographic evidence – 6-8 weeks .
Complication of socket healing Dry Socket/Alveolitis Sicca Dolorosa/Alveolitis Osteitis/Acute Alveolar Osteomyelitis/Alveolagia Most common disintegration of clot 95% in lower premolars & molars Within 2nd or the 3rd day Extremely painful Palliative medicine & dressings Reviewing the patient Pack socket with obtundant .
accompanied by a partial or total disintegration of the intra-alveolar clot.its defined as "postoperative pain in and around the dental alveolus. -. after a dental extraction. which increases in severity during the 1st and the 3rd day. accompanied invariably with a foul smell.First time the term "DRY SOCKET" was used by Crawford in 1896. -.its a post-operative complication that occurs after a dental extraction. .-.
.The condition derives its name from the fact that after the clot is lost the socket has dry appearance because of exposed bone.
. Disintegration of clot may be due to infection of the wound. smoking or excessive traumatic extraction. grayish bone is seen from the socket and bad odor is present at the socket and pus is minimal or not at all. Bacterial enzymes hyaluronidase and fibrinolysin causes lysis of clot. **The bone of the socket becomes necrosed.** It may occur due to frequent and forceful spitting after extraction.
A strip of paste soaked surgical gauze should be placed gently into the socket. ** Antibiotics and analgesics are not effective if used alone because of poor vascularity of the necrosed bone. intra-alveolar pastes consisting of the zinc oxide eugenol paste. anaesthetic and an antibiotic (metronidazole) can be placed. .** For the treatment of dry socket.
Fibrous healing +Rare Loss of labial & lingual plates Dense fibrous mass on exploration This loss of cortical periosteum causes improper healing and scar tissues are found at the site. These fibrous connective tissue may ossify a little or not at all. For the Treatment. . excision of the lesion for the purpose of establishing a diagnosis will sometimes result in normal healing and subsequent bony repair of the fibrous defect.
Methods to control Hemorrhage: Causes: some amount of bleeding is normal after an extraction. . This usually stops after the application of the pressure in a couple of minutes. Excessive bleeding will be seen in hypertensives and where a blood vessel has been severed.
Prevention: excessive bleeding can be prevented by the atraumatic extraction. In the hypertensives make sure that the blood pressure is under control before the extraction. .
incision should be planned properly to avoid any damage to the major vessels.-. -.patients on the anticoagulants should be investigated properly and a physician's opinion should be taken. .
.the first line of management is to apply the pressure on the bleeding site. A gauze moist with saline may be used to apply the firm finger pressure on the area.Management: 1) Pressure pack: -.
2) Visualise: -. to visualise the region and examine. if the bleeding is from the soft tissue area. pressure will stop the bleeding.if the bleeding does not stop then a properly cleaning the the area and then examination is done under proper light. -.if its from the bone then locate the exact point and then open up a gauze piece to make a thin strip and pack tightly into the socket to prevent the bleeding. . -.look for the spot of the bleeding.
3) Local anaesthetic packs: -.these are easily available in the clinics and so can be used for temporarily control the bleeding. But these shouldnt be used as a permanent solution as once the effect wears off the bleeding may start again .
bleeding from the soft tissues may be controlled by placing the sutures as this helps to compress the mucosa against the bone and reduce the bleeding. .4) Sutures: -.
the area is first dried as much as possible and then a hot ball burnisher may be used to cauterize. The exact bleeding point is first located.5) Cautery: --bleeding from the bone may be controlled by the cauterisation.electrocautery may also be used for the same. -. . -.
6) Ligation: -.if a major artery is severed. which acts by disrupting the platelets and establishing a framework with fibrin strands to create a clot.this is a gelatin based sponge. It gets absorbed within 4-6 weeks. then it may be needed to be ligated. . 7) Gel foam: -.
-. leading to the formation of the artificial clot. .8) Oxidised Cellulose: -.it releases the cellulosic acid. which has a marked affinity for the hamoglobin. which thus when applied leads to decrease the bleeding by stabalising the clot formed.these substances may be placed in the socket to enhance the clot formation and thus control the bleeding. 9) Fibrin Glue: --this consists of a fibrinogen and thrombin.
--The patient should be made to wait for some time after extraction in the clinic to confirm the absence of the bleeding.this is the mechanical agent to block the bleeding vessel. .10) Bone Wax: -. --bleeding from the bone may be occluded by placing small piece of bone wax firmly on the spot of bleeding.
