Osd 3 3-2 Aghaloo Wound Healing

Front 1

Definition of a wound

Back 1

any anatomical or functional interruption in the continuity of the tissue that is accompanied with cellular damage and death

Front 2

Etiology of Wounds

Back 2

Traumatic Injuries
Chemical
Physical
Pathologic
Cause disruption of tissues such as carcinomas and non healing ulcers(TB and Sarcodiosis)

Front 3

Physical Injury-*

Back 3

Crushing-rubber dam clamp
Extreme Temperatures
Irradiation-cancer patients
Dessication
Obstruction of arterial inflow or venous outflow-espeically in toes and fingers w/ diabetes and peripheral vascular disease
Denture irritaiton

Front 4

Chemical Injury-*

Back 4

-unphysiologic pH-very acidic or basic
-disrupt of protein integriy
-ischemia
-aspirin
-phenol
-arsenic and acids(ill-advised chemical consumption)

Front 5

Healing definition

Back 5

-Series of coordinated processes initated by injury and directed toward restoring structural and functional integrity

Front 6

Types of Wound Healing

Back 6

Primary-edges are put together-for soft and hard tissue healing(suturing)

Secondary-granulation tissue forms and epithelium migrates across to close up wound
ex. avulsed piece of tissue with too much tissue loss to close the wound-->formation of 2ndary healing

Tertiary Healing-delayed primary closure
ex. if wound is dirty, clean it out and then LATER freshen margins and close it to avoid sealing bacteria in

Front 7

Primary Intention
-tissue?
-how to start it?
-scarring?
-how fast does it feal?
-used for?

Back 7

-minimal tissue loss
-wound edges brought into contact with sutures
-minimal scarring
-rapid healing
-well repaired incisions and well reduced bony fractures

Front 8

Secondary Intention
-wound edges?
-size of defect? filled with?
-scarring?
-healing?
-used for?

Back 8

-Wound edges widely separated from surgery or tissue loss
-defect is large and filled with blood clot(starts healing process)
-scar formation, slow healing
-extraction sockets, avulsive injuries, poorly reduced bony fractures

- dont undermine gingiva and close via unattached mucosa

Front 9

Tertiary Intention

Back 9

Wound left open for period of time then closed with a tissue graft

Front 10

Healing of Extraction Socket
-type of intention
-what happens inititally? for what reason?
what occurs during the first week? what happens in the wound?
-epithelium?
-sequence of events

Back 10

-2ndary intention
-blood clot forms wihtin 24 hrs, coagulates and seals off from oral cavity

1st week: inflammatory phase + fibroplasia
-WBCs debride bacteria, bone, osteoclasts along wound margin


-epithelium migrates along socket wall until it reaches the other side

-2nd week: granulation tissue and new trabecular bone by osteoblasts-delay in pts with osteoporosis or bone problems

-4th week: epithelialization complete-may cause concerns in the anterior region

-4th week: new bone formation though poorly calcified-(refracture of bone is easy so must wait 6-8 weeks before physical activity)

-4-6 weeks: complete healing

Front 11

Stages of Wound Healing

Back 11

Inflammatory Stage-blood clot, inflammatory cells
Fibroblastic Stage(granulation tissue)-fibroblast come in, growth factor release, lattice network of soft/hard tissue laid down
Remodeling Stage-tissue becomes stronger or bone turns over to become lamellar rather than woven(which is initially formed during wound healing)

Front 12

Inflammatory Stage
begins?
how long?
signs?
wound strength?
role of Fibrin?

Back 12

-when tissue injury occurs
-3-5 days
-eat soft foods only and gentle brushing
-erythema, edema, warmth, pain, loss of fxn
-no gain in wound strength
-fibrin holds wound together-gets stronger in later stages

Front 13

Back 13

Front 14

Inflammatory Stage-Vascularity
-immediate reaction?
-initiates?
-releases?
-vasoeffects?
-leukocytes
-max swelling occurs?

