Jemds.com Review Article Healing after Periodontal Surgery - A Review Kiran Rajesh Sethiya1, Prasad V. Dhadse2 1, 2 Department of Periodontics, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences (DMIMS), (Deemed to Be University), Wardha, Maharashtra, India. ABSTRACT The native periodontium includes cementum, a functionally oriented periodontal Corresponding Author: ligament, alveolar bone and gingiva. Pathologic and / or traumatic events may lead Dr. Kiran Rajesh Sethiya, to the loss or damage of this anatomical structure and cause wound. Wound Healing Department of Periodontics, (WH) remained unclear for many years with varying concepts. Studies have shown Sharad Pawar Dental College, DMIMS (Deemed to Be University), that various surgical periodontal procedures can lead to different patterns of Wardha, Maharashtra, India. healing. The general principles of healing, and the cellular and molecular events E-mail:[email protected] observed in nonoral sites, also apply to the healing processes that take place following periodontal surgery. As periodontal-regenerative procedures are time DOI: 10.14260/jemds/2020/824 consuming and financially demanding, there is increasing interest by clinicians to learn factors that may influence the clinical outcome following periodontal How to Cite This Article: reconstructive surgery in order to provide the best possible service to patients. This Sethiya KR, Dhadse PV. Healing after goal can only be achieved if biological aspects of WH and regeneration are taken periodontal surgery - a review. J Evolution Med Dent Sci 2020;9(49):3753-3759, DOI: into consideration. The objectives of the present article are to discuss the basic 10.14260/jemds/2020/824 principles of periodontal regeneration, to illustrate the factors that influence this process and to provide an overview of WH following periodontal surgical Submission 28-07-2020, procedures, including scaling, root planning, curettage, gingivectomy, Peer Review 23-10-2020, depigmentation, flap surgery, apically repositioned flap, replaced flap, pedicle soft Acceptance 29-10-2020, tissue graft, free gingival graft, connective tissue graft, guided tissue regeneration, Published 07-12-2020. enamel matrix derivative, ridge preservation, osseous resection, Wilckodontics and Copyright © 2020 Kiran Rajesh Sethiya et implant. But the discovery of latest techniques have contributed to our al. This is an open access article distributed understanding of the biology of WH. Clinical features of WH of dental procedures under Creative Commons Attribution are not often discussed. The present review focuses on the monitoring of WH License [Attribution 4.0 International (CC procedures and the process of understanding the biology of periodontal tissues in BY 4.0)] periodontal and implant dentistry. KEY WORDS Gingiva, Periodontal Surgery, Wound Healing, Dental Implant J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 49 / Dec. 07, 2020 Page 3753 Jemds.com Review Article BACKGROUND Systemic Factors Age. Nutrition. Monitoring of wound healing (WH) following periodontal Glucocorticoids. surgery is of importance. But it is more important to know Un-controlled diabetics. the term wound or injury which means disturbance of the Haematological abnormalities. anatomical function and structure in any part of body,1 whereas healing is the body reaction to trauma in order to repair normal function and structure. On the basis of the nature of wound, soft tissue loss and PHASES OF WOUND HEALING presence of infection, the wound healing is classified into three general categories: primary, secondary and third The process has been split into 3 phases - intention healing.2,3 Primary intention of WH has following Inflammation phase. features: clean and uninfected; surgically incised; without Granulation phase. abundant loss of tissue and cells ; and margins of wound are Matrix formation and remodelling (maturation) phase.7 closed by sutures. Secondary WH has following features: large tissue defect which is open, sometimes infected; abundant loss of tissues and cells; and the wound is left open Inflammatory Phase not closed by sutures.4 Moreover, tertiary intention occurs The GF (Growth Factor) present in clot recruit when there is considerable loss of tissue, healing occurs by inflammatory cells, and then regulate the granulation contraction of wound edges and Granulation Tissue (GT) process. In few hours, inflammatory cells colonize the clot. formation. Sometimes, the presence of infection or foreign These helps to clean bacterial wound and necrotic tissue via body are suspected, and these wounds intentionally are kept phagocytosis. It also releases enzyme and toxic oxygen open for days till the probable complication is