SCORE Flashcards
A 37-year-old woman has severe intense pain that lasts seconds when the right chin is stimulated by either tactile or thermal stimuli. The pain radiates to her right ear. She denies any traumatic, dental, medical, or surgical etiology. The results of a cone-beam CT study are normal. The pain is resolved with 600 mg of carbamazepine three times daily. These findings are consistent with typical trigeminal neuralgia of the right mandibular (V3) distribution. What is the next diagnostic step for this patient and why?
A. MRI of the brain without contrast to determine if there is compression of the right trigeminal nerve or evidence of demyelination disease
B. CT scan with 1-mm cuts to determine if there is any occult pathology of the right posterior and body of the mandible
C. Nerve blocks of the right inferior alveolar nerve to determine if the pain source is peripheral or central
D. Indomethacin challenge to determine if the pain is associated with hemicrania continua
A. MRI of the brain without contrast to determine if there is compression of the right trigeminal nerve or evidence of demyelination disease
MRI of the brain with and without contrast helps distinguish secondary causes of trigeminal neuralgia from the idiopathic form. It is the imaging modality of choice and is indicated for patients younger than age 60 who present with trigeminal neuralgia, principally to exclude a tumor, vessel compression, or demyelinating disease. CT, nerve blocks, or an indomethacin challenge would not be indicated for this patient with a history and clinical examination consistent with pharmacologically responsive trigeminal neuralgia.
ou are operating on a patient with middle face fractures, including alveolar, Le Fort, infraorbital rim, medial orbital wall, orbital floor, and nasal bone fractures. The fracture happened about 2 weeks ago, and you are having difficulty mobilizing the maxilla to properly reduce it. What should you do next? (NOTE: OMFS curriculum)
A. Use osteotomes to refracture the consolidated areas to obtain adequate mobility of the maxilla before reduction.
B. Use Rowe forceps, paying attention to the alveolar and nasoorbitoethmoid (NOE) components.
C. Put the patient into maxillomandibular fixation (MMF) to see if adequate occlusion can be obtained with the current maxillary position.
D. Choose a top-bottom approach, and start with the orbits before mobilizing the maxilla.
E. Perform an intraoperative CT scan to determine the points of resistance.
B. Use Rowe forceps, paying attention to the alveolar and nasoorbitoethmoid (NOE) components.
Using Rowe forceps is the easiest way to mobilize a fracture that is only 2 weeks old, but the surgeon must avoid propagating the alveolar bone fracture. Most importantly, if the Le Fort fracture is in combination with an NOE fracture, the surgeon must acknowledge the risk of a cranial base fracture at the level of the ethmoid plate, and evaluate the CT scan to confirm the level of the Le Fort fracture. Osteotomes are usually not necessary for a 3-week-old fracture. Putting the patient into MMF without adequate mobilization will tend to dislocate the condyles and lead to malocclusion. Starting with the orbit will not help mobilize the maxilla, and mobilizing the maxilla after fixating the orbital component might damage the fixation. There is no point in performing an intraoperative CT scan when the problem can be seen on the open surgical field. Transoperative CT is used at the end of skeletal fixation to confirm the adequate position of areas that are not easily accessed by surgical approaches, for example, evaluating the adequate reconstruction of the orbital floor.
A 40-year-old man presents as a level 1 trauma patient to the ED after being involved in a work-related accident. A clinical examination reveals a full-thickness scalp laceration involving the temporal region, and the patient has significant bleeding. His medical history is significant for a mechanical heart valve for which he is prescribed warfarin for anticoagulation. His international normalized ratio is 5. Which therapy will predictably reverse the patient’s coagulopathy in this acute, nonelective surgical setting? (NOTE: OMFS curriculum)
A. IV vitamin K and four-factor prothrombin complex concentrates
B. Fresh frozen plasma
C. Platelets
D. Packed red blood cells
A. IV vitamin K and four-factor prothrombin complex concentrates
This combination will provide the quickest reversal of the patient’s warfarin-induced coagulopathy. The IV route is the fastest, and the four-factor prothrombin complex concentrates are superior to fresh frozen plasma in reversing coagulopathy secondary to warfarin. Platelet and blood transfusions do not provide the necessary components to reverse the coagulopathy.
A 25-year-old woman presents to your office stating, “I don’t like my crooked nose.” You complete a thorough clinical examination and determine that the patient has a deviated septum and dorsal hump and will require nasal tip work. The patient asks, “What will you do to straighten my nose?” What is your response? (NOTE: OMFS curriculum)
A. “I will avoid disrupting the perpendicular plate of the ethmoid bone.”
B. “I will mobilize and reattach the septum to the anterior nasal spine.”
C. “I will perform septoplasty in a closed fashion followed by open rhinoplasty for remaining issues.”
D. “I will resect the septum leaving an L strut of at least 10 mm.”
D. “I will resect the septum leaving an L strut of at least 10 mm.”
The nasal septum is the key structure in the deviated nose. It is a supporting structure, particularly for the lower two-thirds of the nose. It forms a fixed tripod with the conjoined upper lateral cartilages. Floating over this fixed tripod is the so-called “floating tripod” of the lower lateral (alar) cartilages, which are attached by various ligaments. These include the lateral scroll ligament and interdomal sling, supported by muscular structures such as the dilator nasi, the pyriform ligament, and the transversalis muscle. Without a proper foundation and with a central septum supported by upper lateral cartilages, there is little hope of achieving a symmetric and stable nose. The key area overlooked with rhinoplasty surgeons who are unfamiliar with the anatomy of the posterior septum is the chondrovomerine spur, which must be released to allow the back of the septum to swing back to the midline. Failure to release this area and the adjacent ethmoid plate results in an invariable postoperative twist. Many surgeons have blamed this postoperative complication on so-called “cartilage memory,” when actually it is a failure to mobilize and stabilize the posterior and inferior margins of the quadrilateral cartilage. The basic premise to achieve a straight nose has to be a central nasal septum with symmetric nasal sidewalls. In correcting a deviated nose, the greatest deficit always occurs on the more vertically placed nasal sidewall, particularly distally, where there is a deficiency in the anterior height of the upper lateral cartilage. Septal deviation is corrected using a variety of techniques, including posterior caudal septal resection, leaving an L-strut with at least 10 mm of cartilage anteriorly. Depending on the type of septal deformity, cartilaginous scoring, partial mobilization of the perpendicular plate and quadrangle cartilage, and anterior nasal spine osteotomy may become necessary.
A 5-year-old boy is referred to your practice by his pediatrician. His mother reports that he has a very sore mouth and decreased oral intake over the past 2 days. She states he has some blisters in his mouth that are causing him pain in addition to his fevers and malaise. His clinical examination is positive for cervical lymphadenopathy in addition to the numerous ulcerations on the buccal and labial mucosa and the tongue. No other lesions are noted elsewhere during the evaluation. Given this patient’s presentation, which condition is most likely? (NOTE: OMFS curriculum)
A. Cat scratch disease
B. Herpangina
C. Hand, foot, and mouth disease
D. Acute herpetic gingivostomatitis
D. Acute herpetic gingivostomatitis
The patient’s age and clinical presentation most align with acute herpetic gingivostomatitis. There are no reported lesions on his hands or feet, which rules out hand, foot, and mouth disease. Herpangina will most commonly present with lesions on the pharynx and tonsils, not the mucosa. Cat scratch disease will present with cervical lymphadenopathy, but not with any oral lesions.
