Wound Management
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PRINCIPLES OF WOUND HEALING
There are five phases of healing of an extraction site.
- Hemorrhage and blood clot formation.
- Granulation tissue replacing the blood clot.
- Replacement of the granulation tissue by connective tissue and epithelialization of the site.
- Replacement of the connective tissue by fibrillar bone.
- Recontouring of the alveolar bone, maturation and remodeling.
Primary intention refers to the healing of closely approximated wound edges. This is the most desirable form of healing due to the speed of healing, lowered risk of infection and minimal scarring. A properly sutured, well-approximated surgical incision or well reduced fracture will heal by primary intention.
Secondary intention refers to healing when there is a large gap between incision edges. It will take longer, requiring a larger amount of epithelial migration, collagen formation, and contraction with more scarring. Granulation tissue will be present. Extraction sockets, ulcers, and avulsions wounds heal by secondary intention.
A periodontal dressing is often used in surgical cases where primary intention cannot be accomplished, to protect the wound and facilitate healing, and to improve patient comfort.
For soft tissues injuries, stages of wound healing are:
- Inflammatory stage – From injury to 2-5 days. Initial vasoconstriction, platelet aggregation and subsequent clot formation result in hemostasis. Inflammation leads to vasodilation and cellular chemotaxis (phagocytosis).
- Proliferation stage – Day 2 to 3 weeks. Marked by granulation tissue formation, epithelialization, angiogenesis, and collagen deposition by fibroblasts. Contraction of the wound edges reduces the defect.
- Remodeling/Maturation – 3 weeks to 2 years. Increased deposition and reorganization of collagen fibers to increase tensile strength, contraction occurs. Scar tissue only carries 80% the strength of the original undamaged tissue.
Fractures can heal by primary/direct bone healing which occurs without callus formation, or secondary/indirect bone healing which occurs with a callus precursor stage. Non-rigid or semi-rigid fixation will result in fixation with callus formation. The stages of secondary bone healing are:
- Inflammatory stage – from injury to 2-3 weeks. Bleeding from the fractured bone and surrounding tissues causes swelling.
- Soft callus – 2-3 weeks to 4-8 weeks. The first part of the repair phase, pain and swelling slowly subsides, the fracture site stiffens and new bone begins to form, though this bone does not appear on radiographs.
- Hard callus – 4-8 weeks to 8-12 weeks. New bone (woven bone), which is visible on radiographs, bridges the fracture.
- Remodeling – 8-12 weeks to years. Ongoing osteoclastic and osteoblastic activity. Chondrocytes undergo terminal differentiation. Remodeling according to Wolff’s law, the bone remodels according to mechanical stress.
Inappropriate healing can result in delayed union (takes longer, but satisfactory end result), non-union, or mal-union (delayed or incomplete/improper position). Many things can inhibit healing including excessive mobility, an impaired immune system, systemic conditions such as diabetes, old age, infections, foreign material, necrotic tissue, ischaemia, steroid therapy and tension on the wound inhibit healing. Wound cleaning is important. Isotonic saline should be used to irrigate wounds. Distilled water is hypotonic and will cause cellular damage.
Compartment syndrome sees so much swelling around the fracture site it causes ischemia and destruction of surrounding muscle tissue.
ASEPTIC TECHNIQUE
Aseptic technique is a standard healthcare practice that prevents the transfer of germs to or from an open wound and other susceptible areas on a patient’s body (healthcare associated infections or HCAI). Clostridium difficile infection and surgical site infection are examples of HCAI. Aseptic techniques range from simple practices (alcohol to sterilize the skin) to full surgical asepsis (sterile gowns, gloves, masks etc.). Aspects of aseptic technique include:
- Barriers – sterile gloves, gowns, mask, drapes, wrappers on sterilized instruments etc.
- Patient and equipment preparation – sterilizing equipment, preventing contamination.
- Environmental controls – maintain the aseptic field by keeping doors closed, limiting personnel movement, one patient per aseptic field.
- Contact guidelines – handwashing, then following sterile to sterile contact guidelines (no contact between sterile and non-sterile items).
SUTURING TECHNIQUE
The needle should be perpendicular when it enters the tissues, with the sutures equal distances apart from the wound margin at equal depths. Sutures should be placed from mobile/thin tissue to secure/thick tissue (free to fixed). They should not be overtightened to avoid soft tissue ischemia (not closed under tensions). Sutures are usually placed 2-3mm apart, with the knot slid to the side of the wound. The interrupted suture is the most commonly placed, benefiting from good strength and flexibility, and if one fails the remaining sutures are not compromised. The major disadvantage is it’s time consuming to place simple interrupted sutures compared to some other techniques.
