HEALING

OF ORAL
WOUNDS
RVG 1
 HEALING OF ORAL
WOUNDS
1. General factors affecting the healing of oral
wounds
2. Biopsy and healing of the biopsy wound
3. Healing of the gingivectomy wound
4. Healing of the extraction wound
5. Complications in the healing of extraction
wounds
6. Healing of fracture
7. Re-plantation and transplantation of the teeth

RVG 2
 HEALING OF ORAL
WOUNDS
General factors affecting the healing of
oral wounds

RVG 3
 Healing of oral wounds
General factors
1. Location of wound-
area with good vascular bed heal
more rapidly
Immobilisation also helps in rapid
healing corner of mouth

RVG 4
 Healing of oral wounds
General factors
2. Physical factors
Severe trauma to tissue slows healing
Local temperature increases rate of healing through
effect oj circulation and cell multiplication.
Hyperthermia- healing accerlerated
Hypothermia- healing delays
X-ray radiation-low doses-stimulates
high focal doses-supresses

RVG 5
 Healing of oral wounds
General factors
3. Circulatory factors-
Anemia- delay healing
Dehydration- delay healing
4. Nutritional factors-
Hypoproteinemia - delays healing
Slows new fibroblasts proliferation and multiplication in the
wounds
Scurvy- delays healing
Interruption in regulation of collagen formation of normal
intercellular ground substance of the connective tissue and
Interruptionin formation of mucopolysaccharides (cementing
substance)
Vit. A and D- retards healing

RVG 6
 Healing of oral wounds
General factors
5. Age of the Patient-
Younger patient- rapid healing
Older patient- delay healing
6. Infection-
Bacterial irritation- slows healing
Germ- free state- also slows healing

RVG 7
 Healing of oral wounds
General factors
7. Harmonal factors-
ACTH and Cortisone- slows healing
Growth of granulation tissue was
inhibited by depression of inflamatory
reaction- inhibition ofprol;iferation of
new fibroblast, endothelial sprouts
Diabetes mallitus- slows healing

RVG 8
HEALING OF ORAL
WOUNDS
BIOPSY AND HEALING OF THE
BIOPSY WOUND

RVG 9
 Healing of oral wounds
BIOPSY
BIOPSY
Biopsy is the removal of tissue from
the living organism for the purposes
of microscopic examination and
diagnosis
TYPES OF BIOPSY-
Excisional Biopsy total excision of a
small lesion for microscopic study
Incisional Biopsy- a small section of a
large lesion removed for microscopic
study RVG 10
 Healing of oral wounds
BIOPSY
Methods of Biopsy
1. Surgical excision by scalpel
2. Surgical removal by cautery or a high
frequency cutting knife
3. Removal by biopsy forceps or biopsy
punch
4. Aspiration through a needle with a
large lumen
5. Exfoliative cytology
RVG 11
 Healing of oral wounds
BIOPSY
Exfoliative cytology-
Surface of the lesion is wiped with sponge
material which is then sectioned, or
scraped and smeared on a microscopic slide
and studied by the pathologist for presence
of atypical or diagnostic cells
the cytologist may classify the smear into
following classes

RVG 12
 Healing of oral wounds
BIOPSY
Class I normal normal cells are present
Class II Atypical minor stypia but no evidence of
malignant changes
Class III interdeterminate- wider atypia that
suggest cancer, but is not clear cut and represent
precancerous lesions- ca in situ, biopsy is
recommended
Class IV - suggestive of cancer- few cells with
malignant characteristics or with many cells with
borderline characteristics. biopsy is mandatory
Class V - positive of cancer,cells are obviously
malignant, biopsy is mandatory
RVG 13
 Healing of oral wounds
BIOPSY
Healing of Biopsy wound-
Primary healing healing which occurs after
excision of a small piece of a tissue with close
apposition of the edges of the wound
Wound heals rapidly
Occurs in clean and infected, surgical incised,
without much loss of cells and tissue and in
which edges of wound are approximated by
surgical sutures.

RVG 14
 Healing of oral wounds
Events in primary healing
Initial haemorrhage immediately bleeding which then
clots
Acute inflammatory response within 24 hrs appearance of
polymorphs, which then is replace by macrophages by the 3 rd
day
Epithelial changes basal layer proliferate and covers the
wounds in 48 hrs
Organisation by 3rd day fibroblast invades, by 5th day new
cllagen fibrills starts forming, 4th week scar tissue forms
and full epithelisation occurs

RVG 15
 Healing of oral wounds
Secondary healing healing by granulation or
healing of an open wound occurs when there is
loss of tissue and the edges of the wound cannot
be approximated
Wound heals slowly, and forms scar
Occurs in open wounds with large tissue defect,
having extensive loss of cells and tissues and
wounds which are not approximated by surgical
sutures that are open.

