wound healing and healing of dental traumas.pptx

about healing classifications, stages,healing in different dental traumas and post treatment

1. WOUND HEALING PRESENTED BY DR LAKSHMI J 1 ST MDS DEPT OF PUBLIC HEALTH DENTISTRY

2. Wound definition Classification of wounds Healing Types of wound healing Stages of wound healing Phases of wound healing Hard tissue healing Factors affecting wound healing Complication CONTENTS: Systemic medication affecting wound healing Healing of root canal therapy Healing of reimplantation Osseointegration of implant Healing of gingivectomy wounds Healing of extraction socket Healing in patients on chemotherapy/radiotherapy Perforation and prognosis of healing Conclusion References

3. It is a circumscribed injury which is caused by external force and it can involve any tissue and organ. WOUND

4. A wound is a break in the integrity of the skin or tissues often which may be associated with disruption of the structure and function. (SRB 4 th edition) A cut or break in the continuity of any tissue, caused by injury or operation. ( Baillière’s 23 rd Ed)

5. Rank and Wakefield classification Tidy wounds Untidy wounds CLASSIFICATION OF WOUNDS

6. Classification based on type of wound Clean incised wound Lacerated wound Bruising and contusion Haematoma Puncture wound Abrasion Crush injury Injuries to bone and joint (maybe open or closed) Injuries to nerve (either clean cut or crush) Injuries to arteries and veins Penetrating wounds

7. Classification based on thickness of wound Superficial wound Partial thickness Full thickness Deep wounds Complicated wounds Penetrating wound Superficial Partial thickness Full thickness Deep wound

8. Classification of surgical wounds Clean wound Clean contaminated wound Contaminated wound Dirty infected wound

9. Healing is the body’s response to injury in an attempt to restore normal structure and function. The process of healing involves 2 distinct processes: A. REGENERATION B. REPAIR  HEALING

10. REGENERATION REPAIR Healing takes place by proliferation of   parenchymal cells and usually results in complete restoration of the original tissues. The goal of all surgical procedures should be regeneration which returns the tissues to their normal microstructure and function. It is a healing outcome in which tissues do not return to their normal architecture and function. Repair typically results in the formation of scar tissue.

11. TYPES OF WOUND HEALING Healing by first intention (wounds with opposed edges) Healing by secondary intention (wounds with separated edges)

12. Healing of wound with following characteristics: Clean and uninfected Surgically incised Without much loss of cells and tissue Edges of wound are approximated by surgical sutures. Wounds with opposed edges Primary union Healing by first intention (wounds with opposed edges)

13. The incision causes death of a limited number of epithelial cells and connective tissue cells disruption of epithelial basal membrane continuity The narrow incisional space immediately fills with clotted blood containing fibrin and blood cells; dehydration of the surface clot forms the well known scab that covers the wound.

14. Within 24 hours Neutrophils appear at margins of incision, moving toward fibrin clot Epidermis at its cut edges thickens as a result of mitotic activity of basal cells Within 24 to 48 hours, spurs of epithelial cells from the both edges migrate and grow along the cut margins of the dermis, depositing BM components as they move. They fuse in the midline beneath the surface scab, thus producing a continuous but thin epithelial layer.

15. By day 3, Neutrophils replaced by macrophages Granulation tissue progressively invades incision space Collagen fibers are now present in the margins of the incision, but at first these are vertically oriented. Epithelial cell proliferation continues, thickening epidermal covering layer

16. By day 5 , I ncisional space is filled with granulation tissue Neovascularisation is maximal Collagen fibrils become more abundant and begin to bridge incision The epidermis recovers its normal thickness, and differentiation of surface cells yields a mature epidermal architecture with surface keratinization

17. During the second week Continued accumulation of collagen and proliferation of fibroblasts Leukocytic infiltrate, edema, and increased vascularity have largely disappeared.

18. Scar comprises a cellular connective tissue devoid of inflammatory infiltrate, covered now by intact epidermis. Dermal appendages that have been destroyed in the line of the incision are permanently lost. Tensile strength of the wound increases thereafter, but it may take months for the wounded area to obtain its maximal strength. By the end of the first month ,

19. Wounds with separated edges Secondary union When there is more extensive loss of cells and tissue Regeneration of parenchymal cells cannot completely reconstitute the original architecture. Abundant granulation tissue grows in from the margin to complete the repair. Healing by second intention

20. Secondary healing differs from primary healing in several respects: Inflammatory reaction is more intense Much larger amounts of granulation tissue are formed Wound contraction occurs in large surface wounds Substantial scar formation and thinning of the epidermis occurs

21. Difference between 1˚ & 2˚ union of wound FEATURES PRIMARY SECONDARY CLEANLINESS CLEAN NOT CLEAN INFECTION NOT INFECTED INFECTED MARGINS SURGICALLY CLEAN IRREGULAR SUTURES USED NOT USED HEALING SMALL GRANULATION TISSUE LARGE GRANULATION TISSUE OUT COME LINEAR SCAR IRREGULAR WOUND COMPLICATION NOT FREQUENT FREQUENT

22. Stage of inflammation. Stage of granulation tissue formation and organisation. Stage of epithelialisation. Stage of scar formation and resorption. Stage of maturation. STAGES OF WOUND HEALING

23. For soft tissue wound healing: Inflammatory phase : It can be broken down into further Clot formation Early inflammation Late inflammation 2.Proliferative phase 3.Maturation phase PHASES OF WOUND HEALING

