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口 腔 病 理 科口 腔 病 理 科 Wound Healing 傷口癒合 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755

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Presentation on theme: "口 腔 病 理 科口 腔 病 理 科 Wound Healing 傷口癒合 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755"— Presentation transcript:

1 口 腔 病 理 科口 腔 病 理 科 Wound Healing 傷口癒合 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

2 學 習 目 標學 習 目 標 1. Regeneration & repair 2. E pithelium & connective tissue 3. E xtraction wound 4. B one fracture

3 參考資料 (1) References 1. Ibsen OAC: Oral Pathology for the dental hygienist. 4th ed., pp. 36- 52 2. Avery JK: Oral Development & Histology, pp. 192-212 3. Horwitz AF: Integrins and Health. Sci Am 1997;May, 68-75 4. Singer AF et al: Evaluation and management of traumatic lacerations. New Eng Med J 1997;337:1142-8 5. Habeck M: Wound-healing genes promote cancer progression. Lancet Oncol 2004;5:138 6. Epstein FH: Cutaneous wound healing. New Eng Med J 1999;341:738-46 7. Kaohsiung Medical University, Oral Pathology Department 8. Sompayrac L. How the immune works Lecture 1. An overview 1999:p.5-16 9. www.mybiology.com/archive_movies 10. http://www.bu.edu/woundbiotech/WoundHealingProcess/

4 參考資料 (2) References 11. http://connection.lww.com/products/taylor/documents/cc37figure37- 1.jpg 12. http://ls.berkeley.edu/bio/gallery_mcb/wound.html 13. www.nchmd.org 14. http://www.ma.hw.ac.uk/~jas/researchinterests/scartissueformation.html 15. http://www.malp-research.de/ 16. http://www.imakenews.com/mvius/e_article000210982.cfm 17. Awang MN. The aetiology of dry socket: a review. Int Dent J 1989;39:236- 40 18. 徐博文、謝耀東 拔牙後齒槽骨傷口之癒合 中華民國口腔植體學會會訊 1997 年 5 月 第 4 期 p.27-30 19. Shafer WG. A textbook of oral pathology. 1 st edition, p.609-10 20. www.unireptile.com/amphibian/newt/newt_web.htm 21. Nanci A. Ten Cate’s Oral Histology 7 th ed., pp. 388-9

5 Regeneration Wound Healing ( 再生 ) 1 2 When tissue damage is slight, the inflamed area may return completely to its normal structure and function This is the most favorable end to acute inflammation and involves: 1.Complete removal of all cells, by-products inflammatory exudate that enter the tissue 2. Return of microcirculation to its preinflammatory state 蠑螈 Ref. 20

6 Repair Wound Healing ( 修復 ) Bruxism - Attrition Brushing- cervical abrasion Repair takes place when complete return of the tissue to normal is not possible because the damage has been too great Some tissues, such as epithelium, fibrous connective tissue, and bone have the ability to undergo repair. Other tissues, such as enamel, dentin, cementum do not Ref. 1

7 Repair Wound Healing Traumatic ulcer Sharp edge tooth Fungus infection Tumor Repair is the body’s final defense mechanism in its attempt to restore injured tissue to its original state During repair process, destroyed cells & tissue are replaced with live cells & new tissue components Repair process cannot be completed until the source of injury is removed or the injurious agents are destroyed Refs. 1, 7

8 Repair Epithelium and connective tissue Extraction wound Bone fracture Wound Healing

9 Repair Wound Healing Injury 1. Inflammation 2. Epithelization 4. Granulation tissue 3. Neurovascularization 5. Contraction 6. Collagen formation7. Scar remodeling Events of wound healing Ref. 1

10 Repair Wound Healing Microscopic events that occur during repair 1. Occurs in both epithelium & connective tissue 2. These events are different for each of these tissues but occur almost simultaneously and are dependent on each other for optimal healing If the source of injury is removed, the repair process is usually completed in 2 weeks Repair process is slightly different in mucosa than in skin because mucosal tissue are wet & a scab does not form

11 Repair Wound Healing Day of Injury. A clot forms as the blood flows into the injured tissue. The clot or meshwork of fibrin is produced in the area of injury as a result of activation of the clotting mechanism The clot consists of locally produced fibrin, clumped red blood cells and platelets (thrombocytes) Platelets are found in blood are important in the formation of a clot

12 Repair Wound Healing Clotting mechanism Blood (Factor XII) 1 2 3 4 Clot Ref. 2

13 Repair Wound Healing Neutrophil One Day After Injury. Acute inflammation takes place in the area of repair Neutrophils emigrate( 攅入 )from microcirculation into the injured tissue, phagocytosis of foreign substance & necrotic tissues Ref. 1