Back 14

-vasconstriction immediate(maynot be possible with anticoagulants)

-clotting cascade from veseel disruption

-Mediators: Serotonin, Histamine, Prostaglandin

-Vasodilation and increased vascualr permeability

-leukocytes(debride) adhere to endothelial cell wall, migrate to interstitial tissues-->edema(max swelling48-72 hrs post procedure...1 week for large surgery)

Front 15

Cardinal Signs of Inflammation

Back 15

Warmth and erythema-->vasodilation

Swelling-->leakage of fluid

Pain and loss of fxn--> release vasoactive amines and pressure from edema

note: vicodin may not be as effective as antiinflammatories if inflammation is the reason for pain

Front 16

Cellular Componenet
-triggered by?
componenets

Back 16

-activation of complement

-C3, C5 chemotactic factors
-neutrophils-initial
-macrophages-debride + growth factors for healing
-lymphocytes

Front 17

Neutrophils
-how soon do they appear?
-mechansim
-fxn

Back 17

-first cells that appear
-6-12 hours
-release lysosomal enzymes(proteases)
-digest necrotic debris and bacteria

Front 18

Macrophages
-type of cells
-fxn?
-attracted by?
-release?

Back 18

-phagocytic cells
-continue debridement
-chemoattractants, fragments of collagen, TGF-B1, thrombin(lattice of fibrin to strengthen wound)
-release biologically active substances like pgs, lks, gfs

Front 19

Growth Factors
-necessary for?
-secreted by?
-examples

Back 19

-necessary for inititiation and propagation of granulation tissue
-secreted by macrophages
-PDGF, TGF-a, TGF-b, EGF, FGF

Front 20

Lymphocytes
-mostly found in?
-tcell function?

Back 20

-T and B cells are found in chronic inflammation
-can cause serious dammage in PA lesion or endodontics

-T-cells secrete lymphokines, chemotactic for fibroblast proliferation

Front 21

ECM
-how much?
-what holds the wound together?

Back 21

-little ECM present
-only fibrin holds wound together at this stage
-fibrin scaffold for fibroblasts to lay down ECM in granulation tissue phase

Front 22

Fibroblastic Stage(Granulation Tissue)
-timing
-what forms
-vascularity?
-type of wound healing
-what do you see?

Back 22

-2-3 weeks-wound starts to strengthen

-Fibrin scaffold

-Collagen deposition

-revascularization

-haphazard wound healing

-macrophages, fibroblast ingrowth, loose connective tissue, angiogenesis

Front 23

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Front 24

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Front 25

Wound Contraction
-occurs at?
-presents significant amounts of?
-what happens to fibroblasts
-how to reduce this?
-what happens to the wound?

Back 25

-movable wound edges
-granulation tissue
-fibroblast phenotypic changes during wound contraction
-inhibit granulation tissue reduces contraction such as skin grafts
-reepithelialization and contraction close wound

Front 26

Remodeling Stage(maturation)
-timing?
-begins with?
-physical changes?
-scar changes?

Back 26

->3 weeks
-begins with remodeling

-increase in tensile strength
-not really possible to tear up wound after this
-reorganization of collagen-not as haphhazard

-scar softens and contracts
-can massage

Front 27

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Front 28

Abnormal Scar Formation
-Hypertrophic scar
-scars usualy present as
-HT presents as
-Keloid
-presents as
-common in
-occurs in people
-how to prevent this?

neither happen intraorally

Back 28

-Hypertrophic
-scar is usually flat w/ less pigment than tissues surrounding area
-raised and pink-ish

Keloid
-extra piece of tissue that proliferates and grows out
-common in asian/african americans
-often shows up in the past-some people more prone
-try intraoral approach to prevent this

Front 29

Surgeon's goal

Back 29

to produce a scar that minimizes loss of fxn and looks as inconspicous as possible

Front 30

Factors that impair wound healing

Back 30

-foreign material
-necrotic tissue
-ischemia
-tension-causes tissues to become ischemic(decreased vascularity and thus healing)

Front 31

Bone Healing and Repair types

Back 31

Direct
Indirect

Front 32

Direct Bone Healing
-contact?
-distance?
-kind of healing
-relies on what type of fixation
-type of bone deposition
-extent of callus?
-what is found in the area?

