Wound healing basic and after periodontal surgery

1. PRESENTED BY:
Heli Patel( PG III )
GUIDED BY:
DR. Bhavin Patel
HEALING AFTER
PERIODONTAL SURGERY

2. INTRODUCTION
Awound/Injury is
Healing is a cell
a disruption of
the anatomic WOUND response to injury in
structure and HEALIN an attempt to restore
function in any G the normal structure
body part. and function.
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4. PROCESS OF HEALING
 It involves 2 distinct processes :
 At times, both the processes take place simultaneously
REGENER-
ATION
REPAIR

5. REGENERATION:
• Regeneration is defined as the reproduction or reconstruction
of lost or injured part in such a way that the architecture and
function of the lost or injured tissue are completely restored.
• Periodontal tissues are limited in their regenerative capacity.

6. Regeneration related to periodontal
tissues
of the gingiva and
Manifested by:
 Mitotic activity in the epithelium
connective tissue of PDL
 Bone remodelling
 Continuous deposition of cementum
chronic
Most gingival and periodontal diseases are
inflammatory process and, as such are, healing lesions.

7. REPAIR:
• It is the biological process by which continuity of disrupted
tissue is restored by new tissues which do not replicate the
structure and function of lost tissue.
 Two processes are involved in the repair:
1. Granulation tissue formation
2. Contraction of wounds

8. Essential molecules for
regeneration

9. GROWTH FACTORS IN PERIODONTAL WOUND
HEALING

12. FACTORS INFLUENCING
HEALING:
LOCAL FACTORS:
• Infection
• Foreign Body
• Venous Insufficiency
• Exposure To UV Light Facilitates Healing
• Exposure To Ionizing Radiation

13. SYSTEMIC FACTORS
• Age and gender
• Sex hormones
• Stress
• Diseases: diabetes, keloids,
fibrosis.hereditary healing
disorders.Jaundice.
• Obesity
• Alcoholism
• Smoking
• Medications: glucocorticoid
steroids, NSAIDS,
chemotherapeutic drugs.
• Immunocompromised
conditions: cancer, radiation
therapy, AIDS
• Nutrition

14. HEALING OF ORAL WOUNDS
Oral wounds heal faster and with less scarring than extra oral
wounds
It is mainly due to:
Ref : Cell Biology Of Gingival Wound Healing, Periodontology 2000, Vol. 24, 2000,127–152
FACTOR MECHANISM
Saliva Moisture, ionic strength, ions – Mg & Ca
Growth factors(EGF,VEGF, TGFΒ,FGF,IGF)
Bacteria Stimulation of macrophage influx,
Direct stimulative action on keratinocyte and fibroblast
Phenotype of
cells
Fetal like fibroblasts with unique response,
Specialized epithelium & Connective tissue

15. HEALING AFTER
PERIODONTAL PROCEDURES

16. 1) HEALING FOLLOWING SCALING :
Carranza FA, Takei HH. Gingival curettage.

17. 2) HEALING FOLLOWING ROOT PLANING:
In 2 hours: Numerous PMN leucocytes seen between crevicular
surface and residual epithelial cells.
After 24 hrs: infiltration of inflammatory cells and keratinocytes
migration seen.
In 2 days: epithelialization of entire pocket is seen.
In 4 - 5 days at bottom of sulcus a new epithelial attachment
appears.
In 1 - 2 weeks depending on the depth of gingival crevice and
severity of inflammation, complete epithelial healing is seen.
Within 3 weeks CT repair by immature collagen fibers occur.

18. 3) HEALING FOLLOWING CURETTAGE:

19. • Formation of clot
2 nd DAY
• Replacement of clot by GT (Granulation
Tissue)
• A part of epithelial surface extends without
rete pegs
4 th DAY
6 th DAY Stratified squamous epithelium covers the wound
16 th DAY
21 st DAY
Novaes AB, Kon S, Ruben MP, et al. Visualization of the microvascularization of the
healing periodontal wound. 3. Gengivectomy. J Periodontol 1969;40(6):359-71
Epithelium with rete pegs and dense collagenous CT
occurs
Well developed epithelial rete pegs and stratum
corneum is thickened
4) HEALING FOLLOWING GINGIVECTOMY:

20. 5) ELECTROSURGICAL
GINGIVECTOMY:
• Malone et al. (1969) and Eisenmann .D et al. (1970) reported
no significant differences in gingival healing by electro surgery
and resection with periodontal knives.

21. • Pope (1968) - Delayed epithelialisation (by 4 days)
- Lack of bleeding and clot formation
• Glickman & Imber(1970) - Delayed healing
- Bone necrosis
• Schneider & Zaki (1974) - No bleeding
- Transiently hyalinised C.T
• Wilhelmsen et al(1976) - Permanent periodontal damage -
burning of cementum, loss of connective tissue attachment,
and significant recession of gingival margin. Avoid
contacting cementum or bone.