POST-OPERATIVE INSTRUCTIONS
For optimal postoperative healing the patient is given the following instructions:
- Keep pressure on the gums in the area where the tooth was extracted. Bite down on the gauze provided for 20-30 minutes after the tooth has been taken out. If the socket bleeds or oozes, roll up the gauze provided and bite down firmly for 20-30 minutes. If bleeding is not stopped or slowed after 30 minutes, please contact the clinician.
- Beware of chewing on your numb lip/cheek/tongue. It is recommended not to eat or drink anything hot until the anesthetic has worn off.
- Limit yourself to calm activities for the first 24 hours. This keeps your blood pressure lower, reduces bleeding, and helps the healing process.
Within the first 48 hours:
- Do not smoke, this will inhibit healing.
- Do not drink alcohol, this may increase bleeding.
- Do not disrupt the blood clot by touching it with your finger, tongue etc. Avoid excessive spitting or sucking, which may cause bleeding.
- Do not rinse out your mouth at all, as this can dislodge the blood clot. After the first day, rinse the area gently with diluted mouthwash or warm salt water 3 times a day until healing has occurred.
- Do drink plenty of fluids, eat soft nutritious foods.
- Do still clean the rest of your teeth, but avoid pushing toothbrush bristles into the blood clot.
Regarding pain relief:
- Unless otherwise instructed, regular over the counter pain medication will be sufficient. Paracetamol/Acetaminophen is recommended. Ibuprofen and other NSAIDS can increase bleeding. DO NOT take Aspirin or Disprin. Do not take pain medication on an empty stomach.
HEMOSTASIS
Soft tissue flap tearing can frequently be avoided by improving the flap design so tissue isn’t stressed during the procedure. Mucosal tears are mended at the end during suturing. Puncture wounds can result from excessive and uncontrolled force during procedures.
Hemostasis enables an organism to close off damaged blood vessels, keep the blood in a fluid state, and remove blood clots after the restoration of vascular integrity. There are three phases of hemostasis:
- Vascular phase – vasoconstriction.
- Platelet phase – platelets aggregate on the “sticky” vessel walls creating a mechanical plug.
- Coagulation phase – blood lost into the surrounding area coagulates through the extrinsic and common pathways.
Hemostasis post extraction is most commonly obtained through direct pressure. Failure can occur for a multitude of reasons, including inferior alveolar artery trauma, a muscular arterial bleed as a result of flap elevation, or a medical problem (warfarin, antiplatelet medication, hemophilia, von Willebrand’s disease, chronic liver problems such as in alcoholism). If direct pressure fails, sutures, electrocautery (thermal coagulation), thrombin, tranexamic acid, cellulose sheet (Surgicel) and gelatine sponges (Gelfoam), Collagen (Avetene), and bone wax has been used to stop bleeding. Local anesthetic containing epinephrine can assist in hemostasis (vasoconstriction).
Primary hemorrhage is postoperative bleeding that occurs immediately after an extraction, within the intraoperative period (bleeding does not stop). Reactive bleeding occurs within the first 24 hours post-op. Most cases of reactive hemorrhage are from failed sutures, but could be due to the vasoconstrictive effects of epinephrine (in local anesthetic) dissipating. Secondary hemorrhage occurs several (7-10) days after the extraction, likely due to clot breakdown because of an infection, or irritation of the wound site. It is often seen in contaminated surgical sites.
MAXILLARY SINUS
An oro-antral communication (OAC) is a potential complication associated with the extraction of upper posterior teeth. The roots of molars sit in close proximity to the antral floor. Removal of a tooth, possibly with bony attachment, can result in a connection between the oral and sinus cavity. Occasionally bone comes away but the pseudostratified ciliated columnar epithelial sinus lining (Scheiderian membrane) is intact. Do not ask the patient to perform the valsalva maneuver which could rupture the membrane.
If left untreated, this communication can epithelialize, leading to an oro-antral fistula (OAF). Close anatomical proximity, periapical pathology, lone standing molars, and divergent roots increase the risk of an OAC. Surgical repair is recommended if the communication is any more than 2mm in diameter. If under 6mm, collagen can be secured with sutures to establish a stable blood clot in the bony socket. Any communication in excess of 6mm would require flap closure (buccal advancement flap for palatal rotational flap). Post operative management includes antibiotics, a nasal decongestant to keep the maxillary ostium (sinus opening to middle meatus) open, and avoidance of a pressure difference between the sinus and mouth (sucking, blowing nose etc).
