The American Board of

Oral and Maxillofacial Surgery

2005 OMSSAT Self Assessment Tool

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Question:
A 36-year-old obese female is in your office requesting a general anesthetic for extraction of a carious
tooth. Your primary concern in regards to her obesity and pulmonary function is:

A. a decreased FEV1.
B. a decreased functional residual capacity.
C. a decreased minute ventilation.
D. a decreased residual volume.

Answer: B

Rationale:
Morbid obesity is characterized by reductions in functional residual capacity (FRC= volume remaining in
the lungs after a normal quiet expiration), expiratory reserve volume (ERV=volume of air that can
forcefully expired after a normal resting expiration) and total lung capacity (TLC). These changes have
been attributed to mass loading and splinting of the diaphragm. Anesthesia compounds these problems
and impairs the ability of the obese to tolerate periods of apnea. Residual volume consists of the gases
remaining in the lung after a forced expiration and is less variable than other parameters. FEV1 is the
forced expiratory volume in 1 second and is most often used as a determinant of inflammation and small
airway obstruction in obstructive lung diseases such as asthma.

Reference:
nd
Stoelting RK & Dierdorf SF. Handbook for Anesthesia and Co-Existing Disease. 2 ed. Churchill
Livingston 2002 pages 333-342.

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Question:
Which of the following is the least likely cause of acute respiratory distress in the traumatized patient
who is conscious when presenting to the emergency department?

A. Cervical fracture above C5

B. Cricoid fracture
C. Flail chest
D. Pneumothorax

Answer: D

Rationale:
All of the above can cause respiratory distress. Blunt trauma to the airway is most commonly secondary
to direct blows. A passenger in the front seat with only a lap belt is susceptible to hitting his symphysis or
neck on the dashboard. Between 10% to 50% of the patients sustaining blunt airway trauma have a
cervical spine injury. Respiratory complications are common with cervical spine injuries. The extent of
the respiratory derangement is associated with the level of the injury to the cervical spine. While the
patient will have some respiratory compromise, diaphragmatic paralysis is spared with injuries at C5 or
below. Fractures of the cricoid cartilage are not common. When they do occur there is a 25% incidence of
damage to the recurrent laryngeal nerve, which results in vocal cord paralysis and airway compromise.
Mortality associated with cricoid fractures is reported to exceed 43%. Application of cricoid pressure to a
patient with a cricoid fracture can result in airway obstruction. A flail chest is by definition fractures of
three adjacent ribs and results in paradoxical chest wall movement. A pneumothorax may impair
respirations but in most situations will not result in acute respiratory distress. This should be distinguished
from a tension pneumothorax and an open pneumothorax which can cause acute distress.

Reference:
Benumof Airway management: Principles of Practice, Mosby 1995 Chapter 34 pages 742-743.

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Question:
Which of the following is a property of metoclopramide?

A. Delays gastric emptying

B. Intensifies activity of the vomiting center
C. Increases gastroesophageal sphincter tone
D. Attenuates extrapyramidal effects

Answer: C

Rationale:
The incidence of aspiration is relatively low at 5 cases per 10,000. This incidence, however, is markedly
increased in the traumatized patient. Pharmacologic measures may decrease the risk of aspiration.
Metoclopramide stimulates gastric emptying, attenuates activity of the vomiting center and increases
gastroesophageal sphincter tone. It must be administered at least 20 minutes prior to induction and its
effect is decreased if administered in conjunction with an opioid. It acts on the dopamine receptor in the
chemoreceptor trigger zone and thus can cause extrapyramidal effects. These effects can be treated with
benzotropine or diphenhydramine.

Reference:
Benumof Airway management: Principles of Practice, Mosby 1995 Chapter 34 pages 746 – 748.

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Question:
Which of the following interventions can facilitate a fiberoptic nasoendotracheal intubation in a patient
with a right temporomandibular joint ankylosis?

A. Anesthetizing the pharyngeal branch of the glossopharyngeal nerve

B. A recurrent laryngeal nerve block
C. An inferior laryngeal nerve block
D. Transtracheal administration of lidocaine

Answer: D

Rationale:
Intubation of an awake patient causes significant airway stimulation and irritation. Anesthetizing the
mucosa of the upper airway can improve comfort and lessen unpleasant stimulation associated with this
procedure. Topical application of local anesthetic agent can be accomplished orally (as a swish and
swallow) or by transtracheal deposition into the tracheal lumen. However, these techniques may blunt the
glottic and cough reflex, increasing the patient's susceptibility to aspiration. The gag reflex can be further
controlled by supplementary nerve blocks to the lingual branch of the glossopharyngeal nerve and the
superior laryngeal nerve. The glossopharyngeal nerve block requires the bilateral deposition of local
anesthetic agent into the caudad portion of the tonsillar pillar. The superior laryngeal nerve block is
accomplished by deposition of local anesthetic agent into the thyrohyoid membrane.

Reference:
Bennett JD, Flynn TR. Anesthetic Considerations in Orofacial Infections, in Oral and Maxillofacial
th
Infections, eds. Topazian, Goldberg, Hupp WB Saunders 4 ed 2002.

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Question:
Which of the following drugs is most protective against bronchospastic activity?

A. Etomidate
B. Methohexital
C. Propofol
D. Thiopental

Answer C

Rationale:
Propofol can produce bronchodilation and decrease the incidence of intraoperative wheezing in patients
with asthma. In one study comparing propofol, methohexital and thiopental propofol demonstrated a
significantly decreased incidence of wheezing after induction and intubation compared to the other
agents. Etomidate has less of a depressant effect on ventilation compared to barbiturates, however, but is
not protective against bronchospasm.

Reference:
Pizov R.,Brown RH.,Weiss YS,Baranov D.,Hennes H. Baker ,. Hirshman CA. Wheezing during induction
of general anesthesia in patients with and without asthma. A randomized, blinded trial Anesthesiology.
82(5):1111-6, 1995 May.

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Question:
A 26-year-male, weighing 80 kg and 6 feet tall is sedated with midazolam 5 mg, fentanyl 100 mcg
followed by methohexital 90 mg. The patient’s heart rate increases from 88 to 102 BPM and his oxygen
saturation drops from 98% to 90%. The patient is making ventilatory efforts with respiratory noises. The
desaturation is most likely secondary to:

A. bronchospasm.
B. hypoxic respiratory depression.
C. Laryngospasm.
D. supraglottic obstruction.

Answer: D

Rationale:
Most anesthetics depress the hypercapneic and hypoxic respiratory drive, diminish upper airway tone,
blunt upper airway reflexes and decrease functional residual capacity. While the respiratory drive may be
blunted and the reflexes diminished the anesthetic doses administered to this size patient will allow
continual spontaneous ventilation if the airway is kept patent either with positioning (e.g. chin – forehead
lift) or airway devices (e.g. nasopharyngeal airway). This patient is making ventilatory efforts. The
respiratory noises are most likely associated with supraglottic obstruction. Alleviating the obstruction
should facilitate ventilation and increase oxygen saturation. The increase in heart rate is most likely
secondary to the methohexital.

