Oral and Maxillofacial Surgery
Oral and maxillofacial surgery: airway, bleeding, and nerve first
Surgical questions reward a systematic approach. Before extraction, review medical history, anticoagulants, bisphosphonates, and airway risk. For impacted third molars, assess root morphology, bone density, proximity to the inferior alveolar nerve, and the lingual plate. Use a flap that gives access without devitalizing bone, section teeth when needed, and close primarily when possible.
Complications are high-yield: bleeding, hematoma, infection, dry socket, trismus, sinus communication, and nerve injury. Dry socket (alveolar osteitis) presents with severe pain and an empty socket days after extraction; treat with gentle irrigation and a medicated dressing, not aggressive curettage. Odontogenic infections can spread to fascial spaces; Ludwig angina is a bilateral submandibular-sublingual infection with airway compromise and requires urgent referral or hospital care. Maxillary sinus communication needs conservative management or closure depending on size.
Traps: prescribing antibiotics instead of drainage for a fluctuant abscess; curetting a dry socket; missing a bleeding disorder; and failing to document nerve status before surgery.
Rule of thumb: in any facial infection, ask “is the airway safe?” before “which antibiotic?” Example: a patient with bilateral submandibular swelling, elevated tongue, and difficulty swallowing needs emergency airway assessment and drainage, not an oral antibiotic prescription alone.