Question 1:

This lesion has arisen quickly in a fourteen year old boy.  It is not particularly tender and bleeds easily
during toothbrushing.

 What is the likely diagnosis of this lesion?

 What is the appropriate treatment?
 What other group of patients may display this lesion?
 How does the treatment differ in this group?

Question 1: Answer
 Angiogranuloma a.k.a. pyogenic granuloma
 Limited excision and promotion of oral hygiene.
  Pregnant women.
 Do not excise as will resolve after delivery.

Question 2:

 What radiographic sign seen here is characteristic of inferior alveolar nerve involvement?
 Name two other radiographic signs of nerve involvement.
 What warning is appropriate for this patient prior to removal of this impacted wisdom tooth?

Question 2: Answer
 Deviation of the canal.
 Constriction of the canal and change in radiodensity of the root.
 Temporary long-term or permanent paraesthesia/ anaesthesia/ dysaesthesia 

Question 3:

This painless ulcer has been present for many months in a sixty-year old man.
  How would you biopsy this lesion?
 What is the likely diagnosis?
 Name two common aetiological factors in the development of this condition.

Question 3: Answer
 Incisional biopsy to include wedge of lesion and margin of normal tissue.
 Squamous Cell Carcinoma.
 Alcohol and tobacco.

Question 4:

This patient presents requesting removal of a painful #15

 How might extraction of this tooth be complicated?

 How should this be managed?
 What symptoms may indicate that this management has failed?

Question 4: Answer
 Creation of oro-antral communication.
 Immediate closure of the socket or (if not possible) advancement of mucoperiosteal flap.
 Escape of air or fluid from the antrum into the mouth with valsalva manoeuvre (inflation of
nose against closed nostrils and glottis) or into the nose with reverse valsalva manoeuvre
(inflation of cheeks). 

Question 5:
The patient returns after removal of this third molar, with persistent bleeding of the socket.

 What tissue is the most likely source of the bleeding?

 Name two other possible sources.
 How is each controlled?

Question 5: Answer
1. Soft tissue - usually gingival margin (a).
2. Bone (b)
Inferior alveolar vessels (c)
3. Suction, good light and pack with gauze, and additionally: 

For (a)   Ligation (mattress) suture or diathermy if bleeding point can be identified.

For (b)   Crush bleeding points or apply bone wax. 

For (c)   Oxidized cellulose (Surgicel) or gelatin foam (Gelfoam) - do NOT diathermy, crush or
apply bone wax - this may further compromise the inferior alveolar nerve.

Question 6:
This bluish lesion on the lower lip of a teenage boy arose after he bit it. The area is painless and quite
soft to palpation.

 What is the most likely diagnosis?

 What else may it be?
 What is the management of choice?

Question 6: Answer
 Mucocoele.
 Salivary tumour or haemangioma.
 Excision (together with any associated minor salivary glands to prevent recurrence) avoiding
the labial artery and mental nerve.

Question 7:

This radiograph was of a seventy-year-old man complaining of intermittent sublingual swelling.

 What is the most likely cause?

 How should it be treated?

 Question 7: Answer
 A sialolith in Wharton's duct.
 If accessible intra-orally, the duct posterior to the stone should be temporarily ligated to avoid
the stone slipping posteriorly, and the duct then opened over the stone to eject it.
 The wound should be left open to drain, and NOT sutured - to avoid ductal stenosis.
 Salivary stimulants and gland massage post-operatively are also important. If the stone is in
the posterior part of the duct and not accessible intra-orally, then the patient should be
referred for gland removal.

Question 8:
This keratotic pattern is present on the cheek of a well-controlled diabetic patient and associated with
a burning sensation.

 What is the likely diagnosis?

 What other lesions may be associated?
 What is the name of the pattern of keratosis?
 What is the name of the syndrome that this patient may have?
 What is the management of the problem?

Question 8: Answer
 Lichen Planus.
 Pruritic rash on extensor surfaces of the skin.
 Wickham's Striae.
 Greenspan's Syndrome. [ Less observed Bullous,warty, and erosive-ulcerative form,
which may develop in patients with diabetes mellitus (Greenspan's syndrome).]
 Biopsy (if diagnosis unsure) and then sparingly applied topical steroid to alleviate symptoms.
Regular review as there is controversy as to whether these lesions are pre-malignant.

Question 9:
This OPG was taken after a fourteen-year-old girl presented with a retained #53.

 Name three other views that could help localise the #13 in the labio-palatal plane.
 Why should this tooth be removed, exposed or regularly reviewed?
 What is the prognosis for exposure and orthodontic extrusion?
 What is the prognosis for #53 if #13 is removed?