Reference:
Stoelting and Miller, Basics of Anesthesia, Churchill Livingstone, 2002.

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Question:
Which of the following medications is most likely to be a contributory factor towards post-operative
agitation and combativeness?

A. Glycopyrrolate
B. Propofol
C. Meperidine
D. Midazolam

Answer: C

Rationale:
There are a number of factors that can contribute to a patient's disorientation or combativeness after an
anesthetic. Combativeness may be manifest as the patient emerges from a general anesthetic until
oriented. The surgeon must always consider that the patient is hypoxic. Tertiary anticholinenergic drugs
(atropine and scopolamine) can cross the blood brain barrier and lead to postoperative delirium.
Glycopyrrolate is a quarternary agent and does not cross the blood brain barrier. Propofol is associated
with rapid recovery and euphoria. Long acting benzodiazpines may also contribute to disorientation on
emergence. In young healthy patients recovery from midazolam is generally not associated with
disorientation. Meperidine, although rare, because of its atropine-like structure can cause post-operative
agitation and combativeness.

Reference:
Harkin CP. Postoperative delirium page 192 – 194 in Complications in Anesthesia eds. Atlee JL WB
Saunders 1999.

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Question:
Which of the following antiemetic agents achieves its primary antiemetic effect by its strong blocking
action on the dopamine receptor located in the chemoreceptor trigger zone?

A. Prochlorperazine (Compazine)
B. Diphenhydramine (Benadryl)
C. Metoclopramide (Reglan)
D. Scopolamine (Transderm Scop)

Answer: A

Rationale:
Serotonin, dopamine, acetylcholine and histamine receptors are located in the chemoreceptor trigger zone.
All of the above agents act to some degree on the dopamine receptor. Of these agents, compazine
achieves its effect by strongly binding to the receptor. Scopolamine and diphenhydramine bind only
weakly.

Reference:
Yagiela J: Review of Antiemetic therapies. Oral and Maxillofacial Surgery Clinics November 1999,
pages 647 – 658.

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Question:
A 42-year-old patient with a history of asthma, hypertension, and TMD presents for the extraction of
multiple carious teeth. The patient smokes 1 pack per day. Medications include hydrochlorothiazide
(HCTZ) 25 mg, singulair (montelukast) 10 mg and elavil (amitriptyline) 75 mg. Vital signs are BP
142/92, heart rate 92 regular, oxygen saturation 98%. The patient’s lungs are clear to auscultation and he
has not required intervention with his albuterol inhaler for over 10 months. Which of the following
anesthetic agents should be avoided in this case?

A. Fentanyl
B. Ketamine
C. Methohexital
D. Midazolam

Answer: B

Rationale:
Tricylcic antidepressants (elavil) prevent the reuptake of catecholamines. Ketamine has sympathomimetic
effects and will be associated with an increase in heart rate and blood pressure. These effects will be
potentiated by the tricyclic antidepressant and compounded by the patient's history of hypertension.
Methohexital is not contraindicated in a patient with controlled asthma.

Reference:
Faberowski LW & Black S. Antidepressants in Complications in Anesthesia eds. Atlee JL WB Saunders
1999 page 99.

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Question:
Which statement is accurate pertaining to the intramuscular administration of the combination of
ketamine and glycopyrrolate?

A. The onset of the antisialogogue effect of glycopyrrolate parallels the onset of the dissociative
effect of ketamine.
B. The incidence of tachycardia with the combination of glycopyrrolate & ketamine is less than that
which occurs with atropine & ketamine.
C. The incidence of emergence phenomenon is lower with the combination of glycopyrrolate and
ketmaine that that which occurs with atropine and ketamine.
D. The incidence of emesis is lower with the combination of atropine and ketamine that that which
occurs with glycopyrrolate and ketamine.

Answer: B

Rationale:
Ketamine is associated with an increase in salivation. An anticholinergic agent is frequently combined
with ketamine to decrease the hypersalivation. Intramuscularly administered glycopyrrolate has a peak
effect in approximately 30 minutes, while intravenously administered glycopyrrolate has a peak effect in
approximately 1 minute. Robinal is a quaternary amine and does not cross the blood brain barrier
compared to atropine, which is a tertiary amine and does cross the blood brain barrier. However, the
incidence of emergence phenomenon is not higher with atropine when compared to glycopyrrolate.
Ketamine has sympathomimetic effects resulting in an increase in heart rate. Atropine has a greater
potential to potentiate the tachycardia associated with ketamine.

Reference:
Morgensen F, Muller D, Valentin N: Glycopyrrolate during ketamine/diazepam anaesthesia: a double
blind comparison with atropione. Acta Anaesthesiol Scand 30:332;1986.

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Question:
A patient with a history of coronary heart disease presents for removal of mandibular tori. Of the
following medications which is most likely to cause the greatest imbalance in myocardial oxygen supply
and oxygen demand?

A. Fentanyl
B. Ketamine
C. Midazolam
D. Propofol

Answer: B

Rationale:
Ketamine has sympathomimetic effects and causes prominent changes in heart rate, cardiac index, and
systemic vascular resistance. These changes cause an increase in myocardial oxygen consumption that
may be detrimental to the patient with CAD.

Reference:
th
Stoelting, RK, Miller RD: Basics in Anesthesia Churchill Livingston 4 edition 2000.

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Question:
Which of the following medications has the least effect on functional residual capacity?

A. Etomidate
B. Ketamine
C. Midazolam
D. Propofol

Answer: B

Rationale:
Most anesthetics depress the hypercapneic and hypoxic respiratory drive, diminish upper airway tone,
blunt upper airway reflexes and decrease functional residual capacity. Ketamine is unique in that it does
not produce significant depression of ventilation. Upper airway muscle tone is maintained, upper airway
reflexes remain intact and FRC is not diminished.

Reference:
th
Stoelting, RK, Miller RD: Basics in Anesthesia Churchill Livingston 4 edition 2000.

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Question:
Which of the following local anesthetic agents has the slowest onset?

A. Articaine
B. Bupivicaine
C. Lidocaine
D. Mepivicaine

Answer: B

Rationale:
Bupivicaine has a slower onset of action compared to the other agents because of its greater degree of
ionization at physiologic pH.

Reference:
Jastak JT, Yagiela JA, Donaldson D: Local Anesthesia of the Oral Cavity. WB Saunders 1995 pg 101.

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Question:
Which of the following agents has the shortest half life?

A. Articaine
B. Bupivicaine
C. Lidocaine
D. Mepivicaine

Answer: A

Rationale:
The molecular structure of articaine contains an ester side chain which is rapidly inactivated by
hydrolysis. The ester metabolite is not para-aminobenzoic acid; and thus not associated with allergic
reactions as were the ester local anesthetics (e.g. procaine). The half life for articaine is 27 minutes,
lidocaine 96 minutes, bupivicaine 162 minutes, and mepivicaine 114 minutes.

