ntroduction to Oral Surgery

and Pain Pathway

OraI surgery
Nervous system
PaIn and Its patbway
Mode oI actIon oI anestbesIa
Dr. Hesbam EI-Hawary
Dr. GamaI Moutamed
2
Oral And Maxillofacial Surgery
t is that branch of dental practice that deals
with:
Diagnosis
Adjunctive and Surgical treatment of diseases
njuries and Defects of human jaws and
associated structures
3
Oral Surgery
nfection control & Aseptic surgical
techniques
Anesthesia & its complications
4
Oral Surgery
Teeth Extraction
Simple forceps extraction
Surgical removal of teeth and roots
mpacted teeth
Complications
5
Oral Surgery 439 439
Oral infection
Oral tumors
Cysts of the oral cavity
Management of patients with
systemic diseases
6
Oral Surgery 439 439
Oro-Facial pain
Maxillary sinus affections
Preprothetic surgery
mplantology
7
Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
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Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
9
Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
10
Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
11
Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
12
Maxillofacial Surgery
Trauma
Temporomandibular
joint disorders
Distraction
osteogenesis
Management of cleft
patients
Orthognathic surgery
Reconstruction
13
nnervation of the face
14
Nervous system
The nervous system is
Network of specialized cells
Communicate information about human
surroundings and himself
t processes this information and causes
reactions in other parts of the body
15
Nervous system 439 439
t is composed of neurons (nerve cells)
The nervous system is divided into two
categories:
Peripheral nervous system
Central nervous system
Neurons generate and conduct impulses
between and within the two systems
16
Nervous system 439 439
The peripheral nervous system is composed of
Grouped sensory neurons
The neurons that connect them to the spinal cord and
brain which make up the central nervous system
n response to stimuli:
Sensory neurons generate and propagate signals
To the central nervous system which then process
and conduct back signals to the muscles and glands
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Nervous system 439 439
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Neuron
The structural unit of the
N.S.
Two types
$ensory neuron (afferent)
Motor neuron (efferent)
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Neuron 439 439
$ensory neurons
(efferent)
Nerve cells that conduct
impulses (as pain sensation)
From all parts of the body
To the CNS centrally
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Neuron 439 439
$ensory neurons
1. Dendritic zone
(free nerve endings):
a. Respond to stimuli
b. Producing an impulse that
is transmitted centrally
along the axon
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Neuron 439 439
$ensory neurons
2. Axon
a. Thin cable like structure
b. Has terminal ending that
form synapses with nuclei
in the CNS
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Neuron 439 439
$ensory neurons
3. CeII body
a. Located at a distance from
the axon or the main
pathway of impulse
transmission
b. Not involved in the
process of impulse
transmission
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Neuron 439 439
$ensory neurons
CeII body .439
c. The primary function of the
cell body is to provide the
vital metabolic support to
the neuron
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Neuron 439 439
Motor neuron
(efferent)
Conduct impulses from
the CNS peripherally
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Nerve Transmission
n response to stimuli, sensory neurons
generate and propagate signals (nerve
impulses) to the central nervous system which
then process and conduct back signals to the
muscles and glands
The process by which nerve impulses are
conducted along a nerve is called nerve
conduction or transmission
26
Nerve Transmission 439
The mechanism of nerve conduction is
described in the following steps:
1. Resting state( Resting potential)
2. Excitation state( Depolarization)
3. Repolarization
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Nerve Transmission 439
28
1. Resting state( Resting potentiaI)
Resting potential is a
negative electrical
potential exists
across the nerve
membrane
i.e., the interior of
the nerve is negative
in relation to the
exterior, (-70 to - 90
mv).
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Resting state( Resting potentiaI) C439
The nerve membrane in the
resting state is:
Permeable to a+ , which
remains outside the nerve
membrane and prevents influx
of it
Fairly permeable to + which
remains inside the nerve
membrane
Fairly permeable to CL-
which remains outside the
nerve membrane
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2. Excitation state( DepoIarization)
Excitation of a nerve
by a stimulus, which
may be chemical,
mechanical or thermal,
leads to increased
permeability of the
nerve membrane to
a+ (a+ infIux)
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Excitation state( DepoIarization) C439
The rapid influx of a+ to the
interior of the nerve causes
depolarization of the
membrane from its resting
state to the firing threshold
(threshoId potentiaI)
i.e. Reversal of the electrical
potential across the nerve
membrane, which means
negatively exterior surface
of the membrane in
relation to the interior (+40
mv)
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3. RepoIarization :
At the end of the
depoIarization, the
permeability of the membrane
to a+ decreases
This is followed by sodium
pump which actively transport
a+ outside the cell while +
move passiveIy in to
restoring the resting
membrane potential
33
Nerve Transmission 439
The rapid sequence of depoIarization and
repoIarization of the nerve is called the action action
potentiaI potentiaI allowing the propagation of the impulse
from one end of the axon to the other
While the impulse remains constant without losing
strength as it passes along the nerve, and this is
called the all all or or non non- - law law of of nerve nerve conduction conduction
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%rigeminaI nerve
Largest of the cranial
nerves
ts name derives from the
fact that it has three
major branches:
OphthaImic nerve (V1)
MaxiIIary nerve (V2)
MandibuIar nerve (V3)
The ophthalmic and
maxillary nerves are
purely sensory
The mandibular nerve
has both sensory and
motor functions.