A 14-year-old girl with maxillary hypoplasia and mandibular hyperplasia and a resulting severe class III malocclusion presents to your office with her parents reporting that she wants corrective jaw surgery. You, the patient, and the patient’s family agree to schedule the surgery as soon as possible, but given the patient’s young age and her mandibular hyperplasia, you are concerned that her future growth could lead to a relapse of the planned mandibular setback. The patient’s parents are nervous about any unnecessary radiation and seem displeased when you suggest a hand-wrist radiograph to help assess the patient’s future growth, so you decide to use her serial cephalometric imaging to assess her C-spine score. You note that the C2, C3, and C4 vertebrae have pronounced concavities on the inferior border that do not appear changed from the previous lateral cephalometric radiograph. You also note that the vertebrate of C3 and C4 have lengthened vertically and are becoming more like vertical rectangles when compared with the previous lateral cephalometric radiograph. What is this patient’s likely C-spine score, and what is your decision on surgical timing? (NOTE: OMFS curriculum)
A. Stage 2: Delay surgery.
B. Stage 3: Delay surgery.
C. Stage 4: Delay surgery.
D. Stage 5: Proceed with surgery.
E. Stage 6: Proceed with surgery.
E. Stage 6: Proceed with surgery.
The C-spine score described in this clinical scenario is most consistent with stage 6, or the final stage of cervical spine maturation. There is a general trend of deepening concavities along the inferior border of the C2, C3, and C4 vertebrae, and the vertebrae will transition from wedges to horizontal rectangles to vertical rectangle-shaped vertebrae. In the final stage, when adolescent growth is essentially complete, the C2, C3, and C4 vertebrae will have pronounced inferior borders, and C3 and C4 will start to take on a more square or vertical rectangular shape. This signals the completion of adolescent growth, which means that continued mandibular growth altering surgical outcomes is unlikely. Proceeding with surgery is therefore a reasonable decision.
While analyzing a patient for orthognathic surgery, you note that the patient’s genial region is deficient clinically. What cephalometric measurement of the skeletal position of the chin should you use to determine if genioplasty may be indicated for this patient? (NOTE: OMFS curriculum)
A. Wits analysis
B. Holdaway ratio
C. Maxillomandibular (Mx/Md) measurement
D. Andrews analysis
B. Holdaway ratio
The Holdaway ratio measures the position of the labial surface of the lower incisors to the NB line compared with the pogonion of the chin to a line NB. The distance should be equal; if not, genioplasty may be indicated. The Wits analysis determines the anteroposterior position of the jaws relative to one another. Mx/Md compares relative position and size. The Andrews analysis determines the esthetic position of the maxilla using forehead angulation and upper incisor angulation.
A 24-year-old man presents to your office with concerns about the appearance of his jaws and chin line. He feels like everything below his nose is “too prominent.” You perform the appropriate imaging and radiographic studies to assess the position of the jaws and find him to have a proper class I occlusion. You also perform two lateral cephalometric tracings and analyses, which reveal that the jaws are in clinically acceptable positions with no overt signs of prognathism. On the lateral cephalometric radiograph, you note that the soft tissues on the lips and overlying the chin are thicker than usual. Looking at your clinical photos, you see that the upper and lower lips extend anterior to the area demarcated by a line through the nasal tip and soft tissue pogonion as well as a line through the subnasal and soft tissue pogonion. What are you using to assess the soft tissue positioning? (NOTE: OMFS curriculum)
A. Subnasale vertical
B. S-line (Steiner analysis)
C. Riedel plane
D. Z-line (profile line of Merrifield)
E. Burstone-Ricketts triangle
E. Burstone-Ricketts triangle
The Burstone-Ricketts triangle includes the Ricketts E-line, which goes from the nasal tip to the soft tissue pogonion, and the Burstone Line, which connects the subnasale with the soft tissue pogonion. These two lines in combination with the columella form a triangle in which the upper and lower lips should reside in a normal population. The upper lip should be slightly anterior to the lower lip. All the remaining measures are single lines and do not outline an area.
A 65-year-old woman presents to your office 1 year after an “all-on-4” placement of zygomatic implants. She reports that in the past few weeks she has experienced several episodes of moderate sinus pressure and rhinorrhea. She has also experienced multiple headaches. How would you initially manage this patient? (NOTE: OMFS curriculum)
A. Provide supportive care.
B. Prescribe augmentin, guaifenesin, and pseudoephedrine HCl.
C. Refer the patient to an otolaryngologist for possible sinus exploration and surgery.
D. Remove the implants.
B. Prescribe augmentin, guaifenesin, and pseudoephedrine HCl.
In patients with acute allergy or sinus infection after integration of zygomatic implants, simple oral measures are a reasonable first-line treatment. Guaifenesin is useful for thinning the mucosa. Pseudoephedrine HCl decreases edema within the mucosa. Augmentin is used for antibiotic coverage. Levaquin may be prescribed for recurrent infections or episodes that do not resolve. This patient requires more than just supportive care. The zygomatic implant is generally well tolerated by the sinus and is rarely the cause of sinus infection. There is no indication that the implants need to be removed.
A 46-year-old woman has persistent pain attributable to the bilateral temporomandibular joints (with no limitations in mandibular range of motion) despite rigorous conservative measures and excellent compliance. Arthrocentesis only resulted in transient relief. The patient decides to undergo bilateral temporomandibular joint discectomy. Intraoperatively, significant bleeding is noted immediately after excising the disc from its posterior attachments. What is likely the source of the bleeding? (NOTE: OMFS curriculum)
A. Retrodiscal tissues
B. Deep temporal artery
C. Maxillary artery
D. Middle meningeal artery
E. Pterygoid venous plexus
A. Retrodiscal tissues
The retrodiscal tissues attach to the articular disc posteriorly. This vascular structure can often cause significant bleeding if not thoroughly controlled. The deep temporal arteries are medial and anterior to the retrodiscal tissue area. Bleeding from the maxillary and middle meningeal arteries and the pterygoid venous plexus occurs when the medial boundaries are violated.
An 11-month-old boy with sagittal suture craniosynostosis is brought to your office by his parents for a consultation about repair. What treatment do you recommend? (NOTE: OMFS curriculum)
A. Physical therapy and repositioning instructions (“tummy time”)
B. Endoscopic sagittal suturectomy with barrel stave osteotomies and postoperative orthotic molding
C. Strip craniectomy
D. Sagittal suturectomy and posterior cranial vault reconstruction
E. Sagittal suturectomy with fronto-orbital advancement and anterior cranial vault reconstruction
D. Sagittal suturectomy and posterior cranial vault reconstruction
Patients with scaphocephaly and sagittal suture craniosynostosis may be treated with one of two typical treatments: (1) endoscopic sagittal suturectomy, barrel stave osteotomies, and postoperative head molding with an orthotic device; or (2) sagittal suturectomy and posterior cranial vault reconstruction. Because the patient is older than the age at which a good outcome can be expected from an endoscopic approach, formal posterior vault reconstruction is the only reasonable choice.
71-year-old man with DM type 1 and a recent history of right maxillary sinus symptoms is referred to you for extraction of tooth #2. During your evaluation, you notice necrosis of the soft tissue and bone in the right maxilla. Surgically, you debride the area and remove several teeth. The specimen that you send to pathology returns with the result of irregular, wide, fungal hyphae with frequent right-angle branching. What is your diagnosis? (NOTE: OMFS curriculum)
A. Aspergillosis
B. Candidiasis
C. Actinomycosis
D. Mucormycosis
D. Mucormycosis
Knowledge of the hyphae branching patterns is critical to answer this question. Mucormycosis has nonseptate, irregular, wide fungal hyphae with right-angle branching. Actinomyces are gram-positive filamentous or rod-shaped bacteria. Aspergillus has septae that branch at acute angles. Candida grows as a yeast, an elongated form without hyphae, and true hyphae with septa form.
A 28-year-old man with a muscular build who has a history of deep vein thrombosis and pulmonary embolism is scheduled for a surgically assisted rapid palatal expansion in the office with deep sedation. The patient’s warfarin is discontinued before the surgery. During the administration of the anesthetic, the patient develops a laryngospasm. Positive pressure ventilation is unsuccessful in breaking the spasm. As the oxygen saturation drops to 80%, a low dose of succinylcholine is administered, and the patient is able to be ventilated. Spontaneous respirations return, and the procedure is completed. In the recovery area, the patient is unable to maintain his oxygen saturation above 88%. What is the most likely cause of the decreased oxygen saturation? (NOTE: OMFS curriculum)
A. Residual sedation
B. Postobstructive pulmonary edema
C. Pulmonary emboli
D. Pneumothorax
B. Postobstructive pulmonary edema
This is a presentation of postobstructive pulmonary edema, which has been classically described in athletic patients. The patient who develops an upper airway obstruction attempts to overcome the obstruction by increasing respiratory effort. When the upper airway obstruction cannot be overcome with increased respiratory effort, the increased negative intrathoracic pressure causes an increase in venous return. This results in a hydrostatic pressure gradient between the intravascular and extravascular compartments, leading to pulmonary edema. A manifestation of pulmonary edema is a reduction in oxygen saturation.
A 27-year-old patient presents to your office for removal of a surgical splint 4 weeks after undergoing a maxillary advancement. Upon removal of the splint, you discover a 5-mm unplanned unilateral posterior open bite on the right side. What is the initial treatment step for this patient? (NOTE: OMFS curriculum)
A. Place elastics, and follow the patient closely.
B. Remove the posterior plate and possibly the anterior plate on the right, and use elastics.
C. Bring the patient back to surgery to correct the malocclusion.
D. Monitor the patient closely to follow the self-correction of the open bite.
A. Place elastics, and follow the patient closely.
Although it may be necessary to remove the plates in the office or take the patient back to surgery, it is possible to correct the open bite with elastic traction. If elastics fail to correct the malocclusion, plates should be removed and elastics reapplied. If the malocclusion is severe or if the first two options are unsuccessful, it may be necessary to take the patient back to the operating room.
You are examining a 3-month-old boy who has rotation of the head to the right along with an increased tension of the right sternocleidomastoid (SCM) muscle that is consistent with congenital muscular torticollis (CMT). This patient is at risk for which condition? (NOTE: OMFS curriculum)
A. Midface hypoplasia
B. Deformational plagiocephaly
C. Unicoronal craniosynostosis
D. Lambdoid craniosynostosis
B. Deformational plagiocephaly
A patient with CMT will have overactivation of the SCM. At mild degrees, this restriction will cause an infant to have the head turned in a constant direction when lying supine. This causes a constant deformational force that ultimately molds the head into a deformational plagiocephalic condition. Craniosynostosis is an intrauterine event, and as such, it is extremely unlikely to have synostosis develop after birth regardless of whether the patient has CMT or not. Patients with more severe forms of CMT not only have deformational abnormalities of head shape because of supine sleeping problems, but they also have cranial base abnormalities secondary to the pull of the SCM on the mastoid process. The downstream effects can cause facial asymmetries; however, midface hypoplasia is not one of the primary outcomes.
A 35-year-old woman presents to your office for consultation regarding surgical treatment for her obstructive sleep apnea (OSA). She relates a history of excessive daytime sleepiness, nonrefreshing sleep, HTN, and type II DM. A physical examination shows a morbidly obese woman (BMI is 40 kg/m²) with mandibular retrognathia and normal temporomandibular joint (TMJ) function. She recently underwent a sleep study, which showed severe OSA (apnea-hypopnea index was 85). After the sleep study, the patient was prescribed continuous positive airway pressure (CPAP) therapy, but she was unable to tolerate it, even after 3 months of trying various modifications to improve her compliance. What treatment recommendation would you provide to this patient? (NOTE: OMFS curriculum)
A. Continue current therapy with CPAP.
B. Use an oral appliance (OA).
C. Obtain a consultation for bariatric surgery.
D. Undergo maxillomandibular advancement (MMA) surgery.
E. Undergo hypoglossal nerve stimulation (HNS).
C. Obtain a consultation for bariatric surgery.
With a BMI of 40 kg/m², the patient may be a candidate for bariatric surgery, likely as an initial surgical procedure, and thus a consultation with a bariatric surgeon would be indicated. Consideration for other surgical procedures (MMA or HNS) would occur after treatment of severe morbid obesity if the patient continues to have OSA. Continuation of CPAP is not a treatment option because the patient has failed CPAP. The patient is not a good candidate for an OA because OAs are more effective in less obese patients with mild-to-moderate OSA.
A 35-year-old woman at 20 weeks’ gestation comes to your office for evaluation after an ultrasound reveals a diagnosis of cleft palate for the fetus. The patient reports that she had been taking valproic acid for a diagnosis of epilepsy but she has since discontinued that medication. In addition, she states that she was not ready for pregnancy and has been anxious, leading her to continue habits such as alcohol consumption and tobacco use. She also reports she has not been taking prenatal vitamins. Which factor in this patient’s history placed her at highest risk for having a child with an isolated cleft palate? (NOTE: OMFS curriculum)
A. Maternal exposure to tobacco smoke
B. Ethanol
C. Folic acid deficiency
D. Valproic acid
A. Maternal exposure to tobacco smoke
Maternal exposure to tobacco smoke has been reported as the teratogen agent with the strongest risk factor for isolated cleft palate. Although other agents have been associated with the development of cleft palate, such as the use of valproic acid, folic acid deficiency, ethanol, excess of vitamin A, poor nutrition, and viral infections, maternal exposure to tobacco smoke is the factor that places the fetus at highest risk.
ou are called to see a patient with an upper eyelid avulsion. Upon examination, you see that it is a partial-thickness defect and you need to determine if the wound can be closed primarily or if it needs to be grafted. What percentage of tissue loss makes it unlikely that you will be able to close the wound primarily? (NOTE: OMFS curriculum)
A. 10%
B. 20%
C. 30%
D. 40%
E. 50%
E. 50%
This is not a closed number, and clinical aspects such as patient age and tissue conditions will play an important role in the final decision, but a wound with a 50% loss of tissue is usually not amenable to primary closure.
A 10-month-old girl who underwent surgery to treat a large complete bilateral cleft palate is brought to the 3-month follow-up visit by her parents. They ask you if her speech will be normal or if she will require additional surgery. What should you explain to the parents about detecting velopharyngeal insufficiency (VPI) after palatal repair surgery? (NOTE: OMFS curriculum)
A. VPI can be properly assessed in toddlers 3 months after primary palatal repair, and if it is present, it should be addressed as soon as possible to decrease the risk of compensatory misarticulations.
B. Cleft-related VPI is typically diagnosed after 3 years of age or when a child has adequate word inventory to provide a diagnostic speech sample.
C. When primary cleft palate repair is completed before 12 months of age, patients present with a higher risk of compensatory misarticulations than can confound the diagnosis of VPI.
D. Patients with VPI after primary palatoplasty present with a palatal fistula, making the diagnosis clinically obvious.
B. Cleft-related VPI is typically diagnosed after 3 years of age or when a child has adequate word inventory to provide a diagnostic speech sample.
The diagnosis of VPI is based on perceptual speech assessment and evidence of incomplete velopharyngeal closure. VPI cannot be readily assessed in most toddlers because of their inadequate word inventory and the subsequent inability of the OMS to get an adequate speech sample. In addition, at least 6 months of palatal healing should be allowed before additional surgery is considered. Patients undergoing palate repair before 12 months of age have a lower risk of compensatory misarticulations. Not all patients with VPI have a palatal fistula, and a palatal fistula is not always associated with VPI.
A 9-year-old boy who sustained a right condylar fracture yesterday is referred to your office. He has a 3-mm open bite on his left side. The condylar fragment is moderately displaced out of the fossa. He has no other injuries and is healthy. How would you manage this patient? (NOTE: OMFS curriculum)
A. Soft diet and exercise
B. Closed reduction with 2 weeks of maxillomandibular fixation (MMF)
C. Open reduction and internal fixation (ORIF) of the condyle
D. Application of MMF appliances, training elastics, and full function
E. Closed reduction with 4 weeks of MMF
D. Application of MMF appliances, training elastics, and full function
Application of MMF appliances, training elastics, and full function is the treatment currently favored by surgeons. The patient has a malocclusion, which will not be managed with a soft diet. Closed reduction with 2 or 4 weeks of MMF is a dated treatment. Condylar ORIF is rarely indicated in children.
A 62-year-old woman presents to your office for surgical evaluation of her severe obstructive sleep apnea (OSA). Her medical history is significant for anxiety and depression, hyperlipidemia, and HTN. Her BMI is 35 kg/m², and her neck circumference is 16 inches (40.6 cm). Compared with a similar person without OSA, which anatomic finding would this patient most likely have? (NOTE: OMFS curriculum)
A. Significantly more lateral pharyngeal wall collapse
B. High hyoid position
C. Bimaxillary protrusion
D. Increased upper airway volume
E. Incompetent internal and external nasal valves
A. Significantly more lateral pharyngeal wall collapse
People with OSA tend to have a greater amount of lateral pharyngeal wall collapse, which contributes to nocturnal obstruction during deep sleep. The other anatomic findings would tend to lead to an increase in upper airway volume and a decrease in upper airway obstruction during deep sleep.
A 44-year-old man presents to the clinic reporting swelling on the left side of his neck. The patient states the swelling has been present for 2 weeks, has slowly enlarged, and is occasionally mildly tender. He reports having a fever of 100 ºF (37.7 ºC) and throat pain 2 days before the swelling became visible. He denies any trouble breathing or swallowing. The patient also denies any medical problems and states that he is not on any medications and has no allergies. A physical examination reveals a 3 × 3-cm sessile nodule of the left neck in level IIA. It is nontender to palpation and has no overlying skin changes. It is soft, and upon manipulation, it is not fixed. What is the next step in the management of this patient? (NOTE: OMFS curriculum)
A. Aspirate the lesion, and send it for culture and flow cytometry.
B. Order CT of the neck with contrast.
C. Perform flexible nasopharyngoscopy.
D. Schedule the patient for an open biopsy.
E. Send the patient for a fine-needle aspiration biopsy (FNAB).
C. Perform flexible nasopharyngoscopy.
Flexible nasopharyngoscopy should be part of the physical examination of all unknown neck masses and should be performed before any invasive diagnostic procedures or advanced imaging. It can provide valuable information and help guide the diagnostic process. Cultures would be sent if an infectious process was suspected, and flow cytometry would be sent if a hematologic malignancy such as lymphoma was suspected. Imaging studies of the mass are certainly warranted; however, they would be done after a thorough physical examination. CT, MRI, ultrasonography, angiography, plain films, and positron emission tomography are all possibilities, depending on the type of lesion suspected or seen on physical examination. An open biopsy may be necessary later in the diagnostic process; however, a thorough physical examination, noninvasive diagnostic studies (ie, endoscopic examination), advanced imaging, and, possibly, FNAB should all be done before this.
A 50-year-old woman comes to your office with concerns about her smile, “long-face,” and anterior open bite. She has been in orthodontic treatment for the past 8 months and feels she is ready for surgery. You evaluate the patient with the appropriate measurements and imaging and determine that she has relative anteroposterior maxillary hypoplasia with vertical maxillary excess with a gummy smile, a steep mandibular plane angle with premature posterior occlusion, and an anterior open bite. You also note that she has a particularly steep forehead. You use the Andrews 6 elements of orofacial harmony philosophy to plan the maxillary advancement. What will be the main determinant as to the amount of advancement you plan to perform? (NOTE: OMFS curriculum)
A. 1 mm posterior to the forehead anterior limit line (FALL)
B. Maxillary tooth show at repose
C. Goal anterior limit line (GALL)
D. Andrews element I
E. Andrews element V
In the Andrews 6 elements analysis, element II is concerned with the proper placement of the jaws in the anteroposterior dimension. The measurement in question is the GALL, which is a function of the FALL. The ideal maxillary position in an Andrews element II maxilla is for the facial surface of the most anterior maxillary central incisor to coincide with the GALL. The GALL is determined by the angle the forehead makes with the FALL. In a patient with a steep forehead or a large angle between the forehead inclination and the FALL, the GALL will be further anterior. The most anterior the GALL can be is up to the true vertical line that goes through the soft tissue glabella. Therefore, when a patient has a steep forehead angle, it is likely that the GALL will coincide with the glabella. There are times where the FALL and GALL are equal; however, placing the jaws 1 mm behind the FALL would not be ideal. Andrews element I addresses the proper orientation of the teeth within the alveolus. Andrews element V involves the optimal chin prominence based on the inclination of the lower incisors and the ideal occlusal plane.
An 18-year-old athletic woman with asthma presents for the removal of four impacted third molars. She receives a general anesthetic consisting of midazolam, fentanyl, and propofol with 50% nitrous oxide and 50% oxygen administered via a nasal hood. The patient’s oxygen saturation is noted to have decreased from 99% to 92% after the extraction of the second tooth. The surgeon opts to discontinue nitrous oxide and administer 100% oxygen via the nasal hood. The surgeon continues with the procedure without interruption but then notes that the patient’s saturation continues to decrease to 87%. Her mouth is suctioned, the pharyngeal curtain is removed, and the pharynx is suctioned. Her chest is auscultated without audible wheezing. Oxygen 100% is administered via a face mask. Ventilation is achieved with ease. The patient is subsequently intubated after the oxygen continues to decrease. Ventilation is again achieved with ease. Albuterol is administered via the endotracheal tube. The patient develops ventricular fibrillation. Emergency intervention is provided, but the patient is not resuscitated. What is the most likely contributing factor in this patient’s outcome? (NOTE: OMFS curriculum)
A. The patient experienced a bronchospastic episode that was refractory to intervention.
B. The patient had undiagnosed hypertrophic cardiomyopathy.
C. The patient’s oxygen line lacked an oxygen sensor.
D. The patient underwent esophageal intubation.
C. The patient’s oxygen line lacked an oxygen sensor.
Anesthetic and surgical gas lines are frequently hidden within walls, delivering the gases from a central storage area to each operatory. It may be assumed that the lines are plumbed correctly because there are various regulations designed to ensure such; however, it is ultimately the surgeon’s responsibility to ensure that the lines are functioning correctly. When office renovations are made, it is important to verify that the gas lines are plumbed accurately. This can be done by tracing the line from the central reserve to each operatory. Because oxygen is the most critical of these gases, correct oxygen line plumbing may alternatively be verified by inserting an oxygen sensor at the oxygen outflow in each operatory. All anesthetic machines used in a Joint Commission operating facility have oxygen sensors incorporated into the machine; however, most oral and maxillofacial surgery (OMS) office anesthetic units lack an oxygen sensor. The lack of an oxygen sensor is not inappropriate in open airway anesthesia, which is typical in most OMS offices, but it should be used when advanced airways (eg, laryngeal mask airways, endotracheal tubes) are used. Therefore, in an OMS office using an open airway anesthetic technique, an oxygen sensor need not remain fixed within the oxygen line. The decrease in oxygen in this patient started before intubation, so esophageal intubation is not likely to be the contributory factor. Undiagnosed hypertrophic cardiomyopathy can contribute to sudden death. An increase in cardiac contractility can worsen outflow, resulting in decompensation and ventricular arrhythmias. Respiratory compromise is usually not the initial manifestation. A bronchospastic event can cause deteriorating oxygen saturation. However, the patient was not wheezing, and ventilatory efforts were achieved with ease. The more common potential etiologies are not consistent with the presentation. Most OMS offices will not experience an event like this, but it has happened. When a major event occurs, it impacts not only the patient but also the doctor and the staff. In a 2012 survey conducted by the American Society of Anesthesiologists, 70% of practitioners said they experienced guilt and reliving of the event, 80% required time to recover emotionally, 19% never fully recovered, and 12% considered a career change.
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
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.
A resident from the NICU pages you for a consult on a 2-day-old boy with an incomplete unilateral cleft lip and palate and no other facial or body anomalies. The mother of the child is at the bedside and asks you about the possibility of her child having an associated syndrome. What is this baby’s chance of having a syndrome associated with a unilateral isolated cleft lip and palate? (NOTE: OMFS curriculum)
A. 20%
B. 10%
C. 30%
D. 50%
E. 70%
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.
A 30-year-old man presents to you for a progress check to prepare for his upcoming orthognathic surgery. He has been in orthodontic treatment for the past 4 months. He initially presented to you with a mild class III malocclusion and a concave facial profile. Your initial workup demonstrated an SNA angle of 79º and an SNB angle of 84º. His lower incisors appeared retroclined at his first presentation with an L1 to NB measurement of 2 mm, which indicated that his mild class III malocclusion is partially masked by a dental compensation. At his current visit, you notice similar SNA and SNB measurements on the lateral cephalometric radiograph, but because the orthodontist has been improving the lower incisor position, you also notice that the L1 to NB measurement is now about 4 mm. What cephalometric analysis are you using here? (NOTE: OMFS curriculum)
A. Wits appraisal
B. McNamara analysis
C. Steiner analysis
D. Sassouni analysis
E. Andrews 6 elements
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.
