QUICK REVIEW SERIES for

BDS
ORAL AND MAXILLOFACIAL
SURGERY
4th Year
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 QUICK REVIEW SERIES for

BDS
ORAL AND MAXILLOFACIAL
SURGERY
4th Year

J Jyotsna Rao
bds, mds, pgcoi (mahe), f isoi
Director, SRS Dental Exams Academy, Bengaluru
Ex-Professor, Department of Oral and Maxillofacial Surgery
The Oxford Dental College, Hospital and Research Centre
Bengaluru, INDIA
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Quick Review Series for BDS 4th Year: Oral and Maxillofacial Surgery, Rao J Jyotsna

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 Dedicated
to
My Paternal Grandparents
Late J Venkat Rao Hazari and Kamala Bai
Late J Laxmipathi and Kanamma
for their love and affection which made my childhood sweet and memorable
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 Foreword

It gives me immense pleasure to write the Foreword for the book titled Quick Review Series for BDS 4th Year: Oral and
Maxillofacial Surgery and to introduce the author Dr Jyotsna Rao. This special effort made by the author is commendable
for making the examination of the undergraduates simple and easy.
I compliment the author for maintaining the standard and depth of the subject of Oral and Maxillofacial surgery
without compromising. The text is simple and concise covering all the topics which makes the students review the
subject and provides the potential to train the students and prepare for the challenge to face the examinations. I sincerely
hope the text caters the needs of the UG students, and I wish the book maintains the acceptability by the BDS students.
I sincerely recommend this book for the final BDS students preparing for the examinations and also for those preparing
for MDS entrance examination.
I congratulate the author Dr Jyotsna Rao and wish her all success.

Dr P Bal Reddy, MDS

Principal, Professor and Head
Dept of Oral and Maxillofacial surgery
Government Dental College and Hospital
Hyderabad, Telangana

vii
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 Preface

This book is a result of my close interaction with the students. There is a lot of information available to students in various
textbooks, which is not only voluminous but also time consuming and daunting to read. This book is not a replacement of
any oral and maxillofacial surgery textbook, but is written keeping the needs of the students in mind and their expectations from
a book for the purpose of excelling in the exams.
To excel in a subject one has to not only understand the same but also remember and present it in a systematic way in
the examinations. The subject like oral and maxillofacial surgery includes concepts of sterilization and asepsis, minor
surgical procedures, maxillofacial pathologies, orthognathic procedures, cleft surgeries, implantology, etc. All these need
to be condensed into a simple and comprehensible text.
The book is planned in a meticulous manner and I have endeavoured comprehensively to refer and include relevant
information from the standard textbooks. Though written in a question and answer format, this book is arranged in a logi-
cal sequence for the purpose of better recapitulation. This makes it easy for the students to rapidly review the entire subject
and also recollect whatever they had studied during the final year of BDS.
This book is primarily intended for undergraduate students, but can also be used as a quick reference book by post-
graduate students to recollect the subject.
J Jyotsna Rao
drjjrao@gmail.com

ix
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 Acknowledgements

First of all I thank almighty for his blessings without which this work would not have been possible.
I would like to first thank my father Mr J Sudharshan Rao who is the key person behind all my successful endeavours.
I am thankful to my mother Mrs S Sujatha Laxmi for her unforgettable sacrifices and choicest blessings. My warmest re-
gards to my husband Mr K Vinayak Rao for his constant support to enhance my software skills in operating computers.
My thanks and love to my son Master Raghasai without whose cooperation this work would not have been possible. I am
thankful to my brother Mr J Jayakrishna for his valuable constructive suggestions.
My sincere thanks to Dr P Bal Reddy Principal, Professor and HOD, Department of Oral and Maxillofacial Surgery,
Government Dental College and Hospital, Hyderabad, for contribution of his valuable time in the sincere correction of the
manuscript. I wish to thank Dr BK Reddy, Ex-Principal, GDC, Hyderabad and Meghana Dental College, Nizamabad for
his blessings and advice.
My sincere thanks to Dr Bhaskar Y, Dr P Chidambar, Dr Laxmikanth, and Mr Kiran (Librarian, Oxford Dental College,
Bangalore) and Narayana Swami for their invaluable support in collecting previous years’ question papers from various
universities.
I would like to specially thank Dr Dharaparekh and Dr Delisha for their valuable contribution in preparing manuscript.
I would like to extend my regards to Dr Rajini and P Nethravathi for their help in correction of manuscripts.
Thanks to Elsevier India, especially Dr Lalit Singh, Mrs Nimisha Goswami, Mr Anand K Jha, Ms Isha Bali and all
other team members for their active contribution in publishing this book.
I would like to take this opportunity to thank all those people who, directly or indirectly were instrumental in suc-
cessfully bringing out this book. Last but not the least, I acknowledge all my friends and colleagues for their best wishes
to boost my morale.

xi
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 Contents

Foreword vii Topic 12 Diseases of Salivary Gland 135

Preface ix Topic 13 Diseases of Maxillary Sinus 147
Acknowledgements xi
Topic 14 Inflammatory Lesions of Jaw
and Orofacial Infections 158
Section I Topic 15 Facial Neuropathology 176
TOPIC WISE SOLVED QUESTIONS Topic 16 Preprosthetic Surgery 184
OF PREVIOUS YEARS 1 Topic 17 Premalignant and Malignant Lesions 194
Topic 1 Introduction to Oral and Topic 18 Management of Medically
Maxillofacial Surgery 3 Compromised Patients
Topic 2 General Principles of Surgery 12 and Medical Emergencies 206
Topic 3 Local Anaesthesia 21 Topic 19 Minor Oral Surgical Procedures
Topic 4 Conscious Sedation and General and Orthognathic Surgery 223
Anaesthesia 39 Topic 20 Implantology and Miscellaneous 230
Topic 5 Principles of Exodontia
and Instrumentation 43 Section II
Topic 6 Impactions 55 MULTIPLE CHOICE QUESTIONS 243
Topic 7 Maxillofacial Trauma 67
Topic 8 Mandibular Fractures 81
Section III
Topic 9 Cysts of Orofacial Region 99
PREVIOUS YEARS’
Topic 10 Benign Tumours of the Jaw 111
QUESTION BANK 253
Topic 11 Diseases of TMJ 123

xiii
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 Section I

Topic Wise Solved Questions

of Previous Years

ORAL SURGERY
Topic 1 Introduction to Oral and Maxillofacial Surgery 3
Topic 2 General Principles of Surgery 12
Topic 3 Local Anaesthesia 21
Topic 4 Conscious Sedation and General Anaesthesia 39
Topic 5 Principles of Exodontia and Instrumentation 43
Topic 6 Impactions 55
Topic 7 Maxillofacial Trauma 67
Topic 8 Mandibular Fractures 81
Topic 9 Cysts of Orofacial Region 99
Topic 10
Benign Tumours of the Jaw 111
Topic 11
Diseases of TMJ 123
Topic 12
Diseases of Salivary Gland 135
Topic 13
Diseases of Maxillary Sinus 147
Topic 14
Inflammatory Lesions of Jaw and Orofacial Infections 158
Topic 15
Facial Neuropathology 176
Topic 16
Preprosthetic Surgery 184
Topic 17
Premalignant and Malignant Lesions 194
Topic 18
Management of Medically Compromised Patients
and Medical Emergencies 206
Topic 19 Minor Oral Surgical Procedures and Orthognathic Surgery 223
Topic 20 Implantology and Miscellaneous 230
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 Section I

Topic Wise Solved Questions

of Previous Years

Topic 1
Introduction to Oral and Maxillofacial Surgery
LONG ESSAYS
Q. 1. Discuss the use of various chemical agents for Various chemical agents used for maintaining sterilization
maintaining sterilization and asepsis in the dental clinic. and asepsis are as follows:
Ans.
l Sterilization is defined as a process by which an article,

surface, or medium is freed of all microbial forms such Disinfectants

as bacteria, viruses, fungi, and spores.
i. Alcohol, e.g., ethyl alcohol and isopropyl alcohol
l Ideally, a sterile field means free of contaminants,
ii. Aldehyde compounds, e.g., formaldehyde and glutaral-
which is difficult to attain. The goal is elimination of
dehyde 2%
infection, not sterility.
iii. Chlorines, e.g., sodium hypochlorite and calcium hypo-
l Chemical agents, rarely achieve sterilization. Instead,
chlorite
they are only expected to destroy the pathogenic organ-
iv. Quaternary ammonium compounds, e.g., benzalkonium
isms in an object.
chloride
l The process of destroying pathogens is called disinfec-
v. Phenolic compounds, e.g., ortho-phenylphenol and
tion, the object is said to be disinfected.
ortho-benzyl-para-chlorophenol
l If the object is lifeless, such as a tabletop, the chemical

agent is known as a disinfectant.

l However, if the object is living, such as a tissue of the
Antiseptics
human body, the chemical is an antiseptic.
l Antiseptics and disinfectants are usually bactericidal, i. Alcohols
but occasionally they may be bacteriostatic. ii. Aqueous quaternary ammonium compounds
l None of the chemicals used for cold sterilization iii. Iodophor compounds
satisfactorily meets all of the requirements for true iv. Chlorhexidine
sterilization. v. Hexachlorophene compounds.

3
4 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
i. Alcohol
l Ethyl alcohol (ethanol) and isopropyl alcohol are water-
soluble chemical substances.
l Alcohols are effective skin antiseptics and valuable dis-
infectants for medical instruments.
l For practical clinical use, the preferred alcohol is ethyl
alcohol. It is active against vegetative bacterial cells, in-
cluding the tubercle bacillus, but it has no effect on spores.
l Usually 50–80% alcohol solution is recommended
because water prevents rapid evaporation, assists pene-
tration into the tissues, and speeds up the process of
protein denaturation.
l A 10 min immersion in 70% ethyl alcohol is generally suf-
ficient to disinfect a thermometer or a delicate instrument.
l It denatures proteins and dissolves lipids, an action that
may lead to cell membrane disintegration.
l Ethyl alcohol is used as a component in many popular
hand sanitizers, as a preservative in cosmetics, and to
treat skin before a venepuncture or injection.
l It mechanically removes bacteria from the skin and
dissolves lipids.
l Isopropyl alcohol (rubbing alcohol) has high bacteri-
cidal activity in concentration as high as 99%.
l Methyl alcohol is toxic to the tissues and is used infre-
quently.
Advantages
l Rapid bactericidal action
l Economical
l Slightly irritating to tissues.
Disadvantages
l Evaporates rapidly
l No sporicidal or virucidal action
l Damage to rubber or plastic goods and to carbon steel
instruments.
ii. Aldehyde Compounds
a. Formaldehyde
l It exists as a gas at high temperatures and as a solid at
room temperatures.
l It is used as water-based solution called formalin, which
is prepared by suspending 37 g of the solid formalde-
hyde in 100 mL of water.
l In microbiology, formalin is utilized for inactivating viruses
in certain vaccines and producing toxoids from toxins.
l In the gaseous form, formaldehyde is expelled into a
closed chamber where it is a sterilizing agent for surgical
equipments, hospital gowns, and medical instruments.
l However, penetration is poor, and the surface must be
exposed to the gas for up to 12 h for effective sterilization.
l Instruments can be sterilized by placing them in a 20%
solution of formaldehyde in 70% alcohol for 18 h.
Formaldehyde, however, leaves a residue, and instru-
ments must be rinsed before use.
l It is used to preserve anatomical specimens and for
destroying anthrax spores in hair and wool.
l Under properly controlled conditions, satisfactory disin-
fection of clothing, bedding, furniture, and books can be
achieved.
l Its uses are limited due to irritating fumes and pungent
odour.
b. Glutaraldehyde
l Glutaraldehyde is an alkylating agent usually employed
as a 2% solution.
l It is a high-level disinfectant with broad-spectrum of
activity and has sporicidal action at room temperature.
l It is one of the most effective chemicals used for steril-
ization purposes. It destroys vegetative cells within
10–30 min and spores in 10 h.
l It is especially effective against tubercle bacilli, spores,
fungi, and viruses.
l To use it for sterilization purposes, materials have to be
pre-cleaned, immersed for 10 h, rinsed thoroughly with
sterile water, dried in a special cabinet with sterile air,
and stored in a sterile container.
l It can be safely used to treat corrugated rubber anaes-
thetic tubes and facemasks, plastic endotracheal tubes,
metal instruments, and polythene tubings.
iii. Chlorines
l Chlorine is available in a gaseous form and as both
organic and inorganic compound.
l They are widely used in municipal water supplies,
where they keep bacterial populations at low levels.
l The chloramines, such as chloramine-T, are organic
compounds that contain chlorine.
l They are valuable for general wound antisepsis and root
canal therapy.
l Chlorine is effective against a broad variety of organ-
isms, including most Gram-positive bacteria, Gram-
negative bacteria, viruses, fungi, and protozoa.
l However, they are not sporicidal.
l In microorganisms, the halogen is believed to cause the
release of atomic oxygen, which then combines with
and inactivates certain cytoplasmic proteins, such as
enzymes.
l Another theory is that chlorine changes the structure of
cell membranes, thus leading to leakage.
l Examples: Sodium hypochlorite and calcium hypochlorite.
iv. Quaternary Ammonium Compounds
l These are widely used as disinfectants and are good
cleansing agents.
Section | I  Topic Wise Solved Questions of Previous Years
l These compounds are bactericidal, virucidal, and fungi-
cidal, but are not sporicidal.
l Example: Benzalkonium chloride.
Uses
l They are low-level disinfectants.
l They are used for ordinary environmental sanitation of
surfaces like walls, floors, and furnitures.
l They can be used as both antiseptics and disinfectants.
v. Phenolic Compounds
l In case of hospital disinfection, phenols occupy a
prominent place.
l Most of phenolic germicides are used as surface disinfec-
tants, e.g., bedside tables, bed rails, and laboratory surfaces.
l They are low-level disinfectants and have corrosive property.
l Examples: Ortho-phenylphenol and ortho-benzyl-para-
chlorophenol.
Antiseptics
i. Alcohols
These are effective skin antiseptics and a valuable disinfec-
tant as already discussed above.
ii. Quaternary Ammonium Compounds
These can be used as both antiseptics and disinfectants.
iii. Iodophor Compounds
l For example: Povidone iodine
l They have broad spectrum of antiseptic action.
l They are formulated as 1% iodine solution.
Halogens
l The halogens are a group of highly reactive elements.
l Two halogens, chlorine and iodine, are commonly used
for disinfection.
Iodine
l Iodine atom is slightly larger than the chlorine atom,
and is more reactive and more germicidal. Iodine acts
by halogenating tyrosine portions of protein molecules.
l Tincture of iodine, a commonly used antiseptic for
wounds, consists of 2% iodine and sodium iodide dis-
solved in ethyl alcohol.
iv. Chlorhexidine
l It is active against a number of bacteria.
l It can be prepared in alcohol or with cetrimide 0.5% 1
70% of alcohol or chlorhexidine with cetrimide or 4%
5
solution with detergent can be used as preoperative
scrub.
v. Hexachlorophene Compounds
l They are less effective against Gram-negative organ-
isms, viruses, and spores.
l In patients, who are sensitive to iodine, they can be used
as surgical site preparation solution.
Hexachlorophene
l It is less effective against Gram negative organisms.
l It can be used as valuable surgical preparation solution
in patients sensitive to iodine compounds.
l It has toxic potential.
Formaldehyde gas
l Formaldehyde gas is widely employed for fumigation of
operation theatres and other rooms.
l The dose of formalin is decided based on the volume of
the room.
l After sealing the windows and other outlets, formalde-
hyde gas is generated by adding 150 g of KMnO4 to
280 mL of formalin for every 1000 cubic feet of room
volume.
l The reaction produces considerable heat, and so heat-
resistant vessels should be used.
l After starting generation of formaldehyde vapour, the
doors should be sealed and left unopened for 48 h.
l A fumigator may be used for this purpose, loaded with
water and about 40% formalin.
Beta-propiolactone (BPL)
l Beta-propiolactone is a condensation product of ketone
and formaldehyde with a boiling point of 163°C.
l It is said to be more efficient for fumigating purposes
than formaldehyde.
l It has a rapid biocide action, but unfortunately has car-
cinogenic activity.
Testing of Disinfectant
Rideal-Walker test
l In the Rideal-Walker test, suspensions containing equal
numbers of typhoid bacilli are submitted to the action of
varying concentrations of phenol and of the disinfectant
to be tested.
l The dilution of the test disinfectant, which sterilizes the
suspension in a given time, divided by the correspond-
ing dilution of phenol, is stated as the phenol coefficient
(phenol 5 I) of the disinfectant.
l This test does not reflect natural conditions as the bac-
teria, and the disinfectant react directly without any
organic matter being present.
l Modifications have therefore been suggested.
6 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Chick-Martin test
l In the Chick-Martin test, the disinfectant acts in the
presence of organic matter.
l Even this modification falls short of simulating natural
conditions.
l Various other modifications have been introduced, but
no test is entirely satisfactory.
Q. 2. Define asepsis. What precaution would you take to
maintain asepsis during a minor oral surgical procedure?
Ans.
Asepsis is a term used to describe the methods which pre-
vent contamination of wounds and other sites by ensuring
that only sterile things come in contact with them.
Or
It is the series of steps which are designed to prevent the
introduction of infection into a wound at the time of opera-
tion or when wounds are dressed.
Precautions taken to maintain asepsis during a minor oral
surgical procedure are described under following heads:
i. Operating room procedures
ii. Hand scrub techniques, and
iii. Preparation of the patient/Surgical site preparation.
i. Operating Room Procedures
l The primary goal of surgical team while in operating
room is preventing surgical site infection.
l The operation theatre should provide an environment
free from bacterial contamination, as far as possible.
l The ceiling, walls, and floor are regularly disinfected,
especially following a contaminated case. The operating
rooms should have two sets of doors.
l The access to operation theatre and the recovery area
is restricted to operation theatre personnel, who are
required in the operating room.
l A surgical head cap is used to cover the hair completely
and a mask is placed and tied over the mouth.
l The people should not walk barefeet in the operating
room. They should ware shoe coversor footwear made
of conductive material to prevent static electricity and
also electrocution from various electrical equipments
present in operating room.
l The various electrical devices in surrounding areas at-
tached to the patient in the operating room are the po-
tential sources of electrical shock. Hence, they should
be disinfected properly with care.
l Once the patient is prepared and draped, only those
personnel, who have scrubbed, gowned, and gloved,
may work at the surgical site.
l The backs of those who are gowned are considered
nonsterile, as also the areas below the waist. Hence, one
must be careful to keep the arms above the waist, when
not operating.
l Some of the hospitals have the detachable and steriliz-
able operating light handles, which can be adjusted by
the surgeon.
l In order to reduce bacterial counts in the air of the oper-
ating room, it may be sent through a filter or may be
passed through UV radiation device.
Fumigation of Operating Room
l The operation theatres are disinfected by fumigation.
l Fumigation can be achieved by the use of fumigators
as well as potassium permanganate reaction technique.
l Fumigation is initiated after setting up of the instrument
(STERI TRAX) in place.
l The fumigator is loaded with water and 40% formalin.
Fumigator is set for 30 min.
Parameters playing role in effective fumigation are as follows:
Relative humidity (RH)
l Relative humidity plays a major role in fumigation.
Higher the humidity, better is the disinfection.
l A minimum of about 70% is essential.
Temperature
l Evaporation of gaseous fumigant is more at the higher
temperature.
l Optimum temperature at around 30–40°C is required.
Formaldehyde Levels in the Air in the Operation Theatre
l The dose of formalin is usually decided by the size of
the room, e.g., as a general rule, about 180 mL is used
for a room of the size 1000 cubic feet.
Antiseptic Environment
l The principle is to minimize bacterial contamination in
the vicinity of operating table and the concept of zones
is useful, and must be employed.
i. Outer or general access zone, e.g., patient reception
area and general office.
ii. Clean or limited access zone, e.g, the area between
reception and general office, dispersal area, corri-
dors, and staff room.
iii. Restricted access zone, e.g., for those properly
clothed personnel engaged in operation theatre
activities, anaesthetic room, etc.
iv. Aseptic or operating zone, e.g., the operation theatre.
Airflow
l The air may be filtered, or allowed to flow past an ultra-
violet radiation device to reduce bacterial counts.
l The two types of airflow in operation theatres are:
(i) conventional and (ii) unidirectional.
Section | I  Topic Wise Solved Questions of Previous Years
l The normal turbulent airflow through theatre is necessary
to maintain humidity, temperature, and air circulation.
l Air is pumped into the room through filter and passed
out of vents in the periphery of operating room and does
not return to operating room.
ii. Hand Scrub Techniques
l Hand scrub is the first step towards aseptic surgical tech-
nique. The surgical team who participate in the operative
procedure needs to scrub and wear sterile gowns.
l It is the single most important and successful method of
controlling the spread of infection in hospital environment.
l The purpose of hand scrub is two-fold:
a. The first is to remove the superficial contaminants and
loose epithelium and is achieved by the mechanical
action of the brush.
b. The second purpose is to reduce bacterial count on
the skin.
l Many techniques of hand scrub have been
suggested.
l The sink that is used for scrubbing should be a
deep one and the taps are operated either with a
foot pedal or have a long handle which can be
operated with elbow.
l All jewellery should be removed before washing.
The nails should be checked for cleanliness. All
gross subnail contamination should be removed.
l The scrubbing may be done with the help of a
brush and antiseptic solution. The scrub brush
may be available as a disposable single use
packed and impregnated with soap solutions or
can be reusable with a soap dispenser.
l Nails should be scrubbed first thoroughly and the
arms are wetted few inches above the elbows.
l The scrubbing begins first at the tip of the fingers
and is continued along the skin surface of fingers,
and the interfinger webbing. Each finger should
be scrubbed separately on all surfaces.
l The scrubbing is continued until all the surfaces
of the hand are clean.
l Then the hands are cleaned along the forearms
and scrubbing is progressed towards the elbow,
extending above the elbow. In the similar manner,
the other hand is scrubbed
l A scrubbed area should not be touched again
because of the possibility of contamination from
an unsterile area.
l After the scrubbing of both the arms, excess of
soap is rinsed with arms elevated above the elbow
height to enable the water to drain from the fin-
gers progressing down the arms and the elbows.
They are not rubbed during the rinse.
l The surgeon approaches the scrub nurse for the
drying towel.
7
l The technique of drying begins at fingertips of
one hand and progresses down then, with the
opposite side of the towel. The other hand is dried
in a similar manner.
Hand Disinfectants
Certain proprietary preparations available for preoperative
washing of hands of surgeons and assistants, which have a
bactericidal effect and do not cause excessive drying of skin
are as follows:
i. Betadine scrub solution - contains 7.5% povidone-iodine.
ii. Hibiscrub and Phisiomed - contains 4% chlorhexidine
gluconate.
iii. Soap containing disinfectants like hexachlorophene.
iv. 70% Hibisol lotion (2.5% chlorhexidine in 70% alco-
hol) may also be applied as extra precaution.
Gloving
l Gloving is essential to protect both the surgeon and the
patient from blood-borne viruses and to prevent wound
becoming contaminated with the surgeon’s skin flora.
l Hand gloves help to protect the operator from infection
by bacteria and viruses from patient’s blood.
l There are two types of gloves:
i. Latex gloves
They are clear and the most common type of gloves.
ii. Brown milled rubber gloves
These are thinner than latex gloves and provide a better
tactile sensation. However, they are more fragile and
require more frequent changes during the operation.
The ‘hand to glove’ and ‘glove to glove’ technique of
donning the gloves should be employed. Double glov-
ing affords extra protection, but at the expense of re-
duced sensitivity and dexterity, and possible discomfort.
iii. Preparation of the Surgical Site
l Preferably just prior to scrubbing, the hair on the skin in
the area of surgical field is removed.
l A lubricating ointment should be applied to patient’s
eyes, and they are covered.
l The external auditory meatus is plugged and blocked, if
bleeding in the vicinity is anticipated.
l The scrubbing should begin in the centre of the site to
be prepared, and moved outwards concentrically, away
from the site of operation. This avoids contamination of
already scrubbed site of surgery.
Draping the Patient
l The purpose of draping a patient is to isolate the surgical
site from other parts of body that have not been prepared
for surgery, and also from nonsterile equipments.
l The patient’s head.
8 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Disposable Items
l Many disposable items are supplied in sterile packs by
their respective manufacturing companies.
l These are sterilized by methods such as gamma
radiation.
l The sterility of such products can be relied upon; if the
supplier is from a reputable manufacturer and the wrap-
per seal is not broken.
l The single-use surgical blades and suture needles are
recommended.
Other precautions taken are:
Preoperative gingival/periodontal care
l It is necessary that the patient should undergo preop-
erative scaling and the patient is given oral hygiene
instructions.
SHORT ESSAYS
Q. 1. Sterilization and disinfection in dental practice
Or
Physical methods of sterilization
Or
Describe briefly about autoclave.
Ans.
Sterilization
Sterilization is defined as a process by which an article,
surface, or medium is freed of all living microorganisms
including bacteria, fungi, spores, and viruses. Sterilization
is the complete destruction of agents that are capable of
causing infections, including spores.
Disinfection
l It is a process that eliminates many or all pathogenic micro-
organisms, except bacterial spores, on inanimate objects.
l Disinfection means the destruction or removal of all
pathogenic organisms except bacterial spores on inani-
mate objects by chemical disinfectants, e.g., aldehydes,
halogens, alcohols, surfactants. This is the destruction
of most microorganisms, but not all viable organisms,
particularly highly-resistant spores.
Various Physical Methods Used
in Sterilization are as Follows:
l Sunlight
l Drying
l Dry heat
l This helps in keeping the bacterial population to a
minimum.
Use of antimicrobial mouth rinse
l The use of an antimicrobial mouth rinse preoperatively
reduces the number of bacteria considerably.
l The action is a combination of mechanical removal and
antisepsis.
l The recommended rinse contains diguanides like
chlorhexidine.
Use of antibiotic prophylaxis
l The clinician relies on the use of antibiotics prophylacti-
cally to reduce the incidence of postoperative infection.
l Antibiotics should be avoided when there is no real and
specific indication as it causes bacterial resistance and
superinfection.
l Moist heat
l Filtration
l Radiation
l Ultrasonic vibration.
Autoclave
Mode of Action of an Autoclave
l The use of saturated steam under pressure is considered
the most practical and effective method of sterilization
l When steam comes in contact with the instrument to be
sterilized, it condenses almost instantly and releases
latent heat, which quickly denatures vital cell proteins.
l The condensed water provides a moist environment for
killing bacteria.
l Saturated steam under pressure is even more efficient
because increasing the pressure in a container of steam
increases the boiling point of water, so that new steam
entering a closed container gradually becomes hotter.
This is the principle of an autoclave.
l Moist heat destroys microorganisms by the irreversible
coagulation and denaturation of enzymes and structural
proteins. The presence of moisture therefore significantly
affects the coagulation temperature of proteins and the
temperature at which microorganisms are destroyed.
Uses
l Steam sterilization should be used whenever possible on
all critical and semi-critical items that are heat- and
moisture-resistant.
Advantages
l This is the most effective form of destruction of all
forms of microbial life.
l It is nontoxic, microbicidal, sporicidal, and rapidly
heats and penetrates fabrics.
Section | I  Topic Wise Solved Questions of Previous Years
l Temperature can be accurately controlled.
l Short sterilizing time. Heating and penetration of heat is
rapid.
l Most economical sterilization technique.
l No remnants of any toxic residue on the instruments
after sterilization.
Disadvantages
l Causes corrosion of delicate instruments.
l Unsuitable for sterilization of greases, oils, or powders.
l Rubber and plastic goods may get damaged or melt.
l Autoclave should be loaded properly; otherwise, it may
not be effective.
Effective sterilization in an autoclave depends upon
l Good cleaning of the instruments with soap and running
water to remove all blood and debris.
l Direct flow of steam to all parts of the sterilizer, and
instruments should be in contact with the steam.
l Periodic monitoring of the sterilizer to check its effec-
tiveness.
Sterilization monitoring
l The steam cycle is monitored by three methods: physical,
chemical, and biological monitors.
Physical monitoring
l Routine observation of dials and gauges indicating time,
temperature, and pressure.
Chemical monitoring
l By using Browns tubes; type I for autoclaves. The colour
changes once the correct time and temperature are reached.
Biological monitoring
l The effectiveness of steam sterilization is monitored
with a biological indicator containing spores of Geoba-
cillus stearothermophilus (formerly known as Bacillus
stearothermophilus) and autoclave indicator tape.
Q. 2. Hot air oven
Ans.
Hot Air Oven or Dry Heat Sterilizers
l This method should be used only for materials that
might be damaged by moist heat or that are impenetra-
ble to moist heat (e.g., powders, petroleum products,
sharp instruments).
l Sterilization is for 12 min at 190°C.
There are two types of dry heat sterilizers:
a. The Static-Air Type
l This is referred to as the oven-type sterilizer as heating
coils in the bottom of the unit cause the hot air to rise
inside the chamber via gravity convection.
9
l Time taken for sterilization is 60–120 min at a tempera-
ture of 160°C.
b. The Forced-Air Type
l Also called the mechanical convection sterilizer.
l It is equipped with a motor-driven blower that circulates
heated air throughout the chamber at a high velocity,
permitting a more rapid transfer of energy from the air
to the instruments.
Another method of dry heat sterilization uses a heat transfer
device.
l This is used for sterilizing endodontic instruments, e.g.,
glass bead sterilizer.
l Small diameter glass beads, salt, or even molten metal
may be used as a head transfer device.
Advantages of Dry Heat Sterilizers Include
l It is nontoxic and does not harm the environment.
l A dry heat cabinet is easy to install and has relatively
low operating costs.
l It is noncorrosive for metal and sharp instruments.
Disadvantages of Dry Heat Sterilizers Include
l Slow rate of heat penetration and microbial killing.
l Time-consuming method as the sterilization process has
to be followed by a cooling process.
l High temperatures are not suitable for most materials
like plastics and rubbers.
Q. 3. Cross infection in dental office
Ans.
l Cross infection is defined as the transmission of infec-
tious agents among patients and staff within a clinical
environment.
l In dentistry, the sources of infection may constitute:
i. Patients suffering from infectious diseases,
ii. Patients, who are in the prodromal stage of certain
infections, and
iii. Healthy carriers of pathogens.
Pathways of cross infection
l There are six common pathways
i. Patient to practitioner,
ii. Practitioner to patient,
iii. Patient to patient,
iv. Clinic to community,
v. Clinic to practitioner’s family, and
vi. Community to patients.
The sources of infection are described in detail below:
Patients Suffering from Acute Illnesses
l The likely source of infection is usually a person, who is
in the prodromal phase of an infection attending the clinic.
10 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The patient at this stage may appear healthy, but the
saliva and blood may be infectious.
l The diseases which can spread easily in this manner are
viral infections, e.g., measles, mumps, and chickenpox.
Healthy Carriers
l They are important factors in the transmission of
disease and can be classified as follows:
a. Convalescent Carriers
l In this stage, the patient suffers an acute illness and
apparently recovers.
l However, the blood and secretions serve as persistent
reservoirs of the infective organisms.
l Such individuals can be identified on the basis of past
history of infection.
Asymptomatic Carriers
l These persons may have a subclinical infection; and are
unaware of it.
l They give no history of past infection, hence cannot be
diagnosed easily.
l These individuals may carry infective organisms in saliva
and blood. The classic e.g., is hepatitis B virus infection.
l Hepatitis B virus infection may manifest with or without
symptoms, and the clinician may be faced with either
convalescent or asymptomatic carriers of such infection.
Routes of transmission
Transmission of infection within a dental clinic may occur
via several routes:
i. Direct contact of tissues with infective biological fluids
such as blood and oral secretions.
SHORT NOTES
Q. 1. Define sterilization and disinfection.
Ans.
Sterilization
Sterilization is defined as a process by which an article,
surface, or medium is freed of all living microorganisms
including bacteria, fungi, spores, and viruses. Sterilization
is the complete destruction of agents that are capable of
causing infections, including spores.
Disinfection
l It is a process that eliminates many or all pathogenic micro-
organisms, except bacterial spores, on inanimate objects.
ii. Indirect contact with contaminated instruments, equip-
ments, or environmental surfaces.
iii. Inhalation of aerosolized infective droplets/particles.
iv. Direct inoculation into cuts and abrasions of unpro-
tected skin or mucosa via contaminated sharps or
instruments.
Infection through any of these routes requires that all three
of the following conditions be present, ‘the chain of infec-
tion’: i.e., pathogen, susceptible host, and microorganism.
Pathogen
l Sufficient infectivity and sufficient dose.
l Exposure portal through which the pathogen may enter
the host.
Susceptible Host
l Dental patients and dental healthcare workers (DHCWs)
may be exposed to a variety of microorganisms via
blood or oral or respiratory secretions.
Microorganisms
l These microorganisms may include the following:
i. Bacteria: Staphylococci, streptococci, M. tuberculo-
sis, and
ii. Viruses: Herpes simplex virus types 1 and 2, cyto-
megalovirus, hepatitis B virus (HBV), hepatitis C
virus (HCV), human immunodeficiency virus (HIV),
and
iii. Other bacteria and viruses, specifically those associ-
ated with upper respiratory tract infections.
l Disinfection means the destruction or removal of all
pathogenic organisms except bacterial spores on inani-
mate objects by chemical disinfectants, e.g., aldehydes,
halogens, alcohols, surfactants. This is the destruction
of most microorganisms, but not all viable organisms,
particularly highly resistant spores.
Q. 2. Principle of autoclave
Ans.
Principle of an Autoclave
l The use of saturated steam under pressure is considered
the most practical and effective method of sterilization.
Autoclave works on pressure cooker principle.
Section | I  Topic Wise Solved Questions of Previous Years 11

l Saturated steam under pressure is more efficient be- Physical Agents

cause increasing the pressure in a container of steam
i. Sunlight
increases the boiling point of water, so that new steam
ii. Drying
entering a closed container gradually becomes hotter.
iii. Dry heat
This is the principle of an autoclave.
iv. Moist heat
l Moist heat destroys microorganisms by the irreversible
v. Filtration
coagulation and denaturation of enzymes and structural
vi. Radiation
proteins. The presence of moisture therefore signifi-
vii. Ultrasonic vibration
cantly affects the coagulation temperature of proteins
and the temperature at which microorganisms are
destroyed. Chemical Agents
Q. 3. Cidex i. Acids
Or ii. Alkalis
iii. Salts
Cold sterilization iv. Halogens
Ans. v. Oxidizing agents
l The Cidex is gluteraldehyde 2% (C5H8O2) and it is an vi. Reducing agents
high-level disinfectant. vii. Formaldehyde
l It has broad-spectrum activity and is sporicidal. viii. Phenol, etc.
l It has a shelf life of 14 days.

l The articles to be sterilized are washed and dried and

Q. 5. Define the terms ‘Antiseptic’ and ‘Disinfectant’.
placed in a tray totally submerged in the solution for Ans.
minimum 6–8 h.
l Before using, instruments should be thoroughly washed

with saline otherwise they will cause severe tissue reaction.
Advantages
l Long activated shelf life of around 14 days.
l Noncorrosive.
l It is active in the presence of organic debris also.
l Rubber and plastic goods may also be sterilized without
any damage.
Antiseptic
l Antiseptic is the chemical that is applied to living tis-
sues such as mucous membrane to reduce the number
of microorganisms present, through inhibition of their
activity or destruction. Antiseptics are germicides
applied to living tissue and skin; in general, antisep-
tics are used only on the skin and not for surface
disinfection.

Disadvantages Disinfectant
l Disinfectant is a chemical used on nonvital, inanimate
l Causes severe tissue irritation and is also allergenic.
objects to kill surface vegetative pathogenic organisms,
l Solution needs to be changed frequently as its activated
but not necessarily spore forms or viruses.
time is completed.
l Disinfectants are not used for skin antisepsis because
l Cannot be used as antiseptic.
they can injure skin and other tissues.
Q. 4. List out few physical and chemical agents used for l If the object is lifeless, such as a tabletop, the chemical
sterilization. agent is known as a disinfectant.
l However, if the object is living, such as a tissue of the
Ans.
human body, the chemical is an antiseptic. Antiseptics
Various physical and chemical agents used for sterilization and disinfectants are usually bactericidal, but occasion-
are as follows: ally they may be bacteriostatic.
12 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
General Principles of Surgery
LONG ESSAYS
Q. 1. Cephalometry used in oral surgery.
Ans.
l Clinical assessment, dental model evaluation, and ceph-
alometric analysis must be used to establish an accurate
diagnosis of a dentofacial deformity.
l Cephalometric analysis of the lateral radiograph is a
two-dimensionaldiagnostic aid.
Salzman (1964) has proved that cephalometrics can
provide valuable information from both clinical and re-
search bases by the following:
l Establishing two-dimensional relationships of craniofa-
cial components.
l Classifying skeletal and dental abnormalities with
respect to cranial base, skeletal pattern, interarch and
intraarch dental relationships, and soft tissue profile.
l Analysing growth and development responsible for den-
tofacial pattern, either for configuration of cranial base,
congenital abnormalities, pathologic conditions, or the most valuable diagnostic, treatment, and follow-up
facial asymmetry.
l For orthodontic treatment planning and/or treatment
planning of surgical procedures.
l Analysing changes after treatment and effectiveness of
different treatment modalities.
l Determining dentofacial growth changes following
treatment.
l Predicting hard and soft tissue contours before initiation
of treatment.
l Diagnostic cephalometric radiographs should be taken,
after patient is placed in cephalometer with head l The proposed ‘10’ measurement analysis for orthogna-
adjusted in natural head position; and sagittal plane of
the patient’s head should be parallel with film.
l Lips should be in repose and teeth should be placed
in centric occlusion. Soft tissues must be reproduced l When the measurements are colour enhanced by using
on the cephalometric film without sacrificing details of
osseous structures.
PA Cephalometric Analysis
l Posteroanterior (PA) cephalometric analysis is mainly
used for assessing asymmetry of the facial skeleton.
l First, a vertical line is drawn joining the midline
of the nose and the chin and the dental arch- midsagittal
line.
l On either side of midsagittal line, a second vertical line
is drawn passing through the zygomatic arch.
Topic 2
l A third vertical line is drawn passing through the angle
of the mandible on either side of midsagittal line.
l These lines will help to evaluate deviation, asymmetry,
or disproportion of facial skeleton; and, comparison can
be made with the normal side measurements.
l Horizontal lines are drawn along zygomatic plane,
occlusal plane, infraorbital plane, plane of the lower
border of the mandible, etc., to assess deviation in rela-
tion to horizontal plane.
‘Quick Ceph’ Dentofacial Planner for
Orthognathic Surgery
l Cephalometrics is still imperfectly understood as a
clinical tool.
l Since proper pretreatment assessment can mean the dif-
ference between successful and unsuccessful treatment.
l This ‘Quick Ceph’ measurement analysis will give
information in a matter of minutes for evaluating an
orthognathic case.
l The entire generation of orthognathic, oral, and maxil-
lofacial surgeons; and, plastic surgeons have been fed
on a surplus of cephalometrics, right from its invention
by Broadbent.
l Many a times, a clinically useful information may be
hidden in a maze of cephalometric analysis like Down’s,
Steiner’s, Tweed’s, Jarabak’s, Ricketts’s and so many
others.
thic surgery will give a quick assessment as the points
and measurements are also simple to locate, identify,
and trace.
different colour pens and pencils, it can also be easily
understood by patients.
Q. 2. Describe uses of lasers in maxillofacial surgery.
Ans.
l The word LASER stands for ‘Light Amplification by
Stimulated Emission of Radiation’.
l Lasers deliver energy in the form of light, which can be
either continuous or intermittent.
l Lasers are very specific in regard to the wavelength
produced. No measurable effect isseen beyond the in-
tended target site.
Section | I  Topic Wise Solved Questions of Previous Years
l The different types of lasers are the carbon dioxide laser,
the Nd:YAG (neodymium or yttrium-aluminium-garnet)
laser, and the argon laser. Each one works in a different
manner and may be used for different treatment options.
Uses of Lasers in Maxillofacial Surgery
l The therapeutic lasers offer improved possibilities in the
treatment planning of wound healing, inflammation,
and oedema.
l Patients undergoing radiotherapy and/or chemoradio-
therapy suffer gravely from the mucositis induced by
the therapy. Nutrition is troublesome and therapy regi-
men may have to be suboptimal for this reason.
l Laser therapy can be even used to reduce mucositis by
mucosal irradiation prior to radiotherapy/chemotherapy.
l Pain is the most frequent complaint among patients.
Laser therapy can reduce or eliminate pain of various
origins.
l Following surgery post-operatively, discomfort can be
substantially reduced by irradiating the operated area
before anaesthesia wears off.
l Laser therapy has been used to eliminate or reduce
paraesthesia that may occur as a result of the surgery,
particularly in the mandibular region. Any such compli-
cations can be reduced or eliminated by laser therapy.
l Many cases of sinusitis are ‘dental origin’. A great num-
ber of patients arrive in the dental office with sinusitis
of a viral or a bacterial background. In most cases, laser
therapy will lead to a fast reduction of the symptoms
making the scheduled treatment easier.
l For TMJ arthritic cases, the treatment is concentrated to the
joint area’; and, in myogenic cases, the muscular insertions
and trigger points are treated. In such cases, laser therapy
should be used always in combination with conventional
treatment to improve the outcome of the treatment.
l The patients suffering from Meniere’s disease (tinnitus/
vertigo) have a significantly increased prevalence of
problems in the masticatory, neck, and trapezius mus-
cles; in addition, problems in the cervical spine, particu-
larly in the transverse processes of the atlas and the axis.
l Laser therapy can be successfully used to promote mus-
cular relaxation and pain relief in these cases.
l Relaxation of the tension in these muscles as well as
occlusal stabilization procedures will reduce or elimi-
nate the symptoms of tinnitus and vertigo in this group
of patients.
l It can also be used in periodontal surgical procedures
like recontouring or reshaping gums, removing the bac-
teria in periodontal pockets to promote healing, to ex-
cise tumours, to help prevent blood loss by sealing small
blood vessels, and to treat some skin conditions like
removal or improve warts, moles, tattoos, birthmarks,
scars, and wrinkles.
13
Q. 3. Explain suturing material for a facial wound and
methods of suturing.
Or
Suture techniques used in oral surgery.
Or
Suturing materials.
Ans.
Suture materials are classified as follows:
A. Based on the Degradation of the Material
within the Tissues
i. Absorbable
ii. Nonabsorbable.
i. Absorbable suture materials
Examples: Catgut, polyglycolic acid (dexon), etc.
l Lose their strength within the tissues and usually
degrade within 60 days. This usually coincides
with the approximate time taken for complete
wound maturation.
l They undergo enzymatic degradation by natural
enzymes present within the body.
Uses
l Deeper layer suturing and suturing of wounds in
patients, who are unable to come for suture removal.
ii. Nonabsorbable suture materials
Examples: Silk, nylon, etc.
l These materials are usually not degraded by the
body.
l Suture removal is required at the end of the heal-
ing phase, i.e., usually between 5–7 days.
B. Based on the Source of the Materials
i. Natural, e.g., silk
ii. Synthetic, e.g., polyglycolic acid
iii. Metallic, e.g., stainless steel
Both absorbable and nonabsorbable materials may be
derived from natural or synthetic sources.
C. Based on the Number of Filaments in the
Suture Material
i. Monofilament
ii. Multifilament
iii. Pseudomonofilament.
i. Monofilament suture materials
l These materials are made of a single strand.
l They have the advantage of least capillary effect
thereby they do not absorb tissue fluids and thus do
not swell. This decreases the chances of infection.
14 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Example: Absorbable: Monocryl
Nonabsorbable: Polyamide, polyester, etc.
Disadvantages
l Main disadvantage of this material is its ‘mem-
ory effect’ due to which the material tends to
come back to its original position. This property
tends to loosen the knot. Multiple throws may be
required to stabilize the knot.
ii. Multifilament suture materials
l These materials are made of multiple thin strands
of the suture material which are eitherrolled,
twisted, or braided together to form a uniform
strand of thread.
l These materials are usually easier to handle and
have good knot tying properties.
l The knot once placed, usually does not slip.
l They are preferred for use in those areas where
good strength is required to hold the wound
edges together.
l As the materials are multifilamentous, they have
more capillary action, whereby tissue fluids and
inflammatory exudates seep through these mul-
tiple filaments harbouring more microorganisms
and forming a source of infection.
Example: Black braided silk.
iii. Pseudomonofilament suture materials
l These materials are microscopically made of nu-
merous strands of fibre which have been pro-
cessed by twisting, grinding, and finally polish-
ing, to give them a monofilamentous appearance.
Example: Catgut.
Sizes of Suture Materials
l Based on the diameter of the thread in cross section,
suture materials are labelled from 1-0 to 10-0.
l With an increase in the number of zeros, the diameter of
the material reduces. Therefore, the diameter of an 8-0
material is less than the diameter of a 3-0 material.
l 10-0: Is generally used for microsurgery repair.
l 5-0, 6-0: Is used for suturing of skin on the face.
l 4-0, 5-0: Is used for suturing in the extremities.
l 3-0: Is used in scalp sutures.
l 3-0, 4-0: Is most commonly used in most oral surgical
procedures.
Techniques of Suturing
i. Simple Interrupted Sutures
l This is the most common and universally used type of
suturing technique.
Indications
l Closure of oral mucosal incisions/lacerations.
l Closure of skin wounds.
Technique
l The needle is held at 2/3rd the distance from the tip of
the needle with a needle holder andpassed through one
side of the flap perpendicular to the tissues and brought
out along the curvature of the needle.
l It is then passed through the other flap at the same dis-
tance from the edge of the flap and also at the same
depth.
l It is brought out of the flap along with the suture mate-
rial, till about 3–4 cm of the free end of the suture mate-
rial is left.
l The needle end of the material is kept longer than the
free end.
l The needle is held in the left hand and wound around
the needle holder once or twice depending on the type
of knot.
l The free end of the suture material is grasped with the
beaks of the needle holder.
l The material that is wound around the needle holder is
made to slip over the beaks by slowly pulling on the
needle end of the suture material.
l The free end of the suture material is pulled minimally
as it will result in wastage of the suture material.
l The knot is stabilized such that it comes to one side of
the flap. It should not rest along the edges of the
wound.
l To complete the knot, the needle is held in the left
hand and the suture material is rolled around the beaks
of the needle holder in the opposite direction. Again,
the free end of the suture material is grasped and the
suture material is glided over this free end to stabilize
the knot. This may be done one more time to get a
stable knot.
l Both the free end and the needle end of the suture mate-
rial are held tight, so that the assistant trims it with a
scissors leaving about 3–4 mm.
Advantages of Interrupted Sutures
l Allows equal distribution of tension along the wound.
l If one of the sutures gets loose, it does not affect the
remaining sutures. It can be replaced separately.
l In case of oedema or haematoma after a surgical proce-
dure, if the tension on the wound edges is too much, one
or two sutures may be removed without disturbing the
other sutures.
Disadvantage of Interrupted Sutures
l Time consuming.
ii. Continuous Sutures
This type of suture may be of two types:
a. Continuous sutures without locking.
b. Continuous sutures with locking (blanket stitch).
Section | I  Topic Wise Solved Questions of Previous Years
a. Continuous Sutures without Locking
Indications
l Where large wounds require to be sutured.
l Intraorally when full quadrant alveoloplasty is done.
Technique
l First, suture should be placed like an interrupted suture.
But, while cutting the suture ends, only the free ends are
cut; leaving the suture material with the needle behind.
l The needle is then passed through the flaps of the
wound alternately to get continuous oblique sutures all
along the length of the wound.
l At the end of the wound, the knot is placed.
Advantages
l Even distribution of tension along the wound margin.
l Enables water-tight closure of the wound.
l It is a much faster technique than interrupted sutures.
Disadvantages
l If one suture gets loose, all the other sutures also get loose.
l It is not possible to remove individual sutures as in case
of oedema/haematoma release.
b. Continuous Sutures with Locking
Indications
l In case of large wounds to be sutured.
l In case of full quadrant alveoloplasty.
Technique
l First, a simple interrupted suture is placed. Then similar
to the suturing technique described above, it is passed
through both the flaps. The needle is then passed
through the loop made by the suture material.
l The assistant is made to follow the suture by holding the
suture material close to the tissues where the needle last
passed through the loop.
l Each time the needle is made to pass through the flaps
and under the suture loop, the assistant should hold the
suture material tightly close to the tissues to prevent the
suture material from slipping and becoming loose.
l At the end of the suture line, the knot is made with the
suture loop and the needle end of the suture material.
Advantages
l Even distribution of tension along wound margins.
l Good water-tight closure, especially for intraoral
wounds.
Disadvantages
l Cumbersome technique.
l Requires assistance.
l Not possible to remove individual sutures.
15
iii. Mattress Sutures
l This type of suturing technique provides wound edge
eversion. It is observed that wounds tend to contract as
they heal, so the edges are everted during closure, and
they approximate with less prominent scarring.
l These are of two types:
a. Horizontal mattress.
b. Vertical mattress.
Indications
l In wounds, where wound eversion is desirable during
closure.
l Wounds on the abdomen, hip, and sometimes neck
incisions.
l Where wounds are under tension and need to be brought
together over a distance.
l Closure in those areas where the wound edges tend to
roll inwards.
a. Horizontal Mattress Sutures
Indications
l Used specifically in those areas, where there is an
underlying bony defect or a deficiency. Examples:
l Closure of oroantral fistula.
l Closure of mucosa over a cystic cavity after enu-
cleation.
l Used for closure over an extraction wound.
l Closure of scalp wound.
Technique
l The needle is first passed through one flap and then at
the same vertical level through the other flap similar to
the placing of an interrupted suture, but the knot is not
placed. The needle is then passed at a distance 3–4 mm
parallel horizontally to where the needle was passed
through the second flap.
l It is then passed through the first flap at the same verti-
cal level as the last bite.
l In this way, the needle comes back through the same
flap where it started at a distance of 3–4 mm from the
entry point.
l The knot is placed and stabilized on that side.
Disadvantages
l Since it runs parallel to the flap edges, it is likely to
compromise the blood supply of the wound edges.
l Be careful not to tighten the knot too much or there may
be necrosis of the wound edges.
Advantages
l It causes eversion of the wound edges and it allows
more amount of raw tissue to be in contact.
l Causes even distribution of tension along the wound.
16 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
b. Vertical Mattress Suture
Indications
l Used for the closure of skin wounds.
l In those areas where the skin edges tend to invert.
Technique
l It is used by the ‘far-far, near-near’ system, where the
needle is first passed far away from the wound edges
and then nearer or at a more superficial level.
l The needle is passed through one wound edge taking a
deep bite of tissue almost 4–8 mm from the wound
edge. This type of suturing requires that the wound
edges are well undermined prior to suturing.
l It is then passed through to the other edge at the same
depth and brought out. A knot is not placed as yet.
SHORT ESSAYS
Q. 1. Indications of bone grafts in maxillofacial surgery.
Ans.
Autografts and processed homografts have been used ex-
tensively in oral surgery.
Indications of bone grafts in maxillofacial surgery
i. To fill the defective bony cavities following the enu-
cleation of large cysts of the jaws, where the bony
cavities are unable to heal by regeneration. Autoge-
nous and inorganic bone grafts are used.
ii. Similarly, alveolar bone grafting in alveolar clefts is
also widely practiced.
iii. In preprosthetic procedures, to obtain an absolute in-
crease in the height of the alveolar ridge.
iv. To treat nonunited fractures, the bone ends are fresh-
ened. In the process, the consequent bony deficiency
is filled by placing the bone graft, so that it will re-
store the continuity ofbone and will hasten the bony
union.
v. In cases of neoplasms, resection of the pathology re-
sults in a defect. Bone graft is utilized to replace the
excised segments of bone, thereby restoring the conti-
nuity of the jaw bone.
vi. In osteotomy procedures, to correct the jaw deformi-
ties, e.g., hypoplasia, the interfragmentary gap can be
bridged by the bone graft.
vii. In reconstructive surgery of the facial bony deformi-
ties, the bone grafts can be used as onlay grafts to re-
contour the bone. Another example is reconstruction
of the floor of the orbit in blowout fractures.
viii. In case of ankylosis of the temporomandibular joint,
surgery isperformed to release the ankylosis; and, the
joint can be reconstructed by providing a costochon-
dral graft to serve as a condyle.
l The needle is then turned around and passed backward
through the second flap at a level more superficial, i.e.,
closer to the wound edges (1–2 mm away).
l The needle is then passed through the first flap at the
same superficial level and brought out. In this way, both
edges’s suture material are on the same side.
l The knot is then placed and stabilized on the side where
the suturing first began.
Advantages
l It causes good eversion of the wound margins bring-
ing greater amount of raw tissue surface into ap-
proximation.
l Since, it runs vertical to the blood supply of the wound
edges, suturing in this manner is not likely to compro-
mise the vascularity of the wound edges.
The success of bone grafting depend on
l Choice of the graft.
l Infection.
l Recipient site.
l Contact between the graft and recipient bone ends.
Q. 2. Magnetic resonance imaging.
Ans.
l For MRI, the patient is placed in a machine which is
basically a large magnet, the protons then act as small
bar magnets and point up or down with a slightly greater
number pointing up.
l Across the magnetic field, when a radiofrequency pulse is
directed, the protons flip and align themselves along it. When
the pulse ceases, the protons relax, and they realign them-
selves along the main magnetic field, thus emitting a signal.
l The hydrogen atom is commonly used as it is abun-
dantly found in the body.
l The values known as Tl and T2 are used to measure the
time taken for these protons to relax.
l A variety of pulse sequences can be used to give differ-
ent information about the tissues.
l MRI gives very accurate soft tissue details.
l It is not very useful to study bony details, as the protons
are held firmly within the bone.
l Bone outline is clearly visible. Imaging of TMJ and
facial soft tissues can best be done with an MRI.
General uses of MRI in maxillofacial region
l It is used when more clarity is required for soft tissue
lesions.
l It is useful in case of internal derangement of TMJ,
where the position of the disc and condyle can be visu-
alized in open mouth and close mouth position.
l Intracranial lesions can be seen clearly.
Section | I  Topic Wise Solved Questions of Previous Years
Q. 3. Cephalometry.
Ans.
l Clinical assessment, dental model evaluation, and ceph-
alometric analysis must be used to establish an accurate
diagnosis of a dentofacial deformity.
l Cephalometric analysis of the lateral radiograph is a
two-dimensional diagnostic aid.
Salzman (1964) has proved that cephalometrics can
provide valuable information from both clinical and re-
search bases by the following:
l Establishing two-dimensional relationships of craniofa-
cial components.
l To classify skeletal and dental abnormalities with
respect to cranial base, skeletal pattern, interarch and
intraarch dental relationships, and soft tissue profile.
l Analyzing growth and development responsible for
dentofacial pattern, either for configuration of cranial
base, congenital abnormalities, pathologic conditions,
or facial asymmetry.
l For orthodontic treatment planning and/or treatment
planning of surgical procedures.
l Analyzing changes after treatment and effectiveness of
different treatment modalities.
l Determining dentofacial growth changes following
treatment.
l Predicting hard and soft tissue contours before initiation
of treatment.
l Diagnostic cephalometric radiographs should be taken
after patient is placed in cephalometer with head l A smear is prepared by spreading samples of fluid and
adjusted in natural head position, sagittal plane of the
patient’s head should be parallel with film.
l Lips should be in repose and teeth should be placed
in centric occlusion. Soft tissues must be reproduced with a Bunsen burner.
on the cephalometric film without sacrificing details of
osseous structures.
Q. 4. Indications and techniques of needle biopsy.
Or
Define biopsy and name the various biopsy techniques.
Ans.
l Biopsy can be defined as a diagnostic procedure which
is done by removing a sample of tissue from patient.
Various Types of Biopsy
i. Aspiration biopsy.
ii. Cone biopsy.
iii. Core needle biopsy.
iv. Endoscopic method of biopsy.
v. Suction-assisted core biopsy.
vi. Punch biopsy.
17
vii. Surface biopsy.
viii. Excisional biopsy.
Indications
l For assessment of any unexplained oral mucosal abnor-
malities that persist despite treatment or the removal of
local irritants.
l Lesions that interfere with oral function such as fibrous
hyperplasia and osseous lumps.
l Lesions of unclear aetiology, particulary when associ-
ated with pain, paraesthesia, or anaesthesia.
l Radiolucent or radiopaque osseous lesions.
Technique
l First, the site from where the biopsy sample is to be col-
lected should be cleansed and then anesthetized with
local anaesthesia.
l The needle is passed into the region of abnormality, e.g.,
a cyst or a tumour and a vacuum is created with the
syringe and multiple in and out needle motions are per-
formed.
l The cells to be sampled are sucked into the syringe
through the fine needle. Usually three or four samples
are collected.
l Prior to microscopic examination, the sample of fluid and
cells is centrifuged at high speed and then a small amount
is placed on a slide and covered with a plastic slip.
cells onto glass slides.The specimens are then fixed and
stained to improve viewing.
l The preservation is often performed by heating the slide
Q. 4. Exfoliative cytology.
Ans.
l Exfoliative cytology is the study of cells which exfoliate
or abrade from the body surfaces.
l Exfoliative cytology is used for the diagnosis of the oral
mucosal lesion.
Technique
l Clean the surface of the oral lesion of debris and mucin,
and then vigorously scraping the entire surface of the
lesion several times with a metal cement spatula, a
moistened tongue blade, or a cytobrush.
l The collected material is then quickly spread evenly
over a microscopic slide and fixed immediately before
the smear dries.
l The fixative may be either commercial preparations
such as Spray-cyte, 95% alcohol, or equal parts of alco-
hol and ether.
18 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l After the slide is flooded with fixative, it should be
allowed to stand for 30 min to air-dry.
l Slides are never flame-fixed as bacteriologic smears.
l It is essential that the procedure is repeated and a second
smear be prepared for submission to the cytologist.
l In preparing duplicate slide, separate scraping should be
done.
The report by the cytologists will fall in following five classes:
i. Class I (Normal): Indicates that only normal cells were
observed.
ii. Class II (Atypical): Indicates the presence of minor
atypia, but no evidence of malignant changes.
iii. Class III (Indeterminate): This is an in-between cytol-
ogy that separate cancer from noncancer diagnosis. Round Bodied Needle
The cells display wider atypia that may be suggestive
of cancer, but are not clear-cut and may represent l
precancerous lesion or carcinoma in situ. Biopsy is
recommended.
iv. Class IV (Suggestive of cancer): A few cells with ma-
lignant characteristic. Biopsy is mandatory.
v. Class V (Positive for cancer): Cells that are obviously
malignant. Biopsy is mandatory.
Q. 5. Needles used in suturing.
Ans.
Suturing needles are made of either stainless steel or carbon
steel.
Classification of Suturing Needles
i. Based on design
l Straight.
l Curved.
ii. Based on cross section
l Round body (tapering).
l Cutting edge: Conventional cutting or reverse cutting.
iii. Based on how material connects to needle
l Eyed needle.
l Swaged needle.
i. Based on the Needle Design
Straight Needles
l These can be either round bodied (tapered) or cutting
needles.
Uses
l Used for suturing in the abdominal region.
l In the maxillofacial region, its use is limited.
l In the absence of an awl, it may be used for circumman-
dibular wiring.
l It can also be used for placing a cheek stitch for the
stabilization of a cheek retractor for intraoral surgical
procedures.
Curved Needles
l Most commonly used in the maxillofacial region.
l These can further be classified based on the curvature
into 1/4th circle, 3/4th circle, 3/8th circle, 1/2 circle
(most commonly used in oral surgery).
Use
l This type of needle may be used for suturing extraoral
incisions on the skin and intraoral mucosal incisions/
lacerations.
ii. Based on the Cross Section
The cross section of this type of needle is round. It
slowly tapers to a point and so it is called a tapered
needle.
Use
l A round body needle is generally preferred for the clo-
sure of all intraoral mucosal wounds as it is gentle on
thin and fragile mucosal tissues.
l It is also used for the suturing of fascia and muscle,
which may tear through if a cutting needle is used.
Disadvantage
l Due to its design, it is more difficult to use.
Cutting Needle
l In cross section, this type of needle has a triangular
body.
l Based on the position of the apex of the triangle, it is
further classified into:
l Conventional cutting needle.
l Reverse cutting needle.
Conventional cutting needle
l This type of needle has the apex facing towards the in-
ner aspect of the curvature of the needle.
Disadvantage
l It may cut through if used on fragile tissue such as
mucosa.
Reverse cutting needle
l In this type of needle, the apex is towards the outer as-
pect of the curvature with the inner part of the needle
being flat.
Uses
l It is used in the suturing of skin wounds and in subcu-
ticular suturing.
Section | I  Topic Wise Solved Questions of Previous Years 19

iii. Based on How the Suture Material l Traumatic entry through the tissues as two strands of
thread have to go through it.
Connects to the Needle
l Chances of slipping out of the thread from the needle
l Eyed needle. during suturing.
l Swaged needle.
Swaged Needle
Eyed Needle
l It is also called atraumatic needle.
l It is also called as traumatic needle. It has a hole or eye l It is available in ready-made sterile packs, where the
which may be round, oval, or square at the broader end manufacturer attaches the suture material into the hol-
of the needle. low of the needle body. This type of needle has no eye.
l The suture material is threaded into this hole of the

needle. Such needles can be sterilized and reused a few Advantages

times till they lose their sharpness. They are thus a l Atraumatic.
cheaper alternative. l Sterile needle for each procedure.

l Single-use sharp needle for each procedure.

Disadvantages
l Multiple uses make it blunt and traumatic to the tissues. Disadvantage
l Chances of infection, if not adequately sterilized. l Needle and material to be discarded after each use.

SHORT NOTES
Q. 1. Incisional biopsy. The structures seen in an IOPA (Intraoral periapical radio-
Ans. graph) are:
l The tooth.
l Some lesions are too large to excise initially without
l The periapical structures.
having established a diagnosis, or are of such a nature
l Lamina dura.
that excision would be inadvisable. In such instance, a
l The alveolar bone surrounding the tooth.
small piece is removed for examination. This is termed
l Inferior dental canal.
as an incisional or diagnostic biopsy.
l Maxillary antrum outline in relation to upper molars.
l It is most useful in dealing with large lesions in which
l Outline of nasal cavity.
the operator suspects may be treated by some methods
other than surgery once the diagnosis is made, or the Q. 4. Risdon’s incision.
diagnosis will determine whether the treatment should
Ans.
be conservative or radical.
l The incision is taken about 1 cm below the angle of the
l The biopsy should include surrounding normal
mandible.
tissue with adequate depth of underlying connective
l It extends forward, parallel to the lower border of the
tissue.
mandible and curves backward slightly behind the angle.
Q. 2. Name few skin grafts. l Approach to neck of condyle and ramus is achieved by

sharply incising through the pterygomasseteric sling

Ans.
and reflecting the masseter muscle laterally, to expose
Following are the skin grafts used for various reconstruc- the neck of the condyle and sigmoid notch.
tions:
l Deltopectoral flap: Used for reconstruction of full thick-

ness cheek defect.

Disadvantage
l Sternomastoid myocutaneous flap for face reconstruction. l Poor access to the condylar head region.
l Temporal flap: Used in reconstruction of full thickness
Q. 5. What is the difference between ‘Square knot’ and
cheek defects.
‘Surgeon’s knot’?
Q. 3. Name the structures seen in IOPA (Intraoral peri-
Ans.
apical X-ray).
Ans.
20 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Square Knot
l After the needle is passed through both wound edges,
the needle end is held in the left hand and rotated around
the beaks of the needle holder one time (clockwise di-
rection), and the free end of the suture material is held
and the knot stabilized on the tissues.
l The suture material is then rotated around the needle
holder once in the opposite direction (anticlockwise di-
rection) and then tightened.
l A third tie is also recommended in the same direction as
the first tie and then stabilized. This ensures complete
stability of the knot.
Surgeon’s Knot
l The suture material is rotated around the needle holder
two times in a single direction (clockwise) and the knot
is placed.
l For the second tie, the suture material is rotated in the
opposite direction (anticlockwise) and then stabilized.
Advantage
l Since the first tie is more stable, it does not slip away
easily while placing the second tie.
Q. 6. Catgut suture.
Ans.
l Catgut was the first absorbable suture material available.
l It is derived from a natural source, which may be puri-
fied connective tissue (mostly collagen) derived from
either serosal layer of cow’s intestine (bovine source) or
submucosal fibrous layer of sheep intestines.
l It is commercially supplied as a package soaked in iso-
propyl alcohol, which acts as a preservative.
l Resorption is by enzymatic degradation by proteolytic
enzymes and phagocytosis.
l When placed inside the tissues, it loses most of its
tensile strength within 10–15 days and is resorbed by
2–3 months.
l Disadvantages of plain surgical gut suture are: It is
allowed to dry during suturing, it becomes stiff, and it
is difficult to handle.
l Since it is degraded by enzymatic action, there is an
intense inflammatory reaction during this process.
l It also allows more bacterial adhesion when compared
to nylon or polypropylene.
l It has poor tensile strength and rapidly loses strength
when placed in the tissues.
Q. 7. Name few indications of bone grafts.
Ans.
Autografts and processed homografts have been used ex-
tensively in oral surgery.
Indications
l To fill the defective bony cavities following the enucle-
ation of large cysts of the jaws, where the bony cavities
are unable to heal by regeneration. In such cases, autog-
enous and inorganic bone grafts are used.
l Similarly, alveolar bone grafting in alveolar clefts is
also widely practiced.
l To obtain an absolute increase in the height of the alveolar
ridge as a preprosthetic procedure.
Q. 8. Mention two LASER applications in oral surgery.
Ans.
Applications of LASER in oral surgery
i. Mucositis
Laser therapy can be used to reduce the postirradiation
mucositis.
ii. Pain
Pain of various origins can be reduced or eliminated with
laser therapy.
iii. Paraesthesia
Laser therapy eliminates or reduces complications of par-
aesthesia following various surgical procedures.
Section | I  Topic Wise Solved Questions of Previous Years
Local Anaesthesia
LONG ESSAYS
Q. 1. Describe in detail about the extracranial course of
trigeminal nerve.
Ans.
l The trigeminal nerve is the largest, mixed cranial nerve
that contains both sensory and motor fibres.
l The trigeminal nerve is attached to the lateral part of the
pons by its two roots, motor and sensory. The two roots
enter the middle cranial fossa.
Divisions of the Trigeminal Nerve
A. Ophthalmic Nerve V1
l The ophthalmic nerve is the first division of the tri-
geminal nerve and it is a sensory nerve.
l Among the three divisions, it is the smallest and it
passes forward and enters the orbit through the superior
orbital fissure.
B. Maxillary Nerve V2
l The maxillary nerve is the second division of the tri-
geminal nerve and it is a sensory nerve.
l It begins at the middle of the semilunar ganglion and
leaves the skull through the foramen rotundum.
C. Mandibular Nerve V3
l This is the largest among the three divisions of the
trigeminal nerve.
l It consists of two roots:
a. Largest sensory root arises from the semilunar
ganglion.
b. Smaller motor root passes beneath the ganglion to
unite the sensory root just after it emerges through
the foramen ovale.
l These three large nerves proceed from the convex bor-
der of the semilunar ganglion.
A. Ophthalmic Division
i. Supratrochlear Nerve
l Sensory from the medial part of the upper and the lower
eyelid, medial part of the forehead; sensory from the
conjunctiva of the upper eyelid.
21
Topic 3
ii. Supraorbital Nerve
l Sensory from the skin of the upper eyelid and the skin
of the forehead and scalp as back as the vertex of the
skull; sensory from the lining of the frontal sinus.
iii. Lacrimal Nerve
l Sensory branch from the skin of the upper eyelid and
lateral part of the eyebrow region; and, as well sensory
branch from the conjunctiva of the lateral part of the
upper eyelid.
iv. Nasociliary Nerve
l Long ciliary branch
l Sensory from the eyeball and ciliary ganglion.
l Infratrochlear
l Supplies to the side of the nose; sensory from con-
junctiva and lacrimal sac.
l Ethmoid branches
a. Anterior ethmoid branch—sensory from the lining
of the frontal sinus and of the anterior ethmoid cells.
b. Posterior ethmoid branch–sensory from the lining of
the posterior ethmoid cells and sphenoid sinus.
l Internal branches
l Sensory from the anterior portion of the septum and
lateral walls of the nasal cavity.
l External nasal branch
l Sensory from the tip of the nose.
B. Maxillary Division—Middle Meningeal
Branch
l In the cranial cavity, the maxillary division sends a sen-
sory branch to the dura.
l In the pterygopalatine fossa, this division gives off two
branches.
a. Zygomatic Nerve and Branches
i. Zygomaticofacial branch
l Sensory from the skin over the prominence of zygo-
matic bone.
ii. Zygomaticotemporal branch
l Sensory from the skin of the side of the forehead and
of the anterior part of the temporal fossa region.
22 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
b. Sphenopalatine Nerves (Pterygopalatine)
Orbital branches
l Sensory from the periosteum of the orbit and from the
lining of the sphenoid sinus and posterior ethmoid cells.
ii. Greater palatine branch (anterior palatine)
l It is sensory from the mucous membrane of the major
part of the hard palate and adjacent part of the soft Sensory from the mucosal layer and the skin of the
palate.
iii. Lesser palatine branches
l Sensory from the mucous membrane of the soft palate
and tonsil area.
iv. Posterior lateral nasal branches
l Sensory over the nasal conches.
v. Nasopalatine branches
l Sensory from the mucous membrane layer of the lower
and the posterior part of the nasal septum and from the
premaxillary part of the hard palate.
vi. Pharyngeal branch
l Sensory from the auditory tube.
c. Posterior Superior Alveolar Nerve
i. Gingival branches
l Sensory from the buccal gingivae of the upper molar
region and from the mucosal layer of part of the cheek.
ii. Alveolar branches
l Sensory from the maxillary molars, except the mesio-
buccal root of maxillary first molar and the mucous
membrane of the maxillary sinus.
iii. In the infraorbital canal region
a. Middle superior alveolar nerve
l Sensory from the maxillary bicuspids and the mesio-
buccal root of the first molar; sensory from the lining
of the maxillary sinus.
b. Anterior superior alveolar nerve
l Sensory from the maxillary incisors and cuspids and
from the lining of the maxillary sinus.
iv. Terminal branches on the face (infraorbital
branches)
a. Inferior palpebral branches
l Sensory from the skin of the lower eyelid.
b. Lateral nasal branches
l Sensory from the skin of the lateral side of the nose.
c. Superior labial branches
l Sensory from the upper lip (skin).
C. Mandibular Division
i. Nervus Tentorii
l Sensory from the dural layer of the posterior cranial
fossa and from the lining of the mastoid cells.
ii. Buccal (Long Buccal) Nerve
l
cheek region; sensory from buccal gingivae of the
mandibular molar region.
iii. Auriculotemporal Nerve
l a. Sensory from the skin over the areas supplied by the
branches of the facial (VII) nerve, that is, zygomatic,
buccal, and mandibular areas.
l b. Sensory from the parotid gland by means of the
parotid branch.
l c. Sensory from the temporomandibular articulation.
l d. Sensory from the skin lining the external auditory
meatus and from the later surface of the tympanic mem-
brane.
l e. Sensory from the skin and scalp over the upper part
of the external ear and the side of the head up to the
vertex of the skull.
iv. Lingual Nerve
l Sensory from the mucosal layer covering the anterior
two thirds of the tongue; sensory from the mucous
membrane of the floor of the mouth and of the lingual
side of the mandibular gingivae; and, sensory from the
submandibular and sublingual glands and their ducts.
v. Inferior Alveolar Nerve
a. Dental branches: Sensory from all of the lower molar
and bicuspid (mandibular) teeth and their periodontal
membranes.
b. Mental nerve: Sensory from the lower lip (skin) and
chin regions and from the mucous membrane lining the
lower lip region.
c. Incisive nerve: Sensory from incisors, cuspid teeth, and
their periodontal membranes.
Q. 2. Define local anaesthesia and classify it. What is the
composition of local anaesthesia (LA) solution and de-
scribe the function of each component? Discuss contra-
indications of local anaesthesia and explain the ideal
requirement of LA. Explain the mode of action of LA.
Ans.
Local anaesthesia is defined as a loss of sensation in a cir-
cumscribed area of the body, caused by a depression of
Section | I  Topic Wise Solved Questions of Previous Years 23

excitation in nerve endings or an inhibition of the conduc-
tion process in peripheral nerves.
Composition of LA
i. 2% Lidocaine hydrochloride—local anaesthetic
agent.
ii. 1:80,000–1:1,00,000—vasoconstrictor prolongs the
action of local anaesthetic.
iii. Sodium metabisulphite—oxidizing agent.
iv. Methyl paraben—preservative.
v. Thymol—antifungal.
vi. Distilled water—solvent.
Classification of LA
A. Based on Duration of Action of LA
C. Classification According to the Biological Site
and Mode of Action
i. Class A agents acting at the receptor site on the external
surface of nerve membrane.
ii. Class B agents acting at receptor sites on the internal
surface of the nerve membrane.
iii. Class C agents acting by a receptor-independent
physico-chemical mechanism.
iv. Class D agents acting by combination of receptor and
receptor-independent mechanisms.
Properties of an Ideal Anaesthetic
l It has reversible action.
l It is nonirritating to the tissues and produces no second-
ary local reaction.
l It has a low degree of systemic toxicity.

1. Injectable l It has a rapid onset and is of sufficient duration to be

a. Low potency and short duration advantageous.

Procaine l It haspotency sufficient to give complete anaesthesia

Chlorprocaine without the use of harmful concentrated solutions.

b. Intermediate potency and long duration l It has sufficient penetrating properties to be effective as

Lidocaine a topical anaesthetic.

Prilocaine l It is relatively free from producing allergic reaction.

c. High potency and long duration l It is stable in solution and undergoes biotransformation

Tetracaine readily within the body.

Bupivacaine l It is either sterile or is capable of being sterilized by heat

Ropivacaine without deterioration.

Dibucaine
2. Surface anaesthetics Contraindications
a. Soluble compounds
Cocaine Absolute Contraindications to LA
Lidocaine
l Myocardial infarction within 6 months.
Tetracaine
l Recent hepatitis A or hepatitis B.
b. Insoluble compounds
l Jaundice.
Benzocaine
l Local infection or sepsis.
Butylaminobenzoate
l Hypersensitivity to lidocaine.
Oxethazaine

Relative Contraindications to LA
B. Based on Amide- and Ester-Linked
l Chronic renal failure.
Amide-linked local anaesthetics l Hyperthyroidism.
Lidocaine l Atypical plasma cholinesterase.
Prilocaine l Pregnancy (during first trimester).
Bupivacaine l Hypertension.
Dibucaine l Malignant hypothermia.
Ropivacaine l Congenital methaemoglobinaemia.
Ester-linked local anaesthetics
Cocaine
Procaine Mechanism of Action of LA
Chlorprocaine l In producing a conduction block, the primary action of
Tetracaine LA is to decrease the permeability of the ion channels
Benzocaine to sodium ions (Na1).
24 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Displacement of calcium ions from the sodium channel
receptor site, permits binding of the LA molecule to this
receptor site, and this produces blockade of the sodium
channel.
l Local anaesthetic molecules may act by competitive
antagonism with calcium for same site on the nerve
membrane.
l Decrease in sodium conductance leads to depression of
the rate of electrical depolarization; and, failure to
achieve the threshold potential level along with a lack of
development of propagated action potentials is known
as conduction blockade.
l The nerve membrane remains in a polarized state, because
the membrane’s electrical potential remains unchanged,
local currents do not develop, and the self-perpetuating
mechanism of impulse propagation is stalled.
l An impulse that arrives at a blocked nerve segment
is stopped, because it is unable to release the energy
necessary for its continued propagation.
l Hence, nerve block produced by LA is called a nonde-
polarizing nerve block.
Q. 3. Describe the complications of LA and its
management.
Or
Complications due to LA solution. Classify and explain
the same.
Ans.
Complications due to LA are classified as:
A. Local complications.
B. Systemic complications.
A. Local Complications
i. Needle Breakage
Needle breakage is rare nowadays because of the use of
disposable needles.
Causes
l Primary cause of needle breakage is weakening of the
dental needle by bending it before its insertion into the
patient’s mouth.
l Sudden unexpected movement by the patient as the
needle penetrates muscle or contacts periosteum can
also lead to breakage of needle.
l Smaller needles are more likely to break than larger
needles.
l Needles that have previously been bent are more likely
to break than unbent needles.
l If a broken needle can be retrieved without surgical
intervention, no emergency exists.
l A Magill intubation forceps or haemostat can be used to
grasp the visible proximal end of the needle fragment
and remove it from the soft tissue.
Management
l Carry calm attitude and inform the patient.
l Removal of needle with Magill intubation forceps or
small haemostat.
l Berman’s locator to locate needles.
l Surgical removal.
ii. Persistent Nerve Paralysis
l Persistent anaesthesia beyond expectation or altered
sensation.
l Numbness, swelling, tingling, and itching after injection.
Causes
l Trauma to nerve, injection of LA containing alcohol or
sterilizing solution leads to irritation, oedema, and par-
aesthesia.
l Trauma to the nerve sheath during injection, electric
shock like feeling.
l Haemorrhage around nerve sheath, increasing pressure.
l Local anaesthetic solution itself may cause damage to
the nerve.
Problems
l Self-inflicted injuries, biting, thermal/chemical insult, etc.
l In lingual nerve involvement, taste alteration.
l Hyperaesthesia and dysaesthesia (painful response)
Management
l Resolve within 8 weeks or else can remain permanent.
l Reassure patient and examine for degree and extent of
paraesthesia.
l Tincture of time is recommended medicine.
l Consult a neurologist in persistent cases.
iii. Facial Nerve Paralysis
l Paralysis of 7th nerve with loss of motor function.
Causes
l Injection of LA into capsule of parotid gland, during
over insertion in inferior alveolar nerve block (IANB)
or Vazirani technique.
l Infraorbital nerve block or infiltration to maxillary
canine.
Features
l Usually transient with minimal or no sensory loss.
l Unable to use muscles of facial expression, face is lop-
sided and eye on affected side is closed.
Section | I  Topic Wise Solved Questions of Previous Years 25

l Protective lid reflex of eye with wrinkling and blinking Cause

abolished. l Young children, mentally or physically disabled child

and adult.
Prevention
l Strict adhering to protocol of IANB and Vazirani Problems
block. l Swelling and significant pain.
l Needle tip contact with bone in IANB. l Behavioural problem.

Management Prevention
l Reassure the patient not to panic. l Local anaesthetic of appropriate volume should be
l Eye patch, artificial tears, etc. used.
l Follow-up of case. l Warn the patient and guardian about anaesthetic

effect.
iv. Trismus
Management
l Trismus occurs due to spasm of jaw muscles, which Symptomatic
causes the normal opening of mouth restricted.
l Analgesic, antibiotic, lukewarm saline rinse, etc.

Causes l Petroleum jelly to cover lesion and minimize

irritation.
l Trauma to blood vessels or muscles in infratemporal

fossa.
l Local anaesthetic with alcohol or cold sterilization vi. Haematoma
solution diffuses into tissues, causing irritation.
l Effusion of blood into extravascular spaces during
l Intramuscular or supramuscular injection has myco-
injection of LA.
toxic properties.
l Tissue density determining factor.
l Excessive volumes of LA in a restricted area with

distension of tissue, after multiple IANBs. Causes

l IANB or PSA block due to nicking of an artery or
Problems
vein.
l Chronic hypomobility with limitation of interincisal
l Haematoma caused by IANBs are intraoral, while PSA
opening.
are extraoral usually.
l Acute phase—haemorrhage, pain, and muscle spasm.

l Haematoma with fibrosis and scar contracture. Problem

l Bruise, trismus, pain, and inconvenience to patient.
Prevention
l Sharp, sterile, and disposable needle.
Prevention
l Aseptic, atraumatic with minimum effective volume
l Proper knowledge of anatomy with minimum trauma to
of LA.
l Avoid repeated and multiple insertion on needle while
tissue.
l Minimal tissue insertion and using short needle for PSA
block.
block.
Management
Management
l Analgesics: Aspirin 325 mg; muscle relaxants; and heat
therapy, i.e., warm saline gargles. Immediate
l Codeine in rare cases: 30–60 mg/6 h. l Direct pressure application not less than 2 min, stop

l Diazepam: 10mg BD or Benzodiazepines can be used. bleeding.

l Physiotherapy: Opening and closing mouth exercises.

l Ultrasound therapy: Antibiotics can be given.

Subsequent
l TMJ infection is rare. Vazirani-Akinosi block in severe l Ice application.

pain cases. l Soreness and limitation of movement—no heat applica-

tion in the first 4–6 h, can be applied next day as it has

analgesic and vasodilating effect.
v. Soft Tissue Injury
l With 12–14 days resolution occurs.
l Self-inflicted injury to lips and tongue. l No treatment during this period is advised.
26 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

vii. Pain on Injection x. Oedema

Causes
l Careless injection technique.
l Rapid deposition of solution, needle with barbs.
l It is swelling of tissue – not a syndrome but a sign.
Causes
l Trauma, infection, haemorrhage, allergy, injecting

Problems irritating solution, etc.

l Increased patient’s anxiety and unexpected movements.
Problems
Prevention l Pain, dysfunction, and embarrassing to patient.

l Angioneurotic oedema.
l Proper technique of injection with sharp needle use.

l Use to topical LA. Prevention

l Using sterile LA with slow injection in tissues.
l Atraumatic injection protocol.
l Temperature of solution should be corrected.

Management
viii. Burning on Injection l Reduction of swelling earliest with solution of cause.

l Allergy induced oedema with blockers and consultation

Causes
with physician.
l pH of the solution deposited in soft tissues.
l Antibiotic therapy in infection-induced oedema.
l Rapid injection of LA.

l Contamination of LA cartridge with sterilizing

solution. xi. Sloughing of Tissue
l Solution warmed to body temperature. Causes
l Epithelial desquamation—long topical LA application.
Problems
l Sterile abscess due to prolonged ischaemia.
l Usually transient indicates tissue irritation.

l Can lead to oedema, paraesthesia, or possible trismus. Problem

l Severe pain and infection rarely.
Prevention
l Slow rate of LA administration, 1mL/min to Prevention
1.8 mL/min. l Topical anaesthesia is used as recommended (1–2 min).
l Alkaline LA solution with storage of solution at room
l Not to use over-concentrated solution of vasoconstrictor.
temperature.
Management
Management
Symptomatic
l Symptomatic management of specific problems.
l For pain, analgesics like aspirin or codeine, or topical

ointment—Orabase to minimize irritation.

ix. Infection
Causes B. Systemic Complications
l Improper technique and poor handling.
i. On Cardiovascular System
l Contamination of needle before entering oral cavity.

l Local anaesthetic decreases electrical excitability of the

Problem myocardium, conduction rate, and force of contraction.
l Low grade infection and trismus. l All these factors together result in myocardial depression

at a dose of 1.5 to 5 mcg/mLof lidocaine, has antiarrhyth-

Prevention mic action.
l Proper handling and preparation of tissue before pene- l It can be used as a potent drug for ventricular tachycar-

tration. dia, ventricular premature contractions, and in cardiac

l Proper handle and care for needle and cartridge. arrest caused by ventricular fibrillation.

Management
ii. On Blood Vessels
l Pain and dysfunction treated with heat and analgesic or

muscle relaxant or physiotherapy. l Local anaesthetics cause vasodilatation of the blood ves-
l Trismus with antibiotics and analgesics. sels except for cocaine, which produces vasoconstriction.
Section | I  Topic Wise Solved Questions of Previous Years
l It primarily produces hypotension at a level approach-
ing overdose due to depression of the myocardium and
smooth muscle relaxation of the vessel wall.
l At lethal levels it causes cardiovascular collapse.
iii. On Central Nervous System
l At low level there is no significant effect.
l Lidocaine causes CNS depression at toxic levels.
l At 0.5 to 4 mcg/mL—anticonvulsive action.
l Due to their depressant action on the CNS, local anaes-
thetics raise the seizure threshold by decreasing the
hyperexcitability of the cortical neurons site from where
the convulsive episodes originate.
l At 4.5 to 7 mcg/mL—preseizure signs and symptoms occur.
l Preseizure signs and symptoms include slurred speech,
shivering, tremor, warm flushed feeling of the skin, light
headedness, dizziness, drowsiness, visual disturbance,
auditory disturbance, etc.
l At .7.5 mcg/mL—convulsive action results; and, at
this dose, lidocaine causes tonic- clonic seizure.
l Seizure continues as long as the drug is present in the
blood.
l The duration of presence of local anaesthesia in blood is
further increased by the increased blood flow to brain.
l Increased cerebral metabolism also leads to progressive
metabolic acidosis which prolongs the seizure activity.
l Further increase in the dose causes CNS depression and
respiratory arrest as a result of respiratory depression.
iv. On Respiratory System
l At nonoverdose levels, it has a relaxant effect on bron-
chial smooth muscles.
l Overdose leads to respiratory arrest as a consequence of
respiratory centre depression (CNS depression).
Q. 4. Give boundaries of pterygomandibular space.
Describe the technique of inferior alveolar nerve block
and the complications associated with it and briefly l Not necessary for localized procedures.
discuss the management of each.
Ans.
Boundaries of Pterygomandibular Space
Anteriorly: Buccal space
Posteriorly: Parotid gland with lateral pharyngeal space
Superiorly: Lateral pterygoid muscle
Inferiorly: Inferior border of mandible
Medially: Lateral surface of medial pterygoid muscle
Laterally: Medial surface of ramus of the mandible.
Inferior Alveolar Nerve Block
Nerves Anaesthetized
l Inferior alveolar nerve and its subdivision.
27
l Lingual (commonly).
l Incisive nerve.
l Mental nerve.
l Buccinator nerves, branch of mandibular nerve.
Areas Anaesthetized
l Mandibular teeth upon one half of the mandible (till
midline).
l Body of the mandible, lower or inferior portion ramus
of mandible.
l Buccal mucoperiosteum, mucous membrane anterior to
the mandibular first molar.
l Tongue (anterior two thirds) and floor of the oral cavity
(lingual nerve).
l Lingual soft tissues and periosteum (lingual nerve).
Indications
l All surgical procedures on multiple mandibular teeth in
one quadrant.
l When buccal or lingual soft tissue anaesthesia (anterior
to first molar) is necessary.
Contraindication
l Infection or acute inflammation in the area of injection
(rare).
l Patients who has the habit of biting either the lip or the
tongue; for instance, a very young child or a physically
or mentally handicapped adult or child.
Advantages
l One injection provides a wide area of anaesthesia, use-
ful for quadrant dentistry.
Disadvantages
l Among all intraoral injection techniques, positive aspi-
ration (10–15%) is highest.
l Anaesthesia of lower lip and tongue is discomfortable
to many patients and possibly dangerous for certain
individuals.
Technique
l The patient should be positioned with the mouth open
and the lower border of body of the mandible parallel to
the floor.
l The operator should stand to the right front side of the
patient and with the left index finger or thumb palpating
the mucobuccal fold.
l The finger is then moved posteriorly until contact is
made with the external oblique ridge and the anterior
border of the ramus of the mandible.
28 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l When the finger or thumb contacts the ramus of the
mandible, it is moved up and down until the greatest
depth of the anterior border of the ramus is identified.
l The palpating finger is moved lingually across the retro-
molar triangle and onto the oblique ridge.
l Keeping the finger or thumb, still in line with the coro-
noid notch and in contact with the internal oblique
ridge, it is moved to the buccal side, taking with it the
buccal sucking pad.
5
l A syringe with a 1 /8 inch length and 25-gauge needle is
then inserted parallel to the occlusal plane of the man-
dibular teeth from the opposite side of the mouth, at a
level bisecting the finger or thumbnail, penetrating the
tissue of the pterygotemporal depression, and entering
the pterygomandibular space while the patient is asked
to keep the mouth wide open.
Common Complications Associated with IANB
i. Haematoma.
ii. Trismus.
iii. Transient facial paralysis
i. Haematoma
l Effusion of blood into extravascular spaces during in-
jection of LA.
l Tissue density determining factor.
Causes
l IANB or PSA block due to nicking of an artery or
vein.
l IANBs are intraoral, while PSA are extraoral usually.
Management
Immediate
l Direct pressure application for not less than 2 min, stops
the bleeding.
Subsequent
l Ice application.
l Soreness and limitation of movement—no heat applica-
tion in the first 4–6 h, can be applied next day as has
analgesic and vasodialating effect.
l Within 12–14 days resolution occurs.
l No treatment during this period is advised.
ii. Trismus
l Muscle soreness or limited movements.
Causes
l Trauma to blood vessels or muscles in infratemporal
fossa.
l LA with alcohol or cold sterilization solution diffuses
into tissue, causes irritation.
l Intramuscular or supramuscular injection has myco-
toxic properties.
l Excessive volumes of LA in a restricted area with dis-
tension of tissue, after multiple IANBs.
Management
l Analgesics like aspirin 325 mg; muscle relaxants; and
heat therapy, i.e., warm saline gargles.
l Codeine in rare cases: 30–60 mg/6h.
l Diazepam: 10mg BD or Benzodiazepines can be used.
l Physiotherapy: Opening and closing mouth exercises.
l Ultrasound therapy: Antibiotics can be given.
l TMJ infection is rare. Vazirani-Akinosi block in severe
pain cases.
iii. Transient Facial Paralysis
l Produced by deposition of local anaesthetic into the
body of the parotid gland.
Sign and symptoms
l Inability to close the lower eyelid and drooping of the
upper lip on the affected side.
Management
l Reassure the patient not to panic.
l Eye patch, artificial tears, etc.
l Follow-up of case
Q. 5. What is trismus? Mention various conditions
resulting in trismus with treatment of each in brief.
Ans.
l Muscle spasm resulting in defective mouth opening is
known as trismus.
Various Conditions Resulting in Trismus are
as Follows
i. Infections
l Odontogenic acute infections like pericoronitis,
Ludwig’s angina, submasseteric, infratemporal
abscess, etc.
l Chronic infections can also cause trismus like tuber-
culous osteomyelitis of ramus, body of mandible, etc.
ii. Trauma
l Fracture of zygomatic arch may impinge on the coro-
noid process and restrict the oral opening.
l Fracture of mandible can cause trismus, because
of pain and tenderness or muscle spasm.
iii. Inflammation
l Myositis or muscular atrophy can bring about
trismus.
Section | I  Topic Wise Solved Questions of Previous Years
iv. Myositis ossificans
l Following trauma, a haematoma can be formed
within the fibres of masticatory group of muscle,
especially masseter, which can progress into ossifi-
cation and muscle stiffness.
v. Tetany
l Typical carpopedal spasm along with trismus can
be seen.
vi. Tetanus
l Following acute infection such as Clostridium
tetani, typical lock jaw symptoms can be seen due
to hypocalcaemia.
vii. Neurological disorder
l Epilepsy, brain tumour, bulbar paralysis, and em-
bolic haemorrhage in medulla oblongata can bring
about trismus.
viii. Psycosomatic trismus
l It is also known as trismus hystericus. It is due to
fear and anxiety associated with hysterical fits.
ix. Drug-induced trismus
l Strychnine poisoning can bring about spasms lead-
ing to trismus.
SHORT ESSAYS
Q. 1. Theories on the mechanism of local anaesthetic
action.
Ans.
Theories for Mode of Action of Local
Anaesthetics
i. Acetylcholine theory
l Acetylcholine is involved in nerve conduction to-
gether with its role as a neurotransmitter at nerve
synapses.
l But, there is no evidence of involvement of acetyl-
choline in neural transmission along the body of the
neuron.
ii. Calcium displacement theory
l Displacement of calcium from certain membrane
sites that controls the permeability to sodium.
l Altering the concentration of calcium ions has no
effect on local anaesthetic policy.
iii. Surface charge theory
l Local anaesthetics bind to the nerve membrane and
change the electrical potential at its surface.
l LA molecules carrying net positive charge make the
electrical potential at the surface of nerve membrane
more positive, thereby increasing the threshold
potential.
29
x. Mechanical blockade
l Elongation, exostosis, osteoma, and osteochon-
droma of coronoid process will cause mechanical
blockade and can interfere with mandibular
movements.
xi. Extraarticular fibrosis
l Chronic cervicofacial sepsis, irradiation therapy,
ossification of sphenomandibular ligament, bands
of scars and burns of the face and neck region, and
oral submucous fibrosis will lead towards progres-
sive trismus.
Management
l Analgesics like aspirin 325 mg; muscle relaxants; and
heat therapy, i.e., warm saline gargles.
l Codeine in rare cases: 30–60 mg/6 h.
l Diazepam: 10mg BD or Benzodiazepines can be
used.
l Physiotherapy: Opening and closing mouth exercises.
l Ultrasound therapy: Antibiotics can be given.
l TMJ infection is rare. Vazirani-Akinosi block in severe
pain cases.
l Recent evidence shows that there is no alteration in
the resting potential by local anaesthetic, and they act
within the nerve membrane channels rather than at
the surface.
iv. Membrane expansion theory
l Local anaesthetic diffuses to hydrophobic regions
and expands the membrane preventing the sodium
permeability.
l Lipid-soluble molecules alter the lipoprotein matrix
of the nerve membrane and decrease the diameter of
sodium channels.
l There is no direct evidence to support this theory.
v. Specific receptor hypothesis
l Specific receptor hypothesis is the most favoured
theory.
l Local anaesthetics act by attaching themselves to
specific receptor in the nerve membrane.
l The local anaesthetic receptor is located at or near the
sodium channel in the nerve membrane, either on its
external surface or on the internal axoplasmic surface.
l Once the receptors access is gained, sodium ion
permeability is decreased or eliminated, and nerve
conduction interrupted.
Q. 2. Mechanism of action of local anaesthesia.
Or
Discuss in brief the mode of action of local anaesthesia.
30 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Ans.
Mechanism of Action of Local Anesthetics
l In producing a conduction block, the primary action of
local anaesthetics is to decrease the permeability of the
ion channels to sodium ions (Na1).
l Displacement of calcium ions from the sodium channel
receptor site, which permit binding of the local anaes-
thetic molecule to this receptor site, which produces
blockade of the sodium channel.
l Local anaesthetic molecules may act by competitive
antagonism with calcium for same site on the nerve
membrane.
l Decrease in sodium conductance, which leads to de-
pression of the rate of electrical depolarization, and
failure to achieve the threshold potential level, along
with a lack of development of propagated action poten-
tials, which is called conduction blockade.
l The nerve membrane remains in a polarized state, because
the membrane’s electrical potential remains unchanged,
local currents do not develop, and the self-perpetuating
mechanism of impulse propagation is stalled.
l An impulse that arrives at a blocked nerve segment
is stopped, because it is unable to release the energy
necessary for its continued propagation.
l Hence, nerve block produced by local anaesthetics is
called a nondepolarizing nerve block.
Q. 3. Contents of local anaesthetic (LA) solutions and
properties of LA.
Ans.
Local anaesthesia (LA) is defined as a loss of sensation
in a circumscribed area of the body caused by a depression
of excitation in nerve endings or an inhibition of the con-
duction process in peripheral nerves.
Composition of LA
i. 2% Lidocaine hydrochloride—local anaesthetic agent.
ii. 1:80,000 to 1:1,00,000—vasoconstrictor prolongs the
action of local anaesthetic.
iii. Sodium metabisulphite—oxidizing agent.
iv. Methyl paraben—preservative.
v. Thymol—antifungal.
vi. Distilled water—solvent.
Properties of an Ideal Anaesthetic
An ideal anaesthetic should
l Have reversible action.
l Be nonirritating to the tissues and produce no secondary
local reaction.
l Have chances of systemic toxicity at a low degree.
l Have a rapid onset of action and it should be for a suf-
ficient duration.
l Have a sufficient potency to give complete anaesthesia.
l Have sufficient penetrating properties to be effective
as a topical anaesthetic.
l Be free from producing allergic reaction.
l Be stable in solution and readily undergo biotransfor-
mation within the body.
l Be either sterile or capable of being sterilized by heat
without deterioration.
Q. 4. Define syncope and its management.
Ans.
l A transient loss of consciousness due to cerebral isch-
aemia caused by a reduction in blood supply to the brain
is known as vasovagal syncope.
l Vasodilatation causes slowing of the heart, which causes
a dramatic fall in blood pressure.
Signs and Symptoms
l Nausea
l Light-headedness
l Pale grey appearance
l Thready, slow pulse
l Hypotension
l Confusion
l Weakness
l Sweating.
Causes
l Psychologic factor—pain or fear
l Postural changes
l Anoxia
l Carotid sinus syndrome.
Pathophysiology of Vasovagal Syncope
l Anxiety causes increased release of catecholamines,
which cause decreased peripheral vascular resistance,
resulting in pooling of blood in the peripheries and fall
in arterial blood pressure.
l Compensatory mechanisms come into play and cause in-
creased heart rate, rapid breathing, pallor, and perspiration.
l Decompensation soon occurs and eventually syncope.
Dental Consideration
Anxiety reduction protocol, adequate postoperative pain
and anxiety control techniques are follwed.
l Premedicate the patient with hypnotics, for a relaxed
sleep, the night before the surgery.
l Premedicate the patient with sedatives on the day of
surgery.
Section | I  Topic Wise Solved Questions of Previous Years
l Schedule the surgery in the morning.
l Minimize the patient’s waiting time, i.e., reduce the
length of appointment.
l Consider psychosedation during surgery.
l Administer adequate pain control during surgery.
l Avoid any anxiety during surgery using relaxing back-
ground music.
l Follow-up postoperative pain and anxiety control.
l Effective postoperative analgesics.
l Telephone highly anxious or fearful patients on the
same day the treatment was delivered.
Management
l Stop all the treatments, make the patient lie flat with
legs raised, and place a cool towel on his/her Pharmacokinetics of local anaesthetics is as follows:
forehead.
l Give supplemental oxygen.
l Monitor vital signs and check for breathing.
l Perform basic life support (BLS) if breathing is absent
and summon for medical assistance.
l If breathing is present hold some ammonia salts under
the patient’s nose to revive consciousness.
l Have the patient escorted home.
Q. 5. Electrophysiology of nerve conduction.
Ans.
The electrical events that occur within a nerve during the
conduction of an impulse are:
l A nerve possesses a resting potential. This is a nerve
electrical potential of -70 mV that exists across the
nerve membrane, produced by differing concentrations
of ions on either side of the membrane.
l The interior of the nerve is negative relative to the
exterior.
Step 1
A stimulus excites the nerve, leading to the following l Tetracaine, chloroprocaine, and propoxycaine also pos-
sequence of events:
l Initial phase includes slow depolarization of nerve.
l The electrical potential becomes slightly less negative
within the nerve.
l When the falling electrical potential reaches a critical
level, and extremely rapid phase of depolarization intense and prolonged vasoconstriction.
results.
l This is termed threshold potential or firing threshold.
l Across the nerve membrane, a reversal of the electrical
potential occurs in the phase of rapid depolarization.
l The interior of the nerve is now electrically positive in
relation to the exterior.
l An electrical potential of 140 mV exists on the interior
of the nerve cell.
31
Step 2
After these steps of depolarization, repolarization occurs.
l The electrical potential gradually becomes more
negative inside the nerve cell relative to outside until
the original resting potential of -70 mV is again
achieved.
l The entire process requires 1 ms, depolarization takes
0.3 ms, and repolarization takes 0.7 ms
Q. 6. Local anaesthetic agent pharmacology.
Or
Pharmacokinetics of local anaesthetics.
Ans.
Uptake
l When injected into soft tissues, the local anaesthetics
exert a pharmacological action on the blood vessels in
the area.
l Almost all local anaesthetics possess a degree of vaso-
activity, producing dilation of the vascular bed into
which they are deposited. Although, the degree of
vasodilation may vary and some may produce vaso-
constriction.
l Ester local anaesthetics are also potent vasodilating
drugs.
l Procaine is the most potent vasodilator used clinically
for vasodilation when peripheral blood flow has been
compromised because of (accidental) intra-arterial (IA)
injection of a drug (e.g., thiopental).
l IA administration of an irritating drug such as thiopen-
tal may produce arteriospasm with an attendant de-
crease in tissue perfusion, that if prolonged could lead
to tissue death, gangrene, and loss of total limb.
l In this situation, procaine is administered IA in an at-
tempt to break the arteriospasm and re-establish blood
flow to the affected limb.
sess vasodilating properties to varying degrees, but not
to the degree of procaine.
l The only local anaesthetic consistently producing vaso-
constriction is cocaine.
l Cocaine initially produces vasodilation, followed by an
l It is produced by inhibition of the uptake of catechol-
amines (especially norepinephrine) into tissue binding
sites.
l This results in an excess of free norepinephrine, leading
to a prolonged and intense state of vasoconstriction.
l This inhibition of the reuptake of norepinephrine has
not been demonstrated with other local anaesthetics,
e.g., lidocaine and bupivacaine.
32 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The significant clinical effect of vasodilation is an in-
crease in the rate of absorption of the local anaesthetic
into the blood, thus decreasing its duration and quality
(e.g., depth) of pain control while increasing the con-
centration of anaesthetic in blood (or plasma) and the
potential for overdose (toxic reaction).
l The rates at which local anaesthetics are absorbed into
the bloodstream and reach their peak blood level vary
according to their route of administration.
Distribution
l In certain ‘target’ organs, the plasma concentration of a
local anaesthetic has a significant bearing on the poten-
tial toxicity of the drug.
l The following factors influence the blood levels of the
local anaesthetic:
i. Rate of absorption of the drug into the cardiovascu-
lar system.
ii. Rate at which drug is distributed from the vascular
compartment to the tissues (more rapid in healthy
patients than in those who are medically compro-
mised).
iii. Elimination of the drug either through metabolic or
excretory pathways in order todecrease the blood
level of the local anaesthetic.
Metabolism
l Metabolism (or biotransformation) of local anaesthetics
is important as the entire toxicity of a drug depends on
a balance between its rate of absorption into the blood-
stream at the site of injection and its rate of removal
from the blood through the processes of tissue uptake
and metabolism.
Q. 7. Infraorbital nerve block.
Ans.
Infraorbital nerve block is also known as anterior and
middle superior alveolar nerve block.
Area Anaesthetized
l Area supplied by the anterior superior alveolar nerve,
middle superior alveolar nerve, and inferior palpebral
nerve.
l Infraorbital nerve along with its branches, lateral nasal
and superior labial nerve are anaesthetized.
l Area of maxillary central incisor, canine teeth, premo-
lar, and mesiobuccal root of maxillary first molar on
injected side; buccal periodontium, bone of the same
teeth, and anaesthesia of lower eyelid along with lateral
aspect of nose, and upper lip.
Landmarks
l Supraorbital notch
l Infraorbital notch
l Pupil of eye
l Infraorbital foramen
l Mental foramen.
Procedure
Basically two techniques: Bicuspid approach and Central
incisor approach.
l Patient position should be in such a way that his/her
maxillary occlusal plane is at an angle of 45o to the
floor.
l The target is determined by palpating the supraorbital
and infraorbital notches.
l A vertical imaginary line is drawn through these
landmarks which will pass through pupil of the eye,
infraorbital foramen, bicuspid teeth, and mental
foramen.
l After palpating the infraorbital margin, the finger is
moved downwards from it where a concavity will be
felt.
l This is the infraorbital depression and the infraorbital
foramen is in its deepest part.
l Maintaining the thumb on this foramen extremely, re-
tract the lip using the index finger to expose the muco-
buccal fold.
i. Biscupid Approach
l In this approach, the needle is held parallel to the bis-
cuspid teeth.
l The puncture is made at a point about 5 mm from the
mucobuccal fold which allows the needle to be ad-
vanced between the levator labii superioris above, and
the levator anguli oris below.
l Maximum penetration of the needle should be about
2 cm; 1mL of the solution should be deposited, and the
overlying tissue gently massaged to aid penetration of
the solution into canal.
ii. Central Incisor Approach
l In the central incisor approach, the needle is directed
such that it bisects the crown of the central incisors of
the same side to the mesioincisal angle to the distoinci-
sal angle.
l The needle is inserted for about 5 mm from the mu-
cobuccal fold and 1 mL of anaesthetic solution is
deposited.
The effectiveness of block is checked by subjective and
objective symptoms.
Section | I  Topic Wise Solved Questions of Previous Years
Q. 8. Inferior alveolar nerve block.
Ans.
Inferior Alveolar Nerve Block
Nerves Anaesthetized
l Inferior alveolar nerve and its subdivision, incisive
nerve, mental nerve, lingual nerve, buccinator nerve,
and branch of mandibular nerve.
Areas Anaesthetized
l All the mandibular teeth of one side to the midline.
l Body of the mandible and inferior portion of ramus.
l Buccal mucoperiosteum and mucous membrane ante-
rior to the mandibular first molar (mental nerve).
l Anterior two thirds of the tongue and floor of the cavity
(lingual nerve).
l Lingual soft tissues and periosteum (lingual nerve).
Indications
l Extraction of multiple mandibular teeth in quadrant.
l When buccal or lingual soft tissue anaesthesia (anterior
to first molar) is necessary.
Contraindications
l Infection or acute inflammation in the area of injection
(rare).
l Patients who has the habit of biting either the lip or the
tongue; for instance, a very young child or a physically
or mentally handicapped adult or child.
Advantage
l One injection provides a wide area of anaesthesia (use-
ful for quadrant dentistry).
Disadvantages
l Not necessary for localized procedures.
l Aspiration may be positive (10–15%, highest of all in-
traoral injection techniques).
l Lingual and lower lip anaesthesia, discomfiting to many
patients and possibly dangerous for certain individuals.
l Partial anaesthesia possible where a bifid inferior alveo-
lar nerve and bifid mandibular canals are present.
l Intraseptal injection for osseous and soft tissue anaes-
thesia of any mandibular region.
Technique
l The patient should be positioned with his mouth open
and the body of the mandible parallel to the floor.
33
l The operator should stand to the right front side of the
patient and with the left index finger or thumb palpating
the mucobuccal fold.
l Then move the finger or thumb posteriorly until contact
is made with the external oblique ridge and the anterior
border of the ramus of the mandible.
l When the finger or thumb contacts the ramus of the
mandible, it is moved up and down until the greatest
depth of the anterior border of the ramus is identified.
l Move the palpating finger lingually across the retromo-
lar triangle and onto the internal oblique ridge, with the
finger still in line with the coronoid notch and in contact
with the internal oblique ridge, is moved to the buccal
side, taking with it the buccal sucking pad.
l Parallel to the occlusal plane of the mandibular teeth, a
syringe with a 15/8 inch, 25-gauge needle is then in-
serted from the opposite side of the mouth, at a level
bisecting the finger or thumbnail, penetrating the tissue
of the pterygotemporal depression, and entering the
pterygomandibular space.
l During insertion of needle, the patient is asked to keep
the mouth wide open.
Q. 9. Posterior superior alveolar nerve block anaesthesia.
Ans.
Posterior Superior Alveolar Nerve Block
Nerve Anaesthetized
l Posterior superior alveolar nerve.
Area Anaesthetized
l The maxillary molars except the mesiobuccal root of
first molar.
l The buccal alveolar process of the maxillary molars,
including structures overlying it—periosteum, connec-
tive tissue, and mucous membrane.
Anatomical Landmarks
l Mucobuccal fold and its concavity.
l Zygomatic process of the maxilla.
l Infratemporal surface of the maxilla.
l Anterior border and coronoid process of the ramus of
the mandible.
l Tuberosity of the maxilla.
Technique for Right Side
l The operator should stand on the right side of the patient
and the patient is positioned, so that the maxillary oc-
clusal plane is at a 45o angle to the floor.
l The operator should move the left forefinger over the
mucobuccal fold in a posterior direction from the
34 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
bicuspid area until the zygomatic process of the max-
illa is reached.
l The finger tip will rest in a concavity in the mucobuccal
fold at its posterior surface.
l At this particular point, the left forefinger should be
rotated so that the fingernail is adjacent to the mucosa
and its bulbous portion is still in contact with the poste-
rior surface of the zygomatic process.
l Then the hand is lowered, keeping the bulbous portion
of the finger still in contact with the zygomatic process,
so that the finger is in a plane at right angles to the oc-
clusal surfaces of the maxillary teeth, and at a 45o angle
to the patient’s sagittal plane.
l The index finger should be pointing in the exact direc-
tion the needle is to follow.
l The insertion is made for a distance of about 1/2 to 3/4
inch, going upward, inward, and backward.
l After aspirating and making certain that the needle
point is not within a vessel, the operator slowly injects
the contents.
l It will not include the mesiobuccal root of the first max-
illary molar, which is innervated by branches of the
middle superior alveolar nerve.
l This root and supporting tissues can be anaesthetized by
infiltrating bucally, the involved root.
Symptoms of Anesthesia
l Subjective symptoms - None.
l Objective symptoms - Instrumentation is necessary to
demonstrate presence of pain sensation.
Q. 10. Gow-Gates technique.
Or
Gow-Gates nerve block.
Ans.
l Dr George Gow-Gates, a general practitioner of den-
tistry in Australia in 1973, devised the technique.
l This technique has an advantage of higher success rate
than inferior alveolar nerve block.
Nerves Anaesthetized
l Inferior alveolar nerve, mental nerve, incisive nerve,
lingual nerve, mylohyoid nerve, auriculotemporal nerve,
and buccal nerve.
Areas Anaesthetized
l Mandibular teeth of one side up to the midline.
l Body of the mandible and inferior portion ramus.
l Buccal mucoperiosteum, mucous membrane anterior to
the mandibular first molar (mental nerve).
l Anterior two thirds of the tongue and floor of the cavity
(lingual nerve).
l Lingual soft tissues and periosteum (lingual nerve).
l Skin over zygoma.
l Posterior portion of cheek and temporal regions.
l Target area: Lateral region of condyle neck, just below
the insertion of lateral pterygoid muscle.
Landmarks
Extraoral
Lower border of tragus of ear corresponds to the centre of
external auditory meatus and corner of the patient’s mouth.
Intraoral
Tip of the needle is placed just below mesiolingual cusp of
maxillary second molar.
Procedure
l Patient is positioned in supine posture with neck ex-
tended and mouth wide open.
l This position facilitates the injection by moving the
condyle anteriorly.
l Palpating the anterior border of the ramus of the mandible
and identify the tendon of temporalis muscle, the needle is
penetrated into tissues just distal to maxillary second molar
tooth at the height of mesiolingual cusp of second molar.
l The needle should be inserted just medial to the tempo-
ral tendon and directed in the direction parallel to an
imaginary line drawn from the corner of the mouth to
the intertragic notch of the ear and advanced until the
fovea region of the condylar neck is contracted.
l With negative aspiration, deposit 1.8 mL of solution
over 60–90 s.
l The patient is asked to keep the mouth wide open for
20–30 s after the injection, to allow bathing of the nerve
within the solution.
Q. 11. Role of vasoconstrictor in local anaesthesia
solution.
Ans.
l The drugs that constrict blood vessels and thereby
control tissue perfusion are called vasoconstrictors.
l To oppose the vasodialatory actions of the local anaes-
thetic solutions, they are added to them.
l Vasoconstrictors are important additions to a local
anaesthetic solution for the following reasons:
i. By constricting blood vessels, vasoconstrictors
decrease blood flow (perfusion) to the site of ad-
ministration.
ii. Absorption of the local anaesthetic into the cardio-
vascular system is slowed, resulting in lower anaes-
thetic blood levels.
iii. Local anaesthetic blood levels are lowered, thereby
minimizing the risk of local anaesthetic toxicity.
Section | I  Topic Wise Solved Questions of Previous Years
iv. Increased amounts of the local anaesthetic remain
in and around the nerve for longer periods, thereby
increasing the duration of action of most local an-
aesthetics.
v. Vasoconstrictors decrease bleeding at the site of ad-
ministration; they are useful when increased bleed-
ing is anticipated (e.g., during a surgical procedure).
vi. The vasoconstrictors are chemically identical or
similar to the sympathetic nervous system media-
tors, epinephrine and norepinephrine.
vii. The actions of the vasoconstrictors so resemble the
response of adrenergic nerve to stimulation that they
are classified as sympathomimetic or adrenergic
drugs.
Q. 12. Local anaesthesia toxicity.
Or
Toxicity.
Ans.
l Signs and symptoms of minimal to moderate overdose
levels of local anaesthetic toxicity are as follows:
l Apprehension.
l Restlessness and nervousness.
l Excitability and talkativeness.
l Slurred speech.
l Euphoria.
l Generalized stutter, leading to muscular twitching
and tremor in the face and
l distal extremities.
l Dysarthria.
l Nystagmus.
l Failure to follow commands or be reasoned with.
l Elevated blood pressure and respiratory rate.
l Light-headedness and dizziness.
l Vomiting.
l Sensation of twitching before actual twitching is
observed.
l Metallic taste.
l Visual disturbances (inability to focus) and auditory
disturbances (tinnitus).
l Drowsiness and disorientation.
l Loss of consciousness.
Moderate to high overdose levels causes the following:
Tonic-clonic seizures followed by:
l Generalized depression of central nervous system.
l Depressed blood pressure, heart rate, and respiratory rate.
Q. 13. Lignocaine hydrochloride.
Ans.
Chemistry
l Lidocaine (diethylamino-2,6-dimethylacetanilide) is the
first nonester type of local anaesthetic compound to be
used in dentistry.
35
l It is a white crystalline power with a melting point of
69oC and is used as the hydrochloride salt.
l The drug is compatible with all vasoconstrictors and
withstands boiling and autoclaving.
l Lidocaine base is only slightly water-soluble, but the
hydrochloride salt is readily soluble in water.
Pharmacology
l In dentistry, lidocaine is the first nonester compound to
be used as a local anaesthetic.
l Lidocaine diffuses readily through interstitial tissues
and into the lipid-rich nerve, giving a rapid onset of
anaesthesia.
l It has an onset time of about 2 to 3 min.
l Duration of action depends on the type of injection,
e.g., nerve block will have longer duration than infiltra-
tion and the amount of vasoconstrictor included in the
solution.
Systemic Effects
i. Nervous System
l Lidocaine, in toxic doses, first produces stimulation
then depression of the central nervous system.
l The patient at times becomes lethargic and sleepy from
systemic absorption of the drug .
l Convulsions may be induced.
ii. Cardiovascular system
l The effect of lidocaine on the vasculature is vasodilata-
tion produced by the direct relaxing effects on the
smooth muscle of the vessel walls.
l In toxic doses this action contributes to hypotension and
cardiovascular collapse.
iii. Respiratory system
l Small doses of lidocaine have a mild bronchodilating
effect on the respiratory system.
l Respiratory arrest (apnea) is one of the most common
causes of death related to the overdose of a local anaes-
thetic.
l In the majority of cases respiratory arrest precedes car-
diac arrest in toxic overdose.
Biotransformation
Lidocaine undergoes biotransformation in the liver
l
rather than hydrolysis in the plasma.
l Lidocaine and its various breakdown products are ex-
creted in the urine to some extent, with 4-hydroxy-2,
6-dimethylaniline being the major urinary metabolite.
36 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

SHORT NOTES
Q. 1. EMLA. b. Mental nerve: Sensory from the skin of the lower lip
Ans. and chin regions and from the mucous membrane lining
l EMLA means Eutectic Mixture of Local Anaesthetics.
the lower lip region.
l The development of an oil-in-water emulsion contain-
c. Incisive nerve: Sensory from incisors, cuspid teeth, and
ing high concentrations of lidocaine and prilocaine in their periodontal membranes.
baseform resulted in EMLA, which has been shown to
Q. 4. Define nerve block.
provide anaesthesia of intact skin, profound enough to
permit venipuncture to be performed painlessly. Ans.
l EMLA consists of 5% cream containing 25 mg/g each
l The nerve block method of securing regional analgesia
of lidocaine and prilocaine.
consists of depositing a suitable local anaesthetic solu-
l It is applied to the skin for at least 1 h before the antici-
tion within close proximity to a main trunk, and thus
pated procedure.
preventing afferent impulses from travelling centrally
l The cream is covered with an occlusal dressing.
beyond that point.
l It is used in paediatrics in many ways, including veni-

puncture, vaccination, suture removal, minor otological Q. 5. Failure of local anaesthesia—causes.

surgery, lumbar puncture, minor gynecological and uro-
logical procedures, and dermatological surgery, including Or
split-thickness skin graft harvesting, argon laser treat-
ments, postherpetic neuralgia, debridement of infected Reasons for failure of local anaesthesia.
ulcers, and inhibition of itching and burning in adults.
l Use of EMLA in infants under 6 months of age is con- Ans.
traindicated because of the possibility of a metabolite of The failure of local anaesthesia can occur due to:
prilocaine inducing methaemoglobinaemia. i. Improper technique used for giving local anaesthesia.
ii. Inadequate knowledge of practitioner.
Adverse Responses iii. Severe infection can be one reason not to achieve
l Transient and mild skin blanching and erythema. proper anaesthesia.
iv. Uncooperative patient.
Q. 2. Ideal local anaesthetic drug.
Q. 6. Action of vasoconstrictors in local anaesthesia.
Ans.
The ideal anaesthetic drug should be: Ans.
l Having reversible action.
Vasoconstrictors are important additions to a local anaes-
l Nonirritating to the tissues and produce no secondary
thetic solution for the following reasons:
local reaction.
i. They reduce blood flow (perfusion) to the site of
l Consisting of a low degree of systemic toxicity.
administration.
l Having a rapid onset and sufficient duration of action.
ii. Absorption of the local anaesthetic into the blood ves-
l Having potency sufficient to give complete anaesthe-
sels is lowered, thereby minimizing the risk of local
sia without the use of harmful concentrated solutions.
anaesthetic toxicity.
l Relatively free from producing allergic reactions.
iii. Increased amounts of the local anaesthetic remain
l Stable in solution and undergo biotransformation
in and around the nerve for longer periods. This in-
readily within the body.
creases the duration of action of most local anaes-
l Either sterile or should be capable of being sterilized
thetics.
by heat without deterioration.
Q. 3. Name the branches of the inferior alveolar nerve. Q. 7. Intraligamentary anaesthesia.
Ans.
Ans.

Inferior Alveolar Nerve has the Following
Branches
a. Dental branches: Sensory from all of the lower molar
and bicuspid (mandibular) teeth and their periodontal
membranes.
l Intraligamentary anaesthesia technique provides single
tooth anaesthesia.
l This consists of forcing the anaesthetic solution under
pressure into the periodontal membrane space of maxil-
lary or mandibular teeth.
l It is, in effect, a type of infiltration technique.
Section | I  Topic Wise Solved Questions of Previous Years 37

Q. 8. Composition of local anaesthesia. l Infraorbital ridge.

l Side of nose.
Ans.
l Lower eyelid.

Composition of Local Anaesthesia Q. 12. Mental nerve block.

l 2% Lidocaine hydrochloride—local anaesthetic agent. Ans.
l 1:80, 000 to 1:1, 00, 000—vasoconstrictor prolongs the

action of local anaesthetic. Nerve Anesthetized

l Sodium metabisulphite—oxidizing agent.

l Methyl paraben—preservative.
l Mental nerve.
l Thymol—antifungal.

l Distilled water—solvent. Areas Anesthetized

Q. 9. Clinical applications of vasoconstrictor agents. l Lower lip.
Or l Mucous membrane in the mucolabial fold anterior to
the mental foramen.
Adrenaline.
Or Anatomical Landmarks
Epinephrine.
l Mandibular bicuspids, since the mental foramen usually
Ans. lies at the apex and just anterior to the second bicuspid
root.
Mode of Action of Adrenaline
l Epinehrine acts directly on both alpha- and beta- Indication
adrenergic receptors, beta effects predominate. l For surgery on the lower lip or mucous membrane in the
mucolabial fold anterior to the mental foramen.
Clinical Applications of Adrenaline
l Management of acute allergic reactions, bronchospasm, Technique
and cardiac arrest. l The apices of the bicuspid teeth should be estimated.
l As a vasoconstrictor for haemostasis and in local anaes-
l A 25-gauge needle with length of 1 inch should be in-
thetic solutions to decrease absorption into cardiovascu- serted into the mucolabial fold after retracting the cheek.
lar system. l The needle is penetrated until the periosteum of the
l As a vasoconstrictor in local anaesthetic, to increase depth
mandible is gently contacted slightly anterior to the
of anaesthesia and duration of action of anaesthesia. apex of the second bicuspid and anaesthetic solution of
l To produce mydriasis.
0.5–1 mL is slowly deposited in this area.
Q. 10. Give the order of anaesthetizing various nerves in
direct pterygomandibular block technique. Symptoms of Anaesthesia
Ans. l Tingling and numbness of the lower lip on the injected
side is seen.
Order of Anaesthetizing Pterygomandibular Q. 13. Complications of broken needle in the pterygo-
Nerve mandibular space and their prevention.
l Inferior alveolar nerve. Ans.
l Lingual nerve.
l Long buccal nerve.
Complications due to broken needle are as follows:
i. Haematoma,
Q. 11. Landmarks for extraoral maxillary nerve block. ii. Trismus,
Ans. iii. Infection, etc.

