Clinical Correlates Flashcards
When does the second phase (late phase) of wound healing start
Day 2-3
Late phase involves what cells (4)
Monocytes
Macrophages
Fibroblasts
Mesenchymal SC’s
Bone vs tissue in wound repair
Last phase can last long in bone- woven bone to mineralized
Most variable phase?
Matrix formation (the last one) 10-100+days
Granulation/tissue formation/proliferation stage involves (2)
T-cells and endothelium
Cells in early phase(1)
PMNs
Hemostasis components involved(3)
RBC
Fibrin
platelets
Pure Mucogingival
Defect 2nd Premolar
Cause?
tooth erupted too buccal/bone was absent to begin with….. Then gingiva was brushed away (from chronic trauma)
How to treat Pure Mucogingival
Defect 2nd Premolar (Graft and donor sites)
Marginal Free Gingival Graft – 1° intention
Donor Site – 2°
intention
Primary intention healing
close the wound
Secondary intention healing
Explain and used in what (2)
leave an ulcerated area (no tissue covering) i.e. extraction socket
ulcerations and gingivectomy
Miller class recession for Pure Mucogingival Defect 2nd Premolar
Class II/III
Treating the Recipient Site Prep for Marginal Free Gingival Graft
Procedure/Prep (3 steps)
Where do you do excision? leave what intact?
- Primary Incisions
- Split-thickness flap
– Sharp dissection - Excision of flap at
base leaving bleeding connective tissue bed with periosteum layer intact
Donor site split flap will heal via what method?
secondary intention
Take tissue from where (labial or near palate?)
split flap is taken off what?
Labial-by cheek
taken off the periosteum
Grafts are mobile or not after surgery?
Immobile-don’t move it
Epithelial (Epi) will start migrating in the repaired area of a graft in how long? What about blood vessels?
12 hours for Epi
24-48 hours for vessels
What is important after surgery (think hemostasis)
Direct pressure to form a thin clot which will seal the wound
Angiogenesis will occur how long after gingival graft in the repaired area?
24-48 hours
Antiseptic mouth rinse post gingival graft?
Some people say yeah (he does), some say no-but…. DO NOT BRUSH (has to be immobile)
Why can you not brush after gingival graft?
It has to be immobile!!!
Who wrote the first paper on gingival grafting and healing? When was it written?
Atkins in 1966…
First 24 hours of healing you only get what
diffusion of oxygen-aka plasmatic circulation?
Red good after grafting?
Yes-means blood vessels are moving in
7 Day Normal Healing
Migration? How much if so?
Sutures?
Incision lines closed
– Epithelial cell migration
– 0.5 mm/day
Remove sutures
– Could slow healing
8 weeks FGG
Tissue attached to what?
What happens the next 3 months?
Tissue attached to root
Remodeling of wound edges over the next 3 months
how long will it take for tissue from graft to heal to the point that they will not know (secondary healing)
~1 week
How long does it take a clot to form in the secondary intention healing? Thus you are past early inflammation phase
~24 hours
Epi (epithelium) migration between clot and CT in secondary intention healing takes how long
48-72 hours
Osteoclast and osteoclast activity takes how long to begin after a large wound is opened in secondary intention healing
Osteoclastic activity
– Maxes out in 2-10 days
Osteoblastic activity takes over…
– Maxes out in 10-28 days
When does CT begin to organize in secondary intention healing at graft site
~7 DAYS, clot will convert to granulation tissue
by 8 wks bone loss has regenerated
Grafting in diabetic patients
Simply a much slower process
Age and healing in grafts
As one ages, wound healing slows
Is the effectiveness of wound healing between healthy and diabetic diff in the long run or just the rate?
Just rate-they will heal equally as well just diabetics will heal much slower
Clinical Consequences of extraction (4)
- Alveolar bone resorption-horizontal & vertical
- Increase functional demands on remaining dentition (more stress)
• Need for restorative
dentistry
• Unesthetic appearance
– Loss of papillae – Shadows
Modernly..Extraction: Clinical Considerations
What are we doing differently? Why?
