Oral Surgery and Anesthesia Flashcards
Which of the following does not represent a
fascial space for the spread of infection?
A. Superficial temporal space
B. Pterygomandibular space
C. Masseteric space
D. Rhinosoteric space
E. Submental space
D. The superficial temporal, pterygomandibular,
masseteric, and submental spaces are potentially
involved in the of odontogenic infection. There is
no rhinosoteric space.
From the list of classifications of impacted teeth
below, which one(s) must always involve both
bone removal and sectioning during the surgical
procedure?
A. Mesioangular impaction
B. Horizontal impaction
C. Vertical impaction
D. A and B only
E. A, B, and C
B. Depending on the ramus relationship the
mesioangular and vertical impactions may not
require removal of bone or sectioning of the
tooth. The horizontal impaction will always
require removal of bone and sectioning.
Which of the following does not represent a possible finding of severe infection? A. Trismus B. Drooling C. Difficult or painful swallowing D. Swelling and induration with elevation of the tongue E. A temperature of 99 ̊ F
E. A patient with severe infection and systemic
involvement unless immunocompromised are
expected to present in a febrile state, or a tem-
perature of greater than 100 ̊F. All the other items
refer to symptoms that indicate potential airway
emergency.
You are performing a 5-year follow-up on a
43-year-old implant patient. When comparing
radiographs you estimate that there has been
almost 0.1 mm loss of bone height around the
implant since it was placed. Which of the
following is indicated?
A. Removal of the implant and replacement with a
larger size implant.
B. Removal of the implant to allow healing before
another one can be placed 4 months later.
C. Remaking the prosthetic crown because of
tangential forces on the implant.
D. The implant is doing well; this amount of bone
loss is considered acceptable.
D. Criteria for implant success include mean vertical
bone loss of less than 0.02 mm annually after the
first year of service. In this question, no further
treatment is necessary at this time.
Upon evaluation of an immediate postoperative
panoramic film of a dental implant replacing
tooth #30, you measure a distance of 1.5 mm
from the apex of the implant to the inferior
alveolar nerve canal. This is a titanium implant
in an otherwise healthy patient. Which of the
following actions is indicated?
A. You may proceed with immediate loading of the
implant.
B. You should continue but only perform a two-stage
procedure.
C. Back the implant out approximately 0.5 mm to
ensure a safe distance from the nerve.
D. Remove the implant and plan a repeat surgery
after 4 months of healing.
C. Implants should be placed a minimum of 2 mm
from the inferior alveolar canal.
Myofascial pain dysfunction may be described as \_\_\_\_\_. A. Masticatory pain and limited function B. Clicking and popping of the joint C. An infectious process D. Dislocation of the disc
A. In myofascial pain dysfunction the source of the
pain and dysfunction is muscular. Here dysfunc-
tion is associated with decreased opening or
inability to chew.
A 21-year-old man is referred to your oral and
maxillofacial surgery practice for an
orthognathic surgery consult. After your routine
exam and review of radiographs, you note the
following problem list: Class III skeletal facial
deformity with a negative overjet of 6 mm and
significant maxillary crowding; missing left
mandibular first molar due to dental decay with
multiple other early carious lesions; and
calculus on the lingual surfaces of teeth #22
through #27 with gingival inflammation. Which
of the following is the most appropriate order in
which this patient’s oral health needs should
be sequenced?
A. Definitive crown and bridge therapy, orthodontics
to relieve crowding and to coordinate arches,
caries management, surgery to correct the
skeletal discrepancy, and periodontal therapy to
control gingival inflammation.
B. Caries management, orthodontics to relieve crowd-
ing and to coordinate arches, definitive crown and
bridge therapy, periodontal therapy to control
gingival inflammation, and surgery to correct the
skeletal discrepancy.
C. Periodontal therapy to control gingival
inflammation, definitive crown and bridge
therapy, orthodontics to relieve crowding and to
coordinate arches, surgery to correct the skeletal
discrepancy, and caries management.
D. Periodontal therapy to control gingival
inflammation, caries management, orthodontics
to relieve crowding and to coordinate arches,
surgery to correct the skeletal discrepancy, and
definitive crown and bridge therapy.
D. Periodontal management is the first step in the
management of this patient. If the patient is unwill-
ing to, or unable to maintain adequate hygiene
prior to placement of orthodontic appliances, their
subsequent placement will only make the peri-
odontal situation more difficult. For the same rea-
sons, dental decay should be treated prior to
orthodontic treatment. The final prosthetic man-
agement should not be completed before the
underlying skeletal anomaly is addressed because
the occlusion will then be constructed to the
best—and final—anatomical location.
Systemic effects of obstructive sleep apnea
syndrome (OSAS) include all of the following
except _____.
A. Hypertension
B. Cor pulmonale
C. Aortic aneurysm
D. Cardiac arrhythmia
C. Systemic sequelae of OSAS include hypertension,
Cor Pulmonale, and cardiac arrhythmia.
Which of the following is not a vital part of the
physical exam for patients with TMJ complaints?
A. Soft-tissue symmetry
B. Joint tenderness and sounds
C. Soft-palate length
D. Range of motion of the mandible
E. Teeth
C. Tissue symmetry, tenderness, joint noises dental
health and occlusion and range of motion are all
critical components of the physical exam in the
TMJ patient. Although the length of the soft palate is
important in the evaluation of patients with sleep
apnea, snoring, patients being sedated, or patients
needing complete denture construction, it does not
contribute directly to TMJ dysfunction.
Which of the following is considered the highest
and most severe classification of maxillary
fracture?
A. LeFort I
B. LeFort II
C. LeFort III
D. LeFort IV
C. Maxillary fractures may be classified as LeFort I,
II, or III. The LeFort III is the highest and most
severe.
Which of the following is not a relative contraindication for routine, elective oral surgery? A. Unstable cardiac angina B. History of head and neck radiation C. Chronic sinusitis D. Hemophilia
C. Chronic sinusitis is not a relative contraindication
to most elective oral surgical procedures.
Unstable chest pain should be evaluated by an
internist or cardiologist prior to any dental treat-
ment. Radiation to the jaws or a history of clotting
disorders would both need further investigation
of the health history and likely alter the patient’s
treatment plan to lessen the likelihood of osteo-
radionecrosis or of bleeding complications.
Which of the following is true regarding
temporomandibular disorders?
A. The primary treatment for the majority of patients
with facial pain is TMJ surgery.
B. Disc displacement without reduction can cause a
decrease in interincisal opening.
C. Myofascial pain is commonly related to
parafunctional habits, but not commonly related
to stress.
D. Systemic arthritic conditions do not affect the TMJ
because it is not a weight-bearing joint.
- B. Disc displacement without reduction can result in
decreased range of motion because the condyle
becomes restricted by the anteriorly displaced
disc, limiting translation.
The following are those properties deemed most
desirable for a local anesthetic, except _____.
A. It should not be irritating to the tissue to which it
is applied
B. It should cause a permanent alteration of nerve
structure
C. Its systemic toxicity should be low
D. It must be effective regardless of whether it is
injected into the tissue or applied locally to
mucous membranes
B. A local anesthetic should not be irritating to the tis-
sue to which it is applied, nor should it cause per-
manent alteration of nerve structure. Its systemic
toxicity should be low. Finally, it must be effective
regardless of whether it is injected into the tissue
or applied locally to mucous membranes. If an
agent causes permanent alteration of nerve struc-
ture, it would not be of benefit.
The majority of injectable local anesthetics used today are \_\_\_\_\_. A. Tertiary amines B. Secondary amines C. Primary amines D. Esters
- A. Most local anesthetics packaged in dental car-
tridges are tertiary amines. Currently, the only local
anesthetic packaged in dental cartridges that has
an ester bond is articaine but the bond in the con-
necting chain in the drug molecule is an amide.
