Wound Healing Problems in the Mouth

Abstract

Wound healing is a primary survival mechanism that is largely taken for granted. The literature includes relatively little information about disturbed wound healing, and there is no acceptable classification describing wound healing process in the oral region. Wound healing comprises a sequence of complex biological processes. All tissues follow an essentially identical pattern to complete the healing process with minimal scar formation. The oral cavity is a remarkable environment in which wound healing occurs in warm oral fluid containing millions of microorganisms. The present review provides a basic overview of the wound healing process and with a discussion of the local and general factors that play roles in achieving efficient would healing. Results of oral cavity wound healing can vary from a clinically healed wound without scar formation and with histologically normal connective tissue under epithelial cells to extreme forms of trismus caused by fibrosis. Many local and general factors affect oral wound healing, and an improved understanding of these factors will help to address issues that lead to poor oral wound healing.

Keywords: dental implant; granulation tissue; inflammation; local and general factors; nerve damage; oral; wound healing.

Figure 1

(A) Granuloma formation after reconstruction surgery through a bone from the anterior iliac crest in region 12. (B) Panoramic radiography indicates a vertical bone deficit in region 12. (C) Exploration of a wound from which the residue of a non-healed bone graft was removed. A large part of the originally implanted bone graft has already disappeared due to necrosis and/or resorption. (D) The necrotic bone graft with an osteosynthesis screw.

Figure 2

(A) A sinus polyp is a manifestation of a poorly healing antrum perforation that does not spontaneously close. This can lead to the bony height of the rest alveolus being too small following tooth extraction, and the connection between the mouth and antrum being too wide. (B) Panoramic radiography shows loss of bone height separating the antrum of the oral cavity in region 26. (C) Brightening of the wound edges reveals the dimension of the connection between the antrum and oral cavity.

Figure 3

(A) Progressive necrosis of a double free flap (fibula + anterolateral femur flap) due to a combination of factors, leading to complete ischemia and death of the free flap. (B) The necrotic flap was removed and temporally replaced with a wick.

Figure 4

A poorly healing wound after extraction of 48. Eight weeks after extraction, the patient continued to complain of pain, and granulation tissue was found in the wound. Wound exploration revealed a pathological fracture together with necrotic bone tissue and bone sequesters.

Figure 5

An 11-year-old boy presented with keloid formation on the upper lip (A) and the thorax (B) after a traffic accident with bicycle. Hypertrophic scarring and keloid formation indicate abnormal wound healing.

Figure 6

(A) A 62-year-old woman presented with repeated postoperative bleeding after extraction of 36. The pictures shows a coagulum. The patient had a history of Crohn's disease for which she took infliximab, and a history of atrial fibrillation for which she used anticoagulants. She also took flecainide and bisoprolol fumarate due to arrhythmias. (B) The wound heal after 6 weeks. Wound healing was likely delayed due to the postoperative bleeding, but possibly also due to the use of Infliximab, which is a TNF-α inhibitor.

Figure 7

Buccosinusal connection after apex resection of 16, in which the incision was incorrectly performed on the opening to the sinus rather than on the healthy bone edges. A broad trapezium-shaped incision would have been desirable.

Figure 8

(A) A 16-year-old patient was referred due to persisting pain and pus in the extraction cavity of 48. Radiography shows incomplete bone healing in loco 48. (B) Wound exploration reveals gauze that remained unnoticed in the wound.

Figure 9

(A) 67-year-old patient presented with Kelly syndrome, maxilla atrophy, 20-year history of smoking, and 9-year use of corticosteroids and methotrexate. Maxilla reconstruction was performed through cranial bone. (B) Status before reconstruction. (C) Wound dehiscence with exposed bone. (D) Healing by second intention after removal of the necrotic bone fragment and wound debris.

Figure 10

A 59-year-old male presented with wound healing problems 2 months after placement of four implants in the mandibula. The patient had been using systemic corticosteroids for the past 15 years due to lung sarcoidosis, and had stopped smoking years ago. Despite excessive alcohol use, neuropathy based on thiamin deficiency, and abnormal liver tests, the patient was able to maintain professional activity and a good social integration.

Figure 11

A 58-year-old female presented with chronic infection, with pus and fistula formation in the neck. The patient had a history of mouth floor carcinoma, alcoholism, depression, axonal polyneuropathy, Crohn's disease, and nephrotic syndrome. Inadequate oral intake due to pain, with secondary hypoalbuminemia and ion disorders, contributed to poor wound healing and low resistance to infections.

Figure 12

(A) A 51-year-old woman presented with peri-implantitis. She was a smoker with unstable diabetes mellitus. Her tooth implants (Nobel Biocare Mk III Ti Unite) had been placed too close to each other, and the central implant in loco 12 had not been used. (B) An attempt was made to remove the infectious tissue without removing the implant, and to substitute through artificial bone (BioOss®) and L-PFR membranes. (C) LPRF membranes (D) End result after recovery attempt, which did not account for numerous factors that impede wound healing.

Figure 13

A 50-year-old patient presented with a neck dissection at the left side. She was known to abuse ethanol, to suffer from undernutrition, and to have a T4N0M0 spinocellular carcinoma of the left alveolar processes. She was referred due to wound healing problems and recurrent necrosis of the reconstruction through free flaps. Both a fibula flap and a lateral radialis flap had failed. The wound in the neck exhibits inflammation, pus formation, and maceration of the wound edges.

Figure 14

A 25-year-old female with progressive necrosis of the maxilla, showing loss of all molars in the right maxilla and the alveolar bone, with the emergence of a buccosinusal connection that occurred after ustekinumab use for Crohn's disease treatment. (A) A panoramic radiography from the first consult, where the complaint of loose teeth was formulated. (B) Three months after the radiography in panel A, we see the loss of elements 18, 17, 16, and 15. (Photo left). Two months later, an antrum perforation spontaneously occurred.