Infraorbital Block Landmarks Prevention

l Pupil of the eye. l Older needle should not be used.
l Infraorbital notch. l Thin needles should not be used in thick bone.
38 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Lateral pressure on the shaft or the needle should be
avoided.
Q. 14. Vazirani-Akinosi technique.
Or
Kazanjian’s technique.
Ans.
Vazirani-Akinosi technique is also known as closed mouth
technique.
Nerves Anaesthetized
l Inferior alveolar nerve, mental nerve, and incisive nerve.
l Lingual nerve, buccinator nerve, and mylohyoid nerve.
Landmarks
l Mucogingival junction of maxillary third or second
molar.
l Maxillary tuberosity.
l Coronoid notch on ramus of mandible.
Procedure
l Patient is placed in supine position with teeth
occluded.
l Lip is retracted to expose maxillary and mandibular
teeth.
l At the level of mucogingival junction of maxillary mo-
lars, the syringe is directed parallel to the occlusal and
sagittal planes.
l Penetrate the needle just medial to the ramus of man-
dible 25–30 mm into the tissues.
l Now the tip of the needle lies in midportion of pterygo-
mandibular space close to the branches of mandibular
nerve.
l About 1.5–1.8 mL of anaesthetic solution is deposited.
Q. 15. Specific receptor theory.
Ans.
l Specific receptor hypothesis is the most favoured theory
of local anaesthesia.
l The local anaesthetic receptor is located at or near the
sodium channel in the nerve membrane either on
its external surface or on the internal axoplasmic
surface.
l Once the receptors access is gained, sodium ion perme-
ability is decreased or eliminated and nerve conduction
interrupted.
l Local anaesthetics act by attaching themselves to spe-
cific receptor in the nerve membrane.
Q. 16. Define pain. Enumerate methods of pain control.
Ans.
Pain is defined as an unpleasant emotional experience, usu-
ally initiated by a noxious stimulus and transmitted over a
specialized neural network to the central nervous system,
where it is interpreted as such.
Following are the methods of pain control:
l Removing the cause.
l Blocking the pathway of painful impulses.
l Raising the pain threshold.
l Preventing pain reaction by cortical depression.
l Using psychosomatic methods.
l The first two methods affect pain perception, the last
two affect pain reaction, and the third may affect both
aspects.
Q. 17. Haematoma.
Ans.
l Effusion of blood into extravascular spaces during in-
jection of LA, causes haematoma.
Causes
l IANB or PSA block due to nicking of an artery or vein.
Management
Immediate
l Pressure application not less than 2 min, stops bleeding.
Subsequent
l Ice application.
l Soreness and limitation of movement—no heat applica-
tion in the first 4–6 h can be applied next day.
l Within 12–14 days, resolution occurs.
l No treatment during this period is advised.
Q. 18. Anaphylaxis.
Ans.
l Anaphylactic reactions is a prototype example of a
type I hypersensitivity immunologic reaction which is
IgE-mediated.
Signs and Symptoms
l Patient becomes extremely apprehensive, intensive
itching occurs, and asthmatic breathing develops.
l Urticaria may develop rapidly.
l Death may occur within a few minutes or several hours
later.
Section | I  Topic Wise Solved Questions of Previous Years
Treatment
l Immediate application of a tourniquet above the site of
injection.
l Epinephrine is the drug of choice because of its
vasopressor, bronchodilator, and antihistaminic l If patient refuses regional analgesia because of fear or
action.
l Dose for adult is 0.3–1 mg subcutaneously or intramus-
cularly..
l If possible, an intravenous route of drug administration
can be started.
l Oxygen under pressure should be given with assisted
respiration.
l Antihistamines such as diphenhydramine 50 mg are
given IV or IM.
Conscious Sedation and General Anaesthesia
LONG ESSAY
Q. 1. Mention the indications for general anaesthesia
in dental setting. Describe the stages of general anaes-
thesia.
Ans.
Indications for General Anaesthesia in a
Dental Setting
l In uncooperative patients, if multiple procedures are
required like extractions, root canal treatment, etc., then
they may be done in one sitting.
l Apprehensive patients.
l Patients allergic to the contents of a local anaesthetic
solution.
Stages of General Anaesthesia
Stage I: Analgesia
l This stage extends from the beginning of induction to
the loss of consciousness.
l There is progressive abolition of pain.
l Patient is conscious but in a dream-like state. The pa-
tient can hear and see.
l Reflexes and respiration remain normal.
l Though minor surgical procedures can be carried out in
this stage, it is difficult to maintain.
39
Corticosteroids such as hydrocortisone 100 mg IV or
l
IM are given for peripheral vascular effects.
Q. 19. Contraindications for regional analgesia.
Ans.
apprehension.
l Infection rules out the use of regional anaesthetics.
l Patient is allergic to various local anaesthetics.
l Patient is below the age of reason.
l Patient is unable to cooperate because of mental defi-
ciencies.
l Major oral surgery makes regional analgesia unfeasible.
l Anomalies make regional analgesics difficult or
impossible.
Topic 4
Stage II: Stage of Delirium
l This stage extends from the loss of consciousness till
the beginning of regular respiration.
l Excitement in the form of violent movements of limbs,
vomiting, and muscle contractions; patient may hold his
breath or have irregular respiration, incoherent speech, etc.
l Raised BP and tachycardia.
l Dilated pupils.
l Surgeries should not be performed at this stage.
l With newer drugs used for anaesthesia, this stage is
bypassed nowadays.
Stage III: Stage of Surgical Anaesthesia
l This stage extends from the beginning of regular spon-
taneous respiration until complete cessation of sponta-
neous respiration. This can be divided into four planes.
Plane 1
l Regular spontaneous respiration and eyelid reflex is lost.
l Vigorous uncoordinated eyeball movements.
l Loss of pharyngeal reflex.
l Loss of conjunctival reflex at the end of plane I.
Plane 2
l Centrally fixed eyes, decreased size of pupil, loss of mus-
cle tone, loss of laryngeal reflex, and loss of corneal reflex.
40 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Plane 3 l This is useful in determining the surgical and anaes-

l Pupillary light reflex is lost. Intercostal muscle paralysis thetic risk prior to the procedure.
occurs. Respiration is diaphragmatic and there is
complete muscle relaxation. ASA I
Plane 4 l The patient has no organic, physiological, biochemical,
l Respiration is gradually depressed and there is progres-
or psychiatric disturbance.
l The pathological process for which the operation is
sive diaphragmatic paralysis.
being conducted is localized and does not entail any
systemic disturbance.
Stage IV: Stage of Medullary Paralysis
l In this stage, respiratory arrest and vasomotor collapse ASA II
take place.
l Pupils are widely dilated.
l Mild to moderate systemic disturbances caused either
l Skin is cold and ashen.
by the condition to be treated surgically or by other
l Pulse is feeble and BP is low.
pathophysiological process.
l Mild organic heart disease, diabetes, hypertension,
l Respiration finally ceases.
anaemia, old age, etc.
Q. 2. Preanaesthetic evaluation of patient undergoing
general anaesthesia and explain assessment of physical
status of the patient. ASA III

Ans. l Limitation of lifestyle due to disease.

l Severe systemic disturbances or diseases, e.g., angina,
Preanaesthetic evaluation is mandatory for all patients history of MI, diabetes, etc.
undergoing surgical procedures under general anaesthesia.
l The patient who is to undergo any surgical procedure
ASA IV
under general anaesthesia, should be assessed thor-
oughly by the anaesthetist prior to the surgery. l Life-threatening severe systemic disorder.
l Thorough evaluation of medical history should be

done.
ASA V
l Any previous history of exposure to anaesthesia (how

long back, any side effects of that procedure) should be l A morbid-end patient not expected to survive more than
found out. 24 h with or without operation.
l Current physical status, use of medications, if any.

l Presence of loose teeth, dentures, crown and bridge on

anterior teeth, etc.
l An informed consent form should be signed by the
patient.
l The patient should be explained about the endotracheal
tube, masks, IV lines, etc. The patient should also be
told that these may be present when he recovers from
anaesthesia. It should not be new and frightening to the
patient.
l Any questions and doubts should be answered in
detail.
l Appropriate laboratory findings should be checked and
ASA VI
l Emergency operation of any variety.
Drugs Used for Premedication
i. Opioids such as morphine or pethidine.
ii. Benzodiazepines such as diazepam and medazolam.
iii. Anticholinergics such as atropine.
iv. Histamine receptor blockers such as cimetidine and
ranitidine.

also the availability of cross matched blood, if required.
A well-prepared patient is usually very cooperative.
Assessment of the Physical Status of the
Patient
l The American Society of Anaesthesiologists adopted
the ASA physical status classification.
The purpose of Premedication
l To reduce anxiety of the patient.
l To produce amnesia.
l To reduce salivary and bronchial secretions.
l To suppress coughing and vomiting.
l To reduce use of GA drugs by providing synergistic
effect.
Section | I  Topic Wise Solved Questions of Previous Years
SHORT ESSAY
Q. 1. General anaesthesia.
Ans.
Depending on the route of administration of the drug, l This stage extends from the beginning of induction to
induction of general anaesthesia (GA) may be by two
means:
i. Inhalation induction
ii. Intravenous induction.
Inhalational Induction
l Gaseous agents used are nitrous oxide or anaesthetic
vapours such as halothane or isoflurane.
l Induction by this method is a slow process and is usu-
ally used for maintenance of anaesthesia.
Intravenous Induction
l Drugs such as thiopentone sodium are injected intrave-
nously for induction of GA.
l Induction of anaesthesia is usually done using intrave-
nous drugs.
l This produces smooth and easier induction and is much
faster so that the classical stages of anaesthesia as bypassed nowadays.
described by Guedel are not seen as the patient is taken
into the stage III rapidly.
Endotracheal Intubation
l This procedure secures the airway by placing a
tube into the trachea either via the nose, mouth, or a
tracheostomy.
l This tube has an inflatable cuff.
l Once the tube is placed into the trachea, the cuff is
inflated. This prevents aspiration of debris.
l This tube is connected to the anaesthetic machine to
allow the delivery of oxygen, nitrous oxide, and an l Loss of conjunctival reflex at the end of plane 1.
inhalational anaesthetic.
l A throat pack is used as a supplement to the cuff to
prevent aspiration of blood, saliva, and debris.
Drugs used for Premedication
l Opioids such as morphine or pethidine.
l Benzodiazepines such as diazepam and medazolam.
l Anticholinergics such as atropine.
l Histamine receptor blocker such as cimetidine and
ranitidine.
Q. 2. Stages of general anaesthesia.
Ans.
41
Stages of General Anaesthesia
Stage I: Analgesia
the loss of consciousness.
l There is progressive abolition of pain.
l Patient is conscious but in a dream-like state. The
patient can hear and see.
l Reflexes and respiration remain normal.
l Though minor surgical procedures can be carried out in
this stage, it is difficult to maintain.
Stage II: Stage of Delirium
l This stage extends from the loss of consciousness till
the beginning of regular respiration.
l Excitement in the form of violent movements of limbs,
vomiting, and muscle contractions; patient may hold his
breath or have irregular respiration, incoherent speech, etc.
l Raised BP and tachycardia.
l Dilated pupils.
l Surgeries should not be performed at this stage.
l With newer drugs used for anaesthesia, this stage is
Stage III: Stage of Surgical Anaesthesia
l This stage extends from the beginning of regular spon-
taneous respiration until complete cessation of sponta-
neous respiration. This can be divided into four planes:
Plane 1
l Regular spontaneous respiration and eyelid reflex is
lost.
l Vigorous uncoordinated eyeball movements.
l Loss of pharyngeal reflex.
Plane 2
l Centrally fixed eyes, decreases size of pupil, loss of
muscle tone, loss of laryngeal reflex, and loss of corneal
reflex.
Plane 3
l Pupillary light reflex is lost. Intercostal muscle paralysis
occurs. Respiration is diaphragmatic and there is
complete muscle relaxation.
Plane 4
l Respiration is gradually depressed and there is progres-
sive diaphragmatic paralysis.
42 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Stage IV: Stage of Medullary Paralysis l Airway should be maintained properly with nasotra-
cheal or nasopharyngeal tube.
l In this stage, respiratory arrest and vasomotor collapse
l Patient’s vital signs should be maintained.
take place.
l Care should be taken to reduce the risk of vomiting and
l Pupils are widely dilated.
excessive restlessness as a result of pain or hypoxia.
l Skin is cold and ashen.
l Airway complication may occur, so all the necessary
l Pulse is feeble and BP is low.
instruments should be kept near by the bed.
l Respiration finally ceases.
l Patient’s blood pressure should be monitored at regular

Q. 3. General anaesthesia vs Conscious sedation. time intervals.

l Fluid and electrolyte balance should be maintained.

Ans.
General anaesthesia
Single sitting i.e., once in a
lifetime procedure.
Used for uncooperative
Conscious sedation
At several visits, the treatment
procedures may be performed.
Patient is cooperative, but
Q. 6. Nitrous oxide.
Ans.
l Nitrous oxide is the most commonly used inhalational
anaesthetic.
l It is an inert, colourless inorganic gas.

patients. anxious and fearful. l It produces different levels of effect depending on the

Basic investigation, No extensive investigation and percentage of exposure.

premedication, and NPO nopremedication are required. l 10–15% causes numbness and tingling of extremities,
is strictly required. No NPO required. and some sedation. 35–40% causes increased sedation
Ventilation is required. Airway is maintained as patient is and mild analgesia.
conscious. l Patient has the sensation of floating; and, noises around

99% success rate reported. No mortality.

him may appear dull and distant.
l There is significant numbness and tingling felt in the
Time-consuming Recovery operation period is hands, feet, and circumoral areas.
procedure. 1–2 min.
l The patient may have a feeling of warmth.
Patient cannot control the Patient feels he is in control of the
situation. situation.
Indications
l Mildly apprehensive and uncooperative adult patients
Q. 4. Preanaesthetic evaluation of patient undergoing
and uncooperative children.
general anaesthesia.
l Patients who have a severe gag reflex.

Ans. l Medically compromised patients such as those with

cardiovascular disorders, asthma etc., who cannot un-

Refer to long essay Q. 2 of same topic. dergo stressful procedures.

Q. 5. Postoperative care of patient treated under general

anaesthesia. Contraindications
Ans. l Patients with upper respiratory tract infection.
l Pregnant patients, especially first trimester of preg-
nancy.
Postoperative Care of Patients Treated Under l Mentally retarded patients and patients who are
General Anaesthesia extremely anxious.
l Such patients are more suitable for procedures under GA.
l Postoperatively, the patient should be looked after in an
intensive care unit for first 24–48 h.

SHORT NOTES
Q. 1. Conscious sedation.
Ans.
l A minimally depressed level of consciousness that re-
tains the patient’s ability to maintain an airway indepen-
dently and continuously, and respond appropriately to
physical stimulation and verbal command is known as
conscious sedation.
Indications for Conscious Sedation
l Uncooperative children and adults.
l Patients with phobia for dental treatments.
l Small children requiring multiple dental procedures.
l Some medically compromised patients who cannot
tolerate stress in the dental procedure.
Section | I  Topic Wise Solved Questions of Previous Years 43

Objectives of Conscious Sedation Q. 3. Name few gaseous anaesthetic agents.

l Mood alteration: Patients who are generally psycho- Ans.
logically apprehensive.
l Elevation of pain threshold: The patient’s pain threshold
Commonly Used Gaseous Anaesthetic Agents
is elevated by the use of certain drugs.
l Amnesia. l Nitrous oxide,
l Halothane,
Q. 2. Intravenous anaesthetic thiopentone sodium in
l Enflurane, and
oral surgery.
l Isofluroane.
Ans.
Q. 4. Name the stages of general anaesthesia.
l Thiopentone sodium is an ultrashort acting barbiturate

with a half-life of 6–8 h. Ans.

l It acts rapidly and can produce unconsciousness within

20 s.
Stages of General Anaesthesia
l It is given in a dose of 4–8 mg/kg.

l Extravasation of the intravenous injection is highly ir- Stage I: Analgesia.

ritating and may produce severe pain. Stage II: Stage of delirium.
l It is a weak muscle relaxant and poor analgesic. Stage III: Stage of surgical anaesthesia.
l This is the most commonly used inducing agent. This stage is divided in to four planes.
Stage IV: Stage of medullary paralysis.

Topic 5
Principles of Exodontia and Instrumentation

LONG ESSAYS
Q. 1. Discuss the indications, contraindications, and l Periodontal disturbances.
complications of dental extractions. l Depending on the
Or a. Success of the periodontal therapy.
b. Patient’s attitude towards the concept of conserving
Discuss in detail indications, contraindications, and such teeth.
principles followed in dental extraction of teeth. Add a c. Economic and time factors.
note on its complications. l Orthodontic reasons

Or a. Therapeutic extractions—to gain space.

What are the complications of extraction of teeth? How
would you avoid them? Describe in detail the treatment
of anyone?
Ans.
The indications of dental extractions are as follows:
l Dental caries
a. If all the conservative procedures have failed.
b. The sharp margins of the teeth repeatedly ulcerate
the mucosa.
c. Leading to deteriorating oral hygiene.
l Pulp pathology: Is studied in cases where endodontic
treatment is not possible.
l Apical pathology: Is studied in cases of apical pathol-
ogy, where it can widen and involve the adjacent teeth.
b. Malposed teeth—to realign them.
c. Serial extraction—extraction of a few deciduous
teeth in chronological order to prevent malocclusion
as the child grows.
Extractions of teeth for orthodontic reasons should be based
onorthodontic assessment,genetic evaluation,and evalua-
tion of the soft tissues, lips, and tongue.
l Prosthetic considerations
a. To provide efficient dental prosthesis.
b. To remove remaining few teeth for purpose of com-
plete dentures.
l Impactions
Removal of impacted tooth for purpose of facial pain, peri-
odontal disturbances of the adjoining teeth, TMJ problems,
44
bony pathology like cysts, and pathological fractures of the
jaws as well as overcrowding of anterior teeth.
l Supernumerary teeth
It may predispose to malocclusion, periodontal distur-
bances, facial pain, bony pathology, or aesthetic problems.
l Tooth in the line of fractures
The tooth is extracted if:
a. It is a source of infection at the site of the fracture.
b. The tooth itself is fractured.
c. The retention may interfere with fracture reduction.
l Teeth in relation to bony pathology
If are involved in cyst formations, neoplasms, or osteomyelitis.
l Root fragments
If they lead to painful ulceration that becomes neoplastic,
bony pathology like osteomyelitis, cyst or neoplasm, and
facial pain or numbness.
l Teeth prior to irradiation
It is indicated only if oral hygiene cannot be maintained in
a sound condition.
l Focal sepsis
l Doubtful teeth with foci of infection are extracted.
l Aesthetics
In cases where conservative, orthodontic, or surgical means
cannot be used.
l Economic consideration
Contraindications
It is better to avoid extraction in cases of absolute contrain-
dications such as:
l Congestive cardiac failure.
l Leukaemia.
l Uraemia.
l Cirrhosis of liver.
l Terminal stages of malignancy.
Other systemic and local contraindications are:
l Diabetes and hypertension: A sure way of preventing
any potential complication is by carrying out extrac-
tion only in patients with controlled diabetes and l Cardiac arrest.
hypertension.
l Patients on steroid therapy: To prevent adrenal crisis
due to stress, the steroid dose should be doubled one or
two days prior to extraction; and, should be continued
one or two days postoperatively after which the dose
can be slowly tapered.
l Pregnancy: Extraction should be carried out only
with the obstetrician’s consent in the first and third
trimester.
l Bleeding disorders: Consent from the haematologist is
necessary for an uncomplicated extraction. Patients on
Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
anticoagulant therapy require physician’s/cardiologist’s
advice.
l Medically compromised patients: Failure to evaluate
the patient preoperatively may pose as a systemic com-
plication that can lead to drug interactions.
l Local contraindications: It is preferable to avoid any
kind of infection by carrying out extractions under
antibiotic therapy.
l Extraction of teeth in recently irradiated patients:
Irradiation in jaws will reduce the blood supply due
to fibrosis. Therefore, extraction is avoided to prevent
osteoradionecrosis.
Complications
The possible complications of tooth extraction are as
follows:
l Failure to secure anaesthesia.
l To remove the tooth with either forceps or elevators.
l Fracture of crown of tooth being extracted.
l Roots of tooth being extracted.
l Alveolar bone.
l Maxillary tuberosity.
l Adjacent or opposing tooth.
l Mandible.
l Dislocation of adjacent tooth.
l TMJ.
l Displacement of root into the soft tissues.
l Into the maxillary antrum.
l Excessive haemorrhage during tooth removal.
l On completion of extraction.
l Postoperatively.
l Damage to adjacent structures.
l Gums.
l Lips.
l Lingual nerve.
l Tongue and floor of the mouth.
l Postoperative pain due to damage to hard and soft tissues.
l Dry socket.
l Acute osteomyelitis of mandible.
l Syncope.
l Respiratory arrest.
l Postoperatively.
l Swelling due to oedema or haematoma formation.
l Infection.
l Trismus.
Q. 2. How would you do an open method of tooth
extraction?
Ans.
l Open method of extraction is also known as ‘transalveo-
lar extraction’ or ‘surgical extraction’.
Section | I  Topic Wise Solved Questions of Previous Years
This method of extraction is indicated if:
i. a tooth resists intra-alveolar form of extraction.
ii. when the retained roots are difficult to grasp with for-
ceps especially when they are in close approximation to
the maxillary antrum.
iii. a heavily restored, root filled or pulpless tooth.
iv. ankylosed or hypercementosed tooth.
v. geminated or dilacerated tooth.
vi. teeth showing complicated root patterns radiograph-
ically.
when denture has to be inserted immediately.
l After securing adequate anaesthesia it is important to
design the mucoperiosteal flap to facilitate the tooth,
root, and bone removal.
l The mucoperiosteal flap should be large anteroposteri-
orly to provide adequate visual and mechanical access.
The base of the flap should be broader when compared
to the free end, as this provides a rich blood supply for
efficient healing.
l The incision should be made with a scalpel through the
mucous and periosteal layer of the gingiva at right angle
to the bone. It should avoid the mental nerve and the
greater palatine artery. The flap can be buccal, lingual,
or palatal. It should involve the dental papilla and
should lie on sound bone structure.
l The mucoperiosteal flap is elevated with the help of a
sharp periosteal elevator to expose the underlying bone.
The alveolar bone removal is limited to only as much as
is required for application of forceps or elevator and to
displace the tooth. All the sharp edges and bony projec-
tions should be removed.
l A dental bur, chisel, or gouge with hand or mallet pres-
sure are usually used for bone removal. The burs com-
monly used are round- or rose-head bur and ash surgical
bur usually size 8.
l The elevated flap is to be held with a flat bladed retrac-
tor. Constant sterile saline should be used to prevent
heat, clogging, and to remove debris.
l A row of small holes are made which are then con-
nected either with the bur or the chisel.
l The tooth is dislocated with forceps in case of firm tooth
or with elevators. In cases of multirooted teeth, the bi-
furcation is used to separate the two roots from below
upwards followed by dislocation of individual roots.
This can be done either with a bur or an osteotome.
l Any bony defects are planed with rongeur forceps or
bone files. Once the bony edges are smooth, the wound
is irrigated with saline and all bone debris and infected
granulation tissues are removed.
l The mucoperiosteal flap is replaced back in position
and sutured to minimize wound contamination with
debris and haemorrhage. A simple interrupted or in-
terrupted horizontal suture is used to close the wound.
45
Q. 3. Classify the instruments used in dental extraction.
Explain in detail elevators used in extraction.
Ans.
The instruments used for closed extraction method are as
follows:
a. The elevators used in dental extraction
According to form
l Straight.
l Angular.
l Crossbar.
Commonly used elevators
l Periosteal elevators.
l Apexo elevators.
l Crossbar elevators.
b. The forceps used for extraction of teeth
l Upper anterior forceps.
l Bayonet forceps.
l Upper molar forceps.
l Upper root forceps.
l Lower anterior forceps.
l Lower molar forceps.
The instruments used for open extraction as per steps
involved are:
l Incision—scalpel blade.
l Elevation of mucoperiosteal flap—Nonbladed retractor.
l Bone cutting—Bur, chisel, or osteotome.
l Tooth separation—Bur or osteotome.
l Displacement of tooth—Elevators or forceps.
l Flap closure—Suturing material.
Elevators are described in detail below:
l Elevators are the instruments used to elevate the tooth
or root from the alveolar socket.
l It has the handle, shaft, and blade. Its effectiveness
depends on the design of the handle and its efficiency
on the design of the blade.
a. Straight elevator
l In straight elevator, the handle, the shaft, and the
blade all are in the same plane.
l It is used to:
- luxate the last tooth in the dental arch.
- luxate the tooth during extractions.
- elevate the mandibular third molars.
b. Winter’s crossbar elevators
l These elevators form a pair. They are indicated in
the removal of mandibular root when the other
root is already removed.
l The tip of the elevator is introduced in empty
socket with concave surface facing the root to be
removed. The elevator is then rotated by the
wheel and axle principle.
l Hence the same elevator can be used on the distal root
of the right side and the mesial root of the left side.
46 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l When both the roots are intact, tip of the elevator
can be applied at the bifurcation from the buccal
side and force is applied using lever principle and
wheel and axle principle to elevate the roots.
c. Cryer’s elevator
l It is a useful instrument used to luxate the maxil-
lary teeth or roots.
l Elevators have the handle at an angle to the shaft,
e.g., Cryer’s elevator.
l It is used to remove erupted maxillary III molars
and maxillary root fragments.
e. Apexo elevators
l They are used for removal of fractured root,
impacted maxillary third molars, and impacted
cuspids.
l They are available in various numbers.
Q. 4. Describe the principles of elevators used in oral
surgery.
Ans.
Principles of elevators used for extraction are as follows:
i. Lever principle of first order.
ii. Wedge principle.
iii. Wheel and axle principle.
i. Lever Principle
l It has three basic components: Fulcrum, effort, and
load.
l It is a lever of first class with the fulcrum in between the
effort and the load.
l In this principle, to gain a mechanical advantage the
effort arm on one side of the fulcrum should be longer
than the load arm on the other side of the fulcrum.
l The force is transmitted at the long effort arm and
a mechanical advantage is gained at the short load mechanical advantage.
arm.
Area of Usage
l This principle is not of much advantage in forceps if
used alone, but if used in combination with wheel and
axle it proves useful.
l The hinge of the forceps acts as a fulcrum, while the two
arms represent each component of the lever.
l The length of the handle compared to the blade repre-
sents the mechanical advantage. To gain a mechanical
advantage, the grip should be farther from the fulcrum
and the blade should be shorter.
l This principle is used in elevators, wherein the handle of
the elevator represents the effort, and the working-end
which engages the tooth represents the load.
ii. Wedge Principle
l The wedge consists of two movable inclined planes
with a base on one end and a blade on the other end,
which overcomes a large resistance at right angles to the
applied force.
l The effort is applied to the base of the plane and the
resistance has its effect on the slant side.
Area of Usage
l Wedge principle can be used alone in extracting
a tooth. However, it is very often used with lever
principle.
l According to this principle, a wedge can be used to
split, expand, or displace the portion of the substance
that receives it.
l Applied to elevators:
Elevators can also be used to luxate a tooth from
its socket, e.g., a straight elevator is applied between
the tooth and the bone to separate the attachment of
the periodontal ligament from the bone as described
previously.
l Applied to forceps:
For carrying out extraction, the tip of the forceps is
inserted in between the mucoperiosteum and surface
of the tooth. To displace the mucoperiosteum, the bony
sockets are expanded which results in slow separation
of the periodontal ligament from the bone.
iii. Wheel and Axle Principle
l Wheel and axle is a simple machine and is a modified
form of lever. The effort is applied to the circumference of
wheel, which will turn the axle so as to raise the weight.
l Greater the diameter of the wheel the more is the
Area of Usage
Applied to Elevator
l Crossbar elevators are used for removing the mandibu-
lar roots by engaging the working point of the elevator
deep into the space between the tooth root and the bone,
and the handle is rotated.
l The root is removed from its socket by moving about a
circumference of the circle which the roots would have
made if they continued on around.
Applied to Forceps
l To remove a tooth, the beaks of the forceps are applied
firmly on either side of the tooth and force is applied in
Section | I  Topic Wise Solved Questions of Previous Years 47

the form of an arc. This results in a bodily rotation of the l Reactive hyperaemia resulting as the effect of adrenalin
tooth in the socket which is ultimately delivered out. wears off.
l To gain a mechanical advantage, always hold the for- l Violent exercise of general peripheral vasodilatation

ceps handle as farther away as possible to increase the and raise in B.P.
effort arm. However, the periodontal attachment gets l The consumption of a number of alcoholic drinks

ruptured due to the bodily rotation of the tooth. perhaps for their analysis or euphoric effect again of
l This principle can be used separately or in conjunction general peripheral vasodilatation.All may trigger such a
with wedge or lever principle in removing the teeth. haemorrhage.
l A fit of coughing in response to a small trickle of blood
Q. 5. Enumerate the various causes for postextraction
or saliva may produce venous congestion and restart
bleeding and discuss the various methods available to
substandard haemorrhage from the wound.
control bleeding from socket.
l The classic reactionary haemorrhage is that which

Or supervenes the high B.P. during the initial recovery

from a severe operation.
Enumerate the causes for postextraction bleeding. How
do you diagnose and manage postextraction bleeding?
iii. Infection at the Wound Site
Ans.
l Secondary haemorrhage is usually due to partial divi-
Causes of postoperative haemorrhage are categorized as
sion of blood vessels in combination of sepsis.
follows:
l The carotid vessels are stripped clean of tissue on their
I. Failure to control haemorrhage at the conclusion of the
superficial aspect. If triradiate part of suture line lies
operation.
over these vessels and wound dehiscence occurs, then
II. A factor restarting haemorrhage in the early postopera-
there is considerable risk of ulceration and rupture of a
tive period.
carotid.
III. Infection at the wound site leading to secondary haem-
orrhage.
Management of Postoperative Haemorrhage
I. Failure to Effect Haemostasis l Determine the site and amount of haemorrhage.
l The blood clot should be grasped in a piece of gauze
l It comes under negligence of operator.
and removed.
l No wound should ever be sutured until adequate haemo-
l A firm gauze pack should be placed firmly over the
stasis has been achieved.
socket and patient is instructed to bite on it.
l Even though the haemorrhage may not be sufficiently
l Tannic acid powder is placed around the pack to arrest
severe to necessitate reopening the wound, in order to
haemorrhage.
control it, the patient will inevitably bleed into the tissue
l Interrupted horizontal mattress suture across the socket
planes of the neck and this results in an unsightly ec-
is advisable in areas of the mucoperiosteum under local
chymosis, or there may be haematoma formation of
anaesthesia to arrest bleeding.
considerable dimensions.
l The mucoperiosteum is tensed over the underlying
l In extreme case, this could result in fatal pressure on the
socket to make it ischaemic.
trachea.
l Ask the patient to bite on a gauze pack following a

suture.
II. Factors Restarting Haemorrhage l If the above measures fail, a gelatin or fibrin foam pack

is tucked into the socket and composition block moulded

During first few hours after operation, haemostasis in the over the area.
smaller vessels is largely due to contraction of the vessel l The patient should be referred to nearest hospital for

and platelet thrombus. further treatment.

Blood clots too not yet matured and contracted. l The patient should avoid repeated rinsing of mouth as

l Mechanical injury of the wound. this promotes bleeding. The oral cavity should be
l Application of heat to wound including local hyperaemia. cleaned with a gauze and cold water.
48 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

SHORT ESSAYS
Q. 1. Dry socket. l All extractions should be completed with the minimum
amount of trauma and maximum care and as rapidly as
Or possible depending upon the experience of the operator.
Dry socket and its management. l In the presence of active infection or ulcerative gingivi-

tis, avoid extraction of lower third molars.

Or l Patient having smoking habits should be advised to stop

Nonhealing socket (dry socket). smoking preoperatively and for at least two weeks post-
operatively until the socket heals.
Or l Extractions should be performed during 23
rd
to 28th
day of the tablet cycle in female patients using oral
Treatment of dry socket. contraceptives.
Ans. l During first 24 h of postextraction period, avoid vigor-

l Dry socket is also known as alveolar osteitis. ous mouth rinsing.

l It has been defined as a postoperative pain in and around l A radiograph should be taken to exclude the possibility

the alveolar socket of tooth, which increases in severity of retained fragments of tooth or foreign body.
at some moment between the first and the third day after l The affected socket must be gently irrigated with 0.12%

a dental extraction, accompanied by partial or total dis- warm chlorhexidine and all debris dislodged and aspirated.
integration of the intraalveolar clot with a foul smell. l Intra alveolar pastes consisting of zinc oxide eugenol,

anaesthetic, and antibiotic (metronidazole) can be

placed. Locally, this increases the drug concentration,
Causes of Dry Socket diminishes their secondary effects, and protects the un-
l Difficult or traumatic extraction. derlying socket and alveolus. Appropriate analgesics
l Patients on oral contraceptives. should be prescribed.
l Female sex. Q. 2. Describe control of haemorrhage during minor
l Tobacco. surgical procedures.
l Inadequate irrigation intraoperatively.
l Advanced age. Or
Describe mode of action of various agents used to
Clinical Features achieve local haemostasis following extraction.

l Pain typically appears on the second or third day Ans.

following the extraction, and it usually lasts for about
10 or 15 days. Control of Haemorrhage During the
l Pain is localized to the extraction socket sensitive to
Operation
even gentle probing.
l A persistent sharp excruciating pain that increases with i. Incision Planning
suction or mastication and lasts several days.
l Underlying large blood vessels are not severed.
l Halitosis.
l Haemorrhage may be profuse if the area to be incised is
l The pain radiates to the ear and the same side of the
inflamed as a result of local infection.
head.
l Once the wound has been opened further dissection
l There is an absence of postextraction blood clot in the
should be conducted in such a manner that sizeable blood
socket.
vessels are identified and dealt in a systematic fashion.
l Sometimes early clot formation in the socket is fol-

lowed by premature clot necrosis or loss, accompanied

by pain and fetor oris. ii. The securing of blood vessels with haemostats
l Most effective haemostats for use in oral surgery—
Preventive Measures curved or straight halsteds and mosquito artery forceps.
l No incision should ever be made through skin, unless an
l Preoperative oral hygiene measures should be taken to
adequate number of haemostats are available for imme-
reduce plaque levels.
diate use.
l An elective transalveolar approach whenever necessary
l Intraorally, the use of haemostats is limited.
in case of difficult extractions.
Section | I  Topic Wise Solved Questions of Previous Years
l It is impractical to clamp the inferior dental artery in the
bone and the use of haemostats on the lingual aspect of
mandibular lower third molar area, as this could lead to
a protracted anaesthesia of the anterior 2/3rd of tongue.
l Haemostats should be applied above and below the
point at which they are to be incised before dividing the
vessels.
l The tips of the curved haemostats should be applied, so
that the curve of the instrument causes the tips of the
blades to face upwards and out of the wound, so that
each severed end of the vessel can be properly exposed
by the assistant in order to facilitate the tying off of the
vessel with catgut.
l Size 3.0 (metric size 2.5) of catgut is satisfactory for
most purposes in oral surgery.
l Many small vessels do not require tying and if the
end of the haemostat is trusted a couple of times before
removing it, the haemorrhage will usually cease.
l Small vessels can also be sealed by briefly touching
the haemostat of a diathermy set for coagulation before
removing it from the vessel.
iii. Haemostasis Through the Application of
Pressure with Swabs
l The most effective method for almost all intrawounds.
l Pressure is a simple, but most effective method of con-
trolling haemorrhage.
l Dry guaze swab is packed into wound, over the bleeding
area and digital pressure is maintained over the swab for
2½ min.
l The normal coagulation time is just over 2 min and it is
useless to control haemorrhage from wound by pressure
of swab for a shorter period than this.
l If there is large raw area which is oozing blood.
l Some operators prefer to use a hot, wet swab to control
the haemorrhage. The swab is soaked in hot normal sa-
line solution (temperature 48.8oC, 120oF) and it is well
wrung out before applying it to the wound. The delicate
tissues of the floor of mouth may be scalded, especially
if there is any excess fluid in the swab.
l When an artery such as inferior alveolar in its canal is
incompletely severed and ends are unable to contract,
haemorrhage persists even after pressure of a dry swab
for an adequate period of time.
l In such circumstances a pack can be left in the wound.
To reduce any risk of infection, ½ inch ribbon guaze
soaked in whitehead’s varnish should be packed into the
wound.
Whitehead’s varnish – Benzoin - 10 parts
Storax - 7.5 parts
Balsam of Tolu - 5 parts
Iodoform - 10 parts
Solvent ether - 100 parts
49
l The pack should be sewn into position to prevent
its subsequent displacement and this precaution
is especially important if patient is being operated
under G.A.
Such packs will always control a persistent haemorrhage
and should be removed in 48 h.
iv. The Use of Haemostatic Agents
Example: Turpentine or tannic acid—frankly dangerous
causes second degree burns at angle of mouth and on the
lips, where material has leaked over the face.
l Commercial preparations—dubious efficacy and more
costly.
l Thrombin and Russell viper venom—precipitate clot
formation when applied on pledget of cotton.
l Both are expensive.
l Oxidized regenerated cellulose (surgicel)—one of the
best commercially absorbable haemostatic agents.
l As it is absorbable it can be safely buried in the
tissues.
l Neverthless, since low pH thrombin solutions should
not be used to the guaze, the activity of thrombin will be
rapidly destroyed.
l Bone wax (horsley’s)—purely mechanically acting hae-
mostatic agent.
l This substance is packed into bleeding bone-ends to
control the haemorrhage.
l Appreciable quantities result in formation of wax gran-
ulomas.
l Composition: Bees wax (yellow) – 7 parts by weight
Olive oil – 2 parts
Phenol – 1 part
v. Hypotensive Anaesthesia and Vasoconstriction
l Hypotensive anaesthesia can be employed when work-
ing under G.A. to reduce operative haemorrhage to a
minimum.
l Technique: B.P. is lowered by use of hypotensive agents
like arfonad and bleeding is greatly reduced.
Disadvantages
i. During the operation, sizeable vessels may be cut without
any obvious bleeding. If overlooked, they are not then
tied off with catgut; however, when operation is over and
the patient’s B.P. is allowed to return to normal, such
damaged vessels bleed profusely and patient may have to
be returned to theatre for haemostasis to be effected.
ii. There is risk of encouraging thromboses, especially in
elderly patients, when the B.P. is lowered to such an
extent and the method itself is not out of risk.
50 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
iii. Hypotensive anaesthesia should not be reserved
for operations, where excessive haemorrhage due
to oozing can be anticipated; or, where visibility is
of utmost importance and a dry field cannot be
obtained by other methods. In such cases, it is of
considerable value.
Use of Vasoconstrictors
l Vasoconstrictors prolong the analgesic effect of L.A.
They are used to reduce capillary haemorrhage.
Example: Adrenalin – 1/80,000 in ligocaine
1/300,000 in prilocaine
l As the effect of adrenalin passes off, a reactive hyperae-
mia occurs. This potentially can result in postoperative
haemorrhage and haematoma formation.
l According to Shanks, octapressin (Felypressin) does not
produce such undesirable sequelae during halothane
anaesthesia and used in concentration of 0.03 IU/mL
with prilocaine 3%, and a satisfactory degree of vaso-
constriction is obtained at the same risk of postoperative
haemorrhage.
l Felypressin solutions and prilocaine are not generally
available and have not so far been widely used l Applied to elevators
as surgical vasoconstrictor. Not . 8–10 mL of
0.03 IU/mL solution should be injected into an adult
at one time.
Q. 5. Elevators - Principles and Use.
Or
Principles of elevators.
Or
Mechanical principles of using the elevators in extrac-
tion of teeth.
Ans.
Principles of elevators used for extraction are as follows:
i. Lever principle of first order.
ii. Wedge principle.
iii. Wheel and axle principle.
i. Lever Principle
l The lever has three basic components: fulcrum, effort,
and load.
l It is a lever of first class with the fulcrum in between the
effort and the load.
l In this principle, to gain a mechanical advantage the
effort arm on one side of the fulcrum should be longer
than the load arm on the other side of the fulcrum.
l The force is transmitted at the long effort arm and
a mechanical advantage is gained at the short
load arm.
Area of Usage
l This principle is used in elevators, wherein the handle of
the elevator represents the effort, and the working end
which engages the tooth represents the load.
ii. Wedge Principle
l The wedge consists of two movable inclined planes with
a base on one end and a blade on the other end which
overcomes a large resistance at right angles to the applied
force.
l The effort is applied to the base of the plane and the
resistance has its effect on the slant side.
Area of Usage
l Wedge principle can be used alone in extracting a
tooth. However, it is very often used with lever
principle.
l According to this principle, a wedge can be used to
split, expand, or displace the portion of the substance
that receives it.
Elevators can also be used to luxate a tooth from its
socket, e.g., a straight elevator is applied between the
tooth and the bone to separate the attachment of the
periodontal ligament from the bone as described
previously.
iii. Wheel and Axle Principle
l Wheel and axle is a simple machine and is a modified
form of lever. The effort is applied to the circumfer-
ence of wheel, which turns the axle so as to raise the
weight.
l Greater the diameter of the wheel the more is the
mechanical advantage.
Area of Usage
Applied to Elevator
l Crossbar elevators are used for removing the mandibu-
lar roots by engaging the working point of the elevator
deep into the space between the tooth root and the bone,
and the handle is rotated.
l The root is removed from its socket by moving about a
circumference of the circle which the roots would have
made if they continued on around.
Q. 6. Surgical extraction.
Or
Section | I  Topic Wise Solved Questions of Previous Years
Transalveolar extraction.
Ans.
Open method of extraction is also known as ‘transalveolar
extraction’ or ‘surgical extraction’.
l After securing adequate anaesthesia, it is important to
design the mucoperiosteal flap to facilitate the tooth,
root, and bone removal.
l The incision should be made with a scalpel. Muco-
periosteal flap is elevated with the help of a sharp
periosteal elevator, to expose the underlying bone.
The alveolar bone removal is limited to only as much
as is required for application of forceps or elevator,
and to displace the tooth. All the sharp edges and
bony projections should be removed.
l A dental bur, chisel, or gouge with hand or mallet
pressure are usually used for bone removal.
l The tooth is dislocated with forceps in case of firm
tooth or with elevators in cases of multirooted teeth.
The bifurcation is used to separate the two roots
from below upwards followed by dislocation of in-
dividual roots. This can be done either with a bur or
an osteotome.
l Any bony defects are planed with rongeur forceps or
bone files. Once the bony edges are smooth, the
wound is irrigated with saline and all bone debris and
infected granulation tissues are removed.
l The mucoperiosteal flap is replaced back in position
and sutured to minimize wound contamination. A
simple interrupted or interrupted horizontal sutures
are used to close the wound.
Q. 7. Contraindications of extraction of teeth.
Ans.
Contraindications of extraction of teeth
It is better to avoid extraction in cases of absolute contrain-
dications, such as:
l Congestive cardiac failure.
l Leukaemia.
l Uraemia.
l Cirrhosis of liver.
l Terminal stages of malignancy.
Other systemic and local contraindications are:
l Diabetes and hypertension: A sure way of preventing any
potential complication is by carrying out extraction only
in patients with controlled diabetes and hypertension.
l Patients on steroid therapy: To prevent adrenal crisis
due to stress, the steroid dose should be doubled one or
two days prior to extraction and should be continued
one or two days postoperatively after which the dose
can be slowly tapered.
l Pregnancy: Extraction should be carried out only with
the obstetrician’s consent in the first and third trimester.
51
l Bleeding disorders: Consent from the haematologist is
necessary for an uncomplicated extraction. Patients on
anticoagulant therapy require physician’s/cardiologist’s
advice.
l Medically compromised patients: Failure to evaluate
the patient preoperatively may pose as a systemic com-
plication that can lead to drug interactions.
l Local contraindications: It is preferable to avoid any
kind of infection by carrying out extractions under anti-
biotic therapy.
l Extraction of teeth in recently irradiated patients:
Irradiation in jaws will reduce the blood supply due
to fibrosis. Therefore, extraction is avoided to prevent
osteoradionecrosis.
Q. 8. Principle of forceps design.
Ans.
Every forceps has a pair of handles, a pair of beaks, and a
hinge. In the lower forceps, beaks are at right angles to the
long axis of the handles, while in the upper forceps, beaks
are in the same line as handles or parallel to it.
i. Upper Anterior Forceps (Ash No.1)
a . Used for extracting upper incisors and canines.
b. Beaks are symmetrical, shorter and are placed in the
same line as the handles, so that the load arm is shorter
than the working arm.
ii. Bayonet Forceps (Ash No. 101-A)
a. Used for removing premolars and rarely for the upper
roots.
b. Beaks are asymmetrical, placed parallel to the handles
to help the beaks to be placed more posteriorly.
c. One end of the handle is concave to provide better and
secured grip for the operator’s fingers.
iii. Upper Molar Forceps (Ash No. 94 and 95)
a . These forceps have asymmetrical, broader beaks.
b. The cross section of the beaks is concave/convex, so
that concave surface is meant for application against the
crown/root surface.
c. One beak is pointed so that it can engage the bifurca-
tion of the tooth. The other beak is rounded, so that it
adapts around the palatal root. Based on the position of
the pointed beak, the forceps can be identified as right
and left.
iv. Upper Root Forceps
a . Designed for removing maxillary roots.
b. Beaks are symmetrical and closely approximate to each
other.
52 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
c. The beaks are narrower and slightly curved to fit to the
circumference of the root.
v. Lower Anterior Forceps (Ash No. 74)
a. They are narrower than the lower molar forceps and at
right angles to the handles.
b. These forceps can also be used as lower root forceps.
vi. Lower Molar Forceps (Ash No. 73)
a. Beaks are symmetrical and at right angles to the
handles.
b. They have sharp pointed tips that can engage the bifur-
cation, both at the buccal and the lingual surfaces.
c. Beaks are broader and stout.
These are the minimum instruments required for extract-
ing the teeth. All these forceps are designed in such a way that
they are applied with the beaks parallel to the long axis of the
tooth. Failure to secure the grip in this way will result in the
application of the force, leading to the fracture of the tooth.
Q. 9. Tooth extraction in a patient who is under antico-
agulant therapy.
Or
Control of bleeding through extraction socket.
Ans.
Tooth Extraction in Patients on Anticoagulant
Therapy
l Anticoagulant therapy predisposes the patient to
prolonged bleeding during any surgical procedure.
l This condition poses a problem as it cannot be
controlled by routine haemostasis.
Following intubation, sometimes it may cause severe
internal bleeding due to blunt injury and rarely can pose
a life-threatening complication.
l Wound healing is delayed.
SHORT NOTES
Q. 1. Extraction in pregnancy.
Ans.
l If the procedures are elective, then the treatment can be
carried out in the second trimester.
l Local anaesthetics such as ligocaine, bupivacaine, and
codeine are considered least harmful to the foetus.
l Emergencies of pain, infection, or acute problems can
be combated with general anaesthesia.
l Drugs such as aspirin, morphine, and carbamazepine
should be avoided.
Required Preoperative Investigations
Routine Blood Tests
i. Complete blood count.
ii. Bleeding and clotting time.
iii. Platelet count.
iv. Haemoglobin.
v. Prothrombin time.
vi. Partial thromboplastin time.
vii. Assay of coagulation factor levels.
l With consent of the physician 4–5 days prior to the
surgical procedure, the anticoagulant therapy should
be stopped.
l If oral anticoagulant therapy cannot be discontinued,
then the patient has to be shifted to intravenous anti-
coagulant therapy like heparin. Once the blood levels
are normal, the patient can be treated as a normal
patient with regards to surgical bleeding.
l Pre and postoperatively, the patient should be cov-
ered with broad-spectrum antibiotics.
Intra and Postoperative Management
l Avoid undue trauma to surrounding tissues to prevent
internal bleeding during any surgical procedure.
l Intraoperative transfusion of blood/blood products, if
found necessary.
l Monitoring of haemoglobin, complete blood counts in-
tra and postoperatively.
l Maintain adequate blood volume and control haemosta-
sis prior to wound closure.
l Monitor the vital parameters for any changes in the fluid
volume indicated by the pulse and blood pressure.
l Postoperatively, the patient may be maintained on sys-
temic oral coagulants like vitamin K for 3–5days.
l Cover the patient with adequate broad-spectrum antibi-
otics.
l Avoid medications that can exacerbate the underlying
condition
Q. 2. Chisel and mallet in dentistry.
Ans.
Chisel
l It is a mono-beveled instrument used for removal of
bone.
l It has a heavy cylindrical handle.
l The bevel has to be sharp.
l For cutting, the bevel has to be placed away from the
bone; and, for chipping it has to be towards the bone.
Section | I  Topic Wise Solved Questions of Previous Years 53

Mallet l Bleeding disorders.

l Extraction of teeth in recently irradiated patients.
l It can be made of wood, rubber, nylon, or stainless steel.
l Stainless steel mallets are preferred, as it can be steril- Q. 8. Forceps in extraction.
ized and can be used for long time.
Ans.
l Mallet is used to deliver controlled force on the chisel

and osteotome. Various forceps used in extraction are:

l Upper anterior forceps.
Q. 3. Elevators.
l Bayonet forceps.

Ans. l Upper molar forceps.

l Elevators are instruments used to elevate the tooth or l Upper root forceps.

root from the alveolar socket. l Lower anterior forceps.

l Its effectiveness depends on the design of the handle l Lower molar forceps.

and its efficiency on the design of the blade.

Q. 9. Dry socket.
l It has the handle, the shaft and the blade.

l Various elevators used in oral surgery are: Ans.

a. Straight elevator. l Dry socket is also known as alveolar osteitis.

b. Winter’s crossbar elevators. l Caused due to loss of clot from the socket.

c. Cryer’s elevator.
d. Periosteal elevators.
Clinical Features
e. Apexo elevators.
l Usually on the second or third day after the extraction
Q. 5. Elevator principles.
pain appears and it usually lasts for about 10 or 15 days.
Or l Halitosis.

Name the principles of elevators.

Treatment
Ans.
l Gentle irrigation of socket should be done with 0.12%
Principles of elevators are:
warm chlorhexidine and all debris needs to be dislodged
l Lever principle of first order.
and aspirated.
l Wedge principle.
l Intraalveolar pastes consisting of zinc oxide eugenol,
l Wheel and axle principle.
anaesthetic, and antibiotic (metronidazole) can be
Q. 6. Enumerate any two complications of the use of placed.
elevators during exodontias. l Increased concentration of the drug locally diminishes

their secondary effects and protects the underlying

Ans.
socket.
l Luxate the adjacent tooth.
l Appropriate analgesics should be prescribed for pain
l Cause perforation of blood vessels, if it slips.
relief.
l Fails to control the force applied. This cause fracture of

maxilla or mandible. Q. 10. Complications of extraction.

l Cause forcing of tooth into antrum, if proper force is not
Ans.
applied.
The possible complications of tooth extraction may be as
Q. 7. Contraindications for extraction.
follows:
Ans. l Fracture of crown of tooth being extracted.

l Congestive cardiac failure. l Roots of tooth being extracted.

l Leukaemia. l Alveolar bone.

l Uraemia. l Maxillary tuberosity.

l Cirrhosis of liver. l Adjacent or opposing tooth.

l Terminal stages of malignancy. l Mandible.

l Dislocation of adjacent tooth.

Other systemic or local contraindications are:
l TMJ.
l Diabetes and hypertension.
l Displacement of root into the soft tissues.
l Patients on steroid therapy.
l Into the maxillary antrum.
l Pregnancy.
l Under general anaesthesia in the dental chair.
54 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l Damage to gums, lips, lingual nerve, tongue, and floor Q. 14. Whitehead’s varnish.
of the mouth.
Ans.
l Postoperative pain due to damage to hard and soft
l Whitehead’s varnish is the only solution which remains
tissues.
uninfected till the stabilization process is complete.
l Dry socket.
l It consists of aromatic resins which are broken down to
l Acute osteomyelitis of mandible.
produce benzoic acid. It is a waterproof solution.
Q. 11. Wound healing.
Whitehead’s varnish contains:
Or l Benzoin 10 gm.

l Iodoform 10 gm.
Healing of extraction wound.
l Storax 7.5 gm.

Ans. l Tolu balsam 5 gm.

l While epithelium covers the clot, the angioblastic in- l Ether 100mL.

growth occurs into the clot and fibroplasia then ensures

Q. 15. Bone wax.
into the clot with cellular elimination of fibrin and blood
debris. Ans.
l There is production of variable amount of osteoid in- l Bone wax is a local mechanical haemostatic agent in

duced by mesenchymal cells. case of bone bleeding.

l Woven bone is formed following osteoblastic and osteo- l Composition of bone wax:

clastic activity that ends in mature bone, often with Bees wax 7 parts
some loss of total bone volume. Olive oil 2 parts
Phenol 1 part
Q. 12. Haemostatic agents.
l However, bone wax acts as a foreign object and can lead

Ans. to formation of wax granuloma.

Commonly used haemostatic agents are: Q. 16. Trismus.
Example: Or
l Turpentine or tannic acid—frankly dangerous and

causes second degree burns, where material has leaked
over the face.
l Thrombin and Russell viper venom—precipitate clot
formation when applied on pledget of cotton.
l Oxidized regenerated cellulose.
List five causes of trismus.
Ans.
l Inability to open the mouth is known as Trismus.
l Trismus indicates muscle spasm.

Q. 13. Mention four bleeding control measures in

Causes
postextraction bleeding.
Or i. Odontogenic l Infective
a. Periodontitis.
Control of haemorrhage by local measures. b. Pericoronitis.
c. Space infections.
Ans. i i. Traumatic l Fractured teeth and jaws.
l Application of pressure. iii. Neoplastic l Tumours eroding the muscles of
l Use of vasoconstrictors. mastication.
i v. Neurotoxic l Tentanus.
l Hypotensive anaesthesia.
v. Psychogenic l Hysteria.
l Use of haemostatic agent.
Section | I  Topic Wise Solved Questions of Previous Years
Impactions
LONG ESSAYS
Q. 1. What are the indications for removal of an im-
pacted tooth? Describe the technique of removal of a
mesioangular impacted lower third molar.
Or
Describe the various surgical steps involved in the re-
moval of mesioangular impacted lower third molar.
Or
Classify impacted mandibular third molar. Write in
detail the steps in surgical removal of impacted man-
dibular left third molar.
Or
Describe in detail surgical procedure for removal of
mesioangular impacted mandibular third molar.
Ans.
A tooth which is completely or partially unerupted and is
positioned against another tooth bone or soft tissue, so that
its further eruption is unlikely is described according to its
anatomic position.
Indications for Removal of Impacted Teeth
i. Adults with partially or completely impacted teeth
develop pericoronitis.
ii. The need and the urgency for its removal depend on
whether tooth is asymptomatic or not as well as its
effects on health.
iii. Second molars are mostly involved with caries or
periodontal problems. Root resorption may be due to
the pressure effect.
iv. Pericoronitis may predispose to temporomandibular
joint problems.
v. Removal of third molars as a preventive measure is
advised in young patients, as young patients tolerate
the surgery very well, hence complications are few.
vi. Pain or paraesthesia may be relieved on removal of
impacted tooth.
vii. These teeth may become foci of infection leading
to the development of premalignant and malignant
lesions of oral mucosa.
viii. Malocclusion and anterior overcrowding may develop
due to pressure on the distal end.
55
Topic 6
ix. Impacted teeth are associated with cystic pathologies
that can lead to fracture of the jaw bone.
x. Autotransplantation to replace the lost first molar and
removal of mandibular third molar tooth before root
formation is indicated.
xi. For prosthetic reasons, a third molar may have to be
removed to avoid ulcerations under the denture. Par-
tially erupted ones may be retained to serve as abut-
ments for constructing fixed bridge prosthesis.
Method for Removal of Mesioangular Third
Molar
Surgical Technique
Once the assessment has been made, the operation can be
planned. It is considered under the following headings.
If necessary, the plan is modified to meet unexpected
conditions.
1. Selection of anaesthesia.
2. Instruments.
3. Incision and refection of the flap (flap design).
4. Bone removal.
5. Luxation and delivery of the tooth.
6. Debridement of the wound.
7. Securing haemostasis and closure of the wound.
8. Postoperative instructions and care.
Selection of Anaesthesia
Choice of anaesthesia for the removal of impacted lower
third molar is influenced by the following factors:
l Available facilities.
l Operator’s choice.
l Temperament of the patient.
l Associated diseases.
l Type of the case.
l If local anaesthesia is selected for the lower
third molar, then an inferior dental nerve block,
lingual nerve block, and long buccal nerve block is
given.
l It is normal to remove the teeth on one side at a time
under local anaesthesia, but in suitable patients, expe-
rienced operator can remove all four wisdom teeth
during same visit.
56 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Without sedation, around 45 min of surgery under
local anaesthesia is as much as most patients find it
tolerable.
l After satisfactory anaesthesia is obtained, the operat-
ing field is prepared with the usual methods.
Instruments
l Cartridge syringe with anaesthesia.
l B.P. knife.
l Periosteal elevator.
l Chisel and mallet (burs).
l Elevators.
l Tooth forceps.
l Bone file.
l Haemostats.
l Artery forceps.
l Needle holders.
l Needle and suture material.
Surgical Procedure
Incision
l The incision for the soft tissue flap is started just to the
lingual side of the external oblique ridge of ramus of
mandible at a distance of ¾ inch distally from lower
second molar; directed anteriorly until it contacts the
midpoint of the distal surface of the second molar;
the incision is continued buccally around the neck of
the second molar to the interproximal space between
first and second molars; and, then it is extended down
toward the mucobuccal fold at 45o angle.
l It is important to keep this incision to the buccal side in
order that postoperative infection and trimus may be
kept at a minimum.
l Incisions are not made along the internal oblique ridge
of the ramus of mandible, because of the proximity of
the lingual nerve to lingual cortical plate.
l To prevent surgical trauma to this nerve, we make our
incisor from midpoint of the distal surface of second
molar distally and buccally.
l The incisions that are directly carried posteriorly, shortly
pass off the osseous structures because the ramus flares
out laterally at this point and open into pterygomandibu-
lar space.
l The buccal flap should meet the basic requirements:
i. It should provide adequate exposure of the operative
site.
ii. It should have a wide base to ensure good blood
supply to the soft tissue.
iii. It should be large enough, so that the soft tissue
over the operative site is not traumatized during the
operation, and so that when flap is replaced, the
edge rest on a wide shelf of bone.
Reflection of flap
l With a help of periosteal elevator, the mucoperiosteum
should be reflected by introducing at the anterior end of
the incision and slipped firmly downwards making certain
that the periosteum is stripped back with the oral mucosa.
Bone removal
l Bone should be removed in order to secure a sound
fulcrum for an elevator to be inserted. It is necessary to
remove the obstruction for easy removal of an impacted
tooth. If the impacted tooth is completely covered, then
the bone overlying it is removed by means of bone burs
or chisels or both.
Removal of impacted tooth from its bed
l Sufficient amount of bone must be removed to allow the
tooth to be lifted from its bed without the necessity of
heavy pressure.
l Luxation of tooth is made with help of straight elevator
or couplands elevator and force should be used to luxate
the tooth. Force should not be applied in the attempted
removal of any impacted tooth, until all resistance due
to dense bone has been removed. This is especially in
lower third molar, since fracture of mandible may result.
l Once the tooth is luxated, delivery of tooth is attempted
with the help of forceps.
l One should be careful to prevent aspiration of tooth
slipping out of dental forceps, while removing the tooth.
Debridement
l The socket toilet should follow the completion of
extraction. Debridement of wound includes removal
of dental follicle which is attached to socket.
l Besides, small bony spicules or any necrosed tissues
should be removed.
l Sharp bony edges due to cutting of bone should also be
made smooth with the help of bone file, especially on
lingual side, as they may irritate patient’s tongue.
l Finally, socket should be flushed with normal saline to
remove any foreign particles remaining.
Haemostasis
l Haemostasis should be secured before closure of wound,
otherwise it might lead to haematoma formation and might
spread into surrounding spaces. This can be done by apply-
ing pressure with a pressure pack soaked in adrenalin.
l If the bleeding does not stop with pressure pack,
then one might consider applying bone wax on bleeding
surfaces of bone. If bone wax is not available, then gel
foam may be packed.
Closure of wound
l It should be done after securing complete haemostasis
by giving interrupted sutures.
Section | I  Topic Wise Solved Questions of Previous Years
l The loop of the stitch should be large enough to facili-
tate its removal, and when flap is reflected back to its
original position it should not rest on dead space.
Postoperative care and instructions
i. Proper antibiotics, anti-inflammatory drugs, analge-
sics, and supportive therapy like B complex are given.
ii. Instructed not to gargle and not to do any hot fomenta-
tion beside advised diet.
iii. Sutures should be removed after seventh postopera-
tive day.
Depending on the Variations in Position of
Impacted Tooth, Some Slight Variation in
Bone Removal and Sectioning of Teeth are
Required as Follows:
l Locked beneath the crown of second molar—requires
sectioning of the tooth.
l Not locked—removal, if possible, without sectioning.
i. Crown to Crown Position
l It requires removal of collar bone superior and lateral to the
root. The tooth is then elevated on the mesial aspect of the
cervical area. The tooth is then sectioned along its furcation.
ii. Crown to Cervix
l Removal of bone over the crown’s occlusal, coronal, dis-
tal, and buccal surfaces down to the contour of the crown.
l Bone removal extends along the long axis of the third
molar. Sectioning of the bifurcation and single root will
require removal of the anterior and occlusal area.
l Remaining portion of tooth is elevated from the mesial
aspect of the tooth.
iii. Crown to Root
l Bone removal on the buccal aspect to expose the supe-
rior and lateral aspect of the third molar followed by
sectioning of the root as above.
iv. Unfused Roots
l The third molar is sectioned along the long axis with
bur/chisel avoiding the thin lingual plate. Then, the dis-
tal half is removed using buccal plate as the fulcrum
followed by removal of other half.
v. Fused Roots
l The tooth is divided along the cementoenamel junction
(CEJ), and the roots are then removed with the help of
apex elevator using purchase point on the tooth and and
the buccal bone as fulcrum.
57
Q. 2. Describe the classification of impacted lower third
molar. What are its complications?
Or
Classify impacted mandibular third molars. Enumerate
the complications likely to be encountered during and
after surgical removal of impacted lower right third
molar teeth.
Or
Classify impacted mandibular third molars. Enumerate
the complications likely to be encountered during and
after surgical removal of horizontally impacted lower
right third molar teeth?
Ans.
Impacted Mandibular Third Molar
It is necessary for the surgeon to classify mandibular im-
pacted third molars to determine the difficulties encounter-
ing the removal as well as to plan the surgical procedure.
Winter’s Classification (1926)
This classification is based on position of the long axis of
the impacted third molar tooth in relation to the long axis of
the second molar.
This can be divided in to eight groups:
1. Vertical.
2. Mesioangular.
3. Distoangular.
4. Horizontal.
5. Buccoangular.
6. Linguoangular.
7. Inverted position.
8. Unusual position.
Pell and Gregory Classification (1933)
l Impacted mandibular third molars were classified very
similar to that of Winter’s classification by utilizing the
three-dimensional tills of its long axis.
a. Relationship of teeth to the ramus of the mandible.
b. Relative depth at which it is placed.
c. The long axis of impacted tooth in relation to second
molar.
Pell and Gregory’s classification includes a portion of
George B. Winter’s classification is an excellent one.
A. Relation of the tooth to the ramus of the
mandibular and second molar
Class I
There is sufficient amount of space between ramus and
distal side of second molar for the accommodation of the
mesiodistal diameter of the crown of the third molar.
58 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Class II
The space between the ramus and distal side of the second
molar is less than the mesiodistal diameter of the crown of
third molar.
Class III
All or most of the third molar is located within the ramus.
B. Relative depth of the third molar in bone
Position A: The highest portion of the tooth is on a level at
or above the occlusal line.
Position B: The highest portion of the tooth is below the
occlusal plane, but above the cervical line of the second
molar.
Position C: The highest portion of the tooth is below the
cervical line of the second molar.
C. The position of the long axis of the impacted
mandibular third molar in relation to the long axis
of the second molar (from Winter’s classification)
1. Vertical.
2. Mesioangular.
3. Distoangular.
4. Horizontal.
5. Buccoangular.
6. Linguoangular.
7. Inverted position.
8. Unusual position.
These may also occur simultaneously in buccal version,
lingual version, and torso version.
Complications Likely to be Encountered
During and After Surgical Removal of
Impacted Lower Third Molar Teeth
i. Possibility of damage to inferior dental nerve
a. During the removal of distal bone—particularly for
deep distoangular impacted teeth.
b. During division of crown of horizontal tooth—
particularly if it lies low in the jaw.
c. During splitting of tooth with an osteotome—if
nerve is in contact with root of the tooth.
d. During mesial application of elevator for MA
tooth—if nerve lies at apex.
e. Where nerve grooves or perforates the root of
tooth—the risk of dividing the nerve is high.
If the risk is anticipated it can be handled by careful
surgery, but not eliminated.
ii. The lingual nerve is at risk
a. From periodontal elevators raising the lingual
flap—if the reflection of flap is too much lingual.
b. From lingual flap retractors—prolonged retraction
of lingual nerve with other lingual tissues results in
a neuropraxia even while it protects the nerve from
more serious damage. Care must be taken to see
that the retractors are between nerve and bone.
c. From the instruments used for both cutting and
grasping the lingual bone; and, from the lingual
plate itself, if split bone technique is used.
d. From a suture which may underrun the nerve, if
large bite of lingual flap is taken.
iii. Patient having difficulty in swallowing due to damage
to superior constrictor muscle, which sometimes hap-
pens because of fracture to the lingual plate.
iv. Trismus, because of damage to masseter and medial
pterygoid muscle.
v. Fracture of angle of mandible if too much force is
employed during luxation of tooth.
vi. Dislocation of TMJ because of not taking mandibular
support during luxation.
vii. Traumatic arthritis since patients keep their mouth
opened for longtime.
viii. Hypersensitivity when patient takes hot and cold, be-
cause of exposure of cementum of second molar.
ix. Damage to neighbouring tooth while removing the
bone.
x. Slipping of impacted tooth into submandibular space,
if the lingual plate breaks.
xi. Aspiration of tooth.
Q. 3. Describe anyone classification for impacted man-
dibular third molar. Discuss radiological assessment of
impacted mandibular third molar.
Ans.
Classification of Impacted Mandibular Third
Molar
It is necessary for the surgeon to classify mandibular im-
pacted third molars to determine the difficulties encounter-
ing the removal as well as to plan the surgical procedure.
Winter’s Classification (1926)
This classification is based on position of the long axis of
the impacted third molar tooth in relation to the long axis of
the second molar.
This can be divided in to eight groups:
1. Vertical.
2. Mesioangular.
3. Distoangular.
4. Horizontal.
5. Buccoangular.
6. Linguoangular.
7. Inverted position.
8. Unusual position.
Section | I  Topic Wise Solved Questions of Previous Years
Pell and Gregory Classification (1933)
l Impacted mandibular third molars were classified very
similar to that of Winter’s classification by utilizing the
three-dimensional tills of its long axis.
a. Relationship of teeth to the ramus of the mandible.
b. Relative depth at which it is placed.
c. The long axis of impacted tooth in relation to second
molar.
Pell and Gregory’s classification includes a portion of
George B. Winter’s classification is an excellent one.
A. Relation of the Tooth to the Ramus of the
Mandibular and Second Molar
Class I
There is sufficient amount of space between ramus and
distal side of second molar for the accommodation of the
mesiodistal diameter of the crown of the third molar.
Class II
The space between the ramus and distal side of the second
molar is less than the mesiodistal diameter of the crown of
third molar.
Class III
All or most of the third molar is located within the ramus.
B. Relative Depth of the Third Molar in Bone
Position A: The highest portion of the tooth is on a level at
or above the occlusal line.
Position B: The highest portion of the tooth is below the
occlusal plane, but above the cervical line of the second
molar.
Position C: The highest portion of the tooth is below the
cervical line of the second molar.
C. The Position of the Long Axis of the Impacted
Mandibular Third Molar in Relation to the Long
Axis of the Second Molar (from Winter’s
Classification)
1 . Vertical.
2. Mesioangular.
3. Distoangular.
4. Horizontal.
5. Buccoangular.
6. Linguoangular.
7. Inverted position.
8. Unusual position.
These may also occur simultaneously in buccal version,
lingual version, and torso version.
59
Assesment of Lower Third Molars
l Successful third molar surgery is dependent upon de-
tailed preoperative assessment and treatment planning
and the skilful application of an appropriate operative
technique.
l Treatment planning is based on a thorough clinical
evaluation of the patient with reference to the general
and local factors. Systemic evaluation is identical to any
other surgical procedures.
General Factors
i. A conscious assessment of general size and built of the
patient.
A large patient treatment of massive mandible presents
a different problem from a small delicately boned
patient.
ii. Patient attitude and demeanour gives valuable clues
as to the way he or she will respond to the stress of
surgery, and therefore type of anaesthesia or sedation
which will be required.
iii. Age and general fitness:
l These are important in the context of any operative
procedure, but undoubtedly increasing-age adds to
the difficulty of the removal of lower third molars.
l Compared with a teenager, the young adult in later
20s will already have bone, which is significantly
more difficult to cut; and, teeth which require more
force to separate them from the bone.
l At a variable age between 40s and late 60s, the man-
dibular bone will develop a hard, brittle quality, and
attached teeth with rigidity, which succumbs to an
extraction force only after a substantial amount of
investing bone has been removed.
iv. Size of the oral cavity, size of the tongue, and behaviour
of the tongue should be noted when it tends to spread
over the occlusal surface of teeth or to move in to area
of examination it can be anticipated that operatory is
complicated.
v. Size of rima oris—the degree to which the patient can
open mouth with extensibility of lips and cheeks. All
these contribute to surgical access.
vi. The condition of the first and second molars may affect
decision to remove the wisdom teeth.
Large crowns, inlays and amalgam fillings in second molar
can be dislodged during elevation of the third molar even
though care is being excised.
Local Examination
l Attention is then focused on each third molar inturn
observing how much of the crown is visible or palpable
if it is unerupted.
60 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l On examination, the state of eruption is noted. If un-
erupted, probing the distal aspect of the second molar
will confirm whether the tooth is in communication
with the mouth and if there is any pocket leading down
to the crown of third molar.
l If partially erupted, the depth of any visible crown
below the occlusal plane and its general relation to
the level of alveolar crest is noted, as it is the distance
between the distal surface of the second molar and
anterior border of the ascending ramus.
l The external and internal oblique ridges of the mandible
are palpated. If the external oblique ridge is low rela-
tively vertical and relatively posterior to the tooth,
then there will be thin alveolar bone, buccal to the third
molar. If the external oblique ridge lies high and well
forward relative to the tooth, then the thick cortex of the
ridge will form the bone, buccal to the third molar.
l If the internal oblique ridge lies wellback, then there
will be thin bone both distally and lingually to the wis-
dom tooth. Conversely, an anteriorly-placed internal
oblique ridge carries thick bone around the third molar
on the lingual side.
l The condition of the soft tissues over the wisdom tooth
itself, is noted whether they are scarred and indented by the
upper third molar. Presence of active pericoronitis or pus
beneath the gum flap is noted. Both these conditions re-
quire treatment and there may be a delay before operation.
l The position and condition of the upper third molar is
checked and its occlusal relationships to the lower third
third molars are noted.
l If the tooth is in a position which makes it difficult to
keep cleanand if it is already carious and if it does not
and will not occlude with a tooth which is to be retained
and particularly if it is overerupted, it should be ex-
tracted. If it bites on the gum flap of the lower third
molar, then its extraction may cut short an attack of
pericoronitis, permitting more latitude in the timing of
lower third molar surgery.
Radiographic Examination
Radiographs used are:
1. IOPA films
l Most commonly used for the assessment of the third
molar teeth.
l Shows whole of lower second and third molars, bone
surrounding the latter, and inferior dental canal.
l Details which they reveal are better than with any other
technique.
l The film should be positioned with care. In general,
the mesial edge of the film should not lie further
forward than the mesial surface of the first molar for
vertical, mesioangular, and distoangular impactions.
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For the horizontal teeth, the mesial edge should not
lie further than the width of first molar.
2. Lateral radiographic views of the mandible
l When the unerupted tooth is deeply buried, it may not be
possible to get whole of it and adjacent structures on the
IOPA film. For this, a lateral projection should be used.
Disadvantage
l Distance between the film and the tooth is greater, so the
definition is reduced.
l The angulation of the central ray is so angulated that
the relationship between second and third molar is not
accurately shown.
Advantages
l Advantages of labial oblique view are that, they will
show those teeth which are deeply buried, grossly mis-
placed, or involved in secondary pathology such as cyst.
3. OPG (Orthopantamograph)
l Some of the disadvantages of lateral oblique can be
overcome by this view.
4. Occlusal views
l It is a radiograph which is difficult to take, but is indi-
cated when the third molar is lying across the arch.
l The view reveals the buccolingual position of at least
the crown of the impacted tooth. It is essential for the
buccolingually placed teeth to identify the way, the
crown is pointing and to show the shape of the roots.
l It is helpful to show the structures of the lingual alveolar
plate, where third molar is buccally placed.
Localizing Mandibular Canal in Relation to
Apices of Lower Third Molar
l As the means of localizing this canal frankly suggested
that a modification of tube shift can be used to
determine whether the mandibular canal is medial to,
lateral to, or below the impacted third molar.
l Principle involved is the same as that of the ‘clark shift
technique’ in localizingthe maxillary impacted cuspids.
Frank’s technique
l By placing two films in identical positions in the mouth
when X-raying lower third molar and by changing the
position of the X-ray tube, we can determine whether
the canal lies lingually or buccally to impaction, or lies
in the same place as the tooth.
o
l To accomplish this, the X-ray angle must be shifted 25
upwards and the second film should be compared to film
taken with the X-ray tube placed parallel to occlusal
plane of teeth.
Section | I  Topic Wise Solved Questions of Previous Years 61

l In the mouth, an X-ray taken from 25o below plane of b. Vertical,

occlusion will make a distant object move downward in c. Semivertical.
relation to object in the foreground. iii. Class III: Impacted cuspids located in both the palatal
l If mandibular canal lies lingual to impaction, then it process and labial or buccal maxillary bone.
will move downwards in relation to roots of third molar. Example: Crown is on palate and root passes through
l Canal on buccal side of roots will appear to move between roots of the adjacent tooth in the alveolar pro-
upward on roots. cess ending in a sharp angle on the labial or buccal
l If canal removes in same position, then it is directly surface of maxilla.
below the roots or between roots or in groove in the root iv. Class IV: Impacted cuspids located in the alveolar process
surface apically, lingually, or buccally. usually vertically between incisors and first bicuspids.
v. Class V: Impacted cuspids located in an edentulous
Evaluation of Factors that Render Third Molar maxilla.
vi. This is also classified based on its unusual position
Surgery Easy or Difficult
liketooth – In the floor of the nose.
l In the antrum.
Factors Easy Difficult
l In infraorbital margin.
1. Pell and Gregory Class I Class III
classification Position A Position C
Horizontal plane
Vertical plane
Surgical Technique
2. Overlying impediment Soft tissue Bone a. Choice of anaesthesia—local or general anaesthesia.
Local anaesthesia—Infra orbital block, palatine nerve
3. Crown Small Large
block, and nasopalatine nerve block.
4. Roots Incomplete Complete General anaesthesia—It is the choice in case of very
Formation Favourable Unfavourable
apprehensive patients or uncooperative patients.
Curvature Conical or Long, slender,
Morphology convergent and divergent b. Choice of instruments
l Retractors.
5. Follicular space Large Thin and small
l B.P. knife.

6. Surrounding bone Elastic or Dense or cortical l Scissors.

cancellous l Periosteal elevators.

7. Relationship Space distal to No space l Haemostats.

Second molar Not related distance l Tooth forceps.

Inferior alveolar canal Related l Bone chisels and mallet.

8. Oral sphincter Large Small l Drills and Ronguer forceps.

l Elevators and suturing materials.

9. Health status Satisfactory Medically
compromised
Procedure
Incision
Q. 4. Classify maxillary canine impactions. How do you
l Depending on position of unerupted canine, either buc-
manage a case of bilaterally impacted upper canine teeth?
cal or palatal incision may be given. If tooth is on the
Or buccal aspect, either semilunar or a U-shaped incision
just above the gingival margin extending upto mucobuc-
How would you extract an impacted canine from the
cal fold or sulcus should be taken.
palate surgically? Give the preoperative and postopera-
l Bilateral impactions—incision from first molar on one
tive management in detail.
side to the first molar on the opposite side of the maxilla.

Classification of Impacted Maxillary Cuspids Reflection of flap

i. Class I: Impacted cuspids located in the palate. l Periosteal elevator is used with a firm grip, since palatal

a. Horizontal, mucosa is firmly attached to the bone. Flap should be

b. Vertical, retracted in such a way that sufficient part of palate is
c. Semivertical (oblique). exposed to permit ready accessibility.
ii. Class II: Impacted cuspids located in the labial or the l Care should be taken to avoid damage to neurovascular
buccal surface of the maxilla. bundle emerging from the incisive and greater palatine
a. Horizontal, foramen.

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62 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Bone removal
l If tooth is on the surface, a bony bulge can be seen
which serves as a landmark for removal of the bone.
The bone is removed until crown of tooth is exposed
and perforation can be enlarged by means of burs and
chisels.
l Care should be taken so that roots of adjacent teeth are
not injured.
l A groove is cut in the bone on mesial side of crown, so
that an elevator can be passed beneath it.
Luxation and delivery of tooth
l Luxation may be attempted after the resistance of
crown.
l Suitable elevator is used to lift the tooth after the crown
emerges into position, which after the application of
extraction forceps the tooth may be removed.
l If delivery of tooth is difficult because of bony resis-
tance, underlying pathology associated with tooth like
dilacerated roots, hypercementosis, or locking with
neighbouring teeth, then sectioning of tooth is indicated.
Debridement
l Includes complete removal of dental follicle, bone chips
(any soft tissue and cartilage), and later susceptible
SHORT ESSAYS
Q. 1. Radiological examination of lower third molar.
Ans.
Radiographic Examination of Lower Third
Molars
Radiographs used are:
1. IOPA Films
l Most commonly used for the assessment of the third
molar teeth.
l Shows whole of lower second and third molars, bone
surrounding the latter, and inferior dental canal.
l Details which they reveal are better than with any other
technique.
l The film should be positioned with care. In general, the
mesial edge of the film should not lie further forward
than the mesial surface of the first molar for
vertical,mesioangular, and distoangular impactions. For
the horizontal teeth, the mesial edge should not lie fur-
ther than the width of first molar.
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bony margins may be trimmed smoothly. Then the
wound is irrigated with normal saline to remove any
leftover bony particles and soft tissue particles.
Hemostasis and suturing
l Before closure of the wound, complete haemostasis is
secured by giving a pressure pack or packing bony cav-
ity with gelfoam. Once haemostasis is secured, wound
may be closed with interdental interrupted sutures pala-
tolabially after closure of wound with suture. A palatal
splint may be given to protect the wound from infection
to control the bleeding and to achieve satisfactory adap-
tation of palatal flap.
Postoperative care and instructions
l Suitable antibiotics, analgesics, supportive therapy,
B-complex, vitamin C, and general therapy may be given.
l Sutures may be removed after seventh postoperative day.
Complications
l Damage to adjacent teeth leading to nonvitality or loos-
ening of adjacent teeth.
l Perforation of maxillary sinus (O-A fistula).
l Perforation of nasal cavity (floor of nose) (O-N fistula).
l Fracture of premaxilla.
2. Lateral Radiographic Views of the Mandible
l When the unerupted tooth is deeply buried, it may not
be possible to get whole of it and adjacent structures on
the IOPA film. For this, a lateral projection should be
used.
Disadvantage
l Distance between the film and tooth is greater, so the
definition is reduced.
l The angulation of the central ray is so angulated that
the relationship between second and third molar is not
accurately shown.
Advantages
l Advantages of labial oblique view are that, they will
show those teeth which are deeply buried, grossly
misplaced, or involved in secondary pathology such
as cyst.
3. OPG (Orthopantamograph)
l Some of the disadvantages of lateral oblique can be
overcome by this view.
Section | I  Topic Wise Solved Questions of Previous Years
4. Occlusal Views
l It is a radiograph which is difficult to take, but is indi-
cated when the third molar is lying across the arch.
l The view reveals the buccolingual position of at least
the crown of the impacted tooth. It is essential for the
buccolingually placed teeth to identify the way the
crown is pointing and to show the shape of the roots.
l It is helpful to show the structures of the lingual alveolar
plate where third molar is buccally placed.
Q. 2. Winter’s lines and their clinical significance.
Or
WAR lines.
Ans.
l Position and depth of an impacted tooth can be deter-
mined by a method first described by George Winter.
l WAR lines are three imaginary lines drawn on the radio-
graph, which are given three distinct colours, i.e., white
line, amber line, and red line.
White Line
l This line is drawn along the occlusal surface of erupted
mandibular molars and extended posteriorly over the
third molar. The axial inclination of the third molar be-
comes evident.
l The occlusal surface of third molar vertically impacted
is parallel to the ‘white line’; while, in case of a distoan-
gular impaction, the white line and the occlusal surface
of third molar converge to meet in the second molar
region. It can also be used as a guidance indicating the
relative depth of the tooth in mandible.
Amber Line
l The second line is drawn from the surface of the bone
lying distal to third molar to the crest of interdental
septum between first and second molar.
l It indicates the amount of alveolar bone enclosing the
tooth. It shows only the tooth above and in front of
the amber line. Hence, it is very essential to differentiate
the shadow cast by external oblique ridge and that of
bone to the tooth.
Red Line
l This third imaginary line of Winter, is used to measure
the depth at which an impacted tooth lies in the mandible.
l This is drawn perpendicular the amber line to an imagi-
nary point of application of elevator. Usually, cementoe-
namel junction on the mesial surface of impacted tooth
is used except for distoangular teeth.
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63
l As the red line increases by 1 mm, more difficult the
extraction will be.
l If red line is 9 mm or more, then the inferior surface of
crown of impacted tooth may beat the level of apex of
second molar or even below. If the distal aspect of the
second molar is denuded, then it is advisable to extract
the second molar instead.
Q. 3. Classification of impacted maxillary third molar.
Ans.
Classification of Maxillary Third Molar
Impaction Based on Anatomic Position
is as Follows:
A. Relative Depth of the Impacted Maxillary
Third Molar in Bone
Class A: Lowest portion of the crown of impacted maxil-
lary third molar is on a line with occlusal plane of second
molar.
Class B: Is between the occlusal plane of second molar
and the cervical line.
Class C: Is at or above the cervical line of second
molar.
B. The Position of the Long Axis of the Impacted
Maxillary Third Molar in Relation to Long Axis of
Second Molar
1 . Vertical.
2. Horizontal.
3. Mesioangular.
4. Distoangular.
5. Inverted.
6. Buccoangular.
7. Linguoangular.
These may also occur simultaneously in buccal version,
lingual version, and torso version.
C. Relationship of the Impacted Maxillary Third
Molar to Maxillary Sinus
i. Sinus approximation (S.A): No bone or a thin partition
of bone between the impacted maxillary third molar
and the maxillary sinus is known as maxillary sinus
approximation.
ii. No sinus approximation (N.S.A): Bone of 2mm or
more thickness between impacted maxillary third molar
and maxillary sinus is known as no maxillary sinus
approximation.
64 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Q. 4. Wharf’s assessment of mandibular third molar. d. During mesial application of elevator for MA
tooth—if nerve lies at apex.
Ans.
e. Where nerve grooves or perforates the root of
l Wharf’s assessment helps beginners to anticipate prob- tooth—the risk of dividing the nerve is high.
lems and avoid difficult impaction. The total scoring to If the risk is anticipated, then it can be sundered by
individual cases is directly related to corresponding dif- careful surgery but not eliminated.
ficulties that one is liable to encounter during removal ii. The lingual nerve is at risk.
of an impacted tooth. Scoring details are as follows: a. From periodontal elevators raising the lingual
flap—if the reflection of flap is too much lingual.
1. Winter’s classification Horizontal 2 b. From lingual flap retractors—prolonged retraction
Distoangular 2 of lingual nerve with other lingual tissues results in
Mesioangular 1 a neuropraxia even while it protects the nerve from
Vertical 0
more resinous damage. Care must be taken to see
that the retractors are between nerve and bone.
2. Height of mandible 1–30 mm 0
c. From the instruments used to both cut and grasp
31–34 mm 1 the lingual bone and from the lingual plate itself if
35–39 mm 2 split, bone technique is used.
3. Angulations of third molar 1–50o 0 d. From a suture which may underrun the nerve if
60–69 o
1 large bite of lingual flap is taken.
70–79o 2 iii. Patient having difficulty in swallowing due to damage
o
to superior constrictor muscle which sometimes hap-
80–89 3
pens, because of fracture to the lingual plate.
90o+ 4
iv. Trismus, because of damage to masseter and medial
4. Root shape Complex 1 pterygoid muscle.
Favourable 2 v. Fracture of angle of mandible if too much force is
Unfavourable 3 employed during luxation of tooth.
5. Follicle Normal 0 vi. Dislocation of TMJ because of not taking mandibular
Possibly enlarged 1
support during luxation.
vii. Traumatic arthritis, since patients keep their mouth
Enlarged 2
opened for long-time.
6. Exit path Space available 0 viii. Hypersensitivity, when patient takes hot and cold
Distal cusp covered 1 because of exposure of cementum of second molar.
Mesial cusp covered 2 ix. Damage to neighbouring tooth while removing the
Both covered 3 bone.
Total 33 x. Slipping of impacted tooth in to submandibular space
if the lingual plate breaks.
xi. Aspiration of tooth.
Q. 5. Early and late complications of impacted third
molar surgeries. Q. 6. Localization of impacted maxillary canine.
Or
Ans.
Intraoperative complications of surgical removal of
In case of doubt whether the tooth is lying buccally or
impacted mandibular third molar.
palatably, then following steps are considered:
Ans. l Shift sketch method: Technique of procedure is to

expose two or more periapical radiographs of same

area shifting the table horizontal between exposures.
Complications l As a result of changes in horizontal angulation, un-

i. Possibility of damage to infection dental nerve. erupted tooth or foreign body moves mesially or distally
a. During the removal of distal bone—particularly for in relation to other or landmarks.
deep DA teeth. l Rule governing this S-S-method: If the unerupted tooth

b. During division of crown of horizontal tooth— moves in the same direction in which tube is shifted,
particularly if it lies low in the jaw. then it is located on the lingual side.
c. During splitting of tooth with an osteotome—if l If it moves in the opposite direction in which the tube is

nerve is in contact with root of the tooth. shifted, then the location is seen on labial or buccal side.

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Section | I  Topic Wise Solved Questions of Previous Years
If there is no obvious change, then the crown probably
lies wedged in arch between adjacent teeth.
Q. 7. Lingual spilt bone technique.
Lingual Split Bone Technique
l It was described originally by Sir William Kelsey Fry.
l Later, popularized by T. Ward.
l Quick and clean technique.
l Creates a saucerization of the socket, thereby reducing
the size of the residual blood clot.
l Used for mandibular third molar removal, especially
those which are placed lingually.
l Supports the mandible at the inferior border.
Steps
l Vertical stop-cut is made by facing the chisel bevel pos-
teriorly, distal to the second molar.
SHORT NOTES
Q. 1. Winter’s imaginary lines.
Or
Mention Winter’s lines with significance of each.
Or
WAR lines in impaction.
Or
George Winter’s/WAR lines.
Ans.
Position and depth of an impacted tooth can be determined
by a method first described by George Winter. This involves
three imaginary lines drawn on the radiograph, which are
given three distinct colours, i.e., white line, amber line, and
red line, and abbreviated as WAR lines.
l White line: This line is drawn along the occlusal surface
of erupted mandibular molars and extended posteriorly
over the third molar. The axial inclination of the third
molar becomes evident.
l Amber line: The second line is drawn from the surface
of bone lying distal to third molar to the crest of inter-
dental septum, between first and second molar. It
indicates the amount of alveolar bone enclosing the
tooth.
l Red line: This third imaginary line of Winter is used to
measure the depth at which an impacted tooth lies in the
mandible.
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65
l With the chisel bevel downward, a horizontal cut is
made backward from the lower end of the vertical limit-
ing stop-cut.
l The buccal bone plate is removed above the horizontal cut.
l The distolingual bone is then fractured inward by plac-
ing the cutting edge of the chisel along the dotted line
A. Bevel side of the chisel is facing upward and cutting
edge is parallel to the external oblique ridge. The chisel
is held at 45° to the bone surface.
l Finally, small wedge of bone, which then remaining
distal to the tooth and between the buccal and lingual is
cut. A sharp straight elevator is then applied and mini-
mum force is used to elevate the tooth. As the tooth
moves upward and backward, the lingual plate gets
fractured and facilitates the delivery of the tooth.
l After the tooth is removed, the lingual plate is grasped
with the haemostat and freed from the soft tissue and
removed.
l Smoothening of the edges is done with bone file.
l Wound irrigated and sutured.
Q. 2. Classify impacted maxillary third molars, based
on relative depth of the impacted maxillary third molar
in bone?
Or
Classify impacted maxillary third molars - any one
classification.
Ans.
Classification of maxillary third molar impaction based on-
relative depth of the impacted maxillary third molar in bone.
Class A: Lowest portion of the crown of impacted
maxillary third molar is on a line with occlusal plane of
second molar.
Class B: Is between the occlusal plane of second molar
and the cervical line.
Class C: Is at or above the cervical line of second molar.
Q. 3. Which teeth are commonly impacted? Mention
four complications of prolonged retention of impacted
teeth.
Ans.
Teeth that are commonly impacted are maxillary third mo-
lars, mandibular third molars, maxillary canines, and man-
dibular premolars.
Complications due to retention of impacted teeth are as
follows:
i. Trismus, because of damage to masseter and medial
pterygoid muscle.
66 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

ii. Fracture of angle of mandible, if too much force is Q. 7. Impacted tooth.

employed during luxation of tooth.
Or
iii. Dislocation of TMJ, because of not taking mandibular
support during luxation. Define impaction of tooth.
Q. 4. Name four incisions for removal of impacted man- Ans.
dibular third molar.
l An impacted tooth is a tooth, which is completely or
Ans. partially unerupted and is positioned against another
tooth bone or soft tissue, so that its further eruption
l L-shaped incision.
is unlikely and described according to its anatomic
l Bayonet flap.
position.
l Envelope flap.
l Triangular flap. Q. 8. Postoperative complications of removal of
impacted mandibular third molar.
Q. 5. Mention four steps in exposure of unerupted incisor.
Ans.
Ans.
Incision of flap.
Complications
l

l Elevation of flap.
l Retraction of flap. i. Trismus, because of damage to masseter and medial
l Bone removal. pterygoid muscle.
ii. Fracture of angle of mandible, if too much force is
Q. 6. Classification of impacted upper canine.
employed during luxation of tooth.
Ans. iii. Dislocation of TMJ, because of not taking mandibular
support during luxation.
Classification of impacted maxillary cuspids
iv. Traumatic arthritis, since patients keep their mouth
i. Class I: Impacted cuspids located in the palate.
opened for long-time.
a. Horizontal,
b. Vertical, and Q. 9. Pericoronitis.
c. Semivertical(oblique).
Ans.
ii. Class II: Impacted cuspids located in the labial or the
buccal surface of the maxilla. l Pericoronitis is defined as the inflammation of the
a. Horizontal, soft tissues of varying severity around an erupting or
b. Vertical, and partially erupted tooth with breach of the follicle.
c. Semivertical. l Mandibular third molars are most often involved.

iii. Class III: Impacted cuspids located in both the palatal l It is one of the common causes for the removal of

process and the labial or the buccal maxillary bone. impacted molars.
Example: Crown is on palate and root passes through
Q. 10. Radiographs used in the assessment of lower
between roots of the adjacent tooth in the alveolar pro-
third molars.
cess ending in a sharp angle on the labial or the buccal
surface of maxilla. Ans.
iv. Class IV: Impacted cuspids located in the alveolar
The radiographs used to view the impacted teeth are:
process are usually vertical between incisors and first
i. IOPA radiograph.
bicuspids.
ii. Lateral view of mandible.
v. Class V: Impacted cuspids located in an edentulous
iii. OPG.
maxilla.
iv. Occlusal view.
vi. This is also classified based on its unusual position like
tooth – In the floor of the nose.
In the antrum.
In infraorbital margin.

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Section | I  Topic Wise Solved Questions of Previous Years
Maxillofacial Trauma
LONG ESSAYS
Q. 1. What are the signs and symptoms in Le Fort ii. Zygomatic complex fractures.
type I fracture? How do you manage the same?
Or
Classify the fractures of the middle third facial skeleton.
Write in detail about the clinical features, investiga-
tions, and management of Le Fort I fracture.
Or
Classify the fractures of maxilla. Write in detail the
clinical features, investigations, and management of a
Le Fort I fracture.
Or
Discuss the signs, symptoms, complications, and treat-
ment of Le Fort type I fracture of maxilla.
Or
Classify middle third fracture of the facial skeleton.
Describe in detail the anatomical extension, clinical fea-
ture, and treatment of Le Fort I fracture.
Or
Describe the signs and symptoms of Le Fort I fracture
and its management.
Or
Classify fractures of the mid face. Describe the clinical
features and management of a Le Fort I fracture.
Or
Classify fractures of middle third of the facial skeleton.
How would you manage a Le Fort I fracture?
Ans.
Fractures of the middle third of facial skeleton are classified
as follows:
I. In 1901, Rene Le Fort, based on his experimental work
with cadavers,classified maxillary fractures according
to the level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
II. A simple classification for ordinary practical purposes
of diagnosis and treatment planning is as follows:
i. Dentoalveolar fractures.
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67
Topic 7
iii. Nasal fractures.
iv. Naso-orbital-ethmoid fractures.
v. Orbital fractures.
vi. Le Fort fractures.
l Le Fort I or low level or infrazygomatic or
Guerin fractures.
l Le Fort II or pyramidal or infrazygomatic
fractures.
l Le Fort III or suprazygomatic fractures.
All these fractures may be unilateral or bilateral
vii. Extended Le Fort fractures.
III. According to Rowe and Williams (1985)
A. Fractures not involving the occlusion
i. Central region:
a. Fractures of the nasal bones and/or nasal
septum
l Lateral nasal injuries.
l Anterior nasal injuries.
b. Fractures of the frontal process of the maxilla.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid).
d. Fractures of type (a), (b), and (c) which
extend into the frontal bone.
ii. Lateral region: Fractures involving the zygo-
matic bone, arch, and maxilla (zygomatic com-
plex) excluding the dentoalveolar component.
B. Fractures involving the occlusion
i. Dentoalveolar.
ii. Subzygomatic
l Le Fort I (low level or Guerin).
l Le Fort II (pyramidal).
iii. Suprazygomatic
l Le Fort III (high level or craniofacial
dysjunction).
Le Fort I (Low Level or Guerin Type Fractures)
l The fracture line extends from the nasal septum to the
lateral pyriform rims, travels horizontally above the
teeth apices, runs below the zygomatic buttrress, and
crosses the lower third of the pterygoid laminae.
Signs and Symptoms
l Slight swelling of the upper lip as well as open bite is
seen, especially if the fractured segment is mobile.
68 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Ecchymosis is seen in the buccal sulcus beneath each
zygomatic arch.
l Disturbance in occlusion along with mobility in the
tooth bearing segment of the maxilla.
l Damage to the cusp, especially premolar of maxilla is
seen due to the impact of the mandibular teeth on them
in impacted type of fractures.
l With Le Fort I, there is movement of the teeth and the
maxilla, but the nose and the upper face will stay fixed.
Fracture of the palate is also seen.
l On percussion of the maxillary teeth, a ‘cracked-pot
sound’ can be heard.
l No tenderness over, or disorganization and mobility of
the zygomatic arch and bones.
Radiographic Examination
I. Routine radiographic examination of the face
Includes the Water’s view, the Caldwell view (PA view),
the lateral view, and sometimes the submentovertex view.
Water’s projection provides the most comprehensive dem-
onstration of the facial skeleton.
II. Computed tomography (CT)
Standard CT protocol of the face includes axial and either
direct or reconstructed coronal images. 3D reconstruction
of the CT scan aids in diagnosis and treatment planning.
Management of Le Fort I Fractures
l Reduction of mobile fractures should be done early.
l In case the repair of impacted fractures is delayed,
then Rowe’s disimpaction forceps can be used. These
forceps are applied to the nasal floor and hard palate.
Otherwise, Hayton-Williams forceps are placed behind
the maxillary tuberosities intraorally.
l Simple MMF for four weeks, without the need for sus-
pension wires can be used to treat the comminuted
fractures.
l Intraosseous wiring can be used sometimes without
postoperative MMF, but a soft diet is indicated for sev-
eral weeks.
l Rigid plating allows early function, but reduction and
plate conformation must be perfect.
l Comminuted fractures that cannot be plated or wired
are treated with MMF and suspension.
l The arch bar of the maxilla is suspended from the pyri-
form fossa, the zygomatic arch, the orbital rims, or
extraskeletally to a halo frame, in patients who have
extensive facial comminution.
l In edentulous patients, a custom acrylic occlusal splint
or the patient’s own denture can be used.
l MMF is removed at the end of the case, if intraoral
fixation is not possible and if rigid fixation is performed.
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Q. 2. Describe the bones involved in Le Fort II fracture.
How will you manage it?
Ans.
A fracture may be defined as a sudden break in the
continuity of the bone and it may be complete or
incomplete.
Fractures of the middle third of facial skeleton are clas-
sified as follows:
I. In 1901, Rene Le Fort, based on his experimental work
with cadavers classified maxillary fractures according
to the level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
II. A simple classification for ordinary practical purposes
of diagnosis and treatment planning is as follows:
i. Dentoalveolar fractures.
ii. Zygomatic complex fractures.
iii. Nasal fractures.
iv. Naso-orbital-ethmoid fractures.
v. Orbital fractures.
vi. Le Fort fractures.
l Le Fort I or low level or infrazygomalic or
Guerin fractures
l Le Fort II or pyramidal or inFrazygomatic
Fractures
l Le Fort III or suprazygomatic Fractures
All these fractures may be unilateral or bilateral.
vii. Extended Le Fort fractures.
III. According to Rowe and Williams (1985)
A. Fractures not involving the occlusion
i. Central region:
a. Fractures of the nasal bones and/or nasal
septum
l Lateral nasal injuries.
l Anterior nasal injuries.
b. Fractures of the frontal process of the maxilla.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid).
d. Fractures of type (a), (b), and (c) which
extend into the frontal bone.
ii. Lateral region: Fractures involving the zygo-
matic bone, arch, and maxilla (zygomatic
complex) excluding the dentoalveolar com-
ponent.
B. Fractures involving the occlusion
i. Dentoalveolar.
ii. Subzygomatic
l Le Fort I (low level or Guerin).
l Le Fort II (pyramidal).
iii. Suprazygomatic
l Le Fort III (high level or craniofacial dys-
junction).
Section | I  Topic Wise Solved Questions of Previous Years
Le Fort II Fracture
l It is also called as pyramidal fracture.
l It is so called, because the force applied at the level of the
nasal bones wherein the fracture line runs from the middle
area of the nasal bone down either side, crosses the frontal
process of the maxilla into the medial wall of each orbit.
l After entering inside each orbit, the fracture line crosses
the lacrimal bone behind the lacrimal sac, before turn-
ing forwards to cross the infraorbital margin slightly
medial to or through the infraorbital foramen.
l It then extends downwards and backwards across the lat-
eral wall of the antrum below the zygomaticomaxillary
suture and divides the pterygoid laminae about halfway up.
l It is separated from the base of the skull completely via
the nasal septum and may involve floor of the anterior
cranial fossa.
Signs and Symptoms
l Due to gross oedema of the middle third of the face, the
moon face appearance is seen.
l Retro positioning of the whole maxilla and gagging of
the occlusion are seen.
l On grasping the maxillary teeth, the midfacial skeleton
moves as a pyramid and the movement can be detected
at the infraorbital margin and the nasal bridge.
l Fracture of the zygomatic buttress causes haematoma
formation in the buccal sulcus opposite to the maxillary
first and second molar teeth.
l Step deformity at the infraorbital rims or nasofrontal
junction is noticed.
l Orbital wall fractures can cause limitation of ocular
movement because of entrapment.
l CSF rhinorrhoea is possible and should be looked for.
l Bilateral circumorbital ecchymosis gives an appearance
of ‘raccoon eyes’.
l In the surrounding area, subconjunctival haemorrhage
develops.
l Diplopia and gross unilateral enophthalmos may be
seen in cases of orbital floor injury.
l Infraorbital nerve damage may lead to anaesthesia or
paraesthesia of the cheek.
l Deformity of nose with epistaxsis.
l ‘Dish face’ or ‘floating maxilla’ terms are given for
lengthening of face due to separation of middle third
from the skull base.
l Midline or paramedian split of the palate is seen.
Management of Le Fort II Fracture
l To establish occlusion, MMF/IMF is done.
l Disimpaction using the Rowe forceps may be needed.
l After occlusion is established, the patient can be treated
with suspension from the maxillary arch bar to the
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69
zygomatic arches, lateral orbital rims,or superior orbital
rims with 24-gauge wire.
l Open treatment can be carried out by exposing, reduc-
ing, wiring, or plating the inferior orbital rim fracture.
l Medial canthal incisions can be created to access the
medial canthal tendon and reduction-fixation of the naso-
frontal area should be performed with wires or plates.
l Labiobuccal or inferior rim incisions can provide expo-
sure of the zygomaticomaxillary suture for fixation with
wires or plates.
l For rigid fixation, the MMF/IMF can be removed at the
end of the procedure.
Malocclusion should be corrected and occlusion should
be rechecked.
Q. 3. Write the clinical features and treatment of Le
Fort III fractures of midface.
Or
Describe signs, symptoms, and management of Le Fort
III fracture.
Or
Classify middle third facial fractures. Describe clinical
features and management of a case of Le Fort III fracture.
Or
Describe Le Fort III fracture and its management.
Ans.
A fracture may be defined as a sudden break in the continu-
ity of the bone and it may be complete or incomplete.
Fractures of the middle third of facial skeleton are clas-
sified as follows:
I. In 1901, Rene Le Fort, based on his experimental work
with cadavers, classified maxillary fractures according
to the level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
II. A simple classification for ordinary practical purposes
of diagnosis and treatment planning is as follows:
i. Dentoalveolar fractures.
ii. Zygomatic complex fractures.
iii. Nasal fractures.
iv. Naso-orbital-ethmoid fractures.
v. Orbital fractures.
vi. Le Fort fractures.
l Le Fort I or low level or infrazygomatic or
Guerin fractures.
l Le Fort II or pyramidal or infrazygomatic
fractures.
l Le Fort III or suprazygomatic fractures.
All these fractures may be unilateral or bilateral.
vii. Extended Le Fort fractures.
70 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
III. According to Rowe and Williams (1985)
A. Fractures not involving the occlusion
i. Central region:
a. Fractures of the nasal bones and/or nasal
septum
l Lateral nasal injuries.
l Anterior nasal injuries.
b. Fractures of the frontal process of the
maxilla.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid).
d. Fractures of type (a), (b), and (c) which
extend into the frontal bone.
ii. Lateral region: Fractures involving the zygo-
matic bone, arch, and maxilla (zygomatic com-
plex) excluding the dentoalveolar component.
B. Fractures involving the occlusion
i. Dentoalveolar.
ii. Subzygomatic
l Le Fort I (low level or Guerin).
l Le Fort II (pyramidal).
iii. Suprazygomatic
l Le Fort III (high level or craniofacial dis-
junction).
Le Fort III Fractures
l Le Fort III fractures also known as suprazygomatic
fractures results from force at the level of orbit.
l It extends from the frontonasal suture transversely back-
wards, parallel with base of the skull, and involves full
depth of the ethmoid bone including the cribriform plate.
l Within the orbit, the fracture runs below the optic fora-
men into the posterior limit of the inferior orbital fissure.
l From the base of the inferior orbital fissure, the fracture
line extends in two directions: (i) backwards across the
maxillary fissure to fracture the roots of the pterygoid
laminae, and (ii) laterally across the lateral wall of the
orbit separating the zygomatic bone from the frontal
bone.
Signs and Symptoms
l Gross oedema of midface.
l Bilateral circumorbital ecchymosis with subconjuncti-
val haemorrhage.
l Dish face appearance with lengthening of the face.
l Facial skeleton as a single unit becomes mobile.
l When lateral displacement occurs, tilting of the occlusal
plane and gagging of one side is seen.
l The bones at the frontozygomatic suture are separated
along with tenderness.
l Separation of the frontozygomatic suture may cause
‘Hooding of eyes’.
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l Deformity of the zygomatic arches along with disorga-
nization and lengthening of the nasal skeleton.
l CSF rhinorrhoea.
l Depression of ocular levels.
l Inability to move lower jaw leads to difficulty in mouth
opening.
Management
The bicoronal flap combined with midfacial degloving al-
lows maximal exposure. However, to maintain attachment
of the soft tissues to the stable skeleton, multiple discon-
tinuous approaches such as labiobuccal, lateral brow, infe-
rior rim, open sky, and others are frequently used.
Q. 4. Classify zygomatic complex fracture. Enumerate
the C/F and its management.
Or
Classify maxillary fractures. Describe the clinical fea-
tures and management of fracture of zygoma.
Or
Describe the clinical findings of zygomatic complex
fracture. Enumerate the various methods of reducing
the zygomatic arch fracture and discuss anyone in
detail.
Ans.
Classification of Zygomatic Complex
Fractures
According to Rowe and Williams (1985)
I. Fractures stable after elevation
a. Arch only (medially displaced).
b. Rotation around the vertical axis.
i. Medially.
ii. Laterally.
II. Fractures unstable after elevation
a. Arch only (inferiorly displaced).
b. Rotation around the horizontal axis.
i. Medially.
ii. Laterally.
c. Dislocation en bloc
i. Inferiorly.
ii. Medially.
iii. Posterolaterally.
d. Comminuted fractures.
Circumorbital ecchymosis.
Clinical Features of Zygomatic Fracture
l Enophthalmos.
l Displacement of palpebral fissure.
Section | I  Topic Wise Solved Questions of Previous Years
l Abnormal nerve sensibility.
l Diplopia.
l Flattening of the malar prominence.
l Flattening over the zygomatic arch.
l Alteration of globe level.
l Tenderness and deformity at the zygomatic buttress of
the maxilla.
l Crepitation from air emphysema.
l Pain.
l Epistaxis.
l Trismus.
Management
I. Reduction and fixation
Intraoral methods
l Indirect reduction is carried out which involves disim-
paction and reduction of the fracture by application of
an instrument to the deep aspect of the zygomatic bone
through an indirect approach, remote from the fracture
line.
l Transverse buccal sulcus incision for access to the infra-
temporal region.
l Cadwell-Luc approach for access to the orbital floor and
zygomatic body.
Extraoral approaches
l The Gillies temporal incision.
l Coronal incision.
l Lateral eyebrow.
l Upper eyelid incisions.
l Lower eyelid (subciliary or infraorbital) incision.
Zygomatic arch fractures
l Zygomatic arch fractures may be reduced effectively by
closed reduction.
l Just below the zygomatic arch anterior to the articu-
lating eminence through a preauricular transcutaneous
stab incision, a J-shaped, curved hook elevator is
inserted.
l After positioning the tip of the hook directly under the
dislocated bone fragments by well-controlled lateral
traction, reduction is achieved.
l There is no need for rigid internal fixation, as the tem-
poralis and masseter muscles and fascia, along with the
adjacent soft tissues splint the arch sufficiently to stabi-
lize the fragments.
l No functional loads should be exerted that will result in
displacement.
l Without fixation means disimpaction and reduction of
fracture by direct application of an instrument to the
deep aspect of the zygomatic bone through an indirect
approach away from the fracture line.
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Gillies temporal fossa approach
l A Bristow’s elevator is passed down through the inci-
sion beneath the zygomatic bone, which is then gradu-
ally reduced to its position.
l The incision is then closed in layers.
Transverse buccal sulcus incision
l A bone hook or curved elevator is passed behind supra-
periosteally, to contact the deeppart of the zygomatic
bone exerting an upward, outward and forward pres-
sure. Since less amount of force is required, this method
is preferred.
l Indirect reduction with fixation is advised for the un-
stable fractures of the zygomatic bone.
II. With fixation
i. Transosseous wiring
a. Frontozygomatic suture: Reduction and fixation of a
separated frontozygomatic suture can be done by an
open reduction and direct approach. The lateral orbital
rim can also be fixed in a similar way.
b. Infraorbital margin: Two small holes are drilled on ei-
ther side of the fracture and the fracture fragments are
reduced and fixed by passing a stainless steel wire.
However, the infraorbital rim is very delicate and wiring
of the fragments is quite difficult, hence rarely used.
ii. Pin fixation
l Less commonly used method.
l The required firmness is achieved by means of bone
pins with self-tapping threads, which are inserted into
the zygomatic bone and another pin into the lateral as-
pect of the supraorbital ridge.
l After the reduction of the fracture, the pins are con-
nected by rods and two universal joints.
iii. Bone plating
l During fracture at frontozygomatic suture, there is a
tendency of the comminuted fractured particles along
the floor of the orbit to contract inwards during healing.
Therefore, small bone plates can sometimes be used
instead of transosseous wiring to establish fixation.
iv. Fixation with a pack in the maxillary sinus
l The pack is used to support the fractured zygomatic com-
plex, especially the comminuted orbital floor fracture.
l An incision in the buccal sulcus bone is exposed,
blood clot and other debris is removed, the zygoma
repositioned gently with fingers, and a pack soaked
in Whitehead’s solution is inserted in a circular pat-
tern. The incision should then be closed at the end of
treatment.
l The pack should remain till the fractured segments
become stable.
72 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Q. 6. Classify midface fracture. Discuss the manage-
ment of malunited zygomatic fracture.
Ans.
A fracture may be defined as a sudden break in the continu-
ity of the bone and it may be complete or incomplete.
Fractures of the middle third of facial skeleton are clas-
sified as follows:
I. In 1901, Rene Le Fort, based on his experimental work
with cadavers, classified maxillary fractures according
to the level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
II. A simple classification for ordinary practical purposes
of diagnosis and treatment planning is as follows:
i. Dentoalveolar fractures.
ii. Zygomatic complex fractures.
iii. Nasal fractures.
iv. Naso-orbital-ethmoid fractures.
v. Orbital fractures.
vi. Le Fort fractures.
l Le Fort I or low level or infrazygomatic or
Guerin fractures.
l Le Fort II or pyramidal or infrazygomatic frac-
tures.
l Le Fort III or suprazygomatic fractures.
All these fractures may be unilateral or bilateral.
vii. Extended Le Fort fractures.
III. According to Rowe and Williams (1985)
A. Fractures not involving the occlusion
i. Central region:
a. Fractures of the nasal bones and/or nasal
septum
l Lateral nasal injuries.
l Anterior nasal injuries.
b. Fractures of the frontal process of the
maxilla.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid).
d. Fractures of type (a), (b), and (c) which
extend into the frontal bone.
ii. Lateral region: Fractures involving the zygo-
matic bone, arch, and maxilla (zygomatic com-
plex) excluding the dentoalveolar component.
B. Fractures involving the occlusion
i. Dentoalveolar.
ii. Subzygomatic
l Le Fort I (low level or Guerin).
l Le Fort II (pyramidal).
iii. Suprazygomatic
l Le Fort III (high level or craniofacial dis-
junction).
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Malunion of the zygomaticomaxillary complex
It will show following signs and symptoms:
i. Cosmetic.
ii. Neurological.
iii. Antral.
iv. Masticatory.
v. Ophthalmic.
Management
i. Cosmetic: Loss of contour or prominence of cheek
will be seen. Correction may be done either by surgical
refracturing or camouflaging the deformity, by means
of onlay bone grafting or alloplastic material like hy-
droxyapatite blocks.
ii. Neurological: The paraesthesia, dysaesthesia, or anaes-
thesia may be present. Observation for recovery of
infraorbital nerve should be done for 6–12 months oth-
erwise surgical exploration of the nerve can be done.
iii. Antral: Persistent sinusitis may be due to presence of
loose necrotic bone pieces or a foreign body, which
should be removed via Caldwell-Luc operation.
iv. Masticatory: Depressed zygomatic arch fracture im-
pinges on the coronoid process bringing about limitation
of the mandibular movements and opening. In extensive
fracture via coronal incision, the arch should be exposed,
refractured, and stabilized by direct fixation method.
Osteotomy and bone grafting can be done, if required.
v. Ophthalmic: Change of the ocular level, diplopia,
enophthalmos, and occulorotatory restriction are the
residual deformities, which are difficult to correct
secondarily.
Q. 7. Write the golden hour of trauma importance and
note on protocol to be followed in road traffic accident
victim management and on life support system.
Or
Describe emergency care in facial trauma.
Ans.
Fundamental principles of treatment with sound surgical
basis should be always followed.
i. Quick and thorough assessment of injured patient.
ii. Life-threatening situations should be quickly recog-
nized and treated.
iii. Acute trauma care involves many specialities, therefore
proper specialized consultations are asked for.
l Facial trauma must be considered in a slightly differ-
ent way compared to trauma elsewhere.
l It is important to restore the function and aesthetics,
to avoid any psychological impact.
l Initial proper treatment is always better than multiple
secondary procedures.
Section | I  Topic Wise Solved Questions of Previous Years
l It also avoids prolonged hospitalization, disability,
and added expenses.
l Sometimes inadequate primary treatment may result
in severe deformities that become difficult to treat
later on.
General Wound Management
l A gauze piece moistened with betadine solution is
spread over the wound to protect it further from con-
tamination.
l Surrounding skin should be cleaned gently with liberal ap-
plication of warm saline, dilute cetavlon, or dilute hydrogen
peroxide, taking care to swab away from the wound margins.
l A male patient should be cleanly shaven and female
patients should have all cosmetics removed. The eye-
brows should never be shaved.
l A careful wound examination including palpation
should be carried out to detect foreign bodies at the
depth of the wound, e.g., blood clots, dirt, wooden
splinters, broken teeth, denture pieces, glass pieces, tar,
hair, bone splinters, etc.
l Solvents, such as ether or benzene, remove tar, oil, grease,
or paint from a wound. Tissue holding forceps or scalpel
can be used to remove the embedded foreign matter.
l It is mandatory to remove the foreign particles, to pre-
vent fibrosis or traumatic tattooing of the skin.
l The wound should be irrigated with copious amount of
saline solution and with suction for intraoral wounds.
l Laceration of the scalp may be masked due to blood
crust and entangled hair.
l Haemostasis is also essential for good wound healing.
l Atraumatic instruments such as fine skin hooks and
Adson’s tissue holding forceps are very helpful in han-
dling and approximation of the tissue of the face.
l Gentle sponging of tissues should be done.
Specific Wounds
i. Abrasions
l The basic wound cleansing should be done followed
by topical application of antibiotic ointment with com-
pression dressing.
l Topical antibiotic is applied to cover superficial abra-
sions and left open.
l Slowly the crust of dried blood and serum will form a
scab and it will fall-off as the healing takes place.
ii. Contusion
Ice pack can be applied to stop further extravasation of blood.
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73
iii. Haematomas
l Most haematomas get reabsorbed and persistent haema-
toma may require incision and drainage.
l Antibiotic cover should be given to prevent haematoma
from getting infected.
iv. Incised Wounds
The wound should be taken care as early as possible. The
wound is cleaned, explored, and the bleeding arrested and
closed by primary intention.
v. Lacerated Wounds
l Cleaning of wound.
l Removal of foreign bodies.
l Debridement.
l Haemostasis.
l Closure in layers—primary closure.
l Dressing.
l Prevention of infection.
l Pain control.
l Follow-up.
Supportive Therapy
Drains: Superficial wounds do not require drainage, but
deeper wounds involving oral cavity, require insertion of
penrose or rubber drain between sutures or by stab inser-
tion. Drains should be removed after 2 to 4 days.
Dressings: Aantibiotic ointment along with dry gauze
dressing should be changed in 48 h. Large wounds
need pressure dressing. Sutures can be removed 5th to
7th day.
Prevention of infection: Strict sterile technique,
wound closure by eliminating all dead spaces, and ade-
quate supportive antibiotic therapy with follow-up is
necessary.
Prophylaxis Against Tetanus
l Whenever there is inclusion of dirt and debris in the
wound, protection against infection by the Clostridium
tentani organism must be provided.
l In a person who has been immunized with previous in-
oculation with the tetanus toxoid, a ‘booster’ dose of 1
mL of tetanus toxoid should be given.
l Passive immunity can be produced by administering
1500 units of tetanus antitoxin at weekly intervals, until
three doses have been given.
74 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
SHORT ESSAYS
Q. 1. Classification of fractures of the middle third of
facial skeleton.
Ans.
A fracture may be defined as a sudden break in the continu-
ity of the bone and it may be complete or incomplete.
Fractures of the middle third of facial skeleton are clas-
sified as follows:
I. In 1901, Rene Le Fort, based on his experimental work
with cadavers, classified maxillary fractures according
to the level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
II. A simple classification for ordinary practical purposes
of diagnosis and treatment planning is as follows:
i. Dentoalveolar fractures.
ii. Zygomatic complex fractures.
iii. Nasal fractures.
iv. Naso-orbital-ethmoid fractures.
v. Orbital fractures.
vi. Le Fort fractures.
l Le Fort I or low level or infrazygomatic or
Guerin fractures.
l Le Fort II or pyramidal or infrazygomatic
fractures.
l Le Fort III or suprazygomatic fractures
All these fractures may be unilateral or bilateral.
vii. Extended Le Fort fractures.
III. According to Rowe and Williams (1985)
A. Fractures not involving the occlusion
i. Central region:
a. Fractures of the nasal bones and/or nasal
septum
l Lateral nasal injuries.
l Anterior nasal injuries.
b. Fractures of the frontal process of the maxilla.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid).
d. Fractures of type (a), (b), and (c) which ex-
tend into the frontal bone.
ii. Lateral region: Fractures involving the zygo-
matic bone, arch, and maxilla (zygomatic com-
plex) excluding the dentoalveolar component.
B. Fractures involving the occlusion
i. Dentoalveolar.
ii. Subzygomatic
l Le Fort I (low level or Guerin).
l Le Fort II (pyramidal).
iii. Suprazygomatic
l Le Fort III (high level or craniofacial dis-
junction).
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Q. 2. Le Fort I fracture.
Ans.
Le Fort I (Low Level or Guerin Fractures)
l The fracture line extends from the nasal septum to the
lateral pyriform rims, travels horizontally above the
teeth apices, runs below the zygomatic buttrress, and
crosses the lower third of the pterygoid laminae.
Signs and Symptoms
l There may be slight swelling of the upper lip as well as
open bite, especially if the fractured segment is mobile.
l Ecchymosis is seen in the buccal sulcus beneath each
zygomatic arch.
l Disturbance in occlusion along with mobility in the
tooth bearing segment of the maxilla.
l Damage to the cusp, especially premolar of maxilla is
seen due to the impact of the mandibular teeth on them
in impacted type of fractures.
l With Le Fort I, there is movement of the teeth and the
maxilla, but the nose and the upper face will stay fixed.
Fracture of the palate is also seen.
l Percussion of the maxillary teeth results in distinctive
‘cracked-pot sound’ (like, when a cracked China pot is
tapped with a spoon).
l No tenderness over, or disorganization and mobility of
the zygomatic arch and bones.
Radiographic Examination
I. Routine radiographic examination of the face
The radiographs to be taken are Water’s view, Caldwell
view (PA view), lateral view, and occasionally submento-
vertex view. Water’s projection provides the most compre-
hensive demonstration of the facial skeleton.
II. Computed tomography (CT)
Standard CT protocol of the face includes axial and either
direct or reconstructed coronal images. 3D reconstruction
of the CT scan aids in diagnosis and treatment planning.
Management of Le Fort I Fractures
l Reduction of mobile fractures should be done early.
l If repair of impacted fractures is delayed, Rowe’s disim-
paction forceps can be used. These forceps are applied
to the nasal floor and hard palate. Otherwise, Hayton-
Williams forceps are placed behind the maxillary tuber-
osities intraorally.
Section | I  Topic Wise Solved Questions of Previous Years
l Simple MMF for 4 weeks, without the need for suspen-
sion wires can be used to treat the comminuted
fractures.
l Intraosseous wiring can be used sometimes without
postoperative MMF, but a soft diet is indicated for sev-
eral weeks.
l Rigid plating allows early function, but reduction and
plate conformation must be perfect.
l Comminuted fractures that cannot be plated or wired
are treated with MMF and suspension.
l The arch bar of the maxilla is suspended from the pyri-
form fossa, zygomatic arch, orbital rims, or extraskele-
tally to a halo frame in patients who have extensive
facial comminution.
l In edentulous patients, a custom acrylic occlusal splint
or the patient’s own denture can be used.
l If intraoral fixation is not possible and if rigid fixation is
performed, then MMF is removed at the end of the case.
Q. 3. Lefort II fracture.
Or
Pyramidal fracture.
Ans.
Le Fort II Fracture
l It is also called as pyramidal fracture.
l It is so called, because the force applied at the level of
the nasal bones wherein the fracture line runs from the
middle area of the nasal bone down either side, crosses
the frontal process of the maxilla into the medial wall of
each orbit.
l Inside each orbit, the fracture line crosses the lacrimal
bone behind the lacrimal sac, before turning forwards to
cross the infraorbital margin slightly medial to or
through the infraorbital foramen.
l Now, it extends downwards and backwards across the
lateral wall of the antrum below the zygomaticomaxil-
lary suture and divides the pterygoid laminae about
halfway up.
l It is separated from the base of the skull completely via
the nasal septum and may involve floor of the anterior
cranial fossa.
Signs and Symptoms
l Due to gross oedema of the middle third of the face, the
moon face appearance is seen.
l Retro positioning of the whole maxilla and gagging of
the occlusion are seen.
l On grasping the maxillary teeth, the midfacial skeleton
moves as a pyramid and the movement can be detected
at the infraorbital margin and the nasal bridge.
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75
l Fracture of the zygomatic buttress causes haematoma
formation in the buccal sulcus opposite to the maxillary
first and second molar teeth.
Step deformity at the infraorbital rims or nasofrontal
junction is noticed.
l Orbital wall fractures can cause limitation of ocular
movement, because of entrapment.
l CSF rhinorrhoea is possible and should be looked for.
l Bilateral circumorbital ecchymosis gives an appearance
of ‘raccoon eyes’.
l In the surrounding area, subconjunctival haemorrhage
develops.
l Diplopia and gross unilateral enophthalmos may be
seen in cases of orbital floor injury.
l Infraorbital nerve damage may lead to anaesthesia or
paraesthesia of the cheek.
l Deformity of nose with epistaxsis.
l ‘Dish-face’ or floating maxilla terms are given for
lengthening of face due to separation of middle third
from the skull base.
l Midline or paramedian split of the palate is seen.
Management of Le Fort II Fracture
l To establish occlusion, MMF/IMF is done.
l Disimpaction is done using the Rowes forceps.
l After establishing occlusion, the patient can be treated
with suspension from the maxillary arch bar to the zy-
gomatic arches, lateral orbital rims or superior orbital
rims with 24-gauge wire.
l Open reduction can be carried out by exposing, reduc-
ing, wiring, or plating the inferior orbital rim fracture.
l Medial canthal incisions are used for access to the medial
canthal tendon and/or reduction-fixation of the nasofron-
tal area should be performed with wires or plates.
l Labiobuccal or inferior rim incisions can provide expo-
sure of the zygomaticomaxillary suture for fixation with
wires or plates.
l In case of rigid fixation, the MMF/IMF can be removed
at the end of the procedure.
l Occlusion should be rechecked after malocclusion is
corrected.
Q. 4. Emergency radiology in facial injury.
Ans.
Radiological examination in facial injury can be also sup-
plemented by CT scan examinations, whenever the facili-
ties are available.
Minimum X-rays are required for the following:
I. In Case of Fractures of Middle Third of the
Face
l 15/30 degrees occipitomental view.
76
l Submentovertex view.
l Cranial posteroanterior view (skull).
l Lateral skull view.
l PA view - Water’s position.
II. For Zygomaticomaxillary Complex
l Occipitomenton view 15° and 30°.
l PA view - Water’s position.
l Submentovertex projection.
l Tomography/CT scan of the orbit.
III. For Mandibular Fractures
l Orthopantomogram (OPG).
l Lateral oblique views of the mandible (right and left).
l PA view of the mandible.
l Towne’s view for fractured condyles.
The occlusal view for mandible or maxilla and intraoral
periapical views for individual tooth may be required to be
taken.
Q. 5. Classification of zygomatic fractures.
Or
Clinical features and management of zygomatic arch
fractures.
Ans.
According to Rowe and Williams 1985, the zygomatic arch
fractures are classified as follows:
I. Fractures that are Stable After Elevation
a . Arch only (medially displaced).
b. Rotation around the vertical axis
i. Medially.
ii. Laterally.
II. Fractures that are Unstable After
Elevation
a . Arch only (inferiorly displaced).
b. Rotation around the horizontal axis.
i. Medially.
ii. Laterally.
c. Dislocation en bloc
i. Inferiorly.
ii. Medially.
iii. Posterolaterally.
d. Comminuted fractures.
Circumorbital Ecchymosis
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Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Clinical Features of Zygomatic Fracture Are:
l Enophthalmos.
l Displacement of palpebral fissure.
l Abnormal nerve sensibility.
l Diplopia.
l Flattening of the malar prominence.
l Flattening over the zygomatic arch.
l Alteration of globe level.
l Tenderness and deformity at the zygomatic buttress of
the maxilla.
l Abnormal nerve sensibility.
l Crepitation from air emphysema
l Pain.
l Epistaxis.
l Displacement of palpebral fissure.
l Trismus.
Q. 6. Blowout fracture of orbit.
Or
Blowout fracture.
Ans.
l Blowout fractures are fractures which result due to di-
rect trauma to the globe, which causes an increase in
intraorbital pressure and decompression due fracture of
the orbital floor.
l Orbital floor fractures can occur alone or in combina-
tion with extensive facial bony disruption.
l Orbital floor fractures may occur in combination
with zygomatic arch fractures, Le Fort type II or III
midface fractures, and medial wall or orbital rim
fractures.
l In case of fracture of the floor of the orbit, the bone frag-
ments are displaced into the antral cavity. These bone
pieces are held on by the periosteum.
l The orbital fat tends to herniate into the antral cavity
through the displaced fracture.
l Enophthalmos is seen as a result of herniation of orbital
contents and also due to increase in orbital volume.
l The inferior oblique muscle and inferior rectus muscle
may get entrapped in the fracture. This restricts the nor-
mal movement of the eye.
l The upward and outward rotation of the eye is restricted
causing diplopia.
l There will also be circumorbital oedema and ecchymosis.
l Paraesthesia in distribution of infraorbital nerve region.
l Rupture of the periostieum leads to subconjunctival
haemorrhage.
l Surgical emphysema.
l Optic foramen reflects most of the fractures, thus pro-
tecting the optic nerve as a result of its density.
Section | I  Topic Wise Solved Questions of Previous Years
l Damage of cranial nerves may cause symptoms such as
ophthalmoplegia, dilation of the pupil, and anaesthesia
in the distribution of ophthalmic branch of the fifth cra-
nial nerve may occur.
Q. 7. Nasal fracture.
Ans.
l Depending on the direction of force applied, the pattern
of nasal fractures varies.
l Force applied from a frontal direction may cause a se-
vere flattening of the nasal bones and septum.
l Lateral forces may result in only a depression of the
ipsilateral nasal bone or may also be forceful enough to
rule out fracture the contralateral nasal bone.
l Forces from below may cause fractures of the
septum.
l Damage to these membranes is serious, since it can lead
to obstruction, increased secretions, or an impaired
sense of olfaction.
Signs and Symptoms
l Pain and oedema.
l Flattening or any other type of deformation of the shape
of nose.
l Epistaxis or bleeding from the nose.
l Rhinitis, which may lead to increased tear production in
the eyes and a runny nose.
l Airway blockage due to bleeding, fluid discharge, or
tissue swelling.
l Crepitance.
l Bruising or discolouration (ecchymosis) of the tissues
around the eyes.
l Nasal septum may be deviated to one side.
l A step-deformity may be palpated.
Management
l Within the first 3 h following injury, the fracture should
be reduced.
l Usually, waiting 3–7 days is preferable as it allows oe-
dema to resolve and positioning the bones correctly
with more stability. It will be easier, since inflammation
and fibrosis may make the fragments less mobile by this
time.
l Walsham’s and Asch’s septal forceps are used for ma-
nipulating the fragments. Direction of force must be in
the opposite direction of the fracturing force, which is
in an anterolateral direction.
l In case of laterally displaced segments, they may be
reduced externally with direct pressure.
l The septal cartilage is grasped and repositioned into its
groove in the vomer.
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77
l Splinting may be required for immobilization, though
some simple fractures require no splinting.
l Types of splinting used are:
a. Intranasal splinting
l Ribbon gauze.
l Stainless steel splint.
b. Extranasal splinting
l laster of Paris.
l Lead splints.
Q. 8. Orbital trauma assessment.
Ans.
l In the infraorbital region in a PNS view, there are usu-
ally two radiopaque lines seen.
l The superior line represents the infraorbital rim and the
inferior line represents floor of the orbit.
l Water’s view projection of the skull shows the ‘hanging
drop’ sign of the orbital floor fracture.
l This appearance is due to the herniated fat and extrava-
sated blood, and appears as a smooth opaque convexity
which faces downwards suspended from the roof of the
maxillary sinus.
l Opacity of the maxillary and ethmoidal sinuses can also
be noted due to extravasation of blood into them.
l Sometimes, in the presence of opacity of the maxillary
sinus, isolated orbital fractures cannot be detected
through the Water’s view, therefore other imaging tech-
niques like computed tomography can be used.
Q. 9. Surgical anatomy of orbit.
Ans.
l The orbit is bounded by medial and lateral surfaces, and
has a roof and a floor.
l The medial orbital wall is very thin and ethmoidal. Air
cells lie beneath this wall.
l The lateral wall and the roof are thick.
l The orbital floor is contributed from the maxillary, zy-
gomatic, and palatine bones.
l It is the shortest of all the walls; it does not reach the
orbital apex, measures 35–40 mm and terminates at the
posterior edge of the maxillary sinus.
l It is very thin in the region of infraorbital groove, which
later becomes the infraorbital canal.
l The infraorbital nerve, a branch of the maxillary nerve
runs in the infraorbital groove and exits through the canal.
l The infraorbital artery, a tributary of the maxillary ar-
tery, and the infraorbital vein are also found within the
infraorbital groove flanking the infraorbital nerve and
exiting the infraorbital canal.
l The floor of the orbit is made up of orbital portion of the
maxillary bone and part of zygomatic bone. Laterally, it
is bounded by the inferior orbital fissure. Posteriorly it
78 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
is made up of the orbital process of the palatine bone,
and a small portion of the ethmoid bone. Medially, the
floor is bounded by lacrimal bone.
l Eyeball is suspended through the Lockwood’s ligament.
The Lockwood’s suspensory ligament is a fascial sling,
which supports the globe of the eye, passing from the
medial attachment in the region of the lacrimal bone, to
get inserted laterally into the Whitnall’s tubercle on the
lateral wall of the orbit just below the frontozygomatic
suture.
l Normally, the eyeball projects slightly beyond the or-
bital rim. The eyeball is filled with vitreous humour, and
remaining of the orbital cavity is filled with fat.
Q. 10. Gilles temporal approach.
Ans.
Gillies Temporal Approach
l Between the temporal fascia and the temporal muscle, a
natural anatomical space exists into which an instru-
ment can be inserted and it can be utilized to elevate the
displaced zygoma or its arch into position.
Technique
l The hair is shaved from the temporal region of the
scalp.
SHORT NOTES
Q. 1. Diplopia.
Ans.
l Diplopia is a very serious complication of the zygo-
matic fracture. It is caused by interference with the ac-
tion of extraoccular muscles and also due to oedema and
haemorrhage around these muscles, which may be ei-
ther temporary or permanent. It is blurred double vision
experienced by patient.
l It is of the following two types:
i. Permanent or temporary.
ii. Monoocular and binocular.
Q. 2. CSF rhinorrhoea.
Ans.
l CSF rhinnorhoea is a complication of the midface
fracture.
l It occurs when the cribriform plate of the ethmoid has
been comminuted. One of the common complaints may
be of a salty taste in the back of the throat when the CSF
passes through it.
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l The external auditory meatus is plugged with cotton to
prevent any fluid or blood getting inside.
l Incision of about 2 to 2.5 cm in length is made and in-
clined forward at an angle of 45 degrees to the zygo-
matic arch well in the temporal region. Injury to the
superficial temporal vessels is avoided.
l The temporal fascia is exposed, which appears as white
glistening structures.
l The incision is taken into the fascia and fibres of tempo-
ralis muscles will be seen.
l Long Bristow’s periosteal elevator is passed below the
fascia and above the muscle.
l The instrument is then inserted through it downward
and forward. The tip of the instrument is adjusted medi-
ally to the displaced fragment.
l A thick gauze pad is kept on lateral aspect of the skull
to protect it from the operating pressure of elevator.
l The operator grasps the handle of the elevator with
both hands. Assistant has to stabilize the head of the
patient.
l The tip of elevator is manipulated upward, forward, and
outward.
l As soon as reduction is complete, a snap sound can be
heard.
l Wound is closed in layers. For 5 to 7 days, pressure
should not be exerted on the area of surgery.
l Patient is instructed to sleep in supine position or not to
sleep on the operated side.
Q. 3. Cavernous sinus thrombosis.
Ans.
Cavernous sinus thrombosis is a sequela of direct extension or
retrograde thrombophlebitis of ethmoid or sphenoid sinuses.
The clinical features are:
l Proptosis.
l Chaemosis.
l Restriction of extraoccular mobility.
l Visual loss.
l Signs of meningitis.
l Intracranial complications occur rarely.
Q. 4. Non-union.
Ans.
l Non-union occurs due to the lack of bone healing
between the segments that persist indefinitely without
evidence of bone healing unless surgical treatment is
undertaken to repair the fracture.
l Characteristics of non-union are pain and abnormal
mobility following treatment.
Section | I  Topic Wise Solved Questions of Previous Years 79

l No evidence of healing can be seen in radiographs. Advantages of Indirect Fixation of Fractures

l Non-union is most commonly caused due to inadequate
l Simplicity.
reduction and immobilization, infection of fracture site,
l Low cost.
decreased vascularity, and systemic factors.
l Less time-consuming
Q. 5. Epistaxis. l Non-invasive.
Ans.
l Epistaxis is the unilateral haemorrhage from the nose.
Disadvantages of Indirect Fixation of
l It occurs whenever there is haemorrhage into the sinus,
Fractures
as a result of disruption of the sinus mucosa. l Oral hygiene.
l Caused because of draining of the maxillary sinus into l Absolute stability not possible.
the nose through the middle meatus. l Atrophy of muscles and loss of biting force.
l TMJ may be affected.
Q. 6. Greenstick fracture.
Ans. Q. 11. Transosseous wiring.

l Greenstick fracture is that type of fracture in which Or

one cortex of the bone is broken with the other cortex Wire osteosynthesis.
being bent.
Ans.
l It is an incomplete fracture seen in young children,

because of inherent resiliency of the growing bone. l Transosseous wiring or intraosseous wiring is cheap, easy
to use, and biologically well tolerated by the patients.
Q. 7. Malunion.
l It is a kind of semirigid fixation.
Ans. l Most of the time it is associated with IMF, if occlusal

l Malunion is defined as improper alignment of the discrepancies exist.

l Two holes are drilled with a small round bur on either
healed bony segments.
l All malunions are not clinically significant.
side at an adequate distance from the fracture line to
l They can be treated with orthodontics or osteotomies
provide stability and to prevent the wire from cutting
after complete bony union. out as it is twisted and tightened.
l It can result in facial asymmetry, enophthalmos, and Q. 12. Miniplate osteosynthesis.
ocular dystopia.
Ans.
Q. 8. Principles of fracture management.
l Monocortical semirigid fixation of maxillary fractures
Ans. with miniplates or screws eliminates bony movements
Principles of fracture management are: and allows primary healing to occur.
l Miniature plates are designed to produce rapid immobi-
l Reduction.
l Fixation.
lization.
l They are often applied in the region of the frontozygo-
l Immobilization.
matic suture, zygomatic buttress, and rim of pyriform
Q. 9. Fixation methods in trauma. aperture.
Ans. l These plates and screws provide three-dimensional sta-

bility and placement of these plates with the provision

Methods of fixation in trauma are as follows:
for two screws on either side of the fracture resists the
I. Closed fixation (indirect fixation)
anteroposterior and rotary movement of the fractured
l Intermaxillary fixation (IMF).
segment.
Internal fixation (direct fixation)
l Intraoral devices Q. 13. Methods of wiring in oral surgery.
l Plates and screws.
Ans.
l Transosseous wiring.

l Extraoral devices
Methods of wiring in oral surgery are:
l Transosseous wiring
External pin fixation.
IMF/MMF
Q. 10. Advantages and disadvantages of indirect fixation l Suspension wires
of fractures. i. Frontal suspension.
Ans. ii. Circumzygomatic suspension.

