WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

WHEN, WHY AND WHERE IN ORAL AND MAXILLOFACIAL SURGERY

PREP MANUAL FOR UNDERGRADUATES AND POSTGRADUATES PART III

111 GOLD COINS AND 1651 QUESTIONS WITH ANSWERS

KC Gupta MDS Professor and Head Department of Oral and Maxillofacial Surgery Modern Dental College and Research Center Indore, Madhya Pradesh, India

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Preface

“A good teacher is the one who creates the interest in his subject.” Round the year, students read the textbooks very thoroughly. At the time of examination, there is little time for revision and also it is difficult to remember all the points. In this book, I have tried to highlight the important points from the examination point of view so that students can revise all the topics in the short span of time. Lastly, Gold Coins may help students from academic as well as clinical points of view.

KC Gupta

Acknowledgments

I am deeply grateful to all my postgraduate students for their untimely support and suggestions. I am also thankful to my family members—my wife Sadhana, my daughter Jeenal and my son Kunal for their support and encouragement. I am also thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-Publishing), Mr KK Raman (Production Manager), Mr Sunil Kumar Dogra (Production Executive), Mr Neelambar Pant (Production Coordinator), Mr Akhilesh Kumar Dubey, Mr Gyanendra Kumar (Proofreaders), Mrs Yashu Kapoor, Mr Inder Jeet (Typesetters), and staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for showing personal interest and trying to the level best to bring the book in present form.

Contents

1. Gold Coins in the Form of Key Points 1 2. Basic Science 11 3. Basic Oral Surgery 36 4. Local Anesthesia 58 5. Exodontia 80 6. Impaction 96 7. Odontogenic Infection 111 8. Disease of Paranasal Sinuses 132 (Disease of Maxillary Sinus) 9. Salivary Gland Disorders 141 10. Nerve Disorders 154 11. Temporomandibular Joint Disorders 164 12. Cysts of the Jaws and Oral Cavity 178 13. Tumors 190 14. General Maxillofacial Trauma 202 15. Preprosthetic Surgery 248 16. Precancerous Lesion/Condition and Oral Cancer 254 17. Cleft Lip/Palate, Dental Implants and 265 Distraction Osteogenesis 18. Orthognathic Surgery 278 19. General Anesthesia 284 20. Miscellaneous 299 Gold Coins in the chapter Form of Key Points 1

1. The LOGIC in reference of radiograph: The radiograph should be read as follows: L—Localization O—Observation G—General consideration I—Interpretation C—Clinical consideration. 2. Luxation is the best policy for extraction of tooth “to avoid fracture of tooth and to have atraumatic extraction”. 3. Patient position for mandibular teeth—occlusal plane should be parallel to the floor and for maxillary teeth, occlusal plane should be 45° to the floor. 4. In case of routine extraction; if there is no pathology-related and oral hygiene is moderate to fair or periodontium is healthy, then no antibiotic therapy is required postoperatively. 5. After any tooth extraction, socket should be compressed with finger pressure “to recontour the expanded socket and to control bleeding”. 6. Three basic principles of elevator and three basic steps in tooth extraction can be correlated in the following way: a. Wedge principle—to luxate the tooth b. Lever and fulcrum—to elevate the tooth c. Wheel and Axle principle—to deliver the tooth from socket. 7. Elevator should be applied on cemento-enamel junction (CEJ) in predetermined direction with finger guard. Never use the adjacent tooth as fulcrum. 2 When, Why and Where in Oral and Maxillofacial Surgery

8. Perfect suturing can increase 40% success rate and surgeon skill. In 99% cases, interrupted suturing is indicated or advised and is advantageous. Suturing avoids food lodgment, delay healing and infection. 9. Collection of anything, e.g. pus, blood, saliva may cause infection; therefore, dependent drainage should always be provided. 10. There is no hard and fast rule that the impacted tooth should be removed with dental elevator; sometimes tooth extraction can be done with the help of extraction forceps also. 11. Irrigation of any wound or cavity as local care—Last irrigation

with H2O2 should be avoided, otherwise it may cause periapical emphysema due to release of nascent O2 which results of increase in pressure in cavity and the patient may complain of severe pain. Thus, last irrigation should be either with normal saline or betadine. 12. In suppurative conditions, whenever possible, avoid suturing. 13. If the patient is diabetic and, in emergency, if fluid replacement is required in case of hypoglycemic shock, then IV DNS is advisable. Best treatment for hypoglycemic unconscious patient is IV 50% Dextrose in water. 14. Radiation therapy should start after 2-3 weeks of tooth extraction. And if the patient is on radiation therapy, extraction should be avoided for at least 3 months. 15. In the management of dry socket, avoid unduly curettage or antibiotic therapy. 16. If an abscess is present and is treated with antibiotic alone and without I and D (where required), it may cause “formation of antibioma”. 17. Basic principle: Before closure of any surgical wound, hemo­ stasis should be achieved. 18. Any intraoral dressing should be changed maximum within 72 hours, otherwise it may act as a source of infection, delayed healing or may act as foreign body. 19. Initially, antibiotic therapy should be prescribed for minimum three days (unless the patient is allergic); frequent changes may Gold Coins in the Form of Key Points 3

cause “Antibioma”. The strength of antibiotic therapy depends upon severity and age of the patient. The dose should be repeated after definite intervals. 20. The golden hour of the trauma refers to “the period of time which is exactly one hour after the trauma is sustained”. 21. The most frequent cause of airway obstruction in an unconscious patient is the “Tongue”. 22. The ABCD of basic life support (BLS) is: A – Airway B – Breathing C – Circulation D – Defibrillation/Drug therapy/Definite treatment. 23. A victim, whose heart and breathing have stopped, has the best chance for survival if the emergency medical services (EMS) are activated and CPR is given within 4 minutes. 24. The three major signs of cardiac arrest are: a. No response b. No adequate breathing c. No signs of circulation. 25. In case of neck injury, airway can be established by three basic maneuvers are: a. Head tilt b. Chin lift c. Jaw thrust. 26. No surgical intervention should be done in acute conditions; otherwise infection may spread to deep fascial spaces resulting in life-threatening conditions, e.g. Ludwig’s angina, cavernous sinus thrombosis. 27. The cause of uncontrolled bleeding at the scalp region is because of its rich blood supply and also the vessels are bound firmly in the dense connective tissue, making it difficult to control the vessel. 28. Avoid hot fomentation in acute conditions or infection; otherwise it may cause spread of infection due to vasodilatation. 29. Hot and cold fomentation should be as follows: Immediately after surgery or first day—COLD fomentation 4 When, Why and Where in Oral and Maxillofacial Surgery

Second day—No fomentation Third day—Hot fomentation (if no infection). 30. Symphysis fracture is best diagnosed in occlusal view; sometimes unable to be diagnosed in OPG. 31. If a patient has a head injury, the most important thing to note is “patient’s ability to open his/her eyes”. 32. More than 50% of mandible fractures are multiple. Associated injuries are present in 43% of the patients. 11% of these patients suffer from cervical spine injuries. 33. In case of maxillofacial injury, if the patient is unable to voluntarily control the tongue, then at the emergency sight, Towel Clipping of tongue avoids the tongue fall. 34. In gross comminuted fracture, if the patient is in shock, then immediately start with Ringer’s Lactate as its high osmotic value maintains the fluid in vascular compartment. 35. The safest initial approach to maintain patent airway in emergency maxillofacial trauma is “Head Tilt, Chin Lift” position. 36. Middle third fracture generally does not undergo any displacement. 37. Root Canal Treatment is contraindicated in fascial space infection (acute or odontogenic condition). 38. Injection Voveran should always be given IM (never IV). 39. In case of Maxillofacial trauma or jaw fracture, during primary care, the goal should be to save the patient’s life instead of achieving normal occlusion. Temporary immobilization can be done: a. To reduce the pain b. To control bleeding from the fracture site c. To prevent further displacement of the fractured fragment. 40. 90% cases of condylar or subcondylar fracture can be treated by closed method (use of surgical elastic or ligature wiring). 41. In pregnant women, 2nd trimester is the safest for extraction; reason being it can lead to abortion in 1st trimester and premature delivery in 3rd trimester. Gold Coins in the Form of Key Points 5

42. In hypertension, if the patient had taken antihypertensive and BP is recorded normal, even then, during surgical procedure the patient’s BP can shoot up high. 43. Dexamethasone (Dexona) is the safest life-saving drug; only contraindication being severe hypertension (>200/ 120 mm Hg). 44. Ibuprofen is absolutely contraindicated in asthmatic patients as it causes bronchospasm. 45. Adrenaline (epinephrine) acts as vasoconstrictor when used locally but, when given systemically, causes bronchodilation, i.e. used for asthmatics. 46. In case of a patient allergic to penicillin, erythromycin is the safest alternative antibiotic. 47. The most important step in the control of bleeding (during or postoperative) is “application of local pressure” to the site. 48. In a cardiac patient, aspirin should be stopped minimum 3 days before any surgical intervention. 49. In a hemophilic patient, aspirin is contraindicated. 50. Atropine is contraindicated in glaucoma. 51. In LA, the loss of function will be in the following sequence— pain, temperature, touch, proprioception and skeletal muscle tone. The return of sensation will be reverse. 52. All local anesthetics readily cross the BBB (blood-brain barrier). They also readily cross the placenta and enter the circulatory system of the developing fetus. 53. In syncope, pupils get “dilated”. 54. Bilateral mandibular nerve block is not contraindicated. 55. The adult on an average should take “1800 mL” of fluid daily. 56. One unit of fresh blood raises the Hb concentration by 1 gm%. 57. 30-60% amount of bone should be destroyed to manifest itself on radiographs. 58. If both the parents have cleft lip and cleft palate, the probability of first child suffering from the same will be 60%. 59. The four clotting factors synthesize in the liver are factors II, VII, IX and X. 6 When, Why and Where in Oral and Maxillofacial Surgery

60. The level of reduced hemoglobin at which a patient becomes cyanotic is 05 gm/dl. 61. Tramadol is a unique analgesic with opioid-like activity for both acute and chronic pain management; side-effects include sedation and dizziness; seizure is rare. It is used with caution in a patient with history of seizure. 62. Heparin increases the normal clotting time (4-6 minutes) to 6-30 mins. The duration of action is 3-4 hours. 63. For every one degree centigrade rise in body temperature, there is corresponding 9-10 beats/minute increase in patient’s heartbeat. 64. Some common cause of postoperative nausea and vomiting are hypoxia, hypertension and narcotics. It is more common in children than in adults and more in women than in men. 65. The average rate of an injured axon’s forward growth is approximately 1-2 mm/day. 66. What are anesthetics artery and why 1. Facial artery 2. Superficial temporal artery Because anesthetic can confirm pulsation during operation. 67. The calvaria or brain case is composed of 8 bones and facial skeleton is composed of 14 bones. 68. What are triple antibiotics and doses—A shotgun approach to potential life-threatening infection when the patient is seriously ill (the therapy is): a. Gram-positive coverage—(e.g. Ampicillin) 1 gram 6 hourly IV in adult. 40 mg/kg 6 hourly IV in children b. Gram-negative coverage—(e.g. Gentamicin) 7 mg/kg IV every 24 hours. This single daily dose is less nephrotoxic than 2 mg/kg every 8 hourly c. Anerobic coverage—(e.g. Metronidazole-Flagyl) 500 mg IV every 6 hourly in adults; 7.5 mg/kg IV every 6 hourly in children. 69. An inhaled foreign body most probably enters into right bronchus. Gold Coins in the Form of Key Points 7

70. Hyoid bone present in the neck is the only jointless bone in the human body. 71. Nails and cornea are the only tissues in the human body which do not take oxygen from the blood. 72. Autogenous cancellous bone graft has greater osteogenic potential than other grafts. 73. Advantages of sharp dissection over blunt dissection are: a. Less traumatic b. Permits muscle splitting than muscle tearing. 74. The patient with maxillofacial injuries should be carried in lateral position but in case of spinal and cervical injury, the patient should be carried in “supine position”. 75. Eyebrows should not be shaved when facial lacerations are repaired because these do not always grow back. 76. In general, for IV fluid, common site is “dorsal vein at the back of the hand”. 77. In case of uncontrolled bleeding after tooth extraction (for example, in case of hemangioma) replacing the tooth in the socket should be the first step to control bleeding. 78. In the case of an unconscious patient with no pulse and dilated pupils, the correct procedure is “to start artificial ventilation at once”. 79. Universal distress signal characterizing the obstructed airway in a conscious adult is “victim’s hand at his throat”. 80. Postoperative edema can be minimized by: a. Gentle manipulation of soft and hard tissues. b. Early application of cold fomentation (acts as a vasocons­ trictor and analgesic effect). c. Postoperative serratiopeptidase accordingly. 81. In case of cardiopulmonary resuscitation (CPR), if efforts are effective, there will be “constriction of pupils”—one of positive sign. 82. The complete physical examination of a patient includes: a. Inspection b. Palpation and percussion c. Auscultation. 8 When, Why and Where in Oral and Maxillofacial Surgery

83. If a normal patient loses 1000 cc of blood due to surgery, it should be replaced by 3000 cc of colloidal fluid. 84. Few drugs that may cause syncope are: a. Antihypertensive drugs b. Overdose of insulin c. Diuretics d. Procaine. 85. ‘5-As’ that may cause postextraction bleeding are: a. Alcohol b. Aspirin c. Anticoagulant d. Antimalignant e. Antibiotic (Sulfonamide). 86. If a patient gives history of allergy to Sulfa drugs, the same patient may be allergic to xylocaine (Lignocaine) because both are having same benzene ring. 87. Adrenal crisis is characterized by “Hypotension, Hypoglycemia­ and Shock”. 88. ‘4-As’ that are important in management of allergic reaction are: a. Aminophylline b. Antihistamine c. Adrenaline d. Airway with oxygen administration. 89. In case of trigeminal neuralgic attack, pain never crosses the midline of the face (either left or right) and never occurs during sleep. 90. Digastric muscle having dual nerve supply, one from mandi­ bular nerve (motor branch from trigeminal nerve) and another from facial nerve (motor branch). 91. The patient with tongue-tie or ankyloglossia cannot pronounce the words like “P, Q, R, S and T”. 92. The central nervous system does not have any lymphatic drainage system. Gold Coins in the Form of Key Points 9

93. Lateral pterygoid muscle is only one of the principal muscles of mastication which are attached to the condyle and responsible for depression of the lower jaw (to open the mouth). 94. Thickness of skin is 0.5-3 mm. 95. Each cardiac cycle takes 0.8 seconds and denotes series of changes which the heart undergoes during each beat. 96. The pain is defined as “an ill-defined, unpleasant sensation, usually evoked by an external or internal stimulus”. 97. Sleep is periodic resting stage for the body, especially the cerebral cortex. 98. Syncope is one of the common complications in dental clinic. It requires immediate attention, otherwise untreatable syncope may turn into shock and may be fatal. 99. The brain works for three minutes after cardiac arrest till the oxygenated blood circulates to the brain. Each cycle takes three minutes. 100. In general, the following drugs should be avoided during pregnancy: a. Aspirin b. Corticosteroid c. Diazepam d. Morphine e. Nitrous oxide f. Phenobarbital g. Carbamazepine. 101. The tip of the tongue is responsible for sweet taste and the lateral wall of the tongue is responsible for other tastes, like bitter, salty, sour. 102. In temporomandibular joint, the articular cartilage and central portion of the disc do not have any nerve supply and blood supply. 103. Aneurysmal bone cyst (ABC) is considered as a giant cell lesion because histopathological examination shows the presence of giant cells. 104. In case of suspected head injury the patient is never given morphine (as sedative and to reduce pain) because morphine 10 When, Why and Where in Oral and Maxillofacial Surgery

mask the head injury symptom and arrests the respiratory center. 105. About 44.6 kg/m to 74.4 kg/m energy is required to fracture the mandible, zygoma and frontal bone. 106. Above 40 years of age, 60-75% patients of facial space infection suffer from diabetes and/or hypertension. Medical history should be evaluated and treatment should be done accordingly. 107. Mild to moderate oral submucous fibrosis is treated conser­ vatively with antioxidant therapy. It is one of the key treatment modalities. 108. Apart from other local hemostatics, hydrogen peroxide also plays an important role in arresting the intraoral bleeding. 109. Crocodile tears (False tears) is a condition that results after the injury to fibers of facial nerves, leading to crying when the patient eats. 110. All the facial muscles receive their innervations along their deep surface except Mentalis muscle, Levator angularis superioris and Buccinator muscle. They receive their innervations along their superficial surface. 111. Three actions must occur at the time of cardiac arrest: a. Active Emergency Response System (AERS) b. Perform CPR c. Use Automated External Defibrillator (AED). chapter Basic Science 2

1. What is the difference between growth and development? Ans. Growth: Craniofacial growth is a complex phenomenon. Growth is quantitative; for example, it is a measurable aspect of the biologic life. Growth is change or difference in quantity, “Growth is increase in size.” Development: In simple words, it means progression towards maturity. Development can be considered as a continuum of casually related events from the fertilization of ovum onwards. Development is a physiological and behavioral phenomenon. “Development is progression towards maturity”. 2. What are the sex difference in the skull? Ans. No sex difference until puberty. Post-puberty the differences are:

Features Male Female i. Weight Heavier Lighter ii. Size Large Small iii. Walls Thicker Thinner iv. Muscular ridge More marked Less marked v. Forehead Sloping Vertical vi. Mastoid process More marked Less marked vii. Vault Rounded Flattened viii. Contour of face Long or chin bigger Rounded ix. Supraorbital margin Rounded Sharp x. Facial bones More rough, massive Smooth, smaller 12 When, Why and Where in Oral and Maxillofacial Surgery

3. Define the following terms: (i) Anatomy; (ii) Surface anatomy (Topographic anatomy); (iii) Applied anatomy (clinical anatomy); (iv) Gross Anatomy; (v) Surgical Anatomy. Ans. i. Anatomy: It is derived from a Greek word “anatome” meaning cutting up. The term ‘dissection’ is a Latin equivalent of the Greek ‘anatome’. ii. Surface anatomy (Topographic anatomy): This is the study of deeper parts of the body in relation to the skin surface. It is helpful for clinical practice and surgical operation. iii. Applied anatomy (Clinical anatomy): It deals with the application of the anatomical knowledge to the medical and surgical practice. iv. Gross anatomy: It includes number, location, size, shape, length, width of structures. v. Surgical anatomy: It includes exact location, contents, boundaries, nerve, arterial, venous supply, lymphatic drainage and muscle attachment of the structures. 4. What are the derivatives of Meckel’s Cartilage (First Arch Cartilage)? Ans. i. Ear ossicles ii. Malleus, incus iii. Anterior ligament of malleus iv. Spine of sphenoid v. Sphenomandibular ligament vi. Musculature derived: – Muscles of mastication – Mylohyoid muscle – Anterior belly of digastric muscle – The tensor of tympani – The tensor veli palatini. 5. How does mandible get developed? Ans. From 1st Brachial Arch or Mandibular Arch. Basic Science 13

6. When does the development of mandible takes place? Ans. At the 4th week. 7. When does the ossification of mandible start? Ans. At the 6th week. 8. When does ossification of maxilla start? Ans. At the 7th week. 9. When do TMJ rudiments take place? Ans. At the 8th week. 10. How does the development of tongue occur? Ans. It develops from 1st/3rd/4th Brachial Arch. 11. When does the tongue development take place? Ans. In the 4th week in the utero. 12. When does the condyle formation occur? Ans. In the 10th week. 13. Where after fertilization is the zygote formed? Ans. In the fallopian tube. 14. What are the other names of Stomodeum? Ans. Primitive Face/Primitive oral cavity. 15. What are the muscles developed from 1st pharyngeal or visceral arch? Ans. • Muscles of mastication • Digastric muscle of anterior belly. 16. How does the development of anterior mid facial skeleton occur? Ans. It occurs from: • Frontonasal process • Lateral process • Maxillary process. 14 When, Why and Where in Oral and Maxillofacial Surgery

17. What are the anomalies (developmental) related to middle 3rd face development? Ans. i. Oblique facial cleft ii. Macrosomia iii. Maxillary sinus hematosis (Enlarged Maxillary Sinus). 18. In which conditions the bilateral condylar hypoplasia is seen? Ans. i. Pierre-Robin syndrome ii. Treacher-Collins syndrome iii. Nager’s syndrome iv. Townes-Brock’s syndrome v. Branchio-otorenal syndrome vi. Branchio-oculofacial syndrome vii. Stickler syndrome. 19. In which conditions is hemimandibular hypoplasia seen? Ans. i. Goldenhar-Gorlin syndrome ii. 1st and 2nd Brachial Arch syndrome iii. Craniofacial Microsomia iv. Dyke-Davidoff-Masson syndrome v. Femoral Facial syndrome 20. What is Hilton’s law’? Ans. Each pharyngeal arch is characterized by its own muscular components. The muscular components of each carry their own nerve and whenever the muscular cell may migrate, they carry their cranial nerve component and, in addition, each arch has its own arterial component. State that: Nerve which supplies a joint also innervate the muscle that move it. 21. Which structures are attached to the lingula? Ans. Sphenomandibular ligament, which is the remnant of Meckel’s cartilage. Basic Science 15

22. What are the two peculiarities of lateral pterygoid muscle, which differs from other principle muscles of mastication? Ans. i. Only muscle attached with condyle. ii. Responsible for depression of the mouth (open the mouth) 23. What are the cranial nerves present in the neck region? Ans. i. Glossopharyngeal nerve (CN 9th) ii. Vagus nerve (CN 10th) iii. Accessory nerve (CN 11th) iv. Hypoglossal nerve (CN 12th). 24. What are the five layers of the scalp? Ans. Scalp is made up of the following five layers (outward to inward): i. Skin ii. Dense connective tissue iii. Gala apponeurotica iv. Loose connective tissue v. Periosteum or pericranial layer. 25. What are the five layers of the pharynx? Ans. There are five layers (inward to outward). i. Mucosa ii. Submucosa iii. Pharyngeal aponeurosis (Pharyngobasilar fascia) iv. The muscular coat v. The buccopharyngeal fascia. 26. What are different parts of the pharynx? Ans. i. Nasal part (Nasopharynx) ii. Oral part (Oropharynx) iii. Laryngeal part (Laryngopharynx). 27. How many cartilages are present in larynx? Ans. Total nine cartilages are present in larynx: • 6 paired, which are: – Arytenoid (two) – Corniculate (two) – Cuneiform (two) 16 When, Why and Where in Oral and Maxillofacial Surgery

• 3 unpaired, which are: – Thyroid (one) – Cricoid (one) – Epiglottic (one) 28. What are the structures present in the floor of mouth? Ans. Structures present in the floor of mouth are: i. Wharton’s Duct (Submandibular gland duct) ii. Lingual nerve iii. Sublingual artery iv. Sublingual gland v. Hypoglossal nerve vi. Submandibular gland. 29. What are the deep structures present in the neck? Ans. i. Gland: Thyroid and parathyroid gland ii. Thymus iii. Arteries: Subclavian and carotid iv. Veins: Subclavian, internal jugular and brachiocephalic v. Nerves: Glossopharyngeal nerve (9th CN) – Vagus N (10th CN) – Accessory N (11th CN) – Sympathetic Chain – Cervical plexus vi. Lymph nodes vii. Thoracic duct viii. Viscera: Trachea and oesophagus ix. Muscles: Scalene muscle x. Cervical pleura, suprapleural membrane xi. Styloid apparatus. 30. Which artery is most commonly involved in extradural hemorrhage? Ans. Middle meningeal artery. 31. When attempting venipuncture in anticubital fossa, which artery is most likely to be encountered? Ans. Brachial artery may be encountered. Basic Science 17

32. From where do the branches of trigeminal nerve pass through? Ans. i. Ophthalmic branches: Superior orbital fissure ii. Maxillary branches: Foramen rotundum iii. Mandibular branches: Foramen ovale. 33. What is the source of motor nerve innervations of larynx? Ans. Vagus nerve (10th CN). 34. From which structure does the facial nerve exit from the skull? Ans. Stylomastoid. 35. Which foramen is associated with middle meningeal artery? Ans. Foramen spinosum. 36. The blood vessels and nerves are absent in which structure of TMJ? Ans. Central portion of the disc. 37. How are Langer’s line usually placed in the face? Ans. Parallel to the natural creases of the face. 38. Which all structures are supplied by hypoglossal nerve? Ans. Hypoglossal nerve provides motor innervations to all intrinsic and extrinsic muscles of the tongue. 39. How many nerves are responsible for the nerve supply of the tongue? Ans. Motor nerve supply: Accessory nerve (11th CN) Hypoglossal nerve (12th CN) Sensory nerve supply: Trigeminal nerve (5th CN) Facial nerve (7th CN) Glossopharyngeal nerve (9th CN) Vagus nerve (10th CN) 40. Which nerve is involved in Bell’s palsy? Ans. Facial nerve. 18 When, Why and Where in Oral and Maxillofacial Surgery

41. Lingual artery is the branch of which artery? Ans. External carotid artery. 42. Which is the triangle of lingual artery? Ans. Lesser’s triangle. 43. Hypoglossal nerve is purely sensory or motor? Ans. It is purely motor nerve. 44. What are the components of posterior triangle of the neck? Ans. Occipital triangle and subclavian triangle. 45. The trigeminal nerve is motor/sensory/mixed in nature? Ans. Mixed in nature. 46. How many branches of the internal carotid artery are present in the neck region? Ans. None of the branches is present in the neck region. 47. What is the name of the cavity in which semilunar/gasserian ganglion is present? Ans. Meckel’s cavity. 48. Ansa hypoglossal is composed of which nerve? Ans. Descending cervical and descending hypoglossal nerve. 49. At which level is CCA divided into ECA and ICA? Ans. At the level of superior border of thyroid cartilage. 50. Which nerve supplies the sensory innervations for taste to anterior 2/3rd of the tongue? Ans. Chorda tympani. 51. Waldeyer’s ring contains what type of tissue? Ans. Lymphoid tissue. 52. Where is the greater palatine foramina situated? Ans. It is situated between the 2nd and 3rd maxillary molar. 53. Which artery is commonly involved in stroke? Ans. Lenticulostriate artery. Basic Science 19

54. Which tissue has less tendency to regenerate tendon or bone? Ans. Tendon has less tendency. 55. Sensory fibers of the lingual nerve supply which structures? Ans. They supply: i. Tongue ii. Lingual surface of mandible iii. Floor of mouth. 56. Which of the following bones does not contain air sinus: Frontal/nasal/sphenoid/ethmoidal? Ans. Nasal bone does not contain any air sinuses. 57. Which muscles are responsible for the make-up of pterygo­ mandibular raphe? Ans. Anteriorly by buccinator muscle and posteriorly by superior constrictor muscle of pharynx. 58. What are Arnold’s nerve and Jacobson’s nerve? Ans. Arnold’s nerve: It is a branch of vagus nerve (10th CN and supplies sensory innervations to the ear (concha and auditory canal). Jacobson’s nerve: It is a branch of glossopharyngeal nerve (9th CN and supplies sensory innervations to the ears (concha, auditory canal and middle ear). 59. What is the interval between open eyelids called? Ans. The palpebral fissure (Rima palpebrarum). 60. Which bones form the orbital cavity? Ans. Lacrimal, ethmoidal, palatine, frontal, sphenoid, zygomatic and maxillary. 61. How many bones form the orbit? Ans. Seven bones form the orbit: i. Orbital roof: Orbital plate of the frontal bone ii. Orbital floor: Orbital plate of the maxilla iii. Lateral wall: Orbital surface of the zygomatic bone and greater wing of the sphenoid bone 20 When, Why and Where in Oral and Maxillofacial Surgery

iv. Medial wall: Composed of 4 bones—ethmoidal bone (centrally) v. Frontal bone (superioanteriorly) vi. Sphenoid bone (posteriorly) vii. Lacrimal bone (inferioanteriorly). 62. What is Whitnall’s orbital tubercle? Ans. It is a bony protuberance present at the lateral orbital wall, approx. 5 mm behind the lateral orbital rim. 63. Which is the only bone that exists entirely within the orbital confines? Ans. The lacrimal bone. 64. Which bone is the keystone of the orbit? Ans. The sphenoid bone. All neurovascular structures to the orbit pass through this bone. 65. Where the superior orbital fissure located and which struc­ tures pass through it? Ans. The superior orbital fissure is a 22 mm cleft that runs outward, forward and upward from the apex of the orbit. Three motor nerving pass through the extraocular muscles of the orbites: i. Oculomotor nerve (CN 3rd) ii. Trochlear nerve (CN 4th) iii. Abducens nerve (CN 6th) The ophthalmic division of trigeminal nerve also enters the orbit through this fissure. 66. What are the structure pass throughing inferior orbital fissure? Ans. Inferior orbital fissure acts as passage for: i. Maxillary division of trigeminal nerve (CN V2) and its branches including the infraorbital nerve ii. The infraorbital artery iii. Branches of sphenopalatine ganglion iv. Branches of inferior ophthalmic vein to the pterygoid plexus. Basic Science 21

67. What are the contents of the carotid sheath? Ans. It contains: i. Carotid artery ii. Jugular vein iii. Vagus nerve (CN 10th) Within the carotid sheath, vagus nerve lies posterior to the common carotid artery and internal jugular vein. 68. At what distance from the stylomastoid foramen does the facial nerve bifurcate? Ans. The average distance is 1.3 cm. The nerve bifurcates into two main trunks, zygomaticofacial and mandibular cervical. 69. At what distance from the external auditory canal does the facial nerve bifurcate? Ans. The point of bifurcation is located 1.5 to 2 cm inferior to the lowest concavity of the bony external auditory canal. 70. What is the “Danger Zone” for the frontal branch of the facial nerve as it crosses the zygomatic arch? Ans. Facial nerve crosses the superficial to the zygomatic arch in an area that lies at 0.8–3.5 cm anterior concavity of the bony external auditory canal (average 2 cm anterior to the canal). The danger zone for injury of the frontal branch of the facial nerve during surgical procedures is in the temporal and pre-auricular regions. 71. What is the “Danger Zone” for the marginal mandibular branch of the facial nerve? Ans. The marginal mandibular branch of the facial nerve is located in an area where incision to approach the mandible and mandibular condyle is given. The danger zone is located between the inferior border of the mandible and a line in the retromandibular and submandibular regions. 22 When, Why and Where in Oral and Maxillofacial Surgery

72. What are the surface anatomy landmarks for tracheostomy? Ans. i. Thyroid notch ii. Cricoid ring iii. Sternal notch iv. Innominate artery. 73. What are the layers encountered during the dissection of trachea from the skin to the trachea? Ans. i. Skin ii. Subcutaneous connective tissue iii. Platysma iv. Investing fascia v. Linea alba of infrahyoid muscle vi. Thyroid isthmus vii. Pretracheal fascia viii. Tracheal rings. 74. What major vessels are encountered with during trach- eostomy? Ans. The anterior jugular vein and jugular venous arch are found in suprasternal space. The infrahyoid vein and artery as well as thyroid artery, all lie in the space between the pretrachea and infrahyoid fascia. 75. What are the possible postoperative complications associated with tracheostomy? Ans. i. Atelectasis: Blood or foreign material is aspirated into the tube ii. Tracheoesophageal fistula iii. Subglottic edema iv. Tracheal stenosis v. Pneumonia vi. Difficult decannulation vii. Persistent fistula. 76. Risus sardonicus is one of the signs of the tetanus. What does it involve? Ans. It involves spasm of the facial muscle causing a fixed smile. Basic Science 23

77. What are the indications for prophylactic antibiotics? Ans. i. To prevent local wound infection ii. To prevent infection at surgical site iii. To prevent metastatic infection. 78. When should the antibiotics be used? Ans. i. Acute onset infection ii. Diagnosed osteomyelitis of the jaw iii. Infection with diffused swelling iv. Involvement of the facial spaces v. Severe pericoronitis vi. Patients with compromised host defenses. 79. When are the prophylactic antibiotics for the prevention of odonto­genic infection not necessary? Ans. Minimal or no benefits in the treatment of: i. Chronic well-localized abscess ii. Dry socket iii. Minor vestibular abscess. iv. Root canal sterilization. 80. What is the most common side effect of the oral admini- stration of ampicillin? Ans. Diarrhea. 81. Which antibiotic is primarily bactericidal? Ans. Gentamycin. 82. What is the choice of the drug in the patient allergic to penicillin? Ans. Erythromycin (E-mycin) or althrocin. 83. Which antibiotic is mainly effective against the gram- negative bacteria? Ans. Kanamycin. 84. In what all conditions is morphine contraindicated? Ans. i. Bronchial asthma ii. Head injury iii. Emphysema. 24 When, Why and Where in Oral and Maxillofacial Surgery

85. What is the common side effect of NSAIDs drug? Ans. Gastric irritation. 86. What is overdose of salicylate in the children causes? Ans. Reye’s syndrome. 87. Why is salicylate contraindicated in pregnancy? Ans. Because it readily crosses the placental barrier. 88. What are the side effects of tetracycline in children? Ans. Discolored teeth. 89. In reference of paracetamol. Ans. i. Contraindicated—In chronic hepatitis ii. Can be safely given: – to a pregnant lady – in the case of congestive cardiac failure. 90. In reference of aspirin. Ans. i. Contraindicated—In peptic ulcers ii. Produces the following effects: – Frank gastric bleeding – Prolonged prothrombin time – Platelets dysfunction – Prolonged bleeding time. iii. Causes hypoprothrombinemia iv. Tendency to produce blood dyscrasias. 91. How will you manage a case of substantial convulsive reaction to a local anesthesia? Ans. Use diazepam and oxygen to reduce convulsive reaction. 92. What do the glucocorticoids reduce—the pain threshold or inflammation? Ans. These decrease the inflammation. 93. Which drug is contraindicated in G6PD deficiency—aspirin or paracetamol? Ans. Aspirin is contraindicated. Basic Science 25

94. Which is the broad spectrum antibiotic—penicillin or tetracycline? Ans. Tetracycline is the broad spectrum antibiotic. 95. How will you manage a case of postoperative cutaneous ecchymosis? Ans. By the application of cold. 96. What is the characteristic clinical sign of hemophilia? Ans. i. Bleeding time is normal. ii. Clotting time/prothrombin time/partial thromboplastin time is prolonged. 97. Which are the new blood clotting factors? Ans. There are three new factors: i. Factor 14: Prekallikrein—Fletcher factor ii. Factor 15: High molecular weight kininogen—Fitzgerald factor iii. Factor 16: Calcium. 98. Which of the following muscles has a dual nerve supply— digastric or masseter muscle? Ans. Digastric muscle has a dual nerve supply. It is supplied by mandibular and facial nerves. It gets the motor nerve supply from both nerves. 99. Which muscle insertion caps the coronoid process— temporalis or pterygoid muscle? Ans. Temporalis muscle insertion caps the coronoid process. 100. Which nerve causes the following disorders? (i) Ptosis; (ii) Trigeminal neuralgia; (iii) Facial paralysis and Bell’s palsy; (iv) Frey’s syndrome; (v) Vagus glossopharyngeal neuralgia; (vi) Glossopharyngeal neuralgia. Ans. i. Occulomotor nerve (cranial nerve III lesion causes ptosis) ii. Trigeminal nerve causes trigeminal neuralgia iii. Facial nerve causes facial paralysis and Bell’s palsy iv. Auriculotemporal nerve and facial nerve cause Frey’s syndrome 26 When, Why and Where in Oral and Maxillofacial Surgery

v. Vagus (cranial nerve X), glossopharyngeal nerve (cranial nerve IX) cause vagus glossopharyngeal neuralgia vi. Glossopharyngeal nerve causes glossopharyngeal neuralgia. 101. Differentiate between hemorrhage, hematoma and ecchymosis. Ans. Hemorrhage is the escape of blood from the vascular system. Hematoma is the collection of blood in extravascular space. Ecchymosis is the collection of blood below the skin and the mucous membrane. 102. Differentiate between thrombosis and embolism. Ans. Thrombosis is the intravascular coagulation of blood, which is attached to the endothelial lining of the vessel known as thrombus. Embolism occurs when the attached clotted blood gets detached from lining and circulates in the blood and detached blood clot is known as embolus. 103. Differentiate between bacteremia, septicemia, toxemia and pyemia Ans. Bacteremia is the presence of small number of bacteria in the blood, which does not multiply significantly and is not detected microscopically, e.g. E. coli, etc. Septicemia is the presence of rapidly multiplying highly pathogenic bacteria in the blood, e.g. pyogenic cocci and bacilli. Toxemia is the condition resulting from the spread of the bacterial product by the blood-stream or the condition resulting from the metabolic disturbances. Pyemia is the dissemination of small septic thrombi in the blood which causes their effect at the site where they are lodged. This can result in pyemic abscess or septic infarcts. 104. Differentiate between sinus and fistula. Ans. Sinus is a blind tract which is open at one end and lined by epithelium. Fistula is a track open at both the ends and lined by epithelium. Basic Science 27

105. In reference to the bleeding time and clotting time, what is the basic difference between hemophilia and purpura? Ans. Hemophilia: Clotting time is increased and bleeding time is normal. Purpura: Clotting time is normal and bleeding time is increased. 106. Which are the important foramina of the base of the skull and which structures pass through them? Ans. Foramina Structures passing through them 1. Incisive foramen a. Terminal part of greater palatine vessels b. Nasopalatine vessels 2. Greater palatine a. Greater palatine vessels foramen b. The anterior palatine nerve 3. Lesser palatine a. Middle and posterior palatine nerves foramina 4. Jugular foramen a. Through anterior part—inferior petrosal sinus b. Through the middle part IX. Glossopharyngeal nerve X. Vagus nerve XI. Accessory nerve. Meningeal branch of ascending pharyngeal artery c. Through posterior part—emissary vein 5. Hypoglossal canal a. Hypoglossal nerve (XII CN) b. Meningeal branch of the ascending pharyngeal artery c. Emissary vein connects the sigmoid sinus with the internal jugular vein 6. Foramen rotundum a. Maxillary division of trigeminal nerve (V2).

107. In which condition does the lymph node become rubbery hard? Ans. In the case of lymphoma. 28 When, Why and Where in Oral and Maxillofacial Surgery

108. In which system is the lymphatic drainage not present? Ans. Central nervous system. 109. What is the basic difference in carcinoma metastasis and sarcoma metastasis? Ans. Carcinoma metastasis is through the lymphatic route. Sarcoma metastasis is through the hematogenous route. 110. Which are the lymphoid organs? Ans. 1. Thymus gland: i. Primary or central ii. Secondary or peripheral 2. Lymph nodes 3. Spleen 4. Tonsils 111. How many lymph nodes are present in an adult body? Ans. Total 400 to 450 lymph nodes are present in an adult body. i. Head and neck = 60 to 70 ii. Arms/superficial thorax = 40 iii. Legs/superficial buttocks = 30 iv. Thorax = 100 v. Abdomen/pelvis = 230 112. What are the functions of the lymph nodes? Ans. i. Defense: To remove microorganisms and other injurious particles ii. Hematopoiesis: Site for the final stage maturation of lympho­cytes and monocytes. 113. What is the composition of lymph nodes? Ans. i. Water—96% ii. Solids—4% – Protein—2 to 6% – Lipid—5 to 15% – Carbohydrates—sugar (glucose) – Non-protein nitrogen substance, e.g. urea, amino acid, creatine – Electrolytes—Na, Ca, K, Cl, bicarbonate – Cellular contents—lymphocytes. Basic Science 29

114. What is the rate of lymph flow? Ans. i. Total rate of lymph flow: 120 ml/hr ii. About 100 ml/hour through thoracic duct iii. About 20 ml/hour through channels iv. About 2 to 3 liters/day. 115. What are the functions of lymphatic system? Ans. i. It collects the waste materials from the tissues ii. It acts as drainage of metabolites iii. It maintains the body fluids and blood volume iv. It helps in the defence mechanism against the foreign bodies and bacteria v. It is the site of formation of lymphocytes vi. It serves to arrest the spread of malignant cells, though temporarily. 116. Define anesthesia and analgesia Ans. Anesthesia: Loss of the touch sensitivity. Analgesia: Loss of the pain sensibility. 117. Define symptoms and signs. Ans. Symptoms are subjective complaints of the patient about his/ her disease. Signs (physical signs) are objective findings of the doctor on the patient. 118. Differentiate between typical trigeminal neuralgia (classic) and atypical trigeminal neuralgia. Ans.

Typical trigeminal neuralgia Atypical trigeminal neuralgia 1. Pain only during attack 1. Pain is of long duration and it is dull boring pain 2. Never crosses midline during 2. Involves other areas of the face and attack or at any time then crosses the midline 3. Attack never occurs during 3. Attack can be during sleep also. sleep 30 When, Why and Where in Oral and Maxillofacial Surgery

119. Define (i) Lymph; (ii) Blood; (iii) Plasma; and (iv) Serum. Ans. i. Lymph: The tissue fluid which enters the lymphatic vessels is called lymph. It is a clear fluid. It has the composition similar to blood and plasma. It contains lymphocytes, large molecule of protein and particulates matter absorbed from the tissue fluid. ii. Blood: It can be defined as a specialized connective tissue in which there is liquid cellular substance known as plasma and formed elements, WBC, RBC and platelets suspended in the plasma. iii. Plasma: It is a light yellow transparent alkaline fluid. It is fluid protein (approximately 55%) obtained from the blood without clotting. iv. Serum: It is plasma fluid procured after blood clotting. 120. Define the following terms: (i) Sensory afferent nerve; and (ii) Motor efferent nerve Ans. i. Sensory afferent nerve carries impulses from periphery to the CNS ii. Motor efferent nerve carries impulses from CNS to the peripheral structure like muscles. 121. Which are the triangles of the neck and which muscle demarks these triangles? Ans. i. Anterior triangles of the neck ii. Posterior triangles of the neck These two triangles are divided by sternocleidomastoid muscle. a. Anterior triangles are divided into: – Digastric triangle – Submental triangle – Carotid triangle – Muscular triangle. b. Posterior triangles are divided into: – Occipital posterior triangle. It is also known as upper posterior triangle of the neck Basic Science 31

– Supraclavicular (subclavian) triangle. It is also known as lower triangle of the neck. – Both the posterior triangles of the neck are divided or demarcated by the inferior belly of the omohyoid. 122. Define the following terms: (i) Tendon; (ii) Ligament; (iii) Belly; and (iv) Aponeurosis. Ans. i. Tendon: The fibrous, non-contractile and cord-like part of the muscle. ii. Ligament: Ligaments are fibrous bands which connect the adjacent bone forming the integral parts of the joints. iii. Belly: The fleshy and contractile part of the muscle. iv. Aponeurosis: The flattened tendon. 123. Define muscle and what are the type of muscles? Ans. Muscle is a contractile tissue which brings about the movement. Type of muscles: i. Skeletal muscle: Voluntary, striated or somatic muscle ii. Smooth muscle: Involuntary, plain, non-striated and visceral muscle iii. Cardiac muscle: Striated, involuntary, automatic and rhythmic contractions of the heart. 124. Why does blood not clot in the vessels? Ans. i. Constant flow of blood in the vessels ii. Smoothness of vessel walls provided by intact endothelial lining iii. Presence of natural inhibitors of coagulation, e.g. heparin in blood with cofactors, anticephalin neutralizes excess thromboplastin. 125. Define the following terms (i) Eupnea; (ii) Dyspnea; (iii) Tachypnea; (iv) Bradypnea; (v) Hypercapnia; (vi) Hypocapnia; (vii) Hypoxemia; (viii) Hypoxia (anoxia); (ix) Cyanosis; and (x) Aphyxia. Ans. i. Eupnea: It is normal respiration at normal rate and amplitude 32 When, Why and Where in Oral and Maxillofacial Surgery

ii. Dyspnea: It is difficult or belaboured breathing iii. Tachypnea: It is rapid breathing iv. Bradypnea: It is slow breathing v. Hypercapnia: It is excess of carbon dioxide (2 to 4%) in body fluid vi. Hypocapnia: It is decreased carbon dioxide in body fluid vii. Hypoxemia: It is decreased oxygen carriage in blood viii. Hypoxia (anoxia): It is the lack of supply and utilization of oxygen ix. Cyanosis: It is blue coloration of skin especially lips, ears, hands, foot and nails x. Asphyxia: It is due to presence of increased amount of reduced Hb in blood. It signifies suffocation. 126. Define: (i) Cerebrospinal fluid (CSF); and (ii) Spinal cord. Ans. i. Cerebrospinal fluid (CSF):CSF is a modified tissue fluid. It is contained in the ventricular system of the brain and in the sub-arachnoid space around the brain and the spinal cord. CSF replaces the lymph in the CNS. It is protective, nutritive and a pathway for the metabolites from the CNS. ii. Spinal cord: Spinal cord is the lower part of the central nervous system, responsible for establishing contacts between the brain in the cranial cavity and the peripheral end organ. 127. Which are the muscles responsible for the following facial expressions? (i) Smiling; (ii) Anger; (iii) Horror; (iv) Closing the mouth; and (v) Whistling Ans. Following are the muscles responsible for various facial expressions: i. Smiling: Zygomaticus major ii. Anger: Dilator naris and depressor septi iii. Horror: Platysma iv. Closing the mouth: Orbicularis oris v. Whistling: Buccinator and orbicularis oris. Basic Science 33

128. Which are the principal muscles of mastication? Ans. i. Temporalis muscle ii. Masseter muscle iii. Medial pterygoid muscle iv. Lateral pterygoid muscle. 129. Which are the accessory muscles of mastication? Ans. i. Suprahyoid muscle: – Digastric – Mylohyoid – Stylohyoid – Geniohyoid. ii. Infrahyoid muscle: – Sternothyroid – Sternohyoid – Thyrohyoid – Omohyoid. iii. Platysma. 130. Define: (i) Trachea; (ii) Esophagus; (iii) Pharynx; and (iv) Larynx Ans. i. Trachea: The trachea is a non-collapsible, wide tube forming the beginning of the lower respiratory passages. It is kept patent because of the presence of C-shaped cartilaginous rings in its wall. The cartilages are deficient in its posterior part, this part of the wall being made up of muscle (trachealis) and fibrous tissue. ii. Esophagus: The esophagus is a muscular food passage lying between the trachea and the vertebral column. The oesophagus is a downward continuation of the pharynx and begins at the lower border of the cricoid cartilage. iii. Pharynx: The pharynx is a wide muscular tube situated behind the nose, the mouth and the larynx. Clinically, it is a part of the upper respiratory passages. Upper part of the pharynx transmits only air, lower part (below the inlet of the larynx) only food but middle part is a common passage for both air and food. 34 When, Why and Where in Oral and Maxillofacial Surgery

iv. Larynx: The larynx is the organ for the production of voice or phonation. It is also an air passage and acts as a sphincter at the inlet of the lower respiratory passages. The larynx lies in the anterior midline of the neck extending from the root of the tongue to the trachea and, in adults it lies in front of the third to six cervical vertebrae but, in females and children, it lies at a little higher level. 131. Which are the layers of a neck? Ans. i. Skin ii. Superficial fascia iii. Investing layers of deep fascia. It is also known as fascia colli. These layers are: – Deep cervical fascia – Pretracheal fascia – Prevertebral fascia – Carotid fascia. 132. What is torticollis or wry neck? Ans. It is a deformity in which the head is bent to one side and the chin points to the other side. This is the result of spasm or contracture of the muscles supplied by the spinal accessory nerve, e.g. sternocleidomastoid muscle and trapezius. 133. Which are the extracranial sites for the branches of maxillary nerve? Ans. There are mainly three sites: i. Branches within pterygopalatine fossa ii. Branches within intracranial canal iii. Branches on the face. 134. List five key points about the taste buds. Ans. i. They are seen in the papillae, mucosa of soft palate and pharynx ii. They are barrel-shaped structures surrounded by stratified squamous epithelium Basic Science 35

iii. They consist of two types of cells: – The taste cells 4 to 20 taste cells per bud known as gustatory or neuroepithelial cells – The supporting cells are called sustentacular cells. 135. Give the full forms of the following abbreviations: (i) AIDS; (ii) HIV; (iii) LASER; (iv) ELISA; and (v) PGL syndrome Ans. i. AIDS: Acquired Immunodeficiency Syndrome ii. HIV: Human Immunodeficiency Virus iii. LASER: Light Amplification of Stimulated Emission of Radiation. iv. ELISA: Enzyme Linked Immunosorbent Essay v. PGL syndrome: Persistent Generalized Lymphadenopathy Syndrome. chapter Basic Oral Surgery 3

1. What is the correct way to ask systemic history for the patient assessment? Ans. Specific points related to the systemic diseases are as follows: i. Allergies ii. Blood disorders iii. Cardiac and respiratory conditions iv. Diabetes—drug taken v. Existence of low or high blood pressure vi. Faints or epilepsy vii. Gynecology problems and pregnancy viii. Hepatic and kidney ailments. 2. Who introduced the first aseptic technique? Ans. Joseph Lister introduced the first antiseptic technique. 3. What are the parts of a needle? Ans. There are four parts of a needle: i. Bevel ii. Shaft iii. Hub iv. Adaptor. 4. Why is PNS view called Water’s view? Ans. This view was described by Water and Waldron (1915). 5. What is the main difference between syncope and shock? Ans. Syncope: Refers to a sudden transient loss of consciousness, usually secondary, to the cerebral ischemia (only one system is involved due to cerebral ischemia). Basic Oral Surgery 37

Shock: It is an acute generalized inadequate perfusion of critical organ that, if continued, will produce serious pathophysiological consequences. Hemodynamic, endocrinal metabolic alteration produce clinical signs of shock (chain of events of pathophysiological consequences of multiple system involvement). 6. List the nerves which innervate the maxillofacial region? Ans. There are four cranial nerves: i. V cranial nerve: Trigeminal nerve ii. VII cranial nerve: Facial nerve iii. IX cranial nerve: Glossopharyngeal nerve. These are sensory fibers to the posterior part of tongue and help in swallowing iv. XII cranial nerve: Hypoglossal nerve is a motor nerve which innervates the tongue. 7. What is the difference between tetany and tetanus? Ans. Tetany is characterized by extensive spasm of skeletal muscle causing severe trismus. There is steady decrease in extracellular calcium followed by parathyroidectomy, resulting in hypocalcemic tetany. Tetanus is a bacterial infection caused by gram-positive anaerobic organism, the Clostridium tetany which causes widespread spasm of the muscle. 8. What is hyperventilation syndrome? Ans. Hyperventilation is simply an increase in alveolar ventilation caused by abnormally rapid and deep breathing. It is most commonly seen in dental clinics among the patients due to anxiety. Hyperventilation syndrome is often caused by anxiety, fear, excitement, nervousness, emotional stress and psychoneurotic reaction. It is most often seen in women. Hyperventilation results in hypocapnia, lowering of the PaCO2 . Hypocapnia causes a reduction in the cerebral blood flow. 9. Which method is used to sterilize the prepacked materials? Ans. Gamma radiation. 38 When, Why and Where in Oral and Maxillofacial Surgery

10. What is the difference between allergy and idiosyncrasy? Ans. Allergy is the acquired systemic complication of local anesthesia and idiosyncrasy is genetically determined by bizarre reaction. 11. On which principle does autoclave work? Ans. Pressure cooker principle/steam under pressure. 12. Define the following terms: (i) Sterilization; (ii) Antiseptic; (iii) Disinfectant; (iv) Sepsis; (v) Asepsis. Ans. (i) Sterilization: It is a process by which all the microbial forms are destroyed or it can be defined as the use of physical or chemical procedure to destroy all forms of microorganisms, including bacteria, spores, fungi and viruses. (ii) Antiseptic: A chemical that is applied to a living tissue, such as skin, mucus membrane, to reduce the number of microorganisms present through inhibition of their activity or destruction. (iii) Disinfectant: A chemical used on nonliving objects to kill the surface vegetative pathogenic organisms but not necessarily spore forms or viruses. (iv) Sepsis: It is the breakdown of the living tissues by the action of microorganisms usually accompanied by inflammation. (v) Asepsis: Medical asepsis attempt to keep the patients, health care staff and objects as free as possible of organisms that cause infection. Surgical asepsis is used to prevent microbes from gaining access to wounds. 13. What is the basic difference between normal cycle and flash cycle in autoclaving? Ans. Normal cycle: i. Temperature: 121°C ii. Time: 15 minutes iii. Pressure: 15 psi. Basic Oral Surgery 39

Flash cycle: i. Temperature: 134°C ii. Time: 3 minutes iii. Pressure: 30 psi. 14. At what percentage does alcohol show maximum antiseptic­ activity? Ans. At 70%, alcohol shows the maximum activity. 15. What is the mechanism by which the disinfectants and antiseptic act on microorganism? Ans. i. Coagulation of bacterial protein ii. Alteration in the properties of bacterial wall iii. Binding of sulfhydryl groups. 16. How does steam autoclaving kill the microorganism? Ans. It kills the microorganism by RNA and DNA breakdown. 17. What is the basic action of dry heat sterilization? Ans. Dehydration and oxidation. 18. What is the time and temperature cycle in dry heat sterilization? Ans. 170°C for one hour. 19. Which materials are sterilized by glass bead sterilizer? Ans. It is used mainly for endodontic files and burs. 20. Which method is used for the disinfection of operation theaters? Ans. Fumigation method is used. 21. What is the status of oral cavity at the time of birth? Ans. At the time of birth, oral cavity is sterile. 22. How much time is required to kill the bacteria by boiling water sterilization? Ans. 100°C for 10 minutes. 40 When, Why and Where in Oral and Maxillofacial Surgery