Socket Grafting/Ridge
Preservation
Post- extraction ridges shrink over time
– 2-3mm horizontal ridge reduction
-1 mm vertical ridge reduction
Study by who and when on extraction socket anatomy
Januario 2011
From what to what is thin bone found (what tooth to what tooth)
Canine to canine, particularly on the facial
Two things supplying blood to the bone area
PDL and gingiva
What happens during– Hemostasis/Inflammation (2)
- Clotting
* PMN clean up
Proliferative phase of socket extraction healing (2)
Angiogenesis/Granulation and provisional matrix
Modeling and remodeling phases of socket extraction
Woven bone to lamellar bone
Most variable stage of healing after graft
The mineralization of bone
Overview: Socket healing by day
Day 1,2-3,7,20,38
This is from what study?
Day1
– Clot forms / PMN’s clean up
Day 2-3
– granulation tissue at base of socket
Day 7
– early CT & bone formation at base
Day 20
and bottom 1/3 of socket – complete clot organization & CT
fills socket
Day 38
– immature bone fills 2/3rd of socket
From Amler 1999
Factors Influencing Resorption (7)
-Smoking
-General systemic health
-Condition of the socket pre and post op
-Influence of the tissue biotype
-Local differences in the sites of the mouth and the dental arches
-Type and quality of the intermin prosthesis
(flipper that does blanch the tissue)
Early socket healing between 2-4 weeks of granulation tissue was studied by who and when
Trombelli 2008
Early socket healing between of granulation tissue in one study was seen as fast as what?
2-4 weeks. This was that Trombelli guy.
Granulation Tissue
– Rapid angiogenesis
– Seen in 4 of 10 samples
– Other 6 samples had moved past this
phase
Provisional matrix in early socket healing at 2-4 wks is made up of what 3 things?
– Densely packed
mesenchymal cells
– Highly vascular
– Dense fibrous tissue
Immature woven bone makes up what % of intermediate socket healing from 6-8 wks?
What is the makeup of the rest???
immature woven bone (~33%)
Provisional matrix
(~60%)
– Cell & fiber rich
Very little granulation tissue remains (<5%)
Early disruption dry socket clot formation research done when
1999
Early disruption dry socket clot formation research… Pus leaving after 20 days means?
bad…. Neutrophils should have left a long time ago
osteomyelitis and why?
infection of the bone, calculus was not removed in extraction
Tx for osteomyelitis
Placed on metronidazole & Chlorhexidine rinses
Why is healing on lower lingual bone hard
cortical bone-thick and does not heal well-little vasculature
What to know about extraction in esthetic zone
prep for healing ahead of time
Fractured ant tooth preferred Tx is what
placement
Extraction #8 &9
• Socket Preservation • Delayed Implant Placement
• FPD #7-10
used to remove coronal aspect of roots
Periostomes
Capset is made of
Calcium phosphate-artificial bone placement/holder
Purpose of capset/FBDA + Biomend in socket
holding place for gingival tissue
If you Flap it, you cause two things to happen…
2
– Lose periosteal blood supply temporarily
– Lose PDL blood supply permanently
SIE stands for what?
• SIE
– Support immersion endoscopy
WOUND repair progression (4 main phases)
Hemostasis –> Inflammation –> Granulation tissue Formation/Proliferation –> Matrix formation/remodelling
Wound contraction starts in which stage and around what day in the phases of wound repair?
In early granulation formation stage which is around day 3
How long after a graft will the stage of re-vascularization take to begin?
~30 hours, before this it is just circulation (oxygen diffusion)
How long after a graft will the stage of vascular re-organization take to begin?
~9 days, goes through 28 days.
When is the stage of organic union?
Part of stage of revascularization and vascular re-organization… Not really sure what this is though.
Late socket healing (12-24 weeks) has components of what (4 things)
What makes up the bulk of most samples?
Woven bone~33%
Lamellar bone in deeper regions ~10%
Adipocytes in marrow spaces
Provisional matrix ~60% and makes up the bulk of most samples
Over time in socket healing, what is replaced by what?
Granulation tissue is essentially replaced by lamellar bone
Dry sockets are caused by a disruption in what
Fibrin clot-at about 2 days
By what day will you have a dry socket after fibrin clot disruption?
~4 days
20-30 days after clot disruption post socket surgery, what will be seen?
Dry sockets which have let to suppurative osteitis w/ boney sequestrum-The point is PMNs dominate the area and it is infected-Osteomyletis
