Oral and Maxillofacial Surgery and Anesthesia
Core concepts
Know exodontia: indications, contraindications, forceps and elevators, the principles of expansion, wedging and leverage, and the management of complicated extractions (root fracture, retained root, oro-antral communication). Know third molar assessment (Winter's and Pell–Gregory classifications, inferior alveolar nerve proximity, coronectomy as an option). Know local anaesthesia: the pharmacology of lidocaine, articaine, mepivacaine, bupivacaine; the role of vasoconstrictor; maximum safe doses (lidocaine 4.4 mg/kg with epinephrine, articaine 7 mg/kg); nerve blocks (inferior alveolar, lingual, long buccal, greater palatine, nasopalatine, mental, buccal) and their complications (positive aspiration, nerve injury, trismus, haematoma). Know complications of anaesthesia (syncope, vasovagal, LA toxicity, methaemoglobinaemia with prilocaine/benzocaine).
Know infection management: odontogenic infections, fascial spaces (submandibular, sublingual, buccal, canine, pterygomandibular, lateral pharyngeal), Ludwig's angina as a bilateral submandibular–sublingual–submental cellulitis with elevation of the floor of the mouth and airway risk, and the principle of incision and drainage plus antibiotics plus removal of the cause. Know trauma: Le Fort fractures, mandibular fractures (angle, condyle, parasymphysis), dentoalveolar trauma, and the ATLS-style priority of airway, breathing, circulation. Know oral surgery procedures: biopsy, cyst enucleation, apicectomy, implant placement, and post-operative care.
Traps
- Ludwig's angina is a clinical diagnosis and an airway emergency - do not wait for imaging.
- Articaine has a higher maximum dose than lidocaine but is associated with a higher rate of paraesthesia after inferior alveolar block.
- Positive aspiration is most common with the inferior alveolar block.
Rule of thumb
In any facial swelling with floor-of-mouth elevation, trismus or dysphagia, secure the airway first and arrange urgent surgical drainage.