RVG 16
 Healing of oral wounds
Events in secondary healing
Initial haemorrhage
Acute inflammatory response
Epithelial changes

Epithelial changes
Granulation tissue formation
Wound contracture

RVG 17
Healing of oral wounds
Healing of Gingivectomy wound

RVG 18
 Healing of oral wounds
Gingivectomy wound
Early healing phase
After 2nd day- surface covered by greyish
blood clot, below there is delicate
connective tissue proliferation and
changes preparatory to epithelization
4th day organization and epithelization

RVG 19
 Healing of oral wounds
Gingivectomy wound
Late healing phase
8 to 10 days- nearly complete organization
10 to 14 days- nearly complete
epithelization
2 weeks- mature epithelium formed
Healing of interproximal tissue lags behind
that adjacent to the labial or buccal
surfaces as the interproximal tissue must
grow in from the labial and lingual areas

RVG 20
Healing of oral wounds
Healing of the extraction wounds

RVG 21
 Healing of oral wounds
extraction wounds
Immediate Reaction following Extraction-
Bleeding and clot formation in the socket
RBCs entrapped in the fine fibrin meshwork
ends of torn BV becomes sealed off
First 24-48 hrs- vasodialatation and
engorgement of BV, mobilisation of
leukocytes

RVG 22
 Healing of oral wounds
extraction wounds
First week wound
Proliferation of fibroblasts from
connective tissue cells in the remnants of
PDL into the clot around the entire
periphery (clot acts as scaffold)
Clot is gradually replace by granulation
tissue
Epithelium shows evidence of proliferation
at the periphery
Crest of alveolar bone shows beginning of
osteoclastic activity
Endothelial cell proliferationin PDL
RVG 23
 Healing of oral wounds
extraction wounds
Second week wound-
New delicate capillaries penetrated to
the center of the clot
The wall of socket appears frayed due to
degeneration of PDL
Trabeculae of osteoid can be seen
Considerable epithelial proliferationover
the surface of wound or completed if
small socket is present
Margin of alveolar socket shows
prominent osteoclastic resorption
RVG 24
 Healing of oral wounds
extraction wounds
Third week wound-
Clot is replaced almost completely by
organised mature granulation tissue
Young trabecuale of osteoid tissue is
forming around the entire periphery
Crest of alveolar bone rounded off by
osteoclasts
surface of wound becomes completely
epithelized.

RVG 25
 Healing of oral wounds
extraction wounds
Fourth week wound-
Wound is in final stage of healing ,there is
continuous deposition and remodelling
resorption of the bone filling the alveolar
socket roentgenographic evidence of bone
becomes prominent after 6th to 8th week

RVG 26
 Healing of oral wounds
extraction wounds
Complications of Extraction Wound Healing-
1. Dry socket-
Most common complication
It is focal osteomylitis in which the blood clot
disintegrate or lost , with production of a foul
odor and severe pain but no suppuration
Etiology difficult or traumatic extractions , in
which there is dislodgement of clot and
subsequent infection of exposed bone

RVG 27
 Healing of oral wounds
extraction wounds
C/f commonly occurs in lower PM and molar
sockets
- extemely painful
-the expose bone is necrotic there may
be sequestration of fragments
-foul odor
T/T irrigation of wound by isotonic saline
- packing the socket with obtundent
material like ZnOE paste on iodoform gauze

RVG 28
 Healing of oral wounds
extraction wounds
2. Fibrous healing of extraction wound
Uncommon complication
Followed by difficult,complicated extraction
Loss of both the lingua; and labial or buccal plates of
bones with loss of periosteum
C/F asymptomatic
R/F well circumscribed radiolucent area in the site of a
previous extraction wound
H/F dense bundles of collagen fibers with only
occasional fibrocytes and few blood vessels
T/T excixion of the lesion

RVG 29
Healing of oral wounds
Healing of fracture

RVG 30
 Healing of oral wounds
fracture
Immediate effects of fracture-
Haversian vessels of the bone, along with
vessels of periosteum and marrow cavity
are torn at fracture site
Loss of local blood supply
Osteocytes die due to Loss of local blood
supply
There is death of bone, and bone marrow
adjacent to the fracture line

