Oral and Maxillofacial Surgery
This domain tests the surgical management of teeth, odontogenic infection, cysts and tumours, facial trauma and the medically complex patient - with heavy emphasis on complication recognition and safe escalation.
Extraction and third molars
Assess third molars with Winter's angulation and Pell and Gregory classification, plus proximity to the inferior alveolar canal. Coronectomy is an option when roots intimately involve the canal and the tooth is vital and asymptomatic. Flap design should respect blood supply, avoid the greater palatine artery and mental nerve, and allow tension-free closure.
Complications
- Dry socket (alveolar osteitis): severe pain from days 2–4, empty socket, no pus. Treat with irrigation and a medicated dressing; do not curette aggressively.
- Bleeding: local measures first - pressure, sutures, haemostatic agents; review anticoagulation and check for a coagulopathy if persistent.
- Oroantral communication: suspect after upper molar extraction if there is a bubble test or Valsalva escape. Small defects under about 5 mm can be managed conservatively with a buccal advancement flap reserved for larger or infected cases.
- Nerve injury: record preoperative sensation and warn patients at risk.
Infection and airway
Odontogenic infection spreads along fascial planes. Ludwig angina is bilateral submandibular, sublingual and submental cellulitis with floor-of-mouth elevation, drooling and airway threat - this is an airway emergency requiring urgent surgical drainage and anaesthetic involvement.
Trauma and medication-related disease
Le Fort I, II and III fractures describe increasing levels of midface separation; mandibular fractures are described by site and displacement. Assess the airway first, following trauma resuscitation priorities. Medication-related osteonecrosis of the jaw requires exposed bone for eight weeks in a patient on antiresorptive or antiangiogenic therapy, with no radiotherapy history - staged for management and prevention rather than aggressive resection of early lesions.
Worked example
A 42-year-old develops pain on the left side of the face and fresh blood in the mouth thirty minutes after an upper second molar extraction. Reasoning: consider oroantral communication or a bleeding vessel. Test for communication with a bubble test, obtain a radiograph, and if a communication is confirmed and small, manage with a protective splint and sinus precautions; if larger than about 5 mm, arrange closure with a buccal advancement flap and review.
Traps that cost marks
- Instrumenting a dry socket and making the pain worse.
- Missing an airway-threatening infection by treating it as a routine abscess.
- Failing to document preoperative nerve status.
- Underestimating the risk of osteonecrosis in patients on long-term antiresorptives after extractions.