22. 6) HEALING FOLLOWING
MELANIN DEPIGMENTATION:
The initial response -
formation of
protective surface
clot
The underlying tissues
become acutely
inflamed, with some
necrosis.
Clot is then replaced
by Granulation
Tissue (GT)
Capillaries derived
from blood vessels
of the PDL migrate
into the GT
Within 2 weeks,
capillaries connect
with gingival
vessels.
Vascularity increases
initially, then begins to
decrease gradually as
healing takes place .
Vascularity returns to
normal in about 2-3
weeks.
After 5-14 days
surface
epithelialization is
generally complete.
Complete
epithelial repair
takes about 1
month.

23. 7) HEALING FOLLOWING FLAP SURGERY:

24. 24 HOURS: Contact is established by blood clot into the
flap and tooth or bone surface
1 TO 3 DAYS: There is thin gap between flap and tooth.
Epithelial cells are present.
1 WEEK: Epithelial attachment to the root has been
established with the help of basal lamina &
hemidesmosomes
2 WEEKS: Collagen fibres appear parallel to tooth
surface.
1 MONTH: A well defined epithelial attachment with
fully epithelized gingival crevices.

25. 8) HEALING OF PEDICLE
AUTOGRAFTS:
Coronally
displaced flap
Lateral
pedicle
Double
papilla
• Healing at the site where the pedicle is placed over
the denuded root surface. (Wilderman & Wentz 1965)

26. STAGE HEALING
ADAPTAION
STAGE
(0-4 DAYS)
• Clot & thin fibrinous exudate b/w flap and root surface
• PMNLs in clot & connective tissue
• Epithelium at margins of flap starts to proliferate – may contact
tooth surface
PROLIFERATION
STAGE
(4-21 DAYS)
• Connective tissue invades the fibrin layer
• 6-10 days- fibroblasts apposed against rootsurface
• Collagen within the flap – oriented parallel to rootsurface
• Thin collagen fibers adjacent to root (no fibrousunion)
• Apical proliferation of epithelium- peaks at 10-14 days
• Osteoclastic resorption (peaks at 6th day) - by 14th day
• Slight cemental resorption
ATTACHMENT
STAGE
(21-28 DAYS)
• Collagen fibers insert into new cementum
• Cementoid deposition(by 28th day – along the entireroot)
• Connective tissue attachment
• New gingival margin, sulcuc & epithelial attachment
• Osteoblastic activity
MATURATION
STAGE
(28-90 DAYS)
• Continuous formation of collagen fibres
• Completely formed gingival sulcus and epithelial attachment
• Bone apposition at alveolar crest

27. 9) FREE GINGIVAL
GRAFT:
Bjorn (1963) , Sullivan & Atkins (1968)
 S zone of attached gingiva
Oliver et al (1968), Nobuto et al (1988) described the healing
into 3 phases

28. Thin grey veil like surface – new epithelium
Normal features – maturation of epithelium
Pale – empty graft vessels
Pink – vascularisation begins
Smooth & shiny – loss of epithelium
Tissue
maturation
Revascularisation (11- 42 days)
(2-11 days)
Initial phase
(0-3 days)

29. PHASE
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HEALING
INITIAL
PHASE
(0-3 DAYS)
• Thin layer of exudate b/w graft & recipient bed.
•Avascular plasmatic circulation (Forman 1960;
Reese & Stark 1961)
• Epithelium of free graft gets desquamated
REVASCULARI
- SATION
(2-11 DAYS)
TISSUE
MA
TURA
TION
(11-42 DAYS)
•Anastomosis b/w graft & recipient site blood
vessels.
• Capillaries proliferate in the graft tissue
• Fibrous union b/w graft & conn tissue bed
• Re epithelialization of the graft
• ↓ in the number of blood vessels to normal by the
14th day.
• Epithelium maturation- formation of keratin layer
• Functional integration – by 17th day
• Morphologically distinguishable for several months

30. • Bissada et al (1978) performed a study to quantitatively assess
FGG with and without periosteum and osseous perforation. They
concluded that there was no difference in the survival or healing
pattern of grafts placed on the periosteum and grafts placed on
bear bone.
• Mormann et al (1981) conducted angiographic studies on the
healing of FGG of varying thickness. They demonstrated that
rapid revascularization can be expected when uniform grafts of
thin to intermediate thickness are placed on a periosteal recipient
site. An uneven, thick graft on a site of denuded bone favored a
prolonged period of re-vascularization and delayed healing.

31. DONOR SITE:
 Granulation tissue fills the donor site.
 Initial healing is usually complete within 2 - 3 weeks after
the removal of a 4 to 5 mm thick graft.
 Patients should wear the surgical stent for about 2 weeks to
protect the healing wound.
 Palate returns to its pre surgical contour after about 3
months.