The ED contacts you about a 32-year-old woman who presented with a 2-day history of painful ulcerations on her palate. She states she had a fever of 102 ºF (38.8 ºC) overnight. She reports that she has not been able to eat secondary to pain and feels a “painful bump” in her upper neck under her jawline. She also reports having a nosebleed the day before as well as waking up coughing blood, which is what prompted the visit to the ED. The ED physician ordered a complete blood count, which showed a WBC count of 12 ×109/L with 60% polymorphonuclear leukocytes. The patient has a blood pressure of 160/101 mm Hg, HR of 95 beats/min, and oxygen saturation of 99%. The patient states she was recently diagnosed with rheumatoid arthritis for which she takes NSAIDs. What is the next step in treatment? (NOTE: OMFS curriculum)
A. Prescribe magic mouthwash because the patient likely has aphthous stomatitis.
B. Order a CT scan with contrast to evaluate for possible oral cancer.
C. Obtain a fine-needle aspiration biopsy (FNAB) of the neck lesion.
D. Perform renal function testing.
E. Consult with the infectious disease team, and place the patient in isolation.
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.
A 17-year-old girl with a history of mandibular prognathism, class III dental malocclusion, and concave facial profile presents to you for follow-up after her bilateral sagittal split osteotomy (BSSO) that was completed 6 months prior. Upon evaluation, you note significant, progressive malocclusion. You suspect hardware failure and explain to the patient that to correct her malocclusion, she will need a reoperation. She is upset and reminds you she does not want to be wired shut. Intraoperatively, after removing the prior bone plates and screws and debride the area, you note a large bony defect bilaterally with the inferior border of the mandible intact. However, you realize the amount of bone available would not allow for a new application of fixation of bilateral mandibular segments. What is your next step? (NOTE: OMFS curriculum)
A. Abort the procedure, and discuss with the patient the possibility of completing an intraoral vertical ramus osteotomy (IVRO) in the future.
B. Place the patient into maxillomandibular fixation (MMF) without redoing a mandibular osteotomy.
C. Place weak bone plates/screws.
D. Perform an IVRO with MMF.
E. Perform an IVRO without MMF.
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.
A patient is to undergo a coronectomy for tooth #32. What is the recommended flap closure for this patient? (NOTE: OMFS curriculum)
A. Bone wax over the residual root plus primary closure
B. Flap left open to facilitate drainage
C. Primary watertight closure with or without periosteal release
D. Simple closure with a single suture at the distal part of the second molar (standard third molar closure)
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.
A patient presents to you requesting treatment with neurotoxin injections to her crow’s feet. She has had previous neurotoxin injections to the forehead and glabella with excellent results. On examination, you see moderate superior, middle, and inferior crow’s feet bilaterally. You discuss the risks and benefits of the treatment, and she asks about the most common risk of neurotoxin injection in the crow’s feet area. What do you tell her? (NOTE: OMFS curriculum)
A. Lid ptosis associated with diffusion to the levator palpebrae muscle
B. Bruising associated with injury to the sentinel vein
C. Eyebrow position asymmetry associated with diffusion to the frontal branch of cranial nerve VII
D. Injection site infection
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.
A 57-year-old healthy woman with edentulous site #4 (extracted 2 years ago) and a nonrestorable tooth #5 presents to your office with a referral for extraction of tooth #5 and implants at sites #4 and #5. On imaging, the patient has 4 mm of bone in vertical height, but the ridge is 3 mm wide. Both sites have adequate keratinized soft tissue. The patient wants teeth at the time of implant placement. How do you manage this patient? (NOTE: OMFS curriculum)
A. Schedule the patient for extraction of #5 and immediate placement of implants in sites #4 and #5 with provisionalization.
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.
C. Schedule the patient for extraction of tooth #5 and placement of implants at sites #4 and #5, but explain to the patient this will be completed in two stages.
D. Schedule the patient for a sinus lift, and then extract #5 and place both implants after the sinus lift heals.
E. Extract #5, and send the patient to a prosthodontist for the fabrication of a tooth-borne bridge.
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.
You are repairing the palate of an 11-month-old infant. During the repair, intravelar veloplasty will involve which of the following? (NOTE: OMFS curriculum)
A. Posterior positioning of the tensor veli palatini muscle for the purpose of speech
B. Development of a superior pharyngeal constrictor flap to insert into the soft palate
C. Injection of autologous fat into the soft palate to aid in speech
D. Posterior repositioning of the levator veli palatini for the purpose of speech
E. Raising and insetting palatopharyngeal myomucosal flaps to the posterior pharynx
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.
On your initial evaluation of a newborn baby girl, you determine she has an isolated cleft palate. The parents ask you if their child is at risk for other anomalies. What do you tell them is the most common congenital disorder their child is at risk for? (NOTE: OMFS curriculum)
A. Heart defect
B. Polydactyly
C. Hydrocephaly
D. Urinary tract defect
E. Deformations
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.
A 19-year-old woman presents to your office stating, “I don’t like the shape of my nose.” The patient has a dorsal hump and a deficient tip, which is also slightly broad. In addition to reducing the hump with appropriate reduction and osteotomies, you complete interdomal and transdomal suturing to improve tip definition and projection. You feel grafting is unnecessary and redrape the skin for the final inspection. Comparing the immediate postoperative result with clinical photographs, you notice that the patient no longer has a natural esthetic tip-defining point. What maneuver needs to be accomplished properly to improve this outcome? (NOTE: OMFS curriculum)
A. Interdomal suturing with horizontal mattress sutures
B. Transdomal suturing with vertical mattress sutures
C. Placement of a longer columellar strut
D. Placement of an onlay tip graft
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.
A 75-year-old man presents to your office reporting that he is unable to wear a mandibular denture. His referring dentist believes he may benefit from a skin graft vestibuloplasty/floor of the mouth lowering procedure. What would be your technique for recipient site preparation and graft inset? (NOTE: OMFS curriculum)
A. Full-thickness mucoperiosteal flap elevation and exposure of the mandibular ridge; inset of a split-thickness skin graft with the dermis side down in contact with the mandibular ridge; and application and fixation of an acrylic splint
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
C. Full-thickness mucoperiosteal flap elevation and exposure of the mandibular ridge; inset of a split-thickness skin graft with the dermis side up in contact with the mandibular ridge; and application and fixation of an acrylic splint
D. 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 up in contact with the mandibular periosteum; and application and fixation of an acrylic splint
E. 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 without the application of an acrylic splint
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.
A 58-year-old woman presents for consultation after undergoing an incisional biopsy of a mixed radiopaque/radiolucent lesion of the anterior maxilla. A diagnosis of desmoplastic ameloblastoma is confirmed. Treatment should be most similar to the treatment of what other lesion? (NOTE: OMFS curriculum)
A. Odontogenic keratocyst
B. Odontoma
C. Follicular ameloblastoma
D. Intraluminal unicystic ameloblastoma
E. Peripheral ameloblastoma
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.
An 8-year-old boy with Crouzon syndrome is brought to your office by his parents for a surgery consultation. He has normal intercanthal distance, the supraorbital ridge is posterior to the cornea on a profile view, the middle third is deficient, and the occlusion is class III with a bilateral posterior crossbite. The parents ask about surgical options they have researched, including Le Fort III osteotomy, monobloc, and facial bipartition. Which of these techniques is the best option for this patient? (NOTE: OMFS curriculum)
A. Le Fort III because it offers less risk as it is an extracranial technique
B. Le Fort III because it offers better control of the occlusion
C. Monobloc because it will address the position of the supraorbital ridge along with the midface deficiency
D. Monobloc because the nasal deformities are better addressed with this technique
E. Facial bipartition because it will expand the maxilla and correct the crossbite
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.
A 42-year-old woman presents to your office for evaluation and management of a calcifying epithelial odontogenic tumor (CEOT) of the right mandibular body. The tumor is 5 × 3.2 cm, and bony cortices remain intact. What is the appropriate surgical intervention for this patient? (NOTE: OMFS curriculum)
A. Observation
B. Enucleation
C. Enucleation with peripheral ostectomy
D. Enucleation with the application of 5-fluorouracil (5-FU)
E. Resection
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.
After you harvest a paramedian forehead flap measuring 1 × 7 cm, you note tension between the skin incisions of the forehead donor site. How do you close the donor site defect? (NOTE: OMFS curriculum)
A. Undermine the forehead in the subperiosteal plane to allow for skin advancement and primary closure.
B. Allow healing by secondary intention.
C. Place a skin graft in the donor site defect.
D. Undermine the skin of the forehead in the subgaleal plane and close primarily.
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.
