Healing of oral wounds

HEALING HEALING OF ORAL OF ORAL WOUNDSWOUNDS

HEALING HEALING OF ORAL OF ORAL WOUNDSWOUNDS

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HEALING OF ORAL WOUNDS

1. General factors affecting the healing of oral wounds

2. Biopsy and healing of the biopsy wound3. Healing of the gingivectomy wound4. Healing of the extraction wound5. Complications in the healing of extraction

wounds6. Healing of fracture7. Re-plantation and transplantation of the

teeth

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HEALING OF ORAL HEALING OF ORAL WOUNDSWOUNDS


General factors affecting the General factors affecting the healing of oral woundshealing of oral wounds

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Healing of oral wounds General factors

1. Location of wound-• area with good vascular bed

heal more rapidly• Immobilisation also helps in rapid

healing – corner of mouth

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2. Physical factors• Severe trauma to tissue slows healing• Local temperature increases rate of healing

through effect oj circulation and cell multiplication.

Hyperthermia- healing accerlerated Hypothermia- healing delays• X-ray radiation-low doses-stimulates high focal doses-supresses

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3. Circulatory factors-• Anemia- delay healing• Dehydration- delay healing4. Nutritional factors-• Hypoproteinemia - delays healing Slows new fibroblasts proliferation and multiplication in

the wounds• Scurvy- delays healingInterruption in regulation of collagen formation of normal

intercellular ground substance of the connective tissue and Interruptionin formation of mucopolysaccharides (cementing substance)

Vit. A and D- retards healing

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5. Age of the Patient-• Younger patient- rapid healing• Older patient- delay healing6. Infection-• Bacterial irritation- slows healing• Germ- free state- also slows healing

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7. Harmonal factors- • ACTH and Cortisone- slows healingGrowth of granulation tissue was

inhibited by depression of inflamatory reaction- inhibition ofprol;iferation of new fibroblast, endothelial sprouts

• Diabetes mallitus- slows healing

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BIOPSY AND HEALING OF BIOPSY AND HEALING OF THE BIOPSY WOUNDTHE BIOPSY WOUND

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Healing of oral wounds BIOPSY

BIOPSY –Biopsy is the removal of tissue from

the living organism for the purposes of microscopic examination and diagnosis

TYPES OF BIOPSY-Excisional Biopsy – total excision

of a small lesion for microscopic study

Incisional Biopsy- a small section of a large lesion removed for microscopic study

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Methods of Biopsy –1. Surgical excision by scalpel2. Surgical removal by cautery or

a high frequency cutting knife3. Removal by biopsy forceps or

biopsy punch4. Aspiration through a needle

with a large lumen5. Exfoliative cytology

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Exfoliative cytology-• Surface of the lesion is wiped with sponge

material which is then sectioned, or scraped and smeared on a microscopic slide and studied by the pathologist for presence of atypical or diagnostic cells

• the cytologist may classify the smear into following classes

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• Class I – normal – normal cells are present• Class II – Atypical – minor stypia but no evidence

of malignant changes• Class III – interdeterminate- wider atypia that

suggest cancer, but is not clear cut and represent precancerous lesions- ca in situ, biopsy is recommended

• Class IV - suggestive of cancer- few cells with malignant characteristics or with many cells with borderline characteristics. biopsy is mandatory

• Class V - positive of cancer,cells are obviously malignant, biopsy is mandatory

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Healing of Biopsy wound-• Primary healing – healing which occurs

after excision of a small piece of a tissue with close apposition of the edges of the wound

• Wound heals rapidly• Occurs in clean and infected, surgical

incised, without much loss of cells and tissue and in which edges of wound are approximated by surgical sutures.

