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1.5. Features of healing of surgical wounds in an oral cavity

The history of treatment of wounds and a wound fever leaves the roots in depth of centuries. So, from papyrus Ebersa found in XIX century, it became known, that for 3000 years BC Egyptians used honey, oil and wine for treatment of wounds and even closed wounds by means of seams and sticking together substances.

From the moment of occurrence of the first descriptions of operations and principles of treatment of wounds the large quantity of ways of performance of surgical interventions, techniques and approaches till now is studied and developed. In history of studying of a histogenesis of a wound process it is possible to plan three periods. During the first, stretched from an extreme antiquity to the middle of XIX century, doctors had a general impression about a course of a wound repair by what it is drawn to a naked eye. Development of microscopical technics in second half XIX centuries and the opened possibility to watch a wound process current any more only on appearance of a wound, but also on the basis
Studying of cellular elements participating in this process have begun the second period proceeding approximately till 50th years of last century. The third, modern, the period in history of studying of a wound process is caused by occurrence histochemical, immunohimicheskih methods of research, a submicroscopy, an autoradiography, allowed to make look fat representation about mutual relation of various cells data on the thin and difficult processes developed thus in each of them [19, 23, 34].

Wound process physiology

For all wounds there are general biological patterns of development and a current of processes of physiological neogenesis and a reparation of the damaged tissue with restoration of its integrity. The tissue thus passes all phases of healing. Last years in clinical practice of domestic surgeons classification of a wound process by M.I.Kuzinu (1977) according to which 3 phases are allocated began to prevail: inflammations - with its separation into two periods (vascular changes and purification); neogeneses, formations granuljatsionnoj tissues; cicatrix and cuticularization reorganisation. From classical types of healing allocate primary, secondary and under a scab.

The wound repair a first intention proceeds without complications, in short terms, there is rather strong adnation of edges of a wound at the expense of formation of a thin layer granuljatsionnoj tissues. At the very beginning of a wound process owing to disturbances in a capillary wall the fibrinogen passes partially in extracellular space, dropping out in the form of fibrin threads. Formation of fibrinous stoppers in capillaries and lymphatic
Vessels promotes an edematization, interfering with excision of a hydropic liquid. Fibrinous barriers detain on a bacterium place, mechanically complicating their penetration. According to a number of authors, fibrin at healing of wounds renders also lejkostaticheskoe and bacteriostatic action, stimulates growth and occurrence of granulations, promotes normal neogenesis. Fibrin and products of its degradation stimulate migration mononuklearov, an angiogenesis and collagen synthesis.

Participation of a fibrinogen and fibrin in the course of healing of wounds is defined by its mechanical properties framing a primary fibrous skeleton, and the chemical properties caused mainly its high sorbtsionnoj by activity [13, 18, 19, 86, 103].

The primary fibrinous soldering replaced with a neogenic definitive connecting tissue for 6-8 days, is condensed in the form of cicatrix and reliably keeps growing together surfaces, excepting presence between them any cavity. To this term cuticularization process comes to the end also. Such outcome of healing is possible only in cases of close contact of edges of a wound. Healing by a second intention occurs in the absence of dense contact of walls and wound edges that is a major factor interfering primary soldering of tissues [4, 16, 35, 37].

Fiber synthesis in a wound is bound basically to formation of collagen and a cuticularization, and crucial importance has formation of the subject connecting tissue providing high-grade neogenesis of an epithelium.
The fibers which are a part of intercellular substance of a connecting tissue, consist of collagen molecules.

One collagenic fiber contains millions separate densely packed monomeric collagenic molecules which now it is accepted to name a tropocollagen. The term collagen usually is used for a designation of the polymeric unit of certain quantity tropokollagenovyh units in the form of long polymeric by chains - fibrils. Being united, fibrils form collagenic fibers. Formation of collagenic fibers is accompanied by formation of cross-section chemical bonds as in one molecule (intramolekuljarnye communications), and between the next molecules (intermolekuljarnye communications). Durability of collagenic fibers and accordingly durability of a healing wound depends On quantity and character of these communications. Definitive formation of collagenic fibers comes to the end with formation of complexes with other components of intercellular substance of a connecting tissue - a fibronectin, matriksnymi the fibers possessing high ability to

kompleksoobrazovaniju. Full end of a fibration occurs only in some weeks after a wound repair. According to a number of authors in which experimental works processes reparativnoj the angenesises were studied, defining value has collagenic balance. It is known, that in a zone of a line of seams there are two opposite processes. The first, defined by mechanical durability of a seam and the having maximum at the moment of applying, depends in a larger measure from rjadnosti suture. The next days mechanical durability and
Tightness steadily decrease, reaching a maximum of depression of these properties for 4-7 days. The second process is a biological durability of a seam which is defined by processes kollagenogeneza. Lizis collagen reaches a maximum also by 4-7th days. Degree of disintegration of collagen depends on character of wound, circulation disturbances, infitsirovannosti a wound and the general reaction of an organism [8, 19, 39, 44, 86].

Thus, depression by 3-7th days mechanical and absence by this time of due biological durability of a wound is the reason of an incompetence of seams, healing by a second intention, formations of defective cicatrix and development of chronic inflammatory process [3, 14, 16, 2].

Features of a current of a wound process in an oral cavity

In spite of the fact that processes reparativnoj to neogenesis of various tissues submit to the general biological laws, there are some differences in a wound process current at damage of a mucosa and a skin of the person. These differences take place at stages of activation of the inflammatory answer, a cuticularization and cicatrix formation. So, after mucosa damage the generated bloody clot, being in liquid medium of an oral cavity, is is much easier vulnerable, thus owing to the larger elasticity it faster eliminiruetsja and will be reorganised, that provides reduction of terms of healing in comparison with a skin [13]. At a hemostasis stage in the tissues entering into a zone of damage, among enzimov, allocated with inflammation cells, it is found out osteopontin. Last accumulates in calcific tissues and is produced by set
Cells, including T-lymphocytes and macrophages. In the foreign literature osteopontinu the role of the factor of early activation T of-lymphocytes is taken away, it also takes part in attraction and activation of macrophages in the damaged tissues. Produced in a zone of damage of a mucosa of an oral cavity osteopontin it is capable to operate as an opsonin, on recognition by macrophages of bacteria and alien substances and-or materials. Experimental researches have shown, that deenergizing of a functional gene osteopontina at laboratory mice, led to disturbance of processes of neogenesis and sensitivity depression to a local becoming infected. Other difference of a current of a wound process in an oral cavity is shorter period of a cuticularization in comparison with that on a skin. This phenomenon is bound to higher rate of migration of epithelial cells which makes from 0,3 to 0,5 mm/days The stage of the organisation of cicatrix on a skin and a mucosa proceeds with participation miofibroblastov which, being reduced, reduce the area ranevoj surfaces. However the cicatrical tissue, organizujushchajasja in an oral cavity, possesses some properties differing from those on a skin. First of all, it is such indicators, as elasticity, elasticity and a pliability. Basic difference of a cicatrical tissue on a skin and on a mucosa till now it is not found, though the carried out researches have shown, that the fibroblasts which are present at a cicatrical tissue of a mucosa, differ a phenotype and have certain similarity to embryonal fibroblasts [10, 16, 26, 41, 51, 103, 106].

Problem of reliability of a surgical seam at operative measures in an oral cavity.

For today there is a wide choice of suture materials, the set of ways ushivanija surgical wounds is developed, however the problem of an incompetence of surgical seams in stomatology keeps the urgency and is maloizuchennoj. Any surgical intervention in an oral cavity can be parted conditionally on following stages: 1) maintenance of surgical access (cut performance) 2) surgical manipulations; 3) suture.

Thus, as a rule, the doctor gives the greatest attention to the first and second stages of operation whereas a finishing part - to suture the supporting role is taken away. The neglect a stage ushivanija wounds and seam formation, aspiration to unreasonable simplification of technics and transformation of the ending of operation in imperceptible auxiliary surgical manualnuju procedure is fraught with development of postoperative complications [16, 24, 39].

Healing of a surgical wound in a solving measure is defined by operational technics, its degree atravmatichnosti. From the factors affecting a course of a wound repair as it is strange, are is much better known what are united under collective concept the general condition (blood structure, level of fibers and their parity, a metabolism condition, hormonal balance and so forth), than the elementary surgical receptions applied at ushivanii of wounds [14].

The saved up historical experience on use of different kinds of seams has allowed to formulate the basic demands to their application: atravmatichnost applyings, exact comparison, uniform grab of all layers on depth and width, liquidation of the closed cavities and pockets, creation of moderate force of a tension in wound tissues, use various on structure and a thickness of suture materials. As the basic necessary condition for a seam solvency exact reconstruction of tissues in the field of a wound [16, 17, 20] is required anatomically.

To the factors interfering or reducing a solvency of seams, it is possible to carry: 1) the pathomorphologic processes occurring in taken in or adjoining tissues; 2) the restrictions bound to comparison of tissues, differing under the physical and anatomic characteristics: to a thickness, mobility, elasticity, elasticity etc.; 3) application during operation of alien bodies in the form of biomaterials, membranes, titanic designs; 4) the technical features of operation characterised in the sizes of subject osteal defect and its locating concerning a line of seams.

Now most often used way of closing of surgical wounds, consists in applying of single noose sutures, what even in routine practice is bound to their incompetence, and at reconstructive operations the risk of a divergence of edges of a wound and, as consequence, its defective healing is much more enlarged, reaching 100 %. Approach change to a stage ushivanija a surgical wound in an oral cavity in the form of working out of the differentiated approach to the given stage of the operation, which principle
Consists in applying of unloading and referring seams, and also in as much as possible exact comparison of edges of a wound, will allow to raise quality of treatment of patients.

Thus, despite the saved up historical experience and active research of processes reparativnoj angenesises, today the urgency of a problem of an incompetence of seams and optimum healing of surgical wounds, in particular in an oral cavity, has not decreased. It frames preconditions for the further profound studying of features of a wound process in an oral cavity, for rising of clinical efficiency of surgical methods of treatment [7, 41, 115].

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Scientific source Grivkov Alexey Sergeevich. the CLINICO-FUNCTIONAL SUBSTANTIATION of the METHOD of CREATION And REALIZATION THREE-DIMENSIONAL DESIGN of the PROJECT REGIONAL PARODONTA AT AESTHETIC PROSTHETICS. The DISSERTATION on competition of a scientific degree of the candidate of medical sciences. Great Novgorod - 2014. 2014

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