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GOOD MORNING

SOFT TISSUE REACTIONS AND

HEALING IN MAXILLOFACIAL

TRAUMA

MODERATOR – DR. RAJASEKHAR G.

PRESENTED BY- DR. SHEETAL

KAPSE

INCLUSIONS • Introduction

• Soft tissue layers in maxillofacial region

• Soft tissue reactions to trauma

• Healing of soft tissues

• Consequences of improper healing

• Factors affecting wound healing

• Conclusion

• References

SkinMuscle

CartilageNerve

Mucosa

INTRODUCTION

• The capacity for self-repair is crucial for the survival

of any organism, because without it the organism

would likely perish after minimal injury.

• A wound is a disruption in the normal anatomic

structure and function of tissue and is accompanied by

cellular damage.

INTRODUCTION

• Wound healing is an intricately coordinated series of

processes that involve cellular and subcellular

responses to tissue injury, leading to the release of

cytokines and growth factors, cell activation, and

resultant tissue regeneration.

INTRODUCTION

• The understanding of the remarkable cascade of events

involved in wound repair and healing is advancing

exponentially with the ongoing discoveries of the roles of

growth factors and signaling pathways.

• There is growing interest in stem cell research,

regenerative medicine applications, and bioactive wound

healing products.

Soft tissue layers in

maxillofacial region

Five layers of critical anatomy:1. Skin 2. Superficial fat compartments3. Superficial

musculoaponeurotic system (SMAS)

4. Retaining ligaments5. Mimetic muscles Deep plane, including the deep fat compartments

M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012

J Ästhet Chir 2015 · 8:157–163 DOI 10.1007/s12631-015-0021-4© Springer-Verlag Berlin Heidelberg 2015

Superficial fat compartments of the face

Superficial musculoaponeurotic system (SMAS)

J Ästhet Chir 2015 · 8:157–163 DOI 10.1007/s12631-015-0021-4© Springer-Verlag Berlin Heidelberg 2015

Ligaments and septa between fat compartments of the face

P. M. Prendergast. Anatomy of the Face and Neck. M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012

Mimetic muscles

Deep fat compartments

The buccal fat padand its extensions

The prezygomatic space. This space extends anteriorly to the infraorbital area.

Michael Miloro, Scott Redlinger, Diane M. Pennington, Tommy Kolodge, In Situ Location of the Temporal Branch of the Facial Nerve. Journal of Oral and Maxillofacial Surgery. 2007; 65(12):2466–2469

Soft tissue reactions to trauma

Cellular responses to cell injury

autolysis, necrosis & apoptosis

gangrene & pathologic calcificationHarsh Mohan. Textbook of Pathology. India; Jaypee Brothers Medical Publishers (P) Ltd; 2015.

Biosynthesis of prostaglandins (PG) and leukotrienes(LT)

Tripathi KD. E,ssentials of Medical Pharmacology. India; Jaypee Brothers Medical Publishers (P) Ltd; 2008.

Fonseca Raymond J, Walker Robert V, Barber H Dexter,

Powers, Michael P, Frost David E. oral and maxillofacial trauma. China: Saunders; 2013.

Healing of soft tissues

Fonseca Raymond J, Walker Robert V, Barber H Dexter, Powers, Michael P, Frost David E. oral and maxillofacial trauma. China: Saunders; 2013.

Wound_Healing_1.flv

Types of wound healing

Healing by primary intension / primary wound closure

Healing by secondary intension

Delayed primary closure / wound repair

Wound healing of SKIN

Epidermal wound healing. Injury to the epidermal layer induces epidermal keratinocytes to undergo a process of migration, mitosis, and maturation to reconstitute the epidermis and restorebarrier function.

Overview of the wound healing response. The panels show progressive phases of wound healing.

A, The early wound (day 2) exhibits many migratory responses.

B, As healing progresses (day 4), there is evidence of mitosis in the several compartments.

C, In the later stages of healing (day 14), the wound is maturing to establish a new homeostasis.

Wound healing of MUSCLE• Stages – 31. Inflammation – 5 days2. Proliferation – 2-6

weeks3. Remodeling - months

• RICE protocol• Role of NSAIDs• Role of steroids• Ideal therapeutic agents• Growth factors – IGF-1, • Gene therapy• Stem cell therapy• Antifibrosis therapy – decortin, suramin,

interferon – Y• Bionic replacement

Wound healing of CARTILAGE• Physiologically cartilage is considered as an isolated tissue

which is devoid of blood, lymphatic channels and free nerve endings.