14 Repair Wound Healing Engulf Phagosome Phagolysome Excretion Refs. 1, 2 www.sumanasinc.com/webcontent/animations/biology.html

15 Repair Wound Healing Stem Cell Differentiation

16 Repair Wound Healing Monocyte (Blood) Macrophage (Tissue) Ref. 1

17 Repair Wound Healing Macrophage Foot Bacterium Refs. 8, 15

18 Repair Wound Healing Ref. 8

19 Repair Wound Healing 2 Days After Injury. Monocytes emigrate from microcirculation into the injured area as macrophage Macrophages continue phagocytosis Neutrophils are reduced in number as chronic inflammatory process proceeds Fibroblasts increase in number within the injured connective tissue Producing new collagen, using fibrin meshwork as a scaffold ( 鷹架 )

20 Repair Wound Healing Need to be removed for proper healing Initial tissue formed in connective tissue is called granulation tissue It has more capillaries & fibroblasts Sometimes the growth is excessive

21 Repair Wound Healing Epithelial new surface Granulation tissue If the surface epithelium is destroyed by injury, epithelial cells create a new surface tissue at the same time that granulation tissue forms in the injured connective tissue Epithelial cells from borders of the healing injured area lose their cell junctions and become mobile They can divide and migrate across injured tissue, using fibrin meshwork as a guide to form a new surface layer Ref. 2

22 Repair Wound Healing Functions of fibrin meshwork 1. Guide for migrating epithelial cells 2. Scaffold for forming connective tissue 3. Protect the two newly formed tissues Clot remains in place is important: 1. Allow optimal repair in both tissues 2. Dressing placed over the clot may be beneficial to healing process

23 Repair Wound Healing Inflammatory phase Ref. 6

24 Repair Wound Healing A: Cell Adheres Infection or injury Detressing signals Resting Activated Neutrophil B: Cell rolls C: Cell stops & flattens D: Cell emigrates ICAM: Intercellular adhesion molecules ICAM From one selectin to adjacent selectin Ref. 3 http://multimedia.mcb.harvard.edu/media.html

25 Repair Wound Healing Reepithelization & neovascularization 1. Guide for migrating epithelial cells 2. Scaffold for collagen 3. Protection Ref. 6

26 Repair Wound Healing pithelium Contact inhibition Epithelium Ref. 4

27 Repair Wound Healing Abnormal mitosis Capillary spouts Ref. 4

28 Repair Wound Healing At the end of 2 days. Lymphocytes & plasma cells emigrate from surrounding blood vessels into the injured area as chronic inflammation and immune response begin Macrophages present in the area assist lymphocytes in the immune response occurring at the site injury Ref. 1

29 Repair Wound Healing Two Days Ref. 1

30 Repair Wound Healing 7 Days After Injury. Fibrin is digested by collagenase & sloughs off, and the initial repair is completed Clinically, surface of repaired injury remains redder because of the thinness of new epithelium and increased vascularity of new connective tissue

31 Two Days Seven Days Repair Wound Healing Ref. 1

32 Repair Wound Healing Contraction 2 Wks After Injury. The initial granulation tissue & its fibers have been remodeled, giving the tissue its full strength The new tissue is called scar tissue and appears whiter or paler at the surface of the repaired injury due to increased collagen and decreased vascularity Refs. 2, 14

33 Repair Wound Healing Ref. 9

34 Repair Wound Healing Amount of scar tissue depends on: Heredity, strength & flexibility needed, type of repair Oral mucosa is lesser scar formation than skin

35 Repair Wound Healing Types of repair: Healing by primarily intention Little loss of tissue, clean edges are joined with sutures to form a small clot, & little granulation tissue Less scar tissue & higher retention

36 Repair Wound Healing Sutured injury (Primary wound healing) Small clot Decreased granulation tissue Less scar tissue Ref. 1

37 Repair Wound Healing Simple Suture ( 前旋 ) Ref. 4

38 Repair Wound Healing Deep Suture Ref. 4

39 Repair Wound Healing Ref. 4 Common techniques of wound closure TreatmentAdvantageDisadvantage Sutures Tissues Adhesives Staples ( 釘書釘 ) Surgical Tapes

40 Repair Wound Healing Healing by secondary intention There is loss of tissue, so the edges of injury cannot be joined A large clot slowly forms, resulting increased granulation tissue (e.g. extraction site) Ref. 7