23. Which is the most commonly detected organism in the mouth of a newborn baby? Ans. Streptococcus salivarius. 24. Which material cannot be sterilized by a hot air oven? Ans. Culture media cannot be sterilized by hot air oven. 25. Which material is used for cold sterilization? Ans. Benzalkonium chloride. 26. At what temperature is ethylene oxide used for gas sterilization? Ans. At 108°C. 27. What is the method of the sterilization of metal instruments? Ans. Infrared radiation. 28. What is the method of the sterilization of catgut suture material? Ans. Ethylene oxide. 29. What is the method of the sterilization of heat and water- sensitive instruments? Ans. Gas sterilization. 30. What is the method of the sterilization of needle, suture material, dressing material? Ans. Ionizing radiation. 31. By which method is air purified in an operation theater? Ans. Ultraviolet rays. 32. Which material is used for the preoperative skin preparation? Ans. Povidone iodine. 33. What is the mode of action of alcohol? Ans. Denaturation of protein. 34. What is the mode of action of phenols? Ans. Precipitation of proteins. Basic Oral Surgery 41

35. What is the purpose of a hand scrub? Ans. i. Remove superficial contaminants ii. Loosen epithelium iii. Reduce bacterial count. 36. What is the time duration for a hand scrub? Ans. 10 minutes. 37. Which is the most commonly used disinfectant for dental unit and handpieces? Ans. Glutaraldehyde is most commonly used. 38. Which is the fastest, safest and the most effective way to sterilize a metal impression tray? Ans. Autoclaving is the best method even above 175°C. 39. What is cidex? Ans. Two percent glutaraldehyde is known as cidex. 40. How should be the edges of skin during the suturing on the face? Ans. Edges should be everted. 41. What is the primary aim of an extraoral dressing? Ans. i. Keep the surgical field free from infection ii. Pressure may help in controlling bleeding. 42. At what time interval should the dressing be changed? Ans. After every 24 to 48 hours. 43. What is the difference between anesthesia and paresthesia? Ans. Anesthesia: It is achieved after injecting a chemical known as local anesthetic agent thereby producing “temporary loss of painful sensation.” Paresthesia: It is a complication in the form of numbness due to nerve injury. 44. Which type of papilla does not contain taste buds? Ans. Filliform papilla. 42 When, Why and Where in Oral and Maxillofacial Surgery

45. Which muscles are present on the floor of the mouth? Ans. Genioglossus and mylohyoid muscles. 46. Which largest muscle is attached with the body of man- dible? Ans. Platysma muscle is attached to the body of mandible. 47. What is the difference between excisional biopsy and incisional biopsy? Ans. Excisional biopsy: It is indicated if the lesion is less than 2 cm in diameter. Incisional biopsy: It is indicated if lesion is more than 2 cm and requires a normal tissue with a pathologic tissue. 48. What is the name of the fixer used for biopsy specimen? Ans. 10% formalin is used. 49. What is incisional biopsy and when is it required? Ans. It is one of the biopsy techniques. It is required for the removal of living tissue (diseased and normal tissues), in case lesion is more than 2 cm in diameter. 50. What is the characteristic feature of excisional biopsy? Ans. Excisional biopsy includes normal tissues and all of the lesion. It implies removal of the entire lesion. It should be employed with smaller lesion less than 1 cm in diameter. 51. What are basic requirements of flap design? Ans. i. Base of flap should be broad ii. Provide adequate blood supply iii. Flap should rest on the healthy bone. 52. List the types of absorbable sutures. Ans. Plain and chromic catgut, polyglycolic, polyglactin. 53. List the types of nonabsorbable sutures. Ans. Silk, nylon, stainless steel. Basic Oral Surgery 43

54. Which suture material elicits more tissue reaction among catgut and silk? Ans. Catgut elicits more tissue reaction. 55. What is the advantage of chromic catgut over plain catgut suture material? Ans. Greater strength, less corrosiveness. 56. Which numbers of blades are used for intraoral and extraoral incision? Ans. Intraoral incision: 15 no. blade Extraoral incision: 10 no. blade. 57. Why are drains used? Ans. i. To provide exit for pus ii. To prevent formation of hematoma iii. To prevent formation of seromas in hard and soft tissues. 58. Which type of needle is used intraorally? Ans. Round body half circle needle is used. 59. What is the basic disadvantage of dry heat sterilization or hot air oven? Ans. Usually 160°C for two hours or 120°C for six hours is widely employed for sterilization of the cutting instruments. This whole process is time-consuming. 60. What is vicryl? Ans. Polyglycolic acid (vicryl) is an absorbable synthetic suture material. 61. What is proline? Ans. Proline is one of the suture materials. Proline or polypropylene is a synthetic, monofilament, non-absorbable suture material having minimal transient acute inflammatory reaction. 62. Which is the most commonly used suture material in an oral surgical procedure? Ans. Black silk (non-absorbable synthetic suture material) is the most commonly used suture material. 44 When, Why and Where in Oral and Maxillofacial Surgery

63. How is gut suture material absorbed? Ans. Absorbable sutures are digested by the tissue enzymes through hydrolysis. 64. In what packing is the catgut suture material supplied? Ans. Surgical gut suture (plain and chromic) supplied with packing fluid like 90% isopropyl alcohol or 0.5% sodium benzoate or 0.5% diethyl ethanolamine. 65. What is the advantage of chromic catgut over plaingut? Ans. Delayed resorption is the advantage over plain catgut. Plain catgut resorbs in 70 days. Chromic catgut resorbs in 90 days. 66. What concentration of alcohol is effective against spores? Ans. 70% ethyl alcohol is effective against spores. 67. A patient is on periodic renal dialysis. When and why should minor oral surgical procedure be performed? Ans. A patient requires elective oral surgery. Elective surgery is best undertaken one day after dialysis has been performed because this allows heparin used during dialysis to disappear and the patient to be in the best physiologic status with respect to intravascular volume and metabolic by-products. 68. Which blood product factor VIII cryoprecipitate or factor VIII concentrate is preferred for preoperative administration to achieve surgical hemostasis in a patient suffering from hemophilia A? Ans. The preferred blood product is factor VIII concentrate. 69. Which agent is used in the management of a hemophilic patient? Ans. Tranexamic acid is used in the management of a hemophilic patient IV 10 mg/kg body weight, 4 to 6 hourly. 70. What percentage of blood loss in case of hemorrhagic shock may cause hypotension? Ans. If blood loss is about 30 to 40%, it may cause hypotension. Basic Oral Surgery 45

71. How does pupil look in the patients of syncope? Ans. Dilated and fixed (dilatation of the pupil). Compression of the 3rd nerve and oculomotor nucleus in brain leads to fixed dilated pupil nonreacted to light. 72. Which is the most common organism associated with an attack of subacute bacterial endocarditis (SABE) of dental origin? Ans. Streptococcus viridans. 73. How will you treat Ecchymosis and hematoma? Ans. Ecchymosis: It consists of immediate application of cold followed by heat if there is no infection. In severe cases, antibiotics are given along with proteolytic enzymes, which causes breakdown of coagulated blood. Hematoma: Ice may be applied to the region immediately on recognition of a developing hematoma. It acts as a vasoconstrictor and it aids in minimizing the size of hematoma. Heat may be applied to the region at the beginning of the next day. 74. What are the early signs of the want of oxygen? Ans. i. Cyanosis ii. Increased pulse rate iii. Tachycardia. 75. What are the important signs of obstruction of air in a conscious patient? Ans. i. Stertorous breathing ii. Pronounced retraction of intercostals and supraclavicular spaces iii. Hands over throat (universal sign). 76. What is the primary hazard for an unconscious patient in a supine position? Ans. Tongue may fall back tongue obstruction. 77. Which common condition is seen in all types of shocks? Ans. Inadequate tissue perfusion. 46 When, Why and Where in Oral and Maxillofacial Surgery

78. When does the hypovolemic shock develop? Ans. After the loss of 40% of blood, hypovolemic shock develops. 79. What is the common type of shock in maxillofacial trauma? Ans. Hypovolemic shock. 80. What is the earliest sign of hemorrhagic shock? Ans. Tachycardia (increased heart rate) is the earliest sign. 81. What is the choice of drug in cardiogenic shock? Ans. Cardiogenic shock occurs as a result of: i. Inadequate cardiac output ii. Impaired oxygen delivery iii. Reduced tissue perfusion. It is caused by the loss of effective contractile function of myocardium. “Dopamine IV” is the vasopressor of choice. 82. What is the main cause and complication of septic shock? Ans. It is caused mostly by gram-negative bacteria. Acute respiratory failure is one of the complications. 83. What is the disadvantage of semilunar incision? Ans. Limited accessibility is the disadvantage. 84. What are the characteristic features of malignant hyper­ tension? Ans. i. Acidosis ii. Rigidity iii. Fever iv. Hypermetabolism v. Myoglobinuria. 85. What is the percentage of total body water? Ans. Total body water is 60% of the body weight in an average male. 86. What is fever? Ans. Fever is a pathologic state reflecting a systemic inflammatory process with a core temperature of more than 38°C but rarely more than 40°C. Basic Oral Surgery 47

87. What is the most common cause of fever in the first 24 hours after surgery? Ans. Aspiration pneumonia. 88. What are the most common causes of fever in the first 24 to 72 hours? Ans. i. Bacterial pneumonia ii. Thrombophlebitis. 89. What is the most common cause of fever 72 hours after surgery? Ans. i. Pneumonia ii. Wound infection iii. Urinary tract infection iv. Pulmonary emboli v. IV catheter infection 90. What are the five ‘Ws’ of postoperative fever? Ans. Possible causes of any postoperative fever are (i) Wind; (ii) Water; (iii) Wound; (iv) Walking and (v) Wonder drugs. 91. What are common signs and symptoms of phlebitis? Ans. Pain, tenderness, edema, erythema and streaking of the limb. 92. How will you manage phlebitis? Ans. Remove the IV catheter. Elevate the affected limbs. Apply warm, moist packs to the infected site. Initiate IV antibiotics. 93. What are the most frequent respiratory complications following oral and maxillofacial surgery? Ans. Pulmonary atelectasis, aspiration pneumonia and pulmonary embolus. 94. What are the common causes of postoperative bleeding? Ans. i. Incompletely ligated ii. Cauterized vessels iii. Wound infection iv. Coagulotherapy v. Rebound effect of hypotension anesthesia. 48 When, Why and Where in Oral and Maxillofacial Surgery

95. What are the common causes of postoperative hypotension? Ans. i. Intravascular hypovolemia ii. Myocardial depression iii. Hypothyroidism. 96. What are the most common causes of postoperative hypertension? Ans. i. Pain and anxiety ii. Hypoxia iii. Hypercapnia iv. Overdistention of the bladder. 97. What are some possible treatment options for postoperative hypotension? Ans. i. Elevation of lower extremities ii. Administration of vasopressors (ephedrine) iii. Administration of carefully monitored fluid. 98. Why is postoperative myocardial infarction difficult to diagnose? Ans. More than one-third of postoperative myocardial infarction is asymptomatic as a result of the residual anesthesia and analgesics administered postoperatively. 99. Define the following terms: (i) Syndrome; (ii) Malformation; (iii) Malformation complex; (iv) Malformation syndrome. Ans. i. Syndrome: It means running together. It means two or more abnormalities in the same individual. The term syndrome can apply equally as well to one of a kind condition as to a many of a kind condition. ii. Malformation: It is defined as a primary structural defect resulting from localized error of morphogenesis, e.g. cleft lip and palate. iii. Malformation complex: It may be defined as a malfor­ mation together with its subsequent derived structural changes. Basic Oral Surgery 49

iv. Malformation syndrome: It may be defined as two or more malformations or malformation complexes occurring in the same patient. For example, Goldenhar syndrome, in which hemifacial microsomia occurs together with lipodermoid, vertebral defect, cardiovascular and renal anomalies (unilateral renal agenesis). 100. What do you understand by the following terms: (i) Paralysis; (ii) Paresis; (iii) Anesthesia; (iv) Ageusia; (v) Analgesia; (vi) Hyperesthesia; (vii) Hyperalgesia/ hypoalgesia Ans. i. Paralysis: Loss of motor function in a particular part in the body ii. Paresis: Incomplete paralysis denoting neuromuscular deficit iii. Anesthesia: Loss of all types of sensation iv. Ageusia: Loss of taste v. Analgesia: Loss of sensitivity to painful stimuli vi. Hyperesthesia: Excessive sensitivity vii. Hyperalgesia/hypoalgesia: More/less painful stimuli. 101. In which sites are releasing incisions are contraindicated? Ans. i. Palate ii. Canine eminence iii. Lingual surface of mandible iv. Through muscle attachments v. In the region of mental foramen. 102. How do the absorbable gelatin sponge (gelfoam) and oxidized­ regenerated cellulose (surgical) assist in hemo- stasis? Ans. They form a matrix or scaffold upon which a clot can form. Gelatin sponge does not become as readily incorporated into the clot as does the oxidized regenerated cellulose. Healing is delayed more often with cellulose than with the gelatin sponge but oxidized regenerated cellulose is the more efficient agent. 50 When, Why and Where in Oral and Maxillofacial Surgery

103. Why are chromic catgut sutures packed in isopropyl alcohol? Ans. To prevent enzymatic degradation. 104. In which condition is the typical rail track scar formed? Ans. In case of delayed wound closure. 105. What are Langer’s lines and what is their importance? Ans. Langer’s lines are usually parallel with skin creases and perpendicular to the action of the underlying muscle. They are important in minimizing the scar. 106. Which is the best method to counteract severe acidosis following CPR? Ans. Administration of sodium bicarbonate IV. 107. Which is the positive sign if efforts in CPR are effective? Ans. Constriction of pupils. 108. Where is the entry point in tracheostomy? Ans. At the cricothyroid ligament. 109. In which patients is preoperative vitamin K indicated? Ans. In patients with liver disease. 110. In which patients is diazepam contraindicated? Ans. Psychic depression. 111. What is the side effect of prolonged use of phenytoin sodium? Ans. Gingival hypertrophy. 112. Which artery is involved in stroke? Ans. Lenticulostrate artery. 113. What is the characteristic sign of hemorrhagic shock? Ans. Increased pulse rate—Tachycardia. 114. Hemorrhagic shock is characterized by: Ans. i. Hypotension ii. Low blood volume iii. Increased pulse rate. Basic Oral Surgery 51

115. There is a case of patient with the history of chest pain on exertion which is relieved by rest and nitroglycerine. What should one suspect—angina pectoris or myocardial infarction? Ans. Angina pectoris. 116. How does aromatic spirit of ammonia act when a patient is made to inhale during syncope apart from the positive action to stimulate respiration? Ans. Aromatic spirit of ammonia is irritating to the sensory endings of the olfactory nerve. 117. What complication may arise in a patient with chronic alcoholism? Ans. Prolonged bleeding secondary to liver dysfunction. Prior to surgery, LFT (liver function test) is advised. 118. A pregnant woman in her third trimester becomes uncon­ scious on the dental chair. What treatment should be given to her immediately? Ans. She should the first lowered in supine position and then turned to her left side. 119. An odor of acetone in one’s breath would give suspicion of what disease? Ans. Diabetes mellitus. 120 There is a case of a patient with the history of polydispia, polyuria and polyphagia.­ What is the most probable diagnosis in this case? Ans. Diabetes mellitus. 121. What is the primary airway hazard for an unconscious patient in a supine position? Ans. Tongue obstruction is the primary hazard. Head tilt and chin lift positions occur in this case. 122. Preoperatively in hemophilic a patient, which blood product should be administered? Ans. Factor VIII concentrate should be administered. 52 When, Why and Where in Oral and Maxillofacial Surgery

123. Give five cardinal principles of antibiotic therapy. Ans. i. An antibiotic should not be used blindly. Use should be appropriate to the anticipated organism ii. Bacterial resistance may result from inadequate antibiotic therapy iii. Bactericidal drugs are not always essential iv. Apart from the right choice of drug, the appropriate dosages, mode and frequency of administrations are important v. Two or more antibiotics should not be used simultaneously and if the patient is allergic to drugs, an alternative drug must be used. 124. What is dog ear suturing? Ans. Dog ear may develop due to faulty suturing. The suturing should be removed and reclosure done or the dog ear should be lifted with tissue forceps and excised. We should avoid creating any dog ear at the end of the wound. 125. Give five cardinal principles of suturing. Ans. i. Generally, needle should be placed from labial or the buccal to lingual and palatal side ii. Generally, intraoral knot should not be placed on an incision line. It should be placed the buccal or labial side without tension iii. The needle always passes from thinner tissue to thicker tissue, from deeper tissue to superficial tissue, from movable tissue to fixed tissue iv. The needle should enter the tissue perpendicular to the tissue surface and the needle should be passed through the tissue along its curve. v. Dog ear suturing should be avoided. 126. Give five cardinal principles of incision and drainage. Ans. i. Incision should be placed at the site of maximum fluctuance Basic Oral Surgery 53

ii. Place the incision in an aesthetically acceptable area and place the incision in a dependent position to encourage drainage iii. Place the drain through and through in case of bilateral space infection, e.g. bilateral mandibular space infection iv. Do not leave the drain in place for an overlying extended period v. Incision should be in healthy skin and mucosa. Wound margins should be cleaned daily. 127. Catgut suture material is sterilized by what? Ans. Ethylene oxide. 128 What are the different positionings of the patient in a dental chair? Ans. i. Elevation ii. Supine position iii. Semisupine position iv. Trendelenburg head-down position v. Lateral position (tilt table position) vi. Table top turn position vii. Orthopedic position viii. Kidney surgery position ix. Neurosurgery position x. Lithotomy position. 129. What is the difference between granuloma, cyst and abscess? Ans. i. Granuloma is literally a tumor made up of granulation tissue. This term is used to designate the situation in the periapical region in which an abscess or localized area of osteolysis is replaced by granulation tissue. ii. Cyst is a cavity occurring in hard or soft tissue with liquid, semisolid or air content. It is surrounded by a definite connective tissue wall or capsule and may or may not be lined by epithelium. 54 When, Why and Where in Oral and Maxillofacial Surgery

iii. Abscess is a localized collection of pus in a cavity formed by disintegration of tissues usually caused by Staphy­ lococcus aureus. 130. After the use of a needle, what is the name of the technique to cover it? Ans. Scooping technique. 131. What is Brown’s test for confirmation of sterilization? Ans. Ampules contain a chemical indicator which changes its color from red through amber to green at a specific temperature. 132. What drugs are used in hemophilic patients for systemic administration? Ans. i. Desmopressin ii. Amicar = EACA (Epsilon Amino Caproic Acid) iii. Cyclokaprone = Tranexamic acid. 133. What are the different types of knots? Ans. i. Square knot: Two ties are given. The second throw is opposite the first throw ii. Surgeon’s knot: Because of the double throw to the first tie, this prevents slippage of the first tie while the second tie is put in place iii. Granny knot: This knot involves a tie in one direction followed by a single tie in the same direction as the first one. However, the third tie squared on the second tie must be made to hold the knot permanently. 134. Give different suturing techniques. Ans. i. Interrupted sutures ii. Continuous sutures iii. Continuous locking sutures iv. Horizontal mattress sutures v. Vertical mattress sutures vi. Figure of 8 suture vii. Subcuticular sutures. Basic Oral Surgery 55

135. What is WHO standardized grading scale to measure the severity of bleeding? Ans. Grade 0—no bleeding Grade 1—petechial bleeding Grade 2—mild blood loss (clinically significant) Grade 3—gross blood loss (serious), needs transfusion Grade 4—debilitating blood loss, (retinal or cerebral) asso- ciated with fatality. 136. What is the anatomic radiolucencies of lower jaw? Ans. i. Mandibular foramen ii. Mandibular canal iii. Mental foramen iv. Mental fossa v. Midline symphysis vi. Medial sigmoid depression vii. Airway shadow viii. Lingual foramen ix. Submandibular fossa x. Anterior Buccal mandibular depression xi. Cortical plate mandibular defect. 137. What is the anatomic radiolucencies of maxilla? Ans. i. Incisive foramen. ii. Incisive canal. iii. Nasal cavity. iv. Naris. v. Nasolacrimal duct. vi. Maxillary sinus. vii. Greater palatine foramen. 138. What are the common radiolucency involving both the jaws? Ans. i. Pulpal chamber and root canal. ii. Periodontal ligament space. 56 When, Why and Where in Oral and Maxillofacial Surgery

139. What are the anatomic radiopacities of jaws? Ans. Radiopacities common to both the jaws are as follows: i. Teeth ii. Bone iii. Cancellous bone iv. Cortical plates v. Lamina dura vi. Alveolar process. 140. What are the anatomic radiopacities of peculiar to maxilla? Ans. i. Nasal septum and boundaries of the nasal fossa ii. Anterior nasal spine. iii. Canine eminence. iv. Walls and floor of maxillary sinus. v. Zygomatic process of maxilla and zygomatic bone. vi. Maxillary tuberosity. vii. Pterygoid plates and pterygoid hamulus. viii. Coronoid process. 141. What are the anatomic radiopacities of peculiar to mandible? Ans. i. External and internal oblique ridge. ii. Mylohyoid ridge. iii. Mental ridge. iv. Genial tubercles. 142. Which are the superimposed radiopacities on the radio­ graphs? Ans. i. Soft tissue shadows ii. Mineralized tissue shadows. 143. Suture material should be removed after how many days? Ans. From oral cavity—5-7 days Head and neck region—5 days Other sites—5-10 days. Basic Oral Surgery 57

144. How will you differentiate between the bleedings from artery, vein and capillary? Ans.

Arterial Venous Capillary hemorrhage hemorrhage hemorrhage 1. It will be bright 1. It will be dark red in 1. An intermediate color red in colour color (bluish color) (between brisk red (brisk red) and bluish color) 2. Pulsating 2. No pulsating quality 2. Capillary blood will be character oozing 3. The flow will be 3. The flow will be less 3. It is nonpulsating in vigorous rapid nature It may be aggressive in nature in oral and maxillofacial region.

145. List the rule of 1 mm/2 mm/3 mm and 5 mm for suturing. Ans. On an average the suturing should be done: i. 1 mm distance from top of the incision line ii. 2 mm distance from the margin of incision line iii. 3 mm depth from the surface iv. 3 to 5 mm distance between two suture. chapter Local Anesthesia 4

1. Which is the first local anesthesia to be used clinically? Ans. Cocaine in 1860 by Albert Niemann. In 1884, William Halstead used cocaine for dental nerve block. 2. Define local anesthetic agent, local anesthesia and general anesthesia? Ans. Local anesthetic agents: These are the drugs which when applied directly to the peripheral nervous tissue, block nerve conduction and abolish all the sensations in the part supplied by the nerve. They are generally supplied by the somatic nerve and are capable of acting on axon, cell body, dendrites and synapses. Local anesthesia: It is the local state of loss of sensation without the loss of consciousness in a circumscribed area of the body due to an inhibition of the conduction process in the peripheral nerves. General anesthesia: It is a state which brings about the loss of all modalities of sensation, particularly pain along with a reversible loss of consciousness. 3. What are the contents of the anesthetic agent Lignocaine? Ans. i. HCl = 2% (20 mg/ml) ii. Adrenaline hydrochloride-vasoconstrictor-1:80000 (0.012 mg) iii. Sodium metabisulfite 0.5 mg (preservative/vasocons­ trictor/reducing agent) iv. Methyl paraben (preservative/bacteriostatic) or Capryl hydrocupreinotoxin which is included in xylotox = 0.1% (1 mg) Local Anesthesia 59

v. Sodium chloride (isotonic solution) = 6 mg vi. Sodium hydroxide = to adjust pH vii. Thymol = fungicidal viii. Ringer’s solution = as vehicle to minimize discomfort during injection ix. Distiled water for dilution. 4. What are the theories to explain the mode of action of local anesthesia (LA) and which theories are the most acceptable? Ans. i. Surface charge theory (Electric potential theory) ii. Membrane expansion theory iii. Specific receptor theory iv. Acetylcholine theory v. Reversible coagulation theory vi. Calcium displacement theory vii. Interference with nerve metabolism. The most accepted theory is “Specific receptor theory”. 5. What is the most accepted specific receptor theory? Ans. It decreases the permeability of the nerve membrane to the sodium ions. 6. Which local anesthetic is used in a hemophilic patient? Ans. Periodontal ligament/Intraligamentous technique. 7. What are the ideal requisites of a local anesthetic agent? Ans. i. It should not be irritating to the tissue. ii. It should not cause any permanent damage to the nerve structure. iii. Its systemic toxicity should be low. iv. The time of onset of anesthesia should be as short as possible. v. The duration of action must be long enough to permit the completion of procedure. vi. It should be stable in solution. 60 When, Why and Where in Oral and Maxillofacial Surgery

vii. It should be relatively free from producing allergic reaction. viii. It should readily undergo biotransformation in the body. ix. It should be capable of being sterilized by heat without deterioration. x. Its action should be reversible. 8. Which content of local anesthesia (amide type) may cause allergic reaction most likely? Ans. Allergic reaction caused by methylparaben used as germicidal or preservative. 9. Which is the alternative content in case a patient is allergic to methylparaben? Ans. Capryl hydrocupreinotoxin, which is included in xylotox. 10. Local anesthetic injection results in the loss of function in which order? Ans. Pain > Temperature > Touch > Proprioception > Motor sensation. 11. What are the other names of the following: (i) Nasopalatine nerve block; (ii) Greater palatine nerve block; (iii) Posterosuperior alveolar nerve block; (iv) Inferior alveolar nerve block; and (v) Long buccal nerve block. Ans. i. Nasopalatine nerve block: a. Posterior palatine nerve block b. incisive canal injection ii. Greater palatine nerve block: Anterior palatine nerve block iii. Posterosuperior alveolar nerve block: Zygomatic block iv. Inferior alveolar nerve block: Pterygomandibular block v. Long buccal nerve block: Buccinator nerve block and buccal nerve block. 12. What is the maximum dose of local anesthesia in ml? Ans. i. Local anesthesia with adrenaline (1: 80000) = 20 ml ii. Local anesthesia without adrenaline = 14 ml Local Anesthesia 61

13. Which is the most effective local anesthetic agent as topical anesthesia? Ans. Benzocaine. 14. Which of the following is not available as topical anesthesia? Ans. Procaine is not available as topical anesthesia. 15. Majority of local anesthetic agent without adrenaline have pH? Ans. pH = 5.5 acidic in nature (The normal tissue pH = 7.0 (approx). 16. Which local anesthetic agent is not affected by the effectiveness of tissue pH? Ans. Benzocaine. 17. Why is lignocaine preferred as the local anesthetic agent in comparison of procaine? Ans. Since it causes less allergic reaction. 18. Which local anesthetic agent causes vasoconstriction without a vasocons­trictor? Ans. Cocaine. 19. What is the average duration of nerve anesthesia with 2% lignocaine with 1 : 200000 adrenaline? Ans. More than 60 minutes. 20. Which is the longest acting LA? Ans. Bupivacaine 0.5% (pharmacologically belongs to the amide group) and tetracaine = 175 minutes is the duration. 21. What is the first choice of drug in anaphylaxis? Ans. Adrenaline 0.5 mg in 1:1000 I/M. 22. What is the exact cause of death due to local anesthetic toxicity? Ans. It is due to medullary depression. 23. What is the rate of deposition of LA? Ans. Local anesthetic should be deposited at the rate of 1 ml per minute. 62 When, Why and Where in Oral and Maxillofacial Surgery

24. In severe liver disease, which local anesthetic drug can be used safely? Ans. Procaine. 25. In case of allergy to procaine, which LA is contraindicated? Ans. Topical spray of tetracaine. 26. How much lidocaine is present in dental cartridge (2 cc) containing 2% lidocaine (xylocaine)? Ans. 1 ml contains 20 mg or 2 grams. So two cc cartridge contains 40 mg or 4 grams. 27. Pain sensation is conducted through which fibers? Ans. A-delta fibers. 28. Where does the LA act and how? Ans. LA acts on the nerve membrane, blocking the conduction of sodium from exterior to interior. 29. In general, what are the standard anesthetic cartridges available? Ans. Cartridges with 1.8 ml and 2.0 ml of the required contents. 30. Where is the LA metabolized in our body? Ans. Plasma, liver and lungs. 31. Which LA undergoes biotransformation in the kidney? Ans. Prilocaine is biotransferred in the kidney. 32. Syncope, trismus, hematoma and facial paralysis—out of these which is the most common complication of the LA? Ans. Syncope is the most common complication in dental clinic. 33. What complication can arise if LA is injected in LA hyper- thyroid patient? Ans. i. Increased sensitivity ii. Toxic crisis iii. Tachycardia iv. Fainting v. Chest pain. Local Anesthesia 63

34. Threshold of pain tolerance depends upon. Ans. i. Fear and anxiety ii. Mental status of the patient iii. Age of the patient iv. Previous experience. 35. How can we prevent syncope during anesthetic injection? Ans. i. By administration of premedication ii. By placing the patient in the reclined position iii. Aspiration of syringe before the deposition of solution (negative aspiration). 36. In syncope, if the patient’s condition deteriorates, what first step should be carried out? Ans. Administration of 100% oxygen can improve the condition. 37. What is the role of inhalation of aromatic spirit of ammonia in the management of the syncope? Ans. It acts as a respiratory stimulant. 38. How will you manage hyperventilation due to LA drug? Ans. The patient is made to rebreathe in and out of a bag, such a waste-paper bag, until recovery occurs. 39. If hyperventilation is not treated, which complication may arise? Ans. Tetany the complication characterized by extensive spasm of skeletal muscle causing Trismus. 40. In the cases of cardiac patients, how many cartridges can be given? Ans. Only two cartridges, approximately 4 ml can be given. 41. Which is safest LA in children and why? Ans. 2-chloroprocaine, due to short duration and less toxicity. 42. Which is the most toxic local anesthetic agent? Ans. Propoxycaine. 64 When, Why and Where in Oral and Maxillofacial Surgery

43. Why is anesthetic effect not obtained in the presence of inflammation or pus formation? Ans. Because pH is decreased due to inflammation or pus formation meaning more acidic media. It results in the abundance of H+ ions outside the nerve sheath and the equilibrium of reaction in the formation of lipophilic molecule [RH] is shifted to the left. Therefore, RH fails to enter the nerve and cannot block the conduction of impulse. 44. How the local anesthetic effect be increased? Ans. Local anesthetic effect can be increased by addition of adrenaline. In small doses, it causes vasoconstriction. 45. What are the advantages of adrenaline in a local anesthetic agent? Ans. Five advantages are: i. It decreases the blood flow to the site of injection because of vasoconstriction. ii. It decreases the rate of absorption of the local anesthetic agent into the cardio­vascular system iii. It lowers the plasma level of the local anesthetic agent, thereby decreasing the risk of the systematic toxicity of the local anesthetic agent iv. Higher volumes of the local anesthetic agent remains around the nerve for a longer period, thereby increasing the duration of action v. It decreases bleeding at the site of injection because of the decreased perfusion. 46. What does the systemic absorption of LA cause? Ans. i. Tonic clonic convulsion ii. Decreased cardiac output iii. Respiratory depression. 47. Accidental intravenous injection of LA, which contains a vasoconstrictor, may cause. Ans. i. Palpitation ii. Convulsion—Most significant adverse consequence. Local Anesthesia 65

iii. Unconsciousness iv. Depressed respiration v. Increased respiration. 48. What is the excess level of lignocaine can cause CVS collapse due to? Ans. Myocardial depression. 49. What is the cause of syncope in the patients receiving LA (ligno­caine-adrenaline 1:80,000) within 30 seconds of injecting it? Ans. The most probable cause is cerebral hypoxia or due to temporary cerebral ischemia. 50. Why is lignocaine used most commonly in dentistry? Ans. Because of the lesser incidence of allergy. 51. In reference to local anesthetic agent (Lignocaine): Ans. i. Pharmacologically belongs to which group—Amide group ii. Nature—Acidic salts and weak base. 52. What is the time of the onset action of LA? Ans. 3-5 minutes is the time of the onset of LA. 53. A patient following local anesthesia manifests pallor and becomes unconscious. What is the reason? Ans. Syncope is the probable reason, which is associated with bradycardia. 54. A patient who fainted during the extraction position should be given, what is the immediate treatment? Ans. The patient’s position should be Trendelenburg or head-down (10° to 15°). 55. Which is most alarming respiratory condition in the dental clinic? Ans. Aponea or respiratory arrest is the most common cause of death due to overdoses of LA in the dental clinic. 66 When, Why and Where in Oral and Maxillofacial Surgery

56. What is the maximum dose of adrenaline in a normal patient and a patient with cardiac problem? Ans. In a normal patient, 0.2 mg is the safe dose. In a cardiac patient, 0.04 mg is the safe dose. 57. What are the symptoms of overdose of epinephrine following LA injection? Ans. i. Restlessness ii. Apprehension iii. Palpitation. 58. A cartridge with LA should not be soaked in alcohol. Why? Ans. Alcohol can diffuse through rubber cap and cause contami­ nation, neurolysis and even may result in paresthesia. 59. What is the drug of choice to control status epilepticus due to overdose of LA? Ans. Diazepam is the drug of choice. 60. What are the clinical signs of toxic signs of LA? Ans. i. Convulsion ii. Asystole iii. Methemoglobinemia. 61. Due to overdose of LA, a patient will observe what hypotension or hypertension? Ans. Hypotension due to the vasodilatation properties of LA 62. What is the role of sodium metabisulfite in local anesthetic agent? Ans. Its role is to act as a reducing agent in local anesthetic to prevent the oxi­dation of vasoconstrictor (adrenaline). It competes with vaso­constrictor for the available oxygen and is oxidized to sodium bisulfate. 63. What are the common drugs used for anesthetic emergencies? Ans. i. Dexamethasone ii. Epinephrine (Adrenaline) Local Anesthesia 67

iii. Atropine iv. Avil v. Aminofilin. 64. What is EMLA? Ans. EMLA consists of 5% cream containing 25 mg/gram lidocaine + 25 mg/gram prilocaine. It is used for skin anesthesia. It is contraindicated in the age-group below six months because of the possibility of prilocaine induced methemoglobinemia. 65. What are the gases present in LA cartridges and why? Ans. The gases present in LA cartridges are: i. Nitrogen ii. Oxygen. The purpose is to prevent the deterioration of vasoconstrictor. 66. Name the gas used in a LA cartridge? Ans. Nitrogen gas is used in dental cartridges in the form of a small bubble about 1-2 mm in diameter. Nitrogen may not always be visible in the normal cartridge. 67. What is hyaluronidase? Ans. Hyaluronidase is an enzyme that breaks down the intercellular content. It is added to LA to speed-up both the onset of the anesthesia and the area of anesthesia. 68. What do you understand by induction time? Ans. Induction time is defined as the timeperiod from the deposition of the anesthetic solution to the complete conduction blockade. 69. Which type of nerve fibers require more concentration of the local anesthetic agent—motor fibers or sensory fibers? Ans. Motor fibers require more concentration of the local anesthetic agent. 70. What is the role of LA on myocardium? Ans. It produces the depressant effect. 68 When, Why and Where in Oral and Maxillofacial Surgery

71. What does a local anesthetic agent initially affects—smaller nerve fibers or larger nerve fibers? Ans. Anesthesia of smaller nerve fibers occurs prior to that of the larger nerve fibers. 72. What is basic difference between lignocaine and cocaine? Ans. Lignocaine Cocaine 1. Action on vessel- 1. Action on vessel- vasodilatation vasoconstriction 2. Synthetic local 2. Natural local anesthetic agent anesthetic agent 3. Produces vasoconstriction 3. Produces vasoconstriction with adrenaline without adrenaline 4. Amide 4. Ester of benzoic acid. 73. Sensitivity of LA is greater in which type of fibers? Ans. Type C fibers. 74. What is the onset time-period of lignocaine, xylocaine or lidocaine? Ans. 3-5 minutes is the onset time-period. 75. Which route of sedation is reversed most rapidly? Ans. Inhalation route is most rapidly reversed. 76. In which condition LA is not effective—local infection or edema? Ans. LA is not effective in the local infection. 77. While giving inferior nerve block, if the bone is not contac­ ted, then there are chances of what ailment? Ans. Transient facial paralysis because the needle may pierce the parotid gland and main trunk of the facial nerve may get anesthetized causing facial paralysis. 78. After inferior nerve block, a patient has the difficulty in opening eyelid on the side of injection. What is the probable cause? Ans. Anesthesia of facial nerve within the parotid gland. Local Anesthesia 69

79. What is the cause of trismus resulting after the inferior nerve block? Ans. Damage to the medial pterygoid muscle. 80. What are the structures passing through the inferior nerve block? Ans. Mucous membrane → Buccinator muscle → Alveolar tissue. 81. Injury to the inferior alveolar nerve may result in what? Ans. Temporary paresthesia of the lower lip. 82. What are the alternative techniques for the IAN block apart from the classical IAN block? Ans. i. Gow-Gates intraoral open mouth technique ii. Akinosi intraoral closed mouth technique. 83. Which is the site of deposition of LA in: (i) Classical inferior alveolar nerve block; and (ii) Gow-Gates technique. Ans. i. Classical inferior alveolar nerve block: Pterygomandi­bular space ii. Gow Gates technique: At the anterior region of the condyle. 84. Why at a time is bilateral lingual nerve block contraindicated? Ans. It may cause the loss of tongue movement and the tongue may fall back, causing airway obstruction. If necessary, tongue may be held with traction suture or it may be gently held. 85. Which facial space causes primary infection in case it is contami­nated during inferior alveolar nerve block? Ans. Pterygomandibular space is primarily involved because the solution is deposited in that space. 86. Sometimes swelling appears immediately after injecting inferior alveolar nerve block on the injecting side. Why? Ans. It may be due to injury to blood vessel. 70 When, Why and Where in Oral and Maxillofacial Surgery

87. Which is the most difficult maxillary tooth anesthetized by the local infiltration technique? Ans. Maxillary first molar due to the thick zygomatic covering. 88. In the posterosuperior alveolar nerve block, what are the direction and position of the needle? Ans. The needle is advanced slowly in upward, inward and backward directions Upward: Superiorly at 45° angle to the occlusal plane Inward: Medially towards the midline at 45° to the occlusal plane. Backward: Posteriorly at 45° angle to the long axis of the second molar. 89. In which nerve block most subjective symptoms are absent? Ans. i. Long buccal nerve block ii. Posterior superior alveolar nerve block. 90. What is the precaution to be taken while giving posterior superior alveolar nerve block? Ans. Short needle—25 mm should be used instead of long needle. Otherwise it may cause damage to: i. Pterygoid venous plexus ii. Posterior superior alveolar artery. 91. In which condition is the inferior alveolar nerve block abso­lutely—contraindicated in the hemophiliac or von Willebrand disease? Ans. In hemophiliac disease, it is absolutely contraindicated. 92. Allergy to local anesthesia is due to, what? Ans. Antigen antibody reaction. 93. Which muscles are inserted on pterygomandibular raphe? Ans. i. Buccinator muscle ii. Superior pharyngeal constrictor muscle. 94. Which two structures form a V-shaped landmark for an inferior alveolar nerve block? Local Anesthesia 71

Ans. i. Deep tendon of the temporalis muscle ii. The superior pharyngeal constrictor muscle. 95. Local anesthesia is the most effective in which medium? Ans. Alkaline medium. 96. A patient with periapical abscess after local anesthesia still complains of pain while removing the tooth. Why? Ans. Inadequate anesthesia due to infection. 97. Which are the structures anesthetized by greater palatine nerve block? Ans. Posterior portion of the hard palate and overlying structure up to the first premolar on the injected side. 98. To achieve palatal side anesthesia in the region of the molar teeth, the needle should enter in which foramen? Ans. The needle should enter the greater palatine foramen. 99. Which nerves are anesthetized in the infraorbital nerve block? Ans. i. Anterior superior alveolar nerve ii. Middle superior alveolar nerve. 100. The patient can be protected best from the toxic effect of LA? Ans. Using an aspirating technique. Before the deposition of the LA, it should be aspirated and if blood comes in the syringe, it should be withdrawn and again inserted. 101. Accidentally intravascular injection of 2% lignocaine with adrenaline 1 : 100,000 are the clinical signs? Ans. Hypertension, tachycardia and headache. 102. A patient susceptible or untoward to epinephrine, even in small amount may suffer from what ailments? Ans. i. Marked increase in BP ii. Increased heart rate arrhythmias. 72 When, Why and Where in Oral and Maxillofacial Surgery

103. A woman having late pregnancy should never be in the supine position on a dental chair. Why? Ans. i. It can produce caval compression ii. The uterus may press on the inferior vena cava iii. It can produce hypotension syndrome. 104. What type of LA can be used in the pregnant or lactating patients? Ans. Lignocaine, prilocaine, or etidocaine can cross the placentrex barrier but these are generally safe unless in excessive amount. 105. After LA with vasoconstrictor, there is an absence of pulse rate and respiration. What is the reason? Ans. Due to the anaphylactic reaction. 106. Due to LA, allergic reaction is characterized by what? Ans. i. Cardiovascular collapse ii. Angioneurotic edema iii. Bronchospasm iv. Urticaria. 107. A patient is allergic to the PABA derivatives. Which LA should be considered as an alternative in this case? Ans. Lidocaine (amide group). 108. Out of the following, which groups of drugs eliminate all the sensations—anesthetics/analgesics/narcotics/sedatives? Ans. Only anesthetics eliminate all the sensations. 109. Which drug counteracts the CNS stimulation due to accidental introduction into the vascular bundle? Ans. Pentobarbital counteracts the CNS stimulation. 110. What is the important data related to the LA 2.3.4.5.6.7.8.? Ans. i. Its molecular weight is 234. ii. Protein binding is 56%. iii. Its PH is just 7.8. 111. Where is the greater palatine foramen present? Ans. Between the second and third maxillary molar. Local Anesthesia 73

112. In greater palatine nerve block, what should be the position of the needle? Ans. The needle should be perpendicular to the mucosa. 113. For extraoral mandibular nerve block, the needle should be inserted from which position? Ans. Below the zygomatic arch. 114. For the extraoral maxillary nerve block, what is the target area? Ans. Anterior to the lateral pterygoid plate. 115. To control the tonic-clonic seizure following lignocaine toxicity the drug of the choice, what would be? Ans. Diazepam. 116. What is the basic difference between asthmatic attack and laryngeal edema in case of respiratory reaction in systemic complication? Ans. Asthmatic attack: Lower respiration system is involved Laryngeal edema: Upper respiratory system is involved which may cause airway obstruction and may even cause death. 117. What is main difference with reference to LA post-injection complication? Ans. i. Herpes simplex: – Viral infection – Site of soft tissue of hard palate (fixed tissue). ii. Recurrent aphthous stomatitis: – Bacterial infection – Site-free movable tissue (buccal vestibule). 118. Which group of patients are called ‘walking bombs’ and why? Ans. ‘Cocaine abuses’ because the risk of death is more in the patients with the use of local anesthesia with adrenaline. Moreover, cocaine has vasodilator action. 74 When, Why and Where in Oral and Maxillofacial Surgery

119. When is the appropriate time to administer an analgesic to control the postoperative pain? Ans. An analgesic should be administered before the anesthetic effects wear off. 120. Which is the drug of choice in the management of acute allergic reaction involving hypotension? Ans. Adrenaline is the choice of drug. 121. Toxic effect the after administration of LA with epinephrine are probably due to LA agent. What is the most significant sign? Ans. Drowsiness is the most significant sign. 122. What is the difference between nerve block and field block techniques of local anesthesia? Ans. Nerve block Field block 1. Local anesthetic solution is 1. The solution is deposited in proximity deposited within the close to the larger terminal branch to proximity to the main nerve achieve regional anesthesia trunk, which blocks the nerve In this method, anesthetic solution impulses. is deposited at or above the apex of 2. Nerve block involves a large the tooth to be extracted area, e.g. pterygomandibular 2. Field block is more circumscribed, block. involving tissue in and around one or more teeth.

123. What are the methods of local anesthesia or regional anesthesia? Ans. The methods are summarized as follows: i. Nerve block ii. Local infiltration iii. Field block iv. Surface anesthesia v. Intraligamentary injection. Local Anesthesia 75

124. What are the different local infiltration methods? Ans. The different local infiltration methods are as follows: i. Submucosal injection ii. Supraperiosteal injection iii. Subperiosteal injection iv. Intrabony injection v. Intraseptal injection vi. Intraligamentary injection vii. Palatal infiltration viii. Intrapulpal injection. 125. What are the two peculiarities of the mental nerve block? Ans. i. Mental nerve is not responsible for any tooth innervation. So, mental nerve block is not indicated for any tooth extraction. ii. Mental nerve block is mainly to anesthetize the mucous membrane of the lower lip and skin of the chin. 126. What is Kurt-Thoma technique for mandibular nerve block? Ans. It is indicated in the patients with limited mouth opening (trismus and ankylosis). The needle is inserted through the skin from below the lower border of the angle of mandible close to the inner surface or ramus, so that the needle finally comes from the medial to the mandibular foramen. Aspiration is done and the solution is deposited. 127. How will you classify a local anesthesia agent according to the time-period of action? Ans. According to the time-period of action, LA can be classified as follows: i. Ultra-short acting: Less than 30 minutes: – 2% lignocaine without vasoconstrictor – Procaine without vasoconstrictor ii. Short acting: 45 to 75 minutes: – 2% lignocaine with 1:100,000 adrenaline – 4% prilocaine when used for nerve block 76 When, Why and Where in Oral and Maxillofacial Surgery

iii. Medium acting: 90 to 150 minutes: – 4% prilocaine with 1:200,000 adrenaline – 2% lignocaine for pulpal anesthesia iv. Long acting: 180 minutes or more: – 0.5% bupivacaine with 1:200,000 adrenaline – 0.5% etidocaine with 1:200,000 adrenaline. 128. What are the immediate and late complications of a local anesthetic agent? Ans. i. Immediate complications: – Pain during injection – Burning sensation during injection – Breakage of needles – Syncope – Hematoma – Toxic reaction – Allergic reaction – Anesthesia in the non-specific areas. ii. Late complications: – Self-indicated trauma – Infection – Difficulty in mouth opening – Paresthesia. 129. What is the sequence of mechanism of action of a local anesthetic agent? Ans. The following sequence was proposed by Covino and Vassallo 1976: i. Displacement of calcium ions from the sodium channel receptor sites ii. Binding of the local anesthetic molecule to this receptor site iii. Blockade of the sodium channel iv. Decrease in the sodium permeability v. Depression of the rate of the electric depolarization vi. Failure to achieve threshold potential Local Anesthesia 77

vii. Lack of the development of propagated action potential viii. Conduction blockade. 130. What are the pain conduction (pain perception) theories? Ans. i. Specific theory ii. Pattern theory iii. Gate control theory. 131. What are vasoconstrictors? What is the systemic action of epinephrine (adrenaline)? Ans. Vasoconstrictors are the chemical agents or adjuncts added to the local anesthetic solutions to appose vasodilation caused by these agents and to achieve hemostasis. Systemic actions of epinephrine are: i. It stimulates myocardium ii. Greater incidence of dysrhythmias iii. It produces dilation of coronary arteries iv. Systolic blood pressure is increased, whereas diastolic blood pressure is decreased in smaller doses and increase in larger doses v. OHCVS: Increased stroke volume, increased heart rate, increased cardiac output, increased blood pres­sure (diastolic and systolic), increased myocardial oxygen consumption vi. Respiratory system: Potent dilator for the smooth muscles vii. CNS: In a normal dose, it does not stimulate CNS. In a high dose, it may stimulate CNS. 132. What are the components of dental cartridge? Ans. i. Cylindrical glass tube ii. Stopper (plunger, bung) iii. Aluminium cap iv. Diaphragm. 133. What are the contraindications of the use of vasoconstrictors? Ans. i. Patients with blood pressure more than 200 mm Hg/ 115 mm Hg 78 When, Why and Where in Oral and Maxillofacial Surgery

ii. Patients with uncontrolled hyperthyroidism iii. Patients with severe cardiovascular disease – Less than 6 months after myocardial infarction – Less than 6 months after cerebrovascular accident – Episodes of angina pectoris – Bypass surgery less than 6 months iv. Patients on tricyclic antidepressants v. General anesthesia with halogenated agents. 134. Should glass cartridges be autoclaved? Ans. No, autoclaving of glass cartridges destroys their seals. The heat of autoclaving also degrades the heat labile vasopressor. 135. Should the dental cartridges be stored in alcohol or a cold sterilizing­ solution? Ans. No, because it may get diffused into the cartridges and may cause burning sensation, irritation or paresthesia. 136. What is the difference between the bicuspid and central incisor techniques for infraorbital nerve block? Ans. Bicuspid approach Central incisor approach 1. The needle is inserted at a distance 1. The needle bisects the crown of the of 5 mm from the labial plate in central incisor into the distoincisal order to pass over the canine fossa. and mesial gingival halves at a distance of 0.5 mm from the bone into the mucobuccal fold.