\_\_\_\_\_ has a shorter half-life than other amides because a portion of its biotransformation occurs in the blood by the enzyme plasma cholinesterase. A. Lidocaine B. Bupivacaine C. Mepivacaine D. Articaine
D. Bupivacaine, mepivacaine, and lidocaine are all
pure amides. Articaine has an ester bond and an
amide bond. Since esters are biotransformed
much more rapidly than amides, articaine has a
much shorter half-life than the others.
Which of the following local anesthetics is
marketed for dentistry in the United States in
more than one concentration?
A. Bupivacaine
B. Mepivacaine
C. Lidocaine
D. Articaine
B. Bupivacaine is only packaged in dental car-
tridges as a 0.5% solution. Likewise, lidocaine is
always a 2% solution (in the United States) and
articaine is always a 4% solution. Mepivacaine is
packaged in both 2% and 3% solutions (in the
United States).
The major factor determining whether aspiration can be reliably performed is \_\_\_\_\_. A. The needle gauge B. The needle length C. The injection performed D. The patient
A. The larger the lumen of the needle, the easier it
will be to determine whether the needle is actu-
ally in a vessel. The needle length is irrelevant, as
is the patient. The injection performed is relevant
as to the frequency of obtaining a positive aspira-
tion but not the reliability of the aspiration per se.
The _____ is recommended for palatal soft-tissue
management from canine to canine bilaterally in
the maxilla.
A. Posterior superior alveolar
B. Inferior alveolar
C. Long buccal
D. Nasopalatine
D. Nasopalatine (NP). The palatal tissue from canine
to canine bilaterally is the premaxilla. The NP
injection anesthetizes this area.
Which of the following local anesthetics has the highest pKa? A. Lidocaine B. Prilocaine C. Mepivacaine D. Bupivacaine
D. The pKa for lidocaine or prilocaine is 7.8, mepi-
vacaine is 7.7, and bupivacaine is 8.1.
Three cartridges of 2% lidocaine with 1:100,000 epinephrine contain \_\_\_\_\_ lidocaine. A. 36 mg B. 54 mg C. 54 μg D. 108 mg
D. A 2% solution of any drug contains 20 mg/mL, by
definition. A dental cartridge of local anesthesia
has a fluid volume of 1.8 mL. 20 mg × 1.8 = 36 mg
of lidocaine per cartridge. Three cartridges of 2%
lidocaine with 1:100,000 epinephrine therefore
contain 108 mg.
Which injection anesthetizes the distobuccal aspect of the mandibular first molar? A. Posterior superior alveolar (PSA) B. Middle superior alveolar (MSA) C. Anterior superior alveolar (ASA) D. Inferior alveolar (IA)
D. All mandibular molars are anesthetized by the
inferior alveolar nerve block. The other three
answers in the question are maxillary injections.
Which of the following is the longest-acting local anesthetic? A. Mepivacaine B. Lidocaine C. Prilocaine D. Bupivacaine
D. The degree of hydrophobicity and protein binding
are the most important factors in determining dura-
tion of action of a local anesthetic. Bupivacaine is
highly hydrophobic (therefore lipophilic) and is
95% bound to protein. The other listed agents are
less hydrophobic and are between 55% and 75%
bound to protein.
If your patient has a history of liver disease,
which of the following would be the safest local
anesthetic?
A. Articaine
B. Prilocaine
C. Lidocaine
D. Bupivacaine
A. All amide local anesthetics are biotransformed in
the liver. One available local anesthetic also has
an ester side chain, which means it has some
degree of extrahepatic biotransformation (out-
side the liver). This drug is articaine and is there-
fore the most appropriate drug for patients with
liver disease.
Which of the following injections has the highest degree of failure? A. Posterior superior alveolar B. Lingual C. Nasopalatine D. Inferior alveolar
D. The inferior alveolar nerve block has a stated
success rate of 85%, the lowest of any intraoral
injection. Lingual and nasopalatine injections
are close to 100% successful, and the PSA
nerve block is also much more than 85%
effective.
All of the following are possible reasons why
some local anesthetics have a longer duration of
action than others, except _____.
A. The addition of a vasoconstrictor
B. Percent protein binding
C. Degree of lipid solubility
D. pKa of the drug
D. The addition of vasoconstrictors will prolong the
duration of action of a local anesthetic. The
percent protein binding also affects duration of
action. Lipid solubility also affects the duration
of action of injected local anesthetics. The pKa
has an effect on onset of action but not on dura-
tion of action.
You have placed a dental implant for replace-
ment of tooth #9. Preoperatively you obtained a
panoramic and a periapical film. During the
surgery, you used a crestal incision, series of
drills, and paralleling pins as necessary. Upon
restoration of the crown, obtaining ideal esthet-
ics is difficult because the implant is placed
too close to the labial cortex, causing the
restoration to appear overcontoured. Which of
the techniques below could most adequately
have prevented this problem?
A. Using an anterior surgical template
B. Obtaining preoperative tomograms of the
alveolus
C. Using a tissue punch technique
D. Using a smaller size of implant
A. The surgical guide template is a critical factor for
the placement of implant in the esthetic area.
The third molar impaction most difficult to remove is the \_\_\_\_\_. A. Vertical B. Mesioangular C. Distoangular D. Horizontal
- C. The most difficult impaction to remove is the dis-
toangular tooth. This is because the withdrawal
pathway runs into the ramus of the mandible and
requires greater surgical intervention.
On a panoramic radiograph of a 13-year-old
patient, there is evidence of crown formation of
the third molars but no root formation yet.
These teeth fall into the category of impacted
teeth.
A. True
B. False
B. An impacted tooth is one that fails to erupt into the
dental arch within the expected time.
Consequently the third molar in a 13-year-old
patient would be classified as unerupted or in the
process of erupting.
Which of the following is not appropriate treat-
ment for an odontogenic abscess?
A. Placing the patient on antibiotics and having
them return when the swelling resolves
B. Surgical removal of the source of the infection
as early as possible
C. Drainage of the abscess with placement of
surgical drains
D. Close observance of the patient during
resolution of the infection
E. Medical management of the patient to correct
any compromised states that might exist
A. The primary principle of management of odonto-
genic infections is to perform surgical drainage and
removal of the cause. Abscesses will not resolve
on antibiotics alone and may progress even if the
patient is on antibiotics.
Before the exploration of any intrabony patho-
logic lesion, which type of biopsy must always
be done? A. Cytologic smear B. Incisional biopsy C. Excisional biopsy D. Aspiration biopsy
D. Any radiolucent lesion that requires biopsy should
undergo aspiration before surgical exploration. This
procedure may yield material for biopsy, and will
rule out a vascular lesion (e.g., AV malformation),
which could be dangerous to enter without prior
diagnosis.
You are performing a 5-year follow-up on a
43-year-old implant patient. When comparing
radiographs, you estimate that there has been
almost 0.1 mm of lost bone height around
the implant since it was placed. Which of the
following is indicated?
A. Removal of the implant and replacement with a
larger-size implant.
B. Removal of the implant to allow healing before
another one can be placed 4 months later.
C. Remaking the prosthetic crown because of
tangential forces on the implant.
D. The implant is doing well; this amount of bone
loss is considered acceptable.
D. Criteria for implant success include mean verti-
cal bone loss of less than 0.02 mm annually after
the first year of service. In this question, no further
treatment is necessary at this time.
The major mechanisms for the destruction of osseointegration of implants are \_\_\_\_\_. A. Related to surgical technique B. Similar to those of natural teeth C. Related to implant material D. Related to nutrition
B. The major causes for loss of osseointegrated
implants are similar to those of natural teeth: poor
hygiene, occlusal load, and the resultant inflam-
matory processes that occur.
After completing your postoperative instruc-
tions for dental implant placement for replace-
ment of tooth #14, your patient asks you how
long it will be before she can get her new tooth.
Which of the following is most correct to allow
complete osseointegration?
A. 3 weeks
B. 6 weeks
C. 3 months
D. 6 months
D. Traditionally 6 months has been the recom-
mended period for integration and subsequent
loading of posterior maxillary implants. Today,
because of technological advancements in spe-
cified cases, earlier loading may be possible.
