Wound healing prosthodontics

V. CHAKRADHAR
1st Year Postgraduate
DEPT OF PROSTHODONTICS
1

CONTENTS
 DEFINITION
 REGENERATION
 REPAIR
 HEALING BY PRIMARY INTENTION
 HEALING BY SECONDARY INTENTION
 FRACTURE HEALING
 HEALING AROUND EXTRACTION SOCKET
2

 DRY SOCKET
 HEALING AROUND IMPLANT
3

INTRODUCTION
4
A wound/injury is a
disruption of the
anatomic structure
and function in any
body part.
Healing is the body
response to injury in an
attempt to restore
normal structure and
function.
woundh
ealing
Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New Delhi:
2000.

 In undamaged skin, the epidermis (surface layer) and
dermis (deep layer) form a protective barrier against
the external environment.
 When the barrier is broken ,a regulated sequence of
events is set into motion to repair the damage.
5
Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New
Delhi: 2000.

6
REGENERATION
REPAIR
H
E
A
L
I
N
G

REGENERATION
 BY PROLIFERATION OF PARENCHYMAL CELLS
 USUALLY RESULTS IN RESTORATION OF ORIGINAL
TISSUES
7

REPAIR
 BY PROLIFERATION OF CONNECTIVE TISSUE
ELEMENTS
 RESULTS IN FIBROSIS AND SCARRING
8

REGENERATION
 In order to maintain proper structure of the tissue the
parenchymal cells undergo constant regulatory control of their
cell cycle.
 CELL CYCLE : defined as the period between two successive
cell divisions.
 it is of 4 unequal phases
9
2000.

10
M (MITOSIS PHASE) PHASE OF MITOSIS
G1 ( GAP 1 PHASE) DAUGHTER CELL ENTER G1AFTER
MITOSIS.
S (SYNTHESIS PHASE) SYNTHESIS OF NUCLEAR DNA TAKES
PLACE.
G2 (GAP 2 PHASE) AFTER DNA DUPLICATION ENTERS G2
PHASE.
G0 (GAP 0 PHASE) QUIESCENT /RESTING PHASE OF CELL
AFTER M PHASE
2000.

11
2000.

• Cells are of 3 types depending on their capacity to divide :
• Labile cells
• Stable cells
• Permanent cells
12
Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New Delhi: 2000.

13
LABILE CELLS :
- continue to multiply through out life under normal
physiologic conditions
- ex: epithelial cells of epidermis
- alimentary tract
2000.

STABLE CELLS
 - cells decrease / loose their ability to proliferate after
adolescence but retain their capacity to multiply in response to
stimuli throughout life
 ex: parenchymal cells of organs like lungs, kidneys, liver and
mesenchymal cells like vascular endothelium.
14
2000.

PERMANENT CELLS
– these cells loose their capacity to proliferate around time
of birth.
ex : neurons , cardiac muscle cells.
15
Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New
Delhi: 2000.

 Regeneration of any type of parenchymal cell involves following two
processes :
 Proliferation of the original cells from the margin of the injury which
migrates so as to cover the gap
 Proliferation of the migrated cells with subsequent differentiation and
maturation so as to reconstitute the original tissue
16
2000.

REPAIR
 Is the replacement of the soft tissue by fibrous tissue .
 Damage to parenchymal cells leads to a situation where , repair
cannot be accomplished by parenchymal regeneration alone.
17
2000.

 Repair involves :
1. Granulation tissue formation.
2.contraction of the wound
18
Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New Delhi: 2000.

19
GRANULATION TISSUE
FORMATION
PHASE OF
INFLAMMATION
PHASE OF CLEARANCE
PHASE OF INGROWTH OF
GRANULATION TISSUE
ANGIOGENESIS
(NEOVASCULARISATION)
FORAMATION OF
FIBROUS TISSUE
(FIBROGENESIS)
2000.

