character is how to treat those who can do nothing for you .

1. Department of oral & maxillofacial surgery
PRESENTED BY :
MD. KALAM SAFI
ROLL NO : 15
KDCH, BDS 10TH BATCH
WOUND HEALING

2. Content to be Covered:
Wound Definition
Classification of wound
Healing
Types of Wound Healing
Stages of Wound
Healing
Phases of Wound
Healing
Factors Affecting Wound
Healing
Complications
Healing of extraction of
wound
Management of Wound
Healing
Medico-Legal aspect of
Wound
Conclusion
References

3. Introduction To Wound
Wound is a circumscribed injury which is
caused by external force & it can involve any
tissue & organ.

4. A wound is a break in the integrity of the skin
or tissue which may be associated with
disruption of the structure and function.
(SRB,4th Edition)
A cut or break in the continuity of an any
tissue, cause by injury or operation.
(Baillere’s,23rd edition)

5. Classification of wound
I.
A. Simple wound
B. Compound wound
II. Rank and wake filed
classification
a. Tidy wound
b. Untidy wound
III.
A. Closed wound
a. Contusion
b. Abrasion
c. Haematoma
B. Open wound
a. Incised wound
b. Lacerated wound
c. Penetrating wound
d. Crushed wound
IV . Acute wound and chronic
wound
a. Acute wound
b. Chronic wound
V. Classification of surgical wound
a. Clean wound/ Tidy wound
b. Clean contaminated wound
c. Contaminated wound
d. Dirty infected wound

7. Wound Healing
• Wound healing is complex method to achieve
anatomical and functional integrity of disrupted
tissue.
OR
Wound healing refers to replacement of destroyed
tissue by living tissue to restore function

8. Types Of Wound Healing
I. Primary Healing (first intention )
II. Secondary Healing(second intention)
III. Healing by third intention (Delayed primary healing )
I. Primary Healing
 It occurs in a clean incised wound or surgical wound
 Wound closed within hours
 Wounds edge approximated with sutures
 Normal collagen synthesis , deposition and cross linking
 Narrow scar

9. II. Secondary Healing
 Occurs in a wound with extensive soft tissues loss like in a
major trauma ,burns and wound with sepsis .
 Allowed to close by wound contraction and epithelisation .
 Wound contraction by myofibroblast
 Wide scar often hypertrophied and contracted
III. Healing by third intention (Delayed primary healing )
 after wound debridement and control of local infections
,wound is closed with sutures or covered using skin graft
 Primary contaminated or mixed wound heal by tertiary
intension

10. STAGES OF WOUND HEALING
Stage of Inflammation.
Stage of granulation tissue formation &
organization.
Stage of epithelisation.
Stage of Scar formation & resorption.
Stage of maturation.

13. PHASES OF WOUND HEALING
1. Inflammatory phase(Lag Phase)
2.Proliferative phase (collagen/ fibroblastic phase)
3.Remodelling maturation (maturation )phase
4.Phase of scar formation
I. Inflammatory phase (lag phase )
 First phase of wound healing
 Features of inflammation are rubor, calor ,
tumour ,dolor ,and loss function .

14. • Chemical factors involved in wound healing are
Growth factor- platelet derived , epidermal ,
transforming
Interleukin
Tumor necrosis factor
Prostaglandins
Collagenase
Elastase etc .

17. II. Proliferative phase :
Between 3rd and 5th day, PMN leucocytes
diminish in number but monocyte increase . They
are specialized scavengers .
By 5th or 6th day ,fibroblast appear , proto collagen
hydroxylase
Protocollagen
Protocollagen
Hydroxylase
Hydroxylation
Collagen

18. Slowly surface cells get keratinized
III.Remodelling phase (maturation)
There is maturation of collagen by cross-linking
which is responsible for tensile strength of the
scar .
It is brought about by specialized fibroblasts
(myofibroblasts )
Corticosteroids , irradiation ,chemotherapy
delay wound contraction
Formation of granulation tissue is the most
important and fundamental step in wound
healing .

19. IV. Phase of scar formation
Fibroplasia and laying of collagen is increased
 vascularity becomes less
Epithelisation continues
Remodelling of collagen takes place with
cicatrisation ,resulting in scar

20. Repair:
Replacement of the lost tissue by granulation
tissue ,is repair .

21. Regeneration:
Replacement of lost tissue by granulation tissue
and results in scaring and replacement by similar
type of tissue .

22. Factors affecting healing of oral wounds
1. Location of wound
Good vascular supply (lips)= more rapid
healing
2. Immobilization of the wound
E.g. Corner of the mouth= Delayed healing
3. Physical Factors
a. Severe trauma/mild trauma
E.g. 2nd injury to previous one heal more
faster

23. b. Temperature
• Hyperthermia – Increased circulation
Wounds heal faster
• Hypothermia – Delayed
c. X-ray radiation
• Low dose – Accelerate healing
• High dose – Retard healing

24. 4.Circulatory factors
Anemia, Dehydration, Retard healing
5. Nutritional factors
Protein – Hypoproteinaemia- delay in fibroblast
synthesis- Delay wound healing
Vitamins(C,A,B,D)- Accelerate wound healing
Mineral- Accelerate wound healing
6. Age
Retardation in healing with increase in age because
of decreases in tissue metabolism & decreased
efficiency of circulation.

