SCORE Flashcards

Question

Seven days after undergoing a scapula free flap harvest for the reconstruction of a mandibular defect, a patient has a protrusion of the medial border of the scapula of the operative side. How could this complication have been prevented during the scapula free flap harvest? (NOTE: OMFS curriculum) A. Avoiding ligation of the branches of the thoracodorsal artery to the serratus anterior muscle B. Avoiding injury to the long thoracic nerve during axillary dissection C. Avoiding harvesting up to the subscapular artery D. Preserving at least 1 cm of bone distal to the glenohumeral joint

Answer 1

B. Avoiding injury to the long thoracic nerve during axillary dissection Arterial branches to the serratus anterior muscle from the thoracodorsal artery may be safely divided without compromising the vascular supply of the serratus anterior muscle. This may be necessary during the elevation of a scapula tip free flap based on the angular artery or a chimeric flap including the scapula and latissimus dorsi muscle. Injury of the long thoracic nerve can occur when dissecting the circumflex scapular artery and vein in the axilla. The long thoracic nerve innervates the serratus anterior muscle, and nerve injury leads to winging of the medial border of the scapula as it lifts off of the posterior thoracic wall. The subscapular artery may be taken with the flap to increase pedicle length and caliber. To prevent injury to the joint capsule during the superior osteotomy, 1 cm of bone should be preserved distal to the glenohumeral joint when harvesting a scapula free flap.

Answer 2

C. 30% Isolated unilateral cleft lip and palate is associated with syndromes in approximately 30% of patients, while the other 70% are cases considered isolated, nonsyndromic defects with no other associated abnormality.

Answer 3

C. Steiner analysis The Steiner analysis is consistent with the values listed in this scenario and is largely based on angular measurements from two main reference lines. The superior measure that approximates the cranial base is represented by the sella-nasion line, and the lower reference line is the mandibular plane defined by a line from the gonion to the gnathion. Even though the Steiner analysis is angular-based, there are certain measurements that include absolute distances, like the L1 to NB distance, which also has an angular counterpart, the L1 axis line to NB in degrees. The Wits appraisal uses the SNA and SNB measurements but does not include the specific L1 to NB measurements. The McNamara analysis, the Sassouni analysis, and the Andrews 6 elements do not use the aforementioned angles or measurements.

Answer 4

D. Perform renal function testing. This patient’s presentation of painful oral ulcers with fever and epistaxis (upper respiratory tract inflammation/vasculitis), hemoptysis (lower respiratory tract vasculitis), and a recent diagnosis of rheumatoid arthritis is most consistent with granulomatosis with polyangiitis (Wegener granulomatosis). Another feature of this autoimmune, medium-vessel vasculitis is renal involvement, specifically a rapidly progressive glomerulonephritis, and thus renal studies should be performed as the next step in treatment. Wegener granulomatosis is usually positive for antineutrophil cytoplasmic antibodies (C-ANCA and rarely P-ANCA). If this patient presents with acute kidney injury together with pulmonary hemorrhage, the patient should be admitted to the ICU for aggressive immunosuppression, renal replacement therapy, and, possibly, plasmapheresis and dialysis, if clinically warranted. Given the patient’s history of hemoptysis and epistaxis, aphthous stomatitis is unlikely. Oral malignancies can present with ulceration and lymphadenopathy, but this patient's symptoms, including hemoptysis and fever, make this diagnosis less likely. An FNAB would not be the next step in this patient’s workup. If head and neck cancer is suspected, a complete head and neck examination with endoscopic evaluation and imaging would be warranted first. If a hematologic malignancy is suspected, further workup, including a peripheral smear and imaging, would be done before an FNAB. Although a contagious infectious process such as tuberculosis can present with hemoptysis, fever, and lymphadenopathy, this patient is also presenting with oral ulcerations, HTN, and arthritis, which are usually not associated with tuberculosis.

Answer 5

A. Abort the procedure, and discuss with the patient the possibility of completing an intraoral vertical ramus osteotomy (IVRO) in the future. This scenario can be complicated. This patient has already undergone one mandibular osteotomy and now has persistent malocclusion that will require another osteotomy to correct it. Because the patient was adamant about not being wired shut, she was not consented for a possible IVRO. However, this situation has arisen intraoperatively, and the surgeon is left with few options given minimal bone stock for additional fixation. The best thing to do in this scenario is to debride the areas of bone plate removal and not proceed with additional procedures the patient has not consented to. After a thorough discussion and an explanation of why an IVRO in the future would be best, the patient may reconsider MMF to avoid needing to wait for several more months of bone healing before repeating the BSSO.

Answer 6

C. Primary watertight closure with or without periosteal release Most authors describe primary watertight closure of the flap as the indicated soft tissue management technique, not simple closure or leaving the site open. Bone wax may sometimes be a chronic irritant and interfere with healing.

Answer 7

B. Bruising associated with injury to the sentinel vein Bruising associated with injury to the sentinel vein is the most common complication associated with neurotoxin injection to the crow's feet area. The medial zygomaticotemporal vein commonly known as the sentinel vein is located 6 to 26 mm from the lateral canthus, the region injected with neurotoxin for treatment of crow’s feet. Bruising, which is the most common complication of neurotoxin injection overall, would be cause by iatrogenic injection injury to the sentinel vein in this region.

Answer 8

B. Explain to the patient that immediate placement of an implant in site #4 will likely require a lateral window sinus lift and that this treatment plan will require multiple stages. This patient has sufficient vertical height for an indirect sinus lift on site #4, but the width of the bone suggests that a direct sinus lift with delayed placement of the implant is advisable. The patient should understand that a clinical condition such as hers will unlikely be compatible with immediately loaded implants and that with the sinus lift she may have to wait up to 6 months before she can have her implant placed in site #4.

Answer 9

D. Posterior repositioning of the levator veli palatini for the purpose of speech The primary purpose of cleft palate repair is to aid in the patient's development of speech. This will require reconstruction of the velopharyngeal mechanism, which is predominantly driven by the levator veli palatini. Repair of this muscle has been termed intravelar veloplasty (IVVP) or radical intravelar veloplasty (rIVVP), depending on the degree of dissection and retrodisplacement during surgery. Although the tensor veli palatini is also repaired at the time of surgery, its function does not assist in speech to the same degree as the levator veli palatini. For patients who develop velopharyngeal insufficiency, several options exist to aid in accomplishing a sealed velopharyngeal mechanism during stop-plosive sounds. This includes the superior-based pharyngeal flap, sphincter pharyngoplasty, and autologous fat grafting.

Answer 10

A. Heart defect Heart defects are the most common congenital disorders associated with isolated cleft palate (31.1%). However, deformities, hydrocephalus, urinary tract defects, and polydactyly have also been described as other abnormalities that can be present in this condition.

Answer 11

A. Interdomal suturing with horizontal mattress sutures In this scenario, the transdomal suture was overtightened, which resulted in an unnaturally shaped tip-defining point. When placing an interdomal suture, be certain to preserve a normal angle of divergence (30 degrees or less) between the intermediate crura to maintain two distinct tip-defining points. Pinching the intermediate crura together will narrow the tip but will create less esthetic appeal because of a lack of tip definition. Place an interdomal suture with a horizontal mattress suture to narrow the nasal tip. Tip projection can be improved with a transdomal suture. Transdomal sutures are placed across the dome of the middle crura in mattress fashion, such that the vestibular skin is not perforated. A local anesthetic can be used to hydrodissect a plane between the cartilaginous dome and the adherent underlying mucoperichondrium to help prevent inadvertent incorporation into the suture bite. A 5-0 polydioxanone suture can be used in a horizontal mattress fashion, leaving the knots on the medial aspect of the dome.

Answer 12

B. Split-thickness flap elevation and exposure of the mandibular ridge in a supraperiosteal plane; inset of a split-thickness skin graft with the dermis side down in contact with the mandibular periosteum; and application and fixation of an acrylic splint The split-thickness skin graft relies on the recipient site for nutritional support during the initial stages of healing. Supporting structures associated with bone, cartilage, and tendon (periosteum, perichondrium, paratenon) have a healthy blood supply and can support the graft. Split-thickness skin grafts are inset with the dermis side down and the epithelial surface up. An acrylic splint is ideal in this situation to aid in immobilization and graft stability.

Answer 13

C. Follicular ameloblastoma Desmoplastic ameloblastoma has unique clinical and histologic features, but it is a subtype of conventional ameloblastoma and exhibits similar aggressive behavior and recurrence potential. As such, it should be treated in accordance with other conventional ameloblastoma subtypes. Odontogenic keratocysts may be decompressed or enucleated with adjunct procedures, and resection is rarely indicated. Odontomas may be observed or removed if they are interfering with the eruption of dentition or causing symptoms. Intraluminal unicystic ameloblastoma may be amenable to conservative treatments because of decreased recurrence potential after conservative therapy. Peripheral ameloblastomas may be excised.

Answer 14

C. Monobloc because it will address the position of the supraorbital ridge along with the midface deficiency Because of the patient's supraorbital ridge deficiency, the Le Fort III osteotomy should not be the first choice, even though it provides less morbidity compared with monobloc and facial bipartition. As the patient is 8 years old, the occlusion is not the primary goal of the surgery and can be addressed at a future procedure when skeletal maturity is reached. Because the intercanthal distance is normal, the facial bipartition will not provide a better result than the monobloc advancement. The posterior crossbite tends to improve with the maxillary advancement and can be further addressed with growth modification techniques or with orthognathic surgery at a later stage.

Answer 15

E. Resection CEOT is described as a benign, locally invasive neoplasm. Observation would result in continued growth. Enucleation with curettage has been described for small lesions (1-1.5 cm), but resection is more likely to result in a cure. Enucleation with the application of 5-FU has been described for the treatment of odontogenic keratocysts, but not CEOT.

Answer 16

D. Undermine the skin of the forehead in the subgaleal plane and close primarily. The forehead is undermined in the subgaleal plane rather than the subperiosteal plane. Additionally, releasing incisions along the hairline can allow for advancement for primary closure. Healing by secondary intention or with a skin graft is associated with poor cosmesis. Flap width is designed to allow for primary closure. A small portion of the donor site defect above the eyebrow may not be closed primarily. At the time of pedicle division, a portion of the pedicle is rotated into this defect for reconstruction.

Answer 17

C. Obtain CBCT for further risk assessment and surgical planning, and then proceed with the extraction. Caries extending into the pulp would be a contraindication for coronectomy. Given the high risk indicated by radiographic makers on the plain film, CBCT will be useful in planning the approach to extraction. The tooth requires extraction, so antibiotics and monitoring the patient would not represent a definitive management option.

Answer 18

A. Recommend neurotoxin treatment for the glabellar lines only. The patient desires correction of the horizontal and vertical rhytids; however, she also presents with brow ptosis and dermatochalasis. Paralysis of the elevator muscles of the forehead (frontalis) to treat the horizontal rhytids will result in increased brow ptosis and secondary dermatochalasis and will potentially limit the patient’s visual field. The vertical rhytids, however, are the result of contraction of the corrugator and procerus muscles, which exert depressor actions on the forehead. Neurotoxin injection in these muscles is advised (in addition to the vertical fibers of the orbicular oculi) to decrease opposition to the frontalis and yield a brow-lifting effect. This patient should be counseled on surgical techniques to reposition the brows, and after surgical correction of the brow position and lid laxity, the remaining horizontal forehead rhytids may be addressed with neurotoxin injection.

Answer 19

B. Papilledema In this setting, the patient almost certainly has increased intracranial pressure (ICP) based on history alone. Head banging in an infant or young pediatric patient is a sign of headaches. The developmental delays of this patient are highly suggestive of elevated ICP. Additionally, multisuture craniosynostosis presents an increased risk for elevated ICP compared with single-suture craniosynostosis. Strabismus can be found in patients with craniosynostosis, especially unicoronal, but it is not part of the fundoscopic examination. Macular degeneration and retinal deterioration are not fundoscopic features of elevated ICP. Papilledema would be the most common finding.

Answer 20

C. Administer flumazenil. Response to painful stimulation indicates a deep level of sedation that requires the support of the airway. The stimulus of the surgery has ceased, but the medications may still be causing relaxation of the muscles of the tongue and pharynx, causing partial airway obstruction. If not recognized and treated, the resulting hypercapnia further exacerbates the sedative and anesthetic effects of the medications as most are highly protein bound. Respiratory acidosis displaces these agents from the plasma proteins, increasing the amounts of free drugs. Management of the airway is important, and reversal agents may need to be administered. The OMS should only administer 50% dextrose if the patient is experiencing severe hypoglycemia. One could consider calling 911 as a backup, but this type of office emergency needs to be managed directly and immediately by the OMS.