Granulation tissue formation : It derives its name from the slightly
granular and pink appearance of the tissue
 Involves three phases :
 PHASE OF INFLAMMATION : following trauma blood clots at site of
injury
 There is acute inflammatory response with exudation of plasma ,
neutrophils and some monocytes within 24hrs.
20

 PHASE OF CLEARANCE :
1.Combination of Proteolytic enzymes liberated by neutrophils
2. Autolytic enzymes from the dead tissue cells
3. Phagocytic activity of the macrophages .
All the above processes leading to clearance of
the necrotic tissue , debris and RBCs .
21

22
PHASE OF IN GROWTH OF
GRANULATION TISSUE :
Angiogenesis
Formation of fibrous tissue

ANGIOGENESIS
 Is necessary to sustain newly formed granulation tissue .
 Takes place by proliferation of endothelial cells from the
margins of the severed vessels .
 Relies on the extra cellular matrix in the wound bed
23

 Initially the endothelial cells are solid buds , but within few hours develop a
lumen and starts carrying blood .
 Newly formed blood vessels are leaky accounting for edematous
appearance of the new granulation tissue .
 Soon these blood vessels differentiate into muscular arterioles , thin walled
venules and true capillaries.
 The process of angiogenesis is stimulated with proteolytic destruction of
basement membrane.
24
Kumar, Abbas, Aster. Robbins& Cotran Pathologic Basis of Disease 7th edition Vol 1, Elsevier pub An
imprint of Mosby; Philadelphia: 2003

FIBROUS TISSUE FORMATION
 Newly formed blood vessels are present in an amorphous ground
substance or matrix. The new fibroblast originate from fibrocytes as well as
the mitotic division of the fibroblasts .
 As the maturation proceeds : there is an increase in the collagen , and a
decrease in the fibroblasts and blood vessels .
 This leads to the formation of scar know as CICATRISATION
26

27
SCAR
• A scar is an area of fibrous tissue that replaces normal skin after an injury.
Definition by American Academy of dermatology.
• It differs in the amount of collagen overexpressed.

28
features HYPERTROPHIC SCAR KELOID SCAR
GENETIC NOT FAMILIAL MAY BE FAMILIAL
RACE NOT RACE RELATED BLACK> WHITE
SEX F = M F > M
AGE CHILDREN 10-30 Yrs
BORDERS REMAINS WITHIN WOUND OUTGROWS WOUND
AREA
NATURAL HISTORY SUBSIDES WITH TIME REARELY SUBSIDES
SITES FLEXOR SURFACES STERNUM,SHOULDER,
FACE

WOUND CONTRACTION
 Wound starts contracting after 2-3 days and completed by 14th
day by approx. 80% of its original size.
 Mainly by interaction of cells, extracellular matrix , cytokins .
 Myofibroblasts mainly correspond to contraction of wound .
30
Harsh mohan,textbook of essential of pathology for dental students 4th edition.

HEALING BY FIRST INTENTION (primary
union)
 Is defined as a wound which has the following characters :
Clean and uninfected
Surgically incised
Without much loss of cells and tissues
Edges of the wound are approximated by the surgical
sutures
31

STAGES OF PRIMARY UNION
 INITIAL HEAMORRHAGE:
Immediately after injury the space between the
approximated surface is filled with blood which then
clots and seals the wound against dehydration and
infection.
32

ACUTE INFLAMMATORY PHASE
o Ensues within 24 hours .
o Margins are infiltrated by neutrophils, monocytes and
swollen by fluid exudate.
o Autolytic enzymes liberated by dead tissue cells .
o Proteolytic enzymes by the neutrophils
33

o Phagocytic activity by monocytes and tissue macrophages
which appear by 3rd day ; clear away necrotic tissue debris and
RBCs .
o Ingested Hb gets converted into hemosiderin and hematoidin .
34

 EPITHELIAL CHANGES :
o Basal cells of the epidermis from both the cut margins start proliferating and
migrating towards incisional space in the form of epithelial spurs
o Migrated epidermal cells separate the underlying viable dermis from
overlying necrotic material and clot.
o Scab which is cast off
 Basal cells from the margins continue to divide.
35

o A well approximated wound is covered by a layer of epithelium
in 48 hours.
o By 5th day , a multi-layered new epidermis is formed which is
differentiated into superficial and deep layers.
36