32. RECIPIENT SITE:
 Tissue form is usually stable after 2 months, but some
shrinkage may occur between the 2nd and 4th months after
surgery.
 Final restorative measures should be initiated until after 4 -
6 months.

33. 10) HEALING OF CONNECTIVE
TISSUE GRAFTS:
• Healing is similar to FGG
• 2nd day - Epithelialization commences
• 7 – 10 days - Initial epithelialization
completed
• 4 weeks - Keratinization commences

34. 11) HEALING FOLLOWING
REGENERATIVE OSSEOUS
SURGERY:
• Ellegaard et al. (1973, 1974, 1975, 1976) and Nielsen et al.
(1980)

35. HEALING CANCELLOUS CORTICAL
Blood clot
(1st week) Similar
Revascularization • Occurs within hrs • Slower rate
• Marrow spaces – rapid • Not penetrated by vesselstill
degenration 6th day
• Space for new channels • Complete within 1-2months
• Complete within 2 weeks
Repair • Initiated by osteoblats • Initiated by osteoclasts
• Mesenchymal cell • Bone apposition occurs only
osteoblast after 12 weeks
• Osteoid deposited around
cores of dead bone
•Dead bone removed by
osteoclasts
•Transplant gets replaced by
viable NEW bone.

36. DRAGOO (1973)
DURATION HEALING
3 days • Vascularity
1 week • Resorption of grafted bone
• No evidence of periodontal membrane
• Union b/w the graft & existing bone
• Beginning of osteogenesis (osteoid)
3 weeks • Beginning of cementogenesis
• Areas of calcification in conn tissue
8 weeks • Developing lamina dura and periodontal membrane
• Further resorption of graft material
• Cementogenesis
• Beginning of attachment of sharpeys fibers to bone
3 months • New bone formation
• Maturation of periodontal membrane with functional arrangement.
• Sharpeys fibers well inserted
4 months • Root resorption in some areas
• Well oriented periodontal ligament
6 months • Root resorption areas repaired
• Many niduses of bone formation

37. 12) HEALING FOLLOWING GUIDED TISSUE
REGENERATION:
• GTR based on the principle of guiding the proliferation of
the various periodontal tissue components during healing
following periodontal surgery. (Melcher’s Concept)
• Placement of barrier covering the periodontal defects in such a
way that gingival tissues are prevented from contacting the
root surface during healing .
• Same time, space is formed between the barrier and root
allowing periodontal ligament cells to produce new connective
tissue attachment and bone cells to form new bone.

38. • 1976, Melcher - Root surfaces may be repopulated by 4 different
types of cells:

39. 13) LASERS IN WOUND
HEALING:
 Investigations have demonstrated more rapid epithelialization,
enhanced neovascularization, and increased production of collagen
by fibroblasts, ultimately leading to accelerated wound healing,
reduced pain and enhanced neural regeneration.
 LOW-LEVEL laser therapy (LLLT) as a therapeutic modality was
introduced by the work of Mester and colleagues(1971,1975,1982)
who noted improvement in wound healing with application of a
low-energy.

40. • The ability of low-power laser to activate and prime the latent TGF-
β1 complex in healing wounds suggests a key role for TGF-β in
mediating the photobiomodulatory effects of low-power lasers.
(Praveen R. Arany et al,2007).
Ref : Praveen R. Arany et al, 2007

41. 14) HEALING FOLLOWING DENTAL IMPLANTS:

42. 15) HEALING FOLLOWING IMMEDIATE
IMPLANTS:

43. 16) HEALING FOLLOWING FLAP VS FLAPLESS
IMPLANT PLACEMENT:

44.  RESPONSE TO SUTURES
• Insertion of suture itself entails incisional damage.
• Each suture track is a separate wound
• Incites the same phenomena as in healing of primary wound
• When the sutures are removed around the 7th day much of
the epi. suture track is avulsed and remaining epi. tissue in
track is absorbed .
HEALING RESPONSE

46. CONCLUSION
 Current scientific evidence points to the presence of:
1. Cells originating from the periodontal ligament
2. Wound stability
3. Space provision
4. Primary intention healing
as fundamental biologic and clinical factors that must be met to
obtain periodontal regeneration.

47.  Wound healing is achieved by a series of coordinated efforts by
inflammatory cells, keratinocytes, fibroblasts and endothelial
cells responding to a complex array of signals.
 Future research will have to be directed towards understanding
in more detail the molecular mechanisms of differential gene
expression in healing wounds.

48. REFERENCES
• Carranza’s clinical periodontology: 10th edition
• Clinical periodontology Jan Lindhe-5th edition.
• Cell biology of gingival wound healing:Periodontology 2000, Vol. 24, 2000,
127–152
• Basic considerations of wound healing. Periodontology 2000 vol19
• General Pathology - Robins
• Basic considerations of wound healing. Periodontology 2000:vol19
• Periodontal therapy : Goldman

49. THANK YOU