Back 32

-edge to edge contact
-< 1mm
-cellular healing
-rigid bone fixation
-Direct lamellar bone deposition
-minimal callus formation
-osteoblasts, haversion canal, osteoclasts

Front 33

Indirect Bone Healing:
-type of callus
-pathway
-what forms?
-effect mobility has on healing

Back 33

-collagenous bridging(callus)

- hematoma-->inflammatory phase-->granulation tissue--?fibrous tissue--?fibrocartilage callus-->cartilage-->osteoid tissue

- woven bone forms by endochondral ossifcation

- poor bone formation-->mal-union of bone-->negatively affects occlusion in jaws

Front 34

Adequate Bone Healing needs?

Back 34

-vascular supply-nourishment and oxygen supply

-immoblization-slight tension to sitmulate continued osteoblastic proliferation and ossification

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Front 38

Complications of Bone healing

Back 38

-nonunion(not immobilized, not enough vascularity, segment too long)
-failure of fracture to heal
-infection
-osteomyelitis(hard to tx b/c hard for antibiotics to penetrate into bone)

Front 39

Implant Osseointegration

-effect on epithelium
-what must happen on implant surface?
how long does it take for full integration?

Back 39

-bone-implant interface inhibits lateral growth of epithelium without contact inhibition

- bone healing onto implant surface must occur before soft tissue forms
-want bone surrounding entire implant
-6 months needed for full integration
-but now can put crown immediatley on and load it

Front 40

implant OI
-distance between bone and implant
-need what kind of bone near the implant
-why do you need a nightguard/splint
-surface needs to be free of?

Back 40

-short distance b/w bone and implant

-viable bone at or near surface of bone along the implant
-can do bone graft or put implant deeper

-no movemment of implant while bone is attaching to its surface

-implant surface free of contamination by organic/inorganic materials

Front 41

IO be careful of

Back 41

excessive loading

Front 42

Factors Affecting Healing

Back 42

IF DINAR

- Infection
-Foreign Material

-Diabetes
-Ischemia(hypoxia)
-Nutrition(protein and vitamin deficiency)
-Age
-Radiation

Front 43

Bacterial Infection
-role in healing?
-what does it do?
-sxs?
-releases?

Back 43

-major cause of impaired healing
-colonization with inflammation leads to further tissue damage
-redness, heat, edema, pain, leukocytosis, fever
-release of proteases and oxygen free radicals, cell lysis, destruction ECM, impaired healing

Front 44

Ischemia(hypoxia)
-how does it impair healing?
-what leads to ischemia
-causes?

Back 44

-decreased O2 impairs healing

-constricting sutures, tissue edema, necrotic tissue
-anemia(not as much blood to tissues), malnutrition, sepsis lowers tissue oxygen

-cell death-->release proteases and glycosidases
-tissue breakdown and impaired healing

Front 45

Radiation
-dependent on?
-type of effects?
-how is it damaging?

Back 45

-dose depdendent
-acute and chronic effects
-Acute-->mucositis, erythema, desquamation
-Chronic-->irreversible, in vessel walls, skin connective tissues and mucosa

-osteoradionecrosis of bone
radiation effects do not get better with time but get worst due to lessening of blood supply

Front 46

Age

Back 46

-more susceptible to wound healing problems
-decline in general health

Front 47

Therapeutic Agents
detrimental?
what stimulates healing?
what do chemotherapeutics do?
can possbily arrest?

Back 47

- detrimental effects on health
-steroids, anticoags, antineoplastics

-growth hormone, Vitamin A and C stimulate healing

-chemotherapeutics inhbit wound repair
-decrease tensile strength

Arrest inflammatory phase
-suppress protein synthesis and cell proliferation

Front 48

malnutrition
-role in wound healing
-good nutrtion does what?

Back 48

-greatest contributor to poor wound healing, esepcially in elderly

-enhance immune response
-stimulate hormone secretion