. -.If any unhealed sockets are present then the patient is asked to wait till the healing is complete.** PROSTHETIC CONSIDERATIONS: ** IMPRESSIONS MAKING : -. should be carried out only when the extraction sockets and the oral mucosa are completely healed.Any impression making.
Once the gum tissues and bones of the jaw have completely healed--which may take at least six to eight weeks.impressions of the unhealed sockets will lead to the pain and discomfort during the procedure and the dentures prepared will not fit as afterwards the healing would have taken place along with the bone formation in the socket. according to the American Dental Association--the patient can be fitted for a set of permanent dentures. . -.-.
-. as well as numbing the pain.** IMMEDIATE DENTURES: -. fabricated for the placement immediately after the removal of the natural teeth.These immediate dentures. -.Troublesome hemorrhage is rare because the immediate dentures act as a bandage themselves. help to protect the gums.its a complete denture or a removable partial denture. .
-.as tissue conditioning materials are used for the correction and the refinement of the dentures fitting surface. so care should be taken so that the material does not get into the extraction socket. .less post-operative pain is likely to be encountered because the extraction sites are well protected by the immediate dentures.-. And for this the extraction socket is covered by the "BURLEW FOIL".
normal socket healing will be then compromised and the ridge will heal with small concavities overlying the extraction sockets leading to the formation of the "KNUCKLE SHAPED RIDGES". . due to swelling. any projections of the tissue conditioning material inside the denture should be trimmed because if this is overlooked. -.dentures should not be removed during the first 24 hours as inflammation and swelling can occur and if the dentures are removed then its difficult to reinsert them for 3-4 days.also.-.
These are called "immediate" implants.** IMMEDIATE IMPLANT PLACEMENT: -. up to a month or more. . to allow for soft tissue healing."Delayed" implants are those placed thereafter in partially or completely healed bone."Immediate-delayed'" implants are those implants inserted after one or more weeks.Dental implants can be placed in fresh sockets immediately after tooth extraction. -. -.
allowing the bone grafted socket site to heal normally with the newly placed implant. .The extraction socket can have an implant placed immediately after a Chronically infected tooth is removed.The advantage of immediate placed implants is the shortened treatment time. Bone height will be maintained thus improving implant bone support and aesthetic results. but needs to have the replacing implant anchored into bone and the site grafted at the same time with a PTFE membrane that excludes soft tissue.-. -.
decline in innate immunity.delayed wound healing occurs in the diabetics due to the decreased polymorphonuclear chemotaxis.Delayed vascularization.they are more prone to the infections as the gingival fluid too contains more of the glucose levels which favors the growth of the microflora. -. decreases in growth factor production. and psychological stresses may be involved in the protracted wound healing of the oral mucosa in diabetics .** WOUND HEALING IN DIABETICS: -. reduction in blood flow. -.
Poor circulation can limit the amount of oxygen and healing nutrients that reach a wound. which derive from bone marrow.Endothelial progenitor cells (EPCs).Poor circulation: If you have had diabetes for a long while.-. you probably have fatty deposits in your arteries that slow down blood flow causing poor circulation. . -. normally travel to sites of injury and are essential for the formation of blood vessels and wound healing.
the numbers of these vital EPCs are decreased in the circulation and at wound sites in diabetes.impaired eNOS activation in diabetes are responsible for the defect in diabetic wound healing. which stimulated nitric oxide production.The high oxygen levels increased the activation of the bone marrow enzyme eNOS. . -.-. helping to produce greater numbers of EPCs. -.
CONCLUSION: Wound healing is a complex and dynamic process of restoring cellular structures and tissue layers. . Its of importance to a prosthodontist in a way as it determines the time during which the prosthesis can be given to the patient. There are various factors which effect the wound healing and we should know all the factors which effect the period of wound healing.
*Essential pathology for dental students –Harsh mohan.REFERENCES: *Robbin’s & Cotron Pathological basis of diseases -7th edn. *Human embryology . 2nd edn .Inderbir Singh 4th edn *Prosthodontic Treatment for Edentulous Patients – *Bouchers 12th edn *Essentials of complete denture Prosthodontics Winkler.3rd edn. *Textbook of oral & maxillofacial surgery – Balaji.
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