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80 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

i ii. Infraorbital. l Orbital floor fractures can occur alone or in combina-

iv. Pyriform aperture. tion with extensive facial bony disruption.
v. Peralveolar. l These fractures may occur along with zygomatic arch

fractures, Le Fort type II or III midface fractures, and

Q. 14. Ebernation.
Ans.
l Ebernation is one of the signs of non-union.
l It is the rounding off and sclerosis of the fractured bone
ends.
l It can be detected radiographically.
Q. 15. Gillies temporal approach.
Or
Gillies approach.
Ans.
Gillies Temporal Approach
l Between the temporal fascia and the temporal muscle, a
natural anatomical space exists into which an instru-
ment can be inserted and it can be utilized to elevate the
displaced zygoma or its arch into position.
l The operator grasps the handle of the elevator with both
hands. Assistant has to stabilize the head of the patient.
l The tip of elevator is manipulated upward, forward, and
outward.
l The snap sound will be heard as soon as reduction is
complete.
l Wound is closed in layers. For 5 to 7 days, no pressure
is exerted on the area of surgery.
l Patient is instructed to sleep in supine position or not to
sleep on the operated side.
Q. 16. CSF rhinorrhoea.
Or
Cerebrospinal fluid rhinorrhoea.
medial wall or orbital rim fractures.
Q. 18. Le Fort classification of maxillary fracture.
Ans.
In 1901, Rene Le Fort, based on his experimental work with
cadavers, classified maxillary fractures according to the
level of injury as:
i. Le Fort I.
ii. Le Fort II.
iii. Le Fort III.
Q. 19. Define Guerins fracture.
Ans.
Le Fort I (low Level or Guerin Type
Fractures)
l The fracture line extends from the nasal septum to the
lateral pyriform rims, travels horizontally above the
teeth apices, runs below the zygomatic buttrress, and
crosses the lower third of the pterygoid laminae.
Q. 20. Give any four signs and symptoms of Le Fort III
facial fractures.
Ans.
Signs and symptoms of Le Fort III facial fractures
l Gross oedema of midface.
l Bilateral circumorbital ecchymosis with subconjuncti-
val haemorrhage.
l ‘Dish face’ appearance with lengthening of the face.
l Facial skeleton as a single unit becomes mobile.
l When lateral displacement occurs, tilting of the occlusal

Or plane and gagging of one side is seen.

C.S.F. rhinorrhoea.
Ans.
l CSF rhinorrhoea is seen in Le Fort II fracture.
l Depending on the damage of the cribriform plate and
involvement of the anterior cranial fossa, cerebrospinal
fluid leak occurs.
l It is usually arrested, if the fracture is reduced.
Q. 17. Define blowout fractures.
Ans.
l Blowout fractures are fractures which result due to di-
rect trauma to the globe, which causes an increase in
intraorbital pressure and decompression due fracture of
the orbital floor.
l The bones at the frontozygomatic suture are separated
along with tenderness.
Q. 21. Diplopia.
Or
What do you understand by the term ‘Monocular
Diplopia’?
Ans.
l Diplopia is a very serious complication of the zygo-
matic fracture caused by interference with the action of
extraoccular muscles and also due to oedema and haem-
orrhage around these muscles which may be either
temporary or permanent.
l It is blurred double vision experienced by patient.

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Section | I  Topic Wise Solved Questions of Previous Years
l It is of the following two types:
i. Permanent or temporary.
ii. Monoocular and binocular.
Monocular Diplopia
It is double vision through one eye when the other eye is
closed. It requires immediate expert opinion. This indicates
a serious cause, such as detached lens or some other trau-
matic injury of the globe.
Q. 22. Clinical features and management of zygomatic
arch fractures?
Or
Name four signs and symptoms of zygomaticomaxillary
complex.
Ans.
Signs and Symptoms of Zygomaticomaxillary
Complex
l Enophthalmos.
l Displacement of palpebral fissure.
l Abnormal nerve sensibility.
l Diplopia.
l Flattening of the malar prominence.
l Flattening over the zygomatic arch.
Q. 23. Asche’s forceps.
Ans.
l Asche’s forceps are used for reduction of nasal fractures
and also for the alignment of nasal septum.
l Both the blades are inserted internally on each side of
the septum. In case of nasal bone fracture reduction, one
Mandibular Fractures
LONG ESSAYS
Q. 1. Classify fractures of mandible. Give your treat-
ment for a compound, comminuted, and unfavourable
fracture of angle of mandible.
Ans.
Mandibular fractures are classified by the anatomic areas
involved.
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81
blade is inserted internally and other externally to hold
nasal bone laterally and medially respectively.
Q. 24. Bristow’s elevator.
Ans.
l Bristow’s elevator is used to reduce the zygomatic fracture.
l Long Bristow’s periosteal elevator is passed below the
fascia and above the muscle. The instrument is then in-
serted through it downward and forward and the tip of the
instrument is adjusted medially to the displaced fragment.
l A thick gauze pad is kept on lateral aspect of the skull
to protect it from the operating pressure of elevator.
l The operator grasps the handle of the elevator with both
hands. Assistant has to stabilize the head of the patient
to reduce the zygomatic bone.
l The tip of elevator is manipulated upward, forward, and
outward. The snap sound will be heard as soon as reduc-
tion is complete.
Q. 25. Whalsham’s forceps.
Ans.
l Whalsham’s forceps are used for reduction of nasal
fractures. It has two curved blades,one is padded and
other unpadded.
l The padded blade is inserted internally into the nostril
and the unpadded blade is placed externally and ma-
nipulated for reduction of nasal fracture.
Q. 26. Hanging drop sign.
Ans.
l ‘Hanging drop’ sign of the orbital floor fracture is seen
in Water’s view projection of the skull.
l This appearance is due to the herniated fat and extravasated
blood. It appears as a smooth opaque convexity, which faces
downwards suspended from the roof of the maxillary sinus.
Topic 8
Dingman and Natvig defined these regions as follows:
1. Midline: It is the fracture between central incisors.
2. Canine region fracture: It is bounded by vertical lines
distal to the canine teeth fractures.
3. Symphysis fracture: This occurs within the area of the
symphysis.
4. Body: It is from distal symphysis to a line coinciding
with the alveolar border of the masseter muscle (usually
82 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
including the third molar/between the canine region and
the angle).
5. Angle: This is triangular region bounded by the anterior
border of the masseter muscle to the posterosuperior
attachment of the masseter muscle (usually distal to the
third molar).
6. Ramus: It is bounded by superior aspect of the angle to
two lines forming an apex at the sigmoid notch.
7. Condylar process: This is the area of the condylar pro-
cess superior to the ramus region.
8. Coronoid process: This includes coronoid process of the
mandible superior to the ramus region.
9. Dentoalveolar process: This region would normally
contain teeth.
Based on presence of serviceable teeth at the fracture
line:
Kazanjian and Converse classifies the mandibular frac-
tures by presence or absence of serviceable teeth in relation
to the line of fracture. This may be helpful in determining
treatment.
1. Class I: On both sides of the fracture line, teeth are
present.
2 . Class II: Only on one side of the fracture line, teeth are
present.
3. Class III: In this class, patient is completely edentulous.
Rowe and Killey have divided mandibular fractures into
two classes:
1. Those involving basal bone—single unilateral, double
unilateral, bilateral, or multiple.
2. Those not involving basal bone—alveolar process
fracture.
Fracture of the Angle of the Mandible
l It is affected by the medial pterygoid muscle and
the masseter muscle. The medial pterygoid is the
stronger one.
l The classification of fractures in this region can be as:
vertically favourable or unfavourable and horizontally
favourable or unfavourable.
l The posterior fragment will be pulled lingually, if the
vertical direction of the fracture line favours the unop-
posed action of the medial pterygoid muscle.
l Similarly, the posterior fragment will be displaced up-
wards, if the horizontal direction of the fracture favours
the pull of masseter and medial pterygoid muscle in
upward direction.
l A favourable fracture line makes the stabilization of the
fragments easier.
l On the posterior segment, the presence of erupted
teeth would prevent gross displacement of this
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fragment if the crown impacts on the opposing up-
per tooth.
Various Treatments for Fracture of Angle of
the Mandible
Transosseous Wiring (Intraosseous Wiring)
l Direct wiring across the fracture line is an effective
method of fixation of jaw bone fractures.
l Transosseous wiring can be done through intraoral or
extraoral approach.
l Holes are drilled in the bony fragments on either side of
the fracture line, after which a length of 26 gauge stain-
less steel wire is passed into the holes and across the
fracture.
l The fracture must be reduced independently with the
teeth in occlusion before the free ends of the wire are
lightened and twisted.
l The twisted ends are cut short and tucked into the near-
est drill hole. The single strand wire fixation in this
horizontal manner is the simplest form of fixation with
intraosseous wiring. It can be modified in various ways
depending on the following:
a. Position of fracture.
b. Muscle forces acting on the fragments.
c. Degree of comminution.
d. Number of fragments to be fixed.
e. Nature of the fracture line—oblique, straight, etc.
l The variations can be two-hole, four-hole, and three-
hole technique.
l Obwegeser’s figure of eight wiring, Hayton-William’s
modification of figure of eight wiring, etc. These varia-
tions are mainly used at the inferior border of the man-
dible through extraoral incision.
Indications for Extraoral Incision with
Transosseous Wiring at the Inferior Border
1. Unfavourable and grossly displaced fracture at the angle
of the mandible.
2. Severe overriding of the fragments.
3. Triangular comminuted fracture at the inferior border
associated with angle fracture.
4. Fracture of edentulous mandible.
5. Malunited fractures.
6. Non-union of the fracture.
7. Fractures with large extraoral lacerations.
The intraoral incision for fixation of transosseous wiring at
the upper border is chosen for the fractures at the angle with
minimum displacement or for the edentulous areas of the
body fracture.
Section | I  Topic Wise Solved Questions of Previous Years 83

Q. 2. Describe different methods of reduction of frac- Disadvantages

tured mandible.
l Surgical procedure.
Ans. l Complications of surgery.
Different methods of reduction of fractured mandible are:
I. Open reduction. II. Closed Reduction
II. Closed reduction.
Example: Arch bar, eyelet wiring, and Risdon’s wiring.
l Closed reduction can be the treatment for most of the
I. Open Reduction mandibular fractures, because of its simplicity, low cost,
and non-invasive nature of treatment.
l Open reduction is usually necessary in multiple dis-
l The presence of teeth will provide an accurate guide for
placed fractures, especially at the angle and parasym-
reduction.
physis region.
l It is important to recognize any pre-existing occlusal abnor-
l Intraosseous wiring or bone plating should be done at
malities, such as anterior open bite as teeth may be brought
lower border of the mandible without damaging the
into contact during reduction, yet be occluding incorrectly
developing teeth buds.
owing to lingual inclination of the fractured fragments.
l Wear facets on the teeth may provide valuable clues to
Indications previous contact areas.
l Unfavourable fracture at the symphysis or body of the
mandible. Indications
l Displaced bilateral condylar fractures.
l Favourable fractures: Closed reduction reduces the risk
l Delayed treatment of non-contacting displaced fracture
of morbidity.
fragments.
l Grossly comminuted fractures: The small fragments of
l Malunion.
the bones can coalesce and heal by excellent blood sup-
l Mandibular fracture opposing an edentulous maxilla.
ply of the face.
l Edentulous mandibular fracture with severe displacement.
l Fractures of the severely atrophic edentulous mandible.
l In cases where closed reduction is contraindicated.
l Closed reduction would not require stripping of the
l Medically compromised patients: Decreased pulmonary
periosteum, which is the major source of blood supply
function, severe seizure disorders, GI disorders, and
to the edentulous mandible.
patients with psychiatric or neurologic problems may
l Lack of soft tissue overlying the fracture site: Bone
need open reduction
plates, screws, and wires interfere with the bone union
l Complex facial fractures: These fractures can be re-
by further disrupting the soft tissue covering.
constructed best after open reduction and fixation of
l Fractures in children involving the developing dentition
the mandibular segments to provide a stable base for
to protect the developing tooth bud.
restoration.
l Infected lower jaw fractures.
l Other fractures: It includes open reduction with primary
l Coronoid process fracture: Extreme trauma may dis-
bone grafting in fractures of a severely atrophic edentu-
place the bone into the temporal fossa, causing trismus
lous mandible with severe displacement of the fracture
and swelling in the region of zygomatic arch, swelling
segments, or a non-union after closed reduction of a
in the retromolar area, and in the lateral crossbite. Usu-
severely atrophic edentulous mandible fracture.
ally, it does not require any treatment unless otherwise
the occlusion is disturbed or the coronoid process im-
Contraindications pinges on the zygomatic arch.
l Condylar fractures: Mostly treated by closed reduction,
l Medically unfit patients.
when there is minimal disturbance in occlusion and in
cases of non-displaced fracture.
Advantages
l Anatomic reduction. Contraindications
l Fixation in desired position. l History of seizures.
l Early return of function. l Compromised pulmonary function.
l No airway compromise. l Psychiatric conditions.
l No nutritional compromise. l GI disorders.

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84 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Advantages
l Conservative procedure.
l No surgical complication.
l Can be done in medically compromised patients.
Disadvantages
l Airway compromise.
l Loss of function.
l Nutrition compromise.
l Occlusion is used as guide.
l Speech—social inconvenience
l Rehabilitation is difficult.
Q. 3. Describe the healing process of a fractured man-
dible. Discuss the early and the late complications aris-
ing in the treatment of mandibular fractures. How will
you manage these complications?
Ans.
Healing of fractured mandible takes place as follows:
i. Primary healing:It takes place if callus formation is
prevented by close approximation, rigid fixation, and
immobilization of fractured fragments.
ii. Healing by secondary intention: Steps involved in frac-
ture healing by secondary intention are as follows:
a. Haematoma Formation
l There is break in the continuity of bone and rupture of
blood vessels from cortex, medulla, periosteum, sur-
rounding muscles, and adjacent soft tissues leading to a
haematoma formation.
l Haematoma surrounds the fractured bone ends and ex-
tends into the marrow space for 6–8 h after the accident.
There is an acute traumatic inflammatory phase.
b. Organization of Haematoma
l The haematoma contains periosteum, bone, muscle,
fascia, bone marrow, new capillaries, and fibrin
network. Polymorphs and macrophages take part in
digestion and removal of devitalized tissues. Osteoclasts
resorb bone spicules and bone fragments. Giant cells are
formed and fibroblasts invade the blood clot.
l Early organization of haematoma is characterized by
proliferation of blood vessels. Theircourse retards blood
flow resulting in stasis and proliferation of mesen-
chyme. Calcium level of the capillaries increases and
granulation tissue is formed.
c. Formation of Provisional Fibrous Callus
l Fibroblastic cells secrete osseomucin, that is deposited
in-between collagen network. Ground substance and
coarse collagen fibres form the matrix known as ‘osteoid
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tissue’. Here, the minerals are yet to be deposited.
l Granulation tissue is replaced by loose connective tissue
and there is obliteration of capillaries. This stage is
called fibrous callus.
d. Primary (bony) Callus Formation
l Calcium deposition commences 10–15 days later. Hence,
the callus is soft and is not visible on the radiograph.
l The alkaline phosphates present in the osteoblasts
are high. Depending on the location and function, the
following callus is formed:
i. Anchoring callus: It is formed on the external
surface of bone, between the anchoring callus and
the two fractured ends. This is cartilaginous and
therefore is thought that it does not occur in man-
dibular fracture.
ii. Uniting callus: It is seen at interfragmentary gap
and by the time it forms, bone resorption takes place
at the bone ends.
iii. Sealing callus: It is seen across bone ends and in
bone marrow spaces.
e. Secondary Callus
l Matured bone replaces immature bone; hence, it is vis-
ible in the radiographs. This process is seen in-between
20–60 days.
l Alkaline phosphatase plays an important role in osteo-
genesis. Acid phosphatase and lysosomal enzymes of
osteoclast act at acidic pH and help in autolysis.
l Definitive callus formation is the last stage of healing.
f. Remodelling of Bone
l Resorption of callus takes place except in interfragmentary
gap. If bone is not subjected to functional stress, true ma-
tured bone will not form. True haversian system oriented
to stress factors replaces non-oriented pseudo-haversian
system of secondary callus. Thus, the bone is moulded and
sculptured to conform to the size of the remainder of bone.
Complications of Mandibular Fracture
Management
l Infection.
l Bleeding.
l Lip numbness.
l Malocclusion.
l Non-union.
l Malunion.
l Trismus.
l Tooth loss.
l Paresis.
l Cosmetic compromise.
Section | I  Topic Wise Solved Questions of Previous Years
Following proper surgical protocols will reduce postop-
erative complications.
A. Early Complications
1. Infection: Patient’s local or general resistance will be
lowered, predisposing to infection. Especially debili-
tated patients, diabetics, and patients on steroid therapy
are prone to infection.
2. Nerve damage: Anaesthesia of the lower lip occurs due
to neuropraxia of the inferior alveolar nerve. It is the
most common complication.
3 . Displaced teeth and foreign bodies: May be swallowed.
Chest X-ray should be done and if needed, bronchos-
copy should be carried out to explore and remove the
foreign body.
4 . Pulpitis.
5 . Gingival and periodontal complications.
B. Late Complications
1. Malunion: It results due to improper fixation method,
early removal of immobilization device, tissue entrap-
ment in the fragments, etc.
2. Delayed union: It results due to local factors such as
infection and general factors such as osteoporosis or
nutritional deficiency.
3. Non-union: Radiologically, there is rounding off and
sclerosis of the bone ends. This condition is called ‘eb-
urnation’. This is caused by:
i. Infection at the fracture site.
ii. Inadequate immobilization.
iii. Unsatisfactory approximation with tissue entrap-
ment.
iv. In an elderly debilitated patient, with the ultra-thin
edentulous mandible.
Considerable loss of bone and soft tissue.
vi. Inadequate blood supply after radiotherapy.
vii. The presence of bone pathology like tumours etc.
viii. General diseases, e.g., osteoporosis, nutritional
deficiency, and disorders of calcium metabolism.
4. Sequestration of bone.
5. Traumatic myositis ossificans: It is rare.
6. Scars.
Q. 4. A 40 year old man who is edentulous posteriorly,
reports with a fracture in angle of mandible. Write in
detail about clinical features, diagnostic means, and
management.
Or
Write about management of unfavourable fracture of
angle region of edentulous mandible in a 60 year old
person.
Ans.
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85
Edentulous Mandibular Fractures
l An edentulous mandible is always resistant to fracture,
since there is a high degree of resorption in the molar
region.
l Bilateral body fracture of an edentulous mandible is
very common to see.
l Attachment of the mylohyoid muscle is at a higher level
when compared to normal dentulous mandible.
With associated medical problems in these patients, there is
i. Alveolar resorption is four times greater in the mandi-
ble than in the maxilla.
ii. Inferior alveolar vascular supply to the bone is greatly
compromised.
iii. Too little cancellous bone for repair (osteoendosteum).
iv. Normal healing potential is retarded.
v. Open reduction amounts to stripping of periosteum,
which impairs osteogenesis, as there is greater depen-
dence on periosteal supply in atrophic mandible.
Signs and Symptoms
l The molar areas may be more prone to fracture.
l Bilateral fracture of the edentulous mandible.
l Extreme downward and backward angulation of the
anterior fractured fragment, that creates a typical ‘bucket
handle’ type of displacement.
l Respiratory distress in an elderly patient.
l Eburnation seen as ‘elephant foot deformity’.
l Non-union due to infection.
l Anterior open bite is seen in bilateral angle fracture.
l Ipsilateral open bite is seen in unilateral angle fracture.
l Retrognathic occlusion and flattened appearance of the
lateral aspect of the face.
l Elongated face may be the result of bilateral angle frac-
tures, allowing the anterior mandible to be displaced
downward.
l Inability to close the jaw causing premature dental contact.
l Swelling at the angle externally and there may be
obvious deformity.
l Step deformity behind the last molar tooth may be visible.
l Undisplaced fractures are usually revealed by the pres-
ence of a small haematoma adjacent to the angle on
either the lingual or buccal side.
l Occlusion is often deranged. Mandibular movements
are painful.
l Trismus is usually present.
l On palpation, bone tenderness at the angle externally
can always be elicited.
Treatment
1 . Early stabilization of the fracture is mandatory.
2. Closed reduction with mandibular prosthesis held in
place by circummandibular wiring.
86 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
3. In non-union or delayed healing, open reduction is with
titanium mesh.
4. In severely atrophic edentulous ridge fracture, open
reduction is with primary bone grafting.
5. Fractured ends should be freshened up, soft tissue
entrapment is cleared off and then fixed.
Techniques for Treatment
1 . Closed reduction with gunning splint fixation.
2. Open reduction (intraoral or extraoral) with transosse-
ous, circumferential wire ligation, and transfixation
with Kirschner wires.
3. Percutaneous intramedullary pinning.
4. Intraoral open reduction with bone graft and maxillo-
mandibular fixation.
5. External splint fixation appliance.
6. Extraoral open reduction and fixation with malleable
mesh.
7. Extraoral open reduction and fixation with bone plating.
Q. 5. Classify fractures of condyle. Describe the clinical
features and management of unilateral condylar fracture.
Or
Classify fracture of mandibular condyle and its signs
and symptoms. How do you manage a case of unilateral
condylar fracture with displacement in an adult?
Ans.
Fractures of Condyle
1 . Unilateral and bilateral fractures.
2. Simple, compound, or comminuted fractures of the
condyle.
3. Wassmund’s five types of condylar fractures.
4. Lindhal’s classification of fractures.
Wassmund’s Classification (1934)
Type I: It is defined as a fracture of the neck of the condyle
with relatively slight displacement of the head. The angle
between the head and the axis of the ramus varies from 10°
to 45°. He states that these fractures tend to reduce sponta-
neously.
Type II: These fractures produce an angle from 45° to
90°, resulting in tearing of the medial portion of the joint
capsule.
Type III: In these fractures, the fragments are not in
contact, and the head is displaced mesially and forward ow-
ing to traction of the lateral pterygoid muscle. The frag-
ments are generally confined within the area of the glenoid
fossa. He recommended an open reduction for this fracture
type.
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Type IV: These fractures of the condylar head articulate
on, or in a forward position with regard to the articular
eminence.
Type V: This group consists of vertical or oblique frac-
tures through the head of the condyle. Wassmund suggested
a bone graft to reconstitute the condylar, when considerable
displacement of the fragments has occurred.
Lindhal’s Classification (1977)
a. Based on anatomic location of the fracture
(level condylar fracture)
l Condylar head: The condylar head is usually defined as
the portion of the condyle superior to the narrow constric-
tion of the condylar neck. Fractures of the condylar head
are intracapsular, since the capsule attaches to the condy-
lar neck. They may be further classified as vertical frac-
tures, compression fractures, and comminuted fractures.
l Condylar neck: This is the thin constricted area located
immediately below the condylar head. Anatomically, it is
the region where the caudal portion of the joint capsule
attaches. These fractures are therefore extracapsular.
l Subcondylar: This region is located below the condylar
neck and extends from the deepest point of the sigmoid
notch anteriorly, and to the deepest point along the con-
cave posterior aspect of the mandibular ramus. Depend-
ing on the location, these fractures are described as
‘high’ or ‘low’ subcondylar fractures.
b. Based on the relationship of the condylar segment
to the mandibular fragment
l Non-displaced.
l Deviated: This involves only an angulation of the con-
dylar fragment in relation to the distal mandibular seg-
ment. The fractured ends remain in contact, with no
separation or overlap.
l Displacement with medial or lateral overlap: The frac-
tured end of the proximal condylar segment lies either
medially or laterally to the proximal end of the distal
mandibular segment. Medially displaced condylar frag-
ment is more common.
l Displacement with anterior or posterior overlap:
l These are uncommon.
l No contact between the fracture segments.
c. Based on the relationship between the condylar
head and the glenoid fossa
l Non-displaced: The condylar head is in normal relation
to the glenoid fossa.
l Displacement: The condylar head remains within the
fossa, but there is alteration in the joint space.
l Dislocation: The condylar head lies completely outside
the confines of the fossa. Usual location of dislocation is
anteromedial, due to the pull of lateral pterygoid muscle.
Section | I  Topic Wise Solved Questions of Previous Years 87

Signs and Symptoms l Rowe’s extension.

l Obwegeser’s modification.
l Swelling and tenderness over the TMJ. l Hockey stick.
l Haemorrhage from ear on affected side. 2 . Retromandibular approach.
l ‘Battle’s sign’: Ecchymosis of the skin just below the 3. Submandibular approach.
mastoid process on same side is known as ‘Battle’s sign’. 4. Bicoronal (bilateral condylar fracture along with frontal
l If the condylar head is dislocated medially and all bone fracture).
oedema has subsided due to passage of time, a charac-
teristic hollow over the region of the condylar head is
observed. Methods of Immobilization of Condyle
l Deviation of the mandible on opening toward the side of l Transosseous wiring.
the fracture. l Kirschner wire.
l Unilateral posterior crossbite and retrognathic occlusion. l Intramedullary screw.
l Paraesthesia of the lower lip in the absence of a fracture l Bone pins.
of the body or angle of mandible on that side. l Bone plating.
l Shortens the ramus and produces gagging of the occlu-
sion on the ipsilateral molar teeth. Q. 6. Describe the signs, symptoms, diagnosis, and treat-
l Painful limitation of protrusion and lateral excursion to
ment of bilateral condylar fractures.
the opposite side. Or
l Rarely the mandible will be locked and middle ear
bleeding may present externally. Write in detail clinical features, diagnosis, and manage-
l Tenderness over the condylar area on palpation.
ment of bilateral condylar fracture in a eight year old
l It may be possible to determine whether the condylar
boy.
head is displaced from the glenoid fossa by palpation Ans.
within the external auditory meatus.
Signs and Symptoms of Bilateral Condylar
Investigations Fractures
The techniques applied are: l The signs and symptoms for unilateral fracture may be
1. Conventional radiography noticed on both sides.
a. Orothopantomogram (OPG). l Swelling over both fracture sites.
b. Reverse Towne’s view. l Overall mandibular movement is usually more restricted
c. Transcranial views of temporomandibular joints. compared to that in unilateral fracture.
2. CT scan. l An anterior open bite is present, if there is displacement
3. MRI. of the condyles from the glenoid fossa or overriding of
4. Arthrography. the fractured bone ends.
l Pain and limitation of opening and restricted protrusion

Treatment and lateral excursions.

l The appearance of an elongated face may be the result
Unilateral intracapsular fracture in adults of bilateral subcondylar fracture.
This kind of fracture does not cause much of a defor- l Bilateral condylar fractures are frequently associated
mity. Therefore, conservative treatment is considered ap- with fracture of the symphysis or parasymphysis.
propriate and IMF for a period of 2 to 3 weeks in case of
malocclusion.
Unilateral extracapsular fracture in adults Investigations
A low condylar neck fracture is treated by open reduc-
tion method in case of severe malocclusion caused by the The techniques applied are:
fracture or dislocation. No effective treatment is under- 1. Conventional radiography:
taken, if the fractured segments are not displaced, and there a. Orothopantomogram (OPG).
is no disturbance to the occlusion. b. Reverse Towne’s view.
c. Transcranial views of temporomandibular joints.
2. CT scan.
Surgical Approach 3. MRI.
1. Preauricular approach 4. Arthrography.
l Alkayat-Bramley.

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88 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
For Children Under the Age of 10
l This age group is more likely to develop ankylosis due
the condylar fracture.
l The treatment is completely functional for both unilat-
eral and bilateral condylar fractures.
l IMF may be required for a period of 7 to 10 days in case
of extreme pain.
Bilateral Intracapsular Fracture in Adults
l An intermaxillary fixation for a period of 3 to 4 weeks
is recommended, as the amount of displacement of both
the condyles may be different.
l Physiotherapy after IMF prevents any restriction of
mouth opening.
Bilateral Extracapsular Fracture in Adults
l Usually, this fracture results in instability and gross
displacement of the mandible.
l IMF is not reliable for the proper reduction of the frac-
tured site, though it may establish occlusion.
l Open reduction of at least one side to establish the nor-
mal height is recommended and then the treatment
protocol is same as that for unilateral extracapsular
fracture.
l When bilateral extracapsular fracture is associated with
other gross midfacial fracture, open reduction of the
both the sides should be considered.
Q. 7. Write in short the principles of fracture manage-
ment in the maxillofacial region. Add notes on different
treatment modalities for a fracture mandible involving
teeth in the line of fracture.
Ans.
Principles of fracture repair include: (i) reduction, (ii) fixa-
tion, (iii) stabilization, and (iv) prevention of infection.
Aims
i. Satisfactory facial form.
ii. Satisfactory functional occlusion.
iii. Satisfactory posttreatment range of movement of the
jaw.
iv. No second surgery for facial recontour in malocclusion.
v. No bone grafting.
Treatment of Fractures Involves Basically
Two Techniques:
i. Closed technique, and
ii. Open technique.
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I. Reduction
a. Closed technique
l Closed treatment is based on the principle that when the
teeth of a fractured segment are in correct occlusion,
then the bone fragments to which they are attached will,
also be satisfactorily reduced.
l Healing of the bone is seen by secondary intention with
callus formation.
External reduction devices
l Manipulation instruments can be employed to bring the
segments to occlusion.
l For example, Rowe’s disimpaction forceps can be
used to disimpact the fractured maxilla and bring it to
occlusion.
l Walsham’s forceps can be used to manipulate certain
nasal fractures.
Intraoral or extraoral traction
They are employed in cases where reduction has delayed
or in cases where muscular trismus prevents effective
manipulation.
l Intraoral traction involves fixation of pre-fabricated
arch bars to the maxillary mandibular arches and elastic
traction of the segment normal occlusion using elastics.
l Extraoral traction, on the other hand, involves anchor-
age from intact skull for traction. The process of traction
extremely slow and the patient is encouraged to open
and close the mouth to facilitate the elastic traction.
When satisfactory occlusion is achieved, elastics are re-
moved intermaxillary. Fixation is done using wires.
b. Open technique
l Open reduction is the surgical intervention for reduction
of the fractured segments.
l After introduction of antibiotics, possibility of surgical
opening of facial bone fractures increased significantly.
l Healing takes place by primary intention; and, no callus
formation occurs during healing.
II. Fixation
Closed fixation (indirect fixation)
Intermaxillary fixation (IMF or MMF): It refers to immobi-
lization of the jaws by wiring in a closed position. It is done
by means of wires, arch bars, and splints.
b. Internal fixation (direct fixation)
Intraoral devices
l Plates and screws.
l Transosseous wiring.
Section | I  Topic Wise Solved Questions of Previous Years 89

Extraoral devices of immobilization period is sufficient, while for mandibu-

l External pin fixation. lar fracture it is 4–6 weeks.
l In condylar fracture, the recommended immobiliza-

tion period is 2–3 weeks only, for prevention of anky-

III. Immobilization
losis of TMJ.
l In this phase, the fixation device is retained to stabilize
the reduced fragments into their normal anatomical po-
IV. Prevention of Infection and Rehabilitation of
sition, until clinical bony union takes place.
l The fixation device is utilized for a particular period to
Function
immobilize the fractured fragments. l Appropriate antibiotics should be used to prevent intra-
l Immobilization period depends on the type of fracture operative and postoperative infections.
and the bone involved. For maxillary fractures 3–4 weeks

SHORT ESSAYS
Q. 1. What is the basic difference between simple and Q. 3. Signs and symptoms of bilateral condylar frac-
compound fracture of bone? tures in children.
Ans. Ans.
Signs and symptoms for bilateral condylar fractures are as
Simple or Closed follows:
l The signs and symptoms for unilateral fracture may be
These are fractures that do not produce wound open to the
present on both sides.
external environment, whether it is through the skin, mu-
l Swelling over both fracture sites.
cosa, or periodontal membrane.
l Overall mandibular movement is usually more restricted
than in unilateral fracture.
Compound or Open l If there is displacement of the condyles from the glenoid

fossa or overriding of the fractured bone ends, an ante-

It is a fracture in which external wound involving skin,
rior open bite is present.
mucosa, or periodontal membrane communicates with
l Pain and limitation of opening and restricted protrusion
break in the bone.
and lateral excursions.
Q. 2. Clinical features of fracture of body of mandible. l The appearance of an elongated face may be the result

of bilateral subcondylar fracture.

Or
l Bilateral condylar fractures are frequently associated

Fracture of body of mandible in children. with fracture of the symphysis or the parasymphysis.
Ans. Signs and symptoms seen in children under the age of 10
are as follows:
Clinical features of fracture of body of mandible are as
l This age group is more likely to develop ankylosis due
follows:
the condylar fracture.
l Swelling and bone tenderness similar to that as seen in
l The treatment is completely functional for both unilat-
fracture of angle of mandible.
eral and bilateral condylar fracture.
l Even slight displacement of the fracture results in de-
l IMF may be required for a period of 7 to 10 days.
rangement of the occlusion.
l Premature contact occurs on the distal fragment. Q. 4. How do you manage a case of unilateral condylar
l Fractures between adjacent teeth tend to cause gingival fracture with displacement in adults?
tears.
Ans.
l When there is gross displacement, inferior dental ar-

tery may be torn, and this can give rise to severe intra-
oral haemorrhage and ecchymosis in the floor of Signs and Symptoms of Unilateral Condylar
mouth. Fractures are as Follows:
l Flattened appearance of lateral aspect of face.

l Inability to open or close the jaw.

l Swelling and tenderness over the TMJ.
l Crepitation on palpation.
l Haemorrhage from ear on affected side.

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90 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Ecchymosis of the skin just below the mastoid process
on same side known as ‘Battle’s sign’.
l If the condylar head is dislocated medially and all oedema
has subsided due to passage of time, a characteristic hol-
low over the region of the condylar head is observed.
l Deviation of the mandible on opening toward the side of
the fracture.
l Unilateral posterior crossbite and retrognathic occlusion.
l Paraesthesia of the lower lip in the absence of a fracture
of the body or the angle of mandible on that side.
l Shortens the ramus and produces gagging of the occlu-
sion on the ipsilateral molar teeth.
l Painful limitation of protrusion and lateral excursion to
the opposite side.
l Rarely, the mandible will be locked and middle ear
bleeding may present externally.
l Tenderness over the condylar area on palpation.
l It may be possible to determine whether the condylar
head is displaced from the glenoid fossa by palpation
within the external auditory meatus.
Investigations
The techniques applied are:
1. Conventional radiography
a. Orothopantomogram (OPG).
b. Reverse Towne’s view.
c. Transcranial views of temporomandibular joints.
2. CT scan.
3. MRI.
4. Arthrography.
Treatment
i. Unilateral Intracapsular Fracture in Adults
This kind of fracture does not cause much of a deformity.
Therefore, conservative treatment is considered appropriate
and IMF for a period of 2 to 3 weeks in case of malocclusion.
ii. Unilateral Extracapsular Approach in Adults
A low condylar neck fracture is treated by open reduction
method in case of severe malocclusion caused by the frac-
ture or dislocation. No effective treatment is undertaken, if
the fractured segments are not displaced, and there is no
disturbance to the occlusion.
Q. 5. Principles of fracture management.
Ans.
Principles of Fracture Repair
i. Reduction,
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ii. Fixation,
iii. Stabilization, and
iv. Prevention of infection.
Aims
i. Satisfactory facial form.
ii. Satisfactory functional occlusion.
iii. Satisfactory posttreatment range of movement of the
jaw.
iv. No second surgery for facial recontouring malocclu-
sion.
v. No bone grafting.
Treatment of Fractures Involves Basically two
Techniques:
i. Closed technique, and
ii. Open technique.
I. Reduction
Closed technique
Closed treatment is based on the principle that when the
teeth of a fractured segment are in correct occlusion, then
the bone fragments to which they are attached will, also be
satisfactorily reduced. Healing of the bone occurs by sec-
ondary intention with callus formation.
External reduction devices
Manipulation instruments can be employed to bring the
segments to occlusion. For example, Rowe’s disimpaction
forceps can be used to disimpact the fractured maxilla and
bring it to occlusion. Walsham’s forceps can be used to
manipulate certain nasal fractures.
Intraoral or extraoral traction
They are employed in cases where reduction has delayed or
in cases where muscular trismus prevents effective manipu-
lation.
l Intraoral traction involves fixation of pre-fabricated
arch bars to the maxillary mandibular arches and elastic
traction of the segment normal occlusion using elastics.
l Extraoral traction, on the other hand, involves anchor-
age from intact skull for traction. The process of trac-
tion is extremely slow and the patient is encouraged to
open and close the mouth to facilitate the elastic trac-
tion. When satisfactory occlusion is achieved, elastics
are removed intermaxillary and fixation is done using
wires.
Open technique
l Open reduction is the surgical intervention for reduc-
tion of the fractured segments. After introduction of
antibiotics, possibility of surgical opening of facial
Section | I  Topic Wise Solved Questions of Previous Years 91

bone fractures is increased significantly. Healing takes
place by primary intention; and, no callus formation
occurs during healing.
II. Fixation
Closed fixation (indirect fixation)
l Intermaxillary fixation (IMF or MMF): It refers to im-
mobilization of the jaws by wiring in a closed position.
l It is done by means of wires, arch bars, and splints.
Internal fixation (direct fixation)
l Subluxation of teeth causes derangement of occlusion.
l Vertical split or a horizontal fracture just below the gin-
gival margin results from indirect trauma against the
opposing dentition or violent impact by a small hard
object such as missile.
Multiple fractured but firm teeth indicate that the jaws
were clenched during trauma. By palpating the mandi-
ble with the thumbs on the teeth and fingers in the
lower border of the jaw and carefully applying pressure,
clinician can detect a crepitation in a fracture.
l Electrical or thermal vitality tests at this stage are

unreliable.
Intraoral devices
Q. 7. Name any four different types of dental wiring
l Plates and screws. techniques. Describe in short any one wiring technique
l Transosseous wiring.
for dentoalveolar fracture.
Extraoral devices Or
l External pin fixation. Methods of wiring in oral surgery.
III. Immobilization Or
l In this phase, the fixation device is retained to stabilize Transosseous wiring.
the reduced fragments into their normal anatomical
position, until clinical bony union takes place. Ans.
l The fixation device is utilized for a particular period to
immobilize the fractured fragments. 1. Intermaxillary Fixation
l Immobilization period will depend on the type of

fracture and the bone involved. For maxillary fractures a. Dental wiring
3–4 weeks of immobilization period is sufficient, while i. Direct interdental.
for mandibular fracture it is 4–6 weeks. ii. Eyelet.
l In condylar fracture, the recommended immobilization pe- iii. Continuous or multiple loop wiring.
riod is 2–3 weeks only, for prevention of ankylosis of TMJ. iv. Risdon’s wiring.
b. Arch bars
IV. Prevention of Infection and Rehabilitation of i. Erich.
Function ii. German silver.
l Appropriate antibiotics should be used to prevent intra iii. Jelenko.
and postoperative infections. c. Cap splints.

Q. 6. Dentoalveolar fractures.
2. Intermaxillary Fixation With
Ans.
Osteosynthesis
l Dentoalveolar injuries are defined as those fractures in a . Transosseous wiring.
which avulsion, subluxation, or fracture of the teeth oc- b. Circumferential wiring.
curs in association with a fracture of the alveolus. c. External pin fixation.
l This may occur alone or in conjunction with some other
d. Bone clamps.
type of mandibular fracture: e. Transfixation with Kirschner wire.
l Fracture of the crown of individual teeth.
f. Hayton-William’s wiring.
l Any missing fragments of crown or missing fillings

should be noted as these may be embedded within the

soft tissues or more rarely swallowed or inhaled. 3. Osteosynthesis without Intermaxillary
l Exposure or near exposure of the pulp chamber, which Fixation
requires immediate treatment.
l Fractures of the roots of teeth.
a . Non-compression small plates.
b. Compression plates.
l Excessively mobile teeth should be noted for later peri-
c. Miniplates.
apical radiographs.
d. Lag screws.

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92 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
The method of dental wiring is employed in situations
where the patient cannot afford the expensive bone plates.
Transosseous Wiring
Transosseous wiring refers to direct wiring across the
l
fracture line.
l It is an effective method of fixation and immobilization
of the mandible and the angle.
l Minimum specialized equipment required for this
method of fixation.
Technique
l Holes are drilled across the fracture lines and soft stain-
less steel wire of 0.45 mm diameter is passed through
the holes across the fracture.
l Accurate reduction of the fractured segments is by
twisting the wires tightly and the twisted wire tucked
into the nearest hole.
l The reduction of the fractured segments should be done
independently with teeth in occlusion.
l Wires are applied on the upper border or the lower
border depending upon the type of fracture.
l Transosseous wiring can be done either through intra-
oral or extraoral approach.
l The transosseous wiring at the upper border of the man-
dible, either through intraoral or extraoral incision is
preferred for the fractures of the angle of the mandible
with minimum displacement or for the edentulous area
of the body fracture.
l It is sufficient for the upper border wire to pass through
the outer cortical plate alone, as the fixation is always
combined with IMF.
Q. 8. Rigid internal fixation.
Ans.
Rigid fixation without IMF is achieved through bone plates.
There are basically two main systems of fixation of man-
dibular fractures:
i. Compression plates.
ii. Non-compression miniplates.
i. Compression Plates
l The compression plates are placed on AO/ASIF princi-
ples. These plates, however, skilfully adapted to mandi-
ble, the upper border and the lingual plates open during
the final tightening of the screws. These plates include
two pear-shaped holes at the extreme ends of the plate.
l These holes have the widest diameter near the fracture
lines. And, compression plate is placed in such a way
that the two holes lie on either side of the fracture line.
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l The screw is inserted in the narrowest part of the bone
such that after tightening, its head comes to rest in the
wider diameter of the bone. A tension band should be
applied at the level of alveolus, before tightening screws.
ii. Non-compression Miniplates
l A natural line of compression exists along the lower
border of the mandible. On the basis of this, they sug-
gested that fractures of the angle of the mandible can be
secured with single plate as near to the upper border as
feasible. In case of fracture of the parasymphysis re-
gion, two plates are ideally advised: One juxtaalveolar,
and the other at the lower border.
l This can be used virtually in all types of mandibular
body fractures determined by the ideal line of osteosyn-
thesis. It is well-known as Champy’s line of osteosyn-
thesis, where miniplate fixation is most stable.
Q. 9. Dynamic compression plates.
Ans.
l Plates and screws are made-up of stainless steel, and
need removal later on. These plates are very bulky.
l DCP system makes compression osteosynthesis possi-
ble, because of the screw holes designed according to
the spherical gliding principle for a 2.7 mm screw.
l In EDCP, eccentric gliding hole principle is used. In ec-
centric dynamic compression plate, there are two lateral
oblique holes in addition to conventional spherical glid-
ing holes.
l When the screw with the spherical head is driven into
the two inner holes, they provide interfragmentary com-
pression. It is possible by means of two outer holes to
produce additional compression at the alveolar margin
of the fractured fragment.
l The two lateral oblique holes takeover the function of
the tension bend in the alveolar margin.
Q. 10. Champy’s osteosynthesis line for monocortical
plating.
Ans.
Champy’s Line of Osteosynthesis
l Mandible is a blunt V-shaped tubular bone. It consists of
dense outer and inner cortical plate with cancellous
bone in-between. Similarly, cortical bone along the ex-
ternal oblique ridge and the inferior region of the chin is
thick and dense.
l The dense bone provides an excellent anchorage for
osteosynthesis screws. However, fixation of the screws
in the region of the alveolar process is difficult due to
presence of roots of the teeth.
Section | I  Topic Wise Solved Questions of Previous Years
l Masticatory forces produce tensional forces in the al-
veolar region or at the upper border and compression
forces at the lower border. This explains the cause of
distraction of fracture segments in the upper border,
and compression in the lower border.
l According to Champy, the transitional zone in-between
the areas of tension and compression is the line of zero
force running along the inferior alveolar nerve. Plates
are placed along this line.
l Champy calculated the forces applied to these plates
under physiological strains and produced the most de-
sirable shape of minimum thickness and reasonable
malleability to neutralize the harmful tension forces that
causes displacement of the fracture segments.
l Originally, Champy made these plates using stainless
steel. But currently titanium plates are also available.
These plates are known as non-compression miniplates.
Areas of Plate Application
l Single non-compression miniplate on the superior bor-
der of the mandibular angle fractures on the external
oblique line was recommended by Champy.
l For fractures posterior to the mental foramen, a single
plate is placed below the dental roots and above the in-
ferior alveolar nerve.
l For fractures anterior to mental foramen, two plates are
necessary to neutralize the torsional forces: One is
placed in the subapical region, and the other along the
lower border of the mandible.
Q. 11. Fracture of the body of edentulous mandible.
Or
Gunning splints.
Ans.
Gunning splints are used as means of closed reduction for
the edentulous mandible.
l Gunning originally made these vulcanite splints for frac-
tured dentate mandible. Gunning splints are modified
dentures which have bite blocks in the place of teeth and
a provision of space in the incisor region for feeding.
l These splints can be used either in the upper or lower
edentulous jaws. In case of completely edentulous pa-
tients, immobilization is carried out by attaching the upper
splint to the maxilla by peralveolar wires and the lower
splint to the mandibular body by circumferential wires.
l The upper and the lower splints are connected with
wires or elastic bands for intermaxillary fixation. A
slightly overclosed relation of the gunning splint helps
in effective reduction.
l To minimize the entry of food particles under the fitting
surface, the splint edges should overextend around the
sulcus.
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93
Construction
l The impression of the mandible is taken and the
splints are constructed on models obtained from these
impressions.
l Using acrylic resin, the splints are constructed and the
fitting surface is lined with black gutta percha.
l In a slightly overclosed relationship, the occluding sur-
faces can be made to fit together satisfactorily.
l Alternatively, a trough can be cut in the occlusal surface
of one splint and filled with gutta percha. The opposing
occlusal surface is then shaped to fit into the trough and
a satisfactory fit obtained at operation by softening the
gutta percha and pressing the two splints together.
l Intermaxillary fixation is done by applying hooks into
each.
l Modification of the patient’s dentures can also be used
as splint, if these have been preserved.
l During operation, it is necessary to adapt the splint to
the alveolus of each jaw after reduction.
Q. 12. Describe the vertically unfavourable fracture line
at the angle of the mandible.
Or
Draw diagrams to explain vertically and horizontally
favourable fracture of mandible.
Ans.
According to the Direction of Fracture and
Favourability for Treatment
a . Horizontally favourable fracture.
b. Horizontally unfavourable fracture.
c. Vertically favourable fracture.
d. Vertically unfavourable fracture.
l This classification is aimed toward the angle frac-
tures. Here, the direction of fracture line is important
for resisting the muscle pull. When the muscle pull
resists the displacement of the fragments, then the
fracture line is considered as favourable. If the mus-
cle pull distracts the fragments away from each other,
resulting in displacement, then the fracture line is
considered as unfavourable. The elevator group of
muscles exert an upward, forward, and medial pull;
while, depressor group of muscles exert a downward
and backward pull in an intact mandible. Whenever
there is a break in the continuity at the angle region,
then these two muscle groups lose their coordinated
movements and have independent action.
l In unilateral angle fracture, posterior ramus fragment
is the lesser fragment, while the body of the mandible
bearing the teeth becomes the greater fragment. The
greater fragment’s position is stabilized to certain
94 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
extent by the occlusion of the teeth, while posterior
ramal fragment can show displacement independently.
a. Horizontally Favourable Fracture
When the fracture line passes from the alveolar margin
downward and forward, then upward displacement of the
posterior fragment is prevented by physical obstruction
caused by the body of the mandible. Hence, such a fracture
line is termed as horizontally favourable.
b. Horizontally Unfavourable Fracture
On the other hand, the line of fracture passes downward
and backward, then the upward movement of the posterior
fragment is unopposed. This type fracture is termed hori-
zontally unfavourable. Sometimes, the upward displace-
ment can be prevented by presence of a tooth on the poste-
rior fragment which comes into contact with maxillary
tooth.
c. Vertically Favourable Fracture
When the angle fracture is viewed from above, or the oc-
clusal surface (in the vertical plane), then buccolingual di-
rection of the fracture line can studied. Here, the displace-
ment of the posterior fragment can be noticed in the medial
direction to the spasm of medial pterygoid and mylohyoid
muscle. Here, the fracture line which passes from outer or
buccal plate obliquely backward and lingually will tend to
resist the muscle pull mentioned, and is thus termed a verti-
cally favourable type fracture.
d. Vertically Unfavourable Fracture
When the fracture line passes from the inner or lingual plate
obliquely backward and buccally inward, then movement
of the posterior fragment will take place as a result of the
medial pterygoid muscle pull. This type of fracture is
termed vertically unfavourable. This classification is of
clinical importance for treatment, planning, and fixation.
Based on this, the amount of placement can be judged and
the type of fixation can be chosen.
Q. 16. Healing of fractures.
Ans.
Healing of fractured mandible takes place as follows:
i. Primary healingIt takes place if callus formation is pre-
vented by close approximation, rigid fixation, and im-
mobilization of fractured fragments.
ii. Healing by secondary intention: Steps involved in frac-
ture healing by secondary intention are as follows:
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a. Haematoma Formation
l There is break in the continuity of bone and rupture of
blood vessels from cortex, medulla, periosteum, sur-
rounding muscles, and adjacent soft tissues leading to a
haematoma formation.
l Haematoma surrounds the fractured bone ends and ex-
tends into the marrow space for 6–8 h after the acci-
dent, and there is an acute traumatic inflammatory
phase.
b. Organization of Haematoma
l The haematoma contains periosteum, bone, muscle,
fascia, bone marrow, new capillaries, and fibrin net-
work. Polymorphs and macrophages take part in diges-
tion and removal of devitalized tissues. Osteoclasts re-
sorb bone spicules and bone fragments. Giant cells are
formed and fibroblasts invade the blood clot.
l Early organization of haematoma is characterized by
proliferation of blood vessels. Their course retards
blood flow resulting in stasis and proliferation of mes-
enchyme. Calcium level of the capillaries increases and
granulation tissue is formed.
c. Formation of Provisional Fibrous Callus
l Fibroblastic cells secrete osseomucin, that is deposited
in-between collagen network. Ground substance and
coarse collagen fibres form the matrix known as ‘oste-
oid tissue’. Here, the minerals are yet to be deposited.
l Granulation tissue is replaced by loose connective tissue
and there is obliteration of capillaries. This stage is
called fibrous callus.
d. Primary (bony) Callus Formation
l Calcium deposition commences 10–15 days later.
Hence, the callus is soft and is not visible on the radio-
graph.
l The alkaline phosphates present in the osteoblasts are
high. Depending on the location and function, the fol-
lowing callus is formed:
i. Anchoring callus: It is formed on external surface of
bone between the anchoring callus and the two frac-
tured ends. This is cartilaginous and therefore is
thought that it does not occur in mandibular frac-
ture.
ii. Uniting callus: It is seen at interfragmentary gap
and by the time it forms, bone resorption takes place
at the bone ends.
iii. Sealing callus: It is seen across bone ends and in
bone marrow spaces.
Section | I  Topic Wise Solved Questions of Previous Years
e. Secondary Callus
l Matured bone replaces immature bone. Hence, it is vis-
ible in the radiographs. This process is seen in between
20–60 days.
l Alkaline phosphatase plays an important role in osteo-
genesis. Acid phosphatase and lysosomal enzymes of
osteoclast act at acidic pH and help in autolysis.
l Definitive callus formation is the last stage of healing.
SHORT NOTES
Q. 1. Name four X-rays taken for fracture mandible.
Ans.
l Panoramic radiograph.
l Lateral oblique radiograph.
l Posteroanterior radiograph.
l Occlusal view.
l Periapical view.
l Reverse Towne’s view.
Q. 2. Non-union.
Ans.
l Non-union indicates a lack of bony healing between the
segments that persist indefinitely without evidence of
bone healing, unless surgical treatment is undertaken to
repair the fracture.
l Non-union is characterized by pain and abnormal mo-
bility following treatment.
l The most likely cause of non-union is inadequate reduc-
tion and immobilization, infection of the fracture site,
decreased vascularity, and systemic fractures.
Q. 3. Pathological fractures.
Ans.
Pathological Fractures
This is a spontaneous fracture of the mandible occurring
from mild injury or as a result of a normal degree of mus-
cular contraction. This is because of weakness caused due
to the pre-existing bone pathology.
Areas of structural weakness may result from the
following:
a. Generalised Skeletal Disease
i. Endocrinal disorders—hyperparathyroidism or post-
menopausal osteoporosis.
ii. Developmental disorders—osteopetrosis and osteogen-
esis imperfecta.
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95
f. Remodelling of Bone
l Resorption of callus takes place except in interfragmen-
tary gap. If bone is not subjected to functional stress,
then true matured bone will not form. True haversian
system oriented to stress factors replaces non-oriented
pseudo-haversian system of secondary callus. Thus, the
bone is moulded and sculptured to conform to the size
of the remainder of bone.
iii. Systemic disorders—reticuloendothelial diseases, Paget’s
disease, osteomalacia, and severe anaemia.
b. Localized Skeletal Disease
Various cysts, odontomes, tumours, osteomyelitis, and
osteoradionecrosis affect the local region.
Q. 4. Horizontal favourable fracture of angle of
mandible.
Ans.
l When the muscle pull resists the displacement of
the fragments, then the fracture line is considered as
favourable.
l If the muscle pull distracts the fragments away from
each other, resulting in displacement, then the fracture
line is considered as unfavourable.
l When the fracture line passes from the alveolar
margin downward and forward, then upward dis-
placement of the posterior fragment is prevented
by physical obstruction caused by the body of the
mandible.
l Hence, such a fracture line is termed horizontally
favourable.
Q. 5. Mention any eight causes for the non-union of
fractured fragments of the mandible.
Ans.
Causes for the non-union of fractured fragments of the
mandible are as follows:
i. Infection at the fracture site.
ii. Inadequate immobilization.
iii. Unsatisfactory approximation with tissue entrapment.
iv. The ultra-thin edentulous mandible in an elderly de-
bilitated patient.
Considerable loss of bone and soft tissue.
vi. Inadequate blood supply after radiotherapy.
vii. The presence of bone pathology like tumours etc.
viii. General diseases, e.g., osteoporosis, nutritional defi-
ciency, and disorders of calcium metabolism.
96 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Q. 6. Unfavourable fracture of mandible. Surgical Technique for Subcondylar Fractures

Ans.
l When the muscle pull resists the displacement of the
fragments, then the fracture line is considered as favour-
able. If the muscle pull distracts the fragments away
from each other, resulting in displacement, then the
fracture line is considered as unfavourable.
l If the line of fracture passes downward and backward,
then the upward movement of the posterior fragment is
unopposed. This type fracture is termed horizontally
unfavourable. Sometimes, the upward displacement can
be prevented by presence of a tooth on the posterior frag-
ment which comes into contact with maxillary tooth.
l When the fracture line passes from the inner or lingual
plate obliquely backward and buccally inward, move-
ment of the posterior fragment will take place as a result
of the medial pterygoid muscle pull. This type of frac-
ture is termed vertically unfavourable.
Q. 7. Green stick fracture.
Ans.
l It is fracture, where one cortex of the bone is broken
with the other cortex being bent.
l It is an incomplete fracture usually seen in young chil-
dren, because of inherent resiliency of the growing bone.
Q. 8. Malunion and non-union.
Ans.
Malunion
l Malunion is defined as improper alignment of the
healed bony segments.
l Not all malunions are clinically significant.
l These malocclusions may be treated with orthodontics
or osteotomies after complete bony union.
l It may also result in facial asymmetry, enophthalmos,
and ocular dystopia.
Non-union
l Non-union indicates a lack of bony healing between the
segments that persist indefinitely without evidence of
bone healing, unless surgical treatment is undertaken to
repair the fracture.
l Non-union is characterized by pain and abnormal mo-
bility following treatment.
l The most likely cause of non-union is inadequate reduc-
l Under general anaesthesia, subcondylar fractures were
first reduced and fixed.
l The fracture can be approached through an incision
along the anterior border of the ascending ramus used
electively for oblique subcondylar.
l The masseter muscle was reflected laterally to the pos-
terior border at a subperiosteal level.
l The sigmoid notch is identified, so that a bauer type
retractor can be positioned into it.
l The proximal condylar segment is then carefully identi-
fied. If the proximal segment is displaced medially,
the mandible is distracted inferiorly with a gag of
the Mason type, so that the proximal segment can be
positioned laterally.
l A four-hole miniplate of the Wurzburg type was then
attached to the proximal segment with one or two
screws.
l The periosteum of the proximal segment is then ele-
vated only to the degree necessary for plate placement
to preserve as good a blood supply as possible.
l A percutaneous trochar is placed through a horizontal
stab incision in the pre-auricular region, so that the cor-
rect angulation could be obtained for making the drill
holes.
l Intermaxillary fixation is instituted using previously
inserted arch bars or wiring. After this, fracture is re-
duced with attention being given to a proper alignment
of the posterior border of the ramus as ascertained by
inspection and instrumental palpation of the fractured
site.
l The plate is then attached to the distal segment with two
further screws.
l The incision is closed. Patients are asked to wear train-
ing elastics between their fixation bars for 2–10 days.
Q. 10. Fixation methods in trauma.
Ans.
Closed Fixation (Indirect Fixation)
Intermaxillary fixation (IMF or MMF): It refers to immobi-
lization of the jaws by wiring in a closed position. It is done
by means of wires, arch bars, and splints.
Internal Fixation (Direct Fixation)
Intraoral Devices

tion and immobilization, infection of the fracture site, l Plates and screws.
decreased vascularity, and systemic fractures. l Transosseous wiring.

Q. 9. Treatment option for subcondylar fractures of

mandible.
Extraoral Devices
l External pin fixation.
Ans.

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Section | I  Topic Wise Solved Questions of Previous Years
Q. 11. Bone plates.
Ans.
l The usage of bone plates had revolutionized the trend
towards the surgical approach of condylar fractures.
l Bone plates provide both rigidity and stabilization with
an added advantage of easy application.
l Bone plates can be applied through intraoral or extraoral
techniques.
Q. 12. Eyelet wiring.
Ans.
Advantages
l This is a firm and stable technique of wiring.
l If any of the eyelets break, only the particular eyelet may
be changed without disturbing the rest of the wiring
Disadvantages
l Requires the presence of firm and healthy teeth adjacent
to each other.
l Time consuming.
l May cause extrusion of the teeth due to wire around the
neck of the tooth.
Q. 13. Circummandibular wiring.
Ans.
l Circummandibular wiring can be used successfully and
effectively in the immobilization of oblique fractures in
edentulous mandible.
l The wiring can be done by passing 0.45 mm stainless
wire circumferentially around the mandible.
l A curved awl is pushed through the skin beneath the
mandible and directed into the mouth on the lingual side
of the bone. One end of certain length of 0.45 mm stain-
less steel is passed through the tip of the awl, which is
pulled on the lingual side.
l Now the awl is withdrawn to lower border of the man-
dible and before withdrawing it out of the skin, it is
pushed into the buccal sulcus where the wire is detached
from the awl and the awl is withdrawn through the
original puncture. The two ends of 0.45 mm stainless
steel wire are tied together and tightened.
Q. 14. Arch bars wiring.
Ans.
Two types of arch bars are available: (i) pre-fabricated and
(ii) made individually for a given patient.
Indications for Use
l When the remaining teeth are insufficient to allow
efficient eyelet wiring.
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97
l When the distribution of the teeth in the arch is such that
efficient intermaxillary fixation is not possible.
l In cases of simple dentoalveolar fractures, or where
multiple tooth bearing fragments in either jaw requires
reduction into an arch form before intermaxillary fixa-
tion is applied.
Q. 15. Lag screws.
Ans.
l Compression of the fractured fragments can be accom-
plished by means of lag screws. This technique is
applied for the treatment of oblique fractures in
long bones.
l Few oblique mandibular fractures can also be treated
through this method. A screw that glides through cortex
of one fragment and engages the cortex of opposite
fragment with its threads draws the fragments together
and compresses them when tightened.
l Gliding holes and thread hole must be coaxial.
Q. 16. Transosseous wiring.
Or
Wire osteosynthesis.
Ans.
l This is used for low subcondylar fractures. The condyle
approach through the submandibular incision and holes
are drilled in the fragmented segments and wire passed
across the major segment. A pull through wire is used for
passing the wire through a hole drilled in minor fragment.
l Pre-auricular incision is preferred for high condylar
fractures. Here, the fragments are drilled obliquely from
the external surface to the fracture surface in order to
decrease the risk of injuring maxillary artery and other
blood vessels, and to facilitate the insertion of wire.
l In case of dislocation of the condyle due to fracture,
transosseous wiring should be assisted with other
methods of fixation to counteract the pull of the lateral
pterygoid.
Q. 17. Compression bone plates.
Or
Dynamic compression plate.
Ans.
l Plates and screws are made up of stainless steel and
need removal later on. These plates are very bulky.
l DCP system makes compression osteosynthesis possi-
ble, because of the screw holes designed according to
the spherical gliding principle for a 2.7 mm screw.
l In EDCP, eccentric gliding hole principle is used. In ec-
centric dynamic compression plate, there are two lateral
oblique holes in addition to conventional spherical glid-
ing holes.
98 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Q. 18. Methods of wiring in oral surgery. Q. 21. Fracture of body of mandible - signs and
symptoms.
Ans.
Ans.
Methods of wiring in oral surgery are:
l Transosseous wiring. Signs and symptoms of fracture of body of mandible are as
IMF/MMF follows:
l Suspension wires l Swelling and bone tenderness similar to that seen in

l frontal suspension. fracture of angle of mandible.

l circumzygomatic suspension. l Even slight displacement of the fracture causes derange-

l infraorbital. ment of the occlusion.

l pyriform aperture. l Premature contact occurs on the distal fragment.

l peralveolar. l Fractures between adjacent teeth tend to cause gingival

tears.
Q. 19. Eburnation.
l When there is gross displacement, inferior dental artery

Ans. may be torn, and this can give rise to severe intraoral
haemorrhage.
Eburnation is one of the signs of non-union.
l Ecchymosis in the floor of mouth.
l It is the rounding off and sclerosis of the fractured bone
l Flattened appearance of lateral aspect of face.
ends.
l Inability to open or close the jaw.
l Can be detected radiographically.
l Crepitation on palpation.

Q. 20. Fracture management in edentulous jaws.

Q. 22. Indications for extraction of tooth related to
Or fracture line.
Gunning type splint. Ans.
Or l Longitudinal fracture involving the crown and the root,
splitting the tooth.
Gunning splint.
l Complete subluxation of the tooth from its socket.

Ans. l Pre-existing large periapical pathology.

l Grossly infected fracture line.

Gunning splints are used as means of closed reduction for
l Bad periodontal status of the tooth and third degree
the edentulous mandible.
mobility due to periodontitis.
l Gunning originally made these vulcanite splints for frac-
l Functionless teeth.
tured dentate mandible. Gunning splints are modified
l Advanced caries.
dentures which have bite blocks in the place of teeth and
l Root stumps.
a provision of space in the incisor region for feeding.
l These splints can be used either in the upper or lower Q. 23. Battle’s sign.
edentulous jaws. In case of completely edentulous pa-
Or
tients, immobilization is carried out by attaching the upper
splint to the maxilla by peralveolar wires and the lower What is a Battle’s sign? What is the differential diagno-
splint to the mandibular body by circumferential wires. sis of it?
l The upper and the lower splints are connected with
Ans.
wires or elastic bands for intermaxillary fixation. A
slightly overclosed relation of the gunning splint helps l Ecchymosis of the skin just below the mastoid process
in effective reduction. on the same side.
l To minimize the entry of food particles under the fitting l This particular physical sign also occurs with fractures

surface, the splint edges should overextend around the of the base of the skull.
sulcus. l This type of sign is seen in unilateral condylar fracture.

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Section | I  Topic Wise Solved Questions of Previous Years 99

Topic 9
Cysts of Orofacial Region

LONG ESSAYS
Q. 1. Classify cysts that occur in mouth. Describe the 2. Incisive canal (nasopalatine duct or median anterior
treatment of dentigerous cyst. maxillary) cyst.
Non-epithelial cysts
Or
1. Solitary bone cyst (traumatic).
Describe various methods of treatment of dentigerous 2. Aneurysmal bone cyst.
cyst. 3. Stafne’s bone cavity.
Cysts of the maxillary antrum
Or
1. Surgical ciliated cyst of maxilla.
Classify odontogenic cyst. Give in detail the treatment 2. Benign mucosal cyst of the maxillary antrum.
plan for large dentigerous cyst in the body of mandible.
Or II. Soft Tissue Cyst
Classify cysts of the jaws and write in detail about den- A. Odontogenic cysts
tigerous cyst. 1. Gingival cysts
a. Adult.
Or b. Newborn.
Classify odontogenic cysts. Give in detail the treatment B. Benign mucosal cyst of the maxillary antrum—non-
plan for large dentigerous cyst. odontogenic cysts
1. Anterior median lingual cyst.
Or 2. Nasolabial cyst (or nasoalveolar cyst).
How do you manage a case of cyst in relation to un- C. Retention cysts
erupted upper canine tooth in patient aged 12 years. Salivary gland cysts
a. Mucocele.
Ans. b. Ranula.
D. Developmental/congenital cysts
a. Dermoid and epidermoid cysts.
I. Intraosseous Cysts
b. Lymphoepithelial cyst (cervical/intraoral).
Epithelial Cysts c. Thyroglossal duct cyst.
d. Cystic hygroma.
Cysts of Odontogenic Epithelial Origin
E. Parasitic cysts
1. Developmental a. Hydatid cysts.
a. Primordial cyst (keratocyst). b. Cysticerosis.
b. Dentigerous (follicular) cyst. F. Heterotropic cysts
c. Lateral periodontal cyst—lateral botryoid odonto- Oral cysts with gastric or intestinal epithelium
genic cyst.
d. Calcifying odontogenic (Gorlin) cyst.
2. Inflammatory Dentigerous Cyst
a. Radicular cyst (apical/lateral periodontal). Dentigerous cyst results because of enlargement of
b. Residual cyst. the follicular space of the hole or part of the crown of an
impacted or unerupted tooth and is attached to the neck of
Cysts of Non-odontogenic Epithelial Origin
the tooth.
1. Fissural
a. Median mandibular.
b. Median palatal.
Site
c. Globulomaxillary. l More frequently in the mandible than in the maxilla.

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100 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Late erupting teeth are most frequently involved in de-
scending order. These arelower third molars, upper
cuspids, upper third molars, and lower bicuspid teeth.
Clinical Features
l Dentigerous cysts have the potential to attain a large
size; often it is the pronounced facial asymmetry or the
problem of ill-fitting dentures that forces a patient to
seek treatment.
l Pain may be a presenting symptom, if secondary infec-
tion is present.
l A tooth from the normal series is usually found to be
missing clinically, unless the cause is a supernumer-
ary tooth; sometimes, other adjacent teeth may also
fail to erupt, may be tilted, or otherwise be out of
alignment.
l A smooth, hard, painless swelling can be seen due to
lateral expansion. Later the bone covering the centre of
the convexity becomes thinned, as the cyst expands and
can be indented with pressure on palpation, with further
expansion. This fragile outer shell of bone becomes
fragmented, and the sensation imparted and sound pro-
duced on palpation over the area is described aptly as
egg-shell crackling, which is also true for other large
odontogenic cysts.
l Still later, the cyst lining may come to lie immedi-
ately beneath the oral mucosa and fluctuation can be
elicited.
Radiological Features
l Unilocular radiolucency is associated with crowns of
unerupted impacted teeth. At times, a multilocular effect
can be seen when the cyst is of irregular shape due to
bony trabeculations.
l Cysts have a defined sclerotic margin.
l With the pressure of an enlarging cyst, the unerupted
tooth can be pushed away from its direction of erup-
tion, e.g., the lower molar may be pushed to the inferior
border or into ascending ramus; whereas, the upper
cuspid may be pushed up into the maxillary sinus or
floor of the nose.
l As compared to the other jaw cysts, dentigerous cysts
have a higher tendency to cause root resorption in adja-
cent teeth.
l Radiologically, the dental follicle expands around the
unerupted or impacted tooth in variations, i.e., (a) cir-
cumferential, (b) lateral, and (c) coronal.
Pathogenesis
l The development of dentigerous cyst is mainly due
to accumulation of fluid between the reduced enamel
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epithelium or within the enamel organ itself of un-
erupted or impacted teeth.
l In case of a dilated follicle, a pericoronal of more than
3–4 mm is considered as a cyst.
l Another possibility suggested for the development of
dentigerous cysts is due to early degeneration of the
stellate reticulum and is likely to be associated with
enamel hypoplasia.
Treatment
In a patient with mixed dentition phase, best possible treat-
ment is marsupialization.
l Treatment via an intraoral approach or extraoral
approach is decided by the size of the cyst, adequate
access, and whether it is desirable to save the involved
tooth.
l Marsupialization (Partsch surgery)
l This is usually indicated in children if large cyst
is present and the involved tooth/teeth are to be
maintained.
l The tooth may erupt into occlusion, as the defect heals
with normal bone, or orthodontic forces may be used to
bring the tooth into occlusion.
Enucleation
l Alternatively, the cyst can be enucleated together with
the involved tooth in adults, as the possibility of the
tooth eruption is low.
l In children, an attempt could be made to salvage the
tooth, in which case, the lining is separated from the
neck of the tooth with a scalpel.
l This procedure is worth attempting, when root forma-
tion is complete, so that the risk of tooth dislodgement
is low.
Behaviour and Prognosis
l It is widely believed that ameloblastomas frequently
arise in dentigerous cysts, and some have even termed
them as pre-ameloblastic lesions.
Q. 2. Classify cystic lesions in jaw. Describe the clinical
features and the treatment of odontogenic keratocyst
involving lower third molar areas.
Or
Classify odontogenic cysts of the jaws. Write in detail
about the management of cysts of the jaw by laying
special emphasis on the management of odontogenic
keratocyst.
Or
Section | I  Topic Wise Solved Questions of Previous Years 101

Write the aetiology, clinical features, diagnosis, and 2. Incisive canal (nasopalatine duct or median anterior
treatment of odontogenic keratocyst of the mandible maxillary) cyst.
affecting a young adult of 20 years. Non-epithelial cysts
1. Solitary bone cyst (traumatic).
Or 2. Aneurysmal bone cyst.
Classify odonotogenic cyst of the jaws and describe the 3. Stafne’s bone cavity.
management of OKC. Cysts of the maxillary antrum
1. Surgical ciliated cyst of maxilla.
Or 2. Benign mucosal cyst of the maxillary antrum.
Define and classify cysts of the jaws and oral cavity. Dis-
cuss the aetiopathogenesis, clincial features, and manage- II. Soft Tissue Cyst
ment of odontogenic keratocyst in the ramus of mandible.
A. Odontogenic cysts
Or 1. Gingival cysts
a. Adult.
What is a keratocyst? What are the causes for recur-
b. Newborn.
rence of keratocyst and normal technique of manage-
B. Benign mucosal cyst of the maxillary antrum—non-
ment of keratocyst occurring in the posterior body and
odontogenic cysts
ramus of the mandible?
a. Anterior median lingual cyst.
Or b. Nasolabial cyst (nasoalveolar cyst).
C. Retention cysts
Discuss the pathogenesis of odontogenic keratocyst and Salivary gland cysts
its management. a. Mucocele.
Or b. Ranula
D. Developmental/congenital cysts
Classify cysts of the jaw and write about keratocyst. a. Dermoid and epidermoid cysts.
b. Lymphoepithelial cyst (cervical/intraoral)
Or
c. Thyroglossal duct cyst.
Classify cysts of the jaw and discuss in detail the pathol- d. Cystic hygroma.
ogy and the management of odontogenic keratocyst of E. Parasitic cysts
the maxilla. a. Hydatid cysts.
b. Cysticerocis
Ans. F. Heterotropic cysts
Oral cysts with gastric or intestinal epithelium
I. Intraosseous Cysts
Epithelial Cysts III. Keratocyst
Cysts of odontogenic epithelial origin Incidence
1. Developmental l Primordial cysts comprise approximately 5–10 per cent
a. Primordial cyst (keratocyst). of odontogenic cysts of the jaws.
b. Dentigerous (follicular) cyst. l Seen predominantly in the second, third, and fourth
c. Lateral periodontal cyst—lateral botryoid odonto- decades of life, though they can occur in any age group.
genic cyst. l They have a slight predilection for the males than females.
d. Calcifying odontogenic (Gorlin) cyst.
2. Inflammatory
a. Radicular cyst (apical/lateral periodontal).
Site
b. Residual cyst. l They are usually seen in the mandible than in the maxilla.
About one half of the former are seen to involve the angle
Cysts of Non-odontogenic Epithelial Origin of the mandible with extension for varying distances into
1. Fissural the ascending ramus and body of the mandible.
a. Median mandibular. l They can also be seen anywhere in the jaws, including
b. Median palatal. the midline, though most of the cysts are seen posterior
c. Globulomaxillary. to the first bicuspids.

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102 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Clinical Features multilocular lesions, i.e., resection of the containing

block, while maintaining the continuity of the posterior
l The physical features of a jaw cyst depend on the
inferior borders as in the ascending ramus, angle, and
dimensions of the lesion.
body of the mandible. In case of difficulty of access,
l A small cyst is unlikely to be diagnosed on routine
extraoral exposure is necessary.
examination of the mouth, and is generally detected
l In case of cystic lining being adherent and in contiguity
accidentally on a radiographic examination.
to the overlying mucosa or muscle, then in such cases it
l In case of the odontogenic keratocyst, patients will not
should be excised along with marginal excision.
show any symptoms until the cysts have reached a large
l The defect is closed primarily and it is left to heal by
size at times involving the entire ascending ramus.
secondary intention or can be filled with hydroxyapatite
l This is because the primordial cyst initially extends in
crystals, autogenous bone graft, corticocancellous
the medullary cavity and clinically observable expan-
chips,allogenous bone powder, or chips or blocks.
sion of the bone occurs later.
l In case of large multilocular lesions with or without
l Displacement of the teeth may be seen due to the enlarging
cortical perforation, may require resection of the
size of the cyst that may lead to percussion of the teeth
involved bone which is usually followed by primary
overlying the cyst and may produce a dull or hollow sound.
or secondary reconstruction with a choice of reconstruc-
l A single missing tooth from the normal series should
tion plates of stainless steel, vitallium, and titanium.
invite suspicion of the existence of an odontogenic kera-
Use of titanium or stainless steel mesh, and bone
tocyst of the primordial type.
grafting procedures with the help of iliac crest graft,
l The teeth adjoining the cyst will have vital pulps unless
costochondral graft, or allogenous bone grafts is
there is coincidental disease of the teeth.
recommended.
l Buccal expansion of the bone is commonly seen, and

lingual and palatal expansion is rare. Carnoy’s Solution

l Large mandibular cysts invariably deflect the neurovas-
l Stoelinga and van Hoelst (1981) proposed a more con-
cular bundle into an abnormal position.
servative approach to treat large keratocysts, i.e. chemi-
l Neuropraxia of the nerve results with the onset of labial
cal cauterization. Composition of Carnoy’s solution–
paraesthesia or anaesthesia, if acute infection is present
Glacial acetic acid, chloroform, absolute alcohol and
along with the accumulation of pus within the sac.
ferric chloride.
l Sensation returns to normal when tension is relieved
l After enucleation, to remove any remaining lining of the
via a sinus tract or surgicaldrainage with spontaneous
cyst this chemical cauterizing agent is applied along the
discharge of pus.
walls of cystic cavity. This solution chemically cauter-
izes any remaining cells of cystic lining thus preventing
Radiological Features recurrence.
l Keratocyst can be either unilocular or multilocular.
Q. 3. Define cyst. Describe the pathogenesis, clinical fea-
l Majority of the unilocular radiolucencies have a smooth
tures, and radiographic appearance of radicular cyst.
periphery. Some may have scalloped margins, which
suggest an unequal growth activity. Or
l Multilocular cysts can have various radiographic ap-
Classify cystic lesions. Describe the management of a
pearances, e.g., one large cyst and some smaller daugh-
radicular cyst.
ter cysts giving the polycystic appearance.
Ans.
Treatment
‘A cyst is a pathologic cavity that may be filled with fluid,
Treatment should always be based on clinical assessment, ac- semi-fluid, or gaseous contents but never pus and may or
curate diagnosis, and appropriate tests of the cystic aspirate. may not be lined by epithelium’.
l If the access is good, small single cysts with regular

spherical outline can be enucleated through an intraoral

approach.
l Extraoral approach is preferred in case of larger or less
accessible cysts with regular spherical.
l All fragments of the extremely thin lining are removed.
l Marginal excision can be done in case of unilocular
Radicular Cysts
l The radicular cyst is defined as an inflammatory cyst,
which results because of infection extending from the
pulp into the surrounding periapical tissues.
l It may develop apically, when it is termed as a periapi-

lesions with scalloped or loculated periphery and small cal (periodontal) radicular cyst, or it may develop on

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Section | I  Topic Wise Solved Questions of Previous Years
the side of the root of a pulpless tooth, when it is
termed as a lateral (periodontal) radicular cyst. This
cyst should be differentiated from a developmental
lateral periodontal cyst, which is associated with a
vital tooth.
Incidence
l They are seen more commonly in males than in
females.
l In the first decade, very few cases are seen and peak
incidence is in the third and the fourth decades.
Site
l Site is usually the anterior maxilla than the mandible,
as the maxillary incisors are most prone to caries,
trauma, and pulpal death, due to developmental de-
fects and irritating effects of synthetic restorative
materials.
l In the mandible, cysts more commonly involve the
mandibular posterior teeth. There may be separate
small cysts arising from each apex of a multi-rooted
tooth.
Clinical Features
l Usually, no symptoms are seen and may be discovered,
when periapical radiographs are taken for teeth with
non-vital pulps.
l Swellings which are slowly enlarging are often com-
plained of radicular cysts and at times attain a large size.
l Pain may be a significant chief complaint in the pres-
ence of suppuration.
l In the beginning the enlargement is bony hard, as the
cyst increases in size; and, the covering bone becomes
thin and exhibits springiness due to fluctuation.
l In the maxilla, buccal and palatal or only palatal
expansion due to the lateral incisor or a palatal root
will be noted. In the mandible, lingual expansion is
very rare.
l The mucosa overlying the cystic expansion, as with the
other cysts, is at first of normal colour; then it may be-
come conspicuous, because of the presence of dilated
blood vessels and finally it will take on a profound dark
bluish tinge in case of large cysts.
l An intraoral sinus tract may be identified with discharg-
ing pus or brownish fluid, when the cyst is infected. The
involved tooth/teeth are found to be non-vital, discol-
oured, fractured, with heavy restorations, or with a
failed root canal.
l They may be sensitive to percussion or hypermobile, or
displaced.
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103
l It may involve deciduous or the permanent dentition.
l Temporary paraesthesia or anaesthesia of the regional
nerve distribution may be evident as with other cysts,
when infection is present.
l Pathologic fracture may be the form of presentation in
the mandible as with other large cysts.
Radiological Features
l The common description of radicular cysts is a round,
pear, or ovoid shaped radiolucency.
l A narrow radiopaque margin is seen that extends from
the lamina dura of the involved tooth/teeth.
l In case of very large cysts or infected cysts, this periph-
eral white line is occasionally absent.
l Resorption of root is rarely seen. A lateral radicular
cyst may be seen, which is associated with an acces-
sory root canal or lateral perforation during root canal
therapy.
Pathogenesis
The epithelial lining is derived from epithelial cell rests of
Malassez in the periodontal ligament, and the development
of the cyst then occurs in three phases:
The exact mechanisms involved in all the phases are
debatable.
1. The phase of initiation: Chronic low grade invasion
from the pulp leads to the formation of the periapical
granuloma. This leads to the activation and proliferation
of epithelial rests in the periodontal ligament in the form
of strands, arcades, or rings.
2. The phase of cyst formation: A cystic cavity forms,
lined by stratified squamous epithelium due to various
possible mechanisms, e.g.,
l Death of the central cells occurs due to increase in
the size and reduction of nutrients and oxygen to
maintain them,
l Central epithelial cells desquamate and others orient
toward the periphery, adjacent to the source of nutri-
tion from the connective tissue, or
l Epithelial cells orient toward the periphery to isolate
the central necrotic zone.
3. The phase of enlargement: Once initiation of cyst has
occurred, the continuation of enlargement may occur
due to various different mechanisms, which is true for
any cyst, i.e..
l Mural growth.
l Accumulation of fluid.
l Retention of fluid.
l Production of a raised intrastatic pressure.
l Bone resorption with increase in cystic size.
104 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Cystic Contents (aspirate)
The uninfected cystic fluid straw-coloured or brownish and
has cholesterol, small quantity of keratin flakes may be
identified.
In case of a long-standing infection, a dirtycaseous
material may be expressed or frank pus present.
Pathology
The cyst is lined by stratified squamous epithelium, the lin-
ing of which may be thin or thick up to 5 mm. An inflam-
matory infiltrate of polymorphonuclear leucocytes will be
seen in the lining. Epithelial lining may show the presence
of Ruston’s or hyaline bodies, mitotic cells or ciliated cells.
The fibrous capsule is composed of collagen and con-
nective tissue. Acute and chronic inflammatory infiltrate
may be found in the fibrous capsule.
Treatment
l Non-vital teeth that are associated with cyst, can either
be extracted (depending on conditions of sufficient bone
support and restorative possibilities), and they can be
retained by endodontic treatment apicoectomy.
l External sinus tracts should always be excised to
prevent epithelial ingrowth.
l The commonly employed surgical procedure for
radicular cyst is enucleation with primary closure.
l Very small cyst is removed through the tooth socket.
l Large period cysts that encroach upon the maxillary
antrum or in the alveolar neurovascular bundle or the
nose, may be preliminarily treated by marsupialization.
Behaviour and Prognosis
Some well-documented studies have been published, which
contend that squamous carcinoma may arise from the epi-
thelial lining of radicular cysts. Browne and others (1972),
reported that epithelium dysplasia and keratin metaplasia
may precede carcinomatous transformation.
Q. 4. Classify odontogenic cysts of the jaw. Describe the
signs, symptoms, and management of the cyst of the
maxilla involving the maxillary antrum.
Odontogenic Cyst of Jaw
1 . Gingival cyst of infants.
2. Gingival cyst of adults.
3. Lateral periodontal cyst.
4. Odontogenic keratocyst.
5. Dentigerous cyst.
6. Eruption cyst.
7. Botryoid odontogenic cyst.
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8 . Glandular odontogenic cyst.
9. Calcifying odontogenic cyst.
Cysts Associated with Maxillary Antrum
1. Surgical Ciliated Cyst of the Maxilla
l These are very uncommon cysts.
l They can be iatrogenic, as the patient always gives
previous history of some surgical procedure that was
carried out in the maxilla, wherein maxillary sinuses
were opened surgically.
Aetiology
l The cysts develop from the epithelial lining of the max-
illary sinus which was trapped in the surgical incision
during closure, following a maxillary surgical proce-
dure that involved the sinus lining, Caldwell-Luc, or
maxillary fractures that had involved the antrum.
Site
l In close proximity to the maxillary sinus, but there is no
communication between them.
Clinical Features
l Dull and localized pain in maxilla; and, the cystic lesion
is otherwise not associated with any tooth.
Radiological Features
l Well defined radiolucent expansion of the maxilla, with
radiopaque margins, that is closely related to the maxil-
lary sinus.
Treatment
l Surgical enucleation.
2. Benign Mucosal Cyst of Maxillary Antrum
l Also known as Mucocele/Retension cyst of maxillary
antrum.
Aetiology
l Occurs due to infection and inflammation of mucous
glands ducts.
Site
l Commonly seen in the floor of the sinus, also other
walls may be involved.
l Generally unilateral, though sometimes, bilateral or
multiple cysts may occur.
Section | I  Topic Wise Solved Questions of Previous Years
Clinical Features
l They are discovered on radiographic examinations.
l Sometimes patient may have dull pain over the antral
region, or sometimes may be a sense of fullness or
numbness in the maxillary region.
l If lateral wall is involved or the cyst is large in size, then
patient may complain of nasal obstruction.
Radilogical Features
l Cystic lesion is spherical or ovoid with radiopacity within
the maxillary antrum that has a smooth uniform outline.
l When suspected on an intraoral radiograph, an orthop-
antomograph must be taken to confirm.
Treatment
l In symptomatic patient, it is advisable to remove the
cystic lesion via Caldwell-Luc approach, and enhance
drainage via cannulation through intranasal antrostomy.
l In symptomatic patients, it is best to follow-up with peri-
odic radiographs, as most cystic lesions remains static or
undergo spontaneous regression with conservative medical
treatment with antibiotic, decongestants, and antral lavage.
Q. 5. Define cyst. Enumerate the method of treatment of
any jaw cyst. Describe anyone method in detail.
Ans.
‘A cyst is a pathologic cavity that may be filled with fluid,
semi-fluid, or gaseous contents but never pus and may or
may not be lined by epithelium’.
l A cyst can be treated either by enucleation or by marsu-
pialization.
Enucleation
Principle
Enucleation allows for the cystic cavity to be covered by a
mucoperiosteal flap and the space fills with blood clot,
which will eventually organize and form normal bone.
Indications
l For treatment of odontogenic keratocysts.
l Recurrence of cystic lesions of any cyst type.
Advantages
l Primary closure of the wound.
l Healing is rapid.
l Postoperative care is reduced.
l Thorough examination of the entire cystic lining
can be done.
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Disadvantages
l It is not possible to directly observe the healing of the
cavity after primary closure, as with marsupialization
l The unerupted teeth in a dentigerous cyst will be re-
moved with the lesion in young persons.
l Mandible will become weak due to removal of large
cyst, making it prone to jaw fracture.
l Adjacent vital structures can be damaged.
l Necrosis of the pulp.
Surgical Technique
l Enucleation and packing: This technique is used when
it is believed that due to a previous infection or in
infected large cysts, a primary closure would be unsuc-
cessful as it could lead to a breakdown of the wound; or,
where there is difficulty in approximating the wound
edges. In such instances, enucleation is performed and
then the cavity is packed as in marsupialization. The
wound heals with granulation tissue until epithelializa-
tion is complete.
This method is also used as a secondary measure, when
there is dehiscence after primary closure.
Marsupialization (Partsch Surgery)
l It is indicated in children, if there is very large size cyst
and the involved tooth/teeth are to be maintained.
l The tooth may erupt into occlusion, as the defect heals
with normal bone or orthodontic forces may be used to
bring the tooth into occlusion.
Advantages of Marsupialization
l It is relatively simple procedure and poses no risk to the
adjacent vital structures.
l It does not create an oronasal or an oroantral fistula.
l It consumes less time and there is less blood loss.
Disadvantages of Marsupialization
l Pathological lining of the cyst cavity is left behind,
which might pose as a cause for development of neo-
plastic changes in the future.
l Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa.
l It has to be regularly irrigated to prevent infection.
l Prolonged healing time.
l Regular cleansing of the cavity is needed. Failing
which, may lead to infection.
l Patient’s inconvenience.
l Formation of cyst-like pockets that may have foodstuffs.
106 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
SHORT ESSAYS
Q. 1. Classification of odontogenic cysts.
Ans.
Odontogenic Cyst of Jaw
1 . Gingival cyst of infants.
2. Gingival cyst of adults.
3. Lateral periodontal cyst.
4. Odontogenic keratocyst.
5. Dentigerous cyst.
6. Eruption cyst.
7. Botryoid odontogenic cyst.
8. Glandular odontogenic cyst.
9. Calcifying odontogenic cyst.
Q. 2. Mention the merits and demerits of enucleation
and marsupialisation procedures of cystic lesions.
Ans.
Marsupialization
Advantages of Marsupialization
l It is relatively simple procedure and poses no risk to the
adjacent vital structures.
l It does not create an oronasal or an oroantral fistula.
l It consumes less time and there is less blood loss.
Disadvantages of Marsupialization
l Pathological lining of the cyst cavity is left behind,
which might pose as a cause for development of neo-
plastic changes in the future.
l Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa.
l It has to be regularly irrigated to prevent infection.
l Prolonged healing time.
l Regular cleansing of the cavity is needed. Failing
which, may lead to infection.
l Patient’s inconvenience.
l Formation of cyst-like pockets that may have food-
stuffs.
Enucleation
Advantages of Enucleation
l Entire cystic lining is removed. Therefore, there is
no fear of any neoplastic change in the remnants of
the lining.
l Rapid healing occurs as the wound is closed primarily.
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Disadvantages of Enucleation
l In young people, germinated tooth or unerupted teeth
involved with the cyst are extracted or removed with the
lining of the cyst.
l Pathological jaw fractures can occur in case of enul-
cleation of a large cyst.
l The procedure endangers the adjacent vital structures.
l Direct observation of wound healing as in case of mar-
supialization is not possible.
Q. 3. Write four indications of marsupialization.
Ans.
Indications of Marsupialization
l Age: In a young child with developing tooth germs, or
when development of the displaced teeth has not pro-
gressed, enucleation would damage the tooth buds. In
the elderly, debilitated patient, marsupialization is less
stressful and a reasonable alternative.
l Proximity to vital structures: When the cyst is present
very close to the vital structures, oronasal or oroantral
fistula can be formed, and it can injure neurovascular
structures or damage vital teeth. In this case, marsupial-
ization should be considered.
l Eruption of teeth: In a young patient with a dentigerous
or pseudofollicular keratocyst, marsupialization will
permit the eruption of the unerupted tooth or any other
developing teeth that have been displaced.
l Size of cyst: In very large cysts where enucleation
could result in a pathological fracture, marsupializa-
tion can be accomplished through a more limited bony
opening.
l Vitality of teeth: When the apices of many adjacent
erupted teeth are involved within a large cyst, enucle-
ation could prejudice the vitality of these teeth.
Q. 4. Mention the principle of marsupialization and give
any four disadvantages of the procedure.
Ans.
Principle of Marsupialization
Marsupialization (Partsch) or decompression refers to cre-
ating a surgical window in the wall of the cyst and evacua-
tion of the cystic contents. This process decreases intracys-
tic pressure and promotes shrinkage of the cyst and bone
fill. The only portion that is removed is the piece removed
to produce the window.
Section | I  Topic Wise Solved Questions of Previous Years
Disadvantages of Marsupialization
l Pathological lining of the cyst cavity is left behind,
which might pose as a cause for development of neo-
plastic changes in the future.
l Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa.
l It has to be regularly irrigated to prevent infection.
l Prolonged healing time.
l Regular cleansing of the cavity is needed. Failing
which, may lead to infection.
l Patient’s inconvenience.
l Formation of cyst-like pockets that may have foodstuffs.
Q. 5. Write four advantages of enucleation of cyst.
Or
What is ‘enucleation technique’? Mention any four
merits of this procedure.
Ans.
Enucleation
Principle
Enucleation allows for the cystic cavity to be covered by a
mucoperiosteal flap and the space fills with blood clot,
which will eventually organize and form normal bone.
Indications
l For treatment of odontogenic keratocysts.
l Recurrence of cystic lesions of any cyst type.
Advantages
l Primary closure of the wound.
l Healing is rapid.
l Postoperative care is reduced.
l Thorough examination of the entire cystic lining can be
done.
SHORT NOTES
Q. 1. Theories of cyst expansion.
Ans.
Theories of Cyst Enlargement
1 . Mural growth.
2. Peripheral cell division.
3. Accumulation of the contents.
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107
Disadvantages
l It is not possible to directly observe the healing of the
cavity after primary closure as with marsupialization.
l The unerupted teeth in a dentigerous cyst will be
removed with the lesion in young persons.
l Mandible will become weak due to removal of large
cyst, making it prone to jaw fracture.
l Adjacent vital structures can be damaged.
l Necrosis of the pulp.
Surgical Technique
l Enucleation and packing: This technique is used when it
is believed that due to a previous infection or in infected
large cysts, a primary closure would be unsuccessful, as
it could lead to a breakdown of the wound; or, where
there is difficulty in approximating the wound edges. In
such instances, enucleation is performed and then the
cavity is packed as in marsupialization. The wound heals
with granulation tissue until epithelialization is complete.
This method is also used as a secondary measure, when
there is dehiscence after primary closure.
Q. 6. Define cyst. Mention various developmental odon-
togenic cysts of jaws.
Ans.
Cyst
A cyst is a pathological cavity or sac within the hard or soft
tissue that may contain fluid, semi-fluid, or gas which may
be lined by epithelium, fibrous tissue, or occasionally even
by neoplastic tissue.
Developmental Odontogenic Cyst of Jaw
1 . Primodial cyst (keratocyst).
2. Dentigerous (follicular) cyst.
3. Lateral periodontal cyst—lateral botryoid odontogenic
cyst.
4. Calcifying odontogenic (Gorlin) cyst.
4 . Hydrostatic enlargement.
5. Secretion (transudation and exudation).
Q. 2. Cornoy’s solution.
Ans.
l Stoelinga and van Hoelst (1981) proposed a more conserva-
tive approach to treat large keratocysts, i.e. chemical cauter-
ization. Composition of Carnoy’s solution–Glacial acetic
acid, chloroform, absolute alcohol and ferric chloride.
108 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l After enucleation, to remove any remaining lining of the
cyst this chemical cauterizing agent is applied along the
walls of cystic cavity. This solution chemically cauter-
izes any remaining cells of cystic lining thus preventing
recurrence.
Q. 3. Causes of recurrence potential of keratocyst.
Ans.
Recurrence Potential of Keratocyst
Keratocysts tend to recur. This aggressive peculiarity was first
reported by Pindborg and Hansen (1963). The recurrence rate
varies from 5 to 62 per cent with most occurring in first 5 years.
Some of the possible reasons that reportthis feature are
as follows:
l Tendency to multiply.
l Presence of satellite cysts.
l Cystic lining is very thin and fragile and portion of it
may be left behind.
l Epithelial lining of keratocysts have growth potential.
l In the oral mucosa, cyst can arise from the basal cells.
l Patients with nevoid basal cell carcinoma syndrome have
a particular tendency to form multiple primordialcysts.
Q. 4. Name the cysts of the maxillary antrum.
Ans.
l Surgical ciliated cyst of the maxilla.
l Benign mucosal cyst of the maxillary antrum.
Q. 5. Aneurysmal bone cyst.
Ans.
Aneurysmal Bone Cyst
It basically consists of blood-filled spaces within the bone
of different sizes surrounded by fibrous connective tissue
and fine trabeculae of reactive immature bone.
Clinical Features
l Usually seen in the long bones. It is uncommon in the
jaws and occurs only in 2% of the total cases.
l Age group is usually , 20 years.
l It is most common in mandibular posterior region; and,
is rare inmaxilla. Appears as a fast-growing swelling in
the jaw, usually not associated with pain or paraesthesia.
l Limitation of movement due to pain or tenderness in the
region.
Radiographic Features
l Unilocular or multilocular radiolucency.
l An occlusal view of the lesion will show thinning and
expansion of the cortical plates.
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l A characteristic ‘honeycomb’ or ‘soap bubble’ appear-
ance has been described in the radiograph.
l It has also been described as a ‘blown out’ bone cavity
lined by supraperiosteal new bone formation.
Treatment
l The treatment of choice is enucleation or curettage.
l Usually, cortical perforation and soft tissue spread is not
reported.
l Once periosteum and thinned out cortex is removed,
then welling up of dark venous blood seen from cavity
described characteristically as ‘blood soaked sponge’
appearance. Reduction in the bleeding is an indication
of complete removal of the entire lesion.
l Surgical defect heals like any other cystic cavity in
about 6–8 months.
l Inadequate removal may lead to recurrence.
Q. 6. Residual cyst.
Ans.
l Residual cyst is retained periapical cyst from teeth that
have been removed.
l It can be found in maxilla or mandible.
l Histology of lining is a non-descriptive stratified squa-
mous epithelium.
l Morphologically, the cyst may present as a well defined ra-
diolucency that can vary in size from few mm to several cm.
l Clinically, these cysts are found on routine radiographic
examination.
l Usually, residual cysts do not expand bone.
l Treatment is by surgical curettage.
Q. 7. Define enucleation.
Ans.
Principle
Enucleation allows for the cystic cavity to be covered by a
mucoperiosteal flap and the space fills with blood clot,
which will eventually organize and form normal bone.
Indications
l For treatment of odontogenic keratocysts.
l Recurrence of cystic lesions of any cyst type.
Q. 8. Marsupialization.
Ans.
Principle
Marsupialization (Partsch) or decompression refers to
creating a surgical window in the wall of the cyst, and
evacuation of the cystic contents. This process decreases
Section | I  Topic Wise Solved Questions of Previous Years
intracystic pressure and promotes shrinkage of the cyst
and bone fill. The only portion that is removed is the piece
removed to produce the window.
Indications
l Age: In a young child, with developing tooth germs,
or when development of the displaced teeth has not
progressed, enucleation would damage the tooth buds.
In the elderly, debilitated patient, marsupialization is
less stressful and a reasonable alternative.
l Proximity to vital structures: When the cyst is present
very close to the vital structures, oronasal or oroantral
fistula can be formed, and it can injure neurovascular
structures or damage vital teeth. In this case, marsupial-
ization should be considered.
l Eruption of teeth: In a young patient with a dentigerous
or pseudofollicular keratocyst, marsupialization will
permit the eruption of the unerupted tooth or any other
developing teeth that have been displaced.
l Size of cyst: In very large cysts, where enucleation could
result in a pathological fracture, marsupialization can be
accomplished through a more limited bony opening.
l Vitality of teeth: When the apices of many adjacent
erupted teeth are involved within a large cyst, enucle-
ation could prejudice the vitality of these teeth.
Disadvantages of Marsupialization
l Pathological lining of the cyst cavity is left behind,
which might pose as a cause for development of neo-
plastic changes in the future.
l Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa.
l It has to be regularly irrigated to prevent infection.
l Prolonged healing time.
l Regular cleansing of the cavity is needed. Failing
which, may lead to infection.
l Patient’s inconvenience.
l Formation of cyst-like pockets that may have foodstuffs.
Q. 9. Globulomaxillary cyst.
Ans.
Globulomaxillary Cyst
l Also known as lateral fissural cyst.
l Believed to arise from epithelial remnants trapped
between the developing frontonasal process and the
maxillary process. In other words, it occurs at the point
of fusion between the pre-maxilla and the maxilla, al-
though the origin of this cyst is highly controversial.
l It is a rare lesion seen between the maxillary lateral inci-
sor and canine.
l Teeth associated with this lesion are vital.
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109
l The cyst may cause displacement of the teeth on
either side of it. Usually, the crowns of the lateral
incisor and canine are seen flaring away from each
other.
Radiographic Features
l This is seen between the maxillary lateral incisor and
canine.
l Classically described as a pear-shaped or teardrop-
shaped radiolucency with the apex towards the alveolar
bone and base towards the crown of the teeth.
l Lamina dura of the teeth associated with the lesion is
intact.
Treatment
Treatment is by enucleation with care taken to protect the
apex of the canine and lateral incisor.
Q. 10. Nasolabial cyst.
Ans.
Nasolabial Cyst
l Rare developmental cyst.
l It is a soft tissue cyst and does not produce any bony
destruction, but occasionally pressure resorption of the
adjacent bone may take place.
Aetiology
l It is a fissural cyst thought to arise from embryonic
remnants of tissue entrapped between the lines of fusion
of the median nasal process, lateral nasal process, and
maxillary process.
Clinical Features
l Usually seen in the region of the upper lip lateral to the
midline in the buccal sulcus just below the ala of the
nose.
l Usually seen in adults in their fouth to fifth decade.
l Female predilection.
l Rarely seen bilaterally.
l Slow growing lesion, gradually causes loss of nasolabial
fold and bulges into the inferior meatus and appears also
in the labial sulcus.
Radiographic Features
l Since it is a soft tissue lesion, no bone destruction is
seen on the radiograph.
l Pressure resorption may be seen on an occlusal view.
110 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Histological Features Q. 12. Benign cystic lesions of the mandible.

l The cyst is lined by pseudostratified columnar epithe- Ans.
lium.
l Goblet cells and cilia are also seen.
Benign Cystic Lesions of the Mandible
Treatment 1 . Dentigerous cyst.
2. COC.
l Enucleation is the treatment of choice. 3. OKC.
l The lesion is approached intraorally via the buccal
sulcus. Q. 13. Apical granuloma.
l Due to its proximity with the ala of the nose, some Or
amount of nasal mucosa may need to be sacrificed for
total removal. Periapical granuloma.

Q. 11. Traumatic bone cyst. Ans.

Ans.
Periapical Granuloma
Traumatic Bone Cyst Chronic periapical periodontitis is also known as periapical
l The traumatic cyst is a pseudocyst (lacks an epithelial granuloma.
lining). It is a low-grade infection and the most common sequelae
l It occurs in other bones of the skeleton. of pulpitis or acute periapical periodontitis.

Clinical Features Clinical Features

l Can be seen most frequently in young person.
l No definite sex prediction, but seen more commonly in
males than females.
l When the cavity is open surgically, a small amount of
serosanguinous fluid, shreds of necrotic blood clot, and
fragments of fibrous connective tissue are seen.
l Involved tooth is usually non-vital and slightly tender to
percussion.
l Patient may complain of mild pain on biting or chewing
on solid food.
l The sensitivity is due to hyperaemia, oedema, and
inflammation of the apical periodontal ligament.
l Many cases are entirely asymptomatic.

Treatment
l Since the definitive diagnosis of solitary bone cyst can-
not be established without surgical exploration after
opening the cavity, enucleation of the lining is done.
l If the cavity is then closed, it has been found that heal-
ing and filling of the space by bone occurs in most cases
in 6–12 months.
l Seldom, a second surgical procedure is necessary.
Treatment
l It consists of extraction of the involved tooth under
certain condition. Root canal therapy with or without
apicoectomy is done.
l If left untreated, then it may undergo transformation
into apical periodontal cyst through proliferation of the
epithelial rests in the area.

