Periodontal healing Attachment, reattachment, new attachment
Plan
-Introduction
1-Definition of healing
2-Some definitions
-Reattach
-New attachment
-Repair
-Regeneration
-Bone filling
-Osteogenesis
-Osteoinduction
-Osteoconduction
3-Factors influencing healing
-Nature of the traumatic agent
-Local conditions
-General conditions
4-analysis of the healing process
-Healing by first intention
-Healing by second intention
5-regenerative potential of periodontal structures
6-healing after periodontal therapy
-Healing after scaling and curettage
-Healing after gingivectomy
-Healing after vestibular deepening
-Healing after Frenectomy
-Healing after graft
-Healing after bone surgery
-Healing after guided tissue regeneration
Conclusion
Bibliography
Periodontal healing Attachment, reattachment, new attachment
Introduction : The ultimate goal that periodontal therapy must achieve is not only the arrest of the progression of progressive periodontal disease but also the restitution of the destroyed parts of the supporting apparatus.
1-Definition of healing : healing is the healing of a wound, that is to say a dynamic process involving all the tissues of the body and tending to restore their anatomy and function.
2-Some definitions:
-Reattachment : this is the reunion of the connective tissue to the tooth after separation of these two elements by incision or injury.
-New attachment : it is the reunion of connective tissue to an exposed root surface due to the evolution of the pathological process. The new attachment is the healing that occurs during the surgical treatment of a periodontal pocket.
-Repair : biological process during which tissue continuity is reestablished by new formations which do not, however, completely restore the architecture and/or function of the damaged tissues.
-Regeneration : biological process by which the architecture and function of tissues damaged during a pathological process are completely restored.
– Creeping attachment: it corresponds to the coronal migration of the marginal gingiva along a dental root presenting a recession and treated for this. This phenomenon is inconsistent and observed in the months following muco-gingival surgery. It occurs between 1 month and 1 year after the intervention.
-Bone filling: it is the clinical restoration of bone tissue in a periodontal lesion.
-Osteogenesis : is the phenomenon by which new bone is formed by bone-forming cells (osteoblasts and pre-osteoblasts), and by osteogenic growth factors contained in the grafted material.
-Osteoconduction : In osteocoduction, the material does not contribute to the formation of new bone directly, but serves as a support for bone formation, which occurs from adjacent natural bone.
-Osteoinduction: it is the property or capacity of a material, a molecule to induce the formation of bone tissue in a non-osseous ectopic site (subcutaneous for example).
3-Factors influencing healing: healing time varies from one individual to another. Certain physiological factors can modify the duration and quality of healing, general pathological manifestations can also modify healing. Healing depends on three categories of factors:
1-Nature of the traumatic agent : the causal agent can be mechanical, physical, chemical, bacterial or electrical. The nature of this agent significantly modifies the conditions of healing.
2-General conditions:
-The possibilities of healing are inversely proportional to the age of the individual.
-black subjects heal more quickly than white subjects.
-some families have higher healing possibilities than others.
-diabetic subjects heal more slowly than non-diabetic subjects.
-a deficient diet can hinder the healing process.
-hormonal disorders have an unfavorable effect.
3-Local conditions : we will take the conditions encountered at the level of the periodontium. The role of bacterial balance, diet, the state of the teeth and especially hygiene is very important.
a-wound characteristics:
– Seat: a correlation between the thickness of the epithelium and healing is always verified.
-The condition of the tissues at the time of the intervention: trauma, necrosis, chronic abscess hinder healing.
-The pressure exerted on the tissues, in the process of healing, is unfavorable.
-vascular stasis and ischemia are unfavorable.
b-nature and technique of the intervention :
-interventions healing by secondary intention will take longer and will be exposed to more frequent complications than interventions with sutured edges.
-the duration of the intervention will be as short as possible.
– local anesthetics may cause adverse vascular reactions.
-hemorrhage is very unfavorable, it interferes with tissue organization and can lead to hyperplastic scarring.
4-Analysis of the healing process:
Periodontal healing by primary intention : for a wound to heal by primary intention, a certain number of conditions must be met:
-the edges of the wound must be exactly joined
– hemostasis must be perfect
– sufficient debridement of the surgical wound
Connective repair : Connective repair can be divided into three phases:
- The inflammation or latency phase (0 to 4 days):
-corresponds to the recruitment of phagocytes (neutrophils and macrophages)
-vasoconstriction followed by rapid vasodilation leads to the formation of a fibrin clot (coagulation)
– neutrophil migration is maximal after 24 hours
-macrophages ensure wound cleansing later (3H-10d)
-appearance of fibroblasts.
Periodontal healing Attachment, reattachment, new attachment
- The granulation tissue formation phase or cellular repair phase (4-9 days):
-neo capillary vascularization
-intense fibroblastic activity (maximum of fibroblasts between 6 and 7 days)
-clinical healing is on the 9th day .
This phase corresponds to an intense centripetal contraction of the edges of the wound due to myofibroblasts rich in contractile material.
