Oral and Maxillofacial Surgery and Anesthesia
Scope
Tests the assessment and execution of extractions, third molar difficulty, recognition and management of complications, and the surgical and anaesthetic emergencies that carry airway risk.
Assessment and technique
- History, medical status, radiograph and anaesthesia; mucoperiosteal flap with a relieving incision for surgical access.
- Third molars: Pell and Gregory classifies depth relative to the occlusal plane (A, B, C) and relation to the ascending ramus (I, II, III); Winter classifies angulation as mesioangular, distoangular, horizontal or vertical.
Complications
- Alveolar osteitis (dry socket): fibrinolysis of the clot with pain on days 3–4; irrigate and place a sedative dressing - antibiotics are not routine.
- Oroantral communication: confirm with the Valsalva test; small defects close spontaneously, larger ones need a buccal advancement flap.
- Nerve injury: lingual and inferior alveolar nerves; document sensation before and after surgery.
Medically complex patients
- Medication-related osteonecrosis of the jaw: antiresorptives and antiangiogenics; staged 0–3; manage conservatively and avoid elective surgery in high-risk patients.
- Ludwig angina: bilateral submandibular and sublingual space infection with elevation of the floor of the mouth; secure the airway first, then drain and give antibiotics.
Worked example
A mandibular third molar lies horizontally, its crown at the cervical line of the second molar, with the distal half overlapped by the ascending ramus. Reasoning: horizontal angulation is Winter class horizontal; a crown at cervical level is Pell and Gregory B; ramus overlap is Class II. This predicts a surgical extraction with bone removal rather than a simple forceps delivery.
Traps
- Treating dry socket with antibiotics instead of irrigation and a dressing.
- Missing a root displaced into the antrum or a fractured tuberosity.
- Stopping anticoagulants without consulting the prescriber.