Answer 21

B. CT scan with contrast of the face and neck Before treatment of the lesion, a full workup should be completed, including a thorough physical examination and imaging such as CT and MRI. Given the high-risk features demonstrated by the lesion (rapid growth, facial nerve palsy), there is an increased likelihood of malignancy, and thus extracapsular dissection would be inappropriate in this setting. Although an FNAB is a useful part of the workup for parotid masses, imaging should be obtained before performing this test. Imaging will be useful both in further evaluating the lesion before any invasive testing/intervention and will help guide the FNAB. Alternatively, a core biopsy may also be performed for cytopathological evaluation of the lesion. There is an insufficient amount of information at this time to proceed with aggressive surgical management. Imaging of the mass should be done first, to help assess the characteristics of the mass (solid vs cystic, borders, location of the mass within the gland, any adverse features). A full body PET/CT scan at this time would be premature because more localized imaging should be performed first. Moreover, a cytological evaluation should also be performed before PET/CT to assess for distant metastasis in the setting of advanced malignancy, but this has not been established in this patient.

Answer 22

C. Extend the spreader graft beyond the anterior septal angle, and suture the medial footplates to the extension graft to set tip projection and provide tip support. An extended spreader graft placed on the concave side of the nasal septum will straighten the dorsal deviation. The medial footplates of the lower lateral cartilage can be sutured to the extended portion of the spreader graft to set tip projection and provide tip support. The lateral crural strut graft to the hypoplastic lower lateral cartilage will not be able to fully address the tip deformity. Ear cartilage will not likely provide the length and rigidity needed for a collumelar strut. A shield graft will provide some tip projection and definition but will not be robust enough to address inadequate tip support. Reducing the nasal dorsum in this situation is not addressing the tip deformity that is present.

Answer 23

A. Microvascular decompression (MVD) MVD confers short- and long-term pain-relief benefits in patients with trigeminal neuralgia. Other modalities such as thermal, glycerol, or balloon-compression rhizotomy and Gamma Knife ablation are successful, but the 5-year pain-free benefits are inferior to those achieved with MVD. Any type of neurolysis (neurectomy, chemical, pharmacologic) is associated with a poor long-term success rate and the potential to cause anesthesia dolorosa.

Answer 24

C. Maxillary hypoplasia and mandibular hyperplasia Maxillary hypoplasia and mandibular hyperplasia is the most likely diagnosis based on the skeletal measurements from the analysis. These measurements are not consistent with the norms for a maxillary or mandibular position. The Steiner cephalometric analysis presents norms of 82º +/−2 for the maxillary position and 80 degrees +/-2 for the mandible position. Skeletal asymmetry is difficult to diagnose from lateral cephalometric film unless there is a cant to the occlusal plane. The preferred way to diagnose asymmetry is with a posteroanterior cephalometric radiograph and a good clinical examination.

Answer 25

A. Acquired retrognathism, an open bite, and a widened face These are the feared sequelae of bilateral condylar and symphysis fractures. Ankylosis is often described but rarely seen. Paresthesia would be a rare event. Malocclusion and midline discrepancy pale in comparison to acquired retrognathism, an open bite, and a widened face.

Answer 26

D. Restoration of the anterior maxillary bone and soft tissue architecture after alveolar cleft grafting A question that is always asked when planning for orthognathic surgery in a patient who has had a repaired nasoalveolar cleft, whether unilateral or bilateral, is whether or not it is acceptable to cross the alveolar cleft within the Le Fort level incision. The most important consideration is whether or not the cleft has been successfully repaired, and the patient has a normalized architecture of basal and alveolar bone, improved vascular supply, and healthy soft tissue. The digital capillary refill test is often used to demonstrate perfusion of soft tissue of the anterior segment of the maxilla. Restoration of the bone and soft tissue architecture of the nasoalveolar cleft is an essential criterion for a successful alveolar cleft graft. This precludes the necessity of a tunneled Le Fort I level incision in a unilateral or bilateral cleft. With a restored alveolar cleft, there is an improvement in blood supply, and improved alveolar and basal bone architecture, thus, a more predictable outcome of the maxillary advancement is observed. In the absence of normal bone architecture and soft tissue health with poor capillary perfusion, there is a need for tunneling of the Le Fort level incision, and there is an increased risk of necrosis of the anterior maxillary segment, reopening of the fistula and nasoalveolar cleft, and nonunion.

Answer 27

D. In-laboratory full-night polysomnogram The first step in any treatment of obstructive sleep apnea (OSA) must be a diagnosis and assessment of severity by a polysomnogram read by a board-certified sleep physician. Once a diagnosis of OSA has been made and its severity has been established, the other diagnostic tests may be performed to better assess the levels of obstruction and determine which surgical procedure would be most appropriate for this patient.

Answer 28

D. Start orthodontic treatment, and plan for the zygomatic reconstruction when the patient is 14 to 15 years old. Even though the zygomatic bone maturity is reached around age 7 and surgical results are stable after that occurs, this patient also presents with findings of middle face hypoplasia. It is preferable to operate on the zygomas along with the maxilla and potentially the mandible. Because maxillary maturity is almost complete, the patient should start orthodontic treatment to prepare the arches for orthognathic treatment and have the surgery around age 15 when the occlusion can be addressed with zygomatic reconstruction

Answer 29

A. Maxillary sinus Pneumatization of the maxillary sinus could lead to sinus perforation during posterior maxillary alveoloplasty. Proper radiographs such as a panoramic radiograph could provide an assessment of the maxillary sinus.

Answer 30

C. Be prepared in advance for a potential harvest of both sides of the anterior ilium or a posterior iliac crest site. Knowing the extent of the cleft defect(s) preoperatively allows for the best surgical plan. Large, bilateral maxillary cleft defects may require more cancellous marrow than can be safely harvested from a single anterior ilium. Bilateral anterior iliac crest harvesting or a single posterior ilium should provide adequate amounts of bone. Expansion with allogeneic freeze-dried bone is acceptable if it does not comprise most of the graft. At this point, using rhBMP-2 is an off-label application. Using platelet-rich plasma can help expand as well, but in pediatric patients, the total allowable blood loss must be considered and adhered to.

Answer 31

E. Bur on a rotary hand piece Although the use of rongeurs and bone files is preferred in alveoloplasty to prevent over-reduction, for large bony defects, a rotary instrument is preferred.

Answer 32

C. When the patient is stable and the edema has completely dissolved The best moment to treat this patient's fracture is when the patient is stable and there is not much edema that can hamper a surgical approach. If it is a simple fracture and the patient has no complications, facial fractures can be treated hours after the trauma; they do not need to be treated as soon as the patient is admitted or as soon as other teams have assessed the patient. For more complex cases that demand initial stabilization, it is better to wait approximately 10 to 14 days so edema can subside.

Answer 33

C. Enucleation AOT responds excellently to conservative surgical management. An anterior maxillectomy is an overly aggressive treatment that would cause unnecessary morbidity and detrimental effects on the patient's quality of life. Cryotherapy, decompression, and intralesional steroid injection treatment options have not been described for the treatment of AOT.

Answer 34

A. Peroneal nerve Injuries to the peroneal nerve will cause decreased sensation in the top of the foot or outer part of the lower leg. A foot drop with an inability to hold the foot up and a slapping gait is also present. The peroneal nerve has both sensory and motor functions. The sural nerve is purely sensory and supplies sensation to the skin of the lateral foot and lateral lower ankle. The tibial nerve, a mixed motor and sensory nerve, supplies motor function to the intrinsic foot muscles, as well as sensation in the medial heel and plantar foot. The femoral nerve is a nerve in the thigh that supplies the skin on the upper thigh and inner leg and the muscles that extend the knee.

Answer 35

D. Under 47ºC For the reduction of large bone defects, the use of a rotary instrument is recommended. Normal saline irrigation is used to keep the bone temperature below 47ºC to maintain bone viability.

Answer 36

B. The articulating surfaces are covered with fibrocartilage, which is less susceptible to degeneration and has a greater repair capacity. Unlike other joints in the body where the articulating surfaces are covered with hyaline cartilage, the TMJ articulating surfaces are covered with fibrocartilage, which has a greater repair capacity.

Answer 37

E. Episodic migraine The patient's symptoms meet the diagnostic criteria for episodic migraine. Rhinorrhea and nasal congestion frequently coexist with migraine due to trigeminal cross-activation of the parasympathetic nerves, and migraine is frequently misdiagnosed as sinus headache. This patient's symptoms do not meet the criteria for the other answer options listed.

Answer 38

A. A radionucleotide thyroid scan should be performed, and if it is a hyperfunctioning nodule, radioactive iodine (RAI) ablation or right hemithyroidectomy is indicated. The first step in the evaluation of thyroid nodules is TSH measurement with a dedicated thyroid ultrasound. If TSH levels are suppressed, a radionucleotide thyroid scan is obtained to assess the functionality of the nodule. A “hot” nodule represents a hyperfunctioning lesion, and in the setting of clinical hyperthyroidism, it should be managed via RAI ablation or thyroid surgery. A diagnosis of thyroid cancer cannot be made at this time without a tissue diagnosis. Further workup including ultrasound-guided fine-needle aspiration biopsy (FNAB) should be performed. Also, because this is likely a hyperfunctioning nodule, the risk of malignancy is less than 1%. The Bethesda classification system evaluates a lesion based on its cytopathological characteristics, but this has not been performed in this patient. A Bethesda IV lesion represents a "follicular neoplasm or suspicious for a follicular neoplasm." Core biopsy is not a routine part of the workup for thyroid nodules, though it can be used in larger masses. Ultrasound-guided FNAB can be performed to obtain a cytological evaluation and tissue diagnosis. A core biopsy can be done if an ultrasound-guided FNAB yields insufficient results.

Answer 39

B. Bone scintigraphy to evaluate abnormal condylar growth As it appears that the mandibular deviation has developed in the last year, it is prudent to screen for condylar hyperplasia. The only radiographic examination that can support active condylar growth is scintigraphy with technetium 99. If the growth is still active, a high condylectomy could be considered in concert with the orthognathic surgery or the surgery can be postponed until condylar growth has ceased.

Answer 40

A. Aggressive physical therapy with joint range-of-motion exercises Failure to restore and maintain mandibular range of motion after arthrotomy procedures results in postoperative mandibular hypomobility. Malocclusion has not been shown to be a significant contributing factor in painful temporomandibular disorder symptoms. Neither intra-articular injections nor arthrocentesis is indicated or beneficial after arthrotomy procedures during the postoperative period.

Answer 41

The patient's headache is consistent with migraine. Given that she has more than four headaches per month, preventive treatment is recommended. Out of the options, topiramate has level A evidence for preventive treatment. Although frovatriptan can be used for preventive treatment during menstrual migraine, it is not recommended in this case as the patient is not experiencing menstrual migraine. Indomethacin is not a preventive treatment.

Answer 42

D. The roots should be spaced at least 2.5 mm apart. Current literature suggests that the minimally acceptable space between roots during interdental osteotomies is 2.5 mm. A space of 0.5, 1.5, or 2 mm between roots is not sufficient to prevent damage.

Answer 43

B. 60 mm Hg Controlled hypotensive anesthesia/deliberate hypotensive anesthesia (DHA) is generally recommended for downfracture of the maxilla and other critical components of the operation. MAPs of 50 to 70 mm Hg are used, based on surgeon and anesthesiologist preference, to minimize intraoperative blood loss and decrease the need for resuscitation with crystalloid solutions and blood products. This translates to a MAP that is 20% to 30% below the patient's usual MAP, with a minimum of 50 mm Hg in American Society of Anesthesiologists class I patients. During DHA, the patient is usually monitored with an arterial catheter and a Foley catheter, along with the usual anesthesia monitors. MAP is calculated with the following formula: MAP = 1/3 (SBP − DBP) + DBP. MAP below 75 mm Hg is considered to be hypotensive. (SBP/DBP 95/65 mm Hg, for example). DHA is reversed before completion of the procedure to ensure wound hemostasis during normotension. MAP below 50 mm Hg is severe hypotension and is associated with an unacceptable risk of end-organ injury.

Answer 44

D. Le Fort I osteotomy with posterior repositioning Le Fort setbacks are not advised because of significant bony interferences. Mandibular premolar extraction in a patient with a class II DFD can often provide a greater degree of advancement. A BSSO advancement is the workhorse osteotomy in patients with class II DFD. A sliding genioplasty a reasonable additional procedure to perform if other osteotomies are not capable of providing a harmonious esthetic outcome alone. Regardless of anteroposterior surgical changes, a transverse discrepancy is typically addressed with a three-piece Le Fort osteotomy.

Answer 45

C. The ability to respond purposefully to stimulation Determining the level of patient responsiveness is the only way to determine the level of sedation. The other choices reflect changes in physiologic parameters that often occur during various depths of sedation; however, none accurately predicts the level of sedation. Importantly, the inability to respond purposefully to stimulation will predict adverse changes in patient physiology.

Answer 46

B. Vertical line drawn from the lateral canthus Distal to the vertical line drawn from the lateral canthus, the facial branches are not amenable to primary reconstruction. The other areas are not landmarks that can help determine if the patient will require facial reconstruction.

Answer 47

C. Between the mylohyoid muscle and the anterior belly of the digastric muscles The submental artery is identified between the mylohyoid and anterior belly of the digastric muscles. The ipsilateral anterior belly of the digastric muscle is dissected from the hyoid bone and inferior mandible and included with the flap to preserve the terminal vascular supply as it passes deep to the muscle.

Answer 48

A. CAD, congestive heart failure, and cerebrovascular accidents Large-scale studies have shown that people with severe OSA are at a much higher risk for CAD, congestive heart failure, and stroke. Although the mechanisms are not entirely delineated, it is thought that sustained sympathetic activation, intrathoracic pressure changes, and oxidative stress bring about these sequelae. Other abnormalities, such as disorders in coagulation factors, endothelial damage, platelet activation, and inflammatory mediators, may also play a role in cardiovascular disease. Endocrine abnormalities are prevalent in patients with OSA, but it is generally thought that the sequelae of endocrine diseases (obesity, acromegaly, hypothyroidism) and the treatment of these metabolic disturbances may help cure OSA.

Answer 49

D. 3 minutes of tidal volume breathing with 100% O2 True preoxygenation requires 3 minutes of tidal volume breathing at 10 to 12 L/min or 8 vital capacity breaths over 60 seconds at 100% FiO2. A nasal cannula at 4 L/min can only provide 36% oxygen. This will not denitrogenate the functional residual capacity (FRC). Room air, even with a tight-fitting face mask, will not enable denitrogenation of the FRC. A level of 75% EtO2 is better than nasal cannula oxygenation, but it will not yield a significant increase in safe apnea time.

Answer 50

B. cT2 Review NCCN Guidelines for Head and Neck Cancer 2020 and “Lip and Oral Cavity Cancer Staging” in the 8th edition of the AJCC Cancer Staging Manual. A cT2 lesion is less than or equal to 2 cm topographically, with depth or invasion greater than 5 mm but less than or equal to 10 mm. The other answer choices represent other T stages and are incorrect. Once the tumor is resected, the TNM stage is preceded by a “p” to indicate the pathologic stage; this supersedes the clinical “c” stage given based on radiographic and clinical features alone.

Answer 51

D. Two-point screw fixation to prevent rotation This patient appears to have rotation of the chin implant. Single-point screw fixation, while better than suturing or no fixation, will not prevent rotation of the implant. A more thorough dissection of the pocket prior to implant placement, more superior placement of the implant, or selection of a smaller implant would also not prevent rotation.

Answer 52

A. 10 days The Centers for Disease Control and Prevention recommend that a dog who bites someone be observed for rabies symptoms for 10 days.

Answer 53

C. Preserve as much bone and soft tissue as possible while removing bony undercuts. Although one of the goals of alveoloplasty is the removal of undercuts, preserving as much bone as possible allows for a more stable base for prosthetic reconstruction.

Answer 54

C. The roof of the nose, leading to a cranionasal fistula After monobloc advancement, there will be a direct communication between the nose and the cranium that must be adequately isolated so that dura and nasal mucosa can heal independently and not lead to a fistula.

Answer 55

E. Evaluate lateral cephalometric radiographs at 6- to 12-month intervals. To be more reliable, the lateral cephalometric radiographs must be taken on the same device. Hand–wrist radiographs could also be compared with templates to evaluate skeletal maturation. Anteroposterior cephalometric radiographs or monitoring for fusion of the midline suture of the maxilla are not reliable. Comparison with family members' cessation of growth is not a dependable predictor.

Answer 56

D. Place tacking sutures between the skin paddle and latissimus dorsi muscle. Injury to the perforators to the skin paddle can occur when there is excess tension on the skin paddle during flap harvest and inset. This complication can be prevented by harvesting a larger skin paddle over the latissimus dorsi muscle, developing a wide tunnel to the head and neck, and placing tacking sutures between the skin paddle and the latissimus dorsi muscle.

Answer 57

C. Sliding advancement genioplasty Reduction genioplasty and advancement can accomplish both reductive vertical changes and add projection by advancing the bony segment. This cannot be achieved with a traditional stock silastic implant. Suction-assisted lipectomy, though helpful as an ancillary procedure, will not help address the true anteroposterior discrepancies that are part of the patient's chief complaint. Dermal fillers would not address the vertical component of his concern, so they are not ideal for this patient.

Answer 58

B. Between 8 and 16 weeks of life The traditional timing for unilateral cleft lip repair has been at 10 weeks, combined with the presence of 10 lb of weight and 10 g of hemoglobin. This guideline is still used because earlier correction has not been shown to improve results. The first 8 weeks are generally considered early and certainly do not give adequate time for presurgical infant orthopedics (PSIO), which is beneficial for many reasons. The ranges of between 16 and 24 weeks, 24 and 36 weeks, and 36 and 52 weeks are beyond the point at which repair with or without PSIO could be accomplished and would delay accruing the benefits of repair (feeding, socialization, etc).

Answer 59

C. Schedule the patient for polysomnography. If suspicion of OSA is the highest on your differential diagnosis, the gold standard for confirmation is polysomnography. Performing a routine screening questionnaire on this patient, such as STOP-BANG, would likely lead to the suspicion of obstructive sleep apnea. This patient demonstrates no clinical signs of a neurologic disorder, so MRI or sumatriptan would not be indicated. The patient does not show signs of clinical depression, so a depression screening would not be the next treatment step.

Answer 60

A. The quality of bone and the planned occlusal forces on the restoration The quality of bone and the planned occlusal force on the restoration influence how many implants should be placed for an implant-retained denture. The maxilla is composed of types 3 and 4 bone, which may result in the failure of implants; overengineering the maxilla with additional implants can be advantageous should an implant fail. Increased occlusal forces and parafunctional habits place untoward stress on implants and will require more implants. Considering the arch form influences prosthetic design requirements (eg, occlusion and cantilever), and more implants may be needed to appropriately distribute forces. Although care should be paid to the opposing occlusion, as it pertains to forces applied to the planned “all-on-X” maxillary restoration, it does not matter if the mandibular dentition is natural or prosthetic—how it occludes is more critical. Although hyperglycemia can have deleterious effects on wound healing, well-controlled diabetes (ie, HbA1c <7-8) is not a contraindication to implant placement. The surgeon may want to consider antibiotic prophylaxis as part of the protocol. The use of bisphosphonates, on the other hand, may increase the risk of implant failure. The AAOMS medication-related osteonecrosis of the jaw position paper recommends a 2-month preprocedure and a 3-month postprocedure drug holiday for oral bisphosphonates and recommends avoidance of implants in patients undergoing IV bisphosphonate therapy.

Answer 61

B. Adenosine 6 mg IV This is a classic presentation of paroxysmal supraventricular tachycardia. The rapid pulse rate along with the decrease in blood pressure would indicate that this patient is symptomatic and requires intervention. Because the patient is under sedation and has received opioid analgesics, he is unable to report pain, so it cannot be evaluated. Although initial management with vagal maneuvers can be started, plans for the administration of adenosine should be rapidly considered and initiated. Adenosine must be rapidly pushed intravenously for it to be effective, followed by a 10-cc saline flush under pressure. Additional doses can be given if the first dose is ineffective (12 mg).

Answer 62

B. Perform columellar strut grafting. A ptotic nasal tip can also be interpreted as an over-rotated tip or a deprojected tip. It is often the result of aggressive cephalic trimming, an over-resected caudal septum, scar tissue formation, or weakened, unsupported medial crura. A ptotic tip is treated with a columellar strut or nasal tip grafting. The other options of securing the septum to the anterior nasal spine or further reducing a dorsal hump would have no effect in preventing this complication, and additional cephalic trimming would make the ptosis worse.

Answer 63

A. CT runoff of the lower extremities An examination of the lower extremities for any evidence of previous trauma or atherosclerotic disease or for peroneus longus is required preoperatively when planning for reconstruction with a free fibula flap. A color flow Doppler evaluation of the lower extremities can be used to evaluate for flow in the three vessels of the lower leg, but in obese patients, CT of the lower extremities with runoff or an angiogram is preferred. A plain film x-ray or an ankle-brachial index test would not be indicated for this patient.

Answer 64

D. Level II or III Additional ports are required for instrumentation to perform a biopsy procedure. These ports are placed in level II and level III arthroscopy procedures but not in level I arthroscopy procedures, where only a single port is placed for the scope.

Answer 65

A. Propofol Variable presentations of seizure-like phenomena are possible with the use of propofol during induction, maintenance, emergencies, and delayed time periods. The etiology is unclear, and resolution occurs with time.

Answer 66

A. Physical therapy Noninvasive treatments may be added to the TMD regimen and should be used before more invasive procedures such as chemodenervation. Other more invasive procedures such as arthroplasty or arthrocentesis would not be indicated.

Answer 67

B. Pemphigoid To answer this question, one must understand splitting/separation patterns. Pemphigoid is noted to have a sub-basilar split during pathologic evaluation. Pemphigus is also a blistering lesion of the mucosa, but the pattern is supra-basilar. Lichen planus and squamous cell carcinoma do not typically demonstrate a sub-basilar splitting pattern.

Answer 68

A. High-flow oxygen High-flow oxygen and triptans are used for acute treatment of cluster headaches. Since a cluster headache attack is severe and reaches maximum severity within minutes, an oral option is not recommended and would be of little benefit. Sumatriptan subcutaneous injection or sumatriptan nasal spray is recommended for acute treatment.

Answer 69

A. Superior orbital rim anteroposterior deficiency The purpose of a formal fronto-orbital advancement and anterior cranial vault reconstruction for metopic craniosynostosis is to remove the synostotic suture, correct the trigonocephalic head shape, and advance the superolateral orbital rims. By definition, removing the synostosis should address the restricted intracranial growth. Hypotelorism, a common feature of metopic craniosynostosis, is not addressed in this procedure. The fronto-orbital advancement inferior limit is the nasofrontal junction. As such, the orbits below this level are not addressed. Harlequin deformity is present in unicoronal synostosis. Ear positions are not corrected surgically during any head shape reconstruction. Biparietal width is addressed with posterior cranial vault reconstruction.

Answer 70

B. Extract tooth #11, and allow mucosa to heal for at least 3 months. Perform segmental Le Fort advancement surgery with differential advancement of the cleft segment to close the alveolar cleft defect, and add additional autogenous bone grafting to the down-fractured maxilla. An additional bone graft procedure after two failed attempts in a scarred recipient bed is unlikely to succeed. Because of the poor attachment of bone and the soft tissue on #11, its long-term viability is poor and likely to worsen after any additional surgery. Performing a differential advancement during Le Fort advancement surgery is well documented and successful. The first premolar can be advanced to the canine position so that an implant or fixed dental prosthesis can be used to restore the missing lateral incisor. In some cases, the first premolar may need to be positioned in the lateral incisor area. Using a tooth-borne distractor can be successful in closing a difficult alveolar cleft, but not when the canine has extensive bone loss. The use of an obturator creates difficulty with hygiene, gingival inflammation, and potentially more attachment loss. It should be used when no further operations can benefit the patient.

Answer 71

D. Careful reapproximation of the mentalis muscle during closure Failure to properly reapproximate the mentalis muscle after intraoral placement of a silastic implant or genioplasty will result in some degree of lip incompetence and possibly a witch’s deformity of the chin. The use of a larger implant could cause impairment of lip movement. Two-point screw fixation only helps secure an implant. A more thorough dissection of the implant pocket will help with more adequate seating of the implant.

Answer 72

C. Patients with SMCP have a zona pellucida. Patients with SMCP have an abnormal tensor and levator veli palatini muscle insertion into the posterior hard palate. This leads to the classic finding of zona pellucida, notched posterior nasal spine, and bifid uvula. Because of the abnormal levator insertion into the posterior hard palate, abnormal speech can develop. In addition, the abnormal insertion of the tensor muscle may lead to abnormal eustachian tube function. Patients with SMCP and complete cleft palate have abnormal posterior hard palate anatomy. Patients with SMCP have a notched posterior nasal spine due to the abnormal levator insertion.

Answer 73

D. Levator veli palatini The levator veli palatini originates from the temporal bone and inserts at the soft palate, elevating the velum. The musculus uvulus extends the velum. The palatopharyngeus adducts the posterior pillars and elevates the pharynx. The palatoglossus retracts the tongue.

Answer 74

C. Elevate the head of the bed 25 degrees. The supine position is the worst position for an obese patient because it allows the weight of the abdomen to press against the lungs, preventing their expansion. The FRC is decreased in obese people. Elevating the head of the bed allows for less compression on the lungs, and thus the FRC can be denitrogenated better. CPAP is helpful in any preoxygenation, but body position is more important in the obese patient to allow the lungs to expand.

Answer 75

B. Use a 25-gauge needle to poke the flap. Flap circulatory disturbances can be divided into arterial insufficiency and venous insufficiency. If a venous clot is the cause of flap failure, the flap generally becomes congested and bluish in color. On occasion, there may be bruising in areas of the flap. To distinguish between bruising and venous insufficiency, poking a flap with a 25-gauge needle, away from the pedicle, can help one judge the flap circulation. If there is a rapid exit of dark red blood, venous congestion is likely the issue. The patient may need to return to the operating room, but the cause of the circulatory disturbance should be determined first. Observation alone would only delay necessary treatment. Heparin administration is not indicated.

Answer 76

C. 6 mm A total of 6 mm of space is required in the arch: 3 mm per side to provide for 3 mm of incisor retraction.

Answer 77

B. Co-management with a hematologist The OMS must collaborate with a hematologist when managing patients with congenital bleeding disorders. The spectrum of disease severity and management varies widely in this population and is beyond the scope of practice for an OMS. The severity of disease and perioperative management will determine the setting for surgical care, the need for and type of local hemostatic measures, and the method of airway management.

Answer 78

B. Placement of an internal nasal splint An internal nasal splint, such as a Doyle splint, is placed after septoplasty to obliterate dead space between the mucosal flaps and prevent hematoma formation. External splints help adapt soft tissue to the underlying skeleton, decrease edema, and prevent hematoma formation underneath the skin flap. Pseudoephedrine nasal spray, head elevation, and silver nitrate are used to manage epistaxis after surgery.

Answer 79

B. Class II If a patient's lower incisors are excessively proclined, the mandible cannot be advanced sufficiently to bring the lower posterior teeth into a full class I relationship with the upper teeth. An orthodontist may need to retract the lower incisors to manage this anticipated problem. Before surgery, this may require premolar extractions, interproximal enamel reduction, or class III elastics. An alternative and reasonable compromise is to accept a less than ideal final occlusion (ie, class II-ish). Maxillary and mandibular incisors with an optimal inclination and occluded in an optimal overbite/overjet will often cause the posterior occlusion to be class I. Maxillary incisors with excessive labial inclination or mandibular incisors with excessive lingual inclination and occluded in an optimal overbite/overjet will often cause the posterior occlusion to be class III.

Answer 80

A. Manage the surgical site with conservative measures such as irrigation and gentle local debridement. As there is no infection, conservative measures should be employed first. In the absence of infection and purulence, a surgical site can heal with secondary intention. At the recipient site, graft dehiscence is the primary complication, and it occurs due to inadequate soft tissue, soft tissue closure under tension, thin mucosal tissues, or excessive contact of the prosthesis with the recipient site. This complication can be prevented by ensuring primary soft tissue closure without tension, gentle handling of soft tissues, and adequate mucosal thickness before bone grafting, which often requires soft tissue grafting before block grafting. Attempting to close the site with sutures at this time will predispose the site to acute infection. Additional grafting is not indicated as the current soft tissue envelope is not sufficient to cover the current graft and additional graft material would be destined to fail. However, the current graft has not yet declared itself as failed, and thus removal is not yet indicated.

Answer 81

D. It allows a “cut as you go” approach that can permit intraoperative subtle modifications to achieve a superior result. This technique allows subtle intraoperative modifications as compared with the somewhat more “rigid” and structured approaches to unilateral or bilateral cleft lip repair. However, this technique can be very challenging in patients with wide cleft deformity, and thus the surgeon relies more heavily (not less) on presurgical treatment with lip taping, PSIO/NAM, or other techniques. Occasionally, surgeons will do an initial surgery to repair just the cutaneous and mucosal edges of the cleft several months before definitive cleft lip repair in such cases of wide deformities. Another issue with this technique as originally used is the creation of a short columella and upper lip, which can lead to a whistle deformity. There is no evidence that this technique reduces the need for cleft rhinoplasty later in life.

Answer 82

B. Central fossae of the mandibular first molars After a patient undergoes a successful BSSO advancement of the mandible when only mandibular right and left first premolars have been extracted, the canines will occlude in a class I relationship with the upper canines, but the palatal cusps of the upper second premolars will occlude in the central fossae of the mandibular first molars. The molars will therefore be in a class III relationship. The surgeon must pay particular attention when assessing the maxillary skeletal transverse dimension because the maxillary second premolar palatal cusp-to-cusp distance (not the palatal cusp-to-cusp distance of the maxillary first molars) must be compared with the fossa-to-fossa distance of the mandibular first molars. The maxillary first molars will occlude with the mandibular second molars. The maxillary first premolars will occlude with the mandibular second premolars.

Answer 83

D. It has significant strength that will withstand cicatricial forces. Rib cartilage offers greater volume and strength than septal cartilage. This patient with a significant deformity is going to require multiple grafts to correct esthetic and functional deficits. Disadvantages of rib cartilage include increased donor site morbidity and the potential for warping. Septal cartilage will generally be a better source for thin, straight strips of cartilage.

Answer 84

B. Use ketamine as part of the pharmacologic agent strategy. Ketamine is a noncompetitive NMDA receptor antagonist that blocks glutamate. Low (subanesthetic) doses produce analgesia and modulate central sensitization, hyperalgesia, and opioid tolerance. It reduces polysynaptic spinal reflexes but does not alter protective airway reflexes, which makes it ideal and the best option for the patient described here.

Answer 85

B. 15% Only 15% of patients will have permanent worsening of VPD after undergoing Le Fort I advancement surgery. Most patients will have transient worsening of VPD that resolves and returns to baseline within 6 months of surgery.

Answer 86

C. Patients with this DFD should be screened for obstructive sleep apnea (OSA) symptoms. Because of the relationship between retrognathic mandibles and diminished airway volume, a patient with a class II malocclusion should be screened for OSA symptoms to provide further information to support operative planning. Patients with a class II DFD typically have an obtuse cervicomental angle because of the retrognathic mandible. The workhorse surgical correction for a class II DFD is a bilateral sagittal split osteotomy (BSSO), not a Le Fort osteotomy. BSSO for correction of a class II DFD may be considered at an earlier age than a Le Fort osteotomy for a class III DFD. Orthodontics alone are not a reliable correction for any significant DFD after cessation of growth.

Answer 87

C. This is hypopnea hypoventilation from deep anesthesia. If changes in the capnograph waves are seen from a typical normal phase I, II, III, and IV, the patient must be evaluated. CO2 readings in open airway techniques are not always inaccurate. Bradypnea hypoventilation from opioids typically shows an increased amplitude and width to the waveform. Hypopnea hypoventilation is seen in spontaneously breathing open airway patients where the tidal volume is significantly decreased and the capnograph is sampling mostly anatomic dead space and some areas of the ventilated lung. The number is low because of this, but if the alveolar CO2 was measured, it would show hypercarbia, not hypocarbia. It is not airway obstruction because airway maneuvers will not correct it. It is not bronchospasm because the lungs are clear and the phases II and III on the capnograph do not show a shark-fin appearance.

Answer 88

D. It may permit avoidance of secondary cleft nasal deformity at skeletal maturity. Because NAM therapy actively repositions the alar nasal region to a much more correct anatomy, secondary nasal surgery has been shown to be less likely needed. NAM has not been shown to change the degree of midface hypoplasia seen in patients with cleft lip and palate as compared with those treated by other means (eg, Latham or even presurgical infant orthopedics [PSIO]). NAM therapy can position the segments in such a manner that gingivoperiosteoplasty (GPP) is more easily done. It is, however, not commonly the case that adequate bone is present after GPP to the point that either implant insertion is possible or that there is adequate bone for cuspid eruption. NAM therapy does not fundamentally change the complexity of tissue rearrangement needed to the degree that it is an “easy” or short operation. Skin incisions are always potentially at risk of hypertrophic scarring irrespective of the method of (or even use of) PSIO treatment.

Answer 89

E. Upper airway length and anteroposterior dimension ratio Upper airway length has been shown to positively correlate and predict OSA severity, while the lateral/retroglossal anteroposterior dimension ratio shows an inverse correlation with OSA severity. The other combinations of anatomic factors have not been shown to have a positive and inverse correlation, respectively, with the severity of OSA.

Answer 90

A. Revision Furlow palatoplasty Pharyngoplasty procedures increase resistance to airflow at the velopharyngeal valve and carry a higher risk of nasal airflow obstruction and OSA. Any implant to the posterior pharyngeal wall may pose a risk of nocturnal upper airway obstruction as well. While narrowing the velopharyngeal port by lengthening the palate is also an aim of revision Furlow palatoplasty, the primary goal is to establish a physiologic muscle repair allowing normal palatal mobility and function. Although all these procedures carry a risk of worsening OSA, a revision Furlow palatoplasty can be expected to have the lowest risk in the long term.

Answer 91

C. Bilateral sagittal split osteotomy (BSSO) for advancement The BSSO is an excellent option for mandibular advancement in class II skeletal deformities. Not only is it the most stable mandibular surgery, it also allows for bony fixation of the segments. In addition, it allows the ability to correct mandibular asymmetries. The other surgeries listed would not be as ideal for this patient as the BSSO.

Answer 92

C. Recommend injection of the orbicularis oris muscle. In this patient, the preoperative lower lip was likely everted by the maxillary incisor teeth, which resulted in an acute labiomental angle and the appearance of a pouty lower lip. This is a common soft tissue presentation of patients with a skeletal class II malocclusion and a deep bite. Mandibular advancement and maxillary impaction resulted in a decreased appearance of the labiomental fold (increased labiomental angle) along with an increase in the nasolabial and angle. Both of these skeletal movements contribute to the patient’s report of decreased overall lip volume and decreased lip eversion. The orbicular oris is a circular muscle extending around the oral aperture. Judicious injection into the orbicularis can address perioral vertical rhytids (not present in this patient) and improve lip eversion in both the upper and lower lip. Injection into the mentalis or inferior labii muscles would increase the labiomental angle and decrease lower lip eversion. Neurotoxin injection is recommend for this patient.

Answer 93

B. Yes, insert the catheter, and remove it at the conclusion of the procedure before extubation. Indwelling urinary catheters should be placed for procedures that are planned to last more than 2 hours and should be removed as soon as possible. The catheter should not be removed in the PACU because keeping it in adds no benefit and is uncomfortable.

Answer 94

A. Consult with a restorative dentist, and fabricate a surgical guide to ensure parallelism of the implants and optimization of occlusal loading. Although all the answer options are important to maintain the viability of the implant-supported restoration, the most common reason that implant prosthetics fail is the loosening of hardware secondary to off-axis loading. Implants should be positioned within the normal form of the denture base and centered beneath the prosthetic teeth, and they should be parallel (especially if they are not connected/splinted).

Answer 95

D. At skeletal maturity Implant placement has the best functional outcome when orofacial growth is complete.

Answer 96

D. Extranodal extension (ENE) ENE (previously “extracapsular extension” or “ECE”) is a high-risk feature for which the addition of platinum-based chemotherapy to radiotherapy is supported. The AJCC staging algorithm has long considered pathologic metastatic nodal status a critical factor in prognosis and management; however, it was not until the most recent edition (8th edition, 2018) that ENE was brought into the clinical and pathologic staging process. ENE currently upstages all oral cavity squamous cell cancers. The other answer choices place the patient at increased risk and do not alone warrant the addition of chemotherapy in the adjuvant setting.

Answer 97

A. Complete the fracture. This scenario describes an unfavorable fracture. The presence of a wisdom tooth at the time of the mandibular split can lead to this. It can also be caused by too much force or incorrect direction of the osteotomes. The key to managing this complication is to first complete the fracture. Once the fracture has been completed, evaluate the amount of bone stock left, and plan where any possible bony fixation can be placed. If there is not enough quality bone for fixation, complete the opposite side osteotomy with its bone plate or screw fixation, and then place the patient into MMF to allow healing of the bony segments.

Answer 98

B. Symphysis Retrospective long-term follow-up studies and systematic reviews have explored the complication rates associated with symphysis grafts. Studies comparing the neurosensory disturbances of the two donor sites have reported that 52% of patients have altered sensation to the chin after symphysis graft harvest, whereas only 4% of patients report permanently altered sensation in the posterior vestibular area after ramus graft. The harvest of a coronoid process graft or a maxillary tuberosity graft does not approach the mental nerve or the inferior alveolar nerve.

Answer 99

A. Acute pulmonary embolism (PE) Acute PE is a common and sometimes fatal disease with a variable clinical presentation. It is critical that therapy be administered in a timely fashion so that recurrent thromboembolism and death can be prevented. PE is the complication that is most concerning in this patient given his history and clinical findings.

Answer 100

A. Observation Odontomas are biologically inert and do not require removal unless they are interfering with the eruption of the dentition, the diagnosis is in doubt, or the patient has concerns regarding the presence of the lesion.

Answer 101

B. Periodontal disease is a contraindication to MADs because they can compromise periodontally involved teeth. Edentulous patients and those with periodontal disease are not good candidates for MADs. TMJ discomfort can happen in any patient in the short term, but long-term pain is associated primarily with patients with preexisting TMJ degeneration and pathology. Unfavorable occlusion changes are not uncommon, but they do not occur in most patients.

Answer 102

B. The oropharyngeal lateral walls and tongue A recent multicenter study found that DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. The other anatomic findings are not attainable with DISE or are not as relevant.

Answer 103

A. Sympathomimetic Ketamine is a rapid-acting general anesthetic agent that possesses sympathomimetic properties (in patients with an intact sympathetic system). Stimulation of the sympathetic system typically increases heart rate, vascular tone, and airway diameter. Commensurate increases in blood pressure are expected. The onset of action is quite rapid when administered intravenously, (clinically similar to propofol and more rapid than midazolam or fentanyl) and slower when given intramuscularly or orally. Caution should be exercised in patients who might not tolerate a sympathetic stimulus, such as those with inadequately treated hypertension or coronary artery disease and patients with psychiatric challenges. Ketamine provides analgesia at subanesthetic doses and is used for chronic pain management as well as an anesthetic agent.

Answer 104

C. Perform septal manipulation in the office under IV sedation. Early manipulation has been shown to be an effective treatment, especially if the septum deviated during the extubation. Waiting 6 months is an option if early manipulation fails. Taking the patient immediately back to surgery is risky but may be warranted in rare instances. Medical management is seen as an adjunctive treatment.

Answer 105

D. Fixate the flap under tension in the desired location, and then 15 to 20 minutes later release and replace the flap under tension in the desired location to account for soft tissue creep. Relapse after a brow lift in a thick-skinned patient is a common problem. The periosteum must be released along the superior orbital rim, and the cut edges should be separated by at least 1 cm. The lateral orbital rim should be subperiosteally elevated at least down to the inferior orbital rim, and the attachment of the temporoparietal fascia should be released. Stable fixation and allowing for soft tissue creep after setting the brow is important. We recommend a fixation technique that allows resetting the brow after allowing for a period for soft tissue relaxation (creep). The brow should always be fixated under tension in an endoscopic browlift.

Answer 106

B. Maxillary advancement of less than 8 mm and a mandibular setback Alloplastic grafts and autographs can increase stability when large maxillary advancements are attempted. However, large advancements, even with bone grafts, are unstable. This patient most likely has a combination of maxillary hypoplasia and mandibular excess. Although dental extractions may lessen the amount needed, the critical element in this question is the magnitude of the advancement.

Answer 107

B. Vestibular A sulcular incision can cause gingival recession in patients with a thin biotype and anterior crowns. Healthy periodontium is also a prerequisite to the sulcular incision to prevent attachment loss. The vestibular incision is associated with wound dehiscence (11%), scar band formation, more pain, and possible chin ptosis compared with sulcular incision, but it is the incision of choice for patients who would be at risk of gingival recession with a sulcular incision. Although a distal buccal release bilaterally would give the best visibility, there is a risk of damage to the mental nerve and vertical gingival defects in the anterior aesthetic region. A bilateral distal buccal release is not an acceptable incision to approach this harvest site.

Answer 108

A. Place the zygomatic implants, and discharge the patient with antibiotics and decongestants. Acute sinusitis is a contraindication to the placement of zygomatic implants, but chronic sinusitis is not a contraindication, provided that it is under adequate control. Any condition that results in deficient sinus drainage should prompt a preoperative consultation with an otolaryngologist. The inability to adequately open one's mouth is also a contraindication to zygomatic implant placement. Preprocedural nasal lavage would not be a sufficient measure to address this patient's chronic sinusitis.

Answer 109

D. Segmental/radical mandibulectomy plus selective neck dissection For patients with oral cavity squamous cell carcinoma, specifically gingival maxillary and mandibular carcinoma, assessment for bony invasion is critical for diagnosis, prognosis, and management. A preoperative clinical examination, imaging (including orthopantomogram and CT), and intraoperative findings may be combined to determine signs of cortical or medullary bone erosion suggestive of an invasive growth pattern (van den Brekel, et al 1998 PMID: 9866760). In addition, oral cavity squamous cell carcinoma from other subsites such as the floor of the mouth, tongue, retromolar trigone, and buccal mucosa often has gingival extension where bone marrow invasion needs to be assessed for oncologic management. The decision to treat with a conservative (rim or marginal) versus radical (segmental or composite) mandibulectomy depends primarily on the increased risk of local failure in those tumors demonstrating a propensity to invade the jawbone (Ord, 1997 PMID: 9146516) and the need to include a maxillectomy or marginal or segmental resection of the mandible. The other choices, including rim mandibulectomy and radical neck dissection with the antiquated commando operation, are not supported by contemporary NCCN guidelines.

Answer 110

C. Make the anterior osteotomy at the mandibular first molar. The anterior osteotomy of the harvest of the ramus graft is best placed along the distal half of the first molar, which has the greatest distance between the buccal cortex and the inferior alveolar nerve. Rajchel et al systematically evaluated the mediolateral position of the mandibular canal at 5 different locations from the mandibular foramen to the mental foramen in 45 adult cadavers. They noted that the greatest distance between the medial side of the buccal cortical plate and the lateral aspect of the mandibular canal was at the furcation of the first molar (4.05 mm − 1.10 mm), followed closely by the distance at the furcation of the second molar. Dissection along the medial aspect of the mandible can cause damage to the IAN where it enters the mandible and is not necessary for the harvesting of this graft. The inferior osteotomy should be placed well above the inferior border of the mandible to avoid buccal exposure of the IAN and loss of support of the mandible, which could predispose the mandible to fracture.

Answer 111

B. Attempt to complete the osteotomy or pack the wound. Although crossmatching blood and hypotension may be beneficial, the first step is to attempt local control of the injured vessel. This may be accomplished by packing the wound and applying direct pressure or, if feasible, completing the osteotomy to provide better visualization of the injured vessel. Ligating the external carotid artery is not indicated.

Answer 112

C. The wound bed is approximately 4 × 5 cm, free from active infection, and with a healthy bed of granulation tissue. A 2-cm area of exposed mandible is present with intact periosteum. An ideal recipient site is well vascularized and free of necrotic debris and infection. Supporting tissue associated with bone, cartilage, and tendon (perichondrium, periosteum, paratenon) will support a graft. Therefore, this is the only answer option that meets these requirements.

Answer 113

A. Pregnant women generally note improvement of migraine headaches in the second and third trimesters. Most women experience an improvement in migraine headaches during pregnancy, particularly during the second and third trimesters because of stable estrogen levels. For this reason, women are at risk for experiencing increased headaches during the postpartum period due to abrupt estrogen withdrawal after birth. Women who experience migraines are at an increased risk for complications during pregnancy. Although treatment options are limited and certain medications are contraindicated during pregnancy, safer preventive treatments should be considered in women with frequent headaches during pregnancy.

Answer 114

C. Assess neuromuscular function, maintain ventilation, and sedate the patient. There are several aspects to this patient’s presentation. The documented history is positive for a prior stroke and hypertension. The patient receives a general anesthetic consisting of propofol, midazolam, and remifentanil. Succinylcholine is administered to facilitate intubation. As the surgery is being completed, the propofol-remifentanil infusion is reduced with the anticipation that the patient will awaken and be extubated. However, the patient remains unresponsive to all stimulation, with the exception that the heart rate and blood pressure have increased. The delayed recovery could be consistent with residual sedation, but the patient’s complete lack of response to various stimulation makes this less likely. If the patient did have residual sedation, the most likely agent contributing to it would be midazolam as the recovery from propofol and remifentanil are more rapid. The residual sedation is also less likely to be caused by an opioid because the pupils are not constricted. In a patient with a prior stroke who is unresponsive and hypertensive after surgery, there is always a possibility that the patient experienced a neurologic event. The pupils, however, are equal and reactive, which decreases the likelihood of a stroke. A CT is not inappropriate. However, the potential for residual neuromuscular blockade secondary to succinylcholine in a patient with a pseudocholinesterase deficiency should be considered, though this event is rare. An office in which intubation is routinely performed with either depolarizing or nondepolarizing agents must have a nerve stimulator. If the patient was intubated with a nondepolarizing agent (eg, rocuronium), it would be routine to assess the recovery of the neuromuscular blockade. This would not be routinely performed after a 50-minute case in which the patient was administered succinylcholine. However, because the patient did not recover as anticipated, this should be one of the first steps in management. If the patient demonstrated neuromuscular blockade, a diagnosis is most likely made. As it would require several hours for the succinylcholine to be metabolized, the patient should be transferred to an appropriate care facility in which he can be ventilated and monitored. The patient should be sedated because he is most likely awake but paralyzed. Therefore, neither flumazenil nor naloxone is appropriate to be administered. Once the patient is resedated, the blood pressure and heart rate should be treated. However, the resedation of the patient will probably reduce the patient's blood pressure and heart rate. Given the patient’s history of stroke, a CT scan may be performed to prevent delay in management if the patient sustained a cerebral injury, though this step should follow an assessment of neuromuscular function using a monitor, which should be available. The entire event may have been prevented by including items pertaining to past individual and family anesthetic events because pseudocholinesterase deficiency is inherited.

Answer 115

C. Improper medial nasal osteotomy placement If a dorsal hump reduction is not performed, a traditional medial osteotomy is typically required to separate the nasal bones from the septum. It is important to note that the medial nasal osteotomy primarily controls the dorsal width. The final consideration in the medial osteotomy is the length of the cut. As the osteotome is gently faded off the sagittal plane, it is imperative to complete the osteotomy before reaching the nasofrontal suture. If the osteotomy is extended through the nasofrontal suture, the thick cephalic bone fulcrums or “rocks” about the suture, resulting in lateralization of the cephalic segment with medialization of the caudal nasal bone. This is called a "rocker deformity." Placing the medial osteotomy too far centrally as it connects with the lateral osteotomy can cause a rocker deformity, where the upper portion of the fractured nasal bone "kicks out," resulting in a widened upper dorsum. It can be corrected by performing a transverse osteotomy caudal to the nasofrontal suture line, and the nasal bone can then be manipulated without fulcruming across the suture.

Answer 116

E. Coagulation tests The provider must suspect that this patient has underlying liver disease secondary to chronic alcohol use. A dysfunctional liver will not reliably produce the coagulation factors necessary to provide normal coagulation during a surgical procedure. Platelet function assay is not necessary as the provider should not suspect a qualitative defect in platelet function. ESR, CRP, and WBC count may be used to evaluate infection response to therapy, but these tests will not give any information that can be used to prevent surgical complications in this clinical setting.

Answer 117

C. To teach parents how to perform appropriate wound and nasal stent care and to make sure the infant’s oral intake is adequate Nasal stents are used to support cleft repair. It is crucial that these stents, which may remain in for many months, remain clean and patent to permit adequate healing and better breathing, so detailed parental instructions on nasal stent management and general care of wounds are provided before discharge. Also, as the repair changes lip anatomy, ensuring the infant is taking adequate fluids before hospital discharge is crucial. Infants are not kept intubated overnight unless there was a nonsurgical issue preventing immediate extubation at the end of surgery. Counseling regarding appearance changes is provided before and after surgery, but it is not a reason for retaining the infant in the hospital. Appliances (such as a Latham) used to prepare for lip repair would be removed immediately before beginning the lip repair in the OR; removal after surgery would potentially disrupt the repair. Finally, infants this age are edentulous, so instruction on dental hygiene is not yet indicated.

Answer 118

B. Implant retained The superstructure over the implants is used to retain the maxillofacial prosthesis. Dental implants can be placed in specific locations in sufficient number to completely support a prosthesis. As a result, when the implant is loaded during function, the underlying tissue is not affected; this is defined as implant-supported. Since there are no functional loads placed on an orbital maxillofacial prosthesis, the maxillofacial prosthesis is considered implant retained. In this case, the implants are being utilized rather than adhesive or the patient's glasses.

Answer 119

D. Undergo maxillomandibular advancement (MMA) surgery. This patient is potentially a good candidate for MMA because it has been shown to be a long-term, effective treatment for patients with severe OSA, including those with CCC during DISE. Continuation of CPAP is not indicated because the patient is not being adequately treated as he has not met the criteria for minimal hours of nightly CPAP use (≥4 hours). The patient is not a candidate for HNS because he has CCC during DISE, which is a contraindication for HNS. The patient is not a good candidate for an OA because OAs are more effective in less obese patients with mild-to-moderate OSA. The patient is not a good candidate for UPPP as the primary procedure because he has normal tonsil size and an enlarged base of the tongue, which predicts a poor outcome for UPPP. Importantly, UPPP as a sole procedure does not reliably normalize the apnea-hypopnea index in patients with moderate-to-severe OSA.

Answer 120

C. Intraosseous labetalol Hypertension is rarely an acute office emergency because most patients with hypertension experience uncontrolled hypertension for long periods of time. These patients are often asymptomatic and may not be diagnosed until they present to the oral surgeon’s office. However, this patient appears to be experiencing an acute hypertensive emergency as evidenced by the severe headache and visual signs, so medical management is indicated. Labetalol is the best medication for this complication because it will lower the blood pressure with less compensatory hypotension. Sublingual nifedipine may reduce the blood pressure but has been “black boxed” for this indication because of problems with overshooting the blood pressure and creating dangerous hypotension. Oral medications are rarely given during an acute emergency because they have a delayed onset and they cannot be titrated.

Answer 121

B. Cone-beam CT The first step in managing a displaced implant is to determine what anatomic space it has entered, so imaging with cone-beam CT is indicated first, before any operative treatment. After its location is determined, it is appropriate to attempt retrieval.

Answer 122

A. Lateral sural nerve The lateral sural cutaneous nerve supplies the area of the skin paddle and can be harvested as a vascularized nerve to allow innervation of the flap. The medial sural cutaneous nerve, peroneal nerve, and tibial nerve would not anatomically supply the skin paddle of the lateral flap.

Answer 123

D. Nasometry is less invasive than nasoendoscopy and helps track changes over time compared with a subject’s baseline nasalance score. Nasometry measures the percentage of oral versus nasal acoustic energy detected by two separate microphones located in front of the nose and mouth while the patient recites standardized speech samples. It is typically reported as a numeric ratio of oral to nasal acoustic energy and a total nasalance score. The score gives useful information relative to previous baseline values and is a useful tool to track changes within subjects over time. The test is cheap and noninvasive and provides valuable information that correlates well with other assessments of VPI. However, it does not in itself confirm the presence or absence of VPI.

Answer 124

B. Anterior to the GV According to a published study, for African American women, the optimal AP position of the maxillary incisors when smiling is anterior to the GV, which is constructed when the head is in an adjusted natural head position. How far forward the maxillary incisors are relative to the GV is correlated with the inclination of the forehead (ie, the more inclined the forehead, the more anterior to the GV the optimal incisor position is). No published studies indicate that the optimal incisor AP position in African American women when smiling is in line with the pronasale or trichion.

Answer 125

B. Wound dehiscence Wound dehiscence is the most frequent morbidity of the listed choices. Facial pain is unusual, as are infection and failure of the graft to consolidate. Patients are warned before surgery that their child's diet will be limited, and this is not perceived to be a morbidity by most.

Answer 126

D. Superior-based pharyngeal flap Success depends on identifying the anatomical cause of the VPI and then selecting the appropriate surgical intervention. A superior-based pharyngeal flap is the best option in this case to treat this patient's VPI. CPAP and speech therapy may work for hypernasality without anatomic VPI. An inferior-based pharyngeal flap is not traditionally used as there is tension on the site of the inset.

Answer 127

E. MRI with contrast Given this patient's pain associated with the fibrosarcoma, a concern for either perineural invasion or adjacent tissue invasion is warranted. The best imaging modality for soft tissue resolution is MRI. MRI allows better interrogation of the perineural invasion as well as adjacent soft tissue involvement such as the pterygomandibular sling, salivary gland, and bone marrow extension. CT angiography is used to evaluate vascular components, not other soft tissue such as nerve or muscle. CBCT is without contrast and is usually best for the evaluation of hard tissue only. A PET scan has poor image quality and is better for assessing metastasis. A Sestamibi scan is commonly used to evaluate parathyroid adenoma.

Answer 128

E. Topiramate Topiramate would be the best option and is least contraindicated in this patient. The possible weight loss and appetite-suppression side effects would be beneficial. Amitriptyline could cause weight gain in an already overweight patient as well as constipation. Verapamil has little evidence for headache prevention. Beta-blockers, including propranolol, are contraindicated in patients with asthma. Sumatriptan is an acute treatment and is not used as a preventive therapy.

Answer 129

C. Perform ORIF with a locking reconstruction plate (LRP) extraorally. Treatment with an LRP is current wisdom. Removing the patient's lower denture and keeping her on a soft diet is incorrect because the fractures are mobile and displaced. This treatment would result in either nonunion or mal-union. Miniplates are unpredictable in atrophic mandibular fractures and tend to break or pull loose. Treatment with modified dentures and MMF is a dated treatment with a long history of poor results and significant morbidity.

Answer 130

A. Placing the inferior osteotomy at least 4 mm superior to the inferior border of the mandible Not leaving enough inferior border of the mandible may reduce the structural support of the mandible and predispose the patient to a mandible fracture. There have been no studies that have found superiority of a bur over a saw in preventing mandible fractures when harvesting symphysis grafts. Prophylactic plating of the mandible is not advised because hardware is at risk for infection, and if adequate bone is left at the inferior border, it is not worth the risk. The superior osteotomy should be placed at least 5 mm away from root apices to avoid damage to their neurovascular bundles. If the volume of graft required will not allow sufficient distance from the root apices and the inferior border of the mandible, an alternate site should be chosen.

Answer 131

B. Construction of an oral appliance (OA) This patient is a good candidate for an OA because this device is generally effective in patients with mild-to-moderate OSA who are less obese and in patients with skeletofacial deformities who have normal TMJ function. This patient does not meet the threshold (≥4 hours of nightly use) for effective control of OSA with CPAP, so continuing this therapy is not indicated. MMA is indicated for patients with moderate-to-severe OSA, so it would be unlikely to be recommended before attempting the use of an OA. The patient is not a good candidate for UPPP because she has normal tonsil size and an enlarged base of the tongue, which predicts a poor outcome for this procedure.

Answer 132

D. Hypernasality Many patients with VPD have articulation errors, facial or nasal grimace, or glottal stops; however, every patient with VPD will have hypernasality.

Answer 133

C. Convert to extraction, and remove the residual root. Mobility of the residual root is an indication to convert to an extraction procedure, and there are no reasonable exceptions to this rule. Therefore, completing the procedure or reducing the root further would not be indicated.

Answer 134

B. A patient with horizontal impaction Horizontal impaction is usually a contraindication because the coronectomy cut would put the inferior alveolar nerve at risk. There may be select cases where the cut can be made below the bone level and not jeopardize the nerve. Vertical impactions will generally not pose this same limitation. Severe immune compromise may also be a contraindication to coronectomy, but patients with adequate control of their DM can undergo the procedure. There is no strict age limitation for coronectomy, and older patients are often at greater risk for total odontectomy.

Answer 135

C. Perform in-out bladder catheterization at the conclusion of the procedure. When unanticipated prolonged surgical time occurs, in-out catheterization should be performed either during surgery or at its conclusion. If there is still significant surgical time remaining, the bladder catheter can be inserted and kept in place until the conclusion of the procedure. Bladder scanning does not have a role here, especially given the amount of IV fluid already administered. Likewise, there is no benefit to leaving the catheter in place after surgery.

Answer 136

C. An infant with an isolated cleft palate In terms of relative syndromic involvement, patients with isolated cleft palate have the highest incidence. Estimates vary, but up to 50% of patients with isolated cleft palate are associated with an underlying syndrome. This has impacted not only the treatment of patients, but also the evaluation of outcomes research.

Answer 137

D. Undergo maxillomandibular advancement (MMA). This patient is a good candidate for MMA because it has been shown to be a long-term, effective treatment for patients with moderate-to-severe OSA who cannot fully adhere to CPAP or who have failed stage I surgical treatment (UPPP). The patient has failed CPAP because he was not able to tolerate therapy, so there is no indication to restart it. Although UPPP reduced the patient’s AHI, an AHI of 35 is still considered severe OSA, which requires treatment. Revision UPPP is not indicated and should only be considered as an adjunctive procedure because as a sole procedure it does not reliably normalize the AHI in patients with moderate-to-severe OSA. The patient is not a good candidate for an OA because OAs are more effective in less obese patients with mild-to-moderate OSA.

Answer 138

C. It may be camouflaged if it becomes visible later in life using follicular unit hair grafts or a second trichophytic lift. The trichophytic lift is the best option to avoid making a tall forehead taller or with modification make the forehead shorter. Women with mild-to-moderate DUPA typically maintain their anterior hairline, thus camouflaging the trichophytic incision, while the hair in the central portion of the scalp becomes thinner. However, predicting hair loss patterns in DUPA patients is inexact, and the patient should be informed that camouflage maneuvers such as hair grafting or touching up the trichophytic incision may be employed later if needed.

Answer 139

B. Patient with a hemiglossectomy defect The pectoralis major myocutaneous flap is unlikely to reach a defect of the orbit. The superior limit of defects reconstructed by the pectoralis major myocutaneous flap is the zygomatic arch because of the arc of rotation. Hemiglossectomy reconstructions using the pectoralis major myocutaneous flap have demonstrated functional outcomes that are comparable to free flap reconstruction. A limitation of pedicled flaps is the inability to raise osteocutaneous flaps for reconstruction of composite defects. Pedicled flaps including the pectoralis major are indicated primarily for soft tissue reconstruction. The pectoralis major myocutaneous flap does not have favorable soft tissue characteristics for the reconstruction of a skin defect of the lower cheek, such as the need for thin pliable tissue with similar color and texture. The pectoralis major flap provides bulky tissue that has a color and texture that would be a mismatch for head and neck defects.

Answer 140

C. 2B In their 2010 article, Brown and Shaw investigated facial reconstruction options and reviewed their own institution's preference for managing these defects to come up with a new classification system. Residents can become familiar with these defects and the potential reconstructive options, which can aid in maxillofacial reconstruction for patients with benign and malignant pathology as well as traumatic defects. 1A is infrastructure maxillectomy and a palatal defect only. 2A is a vertical defect, but it is a palatal defect only. 2D is a vertical defect, but more than one-half of the maxillary defect. 3A involves the orbital adnexa and is a palatal defect only.