Root displacement into the sinus can occur without warning. Periapical pathology, lone standing molars, and divergent roots, and thin/pneumatized sinus floor are risk factors. Specialist management is often sought in the case of root displacement, often retrieved via the Caldwell Luc approach, where access into the sinus is created above the maxillary premolars. The palatal root of the maxillary first molar is the most likely to be accidentally displaced in the maxillary antrum, but maxillary third molars may find themselves displaced into the sinus as well.
THIRD MOLAR DISPLACEMENT
The maxillary third molar can also become displaced into the infratemporal fossa. If you can see the tooth then perhaps try and retrieve the tooth with a hemostat. Otherwise close the area with a suture, prescribe antibiotics, and refer to a specialist. Recall the infratemporal fossa is an irregular space, bounded superiorly by the greater wing of the sphenoid, inferiorly by the medial pterygoid muscle, medially by the lateral pterygoid plate, laterally by the coronoid process and ramus of the mandible, anteriorly by the infratemporal surface of the maxilla, posteriorly by the articular tubercle of the temporal bone. It contains:
- middle meningeal artery, inferior alveolar artery, deep temporal artery, buccal artery
- pterygoid venous plexus, retromandibular vein
- mandibular nerve, inferior alveolar nerve, lingual nerve, buccal nerve, chorda tympani nerve, and otic ganglion.
And the infratemporal fossa communicates with the following structures:
- Middle cranial fossa (foramen ovale and spinosum).
- Temporal fossa.
- pterygopalatine fossa (pterygomaxillary fissure).
- Orbit (inferior orbital fissure).
- parapharyngeal space.
If a tooth is lost down the oropharynx emergency department referral is required. If the tooth went into the airways it would most likely be found in the right bronchus (wider, shorter, more vertical).
POSSIBLE COMPLICATION
Bony fracture can occur, more likely where the alveolar ridge is thin (lingual lower) and in the maxillary tuberosity area. If a maxillary tuberosity fracture is suspected, it may be wise to replace the tooth and splint in place, wait for bony healing, then surgically remove the tooth. If the tuberosity came out with the tooth the socket is sutured, and sinus protocol followed. Ensure to adjust any sharp edges left after cortical fracture.
Nerve injury can result in loss of sensation (anesthesia), altered sensations (paresthesia) like burning or tingling, or increased sensitivity (hyperesthesia). Dysesthesia, hyperalgesia and allodynia describes painful sensations to normal stimuli (for example touching sunburnt skin). Damage to the lingual nerve during third molar extraction could lead to loss of sensation and taste on the ipsilateral (same) side of the tongue. Recall the inferior alveolar nerve usually lies buccal and and slightly apical to the roots of a mandibular third molar. There are 3 varying levels of nerve damage.
- Neurapraxia (Grade I) is a disorder of the peripheral nervous system where there is temporary loss of motor and/or sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery.
- Axonotmesis (Grade II-IV) is an injury where the axons and their myelin sheath are damaged but the endoneurium, perineurium and epineurium remain intact. There is Wallerian degeneration, where the axonal skeleton disintegrates distal to the injury, and the axonal membrane breaks apart, followed by degradation of the myelin sheath and infiltration by macrophages. There is a potential of recovery within 3 months.
- Neurotmesis (Grade V) sees damage to both the nerve and the nerve sheath. Partial recovery may occur, but complete recovery is impossible. No recovery is expected without intervention (surgery).
Dry socket (alveolar osteitis) is still a relatively poorly understood complication that can result from any extraction, but is more likely in traumatic extractions, female patients, patients on oral contraceptives, smokers, older patients, and retained bone fragments/roots or bacterial contamination.
Abnormal fibrinolysis is the most likely culprit. For routine dental extractions 0.5-5% may result in a dry socket. For surgical extraction this can be 10 times higher. The main symptom is mild to strong pain from inside and around the extraction site. It usually comes about 1-3 days after the extraction and is confirmed if partial or total disintegration of the blood clot is observed. Halitosis, low grade fever, and lymphadenopathy may be present. Systemic or topical antibiotics, tranexamic acid, and varied packing materials have been proposed to prevent dry socket, but this is a divisive topic.
Treatment is palliative, with saline irrigation and intra alveolar dressing (like Alvogyl, active ingredient is Eugenol) being the most commonly used. The dressing will delay healing but help with pain. Suturing alvogyl in place is not recommended. Antibiotics are only required if there is obvious evidence of a secondary infection. Pain relief may be necessary. Do not currette the socket.
Postoperative infections are not common in healthy patients, but more likely if a surgical procedure was needed to remove a tooth. Postoperative infections are commonly treated with drainage and antibiotic treatment.