25. 7. Infection
Bacterial infection- Decrease rate of healing
8. Hormonal factors
ACH(cortisone) – inhibits or delayed
production of new fibroblast, endothelial cells
due to inflammatory depression.

26. 9. Miscellaneous factors:
- Enzymes: Trypsin, Streptokinase
-Antibiotics, Anticancer drugs, Immunosuppressive,
drugs, Anticoagulants
- suture materials(weaker effect)
- Non absorbent>absorbent; wound infection;
monofilament<multifilament
- Smoking
- Tissue adhesives- Hastens healing

28. A. Factors delaying wound healing .
I. Local factors
• Infection
• Venous or lymph stasis
• Poor vascular supply
• Tissue tension
• Recurrent trauma
• Wound in highly active site
• Large defect or poor apposition
• Underlying disease

30. II. General factors /systemic factors
• Age: reduced healing with increased age
• Anemia
• Malnutrition
• Jaundice
• Malignancy
• Vitamin deficiency
• Steroids and Cyto- toxic drugs
• Radiations
• Uremia
• HIV and Immunosuppressive disease
• Neuropathies

31. • B. Factors enhancing wound healing
I. Local factors
•Adequate oxygenation
•Adequate hydration
•Rest to wound area
II. Systemic factors
Rapid healing in children
Good nutritional and hydration status

32. Complication of wounds
• Infection
• Pigmentary changes
• Keloid &hypertrophic scar
• Cicatrization
• Implantation cyst
• Deficient scar information
Healing of Pulpal disease
a. Reparative dentin
formation
b. Localized fibrosis
c. Pulpal necrosis
Healing after Periapical
abscess
a. New bone formation
b. Fibrosis

33. Healing of extraction of wound
 Can be described in 5 phases.
1. Immediate reaction
2. First week wound
3. Second week wound
4. Third week wound
5. Fourth week wound

34. Immediate reaction
• Removal of tooth
Blood fills the socket and coagulates
Within 24 hours
Vasodilatation and engorgement of blood vessels,
mobilization of leukocytes immediately around
the clot .
Surface of the blood clot is covered by thick layer
of fibrin

35. First week wound
Fibroblastic proliferation around the periphery
Clot act as a scaffold
Gradually replaced by granulation tissue
Epithelium at periphery proliferate
Clot undergoes organisation : in growth of fibroblasts and
capillaries
Crest of alveolar bone : beginning of osteoblastic activities

36. Second week wound
Fibroblastic grow into the clot
New delicate capillaries – clot centre
Extensive epithelial proliferation over the surface
Margins of alveolar socket - osteoblastic resorption
; PDL remnants degenerate
Bone fragments (necrotic ) resorption

37. Third week wound
Original clot organization
Young trabeculae of osteiod- entire wound periphery
Osteiod produced by osteoblasts derived from
pleuripotent cells of PDL
Crest of alveolar bone – round off by osteoblastic
resorption
Surface of wound – completely epithelised

38. Fourth week wound
Continued deposition and remodeling resorption fill
the alveolar socket
Radiographic evidence of bone formation does not
become prominent until 6th or 8th week
Crest of healed socket below that of adjacent teeth ;
x –ray evidence at 4-6 months
Significant of prosthetic appliance

39. Complication of extractions
1. Dry socket (alveolar process)
 Most common and painful complication
Definition: “the failure of appropriate healing after
tooth extraction due to disruption of initial clot
with eventually lack of organization by
granulation tissue”.

40. Medico legal aspect of wound
1. Homicide
2. Types
I. Lawful
• Justifiable
• Excusable
• II . Unlawful
i. Murder
ii .Culpable homicide
a . Amounting to murder
b . Not amounting to murder
iii. Rash or negligent
homicide .
Disasters and accidents
Physical abuse and neglects
Medical negligence and
malpractice

41. Possible causes :
• Traumatic extraction
• Smoking after extraction
• Excessive rinsing after
extraction
• Oral contraceptive use after
extraction
• Limited blood supply
excessive use of
vasoconstrictor in the local
anaesthesia
• Previous radiotherapy
• Pre – existing pericoronitis
Clinical feature
•Develop after 2-4
days after tooth
extraction
•Female >male
•Site : mandible >
maxilla (third molar)

42. Management
 Irrigates the socket with
antiseptic solution
 The aim is to keep the extraction
socket clean
 Symptomatic treatment
 Local dressing rinse with
antiseptic &dressing iodoform
gauze with Zno eugenol
 Dressing is changed everyday
 Peroxide rinse ,mouth washes
 Intrasocket medications
Intrasocket medications
Resorbable
Dextra monomer granules
Non – reasonable
Eugenol glycerine
Antibiotic : tetracycline
hydrochloride
Fibrous healing
Uncommon complication
Common when extraction is
accompanied by loss of lingual and
buccal cortical plates the
periosteum

44. Conclusion
Wound care is becoming more complex as the
range of wounds increases
 Correction of the underlying causative factors
is essential and multidisciplinary
Overall patient benefit with the different
wound healing strategies remains to be
determined.

45. References :
Peterson ‘s Principle of oral and maxillofacial
surgery (second Edition )
SRB's Manual of Surgery (6th Edition )
Manipal manual of surgery (4th Edition )
Shafer’s Text book of oral pathology (8th
edition) .

46. THANK YOU