Answer 141

A. You explain that the male brow typically follows the natural arch of the superior orbital rim, and this guides the surgeon. However, the patient should also look into a full-face mirror to simulate the lift and see if he likes the way it looks. You recommend performing an endoscopic lift, using a single incision or two superior incisions and two temporal incisions to decrease the chance of scar exposure with later hair loss. This patient is an excellent candidate for this type of brow lift. The patient should also be involved in deciding on the esthetic result. At age 50, a man with a Norwood 2 classification would have minimal chance of seeing substantial hair loss. However, a trichophytic incision would still be contraindicated because some hairline frontal recession is expected. Any hairline incision in the frontal region should be minimized. A direct brow lift would not address forehead heaviness, particularly in the glabellar region, and it often leaves visible scars. Upper blepharoplasty is often recommended for male patients with this set of concerns, but even in conjunction with an indirect brow lift (performed through the blepharoplasty incision), the forehead heaviness would not be addressed.

Answer 142

B. Prescribe behavior modification including alcohol cessation and weight loss. This patient has many easily modifiable behaviors that are likely contributing significantly to his mild OSA. If he engages in a weight-loss and exercise program and avoids alcohol and benzodiazepines, he could improve his OSA and not require further treatment. If he does not respond adequately to behavior modification, CPAP therapy would be appropriate. It would not be advisable to perform surgery as the first step on this patient.

Answer 143

B. Tensor veli palatini The tensor veli palatini is the only velar muscle innervated by the motor branch of the third division of the trigeminal nerve (cranial nerve V3). The other velar muscles are innervated by the pharyngeal branch of cranial nerve X.

Answer 144

B. Aggressive chiseling and deep penetration of the chisel into the medullary space created the nerve transection. The surgical technique for inferior alveolar nerve lateralization or transposition requires finesse and appropriate instrumentation. It is not recommended to use sharp chisels with aggressive force. The recommendation is to use a blunt chisel or ultrasonic cutting instrument of your choice. Significant care around the neurovascular bundle must be taken to avoid transection or iatrogenic damage. The surgical technique in this vignette is the reason for the nerve transection.

Answer 145

C. Operative time longer than 4 hours Surgical procedures lasting more than 3 to 4 hours are associated with a higher risk of pulmonary complications. Researchers conducting a study of risk factors for postoperative pneumonia in 520 patients found an incidence of 8% for surgeries lasting less than 2 hours versus 40% for procedures lasting more than 4 hours. This observation suggests that, when possible, a less ambitious and briefer procedure should be considered for a very high-risk patient.

Answer 146

C. Using local anesthesia or sedation if necessary, gently remove the exposed cancellous bone, leaving the majority of it in place; then place the patient on antibiotics, chlorhexidine, and strict oral hygiene protocol. One of the main advantages of autogenous cancellous bone is its ability to quickly revascularize as compared with allogeneic or cortical bone. This quality makes this type of bone graft more resistant to infection or complete loss. If the wound opens and some of the cancellous fragments become exposed, it is only necessary to remove the superficial exposed bone. Over time, the site may require multiple small debridements before the soft tissue heals completely. Generally, most of the graft will continue to consolidate and heal. Once the soft tissue has fully closed over the graft, a decision can be made regarding when or if an additional bone graft would be necessary.

Answer 147

D. Place a nasopharyngeal airway. The patient is stable, so the surgery can be continued. An oropharyngeal airway is contraindicated because the patient is not unresponsive. The patient is too light for laryngeal mask airway placement. The nasopharyngeal airway should be well tolerated and will relieve the airway obstruction. If the patient reacts to placement, a bolus of propofol can be given to accommodate the airway.

Answer 148

E. Perform an adenotonsillectomy. Children with diagnosed physical airway obstruction are good candidates for surgical management. Nonsurgical management in the context of significant tonsillar hypertrophy is less likely to be successful in addressing this patient's OSA. It is inappropriate to defer therapy because severe OSA can affect a child's growth and development.

Answer 149

A. Fresh autogenous cancellous bone from the ilium Most contemporary cleft surgeons agree that fresh autogenous cancellous bone harvested from the hip is the gold standard for bone graft construction of the cleft maxilla and palate during the childhood years. BMP and or BMP mixed with allogeneic bone is a promising technique, but long-term outcomes and efficacy have not been determined. An autogenous block graft would not be applicable to the three-dimensional nature of the cleft defect, and the use of allogeneic bone alone would not provide an optimal reconstruction.

Answer 150

E. Improper handling and control of the proximal segment intraoperatively Bell has described the failure of control of the proximal segment to be a disadvantage of an IVRO. Stripping of the muscles of mastication (masseter, temporalis, and lateral pterygoid) could make this challenging. For example, excessive stripping of the lateral pterygoid muscle could lead to necrosis of the proximal segment, thereby leading to necrosis of that segment, condylar sag, and malocclusion.

Answer 151

B. Remove the sutures, apply a pressure dressing, and prescribe glycopyrrolate. Because the lesion occurred on the parotid duct area, the clear liquid is most likely saliva, and a pressure dressing plus the antisialogogue will facilitate duct healing. Protecting the wound from sun exposure will not facilitate healing. Antibiotic or operative treatment is not indicated.

Answer 152

E. Videofluoroscopy Videofluoroscopy can be helpful in evaluating speech using dynamic testing. The speech-language pathologist will be present in the radiology suite to administer the verbal testing, and the fluoroscopy will highlight the velum in motion during speech. Nasopharyngoscopy is another test that can diagnose VPI; however, it requires the use of topical anesthetics and compliant behavior of the patient. Often, patients are 4 and 5 years old during evaluation, and nasoendoscopy can be difficult. Although functional MRI is an option to evaluate the musculature of the soft palate during speech, very few centers offer functional MRI. Traditional CT or MRI will not show the motion of the velum, which is necessary to evaluate for VPI. A panorex will not provide an adequate image of the soft palate as there is significant overlap. A lateral cephalogram can show the soft palate at rest, and a second lateral cephalogram can be taken with the patient making a high-pressure consonant sound such as ppp, but this is only a single image in time and does not show function of the soft palate. An orthopantogram will not provide any useful information about VPI.

Answer 153

D. Switching to a bilevel PAP (biPAP) device This patient has several risk factors for leakage of his CPAP device, including nasal obstruction and advanced age. Given the patient's history of a recent MI, he is not a good candidate for surgery at this time, and therefore nasal or oral surgery should be deferred for now. Furthermore, edentulous patients generally have a higher incidence of leakage than patients with teeth. MADs are contraindicated in patients with periodontal disease. The presence of a beard can worsen leakage around a CPAP device. BiPAP therapy, however, does not increase leakage and may be better tolerated in patients who have difficulty in the expiratory phase. Studies have shown increased compliance with CPAP in this subset of patients.

Answer 154

B. Muscle relaxants taken at bedtime Muscle relaxants taken at bedtime may be useful in ameliorating stress-induced nocturnal clenching and grinding. Physical therapy, chemodenervation, and occlusal splint therapy may be used as adjuncts to this initial therapy if required.

Answer 155

C. Frontal view with the lips in repose It is important to be able to evaluate the patient's facial position with the lips in repose. This will allow the clinician to appropriately evaluate the amount of upper incisor show to help determine the appropriate vertical facial positioning. If the lips are pursed, the incisor edge position will be distorted and the soft tissues of the lips can be shifted, creating inaccuracies in the midline and chin positions. Photographing the patient with the mouth open will not enable the clinician to evaluate the amount of upper incisor show.

Answer 156

A. Passavant ridge The Passavant ridge is a collection of muscle fibers within the superior pharyngeal muscle. On activation in some patients, this muscle will thicken and decrease the distance required for the soft palate to transverse during speech. The absence of this structure may increase the chance of velopharyngeal insufficiency. Both the tensor and levator veli palatini muscles are present within the soft palate. The levator muscle aids in closure, but not at the posterior pharynx. The palatoglossus muscle does not aid in the velopharyngeal mechanism as a factor of its insertion and origin. The palatopharyngeus may aid in speech as a local flap during a sphincter pharyngoplasty.

Answer 157

E. Surgery typically is delayed to 12 months of age because of the increased risk of obstructive sleep apnea (OSA) postoperatively. Micrognathia is a defining feature of patients with PRS. Although patients may be able to undergo some degree of "catch-up" growth to the point where operative intervention is not required, concern exists that palatoplasty may create a situation where OSA develops. Allowing the patient to continue to grow within the standard age range for palate repair up to 18 months is reasonable. Typically, this is between 12 and 14 months. Superior-based pharyngeal flaps are not routinely used at the primary repair as they are primarily chosen to treat velopharyngeal insufficiency when patients are at an appropriate age.

Answer 158

B. Facial bipartition will provide the best results. During surgery, a midline osteotomy must be performed to remove excess bone between the eyes and close the space to approximate the right and left orbital cavities. Because compensatory bone growth causes hypertelorism, the patient's treatment will involve the removal of excess bone to approximate both orbits. Only the facial bipartition will address the hypertelorism, and there must be bone removal, not canthal ligament repositioning.

Answer 159

B. Repair with primary neurorrhaphy of the two native nerve ends using 8-0 nylon sutures for a tension-free anastomosis. There has been a witnessed nerve transection. When a nerve transection occurs, immediate repair is the optimal treatment. In this particular instance, primary neurorrhaphy would offer the best chance of neurosensory recovery. The other options listed would not offer a chance for neurosensory recovery.

Answer 160

B. TIg and diphtheria tetanus (DT) Because the wound is prone to tetanus and the patient does not remember having received the vaccine, the patient should receive the TIg and the conventional DT vaccines. The DTP vaccine is preferred for children younger than 7 years.

Answer 161

A. The articular disc is anteriorly displaced but reduces upon opening the mouth. The articular disc is likely anteriorly displaced but reduces upon opening the mouth, which accounts for the clicking and popping. A perforated disc is clinically noted with crepitus and not with clicking and popping. A disc that is anteriorly displaced without reduction will not usually produce any clicking or popping sounds. There is no clinical indication to surgically reposition a displaced disc in the absence of pain or functional impairment.

Answer 162

C. An inadequate inferior border cut Most surgeons agree that inadequate capture of the inferior border cortex is a common pitfall that results in a higher incidence of bad splits. There are no known associations between bad splits and factors such as the use of a saw instead of a burr, the age of the patient, or the presence of a class III DFD. There is much debate over whether the presence of third molars increases the incidence of bad splits, with literature supporting both sides.

Answer 163

B. Maxilla-first surgery may be beneficial because it is uncertain if advancement of the maxilla is achievable. Because of the scarring of the soft tissues, the maxilla may be more difficult to mobilize for a large movement. One strategy to mitigate this is to perform maxillary surgery first. Another option is distraction osteogenesis. Even with prior cleft palate operations, maxillary osteotomies are safe and the treatment of choice for maxillary hypoplasia. Patients with significant maxillary lengthening and advancement benefit from bone grafting.

Answer 164

A. Pretracheal stethoscope Capnography has become the standard of care for monitoring ventilation. In a closed system, the capnographic waveform can provide information about inspiratory and expiratory changes (bronchospasm, obstruction). However, in the open airway used by most oral and maxillofacial surgeons, the interpretation of the capnographic wave is significantly less valuable in identifying respiratory abnormalities. One advantage of the pretracheal stethoscope is the ability to auscultate respiratory sounds. The auscultation of wheezing or a change in the character of the breath sounds may precede a decrease in oxygen saturation.

Answer 165

B. 2 to 3 mm below the residual bone crest The residual root should be 2 to 3 mm below the residual bone crest. It is also important to remove all of the tooth enamel.

Answer 166

E. Extract the supernumerary tooth while having the arches orthodontically expanded, and bone graft both sides of the alveolar/maxillary cleft 3 to 6 months after the extraction using an acrylic splint to stabilize the premaxilla. Removing the supernumerary tooth at least 3 months before bone grafting allows for more mature mucosa to close the wound and prevents having an area where the bone graft can become exposed. Performing orthodontic expansion preoperatively is much easier and faster than if the bone is consolidated, and the expansion also opens the cleft site, making incisions and flap design more accessible. Bone grafting a single side of the cleft leaves the bone graft exposed to the oral cavity and is not recommended. In bilateral clefts, the premaxilla is mobile and needs to be kept clear of the occlusion, often with the use of an acrylic splint, as mobility will prevent the bone graft from consolidating.