 ORGANISATION
 By 3rd day fibroblasts also invade the wound area
 By 5th day new collagen fibrils stat forming which dominate till healing is
completed
 In 4 weeks scar tissue with scanty cellular and vascular elements and few
inflammatory cells and epithelialized surface is formed.
37

RESPONSE TO SUTURES
 Each suture track is a separate wound .
 Incites the same phenomena as in healing of primary wound.
 When sutures are removed around 7th day much of the
epithelized suture track is avulsed and remaining epithelialized
tissue is absorbed .
38

39
Kumar, Abbas, Aster. Robbins& Cotran Pathologic Basis of Disease 7th edition Vol 1, Elsevier pub An
imprint of Mosby; Philadelphia: 2003

HEALING BY SECONDARY
INTENTION
Is defined as-
 Wound open with a large tissue defect, at times infected
 Extensive loss of cells and tissues
 Not approximated by sutures, but is left open
40

Secondary union consists of the following events :
41
Initial
hemorrhage
Inflammatory
process
Epithelial
changes
Granulation
tissue formation
Wound
contraction

WOUND CONTRACTION
 Not seen in primary healing
 Myofibroblasts are the cells responsible for the contraction of
the wound
 1/3rd to 1/4th its original size
42

43
LOCAL
FACTORS
Infection
Foreign
bodies
Poor
blood
supply
Exposure
to uv light
facilitates
healing
Exposure
to ionizing
radiation
Movement

44
Systemic
factors
Age
haematological
abnormalities.
Nutrition
Administration of
drugs eg.
Glucorticoids
Uncontrolled
diabetes

45
 Longterm hyperglycemia leads to development of glycation
 In which glucose bind to proteins and other molecules leads to non-enymatic process
 Results in
- neutrophil dysfuntion
-diminished vascular perfusion
- progressive nerve damage
all of which contribute to poor wound healing.
Shafer, Hine, Levy. Shafer’s Textbook of oral pathology. 8th ed, Elseiver pub An imprint of Mosby;St Louis
Missouri: 2016
Uncontrolled diabetes

46
ANAEMIA - wound healing
Low iron
Tissues
throughout
body do not get
enough oxygen
Healing
process relies
on oxygenation
Halts the
wound healing
stages
Delays the
wound healing

FRACTURE HEALING
 The process of fracture healing can occur in two ways:
- Direct or primary bone healing occurs without
callus formation.
- Indirect or secondary bone healing occurs with a
callus precursor stage
47

 PRIMARY HEALING of fractures involves a direct attempt by the cortex to
re-establish itself after interruption.
 Bone on one side of the cortex must unite with bone on the other side of
the cortex to re-establish mechanical continuity.
 Under few special situations when the ends of fracture are approximated as
done by application of compression clamps .
 In these cases bony union takes place with formation of medullary callus
without periosteal callus formation.
48

Secondary healing of the bone
 Involves classical stages of fracture healing they are:
 1. Hematoma Formation
 2. inflammation.
 3. primary soft callus formation
 4.callus mineralization
 5.callus re-modelling
49

WOUND HEALING AROUND EXTRACTION
SOCKET
 It is divided into 5 stages
 Hemorrhage and clot formation
 Organization of the clot by granulation tissue
 Replacement of the granulation tissue by connective tissue and
epithlisation of the wound .
 Reconstruction of the alveolar process and replacement of the
immature bone by mature bone tissue .
52

FIRST STAGE:
53
 Hemorrhage - Within 30 min bleeding ceases –resulting from clot
formation
 next 24 hours there is beginning of the inflammatory process in the
surrounding tissue .i e . There is hyperemia , exudation of plasma ,
infiltration of leukocytes.