137. What is the reason oozing or bleeding from the extraction socket after the third molar surgery when sometime has elapsed? Ans. During posterior superior alveolar nerve block, if the needle is inserted more deeply, it may cause damage to the following structures: i. Pterygoid plexus of veins ii. Posterior superior alveolar artery. Local Anesthesia 79

138. Why is nasopalatine (sphenopalatine or incisive canal injection) more resistant and painful? Ans. Nasopalatine injection is more resistant and painful because: i. Of the presence of free nerve endings in abundance ii. Thick palatal mucoperiosteal flap causes resistance. iii. Presence of narrow incisive canal, rapid forceful injection may cause pressure on nerve, resulting in painful sensation. 139. List the landmarks to make an imaginary line for infraorbital nerve block. Ans. The pupils of the eye when the patient looks straight: i. Supraorbital notch ii. Infraorbital notch iii. Infraorbital foramen iv. Mental foramen. 140. Typical but True Ans. i. In which nerve block is the syringe/needle position from the opposite side? – Inferior alveolar nerve block – Greater palatine nerve block. ii. In which nerve block – Mouth should be in the wide open position = Inferior alveolar nerve block – Mouth should be-half open position (cheek should be retracted the maximum) = Posterior superior alveolar nerve block – Mouth can be close but upper lip retracted maximum = Infraorbital nerve block. chapter Exodontia 5

1. Define exodontia/tooth extraction. Ans. Exodontia: It is a branch of oral surgery which deals with the extraction of teeth. Tooth extraction: The ideal tooth extraction is the painless removal of the whole tooth or the tooth root with minimal trauma to the investing tissue so that the wound heals uneventfully and no prosthetic problem is created. 2. Which media can be used to transport the avulsed tooth? Ans. i. Saliva ii. Fresh milk iii. Balanced salt iv. Hank balanced salt solution (HBSS): If the tooth is placed in an appropriate medium within 15 to 20 minutes—In saliva the periodontal cells can remain vital for 2 hours. In fresh milk, a tooth can remain vital for 6 hours. In balanced salt solution, a tooth can remain vital for 24 hours. 3. Why is water a harmful medium to transport the avulsed tooth? Ans. As the water is a hypotonic fluid, it may cause periodontal ligament cell death when it enters the cells down the osmotic gradient, causing cell lysis and death. 4. How long should the extruded or avulsed teeth be splinted? Ans. 7 to 10 days. Exodontia 81

5. What are the different positions of an operator for the extraction of teeth from different quadrants? Ans. i. Upper left and right quadrants: Front the right side of the patient ii. Lower left quadrant: Front the right side of the patient iii. Lower right quadrant: – Anterior teeth—Front right side of the patient – First and second premolar—Slightly right side of the patient – First and second molar—Exactly right side of the patient – Third molar—Behind the right side of the patient 6. Which tooth is extracted standing behind the patient? Ans. Ideally mandibular right side third molar should be extracted standing just behind the patient and the right side first and second molar can also be extracted standing behind the patient. 7. What is the height the chair during the maxillary and mandibular teeth extraction? Ans. i. For maxillary teeth: 8 cm (3 inches) below the shoulder level of the operator ii. For mandibular teeth: 16 cm (6 inches) below the elbow level of the operator. 8. How should be the beaks of the tooth extraction forceps on the tooth surface? Ans. The beaks of the tooth extraction forceps should be parallel to the long axis of the tooth surface. 9. What should be the position of the tips of the beak of tooth extraction forceps on the tooth surface? Ans. The tips of the beaks should be on the root as far apically as possible, minimum at the CE junction. 10. Which structure of the tooth receives the maximum force as per the design of the beak of the tooth extraction forceps? Ans. Maximum force should be transmitted to the root of the tooth. 82 When, Why and Where in Oral and Maxillofacial Surgery

11. What should be position of the occlusal plane of the mandibular teeth when they are to be extracted? Ans. The occlusal plane of the mandibular teeth should be parallel to the floor when the mouth of the patient is wide open. 12. What is the important principle during extraction? Ans. Least trauma to bone and mucosa. 13. Give the different parts of a tooth extraction forcep and a dental elevator. Ans. Tooth extraction forcep Dental elevator Beak Blade Hinge Shank (shaft) Handle Handle

14. What should be the position of the patient when the maxillary teeth are to be extracted from a patient’s mouth? Ans. When maxillary teeth are to be extracted, the patient should be positioned in a such a way that the occlusal plane of the maxillary teeth should be at 45° to the floor when the mouth is wide open. 15. What is the sequence of extraction? Ans. The sequence to be followed for extraction is 8, 7, 5, 6, 4, 2, 3, and 1. Maxillary teeth should be extracted before the mandibular teeth. 16. What are the methods of extraction? Ans. i. Close (forceps extraction method) or intra-alveolar extraction ii. Open method (surgical extraction) or transalveolar extraction. Exodontia 83

17. What is the difference between close and open methods of tooth extraction? Ans. Close method Open method 1. It is also known as forceps extrac­­ 1. It is also known as surgical extrac­ tion or intra-alveolar extraction tion or transalveolar extraction 2. The tooth is extracted entirely 2. The operator gains direct access from the tooth socket within to the alveolar bone and root after the alveolar bone raising the overlying soft tissue 3. The technique consists of 3. The technique consists of raising removing the tooth or root by the flap. Removal of the bone the use of forceps or elevator followed by tooth removal. or both

18. What are the five steps of tooth extraction? Ans. The five steps of tooth extraction are: i. Reflection of the mucoperiosteum flap with the help of periosteum elevator ii. Luxation of tooth with or without the use of dental elevator up to grade 1 mobility (up to 1 mm mobility of tooth) iii. Further luxation of tooth with or without the use of dental elevator up to grade 3 mobility (up to 3 mm mobility of tooth) iv. Deliver the tooth from the socket with the help of the tooth extraction forcep. v. Compression of the socket with finger pressure to check the bleeding and recontouring of the alveolar ridge. 19. What are the mechanical principles of the tooth extraction? Ans. Mainly there are three mechanical principles: i. Expansion of bony socket: To permit the removal of the tooth from the socket ii. The use of a lever and fulcrum: To force a tooth or root out of the socket along the path of least resistance 84 When, Why and Where in Oral and Maxillofacial Surgery

iii. The insertion of a wedge or wedges between the tooth root and the bony socket wall, thus causing the tooth to rise in its socket. 20. Explain the following terms: (i) Stobies extraction; (ii) Wilkinson’s extraction; (iii) Rubber band extraction; and (iv) Postage stamp extraction. Ans. i. Stobies extraction: Adjacent teeth round and single root can be cross luxated to facilitate their extraction, e.g. mandibular anterior six teeth, extraction of mandibular premolar teeth ii. Wilkinson’s extraction: Orthodontic extraction of grossly carious lower 1 molar to create space for further eruption of third molar. This technique is not much popular iii. Rubber band extraction: It is done in the patients suffering from hemo­philia (to avoid bleeding) where a rubber band is placed at the cementoenamel of the tooth, the apical movement of which induces coronal tooth migration and eventual exfoliation of tooth due to pressure necrosis of the periodontal ligament iv. Postage stamp extraction: The alveolar bone is cut in the shape of a postage stamp by first drilling multiple holes with a bur and then connecting them. This facilitates direct exposure and removal of tooth mass. 21. List the key points to be remembered while using the dental elevators. Ans. i. Dental elevators should be used on cementoenamel junction of the tooth ii. They are mainly used to luxate, elevate and to deliver the tooth from the socket iii. Tooth can be removed with or without the use of a dental elevator iv. Never use labial, buccal, lingual and palatal cortical plate as fulcrum Exodontia 85

v. Inter-radicular bone can be used as fulcrum. In case of extraction of roots of the tooth, an elevator should be used from the gingival margin vi. Elevators should be used in a predetermined direction and always used with fingerguards to minimize the complication. 22. What is the open-window technique of tooth extraction? Ans. Open-window technique is a modification of the open technique. In this method, a bur is used to remove the bone overlying the apex of the tooth, exposing the fragment. An instrument is then inser­ted into the window and the tooth is displaced out of the socket. For example, when the buccal crestal bone must be left intact; for instance, in case of the removal of maxillary premolars for orthodontic purpose. 23. A patient on steroid therapy needs extraction of chronically infected teeth. What premedication do such patients require? Ans. Such patients should be premedicated with the antibiotic therapy. 24. After giving inferior alveolar nerve block, the needle acci­ dentally pricks the dentist’s finger. The dentist subsequently develops malaise, weakness and elevated SGOT and SGPT. What does this suggest? Ans. This suggests that the dentist has contacted a patient through prick injury suffering from serum hepatitis. 25. A patient receiving systemic corticosteroid therapy requires the surgical removal of tooth. What is the protocol of corti­ costeroid therapy in such patients? Ans. Corticosteroid therapy should be continued. Double the dose preoperative day, operative day and postoperative day. Then gradually reduce the dose; otherwise it may cause adrenal crisis. 86 When, Why and Where in Oral and Maxillofacial Surgery

26. The extraction of maxillary 1 molar has resulted in perfo­ ration of maxillary antrum of about 5 mm in diameter. What is the immediate treatment protocol? Ans. Smoothening of the bony socket margin, airtight suturing across it. Broad spectrum antibiotics along with analgesics, anti- inflammatory properties and supplements. 27. What is the best time for extraction in pregnancy? Ans. Second trimester is the safe time for extraction. The first trimester is the stage of organogenesis of fetus and the fetus is highly susceptible to the developmental malformation, if the mother passes through stress and strain. In third trimester, large quantity of steroids are released into the blood. The pituitary gland secretes oxytocin, which stimulates uterus contraction and increases the chances of premature delivery. 28. A pregnant lady in the 2nd trimester falls in syncope during extraction. What should be the patient’s position on the dental chair? Ans. Left lateral position. 29. For the extraction of which tooth is the rotatory or screw- like movement used? Ans. For the extraction of maxillary canine, the rotator movement is used because the neck or cervical area is more conical. So it is easy to rotate or a mesiodistal or screw-like movement is appropriate. 30. If a tooth is inhaled during extraction, what is the site to enter and what complications can arise? Ans. The tooth enters into the right bronchus. If the tooth is not located in the mouth, take a radiograph of socket and chest. If the tooth is located in the bronchus, it should be immediately removed by bronchoscope. 31. Postoperatively one day after total extraction, a patient complains of blue black spot on the face and neck region. What is the reason? Ans. Postoperative ecchymosis is the cause of blue black spot. Ecchymosis is the extravasation of blood in the subcutaneous tissue Exodontia 87 with facial discoloration caused by the breakdown of hemoglobin. Management consists of cold fomentation. Antibiotics are given with proteolytic enzyme, which cause the breakdown of coagulated blood. 32. What is the first direction and force to be applied for the removal of a tooth with the help of the tooth extraction forceps? Ans. First force is the apical force in the apical direction. First movement is always apical in direction. 33. In which condition is the rubber band extraction indicated? Ans. In case of bleeding disorder like hemophilia and heman- gioma. 34. A known HIV-positive child requires tooth extraction because of the severe pain due to abscess. What should be done initially? Ans. As patient is known to be HIV-positive, firstly the patient should be referred for ELISA test, which is used for diagnosis. 35. In which condition is the following extraction absolutely contra­indicated: central hemangioma or hypertension? Ans. Central hemangioma. 36. A patient had myocardial infarction. When should the elective dental extraction be performed? Ans. The extraction should be postponed for atleast six months have lapsed. 37. Why are the patients with renal disease (late stage) at higher risk when undergoing extraction of teeth? Ans. i. They have increased tendency to bleed ii. They are susceptible to infection iii. They are often on steroid therapy. 88 When, Why and Where in Oral and Maxillofacial Surgery

38. What is the classic triad of the following conditions: (i) Dry socket; and (ii) Osteoradionecrosis. Ans. i. Dry socket – Clot loss or necrosis – Pain – Fetor oris ii. Osteoradionecrosis – Infection – Radiation – Trauma. 39. List the synonyms of dry socket. Ans. Following are the synonyms of dry socket: i. Postextraction syndrome ii. Alveolitis sicca dolorosa iii. Alveolar osteitis iv. Focal osteomyelitis v. Acute alveolar osteitis vi. Alveolagia vii. Postextraction osteomylitic syndrome viii. Postexodontic alveolar osteitis ix. Fibrinolytic alveolitis x. Fibrinolytic osteomyelitis xi. Necrotic alveolar socket xii. Localized alveolar osteitis. 40. What are the hypotheses to explain pathogenesis of dry socket? Ans. There are two hypotheses: i. Birns hypothesis – Birns fibrinolytic theory (1973) – Bacterial hypothesis ii. Nitizen’s hypothesis (1983) Possible anaerobic infection

Plasmin like fibrinolytic activity

Clot dissolution Exodontia 89

41. What is the ideal and primary treatments of dry socket? Ans. Debridement of socket (local care of socket) and sedative dressing (to relieve from the pain). 42. On which day is severe pain experienced in dry socket? Ans. Third day after extraction. 43. Which is the most common site of dry socket? Ans. Lower molar area due to less blood supply. 44. What is the reason for dry socket after extraction? Ans. It results from the loss of blood clot in the socket. 45. What is the cause of hypoglycemia during extraction even after taking of insulin? Ans. If extraction is done on empty stomach, hypoglycemia occurs. 46. A 65-year-old diabetic patient requires extraction even after taking the morning insulin dose. Which preoperative instruction is important in this case? Ans. The patient should maintain normal diet. An empty stomach may cause hypoglycemia. 47. What is the initial treatment when a patient returns after six hours of extraction with persistent bleeding? Ans. Remove the clot and examine the bleeding area to localize the source of bleeding. 48. What is most serious complication after the extraction from area previously irradiated? Ans. Osteoradionecrosis. 49. During the extraction of the maxillary third molar, if maxillary tuberosity is fractured but remains attached to mucoperio­steum, what is the treatment in this case? Ans. Reposition the fractured fragment and stabilize with suture. 50. The displacement of the root into the maxillary sinus is most likely to happen during the extraction of which tooth? Ans. Maxillary 1 molar because the roots are very close to the inferior wall of the maxillary sinus. 90 When, Why and Where in Oral and Maxillofacial Surgery

51. Which root is most likely to be pushed into the maxillary sinus during a dental extraction? Ans. Palatal root of maxillary 1 molar. 52. Why is it contraindicated to curette a dry socket to stimulate bleeding? Ans. Curetting a dry socket can cause the condition to worsen because healing will be further delayed. Any natural healing already taking place will be disturbed and there is a risk of causing the localized inflammatory process to be spread to the adjacent sound bone. 53. Why is the bone removal with an aerator usually contra­ indicated? Ans. It is contraindicated as there is danger of developing emphysema. 54. What is the principle action of aromatic spirit of ammonia? Ans. Syncope is transient loss of consciousness due to cerebral ischemia (anoxia). Predisposing factors like anxiety, fear induce the release of increased amount of catecholamines. This results in lowered peripheral resistance and fall in blood pressure. Spirit of ammonia acts as a respiratory stimulant and it overcomes the cerebral hypoxia. 55. What are the persistent causes of pyrexia after tooth extraction? Ans. Wound infection, cellulitis, dehydration and endocarditis. 56. Why is it contraindicated to curette residual pathologic tissue after removing the maxillary anterior teeth? Ans. The bony crypt should never be scraped after the removal of any tooth. Veins in this region (maxillary anterior teeth region) do not have valve manipulation of the infected material, and thrombi in the extraction site force it into the cranial vault to the cavernous sinus, resulting in a cavernous sinus thrombosis. Exodontia 91

57. After the teeth are removed, when does the radiographic evidence of the bone formation in the extraction site first become evident? Ans. Evidence of bone formation does not become prominent until the sixth to eighth week. There are radiographic differences between the newly formed bone and adjacent alveolar bone for about 4–6 months. 58. Why should mucoperiosteum flap be repositioned accu­ rately? Ans. Since mucoperiosteum is inelastic in nature, manipulation is not possible. So it should be repositioned accurately. 59. What are the causes of postoperative bleeding or hemor­ rhage? Ans. Following are the causes of postoperative bleeding: i. Alcohol ii. Aspirin iii. Antimalignant iv. Antibiotic (Broad spectrum long therapy or sulfonamide) v. Anticoagulant vi. Liver disease. 60. Which muscle is most frequently encountered within an incor­rect infraorbital nerve block? Ans. Quadratus labii superiors. 61. What are the possible complications which can arise during the extraction of isolated residual maxillary molar? Ans. i. Fracture of tuberosity ii. Fracture of floor of the antrum. 62. If a tooth is resistant to luxation with forceps, its removal is best performed by which method? Ans. Transalveolar method or open method or surgical extraction. 92 When, Why and Where in Oral and Maxillofacial Surgery

63. Following the zygomatic block or maxillary tuberosity injection or posterior superior alveolar nerve block within a few seconds, the patient’s face becomes extremely distended and swollen on the injected side. What is the reason and how will you manage this? Ans. Due to angioedema or hematoma formation, there may be injury to the artery or vein (posterior superior alveolar vessels). It should be managed by cold packs and digital pressure on the affected side. 64. What is the role of acriflavine solution? Ans. Acriflavine solution is applied to the alveolar bone to locate a buried root, which is not visible even after the reflection of muco­ periosteum flap. The bone being porous, takes up the orange stain while the non-staining root becomes more obvious against the darker background. But the test is not applicable for the sclerotic areas of the bone as it fails to take up the dye. 65. Explain following terms: (i) Lingual split technique; and (ii) Lateral trephination technique of Bowdler-Henry. Ans. i. Lingual split technique: For removal of impacted mandi­ bular molar by splinting the lingual cortex adjacent of the III molar and facilitates elevator in a distoangular direction. ii. Lateral trephination technique of Bowdler-Henry: Removal of mandibular 3 molars which are unlikely to erupt into occlusion when their roots have only begun to form. An opening is made on the tooth by cutting the buccal cortical plate and the tooth is delivered out by an elevator from the same. 66. Name of the drugs which are relative or absolute contra­ indicated in tooth extraction? Ans. i. Anticoagulant therapy ii. Corticosteroid Exodontia 93

iii. Immunosuppressive drugs iv. Chemotherapeutic drugs. 67. What are the rules for the use of forceps in extraction? Ans. i. The correct forcep should be selected ii. While holding the forcep, the end of the handle should be covered by the palm of the hand iii. The forceps beak must be placed on the sound root structure and not on the enamel of the crown iv. The long axis of the beak of the forceps should be along the long axis of the tooth v. The root structure must be grasped firmly so that when pressure is applied, the beak does not move over the cementum, otherwise breakage may occur vi. Forceps should not impinge the adjacent tooth’s soft tissue, like gingival, lip, cheek, tongue, etc. during the application of force. 68. Which forces are exerted during the teeth extraction? Ans. There are mainly two types of forces exerted: i. Primary forces: To luxate the tooth – Apical pressure: Pushed into the socket – Buccal force: Towards the buccal side – Lingual pressure: Towards the lingual side – Palatal pressure: Towards the palatal side – Labial side: Towards the labial side – Rotational force: Screw-like or rotatory force ii. Secondary forces: At the terminal stage of tooth extraction It is also known as traction force, which finally delivers the tooth from the socket. 69. What are the different steps of healing of the extraction wound or socket? Ans. This process may be divided into five stages: i. Hemorrhage and clot formation ii. Organization of clot by granulation tissue 94 When, Why and Where in Oral and Maxillofacial Surgery

iii. Replacement of granulation tissue by connective and epithelization of the wound iv. Replacement of the connective tissue by coarse fibrillar bone v. Reconstructing the alveolar process and replacement of the immature bone to the mature bone tissue. 70. What is odontotomy? Ans. In some cases, extraction may be simplified by cutting a tooth apart. This is especially desirable in the case of: i. Multi-rooted tooth ii. Severely divergent roots iii. The crown is so decayed that only the shell remains. 71. What are the causes of tooth/root fracture? Ans. i. Improper technique ii. Ankylosed teeth iii. Hypercementosis teeth iv. Divergent root v. Endodontically treated teeth vi. Extensively carious teeth vii. Teeth with gross filling viii. Condensing osteities ix. Improper application of instrument/force x. Uncooperative patient. 72. How many teeth should be extracted in a single visit? Ans. It depends upon the health and fitness of the patient. In case of a planned uncomplicated case, one side upper and lower, either right or left posterior teeth can be removed in one visit (anterior teeth removed later with infiltration). Further surgery, even extraction should be done not earlier than a week till the time swelling and discomfort have disappeared and white cell count has turned to normal. Exodontia 95

73. What is the rule of 3 for the extraction of maxillary first molar? Ans. Rule of 3 for the extraction of maxillary first molar: i. The maxillary first molar having 3 roots. ii. 3 pricks are required. iii. To anesthetize 3 nerves: – Mesiobuccal root = middle superior alveolar nerve – Distobuccal root = posterior superior alveolar nerve – Palatal root = greater palatine nerve 74. Which is the common organism found in dry socket? Ans. Most commonly Treponema denticola is found in dry socket. 75. Which teeth are most likely to slip during the extraction process and the patient may swallow it? Ans. In maxillary arch = Maxillary canine In mandibular arch = First premolar. chapter Impaction 6

1. The word ‘impaction’ is derived from which word? Ans. It is derived the word from ‘IMPACTUS’ 2. What is the basic difference between following terms: (i) Unerupted tooth; (ii) Malposed tooth; and (iii) Impacted tooth. Ans. i. Unerupted tooth: A tooth which is not an erupted or perforated tooth ii. Malposed tooth: A tooth erupted or unerupted, which is in an abnormal position in the maxilla or mandible iii. Impacted tooth: If a tooth cannot assume its normal position in the oral cavity due to any mechanical obs­ truction, it is known as impacted tooth. 3. What are the theories to explain impaction? Ans. i. Physiologic theory ii. Mendelian theory iii. Endocrine theory iv. Pathologic theory v. Orthodontic theory. 4. What points are to be considered as preoperative assessment on the basis of radiographic evaluation for the removal of the impacted third molar? Ans. The following points are to be considered: i. Access ii. Position and depth of impacted third molar tooth iii. Root pattern of impacted mandibular third molar. Impaction 97

iv. Shape of crown of impacted mandibular third molar v. Texture of investing bone vi. Position and root pattern of mandibular third molar vii. Inferior dental canal relationship with mandibular third molar. 5. What is the base of Pell and Gregory classification for impacted third molar? Ans. On the basis of: i. Relationship of the impacted lower third molar to the ramus of the mandible and second molar. ii. Relative depth of the third molar in the bone. 6. What are the different classifications of the impacted mandibular third molar? Ans. 1. I classification: Pell and Gregory classification A. On the basis of the relation of tooth to ramus of mandible and second molar: i. Class I ii. Class II iii. Class III B. On the basis of the relative depth of the third molar in the bone i. Position A ii. Position B iii. Position C 2. II classification: Winter’s classification—On the basis of the position of the long axis of third impacted third molar in relation to the long axis of the second molar, e.g. mesioangular, distoangular, linguoversion, buccoversion, torsoversion (inverted). 3. III classification: Combined classification of the American Dental Association (ADA) and the Association of American Oral and Maxillofacial Surgeons (AAOMS): On the basis of coding system. 98 When, Why and Where in Oral and Maxillofacial Surgery

7. What do you understand by the term torsoversion? Ans. It means inverted tooth. For example, impacted mandibular third molar crown will be downward and the root upward (reverse from the routine pattern). 8. What are George Winter’s imaginary lines? Ans. Three imaginary lines are drawn on the IOPA radiograph to assess the position and depth of the impacted tooth known as WAR lines. i. White line: It indicates the difference in occlusal level of second and third molars. It is drawn touching the occlusal surfaces of first and second molars and is extended posteriorly over the third molar. ii. Amber line: It indicates the amount of the alveolar bone covering the impacted tooth. It is drawn posterior to anterior, from third molar to first molar iii. Red line: It indicates the depth of the tooth in the bone and the difficulty encountered in removing the tooth. Normal depth is 5 mm. 1 mm increase in depth increases three times more difficulty in the removal of the tooth. 9 mm or more increase in depth requires removal of tooth in nasal intubation. 9. What is Wharf’s assessment of impacted third molars? Ans. The six factors determining Wharf’s assessment are: i. Winter’s classification ii. Height of the mandible iii. Angulation of third molar iv. Root shape and morphology v. Follicle development vi. Path of exit of the tooth during removal 10. What is the clinical importance of access as preoperative assessment for the removal of the impacted mandibular third molar? Ans. Access may be determined by noting the inclination of the radiopaque line cast by the external oblique-ridge. If this line is vertical, access is poor and if this line is horizontal, access is excellent. Impaction 99

11. What is the importance of the shape of a clinical crown as pre­operative assessment in the removal of the impacted mandibular third molar? Ans. i. Large square crown and prominent cusps are more difficult to remove ii. Small crown and flat cusps are easy to remove 12. What is the general sequence to remove the bone and make a gutter from the different surfaces of the impacted tooth? Ans. The sequence is as follows: i. Occlusal surface: If the tooth is not visible in the oral cavity ii. Buccal side/surface iii. Mesial side/surface iv. Distal side/surface – Any surgical intervention should be avoided on the lingual side – Gutter should be made up to the minimum cemento- enamel junction because the point of elevation should be below the cementoenamel junction. 13. What are the systemic causes of impaction? Ans. According to Berger: i. Prenatal: Hereditary/misconception ii. Postnatal: Tuberculosis/ malnutrition/congenital syphilis/ rickets/anemia/endocrine dysfunction iii. Rare conditions: Cleft palate/oxycephaly/achondroplasia/ cleidocranial dysostosis. 14. What is the general order of the frequency of impaction? Ans. i. Mandibular third molar ii. Maxillary third molar iii. Maxillary cuspid iv. Mandibular bicuspid v. Mandibular cuspid vi. Maxillary bicuspid vii. Maxillary central incisor viii. Maxillary lateral incisor. 100 When, Why and Where in Oral and Maxillofacial Surgery

15. What are the different classifications of the impacted maxillary canine? Ans. i. 1st classification: Field and Ackerman classification. On the basis of the location of the impacted tooth and relation with adjacent teeth. ii. 2nd classification: On the basis of the angulation of the impacted tooth. 16. What are the basic steps for the removal of the impacted mandi­bular third molar? Ans. The steps are as follows: i. Reflection of adequate flap (mucoperiosteal flap) for accessibility (with the help of different incision, e.g. – Terrance Ward’s standard incision – Envelope flap incision – Coma incision. ii. Removal of the overlying bone either with the help of the surgical bur or chisel or both and making a point of elevation iii. Sectioning of the tooth if required iv. Delivery of the tooth from the socket (elevation and extraction of the tooth from the socket) v. Debridement of the wound vi. Achieve hemostasis vii. Smoothen the bony margins viii. Closure of the wound with suture. 17. Shift tube technique que or Clark’s rule or buccal object rule are used to determine the position of which tooth? Ans. Impacted canine position can be determined by these techniques. 18. What are different incisions for the removal of the impacted mandibular third molar? Ans. Different incisions or approaches are: i. Terrance Ward’s standard incision ii. Modified Ward’s incision (1st modification) Impaction 101

iii. Modified Ward’s incision (2nd modification) iv. Envelope flap incision v. Modified flap incision type 1 vi. Modified flap incision type 2 vii. Tree incision viii. S-shaped incision ix. Lewis incision x. Coma incision xi. Bayonet flap 19. Which incisions are employed for the removal of the maxillary impacted third molar? Ans. i. Buccal sulcular incision ii. Sulcular incision with vestibular extension iii. Palatal incision flap. 20. Which incisions are employed for the removal of the impacted maxillary canine? Ans. i. Semilunar incision—designed on the alveolar mucosa ii. Angulated or trapezoid or crevicular incision—given in the gingival crevice. 21. What are the complications of the removal of impacted maxillary canine? Ans. i. Chances of damaging the nasal mucosa ii. Damaging the infraorbital nerve iii. Displacement of the root/tooth into the nasal cavity or into the maxillary antrum iv. Palatal artery may get damaged v. Chances of oroantral communication vi. Numbness or paresthesia vii. Non-vitality of the adjacent teeth. 22. What is the basic difference at the time of making the point of elevation and the elevation of tooth with the elevator during the removal of the different types of angulated mandibular impacted teeth? Ans. i. Mesioangular: To make a point of elevation on the mesial surface of the impacted tooth. The elevator used is Couplands elevator 102 When, Why and Where in Oral and Maxillofacial Surgery

ii. Distoangular: Ideally, the point of elevation should be on the distal side but it may require more retraction and more bone removal, resulting in more postoperative pain and edema because of its path of delivery into the ascending ramus. To avoid such postoperative problem, make a point of elevation on the buccal surface of the tooth. The elevator used is Couplands elevator. Delivery should be towards the ascending ramus but the elevation should be from the buccal side iii. Horizontal impaction: The point of elevation is on the cervical area of the tooth. The elevator used is Couplands elevator or winter crossbar elevator may also be useful if more force is required, but it should be used with caution. Sometimes, it may cause angle fracture iv. Vertical impaction: To make a point of elevation on the buccal surface below the cementoenamel junction above the bifurcation point. The elevator used is Cryers elevator or the straight elevator at the mesial surface. If the tooth is deeply embedded, it requires more force to be removed. In this case, winter cross bar elevators may be useful to deliver the tooth in the upward direction towards the occlusal surface. 23. Which complication can arise at the time of the following situations? Ans. i. At the time of incision (e.g. standard Wards incision): – Damage to the retromolar artery – Damage to the facial vein and facial artery – Damage to the lingual nerve. ii. At the time of the removal of the bone: – Laceration of the soft tissue – Damaging of the adjacent teeth – Fracture of the mandible and the alveolar process – Sequestra formation. Impaction 103

iii. At the time of the sectioning of the tooth: – Laceration of the hard and soft tissues – Dislodgement of the adjacent tooth iv. At the time of the delivery of tooth/elevation of tooth: – Chances of fracture of root, tooth, mandible or alveolar fracture – Displacement of tooth or root into the lingual pouch – Dislodgment of the adjacent tooth. 24. What is the shift rule as applied to the impacted maxillary cuspids? Ans. This radiographic technique determines the position of the impacted cuspid. A series of periapical radiographs are taken. The film position is kept constant and the head of the -X ray unit is moved either anteriorly or posteriorly after each exposure. If the impacted tooth seems to move with the X-ray head, it is located on the palate. If it moves opposite to the unit head, it will be located on the buccal. This is also referred to as the SLOB rule. Same—Lingual (palatal), opposite—Buccal. 25. Which is the most common impacted tooth after third molar? Ans. Maxillary canine is the next most common impacted tooth after third molar. 26. Which is the most difficult impacted mandibular third molar? Ans. Distoangular is one of the most difficult impacted teeth. 27. Why distoangular impaction is most difficult? Ans. i. Its pathway of delivery is into the ascending ramus ii. Large amount of the distal bone is to be removed iii. Access to the roots is difficult. 28. Which type of the impacted maxillary third molar is most likely to get displaced into the infratemporal space if an improper technique is used? Ans. Distoangular impacted maxillary third molar. 104 When, Why and Where in Oral and Maxillofacial Surgery

29. Which among these two is the systemic cause of im- paction—rickets or tuberculosis? Ans. Rickets. 30. In which syndrome impacted supernumerary teeth is one of the features? Ans. Gardener’s syndrome. 31. What is the orthodontic indication for the removal of an impacted molar? Ans. To facilitate distal movement of the second molar. 32. Where is the inferior alveolar nerve most often located in relation to the root of a mandibular third molar? Ans. Buccal to the root and slightly apical. 33. What are the significant radiographic predictions of a close relationship between the inferior alveolar canal and the impacted mandibular third molar? Ans. Signs of close proximity of the mandibular third molar to the inferior alveolar canal are: i. Darkening and notching of the root ii. Deflected roots at the region of the canal iii. Narrowing of the root iv. Interruption of the canal outline v. Diversion of the canal from its normal course vi. Narrowing of the canal outlines on the radiograph vii. Grooved tunnel. 34. The most common contributing factor to pericoronitis of an impacted mandibular third molar? Ans. Trauma from the opposing maxillary third molar. 35. Facial edema following the surgical extraction of an impacted tooth can be best reduced by which method? Ans. Careful retraction and manipulation of the soft tissue flap during surgery. Impaction 105

36. The line of withdrawal of a tooth is mainly determined by what? Ans. The root pattern of the impacted tooth. 37. Who described originally the lingual split bone technique for removing the impacted mandibular third molar? Ans. It was described by Sir William Kelsey Fry. Later first popularized by Terrance Ward. 38. What are the disadvantage of the lingual split technique? Ans. i. Injury to the lingual nerve ii. Chances of dislodging the tooth or the root in the sublingual space iii. Opening up of the fascial spaces on the lingual side and the floor of the mouth. 39. What are the basic advantages of the lingual split technique for the extraction of the mandibular impacted teeth? Ans. i. Bone loss is minimal ii. Easy and quick method iii. Tissue trauma is minimal. 40. What is the indication of the lateral trephination technique of Bowdler Henry? Ans. Removal of the partially formed unerupted mandibular third molar tooth. 41. What injury can be caused while releasing the incision (vertical incision) for the flap for the mandibular third molar impaction? Ans. Facial artery and vein can get injured. 42. Which is the important suture while closing the Wards incision during the impacted mandibular third molar surgery and why? Ans. Suture of the area immediately distal to the second molar because it may cause pocket formation and hot or cold sensation in second molar region. 106 When, Why and Where in Oral and Maxillofacial Surgery

43. In which type of the impacted mandibular third molar bull’s eye of appearance is seen in the intraoral periapical (IOPA) radiograph? Ans. In case of linguoversion—lingually placed. The crown of the tooth is towards the lingual side. Hence, the crown is very close to the film. The crown looks like the bull’s eye, large in comparison to the root which is away from film. 44. In which type of the impacted mandibular third molar is the lingual split technique contraindicated? Ans. In case of Buccoversion. 45. What are the different methods of the removal of the surrounding bone from the impacted tooth? Ans. i. Sir William Kelsey Fry—The split bone technique with the use of a chisel ii. Moore and Gillbe’s Collar technique with the help of a surgical bur iii. Removal of the tooth using tooth division. 46. A pregnant lady in the second trimester during extraction falls into syncope. What should be the patient’s posture and why? Ans. The patient’s position should be on the left side to relieve the pressure. It should not be kept in the supine or reclined position, otherwise it may cause pressure on the inferior vena cava by the fetus, which results in poor venous return. 47. When is the elective dental extraction to be performed for a patient with myocardial infarction? Ans. After six months, elective dental extraction can be performed. 48. What are the common causes of the secondary hemorrhage after tooth extraction? Ans. It may be due to the rise in the blood pressure and slipping of the ligature. Impaction 107

49. Which is the common site of displacement of the impacted third molar during surgery? Ans. Lingual pouch and pterygomandibular space. 50. A patient has developed facial edema after 24 hours of extrac­tion. Which aid is advantageous, if there is no infection? Ans. In case there is no infection, warm wet application can help reduce the facial edema. 51. A patient is complaining about the radiation pain to the ear after the surgical removal of mandibular third molar on the third day. What is the most probable diagnosis? Ans. Postextraction alveolitis. 52. What are the muscles responsible for these three postopera­ tive complications after the third molar mandibular surgery: (i) Trismus; (ii) Pain in the temporal region; and (iii) Difficulty in swallowing Ans. i. Trismus: Medial pterygoid muscle ii. Pain in the temporal region: Temporalis muscle iii. Difficulty in swallowing: Superior constrictor muscle of the pharynx. 53. What is the best treatment for pericoronitis involving the impacted mandibular/maxillary third molar? Ans. Extraction of the involved third molar is the best treatment. Pericoronitis is recurrent in nature and may cause the damage of the bone around the second and third molars. 54. What is the direction of the bevel of the chisel during bone cutting? Ans. Chisel is monobevelled (osteotome is bibevelled) and used for cutting bone and the bevel is kept facing the bone to be sacrificed. 55. What is the cause of postextraction bleeding in a leukemic patient? Ans. Postextraction bleeding is due to platelets disorder. It may be necessary to perform surgery on a patient with platelet counts in the 108 When, Why and Where in Oral and Maxillofacial Surgery

range of 25,000 because of the difficulty in achieving the platelet level due to the circulating platelet antibodies. 56. Which of the following may cause dry socket—oral hypoglycemias or oral contraceptives and how? Ans. Oral contraceptives may increase the risk of dry socket. High levels of estrogen can increase the risk of dry socket by dissolving the blood clot. Women who take the oral contraceptives are at high risk of developing dry socket due to increased estrogen levels. 57. Which is the common complication after third molar removal? Ans. Dry socket is one of the common complications due to less blood supply. 58. What is the problem associated with the longer root of tooth? Ans. It is more difficult to remove the tooth. 59. What is the more common cause of paresthesia of the lower lip? Ans. Removal of the mandibular impacted third molar as a result of the damage to the inferior alveolar nerve. 60. Why should the posterior incision for the removal of the impacted third molar mandibular be placed more buccally? Ans. i. To prevent damage to the lingual nerve. ii. To prevent damage to the retromolar artery iii. Incision should be on the sound bone iv. Repositioning of the flap should be on the sound bone v. More visibility. 61. If a patient is unable to close the mouth due to subluxation of condyles after the extraction of third mandibular molar. How wiil you manage such a case? Ans. Initially, it should be managed by manually manipulating the mandible. Impaction 109

62. Why distill water is not used for irrigation? Ans. Distill water is a hypotonic solution and will enter the cells down the osmotic gradient causing cellulitis and rapid death of bone cells. 63. While trying to remove the root tip of a mandibular third molar, it disappears from view, where it might be dislodged? Ans. i. Inferior alveolar canal ii. Cancellous bone space iii. Submandibular space. 64. While extracting the third molar, the distal root is missing. Where it is most likely to be? Ans. In the pterygomandibular space. 65. What is the serious complication after the maxillary canine surgical removal? Ans. Cavernous sinus thrombosis. 66. How will you differentiate distoangular impaction radio­ graphically from the normal erupted tooth? Ans. Interdental septum between the second and third molars is much narrower in comparison to the first and second molars. In case of normal erupting of the third molar, there is no difference in distance between first, second and third molars, i.e. interseptal space is similar between first, second and third molars. 67. What are the advantages of mallet and chisel over the drill for bone cutting during the tooth removal? Ans. In case of mallet and chisel: i. There is no need for the coolant ii. The operator can assess after every stroke and can avoid complication like soft and hard tissues injury. iii. The operator can change the chisel position accordingly. iv. The bone can be removed from the poorly accessible area and the less visible area. 110 When, Why and Where in Oral and Maxillofacial Surgery

68. When should the prophylactic removal of the unerupted third molar in a teenager is carried out? Ans. When the root formation is 2/3rd complete. 69. During removal of a impacted tooth if mandible is fractured. What is the immediate line of treatment? Ans. There is more chances of fracture of the mandible at the angle region in case of position “C”. i. Intermaxillary fixation with ligature wire ii. Superior border transosseous wiring iii. Bone plating 70. During the removal of a impacted tooth if lingual plate damage, what is the criteria to manage such situation? Ans. If fractured lingual plate is attached with flap (mucoperio- steum flap) then it should be sutured otherwise it should be removed. Odontogenic chapter Infection 7

ACUTE AND CHRONIC INFECTION OF JAW 1. What is the meaning of (i) Periostitis of jaw; (ii) Osteitis of jaw; and (iii) Osteomyelitis? Ans. i. Periostitis of jaw: It is the inflammation of the periosteum ii. Osteitis of jaw: It is the localized bone infection iii. Osteomyelitis: It is an extensive inflammation of the bone. It involves cancellous portion of the bone marrow, cortex and periosteum. 2. What is the cause of odontogenic infection—aerobic, anaerobic or mixed bacteria? Ans. Mainly it is due to the mixed bacteria. 3. How will you treat Garrey’s osteomyelitis? Ans. Surgical reconstruction is done to recontour the cortical expansion of the jaw. 4. What deals with Hilton’s method? Ans. Drainage of the abscess. 5. What is palatal abscess? Ans. Infection of the maxillary lateral incisor. 6. What is cellulitis? Ans. Cellulitis is a warm, diffused, erythematous, indurated, and painful swelling of the tissue in an infected area. 7. How will you manage cellulitis? Ans. Cellulitis can be easily treated by: 112 When, Why and Where in Oral and Maxillofacial Surgery

i. Antibiotic therapy ii. Removal of cause iii. Surgical incision and drainage is done if no improvement is seen in 2-3 days or if there is evidence of purulent collection. 8. What is abscess? Ans. An abscess is a pocket of tissue containing the necrotic tissue, bacterial colonies and dead white cells. The area of infection may or may not be fluctuant. The patient is often febrile at this stage. Cellulitis, which may be associated with abscess formation, is often caused by anaerobic bacteria. 9. What is the difference between cellulitis and abscess? Ans.

Category of Cellulitis Abscess differentiation i. Duration Acute Chronic ii. Pain Severe, generalized Localized iii. Localization Diffused borders Well circumscribed iv. Size Large Small v. Palpation Indurated Fluctuant vi. Presence of pus No Yes vii. Degree of dangerness Greater Less viii. Bacteria Aerobic Anaerobic

10. What is erysipelas? Ans. Erysipelas is a superficial cellulitis of the skin that is caused by beta-hemolytic streptococci and by group B-streptococci. It usually presents with warm, erythematous skin, spreads rapidly from the release of hyaluronidase by bacteria. It is associated with lymphadenopathy and fever and has an abrupt onset with acute swelling. It may affect the skin of the face. It is managed by parental penicillin. Odontogenic Infection 113

11. If abscess is treated with an antibiotic without I and D, what does it may cause? Ans. There may be the chances of the formation of antibioma. 12. Which organism is commonly associated with subacute bacterial endocarditis? Ans. Streptococcus viridans. 13. Osteoradionecrosis occurs due to the damage of which structure? Ans. Blood vessels. 14. What is the cause of severe pain in the dry socket? Ans. Release of kinin from the degenerative clot and thermal irritation of the exposed nerve endings of the alveolar bone. 15. What is the best imaging modality for detecting sequestra in osteomyelitis? Ans. Computerized tomography: It gives a more definitive picture of calcified tissue involvement, especially with regard to the disrupting cortical plate. 16. What are the synonyms of Garre’s osteomyelitis? Ans. i. Chronic nonsuppurative sclerosing OML ii. Chronic OML with proliferative periostitis iii. Periostitis ossificans iv. Focal gross thickening of the periosteum. 17. What are the synonyms of Noma? Ans. i. Cancrum oris ii. Gangrenous stomatitis iii. Running horse gangrene 18. Which microorganism is responsible for acute osteomyelitis and what does the blood picture show? Ans. Staphylococcus aureus is responsible for acute osteomyelitis. The blood picture shows leukocytosis. 114 When, Why and Where in Oral and Maxillofacial Surgery

19. When should I and D be performed in case of acute infection? Ans. When localization has occurred, stab incision should be given. 20. What are the conditions susceptible to osteomyelitis? Ans. i. Peget’s disease ii. Fibrous dysplasia iii. Radiation. 21. What is the triad of osteoradionecrosis? Ans. Radiation > Trauma > Infection. 22. Who explained HBO for osteoradionecrosis? Ans. Marx. 23. What are three” hypos” which explain osteoradionecrosis? Ans. i. Hypoxia ii. Hypocellularity iii. Hypovascularity 24. What is the main cause of osteoradionecrosis? Ans. “Endarteritis“ of blood vessels. 25. In which condition of the infection of the jaw, one radioactive dye Tc-99 appears as hot spot? Ans. Osteomyelitis of mandible: The radioactive Tc-99 diphenyl monophosphate is injected. The involved side of the mandible appears active or as hot spot. 26. What is difference between sequestrectomy and saucerization? Ans. i. Sequestrectomy: Removal of sequestrum ii. Saucerization: Removal of bony cavity. 27. Define sequestrum. Ans. Sequestrum is a piece of dead and detached bone which is hard, rough, porous, light in weight and color. 28. What are involucrum and sequestra? Ans. Involucrum is a new live bone. Sequestrum is a dead bone. Odontogenic Infection 115

29. Lip paresthesia is one of the classical signs in which type of osteomyelitis? Ans. In acute osteomyelitis of mandible, lip paresthesia is seen. 30. A dead bone is seen in X-ray as radiopaque or radiolucent. What is it called in case of osteomyelitis? Ans. A dead bone seen in an X-ray as white radiopaque is called as sequestrum, one of the radiographic findings of osteomyelitis. 31. Infection of maxillary first molar drains into? Ans. Buccal space and causes buccal space infection. 32. What is the new concept of osteoradionecrosis (ORN)? Ans. The new concept of osteoradionecrosis is based on a radiation induced wound healing defect. According to this hypothesis, the pathophysiology sequence is: i. Irradiation ii. Hypovascular, hypoxic and hypocellular tissue. iii. Tissue breakdown iv. A non-healing wound in which the tissue metabolic demand exceeds supply. 33. What is Hyperbaric Oxygen (HBO)? Ans. Hyperbaric oxygen is an administration of 100% oxygen via head tent mask or endotracheal tube with a special chamber at 2.4 atmospheric absolute pressure (ATA) for 90 minutes each session. The treatment should be once daily, five times a week. 34. A patient with swelling over the angle region is having a rise in temperature and also has difficulty in opening the mouth. What is the possible diagnosis? Ans. All the three symptoms indicate coronal infection of the mandibular third molar. 35. Why is osteomyelitis rare in maxilla? Ans. It is rare due to: i. Extensive blood supply and collateral blood flow in midface 116 When, Why and Where in Oral and Maxillofacial Surgery

ii. Porous nature of membranous bone iii. Thin cortical plates iv. Abundant medullary spaces. 36. Why is mandibular osteomyelitis more common in old age? Ans. i. Mandibular arteries are occluded, leading to ischemia and infarction ii. Impaired immunity in old age iii. Other systemic diseases, if present. 37. What is osteoradionecrosis (ORN)? Ans. After the completion of the radiation treatment, an area of exposed, non-viable bone at the field of radiation that fails to show any evidence of spontaneous healing is diagnosed as osteoradionecrosis. The bone which is exposed because of mucosal or cutaneous ulceration must be atleast 3 to 5 mm in size and must be present in the field of irradiation for atleast 6 months (some require only 3 months for diagnosis). 38. What is the difference in incidence between maxilla and mandible osteoradionecrosis? Ans. Osteoradionecrosis is more common in the mandible than in maxilla because of the lesser blood supply to the mandible and the compact bone structure of the mandibular bone. Mandible involved in the field of irradiation more than the maxilla is mostly in case of oral cancer. 39. What are the clinical features of osteoradionecrosis? Ans. Clinical features of osteoradionecrosis are: i. Exposed bone ii. Loss of soft tissue and bone iii. Pain iv. Paresthesia/anesthesia v. Soft tissue necrosis vi. Trismus vii. Pathologic fracture viii. Orocutaneous fistula Odontogenic Infection 117

40. What are the radiographic features of osteoradionecrosis? Ans. i. Diffuse radiolucency ii. Mottled osteoporosis and sclerotic area can be identified after the bone sequestra are formed iii. CT and scintigraphy can be used to evaluate the extension of the lesion. 41. What are the different modalities for osteoradionecrosis? Ans. i. Conservative treatment approach – Daily local irrigation with normal saline – Chlorhexidine 0.2% – Systemic antibiotics – Avoid irritants like tobacco, alcohol, etc. – Good oral hygiene should be maintained – Removal of sequestrum. ii. HBO surgical approach 42. What are the indications for HBO therapy in oral and maxillofacial surgery? Ans. i. Treatment of osteoradionecrosis (ORN) ii. It is done before bony and soft tissue reconstruction and before the placement of the dental implant in an irradiated bone iii. Treatment of necrotizing fasciitis iv. Treatment of gas gangrene v. Chronic refractory osteomyelitis. 43. What are the possible complications of the HBO treatment? Ans. Complications of the HBO treatment are as follows: i. Barotrauma ii. TMJ rupture iii. Oxygen toxicity iv. Ear and sinus trauma v. CNS reaction vi. Pulmonary reaction vii. Myopia viii. Transient visual problem 118 When, Why and Where in Oral and Maxillofacial Surgery

ix. Pneumothorax x. Air embolism. 44. What are the contraindications for the use of HBO therapy? Ans. Absolute contraindications are: i. Optic neuritis ii. Untreated pneumothorax iii. Congenital spherocytosis iv. Fulminant viral infection. Relative contraindications are: i. Seizure disorder ii. Pregnancy iii. Emphysema iv. Claustrophobia. 45. What are the peculiar features of Garre’s osteomyelitis? Ans. i. Age group: Small children from 6 to 10 years ii. Common site: Mandibular molar region iii. Radiographic appearance: Onion peel appearance. 46. What is marble bone disease? Ans. Osteoporosity characterized by a generalized extreme density of bone. 47. What are the characteristic features of osteomyelitis? Ans. The characteristic features of osteomyelitis are as follows: i. There is a moth-eaten appearance because of the enlargement of medullary spaces and widening of Volkmann’s canals ii. Bone destruction of varied extent in which there are Islands that is sequestra with a trabecular pattern and narrow spaces. A sheath of new bone involucrum is often found, separated from the sequestra by a zone of radiolucency iii. Stippled or granular densification of bone. It is seen as a fine linear opacity. Subperiosteal new bone (involucrum) is superimposed upon that jaw, a delicate fingerprint or orange peel appearance is there. Odontogenic Infection 119

48. What are the goals and basic fundamental principles for the treatment of osteomyelitis? Ans. Goals of treatment are: i. To remove pathological organism ii. Promote healing iii. Re-establishment of vascular permeability. Basic fundamental principles of management are: i. Early diagnosis ii. Bacterial culture and sensitivity test iii. Antibiotic therapy iv. Analgesic for pain control v. Proper surgical intervention vi. Reconstruction, if indicated. 49. Enumerate the various periapical pathology treatments: Ans. i. Periapical granuloma ii. Periapical cyst iii. Periapical abscess. 50. How will you differentiate radiographically a cyst, granu­ loma and abscess? Ans. i. Dental granuloma: Homogenous radiolucency (radio­ lucent cavity) with smooth definite radiolucent outline ii. Dental cyst: Homogeneous radiolucent cavity with definitive sclerotic radiopaque margin iii. Dental abscess: Radiolucent and radiopaque cavity (mixed) with irregular margin (mixed radiolucent and radiopaque). 51. Classify endodontic surgery. Ans. Endodontic surgery is classified as follows: i. Surgical drainage: – Incision and drainage – Fistulative surgery ii. Periradicular surgery: – Curettage – Biopsy 120 When, Why and Where in Oral and Maxillofacial Surgery

– Root end resection – Root end preparation and filling iii. Replantation iv. Implant surgery, e.g. endodontic implant. 52. List the synonyms of apicoectomy. Ans. i. Apical surgery ii. Endodontic surgery iii. Root resection iv. Root amputation. 53. Define apicoectomy? Ans. The term apicoectomy is used for surgery involving the root apex to treat the apical infection. It is cutting off of the apical portion of the root and curettage of periapical necrotic, granulomatous, inflammatory or cystic lesion. 54. What are the contraindications of apicoectomy? Ans. i. Local contraindications: – Inaccessible areas like palatal root of the maxillary molar – Poor bony support – Proximity of roots to the anatomic structures like maxillary sinus, inferior alveolar canal – Short resorbed roots. ii. Systemic contraindications – First trimester of pregnancy – Diabetes/nephritis/cardiac disease/liver disease – Anemia, leukemia, hemophilia. 55. List the complications of the endodontic surgery. Ans. i. Intraoperative: – Bleeding – Damaging the neighboring root – Entering into sinus (upper) – Entering into inferior alveolar canal (lower). Odontogenic Infection 121

ii. Postoperative: – Abscess formation – Fenestration – Sinus tract formation – Increased mobility of the tooth.

FACIAL SPACES/INFECTION/COMPLICATIONS 1. What are the primary facial spaces? Ans. There are six facial spaces: i. Buccal ii. Canine iii. Vestibular iv. Submandibular v. Sublingual vi. Submental. 2. What are the secondary facial spaces? Ans. There are eight secondary facial spaces: i. Pterygomandibular ii. Masticator iii. Infratemporal iv. Superficial and deep temporal v. Masseteric vi. Lateral pharyngeal vii. Retropharyngeal viii. Prevertebral. 3. What are the masticatory spaces? Ans. i. Pterygomandibular space ii. Submassetric iii. Superficial temporal and deep temporal space. 4. What are the seven spaces of Grodinsky and Holyoke in the head and neck region? Ans. Space 1: Between platysma and investing fascia Space 2: Between investing and infrahyoid fascia 122 When, Why and Where in Oral and Maxillofacial Surgery

Space 2 a: Space among infrahyoid muscles Space 3: The pretracheal and retrovisceral spaces Space 4: Between alar fascia and prevertebral fascia—danger space Space 4 a: Between prevertebral and investing fascia above clavicle Space 5: Spaces between the prevertebral fascia. 5. What are the different methods of the drainage of odontogenic infection? Ans. i. Extraction of the offending tooth ii. Endodontic treatment iii. Incision and drainage of the soft tissue collection. 6. What are the surgical principles of incision and drainage? Ans. i. Before incision, obtain the fluid for culture through the aspiration of pus ii. Incise the abscess in the healthy skin or mucosa, using blunt dissection iii. Through the exploration of the involved space iv. Use oneway drainage in intraoral and through and through drainage in extraoral cases v. Remove the drain gradually from the deep sites. 7. Which is the greatest barrier to infection? Ans. Fascia is the greatest barrier. 8. What is the facial space is filled by? Ans. Loose connective tissue. 9. Which fascial space is situated between the two muscles? Ans. Buccal space is situated between the buccinator and masseter muscle. 10. What are the classical signs of the following terms: (i) Canine space; (ii) Buccal space; (iii) Masticatory space; (iv) Infratemporal space; (v) Parotid space; (vi) Submandibular space; (vii) Submental space; (viii) Sublingual space Ans. i. Canine space: Infraorbital swelling, cellulitis of eyelid, swelling lateral to the nose Odontogenic Infection 123

ii. Buccal space: Cheek swelling up to four times more than normal size iii. Masticatory space: Trismus, e.g. – Pterygomandibular space – Submasseteric space – Temporal space. iv. Infratemporal space: Dome-shaped swelling v. Parotid space: Earlobe seems to be everted or lifted up vi. Submandibular space: Plum-shaped swelling but no trismus vii. Submental space: Bulging of the chin viii. Sublingual space: Elevation of tongue by indurated sublingual tissue. 11. What is the distinctive difference in case of swelling of masticator space and lateral pharyngeal space? Ans. Masticator space swelling is not pushed towards the midline but in case of lateral pharyngeal space, swelling is pushed towards the midline. 12. Why does the infection of masticator space not enter into the neck? Ans. The fascia is firmly adhered to the periosteum of the lower border of the mandible. 13. What is the peculiarity of the submasseteric space? Ans. Abscess never points either intraorally or extraorally. 14. Submandibular space lies between which two bellies? Ans. Between the anterior and posterior bellies of diagastric muscle. 15. Which muscle separates the sublingual space from the submental space? Ans. Mylohyoid muscle—which forms a complete diaphragm within the floor of the mouth. 124 When, Why and Where in Oral and Maxillofacial Surgery

16. What is the distinguishing feature of the masticatory spaces? Ans. Trismus is the common and typical feature because the spaces are bounded by the muscles of mastication. 17. Generally in case of a mandibular third molar with pericoronitis, where may the infection spread to? Ans. The infection may spread posteriorly to the pterygoman- dibular space. 18. Which is the most dangerous type of the spread of the infection from the apical abscess and why? Ans. Parapharyngeal space infection (including lateral pharyngeal and retropharyngeal space) is dangerous because the lateral pharyngeal space is intimately related with the carotid sheath the and infection from these spaces spreads directly into the neck and mediastinum. 19. Who did first describe Ludwig’s angina? Ans. It was first described by Wilhelm Von Ludwig. 20. What are the 3 Fs related to Ludwig’s Angina? Ans. 1st F—It should be Feared 2nd F—It rarely becomes Fluctuant 3rd F—It is often Fatal. 21. What are the synonyms of Ludwig’s angina? Ans. i. Angina maligna ii. Carbulus gangrenous iii. Cynanche iv. Morbus strangulatorius—It is so-called because of the chocking effect, which is a victim’s experience v. Garrotillo—It is the Spanish version for Hangman’s Noose. 22. What is Ludwig’s angina? Ans. Ludwig’s angina is a bilateral, brawny board like induration of the submandibular, sublingual and submental spaces due to infection of these spaces. Odontogenic Infection 125

23. What is the bacteriology of Ludwig’s angina? Ans. In Ludwig’s angina, there is the presence of staphylococci, streptococci, gram-negative enteric microorganisms, such as E. coli and Pseudomonas, anaerobes, including bacteriodes (B. oralis and B. corrodens), Peptostreptococcus and fusospirochetosis. 24. What are the facial spaces involved in Ludwig’s angina? Ans. It involves: Submandibular space (bilaterally) Sublingual space (bilaterally) Submental space 25. What is the reason for death in Ludwigs angina? Ans. Respiratory obstruction. In case of Ludwig’s angina, there is dyspnea, i.e. difficulty in breathing due to the backward spread of infection. If it is not treated, it results in edema of glottis and causes complete respiratory obstruction. 26. Which is the most classical intraoral sign of Ludwig’s angina? Ans. Raised tongue against the palate, resulting in airway obstruc­ tion. 27. What are the clinical complications of the classic Ludwig’s angina? Ans. i. Bilateral swelling of the submandibular, sublingual, fascial space and swelling of submental space. ii. Raised tongue iii. Dysphagia iv. Toxemia v. Dehydration vi. Pyrexia. 28. What is the reason that the spread of infection from mandible premolars and first molar may cause sublingual space? Ans. It is because the root apices of these teeth lie above the mylohyoid line. 126 When, Why and Where in Oral and Maxillofacial Surgery

29. How will you manage Ludwig’s angina? Ans. i. Early diagnosis ii. Prompt surgical intervention iii. Definitive airway management iv. Surgical drainage of individual space v. Appropriate antibiotic therapy 30. What is the reason that the spread of infection from the second and third mandibular molars may cause submandibular space? Ans. It is because the root apices of these teeth lie below the mylohyoid line. 31. What is the cavernous sinus thrombosis? Ans. It is an uncommon but potentially lethal extension of odontogenic infection. Valveless veins in the head and neck allow retrograde flow of infection from the face (maxillary anterior or premaxillary region) to the cavernous sinus. The pterygoid plexus of veins and angular and ophthalmic veins may contribute to the retrograde flow. Initial clinical sign: Vascular congestion in periorbital, scleral and retinal veins Other clinical signs: Periorbital edema, proptosis, thrombosis of the retinal vein, ptosis, dilated pupils, absent corneal reflex and supraorbital sensory deficits. 32. In cavernous sinus thrombosis (CST), the infection is spread from anterior maxillary teeth through which veins? Ans. i. Ophthalmic vein ii. Anterior facial vein iii. Angular vein (all are valveless veins) 33. After the extraction of the maxillary central incisor, a patient develops ophthalmoplegia, meningitis and lateral rectus paralysis. What is the diagnosis in this case? Ans. On the basis of Eagleton’s criteria diagnosis is cavernous sinus thrombosis. Odontogenic Infection 127

34. What is the bacteriology of cavernous sinus thrombosis? Ans. The most common microorganisms are Staphylococcus aureus, Staphylococcus albus and streptococci sp. Others include Proteus Pseudomonas, Pneumococcus and Haemophilus along with anaerobic organisms. 35. What are the six Eagleton diagnostic features of cavernous sinus thrombosis? Ans. i. A known site of infection ii. Evidence of bloodstream infection iii. Early diagnosis of venous obstruction in the retina, conjunctiva or eyelid iv. Paresthesia of the third occlumotor, fourth trochlear and sixth abducent, resulting from the inflammatory edema v. Abscess formation in the neighboring tissue vi. Evidence of meningeal irritation. 36. Cavernous sinus thrombosis can occur due to the spread of odontogenic infection through which route? Ans. Hematogenous route. 37. What is the most serious complication can arise after surgery in the maxillary incisors? Ans. Cavernous sinus thrombosis, because of the rapid spread of infection from these into the anterior facial vein, which drains into and infects the cavernous sinus. 38. What is the peculiarity of the propagation of infection in cavernous sinus thrombosis? Ans. Infection from the face can spread in the retrograde direction and can cause cavernous sinus thrombosis. Retrograde infection spreads due to the presence of the valveless vein. For example, facial vein, ophthalmic vein, deep facial vein, superior ophthalmic vein, pterygoid venous plexus. Facial infection may spread to the cavernous sinus by the following two routes or pathways. i. Anterior route by ophthalmic, facial, angular, infraorbital vein ii. Posterior route by pterygoid venous plexus. 128 When, Why and Where in Oral and Maxillofacial Surgery

39. What is the name of the physical test conducted to confirm the cavernous sinus thrombosis? Ans. The name of the test is Tobey-Ayer test. This is performed by compressing the interjugular vein with the fingers. On the side of thrombosis, there will be no rise in the CSF pressure measured by lumbar puncture. There will be a rise in pressure when the jugular is compressed on the normal side. 40. Masticator space infection usually results from. Ans. i. Infection of the last 2 lower molars ii. Nonaseptic technique in LA iii. External or internal trauma to the mandibular angle region. 41. What is the first choice of antibiotic in the management of the cavernous sinus thrombosis and why is penicillin contra­ indicated in the treatment of cavernous sinus thrombosis? Ans. The choice of antibiotic is: Injection chloramphenicol IV, 1 gram 6 hourly. It is contraindicated because it cannot cross the blood brain barrier (BBB). 42. Dumb-bell-shaped swelling is the characteristic of which type of odontogenic space infection? Ans. In deep temporal space because of the zygomatic arch. Swelling is seen superior and inferior to the zygomatic arch, resulting in dumb-bell-shaped swelling. 43. What are the roles of the following drugs in the management of the cavernous sinus thrombosis? Ans. i. Heparin: To prevent extension of thrombosis ii. Manitol: To reduce edema iii. Anticoagulant: To prevent venous thrombosis, but its role is controversial. 44. Which is the most serious complication of the canine space infection? Ans. Cavernous sinus thrombosis. Odontogenic Infection 129

45. What is the standard airway procedure in case of Ludwig angina? Ans. Layrngotomy or cricothyroidectomy (tracheotomy) are always preferred over tracheostomy. 46. What are the fascial spaces directly connected with the lateral pharyngeal space? Ans. i. Retropharyngeal space ii. Submandibular space iii. Sublingual space 47. Muffled or hot-potato voice is characteristic feature of: Ans. i. Peritonsillar abscess quinsy ii. Lateral and retropharyngeal space infection. 48. What is “Lincoln’s Highway” or “visceral vascular space”, which was coined by Mosher? Ans. It is the carotid sheath from jugular foramen and carotid canal at the base of the skull to the pericardium or middle mediastinum. Infections in this space are usually associated with internal jugular vein thrombophlebitis or carotid artery erosion. In case of the spread of infection in head and neck region, infections are easily disseminated either upwards through various foramina at the base of the skull producing brain abscess, meningitis or sinus thrombosis, or are easily disseminated downwards into the carotid sheath towards the mediastinum. Mosher called this pathway as the “Lincoln’s Highway” of the neck. 49. How can an abscessed maxillary canine cause swelling beneath the eyes? Ans. Because the apex of the canine lies above the attachment of the caninus and levator labi superioris muscles. 50. What is danger space and what is its other name? Ans. “Space four of Grid in sky and Holyoke’’ It is the potential space between alar fascia and prevertebral fascia. Its superior limit is the skull base and it extends inferiorly into the posterior mediastinum. 130 When, Why and Where in Oral and Maxillofacial Surgery

51. Why are the infections of the lateral pharyngeal space life- threatening? Ans. There may be dangers of: i. Thrombosis of IJV ii. Erosion of ICA iii. Edema of Larynx. 52. When does the masticatory space become very painful? Ans. When the masticatory space travels to the parotid space, it becomes very painful because the capsule of the parotid does not give way to the developing infection to spread. 53. I and D form abscess of pterygomandibular space from the intraoral approach. Which muscle is most likely to be incised? Ans. Medial pterygoid muscle is most likely to be incised. 54. What do you mean by ‘teeth in line of fire’? Ans. It means teeth in the area of the planned therapeutic radiation. 55. Odontogenic infection mainly caused by which bacteria aerobic/anaerobic/mixed bacteria? Ans. Mainly caused due to the mixed bacteria. 56. What is the life-threatening or severe complication of the parapharyngeal fascial space infection and how will you manage in this case? Ans. It may cause respiratory difficulty and it may require tracheostomy. 57. What is the difference between canine space infection and buccal space infection? Ans. i. Swelling in case of buccal space infection is four times more in the cheek region ii. Infraorbital swelling is present in the canine space infection iii. The main region in case of canine space infection is the canine region, whereas in case of buccal space infection, it is mainly the maxillary I molar region. Odontogenic Infection 131

58. What are the parts of deep cervical fascia. Ans. Deep cervical fascia consists of the following parts: i. A superficial or investing layer ii. The carotid sheath iii. The pretracheal layers iv. The prevertebral layer. 59. What is quinsy? Ans. It is also known as the peritonsillar abscess. It is a deep neck infection. It is usually seen as a complication of acute tonsillitis. It can spread to involve the lateral pharyngeal space. It is characterized by the swelling of the tonsils, uvular displacement, trismus and muffled voice—hot potato in mouth. 60. What are the complications of the orofacial infection? Ans. It is classified as follows: i. Those related to the lower jaw: – Ludwig’s angina – Mediastinitis descending deep cellulitis of the neck – Carotid sheath invasion. ii. Those related to the upper jaw: – Intracranial complications a. Cavernous sinus thrombosis b. Brain abscess c. Dural meninges d. Osteomyelitis of the skull. – Retrobulbar cellulitis: a. Blindness. Disease of Paranasal Sinuses (Disease of chapter Maxillary Sinus) 8

1. What are the paranasal sinus? What are the common pecu­ liarities of these paranasal sinuses? Ans. Paranasal sinuses are four, paired, air-filled, mucosa-lined cavities, which develop in the facial and cranial bones. There are four paired paranasal sinuses: i. Frontal sinus ii. Maxillary sinus iii. Sphenoidal sinus iv. Ethmoid sinus. All of these open into the nasal cavity through the lateral wall. Common peculiarities: These sinuses communicate with the nasal cavity. This is the reason why a patient suffering from cold complains of headache because the nasal cavity communicates with the frontal sinus. 2. In which radiograph, maxillary sinus is best demonstrated? Ans. By 15°C occipitomental radiograph described by Waters and Waldron in 1915. It is also known as Waters view or PNS. 3. McGregor and Campbell’s line is seen in which projection? What are these lines? Ans. McGregor and Campbell’s line is seen in paranasal sinus view or paranasal sinus (PNS) view or occipitomental view. These are the five lines, which are as follows: First line: Path from the zygomaticofrontal suture to the superior orbital margin across the glabella region to the superior orbital margin and zygomaticofrontal suture of the other side. Disease of Paranasal Sinuses (Disease of Maxillary Sinus) 133

Second line: From the zygomaticotubercle to the continuous line of zygomatic arch till it blends into the zygomatic bone and the line continues along the inferior orbital margins across the frontal process of the maxillae and the lateral wall of the nose through the septum and then the same course on the opposite side. Third line: From the condyle across the mandibular notch, coronoid process of the mandible to the lateral wall of the antrum and continues through the medial wall of the antrum or the lateral wall of the nose at the nasal floor level and the same course on the opposite side. Fourth line: Occlusal curve of the unilateral arches. Fifth line: Lower border of the mandible from one angle to the other side angle. 4. What is an another name of the membrane of the maxillary sinus? Ans. It is also known as Schneiderian membrane. 5. What are the peculiarities of the maxillary sinus lining? Ans. i. Name: Mucous membrane of the respiratory type. Pseudostratified columnar ciliated epithelium (PSCCE) ii. Cilia movement =1,000 beats/minute iii. Cilia can move secretion, e.g. mucus = 6 mm/minute. 6. Which root of the tooth is very close to the maxillary sinus? Ans. Maxillary second premolar. 7. What is the radiopaque feature of the maxillary sinusitis? Ans. i. Odontogenic sinusitis: Either totally opaque sinus or with the presence of fluid level ii. Acute maxillary sinusitis: It shows uniform opacity. iii. Chronic maxillary sinusitis: It shows the presence of fluid level. 8. What are the symptoms of maxillary sinusitis? Ans. i. Tenderness over the involved area ii. Postnasal drip iii. Change in phonation. 134 When, Why and Where in Oral and Maxillofacial Surgery

9. How will you manage a case of 0.5 mm perforation created in the maxillary sinus during the extraction of the maxillary molar? Ans. Actually no treatment is required. If the opening is small, a good clot is formed and normally healing occurs without any complication. If the opening is large, immediate closure should be done to reduce the chances of contamination and the formation of oroantral fistula. 10. What are the 5 ‘Es’ as the symptoms of OAF? Ans. In case of fresh oroantral fistula (OAF): i. Escape of fluid: From the mouth to the nose on the side of the extraction during rinsing and gargling ii. Epistaxis (unilateral): Due to blood in sinus escaping through the osteum to the nostrils with or without frothing iii. Escape of air: From the mouth into the nose on sucking or inhaling or drawing of cigarette or puffing cheeks (inability to blow cheeks) iv. Enhanced column of air: It causes alteration in vocal resonance and subsequently a change in the voice. v. Excruciating pain: In and around the region of the affected sinus after LA stops acting. 11. What are the 5 ‘Ps’ as the symptoms of OAF in case of the late stage of OAF? Ans. i. Pain ii. Persistent, purulent or mucopurulent, foul unilateral nasal discharge iii. Postnasal drip iv. Possible sequel of general systemic toxemic condition v. Popping out of an antral polyp. 12. Nasal antrostomy usually done from through. Ans. Inferior meatus: It will result in complete drainage from the sinus to occur into the nose. Disease of Paranasal Sinuses (Disease of Maxillary Sinus) 135

13. Where does the maxillary sinus drain? Ans. Middle meatus. 14. During extraction, if there is an oroantral communication, then how will you manage? Ans. It must immediately be closed surgically. 15. Oroantral fistula most commonly occurs during the extraction of which tooth? Ans. Maxillary first molar, because the palatal root is very close to the maxillary sinus. 16. Caldwell procedure is made through the? Ans. Canine fossa, a semilunar incision is made in the canine fossa from the canine to the second molar area, well above the apices. 17. During the extraction of the maxillary molar, a root tip is left in the maxillary sinus. What is the choice of treatment? Ans. Caldwell procedure is performed. 18. What is the head shaking test? Ans. This test is done to diagnose the position of the root in relation to the maxillary antrum or the foreign bodies in the sinus. The presence of a foreign body such as root fragments or any other things changes its position with the movement of the head. This change in position can be confirmed by serial radiographs. In case the foreign body does not move in consecutive radiograph, then it is either (a) trapped into the polyp thick mucosa, (b) or present between the antral lining membrane and the bony wall. 19. Confirmation of the presence of the OA communication is made by which test? Ans. Nose blowing test. 20. Where is the osteum situated? Ans. Middle meatus. 21. What is pan sinusitis? Ans. Inflammation of most or all of the paranasal sinuses simul- taneously is called as pan sinusitis. 136 When, Why and Where in Oral and Maxillofacial Surgery

22. Bones contain air sinuses except which bone—frontal, nasal or ethmoidal? Ans. Nasal bone is without air sinus. 23. What is the role of the decongestant in sinusitis? Ans. It reduces the vascularity of the lateral wall of the nose. 24. What does the chronic sinusitis transillumination show? Ans. i. Thickened lining membrane ii. Opaque air spaces iii. Antral pathogens. 25. When OAF should be never closed? Ans. If the signs of infection are present. 26. What is the role of nasal decongestant in the management of OAF? Ans. To shrink the antral lining. 27. What is Pott’s puffy tumor? Ans. It is one of the serious complications of the frontal sinusitis, if the periosteal abscess and osteomyelitis of the frontal bone are present. 28. Berger flap procedure is used for which condition? Ans. Modified von R Hermann’s buccal advancement flap is also known as Berger’s flap. It is used as a method of closing the oroantral fistula. 29. What are the functions of the paranasal sinuses? Ans. The functions of the paranasal sinuses are as follows: i. The sinuses give resonance to the voice ii. They help in warming the inspired air iii. They help in reducing the weight of the skull iv. They serve as an insulator to prevent incoming of the cold air v. They act as shock absorbers for the face or skull vi. They provide mechanical rigidity. Disease of Paranasal Sinuses (Disease of Maxillary Sinus) 137

30. What is the Caldwell-Luc operation? Ans. The direct visual examination of the maxillary antrum is best made by cutting a window in the anterolateral wall of the maxillary antrum and this approach is called the Caldwell-Luc operation. 31. What are the indications of the Caldwell-Luc operation? Ans. The indications of the Caldwell-Luc operation are as follows: i. Removal of tooth or root from the antrum ii. Removal of foreign bodies from the sinus iii. In case of chronic maxillary sinusitis, where the removal of the lining of the antrum is desired iv. For the removal of cysts from the antrum v. For the removal of any benign growth of the maxillary sinus vi. For the control of any active hemorrhage following the trauma of the maxillary sinus vii. For lifting the floor of the orbit in case of blowout fracture viii. For the removal of any impacted maxillary canine or third molar ix. For the closure of oroantral fistula by the buccal sliding flap operation. 32. Define oroantral communication and oroantral fistula. Ans. i. Oroantral communication: It is defined as an oroantral perfo­ration, which is unnatural communication between the oral cavity and maxillary sinus ii. Oroantral fistula: It is defined as an epithelialized pathological unnatural communication between these two cavities. 33. What is the purpose of the management of oroantral fistula? Ans. i. To protect the sinus from the oral microbial flora ii. To prevent the escape of the fluids and other contents across the communication iii. To eliminate the existing antral pathology. iv. To establish drainage through the inferior meatus. 138 When, Why and Where in Oral and Maxillofacial Surgery

34. Which different types of flaps are used to close the oroantral fistula? Ans. If the defect is more than 5 mm in the diameter, it requires surgical closure with different flaps, which are as follows: A. Local flaps i. Buccal flaps: a. von R Hermann’s buccal advancement flap b. Sliding flap c. Non-rotating flap d. Transversal flap e. Rotated flap f. Labial vestibule bipedicled flap g. Proctor flap ii. Palatal flap: a. Rotation-advancement flap or Ashley flap. b. Straight advancement flap c. Hinged flap d. Island flap e. Bipedicle advancement flap. B. Distant flap: i. Tongue flap a. Anterior-based partial thickness dorsal tongue flap b. Posteriorly based full thickness lateral tongue flap. C. Graft procedure: a. Bone b. Alloplastic material. 35. What is functional endoscopic sinus surgery (FESS)? Ans. The purpose is to restore the normal paranasal air sinuses mucociliary function, for example: i. Recurrent sinusitis with stenosis ii. Chronic hyperplastic sinusitis with obstructive nasal polyps iii. Chronic sinusitis with mucocele formation iv. Fungal sinusitis Disease of Paranasal Sinuses (Disease of Maxillary Sinus) 139

v. Neoplasm vi. Orbital cellulitis/abscess. 36. List ten key points about the maxillary sinus. Ans. i. Maxillary sinus is one of the largest, pyramidal shaped paired (left and right) ii. It is also known as antrum of high more and maxillary antrum iii. It is present in the body of the maxilla iv. It is lined by pseudostratified columnar ciliated epithe- lium, which is also known as Schneiderian membrane v. Capacity of sinus is 30 ml, situated opposite to the maxillary first molar, with a depth of 3.2 cm and breadth of 2.5 cm vi. Major arterial supply is by the internal maxillary artery, small artery drived from the facial, maxillary, infraorbital and greater palatine artery vii. Venous drainage through the anterior facial vein and the angular vein viii. Lymphatic drainage towards the submandibular lymph nodes ix. Nerve supply through the infraorbital nerve x. During the extraction of the posterior maxillary teeth (second premolar and first molar particularly), it may cause perforation of maxillary sinus resulting in the formation of the oroantral communi­ ­cation. If the tract is epithelialized, it is called oroantral fistula. 37. What are the methods to confirm the presence of the oroantral communication or fistula? Ans. The presence of the oroantral communication or fistula is confirmed by the following methods: i. A silver probe can be used to detect and confirm the presence of the communication or fistula ii. A suction nozzle, when placed over the fistula, will produce a sound like an empty bottle 140 When, Why and Where in Oral and Maxillofacial Surgery

iii. During rinsing of the mouth, fluid can be seen escaping through the nares iv. Nose blowing test: A cotton bud is kept near the fistulous opening and the patient is asked to blow the nose with closed nostril and open mouth. If communication is present, then there will be displacement of the cotton bud. 38. What are the complications of the untreated maxillary sinusitis? Ans. Following are the complications of the untreated maxillary sinusitis: i. Cellulitis ii. Abscess iii. Meningitis iv. Cavernous sinus thrombosis v. Osteomyelitis vi. Oroantral fistula vii. Direct extension to the orbital wall. 39. Which tooth overfilling may cause force to the maxillary sinus? Ans. Overfilling of maxillary first molar. 40. What is the role of the blood clot in the formation of the oroantral fistula? Ans. Fate of the clot—if the clot dislodges or gets infected, it may cause the formation of oroantral fistula. Salivary Gland chapter Disorders 9

1. Give the examples of the salivary glands which secrete serous, mucous and mixed secretions. Ans. i. Serous secretion = Parotid gland ii. Mucous secretion = Minor salivary gland of the cheek iii. Mixed. – Seromucous = Submandibular gland (serous predomi­ nantly) – Mucoserous = Sublingual gland (mucous predomi- nantly). 2. What is the name of ducts of the salivary glands? Ans. i. Parotid gland: Stensen’s duct (opens opposite to the second maxillary molar) ii. Submandibular gland: Wharton’s duct (thin-walled, 5 cm long, opens at the floor of the mouth. Sublingual papilla at the side of the frenum of the tongue iii. Sublingual gland: Bartholin’s duct. 3. Define the following terms: (i) Sialadenitis; (ii) Bacterial sialadenitis; (iii) Mumps/viral parotitis/viral sialadenitis; (iv) Sialadenosis; (v) Sialorrhea/ Ptyalism; (vi) Xerostomia; (vii) Sialolithiasis; (viii) Sialectasis; (ix) Sialodochitis; (x) Sialography; (xi) Sialoceles; (xii) Sarcoidosis; and (xiii) Sialosis Ans. i. Sialadenitis: Inflammation of the salivary gland ii. Bacterial sialadenitis: Inflammation of the salivary gland due to bacterial infection iii. Mumps/viral parotitis/viral sialadenitis: Inflammation of the salivary gland due to viral infection 142 When, Why and Where in Oral and Maxillofacial Surgery

iv. Sialadenosis: Enlargement of the salivary gland v. Sialorrhea/ptyalism: Excessive salivation vi. Xerostomia: Reduction in salivation vii. Sialolithiasis: Formation of salivary calculi or salivary stone in the salivary duct or gland viii. Sialectasis: Swelling of the salivary gland ix. Sialodochitis: Inflammation of the salivary duct x. Sialography: Roentgenographic evaluation of the salivary gland and the ductal system xi. Sialoceles: It is the subcutaneous collection of saliva xii. Sarcoidosis: It is a systemic granulomatous disease of the undetermined etiology. It may involve any body site. Salivary gland is involved in 3 to 10% cases xiii. Sialosis: Non-inflammatory, non-neoplastic enlargement of the salivary gland. 4. How many minor salivary glands are present in the oral cavity? Ans. Approximately 500 minor salivary glands are present. 5. What is the difference between exocrine and endocrine glands? Ans. In the exocrine glands, ducts are present, for example, salivary glands, whereas the endocrine glands are ductless, like the pituitary gland. 6. What is the difference between aplasia and atresia? Ans. Aplasia is the absence of the gland whereas atresia is the absence of the duct or congenital occlusion of the duct. 7. What is the shape of the major salivary gland? Ans. Parotid gland: Pyramidal gland Submandibular gland: Walnut shape Sublingual gland: Almond shape. 8. What is the exact situation of the submandibular gland? Ans. In the anterior part of the digastric triangle. Salivary Gland Disorders 143

9. What are the structures present in parotid gland? Ans. Arteries: External carotid artery, maxillary artery, posterior auricular artery, superficial temporal artery Veins: Retromandibular vein from the superficial temporal vein, maxillary vein Nerves: Facial nerves. 10. In reference to the parotid gland, explain the following terms: (i) Glenoid process; (ii) Facial process; (iii) Accessory part of the gland; (iv) Pterygoid process. Ans. i. Glenoid process: The superior margin of the gland extends upwards behind the TMJ into the posterior part of the mandibular fossa. This part of gland is called the Glenoid process of the parotid gland ii. Facial process: Anterior margin of the gland extends forward, superficial to the masseter muscle to form the facial process iii. Accessory part of the gland: A small part from the facial process, which may be separate from main parotid gland, is called the accessory part of the gland iv. Pterygoid process: The deep part of the gland extends forward between the medial pterygoid muscle and the ramus of the mandible to form pterygoid process. 11. Which structure separates the parotid gland from the submandibular­ gland? Ans. Stylomandibular ligament separates both the glands. 12. What are the causes of ptyalism? Ans. Ptyalism means excessive salivation. The causes of ptyalism are: i. Aphthous ulcer ii. Rabies iii. Heavy metal poisoning iv. Medicines like lithium v. Cholinergic agonists. 144 When, Why and Where in Oral and Maxillofacial Surgery

13. What are the drugs that cause xerostomia? Ans. Xerostomia means the reduction of saliva or dry mouth. The drugs that cause xerostomia are as follows: i. Anticholinergics (atropine) ii. Anticonvulsants iii. Antipyretics iv. Antihypertensives v. Diuretics vi. Expectorants vii. Sedatives. 14. Why is sialography not advisable in a sublingual gland? Ans. Its ductal system has tortuous course. Because of its multi­ ductal anatomy, the sublingual gland does not lend itself well to this examination. 15. Why is sialolithiasis or salivary calculus more common in a submandibular gland? Ans. The following are the reasons: i. The secretion of the submandibular gland is more viscous ii. The presence of an anatomical weakness iii. Secretion with higher concentration of calcium and phosphate iv. The flow of saliva is in an unfavorable direction against the gravity. 16. Which salivary gland lesion is usually associated with the sicca syndrome? Ans. Benign lymphoepithelial lesion. 17. Which is the most common malignant salivary gland tumor in the children? Ans. Mucoepidermoid carcinoma. 18. Which is the most common salivary gland tumor affecting the palatal salivary glands? Ans. Adenoid cystic carcinoma. Salivary Gland Disorders 145

19. Which is the most significant finding clinically in a patient with parotid mass? Ans. Parotid mass may be accompanied by facial paralysis. 20. What is Mikulicz disease? Ans. It is an autoimmune disease. It is a well-known disorder characterized by enlarged lacrimal and parotid glands caused by infiltration with lymphocytes. 21. What are the conditions/lesions for which the bimanual palpa­tion technique is carried out? Ans. For the submandibular, sublingual swelling and ranula. 22. A patient complains of the swelling in the floor of the mouth which increases during the meal. What is the provisional diagnosis? Ans. Siolim of Wharton’s duct 23. There is a cystic lesion below the tongue or floor of the mouth, which occurs due to an obstruction of the salivary gland. What is the name of the lesion? Ans. It is called as ranula (one of the retention cysts). 24. What is the most common reason for mucocele? Ans. Rupture of the salivary gland. 25. What is the most common complication of mumps? Ans. Orchitis is one of the serious complications. 26. What is the other name of adenoid cystic carcinoma? Ans. Cylindroma. 27. If fatty changes occur in the parotid gland then what does it signify? Ans. It is a sign of alcoholism. 28. What are the signs and symptoms of salivary gland malignancy? Ans. i. Rapid tumor growth ii. Pain iii. Peripheral facial nerve paralysis. 146 When, Why and Where in Oral and Maxillofacial Surgery

29. Are sialoliths always visible on radiographs? Ans. No, sialoliths in the early stage of development are quite small and not adequately mineralized to be visible radiographically. 30. Is there any association between salivary disease and AIDS? Ans. Yes, the condition affecting the salivary glands in the AIDS patients includes parotid lymphoepithelial lesions, cyst, lymphadenopathy, Kaposi’s sarcoma, Sjögren’s syndrome like, the condition with xerostomia. 31. What types of lesions can result from the mucous escape? Ans. Mucocele and ranula. 32. What are the structures encountered while removing the submandi­ bular­ gland? Ans. i. Facial artery ii. Facial vein iii. Cervical branch of the facial vein iv. Lingual nerve. 33. How can the submandibular calculus be removed by? Ans. Through the incision of duct and the removal of calculus. 34. What is meant by milking the gland? Ans. A small stone in the distal portion of the duct can be removed by manipulation called as milking the gland. 35. What are the characteristic triad features of the sicca syndrome? Ans. i. Xerostomia ii. Enlargement of the salivary gland iii. Enlargement of the lacrimal gland 36. What are the characteristic features of Frey’s syndrome? Ans. It is caused by damage to the auriculotemporal nerve. Its characteristic features are as follows: i. Flushing and sweating of the involved side of face ii. Chiefly in temporal area during eating iii. Gustatory sweating when eating spicy food. Salivary Gland Disorders 147

37. Café-au-lait spot is seen in which conditions? Ans. i. Sjögren’s syndrome ii. Tuberculous sclerosis iii. Albright syndrome 38. In which condition of the mouth is an increase in the caries activity seen? Ans. Xerostomia (decrease in salivation) may cause an increase in the caries activity. 39. Which is the most common benign tumor of the salivary gland? Ans. The most common benign tumor of the minor or major salivary gland is pleomorphic adenoma. 40. List the synonyms of pleomorphic adenoma. Ans. The synonyms of pleomorphic adenoma are as follows: i. Bizarre tumor ii. Iceberg tumor iii. Mixed tumor of the salivary gland iv. Endothelioma v. Branchioma vi. Dumbbell tumor of the salivary gland. 41. Why is the pleomorphic adenoma of the parotid gland also known as bizarre tumor? Ans. It is also known as bizarre tumor because the tumor constitutes a heterogeneous group of lesion of the great morphologic variation. Its morphologic complexity is the result of the differentiation of the tumor cells. It is characterized by an unusual histologic pattern and is derived from more than one primary tissues. 42. What type of cells are responsible for the origin of pleomorphic adenoma? Ans. Myoepithelial cells. 43. What is the treatment for pleomorphic adenoma of the parotid gland? Ans. Superficial parotidectomy. 148 When, Why and Where in Oral and Maxillofacial Surgery

44. Which salivary gland tumor is radiosensitive? Ans. Pleomorphic adenoma of the parotid gland. 45. What is the difference between primary and secondary Sjögren’s syndrome? Ans.

Primary Sjögren’s syndrome Secondary Sjögren’s syndrome 1. Dry eyes 1. Dry eyes 2. Dry mouth 2. Dry mouth 3. Rheumatoid arthritis 4. Systemic lupus erythematosus 5. Polyarteritis nodosa.

46. What are the diagnostic tests for Sjögren’s syndrome? Ans. The following are the diagnostic tests for Sjögren’s syndrome: i. The patient may show polyclonal hyperglobulinemia and develop cryoglobulins ii. Positive latex test for salivary duct antibody iii. The Schirmer test: It consists of placing a strip of filter paper in the lower conjunctival sac. In a normal patient, the paper will wet up to 15 mm in 5 minutes and in a patient with Sjögren’s syndrome, the paper will wet up to less than 5 mm in 5 minutes iv. The rose Bengal dye test is used to detect the damaged and denuded area of the cornea. The breakup time is (BUT) performed using the slit lamp and noting the interval between a complete blink and the appearance of the dry spot in the cornea v. Sialography demonstrates the cavitary defects which are filled with radiopaque contrast media producing a fruit- laden branchless tree or cherry blossom appearance. 47. What is the triad of Sjögren’s syndrome? Ans. This is a condition originally described as a triad of dry eyes, xerostomia, and rheumatoid arthritis. Salivary Gland Disorders 149

48. What is gustatory sweating? Ans. It is also known as Frey’s syndrome. It is one of the complications of the parotid gland surgery. To a varying degree, there is flushing and sweating of the skin of the upper cheek, temporal region and forehead, coincident with eating. It has been suggested that following damage to the auriculotemporal nerve or to the communicating­ branches to the facial nerve, the secretomotor parasympathetic fibers from the otic ganglion and also the sympathetic fibers to the sweat gland travelling in the same nerve are divided following regeneration, fibers from the otic ganglion come to supply the sweat glands. The only effective cure is to divide the parasympathetic fibers from the glossopharyngeal nerve. 49. In which syndrome is the flushing of face during eating seen? Ans. Frey’s syndrome. It is also known as gustatory sweating or auriculotemporal syndrome. 50. What is the difference between viral and bacterial sialadenitis? Ans.

Viral sialadenitis Bacterial sialadenitis 1. It is also known as mumps or viral 1. It is also known as cat scratch parotitis disease 2. Viral infection 2. Bacterial infection 3. It is caused by paramyxovirus 3. It is caused by organisms, such as 4. Elevation of the ear lobe Staphylococcus aureus, Staphy­ 5. Both the glands enlarge simulta­ lococcus pyogenes, Strepto­ neously or within 24 to 48 hours coccus viridans, Pneumococcus, 6. No pus formation or pus discharge Actinomycetes, etc. from the ductal opening 4. Elevation of the ear lobe is not seen. 5. It is unilateral. It is seen on the affected side. 6. Pus discharge on pressing the duct from the ductal opening. 150 When, Why and Where in Oral and Maxillofacial Surgery

51. In which major salivary gland is: (i) Pleomorphic adenoma more common; (ii) Sialolithiasis more common; (iii) Sialography contraindicated? Ans. i. Pleomorphic adenoma is more common in the parotid gland ii. Sialolithiasis is more common in the submandibular gland iii. Sialography is contraindicated for the sublingual gland. 52. In which condition is the acute nonsuppurative sialadenitis seen? Ans. Mumps. 53. What is sialography? Ans. Sialography is a valuable aid in the diagnosis and management of the salivary gland and ductal abnormalities. Sialography can be defined as the radiographic visualization of the two paired major salivary glands and their ductal system (parotid and submandibular glands). 54. What are the indications of sialography? Ans. Indications of sialography are as follows: i. Detection of calculus/foreign body/fistulae/residual stone ii. Determination of residual tumor and retention cyst iii. Determination of the extent of destruction of the gland iv. Selection of the site for biopsy v. Demonstration of a tumor and its location, size and origin. 55. What are the contrast media used for sialography? Ans. Two types of contrast media are used: i. Water-soluble contrast media – Hypaque 50% diatrizoate sodium – Renografin (diatrizoate meglumine) – Silograph – Isopaque Salivary Gland Disorders 151

– Dionosil – Triosil ii. Fat-soluble or oil-based contrast media – Iodized oil—Ethiodol – Water-insoluble organic compound—Pantopaque. 56. What is the amount of contrast media injected? Ans. Submandibular gland: 0.75 to 1 ml Parotid gland: 1 to 1.5 ml. 57. What are the contraindications of sialography? Ans. The contraindications of sialography are as follows: i. The patient with known sensitivity to iodine compound ii. During the period of acute inflammation of the salivary system iii. If thyroid function test is required, it should be done prior to sialography. 58. What are the steps of the sialography procedure and what is the difference between the parenchymal phase and the evacuation phase of sialography? Ans. The three main steps of the sialography procedure are as follows: i. Primary plain film evacuation ii. The injection or filling phase iii. The parenchymal phase (in case water-soluble contrast media is used) or evacuation phase (in case fat-soluble contrast media is used). 59. What are the complications of the salivary gland surgery? Ans. i. Frey’s syndrome—gustatory sweating ii. Facial paralysis iii. Salivary fistula iv. Infection v. Hematoma 60. Which tumor does not occur in the minor salivary gland? Ans. Warthin’s tumor. 152 When, Why and Where in Oral and Maxillofacial Surgery

61. What are the different sialographic pictures for the follow­ ing conditions? 1. Sjögren’s syndrome; 2. Sialadenosis; 3. Sialodochitis; 4. Parotid gland; 5. Submandibular gland; 6. Salivary gland tumor and benign tumor; 7. Sialectasia; 8. Chronic bacterial sialadenitis; 9. Pleomorphic adenoma; 10. Sialadenitis; 11. Malignant growth; 12. Blockage of buds Ans. Condition Sialographic picture 1. Sjögren’s syndrome Snow storm or branchless fruit-laden tree or cherry blossom appearance 2. Sialadenosis Leafless tree 3. Sialodochitis String of sausage 4. Parotid gland Tree in winter/leafless tree 5. Submandibular gland Bush in winter 6. Salivary gland tumor and Ball in hands benign tumor 7. Sialectasia Bunch of grapes 8. Chronic bacterial sialadenitis Pruned tree 9. Pleomorphic adenoma Grasping fingers appearance 10. Sialadenitis Apple tree in blossom 11. Malignant growth Spillage defect/scattered dye 12. Blockage of buds Offshoot appearance

62. What are the complications of sialography? Ans. The complications are as follows: i. Overdistention of gland may cause temporary swelling and discomfort for a few hours to days ii. Extravasation of the contrast media may result in foreign body reaction iii. Occasionally a chronic inflammatory process may be aggravated and can be subsided by antibiotic therapy. Salivary Gland Disorders 153

63. What is the water and solid ratio in saliva? Ans. Water: 99.5% Solid: 0.5%. 64. What are the functions of saliva? Ans. Saliva is a complex fluid which has several proteins and digestive functions: i. Helps in the formation of bolus by moistening solid food ii. Moistens epithelium and teeth and helps protect them iii. Flushes and cleanses oral cavity iv. Helps in speech by moistening the epithelial surface v. Helps in digestion vi. Helps in perception of taste vii. Excretes the body metabolites viii. Has bacteriolytic action ix. Decreases the blood clotting time. 65. Which are the cysts of the salivary glands? Ans. The cysts of the salivary glands are known as mucoceles. Types of mucoceles: i. Mucocele: This is a swelling due to the accumulation of saliva as a result of the obstruction or trauma to the salivary gland duct. The common sites are lower lip and tongue. ii. Ranula: It is a special type of mucocele. The common site is floor of the mouth. The lesion appears like the belly of the frog. That is why, it is called ranula (rana frog). Ranula is formed because of the trauma to submandibular or sublingual gland duct. chapter Nerve Disorders 10

1. What is neuropraxia? Ans. Temporary sensation loss, no axonal degeneration, mild temporary injury due to compression. Spontaneous recovery within four weeks. 2. What is axonotmesis? Ans. Loss of the continuity of some axons. Recovery is often less and appears after 1 to 3 months. The nerve remains intact. 3. What is neurotmesis? Ans. Complete severance of all the layers of the nerve. No recovery is expected. There is permanent conduction block of all the impulses. 4. What are the common neuralgias in the dental region? Ans. i. Trigeminal neuralgia ii. Glossopharyngeal neuralgia iii. Geniculate neuralgia iv. Symptomatic neuralgia. 5. What are the synonyms of trigeminal neuralgia? Ans. i. Fothergill’s disease ii. Tic dolorosa iii. Tic douloureux iv. Classic trigeminal neuralgia v. Idiopathic trigeminal neuralgia. 6. What are the clinical methods of examining trigeminal neuralgia? Ans. i. Pin-prick method ii. Brush direction discrenation Nerve Disorders 155

iii. Two-point discrenation iv. Static touch. 7. Crocodile tears are related with which nerve disorder? Ans. Bell’s palsy—one of the facial nerve disorders. 8. Which division of the trigeminal nerve contain motor fibers? Ans. Mandibular nerve V3 (third branch). 9. Maxillary nerve does not innervate—upper eyelid or upper lip. Ans. It does not innervate the upper eyelid. 10. Maxillary nerve does not give any branch—cranium or ear. Ans. In ear, it does not give any branch. 11. From where is the mandibular nerve derived? Ans. First branchial arch. 12. What are the trigger zones? Ans. These are the zones which precipitate an attack when touched. The trigger zones of trigeminal neuralgia are as follows: i. Vermillion border of lips ii. Ala of the nose iii. Cheek iv. Around the nose. 13. Which division of trigeminal neuralgia (TN) is most commonly affected in neuralgia? Ans. Mandibular nerve V3 third branch is affected most commonly. 14. In extreme cases of trigeminal neuralgia how does a patient’s face look like? Ans. Frozen face or masked face. 15. What is the drug of choice in trigeminal neuralgia? Ans. Tablet Carbamazepine (Tegretol) 200 mg/day to 1200 mg/ day. 156 When, Why and Where in Oral and Maxillofacial Surgery

16. In case of contraindication of Carbamazepine, which is the drug of choice? Ans. Clonazepam—1.5 mg/day. 17. Tinel’s sign is the indication of. Ans. Nerve regeneration. 18. Which nerve is affected in Saturday night palsy—ulnar or radial nerve? Ans. Radial nerve is affected. 19. Ptosis may be caused by the lesion of which nerve— oculomotor nerve or trigeminal nerve? Ans. It is caused by the lesion of oculomotor nerve. 20. What is the initial stage of paralysis of the facial nerve? Ans. The tongue deviates to the same side on protrusion. 21. What does Bell’s palsy represent? Ans. An inability to close the affected eye. 22. There is sudden onset of idiopathic paresthesia of facial nerve without being related to any other disease. What is this condition? Ans. Bell’s palsy. 23. What is the six inch syndrome? Ans. During the trigeminal neuralgia attack, patient stops all the activities and tries to keep everything away from him/her. The syndrome is characterized by: i. Cleansing of the teeth ii. Screwing of the eyes iii. Sucking of the saliva iv. Rubbing of the skin 24. How will you classify the cranial nerve? Ans. i. Sensory cranial nerve contains only the afferent sensory fibers (sensation towards the brain from the periphery) – Olfactory nerve—cranial nerve I – Optic nerve—cranial nerve II – Auditory (vestibulocochlear) nerve—cranial nerve VIII Nerve Disorders 157

ii. Motor cranial nerve contains only efferent motor fibers (sensation towards the periphery from the brain): – Oculomotor nerve—cranial nerve III – Trochlear nerve—cranial nerve IV – Abducent nerve—cranial nerve VI – Accessory nerve—cranial nerve XI – Hypoglossal nerve—cranial nerve XII iii. Mixed nerves contain both sensory and motor fibers: – Trigeminal nerve—cranial nerve V – Facial nerve—cranial nerve VII – Glossopharyngeal nerve—cranial nerve IX – Vagus nerve—cranial nerve X. 25. What is Weber’s syndrome? Ans. Midbrain lesion causing contralateral hemiplegia and ipsilateral paralysis. 26. Explain the following tests: (i) Rinne’s test; and (ii) Weber’s test Ans. i. Rinne’s test: Vibrating tuning fork held opposite the ear and then on the mastoid process. Ask the patient to compare relative loudness of the fork in two instances. ii. Weber’s test: Vibrating tuning fork placed on the center of the forehead. Vibration is heard better on the side of the middle ear disease. 27. What is the clinical test for the hypoglossal nerve (cranial nerve XII)? Ans. Ask the patient to protrude the tongue, if the nerve is paralyzed. It deviates from the paralyzed side. 28. Enumerate various specific pain syndromes. Ans. i. Idiopathic trigeminal neuralgia (Tic douloureux) ii. Auriculotemporal nerve neuralgia iii. Glossopharyngeal neuralgia iv. Sphenopalatine neuralgia (Sluder‘s syndrome) v. Geniculate neuralgia. 158 When, Why and Where in Oral and Maxillofacial Surgery

29. Enumerate the various symptomatic neuralgias. Ans. Few conditions labeled as symptomatic neuralgias are as follows: i. Costen’s syndrome ii. Plummer-Vinson syndrome iii. Trotter’s syndrome iv. Styloid process syndrome v. Neuromas vi. Sjögren’s syndrome vii. TMJ dysfunction syndrome. 30. Define the following terms: (i) Pain; (ii) Neuralgia; and (iii) Trigeminal neuralgia. Ans. i. Pain: Pain is an ill-defined, unpleasant sensation, usually evoked by an external or internal noxious stimulus. The components of pain are perception, effect or emotion and reaction ii. Neuralgia: It may be defined as paroxysmal (intense, intermittent) pain that is usually confined to specific nerve branch of the head and neck region iii. Trigeminal neuralgia: It is defined as paroxysmal (intense intermittent) pain in the distribution of the trigeminal nerve without any major weakness or demonstrable sensory loss. 31. What are White and Sweet’s five diagnostic features of the trigeminal neuralgia? Ans. The five diagnostic features are as follows: i. Pain is paroxysmal in nature (intense intermittent pain) ii. Majority of the patients will have one or more of trigger points iii. The pain is confined to the area of the cutaneous inner­ vation of the trigeminal nerve iv. The pain affects only one side of the face at a time v. The neuralgic examination between the attack is normal. Nerve Disorders 159

32. What is anesthesia dolorosa? Ans. Following the injury to the trigeminal nerve, a painful area of numbness may develop. This is diagnosed as anesthesia dolorosa. This pain is severe and constant and described as burning, gnawing or stinging. Medications often do not relieve pain. There is limited success in relieving pain with deep brain stimulation and premotor cortex stimulation. 33. What is the differential diagnosis of trigeminal neuralgia? Ans. i. Atypical trigeminal neuralgia ii. Eagle syndrome iii. Frey’s syndrome iv. Paratrigeminal syndrome of Raeder v. Post-therapeutic neuralgia vi. Vagoglossopharyngeal neuralgia vii. Ramsay Hunt syndrome viii. Aneurysm of the ICA ix. Fifth—seven cranial nerve syndrome x. Traumatic neuroma xi. Torture syndrome xii. Migraine 34. Differentiate between typical (classic) and atypical tri- geminal neuralgia. Ans. Typical (classic) trigeminal Atypical trigeminal neuralgia neuralgia 1. Intense intermittent paroxysmal 1. Dull boring pain for long time pain 2. Pain occurs in the distribution of 2. Pain occurs on one side or on particular nerve division the face 3. Attack never occurs at night 3. Pain occurs at night also 4. It never crosses the midline 4. It may also cross the midline. 160 When, Why and Where in Oral and Maxillofacial Surgery

35. List the outline to manage the case of trigeminal neuralgia. Ans. i. Medical care: – Palliative treatment – Drug therapy. ii. If the patient is not responding to the above-mentioned treatment, then surgical treatment is opted: – Peripheral procedure: a. Cryotherapy b. Alcohol block c. Laser d. Neurectomy – Ganglion procedure: a. Thermocoagulation b. Glycerol injection c. Balloon compression – Open operation: a. Microvascular decompression b. Trigeminal root section – Central procedure: a. Tractomy b. Dorsal root entry zone lesions. 36. What are the techniques of inferior alveolar neurectomy? Ans. i. The extraoral approach is through Risdon’s incision. A window is made in the outer cortex ii. Intraoral approach via Dr Ginwalla’s incision. Incision is made along the anterior border of the ascending ramus extending lingually and buccally and ending in a fork-like inverted Y-shape. 37. What are the techniques of infraorbital neurectomy? Ans. i. The conventional intraoral approach: U-shaped Caldwell- Luc incision is made in the upper buccal vestibule in the canine fossa region ii. Braun’s transantral approach: Intraoral incision is made from the maxillary tuberosity to the midline in the maxillary vestibule. Nerve Disorders 161

38. What is the role of balloon compression in management of trigeminal neuralgia? Ans. It is done under general anesthesia. It is a mechanical technique to destroy the root fiber partially by advancing 4FG Fogarty catheter 1 to 2 cm within Meckel’s cave and inflating the balloon at the ventral aspect of the ganglion root. 39. What is the role of the anticonvulsant or antiepileptic therapy as a medical management in trigeminal neuralgia? Ans. Mainly two groups are there: i. Classic anticonvulsant drug: – Carbamazepine (choice of drug is Tegretol): 100 mg to 1,600 mg per day – Phenytoin (dilantin): 200 mg per day to 800 mg per day – Baclofen: 50 to 60 mg/day alone. 30 to 40 mg/day combined with others. ii. Other groups of drugs: – Benzodiazepine: 10 to 15 mg/day – Clonazepam: 1 to 3 mg /day – Alprazolam: 1 to 3 mg/day. 40. What is the disadvantage of long therapy of carbamazepine (tegretol)? Ans. Apart from its toxicity (ataxia, diplopia, blurred vision) main disadvantage in the use of carbamazepine is to induce its own metabolism. Therefore, in the patients receiving carbamazepine, a complete blood count with platelets count and liver functionality test must be done before the treatment and after the first week. 41. What is the difference between facial paralysis and Bell’s palsy? Ans.

Facial paralysis Bell’s palsy It is defined as the paralysis of facial It is an isolated facial paralysis musculature, resulting in functional and of sudden onset caused by cosmetic defor­mity on the affected side, neuritis of the 7th cranial nerve particularly those supplied by 7th cranial within the facial canal. nerve due to injury, infection, tumor, etc. 162 When, Why and Where in Oral and Maxillofacial Surgery

42. Which are the various syndromes that can be considered as the etiology for facial palsy? Ans. Various syndromes considered as etiologic factor for facial palsy are as follows: i. Ramsay Hunt syndrome: Herpes zoster oticus is the common cause of facial paralysis. The patient suffers with pain in the ears, loss of tears, loss of ipsilateral taste, deafness, tinnitus and vertigo ii. Melkersson-Rosenthal syndrome: It consists of triad of recurrent orofacial edema, recurrent facial palsy and lingual plicata (fissural tongue) iii. Marcus Gunn or jaw-winking syndrome: It is a rare condition. It may be congenital or following trauma or surgery in the facial area. The patient complains of ptosis or paradoxical oculopalpebral movements, provoked chewing and mandibular movements. 43. What are the goals in the treatment of facial paralysis? Ans. The goals of the treatment are as follows: i. To achieve normal appearance at rest ii. Symmetry with voluntary motion iii. Control of ocular, oral and nasal sphincters iv. Symmetry with involuntary emotion and controlled balance when expressing an emotion v. No significant functional deficit secondary to the reconstrucutive surgery. 44. What are the different treatment modalities for the management of facial paralysis? Ans. Various modalities are: i. Medicinal therapy: Steroids (tablet Betnesol multivitamins) ii. Physiotherapy iii. Surgical treatment: – Nerve decompression – Nerve anastomosis – Nerve grafting – Repair of facial drooping Nerve Disorders 163

– Reanimation procedures – Repair of facial paralysis by buccal sulcus support – Facial cramp. 45. What is facial cramp? Ans. The spasmodic attacks of the motor nerves of the face leads to twitching. It may be seen as a hemifacial spasm coming intermittently on the face. It is considered to be due to the constriction of the facial nerve in the fallopian canal. Many of the facial tics do not have any organic lesion and are considered as habit spasm. These are seen as tonic contractions involving the orbicularis oculi muscle and cramps producing a constant blinking. Normally, no treatment is required and, at times, a voluntary control helps to control the tics. Temporomandibular chapter Joint Disorders 11

1. Define temporomandibular joint (TMJ). Ans. It is referred to as an articulation between mandible and cranium. It may also be defined as the diarthrodial freely movable articulation between condyle of the mandible and the squamous part of the temporal bone. 2. List the synonyms of TMJ. Ans. The synonyms of TMJ are as follows: i. Craniomandibular syndrome ii. Craniomandibular joint iii. Mandibular joint iv. Jaw joint v. Craniomandibular articulation. 3. Which type of joint is the temporomandibular joint? Ans. It is the ginglymodiarthrodial type of joint. It is capable of hinge and gliding movements. 4. What is the volume of the upper joint space? Ans. 1.2 ml is the volume of the upper joint space. 5. Which structure divides the joint into the superior and inferior compartments? Ans. Articular disc (meniscus). 6. How will you outline the surgical anatomy of the temporo­ mandibular joint? Ans. A. Arterial supply: Temporomandibular Joint Disorders 165

• Through the internal maxillary artery (branch of external carotid artery) peripherally via its deep auricular artery: i. Anterior aspect: – Deep posterior temporal artery – Deep posterior masseteric artery ii. Posterior medial aspect: – Deep auricular artery – Anterior tympanic artery – Middle meningeal artery iii. Posterior lateral aspect: – Superficial temporal artery B. Venous drainage—It drains into the: i. Superficial temporal vein ii. Maxillary vein iii. Pterygoid venous plexus C. Lymphatic drainage: i. From the lateral and anterior surface, it drains into the preauricular and parotid nodes ii. From the medial and posterior surface, it drains into the sub­mandi­bular nodes. D. Nerve supply: i. Anteromedial portion of the capsule: Masseteric nerve ii. Anterolateral portion of the capsule: Posterior deep temporal nerve iii. Medial, lateral, posterior and lateral half of the anterior wall of the capsule: Auriculotemporal nerve. 7. Which are the accessory ligaments of temporomandibular joint? Ans. Stylomandibular ligament and sphenomandibular ligament. 8. What is Pinto ligament? Ans. Mandibulomalleolar ligament of the temporomandibular joint. 166 When, Why and Where in Oral and Maxillofacial Surgery

9. What is arthroscopy? Ans. Arthroscopy is a technique by which the inside of a joint can be seen and operated from outside without any open surgery. 10. What is synovium? Ans. Synovium is the thin epithelioid tissue lining the non-articular surfaces of the diarthrodial joints. In the healthy TMJ, the anterior and posterior recesses of both the superior and the inferior joint spaces are lined with synovium. The synovium contains the specialized cell type A and type B. 11. What is synovitis? Ans. Synovitis is an inflammatory disorder of the synovial membrane which is characterized by hyperemia, edema and capillary proliferation in the synovial membrane. 12. What is the most common form of pain and discomfort associated with the TMJ disorders? Ans. Masticatory myalgia or myofacial pain. 13. What is the common cause of TMJ ankylosis? Ans. Trauma is one of the common causes. Trauma results in extra­vasation of blood into the joint space (hemarthrosis). This predisposes to calcification and finally results in ankylosis. 14. What are the diagnostic features of unilateral TMJ ankylosis? Ans. The following are the features of TMJ ankylosis: i. Facial asymmetry ii. Trismus (partial/complete) iii. Fullness on the normal side of mandible iv. Chin deviated towards the affected side v. Prominent antegonial notch on the affected side. 15. What are the surgical procedures of TMJ ankylosis? Ans. i. Condylectomy ii. Gap arthroplasty iii. Interpositional gap arthroplasty, e.g. tentalium, steel, acrylic, etc. Temporomandibular Joint Disorders 167

16. How can the temporomandibular ankylosis in an 8-year-old child be treated? Ans. Gap arthroplasty with costochondral graft. 17. Is the early movement after surgery in case of TMJ ankylosis harmful or desirable? Ans. Early movement is desirable in this case. According to the internationally accepted protocols for the management of the TMJ ankylosis put forward by Kaban, Perrot and Fisher in 1990, early mobilization and aggressive physiotherapy is required for the period of atleast 6 months postoperatively. 18. What are the causes of the TMJ ankylosis recurrence? Ans. i. Inadequate gap created ii. Fracture of costochondral graft iii. Inadequate coverage of glenoid surface. 19. In case of unilateral TMJ ankylosis, the mandible and chin are deviated to which side? Ans. Mandible and chin are deviated towards the affected side. 20. Which vessels encounter excessive bleeding during the surgical management of the TMJ ankylosis? Ans. i. Inferior alveolar artery ii. Internal maxillary artery iii. Pterygoid plexus of vein. 21. In case of bilateral TMJ ankylosis, the chin is deviated to which side? Ans. Actually there is no deviation of the chin. 22. What is the frequent cause of TMJ dislocation? Ans. Spasm of the muscles of mastication. 23. In which type of treatment eminectomy is done? Ans. TMJ dislocation: Eminectomy involves the excision of the arti­cular eminence and thus allows the condyle head to move anteroposteriorly free of obstruction. 168 When, Why and Where in Oral and Maxillofacial Surgery

24. How will you relocate the TMJ in case of the dislocation of TMJ? Ans. The following are the steps for the management of the dislocation of TMJ: i. Stand in front of the patient ii. Thumb is placed on the mandibular molar iii. Fingers are placed on the chin iv. Apply downward pressure on the molar and the back- ward v. Finally upward pressure on the chin. 25. The most common dislocation of TMJ is in which direction— anterior or posterior? Ans. The most common is the anterior dislocation. 26. What is articular disc (meniscus)? Ans. Articular disc is a biconcave, fibrous structure which is thinner at the periphery than the central portion. 27. What is genu vasculosa? Ans. The posterosuperior aspect of condyle and anterior to bilaminar zone is called genu vasculosa. 28. What is Jokey’s cap? Ans. Rees described the shape of the meniscus as Jockey’s cap. 29. What is capsulorrhaphy? Ans. The capsule tightening procedure is known as capsulorrhaphy. 30. Which is the basic/ideal approach to TMJ surgery? Ans. The preauricular approach. 31. What is the reason for the interposition of the temporal muscle and the fascia in the treatment of TMJ ankylosis? Ans. To prevent reankylosis of TMJ. 32. What are the clinical features or symptomatology of MPDS? Ans. There are four classical features of MPDS given by Laskin, one or more of which are always present: Temporomandibular Joint Disorders 169

i. Pain (unilateral) ii. Joint sound (clicking sound) iii. Limitation of jaw movement and deviation of mandible on opening iv. Tenderness of the muscles of mastication. 33. MPDS can be precipitated by which factors? Ans. i. High filling ii. Malocclusion iii. Bruxism iv. Psychogenic factors. 34. In TMJ osteoarthritis, which medicament is injected in TMJ? Ans. Hydrocortisone is injected. 35. Why is hydrocortisone acetate injected in a painful TMJ arthritis? Ans. To decrease the inflammation. 36. The Alkayat Bramley approach to the TMJ is the modification of which approach? Ans. It is the modification of preauricular incision where the upper part of incision is extended in a question-mark fashion. This approach exposes the joint without damaging the temporal branch of the facial nerve. 37. Which nerve may get damaged in submandibular incision? Ans. Marginal mandibular nerve (branch of facial nerve) may get damaged. 38. Hind’s approach to TMJ is through which area? Ans. Through the postramal approach to expose the TMJ. 39. Explain brisement force. Ans. It is one of the treatment modalities to treat TMJ ankylosis. The forced opening of the jaw using mouth gag under general anesthesia, e.g. Fergusson mouth gag, Doyan’s mouth gag and Heister mouth gag. It is useful in fibrous ankylosis of TMJ. 170 When, Why and Where in Oral and Maxillofacial Surgery

40. List different incisions for the TMJ surgery. Ans. Following are the incisions (approaches) for the TMJ surgery: i. Preauricular incision—Rowe (1972) ii. Preauricular with modification—Irby iii. Postauricular approach—Alexander (1975) iv. Postramal approach (Hind’s approach) v. Retromandibular (intraoral) approach vi. Risdon’s (submandibular) approach vii. Endural (aural or facial) approach viii. Lempert’s endaural approach (1938) ix. Alkayat and Bramley approach (1978) x. Inverted hockey stick (temporal) incision xi. Bicoronal flap or transcoronal frontal flap approach xii. Blair’s incision (1928) (modified preauricular) xiii. Dingman and Moorman’s approach (modification of Lempert’s incision) xiv. Wakeley incision T-shaped incision xv. Ron Gaddis incision (1954) xvi. Martin Dunn’s incision (modified preauricular) xvii. Modified endural incision xviii. Fred Henny’s approach (modified preauricular) xix. Popowich and Crane (1982) (modified Alkayat Bramley incision) xx. Thomas incision (modified preauricular incision), 1958. 41. Enumerate the various TMJ surgeries. Ans. Various TMJ surgeries are as follows: i. Condylectomy ii. High condylectomy iii. Condylotomy iv. Eminectomy v. Meniscectomy vi. Arthroplasty vii. Meniscoplasty viii. Zygomectomy Temporomandibular Joint Disorders 171

ix. Repositioning of the head of the condyle x. Disectomy xi. Lateral pterygoid myotomy xii. Lateral pterygoid myotomy with disectomy xiii. Discoplasty xiv. Condyloplasty xv. Arthroscopy xvi. Capsulorrhaphy xvii. Condylectomy with meniscectomy xviii. Anchor’s procedure xix. Reconstruction of the TMJ articulation structure. 42. What is TMJ arthrocentesis? Ans. Arthrocentesis is the lavage or irrigation of the upper joint cavity in case of limited mouth opening, accompanied by severe pain. 10 cc syringe filled with ringer lactate solution is pushed into the joint cavity (up to 200 ml). On termination of the procedure, 1 ml of hydrocortisone is injected into the joint space. 43. Differentiate between fibrous and bony TMJ ankylosis. Ans. Fibrous/False/Pseudo/Extra- Bony/True/Intracapsular TMJ articular TMJ ankylosis ankylosis It is a chronic condition in which It is defined as immobilization by bony the temporomandibular joint is or fibro-osseous union (consolidation) fixed, immobilized by a flexible between the condyle and glenoid fossa soft tissue that may include the of the TMJ. Frequently fusion may be joint capsule, ligament, tendons, present between the coronoid process of muscles, oral mucosa and conti­ the mandible and the zygoma, mandible guous tissue and maxillary tuberosity.