Reference:
Oertel R, Rahn R, Kirch W. Clinical pharmacokinetics of articaine. Clin Pharmacokinet 33:417;1997.

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Question:
A local anesthetic with epinephrine will have what potential effect when administered to a patient taking
propranolol?

A. Decrease heart rate and decrease blood pressure

B. Decrease heart rate and increase blood pressure
C. Increase heart rate and decrease blood pressure
D. Increase heart rate and increase blood pressure

Answer: B

Rationale:
Propranolol, a nonselective beta-blocker will inhibit the effect of epinephrine binding to the 2 receptor
resulting in a more pronounced effect of the epinephrine binding to the -receptor. This will result in an
exaggerated hypertensive response and a reflex bradycardia. The suggestion is to administer 1 mL of local
anesthetic with epinephrine 1:100,000 and evaluate the response in 5 minutes.

Reference:
Jastak JT, Yagiela JA, Donaldson D: Local Anesthesia of the Oral Cavity. WB Saunders 1995 pg 132.

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Question:
At the level of the lingula, the inferior alveolar artery and vein are located _______ relative to the inferior
alveolar nerve.

A. anterior
B. medial
C. posterior
D. superior

Answer: C

Rationale:
The inferior alveolar artery and vein are located posteriorly and laterally relative to the inferior alveolar
nerve.

Reference:
Jastak JT, Yagiela JA, Donaldson D: Local Anesthesia of the Oral Cavity. WB Saunders 1995 pg 244.

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Question:
The plasma clearance of which of the following drugs is least affected by a four hour continuous
infusion?

A. Fentanyl
B. Alfentanil
C. Methohexital
D. Propofol

Answer: D

Rationale:
The concept of context-sensitive half-time describes the time necessary for the drug concentration to
decrease a predetermined percentage after discontinuing a continuous intravenous infusion of a specific
duration. Depending on the drug's lipid solubility and the efficiency of its clearance mechanism, the
context-sensitive half-time increases in parallel with the duration of continuous intravenous
administration. The time necessary for the plasma concentration of barbiturates like thiopental and
methohexital is prolonged as drug sequestered in fat and skeletal muscles reenters the circulation to
maintain plasma concentration. When multiple doses of fentanyl or alfentanil are administered or when
there is continuous infusion of the drug, progressive saturation of inactive tissue sites occurs prolonging
the duration of action and clearance of the drug from the plasma. Propofol is rapidly cleared from the
plasma by tissue uptake and metabolism. The clearance of propofol is not significantly influenced by the
duration of continuous intravenous infusion.

Reference:
th
Stoelting, RK, Miller, RD, Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
An extremely apprehensive patient presents for the extraction of four teeth. The patient’s medical history
is significant for congestive heart failure that is managed with digoxin. His METs (metabolic
equivalents) are les than 4. Which of the following drugs would be most appropriate for induction of
general anesthesia for this patient?

A. Etomidate
B. Propofol
C. Thiopental
D. Sevoflurane

Answer: A

Rationale:
Etomidate is one of the few anesthetics that suppresses the adrenocortical axis. Etomidate causes
adrenocortical suppression by producing a dose-dependent inhibition of the enzyme 11-beta-hydroxylase
which is necessary for conversion of cholesterol to cortisol. This suppression lasts 4 to 8 hours after an
induction dose of etomidate. Propofol, ketamine, methohexital do not suppress the adrenocortical axis.

Reference:
th
Stoelting, RK, Miller, RD, Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
A patient with a history of grand mal seizures controlled with Tegretol (carbamazepine) presents for
extraction of third molars under general anesthesia. Which of the following drugs is contraindicated for
this patient?

A. Methohexital
B. Phenobarbital
C. Thiamylal
D. Thiopental

Answer: A

Rationale:
Most of the barbiturates cause a decrease CNS activity and a suppression of seizure activity.
Methohexital is an exception and has been shown to activate epileptic foci.

Reference:
th
Stoelting, RK, Miller, RD Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
A healthy 10-year-old presents for the extraction of a mobile tooth. The patient is extremely
apprehensive and a single intravenous injection of anesthetic is planned for this patient. His parents
reported that he had general anesthesia for placement of ear tubes and when he emerged from anesthesia
he was nauseated and vomited. Which of the following agents is most appropriate for this patient?

A. Etomidate
B. Ketamine
C. Methohexital
D. Propofol

Answer: D

Rationale:
Propofol is the only agent in the group that has antiemetic effects. There is a low incidence of
postoperative nausea and vomiting associated with propofol. The barbiturates do not have antiemetic
properties and postoperative nausea and vomiting may be more common with etomidate and ketamine.

Reference:
th
Stoelting, RK, Miller, RD Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
The predominant cardiovascular effect of intravenous methohexital is:

A. decreased heart rate.

B. depressed myocardial contractility.
C. increased cardiac output.
D. peripheral vasodilatation.

Answer: D

Rationale:
Administration of methohexital produces modest decreases in systemic blood pressure that are transient
due to compensatory increase in heart rate. This decrease in systemic blood pressure is principally due to
peripheral vasodilatation. The resulting dilation of peripheral capacitance vessels leads to pooling of
blood, decreased venous return and the potential for decreases in cardiac output and systemic blood
pressure.

Reference:
th
Stoelting, RK, Miller, RD Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
The short duration of a single dose of methohexital is due to:

A. a low pH.
B. low fat solubility.
C. rate of metabolism.
D. rate of redistribution.

Answer: D

Rationale:
Maximal brain uptake of methohexital occurs within 30 seconds after intravenous administration,
accounting for the rapid induction of anesthesia. Prompt awakening after a single intravenous dose of
methohexital reflects redistribution of these drugs from the brain to inactive tissue sites, especially
skeletal muscles and fat. Large or repeated doses of methohexital may saturate inactive tissues sites,
resulting in prolonged effects. When the inactive tissue sites are saturated, drug clearance becomes
dependent on the rate of elimination.

Reference:
th
Stoelting, RK, Miller, RD Basics of Anesthesia (4 Edition) Churchill Livingstone, 2000.

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Question:
Which drug may induce Serotonin Syndrome when combined with a selective serotonin reuptake
inhibitor (SSRI)?

A. Alfentanil
B. Fentanyl
C. Meperidine
D. Morphine

Answer: C

Rationale:
Serotonin syndrome is characterized by confusion, agitation, tachycardia, fever, hyperreflexia, and
myoclonus. Normeperidine is an active metabolite of meperidine metabolism and has a half-life of 15 to
30 hours in an adult. Normeperidine's elimination is dependent upon renal function and can accumulate
with high repeated dosages or in the presence of renal impairment. Serotonin antagonists, SSRI and
tricyclic antidepressants all may enhance the adverse/toxic effects of meperidine that results in serotonin
syndrome.

Reference:
th
Stoelting RK, Dierforf F: Anesthesia and Co-existing Disease, 4 Edition, 186-199, 2002.

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Question:
A patient who is a heavy-smoker had their last cigarette 2 hours before anesthesia is induced. A SpO2 of
90% might be a PaO2 of which value using standard pulse oximetry?

A. 55 – 60 mm Hg
B. 60 - 75 mm Hg
C. 75 - 90 mm Hg
D. 90 - 100 mm Hg

Answer: A

Rationale:
Oxygenated hemoglobin absorbs less red light (600-750nm) and more infrared light (850-1000 nm) than
deoxygenated hemoglobin. All pulse oximeters utilize 2 wavelengths of light, one in the red band and
one in the infrared band. IN a healthy individual, maintenance of SpO2 of above 90% is evidence that the
PaO2 is most likely higher than 60 mmHg. Dyshemoglobins include carboxyhemoglobin (COHb) and
methmoglobin (MetHb) can affect the accuracy of pulse oximetry readings. COHb absorbs very little
light in the infrared spectrum but much light in the visible red spectrum (hence the “cherry red”
appearance of the patient with carbon monoxide poisoning), thus overestimating the O2 saturation as
measured by pulse oximetry. Heavy smokers have COHb levels of 10-15% that may persist for up to 8
hours after the last cigarette.

Reference:
Blitt CD, Hines RI: Monitoring in Anesthesia and Critical Care Medicine, Churchill Livingston Inc., NY
NY pp 374-380, 1995.

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Question:
The recommended preoperative fasting status for infant formula in infants and children is how many
hours?

A. 2 hours
B. 4 hours
C. 6 hours
D. 8 hours

Answer: C

Rationale:
Gastric emptying is influenced by volume (distention), osmolarity (protein and sugar), fat, and sold vs
liquid (fat slows gastric emptying greater than carbohydrates or proteins). Cavell et al reported that the
gastric emptying in healthy infants at 1 and 6 months of age was 48 minutes for human milk and 78
minutes for infant formula. There is insufficient evidence but the Task Force supports a fasting period of
6 hours or more before an elective procedure.

Reference:
Cavell B: Gastric emptying in infants fed human milk or infant formula. Acta Pedaitr Scand 70:639-641,
1981.

American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of
pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients
undergoing elective procedures. Anesthesiology 90:896-905, 1999.

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Question:
You begin a deep sedation procedure in the office setting with a bolus administration of an opioid. Two
minutes later you note a marked cutaneous splotchy erythema, an increase in basal heart rate from 80 to
110 per minute, a drop in diastolic blood pressure from 70 to 50, and profound bradypnea. Which of the
following opioids is the most likely to cause this change in physiostasis?

A. Butorphanol
B. Fentanyl
C. Meperidine
D. Remifentanil

Answer: C

Rationale:
Meperidine is a phenylpiperidine opioid, but differs from other drugs in this category by its atropine-like
characteristic with marked tachycardic effects and prominent histamine releasing propensity. This would
account for the cutaneous erythema and vasodilative hypotension. Like other phenylpiperidines, it has a
strong mu-receptor agonism which can cause significant respiratory depression. Remifentanil is largely
devoid of histamine releasing effects which would mitigate against cutaneous erythema, but can cause
peripheral vasodilation and hence drop blood pressure with a small amount of reflex increase in heart rate.
Remifentanil, like other pure mu receptor agonists, can cause significant respiratory depression.
Butorphanol is a mu receptor antagonist and pentazocine is a partial mu receptor antagonist while both are
agonists of kappa receptors, hence their limited respiratory depression but significant analgesic properties.
Neither of these agonist/antagonist medications exhibits significant histamine releasing propensities.

Reference:
Stricker J, Laurito C: Opioid Pharmacology, in: Weinberg G (ed.): Basic Science Review of
Anesthesiology, McGraw-Hill, New York, 1997 pp. 28-32.

Duthie DJ, Nimmo WS: Adverse effects of opioid analgesic drugs. Br J Anaesth 1987;59:61-77.

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Question:
The pharmacokinetics of which opioid most closely resembles a one-compartment model?

A. Fentanyl
B. Meperidine
C. Morphine
D. Remifentanil

Answer: D

Rationale:
A one-compartment model involves administration of an intravenous medication intravascularly, and
(relatively rapid) metabolism or elimination causing a more or less linear decrease in plasma drug
concentration. A two-compartment model involves both more rapid initial elimination or metabolism of
an intravascular drug plus the slower release of a drug into the blood from non-vascular tissues such as
muscle or fat, causing a secondary beta phase of more slow decrease in plasma drug concentration by
metabolism and/or elimination. The initial rapid pharmacologic onset of opioids is via their rapid initial
crossing of the blood/brain barrier. With one bolus administration, many opioids are then rapidly
redistributed to other tissues and the central nervous system effects are then ended. However, with
continuous infusion or multiple bolus administration, depot storage of an opioid can occur and prolonged
opioid effects can be manifest by a two-compartment release of drug over time. However, remifentanyl is
so rapidly metabolized by ester hydrolysis that significant depot storage does not occur, and a one-
compartment model of pharmacokinetics is approximated, causing rapid emergence from its effects after
cessation of administration. Meperidine, morphine, and fentanyl undergo more slow hepatic degradation
and follow a two-compartment model.

Reference:
Alston T: Pharmacokinetics and Drug-Receptor Interactions, in: Weinberg G (ed.): Basic Science
Review of Anesthesiology, McGraw-Hill, New York, 1997 pp. 1-7.

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Question:
Which agent is most likely to precipitate withdrawal symptoms in the heroin addicted patient?

A. Levallorphan
B. Meperidine
C. Propoxyphene
D. Tramadol

Answer: A

Rationale:
Levallorphan (a structural analog to the mu receptor agonist levorphanol) is an opioid antagonist; and its
administration causes competitive binding at mu opioid sites throughout the nervous system. However,
levallorphan exhibits mild kappa receptor agonism with analgesic properties. A patient with a heroin
addiction may suffer acute withdrawl symptoms with administration of this or other opioid antagonist
medications. Other opioid antagonists include naloxone and naltrexone. Tramadol is a synthetic analog
of codeine and exhibits weak mu receptor agonism, and is useful for mild to moderate pain. Meperidine
is a phenylpiperidine opioid agonist. Propoxyphene is a methadone analog with somewhat less mu
agonist activity than codeine. Tramadol, meperidine, and propoxyphene will not precipitate opioid
withdrawl.

Reference:
Gustein H, Akil H: Opioid Analgesics, in: Hardman J, Limbird L (eds.): The Pharmacological Basis of
th
Therapeutics 10 ed., McGraw-Hill, 2001 pp 569-611.

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Question:
After bolus administration of fentanyl 5 micrograms/kg as part of a general anesthetic induction, the
patient cannot be ventilated with positive pressure via facemask. After insertion of a laryngeal mask
airway, positive pressure ventilation is still quite difficult and cuff leak is noted. Auscultation shows
some ventilatory sounds over the lung fields. What would be the most appropriate next step?

D. Administer epinephrine 0.5 mg IV

E. Administer sevoflurane
F. Administer succinylcholine 1mg/kg
D. Remove the laryngeal mask airway and place a cuffed endotracheal tube

Answer: C

Rationale:
Fentanyl can cause skeletal (including respiratory) muscle static contraction, especially when given as a
bolus dose. This centrally mediated action can occur with bolus administration of any opioid, but is much
more common with fentanyl and its cojoiners. If the patient cannot be adequately ventilated, opioid
antagonist administration can be used to displace fentanyl from central nervous system binding sites thus
this phenomenon, but this may not be advisable in the patient in whom a laryngeal mask airway has been
inserted since gagging may result. Administration of a rapidly acting muscle relaxant can effect skeletal
(hence respiratory) muscle paralysis and allow ventilation in this scenario. Addition of a volatile
anesthetic agent, although causing some skeletal muscle relaxation, would not resolve the respiratory
muscle tonic contracture quickly enough. Use of epinephrine for its beta-2 adrenergic effect would do
nothing for this patient who is not suffering from bronchial muscle constriction. Insertion of a cuffed
endotracheal tube might allow higher peak inspiratory pressure than is possible with a laryngeal mask
airway, but would not treat the causative problem.

Reference:
th
Stolting R, Miller R: Basics of Anesthesia 4 ed., Churchill-Livingstone, New York, 2000 pp71-73.

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Question:
As part of a balanced sedation technique, which of the following would be best suited to intermittent
bolus intravenous administration?

A. Alfentanil
B. Meperidine
C. Sufentanil
D. Remifentanil

Answer: A

Rationale:
th
Alfentanil has a potency 1/10 that of fentanyl and is relatively rapidly metabolized by hepatic
degradation. These two properties allow relative safety in intermittent bolus administration in a sedation
technique, and have made this drug popular as an agent in an outpatient general anesthetic technique.
Sufentanil has a shorter alpha half-life (by redistribution) and a shorter beta half life (by hepatic and renal
metabolism) than does fentanyl. However, its potency is 10 times that of fentanyl and it is recommended
for continuous intravenous infusion only, since a bolus administration of this extremely potent opioid can
yield very high peaks of pharmacologic effect and side-effect. Remifentanil is equipotent to fentanyl.
However, its rapid onset is associated with bradypnea, trunchal rigidity and bradycardia. Although it has
been used as a bolus administration for procedures such as a retrobulbar block it is generally
recommended for continuous infusion. Meperidine undergoes slower metabolization and repetitive
administration can prolong recovery.

Reference:
Vezeau PJ: Anesthetic Agent Update, in: Oral and Maxillofacial Surgery Update Vol. 3, AAOMS,
2002.

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Question:
Of the following agents, the one with the lowest therapeutic index in the presence of epinephrine is:

A. desflurane.
B. halothane.
C. isoflorane.
D. sevoflurane.

Answer: B

Rationale:
A dose of epinephrine greater than 2.1 mcg/kg can induce a dysrhythmia in a patient anesthetized with
halothane. Correct dosing of epinephrine with the use of halothane is especially important in the pediatric
population. The maximum safe epinephrine dose when halothane is used is generally considered to be 1.0
mcg/kg.

Reference:
Elamana V: Anesthetic considerations in patients with cardiac arrhythmias, pacemakers and AICDs.
International Anes Clin 39(4): 21-42, 2001.

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Question:
The binding of carbon monoxide to the hemoglobin molecule in smokers results in:

A. a direct hyperventilatory response.

B. falsely elevated oxygen saturation.
C. a rightward shift in the oxyhemoglobin desaturation curve.
D. more oxygen released to peripheral tissues to compensate for lower carrying capacity.

Answer: B

Rationale:
Carbon monoxide, produced as an end product of burning tobacco has 200x greater affinity than oxygen
to the Hgb molecule. Carboxyhemoglobin which can be as high as 15%, predisposes a patient to
perioperative hypoxia. Pulse oximetry fails to recognize the presence of carboxyhemoglobin as distinct
from oxyhemoglobin. Therefore a patient with 10% COHb may display a saturation of 100% when in
fact the actual saturation may be closer to 90%. In addition, carboxyhemoglobin has the effect of shifting
the oxygen-dissociation curve to the left (less oxygen delivered to tissues). Ventilation, the mechanism of
air exchange between the environment and the lungs, is not directly effected by carbon monoxide.

Reference:
Mardirossan G, Schneider RE, Limitations of pulse oximetry. Anesth Prog 39: 194-196, 1992.

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Question:
A 27-year-old individual has suffered from acute head trauma. He has been noted to be urinating 2 to 3
Liters per four hours of light yellow urine over 4 hours with only a small presence of blood noted. A
preoperative ECG demonstrates flattened T- waves on his chest leads. Prior to taking this individual to
the operating room to repair his fractured mandible, you should consider:

A. obtaining a cardiac work up.

B. obtaining a renal arteriogram.
C. replacing potassium losses.
D. replacing potassium and magnesium losses.

Answer: D

Rationale:
This individual is likely experiencing diabetes insipidus secondary to head trauma. The flattened T-
waves are consistent with hypokalemia, however in order to correct his potassium level he should have
his magnesium level adjusted as well (with replacement using 1g of MgSO4).

Reference:
Adam P: Evaluation and management of diabetes insipidus. Amer Fam Physician 55(6), May 1, 1997.

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Question:
During surgical removal of a lower third molar under sedation using midazolam, fentanyl and propofol,
your patient coughs and begins to have stridorous breath sounds, which lead to absent breath sounds. The
throat pack is removed and a jaw thrust is attempted without improvement in air exchange. Chest
movement continues. What is the most likely diagnosis?

A. Allergic reaction
B. Bronchospasm
C. Laryngospasm
D. Upper airway obstruction.

Answer: C

Rationale:
Midazolam, fentanyl, and propofol all cause a relaxation of the upper airway musculature, a depression of
the hypoxic/hypercapneic respiratory drive and a depression of the pharyngeal and laryngeal reflexes. The
patient's cough followed by stridorous sounds is suggestive of an irritation of the vocal cords resulting in
a laryngospasm. Chest movement without air exchange which is implied may be secondary to upper
airway obstruction, however, while this may not be completely relieved by a jaw thrust it would be
anticipated that there would be some improvement.

Reference:
Stoelting RK, Miller RD: Basics of Anesthesia. 2000. New York. Churchill Livingstone.

Davison JK, Eckhardt WF, Perese DA: Clinical Anesthesia Procedures of the Massachusetts General
Hospital. 1993. Boston. Little, Brown and Company.

Ochs MW: Pulmonary complications and their management. Oral Maxillofac Surg Clin North Am;
1992;4:769.

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Question:
Which of the following statements regarding pediatric airway anatomy is true?

A. The tongue is positioned higher in the oral cavity impinging on the soft palate.
B. The posterior attachment of the vocal cords is more caudal in children as compared to adults.
C. The epiglottis is small and relatively easy to manipulate with the laryngoscope in children as
compared with adults.
D. The larynx in pediatric patients is at a more inferior level than the corresponding level in adults.

Answer: A

Rationale:
Pediatric patients have anatomic differences that make tracheal intubation more challenging. Their
epiglottis is floppy and more difficult to manipulate. Their larynx lies at a more superior level; C3-C4 as
opposed to the adult, where lies at C4-C5. This is an important anatomic consideration to have in mind
for the correct placement of the ETT and position of the tip. The anterior attachment of the vocal cords is
more caudal so they are not perpendicular to the airway as they are in the adults. These factors make it
necessary to displace the tongue and mandible more in order to visualize the infant's vocal cords.
Therefore, straight laryngoscopes blades are used more commonly to intubate the trachea of children.

Reference:
th
Gregory, GA Pediatric Anesthesia 4 edition. Churchill Livingstone, 2002.

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Question:
Which one of the following factors could potentially prolong a mask induction by a volatile agent?

A. High alveolar ventilation

B. Right to left intracardiac shunt
C. Small functional residual capacity
D. Volatile agent with a low blood-gas solubility

Answer: B

Rationale:
A right to left intracardiac shunt will result in less blood perfusing the lungs. This will result in an
increase in alveolar partial pressure but also a decrease in arterial partial pressure. A right to left
intracardiac shunt could potentially speed up an intravenous induction because venous blood carrying the
IV induction agent will return to the heart and bypass the pulmonary circulation, reaching the brain more
quickly. A patient with Tetralogy of Fallot is a classic example of a patient with a right to left
intracardiac shunt.

Functional residual capacity is the volume of lung after the end of a normal TV expiration. A smaller
volume will reach a higher anesthetic concentration more quickly than a larger volume. A small
functional residual capacity will allow the alveolar concentration to quickly approach the inspired
concentration, speeding up induction.

Pediatric patients have a small FRC and high alveolar ventilation resulting in more rapid inhalation
induction compared to adults. Increasing alveolar ventilation will replace more anesthetic taken up by the
pulmonary bloodstream, maintaining a higher alveolar concentration and thus speeding induction.
An agent with low blood gas solubility will equilibrate rapidly resulting in a more rapid induction.

Reference:
Morgan, Mikhail, Murray. Clinical Anesthesiology 2002 Lange/McGraw-Hill.

th
Miller. Anesthesia 5 Ed. 2000 Churchill Livingstone.

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Question:
What is the most likely cause for hypoxia to rapidly develop in children versus adults during general
anesthesia?

A. Smaller airway pathways as compared to adults

B. Smaller blood volume per kilogram as compared to adults
C. Smaller functional residual capacity
D. Smaller lung capacities as compared to adults

Answer: C

Rationale:
While undergoing a general anesthetic, children without lung disease may lose as much as 45 percent of
their FRC. Owing to a higher oxygen consumption and greater loss of FRC in children during general
anesthesia, hypoxia develops in a matter of seconds. To compensate for the higher oxygen consumption,
children have a higher blood volume per kg or compared to adult-(80-100 cc/kg children and 65-70cc/kg
for adults). Children should have their ventilation controlled during anesthesia because hypoventilation
exacerbates their tendency toward hypoxia. Atelectasis may occur in mechanically ventilated children,
but is more likely to occur in children who breathe spontaneously. Children with pulmonary diseases
may lose even more of the FRC, exposing them to increasing ventilation-perfusion mismatch and
hypoxia. An increased inspired oxygen concentration and application of positive end-expiratory pressure
(PEEP) may partially restore FRC. However, PEEP must be applied carefully.

Reference:
th
Gregory, GA Pediatric Anesthesia 4 edition. Churchill Livingstone 2002.

Zaglaniczny, K. Clinical Guide to Pediatric Anesthesia. W. B. Saunders Co. 1999.

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Question:
Neonates, infants and children experience a greater heat loss than adults because:

A. they have a less body surface area to weight.

B. they cannot shiver to maintain body heat.
C. they have less brown fat than adults.
D. during cold stress oxygen consumption decreases.

Answer: B

Rationale:
Neonates, infants, and children have an increased body surface area relative to weight. Because they
cannot shiver to create or maintain body heat they rely on a less efficient process called non-shivering
thermogenesis. This process is dependent upon the fact that children have a greater amount of brown fat
(so named because of its rich vascular supply) than adults. When the newborn is cold stressed, oxygen
consumption will increase and result in the release of norepinephrine (NE). NE will react with the
Lipases in the brown fat to breakdown fat into triglycerides. The cascade continues to as triglycerides are
metabolized to glycerol and non-esterified fatty acids (NEFA). These NEFA are further degraded under
the needed heat generating process to form carbon dioxide and water.

Reference:
Behrman, Kliegman, Jenson, Nelsons, Textbook of Pediatrics, W.B. Saunders Company:2000.
Miller, Anesthesia Fifth Edition, Churchill Livingstone, 2000.

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Question:
Which statement is accurate regarding the morbidly obese patient?

A. Functional residual capacity is maintained.

B. Obesity imposes an obstructive ventilation defect.
C. PaO2 is decreased reflecting ventilation – perfusion mismatching.
D. PaCO2 increases slightly secondary to a slight decrease in the ventilatory response to CO2.

Answer: C

Rationale:
Morbid obesity is defined as a body weight in excess of 100 lbs over ideal weight or a body mass index of
40 or greater. There are a variety of adverse changes associated with obesity. Pulmonary function
changes in obese patients suggest restrictive pulmonary disease characteristics. PaO2 is decreased by
obesity as a result of ventilation/perfusion mismatches. Despite this, PaCO2 and the ventilatory response
to PaCO2 remains normal. Functional residual capacity is decreased and is accentuated by supine
positioning and under anesthesia.

Reference:
nd
Stoelting and Dierdorf: Handbook for Anesthesia and Co-existing disease. Churchill-Livingstone, 2 ed
2002.

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Question:
A 47-year-old male patient returns to your office 6 hours after a nitrous oxide sedation for extractions of
several teeth complaining of shortness of breath and lethargy. He has ashen skin. He is complaining of
palpitations. The ECG shows sinus tachycarida. The pulse oximeter shows 96%. Review of the records
shows that the patient received 9 cartridges of 4% prilocaine and 2 cartridges of 0.5% bupivicaine with
1:200,000 epinephrine. Which medication would you consider administering for the patients condition?