Question 9: Answer
 Tube shift peri-apicals, lateral cephalometic, or vertex occlusal view.
 With any unerupted tooth, follicular cyst formation and expansion may resorb surrounding
teeth.
 In a patient of this age, root closure is yet to occur, and ankylosis is unlikely, thus the
prognosis is good. Prognosis is inversely related to the time elapsed from when the tooth could
have been expected to erupt.
 The prognosis for #53 is guarded even if there is still significant root structure remaining. It
may be damaged or undermined during the process of removal of #13 and will require regular
restoration of its crown to offset the increased wear of deciduous enamel and maintain
aesthetics. Long-term replacement options include a partial upper denture, a bridge (providing
#12 has sufficient root surface area) or an implant. The small size of the #53 space may
mean that an ideally aesthetic restoration may need to be preceded by orthodontics to open
the space.

Question 10:

This radiograph is of a seven-year-old girl. What is happening to the deciduous second molar?

 How should this be treated?

 What will happen if it is not treated?

Question 10: Answer

The molar is ankylosed and is submerging as the alveolus around it grows. The molar should be
removed (it may be extremely difficult due to the ankylosis) and an orthodontic opinion sought
regarding space maintenance for the second premolar.

If not removed, the molar will continue to submerge, will displace the succeeding premolar inferiorly
and may be a source of chronic infection.

Question 11:

This photograph is of a fourteen-year-old girl who dislikes the gap between her front teeth.

 What is the cause of the gap?

 How may surgery help her?

Question 11: Answer

A prominent maxillary midline labial fraenum.

Excision of the fraenum (including its palatal attachment) AFTER closure of the diastema
orthodontically will reduce the bulk of the tissue, improve the aesthetics and help to avoid relapse. 
Removal of the fraenum prior to closure of the diastema will result in compression of the residual scar
tissue during the subsequent orthodontic treatment, and increase the risk of relapse.

Question 12:
This woman requests restoration of the lower right quadrant with implants.

 What systemic conditions may contraindicate implants?

 How would you assess the available bone?
 If insufficient, what options exist?

Question 12: Answer

Any degree of immunosuppression resulting in an increased susceptibility to infection (corticosteroid
treatment, renal disease, diabetes mellitus, organ transplant) or diminished peripheral vascularity
(diabetes mellitus, smoking) or diminished bone quality (osteoporosis) or any musculoskeletal
problem that was an impediment to meticulous oral hygiene (arthritis, cerebral palsy, Parkinson’s
disease).

The available bone must be assessed in terms of adequate height AND width AND density, away from
anatomical structures – in this case the inferior alveolar nerve. This is best assessed with CT scans
reconstructed to provide cross-sectional views along the dental arch (Dentascans).

Inadequate height or width of bone may be able to be corrected by onlay or interpositional grafts of
autologous bone. Localized defects can be treated with guided tissue regeneration and if necessary the
inferior alveolar nerve can be exteriorised from the mandible at the proposed implant sites. These
procedures all carry their own various morbidities.

Question 13:
#43 and #42 were avulsed, washed and dried and not replanted for several hours.

 What is happening to these teeth?

 How should they be managed?
 How could the outcome have been improved at the time of injury?

Question 13: Answer

Internal and external resorption and apparent peri-apical infection of #42.

At an earlier stage, root canal treatment may arrest both processes, but these teeth are probably not
salvageable. They can be extracted immediately to prevent further bone loss (especially if implants
are contemplated) or retained until they become symptomatic or mobile.

For best results, avulsed teeth should be reimplanted immediately, or, at worst, stored in milk or the
patient’s saliva and reimplanted within the hour. The root surface should not be handled except to
rinse off foreign material.

Question 14:

This elderly lady's tongue has been painful for some months.
  What investigations are warranted?
 Assuming no systemic cause can be found, how should she be treated?

Question 14: Answer

After ensuring that she is adequately nourished (as vitamin deficiency can be an important cause of
glossodynia a.k.a. BMS) and that there is no infective cause such as candidiasis, full blood count and
electrolytes should be checked, followed by more specific tests for vitamin B12, folate and iron
levels.  Any degree of xerostomia warrants checking the flow of major salivary glands, and if
reduced, an ESR and auto-antibody screen, together with a sialogram to exclude Sjögrens syndrome
are warranted.

Many of these patients do not find relief, but initially salivary stimulants and artificial saliva should be
trialled to reduce the symptoms of xerostomia. If the pain persists then hormone replacement
therapy and even low dose antidepressant or benzodiazepine therapy may be useful.