- The imaging evaluation of the temporoman-
dibular joint is most likely to include any of the
following except \_\_\_\_\_. A. Panoramic radiographs B. TMJ tomograms C. Xeroradiography D. Magnetic resonance imaging
C. Imaging tools used in the evaluation of TMJ
pathology include panoramic radiographs, tradi-
tional and computer generated tomograms,
MRIs, nuclear imaging, and arthography.
When is distraction osteogenesis preferred over
a traditional osteotomy?
A. When a large advancement is needed.
B. When a small advancement is needed.
C. When exacted interdigitation of the occlusion is
needed.
D. When the treatment needs to be done in a very
short period of time.
E. Distraction osteogenesis is always preferred over
a traditional osteotomy.
A. Distraction osteogenesis is preferred over
traditional osteotomies when large skeletal
movements are required, and the associated soft
tissue cannot adapt to the acute changes and
stretching that results. Larger movements may be
at increased risk of some relapse. This is
particularly true in a patient with a cleft palate,
where there is significant soft tissue scarring from
previous surgeries.
The most common mandibular surgical osteotomy to advance the mandible is \_\_\_\_\_. A. A LeFort I osteotomy B. A segmental maxillary osteotomy C. A bilateral sagittal split osteotomy D. An intraoral vertical ramus osteotomy
C. The BSSO is the most commonly used osteotomy
for mandibular advancement.
Obstructive sleep apnea syndrome (OSAS) often
results in all of the following except _____.
A. Excessive daytime sleepiness
B. Aggressive behavior
C. Personality changes
D. Depression
B. OSAS may result in mood disorders, daytime
fatigue, and personality changes. Aggressive
behavior is not considered a sequela of OSAS.
Which of the following procedures would be considered the least invasive surgical treatment for TMJ complaints? A. Splint therapy B. Arthrocentesis C. Arthroscopy D. Disc removal E. Total joint replacement
C. Although less invasive, arthrocentesis and
splint therapy are not considered surgical inter-
ventions.
Your patient is a 23-year-old college student
whom you suspect may have sustained a
mandible fracture during an altercation.
Which of the following is false?
A. At least two x-rays should be obtained.
B. The most common x-ray obtained would be a
panoramic radiograph.
C. The most likely area for this patient’s mandible
to be fractured is the mandibular dental
alveolus.
D. Point tenderness, changes in occlusion, step
deformities, and gingival lacerations should all
be noted on physical exam.
C. The mandibular condyle is the most common
location of mandibular fractures. The alveolus,
ramus, and coronoid are the least common sites.
Which of the following is not a classification of
mandible fractures?
A. Anatomic location
B. Description of the condition of the bone
fragments at the fracture site
C. Angulation of the fracture and muscle pull
D. LeFort level
D. LeFort level fractures are associated with maxil-
lary injuries. Mandibular fractures are classified
according to anatomic location, condition of the bone and soft tissue, and the muscle pull on the
segments.
Even though the state-of-the-art treatment for
facial fractures is with internal rigid fixation
using bone plates and screws, a proper
occlusal relationship must be established prior
to fixation of the bony segments if the reduc-
tion is to be satisfactory.
A. True
B. False
A. A proper occlusal relationship is a prerequisite for
satisfactory bony reduction. This is most com-
monly accomplished by the use if intermaxillary
fixation, or wiring the jaws closed, during surgery.
Which of the following is true regarding possi-
ble complications resulting from dental extrac-
tions?
A. Patients with numbness lasting more than
4 weeks should be referred for microneuro-
surgical evaluation.
B. Infections are common, even in healthy
patients.
C. Dry socket occurs in 10% of third molar patients.
D. Teeth lost into the oropharynx are usually
swallowed, and thus do not require further
intervention.
A. Most nerve injuries are transient; however, in an
injury that lasts greater than 4 weeks, a surgical
evaluation is indicated.
Which of the following is true regarding the
possibilities for reconstruction of an atrophic
edentulous ridge prior to denture construction?
A. Dental implants are used only as a last resort
after bone grafting attempts have failed.
B. Distraction osteogenesis is too new a technique
to be applied to ridge augmentation.
C. Potential bone graft harvest sites for ridge
reconstruction include rib, hip, and chin.
D. The need for ridge augmentation is more
common in the maxilla than in the mandible.
C. Sites commonly used for the reconstruction of the
atrophic mandibular ridge are dictated by the
deficiency and include chin, hip, ribs, prosthetic
materials, and donor bone (human and bovine).
Dental implants are commonly used, not only as a
last resort. The use of distraction of ridge aug-
mentation has been reported and is useful in cer-
tain applications. The mandibular alveolar ridge is
more problematic in terms of resorption and
denture retention, which more commonly neces-
sitates reconstructive measures.
You are evaluating a patient 5 days after
extraction of tooth #17. The patient complains
of a severe throbbing pain that started yester-
day, 4 days after extraction. The patient most
likely has which of the following conditions? A. Dry socket B. Subperiosteal abscess C. Periapical periodontitis in tooth #18 D. Neuropathic pain
A. A dry socket (alveolar osteitis) occurs on the third to
fourth day after extraction and, except for pain,
does not have the classic signs of infection.
Which of the following would not be expected
to cause delayed healing of an extraction site?
A. A patient older than 60 years of age
B. A patient younger than 10 years of age
C. A patient with diabetes
D. A patient with a heavy smoking habit
B. Older age, diabetes, and smoking are risk factors
for delayed healing.
- The following are all desirable properties of an
ideal local anesthetic, except _____.
A. It should have potency sufficient to give
complete anesthesia even if harmful results
occur at therapeutic doses
B. It should be relatively free from producing
allergic reactions
C. It should be stable in solution and readily
undergo biotransformation in the body
D. It should either be sterile or capable of being
sterilized by heat without deterioration
A. Ideally, a local anesthetic should be relatively
free from producing allergic reactions and it
should be stable in solution and readily undergo
biotransformation in the body. It is an absolute
requirement that it should either be sterile or
capable of being sterilized by heat without deter-
ioration. If proper doses are used and are pro-
perly injected, there is a high success rate of
obtaining anesthesia, while being able to mini-
mize adverse effects.
What is the direct effect of local anesthetics on blood vessels in the area of injection? A. Constriction B. Dilation C. Sclerosis D. Thrombosis
B. All local anesthetics are vasodilators to some
degree.
All of the following describe lidocaine as pack-
aged in dental cartridges except _____.
A. Provided in a 2% solution
B. Provided with or without epinephrine
C. Has a pKa = 8.1
D. Has a rapid onset
C. The pKa of lidocaine is 7.9. It is packaged as a 2%
solution both with and without epinephrine and
has a rapid onset of action.
25-gauge needles are preferred to smaller-diam-
eter ones due to all of the following reasons
except _____.
A. Greater accuracy in needle insertion for
25-gauge needles
B. Increased rate of needle breakage for 25-gauge
needles
C. Aspiration of blood is easier and more reliable
through a larger lumen
D. There is no difference in pain of insertion
B. 25-gauge needles have a much lower incidence of
breakage versus any other needle size commonly
used in dentistry, whereas 30-gauge needles have
by far the worst record.
A 1.0-ml volume of a 2% solution contains \_\_\_\_\_. A. 18 mg B. 20 mg C. 36 mg D. 54 mg
B. A 2% solution is 20 mg/mL. 1.0 mL of a 20 mg/mL
solution is 20 mg.
During local anesthetic administration, the
patient should be placed in a _____ position.
A. Trendelenburg
B. Supine
C. Reclined
D. Semi-supine
B. The supine position is correct. This position will
prevent fainting during or immediately after the
injection of local anesthetic. Reclined or semi-
supine is not back far enough and Trendelenburg
is too far.
According to Malamed, slow injection is
defined as the deposition of 1 ml of local anes-
thetic solution in not less than _____.