A. Diphenhydramine
B. Nitroglycerin
C. Methylene blue
D. Physostigmine

Answer: C

Rationale:
Large doses of prilocaine, generally greater then 600 mg, can result in methemoglobinemia in selected
patients. Intravenous doses of articaine have been reported to cause similar problems. This occurs as a
result of one of the metabolites of the drug converting reduced hemoglobin to methemoglobin. The
patient will experience cyanosis with dark blood. Pulse oximetry remains normal since the monitor
mistakenly interprets methemolgobin as oxyhemoglobin but the actual oxygen carrying capacity is
decreased resulting in the cyanosis. Small doses of methylene blue ( 1-2 mg/kg) will convert the
methemoglobin back to reduced hemoglobin

Reference:
Stoelting and Miller, Basics of Anesthesia, Churchill Livingstone, 2002

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Question:
The earliest sign of impending malignant hyperthermia is:

A. elevated core temperature.

B. increased end tidal CO2.
C. skeletal muscle rigidity.
D. tachycardia.

Answer: D

Rationale:
An increase in heart rate is usually the earliest and most consistent sign to be detected. An increase in
end-tidal CO2 is usually the most sensitive sign in detecting malignant hyperthermia. While increase
temperature and muscle rigidity are hallmark signs of malignant hyperthermia, these manifestations are
less sensitive and may not present as early as the tachycardia and elevated end-tidal CO2. Masseter
muscle rigidity should be distinguished from skeletal muscle rigidity and occurs early.

Reference:
nd
Stoelting RK, Dierdorf SF; Handbook for Anesthesia and Co-existing Disease, Churchill Livingston 2
ed 2002.

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Question:
Which of the following drugs is contraindicated in a patient with acute intermittent porphyria?

A. Methohexital
B. Midazolam
C. Ketamine
D. Propofol

Answer: A

Rationale:
Patients who have acute intermittent porphyria do not tolerate barbiturates. The use of these drugs could
precipitate an attack, which would present with abdominal pain, tachycardia and hypertension, seizures
and autonomic nervous system disorders. Propofol is safe to use. Midazolam and ketamine are probably
safe to use.

Reference:
nd
Stoelting RK, Dierdorf SF; Handbook for Anesthesia and Co-existing Disease, Churchill Livingston 2
ed 2002.

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Question:
The first drug in the management of paraoxysmal supraventricular tachycardia is:

A. adenosine.
B. diltiazem.
C. esmolol.
D. verapamil.

Answer: A

Rationale:
Vagal maneuvers, such as the Valsava maneuver can be tried first. Vagal maneuvers are most effective if
attempted immediately after onset. Adenosine is the first drug of choice if vagal maneuvers are
ineffective.

Reference:
rd
Faust RJ: Anesthesiology Review. 3 ed Churchill Livingston 2002.

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Question:
Which is the first drug of choice in the management of torsades de pointes?

A. Calcium
B. Epinephrine
C. Lidocaine
D. Magnesium

Answer: D

Rationale:
Magnesium should be considered the first drug of choice in the treatment of torsades de pointes. It is
administered as magnesium sulfate 1 to 2 grams over 1 to 2 minutes. Traditional anti-arrhythmic therapy
is not likely to be successful.

Reference:
rd
Faust RJ: Anesthesiology Review. 3 ed Churchill Livingston 2002.

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Question:
A 60-year-old man is undergoing intravenous general anesthesia for full mouth extractions when he
shows signs of labored breathing and cyanosis. The ECG shows evidence of wide complex tachycardia at
a rate of 160. The pulse oximeter is registering poor pulse signal. The systolic blood pressure is 65 mm
HG. Initial treatment should include:

A. administering amiodarone.
B. administering epinephrine.
C. administering vasopressin.
D. defibrillation.

Answer: D

Rationale:
The patient is presenting with an unstable ventricular tachycardia which is treated with prompt
defibrillation.

Reference:
Handbook of Emergency Cardiovascular Care .2002 ed.

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Question:
During sagittal split osteotomy, the possibility of direct injury to the inferior alveolar neurovascular
bundle can be minimized when the vertical component of the osteotomy is made over which of the
following regions?

A. Lateral to the first molar

B. Lateral to the second molar
C. Lateral to the third molar
D. Lateral to the retromolar region

Answer: B

Rationale:
The position of the inferior alveolar neurovascular bundle is an important determinant in the design of the
sagittal split osteotomy. The neurovascular bundle travels just under the facial cortical plate of the
mandible. Whether the osteotomy is made with rotary instruments or a reciprocating saw, the vertical cut
must be carried just through the cortical plate (i.e. monocortical). The thickness of the bone over the
neurovascular bundle is greatest in the area of the second molar. The vertical osteotomy should be placed
lateral to the second molar unless circumstances dictate otherwise.

Reference:
Rajchel J., Ellis E., and Fonseca R.J. The anatomical location of the mandibular canal: its relationship to
the sagittal ramus osteotomy. Int J Adult Orthod Orthogn Surg 1:37-47, 1986.

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Question:
In a distraction osteogenesis procedure, the latency phase of treatment corresponds to which of the
following stages of bone healing?

A. Hematoma formation and inflamation

B. Soft callus formation
C. Hard callus formation
D. Bony maturation

Answer: B

Rationale:
Bony healing after a fracture or osteotomy consists of four histologically distinct stages: an inflammatory
phase, soft callus formation, hard callus formation, and bony maturation/remodeling. During soft callus
formation, fibrovascular structures bridge the osteotomized bone segments and there is recruitment of
fibroblasts and mesenchymal stem cells within the fracture zone. It is this flexible soft callus which is
lengthened via gradual traction during the subsequent distraction phase.

Reference:
Crago C.A., Proffit W.R., and Ruiz R.L. Maxillofacial Distraction Osteogenesis. Pp. 357-393. Proffit
W.R., White R.P., and Sarver D.M. (Eds) Contemporary Treatment of Dentofacial Deformity,
Philadelphia. Mosby. 2003.

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Question:
An 8-month-old female infant undergoes early mandibular advancement with distraction osteogenesis in
order to alleviate airway obstruction related to severe mandibular hypoplasia. Bilateral mandibular
osteotomies are completed and internal distractors are placed and confirmed. Surgery is followed by a 9
day latency phase. Upon activation of the right distractor, heavy resistance is encountered and the bone
segments appear immobile. Which of the following is the most likely cause of this complication?

A. Excessive soft tissue resistance

B. Incomplete osteotomy at the time of surgery
C. Malfunction of the distractor
D. Early consolidation of the osteotomy

Answer: D

Rationale:
In most patients, a latency phase of 5 to 7 days allows for adequate formation of a soft callus before active
distraction is initiated. If activation of the distractors is initiated too early, decreased bone formation
results. If the latency period is too long, conversion to a hard callus begins and early healing of the
osteotomy will prevent mandibular lengthening. In young children, bone healing occurs much faster and
little or no latency phase is required.

Reference:
Crago C.A., Proffit W.R., and Ruiz R.L. Maxillofacial Distraction Osteogenesis. Pp. 357-393. In: Proffit
W.R., White R.P., and Sarver D.M. (Eds), Contemporary Treatment of Dentofacial Deformity.
Philadelphia. Mosby. 2003.

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Question:
The “Holdaway Ratio” is most useful in planning which of the following procedures?