44. What is TMJ arthroscopy? Ans. TMJ arthroscopy consists of the insertion of a specially designed fiberoptic endoscope into the joint compartment for observation (diagnostic) and therapeutic purpose (1.7 mm diameter needle-type arthroscope). 172 When, Why and Where in Oral and Maxillofacial Surgery

45. What are the different types of TMJ ankylosis? Ans. Different types of TMJ ankylosis are as follows: i. – Partial – Complete ii. – Fibrous – Bony iii. – Intracapsular – Extracapsular iv. – Unilateral – Bilateral. 46. What are the synonyms of the following TMJ disorders? Ans. i. TMJ hypomobility—TMJ ankylosis ii. TMJ hypermobility—TMJ subluxation iii. TMJ dislocation—TMJ luxation. 47. What are the different surgical procedures for fibrous and bony TMJ ankylosis? Ans. i. False TMJ ankylosis: – Coronoidectomy ii. Bony TMJ ankylosis – Condylectomy – Arthroplasty a. Gap arthroplasty b. Interpositional arthroplasty – Meniscectomy – Costochondral grafting in children with temporalis muscle flap and ear cartilage. 48. What are the different treatment modalities for myofacial pain dysfunction syndrome (MPDS)? Ans. i. Non-surgical procedure: – Counseling – Occlusal splint – Physical therapy – Therapeutic exercise Temporomandibular Joint Disorders 173

– Corticosteroid injection therapy – Denervation procedure (injection sclerosant, 3% sodium tetradecyl sulfate) – Medication NSAIDs: Ibuprofen, muscle relaxant, narcotic analgesics (morphine) antidepressant ii. Surgical procedure: – High condylectomy – Condylotomy – Lateral pterygoid muscle myotomy. 49. Which muscles are involved in different mandibular move­ ments? Ans. i. Jaw opening (depression): – Lateral pterygoid muscle – Sternohyoid muscle – Digastric muscle – Geniohyoid muscle ii. Jaw closure (elevation): – Masseter – Medial pterygoid – Temporalis iii. Jaw protrusion: – Lateral pterygoid – Medial pterygoid iv. Jaw retrusion: – Temporalis muscle – Masseter muscle – Digastric muscle – Geniohyoid muscle. 50. What do 7 Rs stand for in the context of occlusal rehabi- litation in case of management of MPDS? Ans. i. Remove: Extract ii. Reshape: Grind iii. Reposition: Orthodontics/orthognathic surgery iv. Restore: Conservative dentistry 174 When, Why and Where in Oral and Maxillofacial Surgery

v. Replace: Prosthesis vi. Reconstruct: TMJ surgery vii. Regulate: Control habit and symptoms. 51. Classify the TMJ hypermobility and TMJ subluxation and luxation. Ans. The classification is as follows: i. Hypermobility of TMJ with pain ii. Hypermobility of TMJ without pain iii. Habitual dislocation iv. Fixed dislocation v. Acute dislocation vi. Chronic or recurrent dislocation vii. Permanent or prolonged dislocation. 52. What are the types of hypermobility? Ans. i. Hypermobility syndrome ii. Acquired hypermobility iii. Systemic hypermobility iv. Hypermobility due to occlusal factors 53. What are the different types of condyle of TMJ? Ans. Mainly there are four types of the condyles of TMJ: i. Slightly convex ii. Flat condyle iii. Pointed condyle iv. Bulbous condyle. 54. Which are the articulating and ligamentous structures of TMJ? Ans. i. Articulating surfaces: – Articulating surfaces of glenoid fossa – Articulating eminence – Condyle ii. Ligamentous structures: – Articular disc – Articular capsule (capsular ligament) Temporomandibular Joint Disorders 175

– Synovial membrane – Temporomandibular or lateral ligament – Sphenomandibular ligament (internal ligament) – Stylomandibular ligament – Mandibulomalleolar ligament C Pinto ligament. 55. List the ten key points about TMJ. Ans. i. It is a true synovial joint ii. Both the articulating surfaces carry teeth iii. It is a bilateral articulation with the cranium. So the right and left temporomandibular articulation muscles function together. iv. It performs a variety of movements like: – Opening and closing the mouth (hinge and gingly­ moid) – Lateral side-to-side movement (condyloid) – Translatory chewing movement (gliding) v. The joint is divided into two compartments supero- inferiorly: – Upper compartment, which provides hinge motion – Lower compartment, which sliding or translator motion vi. The lateral pterygoid, masseter and temporalis muscle are closely related to TMJ vii. The TMJ is a complex joint. Each joint has an articular disc (meniscus) situated between the condyle and the temporal bone viii. There is no hyaline cartilage ix. In a newborn baby, the articulating surface of both the bones and disc (meniscus) are covered with synovial membrane but with the use of the jaws, this soon disappears and the membrane is then restricted to a narrow lining of the capsule x. The articular cartilage and the central portion of the disc do not have any nerve supply and blood supply. 176 When, Why and Where in Oral and Maxillofacial Surgery

56. What are the different radiographic projections for TMJ? Ans. There are mainly three projections: i. Transorbital view ii. Transcranial view iii. Transpharyngeal view. 57. Differenciate between TMJ pain dysfunction and man- dibular stress syndrome. Ans. TMJ pain dysfunction Mandibular stress syndrome syndrome It is a syndrome made up of It is a disorder generally confined to highly one of the following: developed communities and thus most 1. Joint clicking frequently associated with neurotic tension 2. Periodic inability to open and emotional stress. The patient displays the jaw fully (locking) one or a combination of the following clinical 3. Pain associated with the features: joint and the muscles of 1. Pain and/or tenderness over the joint mastication 2. Joint noises 3. Altered mandibular function.

58. What is Dautrey’s procedure? Ans. Repeated dislocation of a condyle can be treated by inten- tional fracture of the zygomatic areas and reunion. This procedure is known as Dautrey’s procedure. 59. What is Kaban’s protocol for the management of TMJ ankylosis? Ans. It was given by Perrot and Fisher in 1990. i. Early surgical intervention ii. Aggressive resection—a gap of atleast 1 to 1.5 cm should be created iii. Ipsilateral coronoidectomy and temporalis myotomy are done in most of the cases iv. Contralateral coronoidectomy and temporal myotomy are necessary v. Lining of the glenoid fossa region with temporalis fascia Temporomandibular Joint Disorders 177

vi. Reconstruction of the ramus with a costochondral graft vii. Early mobilization and aggressive physiotherapy for the period of atleast six months postoperatively viii. Regular long-term follow-up ix. When the growth of the patient is complete, perform the cosmetic surgery at the later stage. 60. How can joint cavity be examined without much surgical intervention? Ans. It is done with the help of arthroscopy. Cysts of the Jaws chapter and Oral Cavity 12

1. Define cyst. Ans. Cyst is defined by different authors as follows: i. Killey and Kay: Cyst is a pathologic cavity occurring in hard and soft tissues with a liquid or semi-liquid or air content. It is surrounded by a definitive connective tissue wall or capsule and usually has an epithelial lining ii. Kramer: A cyst is a pathologic cavity having fluid, semi- fluid or gaseous contents which is not created by the accumulation of pus. It is frequently but not always lined by epithelium. 2. List the epithelial developmental odontogenic cysts. Ans. i. Dentigerous cyst (follicular cyst) ii. Odontogenic keratocyst (primordial cyst) iii. Gorlin cyst (calcifying odontogenic cyst) iv. Gingival cyst v. Periodontal cyst. 3. List the epithelial inflammatory odontogenic cysts. Ans. i. Radicular cyst ii. Residual cyst iii. Paradental cyst. 4. List the non-epithelial cysts. Ans. i. Aneurysmal bone cyst (ABC) ii. Traumatic or hemorrhagic bone cyst iii. Stayne’s idiopathic bone cyst. Cysts of the Jaws and Oral Cavity 179

5. List the fissural cysts. Ans. These are non-odontogenic epithelial cysts: i. Globulomaxillary cyst ii. Nasopalatine duct (incisive canal) cyst iii. Nasolabial (nasoalveolar) cyst iv. Median palatine cyst v. Median mandibular cyst. 6. List the examples of parasitic cysts. Ans. i. Hydatid cyst ii. Cysticercosis iii. Trichinosis. 7. List the congenital cysts. Ans. i. Thyroglossal cyst ii. Dermoid and epidermoid cyst iii. Brachiogenic cyst. 8. Which are the soft-tissue cysts of mouth, face and the neck region? Ans. i. Dermoid and epidermoid cyst ii. Lymphoepithelial (branchial cleft) cyst iii. Thyroglossal duct cyst iv. Gingival cyst v. Salivary gland cyst vi. Nasolabial cyst. 9. Which cysts are related to the maxillary antrum? Ans. i. Benign mucosal cyst of the maxillary antrum ii. Surgical ciliated cyst of the maxilla. 10. List the pseudocysts. Ans. i. Traumatic cyst/hemorrhagic cyst/extravasation cyst/ unicameral bone cyst/simple bone cyst/idiopathic cyst ii. Aneurysmal bone cyst (ABC) iii. Stafne’s/Static bone cyst/defect in the mandible/lingual mandibular bone cavity. 180 When, Why and Where in Oral and Maxillofacial Surgery

11. List the bone cysts. Ans. i. Solitary bone cyst ii. Aneurysmal bone cyst (ABC) 12. What are heterotopic cysts? Ans. i. These are oral cysts with gastric or intestinal epithelium ii. Incidence is high in infants and young children iii. Site: Sublingual region, apex and dorsum of the tongue iv. Cysts are lined by partially stratified squamous epithelium and partially by gastric mucosa, gastric glands, goblet cells and muscularis mucosa v. Surgical excision is the line of treatment. 13. What are the theories to explain the cyst enlargement? Ans. These are classified by Harris in 1974 as follows: i. Mural growth ii. Peripheral cell division iii. Accumulation of the contents iv. Hydrostatic enlargement v. Secretion (transmutation/or exudation). 14. Which mechanisms explain the cyst enlargement? Ans. The following mechanisms are forwarded to explain the enlargement of the cystic lesion: i. Increase in the volume of the contents ii. Increase in the surface area of the sac or the epithelial proliferation iii. Resorption of the surrounding bone iv. Displacement of the surrounding soft tissue. 15. What are the cardinal features of the dentigerous cyst? Ans. The cardinal features of the dentigerous cyst are as follows: i. It is one of the epithelial odontogenic developmental cysts. It is also known as follicular cyst or pericoronal cyst. It is defined as a cyst that produces an enlargement of the follicular space about the whole or part of the crown of the tooth Cysts of the Jaws and Oral Cavity 181

ii. Various types are central, lateral, circumferential, crown with odontoma iii. Radiographically cystic lesion appears with supernume­ rary unerupted or malposed tooth with resorption of the root of the adjacent teeth iv. Histologically there is fluid with cholesterol and the lining is not keratinzed v. It is managed by cyst enucleation if the cyst is small and marsupialization followed by cyst enucleation if the cyst is large. 16. What are the cardinal features of odontogenic keratocyst (OKC)? Ans. The cardinal features of OKC are as follows: i. It is one of the epithelial, developmental odontogenic cyst. It also known as primordial cyst associated with bifid rib syndrome and nevoid basal cell carcinoma syndrome ii. It is defined as a cyst arising from the tooth bearing areas of the jaw having thin fibrous capsule and a lining of keratinized squamous epithelium iii. High recurrence rate due to thin fragile lining and the tendency to multiply. It contains creamy white suspen­ sion of keratin that appears like pus without an offensive smell iv. It is aggressive in nature and known to change to the malignant lesion. These cysts are known to carry the satellite daughter cyst v. It can be managed by cryosurgery, chemical cauterization (known as Carnoy’s solution) and routine marsupialization and cyst enucleation. 17. What is the difference between radicular cyst and residual cyst? Ans. i. Radicular cyst (periodontal cyst): It may be periapical and lateral. It will be found where the pulp of the involved tooth has undergone necrosis from an extension of gross caries 182 When, Why and Where in Oral and Maxillofacial Surgery

ii. Residual cyst: When a radicular cyst is overlooked following an extraction of the causative permanent tooth, it is designated as residual cyst. 18. What is the peculiarity of the globulomaxillary cyst? Ans. i. Nonodontogenic cyst—developmental cyst ii. It is also known as intra-alveolar cyst iii. It occurs in the globulomaxillary area iv. It appears pear-shaped v. It is located between the roots of maxillary lateral incisor and canine. 19. What is the peculiarities of thyroglossal cyst? Ans. i. Small cystic swelling in the anterior region of the neck ii. It moves on swallowing iii. It moves on the protrusion of tongue. 20. What are the characteristics of traumatic or hemorrhagic bone cysts? Ans. i. It rarely expands the cortices ii. It does not displace the teeth. 21. What is the peculiarity of the nasopalatine cyst? Ans. i. It is seen between the central and lateral incisor ii. It appears as a heart-shaped radiolucency in the midline iii. Teeth next to the radiolucency are vital. 22. What are the ten peculiarities of Stafne’s bone cavity? Ans. i. It is also known as mandibular salivary gland, depression, latent bone cyst and static bone cavity ii. Actually Stafne’s bone cavity is not a cyst. It is included in the cystic lesions because of their clinical similarity to the cyst of jaw iii. It may be due to the developmental defects that are occupied by a lobe of normal submandibular salivary gland iv. They have been reported below the inferior alveolar canal, approximately in line with the position of the third molar tooth Cysts of the Jaws and Oral Cavity 183

v. Radiographically, it appears as a rounded or oval defect below the inferior alveolar canal, posterior to the first mandibular molar vi. Pathologically, it may be empty cavity or may be containing normal salivary gland tissue or lymph node tissue or abdominal glandular tissue vii. Cystic lesion without epithelial lining viii. There is empty cavity ix. Air on aspiration x. No surgical intervention is warranted. 23. What are the cardinal features of Gorlin’s cyst? Ans. i. It is also known as calcifying epithelial odontogenic cyst. ii. Developmental odontogenic epithelial origin. It resembles to the calcifying epithelioma of Malherbe. It was first described by Gorlin during 1962-1964 iii. The most common site is anterior part of mandible iv. It produces a saucer-shaped depression in the bone and it is symptomless v. Radiographic: It appears as irregular radiopaque specs. The cyst may be associated with a complex odontoma or an unerupted tooth vi. Pathology: There is a lining of stratified squamous epithelium vii. Simple enucleation is the choice of treatment. 24. What are Bohn’s nodules? Ans. It is also known as Gingival cyst of the newborn or cystic swelling of neonates. They are asymptomatic cystic lesions that arise from the remnants of the dental lamina. They appear as discrete white swellings and can be single or multiple. Histologically, there is thin epithelial lining and keratin. 25. What is the relationship of basal cell nevus syndrome with cystic lesion of jaw? Ans. Multiple cysts are a common finding in basal cell nevus syndrome. The cyst may be follicular, primordial and periodontal 184 When, Why and Where in Oral and Maxillofacial Surgery

in nature with all types of histological variations in the epithelial lining. There is a preponderance of the keratocyst. Congenital cysts generally develop earlier than the skin lesions. Therefore, it may be the first to encounter and identify this syndrome by an oral surgeon in the jaw. 26. What are the features of the basal cell nevus syndrome? Ans. i. Bifid rib ii. Multiple radiolucent lesions of the jaw iii. Multiple basal cell nevi iv. Falx cerebri calcification. 27. What are the peculiarities of the nasoalveolar cyst? Ans. i. Swelling in the labial sulcus ii. Difficulty in breathing iii. No radiolucent lesion of the bone iv. On aspiration, straw-colored fluid v. Entirely located in the soft tissue. 28. What are the peculiarities of Aneurysmal Bone Cyst (ABC)? Ans. i. Cystic lining has no epithelial lining. ii. On aspiration (fine needle aspiration), blood may aspirate (brisk red color) iii. Mandible is commonly affected. iv. It is considered as pseudocyst. v. It is a primary lesion of bone. It initiates as an osseous and arteriovenous fistula. 29. What are the different treatment modalities of the cystic lesion oral cavity and jaws? Ans. Different modalities of management are: i. Cyst enucleation of the cyst and primary closure ii. Cyst enucleation and open packing: – With the removal of the tooth – With tooth conservation – Combined with Caldwell-Luc operation – Combined with the fixation of the pathological fracture. Cysts of the Jaws and Oral Cavity 185

iii. Marsupialization: – Partsch I operation (Decompression operation) – Partsch II operation iv. Combination procedure: Marsupialization followed by enucleation after the cavity shrinks, also known as Partsch II operation. 30. What are the basic principles and objectives of management of cystic lesion of oral cavity? Ans. Basic principles of management are as follows: i. To eliminate the lesion ii. The lining should be removed or rearranged in order to eliminate it from the jaw iii. The tooth germ of the unerupted tooth or partially erupted tooth should be conserved as far as possible and should be allowed to erupt iv. Preservation of the adjacent vital structure like neuro- vascular bundle, nasal or antral lining mucosa, etc. v. Restore the normal function. 31. What are the features of the plug used in marsupialization in management of the cystic lesion? Ans. i. Plug should be retentive and maintain the patency of the cavity ii. It should not irritate the mucosa iii. The plug should never reach the depth of the cavity as this would interfere with the bone regeneration and filling process iv. The plug can be attached to the dentures in the case of edentulous patients v. The plug should not build pressure within the cavity vi. The plug should be designed such that it is neither swallowed nor inhaled by the patient vii. It should be removed after every meal for cleaning the cavity. 186 When, Why and Where in Oral and Maxillofacial Surgery

32. What is the choice of treatment of the large cyst? Ans. Waldron’s technique is a combination of marsupialization followed by enucleation. First marsupialization is performed to reduce the intracystic pressure and cavity is allowed to shrink. When the cavity becomes smaller, then enucleation is performed and the cystic lining is completely removed. 33. Which solution is used for chemical cauterization in OKC and what is the composition of the chemical solution used for cauterization? Ans. Carnoy’s solution is used for chemical cauterization in OKC. The composition of the Carnoy’s solution is as follows: i. Alcohol—6 ml ii. Chloroform—3 ml iii. Glacial acetic acid—1 ml iv. Ferric chloride—1 gm. 34. Why is the name Plunging Ranula so-called? Ans. A rare suprahyoid type of ranula termed as plunging or cervical ranula occurs due to herniation of the spilled mucin through the mylohyoid muscle producing swelling within the neck. 35. What is bay cyst? Ans. It refers to an island of squamous epithelium, which have developed from the odontogenic rests of malassez and which can also be found in periapical granuloma without cystic transformation. This granuloma is referred to as bay cyst. 36. What is the choice of treatment in the following cases: i. Case of large radicular cyst with apical involvement of four vital teeth ii. Traumatic bone cyst. Ans. i. Marsupialization is the choice of treatment ii. Opening of the cavity and induced bleeding. 37. By which method is the radicular cyst treated? Ans. Curettage. Cysts of the Jaws and Oral Cavity 187

38. The complete enucleation of the cyst in the palatal area carries the danger of: Ans. The tear of nasal mucosa. 39. What is the diagnostic finding in case of fine needle aspiration in a patient with keratocyst? Ans. A low protein content of less than 4 gm/dl is typical for all keratocysts (for other cysts—5 to 11 gm/dl). 40. On fine needle aspiration, brisk red colour fluid comes out from the cavity. What is the possible diagnosis? Ans. Traumatic or hemorrhagic or aneurysmal bone cyst. It is usually filled with brisk red color fluid. 41. There is a case of 12-year-old boy with a radiographic finding of dentigerous cyst corresponding to the crown of mandibular canine. What is the choice of treatment? Ans. Expose the crown and maintain the same. 42. What is the best method to differentiate between dentigerous cyst and ameloblastoma—by radiographic examination or by microscopic examination? Ans. Microscopic examination is the best method. 43. Cystic fluid containing cholesterol crystals is the result of the breakdown of which cells? Ans. RBCs and exfoliated epithelial cells. 44. Why cystic fluid have increased osmotic pressure? Ans. It contains protein with high molecular weight. 45. What is the cause of mucocele? Ans. i. Obstruction of salivary duct ii. Trauma of salivary duct iii. Congenital atresia: It is managed by excision with the adjacent gland (minor salivary gland). 188 When, Why and Where in Oral and Maxillofacial Surgery

46. Which cyst forms over an erupting tooth? Ans. Dentigerous cyst or eruption cyst. 47. Which method is used to treat the bone cysts that are less than 2 cm in diameter? Ans. Enucleation method. 48. What is the reason for bone swelling in the case of cyst? Ans. It is due to new subperiosteal deposition. 49. What are the causes of the high recurrence rate of kerato­ cyst? Ans. i. Its fragile thin lining ii. Presence of daughter cyst in the cystic lining iii. Presence of daughter cyst in the capsule of the cyst. 50. In which conditions does the cystic lining become thick and adherent? Ans. i. Infection ii. Already decompressed earlier iii. The tooth has been extracted without treating the cyst. 51. What is the differential diagnosis in case large soft swelling is noticed in the floor of the mouth? Ans. i. Thyroglossal cyst ii. Mucous retention cyst iii. Dermoid cyst. 52. Reply for the following questions: i. In which condition is the Nikolsky’s sign present? ii. Port wine stain is a type of what? Ans. i. Pemphigus vulgaris ii. Hemangioma. 53. What are the exact locations of the following cysts? Ans. i. Globulomaxillary cyst: Located between the maxillary central incisor and canine ii. Median palatine cyst/incisive canal cyst/nasopalatine cyst: Located between roots of maxillary central incisors Cysts of the Jaws and Oral Cavity 189

iii. Fissural cyst: Located in the maxilla iv. Solitary bone cyst: Located in the mandible v. Brachial cyst: Lateral side of the neck. 54. The following cysts are located with which syndromes? Ans. i. Multiple OKC: Gorlin-Goltz syndrome ii. Multiple odontogenic cyst: Marfan’s syndrome. 55. Give the synonyms of the following cysts: Ans. i. Odontogenic keratocyst: – Primordial cyst – Benign cystic neoplasm ii. Globulomaxillary cyst: Intra-alveolar cyst iii. Traumatic bone cyst: – Solitary bone cyst – Hemorrhagic cyst iv. Dentigerous cyst: – Follicular cyst – Pericoronal cyst v. Nasopalatine duct cyst: Incisive canal cyst vi. Nasolabial cyst: Nasoalveolar cyst vii. Stafne’s cyst – Static bone cyst – Latent bone cyst – Lingual mandibular bone cyst viii. Aneurysmal bone cyst: Blow-out of the bone ix. Gorlin cyst: Calcifying odontogenic cyst x. Gingival cyst: Bohn’s nodules. chapter Tumors 13

1. What is the difference between tumor and cancer? Ans. i. Tumor (neoplasm): A circumscribed non-inflammatory abnormal growth arising from the body surface ii. Cancer: A general term used to indicate any malignant neoplasm which shows invasiveness and resulting in the death of the patient. 2. Give the synonyms of the following tumors. (i) Ameloblastoma; (ii) Pindborg tumor; (iii) Cementifying fibroma; (iv) Evaginated odontoma; (v) Paget’s disease of bone; (vi) Osteopetrosis; (vii) Brown tumor; (viii) Cherubism; (ix) Ewing’s sarcoma; and (x) Giant cell granuloma. Ans. i. Ameloblastoma: – Adamantinoma – Ewing’s disease ii. Pindborg tumor: – Calcifying odontogenic epithelial tumor iii. Cementifying fibroma: – Multiple cementoma – Peripheral fibros dysplasia iv. Evaginated odontoma: – Leong’s odontomes – Tratman’s odontomes v. Paget’s disease of bone: – Osteitis deformans vi. Osteopetrosis: – Albers-Schönberg disease – Marble bone disease Tumors 191

vii. Brown tumor: – Giant cell lesion of hyperparathyroidism or nodes viii. Cherubism: – Familial fibrous swelling of jaw – Disseminated juvenile fibrous dysplasia ix. Ewing’s sarcoma: – Endothelial myeloma – Round cell sarcoma x. Giant cell granuloma: – Central reparative giant cell granuloma. 3. Enumerate odontogenic tumor Ans. i. Ameloblastoma (Adamantinoma) ii. Pindborg tumor (Calcifying epithelial tumor) iii. Odontogenic/Cementinoma/Myxoma/Fibroma iv. Odontoma v. Adenoid odontogenic tumor. 4. Enumerate the non-odontogenic tumors. Ans. i. Lipoma ii. Osteoma iii. Fibroma iv. Myxoma v. Chondroma vi. Ewing’s sarcoma vii. Ossifying fibroma viii. Ossifying chondroma ix. Osteoid osteoma x. Osteoid blastoma 5. Explain odontogenic fibroma and odontogenic myxoma. Ans. i. Odontogenic fibroma: A benign relatively rare connective tissue tumor that contains a variable amount of inactive odontogenic epithelium. Odontogenic origin of this tumor is confirmed by its formation only in the jaw and by the presence of epithelial rests. It is found to be both intraosseous and extraosseous 192 When, Why and Where in Oral and Maxillofacial Surgery

ii. Odontogenic myxoma: It is benign, non-encapsulated, slow growing, infiltrative tumor of mesenchymal tissue. Odontogenic tumor is based on the evidence that it is distributed in the jaws and the facial skeleton. 6. Explain the following terms. (i) Cementoma; (ii) Osteoma; (iii) Lipoma; (iv) Myxoma; and (v) Fibroma. Ans. i. Cementoma: It is the term given to a group of lesions of the jaw producing cementum-like calcifications. These tumors contain either acellular or cellular cementum. ii. Osteoma: Osteomas are benign odontogenic tumors that consist of a mature, compact, cancellous bone and are found most frequently in the mandible. They are characterized by proliferation of either compact or cancellous bone usually in an endosteal or periosteal location iii. Lipoma: The lipoma is a slow growing benign tumor of adipose tissue developing anywhere in the oral cavity where fat tissue is present iv. Myxoma: It is one of the rare soft tissue intraoral non- odontogenic tumor. It is made up of the tissue resembling primitive mesenchyme. It is composed of stellate cell in a loose mucoid stroma. The lesion is benign and does not metastasize but frequently infiltrates adjacent tissue v. Fibroma: Non-odontogenic benign tumor arising from the submucous and subcutaneous connective tissue of the mouth and face after trauma or it may arise from the periosteum of the jaw. It is usually rounded and firm. It may be sessile or pedunculated. It may grow big in size and may become traumatized from denturation and mastication. 7. What do you understand by the term fibro-osseous lesion? Ans. i. Fibro-osseous lesions of the jaws are disease with similar cellular component Tumors 193

ii. They replace the normal bone by fibrous connective tissue and deorganized calcified component iii. They are benign lesions composed of collagen fibers and fibroblast iv. Radiographic picture depicts a diffused ground glass appearance. 8. What do you understand by the term giant cell lesions? Ans. i. Giant cell lesions are a group of lesions which contain numerous multinucleated giant cells. ii. Current study indicates that giant cell lesions of jaws exhibit a range of activity from benign classic giant cell reparative granulomatous aggressive neoplasm. 9. Enumerate the various giant cell lesions. Ans. i. Central giant cell granuloma ii. Peripheral giant cell granuloma iii. Aggressive central giant cell lesion iv. Giant cell lesion of hyperparathyroidism—Brown tumor v. Giant cell tumor vi. Giant cell tumor of Paget’s vii. Cherubism viii. Osteoblastoma—giant osteoid osteoma. 10. Enumerate the various fibro-osseous lesions. Ans. i. Fibrous dysplasia ii. Fibrous osteoma iii. Ossifying fibroma iv. Ossifying cementifying fibroma v. Fibro-osseous neoplasm. 11. List key points of Ameloblastoma. Ans. i. Ameloblastoma is also known as adamantinoma, adamantoblastoma, and Ewing’s disease ii. A unique feature of the tumors is wide range of biological behaviors that they express 194 When, Why and Where in Oral and Maxillofacial Surgery

iii. Robinson (UNIAC) has defined Ameloblastoma as a uni­centric, non-functional, intermittent growth, anatomically benign and clinically persistent iv. It is derived from the epithelial rests of Malessez, offshoots of cells from the enamel organ v. It may be intraosseous or extraosseous vi. It is mainly found in mandible, 80% in the molar and ramus region. Only 20% is found in the maxilla. The age- group ranges from 20 to 40 years vii. It is a slowly enlarging, painless, ovoid or fusiform bony hard swelling of the jaw. It expands the bone rather than perforate it viii. Radiographic picture describes a lesion having honey- comb or soap-bubble configuration ix. Histological picture reveals mainly two major morphological configurations—follicular and plexiform types x. It is managed by the conservative treatment approach, e.g. curettage, chemical cauterization (Carnoy’s solution), electrocauterization. Surgically, it is managed by en bloc resection, jaw resection with or without reconstruction. 12. Which are the different types of ameloblastoma based on histopathological examination and which is the most common among these? Ans. i. Follicular type ii. Plexiform type iii. Acanthomatous type iv. Basal cell type v. Granular cell type vi. Desmoplastic type Follicular type ameloblastoma is the most common among these. Tumors 195

13. What is the best treatment for odontogenic tumor just 1 cm above the lower border of the mandible? Ans. En bloc is the best treatment. It involves removing the entire tumor with the rim of the normal bone which maintains the continuity of the jaw. 14. What is the line of treatment for adenoameloblastoma? Ans. They can be managed by enucleation because they are encapsulated tumor. 15. List the different treatment modalities to manage odonto­ genic tumor of jaws. Ans. i. Curettage ii. Chemical cauterization (carbolic acid) iii. En bloc resection (marginal mandibular resection) iv. Electrocauterization v. Segmental resection vi. Jaw resection—hemi/complete vii. Jaw resection with reconstruction. 16. Define the following terms: (i) Curettage; (ii) En bloc resection; (iii) Segmental resection; and (iv) Chemical cauterization. Ans. i. Curettage: Curettage involves removal of the pathologic tissue by means of vigorous scrapping ii. En bloc resection: In this procedure, the tumor is removed along with a rim of uninvolved bone while maintaining the continuity of the jaw (maintaining the inferior border of mandible) iii. Segmental resection: In this procedure, the inferior border of the mandible is not maintained depending on the extent of involvement iv. Chemical cauterization: One of the treatment modalities for jaw cyst and tumor. The reason is the invasion of tumor cells into the bony trabeculae beyond the clinical 196 When, Why and Where in Oral and Maxillofacial Surgery

and radiographic interpretations. The bed of tumor is cauterized with concentrated carbolic acid. After this, thorough curettage, small cotton pellets soaked in carbolic acid are applied over the tumor followed by irrigation with normal saline. 17. What is the difference between complex odontoma and compound odontoma? Ans. In general, odontoma means malformation of the dental tissue. i. Complex odontoma consists of an irregular calcified mass of hard and soft dental tissues revealing a disorderly and haphazard arrangement of calcified dental structure ii. Compound odontoma consists of calcified tooth-like structure or miniature teeth – Odontomes can be managed by surgical excision of lesion. 18. List the key points of Pindborg tumor. Ans. i. It is also known as calcifying epithelial odontogenic tumor arising from the epithelial elements of the enamel organ. ii. Mandible is more affected in the molar and premolar regions. It is found mainly along with the impacted or embedded teeth. iii. Radiographic feature reveals the diffused radiopacities within the lesion giving the driven snow appearance. iv. Histological study shows a prominent crenate-like shape—Liesegang ring”. It may occur the amyloid area. v. Marginal and segmental resection is the treatment of choice but enucleation is more conservative treatment option. 19. List the peculiarities of Paget’s disease? Ans. i. Loss of hearing ii. Some loss of visual acuity iii. Enlargement of maxilla. Tumors 197

20. What is Rathke’s pouch tumor? Ans. i. It is also known as pituitary ameloblastoma and cranio­ pharyngiome ii. It is derived from cell rests of the craniopharyngeal duct formed by Rathke’s pouch iii. Neoplasm of the CNS that grows in a pseudoencapsulated mass in the suprasellar or intrasellar area after destroying the pituitary gland iv. Histological study shows irregular calcified masses and foci of metaplastic bone or cartilage, ghost cells and sometimes tooth material v. It is managed by curettage, en bloc resection, peripheral osteotomy and segmental resection. 21. List the cardinal features of Cherubism. Ans. i. Cherubism is a rare developmental jaw condition that is generally inherited as an autosomal dominant. Mesenchymal alteration during the development of jaw bones as a result of reduced oxygenation secondary to perivascular fibrosis is the suggested possible cause for this condition ii. There is painless bilateral swelling of the lower face (mandible is enlarged) iii. Involvement of anterior maxillary segment produces the characteristic deformity. Inverted “V” shape of the palate is due to the maxillary expansion iv. It is considered as a giant cell lesion due to the presence of cellular and vascular fibrous tissue containing many multinucleated giant cells v. Surgical intervention consisting of curettage, reconturing, repeated procedure may be necessary to provide the desired result. 22. What is teratoma? Ans. i. This is a non-odontogenic true neoplasm 198 When, Why and Where in Oral and Maxillofacial Surgery

ii. It is made up of a number of different type of tissues which are not native to the area in which the tumor occurs iii. It may be benign or malignant iv. Benign are usually cystic lesions and often certain hair, sebaceous material, teeth, epithelial appendages, like hair, sweat glands, salivary glands, thyroid and pancreas. v. At times, the respiratory epithelium and nervous tissue may also be present. 23. List the cardinal features of Ewing’s sarcoma. Ans. i. Ewing’s sarcoma is also known as endothelial myeloma or round cell sarcoma ii. Ewing’s sarcoma is an uncommon malignant neoplasm which occurs as a primary destructive lesion of bone. It is believed to arise from the endothelial lining of the blood or lymph vessel iii. Pain is intermittent in nature and swelling of the involved bone is often the first clinical sign and symptom of Ewing’s sarcoma. When there is an involvement of jaws, there is facial neuralgia and lip paresthesia iv. Sunray’s appearance is seen on radiographic study v. It is managed by surgery, multiagent chemotherapy and radiotherapy. 24. List the pecularities of fibrous dysplasia. Ans. i. Fibrous dysplasia is one of the non-neoplastic pathologic conditions of the bone. It is of unknown etiology. It is self-limiting condition, slowly progressive in nature. Fibro-osseous lesion was introduced by Lichtenstein ii. In this lesion, normal medullary bone is gradually replaced by an abnormal fibrous connective tissue proliferation iii. It is mainly of two types: Solitary or monostotic and multifocal or polyostotic lesions. Tumors 199

iv. Radiographic study reveals a ground glass appearance in mature stage. Orange peel appearance, a fingerprint bone pattern can also be seen v. Monostotic involving single bone, asymptomatic painless oral firm and smoothly contouring swelling of the affected jaw vi. Histological study shows bony trabeculae scattered haphazardly, giving Chinese character appearance vii. Polyostotic fibrous dysplasia is related with McCune Albright syndrome viii. It involves the skull and both jaws. It may cause asymmetry and hockey stick deformity of femur is seen ix. Well-defined, generally unilateral tan macules on the trunk, thigh, oral mucosa are seen. It is known as Café- au-lait spots or Coffee with milk pigmentation and sexual precocity in females. It is one of the endocrine manifestations. x. Management ranges from observation for minor lesions to radical resection. Radiotherapy is contraindicated because of its potential for malignant transformation and development of postirradiation bone sarcoma. 25. Comment on Brown Tumor (Nodes). Ans. i. It occurs in hyperparathyroidism and giant cell granuloma, both clinically and cytologically considered as a giant cell lesion ii. These are primary, secondary and tertiary. Primary is due to an adenoma or hyperplasia of gland. Secondary is due to compensatory hyperplasia of gland. Tertiary is due to an autonomous adenoma iii. It may produce smooth painless swelling in both jaws and a reddish or purple hue to the thinned mucosa iv. Histological name is derived from the color imparted to the tissue by hemosiderin and tumor accomplished by widespread of the giant cell 200 When, Why and Where in Oral and Maxillofacial Surgery

v. Radiographic examination shows demineralized surrounding bone or has a ground glass appearance and root resorption vi. Lab finding shows increase in serum calcium and inorganic phosphorus also increases but alkaline phosphatase value is normal and abnormal protein picture is also seen vii. It is managed by surgical removal of the overactive parathyroid. This will allow the brown tumor to heal once calcium metabolism is restored to normal. 26. What is pregnancy tumor? Ans. i. It arises on the gingival tissues of the jaw bones as pedunculated growth during pregnancy as a result of an obscure normal reaction. ii. They appear about the second or third month of pregnancy and persist until parturition iii. It may interfere with mastication iv. It may be multiple also v. Treatment of tumor is local excision followed by electrocoagulation. 27. An odontogenic tumor is managed by simple curettage but recurs frequently. What is the possible diagnosis? Ans. Odontogenic myxoma: The extension of odontogenic myxo- ma occurs beyond the radiographic limits of main tumors. So, curettage is unlikely to cure and results in recurrence of lesion. Excision of the lesion including the normal marginal free bone is the treatment of the lesion. 28. What is the risk involved in enucleation of palatal tumor? Ans. Damage to the nasopalatine nerve. 29. A patient reports with a radiolucent lesion and biopsy shows ‘giant cell’. What is the differential diagnosis? Ans. i. Giant cell granuloma ii. Brown tumor iii. Cherubism Tumors 201

30. Give one-word answers for the following questions: Ans. i. Sunrays radiographic appearance seen in: Giant Osteoid Osteoma (Osteoblastoma) ii. Radiotherapy is contraindicated in: Fibrous dysplasia and central giant cell granuloma iii. Examples of miscellaneous giant cell – Large Aschoff cells of Rheumatic nodule – The Reed-Sternberg cell of Hodgkin’s disease – Warthin Finkeldey giant cells of measles – Epithelial giant cell in Herpes infection. iv. In which condition is one of the pathologic features— Droplets of cementum or rounded masses of cementum seen: Cementifying fibroma. v. Capillary hemangioma is also known as: Port Wine stain vi. Painless lump in the tongue, cheek or lip is seen in: Myomas (muscle tissue tumor) vii. Schwannoma (Neurilemoma) is a benign tumor of Schwann cell origin, and it is also known as: Perineural fibro­blastoma, peripheral glioma and neurinoma viii. von Recklinghausen’s disease (neurofibromatosis): Hamartia disturbances of neuromatous character that is congenital, usually hereditary and occasionally familial ix. Amputation neuroma (traumatic neuroma) is described as: An exaggerated reaction hyperplasia of the peripheral neural elements x. Hand-Schuller-Christian disease (chronic disseminated histocytosis): It is an evolving systemic extension of the basic histiocytic lesion of eosinophilic granuloma xi. Letterer-Siwe disease (acute disseminated histiocytosis) is an acute disseminated form of histiocytosis which occurs predominantly in infants (younger than 3 years). General chapter Maxillofacial Trauma 14

GENERAL MAXILLOFACIAL TRAUMA 1. How will you define fracture clinically and radiographically? Ans. Fracture can be defined as a discontinuity on the hard bony surface or step deformity on a hard bony surface. Radiographically, it can be defined as irregular, radiolucent margin on the hard bony surface. 2. What is “ABCDE” with reference to maxillofacial trauma? Ans. In the management of a patient with maxillofacial trauma, the primary or first aid is as follows: i. Airway ii. Breathing iii. Circulation iv. Drug therapy/Defibrillation v. Exposure or environmental influences. 3. What is the proper way to take the history of a patient with maxillofacial injury? Ans. The following should be inquired about: i. Who: Patient’s name ii. When: Date and time of injury iii. Where: Surrounding of the injury place. It may cause bacterial or chemical contamination iv. How: The mode of injury v. What type of treatment provided earlier if referred from another center General Maxillofacial Trauma 203

vi. What is the general health of the patient vii. Previous history of trauma should be recorded viii. Length of unconsciousness should be recorded ix. Any history of pain/vomiting/unconsciousness/amnesia/ headache/visual disturbances/confusion after accident, malocclusion should be noted x. History of amount of bleeding xi. Information about the patient’s routine medication xii. Blood group of the patient. 4. How will you classify a fracture depending on the mechanism of the fracture? Ans. It can be classified as follows: i. Avulsion fracture ii. Bending fracture iii. Burst fracture iv. Countercoup fracture v. Torsional fracture. 5. Which nerves should be examined in maxillofacial injuries? Ans. The following nerves should be examined: i. Facial nerve: Ask the patient to use the muscle of the facial expression ii. Infraorbital nerve: In case of ZMC fracture and Le Fort II fracture iii. Olfactory nerve: Fracture of midface that involves cribri­ form plate of the ethmoid iv. Oculomotor nerve: Presence of the dilated pupil indicates that oculomotor nerve damage usually results from intracranial nerve compression due to increasing intracranial pressure v. Abducent nerve: Injury to this nerve results in lateral rectus muscle dysfunction vi. Optic nerve: Injury to this nerve results from the fractures surrounding the optic foramen, which may result from the compressing bone. 204 When, Why and Where in Oral and Maxillofacial Surgery

6. What preoperative procedure is to be performed before undergoing closed reduction of the mandibular fracture? Ans. i. Medical history ii. Physical examination iii. Complete blood count iv. Urine analysis. 7. What is the general outline for the management of a patient with maxillofacial trauma? Ans. The management is considered in four following headings: i. First-aid treatment: – Maintenance of airway – Arrest of hemorrhage – Prevention of shock – Relief of pain and anxiety – Temporary immobilization ii. Preliminary treatment at the hospital: – General care – Injection ATS 750-1,500 units – Prevention of dehydration – Tracheostomy, if required – Cleaning and dressing of wound – Temporary immobilization – Control of infection iii. Definitive treatment: – Reduction of fractured fragment in normal anatomical position – Fixation of fractured fragment in normal anatomical position – Immobilization of jaws (if required) iv. Rehabilitation: Medical and oral and maxillofacial: 8. What is the most important thing to note first in a patient with head injury? Ans. His/her ability to open the eyes. General Maxillofacial Trauma 205

9. What is the aim of Glasgow coma scale? Ans. To ascertain the level of consciousness. 10. What is the first step in the management of head injury— secure airway or blood transfusion? Ans. The first step in the management of head injury is to secure airway. If the patient is unconscious, he/she should be carried in lateral position. This allows clearing of blood and mucous from the mouth and nasopharynx and escape of further secretions. 11. What signs are included in the Glasgow coma scale? Ans. i. Eye opening ii. Motor response iii. Verbal response. 12. Which clinical sign does always indicate an obstruction of airway? Ans. Stertorous breathing indicates an obstrcution of airway. 13. A patient is in shock after gross comminuted fracture. What is the immediate treatment to be started with Ringer’s lactate or whole transfusion? Ans. Ringer’s lactate should be started immediately. Usually after trauma, hypovolemic shock is developed due to severe blood loss. Ringer’s lactate solution should be given because due to its high osmotic value, it maintains the fluid in the vascular compartment. 14. What is the safest initial approach to maintain the patent airway in the maxillofacial trauma? Ans. Head tilt-chin lift. 15. After the facial injury if a patient loses voluntary control of the tongue, what is the best emergency treatment to avoid the tongue falling back? Ans. Towel clipping of the tongue. 16. An average-built patient is affected with maxillofacial trauma. How much daily sodium and potassium is required? Ans. 100 mmol per day of sodium and 60 mmol per day of potassium. 206 When, Why and Where in Oral and Maxillofacial Surgery

17. What is the immediate danger to a patient with severe facial injuries? Ans. Respiratory obstruction is the immediate danger. 18. A patient is affected with maxillofacial injury to the middle cranial fossa. What are the clinical complications? Ans. i. Regurgitation ii. Absence of gag reflex iii. Weakening of voice. 19. A patient with maxillofacial injury should be carried in which position? Ans. Lateral position. 20. In which condition is the patient with maxillofacial injury carried in the supine position? Ans. Spinal and cervical injuries. 21. Which facial bone is most frequently fractured—Maxilla or Zygomatic bone or Nasal bone? Ans. Zygomatic bone is most frequently fractured because of its prominency. 22. What is the immediate management of nasal bleeding in facial injuries? Ans. Paraffin gauze packing. 23. During nasal bleeding and CSF leakage, what is the compli­ cation of placing a nasal pack? Ans. Meningitis. 24. What is the earliest measurable circulatory sign of shock? Ans. Tachycardia. 25. What are the common forms of shock encountered in the trauma patients? Ans. Most common is hypovolemic shock. They may also suffer from neurogenic shock, cardiogenic shock or septic shock. General Maxillofacial Trauma 207

26. What is the common cause of shock in a trauma patient? Ans. Hemorrhage. 27. Explain the following terms: (i) Cardiogenic shock; and (ii) Neurogenic shock. Ans. i. Cardiogenic shock: It occurs when the blood flow decreases due to an intrinsic defect in the cardiac function either the heart muscles or the heart valves. ii. Neurogenic shock: It is caused by sudden loss of the descending sympathetic nervous system control of the smooth muscle in the vessel wall. 28. What is the common complication of an open fracture? Ans. Infection is the common complication. 29. What is the ideal time for the facial wounds to be closed as primary closure? Ans. It should be within 24 hours. 30. What are the conditions in maxillofacial injuries in which a tongue tie is indicated? Ans. i. Bilateral parasymphysis fracture ii. Unconscious patient iii. Chin has been destroyed in a gun-shot. 31. What is the importance of the examination of pupils in the maxillofacial injuries? Ans. It is important to examine the pupils because of the following reasons: i. It indicates trauma to the brain ii. It indicates trauma to the optic tract iii. It indicates progress of the patient after trauma. 32. What does golden hour of trauma refer to? Ans. It refers to the period of time exactly one hour after the trauma is sustained. 208 When, Why and Where in Oral and Maxillofacial Surgery

33. What does the ‘matchbox’ injuries of the maxilla- mandibular region refer to? Ans. Fracture to the middle third of the facial skeleton. 34. Which are the fracture sites in the maxillofacial region that may cause anterior open bite? Ans. i. Bilateral condylar fracture ii. Horizontal fracture of the maxilla, e.g. Le Fort I fracture. 35. What is the optimal urinary output for a trauma patient? Ans. In an adult patient, at least 0.5 ml/kg/hr. In the patients older than 1 year, it should be 1 ml/kg/hr. 36. What should be the patient’s position in case of a suspected cervical fracture? Ans. Body and neck should be extended. 37. A patient with maxillofacial injuries presents with ecchy­ mosis in the sulci, floor of mouth and hard palate. Generally, there are more chances of abrasion or fracture? Ans. There are more chances of fracture. 38. What is the minibone plate system? Ans. Monocortical system. 39. What is the minimum number of screws required for the fixation of miniplate? Ans. Minimum two screws on each side of the fracture site are required for the fixation of miniplate. 40. The spherical gliding principle is a feature of: Ans. ASIF plating. 41. What is the spherical glinding principle? Ans. In compression osteosynthesis, bicortical screws are used. As a screw is tightened in the vertical direction, the fractured bone ends move horizontally. This is called spherical gliding principle. General Maxillofacial Trauma 209