Question 15:

This patient complains of pain and tingling in her lower right lip whilst wearing her denture.

 What is the likely cause?

 What surgical options may help?

Question 15: Answer

Resorption of the ridge has resulted in the left mental foramen being positioned at the crest and
adjacent to an exostosis against which the denture compresses the mental nerve.

Removal of the exostosis may improve the symptoms, although initially there will be paraesthesia
from the surgery.  If the problem persists, and conservative measures such as soft denture linings do
not help, consider implant placement to reduce the tissue borne component of the denture, or even
eliminate it, with an implant supported bridge.

Question 16:
This radiolucent area was an incidental finding on this OPG.

 What investigations are required?

 How would you treat this lesion?

Question 16: Answer

Previous radiographs should be retrieved to determine how long the area has been present. The
vitality of any adjacent teeth should be established and if possible, the area aspirated with a wide
bore needle to exclude a vascular lesion. Aspirated fluid should be submitted for cytology and protein
analysis. Fluid from an uninfected keratocyst will characteristically contain squames and a low
protein level. Even if the lesion cannot be aspirated, it may still be possible to retrieve a core of
tissue from the needle to be smeared onto a glass slide and immersed in alcohol for cytology.

Assuming that the lesion is not vascular, the area should be accessed by making a window in the
buccal bone to curette the lesion and then any unsalvageable teeth should be removed. Ideally,
frozen section will reveal the nature of the lesion and whether wider excision and sacrifice of any
adjacent teeth is necessary. Any remaining teeth must be checked post-operatively for vitality and
root canal treatment instituted as necessary.

Question 17:
This patient complains of being unable to bring her front teeth together. Old photos reveal that this
has not always been the case.

 What is causing the problem?

 How should it be investigated?
 How can she be treated?
Question 17: Answer
The mandibular condyles appear to be resorbing and the loss of ramus height is rotating the mandible
open.

It is important to establish whether the problem is systemic by querying involvement of any other
joints, and whether it is progressive – by reviewing old radiographs or arranging serial views, ESR and
Rheumatoid screen and bone scanning.

Treatment involves waiting for the situation to become stable, and then impacting the maxilla to allow
the mandible to rotate closed, or alternatively replacing the joints and re-establishing ramus height
with rib grafts. Either approach may be prone to recurrence.

uestion 18:

This patient requested referral to an orthodontist to get his teeth straightened.

 What is this patient's problem?

 How should it be treated?

Question 18: Answer

The patient has a class III skeletal malocclusion due not only to prognathism, but also due to
maxillary retrusion.

The problem is not correctable by orthodontics alone. The patient requires about 12 months of
presurgical orthodontics to decompensate the dental changes that have occurred as a result of the
skeletal pattern, followed by surgery to advance the maxilla and set back the mandible, followed by 3
– 6 months of finishing orthodontics.

Question 19:

This patient's presenting complaint was of recurrent pain and swelling palatal to the upper incisors.

 Why is this occurring?

 What are the treatment options?

Question 19: Answer

Due to low mandibular angle and mandibular retrusion, the interincisal angle between the upper and
lower incisors is almost 180 degrees and thus there is no barrier to the lower incisors overerupting
into the palatal gingival margins of the upper incisors. Progressive stripping causes periodontal
abscess formation with eventual loss of the upper incisors. The same process can lead to stripping of
the labial gingival of the lower incisors with loss of those as well.

The immediate problem can be solved with periodontal therapy and a palatal splint, however this
cannot be worn to eat, and so the problem is slowly progressive. Orthodontic correction of the
interincisal angle is achieved by proclining the upper incisors and retroclining the lower incisors. This
will create an excessive overjet which will not be stable without permanent retention, or surgical
advancement of the mandible.

Question 20:
This patient complained that his face was crooked and on inspection, the mandibular midline was 7mm
to the left of the maxillary midline.

 What has caused this problem?

 What investigations are needed?
 How should the problem be treated?

Question 20: Answer

Right sided condylar hyperplasia or left sided condylar hypoplasia has resulted in relative elongation
of the right ramus and deviation of the occlusion to the opposite side.

A bone scan will reveal if there is ongoing excessive activity of the right side by comparison with the
left.

If the patient has completed growth, but the condyle is continuing to grow, it should be removed and
replaced with a rib graft, to prevent progressively worsening deformity. Simultaneously, a sagittal
split osteotomy can be performed upon the other side, to advance, and rotate the midline back to
the centre. If there is no growth continuing on either side, then a bilateral sagittal split will allow
rotation back to the midline. If the patient's growth is continuing on both sides, then surgery is
deferred until the normal side stabilises, unless the deformity becomes excessive.