A 33-year-old patient in good general health is seen in consultation for a possible coronectomy on tooth #32. The tooth has been symptomatic, with intermittent, severe localized pain in the area. Panoramic radiography exhibits root narrowing and diversion of the superior aspect of the mandibular canal. The tooth also exhibits caries extending into the pulp. How should treatment proceed? (NOTE: OMFS curriculum)
A. Perform a coronectomy procedure.
B. Obtain cone-beam CT (CBCT), and proceed with coronectomy if CBCT confirms a high risk of paresthesia with extraction.
C. Obtain CBCT for further risk assessment and surgical planning, and then proceed with the extraction.
D. Prescribe antibiotics, and monitor the patient at 6-month intervals.
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.
A 42-year-old woman presents to your office for assessment of rhytids. You note Glogau 3 horizontal forehead rhytids and vertical glabellar lines. She also presents with bilateral superior lid dermatochalasis. Her brow position is measured bilaterally at 0 mm for the medial brow, 4 mm for the apex, and 6 mm at the tail of the brow. How would you counsel the patient with respect to neurotoxin injection for her horizontal and vertical horsehead lines? (NOTE: OMFS curriculum)
A. Recommend neurotoxin treatment for the glabellar lines only.
B. Recommend neurotoxin treatment for the horizontal forehead lines.
C. Recommend neurotoxin treatment for the glabellar lines and the horizontal forehead lines.
D. Recommend no neurotoxin treatment in this patient.
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.
A 15-month-old girl presents for evaluation of head shape abnormality. An outside CT scan reveals unicoronal, sagittal, and left lambdoid craniosynostosis. The family notes that she has had regression of potty training, difficulty feeding herself with a spoon, difficulty walking, and head banging behavior. What is a fundoscopic examination by an ophthalmologist likely to reveal? (NOTE: OMFS curriculum)
A. Macular degeneration
B. Papilledema
C. Retinal deterioration
D. Strabismus
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.
After you remove the third molars of a patient under an IV anesthetic (midazolam, fentanyl, and propofol), you note that the patient remains obtunded and responds only to painful stimulation. The patient is making snoring noises, and you need to pull the tongue forward to maintain an end-tidal CO2 curve. What is the next step in management? (NOTE: OMFS curriculum)
A. Continue to observe the patient.
B. Give 50% dextrose.
C. Administer flumazenil.
D. Call 911.
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.
A 45-year-old man presents to your clinic for evaluation of an enlarging swelling below his left earlobe. He reports that it has been present for about 6 months, but in the last 2 weeks it has begun to enlarge. He reports no pain, fevers, or hearing deficit. His only other report is that he has recently started drooling on that side of his mouth. The patient has a history of type 2 DM, HTN, and hyperlipidemia. He also states that he has smoked 1 pack a day for the last 20 years. A physical examination reveals a 4 × 3-cm sessile nodule just inferior to the left ear lobule. The mass is firm to palpation and is immobile. There are no overlying skin changes, and the nodule is not tender to palpation. What is the next step in the evaluation and management of this mass? (NOTE: OMFS curriculum)
A. Resection of the lesion via extracapsular dissection with intraoperative frozen sections
B. CT scan with contrast of the face and neck
C. Fine-needle aspiration biopsy (FNAB) of the mass
D. Superficial parotidectomy with ipsilateral selective neck dissection
E. Full body positron emission tomography (PET)/CT scan
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.
As you are evaluating a patient with a cleft nasal deformity, you note deviation to the dorsum and associated internal nasal valve dysfunction. The patient also has poor tip projection and alar collapse because of hypoplasia of the lower lateral cartilage. The patient and the patient’s parents elect not to use rib cartilage for structural grafting, so you will harvest cartilage from the nasal septum. After opening the nose and performing a wide dissection, you note a deviated dorsal septum causing dorsal deformity, poor tip support, and a very hypoplastic lateral crus. You have sufficient septal cartilage to fashion a lateral crural strut graft and a spreader graft; however, there is not sufficient cartilage quantity and rigidity to fashion a columellar strut graft to adequately increase tip support and projection. How can this problem be managed? (NOTE: OMFS curriculum)
A. Use the lateral crural strut graft to improve tip support and projection.
B. Harvest ear cartilage to fashion a columellar strut graft.
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.
D. Place a tip shield graft with the remaining cartilage.
E. Reduce the nasal dorsum so the relative tip projection is appropriate.
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.
A 72-year-old man with a diagnosis of trigeminal neuralgia of the left V3 with triggers on the left mentum and labial gingiva cannot tolerate carbamazepine, gabapentin, or baclofen and is seeking a surgical solution. What surgical treatment would you recommend if there are no contraindications from his medical history? (NOTE: OMFS curriculum)
A. Microvascular decompression (MVD)
B. Neurectomy of the left inferior alveolar nerve
C. Chemical neurolysis of the left mental nerve
D. Alcohol block of the left Gasserian ganglion
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.
A patient presents to your office for evaluation for orthognathic surgery. After you conduct your clinical examination and take measurements, you obtain cephalometric film and perform a cephalometric analysis. You note the sella-nasion-A (SNA) angle is 75º and the sella-nasion-B (SNB) angle is 89º. Based upon the cephalometric measurements alone, what is the most likely skeletal diagnosis? (NOTE: OMFS curriculum)
A. Maxillary hyperplasia and mandibular hypoplasia
B. Normal maxilla and mandibular hyperplasia
C. Maxillary hypoplasia and mandibular hyperplasia
D. Maxillary hyperplasia and mandibular hyperplasia
E. Maxillary and mandibular asymmetry
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.
A 24-year-old man sustains bilateral condyle and symphysis fractures in a fall. What is your primary concern for this patient? (NOTE: OMFS curriculum)
A. Acquired retrognathism, an open bite, and a widened face
B. Ankylosis
C. Permanent paresthesia
D. Midline discrepancy
E. Malocclusion
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.
What is the most important consideration when planning a vestibular incision for a Le Fort I osteotomy in a patient with a previously repaired unilateral complete cleft lip and palate? (NOTE: OMFS curriculum)
A. Use of a segmental vestibular incision and tunneling across the maxillary cleft region
B. Adequate vestibular depth in the anterior maxilla to avoid perforating the nasal mucosa
C. Minimal scar tissue in the anterior maxilla to prevent tissue necrosis
D. Restoration of the anterior maxillary bone and soft tissue architecture after alveolar cleft grafting
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.
A 36-year-old man presents to your office reporting excessive daytime sleepiness. He has no bed partner and is uncertain if he snores. He reports being tired on his job as a foreman at a construction site. His BMI is 42 kg/m², and he has a neck circumference of 19 inches (48.3 cm). What is the most appropriate first step to determine if treatment is required for this patient? (NOTE: OMFS curriculum)
A. Friedman score evaluation
B. Drug-induced sleep endoscopy
C. Cephalometric radiograph
D. In-laboratory full-night polysomnogram
E. Upper airway dynamic MRI
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.
A 13-year-old boy with zygomatic hypoplasia presents to your office for treatment. During the examination, you notice a flat middle third, a large nose, and a class III malocclusion. His mandibular position seems to be adequate. The parents want to proceed with surgical reconstruction of the zygomas but are concerned about long-term stability. What is the best treatment approach for this patient? (NOTE: OMFS curriculum)
A. Reconstruct the zygomas because these bones reach maturity by age 7.
B. Wait until the patient reaches complete skeletal maturity, and plan for surgery when he is older than age 18.
C. Perform the zygomatic reconstruction because skeletal maturity is reached after age 7 and the occlusion should be further addressed with orthodontic treatment.
D. Start orthodontic treatment, and plan for the zygomatic reconstruction when the patient is 14 to 15 years old.
E. Plan for orthognathic surgery with the zygomatic reconstruction when the patient is older than age 18.
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
A 60-year-old woman presents to your office to be evaluated for right maxillary posterior alveoloplasty. She had all her maxillary teeth extracted several years ago but never had dentures made, and now her general dentist would like to have alveoloplasty performed in the right maxillary posterior area near the tuberosity to provide a better contour for denture fabrication. Which structure should you consider during your evaluation? (NOTE: OMFS curriculum)
A. Maxillary sinus
B. Nasal floor
C. Orbital roof
D. Inferior alveolar nerve
E. Mental nerve
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.
