Oral and Maxillofacial Surgery, Orthodontics and Paediatric Dentistry
Oral surgery, orthodontics and paediatric dentistry: emergency decision-making, classification and timing of malocclusion, and child-specific restorative and behavioural choices. Prioritisation questions - what comes first - appear frequently here.
Core rules
- Airway first. Ludwig's angina is a bilateral submandibular and sublingual space infection with a raised floor of mouth; treat with high-dose IV antibiotics plus prompt surgical drainage, securing the airway if needed.
- Avulsed permanent tooth: replant immediately if possible, handle by the crown, rinse with saline or store in milk, then flexible splint for 10–14 days. Never replant a primary incisor - the developing permanent germ is at risk. Time out of the socket is the strongest prognostic factor.
- Mandibular fractures are most common at the angle, then the condyle; inferior alveolar nerve paraesthesia is a key sign. Le Fort I is a low transverse fracture, II pyramidal, III craniofacial dysjunction.
- Exodontia complications include dry socket (fibrinolysis, treated by irrigation and dressing), oro-antral communication and nerve injury.
- Angle's classification uses first permanent molars: Class I normal, Class II distal mandible, Class III mesial mandible; Class II division 2 shows retroclined upper centrals.
- Cephalometric norms: SNA ≈82°, SNB ≈80°, ANB ≈2°.
- Paediatric: the first permanent molar erupts at about 6 years and is caries-vulnerable for 12–18 months, so sealants and fluoride are prioritised; stainless steel crowns restore multi-surface primary molars after pulp therapy.
Worked example
A 12-year-old arrives two hours after avulsion of a maxillary central incisor, transported in milk. Replant with gentle pressure, apply a flexible splint for two weeks, check tetanus status and arrange radiographic review; at this age revascularisation is unlikely, so plan endodontic management. Replantation within the first hour is the single most important prognostic factor.
Traps
- Replanting a primary incisor and damaging the permanent successor.
- Superficial drainage of a submandibular infection without airway assessment and proper space drainage.
- Confusing Class II division 1 (proclined centrals) with division 2.
- Extracting a first permanent molar in a crowded arch without an orthodontic and space-management plan.