Second stage :
 2nd or 3rd day organization of the clot, fibroblasts grow into the clot, and
there is formation of capillary network (endothelial cells ).
 Through the above process the clot begins to be replaced by granulation
tissue by about the 7thday .
 There is osteoclastic activity which is also beginning at the alveolar crest .
54

Third stage :
 replacement of granulation tissue by the connective tissue –completed by the
20th day.
 Delicate fibrillar trabaculae are seen in the base of the socket extending from
the alveolus into the clot .
 Simultaneous resorption at the edges of alveolar crest continues ;so that while
the socket is being filled with bone , its total depth is reduced
 Epithelialisation of the socket begins at the gingival margin on the 4th day
55

Fourth stage :
 Two third of the socket is filled with coarse fibrillar bone
by about the 38th day
56

5th stage
 By the 40th day the socket may be entirely filled with fibrillar bone
which is replaced by trabecular pattern of the mature bone.
57

58
Lindhe J, Lang NP. Clinical periodontology and implant dentistry. 5th ed vol1, Wiley Blackwell pub; victoria
Australia : 2008.

59
Lindhe J, Lang NP. Clinical periodontology and implant dentistry. 5th ed vol1, Wiley Blackwell pub; victoria
Australia : 2008

Post operative complications of extraction socket
 Alveolar osteitis (dry socket )
 Hemorrhage
 Ecchymosis and haematoma
 Swelling
 Pain
61

Dry-socket / alveolitis sicca dolorosa
 cf : Delayed post operative pain of extreme intensity is of radiating type
 Loss of blood clot
 Dirty gray appearance of clot
 Foul odor
 Commonly in patients of 40-45 year old
 Mandible more affected than maxilla.
62
Laskin M D. Oral and maxillo - facial surgery. Vol2, All India Traveller Book Company; Delhi : 2002

 The dry socket usually starts by 2-3rd day and was extremly painful.
 The diagnosis is confirmed by gently passing a probe into extraction
wound , in dry socket a bare bone which is extremly sensitive and partially
necrotic clot is encountered.
63

 Brins hypothesis(1973):
 Brin suggested that trauma and infection cause inflammation of
bone marrow with resultant release of tissue activators that convert
plasminogen in clot to plasmin.
 Plasmin is a fibrionolytic agent that dissolves clot and releases
kinins from kinogen leading to severe pain.
64
PATHOGENESIS

65

 Treatment involves :
 Irrigation of the socket with warm sterile isotonic solution or dilute solution of
dilute hydrogen peroxide; to remove the debris.
 Application of an obtundent e g . Eugenol or a topical anesthetic :benzocaine
 Analgesics and antibiotics
 Curettage should never be carried out in the treatment of alveolar osteitis
66

Fibrous healing of extraction socket:
 It is an uncommon complication usually following a complicated or surgical
extraction
 Tooth extraction along with labial and lingual cortical plates and the
periosteum.
 Treatment involves excision of the lesion for establishing diagnosis and
subsequent bony repair of the fibrous defect.
67
Shafer, Hine, Levy. Shafer’s Textbook of oral pathology. 8th ed, Elseiver pub An imprint of Mosby;St Louis
Missouri: 2016

Healing After implant placement
 Good healing requires implant stability
 Healing after placement of an implant-Osseo integration
 Initial stages of implant healing and interface development occurs
in 4 stages
68

69
Hemostasis phase Proteins adsorption , soft tissue
healing,clot formation
Inflammatory stage Neutrophils and macrophage
activation , inflammatory mediators
releasing
Proliferative stage
early stage Angiogenesis , increase in number of
fibroblasts and osteoclasts
Late stage Woven bone formation
Remodeling phase
Early stage Reconstruction of woven bone by
osteoclasts
Late stage Immature woven bone replacement
by mature lamellar bone.

 Stages of osseo - integration by MISCH,
Stage 1 : woven callus formation : 6 weeks
Stage 2 : lamellar compaction – 18 weeks
Stage of maturation :
Stage 3 : interface remodeling –18weeks
Stage 4 : compact maturation 54 weeks
70
Misch CE. Contemporary implant dentistry 3rd edition , Elsevier pub An imprint of Mosby; St Louis
Missouri: 2008.