42. What should be the position of miniplate to prevent injury to the apices of teeth? Ans. At a distance, twice the height of the clinical crown below the alveolar crest. 43. In general, elastic traction is used to reduce the facial fractures. It does so by overcoming? Ans. i. The active muscular pull that distracts the fragments ii. The organized connective tissue at the fracture site iii. The malposition caused by the direction and force of trauma. 44. Why the gunshot fractures of the facial bones should not be treated via open reduction? Ans. The numerous small fragments will lose their vitality when the periosteum is reflected. 45. Define the following terms: (i) Non-union of fracture fragment; (ii) Delayed union; and (iii) Malunion Ans. i. Non-union of the fractured fragment: Non-union of the mandible implies a failure of the fracture hematoma to become transformed into an osteogenic matrix so that it is ultimately converted into non-osteogenic fibrous tissue. Non-union is considered a terminal condition of failed osteogenesis, which is identified by the mobility of the bone ends in all planes after an interval of time-period of 10 weeks. ii. Delayed union: If the bone fragments are in their correct apposition and the formation of the bone is slower than the expected rate for the age of the individual, a delayed union will occur but the functional and esthetic results will be normal. iii. Malunion: If accurate alignment has not been affected but bony union is achieved, either within the normal period 210 When, Why and Where in Oral and Maxillofacial Surgery

of time or after a protracted period, a state of malunion will exist. 46. What are the different types of forceps used for the reduction of different types of fractured fragments in the oral and maxillofacial regions? Ans. i. Mandible fracture: Lion’s bone-holding forcep ii. Maxilla fracture: Rowe’s disimpaction forcep/Hayton- William’s forcep iii. Zygomatic fracture: Freer elevator/zygomatic bone hook/ Dingman zygomatic elevator iv. Zygomatic arch fracture: Bristow’s elevator/periosteum Elevator can also be used v. Nasal fracture: Walsh’s nasal forceps. 47. Differentiate between primary bone healing and secondary bone healing. Ans. There are mainly two types of bone healing: i. Secondary bone repair: Fractures which are generally treated by method of only relatively rigid external immobilization (casts, splints, bandages and traction). This method of union is called secondary union. Sequence of secondary bone healing: a. Initial stage: 0 to 5 days after fracture b. Cartilaginous callus or soft callus formation: 4 to 40 days after fracture ii. Primary bone repair: Under the circumstances where fractures are immobilized by extremely rigid internal fixation, e.g. application of a rigid compression plate or the application of a rigid external device, the mechanism of fracture healing is called primary bone union. The sequence of primary bone healing is: a. Gap healing: 0.3 mm up to 1 mm. Gap healing begins almost immediately b. Contact healing: In this, contact is achieved when the interfragment gap is essentially zero. Healing General Maxillofacial Trauma 211

occurs through the bone metabolizing unit or bone remodelling unit. A special process of bone formation occurs, which is known as contact healing. Vascular and cellular growth cannot proceed in this process. 48. What is mnemonic to assess the patient’s level of conscious­ ness in maxillofacial injuries? Ans. “AVPU” is the mnemonic used. “A”—Alert “V”—Responds to vocal stimuli “P”—Responds to pain stimuli “U”—Unresponsive. 49. List the aims/objectives and goals of management of the jaw fracture. Ans. The objectives of treatment are: i. To avoid infection ii. To provide immobilization iii. To maintain oral hygiene The goals of management are: i. Symmetrical facial contour ii. Normal functional activity. 50. What is the basic difference between closed reduction and open reduction of jaw fracture? Ans. Closed reduction: This is a procedure by which the fractured fragment is brought together in alignment without exposing the fractured bone ends. Occlusion is key to reduction. Open reduction: It is a procedure in which fractured fragment is exposed (fractured bone ends) and brought into alignment under direct vision. The fractured fragment can be exposed intraorally or extraorally. 51. Which examinations are included in the patients with respi­ ratory distress in maxillofacial injuries? Ans. The following examinations should be included: i. Attention to mandibular mobility ii. The size and mobility of the tongue 212 When, Why and Where in Oral and Maxillofacial Surgery

iii. The state and fragility of dentition iv. The amount and viscosity of secretions v. The presence of hemorrhage or masses in the oral cavity and pharynx. 52. What are the contraindications of endotracheal intubation? Ans. Contraindications are rare but relative contraindications include the following cases: i. Cervical spine injury ii. Presence of CSF rhinorrhea or fracture of anterior cranial fossa iii. Presence of retropharyngeal swelling iv. A fractured larynx may make endotracheal intubation impossible. 53. On an emergency basis, what are the indications of tracheostomy? Ans. Following are the indications of tracheostomy: i. Upper airway obstruction caused by trauma, soft tissue swelling, fracture, infection, hemorrhage or foreign bodies ii. Facilitation of tracheobronchial toilet iii. Anticipated prolonged mechanical ventilation iv. Facilitation of management of concomitant problems such as cervical spine injuries. 54. What are the additional advantages of cricothyroidotomy over tracheostomy? Ans. Following are the additional advantages of cricothyroidotomy: i. In emergency situations, the cricothyroidotomy can be performed rapidly, generally in less than 2 minutes ii. Extensive knowledge of neck anatomy is not necessary iii. Rate of operative complications is low iv. The airway entrance in cricothyroidotomy can be isolated from the operative site v. There is potential improved cosmetic of the resultant scar. General Maxillofacial Trauma 213

55. What are the ten cardinal points to summarize heart injury in maxillofacial trauma? Ans. i. Bruise on sternum ii. Fractured sternum iii. Cyanosis of upper half of body iv. Unexplained hypotension v. Massive hemothorax vi. Pericardinal tamponade vii. Atrial or ventricular arrhythmias viii. ECG evidence of myocardial ischemia or infarction ix. New cardiac murmurs x. Muffled heart tones. 56. What is the proper order to examine the oral cavity in the maxillofacial region? Ans. i. Oral examination as follows: – Soft tissue – Nerves – Skeleton – Dentition. ii. Maxillofacial examination as follows: – Soft tissues – Nerves – Skeleton. 57. At the primary level, how can mandible be immobilized in case of jaw fracture? Ans. Extraorally, it can be immobilized with the help of: i. Barrel bandage ii. Four-tailed bandage Intraorally, it can be immobilized with the help of: i. Temporary direct teeth wiring ii. If wire in not available, it can be done with the help of suture. 58. What are the stages of healing of fracture? Ans. i. Clotting of blood of the hematoma ii. Organization of the blood of the hematoma iii. Formation of fibrous callus 214 When, Why and Where in Oral and Maxillofacial Surgery

iv. Formation of primary bone callus v. Formation of secondary bony callus vi. Functional reconstruction of the fractured bone. 59. Explain the Golden Hours in critical care. Ans. i. In emergency, the term “Golden Hour” refers to the first hour following trauma ii. Platinum 10 minutes are first 10 minutes after trauma and refers to the importance of starting first aid within 10 minutes to reduce the chances of death iii. Door to ECG: Time is an important terminology in the treatment of heart attack or MI iv. Door to needle time: In acute case, MI is the time before which the clot dissolving drug should be given v. Door to Balloon time: It is for angioplasty vi. Door to Doctor time: More than 10 minutes in stroke when the mortality is high vii. Door to neurologic time: Less than 15 minutes in case of stroke viii. Door to CT Scan time: Less than 25 minutes in suspected stroke ix. Door to CT interpretation: Less than 45 minutes x. Door to CPA (tissue plasminogen activator) time: In the treatment window in stroke within 60 minutes xi. Door to antibiotic times: In Community Acquired Pneumonia (CAP), it is the time to start antibiotics. 60. What is the Champy’s principle and Champy’s plate? Ans. Champy’s principle: Mini plates are applied using the Champy’s principle, which states that “Natural line of compression exists in the lower border of the mandible”. Plates are fixed on the ideal line of osteosynthesis, which is known as Champy’s line of osteosynthesis. Miniplates with self-tapping screw are applied on the outer cortical plate. Champy’s plate: “Semirigid fixation with monocortical screws”. Champy et al work with intraoral application of the monocortical miniplate for the treatment of mandibular angle fracture. General Maxillofacial Trauma 215

MANDIBLE FRACTURE 1. Define the following terms: (i) Closed fracture; (ii) Compound fracture; (iii) Comminuted fracture; (iv) Complicated or complex fracture Ans. i. Closed fracture: It is also known as simple fracture. It does not produce a wound open to the external environment, e.g. Through mucosa or skin ii. Compound fracture: It is also known as open fracture. It produces an external wound through mucosa or skin which communicates with breake in the bone iii. Comminuted fracture: A fracture in which the bone is splintered or crushed iv. Complicated or complex fracture: A fracture in which there is considerable injury to the adjacent soft tissue or adjacent part. It may be closed or compound. 2. How much energy is required to fracture the mandible? Ans. 45 to 75 kg/m. 3. What are the weak areas in mandible? Ans. i. Angle of mandible ii. Canine region iii. Symphysis menti iv. Neck of condyle v. Presence of foramina vi. Presence of teeth. 4. Which is the most common site of fracture in the mandible? Ans. Angle of mandible is the common site of fracture. Because of the sudden change in angulation, angle is considered as the weakest part of the mandible. 5. What is FLOSA? Ans. It is AO classification of the mandible based on clinical and radiographic finding: i. F—Fracture number ii. L—Localization 216 When, Why and Where in Oral and Maxillofacial Surgery

iii. O—Occlusion iv. S—Soft tissue involvement v. A—Associated fracture 6. How will you classify the angle fracture of mandible? Ans. Angle fracture of mandible is classified as: i. Favorable horizontal angle fracture ii. Unfavorable horizontal angle fracture iii. Favorable vertical angle fracture iv. Unfavorable vertical angle fracture. 7. Which radiograph is the best to visualize horizontal and vertical fractures of the angle of mandible? Ans. i. Orthopantomography (OPG) is the best to visualize horizontal fracture ii. Occlusal view is the best to visualize vertical fracture (favorable or unfavorable). 8. What are the eight cardinal common features of the mandible fracture? Ans. The eight cardinal common features of the mandible fracture are as follows: i. Change in occlusion ii. Abnormal mandibular movement iii. Anesthesia or paresthesia of the lower lip iv. Loose teeth v. Crepitation on palpation/step deformity vi. Laceration/hematoma/ecchymosis vii. Change in facial contour and mandibular arch form viii. Pain/swelling/redness/localized heat (all signs of inflammation) 9. What are the cardinal features of an angle fracture of the mandible? Ans. The cardinal features are: i. It results from the blow over the same side of the mandible between canine and second molar regions General Maxillofacial Trauma 217

ii. It also results from violence to the chin on the opposite side iii. Intraorally undisplaced fracture revealed by the presence of tell-tale hematoma formation iv. Anesthesia or paresthesia on the lower lip on the same side v. Step deformity behind the last molar intraorally. 10. What are the cardinal features of the subcondylar fracture of mandible? Ans. The cardinal features are: i. Most cases results from the trauma to the TMJ region ii. In most cases, condylar fracture results in restricted mouth opening iii. In most cases, occlusion is disturbed. 11. Which is the least common site of the fracture of the mandible? Ans. Coronoid process of the mandible. 12. What is the reason for the forward displacement of the condyle in the condylar fracture? Ans. Lateral pterygoid muscle. 13. To which side is the mandible deviated on protrusion in case of subcondylar region fracture? Ans. To the same side. 14. Which mandibular fractures are likely to be missed on panoramic radiograph? Ans. Symphysis and parasymphysis region fractures of the mandible are likely to be missed on panoramic radiograph because panoramic radiograph is 2D view (flat view) taken by a movable -X ray beam that displays the entire mandible as a flat structure and some overlap and blurring is usually seen. Mandibular condyle is difficult to detect and, when detected, it is difficult to ascertain the degree of displacement of the fracture. 218 When, Why and Where in Oral and Maxillofacial Surgery

15. What is the fracture of the tooth-bearing segment of the mandible known as? Ans. It is known as compound or open fracture. 16. What are the growth centres in the mandible? Ans. Symphysis menti and condylar regions. 17. Why is bone fixation avoided in symphysis menti and condylar regions in the fracture cases for children below 12 years? Ans. These two areas are growth centers. If bone plate is fixed in these areas, growth may be deferred. 18. In which condition bucket handle type of fracture is seen? Ans. It is seen on edentulous patient. The molar area is weakened following alveolar resorption and becomes the site for bilateral fracture of edentulous mandible. There is downward and backward movement of the anterior part of the mandible under the influence of diagastric and mylohyoid muscles. 19. Eburnation is seen in which condition? Ans. It is seen in non-union of fracture and radiograph shows rounding off and sclerosis of bone cells. 20. Which clinical sign is always present in the bone fracture? Ans. Tenderness (pain at the fracture site) is always present. 21. Direct impact on bone causes which type of fracture? Ans. Comminuted fracture (more than one fracture line is joined together). 22. A swelling behind the ear suggests fracture of which area? Ans. Condylar fracture. 23. Gunning splints are used in which cases? Ans. They are used in edentulous patients. 24. What is the other name for parade ground fracture? Ans. Guardsman fracture. General Maxillofacial Trauma 219

25. Guardsman fracture or parade ground fracture is commonly seen in which condition? Ans. It is commonly seen in an epileptic patient. 26. A patient gives history of trauma along with the complaint of bleeding from the ear. Which area fracture is suspected from history? Ans. It suggests the subcondylar fracture. 27. Tell-tale hematoma is seen in which type of fracture? Ans. It is seen in coronoid process fracture. 28. If angle fracture occurs during the removal of impacted mandibular third molar, what is the immediate line of treatment? Ans. i. Superior border transosseous wiring ii. Intermaxillary fixation (IMF). 29. What are the indications for removing a tooth in the line of fracture? Ans. The indications for extracting a tooth in the line of fracture are as follows: i. Presence of obvious pathology such as caries or period­ ontal disease ii. Gross mobility of the involved teeth iii. Teeth that prevent adequate reduction of fractures iv. Teeth with fractured roots v. Teeth whose root surfaces or apices are exposed in the fracture site. 30. What are dynamic compression plating, eccentric dynamic compression plating and passive plating? Ans. i. Dynamic compression plating: Dynamic compression plates compress the fracture site by providing axial guiding inclines for the screw heads to slide down as the screw is tightened. ii. Eccentric dynamic compression plating: It provides comp­ res­sion forces in more than one direction by changing 220 When, Why and Where in Oral and Maxillofacial Surgery

the direction of the guiding incline in the outer holes of the plate. iii. Passive plating: It provides rigid fixation without compres­ sion. 31. What is the best treatment of green-stick fracture of the mandible? Ans. Bringing the teeth into occlusion with interdental wiring. 32. What is the most common complication of the condylar injuries in the growing children? Ans. Ankylosis is the most common complication. To avoid such a complication, early mobilization is indicated. 33. Direct interdental wiring is also called as: Ans. Eyelet wiring. 34. What is the acceptable treatment modality for fracture of mandible in 8-year-old patient? Ans. Circummandibular splinting. 35. What is the reason for high rate of fracture at the canine region of the mandible? Ans. It is due to the long root of the mandibular canine. 36. Which fracture is responsible for the respiratory embarrassment? Ans. Bilateral parasymphysis fracture of the mandible. 37. Which structures may get injured during circummandibular wiring? Ans. i. Facial artery ii. Facial vein 38. Why should the submandibular incision in the angle region be a finger width below the lower border of the mandible? Ans. To prevent injury to the marginal mandibular nerve. General Maxillofacial Trauma 221

39. Which structures are responsible for the posterior displacement of anterior segment of the mandible in the case of bilateral parasymphysis fracture of the mandible or canine region? Ans. It is due to the action of: i. Geniohyoid muscle ii. Genioglossus muscle iii. Anterior belly of the digastric muscle. 40. What is the reason for the tongue to fall back in case of bilateral parasymphysis fracture of the mandible (canine region)? Ans. Removal of tongue attachment to the mandible may allow the tongue to fall back and obstruct the oropharynx. Geniohyoid, genioglossus and anterior belly of the digastrics muscle will tend to pull the mandible back. 41. Which extraoral radiograph is the best to demonstrate the subcondylar fracture? Ans. Towne’s projection. 42. Which structures are divided when the angle of mandible is exposed through a submandibular incision? Ans. From the outer to inner layers, the structures are: i. Skin ii. Superficial fascia iii. Platysma muscle iv. Deep cervical fascia v. Masseter muscle 43. What is the average period of immobilization? Ans. 6 to 8 weeks in adults. 44. A patients below 12 years of age is present with subcondylar fracture with normal occlusion. What is the line of treat­ ment? Ans. If occlusion is not disturbed, no immobilization and no active treatment are required. If occlusion is disturbed, IMF is required for one to two weeks with intermittent mouth exercise. 222 When, Why and Where in Oral and Maxillofacial Surgery

45. In case of subcondylar fracture, in which direction does the condyle move and also name the muscle which influences the movement or displacement of the condyle? Ans. Condyle moves in the anteromedial direction. The lateral pterygoid or the external pterygoid muscle influences the movement. 46. In angle fracture of the mandible, the proximal segment usually displaces in which direction and which muscles are responsible for it? Ans. The proximal segment gets displaced in the anterosuperior direction. It gets influenced by the pull of the medial pterygoid, masseter and temporalis muscles. 47. How will you manage a case of a fracture of the mandible in canine region in a child below 12 years? Ans. The use of acrylic cap splint with circumferential wiring is the best treatment modality. 48. Which is the best treatment option for unfavorable frac­ture of the angle of mandible? Ans. The best treatment modality is open reduction with rigid bone fixation. 49. Which are the sites for bone plating in the mandible? Ans. i. Inferior border of the mandible ii. Superior border of the mandible iii. Zone of tension. 50. Greenstick fracture is most commonly seen in which age- group? Ans. It is most commonly seen in children. One end bends like green stick. 51. Compression osteosynthesis heals the fracture in the mandible by which method? Ans. Primary union without callus formation. General Maxillofacial Trauma 223

52. What is the other name for direct interdental wiring? Ans. Glimer’s wiring. It is a simple method. 53. What is the clinical sign for a patient with left subcondylar fracture? Ans. Such patients are unable to deviate the mandible towards the right side. It is due to the ineffective action of the lateral pterygoid muscle on the fracture side. 54. If there is a fracture of the mandible distal to last molar, how will you manage such cases? Ans. Open reduction with bone plating. 55. If there is an undisplaced fracture of the mandible with full set of teeth, how will you manage such cases? Ans. It can be successfully treated by intermaxillary fixation with arch bar for 6-8 weeks in adults. 56. Which type of fracture of the mandible causes anterior open bite? Ans. Bilateral condylar fracture. 57. Which is the most commonly used splint for dentulous mandibular fracture? Ans. Cap splint is used in the dentulous patients. 58. Which type of wiring is indicated in the symphysis fracture of the mandible? Ans. Risdon’s wiring. 59. Why a displaced, unfavorable fracture is difficult to treat? Ans. It is because of the destruction of the fractured fragment by muscle pull. 60. Which area is suitable for miniplate fixation? Ans. Zone of tension. 61. What is Stout wiring? Ans. It is also known as Col. Stout multiple loop wiring. Here four posterior quadrants are used for wiring followed by intermaxillary fixation. 224 When, Why and Where in Oral and Maxillofacial Surgery

62. Answer the following: i. Give example of closed fractures of the mandible. ii. Which mandible fracture is always a compound fracture? iii. Which mandible fracture does never get displaced and why? Ans. i. Condyle and coronoid fractures of the mandible is one example of closed (simple) fracture of the mandible. They are never exposed either extraorally or intraorally. ii. Fractures involving tooth-bearing areas are always compound fractures. They are open either extraorally or intraorally. iii. Ramus fracture of the mandible never gets displaced because of the pterygomasseter sling (masseter muscle and medial pterygoid muscle) make a sandwich and prevent displacement. 63. List the various classifications for condylar fracture and what is the criteria for classification? Ans. i. First classification: It was given by Lindahl on the basis of radiographic reading, e.g. – Fracture level – Relationship of condylar fragment to the mandible – Relationship of condylar head to fossa ii. Second classification: It is on the basis of relationship of the fractured fragment to the mandible. It is also known as clinical classification. iii. Third classification: Simple classification and it is classified as: – Intracapsular – Extracapsular. 64. What are the different methods for indirect skeleton fixation and immobilization of jaw fracture? Ans. After the closed reduction the methods for indirect skeletal fixation are: General Maxillofacial Trauma 225

i. Direct interdental wiring ii. Indirect interdental wiring iii. Ivy loop or eyelet wiring iv. Continuous or multiple loop wiring v. Arch bars vi. Cap splint vii. Gunning type splint viii. Pin fixation ix. Essig’s wiring x. Gilmer’s wiring xi. Risdon’s wiring xii. Col. Stout’s multiple loop wiring. 65. What are the different methods for direct skeletal fixation and immobilization of jaw fracture? Ans. After open reduction, the methods for direct skeletal fixation are: i. Direct wiring or osteosynthesis or transosseous wiring ii. Bone plating iii. Intramedullary pinning iv. Titanium mesh v. Circumferential straps vi. Bone clamps vii. Bone staples viii. Lag bone screw. 66. What is elephant foot deformity? Ans. In case of edentulous mandible fracture, many times non- union of fracture is seen due to the impaired blood supply or the presence of infection. During open reduction, there is a typical eburnation of the ends of the fractured fragments. In radiograph, this eburnation is seen as the elephant foot deformity. 67. In reference to condylar fracture, define the following terms: (i) Dysarthrosis; (ii) Metarthrosis; and (iii) Pseudoarthrosis. Ans. i. Dysarthrosis: Morphological change is seen in unreduced fracture dislocation producing non-articulating 226 When, Why and Where in Oral and Maxillofacial Surgery

deformed condyle. The patient will have pain and limited movement. ii. Metarthrosis: It is the result of healed fracture in malposi­ tion but it produces no symptoms. Joint with altered anatomy but functionally accepted. iii. Pseudoarthrosis: False joint, very painful during excur­ sions. 68. In reference to management of the mandible fracture, what are the roles of the following materials? (i) Kirschner wires (K wires); and (ii) Lag screws. Ans. i. Kirschner wires (K wires): They are rarely used for temporary fixation of the fracture of the mandible. The fractured segments are held together in position. More recently K wires are also used for comminuted fractures of the body of the mandible. ii. Lag screws: Compression of the fractured fragments can be accomplished by means of lag screws. This technique was applied for the treatment of oblique fracture in long bones. Few oblique mandibular fractures can be treated through this method. 69. Explain the following terms: (i) Strain lines; (ii) Champy’s lines; and (iii) Lines of bone (Trajectories of bones). Ans. i. Strain lines: Strain lines are the lines of tension which are opposite to the site of force application. For example, symphysis menti, mental foramen and condylar neck. ii. Champy’s lines: It is also known as or lines of tension forces. Small plates will take these loads. iii. Lines of bone ‘Trajectories of bones’: These are the lines of orientation of bony trabeculae corresponding to the pathways of the maximal pressure. For example: a. Horizontal buttress General Maxillofacial Trauma 227

b. Vertical buttress. i. Nasomaxillary ii. Zygomatic maxillary iii. Pterygomaxillary. 70. What is the simple guide to the time of immobilization for fracture of the jaw (tooth-bearing area)? Ans. i. Young adult with angle fracture in which tooth is removed from the fracture line = 3 weeks ii. Tooth retained in fracture line = 3 + 1 weeks iii. Fracture at the symphysis region = 3 +1 weeks iv. Age 40 years and over = 3 + 2 weeks v. Children and adolescents = 3 – 1 weeks

MAXILLA FRACTURE 1. How is the facial skeleton divided? Ans. Facial skeleton can be divided into three parts: i. The upper part, i.e. forehead. It is formed by the frontal bone. ii. The lower part is formed by the mandible. iii. Middle third of the facial skeleton: – Superiorly it is bounded by the frontozygomatic suture on both the sides and frontonasal suture in the middle. – Inferiorly it extends up to the occlusal surface of the maxillary teeth. 2. How many bones make up the middle third of the facial skeleton? Ans. Following bones make up the middle third of the facial skeleton (total 17 bones): i. Two maxillae ii. Two zygomatic bones iii. Two zygomatic processes of the temporal bone iv. Two palatine bones v. Two nasal bones 228 When, Why and Where in Oral and Maxillofacial Surgery

vi. Two lacrimal bones vii. The vomer viii. The ethmoid and its attached conchae ix. Two inferior conchae x. The pterygoid plexus of sphenoid. 3. Who was Le Fort? What is Le Fort fracture? Ans. Rene Le Fort was a French surgeon. He was interested in the lines of weakness on the face and the pattern of midfacial fracture. He performed a number of experiments on fresh cadaver heads. He determined three basic fault lines along which the face fractured.He observed that fractures of the midface occurred in three typical patterns and were often bilateral and could be mixed. 4. A patient with Le Fort II, Le Fort III and nasoethmoidal fracture with IMF. What is the best way to intubate such a patient? Ans. Submental intubation is the option because due to IMF, oral intubation is not possible. Nasoethmoidal fracture may create difficulty for nasal intubation. Tracheostomy may be considered as one of the alternatives. 5. List the synonyms of Le Fort I fracture. Ans. Le Fort I fracture is also known as: i. Low level fracture of maxilla ii. Horizontal fracture of maxilla iii. Guerin fracture iv. Telescopic fracture. 6. List the synonyms of Le Fort II fracture. Ans. Le Fort II fracture is also known as: i. Pyramidal fracture ii. Infrazygomatic fracture. General Maxillofacial Trauma 229

7. List the synonyms of Le Fort III fracture. Ans. Le Fort III fracture is also known as: i. Suprazygomatic fracture ii. Craniofacial disjunction iii. High level fracture. 8. A patient with facial trauma with bleeding from the nose (antrum) or bleeding into the antrum. This suggests the fracture of which region? Ans. Le Fort I fracture of the maxilla. 9. Which type of maxilla fracture may cause open bite? Ans. Le Fort I facture—horizontal fracture of the maxilla. 10. In which fracture cases is the floating maxilla typically found? Ans. In case of Le Fort I or Guerin fracture. 11. Name the forcep which is used for the maxillary fracture disimpaction?­ Ans. Rowe’s disimpaction forceps. It is used bilaterally and simulta­ neously. It is a paired instrument. 12. Why is Le Fort I fracture also known as telescopic fracture or impacted fracture? Ans. In case of Le Fort I fracture, sometimes there is an upward displacement­ of the entire fragment, locking it against the superior intact structure. Such fracture will be called as impacted or telescopic fracture. 13. What is the course of the line of Le Fort I fracture? Ans. The course of the line of Le Fort I fracture is: i. Floor of the nose ii. Lower third of the maxilla iii. Palate iv. Pterygoid plate. 14. What is the course of the line of Le Fort II fracture? Ans. Fracture line traverses from: 230 When, Why and Where in Oral and Maxillofacial Surgery

Thin portion of the frontal process extended laterally through the Lacrimal bone

Floor of the orbit

Zygomatic maxillary suture

Infraorbital foramen continues through the Lateral wall of the maxilla through the Pterygoid plates into the Pterygoid maxillary fossa 15. What is the course of the line of Le Fort III fracture? Ans. These essentially run parallel to the base of the skull. i. Nasofrontal suture ii. Floor of the orbit iii. Zygomatic frontal suture iv. Zygomatic arch. 16. What are the cardinal features of Le Fort I fracture? Ans. Following are the cardinal features of Le Fort I fracture: i. Mobility of the upper dentoalveolar portion of the jaw ii. Ecchymosis in the labial and buccal vestibule iii. Nasal bleeding may be observed iv. Swelling (may be slight), edema and laceration of upper lip and intraoral mucosa may be seen v. Occlusion may be disturbed vi. A classic anterior open bite may be seen vii. Percussion of maxillary teeth produces dull cracked pot sound. 17. What are the cardinal features of Le Fort II fracture? Ans. Following are the cardinal features of Le Fort II fracture: General Maxillofacial Trauma 231

i. Step deformity at the infraorbital margins ii. Mobility of midface iii. Anesthesia or paresthesia of cheek iv. Orbital floor injury with possible diplopia v. Pupils tend to be levelled vi. Nasal bones move with midface as a whole vii. CSF rhinorrhea may not be clinically detectable viii. No tenderness over the zygomatic bones and arch. 18. What are the cardinal features of Le Fort III fracture? Ans. Following are the cardinal features of Le Fort III fracture: i. Tenderness and separational at frontozygomatic suture. This will produce lengthening of face ii. Tenderness and deformity of zygomatic arches iii. Characteristic dish-face deformity iv. Hooding of eyes v. Often profuse CSF rhinorrhea vi. Enophthalmos vii. Disorganization of nasal skeleton viii. Gross edema of face with panda facies within 24 to 48 hours ix. Tilting of occlusal plane with gagging on one side only x. Raccoon eyes (bilateral circumorbital/periorbital/ecchy­ mo­sis and gross edema of eyes). 19. List the common features of Le Fort II and III fractures. Ans. Common clinical features of Le Fort II and III fractures are as follow: i. Dish-face deformity ii. Gross edema of middle third of facial skeleton iii. Bleeding from nose or nasal obstruction iv. Bilateral circumorbital edema/ecchymosis/hemorrhage v. CSF rhinorrhea (sometimes it appears) vi. Diplopia and enophthalmos vii. Retroposition of maxilla and gagging viii. Difficulty in mouth opening. Mobility of the upper jaw. 232 When, Why and Where in Oral and Maxillofacial Surgery

ix. Cracked pot sound on tapping the teeth. x. Hematoma of the palate. 20. Cerebrospinal fluid rhinorrhea is found in which conditions? Ans. It is associated with: i. Le Fort II ii. Le Fort III iii. Nasoethmoidal fracture. Associated with comminuted cribriform plate of ethmoid. 21. Epiphora is seen in which fracture and what is the cause? Ans. Epiphora (water from the eyes) is seen in Le Fort II and Le Fort III fracture and severe nasal complex injuries due to partial or complete obstruction of nasolacrimal duct. 22. Panda facies and Raccoon eyes is seen in which cases? Ans. It is seen in Le Fort II fracture. Due to edema and ecchymosis around the eyes, the patient develops black circles around the eyes, which is known as Raccoon eyes. 23. Paresthesia is seen with either zygomaticomaxillary fracture or subcondylar fracture? Ans. Zygomaticomaxillary fracture. 24. Diplopia is commonly seen in either nasal fracture or zygomaticomaxillary complex? Ans. Diplopia is generally seen in zygomaticomaxillary complex fracture and Le Fort II and Le Fort III when fracture line passes above the Whitnall’s tubercle. 25. How can diplopia be checked and recorded? Ans. The diplopia can be tested with forced conduction test and degree of diplopia can be accurately recorded by the method of a Hess Chart. 26. What is the role of pack in maxillary sinus? Ans. i. To support comminuted fracture of the body of zygomatic complex ii. To support and reconstitute comminuted orbital floor fracture. General Maxillofacial Trauma 233

27. Hooding of the eyes is seen in which type of fracture? Ans. Le Fort III fracture: If the fracture line passes above the Whitnall’s tubercle, it removes the support given to the eye by Lockwood’s suspensory ligament and the upper eyelid follows the globe down. That producing hooding of the eyes. 28. Which is the most common site of the leakage of CSF rhinorrhea? Ans. Cribriform plate is the common site. 29. What is Guerin’s sign? Ans. Ecchymosis at greater palatine foramen in Le Fort I fracture. 30. Moon face appearance is seen in which cases? Ans. Le Fort II and Le Fort III fractures due to gross edema of soft tissue overlying the middle third of the facial skeleton. 31. Which are the most common complications of the CSF rhinorrhea? Ans. i. Ascending meningitis ii. Pneumocephalus 32. Which anatomical structure is important during Gillies approach? Ans. Superficial temporal artery. 33. Why is Le Fort III fracture rarely seen in children below eight years of age? Ans. It is rarely seen in children due to the lack of poorly developed ethmoidal and sphenoidal sinus. 34. What is dish-face deformity? Ans. It occurs in Le Fort III fracture. The patient presents with characteristic disc face because the middle third of the face is pushed back or posterior and downward movement of maxilla. 35. What is Battle’s sign and its clinical significance? Ans. Battle’s sign is ecchymosis posterior to ear. It is generally indicative of basilar skull fracture involving the middle cranial fossa. It is a relatively late sign presenting approximately 24 hours after injury. 234 When, Why and Where in Oral and Maxillofacial Surgery

36. The typical cracked pot sound on percussion of upper teeth is indicative of which fracture? Ans. Le Fort I and Le Fort II fracture. 37. Why there is CSF rhinorrhea in Le Fort III frontal bone fracture? Ans. It is because of the following reasons: i. Fracture of the cribriform plate of the ethmoid ii. Fracture of the posterior wall of the frontal sinus iii. Fracture of the roof of the sphenoidal air sinus. 38. Why does a subconjunctival hemorrhage remain bright red in color for a long time? Ans. It is because of the permeability of the conjunctiva to oxygen. 39. Why is penicillin (IM or oral) not effective in the presence of infection in Le Fort II and Le Fort III fracture? Ans. Penicillin does not pass into the CSF in adequate therapeutic concentration and also if a Le Fort II or III fracture is present even without the CSF rhinorrhea. The patient should be given a course of sulfonamide therapy. An initial dose of Sulphadiazine 2 gm is followed by 1 gm 6 hourly and the course is continued for atleast 5 days or longer if there is an established CSF leakage. 40. What is the basic difference between CSF rhinorrhea and CSF Otorrhea? Ans. CSF Rhinorrhea CSF Otorrhea Discharge of CSF through the nose Discharge of CSF Otorrhea through due to skeletal disruption in the base the ear due to skeletal disruption in of anterior cranial fossa produces CSF the base of the middle and posterior rhinorrhea. cranial fossa produces CSF otorrhea.

41. What is the method used to confirm CSF rhinorrhea? Ans. Handkerchief test: CSF Rhinorrhea (leakage of CSF from the nose) is generally associated with bleeding. CSF in the blood can be detected with the help of a single test in which a drop of fluid is placed on the handkerchief—the classic Bull’s eye ring develops. It is also identified by the Tram-line pattern. General Maxillofacial Trauma 235

42. What is diplopia and which muscle is frequently associated with it? Ans. Diplopia is also known as ambiopia or double vision. It is blurred vision and defined as the perception of two images of a single object. The muscle associated with it is inferior rectus muscle. 43. What are the tests for diplopia? Ans. i. Test for the eye-movement—“Nine Gauze test”: A finger is held in front of the patient and moved in all the directions as the patient’s eyes follow the finger. The patient is asked to report any double vision. Diplopia should be tested in all the nine directions of the gauze. ii. Test for the cause of diplopia—“Forced Duction test”: It is carried out under GA with the tissue holding the force of the forcep. Hold the tendon of the inferior rectus muscle and the patient is asked to carry out the entire range of the eye movement. A failure to rotate the eyes superiorly indicates paralysis or entrapment of the muscle within the fracture fragment. iii. Hess test: Hess test is used to measure the degree of diplopia. The test helps in showing which extraocular muscle is not functioning. When done on every alternative day, the progress of diplopia can be monitored. 44. What is the logical sequence of events to manage the fracture of the middle third of the facial skeleton? Ans. The well-established principles are: i. Tracheostomy ii. Facial laceration iii. Reduction of associated mandible fracture iv. The occlusion v. Zygomatic fracture vi. Disimpaction and reduction of the maxillae vii. Open reduction viii. Skeletal fixation 236 When, Why and Where in Oral and Maxillofacial Surgery

ix. Temporary intermaxillary fixation IMF x. Nasal fracture xi. Definitive IMF. 45. Which syndromes are considered as the complications for the middle third the facial skeleton fracture? Ans. i. Superior orbital fissure syndrome: – It is attributed to poor reduction of Le Fort III fracture or malunited zygomatic complex fracture – Hematoma within the fissure affects third, fourth and fifth cranial nerves – The optic nerve is not involved – It may result in ophthalmoplegia, proptosis and retrobulbar pain. ii. Zygomatic syndrome: In addition to facial deformity in the form of flatness of the cheek, pain may be experienced constantly due to impingement of the coronoid process on the opening of mouth iii. Orbital syndrome: The orbital injury may produce proptosis and blindness­ due to transverse fractures of the middle third facial skeleton. The impingement, laceration or hemorrhage of the nerve sheath of optic nerve may produce blindness.

ZYGOMATIC COMPLEX/ORBITAL/ NASOETHMOIDAL FRACTURE 1. What are the diagnostic features of the zygomatic complex fracture? Ans. The diagnostic features of the zygomatic complex fractures are as follow: i. Flattening of cheeks ii. Periorbital hematoma iii. Subconjunctival hemorrhage iv. Intraorally ecchymosis (buccal sulcus) and tenderness over zygomatic buttress General Maxillofacial Trauma 237

v. Diplopia vi. Restricted mandibular movement vii. Tenderness and step deformity of the infraorbital margin viii. Tenderness and separation of frontozygomatic suture ix. Enophthalmos x. Lowering pupil level xi. Epistaxis xii. Possible gagging on the injured side. 2. List the clinical features of the isolated zygomatic arch fracture. Ans. The features of the isolated zygomatic arch fracture are as follow: i. Flattening of cheeks ii. Partial trismus (restricted mouth opening) iii. Depression over the zygomatic arch region iv. Tenderness and step deformity in the zygomatic arch region v. Intraorally buccal sulcus ecchymosis and tenderness. 3. List the clinical features of the blowout fracture. Ans. i. Circumorbital edema and/or circumorbital ecchymosis ii. Proptosis iii. Diplopia iv. Enophthalmos. 4. List the clinical features of blowin fracture. Ans. i. Proptosis ii. Restricted ocular motility iii. Diplopia iv. Superior orbital fissure syndrome v. Optic nerve injury. 5. Which elevator is used to reduce the zygomatic arch fracture? Ans. Bristow’s elevator is used for the reduction of the zygomatic arch fracture. 238 When, Why and Where in Oral and Maxillofacial Surgery

6. In Gillies temporal approach for the reduction of the zygomatic arch fracture, where is the elevator placed? Ans. The elevator is placed between the temporal fascia and temporalis muscle. 7. Hanging drop appearance is seen in which fracture and which radiographic view is advisable? Ans. Hanging drop appearance is seen in blowout orbital fracture and water’s projection of the face (PNS view) is advisable. 8. After trauma, diplopia is due to the entrapment of: Ans. Diplopia is due to the interference with the action of extraocular muscles, mainly due to the inferior rectus and inferior oblique muscle. 9. What is the normal intercanthal distance and case of traumatic telecanthus? Ans. Normal intercanthal distance is 25 mm. In traumatic telecanthus, it increases to 35 to 40 mm. 10. Why does subconjunctival hemorrhage remain bright red color for a long time? Ans. Subconjunctival hemorrhage remains bright red in colour for a long time because oxygenations of hemoglobin cannot take place through thin conjunctiva. 11. Which incision is used for the treatment of traumatic tele­ canthus? Ans. Bicoronal incision gives excellent exposure of the nasoethmoidal complex. 12. In the patients with zygomatic fracture, there is paresthesia of the upper lip over the nasal area. What is the cause of paresthesia? Ans. It is because of involvement of the infraorbital nerve on the same side. General Maxillofacial Trauma 239

13. How will you recognize the depressed fracture of the zygomatic area clinically? Ans. The following features help to recognize the fracture of the zygomatic area: i. Concavity of the overlying tissue in the zygomatic area ii. Difficulty in jaw movement iii. Partial trismus restricted mouth opening. 14. What does detachment of suspensory ligament cause? Ans. Lowering of the papillary level of the eyeball. 15. What is the ring fracture of the middle third of facial skeleton? Ans. In some severe fracture of the nasal complex, the fracture lies at the center of the ring. Fracture of the middle third of the face passes from the frontal bone downward on each side across the medial orbit wall, the infraorbital rim and the anterior wall of the maxillary sinus to link up beneath the anterior nasal spine. Such a fracture causes considerable depression of the central part of the face without any disturbance of the occlusion. 16. What is tripod fracture? Ans. The zygomatic bone is closely associated with the maxilla/ frontal/temporal bones. They are usually involved when a zygomatic bone fracture is referred to as zygomatic complex fracture or zygomaticomaxillary complex fracture or tripod fracture. 17. What are blood-shaded eye and double vision? Ans. Subconjunctival hemorrhage is also known as blood-shaded eye. Diplopia is also known as double vision or blurred vision. 18. When is the nasal packing indicated after the treatment of the nasal fracture? Ans. After the successful reduction of a nasal fracture, intraseptal packing is often used for the following purposes: i. To control bleeding ii. To prevent postoperative septal hematoma iii. To splint the nasal septum into the position iv. To prevent synechiae. 240 When, Why and Where in Oral and Maxillofacial Surgery

19. What are the indications of the posterior nasal packing? Ans. i. It is indicated when posterior nasal area bleeds ii. It is indicated if a posterior nose bleed is visualized iii. Bleeding cannot be controlled with a well-placed anterior pack. 20. How long should a posterior nasal pack be left in place? Ans. For 3 to 5 days. 21. How soon should a nasal fracture be reduced after the injury? Ans. Nasal fracture should be reduced within the first few hours after injury. If this is not done within this period, edema makes of the reduction difficult. The next window of opportunity occurs 3 to 14 days after the injury when edema has resolved but before the bony union. 22. What are the late complications of the nasal fracture? Ans. i. Airway obstruction ii. Nasal deformity or saddle nose deformity or dorsal hump iii. Nasal deviation iv. Septal perforation v. The formation of synechiae vi. Recurrent epistaxis vii. Recurrent sinusitis viii. Headache. 23. What is a saddle nose deformity? Ans. It is the concave appearance of the nasal dorsum, sometimes following the nasal trauma. 24. What is the difference between telecanthus and hyper­ telorism? Ans. i. Telecanthus: Widening of the distance between the medial canthi, usually as a result of trauma. For example, nasoethmoidal fracture. Normal distance is 33 mm approximately. General Maxillofacial Trauma 241

ii. Hypertelorism: It is the widening of the orbits themselves and is measured as the interpupillary distance, normally 60 mm. 25. What is Marcus Gunn pupil? Ans. It is an afferent papillary defect resulting from the lesions involving the retina or optic nerve back to the chiasm. With this defect, a light shown in the unaffected eye produces normal constriction of the pupils of both the eyes but a light shown in the affected eye produces a paradoxical dilation rather than constriction of the affected pupil. 26. What is the incidence of anesthesia of the infraorbital floor with orbital floor fracture? Ans. The incidence is 90 to 95%. 27. What is the most common complication of the untreated orbital floor fracture? Ans. i. Diplopia ii. Enophthalmos 28. What are the causes of traumatic ptosis? Ans. Ptosis refers to the dropping of the upper eyelid. Disruption of the sympathetic fibers, (e.g. Horner’s syndrome) leads to ptosis. Injury to the cranial nerve III (oculomotor nerve) or muscle also results in ptosis. Alteration in the globe position may result in the appearance of ptosis. 29. What is hyphema and how is it managed? Ans. Hyphema is the layering of blood in the anterior chamber of the, globe, usually from the tearing of blood vessels at the root of the iris. It may present with pain/blurred vision and photophobia. Intraocular pressure, treated with topical beta blockers and mannitol, if necessary. Aspirin is absolutely contraindicated. 30. In depressed zygomatic arch fracture, impingement of which structure causes difficulty in mouth opening? Ans. Coronoid process. 242 When, Why and Where in Oral and Maxillofacial Surgery

31. Which is the best radiographic view to visualize the zygomatic arches? Ans. Submentovertex or jug-handle view. 32. What is the use of Walsham forceps? Ans. Reduction of the fracture of the nasal bones. 33. Traumatic telecanthus is associated with which injury? Ans. Nasoethmoidal injury. 34. What is the cause of epiphora (watering from the eyes)? Ans. Blockage of the nasolacrimal duct. 35. Which is the weakest part of the orbit: Floor of the orbit or medial wall of the orbit? Ans. Floor of the orbit is the weakest part of the orbit because of frequent fracturing of the orbital floor. 36. What is the best time for the reduction of the fractured malar bone? Ans. i. When periorbital edema has subsided ii. Three to five days after injury iii. When chemosis has subsided. 37. Why is the orbital fracture called pingpong ball? Ans. Orbital blowout fracture occurs when a rounded object strikes the protruding eyeball, resulting in the fracture of the orbital floor. 38. What is the difference between blowout and blowin fracture? Ans. i. Blowout fracture refers to the fracture of the floor of the orbit. It is accompanied by the displacement of orbital contents into the maxillary sinus ii. Blowin orbital fracture refers to the inward displacement of the orbital rim or walls, resulting in decreased orbital volume. 39. What is pure and impure orbital blowout fracture? Ans. i. Pure orbital blowout fracture: Fracture of the orbital floor into the maxillary antrum without the involvement of the orbital rim is called pure orbital blowout fracture. General Maxillofacial Trauma 243

ii. Impure orbital blowout fracture: If the orbital rim is involved, it is called as impure orbital blowout fracture. 40. Which different materials are used to reconstruct an orbital floor? Ans. i. Alloplastic: Polyethylene, polyvinyl sponge, gelfilm, hydroxyapatite, polymeric silicon ii. Allogenic: Lyophilized dura, allogenic bone and cartilage iii. Autologous: Graft. 41. What are the aims and objectives of the management of the zygomatic complex fracture? Ans. i. To restore the normal contour of the face for cosmetic reasons ii. To re-establish the skeletal protection for the globe of the eye iii. To correct diplopia iv. To remove any interference with the range of the movement of the mandible. 42. Which different incisions are used for zygomatic complex fracture and arch? Ans. i. Periorbital incisions: – Supraorbital eyebrow incision – Lower lid or blepheroplasty incision – Infraorbital incision – Subtarsal incision – Subciliary incision – Transconjunctival incision ii. Alkayat and Bramley incision iii. Coronal incision (bifrontal flap). 43. What are the different methods for the external fixation of the zygomatic complex fracture? Ans. The different methods for external fixation are as follow: i. Either by pin or wire ii. Halo frames iii. Plaster of Paris head cap iv. Box frames. 244 When, Why and Where in Oral and Maxillofacial Surgery

44. What is the exact site of incision for the fractured zygomatic arch reduction? Ans. i. Gillies temporal fossa approach: – Extraoral approach: An incision of about 2.5 cm length is made between the two branches of the superficial temporal artery at an angle of 45° of the upper limit of the attachment of the external ear. – Reduction is done with the help of Bristow’s elevator. Another alternative is to use a long periosteal elevator. ii. Keen’s approach: – Intraoral approach: Intraoral buccal vestibular incision is taken in the first and second maxillary molar regions behind the zygomatic buttress – Reduction is done with the help of Boon Hook or Monk’s pattern pointed elevator or long curved periosteal elevator. 45. List the complications of the zygomatic complex fracture. Ans. i. Functional ophthalmic disturbances ii. Esthetic or cosmetic deformities iii. Neurosensory deficiencies iv. Masticatory compromise. 46. Which neurological and ophthalmic complications can arise due to the malunion of the zygomatic complex fracture? Ans. i. Neurological: – Paresthesia – Dysesthesia or anesthesia, mainly infraorbital nerve may be present ii. Ophthalmic: – Change of the ocular level – Diplopia – Enophthalmos – Occulorotatory restriction. General Maxillofacial Trauma 245

47. Which are the radiological projections for the nasal bone fracture? Ans. i. Lateral view of the nasal bone ii. 15° or 30° occipitomental projection iii. CT scan for higher-level fracture of the nose. 48. What is there open sky technique for the nasal injuries? Ans. • Open sky approach demonstrates multiple fractures of the nasal bones that can be repaired under direct vision • “H” or open sky technique is originally described by converse. The technique combines bilateral medial canthal incisions with a transverse nasal bridge incision giving access to the bony nasal skeleton. Direct wiring of multiple fragments is possible via this approach. 49. List the cardinal signs of fracture of the nasoethmoid complex. Ans. The cardinal signs of fracture of the nasoethmoid complex are as follows: i. Frontal depression ii. Nasal deformity iii. Traumatic telecanthus iv. CSF rhinorrhea v. Diplopia vi. Hemorrhage—Due to the rupture of the anterior and posterior branches of the ethmoid artery vii. Accentuation of the nasofugal skinfold. 50. What are the objectives of the management of the nasal fracture? Ans. The overall objectives are as follows: i. Obtaining a normal airway with maximum esthetic improvement ii. Restoring the septum to midline iii. Maintaining a normal semirigid partition and non- producing a flaccid septum 246 When, Why and Where in Oral and Maxillofacial Surgery

iv. Retaining as much support as possible to resist subsequent trauma v. Preventing the complications of saddle deformity, columella retraction, etc. vi. Preventing postoperative stenosis and scaring vii. Avoiding interference with growth in children by minimal disturbance or removal of normal structure. 51. In which type of fracture is submental intubation an alternative of tracheostomy? Ans. In the case of pan-facial fracture 52. What are the late sequelae of the nasal fracture? Ans. They are summarized as follows: i. Relative hump ii. Wide lateral bony vault iii. Depression of the cartilaginous dorsum iv. External twist and deviation of the radix nasi v. Splayed cartilaginous dorsum and tip vi. Loss of septal and upper lateral cartilage support vii. Saddle deformity viii. Caudal dislocation of the septum ix. Columella retraction with an absence of cartilage x. Depression of the caudal nasal bone xi. Flattened or asymmetrical nostrils xii. Distorted or fractured lower lateral cartilage xiii. Septal deflection, fibrous union, complex angulation xiv. Intranasal scarring xv. Synechiae xvi. Septal perforations 53. In reference to the orbital fracture, what do you understand by the term hot angry eye? Ans. i. Retrobulbar hemorrhage (looks like hot angry eye) condition that can result in the loss of vision where bleeding into the orbital space can result in compression of the optic nerve leading to ischemia and eventually blindness General Maxillofacial Trauma 247

ii. It can be because of the trauma and surgery to the orbital region. 54. Explain the terms proptosis and ptosis. Ans. i. Proptosis: Hematoma and swelling of orbital tissues. Subperiosteal hematoma notably of the orbital root. Persistent proptosis associated with downward displacement of the globe. For example, in the orbital fracture, Graves’ disease. ii. Ptosis: Lesion of oculomotor nerve. Ptosis is defined as drooping of the upper eyelid. It is also referred to as Blepharoptosis and can affect either one or both the eyes. It is seen as a result of the oculomotor nerve (third cranial nerve). Due to drooping of the eyelid only white sclera is visible. For example, Horner’s syndrome. 55. What are the signs of frontal sinus fracture? Ans. Following are the signs of frontal sinus fracture: i. History of a blow to the forehead, resulting in laceration, contusion or hematoma should be suspected to be associated with a possible injury of the frontal sinus ii. Depression of the forehead iii. Supraorbital numbness iv. Subconjunctival hematoma v. Eyelid ecchymosis vi. Subcutaneous air crepitus vii. Cerebrospinal rhinorrhea. Preprosthetic chapter Surgery 15

1. What are the objectives of the preprosthetic surgery? Ans. i. Correcting the conditions that preclude the optimal prosthetic function ii. Enlargement of the denture-bearing area iii. Provision for placing the tooth root analogs by means of osseointegrated dental implants. 2. Which are the preprosthetic surgical procedure and corrective preprosthetic surgical procedure? Ans. i. Preprosthetic surgical procedures: a. Augmentation – Onlay – Interpositional b. Vestibuloplasty c. Implants d. Combination of augmentation, vestibuloplasty and implants. ii. Corrective surgical procedures: a. Soft tissue corrective procedure — To eliminate frena and scars, etc. — To eliminate soft-tissue deformities – Labial frenectomy – Ankyloglossia (lingual frenectomy) – Buccal frena – Double lip – Scar contracture Preprosthetic Surgery 249

b. Hard tissue corrective procedures: — Alveoloplasty — Removal of exostosis (torus palatins, torus mandi­ bularis) — Mylohyoid ridge reduction — Genial tubercle reduction c. Secondary preparation to improve: — Hypermobile tissue — Epulis fissuratum — Papillomatosis of the palate iii. Combination of hard and soft tissue deformation. 3. How will you classify alveolar ridge deficiency? Ans. i. Class I: Alveolar ridge is adequate in height but inadequate in width ii. Class II: Alveolar ridge is deficient in both height and width iii. Class III: Alveolar ridge has been resorbed to the level of the basilar bone iv. Class IV: There is resorption of the basilar bone producing pencil-thin flat mandible or maxilla. 4. Define the following terms: (i) Alveoloplasty; (ii) Alveolectomy; (iii) Zygomaticoplasty; (iv) Vestibuloplasty (sulcoplasty); (v) Tuberoplasty; (vi) Torus (Tori); and (vii) Exostosis. Ans. i. Alveoloplasty: Surgical contouring of the alveolar ridge ii. Alveolectomy: Surgical removal of the alveolar process iii. Zygomaticoplasty: Surgery for the vestibular extension of the atrophied maxilla to improve the maxillary flange height in the buttress region iv. Vestibuloplasty (sulcoplasty): Procedure of deepening of the sulcus to provide relative ridge extension— deepening vestibular sulcus v. Tuberoplasty: Procedure to height on distal aspect of the maxillary tuberosity 250 When, Why and Where in Oral and Maxillofacial Surgery

vi. Torus (Tori): It is a benign slow growing bony projection. It has dense cortical bone and varying amount of cancellous bone vii. Exostosis: It is overgrowth of cortical/corticocancellous bone which is localized to a particular area. Asymptomatic, benign and slow growing. Usually the origin is unknown. 5. What are the different types of alveoloplasty? Ans. i. Simple alveoloplasty ii. Dean’s alveoloplasty/interseptal alveoloplasty iii. Obwegeser’s technique iv. Labial and buccal cortical alveoloplasty v. Reduction of the genial tubercle vi. Reduction of the knife-edge ridge vii. Reduction of the mylohyoid ridge. 6. What is the difference between alveoloplasty and vesti­ buloplasty? Ans. i. Alveoloplasty: It is the hard tissue preprosthetic corrective surgical procedure defined as recontouring of the alveolar ridge ii. Vestibuloplasty: Soft tissue preprosthetic surgical proce­ dure. It is defined as deeping of vestibule or increase in the depth of vestibule. 7. What are the purpose and aim of alveoloplasty? Ans. To eliminate the undercuts that interfere with the seating of the denture and to conserve the bone. 8. What are the different techniques of vestibuloplasty? Ans. i. Mucosal advancement vestibuloplasty: – Closed submucous Obwegeser’s vestibuloplasty – Open view submucous vestibuloplasty ii. Secondary epithelization vestibuloplasty: – Kazanjian’s technique – Clark’s technique – Godwin’s method Preprosthetic Surgery 251