A. 15 seconds
B. 30 seconds
C. 60 seconds
D. 2 minutes
B. Malamed recommends that one cartridge of
local anesthetic be delivered over not less than
1 minute. Therefore, 1 mL (one-half cartridge)
should be delivered over not less than one-half
minute (30 seconds).
The _____ nerve block is recommended for man-
agement of several maxillary molar teeth in
one quadrant. A. Posterior superior alveolar (PSA) B. Inferior alveolar (IA) C. Long buccal (LB) D. Nasopalatine (NP)
A. Posterior superior alveolar (PSA). This is the only
injection listed that leads to pulpal anesthesia in
the maxilla. The nasopalatine (NP) is a maxillary
injection that leads to soft-tissue anesthesia of the premaxilla only. The inferior alveolar (IA) and
long buccal (LB) are mandibular injections.
In an adult of normal size, penetration to a
depth of _____ mm places the needle tip in the
immediate vicinity of the foramina, through
which the posterior superior alveolar (PSA)
nerves enter the posterior surface of the maxilla.
A. 10
B. 16
C. 20
D. 30
B. 16 mm. The proper depth of penetration for the PSA
nerve can be said to be half the length (16 mm) of
a long needle or three-fourths the length (15 mm)
of a short dental needle. Penetration beyond 16
mm has a significantly higher incidence of positive
aspiration and hematoma formation.
The _____ nerve block is useful for dental proce-
dures involving the palatal soft tissues distal to
the canine. A. Nasopalatine (NP) B. Greater palatine (GP) C. Long buccal (LB) D. Inferior alveolar (IA)
B. The greater palatine (GP) injection provides soft-
tissue anesthesia of the hard palate from the
junction of the premaxilla to the junction of hard
and soft palate and from the gingival margin to
the midline of the palate.
Elevation of cardiovascular signs with epineph-
rine, injected in a local anesthetic solution in a
cardiovascularly compromised patient, occurs at about what threshold? A. 40 μg B. 100 μg C. 200 μg D. 1000 μg
A. Jastak and Yagiela have published data demon-
strating that well-monitored, cardiovascularly
compromised patients begin to show elevation of
vital signs when more than about 40 μg (0.04 mg) of
epinephrine is administered in the local anesthetic
solution.
According to Malamed, the maximum local anesthetic dose of lidocaine (with or without vasoconstrictor) is \_\_\_\_\_. A. 1.5 mg/kg. B. 2.0 mg/kg. C. 4.4 mg/kg. D. 7.0 mg/kg.
C. Malamed recommends that 4.4 mg/kg (2.0 mg/lb)
of lidocaine be the maximum administered,
regardless of whether vasoconstrictor is in the for-
mulation. The package insert for lidocaine allows
up to 7 mg/kg when lidocaine is packaged with
vasoconstrictor.
Which of the following injections, when properly
performed, does not lead to pulpal anesthesia?
A. Inferior alveolar (IA)
B. Lingual
C. Posterior superior alveolar (PSA)
D. Infraorbital (IO) (true anterior superior alveolar
nerve block)
B. The inferior alveolar, PSA, and IO injections all
lead to pulpal anesthesia when performed pro-
perly. The lingual injection leads to soft-tissue
anesthesia only.
The optimal volume of local anesthetic solution
delivered for a true anterior superior alveolar
(ASA) nerve block is usually about _____.
A. 0.5 mL
B. 1.0 mL
C. 1.5 mL
D. 1.8 mL
B. The true anterior superior alveolar (ASA) nerve
block, also called the infraorbital nerve block,
requires a volume of one-half cartridge of local
anesthetic solution, or about 1.0 mL.
The local anesthetic agent that is most appro-
priate for use in most children is _____.
A. 3% mepivacaine
B. 2% mepivacaine with 1:20,000 levonordefrin
C. 2% lidocaine with 1:100,000 epinephrine
D. 0.5% bupivacaine with 1:200,000 epinephrine
C. 2% lidocaine with 1:100,000 epinephrine is the local
anesthetic that allows the greatest volume to be
administered safely. Therefore, it is the local
anesthetic drug of choice for administration in
children. Mepivacaine in either 2% or 3% allows
less volume to be safely administered and bup-
ivacaine is not FDA-approved for administration to
children.
Which of the following local anesthetics causes the least amount of vasodilation? A. Lidocaine B. Mepivacaine C. Bupivacaine D. Articaine
B. All local anesthetics cause some amount of
vasodilation. Those packaged as plain drugs
(i.e., without vasoconstrictor) cause less vasodi-
lation than do those drugs that must be pack-
aged with vasoconstrictor to have efficacy. Of the
listed drugs, Mepivacaine is the only one packaged
in dental cartridges without vasoconstrictor.
According to Malamed, how many cartridges of
2% lidocaine can be safely administered to a
child weighing 40 lb?
A. Three cartridges
B. One cartridge
C. Nine cartridges
D. Two cartridges
D. 2% lidocaine contains 36 mg of lidocaine per car-
tridge. Since 80 mg is the amount of lidocaine that
can safely be administered to this child, the
number of cartridges that can be administered is
80 mg divided by 36 mg per cartridge, which is
roughly two cartridges.
If a local anesthetic has a low pKa, then it will usually have a \_\_\_\_\_. A. Greater potency B. Higher degree of protein binding C. Faster onset of action D. Greater vasodilating potential
C. By definition, a low pKa means a fast onset of
action. Hydrophobicity and protein binding
directly affect duration of action and potency.
Anticipating correct administration of the
(long) buccal injection, what areas will be
anesthetized?
A. Soft tissues and periosteum buccal to the
mandibular molar teeth
B. Soft tissues and periosteum lingual to the
mandibular molar teeth
C. Soft tissues and periosteum lingual to the
mandibular premolar teeth
D. Soft tissues and periosteum buccal to the
mandibular premolar teeth
A. The (long) buccal injection anesthetizes the soft
tissues and periosteum buccal to the mandibular
molar teeth.
Which local anesthetic is most hydrophobic
and has the highest degree of protein binding?
A. Mepivacaine
B. Lidocaine
C. Bupivacaine
D. Procaine
C. Lipid solubility (therefore, hydrophobicity) and
protein binding are the most important factors in
determining duration of action of a local ane-
sthetic. Bupivacaine has the longest duration of
action of the listed local anesthetics and also has
the highest hydrophobicity; it is bound 95% to
protein. The other listed agents have lower
hydrophobic qualities and are 75% or less bound to
protein.
A portion of which cranial nerve is anesthetized
when performing an infraorbital nerve block?
A. VII
B. V
C. III
D. II
B. It is the intent with all intraoral injections of local
anesthesia that you anesthetize a portion of the
fifth cranial nerve. With an improperly placed
needle in a mandibular block, it is possible to
inadvertently anesthetize a portion of the seventh
cranial nerve, and it is possible to inadvertently
anesthetize the sixth cranial nerve with certain
second-division nerve blocks.
Which of the following local anesthetics has the shortest half-life? A. Lidocaine B. Prilocaine C. Bupivacaine D. Articaine
D. Articaine has an ester bond and an amide bond.
Since esters are biotransformed much more rap-
idly than amides, articaine has a much shorter half-
life than the others.
Incisional biopsy is a technique used
when a lesion is large > 1 cm, polymorphic suspicious for malignancy, or in an anatomic area with high
morbidity
Excisional biopsy is used
on smaller lesions < 1cm that appear benign and on small vascular and pigmented lesions. It entails the removal of the
entire lesion and a perimeter of surrounding uninvolved tissue margin.
Pt has worn denture for 19 years, now he has a sore on buccal with swelling. What do you do?
a. refer out
b. biopsy
c. cytology
d. relieve denture and re-evaluate in 2 weeks
d. Relieve denture in area and re-evaluate in 2 weeks
White patch on buccal mucosa, what’s best way to get biopsy?