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Section | I  Topic Wise Solved Questions of Previous Years
Benign Tumours of the Jaw
LONG ESSAYS
Q. 1. Classify odontogenic tumours of jaw bones. How
do you diagnose and manage a case of ameloblastoma of
mandible?
Or
Classify odontogenic tumours of the jaw. How do you
diagnose ameloblastoma? Outline the method of
treating tumour involving mandibular third molar
area.
Or
Differentiate between benign and malignant tu-
mours. Describe the signs and symptoms and man-
agement of an ameloblastoma involving the angle of
the mandible.
Or
Classify odontogenic tumours? Write in detail about
ameloblastoma and its management.
Or
Classify odontogenic tumours of the mandible. How do
you manage ameloblastoma involving the anterior body
portion of the mandible? Give clinical signs and symp-
toms of the lesion.
Or
Classify odontogenic tumours of the jaws. Describe
the surgical management of ameloblastoma of the
lower jaw.
Or
Define ameloblastoma. How will you evaluate and
manage a case of ameloblastoma?
Or
Describe the differential diagnosis and management
of radiolucent lesions of posterior body and ramus of
mandible.
Ans.
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111
Topic 10
Classification of Benign Odontogenic
Tumours (Kramer, Pindborg, and Shear, 1992)
1. Odontogenic Epithelium without Odontogenic
Ectomesenchyme
1 . Ameloblastoma.
2. Calcifying epithelial odontogenic tumour (CEOT) or
Pindborg tumour.
3. Clear cell odontogenic tumour.
4. Squamous odontogenic tumour.
2. Odontogenic Epithelium with Odontogenic
Ectomesenchyme with or Without Dental Hard
Tissue Formation
1 . Ameloblastic fibroma.
2. Ameloblastic fibrodentinoma (dentinoma).
3. Odontoameloblastoma.
4. Adenomatoid odontogenic tumour (AOT).
5. Complex odontoma.
6. Compound odontoma.
3. Odontogenic Ectomesenchyme with or
without included Odontogenic Epithelium
1 . Odontogenic fibroma.
2. Myxoma (odontogenic myxoma, myxofibroma).
3. Benign cementoblastoma (true cementoma).
Classification of Odontogenic Tumours
(Gorlin, Chaudhry, and Pindborg, 1961)
1. Epithelial Odontogenic Tumours
A. Minimal inductive change in connective tissue
(ectodermal origin)
a. Ameloblastoma.
b. Adenomatoid odontogenic tumour.
c. Calcifying epithelial odontogenic tumour (CEOT).
B. Marked inductive change in connective tissue
(mixed origin)
a. Ameloblastic fibroma.
b. Ameloblastic odontoma.
112 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

c. Odontoma. 5. Melanotic Neuroectodermal Tumour of

d. Complex odontoma. Infancy.
e. Compound odontoma.
Ameloblastoma
2. Mesodermal Odontogenic Tumours According to WHO, ‘It is a true neoplasm of enamel organ
type tissue, which does not undergo differentiation to a point
a . Odontogenic myxoma.
of enamel formation’. In 1992, WHO classification catego-
b. Odontogenic fibroma.
rized ameloblastoma as a benign, but locally invasive epithe-
c. Cementoma
lial odontogenic neoplasm with strong tendency to recur.
i. Periapical cemental dysplasia (PCD).
ii. Benign cementoblastoma.
iii. Cementifying fibroma. Pathogenesis
vi. Familial multiple (gigantiform) cementoma (Florid 1. Late developmental sources: Cell rests of enamel organ,
Osseous Dysplasia - FOD). either remnants of dental lamina or epithelial cell rests of
Malassez or remnants of Hertwig’s sheath and follicular
WHO Classification of Non-odontogenic sacs.
Tumour of the Jaws (Kramer, Pindborg, and 2. Early embryonic sources: Disturbances of developing
enamel organ, dental lamina, and tooth buds.
Shear, 1992)
3. Basal cells of the surface epithelium of the oral mucosa.
Osteogenic Neoplasms 4. Secondary developmental sources: Epithelium of odon-
togenic cysts, particularly primordial, lateral periodon-
Cemento-ossifying fibroma
tal cyst, dentigerous cyst, and odontomas.
Non-neoplastic bone lesions
5. Heterotropic epithelium in other parts of body, espe-
1. Fibrous dysplasia of the jaws.
cially from the pituitary gland.
2. Cemento-osseous dysplasias
a. Periapical cemento-osseous dysplasia.
b. Focal cemento-osseous dysplasia. Age
c. Florid cemento-osseous dysplasia (gigantiform). It is usually seen in the first decade or as late as the seventh
Other cemento-osseous dysplasias decade. Overall average age is 36 years.
a. Cherubism.
b. Central giant cell granuloma.
Sex
Classification of Benign Odontogenic No sex predilection. It can occur equally in men and
Tumour women.
1. Benign Ectodermal Tumours
Site
a . Ameloblastoma.
b. Adenomatoid odontogenic tumour. l The lesion may occur in either of the jaws.
c. Calcifying epithelial odontogenic tumour. l The ratio of ameloblastoma of the mandible to maxilla
is 5:1.
l The common sites involved are the posterior maxilla
2. Benign Mesodermal Tumours
and the posterior molar ramus region of the mandible
a . Odontogenic myxoma. (60%). In blacks, ameloblastomas occur more fre-
b. Cementoma. quently in the anterior region of the maxilla.

3. Benign Tumours Having Ectodermal and Classification

Mesodermal Elements
a . Central or intraosseous.
a . Ameloblastic fibroma. b. Peripheral or extraosseous: This is usually seen in the
b. Ameloblastic fibro-odontoma. gingiva and mucosa of the alveolar process.
c. Odontoameloblastoma.
Clinical Features (Signs and Symptoms)
4. Odontomas
l Ameloblastoma is typically asymptomatic, and is rarely
a . Complex odontoma.
diagnosed in the early stages of development.
b. Compound odontoma.

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Section | I  Topic Wise Solved Questions of Previous Years
l It remains undiscovered until the lesional growth
produces swelling either in the intraoral and/or
extraoral jaw. Tooth eruption and dental occlusion
disturbances or incidental findings are seen in the
radiograph.
l Patients complain of slow growing, painless, hard, non-
tender, and ovoid swelling, which is often larger in size,
as it causes little discomfort in early stage.
l Other complaints may be mobile teeth, exfoliation of
teeth, ill-fitting dentures, malocclusion, ulcerations, na-
sal obstructions, and inability to occlude properly. In
later stage with nerve involvement, there will be sensory
changes of the lower lip.
l Pain may be experienced if secondarily infected. Large
persistent lesion may exhibit fluctuation and egg-shell
crackling.
Management
Aim
a. Complete eradication of the lesion.
b. Reconstruction of resultant defect.
Successful treatment is the treatment that renders an accept-
able prognosis and causes minimum disfigurement.
Curettage
l Least desirable line of treatment, as it has high recur-
rence chances.
l The characteristic feature of the tumour is that, it micro-
scopically infiltrates bone beyond the tumour–bone in-
terface seen in imaging.
l A safe margin of involved bone is opposite 2 cm for
solid multicystic lesions.
For intraosseous solid multicystic ameloblastoma
1. En bloc resection or marginal resection without continu-
ity defect.
2. Segmental resection with continuity defect.
Aggressive reconstruction in maxilla
1. Tumour confined to maxilla without orbital floor in-
volvement—partial maxillectomy.
2. Tumour involving orbital floor, but not the periorbital
area—total maxillectomy.
3. Tumour involving orbital content—total maxillectomy
with orbital exenteration.
4. Tumour involving skull bone—skull base resection plus
neurosurgical procedure.
Multiple Ameloblastoma
l Recurrence rate up to 50% during first five years.
l Long-term follow-up is a must.
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113
Q. 2. Describe fibro-osseous lesions of the jaws. Enu-
merate the treatment for fibrous dysplasia.
Ans.
Fibrous Dysplasia of the Jaws
Fibrous dysplasia was first described by von Recklinghausen
in 1891. In 1938, Lichtenstein introduced the term ‘fibrous
dysplasia’. The pathogenesis is not understood completely,
but trauma and endocrine disturbances were labelled as cul-
prits. More recently molecular basis has been identified.
It is a self-limiting condition in which there is gradual
replacement of normal medullary bone by an abnormal fi-
brous connective tissue proliferation. The mesenchymal
tissue contains variable amounts of an osseous matrix that
presumably arises through metaplasia and consists only of
woven bone.
Types
l Solitary or monostotic lesion is 80 to 85 per cent more
common (involving a single bone).
l Multifocal or polyostotic lesion (involving bones) is
relatively uncommon.
a. In Jaffe type, three-fourths of the entire may be in-
volved.
b. In Lichtenstein syndrome, the entire skeleton may be
involved, along with cutaneous melanin pigmentation.
c. Mazabraud syndrome—the fibrous dysplasia is as-
sociated with soft tissue myxomas, usually muscular
(adjacent to the FD lesion).
McCune-Albright syndrome: It is more severe. Occurs
commonly in females. The patients with polyostotic fibrous
dysplasia have multiple areas of cutaneous melanotic pig-
mentation (Cafe au lait macules) and autonomous hyper-
function of one or more of the endocrine glands (precocious
sexual development and onset of puberty).
Aetiology
It is unknown. Many hypotheses have been proposed.
i. A non-neoplastic, hamartomatous growth resulting
from altered mesenchymal cell activity or a defect in
the control of bone cell activity.
ii. Focal bone expression of a complicated endocrine dis-
turbance (oestrogen receptors are seen in osteogenic
cells of a patient).
iii. Inherited basis.
Monostotic Fibrous Dysplasia of the Jaws
Onset
It occurs during the first or second decade of life.
114 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
It is characterized by insidious, asymptomatic, painless,
and slow growing lesion.
Sex
Both males and females are affected equally.
Swelling
Swelling is unilateral and slow growing with progressive
enlargement. As the lesion grows, facial asymmetry becomes
more evident and it may be the patient’s chief complaint.
The fusiform oval (low plateau), firm, and smoothly con-
touring swelling of the affected jaw is noticed. It most com-
monly results from the expansion of the buccal cortical plate.
The lingual cortex is rarely involved. In mandible, it may
cause a protuberance and excrescence of the inferior border.
As a rule, the growth of the lesion ceases with skeletal growth.
Initially the teeth involved in the lesion are firm, but
may be displaced by the bony mass or occlusal level can be
changed. The more aggressive clinical form may produce
rapid growth, pain, nasal obstruction, or exophthalmos.
Radiological Feature
It is variable, ranging from radiolucent to a densely
radiopaque mass. Four different pictures can be seen
radiologically:
i. The characteristic feature is ‘ground glass’ appearance
in mature stage, i.e., a homogenous radiopacity with
the numerous trabeculae of woven bone or orange peel
appearance,
ii. In early stage, some lesions may be seen as unilocular
or multilocular radiolucencies,
iii. In intermediate stage, radiolucent lesion intermediate
with patchy, irregular opacities similar to Paget’s dis-
ease can be seen, and
iv. A fingerprint bone pattern and superior displacement of
mandibular canal can be seen.
In maxilla, there is obliteration of the maxillary sinus by the
lesional tissue. Shows increased bone density of base of the
skull involving the occiput, sphenoid, roof of the orbit, and
frontal bones.
The most important characteristic feature of fibrous
dysplasia is the poorly defined clinical and radiological
demarcating margins of the lesion. The lesion appears to
blend into the surrounding normal bone without any evi-
dence of a circumscribed border.
l Serum chemistry levels: Serum calcium, phosphorus,
and alkaline phosphatase are within normal ranges, be-
cause of the slow growth rate.
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l Histologically, the lesion is essentially a fibrous one,
made-up of proliferating fibroblasts in a compact
stroma of interlacing collagen fibres. Irregular bony
trabeculae. It may be scattered haphazardly or ‘c’
shaped trabeculae may occur, giving ‘Chinese’ char-
acter appearance. Bony trabeculae may be coarse
woven bone or lamellar. As the lesion matures, spic-
ules of lamellar bone with osteoblastic rimming may
be seen.
l Differential diagnosis: Is from ossifying fibroma, ce-
mentifying fibroma, Paget’s disease, osteosarcoma, etc.
The usual course of fibrous dysplasia is slow growth for
a decade or so followed by stabilization and slow return
to normal. Occlusion and tooth–jaw relation should be
carefully monitored during the period of skeletal
growth.
Polyostotic Fibrous Dysplasia
(McCune-Albright Syndrome)
l The skull and jaws affliction with resultant facial
asymmetry.
l Simultaneous involvement of both the jaws along with
lone bones is seen.
l ‘Hockey stick’ deformity of the femur is seen with leg
length discrepancy.
l Well defined, generally unilateral tan macules on the
trunk, thighs, and oral mucosa, known as Cafe au lait
(coffee with milk) pigmentations. The margins of these
spots are very irregular in contrast to the spots of neuro-
fibromatosis, which have smooth borders.
Sexual precocity, most commonly seen in females is the
common endocrine manifestation.
l (Breast development, pubic hair, and menstrual bleed-
ing may be seen to occur within first few years of life in
affected girls).
Management
The management of the fibrous dysplasia can be difficult at
times. The treatment plan depends on the extent of involve-
ment, functional disability, danger to function, neurologic
symptoms, and aesthetic consideration. Differentiation
should be made between monostotic and polyostotic form
of the lesion. Complete bone scintigraphy can suggest mul-
tiple involvement.
The treatment ranges from observation for minor le-
sions to radical resection.
In case of small lesions, biopsy for confirmation and
follow-up is required.
Section | I  Topic Wise Solved Questions of Previous Years 115

SHORT ESSAYS
Q. 1. Myxoma.
Ans.
Myxoma
l Myxoma is a heterogenous group of soft tissue tumour,
which is benign and does not metastasize, but in infil-
trates the adjacent tissues.
l It is composed of mucopolysaccharides, mainly hyal-
uronidase.
l Stellate cells arranged in a loose mucoid stroma are
seen, which also contains delicate reticulin fibres.
Clinical Features
l This appears at any age, and there is no definite predi-
lection of gender.
l Most of the lesions are deeply situated, occurring in
skin, subcutaneous tissues, genitourinary tract, gastro-
intestinal tract, or in organs such as liver, spleen, or
even parotid glands.
2. Calcifying epithelial odontogenic tumour (CEOT) or
Pindborg tumour.
3. Clear cell odontogenic tumour.
4. Squamous odontogenic tumour.
B. Odontogenic Epithelium with Odontogenic
Ectomesenchyme with or without Dental Hard
Tissue Formation
1 . Ameloblastic fibroma.
2. Ameloblastic fibrodentinoma (dentinoma).
3. Odontoameloblastoma.
4. Adenomatoid odontogenic tumour (AOT).
5. Complex odontoma.
6. Compound odontoma.
C. Odontogenic Ectomesenchyme with or
without Odontogenic Epithelium
1 . Odontogenic fibroma.
2. Myxoma (odontogenic myxoma, myxofibroma).
3. Benign cementoblastoma (true cementoma).

Oral Manifestations
Classification of Odontogenic Tumours
l It is an extremely rare lesion. (Gorlin, Chaudhry, and Pindborg, 1961)
l The nerve sheath myxoma is a benign tumour, thought
to arise from perineural cells of peripheral nerves and is 1. Epithelial Odontogenic Tumours
characterized by occurrence of stellate cells in a promi-
A. Minimal inductive change in connective tissue
nent mucoid matrix.
(ectodermal origin)
a. Ameloblastoma.
Treatment b. Adenomatoid odontogenic tumour.
l Treatment is surgical, since X-ray is of little benefit. c. Calcifying epithelial odontogenic tumour (CEOT).
l Recurrence is common.
B. Marked inductive change in connective tissue
Q. 2. Define tumour and classify odontogenic tumours. (mixed origin)
Ans. a . Ameloblastic fibroma.
b. Ameloblastic odontoma.
c. Odontoma.
Tumour d. Complex odontoma.
A ceaseless, purposeless, uncoordinated, and uncontrolled e. Compound odontoma.
growth of the tissue resulting from multiplication of its cell
and condition persists even after the stimulus or the initiat- 2. Mesodermal Odontogenic Tumours
ing factors, is removed.
a . Odontogenic myxoma.
b. Odontogenic fibroma.
Classification of Benign Odontogenic c. Cementoma.
Tumours (Kramer, Pindborg, and Shear, 1992) i. Periapical cemental dysplasia (PCD).
ii. Benign cementoblastoma.
A. Odontogenic Epithelium without iii. Cementifying fibrom.
Odontogenic Ectomesenchyme vi. Familial multiple (gigantiform) cementoma (Florid
1. Ameloblastoma. osseous dysplasia - FOD).

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116 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

WHO Classification of Non-odontogenic Signs and Symptoms

Tumour of the Jaws (Kramer, Pindborg, Painless and slow growing mass. If encroached on nasal cav-
AndShear, 1992) ity, then produce nasal symptoms like stuffiness, epistaxis, etc.
Osteogenic Neoplasms
Variety
Cemento-ossifying Fibroma
i. Intraosseous
Non-neoplastic Bone Lesions ii. Extraosseous—non-specific sessile gingival masses
1 . Fibrous dysplasia of the jaws. commonly seen in anterior gingiva.
2. Cemento-osseous dysplasias
a. Periapical cemento-osseous dysplasia. Radiographic Features
b. Focal cemento-osseous dysplasia.
c. Florid cemento-osseous dysplasia (gigantiform). Depending on the stage of development, CEOT presents
Other cemento-osseous dysplasias variable radiographic picture.
a. Cherubism. i. Unilocular or multilocular radiolucency with a well
b. Central giant cell granuloma. circumscribed border or diffuse lesion.
ii. Multilocular honeycomb appearance: Combined pat-
Q. 3. Pindborg tumour. tern of radiolucency and radiopacity with many small,
Or irregular bony trabeculae traversing the radiolucency in
multidirection.
Calcifying epithelial odontogenic tumour. iii. Driven snow appearance: Scattered flakes of calcifica-
Ans. tion throughout the radiolucency can be seen. It can
be seen more concentrated around the crown of the
embedded tooth.
Pindborg Tumour iv. Lesion (mainly unilocular) may be associated with
The tumour was first described by Pindborg in 1955. embedded tooth.

Histopathology
Origin
A locally invasive epithelial characterized by the develop-
Epithelial elements of the enamel organ.
ment of intraepithelial structures, probably of an amyloid
like nature, may become calcified and which may be liber-
Incidence ated when the cells breakdown. The areas of calcification of
concentric rings are termed as ‘Liesegang rings.’ These fuse
It is uncommon, seen 1 per cent of all odontogenic
together to form large complex masses.
tumours.
CEOT shows some potential for recurrence (15%
aggressiveness).
Sex
There is no specific sex predilection. Management
Careful excision of the margin of normal tissue and
Age follow-up.

It is seen in middle age, i.e., 30–50 years. Q. 4. Odontoma.

Or
Site Odontomes.
Mandible is most commonly involved in the molar region Ans.
(two-third of the turnouts). One-third of the turnoouts are
found in the maxilla. Marked predilection for the molar
region in both the jaws Odontoma
Fifty per cent of the turnouts are associated with an The term refers to any tumour of odontogenic origin, in
unerupted or embedded tooth. true sense. This is the growth in which, both epithelial and

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Section | I  Topic Wise Solved Questions of Previous Years
ectomesenchymal cells exhibit complete or incomplete
differentiation of tooth formation. This is considered more
as a hamartomatous malformation, also as composite le-
sion, as it contains more than one tissue.
Radiographically and histopathologically, it is recogniz-
able in two forms:
1. Compound odontoma.
2. Complex odontoma.
Compound Composite Odontoma
It consists of formed calcified tooth-like structures or min-
iature dwarfed teeth.
Complex Composite Odontoma
It is a malformation in which all the dental tissues are rep-
resented with the individual tissues being well formed, but
occurring in a disorderly pattern. Here, the calcified dental
tissues are simply found as an irregular mass bearing no
morphological similarity to the rudimentary teeth.
l Most common type of odontogenic lesion (more than
30%).
l Age: First and second decades (10–70 years).
l Sex: Equal predilection in both sexes.
l Site: Occurs in both the jaws.
Complex odontomas are more common in mandible,
i.e., 67%.
Compound odontomas are more common in maxilla.
Compound odontomas are seen in anterior jaw. Com-
plex odontomas are seen in posterior jaw, in third molar
region.
l Generally asymptomatic.
Radiographical features
Compound odontoma appears as a radiopaque of calcified
structures with an anatomy similar to normal teeth. It is
seen as a pocket of malformed dwarfed teeth or tooth-like
forms surrounded by a narrow radiolucent zone. Some-
times, overlying or alongside, an unerupted tooth or be-
tween the roots of a deciduous tooth. It prevents eruption of
underlying permanent tooth.
Cornplex odontoma may be small, large, or occasion-
ally huge; irregular or ovoid smooth; and, densely radi-
opaque mass, often surrounded by a thin radiolucent zone.
It is frequently overlying a displaced unerupted tooth.
The radiological picture is variable, depending on the
stage of formation at the time of incidental discovery. It will
range from complete radiolucency in the initial stage to the
stage of ‘maturation’, i.e., complete calcified structure. Mixed
radiolucency and radiopacity can be seen in one lesion also.
l Asymptomatic—shows no expansion of the bone and
facial asymmetry.
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117
l Commonly detected on radiographs.
l May show associated unerupted or impacted teeth, and
associated swelling and infection.
Histological features
The compound odontoma shows a connective tissue cap-
sule. The lesion is composed of anatomically distinct, small,
well formed, or distorted teeth with enamel, dentine, pulp,
and cementum. The complex odontoma lacks anatomical
organization and consists of calcified dental tissue in a hap-
hazard manner, bound together in a mass of cementum and
often surrounded by a thin connective tissue capsule.
Management
Completely calcified complex or compound odontoma is
biologically inert and can be left alone.
Reasons for excision
i. Once detected, patient may be psychologically
affected about the diagnosis of the lesion.
ii. To remove the blockade of the favourably placed
unerupted tooth underneath or nearby.
iii. To obtain definite diagnosis between the complex odon-
toma and cementoblastoma or ossifying fibroma or
CEOT, etc.
Surgical treatment (Intraoral approach)
Adequate amount of overlying bone removal should be
done to access the lesion. Compound odontoma is enucle-
ated if the capsule is intact. If the capsule is disrupted, then
the individual teeth forms are removed carefully. Small
complex odontoma can be enucleated. Large complex
odontoma may be fused to the surrounding bone and is very
hard. It should be cut into pieces for removal. If excessive
force is used to elevate the lesion, then the jaw fracture can
occur.
Recurrence is not seen.
Q. 5. Adenoameloblastoma.
Or
Adenomatoid odontogenic tumour.
Ans.
Adenoameloblastoma
l It may be considered as hamartoma.
l Incidence: Accounts for 3–7% of odontogenic tumours.
l Age: Younger age group of 10–20 years (73%). It is
rarely seen in those above 30 years.
l Sex: Predilection to occur in females (65%).
l Site: More common in maxilla (65%) and usually in-
volves the anterior region.
118 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Associated with impacted permanent teeth (invariably
canine tooth in about 74%)
l Painless swelling.
l Radiologically: Impacted tooth has a unilocular radiolu-
cency around the crown, resembling a dentigerous cyst.
Radiolucency may extend apically along the root cross-
ing CE junction. More often the radiolucency show fine
calcification (snowflake). The margins are well defined
and sclerotic.
l Differential diagnosis: Pindborg tumour, CEOC or
Gorlin cyst, and ameloblastoma.
l Histopathology: The lesion is surrounded by a thick,
fibrous capsule.
SHORT NOTES
Q. 1. Define ameloblastoma.
Ans.
Ameloblastoma is defined as unicentric, non-functional,
intermittent in growth, and anatomically benign tumour
that is clinically persistent.
Q. 2. Adenomatoid odontogenic tumour.
Ans.
l First recognized as separate entity by Stafne.
l The term coined by Philipsen and Birn in 1969.
l It may be considered as hamartoma.
l Incidence: Accounts for 3–7% of odontogenic tumours.
l Age: Younger age group of 10–20 years (73%). It is
rarely seen in those above 30 years.
l Sex: Predilection to occur in females (65%).
l Site: More common in maxilla (65%) and usually in-
volves the anterior region.
l Associated with impacted permanent teeth (invariably
canine tooth in about 74%).
l Painless swelling.
l Radiologically unilocular radiolucency around the
crown of an impacted tooth, resembling a dentigerous
cyst. Radiolucency may extend apically along the root
crossing CE junction. More often the radiolucency
show fine calcification (snowflake). The margins are
well defined and sclerotic.
l Differential diagnosis: Pindborg tumour, CEOC or
Gorlin cyst, and ameloblastoma.
l Histopathology: The lesion is surrounded by a thick,
fibrous capsule.
l Shows epithelial cells that are, either polyhedral or even
spindle-shaped with scanty stroma of connective tissue.
Cells are arranged in sheets, cords, or whorled masses,
which may form rosette-like structure about a central
space. Foci of calcification presumed to be abortive enamel
formation or dentinoid/cementum like material are seen.
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l Shows epithelial cells are either polyhedral or even spin-
dle-shaped with scanty stroma of connective tissue. Cells
are arranged in sheets, cords, or whorled masses, which
may form rosette-like structure about a central space.
Foci of calcification presumed to be abortive enamel
formation or dentinoid/cementum-like material are seen.
l Calcification in several forms may be observed.
i. Irregular dystrophic bodies.
ii. Laminated or ring-like calcifications.
iii. Large globular masses.
l Treatment: Conservative excision or enucleation be-
cause of the capsule is possible. Recurrence is rare with
good prognosis.
l Calcification in several forms may be observed.
i. Irregular dystrophic bodies.
ii. Laminated or ring-like calcifications.
iii. Large globular masses.
l Treatment: Conservative excision or enucleation be-
cause of the capsule is possible. Recurrence is rare with
good prognosis.
Q. 3. Management of ameloblastona.
Ans.
Management of Ameloblastoma
Aim
a . Complete eradication of the lesion.
b. Reconstruction of resultant defect.
Successful treatment is the treatment that renders an
acceptable prognosis and causes minimum disfigurement.
Curettage
l Least desirable line of treatment as it has high recur-
rence chances.
l The characteristic feature of the tumour is that it mi-
croscopically infiltrates bone beyond the tumour. Bone
interface is seen in imaging.
l A safe margin of involved bone is opposite 2 cm for
solid multicystic lesions.
For Intraosseous Solid/multicystic
Ameloblastoma
1. En bloc resection or marginal resection without continu-
ity defect.
2. Segmental resection with continuity defect.
Section | I  Topic Wise Solved Questions of Previous Years
Aggressive Reconstruction in Maxilla
1. Tumour confined to maxilla without orbital floor in-
volvement—partial maxillectomy.
2. Tumour involving orbital floor, but not the periorbital
area—total maxillectomy.
3. Tumour involving orbital content—total maxillectomy
with orbital exenteration.
4. Tumour involving skull bone—Skull base resection plus
neurosurgical procedure.
Multiple Ameloblastoma
l Recurrence rate up to 50% during first five years.
l Long-term follow-up is a must.
Q. 4. Unicystic ameloblastoma.
Ans.
Unicystic Ameloblastoma
l Unicystic ameloblastoma is a separate entity from
conventional ameloblastoma.
l Accounts for about 10–15% of intraosseous amelo-
blastoma.
Clinical Feature
a . Seen most commonly in younger aged patients.
b. 90% cases seen in mandibular posterior region.
c. Lesion is often asymptomatic.
Radiographic Features
a . Well circumscribed painless swelling of jaw.
b. Radiolucent area that surrounds the crown of an un-
erupted mandibular third molar.
Histopathology
Three distant types can be seen:
1. Luminal unicystic ameloblastoma: It occurs on the lu-
minal surface of a cyst. Base of tumour is made up of
cystic epithelium backed by connective tissue.
a. Basal layer of columnar or cuboidal cell exhibiting
reverse polarization of nuclei.
b. Overlying cells are loosely arranged resembling stel-
late reticulum.
2. Intraluminal unicystic ameloblastoma: It produces sev-
eral nodular growth which projects from cysts lining
into the cyst lumen.
3. Mural type: Neoplastic cells infiltrates into connective
tissue wall of cyst capsule.
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119
Treatment
a . Enucleation and curettage.
b. Recurrence rate is low compared to CA.
Q. 5. Mention various treatment modalities of amelo-
blastoma.
Ans.
Management of Ameloblastoma
Aim
a . Complete eradication of the lesion.
b. Reconstruction of resultant defect.
Successful treatment is the treatment that renders an accept-
able prognosis and causes minimum disfigurement.
Curettage
l Least desirable line of treatment, as it has high recur-
rence chances.
l The characteristic feature of the tumour is that, it
microscopically infiltrates bone beyond the tumour.
Bone interface is seen in imaging.
l A safe margin of involved bone is opposite 2 cm for
solid multicystic lesions.
For Intraosseous Solid/multicystic
Ameloblastoma
1. En bloc resection or marginal resection without continu-
ity defect.
2. Segmental resection with continuity defect.
Aggressive Reconstruction in Maxillla
1. Tumour confined to maxilla without orbital floor in-
volvement—partial maxillectomy.
2. Tumour involving orbital floor, but not the periorbital
area—total maxillectomy.
3. Tumour involving orbital content—total maxillectomy
with orbital exenteration.
4. Tumour involving skull bone—Skull base resection plus
neurosurgical procedure.
Multiple Ameloblastoma
l Recurrence rate up to 50% during first five years.
l Long-term follow-up is a must.
120 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Q. 6. Fibrous dysplasia.
Ans.
Fibrous Dysplasia
Fibrous dysplasia is a tumour-like condition that is charac-
terized by replacement of normal bone by an excessive
proliferation of cellular fibrous tissue intermixed with
irregular bony trabeculae.
Aetiology
a . It is caused by a mutation in GNAS-I gene.
b. Increased production of melanocytes resulting in café-
au-lait spots with irregular margins as opposed to the
regular outlined spots in neurofibromatosis.
c. cAMP is thought to have an effect on the differentiation
of osteoblasts leading to fibrous dysplasia.
Clinical Feature
Divided into:
1. Monostotic form.
2. Polystotic form.
a. Jaffe’s type.
b. Albright syndrome.
3. Craniofacial form
Treatment
Treatment varies on the type of fibrous dysplasia.
Q. 7. Compound odontoma.
Ans.
Compound Odontoma
l It presents collection of numerous small, discrete, and
tooth-like structure of tumour. Most compound odon-
toma resembles normal anatomic tooth.
l It appears as a radiopaque of calcified structures with an
anatomic similarity to normal teeth.
l Seen as a pocket of malformed dwarfed teeth or tooth-
like forms surrounded by a narrow radiolucent zone.
l Sometimes overlying alongside an unerupted tooth or
between the roots of a deciduous tooth.
l It prevents eruption of underlying permanent tooth.
Q. 8. Saucerization.
Ans.
a . Sequestrum is usually lodged within bone.
b. Once removed, it leaves behind a hollow cavity, which
is basically dead space.
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c. A large clot will form in this cavity and the clot will
most likely get infected.
d. To avoid this reinfection, it is important to eliminate that
dead space.
e. This is done by procedure called saucerisation.
f. The margins of the bone which lodge the sequestra are
trimmed down.
g. This creates a saucer-shaped defect instead of a deep
hollow cavity.
h. This saucer defect accumulates a large clot.
i. The area may be packed with a medicated dressing,
which is changed repeatedly till healing takes place.
Q. 9. Papilloma.
Ans.
Papilloma
l Papilloma is a common benign neoplasm of the oral
cavity, arising from the epithelial tissue.
l It is characterized by an exophytic papillary growth
with a typical cauliflower-like appearance.
l Papilloma is caused by Human Papilloma virus.
Clinical Features
l Most commonly seen in third, fourth, and fifth decade
of life and is equally affected in both sexes.
l Sites: Tongue, lips, buccal mucosa, gingival, hard and
soft palate, etc.
l Papilloma appears as a slow growing, exophytic, soft,
usually pedunclated, and painless nodular growth with
typical cauliflower-like appearance.
l It is characterized by numerous finger-like projection
on their surface, which can be either blunt or pointed.
Because of these projections, it appears as an ovoid
swelling with a rough, corrugated surface.
l The size of the lesion is usually small and varies from
few mm to cm in diameter.
l The base of lesion is either sessile or pedunculated, but
most commonly wellcircumscribed.
l Lesion is mostly white in colour and is firm in consis-
tency, as the surface is highly keratinized.
l Superficial ulceration and secondary infection may occur.
l Multiple papilloma may coalesce together and form a
large lesion in oral cavity and the condition is known as
papillomatosis.
l Papillomatosis of oral mucosa is associated with skin
disorders, e.g., focal dermal hypoplasia, nevus unius
lateris, Cowden syndrome, acanthosis nigricans, etc.
Treatment
l Conservative surgical excision of the lesion including
the base. Recurrence is common.
Section | I  Topic Wise Solved Questions of Previous Years
Q. 10. Define odontoma.
Odontomas are a group of common hamartomatous odon-
togenic lesions with limited growth potential.
These lesions are capable of producing normal appear-
ing enamel, dentine, pulp and cement, etc., in an unorga-
nized fashion.
Q. 11. What are odontomas? Mention its types.
Ans.
Definition
Odontomas are a group of common hamartomatous odon-
togenic lesion with limited growth potential.
These lesions are capable of producing normal appear-
ing enamel, dentine, pulp and cement, etc., in an unorga-
nized fashion.
Types of Odontomas
1. Complex Odontoma: It consists of completely disorga-
nized and diffuse mass of odontogenic tissue with
haphazardly arranged enamel, dentine, and cementum.
2. Compound odontoma: It presents collection of numer-
ous small, discrete, and tooth-like structure. Most
compound odontomas resembles normal anatomic
tooth.
Q. 12. What is complex odontoma? Give brief description.
Ans.
Complex Odontoma
l It consists of completely disorganized and diffuse mass
of odontogenic tissue with haphazardly arranged
enamel, dentine, and cementum.
l Here, the calcified dental tissues are simply found as an
irregular mass bearing no morphological similarity to
the rudimentary teeth.
l Most common type of odontogenic lesion (more than 30%).
l Age: First and second decades (10–70 years).
l Sex: Equal predilection in both sexes.
l Site: Occurs in both the jaws.
More common in mandible (about 67%).
l It may be small, large, or occasionally huge; irregular or
ovoid smooth; and, densely radiopaque mass, often sur-
rounded by a thin radiolucent zone.
l It is frequently overlying a displaced unerupted tooth.
l The radiological picture is variable, depending on the
stage of formation at the time of incidental discovery.
l It will range from complete radiolucency in the initial
stage to the stage of ‘maturation’, i.e., complete calci-
fied structure.
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121
l Mixed radiolucency and radiopacity can be seen in one
lesion also.
l Asymptomatic—shows no expansion of the bone and
facial asymmetry.
l Commonly detected on radiographs.
l May show associated unerupted or impacted teeth, and
associated swelling and infection.
Q. 13. Staging of tumour.
Ans.
TNM Staging
T - Primary Tumour
TX - Primary tumour cannot be assessed.
T0 - No evidence of primary tumour.
TIS - Carcinoma in situ.
T1 - Tumour size 2 cm or less in greatest dimension.
T2 - Tumour size more than 2 cm but not more than 4 cm
in greatest dimension.
T3 - Tumour size more than 4 cm in greatest dimension.
T4 - Tumour invades adjacent structures.
N - Regional Lymph Node
NX - Regional lymph nodes cannot be assessed.
N0 - No regional lymph node metastasis.
N1 - Metastasis in single ipsilateral lymph node, 3 cm or
less in greatest dimension.
N2 - Metastasis in single ipsilateral lymph node, more than
3 cm but less than 6 cm in greatest dimension, or in bilateral
or contralateral nodes (none of them are more than 6 cm in
greatest dimension).
N2a - Metastasis in single ipsilateral lymph node, more
than 3 cm but less than 6 cm in greatest dimension.
N2b - Metastasis in multiple ipsilateral lymph nodes, none
of them are more than 6 cm in greatest dimension.
N2c - Metastasis in bilateral or contralateral lymph nodes,
none of them are more than 6 cm in greatest dimension.
N3 - Metastasis in lymph node, more than 6 cm in greatest
dimension.
M - Distant Metastasis
Mx - Presence of distant metastasis cannot be assessed.
M0 - No distant metastasis.
M1 - Clinical or radiographic evidence of metastasis.
Q. 14. Fibrous dysplasia.
Or
Monostatic fibrous dysplasia.
Ans.
122 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Fibrous Dysplasia central giant cell granuloma, which affects the jaw of chil-
dren bilaterally.
Fibrous dysplasia is a tumour-like condition that is charac-
terized by replacement of normal bone by an excessive
proliferation of cellular fibrous tissue intermixed with ir- Clinical Feature
regular bony trabeculae. a. It affects children at birth and there is no clinically or
radiographical evidence of the disease until 14 months
Aetiology to 3 years of age.
a . It is caused by a mutation in GNAS-I gene. b. Typically, if the lesion appears early, the more rapidly it
b. Increased production of melanocytes resulting in café- progress.
au-lait spots with irregular margins as opposed to the c. When the patient reaches five years of age, the self-
regular outlined spots in neurofibromatosis. limited growth usually begins to slow down and stops
c. cAMP is thought to have an effect on the differentiation by the age of 12–15 years.
of osteoblasts leading to fibrous dysplasia. d. The lesion begins to regress at puberty.
e. Jaw remodelling continues through the third decade of
life, at the end of which the clinical abnormality may be
Clinical Feature subtle.
Divided into: f. Depending on the severity of the condition, the signs
1. Monostotic form. and symptoms appear.
2. Polystotic form g. The jaw lesions are usually painless and symmetric and
a. Jaffe’s type. have a florid maxillary involvement.
b. Albright syndrome. h. The lesion, which commonly involve the molar to coro-
3. Craniofacial form. noid regions are firm to palpation and non-tender. tTe
condyle always being spared, and are often associated
Treatment with cervical lymphadenopathy.

Treatment varies on the type of fibrous dysplasia.

Monostatic Fibrous Dysplasia
a. When the disease is limited to a single bone, it is termed
as monostotic fibrous dysplasia.
b. It accounts for 80–85% of all cases, jaw most com-
monly affected.
c. Most commonly seen in second decade of life.
d. Equal predilection for both sexes.
e. Maxilla more commonly affected than mandible.
Clinical Features
a. Painless swelling of the affected area is the most com-
mon feature.
b. Growth is slow, sometimes rapid.
c. Maxillary lesion also involves adjacent bone and is not
strictly monostotic.
d. But unlike maxilla, mandibular lesions are strictly
monostotic.
Q. 15. Cherubism.
Ans.
Cherubism
Cherubism is an autosomal dominant, non-neoplastic
hereditary fibroosseous lesion of jaw which is similar to
Oral Manifestation
a. Numerous abnormalities have been reported such as
agenesis of second and third molar of mandible, dis-
placement of the teeth, premature exfoliation of the
primary teeth, delayed eruption of permanent teeth, and
transposition and rotation of teeth.
b. In some cases, it is associated with condition known as
Noonan syndrome.
Grading
Grade I - Both mandibular ascending rami are involved.
Grade II - Both maxillary tuberosities as well as the man-
dibular ascending rami are involved.
Grade III - It is characterized by McCune-Albright syn-
drome and the whole maxilla and mandible except the
coronoid process and condyle are involved.
Treatment
a . Surgery to correct the jaw deformity.
b. If surgery is indicated, then it is usually undertaken at
puberty when remission phase of the lesion have been
reached.

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Section | I  Topic Wise Solved Questions of Previous Years 123

Topic 11
Diseases of TMJ

LONG ESSAYS
Q. 1. Describe the aetiology, clinical features, and man- Diseases affecting the joints
agement of ankylosis of temporomandibular joint (TMJ). l Such as rheumatoid arthritis, osteoarthritis, and anky-

Or losing spondylitis bring about degenerative changes and

Describe the eatiology, signs and symptoms of temporo-
mandibular joint ankylosis. Discuss on its management.
Or
Describe the management of ankylosis of TMJ.
Ans.
destruction of the disc followed by the repair process.
This can lead to the ankylosis of TMJ.
Aetiopathology of Ankylosis of TMJ
Trauma
l Congenital: At birth, forceps delivery.

l Haemarthrosis (direct/indirect trauma).

l Condylar fractures: Intracapsular or extracapsular.

Ankylosis l Glenoid fossa fracture (rare).

l Ankylosis means abnormal immobility of joint.

Infections
l Otitis media.
Classification of Ankylosis l Parotitis.

i. False ankylosis or true ankylosis. l Tonsilitis.

ii. Extra-articular or intra-articular. l Furuncle.

iii. Fibrous or bony. l Abscess around the joint.

iv. Unilateral or bilateral. l Osteomyelitis of the jaw.

v. Partial or complete. l Actinomycosis.

l Extra-articular and intra-articular types of TMJ

Inflammation
ankylosis have been described depending mainly
on the anatomic site of the fusion or union. l Rheumatoid arthritis.
l Osteoarthritis.
l Septic arthritis.
Causes l Polyarthritis.
Trauma
Rare causes
l The definite cause of ankylosis of TMJ.
l Measles.
l Two main factors predisposing to the ankylosis are
l Smallpox.
trauma and infection around the joint region.
Systemic diseases
Joint infection
l Scarlet fever.
l It may occur secondary to septicaemia due to osteomy-
l Typhoid.
elitis, septic sore throat, scarlet fever, tuberculosis, l Gonoccocal arthritis.
meningitis, etc. l Scleroderma.

l Beriberi.
Direct spread of infection
l Marie-Strumpell disease.
l It may occur from adjacent areas in cases of otitis media
l Ankylosing spondylitis.
(infection of middle ear), mastoiditis, osteomyelitis of
temporal bone or parotid abscess, soft tissue abscess, Other causes
skin infections, or severe odontogenic submasseteric, l Bifid condyle.
infratemporal abscesses, etc. l Prolonged trismus.

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124 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l Prolonged immobilization. l Oral opening will be less than 5 mm or many times

l Unknown. there is nil oral opening.
l Burns. l Multiple carious teeth with bad periodontal health can

be seen.
l Severe malocclusion and crowding can be seen; and,
Clinical Manifestations
many impacted teeth may be found on the X-rays.
Clinical manifestations vary according to:
a. Severity of ankylosis,
Diagnosis
b. Time of onset of ankylosis, and
c. Duration. Diagnosis is based on the following:
l History of trauma, infection, etc.
Early joint involvement l Clinical findings.

l Less than 15 years: Severe facial deformity and loss of l Radiographic findings are important in arriving at a final

function. diagnosis.

Late joint involvement Management of TMJ Ankylosis

l After the age of 15 years: Facial deformity is marginal
l The treatment of TMJ ankylosis is always surgical cor-
or nil. But, functional loss is severe.
l Those patients in whom the ankylosis develops after full
rection of the ankylosed joint.
growth completion have no facial deformity. Surgical strategy adopted depends on the following:
l Age of onset of ankylosis.
Unilateral ankylosis
l Extent of ankylosis.
Seen in a child or in a person where the onset was usually
l Whether it is unilateral or bilateral.
in the childhood.
l Associated facial deformity.
l Obvious facial asymmetry.

l Deviation of the mandible and chin on the affected side. Aims and objectives of surgery
l The chin is receded with hypoplastic mandible on the
l Release of ankylosed mass and creation of a gap to
affected side. mobilize the joint.
l Roundness and fullness of the face on the affected
l Creation of a functional joint.
side.
l To improve patient’s nutrition.
l The appearance of the flatness and elongation on the
l To improve patient’s oral hygiene.
unaffected side.
l To carry out necessary dental treatment.
l The lower border of the mandible on the affected side
l To reconstruct the joint and restore the vertical height of
has a concavity that ends in a welldefined antegonial the ramus.
notch.
l To prevent recurrence.
l In unilateral ankylosis, some amount of oral opening
l To restore normal facial growth pattern (based on
may be possible. functional matrix theory).
l Interincisal opening will vary depending on whether it
l To improve aesthetics and rehabilitate the patient
is fibrous or bony ankylosis. (cosmetic surgery may be carried out at a later date
l Crossbite may be seen.
or at second phase).
l Class II angles malocclusion on the affected plus unilat-

eral posterior crossbite on ipsilateral side seen. Surgical techniques

l Condylar movements are absent on the affected side.
l A number of techniques have been advocated by differ-

ent surgeons.
Bilateral ankylosis
l Critical analysis of all, filters only to three basic
l Inability to open the mouth progresses by gradual
methods:
decrease in interincisal opening. The mandible is I: Condylectomy.
symmetrical but micrognathic. The patient develops II: Gap arthroplasty.
typical ‘bird face’ deformity with receding chin. III: Interpositional arthroplasty.
l The neck chin angle may be reduced or almost com-
l Most surgical procedures can be done through a preau-
pletely absent. ricular incision alone.
l Antegonial notch is well defined bilaterally.
l The Popowich’s incision is chosen for its obvious
l Class II malocclusion can be noticed.
advantages.
l Upper incisors are often protrusive with anterior open
l Whenever required, additional submandibular incision
bite. Maxilla may be narrow. can be used for fixation of the graft etc.

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Section | I  Topic Wise Solved Questions of Previous Years 125

I. Condylectomy III. Interpositional arthroplasty

l Condylectomy is advised in cases of fibrous ankylosis, l It is believed that recurrence of ankylosis is less likely

where the joint space is obliterated with deposition of when something is interposed between the two cut bony
fibrous bands, but, there is not much deformity of the surfaces.
condylar head. l Interpositional arthroplasty involves the creation of a

l Radiologically and clinically after surgical exposure, gap, but in addition, a barrier (autogenous or alloplastic)
one can see the demarcation between the roof of the is inserted between the cut bony surfaces.
glenoid fossa and the head of the condyle. l This minimizes the risk of recurrence and maintains the

l The condylectomy procedure can be carried out via vertical height of the ramus.
preauricular incision.
Interpositional materials used are:
l Horizontal osteotomy cut is carried out with the help of
a. Autogenous
the surgical bur at the level of condylar neck.
l Cartilaginous graft.
l Vital structures on the medial surface of the condylar
l Temporal muscle.
neck should be protected by using special condylar
l Temporal fascia.
retractor inserted prior to the bony cut.
l Fascia.
l The condylar head then should be separated from the
l Dermis.
superior attachment carefully.
b. Heterogenou
l The rest of the stump should be smooth and wound
l Chromatized submucosa of pig bladder.
closed in layers.
l Lyophilized bovine cartilage.
l Unilateral condyle tends to cause deviation of the man-
c. Alloplastic materials
dible towards operated side on oral opening; and in
bilateral ankylosis, open bite will be caused as a result Metallic: Tantalum foil/ plate, 316L stainless steel, titanium,
of the loss of the vertical rami. and gold.
l Therefore, when the site of the fused joint is treated via Non-metallic: Silastic, teflon, acrylic, proplast, ceramic
condylectomy, then after recontouring, an alloplastic implants etc.
material can be used to maintain space, satisfactory
Q. 2. Enumerate the causes of inability to open the mouth.
occlusion, and joint movements.
Or
II. Gap arthroplasty
What are the causes for inability to open the mouth?
l In the extensive bony ankylosis, a broad, thick bone

deposition obliterates the entire joint, sigmoid, and Ans.

coronoid process.
l Whenever there is a restriction of normal oral opening or
l Identification of the previous structure is impossible and
inability to open the mouth fully, it is termed as trismus.
mobilization at the level of the joint becomes difficult,
l Trismus is also defined as a condition in which
if not impossible.
muscle spasm or contracture prevents opening of the
l The term gap arthroplasty is used to describe the opera-
mouth.
tion in which the level of section is below that of the
previous joint space.
l No substance is interposed between the two cut bony Causes of Trismus
surfaces.
Due to Infection
l Section consists of two horizontal osteotomy cuts and
l Orofacial infections around the joint area can bring
removal of a bony wedge for creation of a gap between
the roof of the glenoid fossa and ramus. about trismus or limitation of oral opening. Infections
l Here it is recommended to create a minimum gap of at
include odontogenic acute infections like pericoronitis,
least 1 cm to prevent re-ankylosis. Ludwig’s angina, submasseteric, infratemporal abscess,
l The width of the bone removed is considered crucial
etc. Chronic infections affecting the jaws also can bring
and is not usually possible to remove the entire block, about trismus, e.g., tuberculous osteomyelitis of ramus,
particularly from the medial aspect, which is in close body, and mandible etc.
proximity to the internal maxillary artery. Hence, bone
is removed carefully by using a large round bur, until Trauma
the medial bone is thinned out enough to be readily re-
moved by using hand chisel or osteotome. l Fracture of the zygomatic arch may impinge on the
l It is important to create a gap of equal dimension both
coronoid process and restrict the oral opening. Fracture
laterally and medially, so that the possibility of medial of the mandible also can bring about trismus, because of
re-ankylosis due to bone contact is avoided. pain and tenderness or muscle spasm.

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126 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Inflammation eminence with collapse of the articular space. The

condyle comes in contact with the anterior slope of the
l Myositis or muscular atrophy can bring about trismus.
eminence and is unable to return to the closed position

Myositis Ossificans
Classification
l Following trauma, a haematoma can be formed within
l Unilateral or bilateral.
the fibres of the masticatory group of muscles, especially
l Acute or chronic.
in the masseter, which can progress into ossification and
l Habitual or recurrent.
muscle stiffness. Clinical and radiographic examination
will confirm the presence of these changes.
Aetiology
Tetany i. Intrinsic trauma: Overextension injury as in yawning,
vomiting, seizures, etc.
l Tetanus following acute infection by Clostridium tetani,
ii. Extrinsic trauma:
the typical lockjaw symptom can be seen associated
l Trauma to the mandible during a fall or blow to the
with other symptoms, because of persistent tonic mus-
mandible.
cle spasm.
l Intubation during GA.

l Endoscopy.
Neurological Disorders l Dental extraction.

l Epilepsy, brain tumour, bulbar paralysis, and embolic
haemorrhage in medulla oblongata can bring about trismus.
Psychosomatic Trismus
l It is also known as trismus hystericus. It is due to ex-
treme fear and anxiety associated with hysterical fits.
iii. Connective tissue disorders: Hypermobility syndrome,
Ehlers-Danlos syndrome, and Marfan syndrome.
iv. Psychogenic causes: Habitual dislocation.
v. Drug-induced: Phenothiazines.
vi. Miscellaneous causes:
Internal derangement, decreased vertical dimension,
and occlusal discrepancies.

Drug-induced Trismus Management

l Strychnine poisoning can bring about spasms leading to l Non-surgical management.
trismus. l Chemical capsulorrhaphy.
l Arthroscopic sclerotherapy.
l Occlusal correction.
Mechanical Blockage
l Physiotherapy.
l Elongation, exostosis, osteoma, and osteochondroma of
coronoid process will cause mechanical blockage and Management of dislocation can be divided into two broad
interfere with the normal mandibular movements. headings:
I. Non-surgical management.
II. Surgical management.
Extra-articular Fibrosis
l Chronic cervicofacial sepsis, irradiation therapy, ossifi- Non-surgical Management
cation of sphenomandibular ligament, bands of scars i. Manual reduction of a dislocated condyle:
and burns of the face and neck region, and oral submu- The main aim is to overcome the resistance of the se-
cous fibrosis will lead toward progressive trismus. vere muscle contraction that accompanies a dislocation.
ii. Sedatives can be given to reduce the anxiety of the patient.
Q. 3. Differentiate between subluxation dislocation
iii. Pressure and light massage over the coronoid process
of TMJ and describe the treatment of chronic TMJ
intraorally is beneficial.
dislocation.
iv. Johnson has described a simple method by which injec-
Ans. tion of local anaesthetic into the glenoid fossa of the
dislocated joint cause spontaneous reduction of the
condyle.
Dislocation
This is probably due to relief of pain and therefore
l Dislocation of the condyle refers to the condition in reduction in muscle spasm and therefore spontaneous
which the condyle is placed anterior to the articular reduction of dislocation.

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Section | I  Topic Wise Solved Questions of Previous Years
v. Most common manual method of reduction:
Patient is made to sit upright. The doctor puts his
thumbs over the occlusal surface of the lower molars II. Hard tissue procedures.
or on the alveolar ridge and pushes the mandible down-
wards, backwards, and upwards.
vi. Chemical capsulorrhaphy
It is done in a patient with recurrent dislocations.
Objective is to produce fibrosis and tightening of the
capsular ligament, thereby limiting motion and thus
preventing dislocation.
Chemical capsulorrhaphy means injecting a sclerosing
agent into the supporting ligaments of the joint or into the
joint to produce fibrosis.
Surgical management
Indications
l Disabling recurrent dislocation.
l Long standing dislocation not responsive to closed ma-
nipulation or other non-surgical treatment.
Surgical procedures can be divided into three types:
A. Procedures to limit condylar translation
B. Procedures to eliminate blocking factors in the condylar
path of closure
C. Combination procedures to limit condylar translation
and to eliminate blocking factors.
A. Procedures to Limit Condylar Translation
a. Capsulorrhaphy
This is a procedure done to tighten the capsule so that it
prevents the excessive moveof the condyle.
This is done in different ways as described below:
i. Removing a wedge of tissue from the capsule and sutur-
ing the defect to tighten the capsule.
ii. Use of dermal flap from occipital region based on cranial
periosteum tunneled and secured to the capto augment
the capsulorrhaphy.
iii. Temporal fascia flap can also be used in the same way.
iv. Capsular plication and ligamentopexy.
b. Anchoring sling
l Gordon used fascia lata transplants and secured it to the
zygomatic arch and the head of the condyle to prevent
excessive anterior movement of the condyle.
l This was followed by removal of the disc.
c. Ligation of Coronoid Process
Coronoid process can be ligated to the zygomatic arch.
d. Lateral pterygoid myotomy
l Myotomy eliminates action of the superior belly of the
lateral pterygoid muscle.
l Silicon sheet placed over pterygoid fossa prevents
reattachment of the muscle.
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127
e. Blocking procedures
I. Soft tissue procedures
Soft tissue procedures
Creating a closed lock:
Konjetzny surgically released the posterior attachment of
the disc and allowed it to move anteriorly and inferiorly. It
is anchored vertically in front of the condyle by suturing
it to the lateral pterygoid muscle and the capsule. This
prevents excessive forward translation of the condyle.
Disadvantage: Causes future pain and disrt.
II. Bony or hard tissue procedures
i. Lidermann performed an oblique osteotomy of the
articular tubercle and turned it down in front of the
condyle head to block movement of condyle.
Drawback: IMF needed. Bone resorption may take place.
ii. Mayer advocated the removal of part of the articular tu-
bercle and placement of graft taken from the zygomatic
arch to increase the height of the articular tubercle.
Drawbacks: IMF needed, bone resorption.
iii. Articular eminence can be augmented by sectioning it and
placing a piece of silastic in between the sectioned parts.
Drawback: Inferior part of the articular eminence is
devoid of blood supply and will resorb.
iv. Dautry’s procedure: The zygomatic arch is osteotomised
and depressed in front of the condylar head. This serves
as an obstacle to abnormal translation of the condyle.
B. Procedures to Eliminate Blocking Factors
in the Condylar Path of Closure
Operations have been designed to eliminate obstacles in
the condylar path that may either trigger a dislocation or
mechanically prevent reduction of the condyle:
i. Discectomy
ii. Eminectomy.
C. Combination Procedures to Limit Condylar
Translation and to Eliminate Blocking Factors
The combined procedures include:
i. Lateral pterygoid myotomy with discectomy
ii. Condylotomy
iii. Condylectomy or high condylectomy.
Chronic/recurrent or habitual dislocation or subluxation
l The term should be reserved for repeated episodes of
dislocation, where there is abnormal anterior excursion of
the condyles beyond the articular eminence. Patient is
able to manipulate it back into position. So, here the con-
dylar head moves unassisted, forward and backward over
the articular eminence.
l This recurrent, incomplete, and self-reducing dislocation is
termed as hypermobility or chronic subluxation of the TMJ.
128 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The triad of ligamentous and capsular flaccidity, emi-
nential erosion, and flattening and trauma is well recog-
nized in the genesis of chronic subluxation.
SHORT ESSAYS
Q. 1. Ankylosis treatment protocol.
Ans.
Internationally Accepted Protocol for the
Management of TMJ Ankylosis
l Put forward by Kaban, Perrot, and Fisher in 1990.
l Early surgical intervention.
l Aggressive resection: A gap of at least 1–1.5 cm should be
created. Special attention should be given to the fusion on
the medial aspect of the ramus. Old malunited condylar
fractured piece can be seen attached on the medial side.
l Ipsilateral coronoidectomy and temporalis myotomy: In
most of these cases, there is always association of elon-
gated coronoid process. After carrying out gap arthro-
plasty, the coronoidectomy on the same side should be
carried out either separately or in combination with the
gap arthroplasty cut from the same extraoral incision.
The coronoid process is cut from the level of sigmoid
notch till the anterior border of the ramus. The tempora-
lis muscle attachments are severed by carrying out
temporalis myotomy. The oral opening is checked after
this procedure by the assistant. If maximum interincisal
opening of greater than 35 mm is obtained, then there is
no need to carry out contralateral coronoidectomy.
l Contralateral coronoidectomy and temporalis myotomy is
necessary: If maximum incisal opening is less than 35 mm,
then uninvolved side coronoidectomy and temporalis my-
otomy can be carried out through intraoral incision.
l Lining of the glenoid fossa region with temporalis fascia.
l Reconstruction of the ramus with a costochondral graft.
l Early mobilization and aggressive physiotherapy for the
period of at least six months post-operatively.
l Regular long-term follow-up.
l To carry out cosmetic surgery at later date, when the
growth of the patient is completed.
Q. 2. Treatment of temporomandibular joint dysfunc-
tion syndrome.
Ans.
l MPDS is a pain disorder, which is unilateral and is re-
ferred from the trigger points to various muscles of the
head and neck.
l Pain is constant and dull in contrast to the sudden sharp,
shooting, intermittent pain of neuralgias (chronic pain).
l The pain may range from mild to intolerable.
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l In such predisposed individuals, yawning or laughing
may precipitate subluxation.
l It is also seen in severe epilepsy, dystrophia myotonia,
and Ehler’s Danlos syndrome.
Treatment of Temporomandibular Joint
Dysfunction Syndrome
Placebo
l Placebo effect for treatment of pain/dysfunction syndrome
is by splints and by mock adjustment of the occlusion.
Reassurance
l The quality of doctor–patient relationship is very im-
portant for the success of treatment, as it may help to
reduce the emotional problem of the patient and they
must be reassured that there is no serious disease. In a
few cases, reassurance alone may be sufficient.
l Patient’s occupation must be considered, as it may be
necessary to advice sick leave.
Occlusal Correction
l Patient should perform bilateral mastication.
l Any dental pain, substandard restoration, and missing
teeth should be treated.
l Habits can be corrected by exercises.
Soft Diet
l Loading forces on joint reduces.
Splints
l A splint inactivates facial muscles, decompresses intra-
capsular tissue, and establishes balanced occlusal plane.
Drugs
l NSAIDs are helpful in reducing pain and inflammation.
l Anti-inflammatory action of corticosteroids is greater
than NSAIDs. Can be given intra-articular or orally.
l Anxiolytics to reduce anxiety, as anxiety and muscle
tension appear to be related, e.g., diazepam 5–10 mg.
l Muscle relaxants like methocarbomol and chloroxazone
are effective.
l Antidepressant loke tricyclic and MAO inhibitors are
effective.
Intermaxillary Fixation
l When pain is severe, application of intermaxillary fixa-
tion relieves symptoms by inducing absolute rest.
Section | I  Topic Wise Solved Questions of Previous Years
Thermal Agents
l They help in decreasing pain, increasing muscle relax-
ation, and increasing the range of motions.
l Superficial moist/dry heat: Superficial heat produces a ther-
apeutic effect by elevating pain threshold, altering nerve
conduction velocity, and decreasing muscle tension. Muscle
relaxation may also result from analgesic effects of heating.
l Deep ultrasound: They help to increase the elasticity of soft
tissues. It has an anti-inflammatory effect. For TMJ inflam-
mation, pulsed ultrasound is applied with a 5 cm or smaller
sound heard at a frequency of 3 MHz and low intensity of
0.5 to 0.8 w/cm2 per 5–8 minutes. Exercise combined with
ultrasound reported a higher percentage of pain relief.
Q. 3. Clinical features and management of dislocation.
Or
Dislocation of TM joint.
Or
Acute dislocation of TM joint.
Or
Acute TMJ dislocation and its causes and treatment.
Ans.
Dislocation
Dislocation of the condyle refers to the condition in which
the condyle is placed anterior to the articular eminence with
collapse of the articular space. The condyle comes in con-
tact with the anterior slope of the eminence and is unable to
return to the closed position.
Classification
l Unilateral or bilateral.
l Acute or chronic.
l Habitual or recurrent.
Aetiology
i. Intrinsic trauma: Overextension injury as in yawning,
vomiting, seizures, etc.
ii. Extrinsic trauma
l Trauma to the mandible during a fall or blow to the
mandible.
l Intubation during GA.
l Endoscopy.
l Dental extraction.
iii. Connective tissue disorders: Hypermobility syndrome,
Ehlers-Danlos syndrome, and Marfan syndrome.
iv. Psychogenic causes: Habitual dislocation.
v. Drug-induced: Phenothiazines.
vi. Miscellaneous causes
Internal derangement, decreased vertical dimension,
and occlusal discrepancies.
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129
Management
l Non-surgical management.
l Chemical capsulorrhaphy.
l Arthroscopic sclerotherapy.
l Occlusal correction.
l Physiotherapy.
Management of dislocation can be divided into two broad
headings:
I. Non-surgical management.
II. Surgical management.
Non-surgical management
i. Manual reduction of a dislocated condyle
The main aim is to overcome the resistance of the se-
vere muscle contraction that accompanies a dislocation.
ii. Sedatives can be given to reduce the anxiety of the
patient.
iii. Pressure and light massage over the coronoid process
intraorally is said to be of benefit.
iv. Johnson has described a simple method by which injec-
tion of local anaesthetic into the glenoid fossa of the dis-
located joint cause spontaneous reduction of the condyle.
This is probably due to relief of pain and therefore
reduction in muscle spasm and spontaneous reduction
of dislocation.
v. Most common manual method of reduction
Patient is made to sit upright. The doctor puts
his thumbs over the occlusal surface of the lower mo-
lars or on the alveolar ridge and pushes the mandible
downwards, backwards, and upwards.
vi. Chemical capsulorrhaphy
l Morrhuate sodium or sodium tetradecyl sulphate are
used as sclerosing agents.
l Disadvantages: Inability to predict the amount of
fibrosis and limitation of joint movement.
vii. Exercise Physiotherapy to restrain excessive mouth
opening.
Surgical management
Indications
l Disabling recurrent dislocation.
l Long-standing dislocation not responsive to closed
manipulation or other non-surgical treatment.
Surgical procedures can be divided into three types:
A. Procedures to limit condylar translation
B. Procedures to eliminate blocking factors in the condylar
path of closure
C. Combination procedures to limit condylar translation
and to eliminate blocking factors.
A. Procedures to Limit Condylar Translation
a. Capsulorrhaphy
This is a procedure done to tighten the capsule so that it
prevents the excessive moveof the condyle.
130 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
This is done in different ways as described below:
i. Removing a wedge of tissue from the capsule and sutur-
ing the defect to tighten the capsule.
ii. Use of dermal flap from occipital region based on
cranial periosteum tunneled and secured to the capto
augment the capsulorrhaphy.
iii. Temporal fascia flap can also be used in the same way.
iv. Capsular plication and ligamentopexy.
b. Anchoring sling
l Gordon used fascia lata transplants and secured it to the
zygomatic arch and the head of the condyle to prevent
excessive anterior movement of the condyle.
l This was followed by removal of the disc.
c. Ligation of coronoid process
Coronoid process can be ligated to the zygomatic arch.
d. Lateral pterygoid myotomy
l Myotomy eliminates action of the superior belly of the
lateral pterygoid muscle.
l Silicon sheet placed over pterygoid fossa prevents reat-
tachment of the muscle.
e. Blocking procedures
I. Soft tissue procedures
II. Hard tissue procedures.
I. Soft tissue procedures
Creating a closed lock:
Konjetzny surgically released the posterior attachment
of the disc and allowed it to move anteriorly and inferi-
orly. It is anchored vertically in front of the condyle by
suturing it to the lateral pterygoid muscle and the cap-
sule. This prevents excessive forward translation of the
condyle.
Disadvantage: Causes future pain and disrt.
II. Bony or hard tissue procedures
i. Lidermann performed an oblique osteotomy of the ar-
ticular tubercle and turned it down in front of the con-
dyle head to block movement of condyle.
Drawback: IMF needed. Bone resorption may take
place.
ii. Mayer advocated the removal of part of the articular
tubercle and placement of graft taken from the zy-
gomatic arch to increase the height of the articular
tubercle.
Drawbacks: IMF needed, bone resorption.
iii. Articular eminence can be augmented by sectioning it and
placing a piece of silastic in between the sectioned parts.
Drawback: Inferior part of the articular eminence is
devoid of blood supply and will resorb.
iv. Dautry’s procedure: The zygomatic arch is osteot-
omised and depressed in front of the condylar head.
This serves as an obstacle to abnormal translation of
the condyle.
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B. Procedures to Eliminate Blocking Factors in
the Condylar Path of Closure
Operations have been designed to eliminate obstacles in the
condylar path that may either trigger a dislocation or me-
chanically prevent reduction of the condyle:
i. Discectomy
ii. Eminectomy.
C. Combination Procedures to Limit Condylar
Translation and to Eliminate Blocking Factors
The combined procedures include:
i. Lateral pterygoid myotomy with discectomy
ii. Condylotomy
iii. Condylectomy or high condylectomy.
Q. 4. Define trismus and enumerate its causes.
Ans.
Trismus
l Whenever there is a restriction of normal oral opening or
inability to open the mouth fully, it is termed as trismus.
l Trismus is also defined as a condition in which muscle
spasm or contracture prevents opening of the mouth.
Causes of Trismus
Due to infection
l Orofacial infections around the joint area can bring about
trismus or limitation of oral opening. These include odonto-
genic acute infections like pericoronitis, Ludwig’s angina,
submasseteric, infratemporal abscess, etc. Chronic infec-
tions affecting the jaws also can bring about trismus, E.g.,
tuberculous osteomyelitis of ramus, body, and mandible, etc.
Trauma
l Fractures of the zygomatic arch impinging on the coro-
noid process or fracture of the mandible also can bring
about trismus.
Inflammation
l Myositis or muscular atrophy can bring about trismus.
Myositis ossificans
l Following trauma, a haematoma can be formed within
the fibres of the masticatory group of muscles, especially
in the masseter, which can progress into ossification and
the muscle stiffness.
Tetany
l Tetanus following acute infection by Clostridium tetani,
the typical lockjaw symptom can be seen.
Neurological disorders
l Epilepsy, brain tumour, bulbar paralysis, and embolic
haemorrhage in medulla oblongata can bring about trismus.
Section | I  Topic Wise Solved Questions of Previous Years
Psychosomatic trismus
l It is also known as trismus hystericus.
Drug-induced trismus
l Strychnine poisoning.
Mechanical blockage
l Elongation, exostosis, osteoma, and osteochondroma of
coronoid process.
Extra-articular fibrosis
l Chronic cervicofacial sepsis, irradiation therapy, ossifi-
cation of sphenomandibular ligament, bands of scars
and burns of the face and neck region, and oral submu-
cous fibrosis will lead toward progressive trismus.
Q. 5. Surgical anatomy of the temporomandibular joint.
Ans.
Components of TMJ
I. Bony articular components: Condylar head and
glenoid fossa.
II. Intra-articular disc.
III. Capsule of the joint.
IV. Ligaments of the joint.
I. Bony Articular Components
The temporomandibular joint consists of basically two
bony articular components, namely:
i. The glenoid fossa of the temporal bone.
ii. The mandibular condyle.
i. The glenoid fossa of the temporal bone
This is a smooth concave depression in the temporal bone
which is thinnest in its deepest part, which separates the
joint from the middle cranial fossa.
ii. The mandibular condyle
This is a paired structure. Condyles on both sides being con-
nected by a single continuity of bone which is the mandible.
II. Intra-articular Disc and its Attachments
l The disc is described as a jockey’s cap placed on the
condylar head.
l The disc is composed of avascular, aneural, and fibrous
connective tissue.
l This divides the joint into two separate compartments:
l The superior joint space (between disc and glenoid fossa).
l Inferior joint space (between lower surface of the disc
and condylar head).
l Functions of the disc:
Probably acts as a shock absorber and also helps in lubrica-
tion of the joint.
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131
III. Capsule of the Joint
l The capsule is a thin ligamentous structure, which
extends from temporal portion of glenoid fossa supe-
riorly, fuses with margins of the disc in the centre, and
continues down to attach to the neck of the condyle
inferiorly.
l Inferior and superior joint spaces which are separated
by the disc are enclosed within the capsule.
l Inner aspect of capsule is lined by the synovial membrane.
l This produces the synovial fluid which lubricates the
joint, helps in smooth movement of the joint, and also
acts as a shock absorber.
IV. Ligaments of the TMJ
The ligaments of the TMJ are:
a. Lateral ligament or the temporomandibular ligament.
b. Sphenomandibular ligament.
c. Stylomandibular ligament.
d. Collateral ligaments.
a. Lateral ligament
l Consists of superficial fibres which are oblique, and
deep fibres which are more horizontal.
l It originates at the root of the zygomatic arch or the
articular tubercle and attaches posteroinferiorly to the
posterior surface of the condylar neck.
b. Sphenomandibular ligament
Origin is at the spine of the sphenoid and attaches to the
lingula on the medial surface of the ramus of the mandible.
c. Stylomandibular ligament
It originates from the styloid process and attaches to the
angle of the mandible.
Collateral or accessory ligaments, make no contribution
to joint activity.
Nerve and Blood Supply
Sensory innervation: Auriculotemporal and masseteric
branch of mandibular nerve.
Vascular supply: Superficial temporal branch of exter-
nal carotid artery supplies the lateral aspect of the joint.
Middle meningeal artery and lateral pterygoid muscle
provide an additional vascularity to the joint.
Movements of TMJ
l Depression of the mandible: Contraction of bilateral
and lateral pterygoid muscles.
l Elevation of mandible:
Contraction of bilateral, masseter contraction, bilateral
medial pterygoid contraction, and bilateral temporalis
contraction.
132 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Lateral excursion of mandible contraction; unilateral,
medial, and lateral pterygoid (same side) relaxation; and
opposite side medial and lateral pterygoid.
l Protrusion of the mandible:
Contraction of bilateral, medial, and lateral pterygoid.
l Retrusion of mandible:
Contraction posterior fibres of temporalis.
Q. 6. Subluxation of TMJ.
Ans.
Chronic Recurrent or Habitual Dislocation
or Subluxation
l The term should be reserved for repeated episodes of
dislocation where there is abnormal anterior excursion
of the condyles beyond the articular eminence. Patient
is able to manipulate it back into position. So, here the
condylar head moves, unassisted, forward, and back-
ward over the articular eminence.
l This recurrent, incomplete, and self-reducing disloca-
tion is termed as hypermobility or chronic subluxation
of the TMJ.
l The triad of ligamentous and capsular flaccidity, emi-
nential erosion, and flattening and trauma is well recog-
nized in the genesis of chronic subluxation.
l In such predisposed individuals, yawning or laughing
may precipitate subluxation.
l It is also seen in severe epilepsy, dystrophia myotonia,
and Ehler’s Danlos syndrome.
Chronic Subluxation with Pain
l Excessive excursive movement or hypermobility of the
mandibular condyle is not necessarily painful.
l But in some of the patients, sudden sharp and severe
pain occurs when the mouth is opened widely. Occa-
sionally, the problem is of such a magnitude that, the
patient becomes reluctant to masticate food.
Q. 7. Interposition osteoarthroplasty.
Or
Interpositional arthroplasty.
Ans.
Interpositional Arthroplasty
l It is believed that recurrence of ankylosis is less likely
when something is interposed between the two cut bony
surfaces.
l Interpositional arthroplasty involves the creation of a
gap, but in addition a barrier (autogenous or alloplastic)
is inserted between the cut bony surfaces.
l This minimizes the risk of recurrence and to maintain
the vertical height of the ramus.
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Interpositional materials used are:
a. Autogenous
l Cartilaginous graft.
l Temporal muscle.
l Temporal fascia.
l Fascia.
l Dermis.
b. Heterogenous
l Chromatized submucosa of pig bladder.
l Lyophilized bovine cartilage.
c. Alloplastic materials
Metallic: Tantalum foil/ plate, 316L stainless steel, tita-
nium, and gold.
Nonmetallic: Silastic, teflon, acrylic, proplast, ceramic
implants etc.
Q. 8. Internal derangements of TMJ.
Ans.
Internal Derangement of TMJ
l Internal derangement is defined as the anteromedial
displacement of the interarticular disc associated with
the posterosuperior displacement of the condyle in the
closed jaw position.
l It is a progressive disorder which can lead from a mild
clicking sound in the joint to osteoarthritis.
Aetiology
l Changes in the joint usually occur as a result of trauma.
l Trauma may be in the form of microtrauma or macro-
trauma.
l Microtrauma to the joint may be in the form of bruxism,
clenching, or orthopaedic instability.
l As a result of such insult to the joint, there is elongation
of the capsular and discal ligaments and thinning of the
articular disc.
Clinical Features
l The patients may have relatively normal mouth opening
in early stages of disorder.
l The restricted mouth opening may be only due to pain
and not due to a mechanical obstruction.
l Clicking sounds may be palpable on opening or both on
opening and closing.
l Deviation of the jaw on opening of the mouth may be seen.
Management
Non-surgical management
I. Anterior repositioning appliances
l This is an appliance placed on the occlusal surface in
an attempt to recapture the disc to its normal position.
Section | I  Topic Wise Solved Questions of Previous Years 133

II. Supportive therapy l Haemarthrosis.

l Decrease loading of the joint, NSAID to control l Intracapsular fracture or extracapsular fracture.
pain, and heat application are adviced. 2. Internal disc displacement
l In case of orthopaedic instability, dental therapy for l Anterior disc displacement with reduction.

occlusal correction may be useful. l Anterior disc displacement without reduction.

3. Arthritis
Q. 9. Enumerate diseases of TMJ.
l Osteoarthrosis (degenerative arthritis, osteoarthritis)

Ans. l Rheumatoid arthritis.

l Juvenile rheumatoid arthritis.

l Infectious arthritis.
Disorders Due to Extrinsic Factors
4. Developmental defects
Masticatory Muscle Disorders l Condylar agenesis or aplasia - unilateral/bilateral.

l Bifid condyle.
l Protective muscle splinting. l Condylar hypoplasia.
l Masticatory muscle spasm (MPD syndrome). l Condylar hyperplasia.
l Masticatory muscle inflammation (myositis).
5 . Ankylosis
6. Neoplasms
Temporomandibular Disorders Due to Intrinsic l Benign tumours: Osteoma, osteochondroma, and

Factors chondroma.
l Malignant tumours: Chondrosarcoma, fibrosarcoma,
1. Trauma and synovial sarcoma.
l Dislocation or subluxation.

SHORT NOTES
Q. 1. Eminectomy. l This divides the joint into two separate compartments:
l The superior joint space (between disc and glenoid
Ans.
fossa).
l Inferior joint space (between lower surface of the
Eminectomy disc and condylar head).
l Functions of the disc:
l Eminectomy involves reduction of height of eminence
to allow free forward and backward movements of Probably acts as a shock absorber and also helps in lubrica-
condyle. tion of the joint.
l It is important to remove medial most part of the

eminence. Q. 3. Mention eight causes that can result in true

l It does not interfere with the internal structure of the
ankylosis of the TM joint.
joint. Ans.

Complications Ankylosis of TM Joint

l Pneumatization of eminence and dural tear during its l Ankylosis is defined as abnormal immobility of a joint.
removal.
l Formation of post-operative osteophytes.

l Crepitus and pain.

Aetiopathology of Ankylosis of TMJ
Q. 2. Articular disc. Trauma
l Congenital: At birth, forceps delivery.
Ans.
l Haemarthrosis (direct/indirect trauma).

l TMJ is a diarthroidial synovial paired joint. l Condylar fractures: Intracapsular or extracapsular.

l The disc is biconcave in sagittal section. The superior

surface is concavoconvex to match the anatomy of the Infections
glenoid fossa and inferior surface is concave to fit over l Otitis media.

the condylar head. l Parotitis.

l The disc is composed of avascular, aneural, and fibrous l Tonsilitis.

connective tissue. l Actinomycosis.

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134 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Inflammation Q. 6. Interposition arthroplasty.

l Rheumatoid arthritis.
Ans.
l Osteoarthritis.

l Septic arthritis

l Polyarthritis.
Interposition Arthroplasty
l Interpositional arthroplasty involves the creation of a
Rare causes
gap, but in addition a barrier (autogenous or alloplastic)
l Measles. is inserted between the cut bony surfaces.
l Smallpox. l This minimizes the risk of recurrence and to maintain

the vertical height of the ramus.

Systemic diseases
l Scarlet fever.
Interpositional materials used are:
l Typhoid.
Autogenous
l Cartilaginous graft.
l Gonoccocal arthritis.
l Temporal muscle.
l Scleroderma.
l Temporal fascia.
l Beriberi.

Heterogenous
Other causes
l Chromatized submucosa of pig bladder.
l Bifid condyle. l Lyophilized bovine cartilage.
l Prolonged trismus.

l Prolonged immobilization.
Alloplastic
Metallic
Q. 4. Frey’s syndrome. l Tantalum foil/plate.

l 316L Stainless steel.

Ans.
l Titanium.

l Gold.
Frey’s Syndrome
Non-metallic
l This auriculotemporal nerve syndrome may follow the l Silastic.
surgery of the parotid gland and TM joint, a facial l Teflon.
wound, or parotid abscess. l Acrylic.
l It is characterized by pain in the auriculotemporal nerve l Proplast.
distribution. l Ceramic implants.
l Associated gustatory sweating and occasionally ery-

thema is seen. Q. 7. Risdon’s submandibular approach.

l There is flushing on the affected side of the face accom-
panied by sweating within the hairline, the periauricular
region, and beneath the pinna.
l A minor starch iodine test is positive in these patients.
Treatment Options for Frey’s Syndrome
l Topical agents.
l Commercial antiperspirants are effective only for milder
symptoms.
Ans.
Submandibular (Risdon) Approach
l In Risdon’s method, the incision is taken about 1 cm
below the angle of the mandible.
l It extends forward, parallel to the lower border of the
mandible and curves backward slightly behind the
angle.
l Approach to the neck of the condyle and ramus is

achieved by sharply incising through the pterygomas-

Surgical procedures
l Skin excision for localized and relative areas.
l Auriculotemporal nerve section results are permanent.
l Tympanic neurectomy is a safe procedure on outpatient
basis.
seteric sling and reflecting the masseter muscle laterally
to expose the neck of the condyle and sigmoid notch.
l Poor access to the condylar head region. Procedures
involving the articular portion of the head and the me-
niscus cannot be performed by this approach.

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Section | I  Topic Wise Solved Questions of Previous Years 135

Topic 12
Diseases of Salivary Gland

LONG ESSAYS
Q. 1. Describe signs and symptoms, diagnosis, and man- Sialolithiasis
agement of sialolith in Wharton’s duct.
l The sialolith is a calcified mass with laminated layers of
Or the inorganic material. It results from the crystallization
Describe the clinical features and treatment of salivary of salivary solutes.
l The sialolith is yellowish white in colour; single or mul-
calculus of Warton’s duct.
tiple; and may be round, ovoid. or elongated having the
Or size of 2 cm or more in diameter.
l The minerals are forms of calcium phosphate like hy-
Enumerate salivary gland disorders and discuss the
management of sialolith in Warton’s duct. droxyapatite, octacalcium phosphate, etc. Calcium and
phosphorus ions are deposited on the organic nidus,
Ans. which may be, desquamated epithelial cell, bacteria,
foreign particle, or product of bacterial decomposition.
l Sialolith frequently occurs in the Wharton’s duct due to
Classification of Salivary Gland Diseases
the following reasons:
I. Developmental i. The long, curved Wharton’s duct has increased
1. Aplasia - absence of the gland. chance of entrapment of organic debris.
2. Atresia - absence of the duct. ii. The secretion of this gland is higher in calcium con-
3. Aberrancy - ectopic gland. tent and thick in consistency.
II. Enlargement of the gland iii. The position of the gland increases the chances for
A. Inflammatory the stagnation of the saliva.
1. Viral: Mumps.
2. Bacterial.
3. Allergic.
Signs and Symptoms
B. Non-inflammatory l Patients complain of periodic painful swelling when
1. Autoimmune. eating, interspersed with periods of remission.
2. Diabetes mellitus. l Spontaneous extrusion of small calculi from the ducts.
3. Nutritional deficiency. l Point tenderness in the region of the hilum or, near
4. HIV associated. Wharton’s duct of the submandibular gland.
III. Cysts l Salivary secretion may be affected only slightly.
1. Extravasation cysts. l A gelatinous, cloudy mucopurulent material is seen in
2. Retention cysts. basically clear and adequate saliva. This mucopurulent
3. Ranula. material is derived from the inflammatory ductal changes
IV. Tumours of salivary glands caused by calculus blockage and salivary stagnation.
A. Benign tumours l If treatment not instituted early, pronounced exacerba-
1. Pleomorphic adenoma. tions are seen, characterized by an acute suppurative
2. Warthin’s tumour. process with attendant systemic manifestations.
B. Malignant tumours l Pus may exude from the duct orifice.
1. Mucoepidermoid carcinoma. l The mucosa around the duct is inflamed, particularly
2. Adenoid cystic carcinoma. in the floor of the mouth where swelling, redness, and
V. Necrotising sialometaplasia tenderness are present along the course of Wharton’s
VI. Salivary gland dysfunction duct.
1. Xerostomia. l The glands are enlarged, tender, and dense.
2. Sialorrhoea. l Palpation of the gland and the duct causes pain and flow

of pus.

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136 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Diagnosis Incision
l An incision of 5 cm is made in the skin crease of the
Radiographs: AP view, lateral, lateral oblique, or occlusal
view. neck approximately 2–3 cm below inferior border of
Sialography: The radiographs demonstrate the presence mandible.
l Incision is done through the platysma.
of salivary calculi, which can be appropriately located by
l Care is taken to protect the marginal mandibular branch
the sialography.
of the facial nerve.
l The facial vein is located, ligated, and cut.
Management l The cervical branch of the facial nerve is identified and

A suitable procedure is selected depending upon the num- protected.

l Beneath the deep cervical fascia, the submandibular
ber, size, and site of the stone in the duct or the gland; and,
age of the patient, etc. gland is found encapsulated.
l The gland and the surrounding structure are freed from
l The smaller sialoliths which are located peripherally

near the ductal opening may be removed by manipula- the under surface of the mandible.
l The facial artery is ligated and divided, as it approaches
tion called milking the gland.
l Larger sialoliths are surgically removed.
the lower border of the mandible.
l The inferior portion of the gland is dissected from the
l Sometimes, the stones which are not impacted may be

extracted through the intubation of the duct with fine digastric muscle.
l The facial artery will be encountered again in this
soft plastic catheter and application of the suction to
the tube. region inferiorly near its origin from the ECA. It is
l Multiple stones or stones in the gland require the
ligated again.
l The gland is retracted laterally to expose the mylohyoid
removal of the gland.
l Modern techniques like piezoelectric shockwave litho-
muscle.
l The mylohyoid muscle is dissected free and retracted
tripsy to fragment the salivary stones can be used.
l The fragments pass through the duct, as the salivary
medially.
l This helps in exposing the hypoglossal nerve inferiorly,
flow is stimulated and enhanced by the use of sialo-
gogues. lingual nerve superiorly at the point of emergence of
the submandibular duct.
l Once these three structures are positively confirmed, the
Transoral sialolithotomy of Warton’s duct
duct is ligated and tansected with the submandibular
l It is a surgical procedure to remove submandibular duct
ganglion.
stones.
l The specimen is removed.
l The exact site of the stone is located by X-rays and
l Drains are placed. Wound is sutured in layers and dress-
palpation.
ing is done.
l Incision is made in the mucosa parallel to the duct.

l Care should be taken not to injure the lingual nerve and

sublingual glands. Complications

l After incision, blunt dissection is carried out.
i. Facial nerve injury.
l The tissues are displaced to locate the duct.
ii. Haematoma formation.
l Once the part of the duct lodging the stone is identified,
iii. Sialocoele (salivary fistula).
a longitudinal incision is made over the stone. iv. Frey’s syndrome
l The stone is removed using small forceps. In case the
l Also known as auriculotemporal syndrome.
stone is large, it can be crushed with the help of the l Common long-term complication of parotid gland.
forceps. l Results from inappropriate autonomic reinnervation
l Following this, a cannula may be passed to aspirate the
of sweat glands of the skin from parotid parasympa-
pieces of stone, mucin, etc. thetics.
l The patency of the duct anterior to the surgical area

should be ensured by passing a probe.

l Sutures are placed at the level of the mucosa. Treatment
l Glycopyrrolate or scopolamine.
Submandibular gland excision l Dermal grafting, fat grafting, sub-SMAS dissection, etc.
l If stone in the submandibular gland is not accessible,

then in such cases submandibular gland excision is done. Q. 2. Describe the sialography of parotid gland in adult.
l This procedure is performed under GA. Or

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Section | I  Topic Wise Solved Questions of Previous Years
What is sialography? Describe its technique. How will
you remove a sialolith from the right Wharton’s duct?
Ans.
Sialography
l Sialography is a specialized radiographic procedure
performed for detection of disorders of the major sali-
vary glands (usually parotid and submandibular glands).
l It involves cannulation and filling with a radiopaque/
contrast agent to make them visible on a radiograph.
l The procedure indicates the changes in the internal
architecture and thus reveals the location and integrity
of salivary glands.
Indications
l Detection of calculi.
l Recurrent swelling of salivary gland.
l Recurrent sialadenitis.
l Pain of unknown cause.
l Dryness of mouth.
l Detection of residual stones.
Contraindications
i. Acute infection of salivary gland.
ii. Patients sensitive to iodine containing compounds.
iii. Calculus present at the entrance of the duct.
Two types of contrast media are available:
i. Water-soluble, and
ii. Fat-soluble.
Water-soluble media: These are principally iodinated benzene
or pyridine derivatives. They have a low viscosity and lower
surface tension and are more miscible with salivary secre-
tions. These characteristics permit filling of the finer ductal
system under low pressure and facilitate prompt drainage.
Fat-soluble media: There are two types present. They are
i. Iodized oil, and ii. Water insoluble organic iodine com-
pounds. Iodized oil compounds are ethiodized poppy (ethiodol)
and iodized poppy seed oil (lipiodol). Ethiodol is a contrast
medium of choice because of its low viscosity and least irrita-
bility than the other oil-based media. It contains 37% iodine
and has high radiographic density, so that it produces a very
clear ductogram and excellent acinar opacification.
Technique
It can be divided into three phases:
I. Preliminary film evaluation—to rule out any obvious
radiopaque pathosis.
II. Injection or filling phase—involves injection of con-
trast material to outline the ductal system.
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137
III. Parenchymal phase (if water-soluble medium is used)
or evacuation phase (if fat-soluble medium is used)
l Evacuation and post-evacuation phase are more help-
ful in the presence of inflammation or an obstruction.
l Delayed or incomplete evacuation may be associated
with process that causes parenchymal destruction
such as autoimmune disorders, chronic infection,
and irradiation.
l The amount of secretion and the functioning capac-
ity of the gland can be determined by observing the
clearance of the contrast media during sialography.
Equipment
i. Polyethylene tubing with a special blunt metallic tip
with side-holes for parotid gland injection. Similar tub-
ing for injection into submandibular gland with an end
terminal hole,
ii. A 5–10 mL syringe,
iii. Lacrimal dilator,
iv. Contrast medium,
v. Lemon slices or artificial lemon extract in a plastic
container.
Procedure
i. Identification of the location of duct orifices: The pa-
rotid duct is located at the base of the papilla in the
buccal mucosa opposite maxillary first and second mo-
lar teeth. The area of the mucosa in the vicinity of the
orifice is dried with a small sponge. The application of
gentle pressure over the area overlying the gland would
lead to expression of saliva, in case the gland has some
degree of function. The submandibular duct orifice is
situated on the summit of a papilla by the side of the
lingual frenulum.
ii. Exploration of the duct with a lacrimal probe: In view
of the tortuous course of the parotid duct, patient’s
cheek must be turned outward prior to the insertion of
the probe into the duct. This eversion of cheek reduces
the chances of penetration of the duct at the sharp an-
gles in its course. In case of the submandibular duct, the
probe should pass through the considerable length of
the floor of the mouth to the level of the posterior bor-
der of mylohyoid muscle, approximately 5 cm. In both
the ducts, the probe should slide easily back and forth,
and also rotate freely without dragging.
Cannulation of Parotid Duct
l The orifice of the parotid duct is located on the buccal
mucosa opposite to the maxillary second molar.
l The duct passes laterally and posteriorly through the
buccinator.
138 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Cannulation is facilitated by pulling the cheek for-
ward, thereby straightening the right angle bend in the
parotid duct.
l Once the duct is cannulated, a syringe is used to inject
the contrast material with gentle pressure.
l The parotid duct system can painlessly accommodate
0.5–0.75 mL of contrast material.
l For the parotid, most common views taken are antero-
posterior, anteroposterior with jaw open, anteroposte-
rior with cheek in blowout position, lateral, or OPG.
Technique
l The orifice of the submandibular duct is smaller and it
opens into a papilla called sublingual caruncle, located
on the floor of the mouth just lateral to the frenulum of
the tongue. It may also open onto the side of the papilla.
l Lemon juice may be required to stimulate the gland and
help in identification of the orifice. The duct opening ap-
pears as a tiny black spot when it opens to deliver saliva.
l Submandibular duct angles posteriorly and downward.
Approximately 1–2 cm below its orifice, the duct be-
comes more horizontal in direction. Accordingly, the
direction of the probe should also be changed.
l The cannula should be advanced fully until the orifice is
obturated. The contrast material is then injected. The
submandibular gland will hold 0.5 mL.
l Once the contrast material is injected, radiographs are
taken.
l Common views for the submandibular gland are lateral
oblique, orthopantomogram (OPG), and occlusal.
Q. 3. Classify tumours of salivary glands and discuss in
detail about pleomorphic adenoma.
Ans.
Tumours of Salivary Gland
Benign
l Pleomorphic adenoma.
l Warthin’s tumour.
l Canalicular adenoma.
l Basal adenoma.
l Oncocytoma.
l Ductal papillomas.
Malignant
l Mucoepidermoid carcinoma.
l Adenoid cystic carcinoma.
l Acinic cell adenocarcinoma.
l Malignant mixed tumours.
l Polmorphous low-grade adenocarcinoma.
l Monomorphic adenocarcinomas.
l Adenocarinoma.
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Pleomorphic Adenoma
l It can affect both the major and minor salivary glands.
It commonly affects the parotid gland. It is believed that
the tumour arises from the myoepithelial cell of the
salivary gland.
l The different tissue types of both epithelial and connec-
tive tissue elements are seen in the tumour giving the
name ‘mixed tumour’.
Clinical Features
l Pleomorphic adenoma most commonly affects the parotid
gland, followed by minor salivary glands of the palate and
lip. It less frequently affects the submandibular gland.
l Majority of the lesions are seen between fourth to sixth
decades.
l More commonly seen in females.
l The tumour starts as a small painless nodule, either at
the angle of the mandible or beneath the ear lobe.
l The nodule slowly increases in size, which may charac-
teristically show intermittent growth.
l The tumour is well circumscribed, encapsulated, firm in
consistency, and may show areas of cystic degeneration.
l The tumour is readily movable without fixity to the
deeper tissues or to the overlying skin. The tumour can
grow to a very large size, but does not ulcerate.
l Tissue destruction, pain, or facial paralysis is not seen.
l The intraoral pleomorphic adenomas which affect the
minor salivary glands of the palate are noticed early,
because of the difficulties in mastication, talking, etc.
The palatal pleomorphic adenoma may show fixity to
the underlying bone, but does not invade the bone.
l Pleomorphic adenoma should be differentiated from
other benign tumours and hyperplastic lymph nodes.
l Though the painless nodular, firm growth with no ulcer-
ation of the overlying skin is suggestive of this tumour,
it can be confirmed by biopsy.
l In case of minor salivary gland lesions, which are
usually not more than 2 cm in diameter, it is better to
perform excisional biopsy.
Differential Diagnosis
i. Warthin’s tumour.
ii. Lipoma.
iii. Hyperplastic lymph nodes.
iv. Neurilemmoma of the facial nerve.
Treatment
l Pleomorphic adenomas are treated by surgical excision.
l The parotid tumours are removed with adequate mar-
gins, whereas the intraoral lesions can be treated little
more conservatively.
l In case of submandibular tumours, excision of the gland
with the tumour is performed.
Section | I  Topic Wise Solved Questions of Previous Years
SHORT ESSAYS
Q. 1. Sialadenitis.
Ans.
Sialadenitis
Sialadenitis is the inflammation of the salivary glands that
can arise from various infectious and non-infectious causes.
Causes
l The most common viral infection is mumps, although a
number of other viruses also can involve the salivary
glands, including coxsackie A virus and ECHO virus.
l Most bacterial infections arise as a result of ductal ob-
struction or decreased salivary flow caused by Staphylo-
coccus aureus, allowing retrograde spread of bacteria
throughout the ductal system. Blockage of the duct can
be caused by sialolithiasis, congenital strictures, or
compression by an adjacent tumour. Decreased flow can
result from dehydration, debilitation, or medications
that inhibit secretions.
l Recent surgery after which an acute parotitis (surgical
mumps) arises may be because, the patient has been
kept without food or fluids, and has received atropine
during the surgical procedure.
l Medications that produce xerostomia as a side effect.
l Non-infectious causes of salivary inflammation include
Sjogren’s syndrome, sarcoidosis, radiation therapy, and
numerous allergens.
Clinical Features
l Most common in the parotid gland and is bilateral in
few cases.
l The affected gland is swollen and painful, and the over-
lying skin may be erythematous in colour.
l An associated low-grade fever may be present along
with trismus.
l A purulent discharge often is observed from the duct
orifice when the gland is massaged.
l Recurrent or persistent ductal obstruction most commonly
caused by sialoliths can lead to a chronic sialadenitis.
l Periodic swelling and pain occur within the affected
gland, usually developing at mealtime when salivary
flow is stimulated.
l Sialography often demonstrates sialectasis (ductal dila-
tation) proximal to the area of obstruction.
l Subacute necrotizing is a form of salivary inflammation
that occurs most commonly in young adults. The lesion
usually involves the minor salivary glands of palate,
presenting as a painful nodule that is covered by intact,
erythematous mucosa. Unlike necrotizing sialometapla-
sia, the lesion does not ulcerate.
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139
Histological Features
l In patients with acute sialadenitis, accumulation of neu-
trophils is observed with the ductal system and acini.
Chronic sialadenitis is characterized by scattered or
patchy infiltration of the salivary parenchyma by lym-
phocytes and plasma cells.
Treatment
l Initial treatment of acute sialadenitis includes appropri-
ate antibiotic therapy and rehydration of the patient to
stimulate salivary flow.
l Surgical drainage may be needed if there is abscess
formation. Mortality rate because of the infection and
sepsis is less.
l Surgical management of chronic sialadenitis depends
on the severity and duration of the condition. Early
cases that develop secondary to ductal blockage
may respond to removal of the sialoliths or other
obstruction.
l If sialectasia is present, dilated ducts can lead to stasis
of secretions and predispose the gland to further sialo-
lith formation.
l If sufficient inflammatory destruction of the salivary tis-
sue has occurred, then surgical removal of the affected
gland may be necessary.
l Subacute necrotizing sialadenitis is a self-limiting con-
dition that usually resolves within two weeks even
without treatment.
Q. 2. Salivary fistula.
Ans.
Salivary Fistula
l Salivary fistula can be defined as escape of saliva or pus
through the opening. It occurs either in the duct or gland
itself.
l These fistulas commonly occur in parotid gland. The
cause for fistula is commonly due to:
i. Traumatic injury.
ii. During surgery in the area of gland or duct.
iii. Infections of gland or duct and subsequent break
down of abscess.
iv. Can also occur at the site of incision.
Clinical Features
i. Leaking of saliva and pus through the fistula.
ii. No signs of saliva passing through the natural orifice
of the duct.
iii. Patient complains of dry mouth.
140 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Treatment
I. Non-surgical
l Conservatively fistulas can be managed by controlling
infections with antibiotics.
l Arresting the flow of saliva by administration of atro-
pine in divided repeated doses allows fistula to heal by
itself.
l X-ray irradiation was also tried which can lead to
atrophy of the gland leading to spontaneous healing of
the fistula.
II. Surgical
l Includes excision of the orifice of the fistula and fistu-
lous tract is completely dissected out. One or two su-
tures may be given in the subcutaneous tissue. The skin
incision is closed with sutures.
l Fistulas were also treated with ligation of the duct distal
to the opening, thus arresting free flow of saliva through
the fistulous tract.
III. Transplantation
l This can be done by locating the duct from the fistulous
area after surgical exploration.
l The duct is neatly freed by sharp and blunt instrument
and all the strictures and fibrous tissue are dissected eating, interspersed with periods of remission.
out. Then, a small polythene tube is inserted, which is
biologically viable to the tissues and to the distal part
of the duct.
l This is tried with nylon atraumatic sutures and the
wound is closed with interrupted sutures. The end of
the polythene tube is drawn into the oral cavity through
the mucous membrane and is retained with sutures.
l This allows the salivary flow in the oral cavity through
an artificial outlet. After 3–4 weeks, tube may be re-
moved so that saliva passes through the tissue passages
which were created by polythene tube. Suitable diet
may be prescribed which will not displace the tube.
Q. 3. Sialolith.
Or
Investigations in salivary calculus.
Or
Submandibular salivary calculi and its management.
Or
Surgical removal of salivary stone from submandibular
duct.
Or
Sialolithiasis and management.
Ans.
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Sialolith
l The sialolith is a calcified mass with laminated layers
of the inorganic material. It results from the crystalliza-
tion of salivary solutes.
l The sialolith is yellowish white in colour; single or mul-
tiple; may be round, ovoid, or elongated having the size
of 2 cm or more in diameter. The minerals are forms of
calcium phosphate like hydroxyapatite, octacalcium
phosphate, etc. Calcium and phosphorus ions are depos-
ited on the organic nidus, which may be desquamated
epithelial cell, bacteria, foreign particle, or product of
bacterial decomposition.
l Sialolith frequently occurs on the Wharton’s duct due to
the following reasons:
i. The long, curved Wharton’s duct has increased
chance of entrapment of organic debris.
ii. The secretion of this gland is higher in calcium con-
tent and thick in consistency.
iii. The position of the gland increases the chances for
the stagnation of the saliva.
Signs and Symptoms
l Patients complain of periodic painful swelling when
l Spontaneous extrusion of small calculi from the ducts.
l Point tenderness in the region of the hilum or near
Wharton’s duct of the submandibular gland.
l Salivary secretion may be affected only slightly.
l A gelatinous, cloudy mucopurulent material is seen in
basically clear and adequate saliva. This mucopuru-
lent material is derived from the inflammatory ductal
changes caused by calculus blockage and salivary
stagnation.
l If treatment not instituted early, pronounced exacerba-
tions are seen, characterized by an acute suppurative
process with attendant systemic manifestations.
l Pus may exude from the duct orifice.
l The mucosa around the duct is inflamed, particularly
in the floor of the mouth where swelling, redness,
and tenderness are present along the course of
Wharton’s duct.
l The glands are enlarged, tender, and dense.
l Palpation of the gland and the duct causes pain and
flow of pus.
Diagnosis
Radiographs: AP view, lateral, lateral oblique, or occlusal
view.
Sialography: The radiographs demonstrate the presence
of salivary calculi, which can be appropriately located by
the sialography.
Section | I  Topic Wise Solved Questions of Previous Years 141

5 . Radionuclide imaging, and

Management
6. Magnetic resonance imaging (MRI).
l A suitable procedure is selected depending upon the
The abnormalities which can be evaluated by diagnostic
number, size, and site of the stone in the duct; or, the
imaging can be divided into:
gland and age of the patient, etc.
i. Developmental,
l The smaller sialoliths which are located peripherally
ii. Inflammatory,
near the ductal opening may be removed by manipula-
iii. Autoimmune,
tion (called milking the gland).
iv. Metabolic,
l Larger sialoliths are surgically removed.
v. Traumatic, and
l Sometimes, the stones which are not impacted may be
vi. Neoplastic
extracted through the intubation of the duct with fine soft
plastic catheter and application of the suction to the tube.
l Multiple stones or stones in the gland require the Conventional Radiography
removal of the gland.
l It is useful in detecting the calcification within the
l Modern techniques like piezoelectric shockwave litho-
glands to know the presence of metastasis to the salivary
tripsy to fragment the salivary stones can be used.
glands. But radiographs are not useful to know the
l The fragments pass through the duct, as the salivary flow
extent of rapid, destructive, invasive lesions, because
is stimulated and enhanced by the use of sialogogues.
the changes can appear in the radiographs only after
Q. 4. Classify salivary gland tumours and how do you 30% of the mineral content is removed.
investigate them? l The posteroanterior, lateral, lateral oblique, and frontal

views may be used for the radiography of the salivary

Ans.
glands.

Tumours of Salivary Gland Sialography

Benign l The technique is employed for examination of both
l Pleomorphic adenoma. parenchymal (acinar) and ductal abnormalities.
l Warthin’s tumour. l It involves cannulation and filling with a radiopaque/

l Canalicular adenoma. contrast agent to make them visible on a radiograph.

l Basal adenoma. l The procedure indicates the changes in the internal

l Oncocytoma. architecture and thus reveals the location and integrity

l Ductal papillomas. of salivary glands.

Malignant Radionuclide Salivary Imaging

l Mucoepidermoid carcinoma. l Radionuclide scanning is a valuable diagnostic tool for
l Adenoid cystic carcinoma. major salivary glands. It is useful for evaluation of
l Acinic cell adenocarcinoma. physiology as well as pathology.
l It is particularly indicated in patients with suspected
l Malignant mixed tumours.
l Polmorphous low-grade adenocarcinoma. obstructive sialadenitis, in whom, the contrast sialogra-
l Monomorphic adenocarcinomas. phy is either contraindicated or cannot be performed
l Adenocarinoma. due to anatomical or technical reasons.
l Radionuclide scans differentiate between acute ob-
Methods of investigating salivary gland tumours are as follows: structive and non-obstructive sialadenitis. It shows the
presence of parenchymal masses greater than 1 cm in
Diagnostic Imaging diameter and identifies specific types of tumour.

Diagnostic imaging plays an important role in the evalua-

CT and MRI
tion of various disorders of major salivary glands. The
modalities used for imaging include: Computerized tomography (CT) and magnetic resonance
1. Conventional radiography, imaging (MRI) studies provide excellent soft tissue details.
2. Sialography, They show: (i) Lesions and also (ii) Involvement of the
3. Ultrasonography, adjacent structures. MRI is especially helpful in showing
4. Computerized tomography, early extension along various neurovascular pathways.

