Wound healing/certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Wound healing, methods to
control hemorrhage, suturing
and bone grafts


Contents :
Wound healing
Regeneration & repair
Healing by primary intention & secondary
intention
Healing of extraction socket & its complications
Methods of control of hemorrhage
Mechanical
Thermal
Chemical
Suturing
Needles
Suture materials
Bone graft materials
Classification & types

Introduction


HEALING OF TISSUE
Is the body response to injury to
restore normal structure and function
Involves 2 processes
Regeneration- parenchymal
Repair – CT


REGENERATION:


REPAIR:
Healing by connective tissue
Granulation tissue is formed in 3-5
days

2 steps in repair
1. granulation tissue formation
2. contraction of wounds

Granulation tissue formation
1. phase of inflammation
2. phase of clearance
3. phase of ingrowth
angiogenesis
fibrogenesis
Contraction of wounds

Scar formation
Fibroblast migration & proliferation

ECM deposition & Scar formation

Tissue remodeling (metalloprotenases)

Wound Healing:
Inflammation
Epithelialization
Granulation
Contraction
Remodeling


Healing by Primary
Intention:
Healing of clean, uninfected,
surgical incisions
Focal disruptions of basement
memb. Continuity
Within 24 hrs.
Netrophils…
Inc. mitotic activity of basal cells
Cells meet in midline below scab

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 - keratinisation


During 2nd week:
Continued collagen accumulation &
fibroblast proliferation
Vascularity, edema, leukocyte
infiltration decrease
Collagen inc.

By end of 1st month:
Scar devoid of inflammatory cells
Dermal appendages lost permanently
Tensile strength www.indiandentalacademy.com
inc. …

Healing by Secondary
Intention:
More extensive wounds – infarcts,
inflamm. Ulcers, abcess or large
wounds
Healing from below upwards &
margain inwards
Slow & leads to scar…


Intial 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

Granulation tissue:
Main bulk
Fibroblasts & neovascularisation
Deep red, granular & fragile but – pale

Wound contraction:
Not seen in primary healing
Due to myofibroblasts
1/3 – ¼ the original size

Healing by secondary
intention


Wound Strength
Sutured wounds – 70% of
unwounded skin
1 week- 10%
4 week- inc
3 month- 70-80%
No further increase


Complications…
Infection
Pigmentation
Implantation
Deficient scar
Hypertropied scar & Keloid
Excessive contraction
Neoplasia
Incisional hernia

Conditions for Healing
•
•
•
•
•
•
•

Well being
Nutrition
Vascular supply/drainage
Clean wound
Minimal trauma
Moist environment
Thermal regulation

Healing of
extraction socket


Healing Of Extraction
Socket
Immediate Reaction :

Blood fills the socket & coagulates
Torn blood vessels – sealed off
Vasodilation & engorgement
Leukoytes around the clot
Clot contraction
Unsupported gingival tissue

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
Focal osteomyelitis- disintegration of
clot
95% in lower premolars & molars
Within 1st few days…
Extremely painful
Palliative medicine & allow healing
Tetracycline hydrochloride…
Pack socket with obtundant

Fibrous healing
Uncommon …
Loss of labial & lingual plates
Asymptomatic
Dense fibrous mass on exploration
Excision causes bony repair


Methods to control
Hemorrhage
Control dependent on :
Vessel contraction
Retraction
Clot formation

Techniques :
Mechanical
Thermal
Chemical

Mechanical methods
Pressure :

Counter hydrostatic
pressure
5 min…
Most common

Use of Hemostats:

Mosquito or straight
Larger vessels - ligation

Sutures & ligation
Large artery – 3-0 non-absorbable
Small artery – catgut & polygalactin
Large pulsatile artery – double
transfixation

Embolisation of vessels
Angiography – bleeding point
Steel coil, polyvinyl alcohol foam, gel
foam, silicon spheres & methyl
methacrylate
Contrast media – catheter…
Lesion mapped, & embolisation done

Thermal Agents
Cautery

Heat transmitted from instrument
Denaturation of proteins

Electrosurgery
Induction
Large vessels

Cryosurgery
-20c - -180c
Cryogenic necrosis –dehydration & denaturation
of lipid mol.
Superficial hemangiomas

Argon beam coagulator
Monoplanar current – flow of argon
Vessels < 3mm
Tip kept 1-2 mm away
No gas embolism

Lasers

Chemical Methods
Local agents:

Astringent & styptics :

Monsel sol.- ferric subsulphate –
capillary & post-extraction bleeding
Tannic acid – ppt. proteins
Tea bag
Mann hemostatic- tannic acid + alum &
chlorambutol
Silver nitrate & FeCl3