Smear
You have a lesion in mouth, you tried to treat it, still looks the same after 2 weeks –
Take biopsy
Biopsy - indicated when
treatment doesn’t work after 14-20 days
- about 2 weeks—any red or white lesion that doesn’t resolve itself in two weeks – BIOPSY THAT SHIT
Patient comes in with preliminary diagnosis of candidiasis on ventral tongue and floor of mouth, white lesion rough and firmly
attached. What do you do?
Incisional biopsy, do cultural testing and confirm that it is/is not candidiasis
Oral candidiasis biopsy of choice is:
a. incisional biopsy
b. excisional biopsy
c. brush biopsy (collects the cells for cytological smear)
d. cytologic smear
d. cytologic smear
White lesion is 2x3x2 cm, what type of biopsy?
excisional biopsy
incisional biopsy
smear
incisional biopsy
What should you not do initially with a patient with desquamative gingivitis: biopsy, topical corticosteroids
encourage OHI
biopsy
When you do biopsy, how do you store the specimen before it gets to oral pathologist?
Formalin (answer)
Patient has a sore, shiny red area that when you blow air on it, a white membrane comes off and the sore starts bleeding. What
should you do?
Culture and Medical management (Or biopsy + Med Man)
To test for malignancy, what test? Cytology, brush biopsy, Incisional biopsy
Incisional biopsy
Diff btween 1 stage and 2 stage implant placement:
(1 stage) immediate loading vs (2 stage) traditional way
What kind of bacteria is under implants?
At the apex of root canal? Gram (-) rods and filaments anaerobic
What bacteria is responsible for implant failure?
gram (–) anaerobic
Bacteria around failing implants?
Gram negative, motile, strictly anaerobic
What is the least important factor when evaluating for implant? concavity of mandible bone density distance to mandibular cancel bone width
concavity of mandible
Minimum distance between adjacent implants?
3 mm
How much space between implant and tooth? 1.5 mm, 2 mm, 3.5 mm, 3mm
1.5 mm
Minimal distance from implant to nerve needed (ex. IAN, mandibular canal)?
2 mm
Implant diameter is 3.75 mm. What is the minimum labiolingual distance required?
5.75mm
If implant with width of 4 mm is used, what should be the bucolingual width of the ridge?
a. 6mm
b. 8mm
c. 4mm
d. 10mm
6mm
Esthetics of a maxillary central anterior implant replacement determines • adjacent tissue • perio health of adjacent • wax up to full contour • emergence profile
• emergence profile
Where should you put implant platform in esthetic area? at level of alv.crest, below opposing tooth gingiva, 1mm subgingival to
adjacent teeth CEJ, etc.
1mm subgingival to
adjacent teeth CEJ
To obtain ideal emergence profile, where should the Implant head be in relation to adjacent gingival margin? 1-2mm above, 3-5
mm above, same level, 1-2 mm apical
1-2 mm apical
Cervical position while placing an implant, how should the implant be placed in relation to adjacent CEJ?
2-3 mm apical the
adjacent CEJ
- Rest platforms placed 2-3 mm below adjacent CEJ.
Which of the following is bad for placing implants except? Radiopaque lesions
Which of the following is bad for placing implants except? Radiopaque lesions
When placing implant in the mandibular posterior, how do you ensure you don’t hit IAN?
Look at panorex and measure with mm caliper
look at PA and put some screen over to measure
move the nerve down and “be very careful when placing implant”
ook at PA and put some screen over to measure
What causes the least buccal-lingual resistance to lateral forces Two 5mm diameter splinted implants Two 4mm diameter splinted implants One 5mm diameter implant One 4mm diameter implant
Two 5mm diameter splinted implants
In anterior maxilla, for a 4mm diameter implant, how far apical to the CEJ of adjacent tooth for optimal emergence profile?
1 mm above cej of adj tooth
1 mm below cej of adj tooth
2-4 mm below cej of adj tooth
2-4 mm below cej of adj tooth
How does titanium of an implant help in osseointegration?
Forms titanium oxide layer
Similarity between bone and implant?
Vascular bundle below the bone
Implants osteointergrate best in?
Anterior mandible
Best area to place implant?
Anterior mand
Worst/least successful implant placement?
MAXILLARY POSTERIOR
- lowest quality/density, more trabulation less cortication in maxillary posterior, Type 4 bone
How does fibers grow from crest of bone to implant?
Perpendicular with implant
parallel with implant
parallel with implant
How does gingival fibers orient next to implant? parallel to implant with no insertion perpendicular with insertion parallel with cuff perpendicular with cuff
parallel with cuff
- Periodontium: you have long JE and CT (parallel and circular only)
Implant success is determined by what?
Mobility
- Basic criteria for implant success are immobility, absence of peri-implant radiolucency, adequate width of the attached gingiva, absence of
infection
- Average bone loss of 0.2mm for the first year is acceptable
acceptable average bone loss for implant
0.2 mm/year for the first 5 years
During uncovering, you realized implant is mobile & there is bone loss -
failed implant, extract it!
What main reason implants fail? Surgical error Lack of early loading Inadequate occlusal design does not osseointegrate
Surgical error
Major mechanisms for the destruction of osseointegration are: Related to surgical technique Similar to those of natural teeth Related to implant material Related to nutrition
Similar to those of natural teeth
What is the worst type of force for an implant?
Horizontal
When you place an implant, widening of crestal bone is seen because of which force?
Horizontal
What causes the greatest incidence of implant failure? Smoking Osteoporosis with HTN Hypotension Allergy to antibiotics
Smoking
Where should implant/abutment interface ideally be?
At height of alveolar crest
All are symptoms of TFO (trauma from occlusion) on an implant except? Gingivitis, pain, loosening of implant, breakage of
abutment screw.
Gingivitis
1 mm crestal bone remains around implant after 1 year, why? inflammation, heavy occlusal load
inflammation
Which of these show clinically acceptable results of implant placement?
Peri-implant pathoses
implant mobility
bone loss less than .1mm per yr.
bone loss less than .1mm per yr.
Pt has an implant. Do the connective tissue and epithelium attach the same as they do to natural tooth, meaning biological width?
A. Both attach the same
B. Neither attach the same
C. epi attaches the same but not connective tissue
D. CT attaches the same but not Epi.
C. epi attaches the same but not connective tissue
Epithelial attachment for implant?
- Hemidesmosome
- fibronectin
hemidesmosome (epithelial attachment to tooth structure and implant are the same)
What speed and torque for implant is used?
High Torque, slow speed
In implant preparation, which of the following can be used? A) hydroxyapatite irrigation b) High Speed Hand Piece c) Low torque Drill d) Saline Coolant
d) Saline Coolant
Why you use irrigation in implant surgery?
To prevent bone from overheating (other options were to keep it clean, etc)
When doing an osteotomy for implant placement, why do you use saline?
to help cool down the bone
When placing an implant, how you keep the temperature of the bone below 56 degrees C?
Alkaline irrigation
What is the temperature limit before bone dies in implant procedure?
47 C for 1-5 minutes
Temperature you don’t want to exceed during implant placement? They had 26, 36, 56.
56
CASE - Case shows a picture of a bridge, when you look at it closely it resembles a Maryland bridge because lateral is intact. What to
do if Maryland is removed?
regular bridge
implant because lateral was intact
Contraindications to implant placement? Adolescents
uncontrolled diabetes
- immunocompromised patients
- reduced volume and height of bone (anatomic considerations)
- bisphosphonate therapy
- bruxism
- tobacco (relative)
- cleft palate
- young kids
are implants contraindicated in old patients?
no
QUESTION: What is the success rate of implants in 10 years?
80%
13 y/o present for implants? wait until
18-20 y/o
All affect implant placement EXCEPT – smoking 1 pack a day, cardiovascular disease, uncontrolled diabetes, radiation of 60 Gy
cardiovascular disease,
What environment factor alters healing?