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142 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Ultrasound Evaluation
The submandibular gland and larger portion of parotid
gland, because of their superficial location, can be readily
examined with high resolution ultrasound. Ultrasound:
(i) Differentiates between intraglandular and extraglandular
masses, (ii) Demonstrates the presence of solid, cystic, and
complex masses; and, sialoliths.
Q. 5. Ranula.
Ans.
Ranula
l Ranula is a term used for retention cysts of salivary
gland origin, occurring in the floor of the mouth. The
name is due to its resemblance to a frog’s translucent
underbelly.
l Formation of ranula occurs by two mechanisms, namely,
partial obstruction of the distal end of the duct with swelling ranging from one to several centimetres in size.
dilation resulting is an epithelial lined cyst (mucous l They are most common in children and young adults.
retention cyst) or disruption of the duct with formation
of a connective tissue line space (mucous extravasation
or pseudocyst).
l The source of the cystic fluid is believed to be the sub-
lingual glands in the most common form of ranula.
Clinical Features
l Two varieties of cysts are seen (simple ranula and
plunging ranula) that have different clinical behaviours
and appearance and that require different methods of
treatment. Simple ranulas are true retention cysts.
l An unusual clinical variant, the plunging or cervical
ranula is a cyst that occurs beyond the mucous mem-
branes of the oral cavity into the floor of the mouth,
through a hiatus of the mylohyoid muscle, and into the
facial planes of the neck. This occurs when the spilled
mucin dissects through the mylohyoid muscle and pro-
duces swelling within the neck.
l Ranula appears as a blue, dome-shaped fluctuant swell-
ing in the floor of the mouth. They are usually painless
and unilateral with increasing size. They can cause examination to confirm the diagnosis and rule out the
deviation of the tongue and can cross the midline sub-
mucosally at times, and they may rupture spontane-
ously with extrusion of a thick, translucent fluid into
the mouth. The wall then rapidly heals and the cyst
subsequently reforms.
Treatment
l Ranulas do not regress spontaneously and require defini-
tive surgical therapy. Marsupialization is the treatment of
choice. If recurrence is seen, exclusion in continuity with
the sublingual gland of origin is done.
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l Marsupialization involves excision of the superior
wall of the lesion and suturing of the inner wall to the
mucosa of the floor of the mouth.
Q. 6. Mucocoele.
Ans.
Mucocoele (Mucous Extravasation
Phenomenon or Mucous Escape Reaction)
l Mucocoele results from rupture of a salivary gland duct
and subsequent spillage of mucin into the surrounding
soft tissues. This spillage is due to local trauma in many
cases. Mucocoeles are not true cysts, because they lack
an epithelial lining.
Clinical Features
l Mucocoele typically appears as dome-shaped mucosal
l The spilled mucin below the mucosal surface often im-
parts a bluish translucent hue to the swelling. However,
deeper mucocoeles may be normal in colour.
l The lesion characteristically is fluctuant, but some long-
standing mucocoeles feel firmer to palpation.
l Lower lip is the most common site for the mucocoeles.
Mucocoeles usually are found lateral to the midline.
Less common sites include the buccal mucosa and ante-
rior ventral tongue, and are known as ranula when oc-
curring in the floor of mouth.
Treatment
l Some mucocoeles are short-lived lesions that rupture
and heal by themselves.
l Many lesions, however, are chronic in nature, and local
surgical excisions are necessary.
l To minimize the risk of recurrence when the area is
excised, adjacent minor salivary glands should be re-
moved as it may be feeding into the lesion.
l The excised tissue should be submitted for microscopic
possibility of a salivary gland tumour.
l The prognosis is excellent, although occasional muco-
coeles will recur, prompting re-excision, especially if
the feeding glands are not removed.
Q. 7. Adenocarcinoma of minor salivary gland in palate.
Ans.
Adenoid Cystic Carcinoma (ACC)
l Adenoid cystic carcinoma is a clinically and pathologi-
cally well defined entity and occurs primarily in the
Section | I  Topic Wise Solved Questions of Previous Years
major salivary glands and relatively frequently in the
oral accessory salivary glands, particularly the palate.
Clinical Features
l Occur in older individuals. Show equal sex predilection.
l Slow-growing tumour.
l Pain and tenderness occur during tumour growth.
l Fixation to skin and surrounding structures develop in
later stages.
l Cause paralysis of facial nerve.
l In minor salivary glands, it presents as a swelling or
mass.
l Symptoms of facial pain and swelling characterize the
ACC of maxillary antrum.
l Radiograph is necessary for assessing the extent of
osseous destruction.
l In minor SG, palate is most common followed by
tongue, cheek, upper lip, floor of mouth, oropharynx,
and lower lip.
l In the tongue, it is the third most common tumour
following squamous cell carcinoma (SCC).
Investigations
1. FNAC
l Aspiration biopsies consist of round or ovoid baso-
philic cells arranged in branching structures.
l Amorphous, hyaline globoid structures with tumour
cells are characteristic features of ACC.
2. Immunohistochemistry
l It reveals the presence of two cell population:
i. Ductal cells, and
ii. Myoepithelial cells.
Differential Diagnosis
l Polmorphous low-grade adenocarcinoma.
l Salivary duct carcinoma.
l Pleomorphic adenoma.
Treatment and Prognosis
l Surgical excision is the treatment of choice.
l As it is very much prone to local recurrence, eventual
distant metastasis adjunct radiotherapy will improve
patient survival.
Q. 8. Mumps.
Ans.
Mumps
l Mumps is the most common non-suppurative, acute si-
aladenitis of viral origin. It is a contagious, generalized
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143
disease that presents as a painful enlargement of the
salivary glands.
l The virus of mumps causes an acute febrile illness with
prodromal period of 2–3 weeks.
Clinical Features
l Mumps primarily infects young adults and classically
6–8 years of age.
l Mumps virus has an incubation period of 2–3 weeks and
is transmitted by contact or in droplets of saliva.
l The onset is sudden fever, headache, and painful swell-
ing of the parotids.
l Usually one gland is infected first and then the other. In
some cases there is bilateral involvement.
l Swelling occurs rapidly, reaches a maximum size within
1–3 days.
l Trismus may be present, with some difficulty in chewing.
l Stensen’s duct orifice is swollen and erythematous, but
there is no purulent material in the saliva. The symp-
toms subside in 3–7 days.
Investigations
Diagnosis is usually made on a clinical basis during epi-
demics. Serum antibodies to the mumps S and V antigens
with a titre of greater than 1:192, indicates infection.
Complications
l Parotid gland sialectasia with recurrent chronic and
acute suppuration.
l Complications of mumps result from generalized virae-
mia and include pancreatitis, architis, mumps, and men-
ingitis (meningoencephalits).
l Other sequelae include sensory neural hearing loss (fre-
quently unilateral), diabetes secondary to pancreatic fi-
brosis, and sterility secondary to gonadal involvement.
The condition resolves spontaneously in 5–10 days.
Symptomatic relief of pain and fever is necessary and
prevention of dehydration is essential.
Q. 9. Pleomorphic adenoma.
Or
Mixed tumour of parotid gland.
Ans.
Pleomorphic Adenoma
l Pleomorphic adenoma can affect both the major and
minor salivary glands.
l It commonly affects the parotid gland. It is believed that
the tumour arises from the myoepithelial cell of the
salivary gland.
144 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The different tissue types of both epithelial and connec-
tive tissue elements are seen in the tumour giving the
name ‘mixed tumour’.
Clinical Features
l Pleomorphic adenoma most commonly affects the
parotid gland, followed by minor salivary glands of it is not a hereditary disease, there is evidence of a
the palate and lip. It less frequently affects the subman-
dibular gland.
l Majority of the lesions are seen between fourth to sixth
decades.
l It is more commonly seen in females.
l The tumour starts as a small painless nodule, either at
the angle of the mandible or beneath the ear lobe.
l The nodule slowly increases in size, which may charac-
teristically show intermittent growth.
l The tumour is well circumscribed, encapsulated, firm in
consistency, and may show areas of cystic degeneration.
l The tumour is readily movable without fixity to the
deeper tissues or to the overlying skin. The tumour can
grow to a very large size, but does not ulcerate.
l Tissue destruction, pain, or facial paralysis is not seen.
l The intraoral pleomorphic adenomas which affect the
minor salivary glands of the palate are noticed early,
because of the difficulties in mastication, talking, etc.
The palatal pleomorphic adenoma may show fixity to
the underlying bone, but does not invade the bone.
l Pleomorphic adenoma should be differentiated from
other benign tumours and hyperplastic lymph nodes.
l Though the painless nodular, firm growth with no ulcer-
ation of the overlying skin is suggestive of this tumour,
it can be confirmed by biopsy.
l In case of minor salivary gland lesions which are
usually not more than 2 cm in diameter, it is better to
perform excisional biopsy.
Treatment
l Pleomorphic adenomas are treated by surgical excision.
l The parotid tumours are removed with adequate mar-
gins, whereas the intraoral lesions can be treated little
more conservatively.
l In case of submandibular tumours, excision of the gland
with the tumour is performed.
Q. 10. Sjogren’s syndrome.
Ans.
Sjogren’s Syndrome
l Sjogren’s syndrome is a chronic, systemic autoimmune
disorder that principally involves the salivary and lacri-
mal glands, resulting in xerostomia and xerophthalmia.
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l Two forms of the disease are recognized:
i. Primary Sjogren’s syndrome (Sicca syndrome
alone; no other autoimmune disorder is present).
ii. Secondary Sjogren’s syndrome (the patient mani-
fests Sicca syndrome in addition to another associ-
ated autoimmune disease).
l The cause of Sjogren’s syndrome is unknown. Although
genetic influence.
l It has also been suggested that viruses, such as Epstein-
Barr virus (EBV) or human T cell lymphotrophic virus,
may play a pathogenetic role in Sjogren’s syndrome, but
evidence for this is speculative.
Clinical Features
l Predominantly women over 40 years of age are affected.
However, it may occur in men and young adults.
l Parotid gland is more frequently involved.
l Typical features of the disease are the dryness of mouth
and eyes, which often results in painful and burning
sensation.
l Apart from this, various secretory glands of larynx,
pharynx, and vagina are involved with this dryness.
Treatment
l Treatment of the patient with Sjogren’s syndrome is
mostly supportive.
l The dry eyes are best managed by use of artificial tears.
In addition, attempts can be made to conserve the tear
film through the use of sealed glasses to prevent evapora-
tion. Sealing the lacrimal punctum pack in the inner
margin of the eyelids also can be helpful blocking of the
normal drainage of any lacrimal secretions into the nose.
l Artificial saliva is available for the treatment xerostomia.
Sugarless candy or gum can help to keep mouth moist.
l Oral hygiene products that contain lactoperoxidase, lyso-
zyme, and lactoferrin are used. Sialagogue such as pilo-
carpine and cevimeline can be useful to stimulate salivary
flow if enough functional salivary tissue still remains.
l Because of the increased risk of dental caries, daily
fluoride applications may be indicated in dentulous pa-
tients. Antifungal therapy often is needed to treat sec-
ondary candidiasis.
Q. 11. Surgical anatomy of submandibular gland.
Ans.
Submandibular Gland
l Submandibular gland is the second largest of the sali-
vary gland weighing 10–15 g. It contains both serous
and mucous secreting glandular elements.
Section | I  Topic Wise Solved Questions of Previous Years
l This gland lies below and in front of the angle of the
mandible. It is situated in digastric triangle.
l It is J-shaped. The largest portion of the gland lies be-
low the mylohyoid muscle. It extends as far anteriorly
as the anterior belly of digastric and posterior to the
stylomandibular ligament which keeps it separate from
the parotid gland.
l At the posterior border of the mylohyoid muscle, a pro-
cess of the gland curves upwards around the muscle and
extends medially towards the genioglossus muscle to lie
in lateral sublingual space.
l It is divided into superficial and deep parts by mylohyoid.
Superior Part
l Inferiorly covered by skin and platysma.
l Laterally covered by submandibular fossa and medial
pterygoid muscle.
Medial Surface
l Anterior part—mylohyoid muscle, artery, and vein.
l Medial—hyoglossus, styloglossus, and lingual nerve.
l Posterior—styloglossus, stylohyoid ligament, and wall
of pharynx.
Deep Part
l Small.
l Lies deep to mylohyoid and superficial to hyoglossus.
l Posteriorly continuous with superficial part.
l Anteriorly extends up to sublingual gland.
SHORT NOTES
Q. 1. Mumps and its clinical features.
Ans.
Mumps
l Mumps is the most common non-suppurative, acute si-
aladenitis of viral origin.
l It is a contagious, generalized disease that presents as a
painful enlargement of the salivary glands.
Clinical Features
l Primarily infects young adults and classically 6–8 years
of age.
l The onset is sudden fever, headache, and painful swell-
ing of the parotids. Usually, one gland is infected first
and then the other. In some cases, there is bilateral salivary glands.
involvement.
l Swelling occurs rapidly, reaches a maximum size within
1–3 days.
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145
Submandibular Duct
Submandibular duct emerges at anterior end of deep part. It
is 5 cm long and runs forward between the mylohyoid and
hyoglossus muscle, and then on to the genioglossus muscle
opening on floor of mouth on the summit of lingual papilla
at the side of frenulum of tongue.
Blood supply
The arterial supply to the gland is from the lingual and
facial arteries. The venous drainage is the anterior facial
vein.
Nerve supply
The parasympathetic nerve supply is via the chorda tym-
pani nerve, which carries preganglionic fibres to the sub-
mandibular ganglia. Post-ganglionic fibres originate in
this ganglion and pass to the gland. The sympathetic
nerve fibres are carried along the lingual artery to the
gland.
Lymphatic drainage
The lymphatic drainage is into the submaxillary nodes and
then to the jugular chain.
Applied anatomy
The tortuous course of the submandibular duct leads to
stagnation of saliva and thus helps in the formation of sali-
vary stone.
l Trismus may be present, with some difficulty in chewing.
l Stensen’s duct orifice is swollen and erythematous.
l The symptoms subside in 3–7 days.
Q. 2. Sialogram.
Ans.
Sialogram
l Sialography is a specialized radiographic procedure
performed for detection of disorders of the major
salivary glands (usually parotid and submandibular
glands).
l It involves cannulation and filling with a radiopaque/
contrast agent to make them visible on a radiograph.
l The procedure indicates the changes in the internal ar-
chitecture, and thus reveals the location and integrity of
l The radiograph that is used to detect this type of disor-
ders is called a sialogram.
146 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Q. 3. Indications of sialography.
Ans.
Indications of Sialography
l Detection of calculi.
l Recurrent swelling of salivary gland.
l Recurrent sialadenitis.
l Pain of unknown cause.
l Dryness of mouth.
l Detection of residual stones.
Q. 4. Sialolithiasis.
Or
Sialolith.
Ans.
Sialolith
l The sialolith is a calcified mass with laminated layers of
the inorganic material. It results from the crystallization
of salivary solutes.
l The sialolith is yellowish white in colour; single or mul-
tiple; may be round, ovoid, or elongated having the size
of 2 cm or more in diameter. The minerals are forms of
calcium phosphate like hydroxyapatite, octacalcium
phosphate, etc. Calcium and phosphorus ions are depos-
ited on the organic nidus, which may be desquamated
epithelial cell, bacteria, foreign particle, or product of
bacterial decomposition.
l Sialolith frequently occurs on the Wharton’s duct.
Q. 5. Sjogren’s syndrome.
Ans.
Sjogren’s Syndrome
Sjogren’s syndrome is a chronic, systemic autoimmune
disorder that principally involves the salivary and lacrimal
glands, resulting in xerostomia and xerophthalmia.
Two forms are recognized:
i. Primary Sjogren’s syndrome (Sicca syndrome alone; no
other autoimmune disorder is present).
ii. Secondary Sjogren’s syndrome (the patient manifests
Sicca syndrome in addition to another associated auto-
immune disease).
Q. 6. What is Wharton’s duct? What is Bartholin’s duct?
Ans.
Submandibular Duct (Wharton’s Duct)
Submandibular duct emerges at anterior end of deep part. It
is 5 cm long and runs forward between the mylohyoid and
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hyoglossus muscle, and then on to the genioglossus muscle
opening on floor of mouth on the summit of lingual papilla
at the side of frenulum of tongue.
Sublingual Gland Duct (Bartholin’s Duct)
There are around 20 small sublingual ducts known as ducts
of Ravinus opening into floor of mouth. Main duct known
as Bartholin’s duct opens into submandibular duct.
Q. 7. Pleomorphic adenoma.
Ans.
Pleomorphic Adenoma
l It can affect both the major and minor salivary glands.
It commonly affects the parotid gland.
l It is believed that the tumour arises from the myoepithe-
lial cell of the salivary gland.
l The different tissue types of both epithelial and connec-
tive tissue elements are seen in the tumour giving the
name ‘mixed tumour’.
Q. 8. Ranula.
Ans.
Ranula
l Ranula is a term used for retention cysts of salivary
gland origin occurring in the floor of the mouth. The
name is due to its resemblance to a frog’s translucent
underbelly.
l Formation of ranula occurs by two mechanisms, namely,
partial obstruction of the distal end of the duct with dila-
tion resulting is an epithelial lined cyst (mucous reten-
tion cyst) or disruption of the duct with formation of a
connective tissue line space (mucous extravasation or
pseudocyst).
l The source of the cystic fluid is believed to be the sub-
lingual glands in the most common form of ranula.
Q. 9. Mucocoele.
Ans.
Mucocoele (Mucous Extravasation
Phenomenon)
l Mucocoele results from rupture of a salivary gland duct
and subsequent spillage of mucin into the surrounding
soft tissues.
l This spillage is due to local trauma in many cases.
l Mucocoeles are not true cysts, because they lack an
epithelial lining.
Section | I  Topic Wise Solved Questions of Previous Years
Diseases of Maxillary Sinus
LONG ESSAYS
Q. 1. Discuss the surgical anatomy, clinical features, and
management of root in the maxillary sinus.
Or
What are the causes of fracture of tooth during extrac-
tion? How do you manage a case of root pushed in max-
illary antrum?
Or
What are the causes for pushing a tooth or a root into a
sinus? How do you diagnose to treat such cases?
Or
Removal of fractured root from the maxillary sinus.
Ans.
Anatomy of the Maxillary Antrum
l Maxillary antrum or sinus is also called as the Antrum
of Highmore as it was described in detail by an English
anatomist Nathaniel Highmore.
l It is the largest of the paranasal sinuses.
Structure of Maxillary Antrum
l The antrum is roughly pyramidal in shape.
l Base of the pyramid is formed by the lateral nasal wall.
l Apex is pointing laterally at the zygomatic process.
l Roof of the antrum: The floor of the orbit forms the roof
of the antrum.
l Floor of the sinus:Alveolar process of the maxilla forms
the floor of the sinus.
l It is closely related to the root apices of the maxillary
premolars and molars. Some of the roots may even pen-
etrate into the antrum.
l Anterior wall: Formed by the facial surface of the
maxilla.
l Posterior wall: Sphenomaxillary wall.
l Medial wall: Lateral wall of the nasal cavity.
Causes of Tooth Displacement into Maxillary
Sinus
l Lack of bone that can be because of pneumatization or
erosion of bone due to apical pathology.
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147
Topic 13
l Indiscrimination and aggressive instrumentation.
l Maxillary molars—solitary and isolated.
l Shape of root.
Diagnosis
l Head-shaking test.
l Radiographs—IOPA, oblique occlusal view, PNS view,
and lateral sinus view.
Treatment
l Nozzle connected to powerful suction kept at fistulous
opening—root can be removed.
l Long roller gauze packed into antrum through tooth
socket and withdrawn in a jerky motion.
l Roots are likely to come out along with gauze, if lying
in antrum.
Oroantral communication can be divided into:
A. Recently created communication.
B. Treatment of delayed cases.
A. Recently Created Communication
l Attempted extraction of maxillary molar root, which
disappears as soon as force is applied with an eleva-
tor. It also denotes its inadvertent displacement
into maxillary sinus and the presence of coexistent
communication.
l Attempted extraction of a partially erupted upper
third molar. The root(s) of such a tooth are adjacent
to maxillary sinus, and the application of extrac-
tion force results in its displacement into maxillary
sinus. This is more likely to occur if the roots of
the partially erupted third molar are conical.
Confirmation of the Presence of Oroantral
Communication/fistula
l If the fistula is large, it can be assessed from inspection;
in case, if its patency is not obvious, the nose blowing
test is useful.
l Compression of anterior nares followed by gentle blow-
ing of nose (with mouth open) causes a rise in intranasal
pressure exhibited by the whistling sound, as air passes
down the open passage.
148 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Escape of air bubbles, blood, etc., may appear at the oral
orifice.
l A wisp of cotton wool held just below the alveolar
opening will usually be deflected by the air stream.
Management
A. Treatment of early cases
In cases where oroantral communication is recent and The orifice in the socket is covered with a piece of
formation of fistula is notestablished, then the treatment is
as follows:
1. Ideal treatment
i. Immediate surgical repair to achieve primary closure,
and
ii. Simultaneous antibiotic prophylaxis to prevent si-
nus infection.
The immediate primary closure
l Is done by a simple reduction of the buccal and the
palatal socket walls, to allow coaptation of buccal and
palatal soft tissue flaps to close over the defect.
l A protective acrylic denture or splint can be used to pro-
vide a barrier to the inadvertent entry of food particles.
Supportive measures
i. Antibiotics
Penicillin and its derivatives:
l It can be started with IV route, and later switched over
to oral route. Penicillin V 250–500 mg six hourly is
adequate.
l In case the organisms are resistant to penicillin, a broad-
spectrum antibiotic is prescribed.
ii. Nasal decongestants
i. Ephedrine nasal drops (0.5%) are instilled intranasally
every 2–3 h.
ii. Steam inhalations: When the nose is clear subsequent to
the use of decongestant drops or sprays, steam inhalations
are helpful in encouraging drainage. It also helps in thin-
ning down the mucous, pus, and has a soothing effect.
iii. Benzoin and Menthol inhalations: A teaspoonful is added
to a pint of hot (not boiling) water and the vapours are
inhaled for 10 min twice a day, after covering the head.
iii. Analgesics
Non-steroidal anti-inflammatory agents:
i. Aspirin 500 mg 1–3 tablets four times daily.
ii. Paracetamol 500 mg three times daily.
iii. Ibuprofen 400 mg three times daily.
Provisional or temporary measures which effect satisfac-
tory repair
i. Whitehead’s varnish pack.
ii. Denture plate.
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i. A strip gauze or ribbon gauze dipped in Whitehead’s
varnish is used to pack over the socket and secured with
sutures. Superficially, the pack is further supported by a
horizontal mattress suture.
ii. Denture plate is indicated when surgical repair of fis-
tula is to be deferred. The purpose of the appliance is to
provide a barrier to prevent entry of food particles into
the antrum.
gauze or tulle grass; a well fitting denture plate is con-
structed to entirely cover the opening.
B. Treatment of delayed cases
Treatment of oroantral fistula seen within 24 h of accident
l If the case of oro-antral communication is seen within
24 hours of its occurrence, and if the edges of the
l Wounds are cleaned. They should be closed immedi-
ately. Usual post-operative treatment of antibiotics and
nasal inhalations are prescribed.
l In a situation where it is not complicated by displace-
ment of a tooth or a root into the antrum, it can be closed
by buccal flap sutured under local anaesthesia.
Treatment of cases seen more than 24 h of accident
l When a period of 24 h has elapsed, the tissue margins
of fistula often get infected.
l It is preferred to defer the surgical closure, until gingival
edges sound healing, i.e., approximately three weeks.
l As a prophylactic measure, antibiotics, analgesics, and
decongestants should be prescribed.
Treatment of oroantral fistula of long duration (more than
one month)
l In these cases, the fistulous tract is usually epithelialzed.
Surgical closure is also required.
Management of Tooth or Fractured Root
Pushed in to the Maxillary Sinus
Caldwell-Luc Operation
Caldwell-Luc operation is defined as a method of gaining
entry into maxillary sinus via canine fossa with nasal
antrostomy.
Indications
l Open procedure for removal of root fragment or foreign
body or an antrolith (stone) from the maxillary sinus.
l To treat chronic maxillary sinusitis with hyperplasial
lining and polypoid degeneration of the mucosa.
l Removal of cysts or benign growths from the maxillary sinus.
l Management of haematoma in the maxillary sinus and
to control post-traumatic haemorrhage in the sinus.
l Zygomaticomaxillary complex fractures involving floor
of the orbit and anterior wall of the maxillary sinus.
Section | I  Topic Wise Solved Questions of Previous Years
l Removal of impacted canine or impacted third molar.
l Along with closure of chronic oroantral fislula associ-
ated with chronic maxillary sinusitis.
Surgical procedure
l The surgical procedure can be performed under LA with
sedation or under GA, which is the preferred method.
l A semilunar incision is made in the buccal vestibule
from canine to second molar area just above the gingival
attachment.
l A mucoperiosteal flap is elevated with the help of peri-
osteal elevator till the infraorbital ridge. Care is taken to
prevent injury to infraorbital nerve.
l An opening or window is created in the anterior wall of
the maxillary sinus with the help of chisels, gouges, or
dental drills.
l The opening is enlarged carefully in all directions with
Rongeur forceps, to permit the inspection of the sinus cavity.
l The size obtained should be about the size of the index
finger. This is to facilitate the palpation of the sinus lining
with the introduction of index finger into the sinus cavity.
l The opening or window created should be well away
from the apices of the roots of the maxillary teeth.
l Pus should be sucked away from the sinus and a thor-
ough irrigation of the maxillary sinus is carried out with
copious saline wash.
l Inspection of the maxillary sinus is done and removal of
root, tooth gauze, cotton or stone or bone wax, etc., can
be done at this stage.
l The thickened, infected lining of the maxillary sinus can
be elevated with Howarth’s periosteal elevator and re-
moved and sent for histopathological examination.
l If there is profuse bleeding, then the sinus can be
packed with ribbon gauze soaked in adrenaline 1:1000
for 1 or 2 min.
l The antral cavity again is irrigated and can be packed
with iodoform ribbon gauze. The end of the same can be
removed through the nasal antrostomy or through the
small incision in the buccal vestibule.
l The incision is closed with 3-0 silk.
Post-operative management
l Antibiotics, analgesics, and anti-inflammatory drugs
for 5 days.
l Pack removal on the fifth day. Tincture of benzoin inha-
lation three times a day, followed by nasal drops.
l Patient is instructed not to blow the nose, have soft diet,
and no vigorous gargling.
Intranasal Antrostomy
l It is performed to facilitate the drainage at the conclu-
sion of an operation performed: i. To close an oroantral
fistula, or ii. To remove a tooth or a root from sinus.
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149
Surgical Procedure for Intranasal Antrostomy
l A small-sized osteotome or gouge is pushed through
the inferior meatus in the nasal cavity into the maxil-
lary sinus.
l Then a big curved artery forceps is passed through this
opening and an iodoform impregnated ribbon gauze
pack’s end is grasped into its beak and pulled out into
the nostril.
l Here a single knot, which is put in the ribbon gauze, will
help to keep it secured in the nostril.
l The other end of the ribbon gauze is then used to sys-
tematically pack the maxillary sinus cavity in multiple
folds, after achieving proper haemostasis (after
Caldwell-Luc operation).
l An antrostomy can be performed by removing approxi-
mately 1 cm of the medial wall of the antrum, which bulges
into the sinus below the level of the inferior turbinate.
l This antrostomy should be extended to the level of the
floor of the nose.
The nasal mucosa is then incised from the antral surface on
three sides and the nasal mucosal flap thus created is
reflected into the antrum.
Q. 2. Write about the embryology and surgical anatomy
of maxillary sinus anddescribe the causes, signs and
symptoms of oroantral fistula. Give the treatment for
closure of chronic oroantral fistula.
Ans.
Embryology/Development of Maxillary Sinus
l It is the first among the paranasal sinuses to develop.
It starts as a shallow groove on the medial surface of the
maxilla during the fourth month ofintrauterine life.
l At birth, it is a small cavity which is usually fluid-filled.
l Growth is usually biphasic with growth occurring dur-
ing the age of 0–3 years and again between 7–8 years.
l It attains its maximum size at adulthood at around
18 years of age.
l During the later phase, pneumatisation proceeds more
inferiorly as the permanent teeth develop completely.
Anatomy of the Maxillary Antrum
l Maxillary antrum or sinus is also called sinus maxillaris.
l It is called the antrum of Highmore as it was described
in detail by an English anatomist Nathaniel Highmore.
l It is the largest of the paranasal sinuses.
Structure of Maxillary Antrum
l The antrum is roughly pyramidal in shape.
l Base of the pyramidal is formed by the lateral nasal wall.
150 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Apex is pointing laterally at the zygomatic process.
Capacity of the maxillary antrum is around 15 mL.
l Dimensions are:
l Height 3.5 cm and width 2.5 cm.
l Anteroposterior depth is 3.2 cm on an average.
Roof of the antrum
l The floor of the orbit forms the roof of the antrum.
l It is the thin plate of the orbital process of the maxilla.
l It lodges the infraorbital canal and groove, which lodges
the infraorbital nerve.
Floor of the sinus
l Alveolar process of the maxilla forms the floor of the
sinus.
l Its level is lower than the level of the floor of the
nose.
l It is closely related to the root apices of the maxillary
premolars and molars (some of the roots may even pen-
etrate into the antrum).
Anterior wall
l Formed by the facial surface of the maxilla.
l The canine fossa is an important structure on this wall.
l The infraorbital foramen located in the mid-superior
portion is present on this wall and the infraorbital nerve
exits from the foramen.
l The thinnest portion of the anterior wall is just above
the canine tooth called the canine fossa.
Posterior wall
l Sphenomaxillary wall.
l A thin plate of bone separates the antral cavity from the
infratemporal fossa.
Medial wall
l Lateral wall of the nasal cavity.
l The opening of the maxillary antrum or the ostium lies
in the middle meatus at the lower part of the hiatus
semilunaris.
l The opening of the sinus is closer to the roof and is at a
higher level than the floor. Therefore the location of this
opening requires that there be a good drainage with the
individual in upright position.
Antral lining
l The sinus is lined by respiratory mucosa, which is
formed by ciliated columnar epithelium. The ciliary
movements help in removal of mucous secretions to-
wards the ostium.
Arterial supply
l Facial artery, infraorbital artery, and greater palatine
artery.
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Nerve supply
l Infraorbital nerve; anterior, middle, and posterior supe-
rior alveolar nerves.
Venous drainage
l Facial vein which then drains into pterygoid venous
plexus.
Lymphatic drainage
l Submandibular lymph nodes and then to deep cervical
lymph nodes.
Oroantral Fistula
l An oroantral perforation is an unnatural communication
between the oral cavity and maxillary sinus.
l An oroantral fistula is an epithelialzed, pathological,
and unnatural communication between these two
cavities.
Aetiology
Oroantral fistula can result from several causes:
l Extraction of teeth.
l Destruction of the portion of the floor of the sinus by
periapical lesions.
l Perforation of the floor of the sinus and sinus membrane
with injudicious use of instruments.
l Forcing a tooth or a root into the sinus during attempted
removal.
l Extensive trauma to face.
l Surgery of maxillary sinus: Removal of large cystic
lesions encroaching on the sinus cavity.
l Chronic infection of maxillary sinus, such as osteo-
myelitis.
l Teratomatous destruction of maxilla, such as gumma
involving palate.
l Infected maxillary implant dentures, and malignant
diseases such as malignant granuloma.
A. Fresh Oroantral Communication
Symptoms
Remember 5 Es.
i. Escape of fluids from mouth to nose on extraction.
This happens when the patient gargles the mouth fol-
lowing extraction.
ii. Epistaxis (unilateral): It is due to blood in the sinus
escaping through ostium into the nostril.
It may or may not be associated with frothing at the
nostril on the affected side.
iii. Escape of air from mouth into nose, on sucking, inhal-
ing or drawing on a cigarette, or puffing the cheeks
Section | I  Topic Wise Solved Questions of Previous Years
(inability to blow cheeks and passage of air into mouth
on sucking).
iv. Enhanced column of air causes alteration in vocal
resonance and subsequently change in the voice.
v. Excruciating pain in and around the region of the
affected sinus, as the local anaesthesia begins to be taken to avoid injury to papillae and duct of parotid
wear off.
In Late Stage Established Oroantral Fistula
Symptoms
Remember 5 Ps.
i. Pain previously a dominant feature is now negligible,
as the fistula is established. It allows free escape of
fluids.
ii. Persistent, purulent, or mucopurulent foul unilateral
nasal discharge from the affected nostril, especially
when head is lowered down. Unilateral foul or foetid
taste and smell.
iii. Post-nasal drip: The tricking of the nasal discharge
from the posterior nares down the pharynx. The con-
tinuous swallowing of the foul mucopurulent dis-
charge may lead to unpleasant taste. This is accompa-
nied by nocturnal cough, hoarseness, earache, or
catarrhal deafness.
iv. Possible sequelae of general systemic toxaemic condi-
tion—fever, malaise, morninganorexia, frontal and
parietal headaches, and in extreme cases anosmia and
cacosmia.
v. Popping out of an antral polyp: The persistent infec-
tion in the antrum may lead to establishment of
chronic long-standing or antral fistula, which may
be occluded by an antra polyp. This can be seen as a
bluish red lump extruding through the fistula.
Treatment
i. Buccal flap/Von rehrmann’s flap
ii. Palatal flap/Ashley flap
iii. Combination technique.
i. Buccal flap/Von rehrmann’s flap
l Injection of LA in the mucobuccal fold:
l It reduces local capillary bleeding by vasoconstriction at
the time of operation and reduces the risk of formation
of post-operative haematoma.
l Excision of fistulous tract:
l An incision is made around the fistulous tract 3–4 mm
marginal to the orifice. As the soft tissue aperture of the
communication is almost always smaller than the diam-
eter of bony defect. The entire epithelialzed tract along
with associated antral polyps is dissected out and ex-
cised gum margins are freshened with blade no. 11.
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151
l Incision making:
l Two divergent incisions are taken with blade no. 15,
from each side of orifice into buccal sulcus for a distance
of 2.5 cm. These incisions are made down till the bone.
While extending the incisions towards cheek, care must
salivary gland. Mucoperiosteal flap is reflected carefully.
Inspection of bony margins of the alveolar ridge is done.
Reduction and smoothening of the same is carried out.
l Advancement of buccal flap:
l In situations, where the buccal mucoperiosteal flap falls
short of covering the fistula, the flap can be advanced. A
horizontal incision is made in the periosteum as high as
possible. This will allow advancement of buccal flap.
l Inspection of maxillary sinus: Maxillary sinus should be
carefully inspected for evidence of infection, either
through fistula or by illumination, or with a fiberoptic
light. Any polypoidal masses or other diseased tissues
should be removed. Antrum is gently irrigated with
warm normal saline.
l In case if antral pathology is present, then Caldwell-Luc
procedure should be carried out before the final closure
of fistula.
l Arrest of haemorrhage:
l Complete arrest of haemorrhage to avoid formation of
haematoma.
l Closure of wound:
l The mucoperiosteal flap is sutured into position across
fistula with interrupted sutures.
ii. Palatal flaps
ii. a. Palatal flap (Ashley’s flap)
l Palatal flap is also known as Ashley’s flap.
l Palate gets blood supply from greater palatine arteries,
which emerges from greater palatine foramen.
l Local anaesthesia is administered. The fistulous tract is
excised. The outline of the palatal flap should be marked.
l An incision is made along the mid-palatal line from just
anterior to the junction of hard and soft palate and
curved laterally towards the affected side.
l It then passes back about 4 mm palatal to the crest of the
edentulous ridge or gingival margin of the fistula when
excised.
l The palatal flap should be elevated carefully preserving
the greater palatine artery.
l Buccal vestibular height is unaffected.
l The palatal flap is rotated across fistula, so that the su-
ture line rests on the sound bone on the buccal side of
the orifices.
ii. b. Palatal island flap
l This procedure dissects out an island of palatal mu-
cosa, but it retains its connection to the greater palatine
artery.
152 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Variation in technique are that by dissecting the greater
palatine neurovascular bundle back to the palatal fora-
men, some extension can be provided and the flap can
be transferred as a well nourished full thickness flap to
a palatal or a buccal site.
iii. Combination flap
l Both buccal and palatal flaps are used for closure of
fistulous tract.
l Buccal flap is elevated and reversed, which is sutured
with palatal margins.
l Palatal flap is rotated and placed in usual manner.
l It is sutured using 3-0 chromic catgut.
l In this raw surface, both the flaps are used against each
other which ensure double layered closure.
l An acrylic splint is given to afford protection during
mastication.
The closure of oroantral fistula should be followed by
Caldwell-Luc operation.
Q. 3. Clinical features and management of acute maxil-
lary sinusitis. Add a note on nasal antrostomy.
Ans.
Maxillary Sinusitis
Maxillary sinusitis is inflammation of maxillary sinus due
to various causes.
Signs of Acute Sinusitis
l Tenderness over the maxilla, especially in the infraor-
bital region.
l Mild oedema of cheek in infraorbital soft tissues.
l Rarely, patient gets earache as a referred pain from an-
trum. This is attributed to acute otitis media.
l Percussion of maxillary premolars and molars related to
affected sinus will lead to pain. Examination of nose
with a speculum shows nasal congestion (red, shiny, and
swollen mucous membrane around ostium).
l Presence of pus or mucopurulent discharge in middle
meatus. This comes from sinus, through ostium, and
from over inferior conchae onto floor of nose.
l Oropharynx: Mucopurulent discharge trackling down
posterior wall of pharynx.
Treatment of Early Cases
In cases where oroantral communication is recent and for-
mation of fistula is not established, then the treatment is as
follows:
Ideal treatment
i. Immediate surgery repair to achieve primary closure,
and
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ii. Simultaneous antibiotic prophylaxis to prevent sinus
infection.
Immediate primary closure
l Is done by a simple reduction of the buccal and the
palatal socket walls to allow coaptation of buccal and
palatal soft tissue flaps to close over the defect.
l A protective acrylic denture or splint can be used to pro-
vide a barrier to the inadverent entry of food particles.
Supportive measures
i. Antibiotics
Penicillin and its derivatives:
l It can be started with IV route and later switched
over to oral route. Penicillin V 250–500 mg six
hourly is adequate.
l In case the organisms are resistant to penicillin, a
broad-spectrum antibiotic is prescribed.
ii. Nasal decongestants
l Ephedrine nasal drops (0.5%) are instilled intrana-
sally every 2–3 h.
l Steam inhalations: When the nose is clear subse-
quent to the use of decongestant drops or sprays,
steam inhalations are helpful in encouraging drain-
age. It also helps in thinning down the mucous, pus,
and has a soothing effect.
l Benzoin and Menthol inhalations: A teaspoonful is
added to a pint of hot (not boiling) water and the
vapours are inhaled for 10 min twice a day, after
covering the head.
iii. Analgesics
l Non-steroidal anti-inflammatory agents:
i. Aspirin 500 mg 1–3 tablets four times daily.
ii. Paracetamol 500 mg three times daily,
iii. Ibuprofen 400 mg three times daily.
Provisional or temporary measures which effect satisfac-
tory repair
i. Whitehead’s varnish pack
l A strip gauze or ribbon gauze is used to pack over the
socket and secured with sutures. Superficially, the pack
is further supported by a horizontal mattress suture.
ii. Denture plate
l Denture plate is indicated when surgical repair of
fistula is to be deferred. The purpose of the appliance
is to provide a barrier to prevent entry of food parti-
cles into the antrum. The orifice in the socket is cov-
ered with a piece of gauze or tulle grass. A well fitting
denture plate is constructed to entirely cover the
opening.
Intranasal Antrostomy
l It is performed to facilitate the drainage at the conclu-
sion of an operation performed: i. To close an oroantral
fistula, or ii. To remove a tooth or a root from sinus.
Section | I  Topic Wise Solved Questions of Previous Years 153

Drawbacks l Here a single knot, which is put in the ribbon gauze, will
help to keep it secured in the nostril.
l It cannot drain the sinus satisfactorily, as the point cre-
l The other end of the ribbon gauze is then used to sys-
ated for drainage is not at the point of dependent drain-
tematically pack the maxillary sinus cavity in multiple
age, due to the fact that antral floor is about 1.5 cm be-
folds after achieving proper haemostasis (after Caldwell-
low nasal floor.
Luc operation).
l It also interferes with ciliary pathways. Thus, impedes
l An antrostomy can be performed by removing approxi-
normal physiological drainage of sinus.
mately 1 cm of the medial wall of the antrum, which
bulges into the sinus below the level of the inferior
Surgical Procedure for Intranasal Antrostomy turbinate.
l This antrostomy should be extended to the level of the
l A small-sized osteotome or gouge is pushed through the
floor of the nose.
inferior meatus in the nasal cavity into the maxillary
l The nasal mucosa is then incised from the antral surface
sinus.
on three sides and the nasal mucosal flap thus created is
l Then a big curved artery forceps is passed through this
reflected into the antrum.
opening and an iodoform impregnated ribbon gauze
pack’s end is grasped into its beak and pulled out into
the nostril.

SHORT ESSAYS
Q. 1. Caldwell-Luc procedure. l A mucoperiosteal flap is elevated with the help of peri-
osteal elevator till the infraorbital ridge. Care is taken to
Ans.
prevent injury to infraorbital nerve.
l An opening or window is created in the anterior wall of

Caldwell-Luc Operation the maxillary sinus with the help of chisels, gouges, or
dental drills.
Caldwell-Luc operation is defined as a method of gaining
l The opening is enlarged carefully in all directions with
entry into maxillary sinus via canine fossa with nasal
Rongeur forceps to permit the inspection of the sinus
antrostomy.
cavity.
l The size obtained should be about the size of the index
Indications finger. This is to facilitate the palpation of the sinus
lining with the introduction of index finger into the
l Open procedure for removal of root fragment or
sinus cavity.
foreign body or an antrolith (stone) from the maxil-
l The opening or window created should be well away
lary sinus.
from the apices of the roots of the maxillary teeth.
l To treat chronic maxillary sinusitis with hyperplasial
l Pus should be sucked away from the sinus and a thor-
lining and polypoid degeneration of the mucosa.
ough irrigation of the maxillary sinus is carried out with
l Removal of cysts or benign growths from the maxillary
copious saline wash.
sinus.
l Inspection of the maxillary sinus is done and removal of
l Management of haematoma in the maxillary sinus and
root, tooth gauze, cotton or stone or bone wax, etc., can
to control post-traumatic haemorrhage in the sinus.
be done at this stage.
l Zygomaticomaxillary complex fractures involving floor
l The thickened, infected lining of the maxillary
of the orbit and anterior wall of the maxillary sinus.
sinus can be elevated with Howarth’s periosteal eleva-
l Removal of impacted canine or impacted third molar.
tor and removed and sent for histopathological
l Along with closure of chronic oroantral fislula associ-
examination.
ated with chronic maxillary sinusitis.
l If there is profuse bleeding, then the sinus can be

packed with ribbon gauze soaked in adrenaline 1:1000

Surgical Procedure for 1 or 2 min.
l The antral cavity again is irrigated and can be packed
l The surgical procedure can be performed under LA with
sedation or under GA, which is the preferred method. with iodoform ribbon gauze. The end of the same can be
l A semilunar incision is made in the buccal vestibule
removed through the nasal antrostomy or through the
from canine to second molar area just above the gingival small incision in the buccal vestibule.
l The incision is closed with 3-0 silk.
attachment.

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154 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Post-operative Management
l Antibiotics, analgesics, and anti-inflammatory drugs for
5 days.
l Pack removal on the fifth day. Tincture of benzoin inha-
lation three times a day, followed by nasal drops.
l Patient is instructed not to blow the nose, have soft diet,
and no vigorous gargling.
Q. 2. Clinical features and management of acute maxil-
lary sinusitis.
Ans.
Maxillary Sinusitis
Maxillary sinusitis is inflammation of maxillary sinus due
to various causes.
Signs of Acute Sinusitis
l Tenderness over the maxilla, especially in the infraor-
bital region.
l Mild oedema of cheek in infraorbital soft tissues.
l Rarely, patient gets earache as a referred pain from an-
trum. This is attributed to acute otitis media.
l Percussion of maxillary premolars and molars related to
affected sinus will lead to pain. Examination of nose
with a speculum shows nasal congestion (red, shiny, and
swollen mucous membrane around ostium).
l Presence of pus or mucopurulent discharge in middle
meatus. This comes from sinus, through ostium, and
from over inferior conchae onto floor of nose.
l Oropharynx: Mucopurulent discharge trackling down
posterior wall of pharynx.
Medical Management
i. Antibiotics
Penicillin and its derivatives:
l It can be started with IV route, and later switched over
to oral route. Penicillin V 250–500mg six hourly is ad-
equate.
l In case the organisms are resistant to penicillin, a broad-
spectrum antibiotic is prescribed.
ii. Nasal decongestants
l Ephedrine nasal drops (0.5%) are instilled intranasally
every 2–3 h.
l Steam inhalations: When the nose is clear subsequent to
the use of decongestant drops or sprays, steam inhala-
tions are helpful in encouraging drainage. It also helps in
thinning down the mucous, pus, and has a soothing effect.
l Benzoin and Menthol inhalations: A teaspoonful is
added to a pint of hot (not boiling) water and the l Mixed aerobic and anaerobic organisms.
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vapours are inhaled for 10 min twice a day, after cover-
ing the head.
iii. Analgesics
l Non-steroidal anti-inflammatory agents:
i. Aspirin 500 mg 1–3 tablets 4 times daily.
ii. Paracetamol 500 mg three times daily.
iii. Ibuprofen 400 mg three times daily.
iv. Hot fomentation
l Local heat application is smoothening to inflamed sinus.
Surgical Management
Antral lavage
l This procedure assists in drainage of the sinus.
l It involves inserting a cannula into the maxillary sinus
through inferior meatus.
l Irrigation of sinus with lukewarm water, which drains
out through ostium along with sinusexudate.
Q. 3. Chronic maxillary sinusitis.
Ans.
Chronic Maxillary Sinusitis
l Infection of the sinus that lasts for months or years is
called chronic sinusitis. It most commonly is an extension
of an acute sinusitis, which failed to resolve completely.
Pathophysiology
l After an acute infection, the ciliated epithelium gets
destroyed and prevents drainage of secretions from the
sinus.
l Thus, there is pooling and stagnation of mucopurulent
discharge within the sinus, which further causes prog-
ress of the infective process.
l Further, mucosal changes, ciliary damage, and oedema
follow. Mucosa may become thick and polypoidal.
Clinical Features
l Symptoms are non-specific unlike acute sinusitis. Pa-
tient may not complain of any pain or tenderness.
l Pain may be the only presenting symptom of an acute
exacerbation.
l Purulent nasal discharge.
l Blocking of nose and change in voice due to loss of
resonance.
l Anosmia.
Causative Organisms
Section | I  Topic Wise Solved Questions of Previous Years 155

Investigations Post-operative management

l Water’s view radiograph.
l Thickening of mucosa and opacity of involved sinus.
l Culture of discharge from the sinus.
Management
l Complete workup to identify aetiological factors, which
obstruct the drainage system of the sinus and identifica-
tion of allergic agents.
l Antibiotics, analgesics, and anti-inflammatory drugs for
5 days.
l Pack removal on the fifth day. Tincture of benzoin inha-
lation three times a day, followed by nasal drops.
l Patient is instructed not to blow the nose, have soft diet,
and no vigorous gargling.
Q. 4. Anatomy of maxillary sinus.
Ans.

Medical management Anatomy of the Maxillary Antrum

l Antibiotics, antihistamines, and decongestants.
l Maxillary antrum or sinus is also called sinus maxillaris.
Surgical management l It is called the antrum of Highmore as it was described
l Any dental infection if present is treated.
in detail by an English anatomist Nathaniel Highmore.
l It is the largest of the paranasal sinuses.
l Antral lavage: If more than three successive punctures

have purulent fluid, then the treatment should be more

radical. Structure of Maxillary Antrum
l Intranasal antrostomy: A window or opening is created
l The antrum is roughly pyramidal in shape.
in the inferior meatus to facilitate drainage of the sinus.
l Base of the pyramidal is formed by the lateral nasal wall.
l Caldwell-Luc operation.
l Apex is pointing laterally at the zygomatic process.

Capacity of the maxillary antrum is around 15 mL.

Caldwell-Luc Operation Dimensions are:
l Height 3.5 cm and width 2.5 cm.
l Caldwell-Luc operation is defined as a method of gain-
l Anteroposterior depth is 3.2 cm on an average.
ing entry into maxillary sinus via canine fossa with
nasal antrostomy. Roof of the antrum
Procedure l The floor of the orbit forms the roof of the antrum.

l It is the thin plate of the orbital process of the maxilla.

l The surgical procedure can be performed under LA with
l It lodges the infraorbital canal and groove, which lodges
sedation or under GA, which is the preferred method.
l A semilunar incision is placed in the buccal vestibule
the infraorbital nerve.
from canine to second molar area just above the gingival Floor of the sinus
attachment.
l Alveolar process of the maxilla forms the floor of the sinus.
l A mucoperiosteal flap is reflected.
l Its level is lower than the level of the floor of the nose.
l An opening or window is created in the anterior wall of
l It is closely related to the root apices of the maxillary
the maxillary sinus with the help of chisels, gouges, or
dental drills. premolars and molars (some of the roots may even pen-
l The opening is enlarged carefully in all directions with
etrate into the antrum).
Rongeur forceps to permit the inspection of the sinus Anterior wall
cavity.
l Formed by the facial surface of the maxilla.
l The size obtained should be about the size of the index
l The canine fossa is an important structure on this wall.
finger. This is to facilitate the palpation of the sinus lining
l The infraorbital foramen located in the mid-superior
with the introduction of index finger into the sinus cavity.
l Pus should be sucked away from the sinus and a thor-
portion is present on this wall and the infraorbital nerve
ough irrigation of the maxillary sinus is carried out with exits from the foramen.
l The thinnest portion of the anterior wall is just above
copious saline wash.
l The thickened, infected lining of the maxillary sinus
the canine tooth called the canine fossa.
can be elevated with Howarth’s periosteal elevator and Posterior wall
removed and sent for histopathological examination.
l Sphenomaxillary wall.
l The antral cavity again is irrigated and can be packed
l A thin plate of bone separates the antral cavity from the
with iodoform ribbon gauze.
l The incision is closed with 3-0 silk.
infratemporal fossa.

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156 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Medial wall Arterial supply

l Lateral wall of the nasal cavity. l Facial artery, infraorbital artery, and greater palatine artery.

l The opening of the maxillary antrum or the ostium lies

in the middle meatus at the lower part of the hiatus Nerve supply
semilunaris. l Infraorbital nerve; anterior, middle, and posterior supe-

l The opening of the sinus is closer to the roof and thus at rior alveolar nerves.
a higher level than the floor. Therefore the location of
this opening requires that there be a good drainage with Venous drainage
the individual in upright position. l Facial vein which then drains into pterygoid venous

plexus.
Antral lining
l The sinus is lined by respiratory mucosa, which is Lymphatic drainage
formed by ciliated columnar epithelium. The ciliary l Submandibular lymph nodes and then to deep cervical

movements help in removal of mucous secretions to- lymph nodes.

wards the ostium.

SHORT NOTES
Q. 1. Definition of oroantral fistula. Indications
Or l Open procedure for removal of root fragment, or foreign
body or an antrolith (stone) from the maxillary sinus.
Oroantral fistula. l To treat chronic maxillary sinusitis with hyperplasia .

Ans. l Removal of cysts or benign growths from the maxillary

sinus.
l Management of haematoma in the maxillary sinus and
Oroantral Fistula to control post-traumatic haemorrhage in the sinus.
l An oroantral perforation is an unnatural communication l Zygomaticomaxillary complex fractures involving floor

between the oral cavity and maxillary sinus. of the orbit and anterior wall of the maxillary sinus.
l An oroantral fistula is an epithelialized, pathological, and l Removal of impacted canine or impacted third molar.

unnatural communication between these two cavities. l Along with closure of chronic oroantral fislula associ-

ated with chronic maxillary sinusitis.

Q. 2. Whitehead’s varnish.
Q. 4. Cause of root displacement into maxillary sinus.
Ans.
Ans.

Whitehead’s Varnish Aetiology of Root Displacement

l Benzoin 10 parts 44 g. into Maxillary Sinus
l Storax 7.5 parts 33 g.
i. Lack of bone that can be because of pneumatization or
l Balsam of tolu 5 parts 22 g.
erosion of bone to apical pathology.
l Iodoform 10 parts 44 g.
ii. Indiscrimination and aggressive instrumentation.
l Solvent—ether to 1 fl oz or 100 parts.
iii. Maxillary molar—solitary and isolated.
Q. 3. Define Caldwell-Luc operation. iv. Shape of root.
Or
Diagnosis
Write four indications of Caldwell-Luc operation.
l Head-shaking test.
Ans. l Radiographs—IOPA, oblique occlusal view, PNS view,
and lateral sinus view.
Caldwell-Luc Operation
Treatment
Caldwell-Luc operation is defined as a method of gaining
entry into maxillary sinus via canine fossa with nasal l Nozzle connected to powerful suction kept at fistulous
antrostomy. opening—root can be removed.

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Section | I  Topic Wise Solved Questions of Previous Years
l Long roller gauze packed into antrum through tooth
socket and withdrawn in a jerky motion. Roots are
likely to come out along with gauze, if lying in antrum.
Q. 5. Medical management of acute sinusitis.
Ans.
Medical Management of Acute Sinusitis
i. Antibiotics
Penicillin and its derivatives
l Penicillin V 250–500 mg six hourly is adequate.
l In case the organisms are resistant to penicillin, a
broad-spectrum antibiotic is prescribed.
ii. Nasal decongestants
l Ephedrine nasal drops (0.5%) are instilled intrana-
sally every 2–3 h.
l Steam inhalations: They are helpful in encouraging
drainage.
l Benzoin and Menthol inhalations.
iii. Analgesics
l Non-steroidal anti-inflammatory agents:
i. Aspirin 500 mg 1–3 tablets four times daily.
ii. Paracetamol 500 mg three times daily.
iii. Ibuprofen 400 mg three times daily.
iv. Hot fomentation
l Local heat application is smoothening to inflamed
sinus.
Q. 6. Mucormycosis involving maxillary antrum.
Ans.
Mucormycosis
l It is the fungal infection involving maxillary sinus.
l It is seen in chronic maxillary sinusitis.
l Patients are put on antifungal drugs such as Ampho-
tericin B and Nystatin.
l Oral mouthwash preparation also is available for
nystatin.
l Treatment is done by Caldwell-Luc operation followed
by nasal antrostromy.
Q. 7. Palatal flap closure for oroantral fistula.
Ans.
Palatal Flap Closure for Oroantral Fistula
l Palatal flap is also known as Ashley’s flap.
l Palate gets blood supply from greater palatine arteries,
which emerges from greater palatine foramen.
l Local anaesthesia is administered. The fistulous tract is
excised. The outline of the palatal flap should be
marked.
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157
l An incision is made along the mid-palatal line from just
anterior to the junction of hard and soft palate and
curved laterally towards the affected side.
l It then passes back about 4 mm palatal to the crest of the
edentulous ridge or gingival margin of the fistula, when
excised.
l The palatal flap should be elevated carefully preserving
the greater palatine artery.
l The palatal flap is rotated across fistula, so that the su-
ture line rests on the sound bone on the buccal side of
the orifices.
Q. 8. Mention in brief about causes of failure of closure
of oroantral fistula.
Ans.
Causes of failure of closure of oroantral fistula are:
i. Post-operative infection.
ii. Inadequate flap design.
iii. Inadequate flap volume.
iv. Post-operative failure to maintain proper oral hygiene
by patients.
Q. 9. Mention any four clinical features of acute maxil-
lary sinusitis.
Ans.
Signs of acute sinusitis are as follows:
l Tenderness over the maxilla, especially in the infraor-
bital region.
l Mild oedema of cheek.
l Rarely, patient gets earache as a referred pain from antrum.
l Percussion of maxillary premolars and molars related to
affected sinus will lead to pain. Examination of nose
with a speculum shows nasal congestion.
l Presence of pus or mucopurulent discharge in middle
meatus.
l Oropharynx: Mucopurulent discharge trackling down
posterior wall of pharynx.
Q. 10. Transillumination test.
Ans.
Transillumination Test
l Transillumination is one of the methods of examination,
and can be carried out because of relative thinness of the
walls of the maxillary sinus.
l It can be carried out by placing a strong light in centre
of mouth of the patient with the lips closed.
l The results of a normal sinus—a definite infraorbital
crescent of light and a brightly lit and glowing pupil.
l In case the antral cavity contains mucus, polyps, blood
and thickened lining, fibro-osseous lesions, or a tumour,
it will not light up as in normal circumstances.
158 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The result will be false negative in cases where there is
a large abscess over maxillary sinus.
l Transillumination is certainly, a less accurate than con-
ventional radiography; but still is a useful method of
examination, if the facilities are available.
Q. 11. Describe in brief the technique of intranasal
antrostomy.
Ans.
Intranasal Antrostomy
l It is performed to facilitate the drainage at the conclu-
sion of an operation performed: i. To close an oroantral
fistula, or ii. To remove a tooth or a root from sinus.
Surgical Procedure for Intranasal Antrostomy
l A small-sized osteotome or gouge is pushed through the
inferior meatus in the nasal cavity into the maxillary sinus.
l Then a big curved artery forceps is passed through this
opening and an iodoform impregnated ribbon gauze
pack’s end is grasped into its beak and pulled out into
the nostril.
l Here a single knot, which is put in the ribbon gauze, will
help to keep it secured in the nostril.
l The other end of the ribbon gauze is then used to sys-
tematically pack the maxillary sinus cavity in multiple
folds, after achieving proper haemostasis (after
Caldwell-Luc operation).
l An antrostomy can be performed by removing approxi-
mately 1 cm of the medial wall of the antrum, which
Inflammatory Lesions of Jaw and Orofacial Infections
LONG ESSAYS
Q. 1. Define osteoradionecrosis. Describe the clinical
features, radiographic picture, and management of
osteoradionecrosis.
Or
Describe the pathophysiology, clinical features, and
management of osteoradionecrosis.
Or
Define osteoradionecrosis. Describe in detail the ill ef-
fects of radiation therapy of oral and perioral structures
and how do you manage them?
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bulges into the sinus below the level of the inferior tur-
binate.
l This antrostomy should be extended to the level of the
floor of the nose.
l The nasal mucosa is then incised from the antral surface
on three sides and the nasal mucosal flap thus created is
reflected into the antrum.
Q. 12. Von rehrmann’s flap.
Ans.
Buccal Flap/Von Rehrmann’s Flap
l Most common flap used for closure of oroantral fistula.
l Performed under LA.
l Incision making:
l Two divergent incisions are taken with blade no. 15,
from each side of orifice into buccal sulcus for a dis-
tance of 2.5 cm. Mucoperiosteal flap is reflected care-
fully.
l Advancement of buccal flap:
l A horizontal incision is made in the periosteum, as high
as possible. This will allow advancement of buccal flap.
l Maxillary sinus should be carefully inspected for evi-
dence of infection, either through fistula or by illumina-
tion, or with a fiberoptic light. Any polypoidal masses or
other diseased tissues should be removed. Antrum is
gently irrigated with warm normal saline.
l Attain complete haemostasis.
l Closure of wound:
l The mucoperiosteal flap is sutured into position across
fistula with interrupted sutures.
Topic 14
Ans.
Osteoradionecrosis
l Osteoradionecrosis (ORN) is an exposure of non-viable,
non-healing, and non-septic lesion in the irradiated
bone, which fails to heal without intervention.
l It is a sequelae of irradiation-induced tissue injury in
which hypocellularity, hypovascularity, and hypoxia are
the underlying causes.
Section | I  Topic Wise Solved Questions of Previous Years
Clinical featuresORN has various clinical and radiographic
presentations and there are no diagnostic signs or tests.
l ORN is a painful and debilitating condition, which is
frequently refractory to treatment.
l Severe, deep, and boring pain, which may continue for
weeks or months.
l Swelling of face when infection develops.
l Soft tissue abscesses and persistently draining sinuses.
l Exposed bone in association with intraoral or extraoral
fistulae.
l Trismus.
l Foetid odour.
l Pyrexia.
l Pathological fracture may be present.
l The signs and symptoms would vary depending upon
the cause. If extraction of tooth is the cause, then an area
of denuded bone may be seen on alveolar process which
may be viable.
l The mucosa may show sloughing and the area of ex-
posed bone shows tendency to become larger.
l There is slow sequestration, because not only the osteo-
blastic, but also osteoclastic activity is destroyed.
l When sequestration occurs, generally, a large piece
of bone is separated from unaffected vital part of v. Bupivacaine (Marcaine), alcohol nerve blocks,
mandible.
l Involvement of fascial spaces of face and neck leading
to deep cellulitis.
l There may be sloughing of adjoining skin and mucosa.
l Clinically, ORN may appear as a sequestrum of dead
bone, osteopenic, and fibrotic in nature.
l Microorganisms are not the causative factors, but they
create complication in the process and they extend the
treatment.
l Exposed bone is not necessarily radiation-compromised
or dead. It may be due to the soft tissue envelope insult
and if conservatively supported, may heal without bone
debridement.
Radiographic Features
l In the early stage, there is little change.
l It may appear as a radiolucent modelling with indefinite
non-sclerotic borders and occasional areas of radiopac-
ity associated with bony sequestrum.
l Sequestra and involucrum occur late or not at all,
because of severely compromised blood supply.
l Initial blood flow assays with nuclear isotope techne-
tium-99 methylene diphosphate scanning can be of some
benefit in assessing regional perfusion of the afflicted areas.
Treatment
l There is no universally accepted treatment for ORN.
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159
l The management of ORN remains controversial and both
radical and conservative treatments have been reported.
Conservative treatment
l It includes systemic antibiotics, selective rinsing topical
antiseptics, selective removal of sequestra, curetting,
and local debridement and burring it out until normal
bleeding from the bone appears.
Radical treatment
It is indicated where acute progressive ORN is refractory to
conservative treatment.
In general the treatment comprises of
i. Debridement.
ii. Control of infection:
l Antibiotics are administered to control acute
infection, if present.
iii. Other supportive treatment:
(i) Hydration: Fluid therapy, (ii) High protein and
vitamin diet.
iv. Analgesics:
l Narcotic and non-narcotic analgesics.
nerve avulsion, and rhizotomy.
Good oral hygiene:
l Oral rinses, such as 1 % sodium fluoride gel,
1 % chlorhexidine gluconate, and plain water
help to prevent radiation-induced caries from the
xerostomia.
vi. Frequent irrigations of wounds:
l Exposed dead bone and small pieces of bone
may become loose and can be removed easily.
vii. Sequestrectomy:
It is preferably performed intraorally, because of
skin and vascular damage resulting from irradiation.
l Pathological fractures are not so common.
l The best form of treatment is excision of ne-
crotic ends of both the fragments and replace-
ment with a large graft.
l Reconstruction of bone defects usually warrants
major soft tissue flap revascularization support.
l Bone resection is performed if there is per-
sistent pain, infection, or pathological frac-
ture. It is preferably done intraorally to avoid
possibility of orocutaneous fistula in radia-
tion-compromised skin.
viii. HBO therapy:
It is a useful adjunct to other treatment modalities.
l Rationale for the use of HBO in association
with surgery in irradiated tissues is to increase
blood to tissue oxygen tension, which will en-
hance the diffusion of oxygen into the tissues.
160 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l This revascularizes the irradiated tissue and also Clinical Features

improves the fibroblastic cellular density, thus fur-
ther limiting the amount of non-viable tissue to be
surgically removed.
Q. 2. Define osteomyelitis. Describe the pathology and
the management of chronic osteomyelitis of mandible.
l Pain and tenderness: The pain is minimal.
l Non-healing bony and overlying soft tissue wounds
with induration of soft tissues.
l Intraoral or extraoral draining fistulae.
l Thickened or ‘wooden’ character of bone.

l Enlargement of mandible, because of deposition of sub-

Or
periosteal new bone.
Define and classify osteomyelitis of jaw bones. How will l Pathological fractures may occur.
you manage a case of chronic suppurative osteomyelitis l Sterile abscess (Brodie’s abscess) common to long
of mandible in an adult? bones is rare in jaws.
l Teeth in the area tend to become loose and sensitive to
Ans.
palpation and percussion.

Osteomyelitis Diagnosis
l Osteomyelitis may be defined as an inflammatory
It is made on the basis of:
condition of bone that begins as an infection of med-
i. Presence of sequestra.
ullary cavity and haversian systems of the cortex,
ii. Areas of suppuration involving the tooth bearing
and extends to involve the periosteum of the affected
area of jaw bone, not responding to debridement and
area.
conservative therapy.
l The inflammation may be acute, subacute, or chronic.
iii. Compromised immune response, either regional or
l It may be localized or may involve a larger portion of
systemic or microvascular decompensation or both.
bone.
l It may be suppurative or non-suppurative.
Treatment
Aetiology l The treatment measures remain the same for acute as
well as for chronic OML.
Osteomyelitis of the jaws is caused by the following:
l In certain circumstances, after performing the necessary
1. Odontogenic infections:
surgical procedures where the soft tissues cannot be
It includes primarily, odontogenic infections originating
closed without leaving dead space or because of rigid
from pulpal or periodontal tissues, pericoronitis, in-
fibrosis, the wound may be dressed with 2” ribbon
fected socket, infected cyst, tumour, etc.
gauze soaked with Whitehead’s varnish.
2. Trauma:
l A differentiation has to be made between the types of
It is the second leading cause: (a) Especially, compound
bone encountered.
fracture, and (b) Surgery-iatrogenic
l The necrotic but unsequestrectomised bone has dirty
3. Infections of orofacial regions derived from:
white colour cortex; while, the living cortical bone has
a. Periostitis following gingival ulceration,
a yellowish hue.
b. Lymph nodes infected from furuncles,
l The viable cortex shows tiny red bleeding spots on cut
c. Lacerations, and
surfaces.
d. Peritonsillar abscess.
4. Infections derived by haematogenous route: Chronic external sinuses require irrigation.
It includes furuncle on face, wound on the skin, upper i. Resection: It is rarely required. When full thickness of
respiratory tract infection, middle ear infection, mas- segment of jaw is involved and a conservative approach
toiditis, and systemic tuberculosis. has failed to cure, resection of the involved part should
The infections from the last two groups account for a be considered.
small percentage of cases. ii. Secondary bone grafting: This should be considered when
the wound has healed completely and is free of infection.
Chronic Osteomyelitis
Management
It can be a. Primary, resulting from organisms which are
less virulent, and b. Secondary, occurring after acute GML, The management includes:
when the treatment does not succeed in eliminating the A. Conservative method of treatment, and
infection. B. Surgical treatment.

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Section | I  Topic Wise Solved Questions of Previous Years
A. Conservative management
l Advised to take complete bed rest.
l Supportive therapy.
l Pain control.
l IV antimicrobial agents.
l Blood transfusion.
l Post-operative care.
l Hyperbaric oxygen (HBO therapy).
B. Surgical management
l Extraction of teeth involved.
l Incision and drainage.
l Continuous or intermittent closed catheter irrigation.
l Sequestrectomy, saucerization, and decortications.
l Resection of jaw with or without immediate delayed
reconstruction with bone graft.
l Post-operative care.
Recommended antibiotic regimens for OML of jaws
1. Regimen I (First choice): As empirical therapy, Penicil-
lin (Penicillin-V) is given.
a. Aqueous penicillin 2 million units given intrave-
nously every 4 hourly.
b. Oxacillin 1 gm IV every 4 hourly.
When the patient has been asymptomatic for 48–72 h,
then switch to oral Penicillin V 500 mg every 4 hourly
with cloxacillin 250 mg orally every 4 hourly for 1. Odontogenic: This is the cause in majority of cases.
2–4 weeks.
2. Regimen II is based on culture and sensitivity results.
Penicillinase-resistant penicillins, such as oxacillin, cloxa-
cillin, dicloxacillin, or flucloxacillin may be given.
In case of allergy to penicillin,the following antibiotics
are used:
i. Clindamycin 300–600 mg orally 6 hourly.
ii. Cephalosporin: a. Cefazolin 500 mg 8 hourly, or b.
Cephalexin 500 mg 6 hourly.
iii. Erythromycin 2g every 6 hourly IV then 500 mg
every 6 hourly orally.
Second choice: Clindamycin
l It is effective against penicillinase producing staphy-
lococci, streptococci, and anaerobic bacteria includ-
ing bacteroides.
l It is used because of its ability to diffuse widely in
bone. It is not recommended as first choice, as it is
bacteriostatic and causes diarrhoea due to pseudo-
membranous colitis.
3. Third choice: Cefazolin or Cephalexin
It is effective against most cocci including penicillinase
producing staphylococci, Gram-negative aerobic bacilli
viz, E. coli, Klebsiella, and Proteus.
Cephalosporins are not recommended as first choice.
4. Fourth choice: Erythromycin
These drugs cannot be used as first choice, as these are:
i. Bacteriostatic, and (ii) Rapidly develop resistant strains.
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161
The dose and duration of antimicrobial therapy is de-
pendent upon severity of infection and its response to
treatment.
Q. 3. Write the clinical features, aetiology, and manage-
ment of Ludwig’s angina and note on systemic compli-
cations.
Or
Define Ludwig’s angina. Mention clinical features and
management of Ludwig’s angina.
Or
Describe clinical features, diagnosis, and surgical treat-
ment as well as antibiotic regime for a case of Ludwig’s
angina.
Ans.
Ludwig’s Angina
Ludwig’s angina is a massive, firm, brawny cellulitis/
induration; acute and toxic stage involving simultaneously
submandibular, sublingual, and submental spaces bilaterally.
Aetiology
The most common teeth involved are mandibular sec-
ond and third molars. It can cause infections in various
other forms:
a. Acute dentoalveolar abscess.
b. Acute periodontal abscess: Deep abscess may in-
volve sublingual spaces.
c. Pericoronal abscess: In relation to erupting mandible
third molars, which can extend to the following
spaces:
i. Submandibular space,
ii. Buccal space,
iii. Sublingual space, and
iv. Pterygomandibular space.
d. Infected mandibular cyst also can spread to form
Ludwig’s angina.
2. Iatrogenic:Use of a contaminated needle for giving lo-
cal anaesthesia.
3. Traumatic injuries to orofacial region: These can be in
the form of:
a. Mandibular fractures—the chances of developing
Ludwig’s angina are more, if the fracture is com-
pounded and comminuted.
b. Deep lacerations or penetrating injuries such as
punctured wounds.
4. Osteomyelitis secondary to compound mandibular frac-
tures or acute exacerbation of chronic osteomyelitis of
mandible may develop into Ludwig’s angina.
162 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
5. Submandibular and sublingual sialadenitis: Acute or
chronic infection from these glands.
6. Secondary infections of oral malignancies: The associ-
ated malignancies of the region may give rise to second-
ary infection leading to the condition.
7. Miscellaneous causes: It includes rare causes such as:
a. Infection in the tonsils or pharynx such as purulent
tonsillitis, etc.
b. Foreign bodies such as fish bone, etc.
c. Oral soft tissue lacerations.
8. Cervical lymphoid tissues.
Pathology
l The condition is a diffuse inflammation of soft tissues
which is not circumscribed or confined to one area, but
in contrast to the abscess, tends to spread through tissue
spaces and along fascial planes.
l Such type of spreading infection occurs in the presence
of organisms that produce significant amounts of hyal-
uronidase and fibrnolysins, which act to break down or
dissolve, respectively hyaluronic acid and fibrin.
l Streptococci, being the potent producers of hyaluronidase
are always associated with classical or true Ludwig’s
angina.
Clinical Features
The following signs and symptoms are present with varying
degree of severity.
General examination
General constitutional symptoms
i. Patient looks toxic, very ill, and dehydrated.
ii. There is pyrexia, anorexia, chills, and malaise.
iii. Marked pyrexia.
iv. Difficulty in swallowing (Dysphagia).
v. Impaired speech and hoarseness of voice.
Clinical examination
l Firm/hard brawny (board-like, woody hard) swelling in
the bilateral submandibular and submental regions,
which soon extends down the anterior part of the neck
to the clavicles.
l Swelling is non-pitting, minimally or non-fluctuant
associated with severe tenderness.
l It shows ill-defined borders with induration.
l Severe muscle spasm may lead to trismus with re-
stricted mouth opening and also jaw movements.
l Typically mouth remains open due to oedema of sublin-
gual tissues leading to raised tongue almost touching
the palatal vault.
l In extreme circumstances, tongue may actually protrude
from the mouth. The tongue movements may be raised.
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l Breathing being shallow with accessory muscles of
respiration being used.
l Cyanosis may occur due the progressive hypoxia.
l Fatal death may occur in untreated case of Ludwig’s
angina within 10–24 h due to asphyxia.
l Intraorally, the swelling develops rapidly, which in-
volves the sublingual tissues and involves:
i. Distends or raises the floor of mouth and woody
oedema of the floor of the mouth and tongue.
ii. Tongue may be raised against palate.
iii. Increased salivation, stiffness of tongue move-
ments, and difficulty in swallowing.
iv. Backward spread of infection leads to oedema
of glottis resulting in respiratory obstruction/
embarrassment.
l Stridor being the alarming sign of this fatal extension
needing emergency intervention to keep airway patent.
l There is reduced control of muscles and jaw posture.
l Salivation is excessive and saliva may be even seen drooling.
l Part of the tongue may get pushed backward making swal-
lowing of even liquid, very difficult or even impossible.
l Oral opening and jaw movements may be reduced.
Principles of Treatment
The treatment is based on the combination of the following
factors:
1. Early diagnosis,
2. Maintenance of patent airway,
3. Intense and prolonged antibiotic therapy,
4. Extraction of offending teeth, and
5. Surgical drainage or decompression of fascial spaces.
Airway maintenance
l This condition is considered to be fatal.
l Death can occur from asphyxia rather than the infection
itself, leading to septicaemia and shock.
l Hence, it is advisable to observe the patient for respira-
tory obstruction and restlessness.
l In case of respiratory embarrassment, the following
points should be considered for using artificial airway:
i. Intubation of the patient
ii. Surgical airway.
Intubation of the patient
l Blind intubation should be avoided.
l Nasoendotracheal intubation is far more reliable and
almost predictable and should be preferred.
Surgical airway
l It may be required in case of severe upper respiratory
obstruction.
l Laryngotomy and cricothyroidotomy (tracheotomy) are
always preferred over tracheostomy.
Section | I  Topic Wise Solved Questions of Previous Years
Use of cuffed endotracheal tube
l Avoid sedatives and narcotic agents that may deteriorate
respiration.
l Degree of respiratory obstruction can be better evalu-
ated using pulse oximeter and evaluating blood gases.
Anaesthesia
It is always better to use local anaesthesia for surgical inter-
vention.
Local infiltration with 2% lidocaine with adrenaline into
skin and superficial tissues of neck is sufficient to fulfil the
need for surgical intervention.
In patients who are already intubated, GA can be consid-
ered after evaluating its advantages over local anaesthesia.
l IV analgesics can be supplemented to relieve pain.
l Surgical intervention: It has two aims: i. Removal of
cause, and ii. Surgical decompression: Decompression
of the spaces involved.
Surgical decompression
As Ludwig’s angina is in fact cellulitis, the aggressive result of bacterial culture and sensitivity testing.
surgical intervention is a debatable.
Advantages of early surgical decompression
i. It reduces pressure of oedematous tissue on airway, re-
ducing respiratory embarrassment.
ii. It allows prompt drainage.
iii. It allows obtaining specimens or samples for staining,
culture, and sensitivity for identification of micro­
organisms; and, accordingly adjustment of antibiotics
later on.
iv. It allows placement of drains, which may be to drain
pus collection as time progresses and irrigation of the
tissues at regular interval.
Care should be taken to preserve or avoid trauma to:
l Facial vessels near angle,
l Lingual nerve, and
l Jugular vein, laterally below angle region.
Antibiotic therapy
l Antibiotics: Antibiotics play a vital role in managing
Ludwig’s angina. Usually, IV antibiotics with proper
dosage and frequency are necessary.
a. Penicillin and its derivatives:
i. Penicillins are the first line of antibiotics in treating
such infection, as it covers the majority of aerobic
Gram-positive microbial flora commonly associated
with this infection. It is administered in the form of
aqueous penicillin G, 2–4 million units, IV 4–6 hourly;
or 500 mg 6 hourly orally.
ii. Semisynthetic derivatives of penicillin:
Ampicillin/amoxicillin: 500 mg 6 and 8 hourly, IV and
orally respectively.
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163
iii. Cloxacillin: 500 mg orally, 8 hourly.
iv. In case of allergy to penicillin: Erythromycin 600 mg
6–8 hourly.
v. Gentamicin has activity against some resistant staphy-
lococci and pseudomonas. 80 mg. 1M BD.
vi. Clindamycin IV 300–600 mg 8 hourly, orally and in-
travenously. Its spectrum of activity includes Gram-
positive cocci including penicillinase resistant staphy-
lococci, and bacteroides.
vii. Metronidazole: It is a useful antibiotic against anaero-
bic flora found in infections. It is administered in the
form of 400 mg 8 hourly, orally or intravenously.
viii. Cephalosporins: These are closely related to penicillin
and have similar spectrum of their activity. These are
usually reserved for resistant infections.
l Usually, a combination of antibiotic therapy is in-
dicated for aggressive management of Ludwig’s
angina, penicillin or its derivative along with met-
ronidazole or gentamicin.
l Antibiotics should be changed subsequent to the
l The therapy should also be changed, if favourable
results are not observed after 48–72 h of therapy.
Q. 4. Describe the mode of spread of infection from
mandibular third molar region. Discuss the line of treat-
ment in such a case.
Or
Describe the pathway of spread of mandibular third
molar and give its management.
Or
Define space infection. Enumerate the tissue that offers
resistance to spread of infection. How does the infection
spread from the lower last molar periodontal flap and
its management?
Ans.
Mandibular Third Molar
l The mandibular third molar is generally positioned me-
dially to the vertical plane of the ramus. Therefore, its
apex is much closer to the lingual than to the buccal
cortical plate.
l In this region, the mylohyoid muscle is attached near
the alveolar margins and its posterior border is just
behind the tooth.
l Because of the relationship, infection from vertically
positioned third molar will extend below the mylohyoid
muscle and localize in the submandibular space.
l With mesioanugular or horizontal positioned teeth, the
infection will extend to the mylohyoid muscle, localiz-
ing in the pterygomandibular space.
164 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l This region is bounded laterally by the medial surface of
ramus of the mandible and medially by the lateral aspect
of the medial pterygoid muscle.
l It is the space into which the needle is passed in
performing an inferior alveolar nerve block injection.
l Posteriorly, this space communicates with the lateral
pharyngeal space.
l An infection from a third molar also can pass directly
into the parapharyngeal space by extension medial to
the pterygoid muscle.
l A patient with pterygomandibular space infection will
show no external evidence of swelling.
l Intraoral examination reveals an anterior bulging of
half the soft palate and the anterior tonsillar pillar with
deviation of the uvula to the unaffected side.
l The patient will have severe trismus and difficulty.
l Despite the limitation in opening, depression of the
tongue blade usually permits inspection of the soft Surgical Anatomy
palate and pharyngeal wall.
l The pterygomandibular space abscess must be distin-
guished from the peritonsillar abscess.
l With the latter, there is less trismus and no dental
involvement.
l Occasionaly, an infection from third molar can involve
the submasseteric space.
l Usually this is the result of pericoronitis, but this can
arise from a periapical infection when linguoversion of
the tooth or an extreme curvature of the root brings the
apex closer to the buccal surface.
l The submasseteric space is bounded laterally by the
masseter muscle and medially by the larteral surface of
the mandibular ramus.
l The anterior boundary is the facial extension of the
paratideomasseteric fascia, and the posterior boundary
is the parotid fascia and retromandibular portion of the
parotid gland.
l Superiorly, the space extends to the level of the zygomatic
arch and communicates with the infratemporal space.
l A submasseteric space infection can be distinguished
from buccal space infection by the fact that its anterior
boundary ends at the anterior border of the masseter
muscle, whereas the posterior border of the buccal
space swelling ends at that point.
Management
l The management of the acute infection involves both
supportive and surgical therapy.
l Surgical therapy consists of extraction of the offending
tooth or teeth, incision, and drainage.
l Supportive therapy involves administration of antibiot-
ics, hydration of the patients, administering an analgesic
for pain, bed rest, application of heat in the form of
moist packs and/or mouth rinses, and opening the tooth
for drainage.
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Q. 5. Give the boundaries of pterygomandibular
space.
Or
Mention the microorganisms and various ways by which
odontogenic infection can spread. Describe the bound-
aries, clinical signs and symptoms, and management of
involvement of the pterygomandibular space.
Or
Describe the boundaries and contents of pterygoman-
dibular space. Write the causes for spread of infection
to the pterygomandibular space and give the clinical
features and management.
Ans.
Boundaries
l Lateral: Medial surface of ramus of mandible.
l Medial: Lateral surface of medial pterygoid muscle.
l Posterior: Parotid gland (deep portion).
l Anterior: Pterygomandibular raphae.
l Superior: Lateral pterygoid muscle forms roof to the
pterygomandibular space. The space just below the
lateral pterygoid muscle communicates with the pha-
ryngeal spaces.
l Contents: Lingual nerve, mandibular nerve, inferior
alveolar or mandibular artery, mylohyoid nerve and
vessels, and loose areolar connective tissue.
Clinical Features
l Even the established cases of pterygomandibular space
infections do not cause much swelling of face over the
submandibular region.
l There is severe degree of limitation of mouth opening.
l Tenderness can be elicited over the area of wall tissues
medial to anterior border of ramus mandible.
l Dysphagia is present.
l Medial displacement of the lateral wall of the pharynx,
and redness and oedematous area around the third molar.
Management
Incision and Drainage
The abscess tends to point at the anterior border of the
ramus mandible and drainage can be easily done by intra-
oral route.
a. Intraoral drainage
l A vertical incision, approximately 1.5 cm length is made
on the anterior and medial aspect of the ramus of mandible.
Section | I  Topic Wise Solved Questions of Previous Years
l A sinus forcep inserted in the abscess cavityis opened
and closed and withdrawn.
l The pus is evacuated and a rubber drain introduced is
secured in position with a suture.
b. Extraoral drainage
l An incision is is made on the skin at the angle of the
mandible.
l A sinus forceps is inserted towards the medial side of
the ramus in an upward and backward direction.
l Pus is evacuated. Drain is inserted from an intraoral ap-
proach and left in position.
Q. 6. What are the boundaries of infratemporal space?
How will you manage a case of infection of infratempo-
ral space?
Ans.
Infratemporal Space
l Infratemporal space is also called ‘retrozygomatic
space’ as it is partly situated behind the zygomatic
bone.
l The space is continuous with upper part of pterygoman-
dibular space anteriorly.
l However, it is separated from it by lateral pterygoid
muscle posteriorly.
l Thus, the infratemporal fossa forms the upper extremity
of pterygomandibular space.
Involvement
i. Infections of the infratemporal space arise from the in-
fection of the buccal roots of the maxillary second and
third molars, particularly from unerupted third molars.
ii. Local anaesthesia injections with contaminated needles
in the area of tuberosity.
iii. Spread from the other spaces infection.
Surgical Anatomy
i. Boundaries
Infratemporal space is bounded:
l Laterally, by ramus of mandible, temporalis muscle and
its tendon.
l Medially, by medial pterygoid plate, lateral pterygoid
muscle, medial pterygoid muscle, lower part of tempo-
ral fossa of the skull, and lateral wall of pharynx.
l Superiorly, by infratemporal surface of greater wing of
sphenoid and zygomatic arch.
l Inferiorly, by lateral pterygoid muscle forms the floor of
the fossa and its lower head is said to mark the border
between pterygomandibular and infratemporal spaces.
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165
l Anteriorly, infratemporal surface of maxilla.
l Posteriorly, by parotid gland.
ii. Contents
l The fossa contains origins of medial pterygoid and
lateral pterygoid muscles.
l The lower head of lateral pterygoid muscle borders the
pterygomandibular and infratemporal spaces.
l It contains pterygoid venous plexus of veins.
l It is traversed by maxillary artery, mandibular nerve,
and middle meningeal artery.
Clinical Features
a. Extraoral
l Trismus: Marked limitation of oral opening.
l Bulging of temporalis muscle.
l Marked swelling of the face on the affected side in front
of the ear overlying the area of the temporomandibular
joint behind the zygomatic process.
l The eye is often closed and is proptosed.
b. Intraoral
l Swelling in the tuberosity area. Elevation of tempera-
ture up to 104°F.
Incision and Drainage
a. Intraoral approach
If the trismus is not marked and fluctuation is detected
early, an intraoral incision is given in the buccal vestibule
opposite the second and third molars.
The exploration is carried out medial to coronoid pro-
cess and temporalis muscle upwards and backwards with a
sinus forceps or a curved haemostat. The space is entered
and drained; and a small piece of corrugated rubber drain is
kept and secured with a suture.
b. Extraoral approach
l In severe intractable infections, extraoral incision is the
only method of drainage. Incision is made at the upper
and posterior edge of temporalis muscle within the
hairline.
l A sinus forceps is then directed upwards and medially.
l Pus is evacuated. Rubber drain is inserted and suture
secured.Dressing is given.
l Despite appropriate and prompt treatment, the lesion
takes long-time to resolve.
l The restriction of opening persists for long-time over
a few weeks and improves in due course of time with
active physiotherapy with jaw exercises.
166 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
SHORT ESSAYS
Q. 1. Write in detail the clinical features and manage-
ment of acute suppurative osteomyelitis.
Ans.
Acute Suppurative Osteomyelitis
l Acute suppurative osteomyelitis of the jaw is a serious
sequel of periapical infection that often results in a dif-
fuse spread of infection throughout the medullary
spaces with subsequent necrosis of a variable amount
of bone.
l Dental infection is the most frequently cause of acute
osteomyelitis of the jaw.
l It may be either well localized infection of one involv-
ing a great volume of bone.
l It is usually a polymicrobial infection.
l Different types of organisms such as, Staphylococcus
aureus, Staphylococcus albus and various streptococci
are involved.
l Anaerobes such as Bacteroides, Porphyromonas, or
Prevotella species also predominate.
Clinical Features
l Acute or subacute osteomyelitis involves either maxilla
or mandible.
l In maxilla, the disease usually remains well localized to
the area of infection.
l In mandible, bone involvement tends to be more diffuse
and widespread.
l The disease may occur at any age.
l A particular form of osteomyelitis referred to as neona-
tal maxillitis in infants and young children is a well
recognized entity, which is nowadays uncommon spaces.
because of use of antibiotics.
l The adult afflicted with acute suppurative osteomyelitis
usually has a severe pain, trismus, and paraesthesia i. Face—buccal, canine, masticatory, and parotid.
of the lips in case on mandibular involvement, and
manifests an elevation of temperature with regional
lymphadenopathy.
l The white blood cell count is elevated.
l The teeth in the area of involvement are loose and sore.
l Pus may exude from the gingival margin.
l Until periostitis develops, there is no swelling or red-
dening of the skin or mucosa.
Treatment
l General principle of management includes debride-
ment, drainage, and antimicrobial therapy.
l If sequestrum is small, it gradually exfoliates through
mucosa.
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l If large, surgical removal may be necessary, since its
removal by normal processes of bone resorption would
be extremely slow.
l Sometimes an involucrum form when the sequetrum
becomes surrounded by new living bone.
l Unless proper treatment is instituted, acute suppurative
osteomyelitis may proceed to the development of peri-
ostitis, soft tissue, abscess, or cellulitis.
l Pathologic fracture occasionally occurs because of
weakening of the jaw by the destructive process.
Q. 2. Classify fascial spaces around the jaws.
Ans.
Fascial Spaces
Classification
A. Based on mode of involvement
i. Direct involvement
a. Primary spaces
b. Maxillary spaces.
c. Mandibular spaces.
ii. Indirect involvement
Secondary spaces
Spaces involved in odontogenic infections
Primary spaces of maxilla—canine, buccal, and infratem-
poral spaces.
Primary spaces of mandible—submental, buccal, sub-
mandibular, and sublingual spaces.
a. Secondary fascial spaces—Masseteric, pterygoman-
dibular, superficial and deep temporal, lateral pharyn-
geal, retropharyngeal, prevertebral spaces, and parotid
B. Based on clinical significance
ii. Suprahyoid—sublingual, submandibular, pharyngo-
maxilary, and peritonsillar.
iii. Infrahyoid—anterovisceral (Pretracheal)
iv. Spaces of total neck—retropharyngeal and space of
carotid sheath.
Q. 3. I and D (Incision and Drainage).
Or
Incision and drainage.
Ans.
Incision and drainage helps in the following ways:
i. Getting rid of toxic purulent material.
ii. Decompressing the oedematous tissues.
Section | I  Topic Wise Solved Questions of Previous Years 167

iii. Allowing better perfusion of blood containing antibiot- Infecting Organisms Antibiotic Alternative
ics and defensive elements.
Staphylococcus aureus (non- Penicillin G Cephalothin
iv. Increasing oxygenation of the infected area. penicillinase producing)
l The abscess is then drained surgically and simulta-

neously dental treatment must also be instituted Staphylococcus aureus Dicloxacillin Methicilliin
(penicillinase producing)
for achieving quick resolution.
l It involves the blunt exploration of the entire ana- Staphylococcus epidermidis Cephalothin Vancomycin
tomic space or the abscess cavity, along with the Staphylococcus faecalis Ampicillin and Vancomycin
opening up of all the tissue planes within the abscess gentamicin
cavity. Streptococcus pyogenes Penicillin G Cephalothin
l Irrigation of the abscess cavity is then done with
Streptococcus viridians Penicillin G Cephalothin
betadine and saline solution. (alpha-haemolytic)
l Thereafter, a drain is inserted into the depth of the

space.
l It may simply pass through a single incision and Q. 5. Principles of antibiotic therapy.
even remain in the depth of the space, or it may be
Or
a through and through drain.
l The drain is secured to one of the margins of the What do you mean by massive antibiotic therapy? What
incisions with a suture; or, to itself in case of a are the conditions in maxillofacial surgery? Where it is
through and through intraoral to extraoral drains and used?
are left in situ, which can again be in the same fas-
Ans.
cial space.
General principles of antibiotic therapy:
Q. 4. Antibiotics for oral infection.
1. Empirical antibiotic therapy has a limited role in the
Ans. prevention and the management of infections.
2. If no response is forthcoming within three days of
Antibiotics used for oral infections based on type of organ-
therapy, then organisms must be identified so that the
isms involved are as follows:
antibiotics can be chosen to act against susceptible or-
ganisms. No single antibiotic is effective against the
Infecting Organisms Antibiotic Alternative pathogens. Once the causative organisms are isolated, it
Actinomyces israelii Penicillin G Tetracycline becomes critical to identify the appropriate antibiotic
therapy.
Bacteroides fragilis Clindamycin Chloramphenicol
3. The most common organisms are streptococci, staphy-
Bacteroides melaninogenicus Penicillin G Tetracycline lococci and bacteroids.
Candida albicans Amphotericin - 4. Culture of the organisms and antibiotic sensitivity test
B (Nystatin assume greater importance in patients with:
topically) a. Compromised defences like diabetes,
Clostridium organisms Penicillin G Tetracycline b. Immunosuppressed patients,
Diphtheroids Penicillin G Add Vancomycin c. Those who are vulnerable to infections like subacute
bacterial endocarditis,
Escherichia coli Kanamycin Cefamandole
d. Patients on dialysis,
Haemophilus influenza Ampicillin Cefaclor e. Patients who are on chemotherapy for malignancy,
Klebsiella organisms Kanamycin Colistimethate and
f. In geriatric patients.
Mycoplasma pneumonia Erythromycin Tetracycline
5. For the drug to be therapeutically effective, the antibiot-
Peptococcus organism Penicillin G Clindamycin ics must be given in proper dose at proper intervals
Peptostreptococcus organism Penicillin G Clindamycin through appropriate route, so that blood concentration
Proteus mirabilis Ampicillin Kanamycin
of the drug is maintained at the desired level.
6. The drug which is least toxic, most economical, and
Proteus organism Gentamicin Kanamycin most effective must be chosen for the therapy.
Pseudomonas aeruginosa Gentamicin Carbenicllin 7. To avoid the development of resistant strains, the drug
Serratia marcescens Kanamycin Ampicillin with least spectrum must be chosen.
8. The patient must be warned about the possibility of the
Saphylococcus albus Cephalothin Vancomycin
side effects and complications. If any such untoward

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168 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
reactions develop, then the patient must discontinue
the therapy henceforth.
9. Caution must be exercised in using newer drugs. Pref-
erence must be given to use the known drug with
proven effectiveness.
10. Wherever possible, judicious methods to accentuate
the efficacy of antibiotics must be utilized.
Q. 6. Pericoronitis.
Or
Pericoronitis and its management.
Ans.
Pericoronitis
l An erupting tooth is covered by a soft tissue flap of the
alveolar mucosa; and when tooth is partially erupted,
sometimes there may be inflammation or infection of
the soft tissue flap covering the tooth.
l This is known as pericoronal infection or pericoronitis.
l Usually seen in erupting mandibular third molar, but
can be associated with any erupting tooth.
Aetiology
l A partially erupted tooth covered partially by a peri-
coronal flap may get infected by accumulation of food
debris between the flap and the surface of the crown.
l Eruption of tooth itself may produce some amount of
inflammation of the pericoronal region.
l Trauma to the inflamed swollen flap may aggravate the
problem.
l Inadequate attached gingival in the region of the erupt-
ing third molar may lead to pocket formation around the
erupting tooth.
l Inflammation of this periodontal pocket may also spread
to a pericoronal infection.
Clinical Features
l Pain and swelling in involved region.
l May be associated with trismus, if a lower molar is in-
volved.
l Indentation from the upper tooth trauma may be seen on
the pericoronal flap.
l Pus discharge from under the pericoronal flap.
l Regional lymph node enlargement.
l Tooth may be tender on percussion.
Management
l Analgesics and antibiotics.
l If infection has spread to adjacent vestibule, then inci-
sion and drainage.
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l Adequate irrigation of the pericoronal flap. Dilute hy-
drogen peroxide can be used to irrigate this region.
l Warm saline mouth rinses in future help to reduce the
acute condition.
l Once the acute condition subsides, the impacted tooth
may either be extracted or the pericoronal flap may be
exicised.
Q. 7. Acute alveolar abscess.
Ans.
Acute Alveolar Abscess
l Also known as dentoalveolar abscess or periapical ab-
scess.
l Periapical abscess is an acute or chronic suppurative
process of dental periapical region.
l It may develop either from acute periapical, periodontal,
or more commonly from a periapical granuloma.
Clinical Features
l It presents an acute inflammation of the apical peri-
odontium.
l Initially it produces tenderness of the tooth, which is
relived by application of pressure.
l Rapid extension to adjacent bone marrow spaces fre-
quently occurs, producing an actual osteomyelitis.
l In such cases, clinical features may be severe and seri-
ous with swelling of the tissue.
l It generally presents with no clinical features, since it
is essentially a mild, wellcircumscribed area of suppu-
ration that shows little tendency to spread from the
local area.
Radiographic Features
l Slight thickening of periodontal ligament space can
be can.
Treatment and Prognosis
l Principle of the treatment is drainage.
l This can be done by opening pulp chamber or extracting
the tooth.
l Sometimes, tooth may be retained and root canal ther-
apy carried out if the lesion can be sterilized. If not
treated, abscess can lead to serious complications
through the spread of infection.
Q. 8. Hyperbaric oxygen therapy.
Or
HBO.
Ans.
Section | I  Topic Wise Solved Questions of Previous Years
Hyperbaric Oxygen Therapy
Method of Delivery
l Hyperbaric oxygen therapy involves the intermittent,
usually daily, inhalation of 100% humidified oxygen
under pressure, greater than one atmospheric absolute
pressure (ATA).
l Patient is placed in a chamber; and O2 is given by mask
or by hood.
l Each dive is 90 min in length.
l The treatment is given five days per week for 30, 60,
or more dives in monoplace chamber at 2.4 ATA for ii. Contents
90 min, while breathing 100% oxygen twice daily.
l It is a potent alternative to surgical reperfusion and is an
adjunctive enhancement to host immune response.
l Its use has increased in the treatment of OML and
ORN.
l HBO therapy increases a dose of oxygen dissolved
in the plasma and also that which is delivered to the and middle meningeal artery.
tissues.
l It results in reduction of hypoxia within the affected
tissues which in turn stimulates angiogenesis in the Clinical Features
hypovascular tissues.
Mechanism of Action of HBO
l Regular, periodic, but not sustained elevation of the
oxygen within hypoxic tissue has been shown.
l Enhances the killing ability of leucocytes.
l Stimulates fibroblast growth and increased collagen
formation.
l Promotes growth of capillaries.
l Toxic to aerobic and anaerobic bacteria.
l Inhibits bacterial toxin formation.
Q. 9. Infratemporal space infection.
Ans.
Infratemporal Space
l It is also called ‘retrozygomatic space’, as it is partly
situated behind the zygomatic bone.
l The space is continuous with upper part of pterygoman-
dibular space anteriorly.
l However, it is separated from it by lateral pterygoid
muscle posteriorly.
l Thus, the infratemporal fossa forms the upper extremity
of pterygomandibular space.
Surgical Anatomy
i. Boundaries
Infratemporal space is bounded:
l Laterally, by ramus of mandible, temporalis muscle and
its tendon.
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169
l Medially, by medial pterygoid plate, lateral pterygoid
muscle, medial pterygoid muscle, lower part of tempo-
ral fossa of the skull, and lateral wall of pharynx.
l Superiorly, by infratemporal surface of greater wing
of sphenoid and zygomatic arch.
l Inferiorly, lateral pterygoid muscle forms the floor of
the fossa and its lower head is said to mark the border
between pterygomandibular and infratemporal spaces.
l Anteriorly, by infratemporal surface of maxilla.
l Posteriorly, by parotid gland.
l The fossa contains origins of medial pterygoid and
lateral pterygoid muscles.
l The lower head of lateral pterygoid muscle forms the
borders of pterygomandibular and infratemporal spaces.
l It contains pterygoid venous plexus of veins.
l It is traversed by maxillary artery, mandibular nerve,
Extraoral
l Trismus: Marked limitation of oral opening.
l Bulging of temporalis muscle.
l Marked swelling of the face on the affected side in front
of the ear overlying the area of the temporomandibular
joint behind the zygomatic process.
l The eye is often closed and is proptosed.
Intraoral
l Swelling in the tuberosity area. Elevation of tempera-
ture up to 104°F.
Incision and Drainage
a. Intraoral approach
l If the trismus is not marked and fluctuation is detected
early, an intraoral incision is given in the buccal vesti-
bule opposite the second and third molars.
l The exploration is carried out medial to coronoid pro-
cess and temporalis muscle upwards and backwards
with a sinus forceps or a curved haemostat. The space is
entered and drained; and a small piece of corrugated
rubber drain is kept and secured with a suture.
b. Extraoral approach
l In severe intractable infections, extraoral incision is the
only method of drainage. Incision is made at the upper
and posterior edge of temporalis muscle within the
hairline.
l A sinus forceps is then directed upwards and medially.
l Pus is evacuated. Rubber drain is inserted and suture
secured. Dressing is given.
170 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Despite appropriate and prompt treatment, the lesion
takes long-time to resolve.
The restriction of opening persists for long-time over a few
weeks and improves in due course of time with active phys-
iotherapy with jaw exercises.
Q. 10. Garre’s osteomyelitis.
Ans.
Garre’s Osteomyelitis
Garre’s sclerosing OML is also known as chronic non-
suppurative sclerosing chronic OML with proliferative
periostitis and periossificans.
It is a non-suppurative inflammatory process, where
there is peripheral subperiosteal bone deposition caused by
mild irritation and infection.
Pathogenesis
l The aetiological agents can be a carious tooth or the
overlying soft tissue infection.
l The infectious process localizes in periosteum or be-
neath the periosteal covering of cortex, spreading
slightly into the interior of bone.
l It generally involves mandible.
l The disease primarily occurs in children and young
adults; and occasionally in older individuals.
Clinical Features
It is characterized by:
l Localized hard, non-tender bony swelling of lateral and
inferior aspects of mandible.
l Lymphadenopathy, hyperpyrexia, and leucocytosis are
usually not found.
Radiography
l A focal area of well calcified bone proliferation may be
seen that is smooth and that often has a laminated or
‘onion skin’ appearance.
l The radiographic appearance is typical.
l There is cortical bone condensation and overgrowth of
bony tissue beneath the periosteum.
l The increase in mass of bone is due to several factors as
follows:
i. Mild toxic stimulation of fibroblasts by attenuated
infection,
ii. Compensatory thickening of bone as a mechanical
adaptation for reinforcing the area weakened due to
disease, and
iii. An exuberant attempt of repair.
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Treatment
It is directed towards removing sources of inflammation:
a. Removal of infected tooth and curettage of socket.
b. Surgical recontouring: This is done to recontour the
cortical expansion of the jaw. This is attempted only if
there is obvious expansion.
c. Endodontic therapy.
d. Antibiotics: If signs of infection are present.
e. Follow-up.
Q. 11. Submasseteric space infection.
Ans.
Submasseteric Space Infection
l Masseter consists of three layers which are fused ante-
riorly, but can be easily separated posteriorly.
l There is potential space in the substance of the muscle
between the middle and the deep heads, while the bony
insertion is firm above and below. The intermediate
fibres will have only a loose attachment.
l It is possible for these fibres to be separated from
bone relatively easily by the accumulation of pus at
this site.
l A submasseteric space abscess is produced when the
pus accumulates between the ramus of the mandible
and the masseter muscle.
Involvement
Infection usually originates from the lower third molars,
either resulting from
i. Pericoronitis related to vertical and distoangular third
molars, or
ii. If a periapical abscess spreads subperiosteally in a dis-
tal direction.
Surgical Anatomy
Boundaries
l Anteriorly: Masseter muscle (Anterior border) and buc-
cinator.
l Posteriorly: Parotid gland and posterior part of masseter.
l Inferiorly: Attachment of the masseter muscle to the
lower border of mandible.
l Medially: Lateral surface of the ramus of mandible.
l Laterally: Medial surface of the masseter muscle.
l Contents: Masseteric nerve, superficial temporal artery,
and transverse facial artery.
l It contains muscles of mastication—masseter, lateral and
medial pterygoids, and insertion of temporalis muscle.
Also contains ramus and posterior part of mandible, and
branches of mandibular division of trigeminal nerve.
Section | I  Topic Wise Solved Questions of Previous Years 171

l These branches include: Buccal, lingual, and inferior Cellulitis

alveolar nerves.
Cellulitis is a diffuse inflammation of the soft tissues, which
is not circumscribed or confined to one area, but, which in
Clinical Features contrary to abscess, tends to spread through tissue spaces
l External facial swelling is moderate in size; and is con- along fascial planes.
fined to the outline of the masseter muscle, i.e., the
swelling is seen extending from the lower border of the Clinical Features
mandible to the zygomatic arch, anteriorly to the ante-
l Patient with cellulitis of face originating from dental
rior border of masseter, and posteriorly to the posterior
infection may be moderately ill and has elevated tem-
border of the mandible.‘
perature and leukocytes.
l There is tenderness over the angle of the mandible.
l Painful swelling of the soft tissue involved, the skin is
l There is almost complete limitation of mouth opening.
inflamed and has an orange peel appearance and is even
Fluctuation may be absent; and if present, cannot be
purplish sometimes.
elicited, because the muscle lies between the pus and
l Regional lymphadenitis is present.
the surface.
l Infection arising in maxilla perforates the outer cortical
l There is pyrexia and malaise.
layer of the bone above buccinators attachment and
l The ramus of the mandible is more dependent upon
causes swelling, initially of the upper half lip of the face.
blood supply from the overlying muscle than the body
l When infection in mandible perforates the outer cortical
of the mandible, which is supplied by inferior alveolar
plates below the buccinators attachment, there is a
artery.
diffuse swelling of the lower half of the face, which is
l As a result, ischaemic changes may take place in that
seen as a superior as well as cervical spread.
part of bone denuded by periosteum by a submasseteric
l Spread to cervical tissue can cause respiratory discomfort.
abscess, so that a low-grade osteomyelitis of lateral
cortical plate may occur with sequestrum formation.
l Often submasseteric infection leads to subperiosteal Treatment and Prognosis
new bone deposition beneath the periosteum.
l Antibiotics including anti-anaerobes and also the re-
l Necrosis of the muscle can also occur.
moval of the cause of infection.
Q. 13. Acute osteomyelitis.
Incision and Drainage
Ans.
There are two approaches:

Intraoral approach Acute Osteomyelitis

l An incision is made vertically over the lower part of
l Acute osteomyelitis is sequel of periapical infection that
anterior border of the ramus of the mandible extending
often results in a diffuse spread of infection throughout
deep to the bone.
the medullary spaces with subsequent necrosis of a vari-
l Along the lateral surface of the ramus, a sinus forceps is
able amount of bone.
passed downwards and backwards and the pus is
drained. The drain is inserted and secured with a suture.
l The abscess is usually situated below the level of inci- Clinical Features
sion and not at a point of dependent drainage, and hence
l In maxilla, the lesion remains well localized to the area
the drainage may be inefficient.
of initial infections.
l In mandible, bone involvement tends to be more diffuse
Extraoral approach
and widespread.
l When the mouth cannot be opened, an incision is placed
l Deep intense pain.
in the skin behind the angle of the mandible to open the
l Abscess.
abscess by Hilton’s method.
l High intermittent fever.
l A rubber drain is inserted and secured in position with
l Pus discharge.
a suture. Dressing is applied.
l Trismus.

Q. 12. Cellulitis. l Paraesthesia or anaesthesia of lip.

l Diffuse swelling.
Ans.
l Loosening of tooth.

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172 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Treatment
General principle of management
l Debridement, drainage, and antimicrobial therapy.
l If lesion is large, surgical removal may be necessary.
l Unless proper treatment is instituted, can progress to
periostitis, soft tissue abscess, or cellulitis.
l Pathological fractures may occur because of weakening
of the jaw by destructive process.
Q. 14. Spread of infections from lower first molar and
its management.
Ans.
Spread of Infections from Lower
First Molar
l Spread of infection from lower first molar can give rise
to buccal space infection, if the infection exits from the
buccal aspect of the bone below the attachment of the
buccinators muscle.
l The oblique line of buccinators attachment on the man-
dible generally results in the root apices being above the
origin of the muscle, thereby causing localization of the
infection within the oral vestibule.
l On the lingual aspect of mandible, the attachment of the
mylohyoid muscle roughly parallels the oblique down-
ward and forward course of the buccinators muscle.
SHORT NOTES
Q. 1. Actinomycosis.
Ans.
Actinomycosis
l Actinomycosis is a chronic granulomatous disease
caused by anaerobic or microaerophilic Gram-positive
non-acid fast and branched filamentous bacteria.
l The most commonly isolated organism is Actinomyces
israeli.
l Actinomycosis bovis produces lumpy jaw in cattle, but
is seldom found to be a pathogen in humans.
l Actinomycosis can be classified anatomically according
to the location of the lesion:
a. Cervicofacial.
b. Abdominal.tt
c. Pulmonary forms.
Clinical Features
l In cervicofacial actinomycosis, the organism may enter
the oral mucous membranes and may remain localized
in the subjacent soft tissue or spread to involve the
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l The apices of the premolar and first molar are always
located above the attachment of this muscle.
l Boundaries of this space:
l It is bounded inferiorly by mylohyoid muscle, laterally
and anteriorly by lingual aspect of mandible, superiorly
by the mucosa of the oral cavity, posteriorly at the mid-
line by the body of the hyoid, and medially by geniohy-
oid, genioglossus, and styloglossus muscles.
l Because of the loose connective tissue interspersed be-
tween the latter muscles as well as between the intrinsic
muscle of the tongue, infection of the sublingual space
usually spreads across the midline to the opposite side
as well as into the body of the tongue.
l Such sublingual infections are also known as Ludwig’s
angina.
Management
l The management of the acute infection involves both
supportive and surgical therapy.
l Surgical therapy consists of extraction of the offending
tooth or teeth, incision, and drainage.
l Supportive therapy involves administration of antibiot-
ics, hydration of the patients, administration of analge-
sic for pain, bed rest, application of heat in the form of
moistpacks and/or mouth rinses, and opening the tooth
for drainage.
salivary glands, bones, or the skin of the face and neck,
producing swelling and induration of the tissue.
l The soft tissue swelling eventually develops into one
or more abscesses, which discharge upon a skin sur-
face liberating pus containing the typical ‘sulphur
granules’.
l Abdominal actinomycosis is an extremely serious form
of the disease and carries high mortality rate.
l It presents with fever, chills, nausea, and vomiting.
l Pulmonary actinomycosis produces similar finding of
fever and chills accompanied by a productive cough and
pleural pain.
l The organisms may spread beyond the lungs to involve
adjacent structures.
Q. 2. Garre’s osteomyelitis.
Ans.
Garre’s Osteomyelitis
l Garre’s sclerosing OML is also known as chronic non-
suppurative sclerosing chronic OML with proliferative
periostitis and periossificans.
Section | I  Topic Wise Solved Questions of Previous Years 173

l It is a chronic non-suppurative inflammatory process Q. 4. Acute osteomyelitis.

where there is peripheral subperiosteal bone deposi-
Ans.
tion, which is caused by mild irritation and infection.

Clinical Features Acute Osteomyelitis

l Acute osteomyelitis is sequel of periapical infection that
It Is Characterized By:
l Localized hard and non-tender bony swelling of lateral
often results in a diffuse spread of infection throughout
the medullary spaces with subsequent necrosis of a vari-
and inferior aspects of mandible.
l Lymphadenopathy, hyperpyrexia, and leucocytosis are
able amount of bone.
usually not found.
Clinical Features
Treatment l In maxilla, the lesion remains well localized to the area
of initial infections.
It is directed towards removing sources of inflammation:
l In mandible, bone involvement tends to be more diffuse
a. Removal of infected tooth and curettage of socket.
and widespread.
b. Surgical recontouring: This is done to recontour the
l Deep intense pain.
cortical expansion of the jaw. This is attempted only if
l Abscess.
there is obvious expansion.
l High intermittent fever.
c. Endodontic therapy.
l Pus discharge.
d. Antibiotics: If signs of infection are present.
l Trismus.
e. Follow-up.
l Paraesthesia or anaesthesia of lip.
Q. 3. Masticatory space. l Diffuse swelling.

l Loosening of tooth.
Ans.

Treatment
Masticatory Space
General principle of management
i. Comprise pterygomandibular, submasseteric, superfi-
l Debridement, drainage, and antimicrobial therapy.
cial temporal, anddeep temporal or temporal spaces.
l If lesion is large, surgical removal may be necessary.
ii. All these spaces are well differentiated and communi-
l Unless proper treatment is instituted, can progress to
cate with other fascial spaces; buccal, submandibular,
periostitis, soft tissue abscess, or cellulitis.
and parapharyngeal space infection from one compart-
l Pathological fractures may occur because of weakening
ment may spread to the other compartments.
of the jaw by destructive process.
iii. Amongst the muscles of mastication, only the outer
surface of masseter and inner face of medial pterygoid Q. 5. Mention in brief the predisposing factors for acute
muscles are covered by fascia. alveolar osteitis (Dry socket).
iv. Masticatory spaces are divided into two by the ramus
Ans.
of mandible:
a. Lateral compartment, and b. Medial compartment.
v. Masticatory space is formed by splitting of investing Dry Socket
fascia into superficial and deep layers, which define
Dry socket is defined as failure of approximate healing after
the lateral and medial extent of space.
extraction due to disruption of initial clot with the eventual
vi. The superficial layer lies along lateral surfaces of mas-
lack of organization by granulation tissue.
seter and lower half of temporalis muscles. Superiorly,
the superficial layer fuses with periosteum of zygoma
and temporalis fascia. The deep layer passes along the Causes
medial surface of pterygoid muscles, before attaching l Traumatic extraction—smoking after extraction.
to base of skull superiorly. l Excessive rinsing after extraction.
vii. The masticatory space borders the number of other l Food impaction in socket.
spaces, which include: l Limited local blood supply.
Posteriorly, the parotid space; medially, the parapha-
l Excessive use of vasoconstrictor in LA.
ryngeal space; and inferiorly, the submandibular and
l Previous radiotherapy.
sublingual spaces.

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174 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Q. 6. Mention any eight clinical signs and symptoms of l Medially, by hyoglossus, genioglossus, and geniohyoid
acute osteomyelitis. muscles.
l Posteriorly, by hyoid bone.
Ans.
l Laterally and inferiorly, by mylohyoid muscle and

lingual side of mandible.

Acute Osteomyelitis
Contents
l Acute osteomyelitis is sequel of periapical infection that
Major contents include: Geniohyoid and genioglossus mus-
often results in a diffuse spread of infection throughout
cles and the hyoglossus muscle complex. It also contains:
the medullary spaces with subsequent necrosis of a vari-
i. Deep part of the submandibular salivary gland and its
able amount of bone.
duct anteriorly,
ii. Sublingual salivary gland,
Clinical Features iii. Lingual nerve, and
iv. Hypoglossal nerve.
l In maxilla, the lesion remains well localized to the area
of initial infections. Q. 8. Mention boundaries and contents of pterygoman-
l In mandible, bone involvement tends to be more diffuse dibular space.
and widespread.
l Deep intense pain.
Ans.
l Abscess.

l High intermittent fever. Surgical Anatomy of Pterygomandibular Space

l Pus discharge.

l Trismus.
l Paraesthesia or anaesthesia of lip.
l Diffuse swelling.
l Loosening of tooth.
Q. 7. Give the boundaries and contents of sublingual
space.
Ans.
Sublingual Space
The sublingual space is a V-shaped trough lying laterally to
muscles of tongue including hyoglossus, genioglossus, and
geniohyoid.
Involvement
The teeth which frequently give rise to involvement of sub-
lingual space are the mandibular incisors, canines, premo-
lars, and sometimes first molars. The apices of these teeth
are superior to the mylohoid muscle. The infection perfo-
rates lingual plate below the level of the mucosa of the floor
of the mouth and passes into the sublingual space.
It is a paired space, but the two sides communicate an-
teriorly. This space communicates with submandibular
space around the posterior border of mylohyoid muscle.
Surgical Anatomy
Boundaries
l Superiorly, by the mucosa of floor of the mouth.
l Inferiorly, by mylohyoid muscle.
Boundaries
l Lateral: Medial surface of ramus of mandible.
l Medial: Lateral surface of medial pterygoid muscle.
l Posterior: Parotid gland (deep portion).
l Anterior: Pterygomandibular raphae.
l Superior: Lateral pterygoid muscle forms roof to the
pterygomandibular space. The space just below the lat-
eral pterygoid muscle communicates with the pharyn-
geal spaces.
Contents
l Lingual nerve, mandibular nerve, inferior alveolar or
mandibular artery, mylohyoid nerve and vessels, and
loose areolar connective tissue.
Q. 9. Mention boundaries and contents of submental
space.
Or
Submental space.
Ans.
Boundaries and Contents of Submental
Space
Boundaries
l Lateral: Lower border of mandible and anterior bellies
of digastric muscle.
l Superior: Mylohyoid muscle.
l Inferior: Suprahyoid portion of the investing layer of

l Laterally, by medial side of the mandible above the

deep cervical facia, which is in turn covered by the pla-
mylohyoid muscle. tysma, superficial fascia, and skin.

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Section | I  Topic Wise Solved Questions of Previous Years
Contents
l Submental lymph nodes and anterior jugular veins. The
lymph nodes lie embedded in adipose tissue, and hence
submental abscesses tend to remain well circumscribed.
Q. 10. State the factors affecting spread of infection of
odontogenic origin.
Ans.
Factors Affecting Spread of Infection of
Odontogenic Origin
A. General Factors
1 . Host resistance.
2. Virulence of microorganisms.
3. Compromised host defences.
4. Combination of both.
B. Local Factors
Intact anatomical barriers
l Alveolar bone: As the infection progresses within
the bone, it spreads in the radical manner and extends to
the cortical plates.
l Periosteum: It is next to local barrier. It does not pro-
vide much resistance and the infection spreads into the
adjacent surrounding soft tissues.
l Adjacent muscles and fascia: It is next site of localization.
Q. 11. Quinsy.
Ans.
Peritonsillar Abscess (Quinsy)
It is a localized infection in the connective tissue bed be-
tween the tonsil and the superior constrictor muscle, and
between the anterior and posterior pillars of fauces.
Involvement
i. Infection coming from the depth of the tonsillar crypt
or supratonsillar fossa.
ii. As a complication of acute pericoronal abscess in
which case, the abscess points near the lower pole of
the tonsil.
Clinical Features
i. Patient looks ill, anoxic, and dehydrated.
ii. Pain on one side of the throat radiating to the ear.
iii. Dysphagia.
iv. Limitation of mouth may not be pronounced.
v. Speech is difficult, especially in bilateral cases and
a peculiar muffled ‘hot potato in mouth’ voice is c. Pulmonary forms.
characteristic.
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175
vi. Drooling of saliva.
vii. When the abscess is fully developed, a large tense
swelling of anterior pillar of fauces and a bulge in the
soft palate on the affected side which in extreme cases
reaches the midline; and pushes the uvula downwards
and forwards, until it impinges against the opposite
tonsil.
viii. Coated tongue with marked foetor oris.
Incision and Drainage
It can be achieved by using a guarded knife and sinus
forceps which are inserted into the most prominent part of
the soft palate where the fluctuation is the maximal.
Spread
Oedema may eventually affect the base of the tongue, epi-
glottis, and aryepiglottic fold. In three to five days duration,
the mass becomes fluctuant and ruptures by pointing usu-
ally through the anterior tonsillar pillar.
Q. 12. Abscess.
Ans.
Abscess
l A circumscribed collection of pus in a pathological
tissue space is known as an abscess.
l A true abscess is a thick-walled cavity containing pus.
l The suppurative infections are characteristic of staphy-
lococci, often with anaerobes, such as bacteroides; and
are usually associated with large accumulation of pus,
which require immediate drainage.
l These microorganisms produce coagulase, an enzyme
that may cause fibrin deposition in citrated or oxalated
blood.
Q. 13. Lumpy jaw.
Ans.
Lumpy Jaw
l Actinomycosis is a chronic granulomatous infection
caused by anaerobic or microaerophilic Gram-positive
non-acid fast and branched filamentous bacteria.
l The most commonly isolated organism is Actinomyces
israeli.
l Actinomycosis bovis produces lumpy jaw in cattle, but
is seldom found to be a pathogen in humans.
l Actinomycosis can be classified anatomically according
to the location of the lesion:
a. Cervicofacial.
b. Abdominal.
176 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Facial Neuropathology
LONG ESSAYS
Q. 1. Nerve injuries in oral surgery.
Or
Classification of injuries of trigeminal nerve.
Ans.
l Injuries to peripheral branches of the fifth (trigeminal)
nerve is ever-present risk during surgical procedures
performed in the oral cavity and associated maxillofa-
cial region.
Classification of Mechanical Nerve Injuries
l Classification of nerve injuries helps the clinician in
making a diagnosis, developing a rational plan of man-
agement, determining the need for and timing of surgical
intervention, and estimating the prognosis of an injury.
Seddon (1943) and Sunderland (1978) have proposed
nerve injury classifications.
l It is applied to both motor as well as sensory nerves.
Seddon’s Classification
1. Neuropraxia
l Mild, temporary injury caused by compression or re-
traction of the nerve.
l There is no axonal degeneration distal to the area of
injury.
l There is a temporary conduction block—sensory loss.
l Spontaneous recovery usually occurs within four weeks
or less time.
l No surgical intervention is required.
2. Axonotmesis
l More significant injury—there is disruption or loss of
continuity of some axons.
l Undergo Wallerian degeneration distal to the site of injury.
l The general structure of the nerve remains intact.
l There is prolonged conduction failure.
l Initial signs of recovery of nerve function do not appear
for 1–3 months after injury.
l Eventual recovery is often less than normal (paresis and
hypoaesthesia).
l Sensory nerve injuries may develop persistent painful
sensation (dysaesthesias).
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Topic 15
3. Neurotmesis
l It is the complete severance or internal physiologic
disruption of all layers of the nerve.
l Wallerian degeneration of all axons occurs distal to the
injury.
l There is a total permanent conduction block of all
impulses (paralysis and anaesthesia).
l The discontinuity gap between proximal and distal
nerve stumps becomes filled up with scar tissue, and
proximal axonal sprouts are prevented from recannulat-
ing distal endoneurial tubules.
l No recovery is expected without surgical intervention.
l Sunderland’s classification is based on pathophysiology
and anatomy of the injured nerve.
l It also incorporates the features of Seddon’s scheme that
includes the amount of nerve tissue damaged and tissue
still intact.
1. Neuropraxia (Seddon)/First degree lesion
(Sunderland)
l It is characterized by a conduction block, the rapid and
virtually complete return of sensation or function with
no degeneration of axon.
l There are three types of first degree nerve injuries based
on the proposed mechanism of conduction block.
a. First degree type I injury: It may be the result of
nerve trunk manipulation, mild traction, or mild
compression, such as during sagittal split ramus
osteotomy, inferior alveolar nerve repositioning, or
lingual nerve manipulation during excision of sub-
lingual or submandibular salivary gland.
b. First degree type II injury: It may be caused by mod-
erate manipulation, traction, or compression of a
nerve.
Trauma of sufficient magnitude to injure the endo-
neurial capillaries cause intrafascicular oedema and
results in a conduction block.
Normal sensation or function returns within 1–2
days following the resolution ofintrafascicular
oedema, generally one week following nerve
injury.
c. First degree type III injury: It results from severe
nerve manipulation, traction, or compression pres-
sure on the nerve, which may result in segmental
demyelination or mechanical disruption of the
Section | I  Topic Wise Solved Questions of Previous Years
myelin sheath. Sensory and functional recoveryare
complete within 1–2 months.
The psychophysical response to this type of injury is
paraesthesia.
Surgery is not indicated for first degree nerve injuries.
a. Axonotmesis (Seddon)/Second Degree
Sunderland Nerve Injury
l It is characterized by axonal injury with subsequent
degeneration and regeneration.
l Traction and compression are the usual mechanisms
of this type of nerve injury and may cause severe Ans.
ischaemia, intrafascicular oedema, or demyelination.
l Even though the axons are damaged, there is no dis-
ruption of the endoneurial sheath, perineurium, or
epineurium. Within 2–4 months following injury there
are signs of sensation or function, which continue to
improve over the next 8–10 months.
b. Axonotmesis (Seddon)/Third Degree
Sunderland Nerve injury
l The aetiology of a third degree nerve injury is typically
traction or compression.
l Not only is the axon damaged, but the endoneurial sheath
is breached resulting in intrafascicular disorganization;
while the perineurium and epineurium remain intact.
l The first signs of sensation or function are evident within
2–5 months and may take another 10 months or so.
l Recovery is never complete.
c. Axonotmesis (Seddon)/Fourth Degree
Sunderland Nerve Injury
l The aetiology of a fourth degree nerve injury may
include traction, compression, injection injury, and
chemical injury.
l The injection of chemical agents into the nerve trunk
may cause irreversible damage to the axons and connec-
tive tissue components of the nerve trunk.
l Fourth degree nerve injuries are characterized by dis-
ruption of the axon, endoneurium, and perineurium in-between the attacks.
with preservation of the continuity of the epineurium,
resulting in severe fascicular disorganization.
l There is poor prognosis for recovery and a high proba-
bility of development of central neuroma incontinuity.
Neurotmesis (Seddon)/Fifth Degree Sunderland
Nerve Injury
l It is characterized by severe disruption of connective
tissue components of the nerve trunks with compro-
mised sensory and functional recovery.
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177
l There is considerable amount of tissue loss also.
l The mechanisms of this injury include laceration, avul-
sion, and chemical injury.
l There is damage to all components of the nerve trunk:
Axon, endoneurium, perineurium, and epineurium.
Q. 2. Describe signs and symptoms and management of
trigeminal neuralgia.
Or
What is trigeminal neuralgia? Describe the various
medical and surgical treatments.
Trigeminal Neuralgia
l Trigeminal neuralgia (TN) is defined as sudden, usually
unilateral, severe, brief, stabbing, lancinating, and re-
curring pain in the distribution of one or more branches
of fifth cranial nerve.
Clinical Features
l Trigeminal neuralgic pain typically arises in persons,
who have no abnormal neurologic deficit such as loss of
corneal reflexes, anaesthesia, paraesthesia, or muscular
atrophy or weakness, etc.
l TN typically manifests as a sudden, unilateral, intermit-
tent paroxysmal, sharp, shooting, lancinating, shock-
like pain, which is elicited by slight touching superficial
‘trigger points’ that radiates from that point across the
distribution of one or more branches of the trigeminal
nerve.
l Pain is usually confined to one part of one division of
trigeminal nerve—mandibular or maxillary, but may
occasionally spread to an adjacent division or rarely
involve all three divisions.
l Pain rarely crosses the midline.
l The pain is of short duration and lasts for a few seconds,
but may recur with variable frequency. Even though
there is a refractory period (complete lack of pain)
between the attacks, some patients report a dull ache
l During an attack, the patient grimaces with pain,
clutches his hands over the affected side of the face
stopping all the activities, and holds or rubs his face,
which may redden the eyes or the eyes water until the
attack subsides.
l Male patients avoid shaving. The oral hygiene is poor,
as patient avoids brushing of teeth.
l The paroxysms occur in cycles, each cycle lasting for
weeks or months and with time, the cycle appears closer
and closer. With each attack, the pain seems to become
more intense and unbearable.
178 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l In extreme cases, the patient will have a motionless
face—the ‘frozen- or mask-like face’.
l Presence of an intraoral or extraoral trigger point that
is provokable by obvious stimuli is seen in TN. It may
be brought on by touching face at a particular site or l Such as bupivacaine with or without corticosteroids
by chewing or even by speaking or smiling, brushing,
shaving, or even washing the face, etc.
l The location of the trigger points depends on which
division of trigeminal nerve is involved.
i. In V2, the points are located on the skin of the upper
lip, ala nasi, cheek, or on the upper gums.
ii. In V3, this is the most frequently involved branch.
Trigger points are seen over the lower lip, and
teeth or gums of the lower jaw. Tongue is rarely
involved.
iii. In V4, the trigger zone usually lies near the supraor-
bital ridge of the affected side.
l It is characteristic of the disorder that attacks do not
occur during sleep.
l Many patients will lead a very poor quality of life,
because of excruciating pain.
l It is very common for these patients to undergo indis-
criminate dental extractions on the affected side without
any relief from pain, because the pain of the trigger
zoneand the pain fibre distributions, often mimic pain of
odontogenic origin.
Management
Treatment can be divided into:
I. Medicinal.
II. Surgical
I. Medicinal management
l This is the first line approach for most of the patients.
l TN does not respond to analgesics including opiates.
l Carbamazapine 100 mg three times a day.
l When carbamazepine is contraindicated, clonazepam
15 mg day can be used.
l Tab. Phenytoin: Dose-100 mg three times a day.
l Tab. Oxcarbazepine 1200 mg/day.
l Valproic acid 600 mg/day.
l Mephenesin Carbamate (Tolceram) 5–15 mL five times
a day for every 3 h.
Other less toxic agents
l Baclofen (Lioresal) 10 mg tds. Side effects include
fatigue and vomiting.
l Neurontin is the recently introduced drug.
l Lamotrigine.
l Gabapentin.
l Felbamate.
l Topiramate.
l Vigabatrin.
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II. Surgical management (Peripheral nerve surgical
treatments)
Peripheral injections
a. Long-acting anaesthetic agents without adrenaline
may be injected at the most proximal possible nerve
site.
l The selective nerve blocks can be given as an emer-
gency measure where the patient is suffering
quite a lot, but the pain-free period will be very
short-lived.
l The injection can be repeated, when the pain recurs.
b. Alcohol injections
Peripheral branches of trigeminal nerve can be blocked
by the intraoral injection of 95% absolute alcohol in small
quantities (0.5–2 mL).
l This produces anaesthesia of the region supplied by the
branch.
l Repeated alcohol injections should be avoided, as it
causes local tissue toxicity, inflammation, and fibrosis.
l It can also cause a complication of burning alcohol neu-
ritis. The results are variable.
l Extraoral injections into maxillary and mandibular divi-
sion of the trigeminal nerve at the level of the base of
the skull also can be given.
l Peripheral injections—infraorbital, mental, and inferior
alveolar nerve blocks can be given depending on the
involvement.
Peripheral neurectomy (nerve avulsion)
l Simple, oldest, and most effective technique which can
be repeated and is the relatively reliable method of
nerve avulsion.
l It acts by interrupting the flow of a significant number
of afferent impulses to central trigeminal apparatus.
l Indicated in patients in whom craniotomy is contraindi-
cated, because of age, debility, or significant systemic
diseases with limited life expectancy.
l Performed most commonly on infraorbital, inferior
alveolar, mental, and rarely lingual nerves.
l It has a disadvantage of producing full anaesthesia or
deep hypoesthesia related dysfunction.
l To achieve better results, the peripheral nerve is always
avulsed both from the bone as well as from the soft tissues.
l The duration of pain remission after neurectomy may be
lengthened, if the cut nerve end is cauterized or redi-
rected and sutured into viable muscle, periosteum, or
bone tissue to prevent active neuroma formation.
l The bony foramen may be plugged with non-absorbable
material or by the bone piece itself.
l The procedure is carried out under general anaesthesia
to ensure successful avulsion.
Section | I  Topic Wise Solved Questions of Previous Years
Infraorbital neurectomy
It can be performed through (i) conventional intraoral l Inadvertent section of the vessels in the pterygopalatine
approach or (ii) Braun’s transantral approach.
i. Conventional intraoral approach
l A U-shaped Caldwell-Luc incision is made in the
upper buccal vestibule in the canine fossa region.
l Mucoperiosteal flap is reflected superiorly to locate
the infraorbital foramen.
l Once the nerve is exposed, all the peripheral
branches are held with the haemostat and avulsed
from the skin surface intraorally.
l Then the entire trunk separated from the skin sur-
face is held with the haemostat at the exit point from
the foramen and is removed by winding it around a
haemostat and pulling it out from the foramen.
l The infraorbital foramen may be plugged with poly-
ethylene plug and wound is closed with interrupted
sutures.
ii. Braun’s transantral approach (1977)
l It has got the potential to have sound treatment for
intractable V2 neuralgia, because of the direct access
and visualization it provides.
l With sectioning of the maxillary nerve, anaesthesia
is created over its entire distribution.
l An intraoral incision is made from the maxillary
tuberosity to the midline in the maxillary vestibule.
l The mucoperiosteal flap is reflected to expose the
anterior and lateral maxillary antral wall, the zy-
goma, and the infraorbital nerve.
l A 3 cm window is made in the anterolateral wall of
the maxillary sinus.
l The operating microscope is usually required for the
remainder of the procedure.
l The lining in the posterosuperior portion of the an-
trum is carefully excised and bone is removed to
create a posterior window.
l Careful dissection is now performed to expose
the descending palatine branches of V2, which
are then traced superiorly to the sphenopalatine
ganglion.
l In order to provide anatomical verification, the
infraorbital nerve is identified in the roof of from the foramen.
the maxillary sinus and is carefully followed poste-
riorly to the trunk of V2 near the sphenopalatine
ganglion.
l Dissection is then completed by isolating and iden-
tifying the trunk of V2 superiorly and posteriorly to
the sphenopalatine ganglion.
l The trunk of the maxillary nerve (V2) is then sec-
tioned posterior near the foramen rotundum to the
inferior orbital fissure.
l The antral mucoperiosteal flap in the vestibule is
repositioned and sutured back.
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179
Complications
fossa.
l Inadvertent sectioning of the branches of the spheno-
palatine ganglion or the vidian nerve entering the pos-
terior aspect of the ganglion.
Inferior alveolar neurectomy
l It can be performed via intraoral or extraoral
approach.
l The intraoral approach is preferred, as it is simple and
more cosmetic.
1. Extraoral approach
l It is through Risdon’s incision, whereafter reflection of
masseter, a bony window is drilled in outer cortex and
nerve is lifted with nerve hook and avulsed from its
superior attachment; and mental nerve is avulsed anteri-
orly through the same approach.
2. Intraoral approach via Dr Ginwalla’s incision
l It is mainly used in dentulous cases.
l Incision is made along the anterior border of ascending
ramus, extending lingually and buccally and ending in a
fork, like an inverted Y.
l Such incision provides better exposure of the field.
l The incision is then deepened on the medial aspect
of the ascending ramus by means of blunt and sharp
dissection.
l The temporalis and medial pterygoid muscles are split,
rather than divided at their insertion and the inferior
alveolar nerve is located.
l Two heavy black linen threads are then looped around
the nerve using nerve hook and then divided between
the two threads.
l This is done as high as possible and the upper end is
cauterized while dividing and lower end is held with the
haemostat.
l Another linear incision is made in the buccal vestibule
overlying the mental foramen.
l A mucoperiosteal flap is reflected to expose the mental
nerve.
l It is then tied with heavy black linen just little away
l The nerve is then caught with the haemostat distal to the
knot and is divided between the two.
l The distal part held between the haemostat is wound
around it and the peripheral branches entering the
mucosa are avulsed out.
l There is puckering of the skin surface seen during this
procedure.
l Now after the mental nerve is freed, then at the man-
dibular foramen, the distal part of the nerve which
is held with the haemostat is pulled, until the entire
nerve length of the canal is avulsed out.
180 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l If any obstruction is encountered, a window may be made l Keeping the two sides of the incision retracted, the dissec-
in the buccal cortex posterior to the mental foramen along tion is continued downwards until the lingual nerve comes
the level of the inferior alveolar canal and the nerve is into view at the border of the medial pterygoid muscle.
lifted out of the canal through the window. l In the region of the floor of the mouth, the nerve lies

l The wound is closed with interrupted sutures. even more superficially and it can be easily found be-
tween the anterior pillar of the fauces at the root of the
Lingual neurectomy tongue.
l A vertical incision is made at the inner border of the l After dissection, the nerve is grasped with a haemostat

ascending ramus, extending from the coronoid process and is then either avulsed or cauterized and cut.
down the level of the floor of the mouth. l The wound is closed with interrupted sutures.

SHORT ESSAYS
Q. 1. Trigeminal neuralgia. l The oral hygiene is poor, as patient avoids brushing of teeth.
l The paroxysms occur in cycles, each cycle lasting for
Or
weeks or months and with time, the cycle appears closer
Clinical features and medical management of trigemi- and closer. With each attack, the pain seems to become
nal neuralgia. more intense and unbearable.
l In extreme cases, the patient will have a motionless
Or
face—the ‘frozen- or mask-like face’.
Any four clinical characteristics of trigeminal neuralgia l Presence of an intraoral or extraoral trigger point that
is provokable by obvious stimuli is seen in TN. It may
Or
be brought on by touching face at a particular site or
Management of trigeminal neuralgia. by chewing or even by speaking or smiling, brushing,
shaving, or even washing the face, etc.
Ans.

Medicinal Management
Trigeminal Neuralgia
Medicinal line of treatment (Modification of the paroxysmal
l Trigeminal neuralgia (TN) is defined as sudden, usually
pain at cortical level)
unilateral, severe, brief, stabbing, lancinating, and re-
l This is the first line approach for most of the patients.
curring pain in the distribution of one or more branches
l TN does not respond to analgesics including opiates.
of fifth cranial nerve.
l Carbamazapine 100 mg three times a day.

l When carbamazepine is contraindicated, clonazepam

Clinical Features 15 mg/day can be used.
l Tab. Phenytoin: Dose-100 mg three times a day.
l TN manifests as a sudden, unilateral, intermittent par-
l Tab. Oxcarbazepine 1200 mg/day.
oxysmal, sharp, shooting, lancinating, and shock-like
l Valproic acid 600 mg/day.
pain elicited by slight touching superficial ‘trigger
l Mephenesin carbamate (Tolceram) 5–15 mL five times
points’, which radiates from that point across the distri-
a day for every 3h.
bution of one or more branches of the trigeminal nerve.
l Pain is usually confined to one part of one division of Other less toxic agents
trigeminal nerve—mandibular or maxillary, but may l Baclofen (Lioresal) 10 mg tds. Side effects include
occasionally spread to an adjacent division or rarely in- fatigue and vomiting.
volve all three divisions. l Neurontin is the recently introduced drug.
l Pain rarely crosses the midline. l Lamotrigine.
l The pain is of short duration and lasts for a few seconds, l Gabapentin.
but may recur with variable frequency. Even though l Felbamate.
there is a refractory period (complete lack of pain) be- l Topiramate.
tween the attacks, some patients report a dull ache in- l Vigabatrin.
between the attacks.
Q. 2. Aetiology and clinical features of Belly’s Palsy.
l During an attack, the patient grimaces with pain, clutches

his hands over the affected side of the face stopping all Or
the activities, and holds or rubs his face, which may red-
Facial palsy.
den the eyes or the eyes water until the attack subsides.
l Male patients avoid shaving. Ans.

