Wound healing/certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call

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Wound healing/certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Wound healing, methods to control hemorrhage, suturing and bone grafts www.indiandentalacademy.com
  3. 3. 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 www.indiandentalacademy.com Classification & types
  4. 4. Introduction www.indiandentalacademy.com
  5. 5. HEALING OF TISSUE Is the body response to injury to restore normal structure and function Involves 2 processes Regeneration- parenchymal Repair – CT www.indiandentalacademy.com
  6. 6. REGENERATION: www.indiandentalacademy.com
  7. 7. 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 www.indiandentalacademy.com
  8. 8. Granulation tissue formation 1. phase of inflammation 2. phase of clearance 3. phase of ingrowth angiogenesis fibrogenesis Contraction of wounds www.indiandentalacademy.com
  9. 9. Scar formation Fibroblast migration & proliferation ECM deposition & Scar formation Tissue remodeling (metalloprotenases) www.indiandentalacademy.com
  10. 10. Wound Healing: Inflammation Epithelialization Granulation Contraction Remodeling www.indiandentalacademy.com
  11. 11. 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 www.indiandentalacademy.com
  12. 12. 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 www.indiandentalacademy.com
  13. 13. 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. …
  14. 14. Healing by Secondary Intention: More extensive wounds – infarcts, inflamm. Ulcers, abcess or large wounds Healing from below upwards & margain inwards Slow & leads to scar… www.indiandentalacademy.com
  15. 15. 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 www.indiandentalacademy.com
  16. 16. 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 www.indiandentalacademy.com
  17. 17. Healing by secondary intention www.indiandentalacademy.com
  18. 18. Wound Strength Sutured wounds – 70% of unwounded skin 1 week- 10% 4 week- inc 3 month- 70-80% No further increase www.indiandentalacademy.com
  19. 19. Complications… Infection Pigmentation Implantation Deficient scar Hypertropied scar & Keloid Excessive contraction Neoplasia Incisional hernia www.indiandentalacademy.com
  20. 20. Conditions for Healing • • • • • • • Well being Nutrition Vascular supply/drainage Clean wound Minimal trauma Moist environment Thermal regulation www.indiandentalacademy.com
  21. 21. Healing of extraction socket www.indiandentalacademy.com
  22. 22. 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 www.indiandentalacademy.com
  23. 23. 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 www.indiandentalacademy.com
  24. 24. 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 www.indiandentalacademy.com
  25. 25. Fibrous healing Uncommon … Loss of labial & lingual plates Asymptomatic Dense fibrous mass on exploration Excision causes bony repair www.indiandentalacademy.com
  26. 26. Methods to control Hemorrhage Control dependent on : Vessel contraction Retraction Clot formation
  27. 27. Techniques : Mechanical Thermal Chemical
  28. 28. Mechanical methods Pressure : Counter hydrostatic pressure 5 min… Most common Use of Hemostats: Mosquito or straight Larger vessels - ligation
  29. 29. 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
  30. 30. Thermal Agents Cautery Heat transmitted from instrument Denaturation of proteins Electrosurgery Induction Large vessels
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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.
  35. 35. Suturing Needles Stainless steel material Carbon steel tapered straight shape curved cutting tapered cutting
  36. 36. 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
  37. 37. 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
  38. 38. C L A S S I F I C A T I O N
  39. 39. 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”.....
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. Non-Absorbable Sutures Silk Most common Slow proteolysis Moderate response Low tensile strength 3 ties per knot
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. Staples Rapid closure of wound Easy to apply Evert tissue when placed properly
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. 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)
  52. 52. 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)
  53. 53. 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
  54. 54. 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 www.indiandentalacademy.com COMPOSITE GRAFT
  55. 55. 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 www.indiandentalacademy.com
  56. 56. Osteoconduction depends on : Porosity Pore-size 3-D architecture Osteoinduction involves : Pluripotent & BMP www.indiandentalacademy.com
  57. 57. 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 www.indiandentalacademy.com
  58. 58. 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 www.indiandentalacademy.com
  59. 59. Ideal requirements of bone grafts: Biologically acceptable Predictability Clinical feasibility Minimal operative hazards Minimal post-operative sequelae Patient acceptance www.indiandentalacademy.com
  60. 60. Classification of bone grafts BASED ON --1.ORIGIN - autograft - allograft - xenograft - bone substitute material www.indiandentalacademy.com
  61. 61. 2. STRUCTURE - cortical graft - cancellous graft - corticocancellous 3. BLOOD SUPPLY - non-vascularized graft - vascularized graft www.indiandentalacademy.com
  62. 62. 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 www.indiandentalacademy.com
  63. 63. Osseous coagulum : (Robinson) Bone dust + blood mixture Uses particles from cortical bone Bone blend: Bone dust + Saline Bone used is cortical & cancellous www.indiandentalacademy.com
  64. 64. Areas for obtaining bone grafts Head & neck Cranium Mandible Thorax Ribs Scapula Forearm Lower limb Hip (Iliac crest) Tibia Fibula 2nd metatarsal www.indiandentalacademy.com
  65. 65. 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 www.indiandentalacademy.com Decalcified freeze dried bone
  66. 66. 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 www.indiandentalacademy.com
  67. 67. 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 www.indiandentalacademy.com Sophisticated lab procedures
  68. 68. 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 www.indiandentalacademy.com
  69. 69. 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 www.indiandentalacademy.com – Dense HA. Porous HA, Bioglass
  70. 70. Advantage : No processing Biocompatible Ease of manipulation Disadvantage : Cost www.indiandentalacademy.com
  71. 71. www.indiandentalacademy.com
  72. 72. …..Conclusion www.indiandentalacademy.com
  73. 73. 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. www.indiandentalacademy.com
  74. 74. Thank you www.indiandentalacademy.com