– Lip switch method – Tortorelli’s modification or periosteal fenestration iii. Grafting vestibuloplasty/lingual vestibuloplasty/ sulcoplasty: – Trauner’s technique – Caldwell’s technique – Obwegeser technique. 9. Which are the possible graft donar sites for vestibuloplasty? Ans. i. Skin ii. Palatal mucosa iii. Buccal mucosa. 10. The lip switch procedure is used for which purpose? Ans. For sulcoplasty. 11. How will you detect sharp and irregular ridges of the bone? Ans. The best way is to place a finger onto the soft tissue flap and palpate. 12. How will you make an incision for the operation of the tongue tie or ankyloglossia? Ans. Make an incision longitudinally along the lingual frenum on both the sides. 13. Which are the techniques to correct the abnormal frenum attachment? Ans. i. Z-plasty ii. V-Y advancement iii. Diamond excision. 14. Which nerve should be protected during the removal of the mylohyoid ridge in an edentulous patient? Ans. The lingual nerve should be protected. 15. By which method are the maxillary tori usually removed? Ans. They are usually removed with the help of burs and chisels as indicated to section and remove tubulation. 252 When, Why and Where in Oral and Maxillofacial Surgery

16. For which purpose, the Z-plasty or Y-V plasty procedure is commonly used. Ans. i. Ankyloglossia ii. Interfering labial frenum. 17. In case of lowering of the floor of the mouth, which muscles should be detached? Ans. i. Mylohyoid ii. Genioglossus. 18. In which condition is a postoperative acrylic splint advised? Ans. In the case of torus palatines reduction. 19. Accidentally during the removal of the maxillary torus, the mid-portion of the palatine process of the maxilla is removed. Which complication can arise in this case? Ans. There are chances of opening into the nasal cavity. 20. During the removal of the torus palatinus, it may cause fracture of the portion of the palatal bone. What is the cause? Ans. The palatal torus should be excised with the help of burs and rongeurs by splitting it into small segments only. Nasal perforation occurs when it is excised with the help of chisel. 21. To allow space for dentures tuberosity reduction may be achieved by. Ans. Only soft fibrous tissue removal instead of removing large part of the bone. 22. How will you manage a case of retromolar pad contacting tuberosity? Ans. Surgical reduction of tuberosity carefully otherwise may cause oroantral communication. 23. What is the lip switch procedure? Ans. Lip switch procedure is a transpositional flap vestibuloplasty. • An incision is made in the labial mucosa. A thin mucosal flap is elevated. The mucosal flap is sutured to the depth of Preprosthetic Surgery 253

the vestibule covering the anterior aspect of the mandible and the denuded tissue on the inner surface of the lip heals by secondary intention. 24. What is tuberoplasty? Ans. Tuberosity is humular notch deepening. The humular notch occurs where the posterior border of the maxillary denture rests. In tuberoplasty, a curved osteotome is used to fracture the pterygoid plates free from tuberosity and displace them in the posterior direction. The tissue is then sutured to the depth of the area creating a new notch. 25. What is combination syndrome? Ans. Combination syndrome is excessive resorption of the anterior maxilla caused by the forces generated by the opposition of the natural mandibular anterior teeth. Precancerous Lesion/Condition chapter and Oral Cancer 16

1. What is the difference between carcinoma and sarcoma? Ans. i. Carcinoma: Malignant growth arising from the epithelium (ectoderm and endoderm) ii. Sarcoma: Malignant growth arising from the connective tissue (mesoderm). 2. What are the precancerous lesions and precancerous conditions? Ans. Precancerous lesions Precancerous conditions 1. Leukoplakia 1. Oral submucous fibrosis 2. Erythroplakia 2. Syphilis 3. Stomatitis nicotina palatini 3. Sederopenic dysphagia 4. Carcinoma in situ 4. Oral lichen planus 5. Bowen’s disease 5. Dyskeratosis congenita 6. Actinic keratosis 6. Lupus erythematous 7. Cheilitis 7. Xeroderma pigmentosum 8. Elastosis 8. Epidermolysis bullosa

3. Which is the most common form of oral cancer? Ans. Squamous cell carcinoma. 4. Which is the best imaging modality to diagnose invasive squamous cell carcinoma? Ans. i. Soft tissue invasion is best assessed by magnetic resonance imaging (MRI). Precancerous Lesion/Condition and Oral Cancer 255

ii. Osseous invasion is best assessed by conventional computed tomography (CT) or DentaScan imaging. 5. What is the clinical presentation of squamous cell carcinoma? Ans. i. An indurated ulcer with poorly defined borders ii. The lesion is characteristically painless unless inflamma­ tion is there from the infection. 6. How is the degree of malignancy classified on the basis of histological study? Ans. Malignant neoplasms are histologically classified as: i. Well differentiated ii. Moderately differentiated iii. Poorly differentiated (anaplastic). They have high degree of malignancy. 7. Which patients are characteristically suggestive of a malig­ nant neoplasm of the oral cavity? Ans. i. Malnourishment ii. Halitosis iii. Difficulty in speech and deglutition iv. Drooling. 8. What is the staging system for oral cancer? Ans. The tumor, node, metastasis (TNM) is the staging system for oral cancer. 9. What are different levels of lymph nodes? Ans. According to the “American Joint Committee Staging Manual 1998: i. Level I A = Nodes in submental triangle (submental group) ii. Level I B = Nodes in submandibular triangle (submandi­ bular group) iii. Level II = Upper deep jugular nodes (skull base to carotid bifurcation) 256 When, Why and Where in Oral and Maxillofacial Surgery

iv. Level III = Midjugular group of nodes (carotid bifurcation to omohyoid) v. Level IV = Lower jugular group of nodes (omohyoid to clavicle) vi. Level V = Nodes in posterior triangle vii. Level VI = Nodes in anterior triangle (central compartment group) viii. Level VII = Upper mediastinal group of nodes. 10. What is the base of TNM classification? Ans. The base of TNM classification is as follows: • T: Extent of the primary tumor • N: Nodes—condition of the regional lymph nodes • M: Metastasis—absence/presence of distant metastasis. 11. Comment on squamous cell carcinoma of the tongue. Ans. i. One of the most common sites for oral cancer ii. There is presence of mass which is painless if located on anterior 2/3rd of the tongue. If it is located on the posterior 1/3rd, it may be painful and sore throat is present iii. Often it is exophytic associated ulceration with indurated margin iv. Histopathologic study shows keratinization, number of mitosis because smoking is one of the major causes of this condition. It is also known as “opium smoker’s tongue”. It consists of a keratotic lesion and sometimes it becomes neoplastic v. It is managed by local surgery/local radiation therapy. 12. Explain carcinoma in situ. Ans. i. It is also known as intraepithelial carcinoma and it is one of the precancerous lesions. ii. Carcinoma in situ is a lesion which arises frequently on the skin but also occurs on mucous membrane iii. Some authorities believe that this lesion represents a precancerous dyskeratotic process but others believe Precancerous Lesion/Condition and Oral Cancer 257

that it is a laterally spreading intraepithelial type of superficial epithelioma or carcinoma iv. Common site is floor of mouth, tongue and lip v. White and ulcerated lesion. 13. What is the classification of neck dissection? Ans. The current classification is as follows: i. Radical neck dissection (RND) It includes: a. Removal of all cervical lymphatics and lymph nodes from IV level b. Sacrifice of spinal accessory nerve c. Sacrifice of sternocleidomastoid muscle d. Sacrifice of internal jugular vein (IJV) ii. Modified radical neck dissection (MRND) It includes: a. Removal of all cervical lymphatics and lymph nodes from IV level b. One or more non-lymphatic structures are sacrificed – The spinal accessory nerve – Sternocleidomastoid muscle – Internal jugular vein (IJV) iii. Selective neck dissection (SND) – This refers to a cervical lymphadenectomy in which there is preservation of one or more lymph node groups along with the preservation of all the three structures (spinal accessory nerve, sternocleido- mastoid muscle, internal jugular vein) iv. Extended neck dissection (EXND) – When the lymph node groups or non-lymphatic structures, other than the ones removed in RND (ASN, SCM and IJV), need to be removed. – For example, ECA, Level VI lymph node. 14. A patient with cancer of the tongue and enlarged lymph nodes. What is the treatment planning? Ans. Commando operation. 258 When, Why and Where in Oral and Maxillofacial Surgery

15. What is commando operation? Ans. It includes: i. En bloc resection of the primary tumor with the involved adjacent osseous structure ii. Total radical neck dissection iii. Palliative therapy iv. The tumor which is not resectable—debulking procedure is done. Reconstruction following resection or oral carcinoma is designed both to repair the cosmetic defect and to re- establish the function of the lost tissue. 16. A patient with squamous cell carcinoma of lip, invasion into alveolus. What is the treatment planning in an edentulous patient? Ans. Radical neck dissection. 17. What is the difference between biopsy and atopsy? Ans. i. Biopsy is the removal of a tissue specimen, either totally or partially for microscopic examination and diagnostic from the living subject. ii. Atopsy is the term used to indicate the removal of a tissue from a dead body. 18. List the different types of biopsies. Ans. i. Soft tissue biopsy ii. Hard tissue biopsy iii. Open tissue biopsy iv. Oral cytology Different types of soft and hard tissue biopsies are as follows: – Excisional biopsy: Excision of the entire small lesion – Incisional biopsy: To remove a part of the lesion – Exploratory biopsy – Punch biopsy – Needle biopsy – Curettage biopsy Precancerous Lesion/Condition and Oral Cancer 259

– Unplanned biopsy – Open tissue biopsy. 19. What is the difference between premalignant lesions and premalignant conditions? Ans. i. Premalignant lesions: A morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart ii. Premalignant conditions: A generalized state associated with a significantly increased risk of cancer. 20. What are 6 “S” for etiology for leukoplakia? Ans. i. Smoking ii. Spirit iii. Syphilis iv. Sepsis v. Systemic disease vi. Sharp edge of tooth. 21. List five peculiar points about leukoplakia. Ans. i. It is also known as idiopathic leukokeratosis. It means white patch. It is defined as a white keratotic patch or plaque occurring on the surface of the oral mucous membrane which will not rub or strip off ii. It is seen more in males over the age of 40 years. It is seen on hard and soft palates, gingival, etc. Etiologic factors include tobacco, vitamin deficiency, etc. iii. Clinically, it appears as wrinkled/rough white grey to yellowish white non-palpable thick papillomatous indurated patches iv. Histological study shows dysplasia of the surface epithelium v. It is managed by administration of vitamins A and B-complex, surgical excision, skin grafting and cryosurgery. 22. Comment on lichen planus. Ans. i. One of the precancerous conditions and generalized dermatological conditions. 260 When, Why and Where in Oral and Maxillofacial Surgery

ii. In the mouth, lichen planus usually appears as a series of radiating white or grey lines which cross each other and rub or strip off iii. The buccal mucosa in the molar area is most commonly affected and lesions often have a violaceous hue iv. The oral condition may be asymptomatic but the patient complains of a burning sensation v. Recent reports suggested carcinomatous changes in the lesion. 23. Classify oral submucous fibrosis? Ans. i. On the basis of functional stage: – Stage A: Mouth opening more than 30 mm – Stage B: Mouth opening 11 to 20 mm – Stage C: Mouth opening less than 10 mm ii. On the basis of mouth opening: – Stage A: Mouth opening more than 45 mm – Stage B: Mouth opening 22 to 44 mm – Stage C: Mouth opening less than 20 mm. 24. Comment of oral submucous fibrosis. Ans. It is also known as atropia idiopathic mucous oris. i. It is defined by Pindborg as “an insidious chronic disease affecting any part of oral cavity or even pharynx. It is slowly progressive disease in which leather-like fibrous bands form in the oral mucosa ii. Common site is buccal mucosa, soft palate, lips and tongue. The etiologic factors are tobacco, spicy food, vitamin deficiency, malnutrition, etc. iii. The disease is always associated with a juxta epithelial inflammatory reaction followed by a fibroelastic change of the lamina propria resulting in stiffness of the oral mucosa. Mucosa becomes blanched causing trismus, inability to eat along with a burning sensation iv. The patient is unable to masticate, to open the mouth, there is difficulty­ in deglutition, there is inability to freely move the tongue and jaw Precancerous Lesion/Condition and Oral Cancer 261

v. The treatment includes restricted habit, high doses of vitamin supplements, antioxidants, corticosteroids (both locally and systemically), excision of fibrous band, placement of skin graft, buccal pad fat, collagen membrane, etc. 25. How does a blanched mucosa look like in oral submucous fibrosis? Ans. Marble-like appearance is there. 26. What factors are to be considered in the evaluation of a patient before the radiation therapy of the head and neck region? Ans. i. Age of the patient ii. Condition of dentition iii. Level of oral hygiene iv. Radiation field and dose v. Urgency of radiation treatment. 27. What is the protocol for dental management before radiation treatment? Ans. i. Complete oral examination and treatment plan ii. Any necessary extraction/surgery iii. Maintenance of teeth and caries control iv. Restoration of carious teeth v. Prosthetic examination to prevent postradiation trauma and also prevent ill-fitting denture. 28. List the guidelines for extraction before the radiation therapy. Ans. i. All carious teeth in the field of radiation should be restored ii. All questionable teeth should be extracted iii. Full bony impacted teeth can be left in place iv. Extractions are done at least 2 weeks before radiation v. Extraction can be done 4 months after the completion of the therapy vi. Perform radical alveolectomy with primary soft tissue closure following extraction. 262 When, Why and Where in Oral and Maxillofacial Surgery

29. What are the effects of radiation on a bone? Ans. The decreased vascularity of the bone causes delayed healing after any trauma to the bone. These effects may become chronic. In the long-time, it may result in osteoradionecrosis. 30. What are the effects of radiation on teeth and periodontium? Ans. The radiation therapy effects on oral tissue are as follows: i. Erythema of the oral mucosa ii. Friable and easily injured gingival tissue iii. The gingival tissue also becomes less cellular and fibrotic iv. Radiation caries 31. What is radiation caries? Ans. Radiation caries is characterized by circumferential decay of the cervical portion of numerous teeth. The contributing factors are xerostomia, change in oral flora, pulpal death, dentine dehydration and enamel loss. Radiation caries is most severe within the radiation field. 32. Does the radiation affect the TMJ and muscles of masti­ cation? Ans. When the TMJ and muscles of mastication are within the field of radiation, the effects of radiation are as follows: i. Trismus and fibrosis of the muscle of mastication ii. Fibrous ankylosis of TMJ iii. Myofacial pain. 33. How will you manage a postradiation patient who needs both oral and maxillofacial surgeries? Ans. The surgery should not be performed four months before the completion of the radiation therapy. The surgery should be done after prophylactic hyperbaric oxygen treatment. 34. How will you manage the case of irradiation mucositis and xerostomia? Ans. The treatment is mostly symptomatic: i. Keep mouth and teeth moist and plaque-free ii. Avoid peroxide rinses for more than three days. Avoid denture adhesive, citrus and spicy food Precancerous Lesion/Condition and Oral Cancer 263

iii. Sugarless candy and gum chewing are encouraged iv. Avoid alcohol and tobacco v. Use saliva substitute (xerotube) vi. Do not wear denture vii. Use water or lubricant to moisten the mouth viii. If toothpaste is irritating, use baking soda. 35. How will you manage the pain caused by irradiation mucositis and xerostomia? Ans. i. Viscous lidocaine 2% half an hour before meal ii. Ulcer can be coated with sucralfate suspension iii. Analgesics start from the ibuprofen to narcotics as needed. 36. What are the principal methods employed for radiotherapy in the management of oral malignancies? Ans. The principal methods are: i. X-ray therapy a. Superficial X-ray therapy 45—100 kV b. Kilovoltage X-ray therapy 300 kV ii. Electron therapy iii. Surface applicator (radium mould) iv. Interstitial implantation—radium or equivalent source. 37. List the common adverse effects of radiation therapy on oral and paraoral tissues? Ans. i. Rampant caries ii. Radiation mucositis iii. Xerostomia iv. Difficulty in swallowing v. Radiation dermatitis vi. Varying degree of trismus. 38. What is the most common laser used in oral and maxillofacial surgery?

Ans. Carbon dioxide (CO2) laser. 264 When, Why and Where in Oral and Maxillofacial Surgery

39. What are the four basic tissue interactions associated with lasers? Ans. i. Reflection (bouncing off the tissue) ii. Transmission (going through the tissue) iii. Scatter (breaking up inside the tissue) iv. Absorption. 40. What are the four main reactions seen in a tissue after laser energy absorption? Ans. i. Photothermal ii. Photochemical iii. Photoablative iv. Photoacoustic. 41. How is the particular laser chosen? Ans. In general, laser choice is determined by matching the wavelength of the laser with the absorption of that wavelength by the intended target tissue. The greater the absorption, the greater is the effect in that tissue. 42. What are YAG lasers? Ans. The crystal of these lasers is made of yttrium, aluminum and garnet is doped with rare earth elements (e.g. neodymium [Nd], holmium [Ho] or erbium [Er]) as the active lasing medium. 43. Define sentinel node? Ans. The sentinel node is any lymph node receiving direct lymphatic drainage from a primary tumor site. 44. What is the main difference between carcinoma in situ and invasive carcinoma? Ans. i. Carcinoma in situ: It is an epithelial dysplasia that includes all the layers of the epithelium but does not extend the basal layers ii. Invasive carcinoma: Malignant cell penetrate the basal layer into the lamina propria and tumor extends deeper into the tissue involving fat, muscle or other structures. 45. What is a chromophore? Ans. A chromophore is a target tissue for a specific laser wave­ length. Cleft Lip/Palate, Dental Implants chapter and Distraction 17 Osteogenesis

1. Define dental implant. Ans. It is a device of biocompatible material placed within or against the mandibular or maxillary bone to provide additional or enhanced support for a prosthesis or tooth. Various systems and various implant configurations are found in each system. 2. Classify dental implant: Ans. It is based on various criteria: i. Depending on the implant tissue interface: – Direct bone implant interface = Endosseous implant – Indirect interface blade and subperiosteal implant ii. Involving the design, implantation, tissue implant response, location: – Submucous – Supraperiosteal – Subperiosteal – Endosseous – Transosseous – Endodontic iii. Based on the function: – Retentive implants – Supportive implants iv. Depending on the implant material: – Metallic implant – Polymer implant – Ceramic implant – Vitreous carbon implant 266 When, Why and Where in Oral and Maxillofacial Surgery

v. Based on biologic consideration: – Biocompatibility of the implant – Stable implant tissue interface – Acceptable load transfer vi. Based on implant design: – Branemark implant – Core-vent implant – IMZ implant – Stryker implant. 3. What are the criteria for a bone for the placement of implant? Ans. i. Bone height ii. Bone width iii. Bone length iv. Bone angulation. 4. Which is the most common type of implant in use? Ans. Endosteal type of implant is used most commonly and it can be: i. Root form ii. Plate form. 5. What are the advantages of root form implant over plate form implant? Ans. The advantages are: i. Greater surface area ii. Fewer pontics iii. Greater bone density. 6. In which part of the body, an endosteal implant is inserted. Ans. It is inserted into the bone. 7. What is the role of transfer coping in an implant? Ans. To position an analog in the impression. Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 267

8. What are the ideal features of an osseointegrated implant? Ans. It is anchored directly to the lining bone as determined by the radiographic analysis. 9. What is the reason for the lack of osteointegration? Ans. i. Premature loading of the implant system ii. Placing the implant with too much pressure iii. Overheating the bone during preparation. 10. What are the indications of implant placement? Ans. i. Inability to wear a removable or complete denture ii. Unfavorable number and locations or natural tooth abutment iii. Single tooth loss. 11 . In reference to implants, what is the importance of 1 mm/ 2 mm/3 mm/4 months/6 months/10 mm? Ans. i. 1 mm = distance between the implant and postligament of the adjacent teeth ii. 2 mm = distance between the implant and the superior aspect of the inferior alveolar canal iii. 1 mm = leave bone between the floor of the sinus and the implant iv. 2 mm = minimum safe distance between an endosteal implant and any adjacent anatomical structure v. 3 mm = distance between the implant and the mental foramen vi. 3 mm = minimum space between an implant vii. 4 months = is the recommended time-interval between surgery and placing load in the posterior mandible viii. 6 months = is the recommended time-interval between surgery and placing load in the maxilla ix. 6 months = time taken for integration of implant in maxilla x. 10 mm vertical and 6 mm horizontal = ideal amount of bone under soft tissue. 268 When, Why and Where in Oral and Maxillofacial Surgery

12. What is ailing implant? Ans. If the implant has lost some bone support and the bone loss is arrested, it is termed as ailing implant. 13. What is the protocol for HBO therapy when used before implant placement in an irradiated patient? Ans. Protocol consists of: i. Strict oral hygiene regimen before and after implant placement ii. Use of the longest and widest implant type iii. Implant surgery delayed until 6 months after irradiation iv. Cessation of smoking v. Preoperative HBO vi. Overengineered implant supported prosthesis vii. A similar protocol for implants in irradiate maxilla and mandible. 14. What are signs present in case of the failure of an implant? Ans. i. Loss of bone around the implant body ii. Horizontal mobility greater than 5 mm iii. Pain during percussion. 15. What is the most useful radiographic sign of an implant failure? Ans. Loss of crestal bone. Rapid progressive bone loss indicates failure. This is accompanied by pain on percussion or function. 16. In a two-stage implant, when is the second surgical procedure involved? Ans. i. In the mandible after 3 months ii. In the maxilla after 6 months 17. What are the surgical complications of an implant therapy? Ans. i. Preoperative conditions leading to complications: – Limited jaw opening – Inadequate alveolar width Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 269

ii. Intraoperative complications: – Malalignment – Nerve injury – Acute or chronic infection at the insertion site – Sinus or nasal floor perforation – Complete displacement of implant into the maxillary sinus or maxillary incisive canal iii. Complications in flapless implant placement: – Implant fracture – Loose implant – Excessive insertion/compression leading to necrosis iv. Postoperative complications: – Postoperative pain – Bone loss during the healing period – Implant periapical lesion—Implantitis 18. What is peri-implantitis? Ans. i. Peri-implantitis is an implant related condition which is increasingly being noticed in the clinical setting contributing to a significant proportion of implant failure ii. It is defined as a nonspecific inflammatory reaction in the host tissue iii. It is due to plaque accumulation and overloading of implant iv. On the radiograph, there is an evidence of bone loss v. Clinically, there is formation of pocket, pain, swelling and bleeding on probing vi. It is managed by the removal of bacterial biofilm, control of plaque formation and reosseointegration. 19. What are the primary requirements for successful implant placement? Ans. i. Mucosal seal ii. Adequate transfer of force iii. Biocompatibility. 270 When, Why and Where in Oral and Maxillofacial Surgery

20. How much force is applied to check the implant mobility? Ans. 500 grams. 21. How many pharyngeal arches are in the human embryo? Ans. There are six pharyngeal arches in the human embryo: i. 1st or maxillomandibular arch ii. 2nd or the hyoid arch iii. 3rd and 4th arches iv. 5th and 6th or rudimentary arches. 22. What does the merger of the mandibular processes form? Ans. The merger of mandibular processes forms the following: i. Mandible ii. Lower lip iii. Lower part of the face. 23. How does a cleft lip develop? Ans. A cleft lip develops from the failure of fusion of the medial nasal process and the maxillary process. 24. Which orofacial muscles are anatomically abnormal in the cleft lip and cleft palate? Ans. i. Cleft lip: The main muscle involved is the orbicularis oris muscle ii. Cleft palate: Several muscles are usually involved depending on one extent of the cleft iii. Complete cleft palate: Levator veli palatini, tensor veli palatini, uvular, palatopharyngeus muscles are involved. 25. What are the common skeletal deformities in the cleft lip and cleft palate patients? Ans. i. Midface deficiency ii. Maxillary transverse deficiency iii. Class 3 skeletal and occlusal deformity iv. Prognathic mandible. Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 271

26. What are the common clefts in orofacial region? Ans. i. Lateral facial clefts ii. Oblique facial clefts iii. Median cleft of the upper lip iv. Median cleft of the lower lip v. Median maxillary anterior alveolar cleft vi. Clefts of lip and palate. 27. What are the factors influencing incidence of cleft lip/cleft palate during pregnancy? Ans. i. Viral infection ii. Exposure to radiation iii. Anemia iv. Anorexia. 28. What is the embryological defect involved in the formation of CL/CP? Ans. Failure of lateral nasal process to make contact with medial nasal process. 29. What are the problems associated with cleft palate? Ans. i. Marked underdeveloped maxilla ii. Ineffective sucking iii. Airway obstruction. 30. Cleft palate shows problem in which activities. Ans. i. Hearing ii. Deglutition. 31. Which rule is followed for the management of cleft lip and palate? Ans. Millard’s rule of ten. 32. Explain Millard’s rule of ten. Ans. Traditionally, the time of repairing of cleft lip was based on the rule of ten. According to this rule, the defect can be closed when the infant is: 272 When, Why and Where in Oral and Maxillofacial Surgery

i. 10 weeks old ii. 10 g/dl Hb iii. 10 lb pounds in weight. 33. At what age should the first surgical intervention for repair of cleft lip be carried out? Ans. 3 to 6 months. 34. Before one to one and a half years, which structure or defect repair should be carried out? Ans. First lip repair and then palate repair is done. 35. What are complete and incomplete cleft lips? Ans. A complete cleft lip is the cleft of the entire lip and underlying premaxilla or alveolar arch. An incomplete cleft lip involves only the lip. 36. What are the goals of successful cleft palate repair? Ans. i. Separation of the nasal and oral cavities through closure of both the mucosal surfaces. ii. Construction of a watertight velopharyngeal valve. iii. Preservation of facial growth iv. Good development of esthetic dentition and functional occlusion. 37. What are the basic techniques for repairing the cleft lip? Ans. The techniques are: i. Lip adhesion procedure ii. The Millard’s rotation advancement flap iii. Tennison-Randall triangular flap. 38. What are the basic techniques of cleft palate closure? Ans. i. V-Y pushback ii. Two-flap palatoplasties iii. von Langenbeck operation iv. Vomer flap v. Four-flap palatoplasty vi. Furlow palatoplasty Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 273

vii. Wardill-Kilner operation viii. Schweckendick’s primary veloplasty. 39. Which is the ideal bone for alveolar cleft repair? Ans. Bone with cancellous marrow is the best choice for grafting an alveolar cleft because the osteoinductive and osteoconductive qualities are most predictable. 40. What is the sequence of procedure to manage a patient with cleft lip and palate? Ans. i. Primary procedures: – Closure of the lip – Closure of the palate ii. Secondary procedures: – Closure of the palatal fistulae – Pharyngoplasty – Alveolar bone grafting – Orthodontic treatment – Orthognathic treatment – Rhinoplasty – Scar revision of the lip. 41. What is the traditional sequence of treatment for cleft lip and palate? Ans. i. At birth, the cleft lip and palate team evaluate the child ii. At 10 weeks, the cleft lip is repaired. iii. At the age of one year, the child is re-evaluated by the cleft lip and cleft palate team iv. At 12 to 18 months, the soft and hard palates are repaired v. At 5 to 8 years, interceptive orthodontics is done vi. At 5 to 7 years, the pharyngeal flap (if necessary) is done. 42. Explain Abbe Flap in reference to the repairing of the cleft lip? Ans. In case of the cleft lip: i. Due to the lack of tissue and short appearance of the upper lip, normal lower lip may look protuberant 274 When, Why and Where in Oral and Maxillofacial Surgery

ii. In a cleft patient, upper lip usually lies on the bony maxilla iii. In some patients, the original lip repair may not result in normal cupid’s bow. – In such cases, transferring a wedge of full thickness flap from the lower lip to upper lip and form a bridge of tissue, which divides the mouth opening into two. This remains in place for 10 to 14 days after which the bridge is divided and both top and bottom lip scars are completed. 43. What is the most common postoperative complication of the cleft palate? Ans. i. Hypernasal speech is the most common. ii. Oral nasal fistula is also common. 44. Who first reported distraction osteogenesis on membranous bone of the craniofacial skeleton? Ans. McCarthy in 1992. 45. What do you understand by distraction osteogenesis? Ans. i. This procedure was first introduced by Dr GA Ilizarov for correcting deficiencies, in which both the bone and soft tissue are expanded ii. In this procedure, a corticotomy and osteotomy cut is given on the deficient side of the jaw and then a distractor is applied. The distractor is then activated daily advancing the bone segment by 1 mm to induce the formation of new bone and soft tissue. The newly created bone is formed in the distracted gap, which is then allowed to ossify. 46. Classify the types of distractors. Ans. They are classified as: i. Extraoral distractors ii. Intraoral distractors. Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 275

47. What are the indications of distraction osteogenesis? Ans. i. Unilateral hypoplasia of the mandible ii. In the case where osteotomies are not possible like in Treacher Collins syndrome, Pierre Robin syndrome iii. Mandibular resection iv. Mandibular hypoplasia due to trauma and/or ankylosis of TMJ v. Hypoplasia of the upper and middle third of face vi. Cleft palate vii. Apert syndrome. 48. What is the latency period of distraction osteogenesis in adults and in younger patients? Ans. i. 5 to 7 days in adults ii. 1 to 2 days in younger patients – Initial healing is to occur by callus formation in order to bridge the cut bony segment. 49. What is the duration of consolidation phase in distraction osteogeneis? Ans. Four to six weeks. 50. What are the four identifiable stages of mature bone formation? Ans. i. Stage of fibrous tissue ii. Stage of extending bone formation iii. Stage of bone remodelling iv. Stage of mature bone formation. 51. What are the advantages of intraoral distractors? Ans. i. They are simple to apply and use. ii. The devices are concealed, so there is better patient compliance iii. No external scar iv. Simple activation v. No damage to the facial nerve. 276 When, Why and Where in Oral and Maxillofacial Surgery

52. What is rhinoplasty? Ans. Final nose and lip revision. 53. What is the age, generally rhinoplasty carried out? Ans. It is carried out between 16 and 18 years of age. 54. How much time is required for a biological process to achieve osseointegration in humans? Ans. It requires four months’ time to achieve osseointegration. 55. What are the features of Pierre Robin syndrome? Ans. i. Cleft palate ii. Mandibular micrognathia iii. Glossoptosis. 56. Why is breastfeeding or sucking difficult for the cleft palate patients? Ans. i. Air in oral cavity ii. Absence of negative pressure in the mouth iii. Tongue obstruction. 57. Define the following terms: (i) Cheilorrhaphy; and (ii) Palatorrhaphy. Ans. i. Cheilorrhaphy: It is the surgical correction of the cleft lip deformity. This term is derived from ‘cheilo’ meaning lip and ‘rhaphy’ meaning junction by seam or suture. It is usually the earliest operative procedure used to correct the cleft deformities ii. Palatorrhaphy: It is usually performed in one-stage operation but occasionally it is performed in two stages also. In two-stage operation, the soft palate closure (e.g. staphylorrhaphy) is usually performed first and the hard palate closure (e.g. uranorrhaphy) is performed second. 58. Explain rhytidectomy. Ans. Rhytids are skin folds, creases or wrinkles. Rhytidectomy or removal of skin wrinkles is more commonly called as face-lift surgery. Face-lift surgery can result in an elevated cheek contour and a refined mandibular neckline. The most common technique Cleft Lip/Palate, Dental Implants and Distraction Osteogenesis 277 uses a type of lazy ‘S’ incision from the temple around the ear and into the posterior hairline. 59. Explain the following terms: (i) Blepharoplasty; (ii) Septorhinoplasty; and (iii) Otoplasty. Ans. i. Blepharoplasty: Blepharoplasty (eyelid rejuvenation) is one of the most common facial esthetic procedure performed in females and males. Aging eyelids exhibit a puffy, dropping and baggy appearance. These are the result of eyelid skin laxity, orbicularis muscle hypertrophy and orbital fat herniation out into the eyelids. ii. Septorhinoplasty: Nasal surgery or rhinoplasty can alter a patient’s nasal appearance. When the nasal septum is also modified the procedure is called septorhinoplasty. Appearance changes may include modifying the nasal profile. iii. Otoplasty: Otoplasty is altering the appearance of the ears. Common ear deformity is overly prominent or protruding cupped ears. 60. Explain the following terms: (i) Facial aging; and (ii) Facial liposuction. Ans. i. Facial aging: Facial aging involves the changes to the skin itself and resultant effects on the skin’s appearance and those of the underlying soft tissue ii. Facial liposuction: Facial liposuction is used to reduce submental and neck fullness. These excessive fat deposits are typically located superficial to the platysma. This can be detected by having the patients tense their necks. Orthognathic chapter Surgery 18

1. What do you understand by the term orthognathic surgery? Ans. Orthognathic (‘ortho’ means straight and ‘gnathic’ means jaw) surgery includes changing the deformed face from distortion to proportion and from disharmony to harmony. It is defined as the surgical correction of the deformities of the jaw which presents with malocclusion of the jaws and the associated facial disfigurement constitutes orthognathic surgery. 2. What are the goals of orthognathic surgery? Ans. The goals of orthognathic surgery are as follows: i. To correct jaw relationships prior to major restorative procedures ii. Shorten orthodontic treatment time and improve orthodontic results iii. Improve periodontal stability and periodontal prognosis. 3. Enumerate the various mandibular osteotomies. Ans. i. Mandibular body osteotomies (intraoral) – Anterior body osteotomy – Posterior body osteotomy – Midsymphysis osteotomy ii. Segmental subapical mandibular surgeries – Anterior subapical mandibular osteotomy – Posterior subapical mandibular osteotomy – Total subapical mandibular osteotomy iii. Genioplasties – Augmentation genioplasty – Reduction genioplasty Orthognathic Surgery 279

– Straightening genioplasty – Lengthening genioplasty iv. Mandibular osteotomies a. Subcondylar ramus osteotomy – Extraoral subcondylar ramus osteotomy (subsigmoid) – Intraoral subcondylar ramus osteotomy (subsigmoid) – Arching ramus osteotomy (extraoral) b. Intraoral modified sagittal split osteotomy. 4. Enumerate the various maxillary osteotomies. Ans. i. Segmental maxillary osteotomies (intraoral) – Single tooth dentoosseous osteotomy – Interdental osteotomy – Anterior maxillary osteotomy – Posterior maxillary osteotomy ii. Total maxillary surgery (Le Fort I, II and III osteotomy) – Superior repositioning of the maxilla – Superior repositioning of the maxilla leaving the nasal floor intact (horse shoe-shaped osteotomy) – Advancement of the maxilla a. Simultaneous expansion of the maxilla b. Simultaneous narrowing of the maxilla – Inferior repositioning of the maxilla – Leveling of the maxilla. 5. In reference to the hard tissue analysis (cephalometric analysis), explain the following terms: (i) Sella (S); (ii) Nasion (N); (iii) Menton (Me); (iv) Prosthion (Pr); (v) Pogonion (Pog); and (vi) Gnathion (Gn). Ans. i. Sella (S): The point representing the midpoint of the pituitary fossa or sella turcica ii. Nasion (N): The most anterior point midway between the frontal and nasal bones on the frontozygomatic suture iii. Menton (Me): It is the most inferior midline point on the mandibular symphysis 280 When, Why and Where in Oral and Maxillofacial Surgery

iv. Prosthion (Pr): The lowest and most anterior point on the upper central incisors v. Pogonion (Pog): It is the most anterior point of the bony chin in the median plane vi. Gnathion (Gn): It is the most anteroinferior point on the symphysis of the chin. 6. In which syndromes the mandibular prognathism is present? Ans. i. Basal cell nevus syndrome ii. Klinefelter’s syndrome iii. Marfan’s syndrome iv. Osteogenesis imperfecta v. Wartenberg’s syndrome. 7. Midface deficiency is associated with which syndromes? Ans. i. Achondroplasia ii. Apert’s syndrome iii. Cleidocranial dysplasia iv. Crouzon’s syndrome v. Marshall’s syndrome vi. Pfeiffer’s syndrome vii. Stickler’s syndrome. 8. Apertognathia is a condition in which case? Ans. Open bite deformity. 9. What are the aims and protocol of mock surgery or model surgery? Ans. The aims of mock surgery are: i. To locate the problem areas preoperatively ii. To determine the feasible surgical plane iii. To determine the direction of movement of dentosseous segment iv. To view the osteotomy sites directly v. To obtain the measurement of osteotomies. Orthognathic Surgery 281

The protocol for mock surgery is as follows: i. Cut the model exactly similar to surgery ii. Avoid apices or root surfaces of teeth during cutting iii. Detect the problematic area. Observe and note the move­ ment of dentosseous segment, like rotation, expansion, etc. iv. Reposition the anterior maxillary segment first v. Keep the mandibular model fixed in two-jaw surgery. 10. What is the basic protocol for osteotomies? Ans. i. Design the soft tissue incision to maintain adequate collateral blood supply and avoid injury to the vital structure ii. Provide optimum exposure to the site of osteotomy iii. Minimum periosteal stripping iv. Gentle soft tissue handling v. Design the osteotomy cuts without damaging the neurovascular bundle vi. Design subapical osteotomy cut atleast 4 to 5 mm away from the apices of the teeth vii. Proper approximation and stable fixation of osteoto­ mized segment viii. Approximation of the osteotomized fragment in class I canine and molar occlusion ix. Adequate soft tissue coverage to prevent wound dehiscence x. Proper follow-up is also important. 11. Sagittal split osteotomy is used to correct which part of the mandibular deformity? Ans. It is used mainly in ramus. The osteotomy split is given in the ramus and the posterior body of the mandible sagittally, which allows either setback or advancement. 12. What is sagittal split osteotomy? Ans. Obwegeser and Turner developed this procedure in 1957. 282 When, Why and Where in Oral and Maxillofacial Surgery

i. This is a very popular and most versatile procedure performed on the mandibular ramus and body ii. It is used for the correction of retrognathic or prognathic mandible and open bite deformity iii. It avoids the external scar and injury to the marginal mandibular nerve. 13. What is Wassmund and Wunderer osteotomy? Ans. i. Wassmund (1962) first reported anterior maxillary osteotomy through the labial approach and repositioning of the anterior maxillary segment. ii. Wunderer developed a procedure to provide a palatally oriented approach to the sectioning and repositioning of the anterior maxillary segment. 14. How will you correct bimaxillary protrusion surgically? Ans. By four premolars and anterior alveolar segment repositioning. Anterior maxillary osteotomy (to correct maxillary prognathism) is combined with anterior subapical mandibular osteotomy (to correct the mandibular prognathism) to correct bimaxillary protrusion. 15. Who first reported “subcondylar osteotomy” for correction of prognathism? Ans. Robinson and Hinds. 16. What is the most common complication of subapical orthognathic surgery? Ans. Devitalization of teeth. 17. Intraoral vertical ramus osteotomy is done for. Ans. Mandibular setback. 18. Genioplasty procedures are used for. Ans. To modify the position of the chin. 19. Augmented genioplasty is done by which methods? Ans. i. Bone graft ii. Silicone implant iii. Sliding horizontal osteotomy. Orthognathic Surgery 283

20. Which type of genioplasty is required in class III facial profile? Ans. Reduction type genioplasty in the symphysis region. The face will have a straight profile. 21. What is visor osteotomy? Ans. A visor osteotomy is a procedure to increase the vertical height of the mandible by vertically splitting the anterior portion of the mandible (anterior to the mental foramen) and repositioning the lingual segment superiorly in relation to the buccal segment. 22. What is sandwich osteotomy? Ans. The sandwich osteotomy horizontally splits the mandible. The cranial fragment is repositioned superiorly and an interpositional bone graft is placed. There is a modification called sandwich-visor Osteotomy which is a combination of these two osteotomies. 23. Myoplasty and sulcus extension procedures are helpful in. Ans. They are helpful in increasing retention and stability. 24. During genioplasty, there are chances of injury to which nerve? Ans. Injury to the mental nerve. 25. What is the basic advantage of sagittal split osteotomy? Ans. No bone grafting is required when the defect is small (less than 8 mm). General chapter Anesthesia 19

1. Define general anesthesia and general anesthetics? Ans. General anesthesia is a medically induced coma and loss of protective reflexes resulting from the administration of one or more general esthetic agents. General anesthetics are the agents which bring about loss of all modalities of sensation, particularly pain along with reversible loss of consciousness. 2. What is ASA in the context of anesthesia? Ans. American Society of Anesthesiologists. 3. Explain the term preanesthetic medication. Ans. It is defined as preliminary medication. It refers to the drugs with specific pharmacological action administered preoperatively with specific goals to achieve. 4. What are the objectives of preanesthetic medication? Ans. i. Relief of pain and anxiety ii. Provide sedation iii. Antisialagogue effect iv. Prophylaxis against allergies and vasolytic action v. Prevent nausea and vomiting vi. Reduction of stomach acidity vii. Amnesia of preoperative events. 5. List the examples of drugs used as preanesthetic medication. Ans. The categories are as follows: i. Sedative and hypnotics a. Benzodiazpines – Diazepam – Medazolam General Anesthesia 285

b. Barbiturates: – Pentobarbital – Secobarbital ii. Antiemetic/sedative/antisialagogue a. Phenergan iii. Antihistamine (antiallergic/antiemetic/sedative) a. Diphenhydramine (benadryle) iv. Analgesic a. Morphine b. Pethidine v. Anticholinergic agent (to prevent vasovagal attack, anti­ siala­gogue/sedation/amnesia) a. Atropine b. Glycopyrolate vi. Aspiration prophylaxis a. Ranitidine vii. Antiemetic a. Phenothiazine. 6. What are the different methods of the administration of general anesthesia (GA)? Ans. The methods are: i. Open method (open drop procedure) ii. Semiopen method iii. Semiclosed method iv. Closed method. 7. Comment on Boyle’s apparatus. Ans. i. Boyle’s apparatus is the equipment for continuous flow of anesthesia by which the operator can deliver a desired concentration of a mixture of anesthetic agents. For example, oxygen-nitrous oxide, air, etc. ii. It has individual flow meter for setting the desired flow of each gas iii. Vaporizers are meant for setting the desired percentage output concentration of the liquid anesthetic agent like halothane, isoflurane, etc. 286 When, Why and Where in Oral and Maxillofacial Surgery

iv. The most dangerous hazard but fortunately rare that can occur with the use of an anesthesia machine is that the delivery of a hypoxic gas mixture leads to hypoxic damage and coma. Even cardiac arrest and death can occur. v. To avoid this hypoxic gas mixture hazard, activate an alarm, either auditory or visual. 8. What is a laryngoscope? Ans. i. Laryngoscope is designed for performing direct laryngo­ scopy (direct viewing of the vocal cords) and to pass an endotracheal tube into the larynx under vision ii. It has three parts: Handle, blade and light bulb iii. The blade is available in different sizes, like neonate (infant), pediatric (child and adult) and extra large. The blade may be straight or curved iv. The handle is a hollow cylinder containing two 1.5 volt batteries. 9. What are the inhalational anesthetics? Ans. i. Five volatile liquids – Enflurane – Halothane – Desflurane – Isoflurane – Sevoflurane ii. One gas – Nitrous oxide. 10. What are the different colors of cylinders used in operation theater for the supply of general anesthesia agents?

Ans. i. N2O: Blue ii. CO2: Green iii. O2: Black iv. Central function pipe: Yellow. General Anesthesia 287

11. What are the stages of general anesthesia? Ans. The stages of general anesthesia are as follows: i. Stage 1: Stage of analgesia ii. Stage 2: Stage of excitement/delirium iii. Stage 3: Stages of surgical anesthesia: – Plane 1 – Plane 2 – Plane 3 – Plane 4 iv. Stage 4: Stage of medullary paralysis. 12. Guedel described the four stages of anesthesia with which general anesthesia agent? Ans. Ether. 13. What are the contraindications of general anesthesia? Ans. i. Acute respiratory infection ii. Hemoglobinopathies. 14. What is the common complication within the first day after the surgery under general anesthesia? Ans. Cardiac failure is the common complication. 15. Which emergency is most frequently encountered with during outpatient general anesthesia? Ans. Respiratory obstruction. Even death can occur due to improper ventilation. 16. What is second gas effect? Ans. This occurs when a particular gas speeds the rate of increase of alveolar partial pressure of the second gas. In theory, the high concentration of one gas (e.g. 70% N2O) could speed up the induction of the second less soluble gas (e.g. halothane). 17. What are the hemodynamic effects of volatile anesthetics? Ans. Volatile anesthetics depress the cardiovascular system and this depression results in a reduced mean arterial pressure. Halothane primarily causes a reduction in heart rate and contractility. 288 When, Why and Where in Oral and Maxillofacial Surgery

18. What adverse reaction can occur if halothane and epineph­ rine are combined? Ans. The potential for life-threatening dysrhythmic effects exists between inhalational anesthetics and vasoconstrictors. The addition of thiopental (pentothal), an ultra-short acting as a barbiturate further enhances these dysrhythmic effects. This adverse reaction is worst when anesthesia and surgery have just begun and local anesthesia containing epinephrine is used by a surgeon. To prevent this reaction, it has been proposed that a local anesthetic should not be injected immediately after the induction of anesthesia with halothane or thiopental. It is prudent to wait for 10 minutes.

19. What are the concerns of the administration of N2O-O2 seda­tion to an obstetric patient?

Ans. N2O crosses placenta and, therefore, has the potential to cause teratogenic effects to the fetus. The greatest potential for the problems exists during the 1st trimester of pregnancy when the organs are forming. Recent researches have refuted the claim that

N2O gas is dangerous to the fetus. N2O-O2 sedation should always be used for short procedures and no more than 50% N2O should be administered. 20. What are neuromuscular blocking agents (NMBs)? Ans. Neuromuscular blocking agents are basically called as muscle relaxants. These drugs are used for skeletal muscle relaxation and can be used to facilitate tracheal intubation. These drugs are very dangerous and inhibit the function of all the skeletal muscles. These drugs are classified into two groups: i. Depolarizing NMBs (e.g. succinylcholine) ii. Nondepolarizing NMBs (e.g. acetylcholine). 21. The heart is a muscle. Do muscle relaxants decrease the contraction of pericardium? Ans. Muscle relaxants have no effect on heart contractility. They have no effect on the smooth muscles. General Anesthesia 289

22. How do you manage a hypoxic event? Ans. Before you ever try to make a diagnosis, give oxygen. The first maneuver for an intubated patient is to hand-ventilate with ambu bag. The mechanical ventilator and breathing circuit must be examined for malfunction. Get a chest X-ray (to rule out pneumothorax and to confirm the correct position of the endotracheal tube). Review the recent premedication and interventions. 23. In case of TMJ ankylosis, a patient is unable to open the mouth. How will you intubate such a patient? Ans. i. GA cannot be given by oral intubation ii. It can be given by: – Blind nasal intubation – Fiberoptic assisted intubation. 24. A patient being operated under halothane not be given? Ans. Lignocaine + Adrenaline. 25. Why glycopyrolate is used during general anesthesia? Ans. To reduce secretions. 26. What are the alternatives of endotracheal intubation?

Ans. i. Mouth-to-mouth ventilation delivers 16% inspired O2 ii. Bag mask ventilation delivers 21% O2 iii. Bag mask ventilation with an O2 supply can deliver up to . 100% of O2 27. What is the advantage of endotracheal intubation? Ans. A relatively secure airway. 28. How do you confirm that the endotracheal tube is in the proper position? Ans. i. Listen to both the lung fields ii. Observe symmetric chest excursion with each tidal breath iii. Listen over the epigastrium. These physical findings are not very reliable. You should confirm the position with a chest X-ray. 290 When, Why and Where in Oral and Maxillofacial Surgery

29. What should be the first consideration if we are unable to ventilate a patient or intubate? Ans. Foreign body airway obstruction. An attempt should be made to visualize the foreign body directly and then remove it with suction or Magill forceps. 30. Which of the anesthetic agents is used as a dissociative agent? Ans. Ketamine.

31. During general anesthesia O2 concentration of blood should not fall below what level of oxygen concentration? Ans. 90% oxygen concentration. 32. Which vein is the optimum site for IV sedation for an outpatient? Ans. Median cephalic vein. 33. In tracheostomy the entry into the trachea is through which rings? Ans. 2nd and 3rd tracheal rings. 34. What is the most common postoperative complication of an outpatient general anesthesia? Ans. Nausea and vomiting. 35. In which stage of anesthesia is endotracheal intubation possible? Ans. Third stage (stage of surgical anesthesia) plane 2. 36. Which is the convenient stage of general anesthesia in which surgery can be performed? Ans. Stage 3 (stage of surgical anesthesia). 37. What is the basis of Guedel criteria for the classification of the depth of general anesthesia? Ans. i. Respiration ii. Eyeball movement iii. Presence and absence of various reflexes. General Anesthesia 291

38. Which stage of anesthesia describes the level of conscious sedation? Ans. Stage 1 (stage of analgesia). 39. Nitrous oxide inhalation sedation is contraindicated in patients with. Ans. i. Nasal obstruction ii. Emphysema iii. Emotional instability.

40. Which is the most common complication with N2O-O2 sedation? Ans. Behavioral problem. 41. What does morphine-scopolamine premedication produce? Ans. i. Amnesia and decreased salivation ii. Psychic sedation iii. Addictive effects with anesthetics. 42. Which drug is used to prevent laryngospasm due to GA? Ans. Succinylcholine. 43. Succinylcholine is administered during GA for what? Ans. Intubation. 44. Which symptom is seen in a patient administered with 20

to 40% N2O? Ans. Floating sensation. 45. Which drug is used to reduce the induction phase of GA? Ans. Thiopentone sodium. 46. If long acting muscle relaxants are used during GA, what is used to terminate their action? Ans. Neostigmine. 47. Which endotracheal tube for nasotracheal intubation is used for GA in case of maxillofacial injuries? Ans. Inflatable cuffed is used for nasotracheal intubation and for oral surgical procedures, nasotracheal tube with throat pack is used. 292 When, Why and Where in Oral and Maxillofacial Surgery

48. At what level should the endotracheal tube be placed for GA? Ans. Above the cricoid. 49. Rotameter on Boyle’s trolley in GA is used to measure what? Ans. Flow of gases in the tubes. 50. What does Goldman vaporizer consist of?

Ans. 50% N2O + 20% O2 mixture.

51. Why is N2O-O2 sedation not contraindicated in the asthmatic patients unless that patient is allergic to N2O? Ans. There are no contraindications to the use of N2O-O2 sedation in asthmatic patients because anxiety is a symptom for asthmatic

attack. N2O-O2 sedation is actually beneficial for these patients.

52. Should a patient with URI be given N2O-O2 sedation with a nasal hood? Ans. No, because the patients with URI have nasal blockage, so

delivery of N2O is limited and the leakage of N2O around the blood is more likely to occur. Therefore, the use of N2O is unwise.

53. Why is N2O sedation contraindicated in the patients with the conditions involving closed gas spaces? Ans. i. The oral and maxillofacial surgeons should be cautious while treating the recent trauma cases (RTA victim). An asymptomatic undiagnosed close pneumothorax can double in size in 10 minutes after the administration of

70% of N2O. ii. N2O-O2 sedation should be postponed in the patients with gastrointestinal obstructions, middle ear infections and sinus infections.

54. What are the important key points for nitrous oxide (N2O)? Ans. i. Anesthetic property the first suggested by Humphrey ii. Only inorganic gas is used for anesthesia iii. It is a noninflammable gas iv. It has a high patient acceptability General Anesthesia 293

v. It has a sweet odor and is known as laughing gas. vi. It produces analgesia at 65%. 55. Why is nitrous oxide not used alone for GA? Ans. It may cause diffusion hypoxia because of the difficulty in maintaining an adequate oxygen concentration. (A mixture of

70% N2O + 30% O2+ 0.2 to 2% other potent anesthetic agents is employed for most surgical procedures).

56. What are the most common side-effects of 2N O-O2? Ans. i. Nausea ii. Diffusion hypoxia iii. Behavioral problems iv. Emphysema v. Emotional instability vi. Upper respiratory tract obstruction.

57. What is the fate of N2O used as a GA agent? Ans. N2O does not combine with Hb. It is carried in the form of a physical solution. N2O does not decompose in the body. It is exhaled unaltered by the lungs. 58. Which drug is called as white stuff in anesthesia? Ans. Propofol. 59. What are the indications of propofol? Ans. i. It is used for induction and maintenance of anesthesia. ii. It causes sedation. 60. What is propofol? Ans. Propofol (diprivan), a substituted isopropylphenol, is a IV sedative hypnotic agent, used for induction and maintenance of anesthesia. It can also be used during conscious sedation. 61. What are barbiturates? Ans. Barbiturates are derivatives of barbituric acid. They exhibit a dose-dependent CNS depression with hypnosis and amnesia. For example, thiopental sodium (pentothal). 294 When, Why and Where in Oral and Maxillofacial Surgery

62. Why is propofol the best agent for an outpatient’s anesthesia? Ans. i. Rapid induction and recovery ii. Lower incidence of nausea and vomiting iii. Shorter recovery period. 63. What is ketamine? Ans. Ketamine is a phencyclidine derivative. It produces dissociative anesthesia. A ketamine 4 mg/kg IM can be administered to an uncooperative patient to facilitate the completion of short procedure. IV sedation dose for ketamine ranges between 0.25 mg/kg and 0.75 mg/kg. 64. What are the clinical uses of benzodiazepines? Ans. i. Preoperative medication ii. Intravenous sedation iii. Induction of anesthesia iv. Maintenance of anesthesia v. Suppression of seizure activity. a. Commonly used are: – Midazolam – Lorazepam – Diazepam. 65. What are the three commonly used anticholinergics? Ans. i. Atropine ii. Scopolamine iii. Glycopyrrolate. 66. Give the key points related to Halothane. Ans. i. It is irritating to the mucous membrane ii. It produces incomplete muscle relaxation iii. It tends to produce hypotension iv. It sensitizes heart to epinephrine v. It is explosive vi. It is highly potent. General Anesthesia 295

67. What is tramadol? Ans. It is a unique analgesic with opioid-like activity. It is used in acute and chronic pain management. The major side-effects sedation and dizziness and the uncommon side-effect is seizures. 68. What is the other name of ether? Ans. Sweet oil or vitriol. 69. What is entonox apparatus?