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Section | I  Topic Wise Solved Questions of Previous Years
Aetiology of Bell’s Palsy
l Change in the atmospheric pressure, e.g., while flying
or dying.
l Malignant tumours of parotid gland and brain.
l Stroke.
l Surgical procedures in the parotid region.
l Meningitits.
l Head injuries.
l Multiple sclerosis.
l Infections:Acute otitis media and Herpes simplex virus
infection.
l Exposure to common cold.
Clinical Features of Bell’s Palsy
l Paralysis of facial nerve causes loss of all or many of the
functions as mentioned.
l Most commonly seen in middle-aged females, mostly
unilaterally.
l The patient cannot close his eyes on the affected side
due to loss of muscle control, which results in constant
watering from eyes that can cause conjunctival dryness
or even ulceration.
l Drooping of the corner of the mouth on the affected side.
l The corner of the mouth on the affected side does not
rise during smile and this gives the patient a typical
‘mask-like’ expressionless appearance.
l Patients have difficulties in speech, taking food, and
there may be even loss of taste sensations.
l They cannot raise their eyebrows and there is no wrinkle
formation in their forehead.
l Patient fails to blow whistle.
Q. 3. Infraorbital neurectomy.
Ans.
Infraorbital Neurectomy
Infraorbital neurectomy can be performed through
(i) Conventional intraoral approach or (ii) Braun’s transan-
tral approach.
I. Conventional Intraoral Approach
l A U-shaped Caldwell-Luc incision is made in the upper
buccal vestibule in the canine fossa region.
l Mucoperiosteal flap is reflected superiorly to locate the
infraorbital foramen.
l Once the nerve is exposed, all the peripheral branches
are held with the haemostat and avulsed from the skin
surface intraorally.
l Then the entire trunk separated from the skin surface is
held with the haemostat at the exit point from the fora-
men and is removed by winding it around a haemostat
and pulling it out from the foramen.
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181
l The infraorbital foramen may be plugged with polyeth-
ylene plug and wound is closed with interrupted sutures.
Braun’s Transantral Approach (1977)
l It has got the potential to have sound treatment for
intractable V2 neuralgia, because of the direct access
and visualization it provides.
l With sectioning of the maxillary nerve, anaesthesia is
created over its entire distribution.
l An intraoral incision is made from the maxillary tuber-
osity to the midline in the maxillary vestibule.
l The mucoperiosteal flap is reflected to expose the ante-
rior and the lateral maxillary antral wall, the zygoma,
and the infraorbital nerve.
l A 3 cm window is made in the anterolateral wall of the
maxillary sinus.
l The operating microscope is usually required for the
remainder of the procedure.
l The lining in the posterosuperior portion of the antrum
is carefully excised and bone is removed to create a
posterior window.
l Careful dissection is now performed to expose the
descending palatine branches of V2, which are then
traced superiorly to the sphenopalatine ganglion.
l In order to provide anatomical verification, the infraor-
bital nerve is identified in the roof of the maxillary sinus
and is carefully followed posteriorly to the trunk of V2
near the sphenopalatine ganglion.
l Dissection is then completed by isolating and identify-
ing the trunk of V2superiorly and posteriorly to the
sphenopalatine ganglion.
l The trunk of the maxillary nerve (V2) is then sectioned
posterior near the foramen rotundum to the inferior
orbital fissure.
l The antral mucoperiosteal flap in the vestibule is repo-
sitioned and sutured back
Complications
l Inadvertent section of the vessels in the pterygopalatine
fossa.
l Inadvertent sectioning of the branches of the spheno-
palatine ganglion or the vidian nerve entering the poste-
rior aspect of the ganglion.
Q. 4. Atypical facial pain.
Ans.
Atypical Facial Pain
Atypical facial pain refers to mixed group of conditions,
which are defined and diagnosed by exclusion of the other
typical patterns of facial pain.
It is also called as typical facial neuralgia, idiopathic
facial pain, atypical trigeminal neuralgia, and trigeminal
neuropathic pain.
182 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
There is occurrence of strong emotional overtones of
the condition.
It is usually psychogenic and occurs in patients who
suffer from depressive reaction, hysteria, or schizophrenia.
Clinical Features
l Common in sixth decade and women most commonly
affected.
l The condition is characterized by pain that is deep,
poorly localized, and vaguely described by the patient.
l Pain is often boring, pressing, pulling, burning, or ach-
ing. Distribution of pain is not anatomical, in general it
is constant.
l Pain is referring to temple, neck, and occipital area.
l The mucosa of the affected person may contain zone of
increased temperature and bone marrow activity show-
ing hot spot on technetium 99m MDP bone scan.
Management
l Opioid analgesics can be given to patient, but they may
be diminished over a period of time.
l Tricyclic anti-depressants like amitriptyline and nortrip-
tyline are used for many cases. These should be given
cautiously for the patient suffering from coronary heart
disease.
l Other therapies like psychotherapy, behaviour modifica-
tion, transcutaneous electrical nerve stimulation, and sym-
pathetic nerve block are helpful in atypical facial pain.
Q. 5. Trigger zones.
Ans.
l Presence of an intraoral or extraoral trigger point that is
provokable by obvious stimuli is seen in TN. It may be
brought on by touching face at a particular site or by
chewing or even by speaking or smiling, brushing, shav-
ing, or even washing the face, etc.
l The location of the trigger points depends on which
division of trigeminal nerve is involved.
i. In V2, the points are located on the skin of the upper
lip, ala nasi, cheek, or on the upper gums.
ii. In V3, this is the most frequently involved branch.
Trigger points are seen over the lower lip, and teeth
or gums of the lower jaw. Tongue is rarely involved.
iii. In V4, the trigger zone usually lies near the supraor-
bital ridge of the affected side.
l It is characteristic of the disorder that attacks do not
occur during sleep.
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l Many patients will lead a very poor quality of life,
because of excruciating pain.
l It is very common for these patients to undergo indiscrimi-
nate dental extractions on the affected side without any re-
lief from pain, because the pain of the trigger zone and pain
fibre distributions, often mimic pain of odontogenic origin.
Q. 6. Analgesics for orofacial pain.
Ans.
Analgesics for Orofacial Pain
l Tab. Carbamazepine 100 mg thrice a day
l Tab. Phenytoin 100 mg thrice a day.
l Valproic acid 600 mg/day.
l Mephenesin carbamate (Tolceram) 5–15 mL five times
a day for every 3 h.
Other less toxic drugs are:
l Baclofen10 mg tds.
l Gabapentin.
l Lamotrigine.
l Felbamate.
l Topiramate.
l Vigabatrin.
Q. 7. Cryosurgery.
Or
Cryosurgery - Principles and indications in oral lesions.
Ans.
Cryosurgery
Cryosurgery is the technique of using extreme rapid cool-
ing to freeze and thereby destroy tissue.
Rapid cooling to temperatures below freezing point
produces a localized destructive effect than slow freezing,
which causes generalized tissue necrosis.
The apparatus consists of:
1. Bottles for storage of pressurized liquid gases.
2. Liquid nitrogen gives a temperature of -196°C, while
liquid carbon dioxide or nitrous dioxide gives a tem-
perature between 220 to 290°C.
3. A pressure and a temperature gauge.
4. A probe: The probe is connected to the bottles via a tube
through which the pressurized gas can be directed at the
tissue to be destroyed.
It is applied in the treatment of malignancies, vascular tu-
mours, and aggressive tumours like ameloblastoma.
Section | I  Topic Wise Solved Questions of Previous Years 183

SHORT NOTES
Q. 1. Bell’s palsy. l The eye on the affected side has to be protected from
infections by using protective glasses, eye drops, and
Or ointments.
Bell’s sign. Q. 2. What are trigger zones? Name their location on
Ans. the face with the relevant nerve.
Ans.
Bell’s Palsy
Bell’s palsy refers to the paralysis of facial nerve resulting Trigger Zones and their Locations on the Face
in inability to control the facial muscles on the affected side l Presence of an intraoral or extraoral trigger point that is
of the face. provokable by obvious stimuli is seen in TN. It may be
brought on by touching face at a particular site or by
Aetiology of Bell’s Palsy chewing or even by speaking or smiling, brushing, shav-
ing, or even washing the face, etc.
l Change in the atmospheric pressure, e.g., while flying l The location of the trigger points depends on which di-
or dying. vision of trigeminal nerve is involved.
l Malignant tumours of parotid gland and brain.
i. In V2, the points are located on the skin of the upper
l Surgical procedures in the parotid region.
lip, ala nasi, cheek, or on the upper gums.
l Meningitits.
ii. In V3, this is the most frequently involved branch.
l Head injuries.
Trigger points are seen over the lower lip, and teeth
l Multiple sclerosis.
or gums of the lower jaw. Tongue is rarely involved.
l Infections: Acute otitis media and Herpes simplex virus
iii. In V4, the trigger zone usually lies near the supraor-
infection. bital ridge of the affected side.
l Exposure to common cold.
l It is characteristic of the disorder that attacks do not oc-

cur during sleep.

Clinical Features l Many patients will lead a very poor quality of life, be-

cause of excruciating pain.

l Paralysis of facial nerve causes loss of all or many of the
l It is very common for these patients to undergo indis-
functions as mentioned.
criminate dental extractions on the affected side without
l Most commonly seen in middle-aged females, mostly
any relief from pain, because the pain of the trigger zone
unilaterally.
and pain fibre distributions, often mimic pain of odon-
l The patient cannot close his eyes on the affected side
togenic origin.
due to loss of muscle control, which results in constant
watering from eyes that can cause conjunctival dryness Q. 3. Cryosurgery.
or even ulceration.
Or
l Drooping of the corner of the mouth on the affected

side. What is cryosurgery?

l The corner of the mouth on the affected side does not
Ans.
rise during smile and this gives the patient a typical
‘mask-like’ expressionless appearance.
l Patients have difficulties in speech, taking food, and Cryosurgery
there may be even loss of taste sensations.
Cryosurgery is the technique of using extreme rapid cool-
l They cannot raise their eyebrows and there is no wrinkle
ing to freeze and thereby destroy tissue.
formation in their forehead.
Rapid cooling to temperatures below freezing point
l Patient fails to blow whistle.
produces a localized destructive effect than slow freezing,
which causes generalized tissue necrosis.
Management The apparatus consists of:
1. Bottles for storage of pressurized liquid gases.
l No specific treatment.
2. Liquid nitrogen gives a temperature of -196°C, while
l Administration of histamines or nicotinic acid has been
liquid carbon dioxide or nitrous dioxide gives a tem-
beneficial in some cases.
perature between 220 to 290°C.
l Physiotherapy is also helpful in some patients.

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184 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

3 . A pressure and a temperature gauge. g

4. A probe: The probe is connected to the bottles via a tube They ascend up a trigeminal lemniscus to reach thalamus
through which the pressurized gas can be directed at the and synapse in VPM nucleus
tissue to be destroyed. g
From here third order fibres take origin and pass through
It is applied in the treatment of malignancies, vascular
internal capsule
tumours, and aggressive tumours like ameloblastoma.
g
Q. 4. Pathways of pain. Ends up in cerebral cortex area no. 3, 1, and 2
(Centre for pain perception)
Ans.
Q. 5. Tinnel’s sign.
Receptors
g Ans.
Fibres carrying pain take origin
g
Tinnel’s Sign
They merely pass through chief sensory nucleus in PONS
g l Tinnel’s sign was used earlier as an indication of the
Fibres descend down in CNS and synapse in spinal nu- start of nerve regeneration.
cleus of V nerve l It is elicited by percussion over the divided nerve, which
g results in a tingling sensation in the part supplied by the
Second order fibre take origin and crosses midline peripheral section.

Topic 16
Preprosthetic Surgery

LONG ESSAYS
Q. 1. Classify preprosthetic surgical procedure and the II. Secondary Preparations
procedure to increase the depth of lingual sulcus. Add a
note on Kazanjian’s technique. . Epulis fissuratum removal.
A
B. Correction of reactive inflammatory papillary
Ans. hyperplasia.
C. Ridge extension procedures.
I. Initial Preparations a. Labiobuccal vestibuloplasty.
i. Mucosal advancement vestibuloplasty.
A. Correction of soft tissue deformities l Closed submucous vestibuloplasty.
a. Frenectomy l Open view vestibuloplasty.
i. Labial. ii. Secondary epithelialization
ii. Lingual. l Labial approach.
b. Correction of mobile soft tissue on the alveolar ridge l Kazanjian’s method.
c. Denture granuloma l Godwin’s method.
B. Correction of hard tissue deformities—alveoloplasty l Lipswitch method.
l Torus removal. l Clark’s method.
l Mandibular. iii. Grafting vestibuloplasty
l Maxillary. l Obwegeser’s method.
l Sharp ridge removal. iv. Maxillary pocket inlay vestibuloplasty
l Shelf reduction. b. Lingual vestibuloplasty
l Resection of genial tubercle. i. Trauner’s technique.
C. Correction of soft and hard tissue deformities—tuberosity ii. Caldwell’s technique.
l Tuberosity reduction. Combination vestibuloplasty (labial and lingual)
l Tuberoplasty. i. Obwegeser’s technique

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Section | I  Topic Wise Solved Questions of Previous Years
. Mental nerve transpositioning.
D Q. 2. What is preprosthetic surgery? Describe how will
E. Ridge augmentation procedures.
F. Alveolar distraction osteogenesis.
Soft tissue attachments on the lingual aspect can interfere
with prosthetic rehabilitation. Posteriorly, the mylohyoid
muscle and anteriorly, the genioglossus muscle on the lin-
gual surface of the mandible are the two problem areas.
I. Technique provides an adequate denture-bearing area,
hence improves retention and stability.
II. Eliminates the muscle attachments that dislodge the
prosthesis.
III. Used in the mandible, when the mylohyoid and genio-
glossus attachments are close to the alveolar ridge.
Following methods are adapted for lingual vestibuloplasty:
l Trauner’s technique.
l Caldwell’s technique.
l Obwegeser’s technique (1963).
Caldwell’s Technique
l An incision is made in the crest of the posterior man-
dibular ridge extending from one molar to the other
region.
l Subperiosteal dissection is carried out and thickness
mucoperiosteal flap is elevated and reflected medially.
l The mylohyoid muscle is detached and mylohyoid ridge
is removed or reduced.
l The subperiosteal stripping is carried out till the
desired depth and so even to the inferior border of the
mandible.
l A rubber catheter is placed in the bottom of the lingual
sulcus and is secured with percutaneous suture. It is left
in place for 7–10 days.
Kazanjian’s Technique for Vestibuloplasty
l An incision is made in the mucosa of the lip and a large
flap of labial and vestibular mucosa is retracted.
l The mentalis muscle is detached from the periosteum to
required depth, and the vestibule is deepened via supra-
periosteal dissection.
l A flap of the mucosa is turned downwards from the at-
tachment of the alveolar ridge and is placed directly
against the periosteum to which it is sutured.
l A rubber catheter stent can be placed in the deepened
sulcus and secured with percutaneous sutures.
l This catheter helps to hold the flap in its new position
and maintain the depth of the vestibule. It is removed
after seven days.
l The labial donor site is coated with tincture of benzoin
compound, and the surface heals by granulation and
secondary epithelialization. Contracture of the wound
margins takes place.
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185
you perform in upper anterior region?
Ans.
Preprosthetic Surgery
‘Preprosthetic surgery is that part of oral and maxillofacial
surgery that restores oral function and facial form rendered
deficient through loss or absence of teeth and associated
structures as a result of disease, trauma, or elective surgery
for tumour and other conditions. This is concerned with
surgical modification of the alveolar process and its
surrounding structures to enable the fabrication of a well
fitting comfortable and aesthetic dental prosthesis’.
Preprosthetic Surgeries For Upper Anterior Region
I. Soft tissue procedures
i. Frenectomy
They are of two types:
i. Labial.
ii. Lingual.
l A frenum is a fold of tissue or muscle connecting
lips, cheek, or tongue to the jawbone.
l A frenectomy is removal of one of these folds of tissues.
l Patients receiving dentures may need a frenectomy
if the position of the frenum interferes with the
proper fit of the denture, thereby frequently ulcerat-
ing and reducing the stability of the denture.
l Procedures performed on the labial frenum and lin-
gual frenum are termed as labial frenecotmy and
lingual frenectomy respectively.
Indications
l High attachments of labial frenum or bands attached
near the alveolar crest in the buccal regions often dis-
place the dentures during function.
l Many times ulceration can be seen at the frenal attach-
ments due to impingement of the denture peripheries.
One option is to relieve the denture borders at these
attachments. But for persistent problem, frenectomy
should be considered.
ii. Alveoloplasty (Dense hydroxyapatite alveolar ridge aug-
mentation)
l Midline maxillary incision initially is carried down
through periosteum unless simultaneous blind submu-
cosal vestibuloplasty is indicated.
l Periosteum is incised after submucosal vestibuloplasty
is performed.
l Incision is performed on facial side of alveolus for pa-
tient with class I and class II deficiency and lateral to
mandibular ridge for those with class III and class IV
deficiency.
186 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l The subperiosteal pockets are then filled with hydroxy-
apatite particles delivered from custom plastic syringe.
II. Hard tissue procedures
i. Ridge augmentation
In this procedure, augmentation of the bone is achieved
by building up the atrophied jawbone using autogenous
bone, homogeneous bone, or alloplastic material.
Criteria for ridge augmentation
l Gross atrophy of the jaws with the possibility of
mandibular fracture.
l Medically fit middle-aged or young individuals.
l Atrophy of the jaws causing prosthetic difficulties.
Goals of ridge augmentation
l Restoration of the optimum ridge height and width,
vestibular depth, ridge form, andoptimum denture-
bearing area.
l To increase retention and stability of the denture.
l To attain a proper interarch relationship to protect the
neurovascular bundle.
ii. Vestibuloplasty/sulcus extension
l Deepening of the vestibule without any addition of
the bone is termed as vestibuloplasty or sulcoplasty
or sulcus deepening procedure.
l Vestibuloplasty can be done in the maxilla or in the
mandible or in both the jaws. 4. Alveoloplasty after post-extraction healing.
l Whenever there is an inadequate vestibular depth
present.
l To increase the retention and stability of the denture.
l For deepening of the vestibule, sufficient amount of
height of the alveolar bone should be available.
iii. Alveolectomy
l Surgical removal or trimming of the alveolar process
is termed as alveolectomy.
l Clinically, after extraction, whenever there is a pres-
ence of sharp margins at interdental, interseptal, or
labiobuccal alveolar crest, they should be trimmed
with rongeur or round bur and smoothened with
bone file.
l The trimming of the alveolar process should be
carried out judiciously.
l Care is taken so that only minimum amount of areas
is trimmed.
l Too much bone loss will result into poor denture base.
Q. 3. Enumerate various alveoloplasty techniques and
describe anyone technique for anterior maxillary object
reduction in detail.
Ans.
Alveoloplasty
Alveoloplasty is the term used to describe the trimming
and removal of the labiobuccal alveolar bone along some
interdental and interradicular bone, and is carried out at the
time of extraction of teeth.
Indications
l Patients with prominent and dense alveolar bone under-
going extraction.
l Done as a procedure prior to immediate denture.
Goals
l To provide optimal ridge contour quickly.
l The alveolar ridges should be left as broad as for maxi-
mum distribution of the masticatory load.
l The ridge need not be perfectly smooth, but sharp irregu-
larities should be removed and the edge should be rounded.
l The mucosa covering the ridge should have uniform
thickness, density, and compressibility for even transi-
tion of the masticatory forces to the underlying bone.
Various alveoloplasty techniques are:
1. Simple conservative alveoloplasty with multiple ex-
tractions.
2. Intraseptal alveoloplasty—Dean’s alveoloplasty with
repositioning of labial cortical bone.
3. Obwegeser’s modification for intraseptal alveoloplasty.
5. Alveoloplasty performed on the edentulous ridge.
Technique
l An impression of the ridge is made before the surgery,
cast is poured, and the areas which require reduction are
marked on the cast.
l Mock surgery is carried out and once the irregularities
are removed from this cast and the shape is ideal, a
template is constructed with clear acrylic.
l When surgery is done at the time of extraction of teeth,
the incision is placed along the free gingival margin and
a full thickness mucoperiosteal flap is elevated, which
extends upto one tooth distance on either side of the
bony surgery. The tooth is extracted and a sharp cutting
rongeur forceps is held with one beak beneath the bony
rim of the socket and the other on the crest of the ridge.
l Small pieces of required amount of bone are then re-
moved and then finally, bone file is used to smoothen
the bone. The mucous membrane is then held with su-
tures over the interradicular bony septa.
l If any excess flap is present, it is trimmed away and the
edges are approximated. Now, previously prepared tem-
plate is fitted on and one should be noted for the pres-
ence of any pressure points indicated by the blanching
of the mucosa under the transparent acrylic template. If
such pressure points are present, then they should be
again trimmed.
Section | I  Topic Wise Solved Questions of Previous Years
Q. 4. Define preprosthetic surgery. Discuss in detail the
various preprosthetic procedures to improve the bony
alveolar ridge.
Or
What do you mean by preprosthetic surgery? What are
the aims of it? Describe various alveolar ridge altering
procedures.
Ans.
Preprosthetic Surgery
‘Preprosthetic surgery is that part of oral and maxillofacial
surgery that restores oral function and facial form rendered
deficient through loss or absence of teeth and associated
structures as a result of disease, trauma, or elective surgery
for tumour and other conditions. This is concerned with
surgical modification of the alveolar process and its
surrounding structures to enable the fabrication of a well
fitting comfortable and aesthetic dental prosthesis’.
Alveolar ridge can be corrected by:
A. Bony surgeries.
B. Soft tissue surgeries.
Bony Surgeries
l Labial alveolectomy.
l Primary alveoloplasty.
l Secondary alveoloplasty
l Excision of tori.
l Reduction of genial tubercle.
l Reduction of mylohyoid ridge.
l Maxillary tuberosity reduction and exostosis removal.
Soft Tissue Surgeries
l Removal of redundant crestal soft tissue.
l Frenectomy—labial and lingual.
l Excision of epulis fissurata and palatal papillary hyper-
plasia.
1. Alveoloplasty
l Alveoloplasty is the term used to describe the trimming
and removal of the labiobuccal alveolar bone along
some interdental and interradicular bone, and is carried
out at the time of extraction of teeth.
l A well contoured smooth ridge is essential for proper
construction of denture. While contouring the ridge, it is
highly essential to remember that greater the excision of
bone greater will be the resultant resorption.
l Therefore, procedure of contouring should be limited to
the excision of irregular sharp ridges and unfavourable
undercuts are unsuitable for the denture construction.
187
2. Torus removal
l Tori are small developmental anomalies that occur in
constant sites on the jawbones.
l A torus palatinus is an exostosis found along the line
of the hard palate. Not all the tori require removal, as all
of them do not cause prosthetic difficulty.
Indications
l Smooth maxillary torus can be ignored. But, when it is
extensively irregular, large, and extends beyond junc-
tion of the hard and soft palate and interferes with the
post-dam seal of the denture, it should be removed.
l Torus that is subjected to constant masticatory trauma.
l When it interferes with normal speech.
l When the patient fears of malignancy.
Mandibular tori
l It is an exostosis located on the lingual aspect of man-
dible in the region of the premolar, above the mylohyoid
line. They may be unilateral or bilateral.
Indications
I. It is removed, if lower denture is to be constructed.
II. It should be removed, if there is chronic irritation.
III. Very rarely it is removed, when the patient fears of
malignancy.
3. Sharp ridge removal
l The irregular and sharp bony edges cause great denture
irritation. They are usually found in the anterior part of
the mandible. Localized tenderness over such ridge on
palpation or on wearing denture is common. As a result,
they are trimmed to a depth of 1–2 mm with the help of
rongeurs, bone files, or burs; and the wound closed with
silk sutures. The ridge can further be supported with a
relined existing denture with soft acrylic.
4. Shelf reduction
l Mandibular lingual shelf along with the mylohyoid
muscle insertion becomes more prominent and superfi-
cial in the due course of time due to atrophy of the
mandible. A sharp lingual shelf interferes with the den-
ture construction and insertion, and the mylohyoid
muscle attachment here dislodges the denture. There-
fore, this shelf needs to be reduced and the mylohyoid
muscle attachment should be released.
5. Resection of genial tubercles
l The two genial tubercles located superiorly are more
prominent than the inferior due to the resorption of
the mandibular ridge. This may elevate the ridge lin-
gually giving a shelf-like appearance making the ante-
rior lingual seal impossible. It is also a frequent site of
ulceration when a lower denture is used, hence needs
trimming.
188 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
6. Alveolectomy
l Surgical removal or trimming of the alveolar process is
termed as alveolectomy.
l Clinically, after extraction, whenever there is a presence
of sharp margins at interdental, interseptal, or labiobuc-
cal alveolar crest, they should be trimmed with rongeur
or round bur and smoothened with bone file.
l The trimming of the alveolar process should be carried
out judiciously.
l Care is taken so that only minimum amount of areas is
trimmed.
l Too much bone loss will result into poor denture base.
Aims of Preprosthetic Surgery
l It should provide adequate residual tissue with proper
configuration, which can support and retain the denture
and withstand masticatory stress.
SHORT ESSAYS
Q. 1. Alveoloplasty.
Or
Dean’s alveoloplasty.
Ans.
Alveoloplasty
This procedure helps in eliminating anterior maxillary
undercuts and reducing the large anterior maxilla.
l The procedure involves separation of six anterior teeth
and sometimes the premolars are included. The advan-
tage of this technique is that since it retains much of
the compact labial cortical bone, it reduces resorption
of the bone post-operatively. This procedure is used at
the time of extraction only.
Dean’s intraseptal alveoloplasty is based on the following
biological principles:
The prominence of the labial and buccal alveolar mar-
gin is reduced to facilitate the reception of dentures.
l The muscle attachments are undisturbed.
l The periosteum remains intact.
l The cortical plate is preserved as a viable onlay bone
graft with an intact blood supply.
l Because the cortical bone is spared, post-operative
resorption is minimized.
According to Dean, the most posterior teeth should be re-
moved first to preserve the integrity of labial cortical plate
and avoid any disturbance to its blood supply. For example,
the cuspids should be removed before the incisors, to avoid
fracturing and removing the labial cortex attached to the
cuspid teeth.
l It should help in proper speech and deglutition.
l It should satisfy the aesthetic concerns of the patient.
l It should remove all the hard and soft tissue protuber-
ances and undercuts.
l It should provide adequate vestibular depth.
l It should provide appropriate frenal attachment.
l It should achieve proper jaw relationship in anteropos-
terior, transverse, and vertical dimension.
l To relocate the mental nerve and establish correct ves-
tibular depth.
l It should reduce the pain and discomfort produced by
the denture pressure on a narrow alveolar ridge and
unsupported (by soft tissue) alveolus due to the pres-
ence of superficial mental nerve or an impacted or bur-
ied tooth or root which was asymptomatic prior to den-
ture placement.
Technique
l Local anaesthesia is secured and incision is made along
the gingival margin with epithelial attachment and inter-
dental papilla left attached to the respective teeth. An en-
velope flap is raised as much conservatively as possible.
l Now, the teeth are extracted starting from the canine to
the incisors. After extraction of the teeth, the interra-
dicular bony septa should be removed with a rongeur
forceps introduced into the socket to separate the labial
and palatal cortical plate.
l A V-shaped excision of the bone is done in the labial
cortical plate distal and posterior to the canine eminence
as close to the alveolus as possible. Thus, three sides of
the labial cortex become free and the labial cortex be-
comes a freely movable osteoperiosteal graft attached to
only the mucoperiosteum from which it receives its
blood supply.
l Now, finger pressure is applied to the labial cortical
plate which is collapsed towards the socket. After the
removal of any infected gingival tissue, sutures are
placed to stabilize the tissues.
Q. 2. Alveolectomy.
Ans.
Alveolectomy
l Surgical removal or trimming of the alveolar process is
termed as alveolectomy.
l Clinically, after extraction, whenever there is a presence
of sharp margins at interdental, interseptal, or labiobuc-
cal alveolar crest, they should be trimmed with rongeur
or round bur and smoothened with bone file.
Section | I  Topic Wise Solved Questions of Previous Years 189

l The trimming of the alveolar process should be carried l The flange of the new denture should be of sufficient
out judiciously. length to maintain the new depth of the sulcus. The
l Care is taken so that only minimum amount of areas is denture flange should not irritate the periosteal surface.
trimmed. l Corticosteroids can sometimes be injected into the ves-

l Too much bone loss will result into poor denture base. tibule to reduce the scar contracture. In spite of all the
efforts to increase the vestibular depth, 50% relapse can
Q. 3. Vestibuloplasty.
take place.
Or l Therefore, overcorrection is done to compensate this

relapse. When the residual bony ridge is too small to

Clark’s vestibuloplasty.
perform overcorrection, a free epithelial graft should be
Ans. considered to cover the wound.
Q. 5. Preprosthetic surgery.
Clark’s Vestibuloplasty Ans.
Clark’s technique is the reverse technique of Kazanjian’s
technique. It is based on the following principles: Preprosthetic Surgery
l Raw surface on connective tissue contracts; whereas, when
‘Preprosthetic surgery is that part of oral and maxillofacial
covered with epithelium the contracture is minimum.
surgery that restores oral function and facial form rendered
l Raw surface on bone does not undergo contracture.
deficient through loss or absence of teeth and associated
l For repositioning and fixation, epithelial flap must be
structures as a result of disease, trauma, or elective surgery
undermined adequately.
for tumour and other conditions. This is concerned with
l Soft tissues which are repositioned tend to return
surgical modification of the alveolar process and its
to their normal position, therefore over correction is
surrounding structures to enable the fabrication of a well
necessary.
fitting comfortable and aesthetic dental prosthesis’.

Technique I. Initial Preparations

In this procedure, a flap is pedicled of the lip along the al- A. Correction of soft tissue deformities
veolar process leaving a raw surface on the bone instead of a. Frenectomy
on the lip. An incision is made slightly at the crest of the i. Labial.
alveolar ridge. The dissection is carried supraperiosteally ii. Lingual.
till the desired depth of the sulcus mucosa is undermined b. Correction of mobile soft tissue on the alveolar
upto the vermilion border, so that free edge of the mucosal ridge.
flap is secured to the periosteum deep in the sulcus. The raw c. Denture granuloma.
surface on the bone heals by granulation tissue formation B. Correction of hard tissue deformities
and epithelialization without contracture. Initially, the i. Alveoloplasty.
depth of the sulcus is maintained for a long-time. But the ii. orus removal—mandibular and maxillary.
drawback of the technique is that, as the days pass, the at- iii. Sharp ridge removal.
tachment of the lip musculature to the alveolar bone shifts iv. Shelf reduction.
toward the alveolar crest thus obliterating the sulcus. v. Resection of genial tubercle.
Q. 4. Describe the steps of Obwegeser’s vestibuloplasty. C. Correction of soft and hard tissue deformities—tuberosity
l Tuberosity reduction.
Ans. l Tuberoplasty.

Obwegeser’s Vestibuloplasty II. Secondary Preparations

l This technique is very similar to Clark’s technique. The . Epulis fissuratum removal.
A
difference is that here the raw surface of the ridge with B . Correction of reactive inflammatory papillary hy-
its periosteal attachment is covered with a split thick- perplasia.
ness skin graft in order to maintain the depth of the C. Ridge extension procedures
vestibule at the desired level. a. Labiobuccal vestibuloplasty.
l Mucosal grafts can also be used for this purpose. In b. Mucosal advancement vestibuloplasty
all the above cases, new prosthesis is made after i. Closed submucous vestibuloplasty.
4–5 weeks. l Open view vestibuloplasty.
190 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

ii. Secondary epithelialization 3. Interpositional or sandwich bone grafting

l Labial approach. a. Bone graft.
l Kazanjian’s method. b. Cartilage graft.
l Godwin’s method. c. Hydroxyapatite blocks.
l Lipswitch method. 4. Visor osteotomy.
l Clark’s method. 5. Onlay grafting.
iii. Grafting vestibuloplasty
l Obwegeser’s method. Maxillary augmentation procedures
iv. Maxillary pocket inlay vestibuloplasty. 1. Onlay bone grafting.
b. Lingual vestibuloplasty 2. Onlay grafting of alloplastic material.
i. Trauner’s technique. 3. Interpositional or sandwich graft.
ii. Caldwell’s technique. 4. Sinus lift procedures.
Combination vestibuloplasty (labial and lingual)
i. Obwegeser’s technique. Augmentation with orthognathic surgery
D. Mental nerve transpositioning. 1. Mandibular osteotomy procedures.
E. Ridge augmentation procedures. 2. Maxillary osteotomy procedures.
F. Alveolar distraction osteogenesis. 3. Combination procedures.
Q. 6. Ridge augmentation procedure. Q. 7. Frenectomy.
Ans. Ans.

Ridge Augmentation Frenectomy

In this procedure, augmentation of the bone is achieved by l A frenum is a fold of tissue or muscle connecting lips,
building up the atrophied jawbone using autogenous bone, cheek, or tongue to the jawbone.
homogeneous bone, or alloplastic material. l A frenectomy is removal of one of these folds of

tissues.
l Patients receiving dentures may need a frenectomy if
Criteria for Ridge Augmentation
the position of the frenum interferes with the proper fit
l Gross atrophy of the jaws with the possibility of man- of the denture, thereby frequently ulcerating and reduc-
dibular fracture. ing the stability of the denture.
l Medically fit middle-aged or young individuals. l Procedures performed on the labial frenum and lingual
l Atrophy of the jaws causing prosthetic difficulties. frenum are termed as labial frenecotmy and lingual fre-
nectomy respectively.
Goals of Ridge Augmentation
l Restoration of the optimum ridge height and width, Indications
vestibular depth, ridge form, and optimum denture- l High attachments of labial frenum or bands attached
bearing area. near the alveolar crest in the buccal regions often dis-
l To increase retention and stability of the denture. place the dentures during function. Many times ulcer-
l To attain a proper interarch relationship to protect the ation can be seen at the frenal attachments due to im-
neurovascular bundle. pingement of the denture peripheries. One option is to
relieve the denture borders at these attachments. But for
Mandibular and Maxillary Augmentation Procedure persistent problem, frenectomy should be considered.
Mandibular augmentation procedures Q. 8. Torus palatinus.
1. Superior border augmentation Ans.
a. Bone graft.
b. Cartilage graft.
c. Alloplastic graft. Torus Palatinus
2. Inferior border augmentation A torus palatinus is an exostosis found along the line of the
a. Bone graft. hard palate. Not all the tori require removal, as all of them
b. Cartilage graft. do not cause prosthetic difficulty.
Section | I  Topic Wise Solved Questions of Previous Years
Indications
l Smooth maxillary torus can be ignored. But, when it is
extensively irregular, large, and extends beyond junc-
tion of the hard and soft palate and interferes with the
post-dam seal of the denture, it should be removed
l Sometimes the torus may be subjected to constant
trauma during mastication.
l When it interferes with normal speech.
l When the patient fears of malignancy.
Technique
l Before surgical excision of the tori, an impression be
made and the cast poured. The tori should be in this cast
and an acrylic stent made. Removal of tori involves a
Y-incision for small tori and a double Y-incision for the
large tori.
l A full thickness mucoperiosteal flap is elevated carefully
to expose the tori entirely. The tori is divided by vertical
and anteroposterior bur cuts to a depth just above the
level of horizontal palatal shelf in order to prevent any
fracture of the palate and perforation into oral cavity.
These cut sections are removed with the the chisel and
mallet. The surface should be finely smoothened using
large bone files or vulcanite bur. The tori can removed
with the help of acrylic bur alone without the chisels, but
this may cause accidental perforation of nasal cavity or
trauma to the soft tissues. This area be copiously irrigated
and the mucoperiosteal is trimmed accordingly and su-
tured back. The acrylic which was initially constructed
must now be inserted. Stent supports the flap and pre-
vents any haematoma formation and covers the wound.
The stent can be used, as the wound healing is completed.
Complications
l The risk of creation of oronasal fistula is more, owing to
the thin palatal shelf.
Q. 9. Give the indications for excision of tori and
describe the procedure of removal of mandibular torus.
Ans.
Mandibular Tori
Mandibular torus is an exostosis located on the lingual as-
pect of the mandible in the region of the premolar, above
the mylohyoid line. They may be unilateral or bilateral.
Indications For Removal
l Removed if lower denture is to be constructed.
l It should be removed, if there is chronic irritation.
l If the patient fears of malignancy.
191
Technique
l Inferior alveolar nerve and lingual nerve block are given
along with local infiltration on the tori.
l Once anaesthesia is secured, incision is made on the
crest of the alveolar ridge for sufficient length to expose
the entire tori.
l In case of edentulous patients, incision can be placed on
the lingual gingival sulcus.
l Soft tissues are elevated using periosteal elevator to
expose the tori.
l Using a chisel, bur, or rongeurs, tori is removed and the
rough bony surface is smoothened using a bone file.
l Excess soft tissue is trimmed and the wound irrigated
and sutured back.
Precaution
l To prevent formation of sublingual haematoma. While
removing bilateral mandibular tori, the flap should be
kept intact in the midline.
l Gauze piece is placed below the torus to prevent
the excised bone into the soft tissues to prevent space
infection.
Q. 10. Describe one surgical procedure for deepening of
mandibular buccal sulcus.
Ans.
Visor Osteotomy
l The goal of Visor osteotomy is to increase the height of
the mandibular ridge for denture support.
l The Visor osteotomy consists of central splitting of the
mandible in buccolingual dimension and the superior
positioning of the lingual section of the mandible,
which is wired in position.
l Cancellous bone graft material is placed at the outer
cortex over the superior labial junction for improving
the contour.
Modified Visor Osteotomy
l Consists of splitting of mandible buccolingually by ver-
tical osteotomy only in the posterior regions and a hori-
zontal osteotomy in the anterior region.
l The posterior lingual segments are then pushed superi-
orly on both the sides and anterior fragment is also
pushed superiorly and fixed with wires to the posterior
newly-mobilized lingual segments.
l Corticocancellous bone graft particles with hydroxyap-
atite granules is placed in the gap between the superior
and inferior anterior segments. Rest of the graft material
can be moulded on the buccal aspect of the posterior
segments.
192 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Advantage
Eighty per cent of the height is maintained at the end of
3–5 years.
Disadvantages
l Nerve paraesthesia and dysaesthesia.
SHORT NOTES
Q. 1. Dean’s alveoloplasty.
Or
Give the names of any four instruments used in the
‘Alveoloplasty’ procedure along with their functions.
Or
Give the indication for Dean’s alveoloplasty. How does
it differ from Obwegeser’s alveoloplasty?
Ans.
Dean’s Alveoloplasty
l According to Dean, the most posterior teeth should be
removed first to preserve the integrity of labial cortical
plate and avoid any disturbance to its blood supply. For
example, the cuspids should be removed before the inci-
sors to avoid fracturing and removing the labial cortex
attached to the cuspid teeth.
Technique
l Local anaesthesia is secured and incision is made
along the gingival margin with epithelial attachment
and interdental papilla left attached to the respective
teeth. An envelope flap is raised as much conservatively
as possible.
l Now, the teeth are extracted starting from the canine to
the incisors. After extraction of the teeth, the interra-
dicular bony septa should be removed with a rongeur
forceps introduced into the socket to separate the labial
and palatal cortical plate.
l A V-shaped excision of the bone is done in the labial
cortical plate distal and posterior to the canine eminence
as close to the alveolus as possible. Thus, three sides of
the labial cortex become free and the labial cortex be-
comes a freely movable osteoperiosteal graft attached to
only the mucoperiosteum from which it receives its
blood supply.
l Now, finger pressure is applied to the labial cortical
plate which is collapsed towards the socket. After the
removal of any infected gingival tissue, sutures are
placed to stabilize the tissues.
l Need for hospitalization.
l Donor site morbidity.
l Inability to wear the dentures for 3–5 months following
surgery.
Q. 2. Mandibular ridge augmentation.
Or
Ridge augmentation procedure.
Ans.
Ridge Augmentation Procedure
l In ridge augmentation procedure, augmentation of the
bone is achieved by building up the atrophied jawbone
using autogenous bone, homogeneous bone, or alloplas-
tic material.
Criteria for Ridge Augmentation
l Gross atrophy of the jaws with the possibility of man-
dibular fracture.
l Medically fit middle-aged or young individuals.
l Atrophy of the jaws causing prosthetic difficulties.
Goals of Ridge Augmentation
l Restoration of the optimum ridge height and width,
vestibular depth, ridge form, and optimum denture-
bearing area.
l To increase retention and stability of the denture.
l To attain a proper interarch relationship to protect the
neurovascular bundle.
Q. 3. Vestibuloplasty.
Or
Kazanjian’s technique for vestibuloplasty.
Ans.
l An incision is made in the mucosa of the lip and a large
flap of labial and vestibular mucosa is retracted.
l The mentalis muscle is detached from the periosteum to
required depth, and the vestibule is deepened via supra-
periosteal dissection.
l A flap of the mucosa is turned downwards from the at-
tachment of the alveolar ridge and is placed directly
against the periosteum to which it is sutured.
Section | I  Topic Wise Solved Questions of Previous Years
l A rubber catheter stent can be placed in the deepened
sulcus and secured with percutaneous sutures.
l This catheter helps to hold the flap in its new position
and maintain the depth of the vestibule. It is removed
after seven days.
l The labial donor site is coated with tincture of benzoin
compound, and the surface heals by granulation and
secondary epithelialization. Contracture of the wound
margins takes place.
Q. 4. Preprosthetic surgery of tuberosity.
Ans.
l In the tuberosity, hamular notch region helps in reten-
tion of denture and also aids in peripheral seal of the
maxillary denture.
l This procedure is undertaken to increase the depth
between the hamular notch and the distal aspect of the
maxilla.
l Tuberoplasty is carried out under general anaesthesia.
In this technique, tuberoplasty is done to deepen the
hamular notch, by repositioning the pterygoid plate and
the hamulus in the posterior direction.
Q. 5. What are possible intraoperative complications
of lingual frenectomy?
Ans.
Intraoperative Complications of Lingual
Frenectomy
l Injury to superior lingual vessels.
l Injury to Wharton’s duct/papilla.
Q. 7. High labial frenum.
Or
Frenectomy.
Ans.
High Labial Frenum and Frenectomy
l A frenum is a fold of tissue or muscle connecting lips,
cheek, or tongue to the jawbone.
l A frenectomy is removal of one of these folds of
tissues.
l Patients receiving dentures may need a frenectomy if
the position of the frenum interferes with the proper fit
of the denture, thereby frequently ulcerating and reduc-
ing the stability of the denture.
l Procedures performed on the labial frenum and lingual
frenum are termed as labial frenecotmy and lingual fre-
nectomy respectively.
193
Indications
l High attachments of labial frenum or bands attached
near the alveolar crest in the buccal regions often dis-
place the dentures during function.
l Many times, ulceration can be seen at the frenal attach-
ments due to impingement of the denture peripheries.
One option is to relieve the denture borders at these at-
tachments. But for persistent problem, frenectomy
should be considered.
Q. 8. Genioplasty.
Or
Genioplasty - Indication diagnosis technique.
Ans.
Genioplasty
l Genioplasty can be used as a single procedure. It can be
used as an adjunctive procedure along with major oste-
otomies of the jawbone.
l The deformities of the chin should be considered in all
three planes, i.e., anteroposterior, vertical, and trans-
verse. Morphology of the symphysis region is highly
variable in different individuals even with the same ba-
sic types of dentofacial deformities.
l Genioplasties can be used to straighten or lengthen
the chin.
Q. 9. Torus palatinus.
Ans.
Torus Palatinus
A torus palatinus is an exostosis found along the line of the
hard palate. Not all the tori require removal, as all of them
do not cause prosthetic difficulty.
Indications
l Smooth maxillary torus can be ignored. But, when it is
extensively irregular, large, and extends beyond junc-
tion of the hard and soft palate and interferes with the
post-dam seal of the denture, it should be removed
l Torus that is subjected to constant masticatory trauma.
l When it interferes with normal speech.
l When the patient fears of malignancy.
Q. 10. Torus mandibularis.
Or
Mandibular tori.
Ans.
194 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Mandibular Tori
l Mandibular torus is an exostosis located on the lingual
aspect of mandible in the region of the premolar, above
the mylohyoid line.
l They may be unilateral or bilateral.
Indications
l It is removed, if lower denture is to be constructed.
l It should be removed, if there is chronic irritation.
l Very rarely it is removed, when the patient fears of ma-
lignancy.
Q. 11. Alveolectomy.
Ans.
Alveolectomy
l Surgical removal or trimming of the alveolar process is
termed as alveolectomy.
l Clinically, after extraction, whenever there is a presence
of sharp margins at interdental, interseptal, or labiobuccal
Premalignant and Malignant Lesions
LONG ESSAYS
Q. 1. Describe the surgical management of squamous
cell carcinoma involving the lateral border of tongue.
Ans.
Squamous Cell Carcinoma
l Squamous cell carcinoma is defined as ‘a malignant
epithelial neoplasm exhibiting squamous differentiation
as characterized by the formation of keratin and/or the
presence of intercellular bridges’.
l The most common malignant neoplasm of the oral
cavity is epidermoid carcinoma. Although it may occur
at any intraoral site, certain sites are more frequently
involved than others.
Aetiology
l Tobacco: Its effect is synergistic with alcohol.
l HIV infected.
alveolar crest, they should be trimmed with rongeur or
round bur and smoothened with bone file.
l The trimming of the alveolar process should be carried
out judiciously.
l Care is taken so that only minimum amount of areas is
trimmed.
l Too much bone loss will result into poor denture base.
Q. 12. Sulcus extension.
Ans.
Sulcus Extension
Deepening of the vestibule without any addition of the bone
is termed as vestibuloplasty or sulcoplasty or sulcus deep-
ening procedure. Vestibuloplasty can be done in the maxilla
or in the mandible or in both the jaws.
l Whenever there is an inadequate vestibular depth present.
l To increase the retention and stability of the denture.
l For deepening of the vestibule.
Sufficient amount of height of the alveolar bone should be
available.
Topic 17
l Immunosuppressed individuals.
l Low consumption of vitamin A and C.
l UV light.
l Syphilitic history.
l Leukoplakia.
l Chronic irritation/trauma.
l Poor oral hygiene.
Clinical Features
l Painless mass or ulcer.
l The tumour begins as a superficially indurated ulcer
with slightly raised borders and may proceed to develop
a fungating, exophytic mass or may proceed to infiltrate
the deep layers of the tongue, producing fixation and
induration without much surface change.
l Typical lesion develops on the lateral border or ventral
surface of the tongue.
l The colour of the lesion is red and white.
l It can appear as exophytic or ulcerated leukoplakia.
Section | I  Topic Wise Solved Questions of Previous Years 195

l In some lesions, tumour cells infiltrate muscle fibres of vii. Cementoma.

the tongue. viii. Odontomes.

B. Malignant
Differential Diagnosis
i. Intra-alveolar carcinoma.
l Ulcerations due to trauma. ii. Squamous cell carcinoma from the cyst lining.
l Primary syphilis.
II. Tumours of Mesodermal Origin
Diagnosis
A. Benign
l Clinical examination includes head and neck examina- i. Odontogenic myxoma.
tion followed by a fiberoptic examination of the laryn- ii. Odontogenic fibroma.
gopharynx. iii. Cementifying fibroma.
l TNM staging.

l Incisional biopsy. B. Malignant

i. Odontogenic sarcoma.
Treatment
l The tumour can be treated through surgery and radiation. III. Tumours of Ectodermal and Mesodermal
l Generally, the primary tumour is excised with 1.5 cm Origin (Mixed)
margins for T1N0M0 lesions. A. Benign
l Treating the neck prophylactically with either an incon-

tinuity functional neck dissection or radiotherapy in a i. Ameloblastic fibroma.

dose of 5000 cGy to 6500 cGy is recommended for ii. Ameloblastic fibro-odontoma.
T2N0M0 and more advanced stages. B. Malignant
l If the incisional biopsy shows that the lesion is greater

than 3 mm depth of invasion for nodal invasion disease i. Ameloblastic fibrosarcoma.

of N1, then functional neck dissection is recommended.
For nodal disease of N2 or N3, modified radical neck
dissection is preferred followed by post-operative radio-
therapy.
Q. 2. Define and classify tumours. T.N.M. classification
and staging in oral malignancy. Add a note on radio-
therapy and chemotherapy in the management of oral
cancers.
Ans.
l A ceaseless, purposeless, uncoordinated, and uncon-
trolled growth of the tissue resulting from multiplication
of its cell; and if the condition persists even after the
stimulus or the initiating factors is removed, then it is
known as a tumour.
Classification of Tumours
I. Tumours of Ectodermal Origin
A. Benign
i. Ameloblastoma.
ii. Adenoameloblastoma.
iii. Calcifying epithelial odontogenic tumour.
iv. Ameloblastic fibroma.
v. Odontogenic fibroma.
vi. Odontogenic myxoma.
T.N.M. Staging System
T.N.M. staging system is developed by The American Joint
Commission for cancer.
Clinical and Histopathological T Classification of
Cancer of the Oral Cavity
TX: Primary tumour cannot be assessed.
T0: No evidence of primary tumour.
T: Carcinoma in situ.
Tl: Tumour 2 cm or less in greatest dimension.
T2: Tumour more than 2 cm, but not more than 4 cm in
greatest dimension.
T3: Tumour more than 4 cm in greatest dimension.
T4: Tumour invades adjacent structures.
Clinical and Histopathological N Classification
of Cancer of the Oral Cavity
NX: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastasis.
Nl: Metastasis in ipsilateral single lymph node 3 cm or less
in greatest dimension.
N2a: Single ipsilateral lymph node greater than 3 cm, but
less than 6 cm in greatest dimension.
196 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
N2b: Multiple ipsilateral nodes up to 6 cm in greatest l 5-fluorouracil.
dimension.
N2c: Bilateral or contralateral lymph nodes up to 6 cm in
greatest dimension.
N3: Metastasis in lymph nodes greater than 6 cm in greatest
dimension.
Clinical and Histopathological M Classification
of Cancer of the Oral Cavity
MX: Distant metastasis cannot be assessed.
Ml: No distant metastasis.
M2: Distant metastasis.
Radiotherapy in the Management of Oral
Cancers
l Tumour cells in stages of active growth are more
susceptible to ionizing radiation than adult tissues. therapy of radiation or surgery or after local treatment.
The faster the cells are multiplying or the more undif-
ferented tumour cells, the more likely that radiation will
be effective.
l Radiation prevents the cells from multiplying, by inter-
fering with their nuclear material. Normal host cells are
also affected by radiation and must be protected as
much as possible during treatment.
The principal methods employed are:
i. X-ray therapy
a. Superficial X-ray therapy 45–100 kV.
b. Kilo voltage X-ray therapy 300 kV.
ii. Electron therapy.
iii. Surface applicator (radium mould).
iv. Interstitial implantation (radium source).
l Most commonly, radiation is delivered externally by
the use of large X-ray generators.
l The normal amount of tolerable radiation for a per-
son should not be exceeded and adjacent uninvolved
areas are spared by the protective shielding.
l The patient’s host tissues are protected from radia-
tion by two mechanisms of delivery:
i. Fractionation, and
ii. Multiple ports.
Chemotherapy in the Management of Oral
Cancers
l Chemicals that act on various types of tumour cells are
used to treat malignancies. They are not very selective
in their action and may harm normal cells as well.
l Chemotherapy is basically palliative in cases having
relapse after extensive surgery and radiation.
l Methotrexate, vincristine, bleomycin, and cisplatin are
used in combination.
l Most recently used drugs are platinum compounds
mostly in combination with
l Taxanes are the newer agents known to stabilize micro-
tubular formation and disrupt cells during M-phase of
cell cycle.
l They are given intravenously. They affect body systems
like the haemopoietic system.
l Multiple agent therapy is preferred to reduce the toxic-
ity of a single agent.
l Intra-arterial therapy is reserved for T3 and T4 lesions,
because of the difficulty in performing and maintaining
catheterization. The drugs are introduced through the
external carotid artery.
l Chemotherapy is of two types: i. Primary chemotherapy
and ii. Adjuvant chemotherapy.
I. Primary Chemotherapy
l It refers to use of chemotherapy before starting local
l It consists of induction of cisplatin and bleomycin com-
bination given for two cycles prior to local treatment.
II. Adjuvant Chemotherapy
l Given after surgery or radiation to eradicate microme-
tastasis.
Q. 3. Discuss the management of oral submucous
fibrosis.
Ans.
Management of Oral Submucous Fibrosis
I. Restriction of the habits: It is safe to restrict betel nut
chewing and to avoid spicy food.
II. Nutritional support: Vitamin B complex and iron
therapy and long-term therapy of anti-oxidants.
III. Intralesional injection: Steroids are injected with the
aim of anti-fibrinolytic andanti-inflammatory therapy.
Intralesional injection of 1 mL suspension containing
hydrocortisone along with 1 mL of lignocaine hydro-
chloride once a week. It may be increased to twice a
week depending on the severity of the disease.
IV. Medications: Antioxidants like retinoid, beta carotene,
and vitamin E prevent the formation of toxic sub-
stances and enhance the indigenous concentration of
vitamin A.The functional and structural ingredients of
epithelial cells are dependent on adequate concentra-
tion of vitamin A.
V. Surgical treatment
l Surgical treatment is indicated in two types of
cases:
a. Patients with marked limitation of mouth
opening.
b. Case, where biopsy has revealed dysplastic or
neoplastic changes.
Section | I  Topic Wise Solved Questions of Previous Years
Skin grafts give better results in small lesions.
l l Taxanes are the newer agents known to stabilize micro-
Coverage of the small area with full thickness flaps
like nasolabial, tongue, and palatal flaps have pro-
vided better long-term relief. Soft laser is used to
reduce scar formation further.
l Severe OSMF involving the lamina propria and up-
per submucosa are excised with a wide field exci-
sion in the area of clinical involvement, until the
soft tissue release is sufficient to gain an opening in
excess of 35 mm between the erupted incisors.
Sometimes, excision of a small portion of muscles
is also required.
l Excision of fibrous bands and covering defect with
split skin graft.
l This procedure can be combined with bilateral tem-
poralis myotomy or coronoidectomy.
l In several patients to give long-term relief of severe
trismus caused by OSMF excision of fibrotic bands
and reconstruction with bilateral full thickness,
nasolabial flaps has been used successfully.
l For surgical excision of fibrous bands and submu-
cosal placement of fresh human placenta grafts,
dexamethasone is injected.
VI. Physiotherapy
l Forceful mouth opening after surgical procedure is
absolutely essential to prevent
l high recurrence rate.
l Heat therapy in the form of warm saline gargles,
short wave diathermy, or microwave diathermy is
given.
Q. 4. What is the role of chemotherapeutic agents used
in the management of oral malignancies?
Ans.
Chemotherapy
l Chemicals that act on various types of tumour cells are
used to treat malignancies. They are not very selective
in their action and may harm normal cells as well.
Chemotherapeutic Approaches
l Combination therapy.
l Induction chemotherapy.
l Concomitant chemotherapy.
l Adjuvant chemotherapy.
l Palliative chemotherapy.
l Chemoprevention.
Commonly Used Chemotherapeutic Agents
l Methotrexate, vincristine, bleomycin, and cisplatin are
used in combination.
l Most recently used drugs are platinum compounds
mostly in combination with 5-fluorouracil.
197
tubular formation and disrupt cells during M-phase of
cell cycle.
l They are given intravenously. They affect body systems
like the haemopoietic system.
l Multiple agent therapy is preferred to reduce the toxic-
ity of a single agent.
l Intra-arterial therapy is reserved for T3 and T4 lesions,
because of the difficulty in performing and maintaining
catheterization. The drugs are introduced through the
external carotid artery.
l Vincristine, bleomycin, and methotrexate are used in
combination. Most recently used drugs are platinum
compounds mostly in combination with 5-fluorouracil.
l Sarcoma is treated with combinations of vincristine,
actinomycin D, cyclophosphamide, and doxorubicin.
Intralesional Chemotherapy
l Intralesional injection of vinblastine, vincristine, or
interferon - alpha has been shown to be effective in
the local control of epidemic Kaposi sarcoma and can
be used incombination with systemic chemotherapy or
radiotherapy.
l If necessary, lesions are re-injected at 3–6 week inter-
vals. No lesions require more than three injections for
initial control; some lesions recurr later and require
additional injections.
Topical Chemotherapy
l Actinic keratotic lesions have been effectively treated
with the application of 5% fluorouracil cream.
l Fluorouracil cream is applied twice daily until the area
exhibits a significant inflammatory reaction and ulcer-
ation (usually 3–4 weeks).
l Similar topical application of fluorouracil in selected
cases of multiple superficial basal cell carcinomas as may
be seen in basal cell nevus syndrome has been effective.
l It is not effective for invasive lesions and results in
needless delay in definitive therapy. Surgical excision is
still the treatment.
Chemoprevention
l Chemoprevention includes strategies to prevent or re-
verse carcinogenesis before an invasive cancer develops
or to prevent a second primary cancer in patients who
have had a previous strategy for upper aerodigestive
tract cancer in cessation of smoking.
l Retinoids: Molecular biology has provided new informa-
tion on how retinoids regulate gene expression. This has
led to the development of synthetic retinoids, which may
be less toxic and more effective in the prevention of cancer.
l The use of chemopreventives should be limited to con-
trolled clinical trials.
198 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Q. 5. Enumerate premalignant conditions and prema- l Lesions may vary greatly in size, shape, and distribu-
lignant lesions of oral mucosa. Describe in detail any tion. The borders may be distinct or indistinct, and
two of them. smoothly contoured or ragged.
l The surface texture can vary from smooth thin surface
Ans.
to leathery appearance with surface fissures referred to
as ‘cracked mud’.
Premalignant Lesions l The non-homogenous type of oral leukoplakia also

known as erythroplakia or speckled leukoplakia may

l Leukoplakia.
have white patches or plaque intermixed with red tissue
l Leukoedema.
elements.
l Erythroplakia.
l Verrucous leukoplakia has papillary projections similar
l Smoker’s palate.
to oral papillomas.

Premalignant Conditions Differential Diagnosis

l Oral submucous fibrosis. i. Lichen planus.
l Lichen planus.
ii. Leukoedema (cheek biting lesions).
l Intraepithelial carcinoma.
iii. Smoker’s tobacco lesions.
iv. Lupus erythematosus.
I. Leukoplakia
l It is defined as a predominantly white lesion of the oral Management
mucosa that cannot be characterized as any other defin- i. Elimination of aetiological factors
able lesion. Discontinuation of habits like alcohol and smoking by
the patients are well established risk factors.
Aetiology ii. Conservative therapy
Vitamin therapy, especially vitamin A and E, B
l Tobacco products. complex,13-cis-retinoic, antioxidant therapy, and ny-
l Ethanol. statin therapy.
l Hot, cold, spicy, and acidic foods and beverages. iii. Surgical therapy
l Alcoholic mouth rinse. l Cold knife surgical excision.
l Occlusal trauma. l Laser surgery.
l Sharp edges of prosthesis and teeth. l Cryosurgery.
l Actinic radiation. l Fulguration.
l Syphilic. l Re-examining the site every three months for the
l Presence of Candida albicans. first year.
l Presence of viruses. l Follow-up for every six months, if the lesion does

not relapse or change in reaction pattern.

Types of Leukoplakia l If new clinical features emerge, then new biopsies

should be taken.
l Homogenous type.
l Speckled type.
l White and red patches. II. Oral Submucous Fibrosis
l Verrucous type.
l It is a chronic scarring disease that affects the oral mu-
cosa as well as the pharynx and upper two-third of the
Clinical Features oesophagus. It is a high-risk precancerous condition.
l Asymptomatic—discovered during routine oral exami-
nation. Aetiology and Pathogenesis
l More common in older age group .35 years, especially
i. Chronic irritation from
in men.
betel nut, i.e., areca nuts;
l Lips, vermillion, buccal mucosa, mandibular gingiva,
chillies, tobacco, and
tongue, oral floor, and hard palate are the most frequent sites.
lime. ii. Genetic predisposition.
l The floor of the mouth, lateral borders of tongue,
iii. Nutritional deficiency.
and soft palate are high-risk sites for malignant trans-
iv. Bacterial infections.
formation.
Section | I  Topic Wise Solved Questions of Previous Years
v. Collagen disorders.
vi. Immunological disorders.
Clinical Features
l It equally affects both the sexes.
l It affects the patients of age group between second and
fourth decades.
l Most frequent locations are buccal mucosa and retromo-
lar areas.
l Most common initial symptoms are burning sensation
of oral mucosa, which is aggravated by spicy food iii. Candidiasis
followed by either hypersalivation or dryness of mouth.
l The first sign is erythematous lesion sometimes associ-
ated with petechiae, pigmentations, and vesicles.
l Initial lesions are followed by paler mucosa, which
comprises marbling.
l Fibrotic bands located beneath an atrophic epithelium
are the most prominent clinical feature.
l Increased fibrosis leads to loss of resilience, which
causes interference with speech, tongue mobility, and a
decreased ability to open the mouth.
l The atrophic epithelium may cause a smarting sensation
and inability to eat hot and spicy food.
l Diagnosis of OSMF is based on clinical feature and
patient’s report of habit of betel quid chewing.
Management
i. Restriction of the habits: It is safe to restrict betel nut
chewing and to avoid spicy food.
ii. Nutritional support: Vitamin B complex and iron ther-
apy and long-term therapy of antioxidants
iii. Intralesional injection: Steroids are injected with the aim
of anti-fibrinolytic and anti-inflammatory therapy. Intra-
lesional injection of 1 mL suspension containing hydro-
cortisone along with 1 mL of lignocaine hydrochloride
once a week is recommended. It may be increased to
twice a week depending on the severity of the disease.
iv. Medications: Antioxidants like retinoid, beta carotene,
and vitamin E prevent the formation of toxic sub-
stances and enhance the indigenous concentration of
vitamin A. The functional and structural ingredients of
epithelial cells are dependent on adequate concentra-
tion of vitamin A.
v. Surgery: Skin grafts give better results in small lesions.
Coverage of the small area with full thickness flaps like
nasolabial, tongue, and palatal flaps have provided required to differentiate this lesion from premalignant or
better long-term relief. Laser is used to reduce scar
formation further.
Q. 6. Classify the white lesions of the mouth. Describe in
detail the clinical features, differential diagnosis, and
managements of oral Lichen planus.
Ans.
199
White Lesions of the Mouth
i. Variations in structure and appearance of the normal
oral mucosa
l Leukoedema.
l Fordyce granules.
l Linea alba and other areas of frictional cornification.
ii. Non-keratotic white lesions
l Habitual cheek biting.
l Burns (thermal, aspirin, and dental medicaments).
l Caused by specific infectious agents.
l Acute pseudomembranous candidiasis.
l Acute atrophic candidiasis.
l Chronic atrophic candidiasis.
l Median rhomboid glossitis.
l Chronic hyperplastic candidiasis.
iv. Keratotic white lesions with no increased potential for
the development of oral cancer
l Stomatitis nicotina.
l Traumatic keratosis.
l Intraoral skin grafts.
l Focal epithelial hyperplasia.
l Psoriasiform lesions.
Lichen Planus
l It is a T-cell mediated autoimmune interface, in
which the basal cell layer of mucosa and/or skin is
attacked.
Clinical Features
l It presents in one of the three clinical forms, i.e., reticu-
lar form, plaque form, and erosive form.
l All forms are seen in patients older than 40 years and
equally in men and women.
l Predilection for buccal mucosa, the tongue, and the at-
tached gingiva is more.
Reticular form is characterized by Wickham’s striae
of lacy white interlacing lines found mostly on buccal
mucosa, attached gingiva, and tongue. These striae are
asymptomatic.
Plaque form is characterized by white patch or leukopla-
kia appearance. These plaques are slightly elevated and
irregular hyperkeratotic in form. They are ususally asymp-
tomatic, but may sometimes cause discomfort. Biopsy is
malignant mucosal changes.
Erosive form is characterized by intense pain and ery-
thematous mucosal inflammation. When it involves buccal
mucosa or tongue, it will produce fibrinous-based ulcers
against a background of erythema and sometimes hyper-
keratotic foci. Some lesions present as vesicle formation
and Nikolsky’s sign.
200 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Differential Diagnosis managed with topical corticosteroids, usually 0.05%

fluocinonide gel four times daily, or combined with an-
l Clinical leukoplakia.
tifungal agent griseofulvin 250 mg of the micronized
l Benign hyperkeratosis.
form twice daily.
l Epithelial dysplasias.
l Intralesional triamcinolone injected in 1 mL increments
l Verrucous hyperplasia.
may also be used for focal symptomatic.
l Verrucous carcinoma.
l Most erosive lichen planus requires systemic corticoste-
l Invasive squamous cell carcinoma.
roid regimen I or II and only rarely III A or III B.
l Hypertrophic candidiasis.
l Griseofulvin or topical fluocinonide or topical fluo-
l Chronic ulcerative stomatitis.
cinonide can be added to either regimen to reduce
the prednisone requirements or help maintain a
Management remission.
l Topical retinoids and vitamin A analog for reticulous
l The milder cases of erosive lichen planus and some
lichen planus.
symptomatic cases of the other forms often can be

SHORT ESSAYS
Q. 1. Leukoplakia. l Lesions may vary greatly in size, shape, and distribu-
tion. The borders may be distinct or indistinct and
Or smoothly contoured or ragged.
l The surface texture can vary from smooth thin surface
Leukoplakia treatment.
to leathery appearance with surface fissures referred to
Or as ‘cracked mud’.
l The non-homogenous type of oral leukoplakia also
Treatment plan of leukoplakia.
known as erythroplakia or speckled leukoplakia may
Ans. have white patches or plaque intermixed with red tissue
elements.
l Verrucous leukoplakia has papillary projections similar
Leukoplakia
to oral papillomas.
It is defined as a predominantly white lesion of the oral mu-
cosa that cannot be characterized as any other definable lesion.
Management
Aetiology i. Elimination of aetiological factors: Discontinuation of
habits like alcohol and smoking by the patients which
l Tobacco products. are well established risk factors.
l Ethanol. ii. Conservative: Vitamin therapy, especially vitamin A
l Hot, cold, spicy, and acidic foods and beverages. and E, B complex, 13-cis-retinoic, antioxidant therapy,
l Alcoholic mouth rinse. and nystatin therapy.
l Occlusal trauma. iii. Surgical therapy: Cold knife surgical excision, laser
l Sharp edges of prosthesis and teeth. surgery, cryosurgery, and fulguration.
l Actinic radiation. iv. Re-examining the site every three months for the first
l Syphilic. year. Follow-up for every six months, if the lesion does
l Presence of Candida albicans not relapse or change in reaction pattern.
l Presence of viruses. v. If new clinical features emerge, new biopsies should be
taken.
Clinical Features Q. 2. Submucous fibrosis.
l Asymptomatic—derived during routine oral examination. Ans.
l More common in older age group .35 years, especially in
men.
l Frequent sites are lips, vermillion, buccal mucosa, man- Submucous Fibrosis
dibular gingiva, tongue, oral floor, and hard palate. l It is a chronic scarring disease that affects the oral mu-
l The high-risk sites for malignant transformation are floor
cosa as well as the pharynx and upper two-third of the
of the mouth, lateral borders of tongue, and soft palate. oesophagus. It is a high-risk precancerous condition.
Section | I  Topic Wise Solved Questions of Previous Years
Aetiology and Pathogenesis
i. Chronic irritation from betel nut, i.e., areca nuts; chil-
lies, tobacco, and lime.
ii. Genetic predisposition.
iii. Nutritional deficiency.
iv. Bacterial infections.
v. Collagen disorders.
vi. Immunological disorders.
Clinical Features
l Equally affects both the sexes and patients are between
second and fourth decades.
l Most frequent locations are buccal mucosa and retromo-
lar areas.
l Most common initial symptoms are burning sensation
of oral mucosa, which is aggravated by spicy food fol-
lowed by either hypersalivation or dryness of mouth.
l The first sign is erythematous lesion sometimes associ-
ated with petechiae, pigmentations, and vesicles.
l Initial lesions are followed by paler mucosa, which
comprise marbling.
l Fibrotic bands located beneath an atrophic epithelium
are the most prominent clinical features.
l Increased fibrosis leads to loss of resilience, which
causes interference with speech,tongue mobility, and a
decreased ability to open the mouth.
l The atrophic epithelium may cause a smarting sensation
and inability to eat hot and spicy food.
l Diagnosis of OSMF is based on clinical feature and
patient’s report of habit of betel quid chewing.
Management
i. Restriction of the habits: It is safe to restrict betel nut
chewing and to avoid spicy food.
ii. Nutritional support: Vitamin B complex and iron ther-
apy, and long-term therapy of antioxidants.
iii. Intralesional injection: Steroids are injected with the
aim of anti-fibrinolytic and anti-inflammatory therapy.
Intralesional injection of 1 mL suspension containing
hydrocortisone along with 1 mL of lignocaine hydro-
chloride once a week is given. It may be increased to
twice a week depending on the severity of the disease.
iv. Medications: Antioxidants like retinoid, beta carotene,
and vitamin E prevent the formation of toxic substances
and enhance the indigenous concentration of vitamin A.
The functional and structural ingredients of epithelial cells
are dependent on adequate concentration of vitamin A.
v. Surgery: Skin grafts give better results in small lesions.
Coverage of the small area with full thickness flaps as characterized by the formation of keratin and/or the
like nasolabial, tongue, and palatal flaps have provided
better long-term relief. Laser is used to reduce scar
formation further.
201
Q. 3. T.N.M. classification.
Ans.
T.N.M. Classification
T.N.M staging system is developed by The American Joint
Commision for cancer.
Clinical and Histopathological T Classification of
Cancer of the Oral Cavity
TX: Primary tumour cannot be assessed.
T0: No evidence of primary tumour.
T: Carcinoma in situ.
Tl: Tumour 2 cm or less in greatest dimension.
T2: Tumour more than 2 cm, but not more than 4 cm in
greatest dimension.
T3: Tumour more than 4 cm in greatest dimension.
T4: Tumour invades adjacent structures.
Clinical and Histopathological N Classification
of Cancer of the Oral Cavity
NX: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastasis.
Nl: Metastasis in ipsilateral single lymph node 3 cm or less
in greatest dimension.
N2a: Single ipsilateral lymph node greater than 3 cm, but
less than 6 cm in greatest dimension.
N2b: Multiple ipsilateral nodes up to 6 cm in greatest di-
mension.
N2c: Bilateral or contralateral lymph nodes up to 6 cm in
greatest dimension.
N3: Metastasis in lymph nodes greater than 6 cm in greatest
dimension.
Clinical and Histopathological M Classification
of Cancer of the Oral Cavity
MX: Distant metastasis cannot be assessed.
Ml: No distant metastasis.
M2: Distant metastasis.
Q. 4. Squamous cell carcinoma of lip.
Ans.
Squamous Cell Carcinoma of Lip
l Squamous cell carcinoma is defined as ‘a malignant
epithelial neoplasm exhibiting squamous differentiation
presence of intercellular bridges’.
l The most common malignant neoplasm of the oral cav-
ity is epidermoid carcinoma.
202 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Squamous cell carcinoma occurs mostly in elderly men.
The lower lip is more commonly involved as compared
to the upper lip.
Aetiology
l Tobacco through pipe smoking. The heat, the trauma of
the pipe stem, and possibly the combustion end prod-
ucts of tobacco may be of some significance.
l Syphilis.
l Sunlight.
l Poor oral hygiene.
l Leukoplakia.
Clinical Features
l The clinical appearance depends on duration of the lesion
and nature of the growth. The tumour usually begins on
the vermillion border of the lip to one side of the midline.
l It starts as a small area of thickening, induration and
ulceration, or irregularity of the surface.
l As the lesion becomes larger, it may create a small
crater-like defect or produce an exophytic and prolifera-
tive growth of tumour tissue.
l Some patients may have small fungating masses in rela-
tively short time, while in other patients the lesion may
be only slowly progressive.
l As it is slow to metastasize, a massive lesion may de-
velop before any regional lymph nodes are involved
except for anaplastic ones.
l When metastasis does occur, it is usually ipsilateral and
involves the submental and submaxillary nodes, and
sometimes contralateral metastasis may occur.
Treatment
l Surgery or X-ray can be used depending on the size of the
lesion, its duration,the presence or absence of metastatic
lymph nodes, and the histologic grade of the lesion.
Q. 5. Erythroplakia.
Ans.
Erythroplakia
l Erythroplakia is used analogously to leukoplakia to des-
ignate lesions of the oral mucosa that present as bright
red velvety plaques, which cannot be characterized
clinically or pathologically as due to any other condition.
Aetiology
l Tobacco products.
l Ethanol.
l Hot, cold, spicy, and acidic foods and beverages.
l Alcoholic mouth rinse.
l Occlusal trauma.
l Sharp edges of prosthesis and teeth.
l Actinic radiation.
l Syphilic.
l Presence of Candida albicans.
l Presence of viruses.
Clinical Features
l Asymptomatic—derived during routine oral examination.
l More common in older age group .35 years, especially
in men.
l Frequent sites are lips, vermillion, buccal mucosa, man-
dibular gingiva, tongue, oral floor, and hard palate.
l The high-risk sites for malignant transformation are floor
of the mouth, lateral borders of tongue, and soft palate.
l Lesions may vary greatly in size, shape, and distribu-
tion. The borders may be distinct or indistinct and
smoothly contoured or ragged.
l The surface texture can vary from smooth thin surface
to leathery appearance with surface fissures referred to
as ‘cracked mud’.
l The non-homogenous type of oral leukoplakia also
known as erythroplakia or speckled leukoplakia may
have white patches or plaque intermixed with red tissue
elements.
l Verrucous leukoplakia has papillary projections similar
to oral papillomas.
Management
i. Elimination of aetiological factors: Discontinuation of
habits like alcohol and smoking by the patients which
are well established risk factors.
ii. Conservative: Vitamin therapy especially vitamin A and
E, B complex, 13-cis-retinoic, antioxidant therapy, and
nystatin therapy.
iii. Surgical therapy: Cold knife surgical excision
l Laser surgery.
l Cryosurgery.
l Fulguration.
iv. Re-examining the site every three months for the first
year. Follow-up for every six months, if the lesion does
not relapse or change in reaction pattern.
v. If new clinical features emerge, then new biopsies
should be taken.
Q. 6. Lichenoid reaction.
Ans.
Lichenoid Reaction
l A characteristic lesion consisting of white, wavy, paral-
lel, and non-elevated striae that do not criss-cross is
Section | I  Topic Wise Solved Questions of Previous Years
observed in habitual betel quid chewers. Sometimes,
these striae radiate from a central erythematous area at
the site of placement of betel quid.
Clinical Features
l The lesions always occur on the buccal mucosa and
mandibular groove areas, which are in intimate contact
with the betel quid.
l The factors involved are the immune mechanism, the
susceptibility of the individual, and the triggering
drug.
There are four general drug reaction mechanisms:
i. Histamine release: Certain drugs directly stimulate
degranulation of fixed tissue mast cells. Common damaged.
offending drugs are narcotics, morphine, meperidine
hydrochloride, and codeine; and many antimicrobials
such as vancomycin and amphotericin B.
ii. IgE-mediated reactions: Other drugs indirectly cause
histamine release, as they contain an antigenic site that
causes it to be bound to IgE fixed to the cell membranes
of mast cells.
iii. Antigen–antibody complexes: If a drug is taken over a
long period, then circulating antibodies to it may slowly
develop. Over time, new antigen–antibody complexes
may get lodged in the skin or any organ to initiate in-
flammation.
iv. Cytotoxic drug reactions: Some drugs become bound
to cell membranes in one or many organs as part of
their mechanism of action or their elimination. If
through sensitization the drug has stimulated anti-
body production by the coupling of antibody to the
antigen fixed to the cell membrane, then the drug may
cause cell lysis.
Treatment
l Identify the drug and discontinue its use.
l If the reaction is anaphylaxis, then full cardiopulmonary
resuscitation and cardiac life support may be needed. fore worsens over time. This explains why irradiated
If the reaction is known to be drug precipitated, then tissue heals slowly or not at all.
SHORT NOTES
Q. 1. Radiotherapy.
Or
Radiotherapy for oral carcinoma.
Ans.
l Tumour cells in stages of active growth are more suscep-
tible to ionizing radiation than adult tissues. The faster
the cells are multiplying or the more undifferented tu-
mour cells, the more likely that radiation will effective.
203
0.3 mL of 1:1000 epinephrine solution subcutaneously
should be part of the resuscitation.
l If the reaction is clinically angioedema, then airway is
observed. For histamine releasing reactions, diphen-
hydramine hydrochloride 50 mg IV remains the best
option for reversal of symptoms.
l If the offending drug cannot be discontinued, then predni-
sone is a reasonable therapeutic choice. It should be in the
lowest dose possible, to maintain control of the reaction.
Q. 7. Cellular change in radiation and its manifestation.
Ans.
l Radiation is high linear energy transferred to tissue with
the intention to kill cancer cells,but normal cells are also
l But cancer cells replicate more frequently than normal
cells, as they are more likely to be irradiated at a vulner-
able time in their cell cycle.
l However, many normal cells are also caught at vulner-
able times in their cell cycle, thereby creating the radia-
tion sensitivity spectrum. Germinal and lymphoreticular
cells are the most sensitive, endothelial cells and fibro-
blasts are of intermediate sensitivity, and the muscle and
the nerve have little sensitivity to radiation.
l It is the intermediate group of endothelial cells and fi-
broblasts that is important to the clinician, because they
are the primary cells involved with healing.
l When radiation energy passes through normal tissue, it
kills a small number of cells immediately. Most cells
survive, but incur internal damage to their DNA, RNA,
enzyme systems, and cell membranes.
l These cells mainly the vascular endothelial cells and
healing related fibroblasts can be considered impaired.
Although they live out their normal life spans or short-
ened life spans, these impaired cells often are not re-
placed by daughter cells when they die.
l Consequently, the tissue becomes less cellular, less vas-
cular, and less oxygenated over time. The well known
‘three H tissue’ develops which progresses and there-
l Radiation prevents the cells from multiplying by inter-
fering with their nuclear material. Normal host cells are
also affected by radiation and must be protected as
much as possible during treatment.
l The principal methods employed are:
i. X-ray therapy
a. Superficial X-ray therapy 45–100 kV.
b. Kilo voltage X-ray therapy 300 kV.
ii. Electron therapy.
204 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

i ii. Surface applicator (radium mould).

Premalignant Conditions
iv. Interstitial implantation (radium or equivalent
source). l It is a generalized state associated with a significantly
increased risk of cancer.
Q. 2. Osteoradionecrosis.
These alterations include genetic changes, epigenetic
Ans. changes, and surface alterations in intercellular inter-
actions.
l The diagnosis of precancers is primarily based on mor-
Osteoradionecrosis phology and its grading on histology (dysplasia).
l Osteoradionecrosis is bone death caused by radiation l Despite the fact that this estimation is subjective and

injury. therefore carries a low prognostic value of an impend-

l It is not an infection of compromised bone, as had previ- ing malignancy, it is still widely practiced to assess the
ously been thought, but an avascular necrosis of bone risk of malignant potential of such lesions.
caused by the three H tissue effects of radiotherapy. l Because of this inherent discrepancy, such lesions may

l Infections associated with oteoradionecrosis are sec- well be designated as potentially malignant.
ondary infections due to the exposure of bone and deep
Example of premalignant condition is oral submucous
tissue plans.
fibrosis.
l There are three types of osteoradionecrosis: Early trauma-

induced osteoradionecrosis, spontaneous osteoradione- Q. 6. Premalignant lesions.

crosis, and late trauma-induced osteoradionecrosis.
Ans.
Q. 3. Oral submucous fibrosis.
Or Premalignant Lesions
Submucous fibrosis. l It is defined as morphologically altered tissue in which
cancer is more likely to occur than in its apparently
Ans.
normal counterpart.
l These alterations include genetic changes, epigenetic
Oral Submucous Fibrosis changes, and surface alterations in intercellular interactions.
It is a chronic scarring disease that affects the oral as well l The sum total of these physical and morphological al-

as the pharynx and upper two-third of the oesophagus. It is terations are of diagnostic and prognostic revelance and
a high-risk precancerous condition. are designated as ‘precancerous’ changes.
l The diagnosis of precancers is primarily based on mor-

phology and its grading on histology (dysplasia).

Aetiology and Pathogenesis l Despite the fact that this estimation is subjective and

i. Chronic irritation from betel nut, i.e., areca nuts; chil- therefore carries a low prognostic value of an impend-
lies, tobacco, and lime. ing malignancy, it is still widely practiced to assess the
ii. Genetic predisposition. risk of malignant potential of such lesions.
iii. Nutritional deficiency. l Because of this inherent discrepancy, such lesions may

iv. Bacterial infections. well be designated as potentially malignant.

v. Collagen disorders. Example of premalignant lesion is leukoplakia.
vi. Immunological disorders.
Q. 7. Neck metastasis.
Q. 4. Carcinoma in situ.
Ans.
Ans.
l Carcinoma in situ is also known as intraepithelial carci-
noma.
Neck Metastasis
l It is a condition which arises frequently on the skin, but l Careful clinical evaluation is done with careful palpa-
occurs also on mucous membranes including those of tion of the neck with specific attention to location, size,
the oral cavity. firmness, and mobility of each node.
l Carcinoma in situ is used for lesions in which epithelial l The groups of nodes are localized between the sterno-
changes occur throughout their entire thickness, but cleidomastoid and trapezius muscle. Parotid nodes drain
without violation of the basement membrane. the buccal mucosa.
l The submandibular nodes drain the ipsilateral, upper
Q. 5. Premalignant conditions.
and lower lip, cheek, nose, nasal mucosa, medical
Ans. canthus, anterior gingiva, anterior tonsillar pillar, soft
Section | I  Topic Wise Solved Questions of Previous Years 205

palate, anterior two thirds of the tongue, and subman-

dibular gland.
l The submental nodes drain the mentum, the middle
portion of the lower lip, the anterior gingiva, and the
anterior portion of the tongue.
l The sublingual nodes drain the anterior floor of the
En Bloc Resection
l In En bloc resection, the tumour is removed along with
a rim of uninvolved bone, while maintaining the conti-
nuity of the jaw.
l This is the treatment of choice for aggressive lesions

mouth and ventral surface of the tongue. with high recurrence rate.
l The other nodes are retropharyngeal nodes, anterior l Intraoral approach is used for lesions anterior to the ra-

cervical nodes, juxta visceral nodes, pretracheal group,
paratracheal nodes, latetral cervica lnodes, the deep
group of nodes, internal jugular chain, deep posterior
cervical group, and post-auricular nodes.
l Radiological investigations of cervical metastasis can
be done by ultrasound, CT scan, MRI, and positron
emission tomography imaging.
Q. 8. Aetiology of leukoplakia.
Ans.
Leukoplakia
mus of the mandible; whereas those lesions involving
the ramus of the mandible are approached extraorally.
Q. 11. Chemotherapy.
Or
Chemotherapy in oral surgery.
Ans.
l Chemicals that act by interfering with rapidly growing
tumour cells are used for treating many types of malig-
nancies.
l Infections and bleeding are therefore common compli-

cations in these patients.

l Leukoplakia is defined as a predominantly white lesion
l They are introduced through branches of the external
of the oral mucosa that cannot be characterized as any
carotid artery including even the superificial temporal
other definable lesion.
branch in a retrograde fashion.
Q. 12. Erosive lichen planus.
Aetiology
Ans.
l Tobacco products.
l Ethanol.
l Hot, cold, spicy, and acidic foods and beverages. Erosive Lichen Planus
l Alcoholic mouth rinse.
l Erosive lichen planus is a T-cell mediated autoimmune
l Occlusal trauma.
interface in which the basal cell layer of mucosa and/or
l Sharp edges of prosthesis and teeth.
skin is attacked.
l Actinic radiation.
l Syphilis.
l Presence of Candida albicans. Clinical Features
l Presence of viruses.
l It presents in one of the three clinical forms, i.e., reticu-
Q. 9. Mention any four premalignant white patches. lar form, plaque form, and erosive form.
l All forms are seen in patients older than 40 years and
Ans.
equally in men and women.
l Predilection for buccal mucosa, the tongue, and the

Premalignant White Patches attached gingiva is more.

l Leukoplakia. Erosive form: It is characterised by intense pain and ery-
l Lichen planus. thematous mucosal inflammation. When it involves buccal
l Leukoedema. mucosa or tongue, it will produce fibrinous-based ulcers
l Lichenoid reaction. against a background of erythema and sometimes hyper-
keratotic foci. Some lesions present as vesicle formation
Q. 10. En bloc resection.
and Nikolsky’s sign.
Ans.
206 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Management of Medically Compromised Patients and
Medical Emergencies
LONG ESSAYS
Q. 1. How do you manage a patient for tooth extraction
witha. Diabetes mellitus, b. Bacterial endocarditis, andc.
Bronchial asthma?
Ans.
A. Diabetes Mellitus
l An absolute or relative deficiency of insulin in the body
causes diabetes mellitus.
l It can be classified as follows:
a. Type 1 (Insulin dependent diabetes mellitus), and
b. Type 2 (Non-insulin dependent diabetes mellitus).
l Type 1 is more commonly seen in young patients, while
type 2 occurs more commonly in adults.
l When the fasting glucose levels are constantly above
140 mg/dL, a patient can be classified as a diabetic.
Preoperative Investigations
i. Routine chest radiograph: PA view of the chest.
ii. Electrocardiogram.
iii. Routine blood investigations
a. Blood sugar fasting and postprandial.
b. Glucose tolerance test.
c. Renal profile (BUN, SC, and SE).
iv. Estimation of urine sugar.
Preoperative Preparation of Patient
l If the patient is on oral hypoglycaemics, then on the day
of surgery he/she must be shifted to insulin.
l The general principle followed in the management of
the patient under general anaesthesia is to provide at
least 200 gm of carbohydrate with adequate insulin to
cover his/her need.
Intra and Post-operative Management of
Diabetics
l The patient’s blood and urine sugar levels are checked
in the morning on the day of surgery with the help of
blood glucose strips and urostrips or glucometer.
l Based on the patient’s sugar levels, a sliding insulin
scale to be followed intraoperatively is prepared.
Topic 18
l Pre and post-operative broad-spectrum antibiotic
coverage.
l Close monitoring of the blood and urine sugar levels is
required intra and post-operatively.
l The patient is prevented from going into ketoacidosis or
hypoglycaemia.
l At the earliest possible, the patient should be shifted to
his regular oral feeds and antidiabetic medications.
B. Bacterial Endocarditis
l The cardiac disease is not an absolute contraindica-
tion even then the surgeon should weigh the benefits
against the risks before deciding the choice of
anaesthesia.
Preoperative Investigations
i. Routine chest radiograph: PA view of chest.
ii. Electrocardiogram.
iii. Echocardiogram.
iv. Stress test.
v. Routine blood tests
l Bleeding and clotting time.
l Prothrombin time and index, in case the patient is on
long-term anticoagulants.
l Lipid profile.
Preoperative Medication
l In case if the patient is on injection penidure every three
weeks, then the surgery should be scheduled immedi-
ately after the scheduled dose to reduce the risk of infec-
tive endocarditis.
Intra and Post-operative Management
i. All these patients should be monitored intra and post-
operatively, by means of an ECG, pulse oximeter, and
arterial line.
ii. A central venous pressure (CVP) cut-down may be
performed, if necessary.
iii. Until oral feeds are given, the patient should be main-
tained on intravenous cardiac drugs.
Section | I  Topic Wise Solved Questions of Previous Years 207

C. Bronchial Asthma Problems Normally Encountered

l In case of asthma, the most important aspect is the a . Altered consciousness.
patient’s respiratory reserve and the patient’s ability b. Chest pain and discomfort.
to tolerate general anaesthesia. c. Respiratory disturbances.
l A bronchodilator inhaler should be kept ready for use d. Allergic manifestations/anaphylaxis.
in case of an emergency, if the patient is treated under
local anaesthesia. Systemic Complications
a . Vasovagal attack.
Preoperative Investigations b. Postural hypotension.
i. Chest radiograph: PA view. c.
Diabetes mellitus.
ii. Blood investigations like arterial blood gases. d.
Primary insufficiency due to pathology of adrenal cortex.
iii. AFB culture of sputum. e.
Epilepsy.
iv. Bronchoscopy, if required. f.
Chest pain and discomfort.
v. Pulmonary function tests. g.
Respiratory emergencies like:
l Prior to the procedure, the patient should be coun- l Foreign body aspiration.

selled and advised to discontinue beedi/cigarette l Bronchial asthma.

smoking. l Hyperventilation.

l Any acute infection should be treated by antibiotics. l Cardiopulmonary arrest.

l Preoperatively and as well intra and post-operatively, . Allergy and anaphylaxis.

h
the patient should be on bronchodilators.
l All the time, patient must carry his/her inhaler with
Syncope
him/her for use in case of an emergency.
l Syncope is the transient loss of consciousness due to
cerebral ischaemia.
Intra and Post-operative Management l Other names of syncope are atrial bradycardia, neuro-

i. Intra and post-operatively, arterial blood gas monitor- genic syncope, psychogenic syncope, and vasovagal
ing should also be carried out. syncope.
ii. Fluid overload should be avoided.
iii. To avoid decrease in the oxygen carrying capacity Predisposing Factors
of blood, blood loss should be replaced by whole blood
or packed cells. Psychogenic factors
iv. Long-term corticosteroid therapy. l Anxiety and emotional stress.
v. Constant monitoring of the vital parameters. l Receipt of unwelcome news.
vi. Broad-spectrum antibiotic coverage: l Fright.

l Sudden and unexpected pain.

As these patients are highly susceptible to infections, they
must be given broad-spectrum antibiotic coverage.
Q. 2. What are the common medical emergencies in
dental practice? How would you manage syncope?
l Sight of blood and surgical instruments.
Non-psychogenic factors
l Erect sitting or standing posture.

l Hunger due to missed meal.

Ans.
l Exhaustion.

l Poor physical condition.

Medical Emergencies in Dental Practice l Hot, humid, and crowded environment.

l Male persons.
l Emergency is defined as an unforeseen or unexpected
l Age range between 16–35 years.
situation requiring immediate attention.
l In oral surgery practice, there are two possibilities:

a. A dental surgeon may be required to manage dental Clinical Features

emergencies, which may not arise as a result of treat-
i. Presyncope
ment, and
b. Sometimes the patient may call upon the dental l Feeling of warmth in the neck and the face.

surgeon, seeking emergency treatment for the l Pale or ashen gray skin colour.

suffering. l Bathes in cold sweat.

208 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l Bad/faint feeling/ nauseous feeling. l Placing the patient in supine position.

l BP is normal and heart rate increases. l Raising the legs above the head will help the blood to
l Pupillary dilation. return from periphery.
l Hyperpnoea. l Airway breathing and circulation maintained.

l Coldness in hands and feet. l Oxygen administered through face mask.

l Disturbed vision. l Ammonia ampoule crushed under patient’s nose.

l Dizziness. l Monitoring of vital signs

l Avoiding the cause of syncope.

ii. Syncope l An anticholinergic, e.g., atropine may be administered

l Loss of consciousness. intravenously or intramuscularly, if bradycardia persists.

l Breathing becomes shallow. l Emergency medical service should be considered, if

l Convulsive movements. patient does not gain consciousness for 15–20 min.
l Muscular twitching of hands and legs or facial muscles.
Q. 3. Describe the treatment plan of extraction in
l Brains become hypoxic.
patients with history of
l Bradycardia.
a. Hepatitis B.
l Heart rate of less than 50 beats/min.
b. Anticoagulant therapy.
l Blood pressure falls to an extremely low level.

l Pulse become weak and thready. Ans.

l Partial/complete airway obstruction.

iii. Post-syncope a. Hepatitis B

l Pallor. l A patient with viral hepatitis should be handled with
l Nausea. care to avoid inadvertent transmission of the disease to
l Weakness. the OT personnel or another patient.
l Sweating. l The risk of transmission depends on the type of hepatitis

l Short period of confusion or disorientation. carrier, the patient is.

l Arterial blood pressure begins to rise.

l Heart rate returns to normal.

Preoperative Investigations
i. Bleeding time and clotting time.
Pathophysiology
ii. Prothrombin time and index.
Stress iii. Assessment of liver enzymes
g a. SGOT (Serum glutamic oxaloacetic transaminase).
Release of cathecholamines, epinephrines, and b. SGPT (Serum glutamic pyruvic transaminase).
norepinephrines into circulatory system iv. Total bilirubin (Direct and indirect bilirubin).
g v. Serum albumin.
Changes in tissue blood perfusion vi. Serum alkaline phosphatase.
g vii. USG liver.
Decrease in peripheral vascular resistance
g Management
Pooling of blood in the muscles
g a . Consult the physician.
Relative decrease in circulating blood volume, drop in ar- b. Avoid any elective procedures.
terial blood pressure, and decrease in cerebral blood flow c.
Minimize or avoid medications and treatment.
g d.
During the treatment:
Compensatory mechanisms are activated Strictly adhere to aseptic techniques like gloves, masks,
g disposables, and adequate sterilization.
Cerebral ischaemia e. Use rubber dam to minimize the contact with saliva and
g blood.
Loss of consciouness
b. Anticoagulant Therapy
Management
l At least 4–5 days prior to surgery, with the physician’s
l Stopping the procedure. consent, patients on long-term anticoagulant therapy
l Loosening the patient’s clothing. should discontinue the anticoagulants.
Section | I  Topic Wise Solved Questions of Previous Years
l The patient should be shifted to intravenous anticoagu-
lants like heparin, if discontinuation of oral anticoagu-
lant therapy is not advisable.
l On the day of surgery, after omission of the anticoagu-
lant therapy, the patient’s bleeding time and clotting
time is checked.
Management
a . Consult the physician regarding therapy.
b. Hospitalization is mandatory.
c. Rescheduling the medication (only in consultation
with the physician for stopping of platelet-inhibiting
drugs).
Aspirin: Five days prior to treatment.
Coumarin: Two days prior to treatment.
Heparin: Six hours prior to treatment.
d. During elective surgery:
e. Use the measures to promote clot formation and its
retention.
f. Medications to be started once stable clots form.
g. Patient to be instructed not to dislodge the clot.
h. Avoid non-steroidal anti-inflammatory drugs.
Q. 5. Haemophilia.
Or
What precautions can you take while carrying out den-
tal treatment for a patient suffering from haemophilia?
Ans.
Haemophilia
l Haemophilia A is a congenital coagulopathy caused due
to lack of factor VIII.
l It is a sex-linked disorder whose gene is localized on the
X chromosome. It affects males and females.
l The disease is characterized by prolonged bleeding
time, as a result of failure of normal clotting procedure.
These usually begin spontaneously without apparent
trauma and the most commonly affected areas are
knees, elbows, ankles, and legs. Muscle haematomas
are also characteristics of haemophilia.
l Although joints and muscles are the most common
sites for the haemorrhage, bleeding can occur at al-
most any site.
l Bleeding should be treated early by raising factor VIII
level. It is accomplished by intravenous infusion of
factor VIII concentrate.
Tests
l Bleeding time.
l Platelet count.
l PIT.
209
l PT.
l Evaluation of clotting factors and time.
Management
l If the bleeding disorder is due to specific coagulation
factor deficiency, the respective factor should be re-
placed before carrying out the surgical procedures. If
the patient is under anticoagulants, ask him to stop the
medication one week prior to surgery.
l Use coagulation promoting factors like fibrin, thrombin,
adrenaline, sutures and pressure packs, etc.
l Once the clot has been formed, the patient is instructed
not to do any activity like blowing, gargling, etc., which
would result in dislodgement of the clot.
l Avoid prescription of NSAIDs, which can prolong
bleeding.
l Avoid drugs that may cause drug interactions and
inhibit warfarin metabolism.
Q. 6. Cardiopulmonary resuscitation.
Ans.
Cardiopulmonary Resuscitation
l When circulation ceases or stops and vital organs are
deprived of oxygen, the cardiac arrest occurs.
l In case of cardiac arrest, CPR is most effective when started
immediately and should be initiated by any person present
at the time of cardiac arrest/when the patient collapses.
Aetiology of Cardiac Arrest
l Cardiac disease.
l Hypoxia.
l Hypotension.
l Hypoglycaemia.
l Effect of drugs.
l Electrolytic changes.
l Vagal reflex mechanism.
l Terminal changes of any disease.
Checking for Response
l In case if there is failure in response, someone is sent
to activate the emergency response system and to get
the AED.
Opening the Airway
l Check for adequate breathing (take at least 5 sec and not
more than 10 sec) by tilting the head and lifting the chin.
l The breath is look for, listened, and tried to feel. If
there is no adequate breathing, then make the chest rise
by giving two breaths.
210 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Checking the Pulse
l To check the pulse, at least 5 sec and not more than
10 sec are taken.
l If no pulse, then cycles of 30 compressions and two
breaths are started.
l AED arrives after two cycles of CPR. Interruptions in
chest compressions are minimized. Interruptions are
tried to be kept to 10 seconds or less.
The AED is put next to the victim and below commands are
followed:
l The AED is turned on and adult pads are attched.
l It is made sure that no one is touching the victim and the
AED is allowed to check the heart rhythm.
l The AED prompts are followed and a shock is delivered.
l Shock delivery is followed. CPR is started immediately
beginning with chest compressions.
For children
l After checking, if there is no response, then one should
shout for help.
l Someone is sent to activate the emergency response
system and to get the AED.
l By tilting the head and lifting the chin, the airway is
opened and checked for 5–10 sec for breathing response.
l The breath is looked for, listened, and felt. If there is no
breathing, then two breaths are given and the chest is
made to rise.
l After checking for 5–10 seconds, if there is no pulse and
the heart rate is less than 60 beats per min, then cycles
of 30 compressions and two breaths are started.AED
arrives after two cycles of CPR. Interruptions are mini-
mized in chest compressions. Interruptions are tried to
be kept to 10 sec or less.
l After 5 cycles, the emergency response system is acti-
vated and the AED is got.
l The remaining steps are followed for adults with child
pads, and adult pads are used, if child pads do not help.
Q. 7. Define shock. Discuss the pathogenesis, clinical
features, and management of hypovolaemic shock.
Or
Discuss ‘shock’ in oral surgery.
Or
Classify the shock. Discuss in detail the pathogenesis,
clinical features, and management of haemorrhagic shock.
Ans.
Shock
l Shock is a pathophysiologic condition, clinically recog-
nized as a state of inadequate perfusion. Due to inade-
quate blood flow, there is inadequate delivery of nutrients
to the tissues and inadequate removal of cellular waste
products from the tissue cells, which results in disruption
of vital organ functions.
Hypovolaemic Shock
l Hypovolaemic shock results from a decrease in the cir-
culating or effective intravascular volume.
l It is the most common type of shock in the victim of
maxillofacial trauma.
l Hypovolaemic shock can be further classified into
haemorrhagic and non-haemorrhagic.
i. Haemorrhagic Shock
l Haemorrhagic shock occurs due to loss of blood from
the body as a result of injury.
l Haemorrhage decreases the mean systemic filling pres-
sure and there is a resultant decrease of venous return,
which results in the fall of cardiac output.
l Approximately 10–15% of the total blood volume loss
will not significantly affect the arterial pressure or car-
diac output.
l 15–25% loss of blood volume may not cause haemo-
dynamic change. If the blood loss is not rapid, then
the metabolic changes associated with shock may be
initiated.
l Shock results due to rapid loss of 30–40% of the blood
volume; and if not treated becomes progressive and may
lead to death.
ii. Non-haemorrhagic Shock
l There is massive fluid shift from intravascular compart-
ment to extravascularcompartment.
l This can result from burns, crush injuries, pancreatitis,
peritonitis, pleural effusion, and ascites.
l Water loss due to severe diarrhoea, vomiting, diabetes
insipidus, hyperglycaemia, nephritis, and excessive di-
uretic use can also lead to non-haemorrhagic hypovo-
laemic shock.
Pathophysiology
l Decrease in arterial pressure caused by blood loss
stimulates powerful sympathetic reflexes that result in
constriction of arterioles, veins, and venous reservoirs;
and there is increase in heart activity.
l The body tries to maintain cardiac output and arterial
pressure to normal levels. There is formation of angio-
tensin and vasopressin, which constricts the peripheral
arteries and cause increased conservation of water and
salt by the kidneys.
l If body reflex mechanisms are not able to raise the arte-
rial pressure sufficiently and no urgent intervention is
Section | I  Topic Wise Solved Questions of Previous Years
done by replacement of fluids, then there is depression
of myocardium and vasomotor centre.
l Blood flow through the tissues becomes sluggish. There
is accumulation of acids due to continued tissue starch solution can be used, as these restore intravascu-
metabolism.
l These acids and other deterioration products from
the ischaemic tissues cause blood agglutination in the
capillaries.
l Due to prolonged hypoxia, the permeability of capillar-
ies gradually increases and large quantities of fluid
transude into the tissues.
l This further decreases blood volume and there is gener-
alized cellular deterioration, generalized and local tissue
acidosis, and tissue necrosis in vital organs.
l This leads to a vicious cycle, i.e., each increase in
degree of shock causes a further increase in the shock.
l After the shock has progressed to a certain stage, trans-
fusion or any other therapy becomes incapable of saving
the life of the person. Therefore, the person is said to be
in irreversible stage of shock.
Clinical Features
l Tachycardia.
l Poor capillary perfusion.
l Decrease in pulse pressure to hypotension.
l Tachypnoea.
l Delirium.
Mild , 20%: Postural hypotension; patient feels cold;
tachycardia; cool, pale, and moist skin; collapsed neck
veins; and concentrated urine.
Moderate . 20–40%: Thirst; supine hypotension and
tachycardia; and oliguria or anuria,
Severe . 40%: Agitation and confusion; and supine
hypotension and tachycardia are invariably present; and
there is rapid deep respiration.
Treatment
l Replacement of fluids and tissue perfusion are the main-
stay of the treatment of shock. Volume resuscitation
must be undertaken promptly.
l The legs raised and body supine is the preferred posture,
as this increases venous return and cardiac index.
l Patient should be kept warm.
l When haemorrhage is massive, type specified matched
transfused blood is the preferred method to correct
hypovolaemia. Typing and cross-matching of blood
takes time sometimes.
l Uncrossed type O 2ve blood should be reserved for
life-threatening blood loss that cannot be adequately
replaced by other fluids.
l Initial resuscitation is done with crystalloids, such as
normal saline or Ringer lactate. It requires up to several
211
litres of fluids, but replacement of interstitial fluid with
crystalloids is preferred.
l After initial resuscitation, colloids such as albumin or
lar volume more effectively.
l All these fluids should be warmed before transfusion,
because hypothermia worsens acid–base disorders and
myocardial function.
l The amount of fluid administration is based upon im-
provement of clinical signs, particularly blood pressure
and pulse pressure and heart rate.
l Central venous pressure and urinary output also provide
indication of restoration of vital organ perfusion.
l Hypotension in patients with hypovolaemic shock
should be aggressively treated with intravenous fluids.
Q. 8. Various types of haemorrhage encountered in oral
surgery and its treatment.
Or
Discuss the management of haemorrhage in oral surgery.
Ans.
Haemorrhage
Types of Haemorrhage
I. Depending on the type of blood vessel involved
1. Arterial haemorrhage.
2. Venous haemorrhage.
3. Capillary haemorrhage.
II. Depending on the time of bleeding
1. Primary bleeding—immediate bleeding.
2. Secondary bleeding—after 24 h to several days.
3. Intermediate bleeding—eight hours after primary bleed-
ing stops.
III. Depending on the confinement of bleeding
1. Internal or concealed bleeding.
2. External bleeding.
Management of Haemorrhage
The techniques for local haemostasis may be classified as:
i. Mechanical,
ii. Thermal, or
iii. Chemical.
I. Mechanical techniques for local haemostasis
i. Pressure
l For at least five minutes, pressure should be applied
directly over the bleeding site firmly with a gauze
pack. One should not be in a hurry and should not lift
212 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
pack every minute to see whether bleeding has stopped
or not.
l Post-traumatic nasopharyngeal bleeding or pharyngeal
bleeding due to maxillofacialtrauma can be controlled
by nasal packing.
ii. Use of haemostats
l Haemostat or mosquito, artery forceps are specially
designed to catch bleeding pointsin the surgical area.
l Electrosurgical thermocoagulation is done after catch-
ing the bleeding point with artery forceps, if the vessel
is small. The large vessels are ligated with suture.
iii. Sutures and ligation
l Transected blood vessel may need to be tied with the
help of ligature.
l When large pulsatile artery needs to be tied, non-
absorbable material is preferred.
iv. Embolization of the vessels
l The exact bleeding point can be localized with the help
of angiography.
l Agents such as steel coils, polyvinyl alcohol foam, gel
foam, silicon spheres, and methyl methacrylate can be
used for embolization.
II. Thermal techniques for local haemostasis
i. Cautery
l Heat achieves haemostasis by denaturation of proteins,
which results in coagulation of large areas of tissue.
l In cauterization, heat is transmitted from the instrument
by conduction directly to the tissues.
ii. Cryosurgery
l Temperature ranging from 220°C to 215°C is used. At
these temperatures, the tissues, capillaries, small arteri-
oles, and venules undergo cryogenic necrosis.
l This is caused by dehydration and denaturation of lipid
molecules. Cryosurgery is specially used to treat super-
ficial hemangiomas.
iii Lasers
l Lasers usually result in bloodless surgical field, as they
effectively coagulate the smallblood vessels during is excessive blood loss due to haemorrhage and there are
cutting of tissues.
III. Chemical methods
i. Local agents
Astringent agents and styptics
l Monsel’s solution contains ferric subsulphate and it acts
by precipitating proteins.
l Tannic acid also helps in precipitating proteins and
causes clot formation.
l Silver nitrate and ferric chloride are other agents, which
can be used in case of minimal capillary bleeding.
Bone wax
l It acts mechanically by occluding the bony canals.
l It should be used judiciously, as large quantities of bone
wax may lead to foreign body granuloma and infection.
Thrombin
l Topical use of thrombin acts by converting fibrinogen
into fibrin clot. It is very kind to tissues and quite
effective.
l It is applied to the bleeding surface via a pack, gelatin
sponge, or surgicel.
Gelfoam
l It exerts pressure along with acting as scaffold for fibrin
network. It is absorbed by phagocytosis.
l Gelfoam should be moistened in saline or thrombin
solution prior to application and all the air should be
removed from interstices.
Fibrin glue
l It is a type of biological adhesive.
l Fibrin glue consists of thrombin, fibrinogen, factor XIII,
and aprotinin.
l Its mechanism of action is that the thrombin converts
fibrinogen to fibrin clot, which is unstable. Factor
XIII stabilizes the clot and aprotinin prevents its
degradation.
Adrenaline
l The adrenaline is used in a concentration of 1:1000 ap-
plied with the help of gauze pack over oozing sites. It
can also be injected along with local anaesthetic in con-
centration of 1:80,000 to 1:2,00,000.
l This drug should not be used in patients, who have hy-
pertension or previously existing cardiac disease.
ii. Systemic agents
Whole blood
l Whole blood transfusion may be indicated, when there
symptoms of hypovolaemic shock.
l All the factors for coagulation are present in fresh whole
blood.
l When specific blood components are not available to
treat the patient’s haemostatic defect, whole blood may
be used.
Q. 9. What are all the various complications that can
occur in oral surgery? Discuss dry socket in detail.
Ans.
Section | I  Topic Wise Solved Questions of Previous Years
Complications in Oral Surgery
Intraoperative Complications that are
Preventable
1 . Primary haemorrhage.
2. Dislocation of the temporomandibular joint.
3. Fracture of the tooth or jawbone.
4. Oroantral fistula.
5. Displacement of the tooth.
6. Damage to the soft tissues.
7. Damage to the neighbouring dental structures.
8. Failure to complete the operation.
Post-operative Complications
1 . Osteomyelitis.
2. Impairment of sensation.
3. Dry socket.
4. Reactionary or secondary haemorrhage.
5. Pain and swelling.
6. Trismus.
Dry Socket
Other terms used are necrotic alveolar socket, alveolalgia,
delayed extraction, wound healing, fibrinolytic alveolitis,
alveolar osteitis, and localized osteomyelitis.
Aetiology
Aetiology can be broadly considered as systemic and local
factors.
Systemic factors
1. Age distribution
It is most commonly seen in the age group of 20–40
years. Extraction of deeper and the more difficult im-
pacted teeth in later years of life become more trau-
matic, thereby predisposing to dry socket.
2. Sex distribution
Female patients have lower threshold and tolerance of
pain. Post-extraction pain is more in females.
General factors
The duration of this lesion is 2–10 days. General resistance
of the patient may be responsible for the occurrence of this
condition.
Local factors
1. Distribution within the dental arches
It is more common in the mandibular molar region, but
very rare in the anterior region. It is much more frequent
after the removal of retained or unerupted teeth, proba-
bly due to the increased trauma during removal.
213
2. Insufficient blood supply to the alveolar socket
Dry socket develops more often if the surgery is per-
formed under local anaesthesia with excess of vasocon-
strictor-like adrenaline injected around dense, sclerosed
bone in the mandibular molar region. Sclerotic bone
changes caused by periapical infection can also result in
decreased blood supply to the alveolus.
3. Pre-existing infections
Pericoronitis and periapical infections are considered to
be the predisposing factors of dry socket.
4. Trauma to the alveolar bone
It is considered to be one of the main causes. Excessive
trauma is known to result in delayed wound healing and
osteitis of the alveolar socket. Smoking and oral contra-
ceptives may also predispose to intravascular thrombosis.
5. Disturbance of the clot
Once the clot formation is complete, energetic and re-
peated irrigation of the socket disturbs the clot and
leaves the socket empty. Similarly, violent curettage
might injure the alveolar bone.
6. Increased fibrinolytic activity
Fibrinolysis is known to be a regulator of the coagula-
tion process where and when clot formation is undesir-
able. Fibrinolysis can be traced in saliva and bacteria.
Fibrinolysis is known to influence the integrity of the
clot and its organization is important for the normal
healing of the extracted socket. Fibrinolysis of the clot
seems to be the most outstanding clinical feature of dry
socket.
7. Microorganisms
Fibrinolysis occurs due to the toxin fibrinolysin released
by Streptococcus viridans. It has been pointed out that
the dry socket is not associated with clinical features of
inflammation like redness, suppuration, swelling, and
pain. Metronidazole is found to reduce the incidence of
dry socket.
Clinical Features
1. The patient usually complains of continuous, throbbing,
and excruciating pain, usually radiating to the ear.
2. The site of pain can be clearly identified as the site of
removal of the tooth 48–72h earlier.
3. The pain is such that it becomes worse during meals. It
also disturbs the patient during sleep.
4. The patient however has relief of pain with analgesics
and local application of heat.
5. The tooth socket appears dry and empty. It may also
contain brownish foul smelling necrotic tissue. The
bone is markedly tender.
6. Halitosis is striking and marked.
7. It resolves in a week or two. The healing may be has-
tened with the trusted local dressing like zinc oxide-
eugenol impregnated cotton or polyantibiotic paste.
214 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Diagnosis
The clinical diagnosis is made on the basis of the following
features:
1. History of extraction a few days back.
2. Empty alveolar socket, covered by greyish necrotic
tissue.
3. The surrounding gingiva exhibits mild inflammatory
reactions.
4. The patient complains of characteristic excruciating
pain and halitosis.
5. The patient complains of feeling of ‘unwell’ due to lack
of appetite and sleep.
Management
l Scaling of teeth and treatment of inflammation of the
gingiva prior to dental extraction.
l The technique must include the use of local anaesthetic
solution with minimum of vasoconstriction.
SHORT ESSAYS
Q. 1. Tracheostomy.
Ans.
Tracheostomy
l Tracheostomy is a preferred opinion for relief of airway
obstruction performed under local anaesthesia, by mak-
ing an opening in anterior wall of the trachea and con-
verting it into stoma on skin surface. If emphysema is
present, there is some difficulty in identifying surgical
landmarks; but, the operation is safer than intubation
through a swollen larynx.
Indications
I. Respiratory obstruction
l Infections: Ludwig’s angina, acute epiglottitis, and peri-
tonsillar and retropharyngeal abscess.
l Trauma to larynx and trachea, mandible fracture, and
maxillofacial injuries.
l Tumour.
l Foreign body.
l Laryngeal oedema due to allergy/irritants/radiation.
l Bilateral abductor vocal cord palsy.
l Congenital anomalies like laryngeal web, cyst, and tra-
cheoesophageal fistula.
II. Retained secretions (Inability to cough)
Technique
l To bring trachea as near the surface as possible, the head
is held firmly with neck fully extended over sand bags.
l Extraction technique must be as least traumatic as
possible.
l Insertion of antibiotics or steroids after extraction or
prophylactic parenteral antibiotic therapy into the
socket, are not found to be useful in reducing its inci-
dence.
l In view of the Gram-negative organisms, metronidazole
600–800 mg per day appears to be effective. Incidence
is high, if the impacted tooth with pre-existing pericoro-
nitis is removed.
l The ‘dry socket’ should be irrigated with warm saline to
eliminate the necrotic material from the socket.
l It is better to avoid surgical curettage. The time-hon-
oured popular remedy of loosely packed cotton impreg-
nated with zinc oxide-eugenol is yet to be replaced by
any other effective remedy.
l Usually, two or three dressings may be necessary de-
pending on the relief of symptoms. Whitehead’s varnish
has also been tried, but it is not as effective as zinc ox-
ide-eugenol dressing.
The thumb and middle fingers of the left hand are used
to palpate and identify the cricoid cartilage, which
should be grasped throughout the operation.
The incision is made from the thyroid notch to a point
l
one centimetre above the sternal notch, through all the
superficial tissues.
l In the technique of high tracheostomy, pretracheal fascia
is incised at the level of cricoids cartilage; while for low
tracheostomy technique, a dotted line indicates incision.
l In children, a low tracheostomy site is advisable as there
will be much bleeding due to congestion. But if the inci-
sion is in the midline, there is no danger. The index
finger of the left hand is placed in the wound to identify
and protect the cricoid cartilage. The incision is deep-
ened on to the trachea.
l If necessary, the thyroid isthmus is divided and the sec-
ond and the third tracheal rings are incised.
l The tracheal incision is dilated with the handle. A rub-
ber tube of half a centimetre diameter will serve to
maintain the airway.
l Care must be taken in placing the tube. Once the tube is
held in place, the emergency is over and respiration
should start, and bleeding should be controlled.
Q. 2. Minor oral surgeries in diabetic patients.
Ans.
Minor Oral Surgeries in Diabetic Patients
l Under local anaesthesia, when a surgical procedure is
to be carried out in a diabetic patient, he should be on
Section | I  Topic Wise Solved Questions of Previous Years
his normal diet and insulin at the usual time and the
operation should commence after about one hour. It is
not necessary to use adrenal-free anaesthetic solutions,
but neither the operation must not be unduly prolonged
nor the meals and snacks on the patient’s schedule be
missed.
l Diabetics, who are on insulin or have to undergo general
anaesthetic treatment, need to be admitted to hospital
where advice of the physician is sought. Those on long-
acting insulin are changed to soluble form and till mid-
night on the day before the operation, the most severe
diabetics will receive their normal insulin and carbohy-
drate. They should be operated first on the next morning
and be given only a saline infusion during the operation,
after which, blood sugar estimation is immediately per-
formed before administering the necessary insulin and
glucose by infusion.
l Till the normal balance is resumed post-operatively,
careful monitoring of the patient is continued.
l More complicated management may be required for
severe diabetics or where a long operation is involved.
l To control infection at the site of operation, the surgeon
must take measures by careful oral prophylaxis.
l The patient can resume his normal diet by providing
dentures as quickly as possible.
Q. 3. Haemophilia.
Or
Haemophilia A.
Or
Haemophilia patient for dental extraction.
Ans.
Haemophilia A
Haemophilia A is a congenital coagulopathy caused due to
lack of factor VIII. It is a sex-linked disorder, whose gene
is localized on the X chromosome. It affects males and
females.
l The disease is characterized by prolonged bleeding
time, as a result of failure of normal clotting procedure.
These usually begin spontaneously without apparent
trauma and the most commonly affected areas are
knees, elbows, ankles, and legs. Muscle haematomas
are also characteristic of haemophilia.
l Although joints and muscles are the most common sites
for the haemorrhage, bleeding can occur at almost pressure.
any site.
l Bleeding should be treated early, by raising factor
VIII level. It is accomplished by intravenous infusion of
factor VIII concentrate.
215
Tests
l Bleeding time.
l Platelet count.
l PIT.
l PT.
l Evaluation of clotting factors and time.
Management
l Use coagulation promoting factors like fibrin, thrombin,
adrenaline, sutures and pressure packs, etc.
l Once the clot has been formed, the patient is instructed
not to do any activity like blowing, gargling, etc., which
would result in dislodgement of the clot.
l Avoid prescription of NSAIDs, which can prolong
bleeding.
l Avoid drugs that may cause drug interactions and in-
hibit warfarin metabolism.
Q. 4. Shock in oral surgery.
Or
Management of anaphylactic shock.
Ans.
Shock
l Shock is a pathophysiologic condition, clinically recog-
nized as a state of inadequate perfusion. Due to inade-
quate blood flow, there is inadequate delivery of nutri-
ents to the tissues and inadequate removal of cellular
waste products from the tissue cells, which results in
disruption of vital organ functions.
Anaphylactic Shock
l When it occurs, it is accompanied by severe circulatory
and respiratory collapse, urticaria, laryngeal oedema,
steep fall in BP, weak pulse, bronchospasm, and loss of
consciousness.
l Syncope (vasovagal attack) is reversible, but anaphy-
laxis is irreversible. Hence, the treatment must be pro-
vided as an emergency to improve the prognosis. Other-
wise, it can be fatal.
l Immediate emergency treatment includes the following:
l Injection epinephrine 1:1000, 0.5–1.0 mL subcu-
taneously.
l Maintenance of ventilation with oxygen under
l If severe bronchospasm develops, then 250–500 mg
of aminophylline is given intravenously.
l Resuscitation methods like cardiac massage and
mouth to mouth breathing, if necessary.
216
l Without any delay, immediate medical consultation and
hospitalization must be arranged to save the life of the
patient. Anaphylaxis may even be due to the drug pre-
servatives added in the local anaesthetic.
Q. 5. Hyperparathyroidism.
Or
Hyperparathyroidism investigations.
Ans.
Hyperparathyroidism
l Hyperparathyroidism is an uncommon disease and
occurs due to an increased activity of parathyroids forearm muscle tissue.
and manifests as hypercalcaemia.
Causes
l Single chief cell adenoma is the most common cause.
l It can be due to diffuse hyperplasia involving all four
glands.
l Very rarely it is due to the carcinoma arising in the para-
thyroid glands.
Clinical Features
l Common in females.
l Female/male ratio is 2:1.
l Age is 20–60 years with the most common being fifth
decade.
l Incidence is 1:1000 patients.
l The most common presentation is asymptomatic hyper-
calcaemia and renal stones.
l Bones—excessive skeletal decalcification, bony pains,
pathological fractures, and subperiosteal erosions.
l Renal disease—renal ischaemias and hypertension.
l Abdominal groans—calcium stimulates gastrin that is a
powerful stimulator of acid that causes pain in abdomen
and pancreatitis.
l Corneal calcification seen on split lamp examination.
l Proximal myopathy and muscle wasting.
Types
l Primary hyperparathyroidism.
l Secondary hyperparathyroidism.
l Tertiary hyperparathyroidism.
Investigations
I. Hyperparathyroidism
l Serum calcium, phosphate, and albumin.
l Serum PTH assay.
Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Alkaline phosphatase.
l X-ray of bones.
II. Localizing parathyroid glands
l Ultrasound of neck.
l Thallium and technetium subtraction scan.
Treatment
l Single adenoma: Excision of the gland. However, an-
other normal parathyroid gland is also removed for
histopathological study.
1 3
l Diffuse hyperplasia: 3 /2 or 3 /4 parathyroids are re-
moved and a small piece is autotransplanted into the
l Carcinoma: All four glands should be removed along
with the thyroid tissue.
Q. 6. Blood groups.
Or
Blood grouping and transfusion.
Ans.
Blood Groups and Transfusion
l Individuals are divided into four major types of blood
groups.
l The A and B antigens are inherited as Mendelian domi-
nants.
l Type A individuals have the A antigen, type B individu-
als have the B antigen,t ype AB have both antigens, and
type O have neither antigens.
l These antigens are present in many tissues including
blood.
l When blood is transfused into an individual with an
incompatible blood type, the red blood cells agglutinate
and haemolyze. Free haemoglobin is liberated into the
plasma.
l The severity of transfusion reaction ranges from asymp-
tomatic to severe jaundice and renal tubular damage
with anuria to death.
l Persons with type AB blood group are universal recipi-
ents, because they have no circulating agglutinins and
can be transfused with any type of blood without delay-
ing a transfusion reaction due to ABO compatibility.
l Type O are universal donors, because they do not have
A and B antigens and hence can be given to anyone
without any transfusion reactions.
l In order to avoid complications, blood should always be
transfused after cross-matching.
Q. 7. Indications for blood transfusion.
Or
Section | I  Topic Wise Solved Questions of Previous Years
Autologous blood transfusion.
Or
Blood transfusion reactions.
Ans.
Blood Transfusion
l When blood is transfused into an individual with an
incompatible blood type, i.e., an individual who has ag-
glutinins against red cells in the transfusion, dangerous
haemolytic transfusion reactions occur.
l When the receipient’s plasma has agglutinins against
the donor’s red cells they agglutinate and haemolyze.
The free haemoglobin is liberated into the plasma. The
severity of transfusion reaction may vary from asymp-
tomatic to severe jaundice and renal tubular damage
with anuria to death.
l Persons with types AB blood group can be given blood
of any type, as they are universal recipients since they
have no circulating agglutinins.
l Type O individuals are universal donors and type O
blood can be given to anyone without any transfusion
reaction.
l Blood should never be transfused without being cross-
matched.
Indications
l When there is excessive blood loss due to haemorrhage
and there are symptoms ofhypovolaemic shock, whole
blood transfusion may be indicated.
l Fresh whole blood contains all the factors for coagu-
lation.
l When specific blood components are not available to
treat the patient’s haemostatic defect, whole blood may
be used.
Autologous Blood Transfusion
l Recently, a procedure that has become popular is to
transfuse the patient’s own blood in elective surgeries.
l In this procedure, patient’s own blood is drawn prior to
surgical procedure and then his blood is infused back
during a surgery, if a transfusion is needed.
l 1000–1500 mL of blood can be withdrawn over a three
week period in patients on iron therapy.
l Banking one’s own blood has become popular to avoid
fear of transmission of AIDS by heterozygous transfu-
sions.
Q. 8. Hepatitis B infection.
Ans.
217
Hepatitis B Infection
l A patient with viral hepatitis should be handled with
care to avoid inadvertent transmission of the disease to
the OT personnel or another patient.
l The risk of transmission depends on the type of hepatitis
carrier, the patient is.
Preoperative Investigations
i. Bleeding time and clotting time.
ii. Prothrombin time and index.
iii. Estimation of liver enzymes
a. SGOT (Serum glutamic oxaloacetic transaminase).
b. SGPT (Serum glutamic pyruvic transaminase).
iv. Total bilirubin (Direct and indirect bilirubin).
v. Serum alkaline phosphatase.
vi. USG liver.
Management
a . Consult the physician.
b. Avoid any elective procedures.
c.
Minimize or avoid medications and treatment.
d.
During the treatment:
Strictly adhere to aseptic techniques like gloves, masks,
disposables, and adequate sterilization.
e. Use rubber dam to minimize the contact with saliva and
blood.
Q. 9. Bacterial endocarditis.
Or
Prophylaxis for subacute bacterial endocarditis.
Ans.
Bacterila Endocarditis
l Infective endocarditis is a microbial infection of endo-
cardium affecting the heart valves and endocardium.
l Damage to the myocardial endothelium allows for the
deposition of platelets and fibrin to form the non-bacte-
rial thrombotic vegetation.
l Persistent bacteremias results from the microorganisms re-
entering the blood from infected cardiac lesions. Antibiotic
prophylaxis is recommended for the patients with the risk.
Endocarditis prophylaxis is recommended for:
l Dental extractions and minor oral surgical procedures.
l Periodontal surgical procedures, e.g., scaling and root
planning.
l Dental implant surgeries.
l Re-implantation of avulsed tooth.
l Endodontic instrumentation or surgery extending be-
yond the apex.
218 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l Initial placement of orthodontic bands. Types of Haemorrhage

l Local anaesthetic injection (intraligamentary injections).
l Oral prophylaxis where bleeding is anticipated.
I. Depending on the Type of Blood Vessel Involved
1 . Arterial haemorrhage.
Situation Antibiotic Regimen 2. Venous haemorrhage.
Standard Amoxicillin Adults 2.0 g and children
3. Capillary haemorrhage.
general 50 mg/kg orally one hour
prophylaxis before procedure
II. Depending on the Time of Bleeding
Cannot use oral Ampicillin Adults 2.0 g IM/IV and chil-
medications dren 50 mg/kg IM/IV within 1 . Primary bleeding—immediate bleeding.
30 min before procedure 2. Secondary bleeding—after 24 h to several days.
Allergic to Clindamycin Adults 500 mg and children
3. Intermediate bleeding—8 h after primary bleeding stops.
penicillin or 20 mg/kg orally one hour
before procedure
III. Depending on the Confinement of Bleeding
Cephalexin, Adults 2.0 g and children
cephadroxil, 50 mg/kg orally one hour 1 . Internal or concealed bleeding.
or before procedure 2. External bleeding.
Azithromycin Adults 500 mg and chil-
or clarithro- dren15 mg/kg orally one Management of Haemorrhage
mycin hour before procedure
Allergic to peni- Clindamycin Adults 600 mg and children
The techniques for local haemostasis may be classified as:
cillin and unable 15 mg/kg IV one hour be- I. Mechanical,
to take oral fore procedure II. Thermal, or
medications III. Chemical.
Or cephazo- Adults 1.0 g and children
lin 25 mg/kg IM/IV within 30
minutes before procedure
I. Mechanical
i. Pressure
Q. 10. Cricothyrotomy. l Pressure should be applied directly over the bleeding site

firmly over a gauze pack for at least five minutes. One

Ans. should not be in a hurry and should not lift pack every
minute to see whether bleeding has stopped or not.
Cricothyrotomy l Post-traumatic nasopharyngeal bleeding or pharyngeal

bleeding due to maxillofacialtrauma can be controlled

l Cricothrotomy is an alternative to tracheostomy
for routine laryngeal fractures and fracture of the
maxilla.
l If the patient is unconscious or has showed signs of
altered consciousness, then this is the most frequent designed to catch bleeding points in the surgical area.
indication to provide an airway by way of endotracheal
intubation.
l In rare and unlikely circumstances that the methods fail
to ensure an adequate airway, a surgical cricothyrotomy
is easily performed through the cricothyroid membrane
and after dilation of the opening, a small endotracheal
tube or tracheostomy tube can be inserted.
l This is a technique that can be rapidly carried out with
low morbidity and without requiring the skills and
equipment needed to perform a tracheostomy.
Q. 11. Types of haemorrhage.
Or
Post-extraction haemorrhage management.
by nasal packing.
ii. Use of haemostats
l Haemostat (Mosquito, artery) forceps are specially
l Electrosurgical thermocoagulation is done after catch-
ing the bleeding point with artery forceps, if the vessel
is small. The large vessels are ligated with suture.
iii. Sutures and ligation
l Transected blood vessel may need to be tied with the
help of ligature.
l When large pulsatile artery needs to be tied, non-ab-
sorbable material is preferred.
iv. Embolization of the vessels
l The exact bleeding point can be localized with the help
of angiography.
l Agents such as steel coils, polyvinyl alcohol foam,

gel foam, silicon spheres, and methyl methacrylate

Ans. can be used for embolization.
Section | I  Topic Wise Solved Questions of Previous Years
II. Chemical Methods
A. Local agents
Astringent agents and styptics
l Monsel’s solution contains ferric subsulphate and it acts
by precipitating proteins.
l Tannic acid also helps in precipitating proteins and
causes clot formation.
l Silver nitrate and ferric chloride are other agents, which
can be used in case of minimal capillary bleeding.
Adrenaline
l The drug is applied with the help of gauze pack in a
concentration 1:1000 over oozing sites. It can also be
injected along with local anaesthetic in concentration of
1:80,000 to 1:2,00,000.
l This drug should not be used in patients, who have
hypertension or previously existing cardiac disease.
B. Systemic agents
Whole blood
l Due to haemorrhage, when there is excessive blood loss
and there are symptoms of hypovolaemic shock, whole
blood transfusion may be indicated.
l All the factors for coagulation are present in fresh whole
blood.
l Whole blood may be used when specific blood components
are not available to treat the patient’s haemostatic defect.
Q. 12. Contents of medical emergency drug tray in dental
office.
Ans.
The following are the important criteria to be taken into
account when selecting appropriate emergency drugs:
i. Drugs which are to be considered essential for the first
line management of medical emergencies, i.e., drugs
which will act within the first 15–20 min of an emer-
gency as an adjunct to basic life support and other life
saving measures.
ii. Drugs which can be used by a dental practitioner at the
dental clinic set up.
Contents of Medical Emergency Drug Tray in
Dental Office
1. Adrenaline (Epinephrine)
l It is required for treating anaphylaxis, cardiac arrest,
and shock.
l In such conditions, administration of adrenaline may
interfere with venous return and tissue perfusion. There
is a possibility of precipitation of ventricular fibrillation
in the ischaemic and irritable myocardium.
l The build up of lactic acid from hypoxic tissues require
compensatory measures.
219
l IV sodium carbonate is useful as adjunctive therapy.
However, adrenaline in grave emergencies including
anaphylaxis has proved to be a drug of choice.
2. Aromatic Spirit of Ammonia
l It is useful in cases of syncope. After positioning the
patient with elevation of legs, inhalation of spiritus
ammonia is helpful.
l It stimulates trigeminal nerve endings, resulting in reflex
stimulation of vasomotor and medullary respiratory centres.
3. Nitroglycerin (Glyceryl Trinitrate)
l It is useful to relieve the anginal pain.
l It is believed to dilate the coronary artery, so that pain
due to myocardial ischaemia is relieved. Since the shelf
life is only six months, periodically, expiry date of the
drug must be monitored.
l 0.6 mg tablet held under the tongue with the patient in
a semi prone or sitting position provides relief from pain
within 23 min.
l Elimination of stressful situations and reassurance and
administration of oxygen are equally important under
such emergency situations. Failure to respond indicates
that it is a case of myocardial infarction.
4. Diphenhydramine (Benadryl)
l After the administration of any drug, if the patient
develops allergic reaction like urticaria and pruritis with
or without respiratory distress, this is useful.
l This drug is indicated in the treatment of extrapyramidal
reactions like spasm of neck muscles, restlessness, tris-
mus, and Parkinson-like movement following phenothi-
azine group of drugs like chlorpromazine.
5. Diazepam
l It is a popular anticonvulsant drug. It is relatively safe if
given intramuscularly or intravenously.
6. 5% Dextrose Solution
l Most of the drugs in emergency situations can be con-
veniently given through intravenous route. Fluid re-
placement is equally important in emergency situations.
Hence, 5% glucose solution must be readily available.
7. Methylprednisolone Sodium Succinate
l It is an important drug in the management of anaphylaxis,
acute adrenocortical insufficiency, and cardiac arrest.
l Dose: 125 mg IV. This is the drug of choice in patients
who are on long-term steroid therapy and collapse in the
dental chair.
220 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Emergency Drugs iii. Vasoconstrictors should be used as minimally as

possible.
Route of iv. No elective procedures in uncontrolled diabetes and
adminis- hypertension.
Drugs Formulations tration Indication v. Hypertensive patient is a potential bleeder.
1. Oxygen Cylinders Inhalation All vi. Monitor patient’s medications.
emergencies vii. Patients on diuretics develop dry mouth.
2. Adrenaline 1 mg in 1 mL Intramus- Anaphylaxis viii. Terminate the appointment, if the patient is over-
(1:1000 solution) cular
stressed.
3. Hydrocorti- 100 mg powder Intramus- Anaphylaxis
sone plus cular and ix. Patients on medication without any renal or cardiac
Sodium 2 mL distilled adrenal crisis problem can be treated.
succinate water
4. Glucose Powder Oral Diabetic hy- Q. 14. Oral manifestations of HIV infection.
poglycemia
Ans.
(conscious)
5. Aspirin 300 mg dispers- Oral Myocardial l AIDS is an infectious disease of the immune system.
ible tablets Infarction
This is considered to be the final stage of the chronic,
6. Chlorpheni- 1 mg in 1 mL Intramus- Anaphylaxis
ramine solution cular progressive disease, believed to be caused by AIDS vi-
maleate rus known as human immunodeficiency virus (HIV).
7. Glucagon 1 mg powder Intramus- Diabetic hy- l The envelope of HIV is made of lipids of the host cell
plus 1 mL cular poglycemia membrane, proteins, and glycoproteins specific to HIV.
sterile water (unconscious)
l Inside the envelope, nucleocapsid contains single
8. Solbutamol 0.1 mg per dose Inhalation Asthma
inhaler stranded RNA molecule.
9. Glyceryl 0.5 mg tablet or Sublingual Angina l AIDS virus is found in all the body fluids like blood,
trinitrate 0.4 mg per dose saliva, tears, urine, etc.
spray
10. Midazolam 10 mg in 2 mL Intramus- Status Some of the oral manifestations of HIV are:
solution cular epilepticus l Kaposi sarcoma.

l Candidiasis.