35
Pain
pain is unpleasant
sensation created by
noxious stimuli, usually
associated with reflex
withdrawal, which is
protective
36
Pain receptors
Pain is received and interpreted in CNS along
specific pathway called pain pathway
Pain receptors:
These are unmyelinated nerve endings
Respond to different stimuli
Provide pain sensation
Proprioceptive receptors:
These are nerve endings
Respond only to pressure
Sensation from teeth:
Pulp: pain sensation
nvesting structures: proprioception
37
C B A-
deIta
A-
gamma
A-
beta
A-
aIpha
- + ++ ++ ++ +++ myelin
0.5-1 1-3 1-4 5-12 5-12 12-20
Diameter
()
1.2 14
12-30 30-70 30-70 70-120
Velocity
m / s
Pain,
temp.,
pressure
Symp Pain,
temp.,
pressure
Touch ,
motor
Touch,
pressure
motor
function
Peripheral Nerve Fibers
38
Pain Nerve Fibers
These are very thin unmyelinated nerves
A-del9, and C fibers, within the nerve
More easily blocked by the L.A. solutions
The thicker and myelinated fibers, such
as A-aIpha, beta, gamma and B fibers,
transmit other sensation such as touch
and pressure with the motor fibers
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Reaction to pain
(Pain Threshold)
Pain threshold is the minimum stimulus
which elicits pain
Differ between individuals
Vary in the same individual on different
occasions
Affected by fear, apprehension, age, sex,
physical fitness, race and fatigue
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Pain Pathway
41
Stimuli from the oral
cavity
received by nerve
fibers
Conducted as
impulses along the
three branches of
the 5
th
cranial nerve
nto the gasserian
(semiIunar)
gangIion (GG)
First Order Neuron
42
The nerve cells in
GG are unipolar
nerve cells
Each has an axon
which bifurcate into
a Y or % shaped
division
First Order Neuron 439
43
The central branches of
the T shaped fibers
make up the sensory
root of the trigeminal
nerve
the peripheral branches
of the T shaped fibers
form the three
branches of the 5
th
cranial nerve
First Order Neuron 439
44
Then from the GG
the impulses are
passed by the
central branches of
the unipolar cells
into the pons
First Order Neuron 439
45
Some branches end in
a collection of nerve
cells in the pons called
the P.S.N., responsible
for touch
other branches
descends through the
medulla where it
terminates in the
A.S.N. responsible for
pain & temp
First Order Neuron 439
46
Originates From
A.S.N. and P.S.N
another nerve fibers
Crosses the midline
and ascends in a
spinothalamic tract
of the 5th cranial
nerve
Terminates in
P.V.N. in the
thalamus
Second Order Neuron 439
47
Originates from
P.V.N. in the
thalamus
Carries the pain
impulse to the post-
central convolution
of the cortex where
all sensations are
felt
Third Order Neuron 439
48
Control of pain
Removing the cause
Raising the pain threshold
Blocking the pathway of the painful
impulses
Preventing the pain reaction by cortical
depression
49
Anesthesia
Anesthesia: the condition of having
sensation blocked (including the feeling of
pain)
Analgesia: blocking the conscious
sensation of pain
Hypnosis: produces unconsciousness
without analgesia
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Types of anesthesia
Local Anesthesia:
Any technique that render part of the body
insensitive to pain without affecting
consciousness
General anesthesia:
Drug-induced loss of consciousness
during which patients are not arousable,
even by painful stimulation
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Mode of Action of Local Anesthesia
Displacing calcium ions from receptors site
The mechanical or reversible coagulation
theory
The physiological theory interference
with the nerve tissue metabolism
Acetyl Choline and enzyme system theory
Electrical potential theory
%hank You %hank You