Ans. It is pressurized premixed N2O and O2 at a maximum cylinder pressure of 2,000 lbs/sq inch. 70. During anesthesia, atropin is contraindicated in the case of. Ans. Tachycardia. 71. Oral airway is used for. Ans. i. Protection of airway ii. Prevent the tongue from falling back iii. Prevent the tongue bite. 72. Who gave the first IAN (inferior alveolar nerve block) by using 4% cocaine? Ans. Niemann. 73. Who invented ethyl ether? Ans. Horace Wells. 74. To achieve deep anesthesia, what anesthetic agent should on achieve? Ans. It should achieve higher alveolar concentration of the anesthetic agent. 75. Which anesthetic agent results in the least loss of reflexes? Ans. Nitrous oxide. 76. Which of these—pupillary dilatation or pupillary constric­ tion—is the positive sign during cardiac resuscitation? Ans. Pupillary constriction is the positive sign. 296 When, Why and Where in Oral and Maxillofacial Surgery

77. How can the level of analgesia be monitored? Ans. It can be monitored with the help of verbal response. 78. Where does the accidental inhalation of foreign body land in? Ans. Right bronchus. 79. In which condition is GA contraindicated? Ans. Severe anemia. 80. What is the most common complication within 24 hours after surgery under GA? Ans. Atelectasis. 81. In Jorgensen technique of intravenous (IV) sedation for dental procedures, which drugs are used? Ans. It includes intravenous administration of opioids: i. Pentobarbitol ii. Scopolamine (hyoscine) iii. Pethidine iv. Meperidine. 82. What is the postoperative complication following aspiration of liquid vomitus into the trachea and bronchus? Ans. Bronchitis and chemical pneumonia. 83. What is the order of depression of different sites under GA? Ans. i. Cortical centre ii. Spinal and medullary. 84. Which is the last area of brain depressed by GA? Ans. PONS. 85. What are the uses of laryngoscope? Ans. i. Direct visualization of the larynx ii. For endotracheal intubation iii. For insertion of the Ryle’s tube.

86. N2O works on which nervous system—central or peripheral? Ans. Central nervous system. General Anesthesia 297

87. Explain the term conscious sedation. Ans. It is a state of mind obtained by IV administration of the combination­ of anxiolytic, sedative and hypnotics and/or analgesics that render the patient in relaxed state and yet allow the patient to communicate, maintain airway and ventilate adequately. 88. What are the advantages and disadvantages of intravenous sedation? Ans. The advantages of intravenous sedation are as follows: i. Highly effective technique ii. Rapid onset of action iii. Control of the possible salivary secretion iv. Nausea and vomiting is less common v. Gag reflex, motor disturbances (epilepsy, cerebral palsy) are diminished. The disadvantages of intravenous sedation are as follows: i. Venupuncture is necessary ii. Delayed recovery iii. More intensive monitoring is required iv. Due to venupuncture, it may cause hematoma formation, thrombophlebitis v. Escord is needed. 89. What are the commonly used drugs in intravenous seda­ tion? Ans. i. Sedative hypnotics and antianxiety a. Benzodiazepines – Diazepam – Midazolam b. Barbiturates ii. Nonbarbiturate hypnotics – Propofol – Ketamine iii. Antihistaminics – Promethazine iv. Narcotic agonists – Pethidine. 298 When, Why and Where in Oral and Maxillofacial Surgery

90. What do you understand by the term day stay surgery? Ans. Short-duration surgery like impaction, cyst enucleation taking 20 to 40 minutes are suitable to be carried out on a day stay basis. The advantages are: i. Less chair side time ii. Avoiding admission to a hospital Certain criteria should be met: i. The patient must be fit ii. Surgery should not be for more than one hour iii. No significant risk iv. Recovery from anesthesia should be rapid. chapter Miscellaneous 20

1. List 15 key points for the successful extraction of tooth. Ans. i. The following five points should be considered while taking a patient’s history: – Past medical history – Past dental history – Any drug allergy – Present medical/dental history – The patient should not be empty stomach ii. Dental chair height: – For maxillary teeth: 8 cm below the shoulder of the operator – For mandibular teeth: 16 cm below the elbow of the operator iii. Operator position: – All maxillary and left mandibular teeth: The operator should stand right in front of the patient – Right anterior teeth: Right in front of the patient – Mandibular right premolars: Just at the right side of the patient – Mandibular first and second molar: Exactly at the right side of the patient – Mandibular right third molar: Just behind the right side of the patient iv. Patient position: – For mandibular teeth: When the patient opens the mouth, the lower border of the mandible should be parallel to the floor 300 When, Why and Where in Oral and Maxillofacial Surgery

– For maxillary teeth: The head should be at 45° to the floor v. Preparation of surgical tray vi. Extraoral and intraoral preparations (with betadine solution and gargle) and drapping vii. Application of topical local anesthetic gel at the site of the LA injection viii. Proper knowledge of the nerve supply of particular tooth/ teeth ix. LA technique—Block/infiltration. x. Confirmation of subjective/objective symptoms xi. Proper application of the instrument xii. Step-by-step extraction of tooth xiii. To achieve hemostasis and, if required, suturing the extraction socket. xiv. Postoperative instruction/care xv. Postoperative medications and follow-up. 2. What is the ‘rule of four’? Ans. i. Four points to describe any instrument: – Name of the instrument – Instrument made up of which material – Parts of the instrument – Indication of the instrument ii. Four points to read a radiograph: – Name of the radiograph – Either extraoral or intraoral – Abnormalities in the radiograph – Comments on the abnormalities, like definition, etiology, classification, clinical features, diagnosis, treatment, complication, etc. iii. Four points to describe any medicine: – Pharmacological name of the drug – Each ml concentration – Route of administration – Indication of the medicine Miscellaneous 301

3. What is the significance of the following drugs used in emergency­ cases? Ans. i. Five drugs starting with ‘A’: – Avil (antihistamine): Antiallergic – Adrenaline: To control local bleeding. Systemic as bronchodilator and in case of cardiac arrhythmias – Atropine: To prevent vasovagal attack/antisialagogue – Aminophylline (deriphyllin): Antiasthmatic – Aromatic spirit of ammonia: Inhalations to stimulate late respiration in case of syncope ii. Two drugs starting with ‘B’: – Betnesol: Anti asthmatic (Bronchial asthma) – Benadryl: Antiallergic (Antihistamine) iii. Three drugs starting with ‘C’: – Coramine: Respiratory distress – Calmpose: Anticonvulsant – Calcium gluconate: Tetany iv. Three drugs starting with ‘D’: – Dexona (Dexamethasone): The safest life-saving drug. Shock/anaphylaxis – Dopamine: Hypotensive shock – Dextrose: Hypoglycemic attack v. Two drugs starting with ‘E’: – Efcorlin: Hypotensive shock – Ethamsylate: Controls the bleeding vi. One drug starting with ‘F’: – Fortwin: Severe pain vii. One drug starting with ‘G’: – Glucose powder: Hypoglycemia (oral) viii. One drug starting with ‘M, N, and O’: – Mephentine: Hypotension – Nifedipine: Hypertension – Oxygen: Hypoxia ix. Four drugs starting with ‘S’: – Sodium bicarbonate: Acidosis – Sorbitrate: Angina pain 302 When, Why and Where in Oral and Maxillofacial Surgery

– Sepguard: To control local bleeding – Steptobion: To control systemic bleeding. 4. Choice of drugs Ans. i. Osteomyelitis: Clindamycin (500 mg/1 tds) ii. Trigeminal neuralgia: Carbamazepine (1600 mg/day) iii. Cavernous sinus thrombosis: Chloramphenicol (1 gram/ 6 hourly IV) iv. Brain abscess: Chloramphenicol (1 gram/ 6 hourly IV) v. Patient allergic to penicillin: Erythromycin (4 times a day). 5. Give the full forms of the following abbreviations: (i) CGCG; (ii) CPR; (iii) CEOT; (iv) MPDS; (v) OPD syndrome; (vi) OKC; (vii) OSMF; (viii) OPG; (ix) PDL; (x) TNM Classification; (xi) TMJ; (xii) WHO Ans. i. CGCG: Central Giant Cell Granuloma ii. CPR: Cardiopulmonary Resuscitation iii. CEOT: Central Epithelial Odontogenic Tumor iv. MPDS: Myofacial Pain Dysfunction Syndrome v. OPD Syndrome: Oto-palatodigital Syndrome vi. OKC: Odontogenic Keratocyst vii. OSMF: Oral Submucous Fibrosis viii. OPG: Orthopanthamogramph ix. PDL: Periodontal Ligament x. TNM Classification: Tumor (size), Nodes (involvement), Metastasis (Presence or absence) xi. TMJ: Temporomandibular Joint xii. WHO: World Health Organization. 6. Give other names for the following lesions: (i) Brown tumor; (ii) Iceberg tumor; (iii) Kuttner tumor; (iv) Warthin’s tumor; (v) Pott’s Puffy tumor Ans. i. Brown tumor: Giant cell lesion of hyperparathyroidism ii. Iceberg tumor: Pleomorphic adenoma iii. Kuttner tumor: Chronic sclerosing sialadenitis of sub- mandibular gland iv. Warthin’s tumor: Adenolymphoma of the parotid gland Miscellaneous 303

5. Pott’s puffy tumor: It is a complication of bacterial frontal sinusitis It consists of a subperiosteal abscess and osteomyelitis of the frontal bone. 7. Describe a patient’s position in different conditions. Ans.

Condition Patient position 1. During recovery from syncope Trendelenburg position (100 head- down position) and semi-reclined 2. During CPR Supine position 3. Syncope during pregnancy Left lateral position 4. Pregnant lady during surgery Upright position or her trunk adjusted slightly to one side 5. Congestive heart failure patient Upright position 6. Cardiac arrest Patient laid flat on the floor with head on one side 7. Respiratory arrest Patient laid flat on the floor and pulling the mandible upward and forward

8. Explain the following terms: (i) George winter’s imaginary lines; (ii) Campbell’s lines; (iii) Trameline pattern; (iv) Langer’s lines; (v) Wrinkle lines or natural lines; (vi) Trapnell’s line. Ans. i. George winter’s imaginary lines: Particular depth and position of the impacted mandibular third molar within the mandible is described as George Winter’s three imaginary lines, commonly known as war lines. These lines are: – White line: It indicates the relative depth of the third molar – Amber line: It represents the bone level covering the Impacted tooth – Red line: It indicates the amount of resistance and difficulty encountered with during the removal 304 When, Why and Where in Oral and Maxillofacial Surgery

ii. Campbell’s lines: (refer to Chapter No. 8) iii. Trameline pattern: In case of facial trauma, cerebrospinal fluid (CSF) rhinorrhea, septal hematoma occur. The CSF is usually associated with bleeding. However, the presence of CSF in the blood can be detected with the help of a simple test in which a drop of fluid is on a handkerchief and a classic bull’s eye ring develops. It is also identified by the trameline pattern. It is also called Bull’s eye ring. iv. Langer’s lines: These lines tend to run parallel with the skin creases, which are generally perpendicular to the action of the underlying muscle. Elective incisions should be made in or parallel to the lines of facial expression or natural skin lines, wherever possible. v. Wrinkle lines or natural lines: These lines are different from Langer’s lines which denote the collagen fiber direction within the dermis. Elective incision can be made in or parallel to the line of facial expression or natural skin. vi. Trapnell’s line: Fifth line of Campbell’s line. Lower border of the mandible from one angle to the other side of the angle. 9. What are the conditions/lesions related to different types of syndromes? Ans. i. Dry socket: Postextraction syndrome ii. Gustatory sweating: Frey’s syndrome or auriculotemporal syndrome iii. OKC: Bifid nevoid basal cell carcinoma syndrome iv. Fibrous dysplasia: Albright’s syndrome v. Sjögren syndrome: Sicca syndrome. 10. What is the composition of the following: (i) Bone wax; (ii) Carnoy’s solution; (iii) Monsel’s solution; (iv) White head varnish; and (v) Talbot’s solution. Ans. i. Bone wax: – Bees wax (yellow) = 7 parts – Olive oil = 2 parts – Phenol = 1 part Miscellaneous 305

ii. Carnoy’s solution: – Alcohol = 6 ml – Chloroform = 3 ml – Glacial acetic acid = 1 ml – Ferric chloride = 1 gram iii. Monsel’s solution: – Ferric sulfate – Act by precipitating proteins iv. White head varnish: – Benzoin = 10 parts – Iodoform = 10 parts – Storax = 7.5 parts – Balsam of tolu = 5 parts – Ether (as solvent) = 100 parts v. Talbot’s solution: – Iodine – ZnI – Glycerine – Water 11. What are the indications of the following: (i) Bone wax; (ii) Carnoy’s solution; (iii) Monsel’s solution; and (iv) White head varnish. Ans. i. Bone wax: To arrest the bleeding from a hard bony surface ii. Carnoy’s solution: Used as a chemical cauterizer, e.g. odontogenic keratocyst, ameloblastoma iii. Monsel’s solution: It is effective in arresting the capillary bleeding and postextraction bleeding in the medullary bone iv. White head varnish: Used as an antiseptic dressing in cystic cavity to reduce dead space and to check bleeding. 12. What are the false anatomic periapical radiolucencies? Ans. i. Mental foramen ii. Incisive foramen iii. Maxillary sinus iv. Dental papilla 306 When, Why and Where in Oral and Maxillofacial Surgery

13. Explain the following terms: (i) Glands of Zeis; and (ii) Glands of Moll Ans. i. Glands of Zeis: The sebaceous gland of the eyelid ii. Glands of Moll: The sweat glands of the eyelid. 14. What are the roles of the following instruments: (i) Bone nibbler; (ii) Bone rongeur; (iii) Chisel; (iv) Osteotome (v) Bone file; (vi) Giglisaw; and (vii) Bone gouge. Ans. i. Bone nibbler: It is an end-cutting instrument. It is used to remove small bony spicules and trimming of bone. ii. Bone rongeur: It is a side-cutting instrument. It is used to remove irregular bone margin and trimming of bone. iii. Chisel: It is an unibeveled instrument. It is used to remove bone on one side and split the tooth iv. Osteotome: It is a bibeveled instrument. It is used to remove the bone on the both sides, make a tunnel, and split the bone through orthognathic surgery v. Bone file: It is used to smoothen the sharp bony margin. unidirectional movement vi. Giglisaw: To cut the bone through and through vii. Bone gouge: For making window in the maxillary sinus. 15. What are the basic differences between the following diseases: Ans.

Disease Deficient factor Bleeding Clotting PT time time Hemophilia A Factor 8: Anti­hemo­philic N ­↑ N globulin Hemophilia B Factor 9: Christmas factor N ­↑ N Hemophilia C Factor 10: Stuart factor N ­↑ N Parahemophilia Factor 5: Labile factor or N ­↑ ­↑ proaccelerin Miscellaneous 307

16. How will you recognize angina pectoris and myocardial infarction clinically after chest pain? Ans.

Angina pectoris Myocardial infarction It is of shorter duration It is more severe and of prolonged duration The condition is relieved after The condition does not subside after the one dose of trinitroglycerine 0.4 dose of trinitroglycerine mg/sublingually The dose should be repeated after three minutes of the first dose.

17. List the differences between hypoglycemia and hypergly­ cemia. Ans.

Hypoglycemia Hyperglycemia It is known as insulin shock It is known as ketoacidosis It results from the mismatch of Usually there is reduction of insulin insulin dose and serum glucose It develops quickly Usually it develops progressively over a period of several days It is seen more frequently The factors that increase the amount of the required insulin include infection, trauma, surgery, pregnancy and emotional stress.

18. What are the “3-S” muscles attached with the styloid apparatus? Ans. i. Styloid muscle ii. Styloglossus muscle iii. Stylopharyngeus muscle. 19. What are muscles attached to the labiobuccal surface of the mandible? Ans. i. Mentalis ii. Depressor labii inferioris iii. Depressor anguli oris iv. Platysma 308 When, Why and Where in Oral and Maxillofacial Surgery

v. Buccinator vi. Masseter vii. Temporalis 20. List the autoimmune diseases. Ans. i. Sjögren’s syndrome ii. Sialosis (Sialadenosis) iii. Mikulicz’s disease (salivary non-inflammatory disease) iv. Cherubism v. Fibrous dysplasia vi. Ossifying fibroma 21. How many sinuses are present in the human body? Ans. 57 different kinds of sinuses are present in the human body, e.g. heart, brain, spleen, uterus, ankle, kidney, anus, skull and coccyx. 22. Describe the procedure for the external chest compression in infants? Ans. The ideal location for applying pressure for the external chest compression in infants is one-finger width below the nipple. Use two fingers to perform the compression. 23. How much hydrocortisone is produced by the adrenal cortices in the body daily? Ans. 20 mg/day. 24. What are the features of adrenal crisis? Ans. i. Hypoglycemia ii. Hypotension iii. Shock. 25. Which is the most accepted theory for the conduction of pain? Ans. Gate control theory proposed by Melzack and Wall in 1965 is the most accepted theory for the conduction of pain. 26. In which syndrome can a patient not smile/cry or close the eyelid during sleep? Ans. Mobius syndrome—congenital facial dysplegia. Miscellaneous 309

27. What is cryosurgery? Ans. In cryosurgery, extreme cooling temperature, ranging from –20°C to –18°C is used. At this temperature range, the tissues, capillaries, smaller arterioles and venules undergo cryogenic necrosis. This is caused by dehydration and denaturation of the lipid molecules. 28. Which agent is used in cryosurgery? Ans. Nitrous oxide is used in cryosurgery. 29. At what temperature does the cell death occur in cryosurgery? Ans. When the temperature falls below –20°C, the cell death occurs. 30. Where is dermatome used? Ans. Dermatome is used to harvest skin graft. It is a special instrument used for cutting the split skin graft. 31. What is the split thickness of split skin graft and full thickness of skin graft in maxillofacial surgery? Ans. The split thickness ranges from 0.3 mm to 0.5 mm whereas full thickness ranges from 1 mm to 1.15 mm. 32. Which blood product is the choice for treatment in a hemophilic patient? Ans. Cryoprecipitate is the choice of blood product. 33. What is Tenon’s capsule? Ans. It is a fascial structure that subdivides the orbital cavity into two halves—an anterior or precapsular segment and a posterior or retrocapsular segment. 34. What are six vital signs? Ans. i. Blood pressure ii. Heart rate and rhythm iii. Respiratory rate iv. Temperature v. Height vi. Weight. 310 When, Why and Where in Oral and Maxillofacial Surgery

35. What advantage do the patients with a pacemaker have? Ans. Such patients do not require any antibiotic prophylaxis and the vasoconstrictor can be administered safely. 36. What is the danger area of face, danger space of neck and danger area of scalp? Ans. i. Danger area of face: Infections from the face can spread in a retrograde direction and cause thrombosis of the cavernous sinus. This is specially likely to occur in the presence of infection in the upper lip and in the lower part of the nose. Hence, this area is called the danger area of the face. ii. Danger space of neck: According to Grodinsky and Holyoke (1938), Space 4 is the danger space (potential spaces of the head and neck region) between the alar and prevertebral fascia. It extends from the base of the skull to the posterior mediastinum. iii. Danger area of scalp: Pericardium of scalp is the danger area of the scalp because vessels attached with pericardium may cause profuse bleeding. 37. How much hemoglobin concentration rises after one unit of fresh blood transfusion? Ans. One gram % after one unit fresh blood transfusion. 38. Why is epsilon-aminocaproic acid (EACA) replaced by tranexamic acid? Ans. The action of EACA is antifibrinolytic activity, which is replaced by tranexamic acid because: i. It is more potent ii. It has longer acting properties iii. It has less side-effects 39. Which are the best oral sedative drugs used in dentistry? Ans. Benzodiazepines. 40. Which antibiotics are effective against the gram-negative bacteria? Ans. Aminoglycosides. Miscellaneous 311

41. Which is the drug of choice for the treatment of anaphylaxis? Ans. 0.2 to 0.5 ml of 1:1000 solution of adrenaline given by IM or SC route. 42. What are the advantages of fresh whole blood against stored blood transfusion? Ans. Banked blood is a poor source of platelets. The factors which are absent in stored blood are factor 5 (Labile factor or Proaccelerin) and factor 8 (Antihemophilic globulin or Antihemophilic factor). Fresh whole blood refers to the blood that is administered within 24 hours of its donation. 43. Which organisms are responsible for the following condition: (i) Acute bacterial endocarditis; (ii) Postoperative endocarditis; and (iii) Subacute bacterial endocarditis. Ans. i. Acute bacterial endocarditis: Staphylococcus aureus ii. Postoperative endocarditis: Staphylococcus albus iii. Subacute bacterial endocarditis (SABE): Streptococcus viridans (Streptococcus sanguis). 44. What is the cardinal symptom of dehydration due to the disturbance of fluid and electrolyte balance? Ans. Polydipsia. 45. What is the characterstic feature of asthma? Ans. Expiratory wheezes. 46. What is the rate of rescue breathing in an adult? Ans. 12 times/minute is the proper rate of rescue breathing. 47. If a normal patient loses one liter of blood during surgery, how much fluid replacement is required in this case? Ans. 3 liters of colloidal fluid’s replacement is required. 48. What are the early signs of the following conditions: (i) Syncope; (ii) Hypovolemic shock; and (iii) Want of oxygen. Ans. i. Syncope: Pallor ii. Hypovolemic shock: Tachycardia iii. Want of oxygen: Tachycardia. 312 When, Why and Where in Oral and Maxillofacial Surgery

49. List the classic triad of the following conditions: (i) Dry socket; and (ii) Osteoradionecrosis. Ans. i. Dry socket: – Loss or necrosis of clot – Pain – Fetor oris ii. Osteoradionecrosis: – Radiation – Trauma – Infection. 50. Which respiratory condition is the most alarming condition during sedation of a patient on a dental chair? Ans. “Apnea” is the most alarming condition. 51. What is acromegaly? Ans. Acromegaly is the disease which is characterized by the excessive growth of the bones and other parts, such as jaws, feet and hands seen during adult life. 52. What is CVA? Ans. CVA means “cerebrovascular accident” or stroke is a serious complication. There is either hemorrhage or thrombosis resulting in focal brain damage. 53. Which is the common site of rib for costochondral graft? Ans. Commonly preferred is 5th or 6th rib but the range is between 5th and 9th ribs. 54. Which sign is seen on a dental chair after IV diazepam? Ans. Verrill’s sign is seen on a dental chair which is characterized by: i. Partial ptosis (50%) ii. Blurring vision iii. Slurring speech that indicates the correct level after diazepam sedation. 55. What is the depth of the external chest compression? Ans. In adults: 1.5 to 2 inches Miscellaneous 313

In children: 1 to 1.5 inches In infants: 0.5 to 1 inch. 56. What is the rate of the external chest compression? Ans. For adults: 100/minute For children: 100/minute For infants: at least 100/minute. 57. What is the duration of time for the assessment of pulse? Ans. In infants, brachial pulse is assessed and for adults and children, carotid pulse is assessed for 5 to 10 seconds. 58. What is the complication of external chest compression? Ans. i. Rib and sternal fracture occur 80% of time ii. Major cardiac or pericardial injuries iii. Bone marrow and fat emboli. 59. What do the following indicate in reference to local anesthesia: (i) One cartridge; (ii) 2% lignocaine; (iii) Dose of one set of action of LA; (iv) Maximum dose of LA with adrenaline; and (v) Maximum dose of LA without adrenaline. Ans. i. One cartridge: It contains 1.8 to 2 ml of LA solution ii. 2% lignocaine: It means 20 mg lignocaine in one ml iii. Dose of one set of action of LA: It is 3 to 5 minutes iv. Maximum dose of LA with adrenaline: It is 20 ml v. Maximum dose of LA without adrenaline: It is 14 ml. 60. Describe chest pain suggesting cardiac ischemia? Ans. i. Uncomfortable squeezing pressure, fullness or pain in the center of the chest lasting for more than 15 minutes ii. Pain radiates to the shoulder, neck, arm and jaws iii. Pain between the shoulder blades iv. Chest discomfort with light headedness, fainting, sweating and nausea v. A feeling of distress and anxiety. 314 When, Why and Where in Oral and Maxillofacial Surgery

61. What are the meanings of the following terms: (i) Tachycardia; (ii) Bradycardia; and (iii) Asystole Ans. i. Tachycardia: It means rapid heart rate. The normal heart rate is between 60 and 100/minute. If it goes more than 100/minute, it indicates tachycardia ii. Bradycardia: It means slow heart rate. Normal heart rate is 60 to 100/minute. If it goes less than 60/minute, it indicates bradycardia iii. Asystole: It indicates the absence of ventricular activity. The patient will be without pulse. 62. What do you mean by the term heart block? Ans. Heart block is used interchangeably with the correct term arterioventricular block, which means a delay or interruption in conduction between the arteria and the ventricles. 63. What are the four life-threatening conditions that may mimic acute myocardial infarction and lead to cardiovascular collapse? Ans. i. Massive pulmonary embolism ii. Cardiac tamponade iii. Hypovolemic and septic shock iv. Aortic dissection. 64. Which is the safest period of time to perform surgery on a pregnant lady? Ans. The second trimester. 65. Why are the first and third trimesters a less optimal time to perform surgery on a pregnant lady? Ans. During the first trimester, the fetus is the most vulnerable in terms of organogenesis and response to exogenous insults. During the third trimester, there is risk of inducing a premature delivery and all its sequelae. 66. Which clotting factors are altered during pregnancy? Ans. Factor XI (Antihemophilic factor) and Factor XII (Hageman factor) are increased during pregnancy. Miscellaneous 315

67. What is the position of the pregnant lady on a dental chair during surgery? Ans. During the second and third trimesters, a decrease in blood pressure can occur while the patient is in a supine position. This is attributed to a decreased venous return to the heart from the compression of the inferior vena cava by the gravid uterus. This also can compress the descending aorta and common iliac arteries. So the chair position should be upright or the patient’s trunk should be slightly on one side. 68. Which radiograph best demonstrates the subcondylar fracture? Ans. Towne’s projection. 69. During the apicectomy in the region of the maxillary incisor teeth, why should one take care not to damage or peforate? Ans. Care should be taken not to damage the floor of the nose to avoid perforation of the nasal mucosa. Otherwise it may cause profuse bleeding. 70. How will you manage irritational fibroma, which is asympto­ matic? Ans. It is managed by simple excision. 71. Nasal antrostomy is usually done from which structure? Ans. It is done from the inferior meatus. 72. What criteria is to be considered while planning the third molar transplantation? Ans. i. The root is atleast half formed ii. The width of the crown approaches the width of the extracted tooth. 73. Eagle’s syndrome is associated with the elongation of which structure? Ans. Styloid process. 74. What is the purpose of taping the eyes shut before surgery? Ans. To prevent corneal abrasion. 316 When, Why and Where in Oral and Maxillofacial Surgery

75. How is the visible bleeding of an artery best treated? Ans. By clamping and ligation of the artery. 76. What is the aim of giving an antibiotic before surgery to a patient with rheumatic heart disease? Ans. To prevent subacute bacterial endocarditis. 77. What is heterograft? Ans. If a graft is obtained from another species of different genetic disposition, it is known as heterograft. 78. When is Vitamin K used in case of management of postextraction bleeding? Ans. In case of prothrombin deficiency. 79. In general, what is the common site for IV fluid therapy? Ans. Common site is the dorsal vein at the back of the hand. 80. Should the eyebrows be shaved when facial lacerations are repaired? Ans. No. They provide a landmark for realignment of tissue edges and do not always grow back. 81. Differentiate between an animal bite and human bite. Ans. i. Infections of human bites are frequently caused by Streptococcus and Staphylococcus organisms. Animal bites are caused by pasteurella multocida ii. In human bite, penicillin or amoxicillin or clavulanic acid is recommended. In animal bite, amoxicillin clavulanic acid is recommended iii. Tetanus immunization is needed for all bites iv. Rabies prophylaxis may be required when animals exhibit suspicious behavior. 82. What are the common causes of graft failure? Ans. i. Hematoma formation ii. Failure of immobilization Miscellaneous 317

83. What is the classification of free skin graft? Ans. They are classified on the basis of thickness of the graft: i. Thin = 0.008 to 0.012 inch ii. Medium = 0.012 to 0.018 inch iii. Thick = 0.018 to 0.030 inch 84. Classify the soft tissue injuries. Ans. i. Contusions ii. Abrasions iii. Lacerations iv. Flap-like lacerations v. Avulsion injuries. 85. What is the role of irrigation of wound preparation? Ans. Irrigation is essential in preventing infections because it removes debris, dirt, microorganisms and devitalized tissue from the wound, which results in the reduction of infection rate. High pressure irrigation with normal saline has been shown to decrease the bacterial count of the wounded tissue and decreases the rate of infection. The use of concentrated povidone-iodine hydrogen peroxide may cause significant tissue damage, which should be avoided. 86. What are radioresistant lesions? Ans. i. Pleomorphic adenoma of parotid gland ii. Chondromas. 87. What is Darrow’s solution? Ans. This is the only solution which contains more of K than available in the plasma or ECF. If K concentration is 36 meq/L, Na 124 meq/L , Cl 104 meq/L and lactate 56 meq/L, obviously this is the best solution to combat hypokalemia. It supplies K at a relatively safe rate provided alkalosis is not present. The rate of infusion should be slower than other solutions to avoid hyperkalemic state, which is more dangerous and should be given more than 60 drops per minute. 318 When, Why and Where in Oral and Maxillofacial Surgery

88. In reference to the mid-face injury, the ecchymosis of the following are indicating presence or signs of: (i) Ecchymosis of the mastoid area; (ii) Ecchymosis at greater palatine foramen area; (iii) Ecchymosis in sublingual area; and (iv) Ecchymosis in zygomatic buttress area. Ans. i. Ecchymosis of the mastoid area = Battle’s sign ii. Ecchymosis at greater palatine foramen area = Guerin’s sign iii. Ecchymosis in sublingual area = Coleman’s sign iv. Ecchymosis in zygomatic buttress area = Raccoon’s sign. 89. In reference to the maxillofacial injury what is the tongue tie indicated in? Ans. i. Bilateral parasymphysis fracture ii. Chin has been destroyed in gun shot iii. Unconscious patient. 90. What is the other name of isograft? Ans. Syngraft is the other name. 91. What are the disadvantages of autogenous bone graft? Ans. i. Extensive resorption after grafting ii. Need for donor site surgery iii. Two sites of surgery. 92. Generally bone marrow for grafting the defect is obtained from where? Ans. Iliac crest graft. 93. What are the characteristics of an ideal graft? Ans. i. It should withstand the mechanical force ii. It should not produce any immunologic response iii. It should actively assist osteogenic potential of host. 94. What is the term used for bone transplant from one human to another? Ans. Homologous bone graft. Miscellaneous 319

95. Which is the best graft utilized for the reconstruction of large mandible defect? Ans. Iliac crest graft is the best graft. 96. Ideally iliac crest graft should be taken from where? Ans. Medial aspect of iliac crest. 97. What do the composite grafts consist of? Ans. Bone and soft tissue. 98. Which is the choice of graft in a young patient treated with ameloblastic resection — free iliac crest graft or free vascularized iliac crest graft? Ans. Free vascularized iliac crest graft. 99. Hyperventilation in an anxious patient may cause? Ans. Carpopedal spasm. 100. Which nerve is involved in Saturday night palsy? Ans. Radial nerve is involved. 101. What are the conditions that indicate early oxygen requirement? Ans. i. Cyanosis ii. Increased pulse rate—tachycardia. 102. In an elective tracheostomy, where should the entry be made? Ans. Below the cricoid cartilage. 103. What is factor IV and what is its peculiarity? Ans. Factor IV is calcium. It is the only factor which is non- proteinaceous. 104. What can happen if there is blow to the chin? Ans. i. If on midline: Bilateral subcondylar fracture ii. If on one side (left/right side): Fracture of opposite side of angle iii. Including both sides of chin: Bilateral parasymphysis fracture of the mandible. 320 When, Why and Where in Oral and Maxillofacial Surgery

105. A patient taking warfarin sodium therapy. Which drugs are contraindicated for him? Ans. i. Ibuprofen ii. Aspirin. 106. What is the rate of infusion of IV diazepam? Ans. It should be 1 ml per minute. 107. For how many days is postoperative antibiotic therapy continued in subacute bacterial endocarditis (SABE) patient? Ans. It should be continued for atleast two days. 108. What history does a patient suffering from diabetes mellitus give? Ans. i. Easily bruising ii. Nocturia iii. Excessive thirst iv. Low resistance to infection. 109. A laboratory report indicates WBC count of more than one lac. Most likely the patient is suffering from which disease? Ans. Leukemia. 110. What are the possible clinical complications in a patient with a history of congestive heart failure? Ans. i. Dyspnea ii. Orthopnea iii. Edema of the ankle iv. Palpitation. 111. What is the possible clinical complication in patients with Hyperthyroidism? Ans. i. Recent weight loss ii. Fatigue iii. Tremors iv. Tachycardia v. Tremors and sweaty palms on examination vi. Anxious nervous patient. Miscellaneous 321

112. Which among the two bony lesions is the most fatal— multiple myeloma or odontogenic myxoma? Ans. Multiple myeloma is the most fatal which is characterized by: i. Increased Bence-Jones proteinuria ii. Multiple radiolucent area in the skull. 113. An obese patient during jogging falls and becomes uncon­ scious. What points should be considered to differentiate cardiac arrest from other reasons? Ans. i. Pulse, ‘carotid or femoral’ is present or absent ii. Pupils are constricted or dilated iii. Respiration is present or absent. 114. What is pinpoint hemorrhage on skin called as—ecchymosis or petechiae? Ans. It is called as petechiae. 115. Which among the two drugs salicylates or adrenaline is contraindicated in a hyperthyroid patient? Ans. Adrenaline is contraindicated. 116. What are the possible complications of blood transfusion? Ans. i. Circulatory overload ii. Thrombophlebitis iii. Immediate and delayed hemolytic reaction. 117. Define the following terms: (i) Autograft; (ii) Allograft; and (iii) Xenograft. Ans. i. Autograft: It is transplanted from one region to another into the same individual ii. Allograft: It is transplanted from one individual to a genetically non-identical individual of the same species iii. Xenograft: It is transplanted from one species to another. 118. Explain the following terms: (i) Osteoinduction; (ii) Osteoconduction; and (iii) Osteogenesis. Ans. i. Osteoinduction: It refers to new bone formation from the differentiation of osteoprogenitor cells derived from primitive mesenchymal cell into secretory osteoblasts 322 When, Why and Where in Oral and Maxillofacial Surgery

ii. Osteoconduction: It is the formation of new bone from host derived from or transplanted osteoprogenitor cells along a biologic or alloplastic framework iii. Osteogenesis: It is the formation of new bone from osteoprogenitor cells: – Spontaneous osteogenesis is the formation of new bone from osteoprogenitor cells in a wound – Transplanted osteogenesis is the formation of new bone from osteoprogenitor cells placed into the wound. 119. What is bone morphogenic protein (BMP)? Ans. i. BMP is a protein complex responsible for initiation of osteoinduction ii. BMP is a part of cytokine family of growth factor which occurs in the organic portion of the bone called the bone matrix iii. BMP is osteoinductive iv. It acts on the progenitor cells to induce differentiation into osteoblasts and chondroblasts v. BMP may act as the main signal regulating skeletal forma­ tion and repair and is known to induce bone formation de novo vi. BMP appears to be stored within the bone matrix and released with resorptive activity. 120. Cortical bone or cancellous bone—which among the two contains more BMP? Ans. Demineralized cortical bone has been shown to contain more BMP than demineralized cancellous bone. 121. What is platelet-rich plasma? Ans. Platelet-rich plasma is an autologous source of platelet derived growth factor (PDGF) and insulin like growth factor (IGF) and transforming growth factor beta 1 and 2 (TGF beta 1 and TGF beta 2). These factors have been shown to increase bone graft maturation rates and bone density. Miscellaneous 323

122. What are the seven anatomical structures that attach to the anterior iliac crest? Ans. i. Fascia latae ii. Inguinal ligament iii. Tensor fascia latae iv. Sartorius v. Iliacus vi. Internal abdominal oblique muscle vii. External abdominal oblique muscle. 123. Why is the mandibular defect that crosses the midline the most difficult? Ans. In this area there is need for hard tissue support for the chin’s soft tissue as well as suspension of the extrinsic tongue musculature. 124. What are the major considerations in repair of large mandibular defects? Ans. i. Soft tissue coverage ii. Amount of bone replacement iii. Stabilization of the graft iv. Occlusal rehabilitation. 125. What are the advantages and disadvantages of cancellous bone graft? Ans. Advantages: i. Cancellous bone grafts provide an immediate reserve population of viable bone forming cells as well as a population of progenitor cell that are capable of differen­ tiating into osteoblasts ii. The porous microstructure of cancellous graft allows in the growth of endothelial buds and provides a large surface area for osteoblastic/osteoclastic activity. Disadvantage: i. It does not have any macroscopic structural integrity. 324 When, Why and Where in Oral and Maxillofacial Surgery

126. What are the advantages and disadvantages of cortical bone grafts? Ans. Advantages: i. Its rigid lamellar architecture does not deform with compression or tension allowing rigid fixation of the graft and its use in load bearing or structural applications. ii. Cortical bone also has a higher concentration of BMP and cortical chips. Disadvantages: i. Cortical bone does not carry a large population of osteocompetent cells ii. Lamellar bone provides little surface area for remodelling activity iii. Lamellar bone makes the graft more susceptible to infection. 127. What are the objectives of facelift rhytidectomy? Ans. Rhytidectomy removes the lax and redundant skin of the face and neck including prominent nasolabial folds and submental region that contribute to the aged appearance of the face. 128. What are the complications of rhytidectomy? Ans. Sequelae of rhytidectomy includes: i. Swelling ii. Discomfort iii. Hematoma iv. Paresthesia v. Ecchymosis vi. Sloughing of the flap vii. Facial nerve injury viii. Unfavorable scarring ix. Earlobe deformities 129. What are the advantages and disadvantages of open rhinoplasty operation? Ans. Advantage: Miscellaneous 325

i. Direct visualization of the structure clearly demonstrates the effect of surgical technique like, nasal deformity and cleft lip. Disadvantages: i. Unfavorable scarring occurs ii. Prolonged edema iii. Paresthesia of nasal tip iv. Skin loss or slough. 130. Define the following terms: (i) Syndrome; (ii) Malformation; (iii) Deformation (iv) Disruption Ans. i. Syndrome: A syndrome is a set of symptoms that occur together. A particular syndrome may have three, four or ten manisfestations but a key sequence of symptoms leads to the diagnosis of particular syndrome ii. Malformation: A malformation is a morphologic defect of an organ, part of an organ or larger region of the body. For example, cleft lip or palate (embryonic occurrence) iii. Deformation: Abnormal form or position of part of a body caused by nondisruptive mechanical forces (fetal occurrence) iv. Disruption: Morphological defect of an organ, part of an organ or larger region of the body resulting from the breakdown of or an interference with an originally normal developmental process. 131. List the peculiarities of mobius syndrome. Ans. i. Mobius syndrome affects 6 cranial nerves: – III cranial nerve (oculomotor) – V cranial nerve (trigeminal) – VI cranial nerve (abducent) – VII cranial nerve (facial) – IX cranial nerve (glossopharyngeal) – XII cranial nerve (hypoglossal) 326 When, Why and Where in Oral and Maxillofacial Surgery

ii. The most commonly affected muscle is the lateral rectus muscle by paralysis with defect of the abducent cranial nerve (VI CN) iii. The cardinal clinical complications are: – Mask-like faces due to paralysis of lateral rectus muscle. So the patient cannot cry or smile – Drooping of angles of the mouth – Inefficient sucking and swallowing and speech impairment – Mild mental retardation – High and broad nasal bridge with hypoplastic mandible. 132. Which syndrome is referred as to hysterical dysphagia? Ans. Plummer Vinson syndrome. Its features are: i. Seen in 4th and 5th decades of life ii. Most commonly seen in women iii. Manifestation of iron deficiency anemia: – Cracks at commissures – Lemon-tinted skin color – Red and smooth painful tongue – Dysphagia from esophageal stricture. 133. What is coloboma and with which syndrome is it associated? Ans. Coloboma is a notch on the lower eyelid. It is present in 75% Treacher-Collins syndrome. 134. Which are the syndromes associated with the mandibular prognathism? Ans. i. Basal cell nevus syndrome (Gorlin syndrome) ii. Klinefelter’s syndrome iii. Marfan’s syndrome iv. Osteogenic imperfecta v. Waardenburg syndrome. 135. What are the malformation syndromes associated with the midface deficiency? Ans. i. Achondroplasia ii. Apert’s syndrome Miscellaneous 327

iii. Cleidocranial dysplasia iv. Crouzon’s syndrome v. Marshall’s syndrome vi. Pfeiffer syndrome vii. Stickler syndrome. 136. In which diseases is the café au lait spot seen? Ans. i. Neurofibromatosis or—von Recklinghausen’s disease ii. McCune-Albright syndrome. 137. What is alloplast? Ans. The term ‘alloplast’ is synonymous with the synthetic produced from inorganic sources and contains no animal or human compo­nents. 138. What are the indications of polymethyl metha­crylate (PMMA)? Ans. The PMMA is most often used in: i. Forehead contouring ii. Cranioplasty procedure for full thickness defects of skull. 139. Define the following terms: (i) Snoring; (ii) Apnea; and (iii) Hyponea Ans. i. Snoring: Snoring is a partial airway and pharyngeal flow obstruction that does not awaken an individual. Movement of air through an obstructed airway creates the snoring sound ii. Apnea: Apnea is the cessation of airflow lasting for more than 10 seconds iii. Hyponea: It refers to a greater than 2/3rd decrease in tidal volume. Apnea and hyponea show a decrease in oxygen saturation of atleast 2%. 140. A patient is on periodic renal dialysis. When should the minor oral surgical procedure be undertaken? Ans. One day after dialysis. 141. What is venepuncture? Ans. This technique is used to obtain blood sample for either hematological or biochemical examination and to give IV injection 328 When, Why and Where in Oral and Maxillofacial Surgery

in emergencies. The preferred site is within the elbow, where the veins are easily visible. 142. What are the clinical applications of epinephrine (adrena­ line)? Ans. i. For the management of acute allergic reaction ii. For the management of bronchospasm iii. For the management of cardiac arrest iv. As a vasoconstrictor for hemostasis v. To increase the depth of anesthesia. 143. Name of the other vasoconstrictor which can be used in dentistry other than vasoconstrictor? Ans. Levonordefrin, but it is still not available in market. 144. What are the conditions that may cause trismus in case of trauma, infection and neurogenic condition? Ans. i. Trauma – Unfavorable angle fracture of the mandible – Displaced subcondylar fracture of mandible – Zygomatic arch fracture ii. Infection – Pericoronitis (third molar region) – Masticatory spaces infection, e.g. pterygomandibular space infection, infratemporal space infection, masseteric space infection – TMJ ankylosis (mainly fibrous) – TMJ arthritis – TMJ dislocation – Dentoalveolar abscess (acute alveolar abscess) iii. Neurogenic condition. – Tetanus (Bacterial infection) – Tetany (Hypocalcemia). 145. What is the method of describing any instrument? Ans. Any instrument should be described in the following way: i. Name of the instrument [e.g. tooth extraction forcep] ii. Material of the instrument [stainless steel] Miscellaneous 329

iii. Parts of the instrument [beak, hinge and handle] iv. Indications of the instrument [removal of the maxillary anterior teeth]. 146. After the extraction of tooth, one encounters bleeding due to hemangioma. What is the first step in the treatment? Ans. Replacing the tooth in the socket should be the first step to control the bleeding. 147. List the key points about hemophilia. Ans. i. Hemophilia is sex-linked congenital hereditary disorder of the clotting mechanism ii. Males are affected and females act as the carriers iii. It is mainly due to the deficiency of blood clotting factor VIII antihemophilic globulin (AHG) iv. It is characterized by a prolonged coagulation time (CT increases) but bleeding time (BT) is normal with bleeding tendency v. In hemophilic patient, intraligamentous injection of the local anesthetic agent is indicated to avoid bleeding. Nerve block is absolutely contraindicated. 148. Which is the common site of the metastasis from mandible? Ans. Lungs are the common site. 149. What do you understand by primary, secondary and reactionary hemorrhage? Ans. Hemorrhage means escape of blood from the blood vessels due to any cause that may rupture the vessels. i. Primary hemorrhage: It occurs as a part of surgery or from laceration ii. Reactionary or intermediate hemorrhage: Hemorrhage which occurs within 24 hours postoperatively iii. Secondary hemorrhage: This occurs during postoperative phase after the initial 24 hours. Generally, it occurs due to the breakdown of clot due to infection. 330 When, Why and Where in Oral and Maxillofacial Surgery

150. What are the indications (therapeutic and prophylactic) of the antibiotic therapy? Ans. It can be summarized as follows: i. Acute cellulitis of dental origin ii. Acute pericoronitis with elevated temperature and trismus iii. Deep fascial space infection iv. Open (compound) fracture of the mandible, maxilla and other facial bones v. Extensive, deep or old (more than 6 hours) orofacial lacerations vi. Dental infection or dental surgery vii. Prophylaxis for dental surgery in a cardiac patient. 151. List the various diagnostic tests conducted in the following conditions: (i) Cavernous sinus thrombosis; (ii) CSF rhinorrhea; (iii) Facial paralysis; (iv) Diplopia; and (v) Frey’s syndrome. Ans. i. Cavernous sinus thrombosis: Tobey Ayer test ii. CSF rhinorrhea: Handkerchief test (Tramline pattern) iii. Facial paralysis: Conduction test iv. Diplopia: Forced duction test v. Frey’s syndrome: Iodine dust test 152. List the radiographic features of the following lesions: (i) Osteosarcoma; (ii) Chronic osteomyelitis; and (iii) Ameloblastoma. Ans. i. Osteosarcoma: Sunburst appearance or Sunray’s appearance ii. Chronic osteomyelitis: Sequestra formation or moth-eaten appearance iii. Ameloblastoma: Honeycomb appearance or soap bubbles-like appearance. 153. What is the importance of the rule of the three ‘S’ in the evaluation of a patient with head injury? Ans. A precise approach is necessary in the evaluation of the patient with head injury. One should adhere to the rule of the three ‘S’: Miscellaneous 331

i. Simple: To facilitate triage, the examination should be simple to perform ii. Systemic: An accurate and reliable format will ensure that all the organs are assessed and the treatment is started in a timely fashion iii. Standardized: The examination should be easily recorded and standardized so that multiple examinations may be performed and recorded. Along with that the neurological changes should be examined and noted. 154. Define the following terms: (i) Concussion of the brain; (ii) Compression of the brain; and (iii) Contusion or laceration of brain. Ans. i. Concussion of the brain: Unconsciousness immediately after injury is a sign of concussion of the brain. The patient regains consciousness after some time depending on the type of injury (e.g. mild, moderate and severe) ii. Compression of the brain: When the patient is conscious following trauma, then after some time he starts going into the unconsious state. It is a sign of compression of the brain. There is a rupture of the vessel, mainly the middle meningeal artery, resulting in intradural or extradural hemorrhage. Blood starts collecting in the skull, resulting in the compression of the brain. iii. Contusion or laceration of the brain: It is the hemorrhage in the brain tissue. Laceration is the tearing of the brain tissue. The tissue will lose its sensation or function depending upon the injury to the nerve cell. 155. In case of maxillofacial trauma, what are the primary and secondary surveys? Ans. The primary survey includes: i. A = Patency of airway ii. B = Breathing iii. C = Assessment for circulation iv. D = Disability in terms of neurological evaluation is assessed 332 When, Why and Where in Oral and Maxillofacial Surgery

v. E = Environment control to save the patient from further injury. The secondary survey includes: i. Proving patency of airway ii. Control of bleeding iii. Management of cranial injuries and insult to brain, CSF leak, injuries of cervical spine and chest, any diplopia iv. Status of dentition/denture and drug consumed. v. Status of eyes and ears vi. Fracture of bones vii. Coma with history of events viii. Infection control. 156. What are the surgical procedures which may cause damage to the nerve, vein and artery? Ans. i. Nerve: – Lingual nerve: Removal of the impacted mandibular third molar – Auriculotemporal nerve: TMJ surgery – Facial nerve: Parotid gland surgery – Inferior alveolar nerve/mental nerve: Removal of the impacted mandibular third molar – Infraorbital nerve (infraorbital nerve block): Orbital fracture ii. Vein: – Pterygoid venous plexus: Posterior superior alveolar nerve block, Le Fort I osteotomy – Facial vein: Submandibular gland surgery iii. Artery: – Superficial temporal artery: TMJ surgery (preauricular incision) – Facial artery: Fracture of the body of the mandible, mandibular impacted third molar surgery, sub- mandibular gland surgery – Internal maxillary artery: TMJ ankylosis, maxillary sinus surgery (posterior wall) Miscellaneous 333

d. Lingual artery: Glossectomy, floor of the mouth surgery e. Retromolar artery: Surgery in the retromolar area. 157. What do the following signs signify: (i) Guerin’s sign; (ii) Coleman’s sign; (iii) Murphy’s sign; (iv) Virell’s sign; (v) Battle’s sign; (vi) Raccoon sign (vii) Bell’s sign (viii) Levine sign (ix) Tinel’s sign; (x) Chvostek’s sign; and (xi) Trousseau’s sign. Ans. i. Guerin’s sign: Ecchymosis at the greater palatine foramen in Le Fort I fracture ii. Coleman’s sign: Ecchymosis in the lingual sulcus, patho­ gnomic of the mandibular fracture (fracture in the symphysis region of mandible) iii. Murphy’s sign: Seen in cholecystitis iv. Virell’s sign: The following three symptoms are seen: – 50% eyelid ptosis – Blurring of vision – Slurring of speech indicating the correct level after diazepam sedation v. Battle’s sign: This gives rise to the ecchymosis of skin just below the mastoid process on the same side in case of the fracture of the base of the skull and condyle vi. Raccoon sign: It is seen in case of Le Fort II and III fracture of maxilla. Bilateral circumorbital or periorbital ecchymosis and gross edema occur giving an appearance of Raccoon eyes vii. Bell’s sign: It can be defined as an idiopathic paresis or paralysis of the facial nerve. In an attempt to close the eyelid, the eyeball rolls upwards so that the pupil is covered and only the white sclera is visible viii. Levine sign: It is one of the symptoms of myocardial infarction. It is characterized by the patient as fist clenched over the sternum describing the discomfort ix. Tinel’s sign: It is seen during the starting of the nerve regeneration. It is elicited by percussion over the divided 334 When, Why and Where in Oral and Maxillofacial Surgery

nerve that results in the tingling sensation in the part supplied by the peripheral section x. Chvostek’s sign: It is twitching of the facial muscle as a result of the tapping over the facial nerve in the preauricular area xi. Trousseau’s sign: It is carpopedal spasm due to the occlusion of the brachial artery when a blood pressure cuff is applied above the systolic pressure for three minutes. 158. Nerve injury caused by different incision approaches: (i) Denker’s operation; (ii) Mylohyoid ridge removal; (iii) Transoral sialolithotomy of the submandibular; (iv) Surgical removal of the parotid gland; (v) Submandibular or Risdon’s incision; and (vi) Preauricular incision. Ans. i. Denker’s operation: Anterior superior alveolar nerve ii. Mylohyoid ridge removal: Lingual nerve iii. Transoral sialolithotomy of the submandibular duct: Lingual nerve iv. Surgical removal of the parotid gland: Facial nerve v. Submandibular or Risdon’s incision: Marginal mandibular branch of facial nerve vi. Preauricular incision: If the incision is downward behind the attachment of pinna—facial nerve If the upper incision is curved anteriorly it may otherwise cause damage to the auriculotemporal nerve. 159. Explain the following techniques of tooth extraction: (i) Stobi’s technique; (ii) Wilkinson’s technique; (iii) Postage stamp technique; and (iv) Open window technique. Ans. i. Stobi’s technique: Extraction of six mandibular anterior teeth in a single setting ii. Wilkinson’s technique: Extraction of the first molar to create space for eruption of third molars is called as Wilkinson’s extraction or extraction is done to permit an eruption of third molars in proper position Miscellaneous 335

iii. Postage stamp technique: A method of bone removal in transalveolar extraction iv. Open-window technique: Modification of open technique with the help of bur, removing the bone overlying the apex of the tooth and exposing the fragment, and the tooth is displaced from the socket with the help of an elevator. 160. What is the rule of “5” anatomic limitation of bone harvesting in the symphyseal region (bone grafting)? Ans. 5 mm of bone should be left from the following: i. Mental foramen ii. Apex of the root iii. Lower border of the mandible