Oral and Maxillofacial Surgery
This domain tests surgical assessment and decision-making: when to extract, when to refer, how to recognise nerve risk, and how to manage odontogenic infection and maxillofacial trauma in a safe sequence.
Third molars
- Assess on panoramic imaging with Winter's angulation (mesioangular is most common), Pell and Gregory depth and ramus relationship, and radiographic signs of inferior alveolar nerve proximity: darkening or deflection of the root, narrowing of the root, interruption of the canal wall and diversion of the canal.
- Coronectomy is preferred when nerve risk is high and the pulp is vital and asymptomatic.
- Dry socket is fibrinolysis presenting on days 3 to 4 with pain and an empty socket; incidence is roughly 1 to 4 percent for mandibular third molars. Irrigate and place a dressing; smoking and oral contraceptives raise risk.
Infection
Ludwig's angina is a bilateral submandibular, sublingual and mental cellulitis with a raised floor of the mouth. Priorities are airway, intravenous antibiotics such as amoxicillin-clavulanate plus metronidazole, incision and drainage, and removal of the causative tooth.
Trauma
Le Fort I is a low-level maxillary fracture with a mobile palate; Le Fort II is pyramidal; Le Fort III is craniofacial dysjunction. Mandibular angle fractures are plated along Champy's ideal line of osteosynthesis.
Worked example
A 45-year-old with poorly controlled diabetes has a three-day swelling, trismus and dysphagia, with a raised floor of the mouth and no fluctuance. The diagnosis is Ludwig's angina, a clinical emergency. Sequence: secure the airway, start intravenous antibiotics, drain all involved spaces, extract the offending molar, admit and monitor glucose.
Traps
- Extracting a tooth during acute pericoronitis before the infection settles.
- Ignoring postoperative paraesthesia.
- Prescribing antibiotics for a drainable abscess instead of draining it.
- Forgetting tetanus prophylaxis.
- Not warning about oro-antral communication after upper molar removal.