Q. 13. Describe briefly the management of a hyperten- l Oral hairy leukoplakia.

sive patient for teeth extraction in dental chair. l HIV associated periodontal diseases.

l Other opportunistic infections.

Ans. l The main clinical sign noted in children and in earlier

Drug therapy aims at: stages of the disease is parotidenlargement, which is

i. Peripheral resistance and bilateral and associated with cervical lymphadenopathy.
ii. Cardiac output l As HIV progresses, salivary glands are infiltrated with

since the maintenance of BP depends on both these CD8 lymphocytes leading to diffuse infiltrative lympho-
factors. cytosis syndrome resulting in salivary gland enlargement.
l Patients are at a risk of B cell lymphoma.

l Xerostomia is experienced by HIV-associated patients

Management of Hypertensive Patient with the cause being drugs, oral diseases, and progres-
i. Anxiety reduction protocol should be followed. sion of the HIV diseases.
ii. The appointment should be in the mornings and l The symptoms include dryness of the mouth, predispo-

mostly should be of short duration. sition to fungal diseases, and dental caries and infection.

SHORT NOTES
Q. 1. Define tracheostomy and mention five of its indica- Tracheostomy
tions.
Tracheostomy is a preferred opinion for relief of airway
Or obstruction performed under local anaesthetic by making
Tracheostomy. an opening in anterior wall of the trachea and converting it
into stoma on skin surface.
Ans.
Section | I  Topic Wise Solved Questions of Previous Years 221

Indications returns almost immediately, and within a short period of

time the victim appears to be completely recovered.
i. Respiratory obstruction
l The early signs and symptoms include pale or ashen
l Infections: Ludwig’s angina, acute epiglottitis, and peri- gray skin, heavy perspiration, nausea, tachycardia, and
tonsillar and retropharyngeal abscess. feeling of warmth in neck or face.
l Trauma to larynx and trachea; mandible fracture; and l The late symptoms show coldness in hands and feet, hy-
maxillofacial injuries. potension, bradycardia, dizziness, visual disturbance,
l Tumour. pupillary dilation, hyperpnoea, and loss of consciousness.
l Foreign body.

l Laryngeal oedema due to allergy/irritants/radiation.

Q. 5. Name four blood products that can be transfused
l Bilateral abductor vocal cord palsy.
parenterally with one indication for each.
l Congenital anomalies like laryngeal web, cyst, and tra- Ans.
cheoesophageal fistula.
Blood transfusion products Indications
ii. Retained secretions.
Plasma and platelet products Post-partum haemorrhage
Q. 2. Cricothyroidotomy. Whole blood Haemorrhagic shock
Ans. Packed red blood cells Haematemesis

Erythrocytes Severe anaemia

Cricothyroidotomy
l In rare and unlikely circumstances that the methods fail
to ensure an adequate airway a surgical cricothyroidot-
omy is easily performed through the cricothyroid mem-
brane; and after dilation of the opening, a small endotra-
cheal tube or tracheostomy tube can be inserted.
l This is a technique that can be rapidly carried out with
low morbidity and without requiring the skills and
equipment needed to perform a tracheostomy.
Q. 3. Define shock.
Q. 6. H.I.V.
Ans.
H.I.V.
l AIDS is an infectious disease of the immune system.
This is considered to be the final stage of the chronic,
progressive disease, believed to be caused by AIDS
virus known as human immunodeficiency virus (HIV).
l The envelope of HIV is made of lipids of the host cell

membrane, proteins, and glycoproteins specific to HIV.

Ans. l Inside the envelope, nucleocapsid contains single

stranded RNA molecule. AIDS virus is found in all the

Shock body fluids like blood, saliva, tear, urine, etc.
l Shock is a pathophysiologic condition, clinically recog- Q. 7. Post HIV exposure prophylaxis.
nized as a state of inadequate perfusion. Ans.
l Due to inadequate blood flow, there is inadequate deliv-

ery of nutrients to the tissues and inadequate removal of

Type Drugs Regimen
cellular waste products from the tissue cells, which re-
sults in disruption of vital organ functions. Basic Zidovudine 1 600 mg/day (300 mg bid,
(28 days) lamivudine 200 mg tid, or 100 mg
Q. 4. Neurogenic shock. 4 hourly) 1150 mg

Ans. Expanded As above 1 indi- 800 mg 8 hourly, 750 mg

(28 days) navir or nelfinavir, tid, or 200 mg bid
or neviriapine
Neurogenic Shock
l Vasovagal syncope or emotional fainting most com- Q. 8. Bacterial endocarditis.
monly seen in dental clinics is caused by excitation of Ans.
the parasympathetic nerves to the heart and vasodilator
nerves to the skeletal muscle, thereby slowing the heart
and reducing the arterial pressure.
Bacterial Endocarditis
l There is a decrease in cerebral blood flow below a critical l Infective endocarditis is a microbial infection of endo-
level and the patient usually falls down. Consciousness cardium affecting the heart valves and endocardium.
222 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Damage to the myocardial endothelium allows for the
deposition of platelets and fibrin to form the non-bacte-
rial thrombotic vegetation.
l A persistent bacteraemias results from the microor-
ganisms re-entering the blood from infected cardiac
lesions.
l For the patients with the risk, antibiotic prophylaxis is
recommended.
Q. 9. Hyperthyroidism.
Ans.
Hyperthyroidism
l Hyperthyroidism is a type of thyrotoxicosis, in which
there is increased thyroid synthesis and secretion by the
thyroid gland,
l Causes of thyrotoxicosis include autoimmune disease
like Graves’ disease, lymphocytic thyroiditis, multi-
nodular goitre, and subacute thyroiditis.
l Rapid pulse; tremor; eyelid lag; warm, moist, and hy-
perpigmented skin; weight loss; palpitation; tachycar-
dia; excessive sweating; and sometimes exophthalmos.
Q. 10. Hyperventilation.
Ans.
Hyperventilation
l Hyperventilation is a hysteria anxiety component mani-
fested at the conscious level.
l It results in respiratory alkalosis.
l Decreased blood and ionized calcium leads to paraes-
thesia and numbness of extremities and perioral region,
cramps, and even convulsions.
Management
l Reduction of anxiety level.
l Advising the patient to hold the breath to reverse the
respiratory alkalosis.
l Reassurance of the patient and regulation of breathing.
l Patient is made to sit in the upright posture.
l Hospitalization, if necessary.
Q. 11. Anaphylaxis.
Ans.
Anaphylaxis
l Anaphylaxis is the type I allergic reaction.
l The specific antibody is cell bound to mast cells.
l Antigen triggers the release of substances producing
vasodilation, contraction of bronchial muscles, and in-
creased capillary permeability.
Q. 12. Haemophilia.
Ans.
Haemophilia
l Haemophilia is due to an inherited X-linked recessive
character, which clinically manifests only in males.
l It is known to be transmitted through clinically normal
female carriers.
l It is a disorder of blood coagulation characterized by the
tendency to bleed excessively and prolonged coagula-
tion time.
Q. 13. Secondary haemorrhage.
Ans.
Secondary Haemorrhage
l It occurs 4–10 days after the surgical procedure. During
the immediate post-operative period if the blood clot
gets infected by streptococci, then the toxins like fibri-
nolysin dissolves the clot, thereby wound starts bleed-
ing profusely.
l Sometimes, onset of acute vincent’s infection may also
result in secondary haemorrhage. A course of appropri-
ate antibiotics with haemostatic measures will arrest
such a haemorrhage.
Q. 14. Reactionary haemorrhage.
Ans.
Reactionary Haemorrhage
l Reactionary haemorrhage occurs due to the following
reasons:
i. Reactionary vasodilation of vessels which are
contracted during surgery, because of the use of
vasoconstrictors with local anaesthetic drugs.
ii. The blood clots are yet to be matured and contracted
a few hours after extraction.
The patient may disturb the clot
a. By vigorously gargling with warm liquids.
b. By the application of heat inducing local hyper-
aemia.
c. Due to the rise of blood pressure after surgery.
d. Due to violent exercise resulting in general pe-
ripheral vasodilation with alcohol triggering the
reactionary bleeding.
Section | I  Topic Wise Solved Questions of Previous Years
Minor Oral Surgical Procedures and
Orthognathic Surgery
LONG ESSAYS
Q. 1. Describe the technique of apicoectomy. Enumerate
the indications and complications of apicoectomy.
Ans.
Apicoectomy
l Apicoectomy, apical surgery, endodontic surgery, root
resection, and root amputation are the terms which
are used for surgery involving the root apex to treat the
apical infection.
l It is the cutting off of the apical portion of the root and
curettage of periapical necrotic, granulomatous, inflam-
matory, or cystic lesions.
Indications
l Apical anomalies of root tip—dilacerations, intracanal
calcification, and open apex.
l Presence of lateral accessory canal apical region perfo-
rations.
l Roots with broken instruments/over fillings.
l Fracture of apical third of the root.
l Formation of periapical granuloma/cyst draining sinus
tract/non-responsive to RCT.
l Extension of root canal sealant cement filling beyond
the apex.
l Teeth with ceramic crowns.
l When patient with chronic periapical infection will not
be available for follow-up.
Contraindications
l Presence of systemic diseases like leukaemia, uncon-
trolled diabetes, anaemia, thyrotoxicosis, etc.
l Teeth damaged beyond restoration.
l Teeth with deep periodontal pockets and grade III
mobility (Pre-existing bone loss).
l When traumatic occlusion cannot be corrected.
l Short root length.
l Acute infection which is non-responsive to the
treatment.
l Root tips close to the nerves, e.g., mental nerve, inferior
alveolar nerve, or in maxilla close to the maxillary
sinus.
223
Topic 19
Procedure
Three accepted procedures
i. Root canal filling and immediate apicoectomy and
curettage.
ii. Root canal filling is done several days/weeks/months
earlier followed by apicoectomy and curettage.
iii. Increase in the periapical lesion even after root canal
filling and draining sinus. May be due to faulty filling,
which is redone and then followed by root amputation
andcurettage.
Steps
l Local anaesthesia with infiltration technique.
l Mucoperiosteal flap—either semilunar or submarginal en-
velop flap with extension of at least one tooth on either side.
l Submarginal envelop flap is known as Leubke Ochsen-
bein flap design.
l It is indicated when the aesthetics of gingival margin
cannot be compromised.
l Raise the mucoperiosteal flap with periosteal elevator.
l Retract the flap away with Langenback retractor.
l Identify the apex in the intact buccal plate and create a
bony window with surgical bur over the root apex area.
Care should be taken not to damage adjacent structures.
l Locate the apex.
l Section the root tip horizontally. No bevel angle is
advocated for sectioning (0 to 10 degrees).
l Remove all periapical granulation tissues with angu-
lated curettes.
l Use hot burnisher to seal the root tip.
l Close flap and suture.
Retropreparation
l Ultrasonic tip is used for retropreparation.
l The tip is at the apical opening of the canal and guided
gently deeper into the canal as it cuts.
l Once the retropreparation is completed, the prepared
cavity is inspected.
l The gutta-percha at the base is re-condensed with small
mm microplugger.
l The aim of placing root-end filling material is to estab-
lish an apical seal that inhibits the leakage of residual
irritants from the root canal into the surrounding tissues.
224 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l A wide variety of retrograde filling materials have been
used, such as gutta composite resin, polycarboxalate
cement, silver points, etc.
l For the defect in the periapical region, hydroxyapatite
can be packed to enhance the bony healing.
Complications
Intraoperative
l Bleeding control with local application of adrenaline
pack 1:1000and pressure pack/gel foam.
l Damage to the neighbouring root.
l Entry into sinus/inferior alveolar canal.
Postoperative
l Abscess formation.
l Fenestration and sinus tract formation.
l Increased mobility of the tooth.
Q. 2. Describe various orthognathic surgeries of
maxilla. Describe in detail LeFort I osteotomy.
Ans.
Various Maxillary Osteotomies
l Segmental maxillary osteotomy.
l Posterior maxillary osteotomy.
l Total maxillary surgery.
l LeFort I.
l Maxillary advancement.
l Inferior positioning of maxilla.
l Levelling of maxilla.
l Superior repositioning of the maxilla.
l Superior positioning of maxilla, leaving the nasal floor
intact(Horseshoe- shaped osteotomy).
LeFort I Osteotomy
Indications
l Low midface hypoplasia.
l Maxillary hypo/hyperplasia.
l Vertically short or long midface.
l For correcting cant of occlusion.
l Cleft patients with midface deficiency.
Incision
l A horizontal incision is made in the buccal sulcus
through the periosteum just above the apices of the teeth.
l Incision extends from the zygomatic buttress to the mid-
line and to the opposite side of zytgomatic buttress region.
l In the midline, in the region of the frenum, the incision
is curved into a small V to accommodate the frenum.
Procedure
Osteotomy cuts
l Bone cut is made 5 mm above the apices of the canine
and molar teeth.
l The cut is started high in the aperture area and extended
posteriorly sloping downwards and backwards to the
tuberosity area.
l Bone cuts can be made with burr or with a Stryker saw.
Where the reduction of the vertical height of the maxilla
is required, the wedge bone to be removed is collected
and preserved to be used as free bone graft.
l Once the lateral cuts are completed, an osteotome is
used along the lateral wall of the piriform aperture
to separate the dentoalveolar part from the rest of the
maxilla.
l The nasal septum is separated from maxilla by using a
notched nasal septal chisel directed along the floor of
the nose.
l A finger is placed along the junction of the hard and soft
palate to confirm the separation.
l The maxillary tuberosity is then separated from the
pterygoid plates using a curved Tessier osteotome,
which is directed downwards and medially.
l With firm pressure applied over the anterior alveolus,
the maxilla can be down-fractured to complete the
separation.
l The maxilla is positioned using a splint in the pre-
planned position and fixed using bone plates.
l After the osteotomy cuts are made, the maxilla may be
mobilized and repositioned superiorly, inferiorly, anteri-
orly, and posteriorly.
l Maxilla can also be positioned to correct cant of
occlusion.
l Wound is closed.
Complications
l Injury to Stensen’s duct.
l Infraorbiatl nerve traction injury.
l Unanticipated fractures.
l Injury to maxillary artery and its branches.
l Lacrimal duct injury.
l Avascular necrosis.
l Maxillary sinusitis.
l Velopharyngeal insufficiency.
l Nasal septal deviation and buckling.
l Flaring of alar base.
l Arteriovenous fistula.
Section | I  Topic Wise Solved Questions of Previous Years 225

SHORT ESSAYS
Q. 1. Cleft lip and cleft palate. of mucosa and hypoplasia of muscles which are abnor-
mally inserted.
Ans.

Problems Associated with Cleft

Internationally Approved Classification
i. Associated deformities of vital organs like heart or
A. Group I Cleft of the Anterior (primary) airways, requires urgent attention of paediatrician to
Palate alleviate threat of life and future complication.
a. Lip: Unilateral—Rt/Lt and total/partial. ii. Speech problems.
Bilateral iii. Ear infections.
b. Alveolus: Unilateral—total/partial iv. Cosmetic defects.
Bilateral
Management
B. Group II Cleft of Anterior and Posterior Sequence of procedure
(primary and Secondary) Palate 1. Primary
a. Lip: Unilateral—Rt/Lt and total/partial l Closure of lip.

Bilateral l Closure of palate.

b. Alveolus: Unilateral—Rt/Lt and total/partial 2. Secondary

Bilateral l Closure of palatal fistulae.

c. Hard palate: Total/partial l Pharyngoplasty.

l Alveolar bone grafting.

l Orthodontics treatment.
C. Group III Clefts Of Posterior (secondary)
l Orthognathic procedures.
Palate l Rhinoplasty and scar revision of the lip.

a . Hard palate—Rt/Lt
b. Soft palate Flaps for cleft lip used
l Tennison triangular flap.

l Millard rotation advancement repair.

D. Group IV Rare Facial Clefts
Cleft palate repair
Bilateral Cleft Lip
l Bardach’s two flap technique.
l In complete cases, central frontonasal segment is not l Cutting technique.
attached to the maxilla and so there is marked forward l Salyer’s modified technique.
projection of the pre-maxilla. l Oxford technique.
l The abnormal forward projection of the pre-maxilla is
l OSLO technique.
due to a marked forward position of the alveolar bone l Delaire’s technique.
and the hypoplastic maxilla on both sides.
Q. 2. Indications and technique of augmentation genioplasty.
Ans.
Cleft Palate
When the muscles of the cleft palate are unable to
Techniques of Genioplasty
l
meet each other across the midline of the cleft, they
become reoriented towards a fixed point and stream i. Augmentation genioplasty.
towards half of the posterior nasal spine of their side ii. Reduction genioplasty.
of the defect. iii. Straightening genioplasty.
l There is convergence of the fibres of levator veli palitini, iv. Lengthening genioplasty.
palatopharyngeus, and uvular muscles to form a com-
pact bundle, which is inserted into the post-nasal edge Augmentation Genioplasty
of cleft and posterior edge of hard palate. The levator
veli palatini and tensor veli palatini are thinner hypo- Augmentation genioplasty is used to increase projection. It
plastics in cleft palate. can be done by:
l In clefts of hard palate, there is deficiency of muscle and l Sliding horizontal osteotomy of the symphysis.

bone; whereas in cleft of soft palate, there is deficiency l Using autogenous bone graft.
226 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Using alloplastic material like silastic and hydroxy-
apatite.
Augmentation genioplasty procedure
l The entire border of the symphysis is degloved by using
V incision.
l The digastric muscles are separated from mandible to
reduce the tension after advancement.
l Periosteal releasing incision also should provide ade-
quate coverage after advancement. The AP dimension
of the symphysis is about 8–12 mm, so the same amount
of advancement is possible.
l The horizontal osteotomy cut is made at least 4–5 mm
below apices of canines. The cut is completed through
both buccal and lingual cortices.
l The segment is mobilized inferiorly and forwardly with
the help of osteotome. This mobilized segment is pedi-
cled over geniohyoid muscles with some amount of
lingual periosteum.
l Any bony interference for advancement is removed un-
der direct vision.
l The mobilized segment should be then advanced to de-
sired position by using towel clips and then external
facial contour should be checked and the fragments are
positioned to the final desired level.
l It can be fixed to the superior body with two intraosse-
ous wirings in canine region or two mini bone plates.
l With major advancement, the periosteal relaxing inci-
sion should be made prior to suturing. Suturing is done
in two/three layers.
l Alloplastic augmentation can be done using the same
incision, but which is relatively short in length.
l On both sides, little tunnelling is done to create a pocket
into which the onlay grafting material can be slided for
better fixation.
Q. 3. Principles of flap design and types of flap.
Or
Enumerate various principles of intraoral flap design-
ing and name variousmucoperiosteal flaps employed in
oral surgery.
Ans.
Principles of Flap Designing
l Intraoral surgical flaps are made to gain surgical access
to the area to be operated or to move tissues from one
place to another.
Indications
l For basic oral surgical procedures to allow complete
visualization of the operative field and to access osseous
tissue, whenever required.
Types of Flaps
1 . Full thickness mucoperiosteal flap.
. Partial thickness mucoperiosteal flap.
2
Based on the number of sides, the flaps may also be of the
following types:
i. Envelop flap
ii. Two-sided triangular flap
iii. Three-sided rhomboid flap
iv. Semilunar flap.
Based on the position of incision, flaps may be:
i. Labial/buccal flaps
ii. Palatal/lingual flaps.
Envelop Flap
l It is the most common type of flap.
l The incision is made to any length depending on the
amount of exposure needed intramsulcularly around the
necks of the teeth along the free gingival margin on the
buccal or lingual aspect including the interdental papillae.
l The entire mucoperiosteal flap is raised by using perios-
teal elevator to a point to the apical one-third of the tooth.
l This is mainly used for the surgical extraction of a tooth
or root.
Two-sided Triangular Flap
l In addition to the envelop flap, a vertical releasing inci-
sion is used in order to have better access to the area.
l This vertical releasing incision is made on one side
of the envelop flap at the proximal or distal end, going
divergent towards the buccal vestibule forming an
obtuse angle at the free gingival margin.
l The vertical incision should be made in the interproxi-
mal area, as the tissues here are thick.
l To avoid periodontal defect, the incision should never
lie directly on the facial aspect of the tooth.
l Once the incision is taken, then the two-sided triangular
flap is reflected towards the base of the flap by using
periosteal elevator.
Three-sided Rhomboid Flap
This is the modification of earlier flap to improve visi-
l
bility and access.
l An additional vertical incision is added in the opposite
direction from the earlier release.
l Here, care should be taken so that the base of the flap
must be wider than the apex for good blood supply.
Semilunar Flap
l Whenever the periapical area is required to be exposed
to carry out periapical surgery, this is designed.
Section | I  Topic Wise Solved Questions of Previous Years 227

l Again the base of the flap should be broader than the
apex and the suture line should not lie on bony defect.
l The incision is taken at least 5 mm away from the
gingival margin.
l This flap is useful to avoid dam interdental papilla
l For setback procedure, the vertical osteotomy cut is
taken laterally to second molar. However, in major
advancement cases, vertical cut is placed forward in
the region of the premolar.
l Vertical cut is completed through the lateral cortex only.

and to prevent periodontal surgical defects. l The cut extends through both the cortical plates at the

l In case of crowding, suturing is not a problem with this flap. inferior border of the mandible.
l The only advantage of this flap is that it often lies on l With osteotome, all bony cuts are checked for their

the defect. completeness.

l Two osteotomes are then inserted and used as levers
Q. 4. BSSO
to separate the segments. Spreader can be used to
Ans. finally separate the segments.
l The same procedure is repeated on the other side.

In case of advancement, the bony interferences should

BSSO be checked and the distal fragment is advanced and
l Bilateral sagittal split osteotomy (BSSO) is a very locked into desired occlusion.
popular and most versatile procedure performed on the l The fixation of the fragments can be done by intraosse-

mandibular ramus and body. ous wiring or lag screws or by bone plates.
l First described by Trauner and Obwegeser and later
Q. 5. How will you evaluate a patient for orthognathic
modified by Dalpont, Hunsuck, and Epker.
surgery?
l The osteotomy splits the ramus and the posterior body

of the mandible sagittally, which allows either setback Ans.

or advancement.
l This is a highly cosmetic procedure, as it is done intraorally.
1. Patient concerns
l To determine the patient’s feelings about the existing
l For mandibular advancement, there is no need for bone

grafts. Thus, donor site morbidity and second operative problems and their expectations for treatment results.
site for the bone graft is totally avoided. 2. Clinical evaluations
l Facial form.
l Only drawback is the technique demands high level of
l Relationship of facial thirds.
operative skill and experience, to minimize the surgical
l Relationship of soft tissues to dentition smile line,
complications.
occlusal cant, and dental midlines vs soft tissues.
3. Clinical measurements
Surgical Procedure l Vertical dimension.

l Anteroposterior dimension.
l A bite block is inserted on the side in-between the upper
l Transverse dimension.
and lower teeth for easy access and projecting the ramus
l Intra-arch dimension.
anteriorly.
l An incision is made on the lateral aspect of the anterior of 4. Radiographical analysis
l Cephalometric—lateral and anteroposterior.
the ramus, overlying the external oblique ridge, from the
l Orthopantomogram.
midway up the ascending ramus to avoid buccal fat down-
ward into vestibular depth till mandibular first molar region. 5. Dental study analysis
l Accurate bite registration.
l Medially the soft tissues are reflected, until the lingual
l Two jaw cases require duplicate models.
and the inferior alveolar nerve bundle and mandibular
foramen is identified. Medial soft tissue dissection is Q. 6. Name the procedure to correct mandibular
stopped slightly and superior to the lingula. defects.
l While the medial soft tissues are being retracted, the

medial bone cut is made through only the lingual cortex Ans.
about 2 mm above the neurovascular bundle and just
posterior to the lingual.
l Following the completion of horizontal medial osteot-
Procedures to Correct Mandibular Defects
omy, cut is then carried down the lateral-most aspect of Mandibular Body Osteotomies
the anterior border of’ the ascending ramus to the region
of the second molar. i. Mandibular body osteotomies - Intraoral
l This osteotomy is made parallel to the lateral cortex. procedures
l The bite block is removed and the periosteum from the a. Anterior body osteotomy.
lateral aspect of the mandible is elevated in the molar b. Posterior body osteotomy.
area till the inferior border of the mandible. c. Midsymphysis osteotomy.
228 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

ii. Segmental subapical mandibular surgeries Maxillary Osteotomy Procedures - Intraoral

a. Anterior subapical mandibular osteotomy.
b. Posterior subapical mandibular osteotomy.
c. Total subapical mandibular osteotomy.
iii. Genioplasties—horizontal osteotomy in the chin
region
a. Augmentation genioplasty.
b. Reduction genioplasty.
c. Straightening genioplasty.
d. Lengthening genioplasty.
Mandibular Ramus Osteotomies
i. Subcondylar ramus osteotomy
a. Extraoral subcondylar ramus osteotomy (subsigmoid).
b. Intraoral subcondylar ramus osteotomy (subsigmoid).
c. Arching radial osteotomy—extraoral andintraoral mod-
ified sagittal split osteotomy.
Procedures
i. Segmental maxillary osteotomy procedures
a. Single tooth dento-osseous osteotomy.
b. Interdental osteotomies.
c. Anterior maxillary osteotomy.
d. Posterior maxillary osteotomy.
ii. Total maxillary surgery - Le Fort I osteotomy
a. Superior repositioning of the maxilla.
b. Superior repositioning of the maxilla leaving nasal floor
intact (Horseshoe-shaped osteotomy).
c. Advancement of maxilla
l Simultaneous expansion of maxilla.
l Simultaneous narrowing of maxilla.
d. Inferior repositioning of maxilla
l Levelling of maxilla.

SHORT NOTES
Q. 1. Apertognathia. l Mandibular body osteotomies.
Ans. l Mandibular ramus osteotomies.
l LeFort I maxillary osteotomy.

Apertognathia Q. 2. Maxillary osteotomies.

l Open bite, where teeth in opposing jaw fails to contact. Ans.

Classification Maxillary Osteotomies

1 . Dentoalveolar. i. Segmental maxillary osteotomy.
2. Skeletal base. ii. Posterior maxillary osteotomy.
3. Combination of both. iii. Total maxillary surgery
l LeFort I.

l Maxillary advancement.
Aetiology
l Inferior positioning of maxilla.
Anterior open bite l Levelling of maxilla.

l Tongue thrust. l Superior repositioning of the maxilla.

l Thumb sucking. l Superior positioning of maxilla leaving the nasal

floor intact (Horseshoe- shaped osteotomy).

Posterior open bite
Q. 3. Torus palatinus.
l Deficient eruption of posterior teeth.

l Facial asymmetry which develops after growth is Ans.

completed.
Torus Palatinus
Management l Other name is Maxillary tori.
Management depends on cause of the defect. l Tori or exostosis can be described as projections of bone
1. Quitting habits. on a ridge.
2. Surgical method. l It is a benign slow-growing bony projection of the

3. Segmental orthognathic surgery. palatine process of maxilla and occasionally of the

4. Total orthognathic surgery: horizontal plate of the palatine bone.
Section | I  Topic Wise Solved Questions of Previous Years
l It occurs bilaterally along the median suture on the
oral surface of the hard palate.
l It is more prevalent in females.
l Aetiology is unknown. Causes can be superficial trauma,
malocclusion, hereditary, or a functional response to
mastication.
Q. 4. Wassmund’s technique.
Ans.
Wassmund’s Technique
Incision
l Vertical incision is made in the premolar region.
l Small midline vertical incision is made to expose ante-
rior nasal spine and nasal septum.
l Premolars are extracted from both the sides.
l Blood supply to the osteotomized segment will be from
the palatal mucoperiosteum.
Procedure
Osteotomy cuts
l Buccal bone cuts are made first through the socket of
the extracted tooth vertically.
l The cut is then turned medially towards the piriform
aperture.
l Care should be taken to protect the nasal mucosa.
l The palatal cortical plate of the extracted premolar socket
is cut vertically. This is then continued on the palatal bone
by tunnelling under the palatal mucoperiosteum.
l The nasal segment is attached to the nasal aspect of the
hard palate and needs to be detached for immobilization
of the palate.
l The nasal septum is freed from the palate using a nasal
septal chisel anteriorly through a midline vertical buccal
incicsion.
l If superior repositioning of anterior segment of maxilla is
required, length of nasal septum is reduced using a rongeur.
l Segment is mobilized completely and repositioned as
desired and fixed using orthodontic wires or with an
arch bar.
l Mucoperiosteal flap is closed using simple interrupted
suture.
Q. 5. Cleft lip and palate protocol.
Ans.
1. Immediately after the birth
l Pediatric consultation, counselling, feeding instruc-
tion, and evaluation by geneticist to decide whether
229
it is an isolated cleft or if the cleft is part of the
syndrome; and diagnosis of life expectancy of a
child and diagnostic tests.
2. Within first few weeks of life
l Team evaluation, including hearing testing.
3. At 10–12 weeks
l Surgical repair of lip, 3–6 month in India.
4. Before age 1 year to 18 months
l Team evaluation and surgical; repair of cleft palate
and placement of pressure equalization tubes.
5. Three months after palate repair
l Team evaluation for speech and language assessment.
6. Three to six years
l Team evaluation—medical and behaviour interven-
tion as needed. Speech therapy, treatment for mid-
dle ear infection, fistula repair, soft tissue lengthen-
ing, and psychological evaluation.
7. Five to six years
l Lip and nose revision, if necessary. Pharyngeal
surgery.
8. At seven years
l Orthodontic treatment phase I.
9. Nine to eleven years
l Prealveolar bone grafting.
10. Twelve years to eighteen years
l Full orthodontic treatment phase II.
11. Fifteen to eighteen years
l At the end of orthodontic treatment, placement of
implants, fixed bridges, etc., for missing teeth.
12. Eighteen to twenty-one years
l When most growth is completed. Surgical advance-
ment of maxilla, if required.
13. Final nose and lip revision
l Rhinoplasty at 16–18 years.
Q. 6. What are the preoperative methods of estimation
of results in orthognathic surgeries?
Ans.
Various preoperative methods of estimation of results in
orthognathic surgeries are:
l Photographs.
l Radiographs.
l Study models.
l Cephalometric analysis.
l Mock surgery on models.
230 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Implantology and Miscellaneous
LONG ESSAYS
Q. 1. Define dental implant. Classify, and discuss the
indications, contraindications, and complications.
Or
Evaluation of implant and the procedure of single tooth
loss replacement withimplant.
Ans.
Dental Implant
l Dental implants are surgically fixed substitutes for roots
of missing teeth.
l Embedded in jaw bone they act as anchors for a replace-
ment tooth, also known as crown or a full set of replace-
ment of teeth.
Classification of Implants
I. Based on its placement in relation to bone
i. Endosteal implants
l These are implants that are placed completely within
the alveolar and basal bone.
l These implants receive their support by osseointegra-
tion with the alveolar bone into which they are placed.
l They can be of different types depending on the
shape that is used: blade type, root form, etc.
ii. Subperiosteal implants
l These implants are placed just below the periosteum
and rest on sound bone.
l Instead of penetrating the alveolar bone they rest on
its surface.
l They are inserted by a surgical procedure where the
mucoperiosteum is reflected and the alveolar bone is
visualized. The implant is made to rest on the alveo-
lar bone with its posts protruding from the surface of
the mucosa.
l These implants are indicated in case of an atrophic
mandible where there is not enough bone for the
placement of an endosteal implant.
iii. Transosseous implants
l These implants are used in the anterior region of the
mandible.
l It consists of a horizontal plate on which the body of
the implant (pins or staples) are fixed.
Topic 20
Indications for Implants
l Completely edentulous patient.
l Partially edentulous patient.
l Partially edentulous jaw with distal free end situation.
l Single missing/extracted tooth.
l Replacement of teeth in an edentulous jaw with oppos-
ing natural teeth.
l Patient unable to wear a removable denture prosthesis
due to:
a. Parafunctional habits such as bruxism.
b. Gag reflex displacing the denture. Patients are not
satisfied with removable denture.
c. Psychological causes preventing the use of a remov-
able denture.
d. Inadequate number of abutment teeth for the place-
ment of fixed partial denture.
Contraindications for Implant Placement
l Unfavourable intermaxillary relationships: In patients
with unsatisfactory intermaxillary relationships, im-
plant procedures should not be considered.
l Problematic occlusal and functional relationships.
l Pathologic conditions of the jaws: cysts, tumours, in-
flammatory manifestations, etc., form temporary con-
traindications. Such patients should be re-evaluated
after treatment of the jaw condition.
l Radiation therapy in the jaw region: Implantation is
usually avoided in such cases due to compromised vas-
cularity and likely damage to the cells and associated
problems with wound healing.
l Pathologies affecting the oral mucosa: Leukoplakia and
lichen planus contraindicate implant procedures.
l Xerostomia: Salivary flow has a cleansing effect and reduces
the bacterial count in the oral cavity. Reduced salivary flow
is a relative contraindication to implant placement.
l Macroglossia.
Temporary medical contraindications
Certain conditions affecting the patient may be temporary
situations and serve as only relative contraindications to
implant placement such as:
l Acute inflammatory diseases or infections: Sinusitis, bronchi-
tis, etc., may be treated prior to surgical placement of implant.
Section | I  Topic Wise Solved Questions of Previous Years 231

l Pregnancy: Surgical procedure is best avoided during 3 . Sinusitis.

pregnancy usually due to stress factors and also because 4. Nerve damage.
of the possibility of pregnancy- associated gingivitis. 5. Mucosal irritation.
l Medications: These include anticoagulants, immuno-

suppressants, etc. Treatment may be started after the Steps in Placement of an Implant
medication has been discontinued.
l Poor patient compliance: The patient must be fully pre- 1. Incision
pared for the procedure. If not, other non-invasive l A crestal incision with buccal-releasing incision, buc-

means of tooth replacement may be done. cally-based flap, or lingually-based flap may be planned.
l The incision should be planned in such a way that after
The general medical contraindications to placement of
the implant is placed and the flap is replaced, it should
implants are:
cover the implant completely.
l General nutritional condition.

l Metabolic disorders such as diabetes and hyperthyroid- 2. Reflection of mucoperiosteal flap

ism must be controlled prior to treatment.
l Once the incision has been placed, the mucoperiosteal
l Haematological disorders: Disorders such as anaemia or
flap is reflected using a periosteal elevator.
any haemorrhagic diathesis represent absolute contrain-
l Care is taken not to button-hole the flap.
dications to the procedure.
l Care should also be taken not to strip the bone exces-
l Cardiac and circulatory disease: The patient must be
sively. Only as much as is required to place the implant
thoroughly evaluated prior to surgery and the necessary
must be reflected to allow good periosteal cover for the
precautions must be taken to prevent any complications.
bone for good healing.
l Osseous and metabolic disturbances: Osteoporosis, os-

teogenesis imperfecta, etc., will hamper the success of 3. Placement of implant

the implant.
l The implant size is chosen, based on the radiographic
l Collagen disorders: Conditions such as scleroderma,
analysis of the amount of bone available.
rheumatoid arthritis, etc., represent contraindications.
l Care should be taken to choose the size of the implant
l Dental implant as a potential bacterial focus: Patient
which has a gap of at least 2 mm from all important
with a history of bacterial endocarditis or with heart
anatomic structures and also the bone margins.
valve prosthesis presents a high-risk of bacteraemia due
l The position and angulation of the implant as deter-
to the dental implant.
mined by the model analysis should be maintained
when the implant is being drilled into place.
Complications l A stent is fabricated with acrylic.

l This is placed on the alveolar ridge and the exact loca-

I. Intraoperative complications tion of the implant is marked on the stent.
1. Haemorrhage. l A hole is then drilled in the stent in this accurate posi-
2. Nerve injury. tion and angulation.
3. Perforation of antrum. l This stent is then used as a guide for the placement of
4. Fracture of jaw. the implants.
5. Perforation into nasal cavity. l Preparation of the implant bed is done using relatively
6. Complication due to improper placement high-speed (max speed 2000 rpm) standardized steel
l Bone dehiscence. drills.
l Damage to adjacent teeth. l The drills are made of specific sizes corresponding to
l Lack of stability. the size of the implant.
l For minimal trauma, the drill is used with very slight
II. Immediate post-operative complications axial force and under copious saline irrigation.
1. Haematoma. l During drilling, the drill is moved up and down to en-

2. Oedema. sure adequate cooling of the bone that is being cut.

3. Infection. l Usually the distance between two implants should be as

4. Wound dehiscence. much as the diameter of the implant when multiple im-
5. Mobility of implant. plants are to be placed.
l Titanium instruments provided in the kit are used for
III. Late complications this procedure.
1. Peri-implant pathology. l A thread cutter or a screw tap is next used to prepare the

2. Fracture of implant. screw threads in the bone, if a screw type implant is used.
232 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

l The precise sized implant is then inserted carefully us-
ing a wrench to tighten it till the surface of the implant
is flushed with bone surface.
l Cover screws are placed on the implant body.
l These are placed so that the hollow cylinder of the im-
plant is left intact without the growth of bone or connec-
tive tissue into it. This allows the placement of the
prosthetic part of the implant, when it is uncovered.
4. Uncovering the implant
l In a two-stage implant, this second surgical procedure is
used to uncover the implant after the healing-in phase.
l This is done usually about three months after placement
b. Use of tissue punch or soft tissue trephine for uncover-
ing the implant.
c. Electrosurgical uncovering of the implant.
Once the implant is uncovered, remove the cover srew
gently and test the osseous union of the implant. The
peri-implant soft tissue is checked.
Prosthetic Treatment
l The prosthetic replacement is fabricated to suit the oc-
clusal configuration, as decided by the model analysis.
This is then fixed on to the transmucosal connector.
l The implant can now be loaded by masticatory forces.

of the implant in the mandible and after six months in
the maxilla.
l This procedure can be done under local anaesthesia.
Various techniques may be employed:
a. Use of crestal incision in the middle of the keratinized
mucosa and reflection of a buccal and palatal/lingual
flap. This is followed by apical repositioning of the
buccal flap.
Q. 2. Discuss the lymphatic drainage of face.
Or
Discuss in detail lymphatic drainage of head and neck
and its relevance to neck dissection.
Ans.

Structure Lymph node Drainage

Upper jaw Submandibular nodes. Deep cervical
Upper jaw including teeth, gingivae, and palate. Directly to the retropharyngeal nodes.
Lateral part of hard palate.
Lower jaw Submental nodes. Either to submandibular nodes and
Anterior part of mandible, the incisor teeth, Submandibular nodes. then to deep cervical or directly to
gingiva, and chin. deep cervical.
Lower jaw including remaining teeth gingivae. Deep cervical.
Lip Submandibular nodes. Upper internal jugular nodes.
Upper lip and lateral parts of lower lip. Submental nodes. Either submandibular nodes and
Medial part of lower lip. Superficial cervcal. then to deep cervical or directly to
Some part of upper lip. deep cervical.
Deep cervical.
Tongue Bilaterally to submental nodes. All lymph nodes from tongue
Tip Unilaterally to submandibular nodes. drains into the jugulo-omohyoid
Anterior two-third Overlaps bilaterally to submandibular nodes. nodes and upper deep cervical
Lateral part Bilaterally to jugulo-omohyoid nodes. group
Midline
Posterior third.
Floor of the mouth Submental nodes. Either to submandibular and then
Anteriorly. Submandibular nodes. to deep cervical
Remainder.
Tonsils Jugulodigastric nodes
Cheeks and buccal mucosa - Submandibular nodes and some passing by Deep cervical
buccal nodes.
- Parotid nodes.
- Direct to the superficial upper deep cervi-
cal nodes.

Salivary gland Parotid nodes. Dee cervical

Parotid. Chiefly to deep cervical chain remainder to
Submandibular. the submandibular nodes.
Sublingual. Submandibular nodes.
Anterior part. Upper deep cervical group
Posterior part.
Section | I  Topic Wise Solved Questions of Previous Years 233

Structure Lymph node Drainage

Nose Parotid group Deep cervical
External and anterior part.
Root of nose and adjacent upper eyelids.
Posterior nasal cavity.
Antrum Doubtful if it has an external lymphatic
drainage, but possibly submandibular nodes.
Frontal and ethmoidal sinuses Submandibular nodes
Eyelids andconjunctiva Parotid and submandibular nodes, bular Deep cervical.
nodes.
Orbit and content Preauricular group. Deep cervical.
Lacrimal gland Submandibular nodes. Deep cervical.
Ear Preauricular and mastoid nodes. Nodes along external jugular vein.
Auricle. Parotid nodes. Deep cervical.
Lateral surface. Parotid and retropharyngeal nodes. Upper deep cervical.
Middle ear. Mastoid nodes.
Mastoid air cells.
Scalp Occipital, mastoid, and parotid nodes Deep cervical

Front of scalp Submandibular nodes Deep cervical

SHORT ESSAYS
Q. 1. Classification of steroids. l Acute gout.
Or l Severe allergic reactions.
l Bronchial asthma.
Classification and indications of steroids. l Collagen diseases.
l Eye diseases.
Ans.
l Renal diseases
l Skin diseases.
Classification of Steroids l Gastrointestinal diseases.
l Liver diseases.
A. Short-acting (8–12 h)
l Haematologic disorders.
I. Hydrocortisone.
l Cerebral oedema.
II. Cortisone.
l Lung diseases.
B. Intermediate-acting (18–36 h)
l Organ transplantation.
I. Prednisolone.
l Bell’s palsy.
II. Methylprednisolone.
l Acute polyneuritis
III. Triamcinolone.
l Myotonia.
C. Long-acting (36–54 h)
I. Paramethesone. Q. 2. Ampicillin.
II. Dexamethsone.
III. Betamethasone. Ans.

Ampicillin
Indications for Steroids
l Ampicillin is an extended-spectrum antibiotic grouped
i. Endocrinal under aminopenicillins.
l Acute renal insufficiency.
l Active against all organisms sensitive to PnG; Gram-
l Chronic adrenal insufficiency (Addison disease).
negative bacilli, e.g., H. influenza, E. coli, Proteus,
ii. Non-endocrinal Salmonella, and Shigella.
l Arthritis—rheumatoid arthritis.

l Osteoarthritis.

l Rheumatoid fever.
234 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Pharmacokinetics
l Ampicillin is not degraded by gastric acid; oral absorp-
tion incomplete, but adequate.
l Food interferes with absorption.
Doses
Depending on the severity of the infection, ampicillin l The exotoxin acts at the synapse of the interneurons of
0.5–2 g oral/IM/IV should be given every six hourly and in
children, 25–50 mg/kg/day.
Uses
i. Urinary tract infection: In these infections, ampicillin
is the drug of choice; but because of increased
resistance, flouroquinolone/cotrimoxazole is now
preferred.
ii. Respiratory tract infection: Include bronchitis, sinus-
itis, otitis media, etc.
iii. Meningitis: Ampicillin is used in combination with
third-generation cephalosporin/chloramphenicol for
initial therapy.
iv. Gonorrhoea: It is one of the first line drugs for oral
treatment of non-penicillinase producing gonococ-
cal infections. A single dose of 3.5 g ampicillin
plus 1g probenecid is adequate and convenient for
urethritis.
v. Typhoid fever: Due to emergence of resistance, it is
now infrequently used when ciprofloxacin and other
drugs cannot be given.
vi. Bacillary dysentery: Shigella often responds to ampi-
cillin, but many strains are now resistant. Quinolones
are now preferred.
vii. Cholecystitis: It is a good drug because high concen-
trations are attained in bile.
viii. Subacute bacterial endocarditis: Ampicillin 2 g IV six
hourly may be used in place of PnG. Concurrently,
gentamicin is advocated.
ix. Septicaemias and mixed-infection: Injected ampicillin
may be combined with gentamicin or one of the newer
cephalosporins.
Adverse Effects
l Diarrhoea is frequent after oral administration.
l Produces high incidence of rashes, especially in
patient with AIDS, EB virus infections, or lymphatic
leukaemia.
l Patient with immediate-type of hypersensitivity to PnG
should not be given ampicillin.
Q. 3. Tetanus.
Ans.
Tetanus
l Tetanus is an acute infection of the nervous system cha-
raterized by intense activity of motor neurons and re-
sulting in severe muscle spasms.
l It is caused by the anaerobic Gram-positive bacillus,
Clostridium tetani that is commensal in human and ani-
mal gastrointestinal tracts and soil.
inhibitory pathways and motor neurons to produce
blockade of spinal inhibition.
Clinical Features
l Is characterized by lock-jaw or spasm of masseter,
which is the initial symptom.
l Dysphagia; and stiffness or pain in the neck, shoulder,
or back muscle appears concurrently.
l Rigidity interferes with the movements of chest and
impairs cough and swallowing reflexes.
l Laryngeal spasms can lead to asphyxia.
l Hands and feet are relatively spared and sustained con-
traction of facial muscles results in a grimaces or sneer
called as risus scardonicus.
l The contraction of muscle of the back produces an
arched back called opisthonous.
Treatment
General measures
l Aim of the treatment is to remove spores at the site of
the wound and prevent muscular spasms.
l Cardiopulmonary monitoring should be maintained.
Antibiotics should be given, such as
Penicillin 110–112 million units IV for 10 days,
Metronidazole 1gm every 12 hours should be administered.
l Clindamycin or erythromycin can be used as an alterna-
tive for penicillin-allergic patients.
l Antitoxins are injected to neutralize circulating toxin
with wound.
l Human tetanus immunoglobulin (TIG) 3000–6000 units
IM in individual doses.
Prophylaxis
Wound debridement and booster doses of TT.
Unimmunized individual
l Anti-tetanus serum 1500 units or TUG 250 units should
be given.
Q. 4. Analgesics.
Or
Analgesics in oral surgery.
Ans.
Section | I  Topic Wise Solved Questions of Previous Years
Analgesics
l Analgesics are the drugs that relieve pain regardless of
its source and type.
l Control of post-operative pain following oral surgery
involves choosing the analgesic regime that is appropri-
ate for each patient.
l Analgesics can be divided into two groups based on
their site of action:
i. Peripherally acting analgesics—NSAIDs, and
ii. Centrally acting analgesics—opioids.
Non-steroidal Anti-inflammatory Drugs
(NSAIDs) and Opioids
To adequately treat oral and maxillofacial surgery patients,
management of acute post-surgical pain is essential.
Advantages associated with use of NSAIDs
l For control of post-surgical pain, NSAIDs are effective
and useful analgesics; and can be administered in the
form of oral tablets and syrups in required dosages.
l A main advantage of these agents is that there is no risk
of addiction and abuse potential is low.
l The adverse effects associated with NSAIDs are rarely
seen, especially when the patient is monitored post-
surgically for unanticipated or continuing pain.
l Moreover, fewer adverse effects are seen in cyclooxy-
genase-2 pathway inhibitors.
l NSAIDs have a topical effect when applied to a surgical
wound and a local effect when injected in or around an
area of wounded tissue.
l If the topical route of administration proves to be fea-
sible, then it is possible that many of the adverse effects
associated with NSAIDs might be avoided.
Ibuprofen
Mode of action
l Non-steroidal anti-inflammation reduces prostaglandin
activity in prostaglandin synthesis.
Indications
l Control post-surgical pain.
Side effects
l Gastrointestinal problems like nausea, heartburn, vomit-
ing, and abdominal pain occur.
l In patients using ibuprofen for prolonged period like up
to one year, more severe problems such as gastric ulcer
and bleeding can occur.
Contraindications
l Allergic reactions to ibuprofen, other NSAIDs, and aspirin.
l Contraindicated in pregnant or nursing women.
235
Precautions
l Ibuprofen inhibits platelet aggregation, but its effect
usually causes small changes in bleeding time in normal
patients.
l Patients on anticoagulant therapy or with intrinsic
bleeding disorders can be at risk for haemostatic prob-
lems with the concurrent use of ibuprofen.
l While taking ibuprofen, patients with decreased renal or
liver function, heart failure, or who are under diuretic
therapy can be at risk for liver dysfunction, renal failure,
and fluid retention.
Q. 5. Principles of antibiotic therapy.
Or
Antibiotics in oral surgery.
Ans.
General Principles of Antibiotic Therapy
i. Empirical antibiotic therapy has a limited role in the
prevention of the management of infections.
ii. If no response is forthcoming within three days of
therapy, then organisms must be identified so that the
antibiotics can be chosen to act against susceptible
organisms. No single antibiotic is effective against the
pathogens. Once the causative organisms are isolated,
it becomes critical to identify the appropriate antibi-
otic therapy.
iii. The most common organisms are streptococci, staphy-
lococci, and bacteroids.
iv. Culture of the organisms and antibiotic sensitivity
test assume greater importance in patients with
(a) compromised defences like diabetes, (b) immu-
nosuppressed patients, (c) those who are vulnerable
to infections like subacute bacterial endocarditis,
(d) patients on dialysis, (e) patients who are on che-
motherapy for malignancy, and (f) in geriatric
patients.
v. For the drug to be therapeutically effective, the antibi-
otics must be given in proper dose at proper intervals
through appropriate route, so that blood concentration
of the drug is maintained at the desired level.
vi. The drug which is least toxic, most economical, and
most effective must be chosen for the therapy.
vii. To avoid the development of resistant strains, the drug
with least-spectrum must be chosen.
viii. The patient must be warned about the possibility of
the side effects and complications. If any such untow-
ard reactions develop, then the patient must discon-
tinue the therapy forthwith.
ix. Caution must be exercised in using newer drugs. Pref-
erence must be given to use the known drug with
proven effectiveness.
236 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

x. Wherever possible, judicious methods to accentuate Q. 8. Ibuprofen.

the efficacy of antibiotics must be utilized.
Or
Q. 6. Action, side effects, and dosage of amoxicillin.
Enumerate indications, doses, and side effects of
Ans. ibuprofen.
Ans.
Amoxycillin
Amoxycillin is a close congener of ampicillin, but similar to Ibuprofen
it in all respects except,
i. Oral absorption is better and food does not interfere Mode of Action
with absorption. Higher and more sustained blood lev- l Non-steroidal anti-inflammation reduces prostaglandin
els are produced. activity in prostaglandin synthesis.
ii. Incidence of diarrhoea is less.
iii. It is less active against Shigella and H. influenzae.
Indications
Dosage l Control post-surgical pain.
l Majority of cases resolve with 250–500 mg TDS given
for five days. Side Effects
l 0.25–1mg TDS oral/IM amoxycillin

(Trade names: Novamox, Synamox 250, 500 mg cap,
125 mg/5 mL dry syrup;
Amoxil, Mox 250, 500 mg Cap; 125 mg/5 mL dry
syrup; 250, 500 mg/vial injection;
Amoxicillin 250 mg plus probenecid 500 mg tab (also
500 mg plus 500 mg DS tab).
Q. 7. Prophylactic antibiotic protocol for high-risk patients.
Ans.
l Gastrointestinal problems like nausea, heartburn, vomit-
ing, and abdominal pain occur.
l In patients using ibuprofen for prolonged period like up
to one year, more severe problems such as gastric ulcer
and bleeding can occur.
Contraindications
l Allergic reactions to ibuprofen, other NSAIDs, and
aspirin.
l Contraindicated in pregnant or nursing women.

Adult, not 2.0 g amoxicillin one Within 30 min be-

Precautions
allergic to hour before procedure. fore procedure 2 g l Ibuprofen inhibits platelet aggregation, but its effect
penicillin 600 mg clindamycin ampicillin IM or IV.
usually causes small changes in bleeding time in
Adult, allergic one hour before Within 30 min
to penicillin procedure or 2 g before procedure normal patients.
cephalexin one hour 600 mg clindamycin l Patients on anticoagulant therapy or with intrinsic
before procedure. IV. bleeding disorders can be at risk for haemostatic prob-
Or lems with the concurrent use of ibuprofen.
Within 30 min be-
l While taking ibuprofen, patients with decreased renal or
fore procedure 1.0
g cefazolin IM or IV. liver function, heart failure, or who are under diuretic
therapy can be at risk for liver dysfunction, renal failure,
Children, not One hour before pro- 50 mg/kg ampicillin
allergic to cedure 50 mg/kg IM or IV 30 min
and fluid retention.
penicillin amoxicillin. prior to procedure. Q. 9. Tetracycline.
Children, One hour before pro- 30 min prior to Ans.
allergic to cedure procedure a dose
penicillin 20 mg/kg clindamycin. of 20 mg/kg IV l The broad-spectrum bacteriostatic tetracycline antibiot-
Or clindamycin. ics have been employed extensively in the treatment of
50 mg/kg cephalexin Or
or cefadoxil one hour 30 min before
infections.
before procedure. procedure l Their widespread use, and often misuse, has resulted in

Or 25 mg/kg or IV the appearance of a number of resistant bacterial strains,

15 mg/kg azithromycin cefazolin. a fact that has reduced their clinical usefulness.
or clarithromycin one l Tetracyclines used for treatment of orodental infections
hour before procedure.
are tetracycline, minocycline, and doxycycline.
Section | I  Topic Wise Solved Questions of Previous Years
l At best, the tetracyclines are fifth-choice antibiotics,
behind the penicillins, macrolides, cephalosporins, Anti-inflammatory Action
and c1indamycin in the treatment of acute orodental
infections.
l Tetracyclines may be useful in treating certain types of
periodontal diseases.
l A two-week course of tetracycline therapy has been
found to be effective in patients with advanced peri-
odontitis unresponsive to conventional therapy alone.
l Odontitis and early onset periodontitis.
l Higher concentration of tetracyclines, especially mino-
cycline, in gingival fluids, may help eradicate bacteria
resistant to concentrations that can normally be achieved
in the plasma.
l Studies of tetracycline and doxycycline have indicated
enhanced repair and tissue regeneration of the periodon-
tium and prevention of recurrent periodontitis in high-
risk patients.
l At least a part of this beneficial effect is due to the tis-
sue collagenase-inhibiting effect of the tetracyclines,
which is relatively marked in the gingival crevice, be-
cause the drugs are concentrated several fold in sulcu-
lar fluid.
l Although, tetracyclines should not be used as a penicillin
substitute for prophylaxis against bacterial endocarditis.
l Since many of the causative organisms are resistant,
they may have a role in preventing endocarditis after
dental therapy.
Q. 10. Classification of NSAIDs.
Ans.
Classification of NSAIDs
A. Non-selective COX Inhibitor (conventional
NSAIDs)
i. Salicylates: Aspirin.
ii. Propionic acid derivatives: Ibuprofen, Naproxen,
Ketoprofen, and Flubiprofen.
iii. Anthranilic acid derivatives: Mephenamic acid.
iv. Aryl-acetic acid derivatives: Diclofenac.
v. Oxicam derivatives: Piroxicam and Tenoxicam.
vi. Pyrrolo-pyrrole derivatives: Ketorolac.
vii. Indole acetic acid derivatives: Indomethacin.
viii. Pyrazolone derivatives: Phenylbutazone and oxyphen-
butazone.
B. Preferential COX-2 Inhibitors
Nimesulides, Meloxicam, and Nabumetone.
C. Selective COX-2 Inhibitors
Celecoxib, Rofecoxib, Valdecoxib, and Etoricoxib.
237
D. Analgesic—antipyretics with Poor
i. Paraaminophenol derivative: Paracetamol (Acteaminophen).
ii. Pyrazolone derivatives: Metamizol (Dipyrone) and Pro-
piphenazone.
iii. Benzoxazocine derivative: Nefopam.
Q. 11. Corticosteroids in oralsurgery.
Ans.
Preoperative Corticosteroids Used
l Preoperative corticosteroids have been advocated for
reduction of pain, oedema, and trismus, following oral
surgical procedures.
l Corticosteroids reduce the amount of inflammation as-
sociated with oral surgery, especially oedema.
l Objective evaluation of corticosteroid use subsequently
has shown consistent reductions in oedema.
l No significant adverse reactions were noted with corti-
costeroid doses ranging from 80 to 625 mg hydrocorti-
sone equivalent anti-inflammatory dosage.
l The use of preoperative corticosteroids appears to be a
safe and rational method of reducing post-operative
complications.
l The potential for complications induced by preoperative
corticosteroid use, such as adrenal suppression and de-
layed wound healing, should also be considered.
l In patients with prolonged steroid therapy, the adreno-
cortical activity is suppressed; in such patients, supple-
mentary hydrocortisone should be given.
l Prolonged presence of steroid in blood results in de-
creased output of ACTH. This results in decreased func-
tion and atrophy of the adrenal cortex.
l Rapid withdrawal of hydrocortisone results in adrenal crisis.
For the routine activity, level of secretion may be sufficient.
l But in case of stress as in any minor or major dental
surgical procedure, the adrenal cortex may be unable to
secrete more to cope up with the stress.
l Even minor surgery may prove disastrous. Therefore,
such patients should be hospitalized and supplemented
with double the usual dose two days before surgery and
two days after surgery.
l Later on the dose is gradually tapered.
Q. 12. Dental implants -Indications and contraindications.
Ans.
Indications for Implants
l Completely edentulous patient.
l Partially edentulous patient.
l Partially edentulous jaw with distal free end situation.
l Single missing/extracted tooth.
238 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l Replacement of teeth in an edentulous jaw with oppos-
ing natural teeth.
l Patient unable to wear a removable denture prosthesis due to:
a. Parafunctional habits such as bruxism.
b. Gag reflex displacing the denture. Patients are not
satisfied with removable denture.
c. Psychological causes preventing the use of a remov-
able denture.
d. Inadequate number of abutment teeth for the place-
ment of fixed partial denture.
Contraindications for Implant Placement
l Unfavourable intermaxillary relationships: In patients
with unsatisfactory intermaxillary relationships, im-
plant procedures should not be considered.
SHORT NOTES
Q. 1. Methicillin-resistant Staphylococcus aureus.
Ans.
l Also known as MRSA.
l It is emerging increasingly, because of indiscriminate
use of antibiotics.
l MRSA is responsible for more than 50% nosocomial
infections.
l They are resistant to most of the antibiotics, because
they carry large plasmid-bearing resistance determi-
nants for MRSA.
l Vancomycin is the drug of choice.
Q. 2. Little’s area.
Ans.
l The anteroinefrior part or the vestibule of the septum
of nose contains anastomoses between the septal ra-
mus of the superior labial branch of the facial artery,
branch of sphenoplatine artery, and of anterior eth-
moidal artery.
l These form a large capillary network called the
Kiesselbach’s plexus.
l This is a common site of bleeding from the nose, i.e.,
epistaxisis, and is known as Little’s area.
Q. 3. Pentazocine.
Ans.
l This benzomorphine derivative has a potent analgesic
and a weak opioid antagonist activity.
l It does not cause diarrhoea.
l As an analgesic, it is half as effective as morphine, can
cause respiratory depression.
l It has a shorter duration of action than morphine, hence
is not recommended in myocardial infarction.
l Problematic occlusal and functional relationships.
l Pathologic conditions of the jaws: Cysts, tumours, in-
flammatory manifestations, etc., form temporary con-
traindications. Such patients should be re-evaluated af-
ter treatment of the jaw condition.
l Radiation therapy in the jaw region: Implantation is
usually avoided in such cases due to compromised vas-
cularity and likely damage to the cells and associated
problems with wound healing.
l Pathologies affecting the oral mucosa: Leukoplakia and
lichen planus contraindicate implant procedures.
l Xerostomia: Salivary flow has a cleansing effect and
reduces the bacterial count in the oral cavity. Reduced
salivary flow is a relative contraindication to implant
placement.
l Macroglossia.
Q. 4. Endosseous implants.
Ans.
l Endosseous implants are implants that are placed com-
pletely within the alveolar and basal bone.
l These implants receive their support by osseointegra-
tion with the alveolar bone into which they are placed.
l They can be different types depending on the shape that
is used: blade type, root form, etc.
Q. 5. Role of antibiotics in oral surgery.
Ans.
Antibiotics are chemical substances produced by microor-
ganisms, which has the capacity to inhibit the growth of or
kill other organisms.
Mechanism of Action of Antimicrobials
l Penicillins, cephalosporins, bacitracin, and vancomycin
inhibit the cell wall synthesis of microorganisms.
l Polymixin, collistin, polyene, and antifungal antibiotics
inhibit the cytoplasmic membrane of the microorganisms.
l Aminoglycosides, tetracyclines, chloramphenicol, macro-
lide antibiotics, and lincomycin inhibit the protein synthe-
sis and cause impairment in the function of ribosomes.
l Quinolones and metronidazole interfere in transcrip-
tion/translation of genetic information.
l Sulfonamides and trimethoprim have antimetabolite action.
l Vidarabine and acyclovir binds to viral enzymes essen-
tial for DNA synthesis.
Q. 6. Broad-spectrum penicillins.
Ans.
1. Aminopenicillins—ampicillin
l Active against Gram-negative bacilli, e.g., H. influenzae,
E. coli, Proteus, Salmonella, and Shigella.
Section | I  Topic Wise Solved Questions of Previous Years 239

2. Carboxy penicillins l Of the orally active cephalosporins, only cefaclor, cefurox-

l Active against Pseudomonas aeruginosa and indole- ime, and cefprozil have significant activity against anaer-
positive Proteus. obes, and are therefore preferred for orodental infections.
3. Ureidopenicillins l Some first-generation cephalosporins, despite poor an-

Piperacillin: Active against Klebsiella and is mainly aerobic activity, are used to treat dental infections such
used for neutropenic/ immunocompromised patients as dentoalveolar abscess.
having serious Gram-negative infections and in burns. l Their clinical effectiveness may be due to their activity

Meziocillin: Active against Pseudomonas and Klebsiella. in killing aerobes that deplete oxygen in the local envi-
4. Mecillinam (Amdinocillin) ronment and facilitate the growth of anaerobes.
l It acts by inhibiting the bacterial cell wall synthesis. l The major problem with resistance has been with

l It is active against gram negative bacilli, e.g., E. coli,
Salmonella, Klebsiella, and Enterobacter, but not
against Gram-positive cocci like pseudomonas.
Q. 7. Diclofenac sodium.
Ans.
Diclofenac Sodium
l It is an analgesic–antipyretic anti-inflammatory drug.
staphylococci, which are rarely present as aetiologic
agent in orodental infections, but are important con-
taminants of surgical or traumatic skin wounds.
l A number of cephalosporins may reach therapeutic concen-
trations in osseous tissues after administration of usual
doses and are useful for bone and joint infections caused by
susceptible microorganisms. Cephalexin, for example, has
been shown in alveolar bone and is active against various
Gram-positive aerobic bacteria found in dental infections.
l A cephalosporin would be an appropriate antibiotic for

l It inhibits PG synthesis and has short-lasting anti-plate- those rare infections known to be caused by a cephalo-
let action. sporin-susceptible strain of Klebsiella. Nevertheless, if
l It is well absorbed orally and has plasma half life of 2 h. penicillins are effective, cephalosporins offer no advan-
tage and should not replace the penicillins.
l The bactericidal action of cephalosporins is beneficial
Adverse Effects
for patients with a compromised immune system.
Adverse effects are generally mild. l The restricted activity of the orally active first-genera-
l Dizziness. tion and third-generation cephalosporins against anaer-
l Nausea. obes limits their usefulness in treating orodental infec-
l Headache. tions of anaerobic aetiology (e.g. periapical abscesses).
l Epigastric pain. l Some of the orally active second-generation cephalospo-
l Gastric ulceration and bleeding is less common. rins, such as cefaclor, cefuroxime, and cefprozil, are active
l Rashes. against both Gram-positive and Gram-negative aerobic
bacteria and some anaerobic bacteria involved in orodental
Uses infections and may be useful in treating such infections.

l Can be used in rheumatoid and osteoarthritis patient. Q. 9. Newer antibiotics.

l Toothache. Ans.
l Bursitis.
l Ankylosing spondylitis. l Carbenicillin and Ticarcillin are some of the recently
l Dysmenorrhoea. introduced antibiotics.
l These are similar to penicillin, which are useful against
l Post-traumatic and post-operative inflammatory condi-
tions such as pain and wound oedema. pseudomonas and other Gram-negative organisms in
hospital infections.
Q. 8. Cephalosporins. l Newer aminoglycosides like gentamicin and amikacin

Ans. are also used in such hospital infections.

l Newer anti-tubercular drugs are rifampicin and etham-

butol in the form of multidrug therapy along with strep-

Cephalosporins tomycin and isoniazid.
l The cephalosporins comprise a group of beta-lactam Q. 10. Clark’s shift cone technique.
antibiotics that structurally resemble the penicillins.
Ans.
l There are over 20 cephalosporins in the market, of

which eight can be given orally. l Two radiographs are taken at different angles and the
l The mechanism of action of cephalosporins is almost position of the object in question on each radiograph
identical to that of the penicillins. with reference structure is compared.
240 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
l If the tube is shifted and directed at the reference object
(apex of tooth) from more mesial angulation and the object
in question also moves mesially with respect to the refer-
ence object, the object lies lingual to the reference object.
l Alternatively, if the tube is shifted mesially; and object
in question moves distally, it lies on the buccal aspect of
the reference object.
Q. 11 Aspirin -Mechanism of action.
Ans.
l Aspirin is an effective analgesic for mild to moderate
degrees of pain.
l Aspirin acetylate inhibits the enzymes cyclo-oxygenase
and TX-synthase, inactivating them irreversibly.
l Platelets are exposed to aspirin in the portal circulation,
before it is deacetylated during first pass in liver; and
because platelets cannot synthesize fresh enzyme,
TXA2 formation is suppressed at very low doses and till
fresh platelets are formed.
l Prolongation of bleeding time induced by aspirin lasts
for 5–7 days.
l In vessel walls, aspirin also inhibits PGI2 synthesis.
Since intimal cells can synthesize fresh enzymes, activ-
ity returns rapidly.
l It is possible that at low doses TXA2 formation by
platelets is selectively suppressed, whereas higher doses
may decrease both TXA2 and PGI2 production.
l The release of ADP from platelets is inhibited by aspirin
and their sticking, to each other also.
l Side effects: Sensitive reactions may manifest as rashes,
swelling, asthma, and rarely anaphylaxis. Ingestion can
promote nausea, vomiting, bronchospasm, and gastroin-
testinal bleeding due to erosion of mucous membrane.
l Precautions: Young children are highly susceptible to
aspirin poisoning (therapeutic overdose).
Q. 13. Apert’s syndrome.
Ans.
Apert’s Syndrome
l It is also called as Acrocehalosyndactyly.
Skeletal Deformity
There is syndactyly (fusion of fingers) of second, third, and
fourth digit of hand and acrobrachycephaly (tower skull). In
some cases like kleeblattschadel deformity (cloverleaf
skull), the skull is ovoid, brachycephalic, and often presents
a horizontal supraorbital groove.
Facial Deformities
The middle third of face is underdeveloped.
Oral features
l High palaptal vault and V-shaped maxillary alveolar ridge.
l Trapezooidal-shaped appearance of lip, when lip is relaxed.
l There is posterior palatal cleft and bifid uvula.
l Retarded eruption and dental malocclusion.
l Class II malocclusion.
Q. 14. Endosseous implants.
Ans.
l These are implants that are placed completely within
the alveolar and basal bone.
l These implants receive their support by osseointegra-
tion with the alveolar bone into which they are placed.
l They can be different types depending on the shape that
is used: blade type, root form, etc.
Q. 15. Osteointegration.
Ans.
Osteointegration
l Osteointegration has been defined as the direct func-
tional and structural bond between organized vital bone
and the surface of an inanimate, alloplastic material.
Factors affecting osteointegration
l Occlusal load.
l Biocompatibility of the material.
l Implant design.
l Implant surface.
l Implant bed (surgical site).
l Infection.
Q. 16. Types of implant supported prosthesis.
Ans.
i. Single tooth replacements.
ii. Partially edentulous segment restorations.
iii. Fully edentulous lower jaw.
iv. Fully edentulous upper jaw.
Q. 17. Metronidazole.
Ans.
Metronidazole
Metronidazole is a nitroimidazole, a powerful amoebicide.
Mechanism of Action
Susceptible microorganism reduces the nitro group of metro-
nidazole by anitroreductase and converts it to a cytotoxic de-
rivative, which binds to DNA and inhibits protein synthesis.
Pharmacokinetics
l It is well absorbed and reaches adequate concentration
in the CSF; and has a plasma half life of 8 h.
Section | I  Topic Wise Solved Questions of Previous Years 241

l It is metabolized in liver by oxidation and glucuronidase
conjugation.
Adverse Effects
l Nausea, anorexia, abdominal pain, and most frequently
metallic taste in mouth are most common.
l Headache, stomatitis, glossitis, furry tongue, dizziness,
insomnia, ataxia, and vertigo.
l Pruritis, urticaria, and skin rashes also occurs.
Q. 18. Uses of steroids in oral surgery.
iii. Less likely to induce vomiting, and pharyngeal and la-
ryngeal reflexes are only slightly affected.
iv. It is of particular value in children and poor-risk pa-
tients; and also in asthmatic patients, since it does not
induce bronchospam.
Disadvantages
l Hallucinations and involuntary movements may occur
during recovery, if used as a sole agent.
l May be dangerous in hypertensives, as it raises BP.
l Ketamine increases cerebral blood flow and intracranial

pressure.
Indications
Q. 20. Amoxycillin.
A. Endocrinal
l Acute renal insufficiency. Ans.
l Chronic adrenal insufficiency (Addison disease).
l Amoxycillin is effective against Gram-negative as well
B. Non-endocrinal
as Gram-positive bacteria and most oral anaerobes.
l Arthritis—rheumatoid arthritis.
l It is slightly less active than penicillin V against
l Osteoarthritis.
Gram-positive cocci, except enterococci for which it is
l Rheumatoid fever.
more active.
l Acute gout.
l Chemistry: Beta-lactam antibiotic.
l Severe allergic reactions.
l Source: Semisynthetic.
l Bronchial asthma.
l Mechanism of action: Inhibits cell wall synthesis.
l Collagen diseases.
l Major action: Antibiotic and bactericidal.
l Eye diseases.

l Renal diseases. Q. 21. Carotid ligation.

l Skin diseases.

l Gastrointestinal diseases.
Ans.
l Liver diseases.

l Haematologic disorders. Carotid Ligation

l Cerebral oedema.

l Lung diseases. Indications

l Organ transplantation. l Bleeding from oral malignancies.
l Bell’s palsy. l Slipping of superior pedicle of thyroid gland.
l Acute polyneuritis. l Arteriovenous malformation of scalp.
l Myotonia.

Q. 19. Ketamine. Anaesthesia

Ans. l General anaesthesia.

Ketamine Position of Patient

l Ketamine is highly lipid-soluble and gets rapidly dis-
tributed into highly perfused organs and then redistrib-
uted to less vascular structures.
l Ketamine hydrochloride given 1–2 mg/kg slow IV or 10
mg/kg IM produces dissociative anaesthesia within 3–5
min, which lasts for 10–15 min after a single injection.
Advantages
i. Provides analgesia and amnesia. It can be used as a sole
agent for minor procedure.
ii. Respiration is not depressed. It does not induce hypo-
tension.
l Supine with neck extended to opposite side.
Procedure
l Skin and platysma are cut along the line of incision.
l Anterior border of sternomastoid is retracted posteriorly.
l Internal jugular vein is identified.
l Common carotid artery is found medial to IJV.
l Bifurcation of the common carotid artery defined.
l External carotid artery is identified by its branches.
l Internal carotid artery has no branches in the neck.
l Safeguard the hypoglossal nerve, which crosses LCA
and ECA just above hyoid bone.
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 Section II

Multiple Choice Questions

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 Section II

Multiple Choice Questions

1. Main disadvantage of dry heat used for sterilization is 6. The sterilizing units should be monitored at which of
that the following intervals?
a. It is time-consuming a. Daily
b. Rusts the instruments b. Weekly
c. Dulls the sharp instruments c. Biweekly
d. Ineffective sterilization d. Monthly

2. Which of the following is most commonly used to dis- 7. The correct temperature and holding time of autoclave is
infect dental units and hand pieces? a. 110°C 15 min
a. Clorox b. 121°C 15 min
b. Glutaraldehyde c. 160°C 10 min
c. Betadine d. 110°C 20 min
d. Ethyl alcohol
8. The method of sterilization of metal instrument is by
3. What is the fastest, safest, and most effective way to a. Infrared radiation
sterilize a metal impression tray with a solder that melts b. Sintered glass filters
at a temperature above 175oC? c. 3% Lysol solution
a. Filtration d. Soap and water
b. Autoclaving
c. Dry heat sterilization 9. The minimum time required for the sterilization of
d. Soaking in 2% glutaraldehyde surgical instruments by moist heat at 134°C is
a. 3 min
4. Cidex is b. 15 min
a. Glutaraldehyde c. 30 min
b. Alcohol d. 60 min
c. A phenolic compound
d. A caustic agent 10. AIDS infected bloody instrument is best sterilized by
a. Moist heat autoclave
5. The main objective for efficacy of sterilization practice b. Clean the instrument and then use dry heat
is destruction of c. Soak overnight in glutaraldehyde
a. Cocci d. Wipe clean with Cidex
b. Viruses
c. Bacteria 11. Normal bleeding time range by Duke’s method is
d. Spores a. 10–30 sec
b. 3–5 min
c. 3–9 min
d. 1–5 min

1. d 2. b 3. b 4. a 5. d 6. b 7. b 8. a 9. a 10. b 11. d

245
246 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

12. Of the following, which is screening test for scurvy? 19. Diagnostic test for multiple myeloma is
a. Tourniquet test a. Bone marrow biopsy
b. Immunoassay for total body Vit C b. Bence-Jones protein test
c. Melkerson-Rosenthal test c. X-ray of long bones
d. None of the above d. X-ray of skull

1 3. Prolonged prothrombin time is seen in all of the fol- 20. Maxillary antrum is best viewed on
lowing except a. Water’s view
a. Factor VII deficiency b. Towne’s view
b. In patient with coumarin therapy c. P.A. view
c. Factor V deficiency d. Submentovertex view
d. Factor XI deficiency
21. The following two laboratory tests should be consid-
14. Serum alkaline phosphatase increase in all of the fol- ered before deciding whether touse general anaesthe-
lowing conditions except sia or not
a. Scurvy a. Total WBC count and prothrombin time
b. Hyperparathyroidism b. Total WBC count and urine analysis
c. Paget’s disease c. Bleeding time and clotting time
d. None of the above d. Complete blood count and urine analysis

15. Which of the following condition can be diagnosed by 22. Commonest cause of TMJ ankylosis is
differential white blood cell count? a. Trauma
a. Anaemia b. Developmental disturbances
b. Spherocytosis c. Infections
c. Thrombocytopenic purpura d. Atrophy
d. Eosinophilia
23. Compared to inhalation, IV sedation
1 6. Of the following, which is the most commonly used a. Produces more predictable amnesia
fixative b. May produce more serious complications
a. 10% alcohol c. May result in deeper sedation
b. l0% formalin d. All of the above are correct
c. 20% formalin
d. 20% alcohol 24. Among the following, which is least likely to block
reflexes for surgery completely when used alone
1 7. Incisional biopsy of an ulcer is taken a. Nitrous oxide
a. At the centre of the lesion b. Halothane
b. Edge of the lesion c. Ethane
c. Edge of the lesion along with normal tissues d. Thiopentone sodium
d. At any part of the lesion
25. Most common cause of death occurring under GA is
1 8. Which one of the following should not be done during due to
an incisional biopsy of soft tissue a. Reflex cardiac standstill
a. Place suture through the intended specimens before b. Overdosage of anaesthetic agent
removing it c. Excessive carotid sinus stimulation
b. Infiltrate local anaesthetic solution around the in- d. Airway obstruction with improper ventilation
tended site
c. Place the specimens in saline, if 10% formalin is
unavailable
d. Obtain some adjacent normal tissue, if possible

12. a 13. d 14. a 15. d 16. b 17. c 18. c 19. b 20. a 21. b 22. a 23. d 24. a 25. d
Section | II  Multiple Choice Questions 247

26. Three common symptoms indicating the correct level 33. Genioplasty procedure is used
of sedation afterdiazepam administration is a. To change the attachment of genioglossus muscle
a. Blurring of vision, slurring of speed, and loss of in preprosthetic procedure
GAG reflex b. To change the position of genial tubercles
b. 50% ptosis eyelids, blurring of vision, and slurring c. To modify the position of the chin
of speech d. To modify the attachment of anterior belly of
c. Paraesthesia of lips, tongue, and fingers digastrics
d. Sweating over the face, itching of the nose, and loss
of gag reflex 34. Limited accessibility is one of the most disadvantages
of the following flap
27. Preferable patient position in recovery room after am- a. Envelop flap
bulatory general anaesthesia is b. Semilunar flap
a. Supine c. Three cornered flap
b. Sitting d. Four cornered flap
c. Prone
d. Lateral 35. According to Nitzin’s theory, the following microor-
ganisms are responsible for dry socket
28. Which is the best monitor of the level of analgesia? a. Treponema denticola
a. Eye movements b. Leprospira pyrogen
b. Respiratory movements c. Pseudomonas
c. Muscle tone d. Bacillus subtilis
d. Verbal response
36. Most common site for dry socket
29. Of the following, in which condition general anaesthe- a. Lower incisor area
sia is contraindicated? b. Upper incisor area
a. Haemoglobinopathy c. Lower molar area
b. Allergy d. Upper molar area
c. Diabetes mellitus
d. All of the above 37. ‘Postage Stamp’ method is
a. A method of bone removal in transalveolar
30. Sedation by which of the following routes can be re- extraction
versed rapidly? b. A method of extraction of maxillary canines by intra-
a. Intravenous alveolar method extraction
b. Oral c. A method of bone grafting
c. Inhalation d. None of the above
d. Intramuscular
38. The best example of an elevator which works on wheel
31. The following are indication for suturing following and axle principle
exodontia except a. Howarth’s periosteal elevator
a. Blood clot protection b. Winter cross bar elevator
b. Re-approximation of mucoperiosteal flaps c. Miller’s apexo elevator
c. Immobilization of tissues d. None of the above
d. Haemostasis
39. Ten teeth have been removed for a patient who was
32. In the extraction of mandibular third molars, the main premedicated. The proper position of the patient in the
reason why the posterior incision should be placed recovery room is
more buccally is a. Head elevation 30° with patient on his back
a. To prevent damage to lingual nerve b. Trendelenburg position—patient head is almost
b. Incision should be on the sound bone parallel to the floor
c. To prevent damage to retromolar artery c. Reverse Trendelenburg position
d. All of the above d. Supine position

26. b 27. d 28. d 29. a 30. c 31. a 32. d 33. c 34. b 35. a 36. c 37. a 38. b 39. a
248 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

40. A swelling overlies an extraction wound and it crack- 47. Amber Hoe of the ‘WAR’ Hoe indicates
les on palpation. Most likely diagnosis is a. Corresponding to the occlusal plane
a. Ecchymosis b. Denotes the alveolar bone covering the impacted
b. Cellulitis tooth and portion not covered by bone
c. Emphysema c. The depth of the tooth in the bone
d. Empyema d. None

41. A dentist planning to remove an impacted tooth will 48. The most common reason for the removal of impacted
need which of the following radiographs mandibular third molars is
a. A periapical film will be all that is required a. Referred pain
b. A bite-wing film will be of little or no use b. Orthodontic treatment
c. A lateral view will be all that is required c. Recurrent pericoronitis
d. An anteroposterior view is all that is required d. Chronic periodontal disease

42. In radiographic study of impacted teeth 49. In a pericoronal abscess related to distoangular im-
a. Bite wing X-rays are of no use pacted lower third molars, the infection may spread to
b. Occlusal view is useless a. Submasseteric space
c. Bite wing X-rays are indispensable b. Sublingual space
d. All of the above c. Submental space
d. Buccal space
43. Common cause of lingual nerve damage causing par-
aesthesia is 50. The most common reason for the removal of impacted
a. Fracture of the lingual plate mandibular third molars
b. Lingual flap design a. Referred pain
c. Damage to the lingual flap during the III molar b. Orthodontic treatment
removal c. Recurrent pericoronitis
d. All of the above d. Chronic periodontal disease

44. Which of the following statement about the surgical 51. Tramline pattern on the face is due to
removal of an upper wisdom tooth is true? a. Sutures placed with tension
a. There is a greater chance of producing an oroantral b. CSF rhinorrhoea
fistula than when an upper first molar is removed c. Circumorbital ecchymosis
b. It rarely produces infraorbital paraesthesia d. Subconjuntival haemorrhage
c. Post-operative bleeding is usually due to an unrec-
ognized fracture of the maxillary tuberosity 52. Of the following, which is the weakest part of the orbit
d. None of the above a. Medial wall
b. Lateral wall
45. During the extraction of a wisdom tooth, a pregnant c. Floor of the orbit
woman in the late second trimester faints. In which of d. Roof of the orbit
the following position should she be placed
a. Left lateral 53. Depressed fracture of the zygomatic area may be
b. Supine, horizontal clinically recognized by
c. Supine, head-down a. Concavity of the overlying tissue in the zygomatic
d. Supine, head-up arch area
b. Interference with movements of the mandible
4 6. Reducing the amount of post-surgical swelling can be c. Subluxation of condyles
accomplished by d. Both a and b
a. Careful surgical manipulation of bone and soft tissues
b. Judicious administration of antihistamines in thera- 54. Which of the following is characteristic of LeFort I fracture?
peutic doses a. CSF rhinorrhoea
c. Immediate applications of hot packs to the affected area b. Bleeding from the ear
d. Application of heat and cold intermittently c. Bleeding into the antrum
d. Both a and b

40. c 41. b 42. a 43. c 44. c 45. a 46. a 47. b 48. c 49. a 50. c 51. b 52. c 53. d 54. c
Section | II  Multiple Choice Questions 249

55. After a depressed fracture of zygomatic arch, mandib- 62. Submentovertex view is best used for viewing
ular movement is restricted. The most probable reason a. Sinuses
is b. Zygomatic fractures
a. Disruption of TMJ c. Mandibular fractures
b. Spasm of the lateral pterygoid muscle d. Maxillary fractures
c. Mechanical impingement of the fracture fragment
on the coronoid process 63. Nasal antrostomy is done in
d. Splinting action of masseter and medial pterygoid a. Superior meatus
muscle b. Middle meatus
c. Inferior meatus
56. Of the following, which view is best to visualize zygo- d. Inferior concha
matic arches
a. Submentovertex or Jug Handle view 64. In Caldwell-Luc procedure, the entrance into a sinus is
b. Occipitomental view made through the
c. Orthopantamogram a. Malar eminence
d. Skull PA view b. Canine fossa
c. Tuberosity
5 7. Of the following, which view is best for the evaluation d. Zygomatic ridge
of middle face fracture?
a. Lateral skull 65. Nasal antrostomy is usually done through
b. PA skull a. Middle concha
c. Towne’s view b. Inferior concha
d. Water’s view c. Middle meatus
d. Inferior meatus
5 8. Hanging drop effect in Blowout fracture is due to
herniation of 66. Which of the following tooth extractions has the com-
a. Superior oblique and inferior oblique muscles plication of displacement into maxillary antrum
b. Inferior oblique and inferior rectus muscles a. First molar
c. Superior rectus and superior oblique muscles b. First premolar
d. Inferior oblique and superior rectus muscle c. Second premolar
d. Second molar
5 9. In a patient with maxillofacial injury, narcotics like
morphine is contraindicated because 67. Mobility of teeth in carcinoma of maxillary sinus is
a. Morphine causes myosis due to involvement of tumour by
b. Morphine causes mydriasis a. Anterior wall of the sinus
c. Morphine is respiratory irritant b. Posterior wall of the sinus
d. Morphine is circulatory depressant c. Roof of the sinus
d. Floor of the sinus
6 0. Restricted mandibular movements with depressed zy-
gomatic arch fracture is due to 68. A male patient had a pinpoint oroantral communica-
a. Myospasm of lateral pterygoid muscle b. Splinting tion. The treatment is
action of masseter and temporalis a. Berger flap
c. Damage to the TMJ b. Palatal flap
d. Mechanical impingement of zygomatic arch on the c. Caldwell procedure
coronoid process d. None

61. Radiographic features of sinusitis include 69. Sinusitis may cause referred pain in
a. Fluid levels a. Maxillary anterior teeth
b. Erosion of bone b. Maxillary posterior teeth
c. Clouding of the antrum c. Mandibular anterior teeth
d. Clouding and fluid levels d. Mandibular posterior teeth

55. c 56. a 57. d 58. b 59. a 60. b 61. d 62. b 63. c 64. b 65. d 66. a 67. d 68. d 69. b
250 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

70. During extraction of a maxillary molar, a root tip is left 77. When draining pus from an abscess of the pterygo-
in the maxillary sinus. The treatment of choice is mandibular space from an intraoral approach, the
a. Perform Caldwell-Luc to remove tip muscle most likely to be transected is the
b. Perform hemimaxillectomy a. Masseter
c. Enlarged opening in the socket area b. Buccinator
d. No treatment indicated c. Temporalis
d. Medial pterygoid
71. Infection from peripical region of molars penetrates
below the buccinator buttons subperiosteally into 78. An effective oropharyngeal curtain can be placed by
a. Submassetric space using a
b. Pterygomandibular space a. McKesson prop
c. Sublingual space b. 434 guaze sponge
d. Parotid space c. Lap pad
d. Pick up forceps
72. Osteomyelitis of the temporomandibular joint can be
treated by 79. In Ludwig’s angina, there may be hoarseness of voice
a. Condylectomy of the patient. This can be due to
b. Incision and drainage a. The elevation and protrusion of tongue
c. Irradiation b. Involvement of recurrent laryngeal nerve
d. Incision and drainage, if needed, condylectomy c. Difficulty in breathing
d. Bilateral cellulitis
73. Treatment of the abscess with specific antibiotics with-
out adequate incision and drainage can lead to 80. Hilton’s method deals with
a. A suppurative inflammatory reaction a. Decompression of a cyst
b. A non-suppurative inflammatory reaction b. Drainage of an abscess
c. Formation of a haemangioma c. Biopsy removal
d. Formation of an antibioma d. Preanaesthetic check-up

74. A patient with Ludwig’s angina has bilateral involve- 81. Reactionary haemorrhage occurs after extraction,
ment of which of the following tissue space? because of
a. Submandibular and masticatory spaces a. Broken roots
b. Sublingual and lateral pharyngeal spaces b. High blood pressure
c. Submandibular, sublingual, and submental spaces c. Sharp interdental septum
d. Submental space with extension into the tongue d. Gingival laceration

75. The most definite clinical sign indicating extension of 82. A patient who is on dicoumorol therapy requires a
an odontogenic infection into the masticatory space is tooth extraction. Which laboratory test is the most
a. Trismus valuable in evaluating this patient’s surgical risk?
b. Xerostomia a. Clotting time
c. Difficulty in swallowing b. Bleeding time
d. Swelling in the submandibular area c. Prothrombin time
d. Complete blood cell count
7 6. The trismus associated with infection in the lateral
parapharyngeal space is related to irritation of the 83. The use of medical history in patients undergoing
a. Medial pterygoid muscle dental extraction is
b. Masseter muscle a. In medicolegal cases
c. Lateral pterygoid muscle b. To assess the growth stage of a tooth
d. Medial constrictor of the pharynx c. To determine bleeding disorder
d. To determine communicable disease

70. a 71. a 72. d 73. d 74. c 75. a 76. b 77. b 78. b 79. b 80. b 81. b 82. c 83. c
Section | II  Multiple Choice Questions 251

84. For a patient undergoing anticoagulant therapy, who 91. Inadvertent displacement of the teeth into inaccessible
requires unavoidable dental surgical treatment, the areas of head and neck be effectively prevented by
dental surgeon should: a. Use of prudent surgical technique
a. Not take up the patient, till the therapy is over b. Use of gauze pharyngeal curtain
b. Bring down the dosage and proceed further c. Evaluation of radiography prior to surgery
c. Adjust the dosage before and after dental visit d. All of the above
d. Consult the physician of the patient for joint
decision 92. Cavernous sinus thrombosis following infection of
maxillary and anterior teeth most often results from
85. Hypoglycaemia may occur in a patient taking insulin spread of infected emboli along the
and undergoing extraction when a. Pterygoid plexus
a. Extraction is done on empty stomach b. Ophthalmic vein
b. Patient had an infection c. Facial artery
c. Patient had no exercise in the morning d. Angular artery
d. Patient consumed breakfast before extraction
93. Members of the sterile professional team include
86. A patient is on periodic renal dialysis. Minor oral sur- a. Surgeon, assistants, and scrub nurse
gery should be performed b. Surgeon, scrub nurse, and circulating nurse
a. One day before dialysis c. Surgeon, scrub nurse, circulating nurse, and anaes-
b. On the day of dialysis thesiologist
c. One day after dialysis d. Both a and b
d. One week after dialysis
94. The purpose of gas filled bubbles in anaesthetic car-
87. The blood product of choice for treatment of haemo- tridge is
philiacs is a. Indicate the level of anaesthetic agent
a. Fresh blood b. Prevent deterioration of the vasoconstrictor
b. Cryoprecipitate c. Formed during the manufacturing process
c. Fresh frozen plasma d. Both a and c
d. Plasma
95. Risk of death is more in some patients with the use of
88. After the surgical removal of chronically infected teeth local anaesthesia with adrenaline. Which of the follow-
in a controlled diabetic patient, which of the following ing group of patients are called as walking time
is of utmost importance bombs?
a. Post-operative check of patient for bleeding a. Cocaine abusers
b. Return of patient to diet of a normal individual b. Hypertensive
c. Revaluation of insulin dosage being taken by the c. Hyperthyroidism patients
patient d. Patients under MAOI (MAO inhibitors) treatment
d. Medication for marked post-operative pain and
discomfort 96. The following deep bony landmarks is important in
performing a block of the II and the III divisions of the
89. Ammonia inhalation in the treatment for syncope acts trigeminal nerve from the lateral approach
by producing a. Temporal surface of sphenoid
a. Bronchodilatation b. Perpendicular plate of the palatine bone
b. Vasoconstriction c. Lateral plate of the pterygoid process
c. Sedation d. Styloid process
d. Mucosal irritation
97. ‘Vital signs’ include which of the following
90. Osteotome is a. TPR (temperature, pulse, respiration)
a. Monobeveled b. B.P. (blood pressure)
b. Bibeveled c. All of the above
c. Tetrabeveled d. None of the above
d. Not contain any bevels

84. d 85. a 86. c 87. b 88. c 89. d 90. b 91. d 92. b 93. a 94. b 95. a 96. c 97. c
252 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

98. Among the following, in which condition one might 1 00. Fordyce disease is due to
see Hutchinson’s incisors? a. Hyperkeratosis
a. Acquired syphilis b. Capillary fragility
b. Congenital syphilis c. Aberrant sebaceous glands
c. Secondary syphilis d. Cholesterol deposits
d. Tertiary syphilis

9 9. Bifid ribs, multiple radiolucent lesions of the jaws,

multiple basal cell nevi, and falx cerebri calcification
are found in
a. Basal cell nevus syndrome
b. Sturge–Weber syndrome
c. Horner syndrome
d. Hereditary intestinal polyposis

98. b 99. a 100. c

 Section III

Previous Years’ Question Bank

This page intentionally left blank

Previous Years’ Question Bank
Introduction to Oral and Maxillofacial Surgery
Long Essays
1. Define asepsis. What precaution would you take to
maintain asepsis during a minor oral surgical proce-
dure? [NTR-OR Apr 1996]
2. Discuss the use of various chemical agents for maintain-
ing sterilization and asepsis in the dental clinic. [MUHS
May 1994]
Short Essays
1 . Moist heat sterilization. [RGUHS Aug 2013]
2. Sterilization and disinfection in dental practice [NTRUHS
Aug 2009]
3. Sterilization. [RGUHS 2007(RS); MUHS Mar 1992]
4. Autoclave [RGUHS Apr 2002]
5. Physical methods of sterilization. (MUHS May 1999]
Short Notes
1. Autoclave. [RGUHS Sep 2002, Aug 2013; TN Feb
2007]
Section III
Topic 1
2. Sterilization and disinfection. [TN Feb 2012]
3. Bacterial endocarditis. [RGUHS Apr 2003]
4. Moist heat sterilization. [NTR-NR Oct 2004]
5. Cold sterilization. [NTR-NR Oct 2006]
6. Cross infection in dental office. [NTR-NR Apr 2004]
7. Classify the methods of sterilization of oral surgery
instruments and list six methods of sterilization.
[MUHS Jun 2004]
8. Various methods of sterilization in oral and maxillofa-
cial surgery. [MUHS Jul 2005]
9. What is disinfection? Name five disinfectants. [MUHS
Nov/Dec 2007]
10. Define the terms ‘Antiseptic’ and ‘Disinfectant’.
[MUHS Nov 2006]
1 1. Hot air oven. [RGUHS Jul 2008 (RS 2)]
12. Chemiclave. [TN Aug 2009]
13. Asepsis. [NTR-OR Oct 1991]
14. Sterilization. [NTR-OR May 1994, NTR-NR Oct
2002, Apr 2005, Sep 2002 RGUHS Aug 1991, Mar
1997]
255
256
General Principles of Surgery
Long Essays
1 . Ludwig’s angina. [RGUHS 2007 (RS)]
2. Describe the uses of lasers in maxillofacial surgery.
[RGUHS 2007 (RS)]
3. Cephalometry used in oral surgery. [MUHS Oct 1991]
Short Essays
1. Suture techniques used in oral surgery. [RGUHS Dec
2009 (RS2); Jul 2008 (RS)]
2. Suturing materials. [RGUHS Apr 2008 (RS2)]
3. Cephalometry. [RGUHS Feb 2007 (RS)]
4. Explain suturing material for a facial wound and method
of suturing differently. [RGUHS Apr/May 2007 (RS)]
5. Magnetic resonance imaging. (MRI) [RGUHS Apr/May
2007 (RS)]
Short Notes
1. Suture materials. [TN Feb 2012; BUHS Apr 1987, Mar
1988, Jun 1989, Sep 1992, 1994, 2000, Feb 1996, Aug
1996, Oct 2004; TN Aug 2006]
2. BSSO. [TN Feb 2011]
3. I and D (Incision and Drainage). [TN Feb 2011]
4. IOPA (Intraoral Periapical X-ray). [TN Feb 2011]
5. Resorbable suture materials. [TN Feb 2007]
6. Suture techniques. [TN Aug 2007]
7. Alloplastic material. [TN Aug 2009]
8. Bone grafts. [BUHS Jan 1990; TN Feb, Aug 2008, Feb
2009]
9. Exfoliative cytology. [NTR-NR Apr 2004; RGUHS
Jul 2008 (RS 2); Feb 2007 (RS)]
10. Catgut suture. [RGUHS Feb 2007 (RS)]
11. Incisional biopsy. [NTR-NR Oct 2006]
12. Suturing. [NTR-NR Oct 2006]
13. Types of mucoperiosteal flaps. [NTR-NR Oct 2006]
Local Anaesthesia
Long Essays
1. Discuss in detail about infraorbital nerve block. Write
its landmarks, techniques, and complications. [RGUHS
Aug 2013]
Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
Topic 2
14. Horizontal mattress suturing. [RGUHS Mar 2006,
2003]
15. What is the difference between ‘Square knot’ and
‘Surgeon’s knot’? [MUHS Nov 2006]
16. Eburnation. [RGUHS Aug 2006 (OS)]
17. LASER application in oral surgery. [TN Aug 2005]
18. Suture material and suturing techniques. [NTR-NR
Oct 2002; TN Aug 2004]
19. What is biopsy? Give its types [MUHS May 2003,
2004]
20. Catgut. [RGUHS Mar 2005, Apr 2002]
21. Aspiration biopsy. [GOA 2003]
22. Needles used in suturing. [GOA 2003]
23. Indications and techniques of needle biopsy. [RGUHS
Apr 2003]
24. Cephalometry. [NTR-NR Apr 2002]
25. Name various flap designs used for minor oral surgery.
[NTR-NR Apr 2002]
26. Cephalometric analysis. [NTR-NR Oct 2002]
27. Biopsy indications and diagnosis techniques. [NTR-
NR Apr 2002]
28. Define biopsy and what are the various biopsy tech-
niques? [RGUHS Sep 2002]
29. Cephalometry in oral surgery? [NTR-DR Oct 2001]
30. Suture materials used in oral surgery? [NTR-NR Oct
2001]
31. Miniplate osteosynthesis. [NTR-OR Oct 1999]
32. Mucoperiosteal flaps. [NTR-OR Apr 1997]
33. Biopsy - indication and various techniques. [MUHS
Aug 1993]
34. Bone plates. [NTR-OR Feb 1989]
35. Biopsy. [NTR-OR May 1993, Apr 1998, NTR-NR Oct
2002: NTRUHS Aug 2009; RGUHS Aug 2006 (OS);
RGUHS Aug 2005; GAO 2004; TN Feb 2006; BUHS
Jul 1990, Aug 1991, 1995, Sep 1992, 1996, RGUHS
Aug 2005, 2006; TN Aug 2007]
Topic 3
2. Describe in detail about the extracranial course of
trigeminal nerve. [RGUHS Jul 2008 (RS2)]
3. Write in detail about complication of local anaesthesia
and their management. [TN Aug 2007]
Section | III  Previous Years’ Question Bank
4. Describe in brief treatment of trigeminal neuralgia.
[MUHS 2007]
5. Discuss about pharmacology, composition, and indica-
tions for use of local anaesthetic agent. Write a note on
complications of inferior alveolar anaesthesia. [NTR-
NR Mar 2005]
6. Define local anaesthesia. Explain in detail posterior
superior nerve block. [GOA Dec 2005]
7. Describe biotransformation of local anaesthetic agents.
[NTRUHS Aug 2005]
8. What is trigeminal neuralgia. Describe the various
medical and surgical treatments. [TN Aug 2005]
9. Enumerate the properties of ideal local anaesthetics.
Describe in detail the various intraoral techniques to
anaesthetize the mandibular nerve and its complica-
tion. [TN Aug 2005]
10. Enumerate in detail the course of mandibular branch of
trigeminal nerve and explain the technique of classical
pterygomandibular nerve block. [NTR-NR Oct 2004]
11. Discuss in detail about surgical anatomy, indications
and contraindications, and technique of inferior alveo-
lar nerve block anaesthesia. [NTR-OR Apr 2004]
12. Compare classical inferior alveolar nerve block with
closed mouth technique of blocking inferior alveolar
nerve. [GOA 2004]
13. Enumerate the various local systemic causes for post-
extraction bleeding. What options do you have in
managing such conditions? [RGUHS Sep 2003]
14. Describe the indication and composition of local an-
aesthesia and give anyone technique (infraorbital) of
maxillary nerve block. Give the boundaries of tempo-
ral space. Discuss the management of its involvement.
[MUHS 1998, 1999, 2003]
15. Enumerate the complications of local anaesthsia. De-
scribe in detail the treatment of different toxic reac-
tions to local anaesthetic solution. [MUHS 1990, 2003]
16. Complication due local anaesthetic solution. Classify
and explain the same. [GOA 2003]
17. Ranula. [MUHS 2002]
18. What is the composition of local anaesthetic solution?
What are the signs and symptoms of lignocaine toxic-
ity? [GOA 2002]
19. Classify local anaesthetic drugs. What are the ideal
properties of the local anaesthetic solution? Describe
in brief the technique of inferior alveolar nerve block.
[MUHS 2003, 1989, 2002]
20. Describe the indications, technique, and complications
of the tuberosity block. How will you avoid of the
tuberosity block? How will you avoid and manage
these complications? [TN Nov 2001]
21. Enumerate the complications of local anaesthesia and
treatment of different toxic reactions of local anaesthe-
sia solution. [MUHS 1999]
22. Describe in brief different methods of pain control.
What is the composition of local anaesthesia solution?
257
Describe the function of each component. [MUHS
1999]
23. Indication for extraction under general anaesthesia.
Describe mode of action of local anaesthesia agents.
[MUHS 1999]
24. Describe in brief different methods of pain control.
What is the composition of L.A. solution? Describe the
function of each component. [MUHS 1999]
25. What is trismus? Mention various conditions resulting
in trismus with treatment of each one in brief. [MUHS
1998]
26. Enumerate the complications of local anaesthesia. Dis-
cuss in detail the signs, symptoms, and management of
anaphylaxis. [MUHS 1998]
27. Describe the technique of inferior denta1 nerve block
anaesthesia. Enumerate the complications of the tech-
nique. [NTR-OR Apr 1998]
28. Discuss toxicity to local anaesthesia in detail. [MUHS
1997]
29. Describe the landmarks of intraorbital nerve block.
Describe the technique of infraorbital nerve block and
its complications. [BUHS Aug 1996]
30. Classify the local anaesthetic agents. Discuss the role
of vasoconstrictor in the local anaesthetic solution.
[RGUHS Aug 1996, May 1994]
3 1. Preanaesthetic medication. [MUHS 1995]
32. Mention the complications due to local anaesthetic
injection (Lignocaine HCL). Describe the manage-
ment of any two in detail. [MUHS 1995]
33. Describe the mandibular division of trigeminal nerve.
Describe the technique of pterygomandibular nerve
block anaesthesia and give its complications. [MUHS
1992, 1995]
34. What are the causes for inability to open the mouth?
Describe in SHORT, the methods of managing it.
[RGUHS Mar 2004, 1994]
35. Discuss the indications and contraindications of local
anaesthesia. [NTR-OR Nov 1994]
36. Define local anaesthesia. What are the components of
a standard local anaesthetic solution? Discuss the indi-
cations and contraindications of local anaesthesia.
[NTR-OR May 1994]
37. Preanaesthetic evaluation of patient undergoing gen-
eral anaesthesia. [MUHS 1994]
38. Describe the local anaesthesia drugs and describe their
mode of action. [MUHS 1993]
39. Post-operative care of patient treated under general
anaesthesia. [MUHS 1993]
40. Mention the composition and ideal requirement of lo-
cal anaesthesia. Describe the complications of LA and
its management. [RGUHS Sep 1992, Feb 1993]
41. Enumerate the various causes for post-extraction
bleeding and discuss the various methods available to
control bleeding from socket. [RGUHS Jan 1989, Aug
1993]
258 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
42. Describe the complications associated with mandibu-
lar nerve block and briefly discuss the management of
each. [RGUHS Apr 1987, Feb 1993] 2005]
43. Describe the technique of inferior alveolar nerve block.
Enumerate the various courses for breakage of needle
while giving block anaesthesia. [RGUHS Sep 1992]
44. Describe the mandibular division of trigeminal nerve.
Describe the technique of pterygomandibular nerve
block anaesthesia and give its complications. [MUHS
1992]
45. Discuss the technique and composition of PSA nerve
block. [MUHS 1992]
46. Preanaesthetic evaluation prior to dental extraction.
[MUHS 1989, 1992]
47. Describe the indication, technique, and complication
of tuberosity block. What are the boundries of infra-
temporal space? Name the space communcating with
this space. [MUHS 1991]
48 Write the branches of mandibular nerve. Describe the
signs, symptoms, and treatment of right inferior alveo-
lar neuralgia. [MUHS 1990]
49. Define the boundaries of pterygomandibular fossa.
Describe anyone technique of blocking the inferior
dental nerve. [NTR-OR Jun 1982]
Short Essays
1. Gow-Gates technique. [RGUHS Sep 1994, Aug 2006,
2007 (RS); NTRUHS Feb 2011; RGUHS Aug 2013]
2. Complication of local anaesthetics. [RGUHS Dec
2001/Jan 2012, Jul 2008 (RS)]
3. Local and systemic complications of local anaesthesia.
[NTRUHS Mar 2004; Feb 2011]
4. Classification of injuries of trigeminal nerve. [RGUHS
Oct 2009 (RS)]
5. Composition of local anaesthetic solution and its parts.
[NTR-OR Apr 1996; NTRUHS Aug 2009]
6. Inferior alveolar nerve block and its action. [NTR-NR
Apr 2006; RGUHS Dec 2009 (RS2)]
7. EMLA. [RGUHS Apr 2008 (RS2)]
8. Infraorbital nerve block. [RGUHS Jul 2008 (RS)]
9. Theories of local anaesthetic action. [RGUHS Feb
2007 (RS)]
10. Analgesics in oral surgery. [RGUHS Feb 2007 (RS)]
11. Theories of mechanism of local anaesthesia. [RGUHS
2007 (RS)]
12. Syncope. [RGUHS Aug 2005; Feb 2007 (OS)]
13. Intravenous sedation in oral surgery. [RGUHS Aug
2006]
14. Contents of local anaesthetic solutions. [NTR-NR Apr
2006]
15. Gow-Gates nerve block. [RGUHS Aug 2006 (RS)]
16. Systemic complications of local anaesthesia. [RGUHS
Aug 2006 (RS)]
1 7. Nerve injuries in oral surgery. [RGUHS Aug 2005]
18. Theories of action of local anaesthetic. [RGUHS Mar
19. Mechanism of action of local anaesthesia. [NTR-NR
Apr 2001, RGUHS Mar 2005]
20. Posterior superior alveolar nerve block anaesthesia.
[NTR-NR Oct 2005]
21. Post-operative complications of LA. [RGUHS Aug
2005]
22. Theories of action of LA. [RGUHS Mar 2005, Oct
2001]
23. Trismus. [RGUHS Mar 2002, 1995, Aug 2005; MUHS
1993]
24. Dry socket and its management. [RGUHS Mar 2004]
25. Local and systemic complications of LA. [RGUHS
Mar 2004]
26. Properties of an ideal local anaesthetic drug. [NTR-NR
Oct 2004]
27. Enumerate the various infiltration techniques of local
anaesthesia. [MUHS 2004]
28. Cavernous sinus thrombosis. [RGUHS Mar 2003]
29. NSAIDs. [MUHS 2002]
30. Give four advantages of using adrenaline in the local
anaesthesia solution. [MUHS 2002]
31. Lignocaine hydrochloride. [NTR-NR Oct 2002]
32. Theories of action of LA. [BUHS Mar 1995, RGUHS
Oct 2001]
33. Dry socket. [RGUHS Feb 1996, Aug 1996, Sep 2000]
34. Electrophysiology of nerve conduction. [RGUHS Mar
2000]
35. Complications of mandibular nerve block anaesthesia.
[RGUHS Mar 2000]
36. Electrophysiology of nerve conduction. [RGUHS Mar
2000]
37. Complications of inferior alveolar nerve block. [NTR-
NR Apr 2000]
38. Complications of mandibular nerve block anaesthesia.
[RGUHS Mar 2000]
39. Classify ibuprofen. Give the indications, doses, and
side effects of ibuprofren. [MUHS 1999]
40. Describe the mode of action of various agents used to
achieve local haemostasis following extraction.
[MUHS 1998, 1999]
41. Local anaesthesia toxicity. [MUHS 1997]
42. Role of vasoconstrictor in local anaesthesia solution.
[MUHS 1996]
43. Nerve block. [NTR-OR Apr 1995]
44. Mechanism of action of local anaesthesia. [RGUHS
Mar 1995]
45. Post-extraction bleeding. [RGUHS Aug 1995]
46. Preanaesthetic medication. [MUHS 1995]
47. Pentazocaine. [MUHS 1995]
48. Lignocaine hydrochloride. [MUHS 1995]
49. Toxicity. [MUHS 1995]
Section | III  Previous Years’ Question Bank
50. Preanaesthetic evaluation of patient undergoing gen-
eral anaesthesia. [MUHS 1994]
51. Discuss in brief the mode of action of local anaesthe-
sia. [MUHS 1994]
52. Name the branches of the mandibular nerve. [MUHS
1994]
53. Post-operative care of patient treated under general
anaesthesia. [MUHS 1993]
54. Local anaesthetic agent pharmacology. [NTR-OR Nov
1992]
55. Ideal local anaesthetic drug. [NTR-OR Oct 1991]
56. Ibuprofen. [MUHS 1989]
57. Analgesics. [MUHS 1989]
Short Notes
1. Syncope. [RGUHS Aug 2013]
2. Infiltration anaesthesia. [RGUHS Aug 2013]
3. Pterygomandibular space boundaries. [RGUHS Aug
2013]
4. Infraorbital nerve block. [TN Feb 2013]
5. Nerve injuries in oral surgery. [TN Feb 2006, 2013]
6. Vasoconstrictors. [RGUHS Dec 2001/Jan 2012]
7. Local and systemic complications of LA. [RGUHS
Mar 2004; TN Feb 2012]
8. Lignocaine hydrochloride. [TN Feb 2011]
9. Vasoconstrictors in local anaesthesia. [TN Aug 2010]
10. Specific receptor theory. [TN Aug 2009]
11. Failure of local anaesthesia. [TN Aug 2009]
12. Haematoma. [NTRUHS Aug 2009]
13. Mental nerve block. [NTRUHS Aug 2009]
14. Adrenaline. [RGUHS Jul 2008 (RS 2)]
15. Vazzironi-Akinosi technique. [TN Aug 2008]
16. Posterior superior alveolar nerve blocks. [NTRUHS
Feb 2011; TN Feb 2008]
17. Epinephrine. [RGUHS Feb 2007 (OS)]
18. Management of syncope in dental chair. [TN Aug
2007]
19. Closed mouth technique. [TN Aug 2007]
20. Write SHORT note on facial paralysis. [MUHS 2007]
21. Give composition of local anaesthetic solution with
values of two major contents. [MUHS 2007]
22. Bell’s Palsy. [MUHS 1993, 2002; RGUHS Aug 2005,
Jul 2008; TN Feb 2005, Nov 2001, Aug 2007]
23. Lignocaine. [RGUHS Mar 2006]
24. Classification of local anaesthetic drugs. [RGUHS Aug
2006; RGUHS Aug 2006 (RS)]
25. Landmarks for extraoral maxillary nerve block.
[RGUHS Aug 2006; RGUHS Aug 2006 (RS)]
26. Systemic complications of local anaesthesia. [RGUHS
Aug 2006]
27. Intravenous sedation in oral surgery. [RGUHS Aug
2006 (RS)]
28. Syncope. [TN Nov 2001; TN Aug 2006]
259
29. Electrophysiology of nerve conduction. [TN Aug
2004; 2006]
30. Mechanism of action of local anaesthesia [TN Aug
2006]
31. Mode of action of local anaesthetic. [TN Feb 2006]
32. Complications of local anaesthesia. [TN Feb 2006]
33. Kazanjian’s technique. [TN Feb 2006]
34. Nerve block. [RGUHS Mar 2005]
35. Gow-Gates technique. [RGUHS Feb 1996; RGUHS
Aug 2006 (OS); TN Aug 2005]
36. Vasoconstrictor. [NTR-NR Oct 2002; RGUHS Aug
2005; GOA Dec 2005]
37. Facial artery. [GOA Dec 2005]
38. Anaphylaxis [RGUHS Mar 2005]
39. Post-operative complications of LA. [RGUHS Aug
2005]
40. Anaphylaxis. [NTR-NR May 2004, Mar 2005]
41. Surgical anatomy of seventh cranial nerve along with a
diagram. [MUHS 2005]
42. Anaphylaxis. [TN Feb 2005]
43. Tuberosity block. [TN Feb 2005]
44. Bell’s palsy. [TN Feb 2005; Sep 2002]
45. Define pain and enumerate the five methods of pain
control. [MUHS 2004]
46. External carotid artery. [GOA 2002; 2004]
47. Reasons for failure of local anaesthesia. [MUHS
2003]
48. Lignocaine. [RGUHS Mar 2003]
49. Complication of LA. [RGUHS Jun 1989, Sep 2003]
50. Complication of LA. [BUHS Apr 1999, RGUHS Sep
2003]
51. Give the order of anaesthetizing various nerves in di-
rect pterygomandibular block technique. [NTR-NR
Apr 2002]
52. Composition of local anaesthetic solution. [NTR-NR
Oct 2002]
53. Role of vasoconstrictor in local anaesthetic solution.
[NTR-NR Apr 2002]
54. Enumerate the methods of pain control. [MUHS 2002]
55. Contraindications for regional analgesia. [MUHS
2002]
56. Complication of ptrtygomandibular block. [TN Nov
2001]
57. Nerve injuries. [TN Nov 2001]
58. Whitehead’s varnish. [RGUHS Sep 2001]
59. Composition of local anaesthesia. [RGUHS Sep 2000]
60. What is the difference between toxicity and anaphy-
laxis? How can the occurrence and severity of toxicity
be avoided? [MUHS 2000]
61. Post-extraction bleeding. [RGUHS Sep 1992, Mar 1997]
62. Dry socket. [RGUHS Apr1987, Jul 1990, Sep 1994,
Aug 1996]
63. Trismus. [RGUHS Jan 1989]
64. Mechanism of action of LA. [RGUHS Oct 1988]
260 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery

Conscious Sedation and General Anaesthesia
Short Essays
1. Indications for general anaesthesia. [RGUHS Jul 2008
(RS 2); NTR-NR Apr 2004]
2. Different diagnosis of unconsciousness in the dental
office. [RGUHS Apr 2008 (RS2)]
3. General anaesthesia vs local anaesthesia. [NTR-NR Oct
2005]
4. General anaesthetic drugs. [NTR-OR Apr 1995]
5. Stages of general anaesthesia. [NTR-OR May 1993]
Topic 4
Short Notes
1. Radiological assessment of an impacted lower third
molar tooth. [RGUHS Apr 2008 (RS2)]
2. Conscious sedation. [BUHS Apr1999; TN Feb 2007]
3. Intravenous sedation in oral surgery. [RGUHS Aug 2006]
4. Gaseous anaesthetic agent. [NTR-NR Apr 2006]
5. Stages of general anaesthesia. [TN Feb 2005, 2006, Aug
2004]
6. Nitrous oxide. [GOA 2002]

Topic 5
Principles of Exodontia and Instrumentation
Long Essays 10. How do you manage minor oral surgeries in patients
with history of
1. Discuss in detail the indications, contraindications, and
a. Uncontrolled diabetes mellitus,
principles followed in dental extraction of teeth and add
b. Long-term steroid therapy, and
a note on its complications. [NTRUHS Aug 2009]
c. Valvular heart diseases? [RGUHS Sep 2002]
2. Enumerate the various local and systemic causes for
11. Enumerate the causes for post-extraction bleeding.
post-extraction bleeding and its management. [TN Aug
How do you diagnose and manage post-extraction
2009]
bleeding? [TN Nov 2001]
3. Discuss the indications, contraindications, and compli-
12. Describe the objectives of tooth extraction? [NTR-OR
cations of dental extractions. [RGUHS Apr 2003, Mar
Apr 1995]
2005]
13. Principles of elevation and name elevators used in oral
4. Discuss in detail the indications, contraindications, and
surgery. [MUHS Dec 1994]
principles followed in dental extraction of teeth. Write a
14. Enumerate the various causes for post-extraction
note on its complications. [NTR-NR Oct 2005]
bleeding and discuss the various methods available to
5. Discuss the indications, contraindications, and compli-
control bleeding from socket. [BUHS Aug 1993]
cations of dental extractions. [RGUHS Apr 2003, Mar
15. How will you manage to do extraction in a patient with
2005]
history of long-term steroid therapy, anticoagulant
6. Enumerate the various local and systemic causes for
therapy, and rheumatic fever? [RGUHS Mar 1992]
post-extraction bleeding. What options do you have in
16. Discuss the objectives of tooth extractions. [NTR-OR
managing such conditions? [RGUHS Sep 2003]
Apr 1995]
7. Classify the instruments used in dental extraction. Explain
17. What are the complications of extraction of teeth?
in detail, elevators used in extraction. [GOA 2003]
How would you avoid them? Describe in detail the
8. What are the indications and contraindications for
treatment of anyone? [NTR-OR Jun 1982]
extraction of teeth? How would you do an open method
of tooth extraction? [GOA 2002]
9. Write the indications and contraindications for extrac-
Short Essays
tion of teeth. Explain the technique and complications 1. Uses of elevators and their complications. [NTRUHS
of posterior alveolar nerve block. [GOA 2002] Aug 2009]
Section | III  Previous Years’ Question Bank
2. Contraindications of extraction of teeth. [RGUHS Feb
2007 (RS); Oct 2009 (RS)]
3. Post-extraction bleeding. [RGUHS Jul 2008 (RS)]
4. Principle of forceps design. [RGUHS Feb 2007 (RS)]
5. Tooth extraction in a patient who is under anticoagu-
lant therapy. [RGUHS Apr/May 2007 (RS)]
6. Mechanical principles of using the elevators in extrac-
tion of teeth. [RGUHS Aug 2006; RGUIHS Aug
2006 (OS)]
7. Post-extraction haemorrhage. [RGUHS Aug 2006
(RS)]
8. Transalveolar extraction. [RGUHS Mar 2005]
9. Elevators in exodontia. [RGUHS Aug 2005]
10. Dry socket. [NTR-OR Apr 1996, 1999, NTR-NR Oct
2006; TN Aug 2005] 11. Complication of tooth extraction and its management.
11. Dry socket and its management. [RGUHS, NTRUHS
Mar 2004]
12. Elevators. [NTR-OR Nov 1994, Apr 1999, NTR-NR
Apr 2004, 2005]
13. Indications and techniques of needle biopsy. [RGUHS
Apr 2003]
14. Elevators - Principles and Uses. [MUHS Oct 1991,
2003]
15. Surgical extraction. [RGUHS Apr 2002]
16. Define biopsy and what are the various biopsy
techinques? [RGUHS Sep 2002]
17. Anaphylaxis. [NTR-OR Apr 2001]
18. Dental elevators. [NTR-OR Apr 1997, Oct 1998]
19. Syncope. [NTR-OR Apr 1994, 1999, Oct 1998] 21. Whitehead’s varnish. [RGUHS Sep 2001]
20. Use of elevators in exodontia. [MUHS Aug 1993]
21. Principles of elevators. [NTR-OR Nov 1992, May
1993]
Short Notes
1. Dry socket. [NTR-NR Oct 2002; NTRUHS Aug 2009;
TN Sep 2002]
Impactions
Long Essays
1. Explain the classification of mandibular third molar and
surgical removal of mesioangular tooth #38. [RGUHS
Dec 2009 (RS2)]
2. Classify in detail the impacted maxillary canine and
discuss the various surgical procedures to remove the
impacted maxillary canine. [TN Aug 2008]
261
2. Haemostatic agents. [TN Aug 2007, Feb 2009]
3. Systemic causes for post-extracion haemorrhage
[RGUHS Apr 2008]
4. Whalsham’s forceps. [RGUHS Feb 2007 (OS)]
5. Bristow’s elevator. [RGUHS Feb 2007 (OS)]
6. Principles of elevators [RGUHS Sep2002; TN Aug
2006; NTR-NR Oct 2004]
7. Complications of extraction. [NTR-OR Oct 1995,
1996, Apr 2001, RGUHS Mar 1994, NTR-NR Oct
2006]
8. Syncope. [NTR-NR Oct 2006]
9. Contraindications for extraction. [NTR-OR Nov 1992;
RGUHS Aug 2006 (RS)]
10. Catgut. [RGUHS Mar 2005, Apr 2002]
[TN Aug 2005]
12. Bone wax. [RGUHS Aug 2005]
13. Anaphylaxis. [NTR-NR Apr 2004, 2005]
14. Biopsy. [RGUHS Jul 1990, Aug 1991, 1995, 2005, Sep
1992, 1996]
15. Cross bar elevators. [RGUHS Apr 2003]
16. Chisel and mallet in dentistry. [GOA 2002]
17. Wound healing. [TN Sep 2002]
18. Enumerate any two complications of the use of elevators
during exodontia. [MUHS May 2002]
19. Elevators. [RGUHS Jun 1989, Aug 1995; TN
Sep 2002]
20. Elevator principles. [TN Apr 2001]
22. Principles of forceps extraction. [NTR-OR Apr 1996]
23. Suture material. [RGUHS Apr 1987, Mar 1988, Jun
1989, Sep 1992, 1994, 2000, Feb 1996, Aug 1996]
24. Forceps extraction. [NTR-OR Apr 1992]
25. Extraction in pregnancy [RGUHS Jan 1989]
26. Mechanical principal of extraction. [RGUHS
Oct 1988]
Topic 6
3. Classify impacted mandibular third molar. Write in detail
the steps in surgical removal of impacted mandibular left
third molar. [NTR-NR Oct 2006; TN Aug 2005, Feb
2007]
4. Classify impactions of lower third molar. Describe the
various surgical steps involved in the removal of mesio-
angular impacted lower third molar. [BUHS Feb 1993,
Sep 1994; TN Feb 2006]
262 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
5. How do you evaluate impacted lower third molar?
Describe the surgical steps involved in the removal of
mesiongular impacted lower third molar. [TN Feb
2005]
6. How do you evaluate impacted lower third molars?
Describe the surgical steps involved in the removal of
mesionagular impacted lower third molar. [TN Feb
2005]
7. Define impacted teeth. Give reasons for impaction of
teeth. Explain complications of third molar extraction.
[GOA 2004]
8. Define impaction of a tooth. Classify mandibular third
molar impaction and management of a horizontally
impacted mandibular third molar. [TN Sep 2002]
9. What is impaction? Write the classification of im-
pacted mandibular third molar tooth. Add a note on
various techniques of surgical extraction? [NTR-NR
Oct 2002]
10. Write the theory of impactions and classify the upper
canine impacted tooth complications during surgical
removal. [NTRUHS Apr/May 1999]
11. Classify the impaction of mandibular third molar
tooth. How will you manage mesio-oblique impac-
tions? [NTR-OR Oct 1998]
12. What are the possible complications of an impacted
lower third molar? Mention briefly how could you as-
sess an impacted lower third molar? [NTR-OR
Apr1997]
13. Classify impactions of lower third molar. Describe the
various surgical steps involved in the removal of me-
sioangular impacted lower third molar. [RGUHS Feb
1993, Sep 1994, Mar 1997]
14. Define impaction. Write about the classification, surgi-
cal management, and associated complications. [NTR-
OR May 1993]
15. Classify impacted mandibular third molars. Enumerate
the complications likely to be encountered during and
after surgical removal of horizontally impacted lower
right third molar teeth. [RGUHS Aug 1993]
16. Classify maxillary canine impactions. How do you
manage a case of bilaterally impacted upper canine
teeth [RGUHS Sep 1992]
17. Classify impactions and discuss the management of
impactions? [NTR-OR Oct 1991]
18. What are the indications for removal of an impacted
tooth? Describe the technique of removal of a mesio-
angular impacted lower third molar. [RGUHS Aug
1991]
19. Describe the classification of impacted lower third
molar. What are its complications? [RGUHS Jan 1990]
20. Discuss the complications which may occur during
and after surgical extraction of an impacted third man-
dibular molar. How will you deal with these complica-
tions? [RGUHS Jan 1989]
21. How will you proceed to extract a mesioangular im-
pacted lower third molar tooth. Write in brief the tech-
nique of obtaining an aesthesia to extract the above
tooth. [RGUHS Aug 1988]
22. Describe preoperative assessment of impacted man-
dibular third molar and briefly describe the technique
of removal of horizontally impacted third molar.
[RGUHS Oct 1987]
23. How would you extract an impacted canine from the
palate surgically? Give the pre and post-operative
management in detail? [NTR-OR Jun 1982]
Short Essays
1. Wharf’s assessment of mandibular third molar.
[RGUHS Jul 2008 (RS 2)]
2. Intraoperative complications of surgical removal
of impacted mandibular third molar [RGUHS 2007
(RS)]
3. Impacted canine teeth. [RGUHS Aug 2006; Aug 2006
(RS)]
4. Classification of mandibular third molar impaction.
[RGUHS Aug 2006; RGUHS Aug 2006 (OS)]
5. Winter’s lines and their clinical significance. [RGUHS
Mar 2005]
6. Transalveolar extraction. [RGUHS Mar 2003; 2005]
7. Classification and surgical steps in removal of impact
third molar. [RGUHS Mar, Sep 2002]
8. Early and late complications of impacted third molar
surgeries. [RGUHS Sep 2003]
9. Role of radiograph in impacted third molar. [RGUHS
Sep 2000]
10. Classification of impacted third molar. [NTR-OR Apr
2000]
11. Winter’s classification of impacted lower third molar?
[NTR-OR Apr 2000]
12. Clark’s technique for localization of impacted maxil-
lary. [NTR-OR Apr 2000]
13. Maxillary canine impaction. [NTR-OR Oct 1999]
14. Radiological assessment of lower third molar. [NTR-
OR Apr 1999]
15. Localization of impacted maxillary canine. [NTR-OR
Apr 1996]
Short Notes
1. Impacted maxillary canine. [RGUHS Jul 2008 (RS); TN
Feb 2013]
2. George Winter’s WAR line. [TN Feb 2012]
3. Radiological assessment of lower third molar. [TN Aug
2010]
4. Transalveolar extraction. [RGUHS Mar 2005; TN Aug
2006, 2007, Feb 2008]
5. WAR line in impaction. [TN Aug 2008]
Section | III  Previous Years’ Question Bank 263

6. Open method of extraction of teeth. [NTR-NR Apr
2005; RGUHS Feb 2007 (RS)]
7. Pericoronitis. [TN Sep 2002, Feb 2007]
8. Impacted tooth. [NTR-NR Apr 2006]
9. Define impaction of tooth. [NTR-NR Oct 2006]
10. Pell’s and Gregory classification of impacted lower
third molars. [RGUHS Mar 2006]
11. Winter’s lines and their clinical significance. [TN Aug
2006]
12. Classification of impacted upper canine. [TN Feb
2006]
13. Complication of third molar surgery. [GOA Dec 2005]
14. Complications of impacted third molar tooth. [NTR-
NR Apr 2005]
15. Transalveolar extraction. [NTR-OR Oct 1991, 1995,
Apr 1999, 2000, NTR-NR Oct 2004, Mar 2006]
16. Classification of impacted third molar [RGUHS Mar
2004; NTRUHS Mar 2004]
17. Winter’s imaginary lines. [RGUHS Sep 2003]
18. Pell’s and Gregory classification of impaction. [RGUHS
Feb 1996; RGUHS Mar 2003]
19. Surgical extraction. [RGUHS Apr 2002]
20. List the spaces where the lower third molar root piece
can get displaced? [NTR-NR Apr 2002]
21. Wharf’s assessment in impacted third molar. [RGUHS
Sep 2001]

Topic 7
Maxillofacial Trauma
Long Essays 11. Classify fractures of the midface. Describe the clinical
features and management of a Le Fort I fracture. [TN
1. Classification and the clinical features of mandibular
Feb 2007]
fractures. Management of unfavourable fracture of
12. Write in detail the clinical features, diagnosis, and
angle of mandible. [RGUHS Aug 2013]
management of bilateral condylar fracture in a eight
2. Discuss in detail the aetiology, signs and symptoms of
year old boy. [TN Aug 2007]
Le Fort I fracture of the maxilla and itssurgical man-
13. Describe Le Fort III fracture and its management.
agement. [TN Feb 2012]
[RGUHS 2007(RS)]
3. Describe the classification of condylar fractures of the
14. Classify fracture zygomatic complex. How will you
mandible, and the clinical signs and symptoms. How
manage a case displaced zygomatic fracture? [RGUHS
will you manage the same in children? [RGUHS Dec
Feb 2007 (OS)]
2001/Jan 2012]
15. Classify the fracutres of maxilla. Write in detail the
4. What are the signs and symptoms in Le Fort type I
clinical features, investigation, and management of a
fracture? How do you manage the same [NTRUHS
Le Fort I fracture [RGUHS Feb 2007 (RS)]
Feb 2011]
16. Classify mandibular fractures. Describe the clinical
5. Classify fractures of middle third of the facial skeleton.
features and management of unfavourable fractures of
How would manage a Le Fort I fracture? [TN Aug
angle of mandible [RGUHS Sep 2003; TN Feb 2005,
2010]
Aug 2006]
6. Emergency care in facial trauma. [RGUHS Oct 2009]
17. Classify zygomatic bone fracture. What are the signs
7. Classify fractures of mandibular and write about man-
and symptoms? How would you treat a case of dis-
agement of unfavourable fracture of angle region of
placed zygoma [RGUHS Aug 2005; TN Feb 2006]
edentulous mandible in a 60 year old person. [RGUHS
18. Classify mandibular fractures. Discuss in detail about
May 2009 (RS2)]
the incidence and clinical features of mandibular frac-
8. Classify the fractures of the middle third facial skele-
tures. Write about various treatment modalities of
ton. Write in detail about the clinical features, investi-
unilateral mandibular fractures. [RGUHS Mar 2006]
gations, and management of Le Fort I fracture [RGUHS
19. Write in SHORT the principles of fracture management
Jul 2008 (RS2)]
in the maxillofacial region. Add notes on different treat-
9. Classify midface fracture. Discuss the management of
ment modalities for a fracture mandible involving teeth
malunited zygomatic fracture. [RGUHS Apr 2008 (RS2)]
in the line of fracture? [RGUHS Aug 2006 (RS)]
10. Discuss in detail the various classifications of fracture
20. Classify condylar fractures and describe the signs and
of the mandible and the management of fracture of the
symptoms. How will you manage in children? [RGUHS
mandibular condyle. [TN Feb 2008]
Aug 2006]
264 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
21. Name four fractures of the jaws that can produce as
anterior open bite. [MUHS Jun 2006]
22. Describe with diagrams (Clinical classification of frac-
tures of condylar process) Maclennan’s classification.
[MUHS 2006]
23. How will you classify condylar fracture? Describe in
detail the management of condylar fracture and its
complication. [TN Feb 2006]
24. Discuss in detail the various classifications of frac-
ture of the mandible and management of fracture of
the mandibular condyle. Define Ludwig’s angina.
Write in detail the clinical features and management
of Ludwig’s angina add a note on its antibiotic re-
gime. [TN Aug 2006]
25. Describe the signs and symtoms of Le Fort I fracture
and management. [TN Aug 2006]
26. Classify zygomatic complex features. Write in detail
about the clinical radiological feature and management
of zygomatic arch fracture. [TN Feb 2006]
27. How will you classify condylar fracture? Describe in
detail the management of condylar fracture and its
complications. [TN Feb 2006]
28. Classify fractures of middle third of facial skeleton.
And add a note on its clinical signs and symptoms.
[RGUHS Apr 2003, Mar 2005]
29. Write the golden hour of trauma importance and note
on protocol to be followed in road traffic accident vic-
tim management and on life support system? [NTR-
NR Apr 2005]
30. Write the clinical features and treatment of Le Fort III
fractures of midface. [NTR-OR Oct 2005]
31. Classify fractures of middle third of facial skeleton.
And add a note on its clinical signs and symptoms.
[RGUHS Apr 2003, Mar 2005]
32. Classify zygomatic bone fracture. What are the signs
and symptoms? How would you treat a case of dis-
placed zygoma? [RGUHS Aug 2005]
33. Classify mid-third facial fractures. Describe the clini-
cal features and management of a case of Le Fort III
fracture case. [MUHS Oct 2005]
34. Classify the fractures of middle third of the facial skel-
eton and add a note on its clinical signs and symptoms.
[RGUHS Aug 2005]
35. Classify fractures of the condyle. What are the indica-
tions for open and closed reduction of the condyle.
How will you manage a case of subcondylar fracture in
a 17 year old girl patient. [GOA Dec 2005]
36. Principles of antibiotic therapy. [GOA Dec 2005]
37. Classify condylar fracture. How will you manage a
case of bilateral condylar fracture of mandibular in a
18 year old man. [GOA Dec 2005]
38. Classify mandibular fracture. How do you diagnose
and treat a case of unfavourable fracture of the angle of
the mandible? [TN Feb 2005]
39. Classify middle third fracture of the facial skeleton.
Describe the anatomical extension, clinical features,
and treatment of Le Fort IV fracture. [TN Aug 2005]
40. Classify middle third fracture of the facial skeleton.
Describe in detail the anatomical extension, clinical
feature, and treatment of Le Fort I fracture. [TN Feb
2005]
41. Classify mandibular fracture. Enumerate the clinical
features. How would you manage a case of fracture
involving both the condyles? [TN Aug 2005]
42. Classify fractures of zygomatic complex and write
about the clinical features and management of frac-
tures of zygomatic arch. [NTR-OR Oct 2004]
43. Classify fractures of the mandible. How will you diag-
nose and manage unfavourable fracture of angle of
mandible. [GOA 2004]
44. Classify fractures of the middle third of the face. De-
scribe the clinical features and management of Le Fort
II fracture in a 35 year old male patient. [MUHS Nov
2004, 1991, 1995]
45. Classify mandibular fractures. Describe the clinical
features and management of unfavourable fractures of
angle of mandible. [RGUHS Sep 2003]
46. Describe the clinical findings of zygomatic complex
fracture. Enumerate the various methods of reducing
the zygomatic arch fracture and discuss anyone in de-
tail. [MUHS May 2000, 2003]
47. Define fracture. How will you classify, diagnose, and
treat mandibular angle fracture in adult? [MUHS 2003]
48. Define fracture. How will you classify, diagnose, and
treat mandibular angle fracture in adult? [MUHS May
2003]
49. What are the signs and symptoms of unilateral fracture
zygoma? How do you manage a simple case of unilat-
eral depressed fracture aygomatic? [TN Sep 2002]
50. Classify midface fractures. Describe the clinical fea-
tures and management of Le Fort II fracture. [GOA
2002]
51. Describe Le Fort I and Le Fort II fracture lines. Give
the clinical features and management of Le Fort I frac-
ture. [MUHS May 2002]
52. Describe the clinical findings of zygomatic complex
fracture. Enumerate the various methods of reducing
the zygomatic arch fracture and discuss anyone in de-
tail? [NTR-NR Apr 2002]
53. A 40 year old man who is edentulous posteriorly re-
ports with a fracture in angle of mandible. Write in
detail about clinical features, diagnostic means, and
management. [RGUHS Sep 2001]
54. Describe the lines of Le Fort I and II fractures. De-
scribe the clinical features and treatment of Le Fort I
fractures. [NTR-OR Apr 2001]
55. A 40-year-old man who is edentulous posteriorly re-
ports with a fracture in angle of mandible. Write in
Section | III  Previous Years’ Question Bank
detail about clinical features, diagnostic means, and
management. [RGUHS Sep 2001]
56. Define fracture. Classify mandibular fractures. Write
the treatment plan for a horizontal unfavourable frac-
ture in the angle of mandible. [TN Apr 2001]
57. Classify fracture of condyle. How would you treat a
case of law subcondylar fracture? [NTR-OR Apr 2000]
58. Describe the signs, symptoms, and management of Le
Fort III fracture. [MUHS Nov 1999]
59. Signs, symptoms, and treatment of Le Fort I fracture.
[MUHS Oct 1991, 1999, 1989, 1997]
60. Classify fractures of maxilla and mandible. How would
you treat a case of fracture mandible in angle region?
[NTR-OR Apr 1999]
61. Describe classification and clinical features of zygo-
matic bone complex. Write the indications for surgical
treatment. [NTR-OR Oct 1999]
62. Describe different methods of reduction of fractured
mandible. [MUHS 1989, 1998]
63. Classify mandibular fractures. Describe the clinical
signs, symptoms, and management of a displaced man-
dibular angle fracture. [MUHS 1998]
64. Describer the management of a case of fracture of an-
gle of mandible, distal to the III molar tooth. [NTR-OR
Oct 1998]
65. Outline overall management of roadside accident in a
patient having low level middle 1/3 fracture. [MUHS
Jul 1996, 1998, 1992]
66. Give signs and symptoms and management of pyrami-
dal fracture of middle third facial skeleton. [RGUHS
Mar 1997]
67. Classify fractures of condyle. Describe the clinical
features and management of unilateral condylar frac-
ture. [RGUHS Aug 1996]
68. Describe the healing process of a fractured mandible.
Discuss the early and late complications arising in the
treatment of mandibular fractures. How will you man-
age these complications? [MUHS 1995]
69. Describe etiology, signs, symptoms and treatment of
unilateral subcondyllar fract1.ire in adult. [MUHS
1995]
70. Classify ankylosis of TMJ. Describe CIF and diagnosis
and treatment for a unilateral bony ankylosis in case of
child of nine years [RGUHS Mar 1995, Aug 1995]
71. Describe the fractures of zygomatic complex and their
management. [NTR-OR Apr 1995]
72. Describe various fractures of jaws. [NTR-OR
Nov1994]
73. Discuss the signs and symptoms of fractures at the
angle of the mandible. How will you treat a case of
unfavourable angle fracture? [MUHS 1994]
74. Classify fractures of maxilla and mandible. Discuss
the management of mandibular fractures. [NTR-OR
May 1993] skeleton. [RGUHS Dec 2009 (RS2)]
265
75. Classify maxillary fractures. Describe the clinical fea-
tures and management of fracture of zygoma. [RGUHS
Sep 1992]
76. Define fracture. Classify the fracture of middle third of
facial skeleton and write in brief the clinical signs,
symptoms, diagnosis, and management of Gueirn’s
fracture. [NTR-OR Nov 1992]
77. Enumerate the general and specific classification of
mandibular fractures. How would you treat a case of
mandibular fracture involving the angle. [RGUHS Aug
1991]
78. Describe the management of ankylosis of TMJ.
[RGUHS Jan 1990]
79. Describe the bones involved in Le Fort fracture. How
will you manage it? [RGUHS Jan 1990]
80. Describe the signs, symptoms, and management of Le
Fort II fracture involving zygomatic complex. [MUHS
Oct 1993, 1990]
81. What are the signs and symptoms in Le Fort I type of
fracture? How do you manage the same? [RGUHS Jan
1989]
82. Discuss the signs, symptoms, complications, and treat-
ment of Le Fort type I fracture of maxilla. [RGUHS
Mar 1988]
83. Classify fracture of mandibular condyle and its signs
and symptoms. How do you manage a case of unilat-
eral condylar fracture with displacement in an adult?
[RGUHS Aug 1988]
84. Describe the classification of ankylosis of TMJ. Give
the signs and symptoms and treatment of bilateral sub-
condylar fracture. [RGUHS Apr1987]
85. Elaborate the cases, signs and symptoms of ankylosis
of TMJ. How will you treat a case of bilateral ankylo-
sis? [RGUHS Oct 1987]
86. Classify zygomatic complex fracture. Enumerate the
CIF and its management. [RGUHS Apr 1987]
87. Classify fractures of mandible. Give your treatment for
a compound, comminuted, and unfavourable fracture
of angle of mandible. [RGUHS Oct 1987]
88. Give the classification, signs and symptoms of middle
third fracture of face. Discuss the treatment of Le Fort
I fracture. [RGUHS Apr 1987]
89. Describe the signs, symptoms, diagnosis, and treat-
ment of bilateral condylar fractures. [NTR-OR Jun
1982]
Short Essays
1 . Pyramidal fracture. [NTRUHS Feb 2011]
2. Healing of fractures. [RGUHS Oct 2009 (RS)]
3. Asepsis and wound infection. [RGUHS Oct 2009 (RS)]
4. Dislocation and subluxation. [NTRUHS Aug 2009]
5. Classification of fracture of the middle third of facial
266 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
6. Management of fracture of angle of mandible.
[NTRUHS Aug 2009]
7. Surgical anatomy of orbit. [RGUHS Apr 2008 (RS2)]
8. Cavernous sinus thrombosis [RGUHS Apr 2008 (RS2)]
9. CSF rhinorrhoea. [RGUHS Jul 2008 (RS)]
10. Non-union. [RGUHS Sep 1994; Jul 2008 (RS)]
11. Orbital trauma assessment. [RGUHS Apr/May 2007
(RS)]
12. Tinnel’s sign. [RGUHS 2007 (RS)]
13. Nasal fracture. [RGUHS 2007 (RS)]
14. Non-union and mechanism of local anaesthesia.
[RGUHS 2007 (RS)]
15. Name four X-rays taken for fracture mandible. [MUHS
Oct 2007]
16. Management of dentoalveolar fracture. [NTR-OR Oct
2006]
17. Epistaxis. [RGUHS Apr 2002, Aug 2006]
18. Blowout fracture of orbit. [NTR-NR Apr 2006]
19. Principles of fracture management. [RGUHS Mar
2005]
20. Blowout fracture. [GOA Dec 2005]
21. Condylar fracture of mandible. [NTR-NR Apr 2005]
22. Gunning splint. [NTR-NR Oct 2005]
23. Principles of fracture and its management. [RGUHS
Apr 2002, Mar 2005]
24. Healing of extraction wound. [NTR-NR Apr 2004]
25. Dental wiring (write on osteosynthesis). [NTR-NR
Apr 2004]
26. Clinical features and management of zygomatic arch
fractures. [RGUHS Sep 2003]
27. What is the basic difference between simple and com-
pound fracture of bone? [MUHS Oct 2003]
28. Gillies temporal approach. [RGUHS Mar 2003]
29. Classify mandibular fracture. [RGUHS Apr 2002]
30. Epistaxis. [RGUHS Apr 2002]
31. Le Fort II fracture. [NTR-NR Apr 2002]
32. Rigid internal fixation. [NTR-NR Oct 2002]
33. Classify mandibular fracture. [RGUHS Apr 2002]
34. Describe the vertically unfavourable fracture line at the
angle of the mandible. [MUHS May 2002]
35. Draw diagrams to explain vertically and horizontally
favourable fracture of mandible. [MUHS May 2002]
36. Name the any four different types of dental wiring
techniques. Describe in SHORT any one wiring tech-
nique for dentoalveolar fracture. [MUHS 1999]
37. Transosseous wiring. [NTR-OR Oct 1999]
38. Pathological fractures. [NTR-OR Oct 1998]
39. Zygomatic fractures. [NTR-OR Oct 1998]
40. Condylar fracture in children. [NTR-OR Oct 1998]
41. Fracture of body of mandible in children. [NTR-OR
Apr 1998]
42. Condylar fractures in children. [NTR-OR Oct 1998]
43. Fracture of body of the mandible in children. [NTR-
OR Apr1998]
4 4. Diplopia. [NTR-OR Apr 1996, 1998]
45. Le Fort I fracture. [NTR-OR Oct 1997]
46. CSF rhinorrhoea. [NTR-OR Apr 1997]
47. Fracture of the body of edentulous mandible. [NTR-
OR Oct 1997]
4 8. Condylar fractures. [RGUHS Aug 1995]
49. Emergency radiology in facial injury. [NTR-OR Apr
1995]
5 0. Dynamic compression plates. [MUHS 1995]
51. Non-union. [BUHS Sep 1994]
52. Tuberosity fracture. [NTR-OR May 1994]
53. Fracture of body of mandible. [NTR-OR Nov 1994]
54. How do you manage a case of unilateral condylar frac-
ture with displacement in adults? [NTR-OR Feb 1989]
55. Fractured root at middle 1/3rd. [RGUHS Mar 2003]
Short Notes
1. Arch bars. [RGUHS Aug 2013]
2. Le Fort classification of maxillary fracture. [TN Feb
2013]
3. Miniplate osteosynthesis [TN Feb 2006, 2013]
4. Cavernous sinus thrombosis. [TN Feb 2011, 2013]
5. Fracture angle of the mandible. [TN Feb 2012]
6. Whitehead’s varnish. [RGUHS Dec 2001/Jan 2012]
7. Green stick fracture. [RGUHS Dec 2001/Jan 2012]
8. Gunning type splint. [RGUHS Dec 2001/Jan 2012]
9. Town’s projection. [RGUHS Dec 2001/Jan 2012]
10. Gillies temporal approach. [RGUHS Sep 2001;
NTRUHS Feb 2011]
11. Guerin’s fracture. [RGUHS Apr 2002, Mar 2005; TN
Aug 2009, 2008, Feb 2011]
12. Dynamic compression plate. [TN Aug 2010]
13. Arch bars wiring [NTRUHS Feb 2011; TN Aug 2007]
14. Le Fort I fracture. [TN Feb 2009]
15. Cerebrospinal fluid rhinorrhoea. [NTRUHS Aug 2009]
16. Fixation methods in trauma. [TN Feb 2009]
17. Gunning splint. [MUHS Oct 1988, Nov 1999; TN
Feb 2009, 2007]
18. CSF rhinorrhoea. [RGUHS Oct 1988, Apr 2008 (RS2),
Aug 2006 (OS); TN Feb 2008, Nov 2001, Apr 2001]
19. Diplopia. [RGUHS Aug 1991; TN Aug 2007, 2008]
20. Blowout fractures. [RGUHS Mar 2004; Jul 2008 (OS);
Feb 2007 (OS)]
21. Condylar fractures. [BUHS Aug 1995; TN Feb 2006,
Aug 2008]
22. Signs and symptoms of Le Fort fracture. [MUHS May-
Jun 2008]
23. Le Fort III fracture. [RGUHS Jul 2008 (OS)]
24. Unfavourable fracture of mandible. [RGUHS Jul 2008
(OS)]
25. Unilateral epistaxis. [RGUHS Jul 2008 (RS)]
26. Denture granuloma. [RGUHS Jul 2008 (RS)]
27. Transosseous wiring. [RGUHS Jul 2008 (RS 2)]
Section | III  Previous Years’ Question Bank
28. Fracture management in edentulous. [RGUHS Apr
2008 (RS2)]
29. Name four signs and symptoms of zygomaticomaxil-
lary complex. [MUHS Dec 2007]
30. Mention any eight causes for the non-union of frac-
tured fragments of the mandible. [MUHS 2006]
31. Miniplate osteosynthesis. [TN Feb 2006]
32. Healing of extraction wound. [NTR-NR Apr 2006]
33. What do you understand by the term ‘Monocular dip-
lopia’? [MUHS Nov 2006]
34. Epistaxis. [RGUIHS Aug 2006 (OS)]
35. Eburnation. [RGUIHS Aug 2006 (OS)]
36. Malunion and non-union. [TN Feb 2005, 2006]
37. Nerve injuries in oral surgery. [TN Feb 2006]
38. Mode of action of local anaesthetic. [TN Feb 2006]
39. Complications of local anaesthesia. [TN Feb 2006]
40. Vaggironi-Akinosi technique. [TN Feb 2006]
41. Gillies temporal approach. [TN Aug 2006]
42. Clinical features of condylar fractures. [RGUHS Mar
2006, 2003]
43. Cavarnous sinus thrombosis. [TN Feb 2005, Aug 2006,
2005]
44. Types of dental injuries. [RGUHS Mar 2005]
45. Guerin’s sign. [RGUHS Mar 2005]
46. Stages of general anaesthesia. [GOA Dec 2005]
47. Wire osteosynthesis. [GOA Aug 2005]
48. Compression bone plates. [GOA Aug 2005]
49. Principles of fracture and its management. [RGUHS
Apr 2002, Mar 2005]
Cysts of Orofacial Region and Benign Tumours
of the Jaw
Long Essays
1. Classify cysts of the jaw, discuss in detail the pathology
and management of odontogenic keratocyst of the
maxilla. [TN Feb 2012]
2. Classify cysts of the jaw and write about keratocyst.
[TN Feb 2011]
3. Classify odontogenic tumour of jawbones. How do you
diagnose and manage a case of ameloblastoma of man-
dible. [RGUHS Feb 1993; RGUHS Jul 2008 (RS 2);
NTRUHS Feb 2011]
4. Classify odontogenic cysts. Write about the clinical
features, diagnosis, and management of odontogenic
keratocyst occurring in the mandibular third molar re-
gion. [NTRUHS Aug 2009]
267
5 0. Eyelet wiring. [NTR-NR Oct 2004]
51. Classification of mandibular condylar fractures. [NTR-
NR Oct 2004]
52. Circummandibular wiring. [TN Aug 2004]
53. Non-union. [RGUHS Sep 2003]
54. Clinical features and management of zygomatic arch
fractures. [RGUHS Sep 2003]
55. Give signs and symptoms of Le Fort II fracture.
[MUHS May 2003]
56. Indications for extraction of tooth related to fracture
line. [MUHS May 2003]
57. Subluxation. [RGUHS Mar 2003]
58. Horizontal favourable fracture of angle of mandible.
[GOA 2003]
59. Lag screws. [GOA 2003]
60. Advantages and disadvantages of indirect fixation of
fractures. [MUHS Oct 2002]
61. Treatment options for submandibular fractures. [NTR-
NR Oct 2002]
62. Give any four signs and symptoms of Le Fort III facial
fractures. [MUHS Oct 2002]
63. Malunion. [NTR-NR Oct 2002; TN Apr 2001; RGUHS
Feb 1996]
64. Pyramidal fractures. [TN Apr 2001; RGUHS Mar
1994]
65. Sterilization. [TN Nov 2001]
66. Bone plates. [TN Nov 2001]
67. Gillies temporal approach. [RGUHS Aug 1991]
Topic 9 and 10
5. Classify odontogenic tumours of the jaw. Discuss in
detail the management of ameloblastoma of the man-
dible. [TN Feb 2008, 2009]
6. Define cyst. Discuss in detail the management of
odontogenic keratocyst of the jaws. [TN Aug 2008]
7. Write on classification and diagnosis of odontogenic
cyst and write on treatment of odontogenic keratocyst
of angle mandible. [NTRUHS Apr 2007]
8. Classify cysts of the jaw and write in detail about den-
tigerous cyst. [TN Aug 2007]
9. Define cyst. Discuss in detail the management of
odontogenic keratocyst of the jaw. [TN Aug 2006]
10. Discuss the pathogenesis of odontogenic keratocyst
and its management. [TN Feb 2006]
268 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
11. Define a cyst. Classify intraosseous cysts of the jaw
bones. [MUHS 2006]
12. Classify odontogenic tumours. Write in detail about
ameloblastoma and its management. [RGUHS Mar
2006]
13. Classify about the embryology and surgical anatomy
of maxillary sinus discuss in detail oroantral fistula.
[RGUHS Mar 2005]
14. Define ameloblastoma. How will you evaluate and
manage a case of ameloblastoma? [Goa Dec 2005]
15. Describe the differential diagnosis and management of
radioluscent lesions of posterior body and ramus of
mandible. [TN Feb 2005]
16. What is a keratocyst?. What are the causes for recur-
rence of keratocyst and the technique of management
of keratocyst occurring in the posterior body and ra-
mus of the mandible? [TN Feb 2005]
17. Define cyst. Describe the pathogenesis, clinical fea-
tures, and radiographic appearance of a radicular cyst.
[NTRUHS Mar 2004]
18. Define cyst. Describe the pathogenesis, clinical fea-
tures, and radiographic appearance of radicular cyst.
[RGUHS Mar 2004]
19. Define and classify cysts of the jaws and oral cavity.
Discuss the aetiopathogenesis, clinical features, and
management of odontogenic keratocyst in the ramus of
mandible. [MUHS 2004]
20. Classify odontogenic tumours. Write in detail about
ameloblastoma and its management. [RGUHS Mar
2003]
21. Classify odontogenic tumours of the mandible. How
do you manage ameloblastoma involving the anterior
body portion of the mandible? (Give clinical signs
and symptoms of the lesion.) [MUHS 1991, 2002,
2003]
22. Write aetiology, clinical features, diagnosis, and
treatment of odontogenic keratocyst of the mandible
affecting a young adult of 20 years. [NTR-NR Oct
2002]
23. Differentiate between benign and malignant tumours.
Describe the signs and symptoms and management of
an ameloblastoma involving the angle of the mandible.
[NTR-NR Apr 2002]
24. Classify cystic lesions. Describe the management of a
radicular cyst. [MUHS 2001]
25. Classify odontogenic cysts of the jaw. Describe the
signs, symptoms, and management of the cyst of the
maxilla involving the maxillary antrum. [TN Nov
2001]
26. Classify cysts. Describe the aetiology, clinical fea-
tures, and treatment of a periapical cyst of maxillary
Short Essays
incisors. [NTR-NR Apr 2001]
27. Classify odontogenic cysts of the jaws. Write in
detail about the management of cysts of the jaw laying
special emphasis on the management of odontogenic
keratocyst. [RGUHS Aug 2000]
28. Classify odontogenic tumours of the jaw. How do you
diagnose ameloblastoma? Outline the method of treat-
ing tumour involving mandibular third molar area.
[RGUHS Aug 1988, Mar 1997]
29. How would you diagnose benign arterial lesions of the
jaws? [NTR-OR Apr 1996]
30. Define cyst. Classify cysts of jaws. Describe the treat-
ment of large cyst accruing at angle of mandible.
[RGUHS Aug 1995]
31. Classify odontogenic tumours of the jaws. Describe
the surgical management of ameloblastoma of the
lower jaw. [MUHS 1989, 1995]
32. Discuss the surgical management of oral submucous
fibrosis. [MUHS 1995]
33. What are the chemotherapeutic agents used in the
management of oral malignancies? [MUHS 1995]
34. Discuss signs, symptoms, and treatment of keratocyst.
[MUHS 1994]
35. Classify cystic lesions of the oral cavity; discuss its
pathogenesis, diagnosis, and treatment. [NTR-OR
May 1994]
36. Classify cystic lesions in jaw. Describe the clinical
features and treatment of odontogenic keratocyst
involving lower third molar areas. [RGUHS Mar
1994]
37. Signs, symptoms, and management of primordial cyst.
[MUHS 1993]
38. Classify cysts that occur in mouth. Describe the treat-
ment of dentigerous cyst. [RGUHS Aug 1993]
39. How do you manage a case of cyst in relation to un-
erupted upper canine tooth in patient aged 12 years
[RGUHS Sep 1992]
40. Define cyst. Enumerate the method of treatment of any
jaw cyst. Describe anyone method in detail. [MUHS
1990]
41. Describe the various methods of treatment of dentiger-
ous cyst. [RGUHS Jan 1989]
42. How do you diagnose ameloblastoma? Outline the
methods of treating this tumour involving the man-
dibular third molar area? [NTR-OR Feb 1989]
43. Discuss differential diagnosis of swelling at the angle
of mandible. [MUHS 1989]
44. Classify odonotogenic cyst of the jaws and describe
the management of OKC. [MUHS 1989]
45. Classify odontogenic cyst. Give in detail treatment
plan for large dentigerous cyst in body of mandible.
[RGUHS Oct 1987]
1. Marsupialization. [NTR-OR Oct 1998, NTR-NR Oct
2004; RGUHS Aug 2013]
Section | III  Previous Years’ Question Bank 269

2. Calcifying epithelial odontogenic tumour. [RGUHS Short Notes

Dec 2001/Jan 2012]
1. Saucerization. [RGUHS Dec 2001/Jan 2012]
3. Globulomaxillary cyst. [RGUHS Dec 2001/Jan 2012]
2. Adenomatoid odontogenic tumour. [TN Aug 2010]
4. Describe the giant cell lesion of the jaw. Write on the
3. Fine needle aspiration cytology. [TN Feb 2009]
differential diagnosis and its management. [RGUHS
4. Papillomatosis of palate. [TN Aug 2009]
Oct 2009 (RS)]
5. En bloc resection. [NTRUHS Aug 2009]
5. Pathogenesis and signs and symptoms of ameloblas-
6. Cryosurgery. [RGUHS Jul 2008 (RS 2); TN Feb 2009]
toma. [RGUHS Dec 2009 (RS2)]
7. Traumatic bone cyst. [RGUHS Jul 2008]
6. Dentigerous cyst. [RGUHS Aug 2005, Dec 2009
8. Mention various treatment modalities of ameloblas-
(RS2); NTR-OR Nov 1994, Oct 1999; MUHS 1999]
toma. [MUHS 2008]
7. Myxoma. [RGUHS Apr 2002; Jul 2008 (RS 2)]
9. What is enucleation technique? Mention any four merits
8. Osteoradionecrosis and its treatment. [RGUHS Jul
of this procedure. [MUHS 2008]
2008; Jul 2008 (RS2)]
10. Marsupialization. [RGUHS Jan 1990, Mar 1995,
9. Odontogenic keratocyst - clinical features and man-
Mar2002, Aug 1996, Sep2000; Jul 2008 (RS 2); TN
agement. [RGUHS Feb 2007 (RS)]
Aug 2006, 2004, Goa 2002]
10. Enucleation. [RGUIHS Aug 2006 (OS)]
1 1. Aneursymal bone cyst. [RGUHS Jul 1990; 2008]
11. Odontogenic keratocyst. [RGUHS Mar 2006, Aug
12. Carnoy’s solution. [TN Feb 2007]
2006; RGUHS Mar 2003]
13. Write four indications of Caldwell-Luc operation.
12. Residual cyst. [NTR-OR Apr 1999, 2006]
[MUHS 2007]
13. Marsupialization. [Goa Dec 2005]
1 4. What is cryosurgery? [MUHS 2007]
14. Define tumours and classify odontogenic tumours.
15. Write four advantages of enucleation of cyst. [MUHS
[NTRUHS Mar 2004]
2007]
15. Define tumours and classify odontogenic tumours.
16. Odontogenic keratocyst. [NTR-NR Oct 2005; TN
[RGUHS Mar 2004]
Aug 2007; Goa 2003]
16. Clinical features and management of ameloblastoma
1 7. Osteoradionecrosis. [TN Feb 2006]
in the mandible. [RGUHS Apr 2003]
18. Residual cyst. [TN Feb 2006]
17. Mucocele. [MUHS 2003]
19. Unicystic ameloblastoma. [TN Feb 2006]
18. Classification of odontogenic cysts and its treatment.
20. Mention the principle of marsupialization and give
[RGUHS Sep 2002, Mar 2002]
any four disadvantages of the procedure. [MUHS
19. Odontoma. [NTR-OR Oct 1997, 2001]
2006]
20. Management of ameloblastoma in mandible. [RGUHS
21. Theories of cyst expansion. [RGUHS Aug 2006;
Sep 2000]
RGUHS Aug 2006 (RS)]
21. Traumatic bone cyst. [NTR-OR Apr 2000]
22. Enucleation. [RGUHS Sep 1994, Aug 2006; TN
22. Globulomaxillary cyst. [NTR-OR Apr 2000]
Feb 2006]
23. Radicular cyst. [NTR-OR Oct 1999]
2 3. Keratocyst. [RGUHS Aug 2005]
24. Nasolabial cyst. [NTR-OR Apr 1999]
24. Odontoma. [RGUHS Feb 1991, Apr 2003; TN
25. Pindborg tumor. [NTR-OR Oct 1999]
Feb 2005; TN Feb 2005]
26. Adenomatoid odontogenic tumour. [NTR-OR Oct 1999]
25. Mention the various treatment modalities of benign
27. Torus palatinus. [NTR-OR Oct 1998]
cystic lesions of jaw. Mention advantages and disad-
28. Odontomes. [NTR-OR Oct 1998; MUHS 1989, 1990,
vantages of marsupialization. [MUHS 2005]
1992, 1998]
2 6. Sequestrectomy. [RGUHS Mar 2005]
29. Primordial cyst. [NTR-OR Apr 1998]
27. Osteoradionecrosis. [RGUHS Mar 2005; Goa 2002]
30. Keratocyst. [NTR-OR Apr 1998]
28. Broken needle in pterygomandibular space. [TN
31. Adenoameloblastoma. [NTR-OR Oct 1997]
Feb 2005]
32. Keratocyst. [RGUHS Feb 1996]
2 9. Management of ameloblastoma. [TN Aug 2004]
33. Adamantinoma. [NTR-OR Apr 1995]
30. Management of ameloblastoma. [GAO 2004]
34. Pleomorphic adenoma. [NTR-OR Nov 1994]
31. Mention any four premalignant white patches. [MUHS
35. Ameloblastoma. [NTR-OR May 1993, Apr 1999;
2004]
MUHS 1994]
3 2. Write four indications of marsupialization. [MUHS 2004]
36. Epulis. [MUHS 1989, 1992]
33. Give the surgical steps and advantages of marsupial-
37. Benign cystic lesions of the mandible. [NTR-OR Oct
ization. [MUHS 2003]
1991]
34. Define cyst. Mention the various developmental odon-
38. OKC - Clinical features and incidence. [MUHS 1990]
togenic cysts of jaws. [MUHS 2003]
39. Periapical granuloma. [NTR-OR Jun 1982]
270 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
35. Causes of recurrence potential of keratocyst. [MUHS
2003]
36. What are odontomes? Mention its types. [MUHS 2003]
37. Papilloma. [RGUHS Apr 2003]
38. Ranula. [RGUHS Apr 2002 Feb 1991, Sep 2003]
39. Mucocele. [RGUHS Jan 1989; Mar 2003]
40. Papilloma [RGUHS Apr 2003]
41. Torus palatinus. [RGUHS Apr 2002]
42. Difference between enucleation and marsupialization.
[NTR-OR Apr 2002]
43. Mention the merits and demerits of the enucleation and
marsupialization procedures of cystic lesions. [MUHS
2002]
Diseases of TMJ
Long Essays
1. Classify temporomandibular joint ankylosis. Discuss
the aetiology, clinical features, and management of
bilateral TMJ ankylosis in a 12 year old boy. [RGUHS
May 2009]
2. Discuss the surgical anatomy of TM joint. Describe the
surgical management of TM joint ankylosis. [MUHS
May-Jun 2008; Goa 2002]
3. Classify ankylosis of TMJ. Describe the clinical fea-
tures and treatment for a unilateral bony ankylosis in a
35 year old adult. [TN Feb 2007]
4. Define ankylosis. Classify ankylosis of TMJ. Write in
detail the aetiology, clinical features,radiological fea-
tures, and management of unilateral bony ankylosis in
a 10 year old child. [TN Feb 2006; Feb 2006]
5. Describe the aetiology, signs and symptoms of tem-
poromandibular joint ankylosis. How will you man-
age? [RGUHS Aug 2006; RGUHS Aug 2006]
6. Discuss in detail the clinical features, pathogenesis, and
surgical management of unilateral temporomandibular
joint ankylosis in an 11 year old boy. [TN Feb 2005]
7. What is ankylosis of TM joint? Give the clinical pic-
ture and management of unilateral TM joint ankylosis
in a seven year old patient. [GAO 2004]
8. What are the causes for inability to open the mouth?
Describe in SHORT the methods of managing it?
[BUHS Mar 1994, RGUHS Mar 2004]
9. Define ankylosis. Describe in detail the clinical features
and management of unilateral TM joint ankylosis.
[MUHS May 2002, 2003, 1990, 1991, 1999, 1997, 1998]
10. Enumerate the causes of inability to open the mouth.
How would you treat a case of bony ankylosis? [NTR-
OR Apr 1999]
44. Name the cysts of the maxillary antrum. [MUHS
2002]
45. Classify cystic lesions of the head, neck, and face
region. [MUHS 2002]
46. What is complex odontome? Give brief description.
[MUHS 2002]
47. Management of mandibular ameloblastoma. [Goa
2002]
48. Radicular cyst. [TN Nov 2001]
49. Dentigerous cyst. [MUHS 2002; TN Apr 2001]
50. Fibrous dysplasia. [RGUHS Sep 2001]
51. Ameloblastoma. [RGUHS Aug 1995]
52. Compound composite odontoma. [RGUHS Jan 1990]
Topic 11
11. Define ankylosis of TMJ. Mention the aetiology, clini-
cal features, and management of unilateral ankylosis in
a 10 year old patient. [NTR-OR Apr 1997]
12. Describe the aetiology, clinical features, and manage-
ment of ankylosis of TM joint. [NTR-OR Oct 1997]
13. Enumerate the aetiology of TMJ ankylosis. Describe
the clinical signs and management of unilateral anky-
losis in a 10 year old child. [MUHS Jun 1998, 1995]
14. Classify ankylosis of TMJ. Describe CIF and diagnosis
and treatment for a unilateral bony ankylosis in case of
child of nine years. [RGUHS Mar 1995, Aug 1995]
15. Differentiate between sublaxation and dislocation of
TMJ and describe the treatment of chronic TMJ dislo-
cation. [MUHS Oct 1994]
16. Describe the management of ankylosis of TMJ.
[RGUHS Jan 1990]
17. Elaborate the cases, signs, and symptoms of ankylosis
of TMJ. How will you treat a case of bilateral ankylosis?
[RGUHS Oct 1987]
18. Describe the classification of ankylosis of TMJ. Give
the signs and symptoms and treatment of bilateral sub-
condylar fracture. [RGUHS Apr1987]
Short Essays
1 . TMJ ankylosis. [RGUHS Aug 2013]
2. Surgical anatomy of the temporomandibular joint.
[RGUHS Oct 2009 (RS)]
3. Ankylosis treatment protocol? [NTR-NR Apr 2005;
NTRUHS Aug 2009]
4. Temporomandibular joint dysfunction syndrome.
[RGUHS Jul 2008]
5. Articular disc. [RGUHS Apr 2008]
6. True ankylosis. [RGUHS Feb 2007 (RS)]
Section | III  Previous Years’ Question Bank
7. Internal derangements of TMJ. [RGUHS Aug 2006:
Aug 2006 (RS)]
8. Surgical management of TMJ ankylosis. [NTR-NR
Oct 2006]
9. Ankylosis of TMJ. [RGUHS Mar 2005]
10. Subluxation of TMJ. [NTR-OR May 1994, Oct 1997,
Apr 1999, NTR-NR Apr 2000, Oct 2005; MUHS Jun
1989, 1999]
11. Temporomandibular joint. [NTR-OR Apr 1995, NTR-
NR Oct 2004]
12. Clinical features and management of dislocation.
[RGUHS Sep 2003]
13. Clinical features and management of TMJ ankylosis.
[RGUHS Apr 2003]
14. Acute TMJ dislocation - Causes and treatment. [NTR-
NR Oct 2001; MUHS May 1999, 1998, 2002]
15. Interposition osteoarthroplasty. [NTR-NR Apr 2001]
16. Pain dysfunction syndrome. [RGUHS Sep 2000]
17. Dislocation of TM joint? [NTR-OR Apr 1996, Oct
1999]
18. Pain dysfunction of TM joint? [NTR-OR Nov 1994,
Apr 1996, Oct 1999]
19. Eminectomy. [MUHS Dec 1999]
20. Enumerate the diseases of TMJ. [MUHS Dec 1998]
21. Acute dislocation of TM joint? [NTR-OR Apr 1998]
22. Ankylosis. [NTR-OR May 1993, Apr 1995]
23. Trismus. [NTR-OR Feb 1989, Nov 1994]
Short Notes
1. Temporomandibular joint ankylosis. [TN Aug 2010,
Feb 2012]
Diseases of Salivary Gland
Long Essays
1. Classify tumours of salivary glands and discuss in detail
about pleomorphic adenoma. [TN Aug 2007]
2. Enumerate salivary gland disorder and discuss the manage-
ment of sialolith in Warthin’s duct. [MUHS 1992, 2002]
Short Essays
3. Describe the clinical features and treatment of salivary
calculus of Warthin’s duct. [NTR-OR Oct 2001]
4. Describe the sialography of parotid gland in adult.
[MUHS 1996]
5. Why statolith is common in submandibular duct. Describe
the signs and symptoms, diagnosis, and management of
sialolith in Wharton’s duct. [RGUHS Aug 1991]
271
2. Ankylosis temporomandibular joint. [TN Feb 2011]
3. Dislocation of TMJ. [RGUHS Jan 1989, Feb 1995,
Sep 1994, Mar 2004; TN Nov 2001, Aug 2007, Feb
2009]
4. Ankylosis of TMJ. [TN Aug 2006, Feb 2008]
5. Chronic recurrent dislocation. [TN Aug 2007, 2008]
6. Frey’s syndrome. [TN Feb 2008]
7. Define ankylosis of TM joint. Enumerate the causes of
ankylosis of TM joint. [MUHS May-Jun 2008]
8. Gap arthroplasty. [TN Feb 2006, Aug 2008]
9. Write four signs and symptoms of temperomandibular
joint. [MUHS 2007]
10. Subluxation. [RGUHS Jan 1989, Jul 1990, Sep 2002,
Mar 2006]
11. Mention eight causes that can result in true ankylosis
of the TM joint. [MUHS May 2006]
12. Gap arthroplasty. [TN Feb 2006]
13. Subluxation and dislocation. [TN Aug 2006]
14. Define dislocation. Briefly mention any two surgical
techniques for the management of chronic TM joint
dislocation. [MUHS May 2006]
15. Ankylosis of the TM joint. [TN Feb 2005]
16. Interposition arthroplasty. List the ligaments of tem-
poromandibular joint. [NTR-NR Oct 2005, Apr
2002]
17. Habitual dislocation. [RGUHS Apr 2003]
18. Risdon’s submandibular approach. [RGUHS Apr
2003]
19. Enumerate any four aetiological factors leading to-
wards temporomandibular ankylosis. [MUHS May
2002, 2003]
20. Dislocation of TMJ. [TN Apr 2003]
Topic 12
6. What is sialography? Describe its technique. How will
you remove a sialolith from the right Wharton’s duct?
[MUHS 1990]
1. Surgical anatomy of submandibular gland. [RGUHS
Oct 2009 (RS)]
2. Sialolithiasis and its management. [RGUHS Jul 2008]
3. Sialolith. [MUHS 1993, 1995, 1998, 2003; RGUHS
2007 (RS); TN Feb 2005, 2001, Sep 2002]
4. Adenocarcinoma of minor salivary gland in palate.
[NTR-NR Apr 2006]
272 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
5. Submandibular salivary calculi and its management.
[RGUHS Mar 2005]
6. Sialadenitis. [NTR-OR May 1993, NTR-NR Apr 2001,
Oct 2005]
7. Mixed tumour of parotid gland. [NTR-NR Apr 2005]
8. Mucocele. [NTR-NR Oct 4005; MUHS 1997]
9. Sialogram. [RGUHS Mar 2004]
10. Ranula. [NTR-OR Apr 1996, 2004, Oct 1997, NTR-
NR Oct 2001]
11. Sialography. [NTR-OR Nov 1992, NTR-NR Apr 2004;
MUHS 1989, 1995]
12. Classify salivary gland tumours. How do you investi-
gate them? [RGUHS Sep 2003]
13. Sialadenitis. [RGUHS Apr 2002]
14. Sialolith? [NTR-0R Apr 1997, 1999, NTR-NR Apr
2002]
15. Mumps. [RGUHS Sep 2001]
16. Submandibular salivary calculi. [NTR-OR Oct 1997]
17. Salivary fistula. [RGUHS Feb 1996]
18. Sjogren’s syndrome. [BUHS Mar 1995]
19. Pleomorphic adenoma. [NTR-OR Nov 1994]
20. Surgical removal of salivary stone from submandibular
duct. [MUHS 1992]
Diseases of Maxillary Sinus
Long Essays
1. Enumerate the causes of oroantral fistula. How would you
manage a chronic oroantral communication/ [TN Aug 2010]
2. Write about the embryology and surgical anatomy of
maxillary sinus. Discuss in detailoroantral fistula.
[RGUHS Jul 2008]
3. Define oroantral fistula. Describe the aetiology, clinical
feature, and management oforoantral fistula. [RGUHS
Jul 2008 (RS); TN Nov 2001]
4. What are the various causes of oroantral communica-
tion? How do you diagnose and treat a case of oroantral
communication. [TN Feb 2007]
5. What is an oroantral fistula? What are the factors involved
in the success of closure of the fistula? Describe the various
surgical procedures for closure. [RGUHS Aug 2006 (RS)]
6. Discuss the surgical anatomy, clinical feature, and man-
agement of root in the maxillary sinus. [Goa Dec 2005]
7. Describe surgical anatomy of maxillary sinus. How
would you manage a case of oroantral fistula in the right
upper first molar region? [RGUHS Aug 2005]
8. Diagnosis and management of oroantral fistula.
[RGUHS Apr 2003]
21. Investigations in salivary calculus. [RGUHS Apr 1987,
Mar 1988, Feb 1991]
Short Notes
1. Ranula. [TN Feb 2005, 2013]
2. Pleomorphic adenoma. [TN Feb 2008]
3. Lumpy jaw. [TN Aug 2007]
4. FNAC. [TN Aug 2007]
5. Sialolith. [RGUHS Mar 2003, Aug 2006 (OS), 2013;
Goa 2002; TN Feb 2005, 2007]
6. Sialography. [RGUHS Oct 1987, Aug 1993, Aug 2005,
Sep 2002; Aug 2005; Feb 2007 (OS); TN Feb 2006,
2011, Aug 2007]
7. Sialolithiasis. [RGUHS Aug 2005; TN Aug 2007]
8. Submandibular salivary calculi and its management.
[TN Aug 2006]
9. What is Wharton’s duct? What is Bartholin’s Duct?
[MUHS 2006]
1 0. Sialogram. [RGUHS Mar 2004; TN Nov 2001]
11. Submandibular gland sialolithiasis. [Goa 2002]
12. Mumps. [RGUHS Sep 2001]
13. Sjogren’s syndrome. [RGUHS Mar 1995]
Topic 13
9. Clinical features and management of acute maxillary
sinusitis. [RGUHS Sep 2003]
10. Diagnosis and management of chronic oroantral fistula.
[RGUHS Sep 2002]
11. Describe the surgical anatomy of the maxillary sinus.
Discuss the management of chronic maxillary sinusitis.
[MUHS 2001]
12. Describe the signs, symptoms, and treatment of oroan-
tral fistula in first molar region. [MUHS 1989, 1998]
13. Removal of fractured root from the maxillary sinus.
[NTR-OR Oct 1997]
14. Surgical closure of oroantral fistula. [BUHS Feb 1996]
15. Describe the causes, signs, and symptoms of oroantral
fistula. Discuss the procedure for repair of chronic
oroantral fistula. [RGUHS Aug 1996]
16. Signs, symptoms, and treatment of acute maxillary
sinusitis. [MUHS 1995]
17. Describe the removal of displaced root piece of maxil-
lary first molar from antrum. [MUHS 1992]
18. What are the courses for pushing a tooth or a root into
a sinus? How do you diagnose to treat such cases?
[RGUHS Mar 1992]
Section | III  Previous Years’ Question Bank
19. What are the causes of fracture of tooth during extrac-
tion? How do you manage a case of root pushed in
maxillary antrum. [RGUHS Feb 1991]
20. Define boundaries of maxillary sinus. Describe the tech-
nique for closure of an oroantral fistula. Write on the
complications encountered following extraction of max-
illary first molar and give detailsabout post-operative
care. [MUHS 1991, 1996, 1988]
21. Describe the causes, signs, and symptoms of oroantral
fistula. Give the treatment for closure of chronic oro-
antral fistula. [RGUHS Mar 1988]
Short Essays
1. Oroantral fistula. [RGUHS Sep 1994; Feb 2007 (RS),
Aug 2013]
2. Mucormycosis involving maxillary antrum. [RGUHS
Apr 2008 (RS2)]
3. Caldwell-Luc procedure. [RGUHS Feb 2007 (OS)]
4. Clinical features and management of acute maxillary
sinusitis. [RGUHS Sep 2003]
5. Nasal antrostomy - Indications and technique. [MUHS
2003]
6. Interpositional arthroplasty. [MUHS 2003]
7. Diagnosis and management of oroantral fistula.
[RGUHS Apr 2003, Sep 2002]
8. Von-Rehrmann’s flap. [MUHS 2002]
9. Anatomy of maxillary sinus. [MUHS 1999, 1990]
10. How will you assess and treat a case of oroantral com-
munication. [MUHS 1997]
11. Surgical closure of oroantral fistula. [RGUHS Feb 1996]
12. Chronic maxillary sinusitis. [MUHS 1996]
Inflammatory Lesions of Jaw and Orofacial Infections
Long Essays
1. Define and enumerate fascial spaces, and discuss in
detail the management of Ludwig’s angina and its com-
plications. [TN Feb 2013]
2. Describe fibro-osseous lesions of the jaws. Enumerate
the treatment for fibrous dysplasia [RGUHS Dec 2001/
Jan 2012]
3. Classify osteomyelitis of the jaw. Write in detail about
treatment of chronic osteomyelitis of the mandible. [TN
Feb 2011]
4. Discuss the pathway of spread of infection from mandibu-
lar third molar and describe in detail about Ludwig’s
angina. [TN Feb 2009]
273
Short Notes
1. Oroantral fistula. [RGUHS Aug 1996, Mar 2004;
NTR-NR Apr 2005; TN Feb 2012, Aug 2007]
2. Gillies approach. [TN Feb 2007]
3. Palatal flap closure for oroantral fistula. [MUHS 2007]
4. Caldwell-Luc procedure. [TN Aug 2007]
5. Acute sinusitis management. [RGUHS Aug 2006
(RS)]
6. Give one point of differentiation between a sinus tract
and a fistula. Mention any four clinical features of
acute maxillary sinusitis. [MUHS 2006]
7. Mention the various treatment modalities of oroantral
fistula with diagrams. [MUHS 2005]
8. Antrum of Highmore. [RGUHS Mar 2004]
9. What is oroantral fistula? Enumerate its causes.
[MUHS 2004]
10. Mention different types of flaps for closure of oroan-
tral fistula. [MUHS 2004]
11. Maxillary sinus. [Goa 2003]
12. Mention in brief about causes of failure of plastic clo-
sure of oroantral fistula. [MUHS 2003]
13. Describe in brief the technique of intranasal antros-
tomy. [MUHS 2003]
14. Transillumination test. [RGUHS Apr 2003]
15. Definition of oroantral fistula and communication.
[NTR-NR Apr 2002]
16. Treatment of chronic maxillary sinusitis. [RGUHS
Sep 2001]
17. Oroantral communication. [RGUHS Sep 2000]
18. Roots in sinus. [RGUHS Feb 1993]
19. Cadwell-Luc operation. [RGUHS Aug 1991]
Topic 14
5. Orofacial infection. [RGUHS May 2009]
6. What are the causes for inability to open the mouth?
Describe in detail the method by which each of these
conditions will be managed. [RGUHS Jul 2008 (RS)]
7. Write in detail the clinical features and management of
acute suppurative osteomyelitis. Add a note on differ-
ential diagnosis. [RGUHS Feb 2007 (RS)]
8. Discuss the aetiology, clinical features, and manage-
ment of Ludwig’s angina. [RGUHS 2007 (RS)]
9. Write the clinical features, aetiology, and management
of Ludwig’s angina and note on systemic complica-
tions? [NTR-NR Apr 2006]
10. Define osteoradionecrosis. Describe in detail the
ill effects of radiation therapy of oral and perioral
274 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
structures and how do you manage them? [RGUHS
Aug 2006]
11. Mention the microorganisms and various ways by which
odontogenic infection can spread. Describe the bound-
aries, clinical signs and symptoms, and management of
involvement of the pterygomandibular space. [MUHS
2006]
12. Define osteomyelitis. Describe the pathogenesis,
aetiology, signs and symptoms, and management of
embryonic osteomyelitis of the jaw. [TN Aug 2006]
13. Define Ludwig’s angina. Describe the aetiology, clini-
cal signs and symptoms, and management of the same.
[TN Aug 2006]
14. Define Ludwig’s angina. Write in detail the clinical
features and management of Ludwig’s angina. Add a
note on its antibiotic regime. [TN Aug 2006]
15. Define space infection. Enumerate the tissue that offers
resistance to spread of infection. How does the infec-
tion spread from the lower last molar pericoronal flap?
Write a note onits management. [TN Feb 2005]
16. Write the classification of infection of jawbone. Write
in detail the boundaries, clinical features, evaluation,
and management of pterygomandibular space. [Goa
Dec 2005]
17. Classify and write on the aetiology of impaction of
mandibular third molars. Explain the various surgical
techniques used in the management of impacted third
molar. [Goa Dec 2005]
18. What are the causes for inability to open the mouth?
Describe in SHORT the methods of managing each of
them. [NTRUHS Mar 2004]
19. What is Ludwig’s angina? Describe the clinical fea-
tures, diagnosis, and surgical management of the same.
Add a note on antibiotic regime for a case of Ludwig’s
angina. [TN Aug 2004]
20. Define and classify osteomyelitis. Describe the clinical
feature, radiographic picture, and management of ra-
dionecrosis. [Goa 2003]
21. Define and classify osteomyelitis of jaw bones. How
will you manage a case of chronic suppurative osteo-
myelitis of mandible in an adult? [MUHS 2003, 1998]
22. Define Ludwig’s angina. Describe the aetiology, clini-
cal signs and symptoms, and steps in the management
of Ludwig’s angina. [RGUHS Mar 2002]
23. Define Ludwig’s angina. Describe the aetiology, clini-
cal signs and symptoms, and steps in the management
of Ludwig’s angina. [RGUHS Mar 2002; TN Sep
2002]
24. Discuss the factors responsible for spread of the
infection and describe the signs, symptoms, and man-
agement of anyone life-threatening complication from
odontogenic infection. [MUHS 1993, 1998, 2002]
25. Describe the boundaries and contents of pterygo-
mandibular space. Write the causes for the spread of
infection to the pterygomandibular space and give
the clinical features and management. [Goa 2002]
26. A 45 year old lady reports to you with a complaint of
sharp, lancinating type of pain on the right side of face
since two weeks, and inability to touch that side due to
pain. What could be the problem and how would you
manage it? [Goa 2002]
27. Classify space infectious in relation to mandible. De-
scribe the aetiology, clinical signs, symptoms, and
management of chronic osteomyelitis of mandible.
[RGUHS Sep 2000]
28. Classify fascial spaces around the jaws. Discuss the
sequel of fascial space infection of upper anterior teeth
and management. [NTRUHS Apr/May 1999]
29. Describe the aetiology, clinical features, and manage-
ment of chronic osteomyelitis of the mandible. [NTR-
OR Oct 1997]
30. Describe the spread of infection from mandibular first
molar. Describe the boundaries, contents, signs, symp-
toms, and treatment. Give in detail about pterygoman-
dibular space. [MUHS 1997]
31. What is Ludwig’s angina? Describe in detail its aetio-
pathogenesis, signs, symptoms, and management.
[MUHS 2004, 1995, 1997]
32. Define Ludwig’s angina, Describe pathophysiology,
signs and symptoms and management of Ludwig’s
angina [RGUHS Aug 1996]
33. Define Ludwig’s angina. Mention the clinical features and
management of Ludwig’s angina. [RGUHS Aug 1996]
34. Describe the clinical features, diagnosis, and surgical
treatment as well as antibiotic regime for a case of
Ludwig’s angina. [RGUHS Mar 1995]
35. Define osteomyelitis. Describe the pathology and man-
agement of chronic osteomyelitis of mandible. [RGUHS
Feb 1991, Sep 1994]
36. Define osteomyelitis. How will you treat a case of
chronic osteomyelitis present in ramus of an adult
patient? [RGUHS Aug 1993]
37. Give the boundaries of pterygomandibular space.
[RGUHS Aug 1993]
38. Describe the pathophysiology, clinical features, and
management of osteoradionecrosis. [RGUHS Mar 1992]
39. Describe the pathway for the spread of infection from
mandibular third molar and give its management.
[MUHS 1991]
40. Describe the mode of spread of infection from man-
dibular third molar region. Discuss the line of treat-
ment in such a case. [RGUHS Jul 1990]
41. What are the boundaries of infratemporal space? How
will you manage a case of infection of infratemporal
space? [MUHS 1989]
42. What is osteomyelitis? Describe the signs, symptoms,
and treatment of chronic osteomyehtis. [MUHS 1992,
1994, 1995, 1989]
Section | III  Previous Years’ Question Bank
43. Name the boundaries of submandibular space. Give
the signs, symptoms, and treatment of Ludwig’s an-
gina. [RGUHS Apr 1987]
Short Essays
1. Submandibular abscess. [RGUHS Dec 2009 (RS2)]
2. Retromandibular space infection. [RGUHS Jul 2008]
3. Pterygomandibular hypertrophy. [RGUHS Jul 2008
(RS 2)]
4. Lymphadenitis in maxillofacial region. [RGUHS
Aug 2006 (RS)]
5. Microbiology of odontogenic infections. [RGUHS
Aug 2006 (RS)]
6. Chronic suppurative osteomyelitis. [NTR-NR Oct 2006]
7. Chronic osteomyelitis of mandible. [NTR-NR
Apr 2006]
8. Microbiology of odontogenic infections. [RGUHS
Aug 2006]
9. Cavernous sinus thrombosis. [RGUHS Mar 2006]
10. Submasseteric space infection. [NTR-OR Apr 1998;
RGUIHS Aug 2006 (OS)]
11. Submandibular space infection and its management.
[RGUHS Mar 2006, 2003]
12. Pterygomandibular space. [NTR-OR Apr 1999, 1999;
RGUHS Mar 2005]
13. Periapical cyst. [NTR-NR Apr 2005]
14. Pterygomandibular space infection and its manage-
ment. [RGUHS Mar 2005]
15. Pericoronitis and its management. [RGUHS Mar 2004]
16. Clinical features of Ludwig’s angina and management.
[RGUHS Mar 2004]
17. Spread of infections from lower first molar and its
management. [RGUHS Apr 2003]
18. Acute osteomyelitis. [MUHS 2003]
19. Ludwig’s angina? [NTR-OR Jun 1982, Oct 1991,
1995, 2004, Nov1992, Apr 1999; RGUHS Sep 2003,
1994]
20. Clinical features and management of chronic osteomy-
elitis. [RGUHS Mar 2002]
21. Intratemporal space. [NTR-OR Oct 2001, Apr 2002]
22. Acute osteomyelitis. [NTR-NR Apr 2002]
23. Clinical features and management of chronic osteomy-
elitis. [RGUHS Mar 2002]
24. HBO. [MUHS 2001]
25. Submandibular space. [MUHS 1989, 1990, 2001]
26. Hyperbaric oxygen therapy. [NTR-NR Apr 2001]
27. Treatment of Ludwig’s angina. [NTR-OR Apr 2001]
28. Submandibular space infection. [NTR-OR Apr 2000]
29. Infratemporal space. [MUHS 2000]
30. Sequestrectomy. [MUHS 1999]
31. Pericoronitis. [NTR-OR Apr 1996, Oct 1999]
32. Garre’s osteomyelitis. [NTR-OR Oct 1998]
33. Osteoradionecrosis. [NTR-OR Feb 1989, Apr 1997, 1998]
275
3 4. Ludwig’s angina. [MUHS 1998]
35. Osteoradionecrosis [RGUHS Feb 1996]
36. Hyperbaric 02. [MUHS 1989, 1996]
37. Submental space. [MUHS 1995]
38. Infections of the oral cavity. [NTR-OR Apr 1995]
39. Acute alveolar abscess. [NTR-OR Feb 1989, Nov 1994]
40. Osteomyelitis. [NTR-OR May 1994]
41. Epulis. [NTR-OR May 1993]
42. Apical granuloma. [NTR-OR Jun 1982]
43. Anatomical boundaries. Communication of mandibu-
lar spaces. [MUHS 1992]
4 4. Cellulitis. [MUHS 1991]
45. Cancrum oris. [NTR-OR Oct 1991]
46. Osteoradionecrosis. [MUHS 1990]
47. Cavernous sinus thrombosis. [NTR-OR Jun 1982]
Short Notes
1. Ludwig’s angina. [RGUHS Jul 2008 (OS); TN Feb
2005, 2012]
2. Cherubism. [TN Aug 2010]
3. Garre’s osteomyelitis. [NTRUHS Aug 2009; RGUHS
Aug 2005, Apr 2003, 1995]
4. Quinsy. [RGUHS Jul 2008 (RS 2)]
5. Acute osteomyelitis. [RGUHS Jul 2008]
6. Denture granuloma. [RGUHS Jul 2008 (RS)]
7. Fibrous dysplasia. [TN Feb, Aug 2008]
8. Define Ludwig’s angina. Mention in brief the manage-
ment of this condition. [MUHS 2008]
9. Give the boundaries and contents of sublingual space.
[MUHS 2008]
10. Hyperbaric oxygen therapy. [NTR-NR Oct 2002,
2004; TN Feb 2007]
11. Hyperbaric oxygen. [RGUHS Apr 2003; Feb 2007 (OS)]
12. Abscess. [RGUHS Feb 2007 (RS)]
13. Management of chronic osteomyelitis of mandible.
[MUHS 2007]
14. Garre’s osteomyelitis. [RGUHS Mar 2003; Feb 2007
(OS)]
15. Residual cyst. [NTR-NR Oct 2006]
16. Masticatory space infection. [NTR-NR Oct 2006; TN
Feb 2005]
17. Submandibular space boundaries. [NTR-NR Oct 2006]
18. Define suppurative cellulitis. Give any four factors on
which the prognosis of the cellulitis depends on.
[MUHS 2006]
19. Name two oropharyngeal bacteroides. [MUHS 2006]
20. Mention any eight clinical signs and symptoms of
acute osteomyelitis. [MUHS 2006]
21. Define osteomyelitis. [MUHS 2006]
22. Periapical cyst. [NTR-NR Apr 2005]
23. Cavernous sinus thrombosis. [NTR-NR Apr 2005]
24. Chronic osteomyelitis. [TN Feb 2005]
25. Ludwig’s angina. [TN Apr 2001; TN Feb 2005]
276 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
2 6. Broken needle in pterygomandibular space. [TN Feb 2005]
27. Mention the boundaries of submandibular space with its
contents. Draw a diagram of this space. [MUHS 2005]
28. Name various facial spaces involved in Ludwig’s
angina and its clinical features. [MUHS 2005]
29. Define and classify osteomyelitis of jaw. Describe the
aetiology, clinical features, and management of a case
of chronic osteomyletis of mandible. [MUHS 2005]
30. Sequestrectomy. [RGUHS Mar 2005, Apr 2002; TN
Sep 2002]
31. Osteoradionecrosis. [RGUHS Mar 2005, 1988, Sep 2001,
Apr 2002]
32. Clinical features of Ludwig’s angina and management.
[NTRUHS Mar 2004]
33. Mention in brief predisposing factors for acute alveo-
lar osteitis. [MUHS 2004]
34. Boundaries of submandibular space. [GAO 2004]
35. State the factors affecting the spread of infection of
odontogenic origin. [MUHS 2004]
Facial Neuropathology
Long Essays
1. What is trigeminal neuralgia? Give the aetiological fac-
tors, clinical signs and symptoms, and discuss the extra-
cranial neurectomy procedures for the involvement of
the mandibular branch. [MUHS 2006]
2. Define trigeminal neuralgia. Enumerate the aetiology,
signs and symptoms, and management of the same. [TN
Aug 2006]
3. Enumerate the aetiology, clinical features, and manage-
ment of a case of V2 trigeminal neuralgia. [MUHS
2001]
4. Enumerate the premalignant conditions and premalig-
nant lesions of oral mucosa.Describe in detail any two
of them. [NTR-NR Oct 2001]
5. Describe the clinical varieties of leukoplakia. Add a note
on the aetiology of leukoplakia. [NTR-NR Apr 2001]
6. Classify social pain. Describe aetiopathogenesis, clini-
cal features, and management of trigeminal neuralgia.
[NTR-OR Oct 1999]
7. Write in detail the clinical features and management of
paroxymal trigeminal neuralgia. [NTR-OR Oct 1999]
8. Classify social pain. Describe in detail the aetiology,
clinical features, and management of idiopathic tri-
geminal neuralgia. [NTR-OR Feb 1998]
36. Classification of osteomyelitis of jawbones. [NTR-NR
Oct 2004]
37. Mention the boundaries and contents of pterygoman-
dibular space. [MUHS 2003]
38. Mention the boundaries and contents of submental
space. [MUHS 2003]
49. Name the structures in the middle meatus. [NTR-NR
Apr 2002]
40. Hyperbaric oxygen therapy indications. [NTR-NR
Apr 2002]
41. Give anatomical boundaries of submandibular space.
[MUHS 2002]
42. Hyperbaric 02. [MUHS 2002]
43. Chronic suppurative osteomyelitis. [Goa 2002]
44. Give the boundaries and contents of sublingual space.
[MUHS 2001]
45. Garre’s osteomyelitis. [TN Nov 2001]
46. Actinomycosis. [RGUHS Sep 2000]
47. Saucerization. [RGUHS Jan 1990]
Topic 15
9. Signs, symptoms, and management of trigeminal neu-
ralgia involving inferior alveolar nerve. [MUHS 1998]
10. Enumerate the premalignant conditions and lesions of
oral mucosa. Describe in detailany two of them. [NTR-
OR Oct 1997]
11. Describe the signs, symptoms, and treatment of right
inferior alveolar neuralgia. Write the branches of man-
dibular nerve. [MUHS 1991, 1997]
12. Describe the signs and symptoms of Tic douloureux.
Briefly discuss its aetiological factors and outline the
various modalities of treatment. [MUHS 1997, 1995]
13. Define Tic douloureux. Describe the aetiology, signs,
symptoms, and management of the same. [RGUHS Jan
1989, Mar 1994]
14. Classify the white lesions of the mouth. Describe in
detail the clinical features, differential diagnosis, and
managements of oral Lichen planus. [NTR-OR Mar
1991]
15. Describe the signs and symptoms of trigeminal neural-
gia and how do you manage it? [RGUHS Jan 1989]
16. Discuss the aetiology, signs, symptoms, and treatment
of trigeminal neuralgia. [RGUHS Aug 1988]
17. Describe the signs and symptoms and management of
trigeminal neuralgia. [RGUHS Feb 1996]
Section | III  Previous Years’ Question Bank
Short Essays
1. Trigeminal neuralgia and its management. [RGUHS
Aug 2013]
2. Surgical management of trigeminal neuralgia.
[RGUHS Dec 2009 (RS2)]
3. Trigeminal neuralgia. [RGUIHS Aug 2006 (OS);
NTR-OR Apr 1998, Oct 1998, NTR-NR Apr 2001;
RGUHS Feb 1991, Aug 1995; Mar 2003]
4. Neuralgia. [RGUHS Mar2005, Sep 2000, Apr 2002]
5. Oral precancerous lesions. [NTR-NR Oct 2004]
6. Medical management of trigeminal neuralgia. [NTR-
NR Oct 2004]
7. Aetiology and clinical features of Belly’s palsy.
[RGUHS Apr 2003]
8. Aetiology and clinical features of Belly’s palsy.
[RGUHS Apr 2003]
9. Analgesia. [RGUHS Mar 1992, Aug 1995, Sep 2003]
10. Clinical features and management of trigeminal neu-
ralgia. [RGUHS Mar 2002, Sep 2002]
11. Leukoplakia – treatment. [NTR-NR Apr 2002]
12. Subauricular pain. [NTR-NR Apr 2001]
13. Lichenoid reaction. [NTR-OR Oct 2001]
14. Submucous fibrosis. [NTR-OR May 1993, Apr 1998,
NTR-NR Oct 2001]
15. Treatment of trigeminal neuralgia. [NTR-NR Oct 2001;
MUHS 1989, 1999]
16. Intraorbital neurectomy. [MUHS 1989, 2001]
17. Erythroplakia. [NTR-OR Oct 1999]
18. Any four clinical characteristics of trigeminal neuralgia.
[MUHS 1999]
19. Atypical social pain. [NTR-OR Apr 1999]
20. Infraorbital neurectomy. [MUHS 1998]
Preprosthetic Surgery
Long Essays
1. Define preprosthetic surgery. Discuss in detail the
various preprosthetic procedures to improve the bony
alveolar ridge. [TN Feb 2013]
2. Describe one surgical procedure for deepening of man-
dibular buccal sulcus. [MUHS 2007]
3. What do you mean by preprosthetic surgery? What are
the aims of it? Describe the various alveolar ridge
altering procedures. [MUHS 2007]
4. Classify preprosthetic surgical procedure and your pro-
cedure to increase the depth of lingual sulcus. [RGUHS
Apr 2002; TN Feb 2005]
5. Write in detail the clinical features and management of
paroxysmal trigeminal neuralgia. [NTR-OR Oct 1999]
277
2 1. Diplopia. [NTR-OR Apr 1996, 1998]
22. Inferior alveolar neurectomy. [MUHS 1996, 1997]
23. Management of trigeminal neuralgia. [NTR-OR Apr 1996]
24. Sphenopalatine gangilion. [MUHS 1994]
25. Trigger zones. [MUHS 1994]
26. Treatment plan of leukoplakia. [NTR-OR May 1993]
27. Surgical treatment of trigeminal neuralgia. [RGUHS
Oct 1987]
Short Notes
1. Bell’s sign. [RGUHS Mar 1988, Aug 2013]
2. Medical management of trigeminal neuralgia.
[NTRUHS Aug 2009]
3. Describe the clinical features of trigeminal neuralgia.
[MUHS 2008]
4. Trigeminal neuralgia. [TN Aug 2006]
5. What is neuroleptanalgesia? Mention the names of two
drugs commonly used for the same. [MUHS 2006]
6. Erosive lichen planus. [NTR-NR Apr 2006]
7. Bell’s palsy. [RGUHS Aug 2005]
8. Management of submucous fibrosis. [NTR-NR Apr
2005]
9. Neuralgia. [RGUHS Mar 2005]
10. Classify and enumerate the management modalities of
trigeminal neuralgia. [MUHS 2004]
11. Atrophic lichen planus. [NTR-NR Oct 2002]
12. Name the drugs with their therapeutic dosage used for
treatment of trigeminal neuralgia. [MUHS 2001]
13. Mention four possible aetiological factors responsible
for trigeminal neuralgia. [MUHS 2001]
14. What are trigger zones? Name their location on the
face with the relevant nerve. [MUHS 2001]
Topic 16
6. Enumerate the various alveoloplasty techniques and
describe anyone technique for anterior maxillary over-
jet reduction in detail. [MUHS 1998]
7. Describe the signs and symptoms and management of
trigeminal neuralgia. [BUHS Feb 1996]
8. What is preprosthetic surgery? Describe how you per-
form in upper anterior region. [MUHS 1995]
9. Define Tic douloureux. Describe the aetiology, signs,
symptoms, and management of the same. [BUHS Jan
1989, Mar 1994]
10. Classify preprosthetic surgical technique and describe
anyone technique for vestibuloplasty. [MUHS 1990, 1994]
11. Define trigeminal neuralgia and discuss in brief its
aetiology, clinical signs, symptoms, and management.
[NTR-OR Nov 1992]
278 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
12. Describe the signs and symptoms of trigeminal neural-
gia and how do you manage it? [BUHS Jan1989]
13. Discuss the aetiology, signs, symptoms, and treatment
of trigeminal neuralgia. [BUHS Aug 1988]
Short Essays
1. Lingual split bone technique. [RGUHS Aug 2013]
2. Vestibuloplasty. [NTR-OR Apr 1998; RGUHS Jul 2008]
3. Surgical management of trigeminal neuralgia. [NTR-
NR Oct 2006]
4. Alveoloplasty. [NTR-OR Apr 1997, 2006; MUHS 1995]
5. Trigeminal neuralgia. [NTR-OR Oct 1991, 2005, May
1994, Oct 1995, Apr 1998, 2000; BUHS Feb 1991,
Aug 1995, RGUHS Mar 2006, Aug 2006]
6. Analgesics for orofacial pain. [NTR-NR Oct 2005]
7. Neuralgia. [RGUHS Mar 2005, Sep 2000, Apr 2002]
8. Nerve injuries following trauma in facial region.
[NTR-NR Apr 2005]
9. Facial palsy. [NTR-NR Apr 2004]
10. Medical management of trigeminal neuralgia. [NTR-
NR Oct 2004]
11. Aetiology and clinical features of Belly’s palsy.
[RGUHS Apr 2003]
12. Analgesia. [BUHS Mar 1992, Aug 1995, RGUHS
Sep 2003]
13. Clinical features and management of trigeminal neu-
ralgia. [RGUHS Mar 2002, Sep 2002]
14. Clark’s vestibuloplasty. [MUHS 1996, 2002]
15. Ridge augmentation procedure. [RGUHS Sep 2000]
16. Give the indications for excision of Tori and describe the
procedure of removal of mandibulr torus. [MUHS 1999]
17. Describe the steps of Obwegeser’s vestibuloplasty.
[MUHS 1999]
18. Dean’s alveoloplasty. [MUHS 1997, 1998]
Premalignant and Malignant Lesions
Long Essays
1. Describe the surgical management of squamous cell
carcinoma involving the lateral border of tongue.
[RGUHS May 2009]
2. Define and classify tumours. TNM classification and
staging in oral malignancy. Add a note on radiotherapy
and chemotherapy in the management of oral cancers.
[TN Feb 2007]
Short Essays
1 . TNM classification. [TN Feb 2012]
2. Premalignant conditions. [NTR-NR Apr 2006]
1 9. Frenectomy. [MUHS 1998, 1989]
20. Nerve injuries. [NTR-OR Apr 1996, 1997]
21. Vestibuloplasty. [MUHS 1997]
22. Methods of wiring in oral surgery. [MUHS 1995]
23. Torus palatinus. [MUHS 1995]
24. Preprosthetic surgery. [NTR-OR May 1994]
25. Alveolectomy. [NTR-OR Nov1994]
26. Trigger zone. [NTR-OR May 1993]
27. Sulcus extension. [NTR-OR Nov1992]
Short Notes
1. Frenectomy. [RGUHS Aug 2013]
2. Define preprosthetic surgery. Enumerate the various
preprosthetic surgeries. [MUHS 2008]
3. Vestibuloplasty. [TN Feb 2007, 2008]
4. Dean’s alveoplasty. [NTR-NR Oct 2006]
5. Implant supported prosthesis. [NTR-NR Apr 2006]
6. What are the possible intraoperative complications of
lingual frenectomy? [MUHS 2006]
7. Bell’s palsy. [NTR-NR Apr 2005]
8. Mention the various preprosthetic surgical procedures
and the requirements of an ideal ridge. [MUHS 2005]
9. Mandibular ridge augmentation. [NTR-NR Oct 2004]
10. Name the surgical treatment modalities from trigemi-
nal neuralgia. [NTR-NR Apr 2002]
11. Give the names of any four instruments used in the
‘Alveoloplasty’ procedure along with their functions.
[MUHS 2002]
12. Give the indication for Dean’s alveoloplasty. How does
it differ from Obwegeser’s alveoloplasty. [MUHS 2001]
13. Surgical procedure for excision of midpalatine torus.
[MUHS 2001]
14. Preprosthetic surgery of tuberosity. [NTRUHS Mar 1996]
15. Bell’s sign. [RGUHS Mar 2005]
Topic 17
3. Submucous fibrosis. [RGUHS Aug 2006 (OS); NTR-
OR Oct 1997]
4. Squamous cell carcinoma of lip. [NTR-NR Apr 2004]
5. Analgesics in OMF surgery. [NTR-NR Oct 2002]
6. Leukoplakia. [NTR-OR Oct 1997]
Short Notes
1 . Leucoplakia. [TN Apr 2003, Sep 2002, Feb 2013]
2. Oral submucous fibrosis. [TN Aug 2010]
3. Monostatic fibrous dysplasia. [TN Aug 2010]
4. Submucous fibrosis. [TN Feb 2008]
5. TNM staging in oral cancer. [TN Aug 2008]
6. Premalignant lesion. [RGUHS Jul 2008]
Section | III  Previous Years’ Question Bank
7. Staging of cancer. [RGUHS Feb 2007 (RS)]
8. Neck metastasis. [TN Feb 2006]
9. Carcinoma in situ. [RGUHS Mar 2006]
10. Premalignant conditions. [RGUHS Aug 2006 (RS)]
11. Radiotherapy for oral carcinoma? [NTR-NR Apr2006]
Management of Medically Compromised Patients
and Medical Emergencies
Long Essays
1. Medical emergencies in oral and maxillary facial sur-
gery. [RGUHS May 2009]
2. Classify the shock. Discuss in detail the pathogenesis,
clinical feature, and management of haemorrhagic
shock. [RGUHS Apr 2008 (RS2)]
3. How do you manage a patient for tooth extraction with
a. Diabetes mellitus,
b. Bacterial endocarditis,
c. Bronchinal asthma, and
d. Long-term steroid therapy? [TN Feb 2007]
4. Define osteoradionecrosis. Describe in detail the ill
effects of radiation therapy to oral and perioral struc-
tures and how do you manage them? [RGUHS Aug
2006 (RS)]
5. What are the common medical emergencies in dental
practice? How would you manage syncope? [TN
Feb 2006]
6. AIDS in children. [NTR-OR May 2004]
7. Oral manifestations of HIV infection. [NTR-NR
Oct 2004]
8. Describe the oral manifestations of endocrine diseases.
[NTR-OR May 2004]
9. Enumerate the various local and systemic causes for
post-extraction bleeding. What options do you have in
managing such conditions? [RGUHS Sep 2003]
10. Minor oral surgeries in haemophiliacs and diabetic
patients. [RGUHS Sep 2003]
11. Classify preprosthetic surgical procedures and your
procedure to increase the depth of lingual sulcus.
[RGUHS Apr 2002]
12. How do you manage minor oral surgeries in patients
with history of
a. Uncontrolled diabetes mellitus,
b. Long-term steroid therapy, and
c. Valvular heart diseases? [RGUHS Sep2002]
13. Cardiopulmonary resuscitation. [MUSH May 2002]
14. What are all the various complications that can occur
in oral surgery? Discuss. [TN Sep 2002]
279
1 2. Radiotherapy. [NTR-NR Oct 2002; TN Aug 2005]
13. Staging of tumour. [NTR-NR Oct 2005]
14. Osteoradionecrosis. [Goa Dec 2005]
15. TNM classification of oral cancer. [TN Aug 2005;
Apr 2001]
Topic 18
15. Describe your treatment plan of extraction in patients
with history of
(a) Long-term corticosteroid therapy,
(b) Hepatitis B, and
(c) Anticoagulant therapy? [TN Apr 2001]
16. Write the various investigations required to diagnose bleed-
ing diasthesis and management of a case of haemophilia
patient for dental extraction. [NTRUHS Apr/May 1999]
17. HIV-associated periodontitis. [NTR-OR Apr 1999]
18. Haemophilia. [MUHS Nov 1993, 1998]
19. Define shock. Discuss the pathogenesis, clinical fea-
tures, and management of hypovolemic shock. [MUHS
Nov 1998]
20. Discuss ‘shock’ in oral surgery. [MUHS Dec 1995]
21. Discuss the management of haemarrhage in oral sur-
gery. [MUHS Oct 1989, 1993]
22. Enumerate the various causes for post-extraction bleed-
ing and discuss the various methods available to control
bleeding from socket. [BUHS Jan 1989, Aug1993]
23. Various types of haemarrhage encountered in oral sur-
gery and its treatment. [MUHS Nov 1992]
24. What precautions can you take while carrying out den-
tal treatment for a patient suffering from haemophilia?
[NTR-OR May 1990]
Short Essays
1. Indications for blood transfusion. [RGUHS Jul 2008
(RS 2)]
2. Medical emergency drug tray in dental office. [RGUHS
Jul 2008 (RS 2)]
3. Haemophilia A. [NTR-OR Apr 1998; RGUHS Jul 2008;
Feb 2007 (OS)]
4. Prophylaxis for subacute bacterial endocarditis. [RGUHS
Feb 2007 (OS)]
5. Hepatitis B infection. [RGUHS Feb 2007 (RS); TN Nov
2001]
6. Haemophilia. [NTR-OR Oct 1997; TN Aug 2006]
7. Haemophilia patient for dental extraction. [NTR-NR
Apr 2006]
280 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
8. Blood transfusion reactions. [NTR-NR Apr 2002, Oct
2006]
9. Haemorrhagic shock. [NTR-NR Oct 2006]
10. Post-extractions haemorrhage management. [NTR-NR
Apr 2005]
11. Secondary haemorrhage. [RGUHS Apr 2002, Mar 2005]
12. Autologous blood transfusion. [NTR-NR Oct 2004]
13. Management of post-extraction haemorrhage. [NTR-
NR Oct 2004]
14. Haemostatics. [MUHS 2003]
15. Hypovolemic shock. [MUHS 1991, 1996, 2003]
16. Minor oral surgeries in haemophiliacs and diabetic
patients. [RGUHS Sep 2003]
17. Frenectomy. [RGUHS Apr 2002]
18. Management of haemorrhage in oral surgery. [NTR-
NR Apr 2002]
19. Hyperparathyroidism - Investigations. [NTR-NR Apr 2002]
20. Non-progressive shock. [MUHS 200l]
21. Reactionary haemorrhage. [RGUHS Oct 2001]
22. Management of anaphylactic shock. [MUHS 1999]
23. Hyperparathyroidism. [NTR-OR Apr 1999]
24. Syncope. [NTR-OR Oct 1998, Apr 1999]
25. Shock in oral surgery. [NTR-OR Apr 1995, 1998]
26. Shock in oral surgery. [NTR-OR Apr 1998]
27. Syncope. [MUHS 1999, 1998]
28. Post-extraction haemorrhage. [MUHS 1997]
29. Types of haemorrhage. [MUHS 1996]
30. Blood grouping and transfusion. [NTR-OR Nov 1994]
31. Post-extraction bleeding. [NTR-OR May 1993, Nov 1994]
32. Blood groups. [NTR-OR Nov 1992]
33. Control of bleeding through extraction socket. [MUHS
1989]
Short Notes
1 . Prophylaxis for infective endocarditis. [TN Feb 2013]
2. CPR (Cardio Pulmonary Resuscitation). [TN Aug 2010]
3. Hyperparathyroidism. [TN Aug 2010]
4. Control of haemorrhage - local measures. [RGUHS
Jul 2008]
Minor Oral Surgical Procedures and Orthognathic
Surgery
Long Essays
1. Discuss the fluid and electrolyte balance in a post-oper-
ative patient who has undergone a major maxillofacial
surgery. [RGUHS Oct 2009 (RS)]
2. Write about sagittal spilt mandibular osteotomy and as-
sociated surgical complication. [RGUHS Oct 2009 (RS)]
5. Neurogenic shock. [RGUHS Jul 2008 (RS 2)]
6. Hyperthyroidism. [RGUHS Feb 2007 (RS)]
7. Endocarditis prophylaxis. [TN Feb 2007]
8. Mention four bleeding control measures in post-
extraction bleeding. [MUHS 2007]
9. Post-HIV exposure prophylaxis. [TN Feb 2006]
10. Secondary haemorrhage. [RGUHS Aug 2006 (OS);
RGUHS Mar 2005; TN Feb 2006]
1 1. Significance of AIDS in dentistry. [NTR-NR Oct 2006]
12. Anaphylaxis. [RGUHS Sep 2003, Mar 2005]
13. Secondary haemorrhage. [RGUHS Apr 2002, Mar 2005]
14. Anaphylactic shock. [MUHS 2005]
15. HIV. [NTR-NR Apr 2004]
16. Describe briefly the management of a hypertensive
patient for teeth extraction in dental chair. [MUHS Oct
2004]
17. Shock. [RGUHS Mar 2004, Sep 1992; NTRUHS Mar
2004]
1 8. Vestibuloplasty. [RGUHS Mar 1985, 1989, 2004]
19. Bacterial endocarditis. [RGUHS Apr 2003]
20. Enumerate the coagulation factors. [MUHS 2003]
21. Premedication. [RGUHS Mar 2002]
22. Prophylactic antibiotics regimen for cardiac compro-
mised patient. [NTR-NR Oct 2002]
2 3. Reactionary haemorrhage. [RGUHS Oct 2001]
24. Name four blood products that can be transfused par-
enterally with one indication for each. [MUHS 2001]
25. Mention any eight precautions that have to be gener-
ally employed in the management of a patient who has
haemophilia and requires a dental extraction. [MUHS
2001]
2 6. Alveolectomy. [RGUHS Mar 1988, Sep 2001]
27. Ridge augmentation procedure. [RGUHS Sep 2000]
28. Haemophilia. [RGUHS Oct 1987, Mar 1992, Sep 2000]
29. Syncope. [RGUHS Oct 1987, Jul 1990, Feb 1991, Sep
1994, Mar 1995, Aug 1996]
3 0. Preprosthetic surgery of tuberosity. [RGUHS Mar 1988]
31. Preprosthetic surgery. [RGUHS Feb 1991]
32. Torus palatinus. [RGUHS Mar 1988, Feb 1993]
33. High labial frenum. [RGUHS Jan 1989]
Topic 19
3. Distraction osteogenesis in maxillofacial surgery.
[RGUHS Oct 2009]
4. Describe the various orthognathic surgeries of maxilla. De-
scribe in detail Le Fort I osteotomy. [MUHS May-Jun 2008]
5. Fluid and electrolyte balance following major maxillo-
facial surgery. [RGUHS Apr 2008]
Section | III  Previous Years’ Question Bank 281

6. What is orthognathic surgery? Define and classify jaw Short Essays

deformities. How will you diagnose, plan, and correct
1. Indications and technique of sulcus extension proce-
a bimaxillary proclination in a 22 year old girl?
dure. [RGUHS Dec 2009 (RS2)]
[MUHS Oct 2007]
2. Lingual spilt bone technique. [RGUHS Jul 2008
7. Write about facial proportions and also write note on
(RS 2)]
class I and class II prognathism and method to plan
3. Alveoplasty. [RGUHS Jul 2008 (RS 2)]
treatment by orthognathic surgery. [NTR-NR Apr 2006]
4. Cricothyrotomy. [RGUHS Apr 2008 (RS2)]
8. Describe in detail the surgical procedure for removal
5. Alveolar osteitis. [RGUHS 2007 (RS)]
of mesioangular impacted mandibular third molar.
6. Treatment for mandibular prognathism. [RGUHS Aug
[MUHS Jun 2004, 1995]
2006 (RS)]
9. Enumerate the preoperative assessment of a patient
7. Vestibuloplasty. [RGUHS Aug 2006 (RS)]
undergoing orthognathic surgery. Describe anyone sur-
8. Tracheostomy. [Goa Dec 2005]
gical technique for the management of a patient with
9. Indication of transalveolar extraction. [Oct 1998,
mandibular prognathism. [MUHS May 2003]
2002]
10. How will you evaluate a patient for orthognathic sur-
10. Winter’s lines. [MUHS Nov 2002]
gery? Explain bilateral sagittal spilt osteotomy. [Goa
11. Indications and technique for genioplasty. [MUHS Oct
2003]
1992, 1994, 2001]
11. Give the indications, advantages, and the surgical tech-
12. Maxillary osteotomies. [MUHS May 2001]
nique of the ramus sagittal split osteotomy procedure.
13. Non-healing socket (dry socket). [MUHS Oct 1999]
[MUHS Jun 2002]
14. Post-extraction haemorrhage. [MUHS 1998]
12. Describe anyone classification for impacted mandibu-
15. Cleft lip. [NTR-OR May 1994, Apr 1995, Oct 1997]
lar third molar. Discuss radiological assessment and
16. Methods of wiring in oral surgery. [MUHS Nov 1995]
technique for extraction of a mesioangularly impacted
17. Classification of lower third molar impacted teeth.
mandibular third molar. [MUHS Oct 1993, 2001,
[MUHS Nov 1995]
1998, 2002]
18. Healing of extraction wound. [MUHS May 1995]
13. Give the clinical assessment of maxillary canine impac-
19. Treatment of dry socket. [MUHS 1995]
tion. Discuss the surgical procedure for the removal of
20. Apicocectomy. [MUHS May 1995]
a palatally placed impacted maxillary canine. [MUHS
21. Syncope. [MUHS 1989, 1994]
Oct 1989, 1998]
22. Control of bleeding from extraction socket. [MUHS
14. Classification of impacted lower third molar. [MUHS
1994]
May 1995]
23. Cleft palate. [NTR-OR Oct 1991, May 1993]
15. Surgical technique for bimaxillary prognathism in
24. Clinical features of bimaxillary protrusion. [MUHS
young patient. [MUHS Dec 1994]
Nov 1990]
16. Intraoperative complication of mandibular third molar
25. Non-healing socket. [MUHS 1989]
surgery. [MUHS Dec 1994]
26. Trismus. [MUHS 1989]
17. Enumerate the different techniques for surgical correc-
tion of mandibular retrognathism and describe anyone
in detail. [MUHS Oct 1993] Short Notes
18. What is indication and contraindication for extraction
of tooth? How will you proceed to remove a fractured 1. Genioplasty. [TN Feb 2006; RGUHS Aug 2013]
mandibular first molar? [MUHS Nov 1992] 2. Bilateral sagittal split ramus osteotomy. [TN Feb 2009,
19. Describe the surgical management of maxillary protru- 2012]
sion. Enumerate developmental deformity of jawbone. 3. Ashley’s fracture. [TN Feb 2011]
[MUHS May 1991] 4. Timing of repair of cleft lip and palate. [RGUHS
20. Enumerate the different techniques for surgical correc- Dec 2009 (RS2)]
tion of mandibular prognathism and describe anyone 5. Replantation duct sialolith. [RGUHS Dec 2009 (RS2)]
in detail. [MUHS May 1991] 6. Torus mandibularis. [RGUHS Dec 2009 (RS2)]
21. Describe the technique of apiectomy. Enumerate the 7. Tracheostomy. [RGUHS Jul 2008 (RS2), May 2009]
indications and the complications of apiectomy. 8. Apiectomy. [RGUHS Sep 2003; Jul 2008 (RS 2); TN
[RGUHS Feb 1991] Feb 2005]
22. Discuss preoperative assessment and treatment of 9. Actinomycosis. [RGUHS Jul 2008 (OS)]
impacted third molar. [MUHS Jul 1989] 10. Define impaction. Mention any two classifications of
23. Describe the technique of apiectomy. Enumerate the mandibular third molar impactions. [MUHS May-Jun
indications and the complications of apiectomy. 2008]
282 Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
1 1. Define syncope and its management. [MUHS 2008]
12. Trismus. [RGUHS Jul 2008]
13. Apertognathia. [RGUHS Jul 2008 (RS2)]
14. Indications of saggital split osteotomy. [RGUHS
Feb 2007 (RS)]
1 5. Consent for surgery. [RGUHS Feb 2007 (RS)]
16. Cricothyroidectomy. [RGUHS Feb 2007 (RS)]
17. Name four incisions for removal of impacted mandibu-
lar third molar. [MUHS May 2007]
18. Mention four steps in exposure of unerupted incisor.
[MUHS May 2007]
19. How will you evaluate a case of purpose for extrac-
tion? [MUHS Nov/Dec 2007]
2 0. Ventibuloplasty. [TN Aug 2006]
21. Principles of flap design and types of flap. [TN Feb
2006]
22. Which teeth are commonly impacted? Give Winter’s
classification of impacted mandibular third molars.
Mention four complications of prolonged retention of
impacted teeth. [MUHS Nov 2006]
23. What is ‘Difficulty Index’ in relation with removal of
impacted mandibular third molar? What is total ‘diffi-
culty score’ of distoangularly impacted level B (depth)
class II (Ramus relation) wisdom molar in mandible?
[MUHS May 2006]
2 4. Torus palatinus. [RGUHS Mar 2005]
25. Alveolar osteitis sinoc [TN Feb 2005; TN Feb 2005]
26. Alveolectomy. [TN Apr 2001; TN Feb 2005]
27. Enumerate the various principles of intraoral flap
designing and name various mucoperiosteal flaps
employed in oral surgery. [MUHS Jul 2005]
28. Cleft lip and palate protocol. [NTR-OR Oct 2005]
Implantology and Miscellaneous
Long Essays
1. Evaluation of implant and the procedure of single tooth
loss. [RGUHS Oct 2009 (RS)]
2. Bone grafts in maxillofacial surgery. [RGUHS May 2009]
3. TMJ ankylosis. [RGUHS May 2009]
4. Define dental implant. Classify and discuss the indica-
tions, contraindications, and complications. [TN
Aug 2009]
5. Discuss the lymphatic drainage of face. [RGUHS
Apr 2008]
6. Discuss in detail the lymphatic drainage of head and
neck and its relevance to neck dissection. [RGUHS Apr
2008 (RS2)]
7. Tetracycline. [MUHS Nov 1989, 2000]
29. Treatment of mandibular prognathism. [NTR-NR Apr
2005]
30. Apicoectomy. [NTR-OR Oct 1998, 2001 NTR-NR
Apr 2005; TN Feb 2005]
31. Frenectomy. [NTR-OR Apr 2001; RGUHS Aug 2005]
32. Vestibuloplasty. [NTR-OR Apr 1998; GAO 2004]
33. Describe the amber and red line. [MUHS Oct 2004]
34. List five post-operative complications of removal of
impacted mandibular third molar. [MUHS Oct 2004]
35. Classify impacted third molar impactions of mandible
with diagrammatic presentation. [MUHS Jul 2004]
36. What are the preoperative methods of estimation of
results in orthognathic surgeries? [MUHS Jun 2004]
37. List 10 causes of trismus. [MUHS 2004]
38. Classify impacted maxillary third molars - any two
classifications. [MUHS May 2003]
39. Re-implantation. [NTR-NR Oct 2002]
40. Frenectomy. [NTR-OR Oct2002]
41. Genioplasty? [RGUHS Sep 2000, Mar 2002]
42. Describe the ‘Winter’s lines’ used for lower third
molar impactions. [MUHS Nov 2002]
43. Syncope. [MUHS 2002]
44. Genioplasty. [RGUHS Mar 2002, Sep 2000]
45. Wassmund’s technique. [RGUHS Sep 2001]
46. Genioplasty – Indication, diagnosis, and technique.
[NTR-NR Oct 2001]
47. Mention Winter’s lines with the significance of each.
[MUHS Oct 200l]
48. Prognathism. [NTR-OR Oct 1997]
49. Tooth transplantation. [NTR-OR Nov1994]
50. Sulcus extension. [NTR-OR Nov1992]
51. High labial frenum. [BUHS Jan 1989]
Topic 20
8. Corticosteroid in oral surgery. [MUHS Dec 1999]
9. Antibiotics in oral surgery. [MUHS Dec 1999]
10. Prophylactic antibiotic protocol for high-risk patients.
[MUHS May 1995]
11. Ampicillin. [MUHS May 1994]
12. Action, side effects, and dosage of amoxicillin. [MUHS
Oct 1993]
Short Essays
1 . Waste disposal. [RGUHS Aug 2013]
2. Methicillin-resistant Staphylococcus aureus. [RGUHS
Oct 2009 (RS)]
3. Components of computers. [RGUHS Oct 2009
(RS)]
Section | III  Previous Years’ Question Bank
4. Antibiotics for oral infection. [RGUHS Dec 2009
(RS2)]
5. Principles of antibiotic therapy. [NTRUHS Aug 2009;
RGUHS Apr 2008]
6. Mandibular hypertrophy. [RGUHS Jul 2008 (RS 2)]
7. Indications of blood transfusion for maxillofacial
surgery. [RGUHS Apr 2008]
8. Little’s area. [RGUHS Apr 2008]
9. Deglutition. [RGUHS Apr 2008]
10. Tetanus. [RGUHS Apr 2008 (RS2)]
11. Cellular change in radiation and its manifestation.
[RGUHS Apr 2008 (RS2)]
12. NSAID. [RGUHS Feb 2007 (OS)]
13. What do you mean by massive antibiotic therapy?
What are the conditions in maxillofacial surgery?
Where it is used? [MUHS Nov/Dec 2007]
14. Write four antibiotics used in oral surgery with its
doses. [MUHS May 2007]
15. Open cap splint osteosynthesis. [NTR-NR Apr 2006]
16. Champy’s osteosynthesis line for monocortical plat-
ing. [NTR-NR Apr 2006]
17. Lymphadenitis in maxillofacial region. [RGUHS
Aug 2006]
18. Trismus. [RGUHS Aug 2005]
19. Classification and indication of steroids. [NTRUHS
Mar 2004]
20. Classification of steriods. [RGUHS Mar 2004]
21. Prophylactic antibiotics. [Goa 2002]
22. Tracheostomy? [NTR-NR Oct 2001]
23. Cryosurgery - Principles and indications in oral
lesions? [NTR-OR Apr 2001]
24. Preanaesthetic preparation of a patient. [NTR-OR
Apr 2001]
25. Class shift cone technique. [RGUHS Sep 2001]
26. Cryosurgery. [NTR-GR May 1994, Apr 1995,
Oct 1998]
27. Visualized treatment objective planning (VTO).
[MUHS 1995]
28. Endosseous implants. [MUHS 1995]
29. Carotid ligation. [NTR-OR Nov 1992]
30. Partech method. [MUHS 1991]
31. Cavernous sinus thrombosis. [MUHS 1991]
Short Notes
1 . Cryosurgery. [RGUHS Aug 2013]
2. Penicillin. [RGUHS Apr1987, Sep 2000; NTR-OR
Apr 2000; TN Feb 2013]
3. NSAID. [TN Feb 2011]
4. Dental implant. [TN Feb 2009]
5. Dexamethosone. [TN Aug 2009]
6. Laser in oral surgery. [TN Aug 2009]
7. Kole’s procedure. [TN Aug 2009]
8. Nerve antibiotics. [TN Aug 2009]
283
9. Genioplasty. [RGUHS May 2009]
10. Skin grafts. [RGUHS May 2009]
11. Alveolar bone grafting. [RGUHS May 2009]
12. Ketamine. [NTRUHS Aug 2009]
13. Amoxicillin [NTRUHS Aug 2009]
14. Microgenia. [RGUHS Jul 2008]
15. Endosseous implants. [RGUHS Jul 2008]
16. Osteointegration. [RGUHS Jul 2008]
17. Define syncope and its management. [MUHS 2008]
18. Chemotherapy. [NTR-NR Apr 2004; RGUHS
Jul 2008]
1 9. Uses of steroids in oral surgery. [TN Feb 2007]
20. Metronidazole. [TN Aug 2007]
21. Preanaesthetic medication. [TN Aug 2007]
22. Indications for implants in oral surgery. [RGUHS
Feb 2007 (RS)]
23. What is a Battle’s sign? What is the differential diag-
nosis of it? [MUHS 2007]
24. What are the branches of external carotid artery?
[MUIHS 2007]
25. Write a note on cavernous sinus thrombosis. [MUHS
2007]
2 6. Late labial segment imbrication. [TN Feb 2006]
27. Principles of antibiotic therapy. [NTR-NR Oct 2006]
28. Steroids in maxillofacial surgery. [TN Feb 2006]
29. Non-steroidal anti-inflammatory drugs - its pharmaco-
logical actions. [RGUHS Aug 2006 (RS)]
3 0. Pathways of pain. [NTR-NR Oct 2006]
31. Apert’s syndrome. [NTR-NR Apr 2006]
32. Intraligamentary anaesthesia. [NTR-NR Oct 2006]
33. Eburnation. [RGUHS Aug 2006]
34. Verrill’s sign. [RGUHS Aug 2006]
35. Neurotemesis. [RGUHS Aug 2006 (RS)]
36. Hyperventilation. [RGUHS Aug 2006 (RS)]
37. Classification of NSAIDs. [RGUHS Aug 2005]
38. Prophylactic antibiotic therapy. [NTR-NR Oct 2005]
39. Functional neck dissection. [NTR-NR Apr 2005]
40. Classification of NSAID. [RGUHS Aug 2005]
41. Beta-lactam antibiotics. [Goa Dec 2005]
42. Premedication. [NTR-OR Nov 1992, Apr 1997, 1998,
NTR-NR May 2004, Apr 2005]
4 3. Antibiotic for orofacial infection. [NTR-NR Apr 2004]
44. Presurgical antibiotic prophylaxis. [NTR-NR Oct 2004]
45. Classification of steroids. [RGUHS Mar 2004]
46. Diazepam. [NTR-NR Oct 2004]
47. Risdon’s incision. [NTR-NR Apr 2004]
48. Giant cell lesions. [NTR-NR Apr 2004]
49. Intraoral incision. [NTR-NR Apr 2004]
50. Write in brief the signs and symptoms of AIDS.
[MUHS 2004]
51. Define tracheostomy and mention five of its indica-
tions. [MUHS 2004]
52. Cephalosporins. [RGUHS Sep 2001, Mar 2004; NTR-
OR Oct 1999]
284
5 3. Analgesics. [RGUHS Sep 2003]
54. Submucous fibrosis. [RGUHS Sep 2003]
55. Analgesic in OMF surgery. [NTR-OR Oct 2002]
56. Idiosyncrasy. [NTR-NR Oct 2002]
57. Incision and drainage. [NTR-NR Oct 2002]
58. Battle’s sign. [RGUHS Mar 2002]
59. Chemotherapy in oral surgery. [TN Sep 2002]
60. Antibiotics. [RGUHS Sep 1994; TN Sep 2002]
Quick Review Series for BDS 4th year: Oral and Maxillofacial Surgery
6 1. Clark’s shift cone technique. [RGUHS Sep 2001]
62. Anti-inflammatory drugs. [NTR-NR Oct 2001]
63. Broad-spectrum penicillins. [NTR-OR Apr 2001]
64. Diclofenac sodium. [NTR-OR Apr 2000]
65. Tachyphylaxis. [RGUHS Sep 2000]
66. Aspirin. [NTR-OR Apr 1997]
67. Pentazocine. [NTR-OR Nov 1992]
68. Role of antibiotics in oral surgery. [RGUHS Oct 1987]