• Inflammatory phase is absent in healing process

• Superficial injury – defects remain unchanged for 2 years• Penetrating injuries – repair by hyaline cartilage like

tissues.• Blunt impact – rapid degeneration & osteoarthitic lesions.

• Future trend – tissue engineering & growth factors.

Wound healing of NERVE

CLINICAL ASSESSMENT OF HEALING NERVE INJURY• An assessment of the status of the sensory nerve can be done in a relatively

short time in everyday clinical setting.

score responseS0 no recovery

S1 recovery of deep cutaneous pain

S1+ recovery of superficial pain

S2 same as S11 with addition of some touch Sensation

S2+ same as S2 but with hyperesthesia

S3 same as S2 but without hyperesthesia and with 2-point discrimination greater than 15 mm,

S3+ same as S3 with good localization of stimulus and 2-point discrimination of about 7 to 15 mm

S4 complete recovery (2-point discrimination is now 2 to 6 mm)

Thomas G. Auyong, Anh Le. DentoalveolarNerve Injury. Oral

Maxillofacial Surg Clin N Am 23 (2011) 395–400

Wound healing of MUCOSA

Dressings and topical agents 1. Dressings

2. Negative pressure wound therapy3. Topical agents4. Growth factors

Open v/s closed Dry v/s moist

Consequences of improper healing

1. Dehiscence2. Evisceration 3. Hemorrhage 4. Adhesion5. Herniation6. Sinus tract and

Fistula formation7. Suture

complications8. Hypertrophic scar9. Keloid

Factors affecting wound healing

Local Systemic Foreign bodies Aging

Venous insufficiency Smoking

Pressure, trauma Diabetes

Ischemia, hypoxia Corticosteroids

Radiation Immunocompromised state

Salivary contamination Malnutrition

Scarring Cytotoxic chemotherapy

Hematoma Vitamin deficiency

Chronic illness

Peripheral artery disease

Conclusion

• When treating facial injuries, knowledge of the wound healing process is crucial to maximize healing and minimize adverse outcomes such as infection, malunion and disfiguring scarring.

• In the trauma arena, oral and maxillofacial surgeons must not only treat acute traumatic wounds appropriately, but must also do everything possible to optimize the wound healing conditions.

• Knowledge of the technologic advances in wound care, regenerative medicine, and tissue engineering will allow the surgeon treating maxillofacial trauma to achieve the best possible outcome in these potentially devastating facial injuries.

References 1. Fonseca Raymond J, Walker Robert V, Barber H Dexter,

Powers, Michael P, Frost David E. oral and maxillofacial trauma. China: Saunders; 2013.

2. Harsh Mohan. Textbook of Pathology. India; Jaypee Brothers Medical Publishers (P) Ltd; 2015.

3. Tripathi KD. E,ssentials of Medical Pharmacology. India; Jaypee Brothers Medical Publishers (P) Ltd; 2008.

4. Hom, Hebda, Gosain, Friedman. Essential tissue healing of the face and neck. India. Peoples medical publishing house.

5. M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012

References 6. J Ästhet Chir 2015 · 8:157–163 DOI 10.1007/s12631-

015-0021-4 © Springer-Verlag Berlin Heidelberg 2015

7. Michael Miloro, Scott Redlinger, Diane M. Pennington, Tommy Kolodge, In Situ Location of the Temporal Branch of the Facial Nerve. Journal of Oral and Maxillofacial Surgery. 2007; 65(12):2466–2469.

8. Thomas G. Auyong, Anh Le. Dentoalveolar Nerve Injury. Oral Maxillofacial Surg Clin N Am 23 (2011) 395–400

9. P. M. Prendergast. Anatomy of the Face and Neck. M.A. Shiffman and A. Di Giuseppe (eds.), Cosmetic Surgery, DOI 10.1007/978-3-642-21837-8_2, © Springer-Verlag Berlin Heidelberg 2012

“ God heals, and the doctor

takes the fees ”

Benjamin Franklin(American Statesman, scientist, Philosopher)