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Healing of oral wounds

Events in primary healing• Initial haemorrhage – immediately bleeding which then

clots• Acute inflammatory response – within 24 hrs

appearance of polymorphs, which then is replace by macrophages by the 3rd day

• Epithelial changes – basal layer proliferate and covers the wounds in 48 hrs

• Organisation – by 3rd day fibroblast invades, by 5th day new cllagen fibrills starts forming, 4th week scar tissue forms and full epithelisation occurs

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• Secondary healing – healing by granulation or healing of an open wound occurs when there is loss of tissue and the edges of the wound cannot be approximated

• Wound heals slowly, and forms scar• Occurs in open wounds with large tissue

defect, having extensive loss of cells and tissues and wounds which are not approximated by surgical sutures that are open.

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Events in secondary healing• Initial haemorrhage• Acute inflammatory response• Epithelial changes• Granulation tissue formation• Wound contracture

Epithelial changes

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Healing of oral Healing of oral woundswounds


Healing of Gingivectomy woundHealing of Gingivectomy wound

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Healing of oral wounds Gingivectomy

woundEarly healing phase –• After 2nd day- surface covered by

greyish blood clot, below there is delicate connective tissue proliferation and changes preparatory to epithelization

• 4th day – organization and epithelization

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Healing of oral wounds Gingivectomy

woundLate healing phase – • 8 to 10 days- nearly complete organization• 10 to 14 days- nearly complete

epithelization• 2 weeks- mature epithelium formed• Healing of interproximal tissue lags behind

that adjacent to the labial or buccal surfaces as the interproximal tissue must grow in from the labial and lingual areas

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Healing of the extraction Healing of the extraction woundswounds

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Healing of oral wounds extraction

woundsImmediate Reaction following

Extraction-• Bleeding and clot formation in the socketRBCs entrapped in the fine fibrin meshwork

ends of torn BV becomes sealed off• First 24-48 hrs- vasodialatation and

engorgement of BV, mobilisation of leukocytes

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Healing of oral wounds extraction wounds

First week wound• Proliferation of fibroblasts from

connective tissue cells in the remnants of PDL into the clot around the entire periphery (clot acts as scaffold)

• Clot is gradually replace by granulation tissue

• Epithelium shows evidence of proliferation at the periphery

• Crest of alveolar bone shows beginning of osteoclastic activity

• Endothelial cell proliferationin PDL23RVG

Healing of oral wounds extraction wounds

Second week wound-• New delicate capillaries penetrated to

the center of the clot• The wall of socket appears frayed due

to degeneration of PDL• Trabeculae of osteoid can be seen• Considerable epithelial

proliferationover the surface of wound or completed if small socket is present

• Margin of alveolar socket shows prominent osteoclastic resorption

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woundsThird week wound- • Clot is replaced almost completely by

organised mature granulation tissue• Young trabecuale of osteoid tissue is

forming around the entire periphery• Crest of alveolar bone rounded off by

osteoclasts• surface of wound becomes completely

epithelized.

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woundsFourth week wound- • Wound is in final stage of healing ,there

is continuous deposition and remodelling resorption of the bone filling the alveolar socket roentgenographic evidence of bone becomes prominent after 6th to 8th week

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woundsComplications of Extraction Wound Healing-1. Dry socket- • Most common complication• It is focal osteomylitis in which the blood clot

disintegrate or lost , with production of a foul odor and severe pain but no suppuration

• Etiology – difficult or traumatic extractions , in which there is dislodgement of clot and subsequent infection of exposed bone

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wounds• C/f – commonly occurs in lower PM and molar

sockets - extemely painful -the expose bone is necrotic there

may be sequestration of fragments -foul odor• T/T – irrigation of wound by isotonic saline - packing the socket with obtundent

material like ZnOE paste on iodoform gauze

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wounds2. Fibrous healing of extraction wound• Uncommon complication• Followed by difficult,complicated extraction• Loss of both the lingua; and labial or buccal plates of

bones with loss of periosteum• C/F – asymptomatic• R/F – well circumscribed radiolucent area in the site

of a previous extraction wound• H/F – dense bundles of collagen fibers with only

occasional fibrocytes and few blood vessels• T/T – excixion of the lesion

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Healing of fractureHealing of fracture