71
FACTORS AFFECTING IMPLANT HEALING
 Lack of adequate oxygen supply Results in differentiation of primary stem cells
to fibroblasts leads to fibrotic tissue formation.
 Overheating and overpressing of
bone during preparation and
excessive torque
Leads to necrosis and sequesterm
formation.
 Over loading/immediate loading
Micromotions over 150micro
meters leads to osteoblast
differentiation and fibrous tissue
formed.

72
SYSTEMIC CONDITIONS AND THEIR AFFECT ON OOSEOINTEGRATION
 osteoporosis Reduced bone density , possibility of osteo-
necrosis in patients using bisphosphonates
 Immune deficiency Increased infection risk, imparied wound
healing
 Cardio vascular
disease
Imparied tissue repair due to insufficient
oxygen delivery in severe cases
 Tobacco/smoking Leads to osteoporosis,bleeding
tedency,immunedeficiency,malnutrition

73
 Bioactive modifications like biomolecular coatings
seems to promote peri implant bone
formation,resulting in enhanced osseointegration
during early stages of healing.

Prosthodontic considerations
Immediate dentures :
 Are the dentures constructed before all the remaining teeth
have been removed and inserted immediately after the
removal of the remaining teeth
 The inner surface of the immediate denture should be smooth
74
. Winkler S. Essentials Of Complete Denture Prosthodontics. 2nd ed A.I.T.B.S. Publishers; Delhi: 2000.

 Acts as a protecting splint over the operated site, thereby, reduces
discomfort and inconvenience.
 Delayed and transitional dentures :
 Are inserted 1to 2 weeks after the extraction
 Objective is to avoid the make and break contact of the denture with the
surgically treated tissue which may cause transient bacteremia during the
early post operative period.
75
. Winkler S. Essentials Of Complete Denture Prosthodontics. 2nd ed A.I.T.B.S. Publishers; Delhi: 2000.

76
• There is a healing quality to nature, which has been known
for centuries , be it taking time to smell the roses , meditating
on a mountain or lying in a wild flower field ….
• ‘HIPPOCRATES’ the father of modern medicine has
recognized this powerful attribute in his humbling statement-
‘NATURE CURES NOT THE PHYSICIAN’
Conclusion :

77
REFERENC
ES
1. Kumar, Abbas, Aster. Robbins& Cotran Pathologic Basis of Disease 7th edition Vol 1, Elsevier pub An
imprint of Mosby; Philadelphia: 2003.
2. Mohan H, Mohan S . Essential of pathology for dental students . 4th ed, Jaypee Publications: New Delhi:
2000.
3. Lindhe J, Lang NP. Clinical periodontology and implant dentistry. 5th ed vol1, Wiley Blackwell pub;
victoria Australia : 2008.
4. Laskin M D. Oral and maxillo - facial surgery. Vol2, All India Traveller Book Company; Delhi : 2002
5. Shafer, Hine, Levy. Shafer’s Textbook of oral pathology. 8th ed, Elseiver pub An imprint of Mosby;St
Louis Missouri: 2016
6. Misch CE. Contemporary implant dentistry 3rd edition , Elsevier pub An imprint of Mosby; St Louis
Missouri: 2008.

78
7. Winkler S. Essentials Of Complete Denture Prosthodontics. 2nd ed A.I.T.B.S. Publishers; Delhi: 2000.
8. Jain M, Thukral H, Kukreja S, Arora G, Ray A, Arora D. Concept of healing after implant placement.
World J Pharm Pharmaceutic Sci 2017;6(8): 1250-57.
9. Kiani S, Razavi SM, Movahedian B, Khalesi S. The effect of common local and systemic conditions
on dental implant osseointegration: A review of literature. Avicenna J Dent Res 2015;7(2):24339- 49.

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