41 Repair Wound Healing Large injury (Secondary wound healing) Large Clot Increased granulation tissue Increased scar tissue Ref. 1

42 Repair Wound Healing Healing by tertiary intention (delayed primary) If infected wound left open for a few days, edges not surgically joined until infection is controlled Waiting to close as if primary until infection is resolved

43 Repair Wound Healing Tertiary Intention Wound Increased granulation Late suturing with wide scar Ref. 11

44 Repair Wound Healing keloid Keloid Excessive scarring in skin, sometimes need surgically removed Ref. 1

45 Repair Wound Healing Ref. 10

46 Repair Wound Healing Ref. 10

47 Repair Wound Healing Ref. 10

48 Repair Wound Healing Ref. 10

49 Repair Wound Healing Ref. 10

50 Repair Wound Healing Ref. 10

51 Repair Wound Healing Ref. 10

52 Repair Wound Healing 維他命 C Refs. 13, 16 高壓氧

53 Repair Wound Healing Ref. 10

54 Repair Wound Healing Extraction Wound

55 Repair Wound Healing Extraction Wound Ref. 18

56 Repair Wound Healing Extraction Wound Ref. 18

57 Repair Wound Healing Ref. 18

58 Repair Wound Healing Extraction Wound Ref. 18

59 Repair Wound Healing Extraction Wound Ref. 21 Comparison of Repair Responses in Skin and Teeth Repair Response Repair Response In skin In teeth

60 Repair Wound Healing Extraction Wound Ref. 21 The tooth in situ Repair response after tooth extraction Hemostatic response: The socket fills with clot

61 Repair Wound Healing Extraction Wound Ref. 21 Epithelial response: 1. Proliferation & migration of cells to epithelialize the socket (10 days) Inflammatory response: 2. Polymorph response 3. Macrophage response 4. Cells with osteogenic potential invade the clot from adjacent bone marrow (10 days)

62 Repair Wound Healing Extraction Wound Ref. 21 Proliferative and synthesizing phase: New osteoblasts differentiate and proliferate, and form new bone to fill the extraction (10-12 weeks)

63 Repair Wound Healing Extraction wound Normal Healing Delayed Healing (dry socket) Extraction Wound Ref. 17

64 Repair Wound Healing Repair of a bone injury is similar to the process that takes place in fibrous connective tissue except that it involves the creation of bone tissue, produced by osteoblasts

65 Repair Wound Healing Mechanisms of Bone Healing: Formation of new bone at fracture site Clotting of blood and formation of hematoma; 6-8 hr Organization of hematoma: 10 days to complete a. fibrin b. phagocytic activity c. granulation tissue Formation of fibrous callus

66 Repair Wound Healing Formation of primary bony callus; 10-30 days to complete a. Stages of primary bony callus 1. Anchoring callus 2. Sealing callus 3. Bridging callus 4. Uniting callus b. Low calcium; no radiographic image

67 Repair Wound Healing Anchoring callus Bridging callusUniting callus Sealing callus Fracture site Formation of Primary Callus Ref. 19

68 Repair Wound Healing Formation of secondary bony callus 20-60 days a. Irregular bone; influx of calcium radiographic image b. Removal of cast; 4-5 week for jaw bone Reconstruction and remodeling a. Alignment to stress b. Removal of excess

69 Repair Wound Healing Healing of bone depends on Interrupted by removal of osteoblast-producing tissues Increased movement of bone Presence of edema or infection

70 Repair Wound Healing Fixation 2 Fixation 1

71 Repair Wound Healing Wound healing genes promote cancer progression Ref. 7 It has long been recognized that carcinoma cells & their surrounding stroma behave in a remarkably similar way to cells in a healing wound with characteristics such as rapid division, migration, remodelling & invasion of connective tissue, and in ability to induce angiogenesis. In 1986, Harold Dvorak (Berth Israel Deaconess Medical Center, Boston, MA, USA) made the most graphic analogy between wound healing & cancer when he said that tumors are wounds that do not heal. It has long been recognized that carcinoma cells & their surrounding stroma behave in a remarkably similar way to cells in a healing wound with characteristics such as rapid division, migration, remodelling & invasion of connective tissue, and in ability to induce angiogenesis. In 1986, Harold Dvorak (Berth Israel Deaconess Medical Center, Boston, MA, USA) made the most graphic analogy between wound healing & cancer when he said that tumors are wounds that do not heal.

72 口 腔 病 理 科口 腔 病 理 科 1. Regeneration & repair 2. E pithelium & connective tissue 3. E xtraction wound SUMMARIES Processes, types, characteristics 4. B one fracture


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