Smoking
All these are contributing factors for why implant would fail in this pt except? smoking, diabetes, age
age
Implant treatment are better option for smoker than perio surgery because perio surgery in smoker doesn’t work as well as non-
smoker.
a. Both statements are true but unrelated
b. Both statements true and related
c. First statement true but reason is not
d. Neither the statement or the reason is true
. Neither the statement or the reason is true
When getting crown for implant, what occlusal scheme is preferred?
Metal occlusal is preferred
When you use screw over cement retained?
when you don’t have space occlusally
- need more interocclusal space for cemented
What is the purpose of external hex screw?
Anti-rotational
- Hex screw implant – prevent rotation of the crown
Implant internal component helps with what?
Prevents rotation of the abutment
A lot of implants have external hex, what is it used for?
• Stabilization of abutment
• For cementation
Stabilization of abutment
What is the component of the implant that replicates implant in cast?
Analogue
What is most important for osseointegration in implant procedures?
How well the surgical procedure is managed.
Osseointegration of implants should be assessed:
prior to placement of restorative abutment
At what appointment do you first check osseointegration?
a) before taking the final impression
b) before placing the abutment
c) before cementing the crown
b) before placing the abutment
QUESTION: All of the following are true about surgical stents except?
number of implants you can place,
angulation of implant, location implant,
thickness of implant
number of implants you can place,
Why do you use a stent?
make sure implants are aligned properly
Stent - surgical template for
angulation of bur for implant placement
What will you do when implant is inclined too buccally & you don’t want the screw to be seen on the buccal surface of crown?
Angled abutment
Implant placed in facial angulation, what do you do to prevent facial access for screw abutment?
place an angled abutment &
cement it down; other options is correct implant placement or put composite where facial access for screw will be
Implant placed at angle where screw hole will be on buccal surface. What do you do so that you can’t see screw on buccal?
Cover with composite
Angled abutment cemented
Remove implant
Angled abutment cemented
Preload of implant is comparable to what force
a. torque
b. compressive
compressive
- Compressive force presses the components of the system together & normally does not introduce any mechanical problems in the
anchorage unit itself. - Tensile loading refers to a force that tends to separate components
What is the problem with preloading a screw implant?
Low loading can make it loose
high loading can make it loose
low loading can lead to implant creep or something
High loading can lead to implant creep
High loading can lead to implant creep
- High frictional forces between components decrease as a result of creep leads to a decrease in preload
What do you want to do first when taking an impression of the implant and abutment splinting the 3 implants with a bar?
Make sure the abut is attached right when the pt comes
check fit of custom tray
insert impression coping
insert imp coping with acrylic
Make sure the abut is attached right when the pt comes
Advantages of an open tray impression -
Reduce effect of implant angulation
Most common complication for crown?
Screw loosening
When not to immediately load an implant?
• Denture in contact
• Bone grafting with GTR
• Bone grafting with GTR
Do we probe like normal for an implant?
Yes
How to clean implant-
prophy cup, plastic scalers, not stainless steel!
You are considering the placement of an upper and lower implant-retained complete denture. How many implants will you place in the anterior region? a. maxillary one and mandibular one b. maxillary two and mandibular two c. maxillary four and mandibular two d. maxillary four and mandibular six
c. maxillary four and mandibular two
- If implant supported complete denture, add 2 more screws to each.
When there is FPD from natural tooth to implant, the max stress is concentrated on the
SUPERIOR PORTION OF THE IMPLANT.
QUESTION: If implant and bridge are done with natural tooth, what is the complication? t
here is a lot of force on crown of implant that causes
fracture. à diff mobility
Where do you put occlusal rests for implant supported RPD?
NONE
After implant placement, an edentulous patient should:
a. avoids wearing anything for 2 weeks
b. immediately have healing abutments placed over the implants
c. should wear an immediate denture to protect the implant site
a. avoids wearing anything for 2 weeks
At the time of delivery of an implant supported prosthesis, only 2 of the 3 implants seat. What do you do next?
separate the
prosthesis and re-index it
Implant retained fixed prosthesis, doctor took radiograph and it showed 2 out of 3 implants seat positively with good margin. What
should doctor do after?
- section and index
- tighten screw
- take another x-ray
• section and index
The most frequently impacted teeth are
MANDIBULAR 3rd MOLARS (followed by maxillary 3rd molars and maxillary canines).
Most common impacted tooth? (3rd molars not an option) –
maxillary canines
Which tooth is least likely to be missing?
Canine
2nd pm
Lateral incisors
3rd molar
Canine
- Most commonly missing teeth are the 3rd molars, 2nd premolars and upper lateral incisors
What is least missing tooth congenitally? – canines, premolars, 3rd molars, lateral incisors
canines
Extractions in ortho tx:
max 1st premolars
Where does man branch of trigeminal nerve come thru?
Foramen Ovale
Ectopic eruption of mand 1st molar in relation to primary mand 2nd molar cause some resorption, tx management? Extraction of
primary 2nd molar, separation, disking of 2nd molar
Extraction of
primary 2nd molar,
What order do you extract upper posterior molars & why?
Order of extraction of teeth in maxillary molars- 3rd M, 2nd M, 1st M to
prevent fracture of tuberosity (most posterior teeth first)
Most likely to cause nerve damage during extraction? Nerve canal overlaps root apices, nerve canal narrows
Nerve canal overlaps root apices
MOST common complication of extraction? Hemorrhage, infection, root fracture
root fracture
Radiograph of mandibular molar extraction site. Patient came back having pain & pus in that area: did not have dry socket as a
choice?
Osteomyelitis
- Osteomyelitis common following tooth extraction – bone infxn
X-ray of older woman, tooth extract 3 years ago. The area still hurts and has exudate, shows cotton-wool radiograph over the ridge
area, “prob wrong”) what is it? Residual cyst, osteomyelitis, 2 other lesions that are radiolucent
osteomyelitis
Patient w/ osteomyelitis after EXT, what do you do?
curettage the walls of the socket to remove infection
QUESTION: Extraction of #30, which way do you section?
Buccal- lingual
Resorption of bone takes place in which direction after extraction?
downward/inward
downward outward
forward inward
downward/inward
After fx a mesial root tip on a molar extraction, what’s the first thing you do? get hemostasis and visualize the root, take an
x-ray, pick at it with root pick, surgical retrieval
get hemostasis and visualize the root
Which direction do you luxate the tooth?
Children: Palatally b/c molars are positioned more palatablly and palatal root is strongest.
Adults: buccally!
When do you do serial extraction?
a. for space deficiency in mandibular anterior region
b. for space deficiency in mandibular posterior region
c. for space deficiency in maxillary anterior region
d. for space deficiency in maxillary posterior region
a. for space deficiency in mandibular anterior region
Biggest risk with extracting a lone single remaining maxillary molar?
Fracturing tuberosity
When extracting an erupt max molar, what is most like cause of complication?
you can have broken tuberosity/sinus floor
Minimum platelet count for oral surgery?
Routine ok w/ 50,000
- emergency can be done w/ as little as 30,000 if work w/ hematologist and use excellent tissue management technique
You extracted a tooth & give Penicillin. The next day, patient has high fever, swelling, & dysphagia. What do you do?
Change to different antibiotic
Refer to OMFS
Add another drug to regimen
Change to different antibiotic
hardest 3rd molar to remove on mx
mesioangular
hardest 3rd molar to remove on md
distoangular
When extracting, where is the max 3rd molar most likely to be displaced?