24. The inflammatory and proliferative phases are similar to those for soft tissue. The maturation phase differs markedly from that for soft tissues because of the tissue involved. HARD TISSUE HEALING

25. Local factors : Infection Presence of necrotic tissue and foreign body Poor blood supply Venous or lymph stasis Tissue tension Hematoma Large defect or poor apposition FACTORS AFFECTING WOUND HEALING:

26. viii. Recurrent trauma ix. X-ray irradiated area x. Site of wound, eg.wound over the joints and back has poor healing xi. Underlying diseases like osteomyelitis and malignancy

27. 2) General factors: Age, obesity,smoking Malnutrition, zinc, copper Vitamin deficiency ( vit C, vit A) Anemia Malignancy Jaundice Diabetes HIV and immunosupressive diseases Steroids and cytotoxic drugs

28. Deficient scar formation: a) Wound dehiscence b) Ulceration Excessive formation of the repair components: a) Aberrations of growth: -hypertrophic scar - keloid b) Excessive amount of granulation tissue formation COMPLICATION:

29. c) Exuberant proliferation of fibroblasts and other connective tissue elements: Desmoids or Aggressive fibromatoses 3. Formation of contractures

30. Bisphosphonates Glucocorticoids NSAIDS Cyclooxygenase -2 inhibitors SYSTEMIC MEDICATION AFFECTING WOUND HEALING:

31. Follows the general principle of wound healing largely accomplished by regeneration and to some degree by fibrosis. The process of periapical wound healing after nonsurgical root canal therapy may be similar to wound healing following guided tissue regeneration in periodontal therapy Periapical Wound Healing After Nonsurgical Root Canal Therapy

32. Root resorption that involves cementum or both cementum and dentin can only be repaired by cementoid tissue, because multipotent stem cells of the periodontal ligament are incapable of differentiating into odontoblasts that produce dentin.

33. Following replantation the clot forms between the root surface and ruptured periodontal ligament. Proliferation of the fibroblasts and the endothelial cells occurs in  the periodontal ligament remnants on the side of  the alveolar bone. The reconnection of the periodontal ligament is evident by the extension of collagen fibers from the cementum to the alveolar  bone . Healing after replantation

34. The epithelium is reattached to the tooth at the end of the first week. Complete regeneration of the periodontal  ligament takes place between two to four weeks. In the course of time, a number of teeth results in resorption or  ankylosis .

35. Osseointegration  is a direct structural and  functional connection between ordered living bone and the surface of the load carrying implant. During healing, compact and cancellous bone forms around the implant together with variable amount of fibrous marrow. Implants do not have a direct contact with the bone and a certain amount of bone marrow and soft tissue are interposed between the bone and the implant. Osseointegration of implants

36. The connective tissue of the mucosa  forms  the intimate contact with the implant . The collagen fibers of the connective  tissue runs parallel to the long axis of the implant , and the epithelium is attached to the implant by means of basal lamina and hemidesmosomes .

37. Early healing phase Late healing phase After 2 nd day-surface- greyish blood clot,below delicate CT 4 th day-organization and epithelialization 8-10 days –nearly complete organisation 10-14 days-nearly compkete epithelialization 2 weeks – mature epithelium formed Gingivectomy wounds

38. Immediate reaction – Bleeeding and clot formation in the socket – rbc entrapped in the fine fibrin meshwork First 24-48hrs – vasodilation and engorgement of BV , mobilisation of leukocytes first week wound Proliferation of the fibroblast from connective tissue cells in the remanants of PDL into the clot around the entire periphery Extraction sockets

39. Clot is gradually replaced by granulation tissue Epithelium shows evidence of proliferation at the periphery Crest of alveolar bone shows beginning of osteoclastic activity Endothelial cell proliferation in PDL

40. These patients have impaired healing responses. Pulp may become necrotic during radiation therapy. Symptomatic nonvital teeth should be endodontically treated 1 week before initiating radiation or chemotherapy whereas asymptomatic nonvital teeth may be delayed. HEALING IN PATIENTS ON CHEMOTHERAPY/ RADIATION THERAPY

41. Any perforation located near the gingival sulcus promoted inflammation and loss of epithelial attachment, resulting in periodontal pocket formation. Apical and midroot perforations without communication to the oral cavity has a good prognosis provided an immediate seal was obtained . PERFORATION AND PROGNOSIS FOR HEALING

42. Small perforations of the canal space promote a direct and immediate restoration of the defect. It offers fewer chances for periodontal breakdown and epithelial proliferation within the perforation site.

43. Understanding of wound healing is as important as knowing the pathogenesis of disease, because satisfactory wound healing is the ultimate goal of treatment. If we are able to understand the mechanism of periapical wound healing, we can design treatment approaches that maximize favorable conditions for wound healing to occur. Conclusion:

44. Robbins and Cotran , Pathologic Basis Of Disease, 7 th edition SRB’S Manual Of Surgery, Sri Ram Bhatt, 4 th Edition Cohen’s Pathways Of the Pulp,9 th edition Ingle’s Endodontics,6 th edition Textbook of Endodontology , Gunnar Bergenholtz , Preben Horsted - Bindslev , Claes Rait , 2 nd Edition Essentials of Endodontics , Vimal K Sikri Textbook of Endodontics , Nisha Garg , 2 nd Edition References: