Ef icacy of L-Ascorbic acid in the healing of extraction site after trans alveolar extraction of third molar teeth

Wound healing monitoring after every surgery is the most vital concern to deal with. The surgical removal of the teeth involves guttering of overlying bone, splitting the tooth (odontectomy), delivery of the tooth, irrigation of the socket, achieving haemostasis and closure of the soft tissue lap. This leads to big surgical insults resulting in post-operative in lammatory response like pain and swelling, dif iculty in mouth opening, fever, etc. In some cases, other rare complications, including infection, nerve damage, have also been reported. The objective of this study is to evaluate the effects of submucosal injection of vitamin c (L-Ascorbic Acid) in wound healing after trans alveolar extraction of teeth. Thirty patients requiring trans alveolar extraction of teeth were included in this study. Patients were divided into two groups, Group S (Vit c) andGroupB (Control). Healingof extraction socketwasobservedon3 and 7 post-operative days. The study group (Vitamin C) had better healing indices than the controls at 7 post-op day. There was no signi icant difference in 3 post-op day. There was no signi icant reduction in pain on 3 and 7 post-operative days. L-Ascorbic acid injection provides satisfactory postoperative healing following trans alveolar extraction of teeth. But it does not decrease the post-operative pain following surgery.


INTRODUCTION
Wound healing monitoring after every surgery is the most vital concern to deal with. The surgical removal of the teeth involves guttering of overlying bone, splitting the tooth (odontectomy), delivery of the tooth, irrigation of the socket, achieving haemostasis and closure of the soft tissue lap (Farina and Trombelli, 2011). This leads to big surgical insults resulting in post-operative in lammatory response like pain and swelling, dif iculty in mouth opening, fever, etc. In some cases, other rare complications, including infection, nerve damage, have also been reported. In addition to this, the residual bony defect takes several weeks to months even a year to slowly ill with blood and gradually with bone and to reossify (Choukroun et al., 2006). Vitamin C involves many physiologic functions in the human body, and it has an important role in collagen formation (Lis and Baar, 2019). Because of its role in collagen formation, it helps in wound healing (Pullar and Vissers, 2020). Ascorbic acid is a cofactor in the hydroxylation of proline and lysine, which is a necessary step in collagen formation (Peterkofsky, 1972). The objective of this study is to evaluate the submucosal injection of vitamin C (L-Ascorbic acid) in wound healing of extraction site after trans alveolar extraction of teeth

Aim
To evaluate the clinical ef icacy of Vitamin C injection in soft tissue healing following trans alveolar extractions of teeth.

Objective
To evaluate the soft tissue wound healing at the extraction site on 3 rd and 7 th post-operative day.
To compare post-operative pain using a standard scale.

MATERIALS AND METHODS
The study was conducted in 30 patients who were reported to the Oral Surgery clinic for the trans alveolar extraction of teeth. The patients were randomly allocated into two groups. Group S, who received intra mucosal Vitamin injection 200mg and control group Group C received placebo. Trans alveolar surgical extraction of teeth was carried out in all patients. Patients in Group S were given an intramucosal injection of Vitamin C (l-ascorbic acid) 200mg after the closure of the mucoperiosteal lap. Healing is measured by Landry et al. (1988) (Figure 1) on 3 rd and 7 th post-operative day.

RESULTS
The healing was measured by Landry et al. index. Table 1 represents the mean index of the study group on 3 rd and 7 th post-operative day was 2.86 and 4.93, respectively. The mean index of the control group on group 3 rd and 7 th post-operative day was 2.30 and 3.03 respectively Study group had satisfactory healing indices than the controls on the 7th post-op day. There was no satisfactory difference on 3 rd post-op day. There was no signi icant difference in accordance with pain between the groups. A VAS scale measured the pain.

DISCUSSION
Vitamin C involves many physiologic functions in the human body, and it has an important role in collagen formation (Carr and Lykkesfeldt, 2018). Because of its role in collagen formation, it helps in wound healing. Ascorbic acid is a cofactor in the hydroxylation of proline and lysine, which is a necessary step in collagen formation. To stabilise the triple helix structure of collagen, hydroxyproline and hydroxylysine is needed (Nusgens et al., 2001). In the absence of this stabilisation, the structure disintegrates (Nusgens et al., 2001). Vitamin C or Ascorbic acid provides tensile strength to the newly formed collagen, which is essential for stretching without tearing. For ulcer healing tensile strength is important. If it fails to stretch the healed ulcer may face a future breakdown. For the functioning of a proper immune system, this Vitamin C is important especially in the patients with open wounds (Blomhoff, 1994;Yue and Rao, 2020).
Vitamin C has Other essential functions also which include: 1. First, it is an antioxidant. It inhibits damage to body cells 2. It is an anti-in lammatory agent which helps in reducing post-operative in lammatory sequelae 3. Carnitine which is essential for the transport of fat to mitochondria is synthesised with the help of Vitamin C 4. It also plays a vital role in the synthesis of Norepinephrine, a neurotransmitter 5. It inhibits the oxidation of iron in the intestine and promotes the absorption of iron.
6. It also inhibits the oxidation of Vitamin E in the blood.
In spontaneous healing after an extraction, the socket is immediately illed by the blood, which is usually completely replaced gradually by increasing granulation tissue density within 2-7 days. Epithelialization starts within 24 hours, and it gets completed after 1-4 weeks (Amler, 1969(Amler, , 1999.
In this study, Vitamin C was injected submucosally of the teeth to be extracted. The total numerical index was evaluated, resulting in an average value per each patient. This analysis indicates a 100% reduction in gingival in lammation from the average baseline value over a week to one month. The evaluated per cent indicated a signi icant reduction in the gingival in lammation to the surgical site. It is mandatory to handle soft tissues, especially the thinner ones, more carefully to avoid necrosis. Improvement of the tissue colour and consistency was carefully observed in the recall visits on 3 rd and 7 th POD.
Other signi icant changes which were observed after Vitamin-C (L-Ascorbic acid) administration were in accordance with Nusgens et al. (Lang and Lindhe, 2015;Farina and Trombelli, 2011). An elevated number of ibroblasts was detected, forming more collagen ibres which could be seen clinically. Many newly formed minute blood capillaries were also detected clinically. These changes are consistent in the formation of new connective tissue in a healing wound. This is because Vitamin C plays a vital  Collagen is an essential component in the wall of blood vessels. That is why, despite the increase in the number of blood vessels, redness and bleeding tendency markedly decreased clinically. These vessels provide more nutritional and enough oxygen supply to chronically irritated, damaged mucosal areas, thereby it improves their healing.

CONCLUSION
Submucosal Vitamin C improves post-operative wound healing following Transalveolar extraction of teeth. But it does not decrease the post-operative pain or swelling associated with the surgery.