Bone wax

Mechanical occlusion
Foreign body granuloma & infection

Thrombin
Fibrinogen to fibrin
Pack, gelatin sponge or surgicel

Gelfoam
No hemostatic action…
Pressure & scaffold for fibrin retention

Oxycel
Oxidized cellulose – affinity for Hb –
artificial clot
To be applied dry

Surgicel
Glucose polymer based knitted fabric
Hb – oxycellulose binding…
Does not inhibit epithelisation

Fibrin glue
Thrombin + fibrinogen + factor 13 + apoprotinin
Unstable clot
Stabilizes clot
Prevents degradation

Adrenaline
Vasoconstriction
Hypertensive & Cardiac pt.

Suturing
Needles
Stainless steel
material

Carbon steel
tapered
straight

shape
curved

cutting
tapered
cutting

Straight needle :

Skin closure – adequate access
Circumzygomatic & circummandibular wires

Curved needle

Skin & mucus memb.
¼, 3/8, ½ & 5/8 circle…
Cutting edge :
Conventional
Reverse cutting

Suture attachments :
Swaged
Eyed needle

Suture materials
Ideal property of suture material.:
Strength
Good handling & knot tying
Sterlizable
Evoke little tissue reaction

No 3 largest & 7-0 smallest
5-0 , 6-0 – skin closure
3-0 , 4-0 - intraoral

Suture Size
Sized according to diameter with “0” as reference
size
Numbers alone indicate progressively larger sutures
(“1”, “2”, etc)
Numbers followed by a “0” indicate progressively
smaller sutures (“2-0”, “4-0”, etc)

Smaller ------------------------------------Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

Absorbable Sutures
Gut :

Oldest…
Sheep intestinal mucosa & bovine intestinal
Serosa
Monofilamentous but microscopically…
Smallest tensile strength – Herrmann(1971)
Enzymatic degradation…
3-5 days…
Disadvantage:
Stiff
Insecure knot tying when wet

Chromic gut :
Tanned with Cr
Cr salts :
Cross linking agent
Increase tensile strength
Resistance to absorption

Degraded in 7 days

Collagen
Deep flexor tendon of cattle
Not used

Polyglyolic acid & polygalactin 910
Resorbed by hydrolysis
Synthetic polymers – little tissue
reaction
Polygalactin 910 – copolymer of
glycolide & lactide
Strongest absorbable suture mat.
Last in excess of 14 days (Wallace,
Maxwell & Calavaris) – so cut at 5 days
Difficult in tying… wet with saline

Non-Absorbable Sutures
Silk

Most common
Slow proteolysis
Moderate response
Low tensile strength
3 ties per knot

Nylon
Braided or monofilamentous
Minimal tissue reaction – antibacterial
‘Memory’ …
Knots slip & untie
‘one knot for every day ‘
Good tensile strength
Not used intraorally :
Large knot needed
Tendency to tear non-keratinized mucosa
Stiffness

Cotton & linen
Noncontinous natural fibres of cotton
Linen stronger than cotton

Dacron polyester, polypropylene,
polyethylene, silicone coated dacron
polyester:
Greatest tensile strength & knot holding
ability
Minimal tissue reaction
High coefficient of friction…

Metal :
Stainless steel & tantalum
Braided or monofilamentous
Strongest & most secure knot
Stiff materials…
Suspension of splints & arch bars

Steri-strips
Sterile adhesive
tapes
Available in
different widths
Frequently used with
subcuticular sutures
Used following
staple or suture
removal
Can be used for
delayed closure

Staples
Rapid closure of
wound
Easy to apply
Evert tissue when
placed properly

Principles of Suturing:
Grasp needle at ¾ from point

Needle to enter perpendicular
To follow curvature
Equal distance & depth from
incision line
From free to fixed side
From deeper to superficial side

Distance in tissues greater than
distance from tissue edge
No closure under tension thus
approximated not blanched
Knot not over incision line
3-4 mm apart
Prevent dog-ear formation

Suturing techniques:
Simple Sutures
Simple interrupted
stitch

Single stitches,
individually knotted
(keep all knots on one
side of wound)
Used for
uncomplicated
laceration repair and
wound closure

Mattress Sutures
Horizontal mattress
stitch

Provides added strength
in fascial closure; also
used in calloused skin
(e.g. palms and soles)
Two-step stitch:
Simple stitch made
Needle reversed and 2nd
simple stitch made
adjacent to first (same
size bite as first stitch)

Mattress Sutures
Vertical mattress
stitch

Affords precise
approximation of skin
edges with eversion
Two-step stitch:

Simple stitch made –
“far, far” relative to
wound edge (large bite)
Needle reversed and
2nd simple stitch made
inside first – “near,
near” (small bite)

Subcuticular Sutures
Usually a running
stitch, but can be
interrupted
Intradermal
horizontal bites
Allow suture to
remain for a longer
period of time
without development
of crosshatch
scarring

Bone Graft Materials :
Definition :
‘A graft is a viable tissue that
after removal from a donor site is
implanted within the host tissue
which is then restored, repaired
or regenerated.’
GRAFT
SOFT TISSUE GRAFT

BONE GRAFT

COMPOSITE GRAFT

Bone graft materials support bone
growth by :
Osteogenesis :
– Direct formation through osteoblasts

Osteoinduction :
– Transformation of mesenchymal cells to
osteoblasts

Osteoconduction :
– Stimulation of attachment, migration &
distribution of vascular & osteogenic cells


Osteoconduction depends on :
Porosity
Pore-size
3-D architecture

Osteoinduction involves :
Pluripotent & BMP

Kazanjian’s rules : (1952)
Adequate blood supply of recipient site
Bone to bone contact – ‘ creeping
substitution’
Rigid fixation
Bone graft to be placed in healthy tissue


BONE GRAFTS are used —
Management of non union & delayed
union
Filling of osseous defects
Replacement of bone & joint loss
Augmentation of skeletal deficiency
Fusion of growth plate cartilages


Ideal requirements of bone grafts:
Biologically acceptable
Predictability
Clinical feasibility
Minimal operative hazards
Minimal post-operative sequelae
Patient acceptance

Classification of bone grafts
BASED ON --1.ORIGIN
- autograft
- allograft
- xenograft
- bone substitute material

2. STRUCTURE
- cortical graft
- cancellous graft
- corticocancellous

3. BLOOD SUPPLY
- non-vascularized graft
- vascularized graft

Autografts :
defined as tissue transplanted from one
site to another within the same individual.
considered as gold standard
ADVANTAGES:

No immunologic sequelae
Rapid technique
Disadvantages :
insufficient amount
cortical bone is obtained

Osseous coagulum : (Robinson)
Bone dust + blood mixture
Uses particles from cortical bone

Bone blend:
Bone dust + Saline
Bone used is cortical & cancellous

Areas for obtaining bone grafts
Head & neck
Cranium
Mandible
Thorax
Ribs
Scapula
Forearm
Lower limb
Hip (Iliac crest)
Tibia
Fibula
2nd metatarsal


Allografts : Defined as a tissue graft between
individuals of same species (i.e.,humans) but
of non-identical genetic composition
Cadavers are common source
Allograft

Fresh frozen

Freeze dried bone


Decalcified freeze
dried bone

FRESH FROZEN
- Harvested under sterile condition
- kept frozen at -80—does not undergo enzymatic
destruction
FREEZE DRIED (lyphophylized) bone (FDB)
- Mainly used as a composite
- bending strength is lowered to 55-90%
- retain its antigenicity
DECALCIFIED FREEZE DRIED BONE (DFDB)
- retains its osteoinductiveness
Treated with radiations, freezing & chemicals

Advantages :
Sufficient quantity can be obtained
Bone banks
Can be stored at room temperature

Disadvantages :
Difficulty in finding donor
Risk of disease transmission
Immunological reaction
Sophisticated lab procedures

XENOGRAFT-- defined as a tissue
graft between two different species
Examples :
- Kiel bone
- Frozen calf bone
- Freeze dried calf bone
- Decalcified Ox bone
- Ospurum
- Anorganic bone
- Boplant

Alloplasts / non- bone graft materials:
Examples :
- POP
- cartilage
- sclera of eye
- collagen material
Ceramic or synthetic bone grafts:
Resorbable
– Tricalium phosphate, resorbable hydroxyapatite

Non-resorbable
– Dense HA. Porous HA, Bioglass

Advantage :
No processing
Biocompatible
Ease of manipulation

Disadvantage :
Cost


…..Conclusion


1.
2.
3.
4.
5.
6.
7.

REFERENCES

Robbin’s & Cotron Pathological basis of
diseases -7th edn.
Essential pathology for dental students –Harsh
mohan,3rd edn.
Text book of oral pathology – Shafer 4th edn.
Contemporary oral & maxillofacial surgery –
and maxillofacial surgery –
Peterson.
Textbook of oral and maxillofacial surgery –
Neelima Malik
Textbook of oral and maxillofacial surgery –
Laskin vol 1
Short practice of surgery – Bailey and Love 23rd
edi.

Thank you


Wound healing/certified fixed orthodontic courses by Indian dental academy

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Wound healing/certified fixed orthodontic courses by Indian dental academy