Answer 167

A. Communicate that the patient is at a suitable stage for maxillary/alveolar bone grafting, which should be performed using cancellous bone from the anterior iliac crest. Although not always present or morphologically viable, the lateral incisor needs to be assessed. If it is present and of the correct shape, it will dictate that cleft bone grafting be done before it erupts. If the lateral incisor is not present or if it is malformed, alveolar graft timing occurs when the canine root is at least halfway formed and before it breaks through the mucosa. Autogenous cancellous bone is still the gold standard for cleft grafting, and it is usually obtained from the medial anterior iliac crest. Many oral surgeons use rBMP-2 in combination with allogeneic bone and obtain comparable results, but this remains an off-label use.

Answer 168

A. Deviation of the septum during extubation All of these answers are a possibility when a patient presents with a deviated septum after surgery, but deviation of the septum during extubation is the most likely option. A preexisting deviation of the septum should have been seen before surgery. Because oral surgeons are usually only dealing with the inferior portion of the septum, they have limited ability to address a preexisting deviated septum during surgery. Deviation of the septum during the maxillary impaction should have been noted and addressed in the operating room. Trauma to the nose after surgery is unlikely.

Answer 169

D. Complete neurosensory testing, and tell the patient that neurosensory disturbance is common after nerve lateralization and close monitoring will be necessary over the next 6 months. The overwhelming majority of patients have immediate postoperative neurosensory disturbances. Abayev et al found that 376 of 378 patients undergoing either nerve lateralization or nerve transposition experienced neurosensory disturbance for 1 to 6 months. Only 2 of 378 patients had permanent disturbances. It would be a common postoperative finding for the patient in this question to have neurosensory disturbance 1 week after surgery. The appropriate way to evaluate sensory disturbances is to complete neurosensory testing. The patient should also be told that recovery is likely.

Answer 170

D. The patient can start orthodontic treatment now, and the operation can be performed when the patient is 15 years old. Because this is a hypoplastic deformity, it is unlikely that there will be disproportional growth after surgery to jeopardize the surgical result.

Answer 171

C. Evaluate the effect of side and prone positioning on the breathing pattern. Evaluating the effect of side and prone positioning on the breathing pattern is a good first step to determine if the airway obstruction can be resolved without operative management. Although a small percentage of patients will ultimately require a gastrostomy tube, this is not an early step in treatment. Ordering a maxillofacial CT scan to evaluate mandibular anatomy can be done for further workup and in preparation for surgery, but it is not useful as a first step in management. Mandibular distraction osteogenesis is a possibility, but it is premature to recommend an operation without first trying nonoperative maneuvers. It is unclear at this point if the airway obstruction will resolve spontaneously.

Answer 172

D. Computer navigation Navigation technology has been gaining popularity as an adjunct during the resection of complex locations because it is an improvement over 2D scans on the computer for the surgeon's orientation. One additional key benefit is the real-time feedback it offers, which allows verification of the planned resection, especially when the complexity of the resection does not allow full direct visualization. In addition, it also correlates with CT or MRI, which can aid in the visualization of critical structures and the tumor. MRI does not offer real-time visualization for resection margins. Indocyanine green fluorescent imaging aids in evaluating tissue perfusion, not resection. Although an intraoperative CT scan is useful to delineate the adequacy of hardware placement intraoperatively, it is not a real-time adjunct for resection. A coupler is used in vein anastomosis during free tissue transfer.

Answer 173

D. Continue the DOAC throughout the perioperative period, and plan for local hemostatic measures. This is a case of judgement on the part of the treating OMS. The risk of bleeding must be measured against the risk of a thromboembolic event. There is a low risk of unmanageable surgical bleeding because of the procedure (extraction and socket preservation of two teeth), but there is an intermediate risk of a thromboembolic event if the patient discontinues her DOAC. Therefore, continuing the DOAC throughout the perioperative period would be prudent. There is no testing that can be performed to evaluate the effectiveness of the DOAC, so the INR and coagulation studies are not warranted. Heparin bridging is reserved for patients on warfarin.

Answer 174

E. Embolize the lesion, and then perform surgical resection within 24 to 48 hours. Given the clinical appearance of this lesion, it is likely a high-flow vascular lesion. Studies have shown that 24 to 48 hours is the ideal time frame for the surgical excision of an arteriovenous malformation, before the formation of collateral circulation. It would be prudent to perform any intervention in the controlled setting of an operating room, not in the clinic, because excessive bleeding is likely to occur. Although aspiration of a lesion before biopsy is often good practice to rule out a vascular lesion, clinically this patient appears to have a high-flow vascular malformation, and thus aspiration would provide minimal additional information. Sclerotherapy is unlikely to work as a treatment as it is often reserved for low-flow venous malformations. Kaposi sarcoma (KS) represents a disease entity that would be considered in the differential diagnosis, but this patient's clinical history is not consistent with this diagnosis, so HIV testing is not indicated. She has had a singular lesion for 5 years, and generally speaking, HIV/AIDS-associated KS is more aggressive and widespread and would likely show multiple lesions on the body at this point. KS does not typically enlarge during pregnancy, a feature that is consistent with a vascular malformation in response to hormonal fluctuations, and it does not usually demonstrate a bruit/thrill on auscultation.

Answer 175

D. The surgeon's and orthodontist's preference to develop the maxillary arch form with the goal of creating a low maintenance occlusion with no need for prosthetic treatment Although the state of the development of the teeth adjacent to the cleft is an important element to consider when determining the timing of bone graft construction of the cleft maxilla and palate, the collective decision of the team members is the most important.

Answer 176

C. Formalin solution and Michel solution Because of concern for possible pemphigus or pemphigoid based on the clinical scenario, immunofluorescence will likely be part of the diagnostic process. Michel solution is the transport medium of choice when performing immunofluorescence. A standard hematoxylin and eosin (H&E) staining process should also be performed on the tissue to assist in the diagnostic process. Clinical conditions such as lichen planus, which should be included in the differential diagnosis for patients with oral ulcers and blisters, are best evaluated after being sent to the pathologist in formalin.

Answer 177

D. The patient's natural head position must be established. When treating a patient with facial asymmetry, the OMS must determine the natural head position. Often, orbital dystopia is present, and establishing a natural head position on skeletal markers alone may result in an untoward outcome. Investigating idiopathic condylar resorption or condylar hyperplasia is only necessary when the status of condylar turnover is in question. In patients with facial asymmetry, establishing the correct position of the maxilla and mandible often corrects the symmetry of the chin. Virtual surgical planning offers many advantages when analyzing skeletal symmetry in addition to the dentition. Sometimes even with correction of the occlusion, inferior border asymmetry is introduced.

Answer 178

D. Nasoalveolar molding (NAM) The repair of a wide unilateral cleft lip is particularly challenging because of the distances that exist between the anatomical structures that ultimately must be precisely reapproximated during surgery. For this reason, NAM is particularly important in this type of case to align the lesser segment to the greater segment and to refine nasal structure shape and positioning. According to most surgeons, the outcomes for children undergoing NAM justify the delay of when primary lip repair can occur (weeks) and the efforts needed by parents and clinicians. Lip taping seems quite similar to NAM in some ways and was a standard treatment for many years; however, research has clearly shown that lip taping in isolation narrows the soft tissue cleft but does little to actually move the truly important anatomical structures into better alignment. External compression of the cheek itself would similarly be ineffective. Latham appliances are still used in some centers, but patients who used Latham appliances have been shown to have greater degrees of eventual midface hypoplasia compared with those who had not used these devices or compared with patients treated with NAM.

Answer 179

D. A trichophytic brow lift, with subgaleal dissection posteriorly to the vertex and scalp advancement towards the brows, held in place by a retentive device; elevation of the forehead and brows with attention to asymmetry in the subcutaneous plane, retention achieved by excising forehead skin in a trichophytic fashion Of the lifts mentioned, only the trichophytic lift has the possibility of lowering the hairline. However, lowering the hairline requires a modification to the standard subcutaneous trichophytic lift, where the posterior flap is mobilized in the subgaleal plane and advanced and fixated in the new, lower position. The subcutaneous dissection to raise the brows is performed as usual.

Answer 180

A. Perioral The diffusion of neurotoxin to the adjacent musculature can result in unaesthetic outcomes. The perioral region requires symmetric distribution of neurotoxin to maintain symmetry, typically at four points across the upper lip and two symmetric points at the lower lip. Decreasing the number of injections in this area would require a single injection site in the bilateral upper lip at 4 units per site. This larger bolus would increase the risk of diffusion into the adjacent musculature of the upper lip—including the levator labii muscles or zygomaticus muscles. The crow's feet can typically be injected at two sites, and the dose here is minimal and unlikely to contribute to significant diffusion. The glabella can be injected at three sites medially (medial corrugators and procerus), and this injection pattern may be favorable to avoid inadvertent diffusion into the frontalis muscle with injection into the lateral corrugator muscles. The frontalis muscle can be adequately injected with six sites.

Answer 181

C. It will increase. When the mandible is surgically advanced with an excessive curve of Spee in the lower arch, the mandible will rotate clockwise and increase the lower third facial height. This would likely be a favorable change in a patient with a class II deep bite (dentally and skeletally). After surgery, the orthodontist can level the lower arch with elastics and a light lower archwire. If clockwise mandibular advancement would result in an unfavorable increase in the lower third facial height, the mandibular anterior facial height can be reduced with genioplasty. Prediction tracing will indicate that the lower third of the face would not decrease or remain unchanged.

Answer 182

A. Adenotonsillectomy frequently relieves OSA in this population. Adenotonsillectomy is the most efficacious operation to relieve pediatric OSA in patients with and without craniofacial anomalies. Midfacial advancement may be a reasonable option for relieving the OSA, though it is premature to decide if this is indicated for this patient. Although tracheostomy may be necessary, it is not considered a first-line treatment. The site of obstruction in this population is most prominent in the nasopharynx, so maxillary/midfacial advancement is necessary to provide relief. Midfacial advancement is the most efficacious skeletal operation, not maxillomandibular advancement.

Answer 183

A. Risk for fire A fire in the OMS office is a rare event, but it can happen. It is usually associated with the use of electrocautery or laser in a patient breathing oxygen through a nasal cannula or nasal hood. The fire triangle is dependent on an ignition source, an oxidizer, and a fuel. Fuels are any flammable item (eg, gauze throat pack, nasal cannula or hood). An oxidizer is oxygen and nitrous oxide (which exothermically dissociates to oxygen). An ignition source can be sparks generated by a dental bur against restorative material (eg, zirconia, titanium). An oxygen-enriched environment by definition is an oxygen concentration above 23.5%. The surgeon must be aware of the risk for fire when using oxygen with a drill when sparks may be generated. Although nitrous oxide administration in the OMS office can result in occupational exposure, exposure is reduced when a scavenging device is used. Ideally, the room air exchange should meet institutional standards to reduce occupational exposure further. Females exposed to nitrous oxide in an office in which nitrous oxide is not scavenged have been shown to have a higher than normal rate of miscarriages, but females exposed to nitrous oxide in offices in which a scavenger unit is used have been shown to have no higher incidence of miscarriage compared with females who are not exposed to nitrous oxide. Chronic exposure can cause neurologic disorders that may mimic multiple sclerosis, not Parkinson disease. Nitrous oxide is less dense than

Answer 184

B. Placement of a stock silastic chin implant A silastic chin implant is the best option to address this patient's chin size and projection concerns. The patient's class I dental occlusion would preclude the need for orthognathic surgery. The normal lower facial third height makes genioplasty less of a desirable treatment option. Hyaluronic acid fillers are an option, but they are not permanent.

Answer 185

A. Cancel the procedure, and refer the patient to the primary care physician. If the patient is conscious and responsive, activating 911 is not necessary, especially since the patient would be required to have an escort present for the planned ambulatory anesthetic. Management of hyperglycemia will often require insulin, but this is not indicated as an emergency drug in this case and should be deferred. The patient’s primary care physician should be contacted to determine if the patient should be seen or if the patient should be sent to an urgent care facility. The patient may have been instructed (appropriately so) to hold some or all of the routine antihyperglycemic medications, so more control may be needed when the patient is rescheduled.

Answer 186

D. Geniculate neuralgia This patient has pain localization within the distribution of the nervus intermedius and is experiencing severe, deep ear pain that is usually sharp and often described as an "ice pick in the ear." The pain is neuralgic in nature and stimulated by tactile means. Symptoms of painful internal derangements are denied. The pain is outside the distribution of the trigeminal nerve responsible for trigeminal neuralgia. Cluster headache pain is usually nocturnal, not tactile or thermal induced, and it is usually over the second division of the trigeminal nerve as the proposed stimulator is the sphenopalatine ganglion.