ORAL WOUND HEALING

Submitted by- Brajesh Bhattrai(615)

Chanchal shah(616)
submitted to- Dr. Ashish shrestha
Contents
Definition
Classification
Phases of wound healing
Factors affecting wound healing
Complications of wound healing
Biopsy and healing of biopsy wound
Healing of fracture
Healing of gingivectomy wound
Replantation and transplantation
Osseointegration of implant
Oral Wound Healing
Wound is defined as a cut or break in the continuity of any tissue, caused

by injury or operation.

Healing refers to the replacement of damaged tissue by living tissue to

restore function.

Classification :

Primary

Secondary

Delayed primary/Tertiary
Primary wound healing

Occurs when the edges are clear and held together with
ligature.
Occurs quickly
Rapid ingrowth of wound
healing cells (macrophage ,
fibroblast etc)
restoration of gap by a small
amount of scar tissue.
 Secondary wound healing

Excessive tissue loss

When skin edges are not
close together or when
pus has formed
may be treated with a
drainage or by packing
the wound.
Cavity begins to fill with
granulation tissue.
 Scarring is greater in a larger wound

Examples:
crash injury

infected wounds

burns

Complications:
late wound contracture

hypertrophic scarring.
0
 Factors affecting wound healing
Location of wound
Immobilization
Physical factors:
severe trauma, local temperature, X-ray radiation
Circulatory factors:
Anemia, dehydration
Nutritional factors-
Protein, vitamins
Age of patient
Infection
Hormonal factors
Miscellaneous factors
 Location of wound :
wound with good vascular bed heals more rapidly than avascular.

Immobilization :
Connective tissue formation is disrupted if wound is present in areas
subjected to continuous movement(e.g. corner of mouth).
Bony union is completely inhibited or delayed without immobilization

Severe trauma :
is deterrent to rapid wound healing while mild trauma favors healing

Local temperature :
hyperthermia-accelerated wound healing
hypothermia- delayed
 : Infection:

Severe bacterial infection slows the healing of wounds but

however wounds that are completely protected from
infection heal considerably more slowly than wounds which
are exposed to mild bacterial infection.

Hormonal factors:

Adrenocorticotropic hormone(ACTH) and cortisone delays

healing. Wounds of diabetic patients are slow to heal and
frequently show complications in repair processes.
 Circulatory factor:
Anemia delays
Dehydration- alter adversely

Nutritional factor:
Delayed in person who is deficient in variety of essential
foods like protein deficiency, vitamin deficiency like
vitamin C which regulate the collagen formation and
formation of normal intracellular substance.

Age of the patient:

Rate of wound healing appears to be in inversely
proportional to the age of the patient.
 Biopsy
Biopsy is the removal of tissue from the
living organism for the purposes of
microscopic examination and diagnosis.
Excisional biopsy
Total excision of small lesion for
microscopic study.
is preferred if the size of the lesion can
be removed along with the margin of a
normal tissue and wound can be closed
primarily.
Incisional or diagnostic biopsy
a small piece is removed for
examination.
it is indicated for larger lesion.
 Healing of biopsy wound
Nature of healing process depends upon-

1)whether the edges of wound can be brought into apposition, often by

suturing

2) whether the lesion must fill in with granulation tissue.

Classified as:

primary healing ( healing by 1st intention)

secondary healing ( healing by 2nd intention or granulation)

Primary healing
After excision of piece of tissue with
apposition of edges of wound.

Blood cells and leukocytes mobilized to

excisional area.

Connective cells immediately transforms

into fibroblast

Fibroblast undergo mitotic division and

new fibroblast begin to migrate into and
across line of incision.
Continue
Cells forms delicate collagen fibrils which interwine
and coalesce parallel to surface of wound.

Endothelial cells of capillaries proliferate.

Small capillary bud grows across wound.

Bud grows and form new capillaries which fill with

blood

Young capillary and capillary loops formed.

Secondary healing
Healing of open wound occurs when there is
loss of tissue and the edges of wound cannot
be approximated.

After the removal of lesion , blood fills

the defects,clots and repair process
begin.

More granulation tissue are formed and

fibroblast and capillaries need to travel
the greater distance.
Continued..

Cellular proliferation around periphery of

wound.

After the granulation tissue mature, it

become more fibrous through condensation
of collagen bundles and complete the
epithelization.
Healing of fracture

Fracture is a Break in continuity of a bone.