- The maturation phase (from the 9th day )
-formation of a new collagen matrix
-functional remodeling of tissues
-after 30 days, the wound is macroscopically normal
Epithelial repair : includes four phases
Differentiation (0-24h). The basal cells of the wound edges differentiate, we observe the appearance of contractile micro filaments in the cytoplasm.
Migration (12-24H). The edges of the wound migrate on the fibrin framework
Proliferation (12-48h) there is cell proliferation
Maturation . This results in keratinization and reorganization of the different cell layers.
Healing by secondary intention : the biological process of healing remains the same in these major phases, some modifications can be noted. Healing by secondary intention occurs whenever a loss of substance prevents the edges of the wound from joining together or when infectious complications arise on a sutured wound leading to the wound’s disunion. What dominates healing by secondary intention is the risk of secondary infection. It corresponds to a variable loss of substance. It includes three distinct phases.
– suppurative detersion : this inflammatory and vascular phase results in the elimination of necrotic tissues by enzymatic cleavage by inflammatory and bacterial cells.
– budding : a proliferation of fibroblasts is observed. The bottom of the wound buds and histologically gives a transient fibrous granulation tissue: the fleshy bud (symbol of healing by secondary intention). This bud gradually fills the height of the loss of substance. Its surface area decreases thanks to the progressive rapprochement of the edges of the wound.
– epithelialization: this is the closure of the wound, done from the edges by covering the granulation tissue which fills the loss of substance. This phase is characterized by scar retraction linked to the contraction of myofibroblasts (rich in actin and myosin)
5-Regenerative potential of periodontal structures : several types of healing can occur depending on the tissue that ensures periodontal-tooth coaptation
-The long junctional epithelium is the most commonly encountered situation.
– Connective tissue adaptation without formation of gingivo- dental fibers (fibrous sleeve under the junctional epithelium)
-Ankylosis when bone tissue colonizes the dental surface, leading to rhizosis and loss of the dental organ.
-Periodontal regeneration which is the goal sought by RTG techniques with obtaining a new attachment system by formation of new cementum, a new ligament and new bone tissue.
6-Healing after periodontal therapy
Healing after scaling and curettage: Restitution and epithelialization occur within two to seven days. Immature collagen fibers appear within 21 days after treatment. Healthy gingival fibers that were inadvertently cut during scaling, root planing, and curettage, as well as tears in the sulcular epithelium and epithelial attachment, are repaired during the healing process.
Periodontal healing Attachment, reattachment, new attachment
Healing after gingivectomy:
-After external bevel gingivectomy (EBG) : surface epithelialization is usually complete after a period of time that varies between 5 and 14 days. Healing of a gingivectomy wound is completed in 4 to 5 weeks, although on clinical inspection the gingival surface may appear to be already healed after about 14 days. Healing after external bevel gingivectomy is by secondary intention.
-After internal bevel gingivectomy (IBG): it is done as a first intention .
Healing after vestibuloplasty : After the denudation or partial thickness flap technique, the cruent area is covered with granulation tissue from the marrow spaces, the periosteum left in place and the gingiva as well as the surrounding alveolar mucosa.
Healing after frenectomy: healing is first intention at the bottom of the vestibule, but second intention at the level of the triangle (insertion of the frenulum) where the fenestration was performed. Epithelialization occurs in one week.
Healing after gingival grafts : example of epithelial-connective graft:
-Donor site: this is healing by secondary intention: epithelialization from the edges of the wound is complete after about 2 weeks for a medium-sized graft. Clinical healing is complete after one and a half to two months.
-Recipient site: Unlike the donor site, the recipient site heals by primary intention. Clinical healing is generally faster than at the donor site.
Healing after bone surgery: the healing phase is systematically accompanied by postoperative resorption of the alveolar bone in height and thickness. Healing and maturation of the bone are longer after osteoplasty than during simple bone exposure in the context of access surgery.
Healing after guided tissue regeneration: the guided tissue regeneration technique makes it possible to recreate the periodontal structures degraded by the disease, i.e. new cementum, new bone, new ligament and new connective tissue attachment.
Conclusion: Healing is a dynamic process lasting several weeks, the final result of which will depend on the quality of the intervention, the surrounding local factors and the general terrain on which the surgical procedure was performed.
Bibliography:
-BERCY. TENENBAUM Periodontology from diagnosis to practice preface by Pierre Lewansky de Boeck-university.
-Francois Vigouroux Practical guide to periodontal surgery Elsevier Masson SAS, 62, rue Camille-Desmoulins, 92442 Issy-les-Moulineaux cedex
-Jan Lindhe manual of clinical periodontology cdp edition
-JJBARRELLE Simon HIRSH Introduction to periodontology publication AGECD legal deposit 2nd quarter 1973.
-Irving Glickman
-Philippe Bouchard periodontology implant dentistry volume 1 periodontal medicine Lavoisier Medicine
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain