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5. HEALING OF TISSUE
Is the body response to injury to
restore normal structure and function
Involves 2 processes
Regeneration- parenchymal
Repair – CT
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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
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8. Granulation tissue formation
1. phase of inflammation
2. phase of clearance
3. phase of ingrowth
angiogenesis
fibrogenesis
Contraction of wounds
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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
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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
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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. Healing by Secondary
Intention:
More extensive wounds – infarcts,
inflamm. Ulcers, abcess or large
wounds
Healing from below upwards &
margain inwards
Slow & leads to scar…
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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
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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
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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
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25. Fibrous healing
Uncommon …
Loss of labial & lingual plates
Asymptomatic
Dense fibrous mass on exploration
Excision causes bony repair
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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. 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. 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. 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.
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. 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
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. 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
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. 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. 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.
52. 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)
53. 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)
54.
55. 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
56. 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
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COMPOSITE GRAFT
57. 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
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59. 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
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60. 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
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61. Ideal requirements of bone grafts:
Biologically acceptable
Predictability
Clinical feasibility
Minimal operative hazards
Minimal post-operative sequelae
Patient acceptance
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62. Classification of bone grafts
BASED ON --1.ORIGIN
- autograft
- allograft
- xenograft
- bone substitute material
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64. 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
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65. Osseous coagulum : (Robinson)
Bone dust + blood mixture
Uses particles from cortical bone
Bone blend:
Bone dust + Saline
Bone used is cortical & cancellous
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66. Areas for obtaining bone grafts
Head & neck
Cranium
Mandible
Thorax
Ribs
Scapula
Forearm
Lower limb
Hip (Iliac crest)
Tibia
Fibula
2nd metatarsal
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67. 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
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Decalcified freeze
dried bone
68. 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
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69. 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
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Sophisticated lab procedures
70. 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
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71. 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
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– Dense HA. Porous HA, Bioglass
75. 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.
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