A. infratemporal fossa
B. maxillary sinus
A. infratemporal fossa
Extraction of molars with divergent roots:
hemisection
QUESTION: In which direction do you luxate a distoangular maxillary 3rd molar? distal palatal, distobuccal,
palatal, mesial
distobuccal
Easiest mx 3rd molar impaction to remove:
distoangular
32 - Complete horizontal bony impaction, what is the main concern?
damage to nerve
16 - half in bone, half in gum à It is the most common kind of impaction & easiest to take out
(both FALSE)
Greatest risk to injure IA nerve on extraction of 3rd molars:
Lack of visualization of end of roots
Root tips sit on top of mandibular canal
Horizontal impaction
Root tips sit on top of mandibular canal
QUESTION: Indication to extract 3rd —
making space for ortho, prevent crowding, pt has pain during eruption, there’s an infection
65 y/o has hypertension and congestive heart disease, referred to you to TE impacted molar, absolute indication to do the TE is when: radiograph shows bone pathology prevent distal pocket of 2nd molar prevent jaw fracture prevent distal caries for 2nd molar
radiograph shows bone pathology
Patient has pain, trismus, inflammation for 3rd molar, Tx?
exo
Know pericoronitis treatment
- W/out surgery = clean and antibiotics
- With surgery = Before surgery, control infection. IND, irrigate drain, antibiotics, then remove the 3rd molar
Which direct do you luxate tooth #1 and #16? –
Distally and Buccally
md most common angulation of 3rd molar
mesioangular
mx most common angulation of 3rd molar
vertical
< 2mm oro-antral communication tx
do nothing
2-6 mm oro-antral communication
ABb, nasal decongestant + figure 8 suture
> 6 mm oro-antral communication
flap surgery
Mylohyoid surgery can accidentally damage to what nerve?
Lingual nerve
Where are you most likely to damage a nerve in vertical release of flap?
lingual, Wharton’s duct and the sublingual gland
- void vertical incisions in lingual and palatal
When doing flap surgery on mandible, what structure do you watch for? mental nerve, mentalis attachment
mental nerve
Oro-antral communication 2mm tx
Do nothing
QUESTION: Oro-antral communication of 4mm, what do you do? Observe, buccal flap, palatal flap?
FIGURE 8 suture
You see sinus is open by 2mm after an extraction, what do you do?
Do nothing and observe
- If the opening is 4 mm, do figure 8 suture.
- If the opening is 6 or more, do flap surgery
QUESTION: If you have 3mm uninfected root into sinus, what you do?
You do one an attempt, and if unsuccessful, leave it alone, no surgery.
What is the Caudwell lock technique?
Removal of root tip from max sinus, incision over canine fossa.
5 yr. old kid with Adderall prescription that needs an extraction. Do you need to change the dosage?
No change
Patient is about to undergo radiotherapy, what do you? – EXT all questionable teeth before radiation, EXT all
teeth before radiation
EXT all questionable teeth before radiation,
Therapy to avoid osteoradionecrosis?
Extract questionable teeth in area to receive 60+grays
A patient has begun radiation therapy in the mandible and needs teeth extracted. What do you do?
Do endo, and amputate the
crown without any trauma to soft tissue or bone
QUESTION: A patient received radiation therapy and requires extraction, what should the treatment be?
Extraction
extraction with alveoloplasty and sutures
extraction with alveoloplasty of basal bone and suture
pre-extraction and post-extraction hyperbaric oxygen
pre-extraction and post-extraction hyperbaric oxygen
QUESTION: Patient is taking IV bisphosphonates and need TE? RCT then coronotomy and seal hyperbaric oxygen followed by TE antibiotics and TE atraumatic TE
RCT then coronotomy and seal
- Best tx is do RCT and section crown off (as oppose to ext.)
QUESTION: It pt has been on IV bisphosphonates for two years?
Do root canals and keep roots, no TE!
All of the following are contraindicated for bisphosphonates, except?
Do RCT (other choices were invasive procedures)
Patient is on 6 months of IV bisphosphonate therapy, what do you do?
Hypo dives and extract
atraumatic extraction
endo with crownectomy & place sealants
endo with crownectomy & place sealants
QUESTION: Patient has BRONJ & bone is exposed, what is treatment? hyperbaric oxygen, sc/rp, chlorhexidine rinse (anti-bacterial rinse, and
oral antibiotics)
systemic: pain tx, Abx, antibact rinse
Osteoradionecrosis: Swelling, degeneration and necrosis of the blood vessels with resulting thickening of the vessel wall.
Use
hyperbaric oxygen for angiogenesis
open tray implant features
pick up, reduces angulation, more accurate, don’t have to put coping back into impression, less impression deformation
closed tray implant features
transfer, easier, better for short interarch distance, NOT suitable for deep implants, does not work for non-parallel implants, less accurate
74 ash forceps
mand PM
151A
md PM only
cryer elevator
single retained root of extracted md molar
17
md molars but not fused root
23 md cowhorn
molars
222
md molars but fused conical root
md molars with fused root
222
md premolars
74 ash and #151A
md molars but not fused root
17
md molars
23 md cowhorn
single retained root of extracted md molar
cryer elevator
mx root tips
286
upper molars
88 cowhorn
universal mx forceps
150
mx incisors or roots forceps
65 bayonet
65 bayonet
mx incisors or roots
150
universal mx forceps
88 cowhorn
upper molars
286 forceps
upper root tips
What number forceps to use when extracting mand premolars:
151A
also 74
What forceps are best for a mandibular premolar extraction? #17, #23, #74, #151, #150
74
The universal forceps #151 is commonly used for extracting _______________.
a. maxillary anteriors b. maxillary molars c. mandibular molars d. maxillary premolars
mandibular molars
The #65 forceps is typically used for removing ____________.
a. canines b. premolars c. molars d. root tips
root tips
During extraction a mandibular molar, the mesial root break. What instrument you use for root tips?
Cryer forceps
Elevator can be used to advantage when…
a. Interdental bone is used as fulcrum
b. Multiple adjacent teeth are to be extracted
Interdental bone is used as fulcrum
Elevator in oral surgery acts as what type of machine? Lever, wedge
Lever
What kind of suture do you use if you are only removing on one side of tooth? sling, continuous, interrupted
interrupted
What suture do you use when only buccal tissue is displaced?
Interrupted
What suture do you place when you only displace facial surface of mandibular teeth? Interrupted, mattress, continuous,
Interrupted
What does an interrupted suture accomplish?
a. brings the flap closer
b. covers all exposed bone
c. immobilizes the flap
c. immobilizes the flap
What suture contains wicks that allows bacteria to enter/invade extraction site?
Gut
Silk
Nylon
Silk
There is an incision on the corner of lip, where do you put suture?
movable to fixed tissue
- Most important is the vermilion border
If there is a 2 cm laceration on lip, what type of suture do you do?
Continuous, in middle and work both ways, reconnect orbicularis
oris first, reconnect vermillion border first
Most common negative outcome of routine TE? alveolar osteotitis, hemorrhage, infection
alveolar osteotitis,
Pt is a smoker, what is pt more at risk of getting after extraction?
dry socket
Pathophysiology of dry socket. How do dry sockets develop?
Blood clots not forming.
- Dry socket: Loss of healing blood clot (fibrinolysis of clot)
What causes alveolar osteitis (dry socket)?
Active dislodgement of blood clot (fibrinolysis of the clot)
MAIN CAUSE OF ALVEOLAR OSTEITIS (DRY SOCKET)?
Blood clot diminished & fell out
Main symptom of alveolar osteitis –
pain
Alveolar osteitis (dry socket) tx?
NO ANTIBIOTICS or curettage needed. Just medicinal dressing.
Acute osteitis (dry socket), how to take care of it?
Gentle irrigation and Medicated dressing
Ways to tx dry socket except:
a. curette walls to make socket bleed
b. no non-narcotic analgesic as needed
c. sedative dressing
d. flush out debris w/ sterile solution
. curette walls to make socket bleed
All are treatment for dry socket except?