Fracture of jaws (common)

ranges from minor alveolar fracture to destructive

maxillofacial injury
Immediate effects of
fracture.
Fracture of bone due to any cause

Haversian canal ,vessels of periosteum and marrow cavity are torn

Acute Inflammation of soft tissue results in

Interruption in flow of blood lead to Extravasations of blood

Loss of circulation and Bone cells or Osteocytes of haversian

system die

dead bone extends to the anastomosing circulation

Callus formation
Callus in Latin word means overgrowth of hard skin

It is composed of fibrous tissue, cartilage & Bone

Periosteum is a important structure in callus formation and

healing.

Cells of periosteum adjacent to the site of fracture line dies but at

periphery they show a flurry of cellular activity within an hour
after the injury

Outer fibrous layer of periosteum is inert and lifted away from

surface of bone by proliferation of cells in osteogenic periosteum.
These cells assume the features of Osteoblast & forms a
collar of callus around the surface of fracture

- New bone forming in external callus consists of

irregular trabeculae

- Differentiation of cells into osteoblast and formation

of bone occur in deep layer of callus collar

-various osteogenic layer diffrentite into chondroblast to

form cartilage
Remodelling of callus

External and internal (unites the 2 fragements of

bone)calluses must be remodeled as there is always
an abundance of new bone produced to strengthen
the healing site.

New bone is joined to the fragments of original

dead bone that slowly resorbs due to normal stress
pattern & are replaced by mature type of bone

External callus should be remodeled so that in time

the excess bone is removed
Fracture healing
Complication of fracture
healing
Delayed union & non-union of fragments results when calluses of

osteogenic tissue of 2 fragments fail to meet & fuse or when endosteal

formation of bone is inadequate.

Fibrous union results when there is a lack of immobilization of damaged

bone, the fragments ends unite by fibrous tissue and fail to ossify.

Lack of calcification of the callus of newly formed bone but only when there

is dietary deficiency or mineral imbalance

 Healing of gingivectomy wound
Takes place rapidly regardless of post-operative pack is used.

Early Healing Phase:

2days
Grayish blood clot .
Connective tissue & epithelial cells proliferation .

4 days
Superficial Number of PMNL entrapped in fibrinous meshwork
Proliferation of young capillaries and fibroblast
Extension of epithelium between the clot and connective tissue
Late healing phase:

8-10 days
Condensation of connective tissue

Nearly complete organization of clot

wound appear red, granular and bleeds readily

10-14 days
Complete epithelialization

>14 days
Epithelium matures & forms rete pegs
Gingivectomy
 Healing after replantation
Insertion of a vital/nonvital tooth in alveolar socket

Clot forms between root surface and ruptured PDL

In PDL remnants of alveolar bone side proliferation of fibroblasts

and endothelial cells occur

At the end of 1st week, epithelium is reattached to the tooth

Within 2-4 weeks, complete regeneration of PDL takes place

No. of replanted teeth undergo root resorption or ankylosis

Superficial resorption is repaired by cementum deposition

Healing after replantation
Variation in root resorption
is seen

In some cases root

resorption begins within
few weeks while in others
might take ten years

If tooth is maintained
beyond 2 years-considered
successful
Transplantation and healing

Replacement of teeth damaged beyond repair by caries

Autotransplants/Allotransplants
Mandibular 1st molar replaced by developing 3rd molar
Healing :
Pulp becomes revascularized
Continuous growth of root dentin
Functional, viable, highly cellular PDL develops
Tooth reattaches in bony socket
Gingival attachment and epithelial attachment closely
resemble normal
Normal colour and lustre maintained
Osseointegration of implant
 Osseointegration implants
Direct structural and functional connection between ordered
living bone and surface of load carrying implant
Healing
10-12weeks required
Compact and cancellous bone form around implant together with a
variable amount of fibrous marrow
Implants and mucosal interface serve similar function as
dentogingival junction
CT of mucosa forms intimate contact with implant
Epithelium attaches to implant by means of basal lamina and
hemidesmosomes
Summary
 Summary

Local factors Systemic factors

FACTORS AFFECTING WOUND HEALING
INFECTION NUTRITIONAL FACTORS

LOCATION OF THE WOUND AGE OF THE PATIENT

IMMOBILISATION SYSTEMIC INFECTION

PHYSICAL FACTORS ADMINISTRATION OF

GLUCOCORTICOIDS

UNCONTROLLED DIABETES
Summary
 Reference
Robins and Cotran Pathologic basis of disease

R. Rajendran, B. Sivapathasundharam;Shafers Textbook of Oral

Pathology;7th Edition;Elesvier;2012

Daniel M. Laskin Oral and Maxillofacial surgery