solved. When products. In 3 days period, inflammatory reaction moves into resolution occurs, the wound margins are approximated and late phase. Macrophages emigrate the area of wound and proceeds to heal. A fourth type of WH occurs when overlying helps in cleaning with the help of PMN (Poly-Morpho- tissue is partially lost or purposely removed, so a de- Nuclear) leukocytes and erythrocytes via phagocytosis. epithelialized Connective Tissue (CT) layer is open. It is Macrophages also releases inflammatory cytokines and tissue healed by re-epithelialization from adjoining epithelium.3 GF which restore inflammatory cells, endothelial cells and fibroblasts, thus play a role in transformation of inflammatory into the granulation tissue formation phase. Outcomes of Periodontal Wound Healing 5 Regeneration, repair and new attachment are the aspects of healing that have a special bearing on the outcome of Granulation Phase periodontal treatment. The neutrophil population is overtaken by macrophages Regeneration: It is biological process by which the within a few days. Macrophages also serve the purpose of function and architecture of lost tissues restored completely wound decontamination. They play key role in GT formation. by formation of new cementum, periodontal ligament and It starts fourth day approximately. Macrophages alveolar bone. constitutively releases GF that promote the process of Repair: It is healing of tissues in which the lost tissues are healing. GF and cytokines secreted by macrophages are not completely restored. involved in proliferation and migration of endothelial cells, New Attachment: Reunion of CT with the surface of root smooth muscle cells and fibroblasts in the area of wound. that is exposed pathologically. Cells extending near the radius of wound site developing cell‐ Reattachment: Reunion of CT and surface of root that is to‐cell and cell‐to‐matrix connections. Macrophages and separated by injury or incision. fibroblasts releases GF that regulate the process of healing in an exocrine and autocrine manner. Studies have shown that wound sites supplemented with growth factors have an accelerated rate of granulation tissue formation.8,9 At 7 days, FACTORS THAT AFFECT HEALING 6 initiation of WH, granulation dominates the wound site and the initial collagen fibres are being formed. Ultimately, cells Local Factors and matrix form cell‐to‐cell and cell‐to‐matrix links that Healing after gingival and periodontal surgery can be delayed produces a concerted tension results in contraction of tissue. and altered by numerous local factors. Some of these factors Formation of GT slowly progresses into the final phase of include - healing which alters, more cell‐rich tissue undergoing Plaque microorganisms. maturation and remodelling to reach functional needs. Extreme tissue manipulation throughout surgery. Damage to tissues. Maturation Phase Presence of foreign bodies. Fibroblasts responsible for renewal of ECM (Extra- Repeated surgical treatment may break cellular activity Cellular Matrix) yield a new collagen‐rich matrix. 1 week after during the healing. wounding and collagen matrix synthesizes, few fibroblasts Inappropriate vascular perfusion to the surrounding are converted into myofibroblasts and exhibit α‐smooth area. J Evolution Med Dent Sci / eISSN - 2278-4802, pISSN - 2278-4748 / Vol. 9 / Issue 49 / Dec. 07, 2020 Page 3754 Jemds.com Review Article muscle actin. Due to conversion and synthesis there is Healing Following Curettage 11 contraction of wound. Endothelial cells cause angiogenesis Immediately blood clot is seen in gingival sulcus which which transfer into wound matrix forming vascular loops and does not have epithelial lining. tubes. As matrix matures, endothelial cells undergo apoptosis Large number of PMNs occupy site of wound after which leading to reduction in number of vascular units. GT there is rapid GT proliferation. maturation causes regeneration or repair of the injured Epithelium: Healing of sulcular epithelium takes 2 - 7 tissues. days and JE (Junctional Epithelium) 5 days. Connective tissue: Within 3 weeks immature collagen Tissue Type Healing Rate (Approximately) fibres appears. Junctional Epithelium 5 days Sulcular Epithelium 7 - 10 days Gingival Surface Epithelium 10 - 14 days Connective Tissue 21 - 28 days Healing Following Surgical Gingivectomy 12 Alveolar Bone 4 - 6 Weeks Healing Rates of Various Periodontal Tissues10 2nd day Formation of clot 4th day Clinical Requirements for Effective Healing Replacement of clot by GT (Granulation Tissue) after Periodontal Surgery A part of epithelial surface extends without rete pegs The application of initial therapy prior to surgical There is dense inflammatory infiltration intervention 6th day