RVG 31
 Healing of oral wounds
fracture
1. Procallus formation-
Hematoma formation
Inflamatory changes
Granulation tissue formation
Callus formation-
callus is the structure which unites the
fractured ends of bone , and it is
composed of fibrous tissue, cartilage and
bone

RVG 32
 Healing of oral wounds
fracture
External callus- new tissue which forms aroun the
outside of the two fragments of bone
Internal callus- new tissue arising from marrow
cavity
Periosteum is an important structure in callus
formation, hence its preservation is essential
Inner layer of periosteum shows osteogenic
activityand forms a collar of callus around or over
the surface of the fracture

RVG 33
 Healing of oral wounds
2. Osseous callus formation
3. Remodelling
As there is over abundance of new boneto
strenthen the healing site
New bone frequently joined with fragment
of dead bone which should be resorbed
and replaced by mature bone

RVG 34
 Healing of oral wounds
Complications of fracture healing-
1. Nonunion- Callus fails to meet and
fuse or when endosteal formation
of bone is inadequate
Common in elderly ,where there is lack
of osteogenic potential of cells

RVG 35
 Healing of oral wounds
2. Fibrous union- (pseudoarthrosis)
due to lack of immobilization
Fractured fragments joint by fibrous
tissue
There is failure of ossification
3. Lack of calcification-

RVG 36
Healing of oral wounds
Replantation of teeth

RVG 37
 Healing of oral wounds
Replantation of teeth
Insertion of a vital or nonvital tooth into
the same alveolar socket from which it was
removed or otherwise lost
Great use after traumatic injuries
resulting in avulsion or other accidental
loss of teeth, or to replace the tooth
involved in dentigerous cyst after removal
of cyst

RVG 38
 Healing of oral wounds
Incompletely formed roots and open apex -
Replantation without RCT is done
The pulp tissue undergoes necrosis or shows
revascularization and re-innervation, with vital
pulp response
Mature teeth with complete root formation-
Replantation with RCT
If RCT is not done then there will be either pulp
necrosis or gradual obliteration of pulp chamber
or root canal by bone like material

RVG 39
 Healing of oral wounds
Presevation of PDL is an important factor
Partially formed teeth have the ability to
complete root formation and establish a
normal PDL space
There will bevarying degreeof resorption
of cementumand dentin followed
bysubsequent replacement by bone
resulting in ankylosis

RVG 40
 Healing of oral wounds
Factors influencing the success of Replantation-
Extraoral period of the tooth to be Replanted
should not exeed more than 60 minutes ,
otherwise the success rate reduces
The tooth should be kept in moist environment
No strippling or tearing of PDLfibers or of
cementum
Splinting appliances includes StSt wires ,acrylic
splints, orthodontic wires with ligatures and even
surgical cements with guaze

RVG 41
 Healing of oral wounds
Fate of replantation-
Root resorption that may be slow or
gradual.

RVG 42
Healing of oral wounds
Transplantation of Teeth

RVG 43
 Healing of oral wounds
Transplantation of Teeth
Replacement of tooth damaged
beyond repir by caries by another
tooth
Common tooth to be replaced-
mandibular 1st molar by developing
mandibular 3rd molar

RVG 44
 Healing of oral wounds
Criteria of satisfactory Transplantation-
Has become organicallyintegrated with its new
environment
Is free of discernible periapical or lateral lesions,
Is capable of effective masticatory function
Shares adequetly in the maintainence of physiologic
maxillomandibular and muscular relations
Display clinically and reongenographically compatible
status of gingiva, PDL and bone (lamina dura and
supporting bone) root length and over-all stability with
indefinite maintainence
Esthetically acceptable

RVG 45
 Healing of oral wounds
No generalized pulpal necrosis occur after
Transplantation
Pulp becomes revascularised and there is
comtinued growth of root dentin
Pdl ligament is functional viable ,highly cellular
reattaching the tooth in bony socket with gingival
attachment and epithelial attachment resembling
the normal tooth
There is normal color and lusture of tooth

RVG 46
 Healing of oral wounds
Tooth banks are set preserving the
tooth by various techniques-
1. Regular freezing
2. Freeze-drying or lyophilization
3. Vitrification
4. Chemical coagulation by Merthiolate

RVG 47