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Healing of oral wounds fracture

Immediate effects of fracture-• Haversian vessels of the bone, along

with vessels of periosteum and marrow cavity are torn at fracture site

• Loss of local blood supply• Osteocytes die due to Loss of local

blood supply• There is death of bone, and bone

marrow adjacent to the fracture line

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1. Procallus formation- • Hematoma formation• Inflamatory changes• Granulation tissue formation• Callus formation- callus is the structure which unites the

fractured ends of bone , and it is composed of fibrous tissue, cartilage and bone

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• External callus- new tissue which forms aroun the outside of the two fragments of bone

• Internal callus- new tissue arising from marrow cavity

Periosteum is an important structure in callus formation, hence its preservation is essential

Inner layer of periosteum shows osteogenic activityand forms a collar of callus around or over the surface of the fracture

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2. Osseous callus formation3. Remodelling As there is over abundance of new

boneto strenthen the healing siteNew bone frequently joined with

fragment of dead bone which should be resorbed and replaced by mature bone

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Complications of fracture healing-1. Nonunion- Callus fails to meet and

fuse or when endosteal formation of bone is inadequate

Common in elderly ,where there is lack of osteogenic potential of cells

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2. Fibrous union- (pseudoarthrosis)• due to lack of immobilization• Fractured fragments joint by fibrous

tissue• There is failure of ossification 3. Lack of calcification-

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Replantation of teethReplantation of teeth

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Replantation of teeth• Insertion of a vital or nonvital tooth into

the same alveolar socket from which it was removed or otherwise lost

• Great use after traumatic injuries resulting in avulsion or other accidental loss of teeth, or to replace the tooth involved in dentigerous cyst after removal of cyst

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• Incompletely formed roots and open apex - Replantation without RCT is done

The pulp tissue undergoes necrosis or shows revascularization and re-innervation, with vital pulp response

• Mature teeth with complete root formation- Replantation with RCT

If RCT is not done then there will be either pulp necrosis or gradual obliteration of pulp chamber or root canal by bone like material

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• Presevation of PDL is an important factor

• Partially formed teeth have the ability to complete root formation and establish a normal PDL space

• There will bevarying degreeof resorption of cementumand dentin followed bysubsequent replacement by bone resulting in ankylosis

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Factors influencing the success of Replantation-

• Extraoral period of the tooth to be Replanted should not exeed more than 60 minutes , otherwise the success rate reduces

• The tooth should be kept in moist environment• No strippling or tearing of PDLfibers or of

cementum• Splinting appliances includes StSt wires ,acrylic

splints, orthodontic wires with ligatures and even surgical cements with guaze

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Fate of replantation-Root resorption that may be slow or

gradual.

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Transplantation of TeethTransplantation of Teeth

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Transplantation of Teeth• Replacement of tooth damaged

beyond repir by caries by another tooth

• Common tooth to be replaced- mandibular 1st molar by developing mandibular 3rd molar

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Criteria of satisfactory Transplantation-• Has become organicallyintegrated with its new

environment• Is free of discernible periapical or lateral lesions,• Is capable of effective masticatory function• Shares adequetly in the maintainence of

physiologic maxillomandibular and muscular relations

• Display clinically and reongenographically compatible status of gingiva, PDL and bone (lamina dura and supporting bone) root length and over-all stability with indefinite maintainence

• Esthetically acceptable

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• No generalized pulpal necrosis occur after Transplantation

• Pulp becomes revascularised and there is comtinued growth of root dentin

• Pdl ligament is functional viable ,highly cellular reattaching the tooth in bony socket with gingival attachment and epithelial attachment resembling the normal tooth

• There is normal color and lusture of tooth

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Tooth banks are set preserving the tooth by various techniques-

1. Regular freezing2. Freeze-drying or lyophilization3. Vitrification4. Chemical coagulation by

Merthiolate

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Date post:	07-Aug-2015
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Healing of oral wounds

Health & Medicine