Need for oral antibiotics
Treatment of alveolar osteitis:
placement of a palliative medicament/dressing
which exo complication does not need ABx
dry socket/alveolar osteitis
Le fort i
separation of maxilla
Le Fort II -
separation of the maxilla, attached nasal complex from the orbital and zygomatic fractures
Le Fort III -
Nasoethmoidal complex, the zygomas, and the maxilla from the cranial base which results in craniofacial separation
- Pathognomonic sign: Periorbital ecchymosis/hematoma, diplopia (double vision) and /or subconjunctival hemorrhage, infra-orbital nerve
damage
Periorbital ecchymosis/hematoma, diplopia (double vision) and /or subconjunctival hemorrhage, infra-orbital nerve
damage is pathognomonic of which fracture
le fort 3
le fort 3 pathognomonic sign
Periorbital ecchymosis/hematoma, diplopia (double vision) and /or subconjunctival hemorrhage, infra-orbital nerve
damage
best x-ray to visualize md fracture
pano
best x ray to visualize condyle frx
reverse towne’s (bodlivaya korova)
best x ray to visualize zygomatic frx
submentovertex
best x ray to visualize mx sinus
waters (kissing)
best x ray to visualize facial fracture
CT
reverse towne’s is to visualize what
condyle frx
submentovertex is to visualize what
zygomatic frx
Key sign of mandibular fracture?
Occlusal discrepancy or change in occlusion
Patient has a condylar fracture, what happens when mandible grows?
asymmetric growth with damaged side lagging (unaffected
side will continue to grow)
- The fractured side will lag. The unaffected will continue growth.
Child has mandibular trauma, what do they have later?
Midline facial asymmetry
What is primary consequence of trauma to jaw in kids? (normal def. of jaw, vs retarded growth vs hypertrophic growth on one side,
etc):
retards growth
Fracture 1 condyle the other lags behind, which causes:
Malocclusion
Most common area of fracture in children? symphysis, condyle, coronoid
condyle
- MOST COMMON: condyle (29%) 2nd most (angle of mandible 24.5%) – still growing, mostly cartilage
- LEAST COMMON: coronoid (1.3%) 2nd least (ramus of mandible 1.7%) – not attached to anything
least common frx in children
coronoid least common
2nd least common ramus of md
most common frx in children
condyle
2nd most common angle of md
Ankylosis of condyle most likely due to? Trauma or Fracture
Fracture
Splinting closes a bone fracture in –
6 weeks
Pt has a fractured mandible. Keep it splinting in closed reduction for how long?
6 weeks
Closed reduction, immobilize mandible for how long?
6 weeks,
- The standard length of maxillomandibular fixation (MMF) is 4-6 weeks.
QUESTION: Paresthesia occurs most commonly in what type of mandibular fracture?
Angle fracture
Lower lip numbness is seen in what kind of mandibular fracture?
Body fracture
Angle fracture
angle frx
fracture distal to mandibular foramen, close to IAN)
- angle of mandible fracture increases chance of IAN paresthesia and numbness
Most common surgery for maxilla:
LeFort I
Lefort I fracture are associated with? nasoethmoidal air cell frontal sinus maxillary sinus mastoid air cell
maxillary sinus
Guerin sign is a feature of what Le Fort fracture?
Le Fort 1 fracture
- Guerin’s sign: ecchymosis in the region of greater palatine vessels.
LeFort I =
brings the lower midface forward, from the level of the upper teeth, to just above the nostrils.
- Lefort I fracture: “floating palate”, Disturbed occlusion, palpable crepitation in upper buccal sulcus
LeFort II =
separation and mobility of the midface, Gagging on posterior teeth, Anterior open bite
QUESTION: LeFort III =
brings the entire midface forward, from the upper teeth to just above the cheekbones.
Lefort II most common injured nerve:
infraorbital nerve
Subconjunctival hemorrhage seen in what fracture? Lefort 1, nasal, frontal sinus, zygomaticomaxillary complex
zygomaticomaxillary complex
QUESTION: A patient experiences numbness of the left upper lip, cheek, and the left side of the nose following a fracture of his midface. This symptom follows a fracture through the A. nasal bone. B. zygomatic arch. C. maxillary sinus. D. infraorbital rim.
D. infraorbital rim.
What was the most common fracture in the face?
Zygomcomplex fracture
Which radiograph would you use to view a fracture of the mandibular symphisis?
A-P or CT
What age does mandibular symphysis fuse/close? 0-3, 3-6, 6-9, 9-12 months
6-9 months
Fracture of which part of the face would compromise pt’s respiration?
• Fracture through the body of mandibular
• Fracture to condyle
• Fracture to angle of mand
Fracture through the body of mandibular (bilateral)
You get punched on lower right & broke the jaw. What do you worry about?
Contralateral condylar fracture
if hit in the jaw what fractures
always opposite side condyle
What X-rays do you take to confirm horizontal fracture? 3 x-rays moving horizontally, 3 X-rays moving vertically
3 X-rays moving vertically
Horizontal fracture easily seen with –
multiple vertical angulated x-rays
What is best view to see zygomatic process?
Submentovertex (SMV)
Which of the following images shows better the mid-facial fracture?
Waters
What causes trauma in the US?
auto-accidents (in 3rd world is knife fights)
Pan showing lucency going inferior over the body of mandible close to the angle. You are informed that the patient was involved in an accident. Identify the lucency: a. pharyngeal airspace b. fracture c. artifact-retake radiograph
fracture
Osteotomy:
surgery where bone is cut to shorten, lengthen, or change its alignment
Distractive Osteogenesis (DO):
surgical process used to reconstruct skeletal deformities and lengthen the long bones of the body.
- benefit of simultaneously increasing bone length and the volume of surrounding soft tissues.
- easier in children, shows less relapse.
- 2 surgical procedures, hospitalization time is less but more discomfort – Compliance of patient and parent is a difficulty in DO
Bilateral Sagittal Split Osteotomy (BSSO) –
surgery where mandibular is split bilateral & moved to more balanced/functional position, correct
malocclusions. Stable for normal/decreased facial height but high relapse for pt w/ high mandibular plane angles.
- BSSO is the most commonly used osteotomy for mandibular advancement or retraction
Most commonly used surgery for mandibular augmentation?
Bilateral sagittal osteotomy
BSSO = Vertical Osteotomy used to:
push mand. forward or backward for class II.
How would you repair a Class II malocclusion?
BSSO (bilateral sagittal split osteotomy) - Correction of severe class II:
- Maxillary Impaction and autorotation of the mandible
- BSSO
QUESTION: Worst complication of BSSO:
Damage to IAN/Paresthesia
Most common complication of sagittal osteotomy:
IAN, loss of sensitivity
During which surgery do you have most chance of paresthesia of lip & tongue?
BSSO
vertical ramus osteotomy
inverted L
BSSO
Patient wants to fix Class III occlusion, what you going to do? Lefort 1 with BSSO Lefort 1 BSSO Max palatal expansion with BSSO
Lefort 1 with BSSO
- BSSO is for CLASS II (lengthen undeveloped mandible)
- Rapid palatal expander is for crossbite or minimal class III
- Rapid palatal expander is tx for
crossbite or minimal class III
just BSSO is tx for which malocclusion
class II (lengthen undeveloped mandible)
16 y.o. girl need to do what to correct class iii?
Lefort + BSSO – can’t do RPE because she’s too old
How long do you splint mandibular BSSO?
You don’t do MMF, as there is internal plate. Use an occlusal splint to help with occlusion
but not wired shut. Keep splint on 4-6 week.
Which of the following is the MOST common postoperative problem associated with mandibular sagittal-split osteotomies?
a. infection
b. TMJ pain
c. Periodontal defects
d. Devitalization of teeth
e. Neurosensory disturbances
e. Neurosensory disturbances
A patient has a skeletal deformity with a Class III malocclusion. This deformity is the result of a maxillary deficiency. The treatment-
of -choice is
A. orthodontics.
B. surgical repositioning of the maxilla.
C. anterior maxillary osteotomy.
D. posterior maxillary osteotomy.
E. surgical repositioning of the mandible.
surgical repositioning of the maxilla.
What’s the main difference between distraction osteogenesis and a regular osteotomy?
DO has more stability during wide span of
movements
Distraction osteogenesis: when to use over convention:
bigger stable movements
Complication following distraction osteogenesis (DO):
Long term follow up