In preparation for bone grafting a patient’s bilateral maxillary/alveolar cleft, you notice that orthodontic expansion has left quite large bilateral alveolar defects at the bone graft sites. The occlusion is no longer in a crossbite, and the premaxilla is positioned well. You wonder if a single-sided anterior iliac crest will be sufficient to fill the defects completely. What course of treatment best considers the needs of this patient? (NOTE: OMFS curriculum)
A. Add recombinant human bone morphogenetic protein-2 (rhBMP-2) and acellular collagen sponge to expand the graft you plan to harvest from the left anterior ilium.
B. Use all the autogenous graft on one side of the cleft, and return to the operating room 3 months later to graft the other side with the opposite anterior iliac crest as a harvest site.
C. Be prepared in advance for a potential harvest of both sides of the anterior ilium or a posterior iliac crest site.
D. Expand a unilateral anterior iliac crest cancellous graft with allogeneic freeze-dried bone.
E. Expand a unilateral anterior iliac crest cancellous graft with platelet-rich plasma.
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.
A 77-year-old man presents to your office for alveoloplasty of the right lower quadrant 6 months after undergoing extractions. His restorative dentist would like to have a large buccal prominence in the right mandibular canine area removed. After your raise a full-thickness subperiosteal flap, you use a rongeur to remove the buccal bony prominence; however, undercuts remain. What is the next instrument of choice to consider? (NOTE: OMFS curriculum)
A. Extraction forceps
B. Curette
C. Periosteal elevators
D. Bone file
E. Bur on a rotary hand piece
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.
A 28-year-old man is admitted to the ED after an altercation that took place 1 hour before admission. The patient has been evaluated by the trauma and neurology teams, and there is no concern about his neurologic status. A clinical examination shows subconjunctival and periorbital ecchymosis, minimal edema, small dystopia, and limited eye movement. CT shows fractures at the level of left zygomaticofrontal suture, infraorbital rim, and orbital floor, with herniation of orbital contents into the maxillary sinus. What is the best time to treat this patient’s facial fractures? (NOTE: OMFS curriculum)
A. As soon as the patient is admitted to the ED
B. As soon as the patient is discharged by other specialties involved in the initial treatment
C. When the patient is stable and the edema has completely dissolved
D. Between 7 and 21 days after the trauma event
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.
An 18-year-old woman presents to your office with a biopsy-proven adenomatoid odontogenic tumor (AOT) of the anterior maxilla. What is the best treatment option for this patient? (NOTE: OMFS curriculum)
A. Cryotherapy
B. Anterior maxillectomy
C. Enucleation
D. Decompression
E. Intralesional steroid injection
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.
A 25-year-old man who underwent free fibula flap reconstruction of his mandible for a large benign lesion 7 weeks ago presents to your office for follow-up. The patient states that he has just started to walk without his boot, but he is unable to hold his foot up and has decreased sensation on the top of his foot extending into the outer part of the lower leg. What nerve was injured during the fibula harvest? (NOTE: OMFS curriculum)
A. Peroneal nerve
B. Sural nerve
C. Tibial nerve
D. Femoral nerve
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.
A 65-year-old man presents for extraction of remaining mandibular dentition #21 through #27 and alveoloplasty in preparation for future conventional mandibular complete denture fabrication. After you use rongeurs to perform the alveoloplasty, you notice there are still undercuts in the buccal area of #27, so you plan to use a surgical drill with an egg-shaped bur to remove the undercut. You ask your assistant to irrigate while you use the rotary instrument to smooth down the undercut so that you can keep the bone temperature to which level? (NOTE: OMFS curriculum)
A. Under 87ºC
B. Under 100ºC
C. Under 67ºC
D. Under 47ºC
E. Under 75ºC
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.
A 43-year-old woman has been experiencing pain and intermittent locking in her right temporomandibular joint (TMJ) for many years. She has been treated with occlusal splint therapy and muscle-relaxing medications but has found only partial symptomatic relief. She is treated by arthroscopic lysis and lavage, and during the procedure, the surgeon notes that there is intact, avascular cartilage covering the anterior glenoid fossa and the slope of the articular eminence. What does this finding indicate? (NOTE: OMFS curriculum)
A. The articulating surfaces are covered with hyaline cartilage, which is less susceptible to degeneration and has a greater repair capacity.
B. The articulating surfaces are covered with fibrocartilage, which is less susceptible to degeneration and has a greater repair capacity.
C. The articulating surfaces are covered with fibrocartilage, which is more susceptible to degeneration and has a lower repair capacity.
D. The TMJ is not susceptible to degenerative joint disease (osteoarthritis).
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.
A 35-year-old woman presents with three to four severe, debilitating headaches per month. The headaches last 1 to 2 days. They are localized to the right temple, right frontal region, and behind the right eye. There is often rhinorrhea and congestion associated with the headaches. There is no aura. The pain is described as throbbing. She can have nausea but no vomiting. She has to wear sunglasses and go to a quiet room because she “can’t function.” What is the most likely diagnosis? (NOTE: OMFS curriculum)
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.
A 58-year-old woman presents to your office as a referral from her primary care provider for evaluation of a thyroid lesion. The patient initially presented to her provider reporting increasing instances of sweating profusely, “pounding heartbeat,” and anxiety. Suspecting hyperthyroidism, the provider assessed the patient’s thyroid-stimulating hormone (TSH) level, which was 0.1 mIU/L (normal range 0.4-4 mIU/L). The patient was sent for an ultrasound of her thyroid gland, and a single 1.6 × 1.8-cm hypoechoic solid nodule was noted in the right lobe of the thyroid gland. What is the next step in treatment? (NOTE: OMFS curriculum)
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.
A 17-year-old girl is referred to you by her orthodontist. She has been in orthodontic treatment for 1 year and is reportedly ready for surgery. Upon examination, she has mandibular prognathism and a 5-mm deviation of the mandibular midline to the left side that was not present on initial orthodontic records obtained 1 year ago. Before surgery, what screening examination should you order? (NOTE: OMFS curriculum)
A. Lateral cephalometric radiographs to evaluate any discrepancy on the mandibular inferior border
B. Bone scintigraphy to evaluate abnormal condylar growth
C. Panoramic radiographs to evaluate any discrepancy between the condyles
D. MRI to screen for temporomandibular joint pathology
E. Cone beam CT to evaluate condyle morphology
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.
After undergoing bilateral temporomandibular joint discectomy without replacement, a patient has resolution of her arthralgia 1 week after the procedure. Which treatment measure should be implemented for the postoperative period? (NOTE: OMFS curriculum)
A. Aggressive physical therapy with joint range-of-motion exercises
B. Intermaxillary fixation for 4 to 6 weeks to promote healing of the articular surfaces
C. Orthodontic or restorative dental treatment to address occlusal problems
D. Intra-articular corticosteroid injections
E. Arthrocentesis to dilute and remove inflammatory mediators within the joint space
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.
A 37-year-old woman presents with a 2-year history of headaches. She reports severe, right-sided, throbbing headaches with nausea, photophobia, and phonophobia that occur more than 8 days a month. She denies that the headaches occur only when she is menstruating, stating that they occur sporadically throughout the month. Which medication is most appropriate for this patient? (NOTE: OMFS curriculum)
A. Frovatriptan
B. Gabapentin
C. Indomethacin
D. Topiramate
E. Verapamil
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.
A patient who just underwent a segmental osteotomy of the maxilla during Le Fort I surgery returns for the first-week postoperative check. Clinically, it is noted that the mesial tooth next to the segmental osteotomy has turned pink and the side of the root is damaged on the postoperative films. How could this root damage have been prevented? (NOTE: OMFS curriculum)
A. The roots should be spaced at least 0.5 mm apart.
B. The roots should be spaced at least 1.5 mm apart.
C. The roots should be spaced at least 2 mm apart.
D. The roots should be spaced at least 2.5 mm apart.
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.
ou are about to perform the downfracture step of a Le Fort I osteotomy. You notice that the patient has oozing from the lateral maxilla on the right. You use a hemostatic agent and pack the area. Before proceeding with the downfracture, what mean arterial pressure (MAP) will you ask for from the anesthesia team? (NOTE: OMFS curriculum)
A. 50 mm Hg
B. 60 mm Hg
C. 70 mm Hg
D. 80 mm Hg
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.
A 13-year-old boy is referred to your oral surgery office by his orthodontist for a dentofacial deformity (DFD) consultation. He has a class II malocclusion and a marked diminished SNB angle. Which operation should be avoided in this patient? (NOTE: OMFS curriculum)
A. Mandibular premolar extraction when severe crowding is present
B. Bilateral sagittal split osteotomy (BSSO) and advancement
C. Sliding genioplasty
D. Le Fort I osteotomy with posterior repositioning
E. Three-piece Le Fort I osteotomy for transverse discrepancy
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.
A 24-year-old man with obesity presents to the office for removal of four impacted wisdom teeth. The OMS anticipates difficulty in maintaining a patent upper airway during sedation and agrees to provide moderate-to-deep sedation. Which manifestation in this patient will most accurately predict the level of sedation? (NOTE: OMFS curriculum)
A. A drop in blood pressure
B. An increase in heart rate
C. The ability to respond purposefully to stimulation
D. A decrease in ventilatory rate
E. The loss of upper airway patency
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.
A 33-year-old man presents to the ED after being stabbed with a knife in his right cheek. During the examination, you observe paresis of the upper lip. What facial landmark will you use to determine if the patient requires facial nerve reconstruction? (NOTE: OMFS curriculum)
A. Close to the mandibular inferior border
B. Vertical line drawn from the lateral canthus
C. Over the mastoid region
D. Near the ear canal
E. In communication with the oral cavity
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.
You are raising a submental island flap for reconstruction of a total parotidectomy contour defect. During your harvest of the submental island flap, where do you locate the submental artery? (NOTE: OMFS curriculum)
A. Between the hyoglossus and genioglossus muscles
B. Between the sternocleidomastoid muscle and the posterior belly of the digastric muscles
C. Between the mylohyoid muscle and the anterior belly of the digastric muscles
D. Between the mylohyoid and genioglossus muscles
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.
A 65-year-old man with long-term obstructive sleep apnea (OSA) presents to your office with his spouse for a surgical consultation. The patient denies chest pain but states that he engages in limited exercise and has a family history of coronary artery disease (CAD). His spouse states that the patient shows declining attention to detail. The patient and his spouse ask you to describe what sequelae the patient may experience because of the OSA. What do you tell them? (NOTE: OMFS curriculum)
A. CAD, congestive heart failure, and cerebrovascular accidents
B. Obesity, HTN, and MI
C. HTN, cardiac arrhythmias, and acromegaly
D. Cardiac arrhythmias, cerebrovascular accidents, and thyromegaly
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.
A healthy 18-year-old patient presents to your office for the excision of four third molars. The surgical plan is to intubate the patient. How best can you preoxygenate this patient? (NOTE: OMFS curriculum)
A. Nasal cannula at a flow of 4 L/min for several minutes
B. Room air with a full face mask for 3 minutes
C. 100% oxygen by face mask until end-tidal oxygen content is 75%
D. 3 minutes of tidal volume breathing with 100% O2
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.
A 33-year-old man presents to your office with an exophytic lesion arising from the right tongue. The results of your incisional biopsy demonstrate invasive keratinizing squamous cell carcinoma. You measure the lesion topographically at 1 × 1 cm, and on palpation, you expect it is greater than 0.5 cm deep but less than 1 cm deep. You are unable to palpate any lymphadenopathy in the neck. You do not identify any regional or distant metastatic disease on CT of the neck and chest with contrast. What is the clinical T stage of this patient? (NOTE: OMFS curriculum)
A. cT1
B. cT2
C. cT3
D. cT4a
E. cT4b
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.
A 24-year-old woman presents 6 months after placement of a silastic chin implant reporting that she was initially very happy with her results but now feels like the implant has moved. A physical examination reveals a gross asymmetry of her chin point with a palpable wing of the implant below the inferior border of the mandible on the patient’s left side. Which measure would most likely have prevented this complication? (NOTE: OMFS curriculum)
A. More thorough dissection of the pocket prior to implant placement
B. More superior placement of the implant
C. Selection of a smaller implant
D. Two-point screw fixation to prevent rotation
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.
A 5-year-old boy is brought to the ED after being bitten by the neighbor’s dog. The family reports that they have no information about the dog’s vaccination history and ask if the child should receive the rabies vaccine. How long should the neighbor’s dog be observed for the development of rabies symptoms before it can be determined whether the patient needs the vaccine? (NOTE: OMFS curriculum)
A. 10 days
B. 15 days
C. 20 days
D. 30 days
E. 40 days
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.
A 45-year-old woman presents to your office for extraction of her remaining dentition with alveoloplasty to prepare for the fabrication of conventional dentures. What is your goal during this procedure? (NOTE: OMFS curriculum)
A. Remove all alveolar bone.
B. Create undercuts.
C. Preserve as much bone and soft tissue as possible while removing bony undercuts.
D. Avoid any alveolar bone removal.
E. Create a thin alveolar ridge.
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.
You perform an uneventful monobloc advancement in an 8-year-old patient who is now on the first postoperative day. The nurse reports that during the night the patient experienced episodes of nausea and vomiting and that during one of the vomiting episodes cerebral spinal fluid was identified. What is the most likely region that caused the leak, and what is the potential complication that can develop as a result? (NOTE: OMFS curriculum)
A. Mastoid cells of the temporal bone, leading to an ear infection
B. The ear canal, leading to an ear infection
C. The roof of the nose, leading to a cranionasal fistula
D. Ethmoid cells, leading to epiphora
E. The posterior orbit, leading to blindness
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.
A 15-year-old girl with mandibular prognathism is eager to undergo orthognathic surgery, but her parents want to wait until she reaches skeletal maturity to get stable results. What should you do to assess her growth to provide the patient and parents with the best information regarding treatment? (NOTE: OMFS curriculum)
A. Evaluate the root development of the wisdom teeth.
B. Obtain an occlusal radiograph to evaluate if the midline maxillary suture is completely calcified.
C. Ask the family at what age the older siblings reached maturity and stopped growing.
D. Evaluate anteroposterior cephalometric radiographs at 6- to 12-month intervals.
E. Evaluate lateral cephalometric radiographs at 6- to 12-month intervals.
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.
During the harvest of a latissimus dorsi myocutaneous flap, you tunnel the flap through the axilla and neck to reconstruct a defect in the oral cavity. After tunneling, you note the skin paddle appears dusky and appears to have sheared away from the underlying muscle. How could this have been prevented? (NOTE: OMFS curriculum)
A. Design a small skin paddle overlying the latissimus dorsi muscle.
B. Develop a narrow tunnel to the head and neck.
C. Tack sutures between the latissimus dorsi muscle and the pedicle.
D. Place tacking sutures between the skin paddle and latissimus dorsi muscle.
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.
A 28-year-old man presents with concerns over the appearance of his chin. He feels like his chin is too long and does not project enough. A physical examination of the patient reveals him to be dolichocephalic with a long lower third of the face and a class I dental occlusion. The patient exhibits some lip strain as well. Which treatment option would best address this patient’s concerns? (NOTE: OMFS curriculum)
A. Stock silastic chin implant
B. Dermal fillers to the chin
C. Sliding advancement genioplasty
D. Suction-assisted submental lipectomy
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.
You are asked by the parents of a newborn female infant with a left unilateral cleft lip and palate deformity when this could be surgically repaired. What do you tell them? (NOTE: OMFS curriculum)
A. Within the first 8 weeks of life
B. Between 8 and 16 weeks of life
C. Between 16 and 24 weeks of life
D. Between 24 and 36 weeks of life
E. Between 36 and 52 weeks of life
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).
A 50-year-old man presents to your office with his spouse because he is experiencing headaches in the morning. He states that he feels sleepy at work and while driving. His spouse states that the patient snores heavily at night. The patient states that he otherwise feels well, and no other medical history is reported. His body mass index is 35 kg/m2. What is the next step in the treatment of this patient? (NOTE: OMFS curriculum)
A. Screen the patient for depression.
B. Obtain an MRI of the patient’s brain.
C. Schedule the patient for polysomnography.
D. Start the patient on sumatriptan.
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.
A 50-year-old woman with a history of maxillary edentulism presents to your office inquiring about implant options to convert her removable denture to a fixed dental prosthetic. Which factor is critical in determining how many implants should be placed to rehabilitate her edentulous maxilla with a fixed dental prosthetic? (NOTE: OMFS curriculum)
A. The quality of bone and the planned occlusal forces on the restoration
B. Whether the patient is dentate or edentulous in the mandible
C. A medical history of osteoporosis without concomitant bisphosphonate therapy
D. A medical history of well-controlled diabetes
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.