A. Maxillary osteotomy
B. Mandibular osteotomy
C. Bimaxillary osteotomies
D. Genioplasty

Answer: D

Rationale:
The Steiner analysis is a cephalometric approach utilized to directly evaluate the protrusion of the upper
and lower incisors. The position of the maxillary and mandibular incisors is related to Nasion-A point
(N-A) and Nasion-B point (N-B) lines using both angular and linear measurements. Within this analysis,
the “Holdaway Ratio” is used to evaluate the prominence of the mandibular incisors and bony chin. The
ratio is calculated by comparing the distance of the lower incisor edge and pogonion to the N-B line.
Ideally, the Holdaway Ratio should be approximately 1.0 in males and 0.5 to 1.0 in females. This
relationship is useful in planning for genioplasty.

Reference:
Proffit W.R., Sarver D.M. Diagnosis: Gathering and Organizing the Appropriate Information. Pp. 127-
170. In: Proffit W.R., White R.P., and Sarver D.M. (Eds) Contemporary Treatment of Dentofacial
Deformity, Philadelphia. Mosby. 2003.

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Question:
A 17 year old female patient presents for correction of her Class III dentoskeletal deformity consistent
with a diagnosis of mandibular hyperplasia. A 4 mm of reverse overjet is noted. A submentovertex
radiograph obtained during the initial evaluation reveals a “V” shaped mandible with divergent rami.
Which surgical procedure for mandibular setback would result in the greatest alteration in intercondylar
width in this patient?

A. Bilateral sagittal split osteotomies with lag screw fixation

B. Transoral vertical ramus osteotomies with lag screw fixation
C. Bilateral Inverted “L” osteotomies with miniplate fixation
D. Bilateral “C” osteotomies with miniplate fixation

Answer: A

Rationale:
One of the technical considerations that must be considered when choosing a specific procedure for
mandibular setback surgery is the actual shape of the mandibular arch form and rami. In patients with a
“U” shaped mandible, either bilateral sagittal split osteotomies (BSSO) or a transoral vertical ramus
osteotomy may be utilized for mandibular setback in Class III patients. When the mandible is “V” shaped
with flared rami, then the procedure that results in the least condylar width change is the transoral vertical
ramus osteotomy. If a patient with a “V” shaped mandible undergoes BSSO, a gap is created posteriorly
between the cortical plates of the proximal and distal segments. If lag screws are used for rigid fixation,
the gap is closed and there is narrowing of the intercondylar width.

Reference:
Tucker M.R. Surgical correction of mandibular excess: technical considerations for mandibular setbacks.
Atlas Oral Maxillofac Surg Clin North Am. 1993 Mar;1(1):29-39.

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Question:
Which of the following is a special consideration when performing sagittal split osteotomy for mandibular
advancement in children?

A. The lingula and inferior alveolar foramina are located in a more superior and posterior position in
the ramus of children than in adults.
B. The sagittal bone cuts should be positioned as far medially as possible.
C. The propensity for “greenstick” fracture of the inferior border of the mandible is lower in children
than in adults.
D. Simultaneous removal of partially developed third molar teeth is not possible in children.

Answer: A

Rationale:
The lingula and inferior alveolar foramina are located in a more superior and posterior position in this age
group. This has technical implications in determining the vertical placement of the medial osteotomy of
the ramus. If the medial bone cut is positioned high on the ramus, then injury to the nerve is avoided , but
the risk of unfavorable split (i.e. buccal plate fracture) increases. In children, the sagittal component of
the osteotomy design should be placed as far laterally as possible in order to avoid injury to the
developing teeth. Children will have a higher propensity for “greenstick” fracture along the inferior
border of the mandible. Their bone is more cancellous in nature and this often results in a longer area of
fracture along the inferior border of the mandible. Developing third molars can be removed after the
mandibular ramus has been split. In cases where the third molar teeth are only partially developed, they
can still be enucleated while the proximal and distal segments are separated

Reference:
Bell WH: Mandibular Advancement in Children Special Considerations. In Bell WH, Modern Practice
in Orthognathic and Reconstructive Surgery, Vol. 3, 1992, WB Saunders, pp. 2516.

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Question:
Which of the following is a contraindication for the use of a total mandibular subapical osteotomy?

A. Condylar hypoplasia
B. Relapse after sagittal split osteotomy
C. Skeletal apertognathia
D. Mandibular vertical alveolar deficiency

Answer: C

Rationale:
Skeletal anterior open bite (i.e. apertognathia) is the result of a maxillary growth problem and is
frequently associated with a concomitant transverse maxillary discrepancy. The use of a total mandibular
subapical osteotomy for correction of an anterior open bite requires counterclockwise movement of the
dentoalveolar segment, does not address the maxillary deformity, and is associated with a high rate of
skeletal relapse. Appropriate management of apertognathia requires correction of the maxillary problem
usually consisting of segmental Le Fort I level surgery.

The use of the total mandibular subapical osteotomy is limited to correction of malocclusions that can be
addressed by repositioning the mandibular alveolar process only. The subapical osteotomy does not
change the anatomical position of the mandibular body or symphysis. As a result, application of the total
mandibular subapical osteotomy is limited to situations where there is retrusion of the dentoalveolar
process with an otherwise normal facial morphology.

Reference:
Frost DE: Orthognathic Surgical Techniques. In Ward-Booth et al, Maxillofacial Surgery. Vol. 2, 1999,
Harcourt Brace. pp. 1291.

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Question:
A 16-year-old female patient undergoes a Le Fort I osteotomy for maxillary impaction. Two days after
surgery, guiding elastics are removed and assessment of the patient’s occlusion reveals an anterior open
bite. What is the most likely cause of this complication?

A. Severe condylar resorption associated with fixation

B. Failure of maxillary hardware
C. Incomplete seating of the condyles during surgery
D. Incomplete downfracture of the maxilla during surgery

Answer: C

Rationale:
Le Fort I level osteotomy may be complicated by intraoperative malpositioning of the maxillomandibular
complex after the jaws have been wired together. Pressure applied to the chin may bring the maxillary
osteotomy together while unintentionally displacing the mandibular condyles. This is often caused when
bony interferences along the posterior maxilla exist.

Reference:
Bays R.A. Complications of Orthognathic Surgery. In: Kaban L.B., Pogrel M.A., and Perrott D.H. (Eds),
Complications in Oral and Maxillofacial Surgery. W.B. Saunders, Philadelphia, pp. 193-221. 1997.

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Question:
A 23-year-old female undergoes maxillary superior positioning with a midline splitting of the maxilla to
widen the transverse dimension 9 mm. Following an uneventful early post-operative course, she returns
one year later with an anterior open bite. Which of the following would most likely explain the open
bite?

A. Poor positioning of the mandibular condyles intra-operatively

B. Relapse of the transverse widening of the maxilla
C. Idiopathic condylar resorption
D. Failure of the hardware placed in the anterior maxilla

Answer: B

Rationale:
Transverse expansion of the maxillary arch is often complicated by lack of long term stability. This is
especially true when large movements are undertaken. As transverse relapse occurs, the lingual cusps of
the maxillary posterior teeth move along the lingual inclines of the lingual mandibular cusps and the
anterior open bite deformity is recreated.

Reference:
Long Face Problems in Contemporary Treatment of Dentofacial Deformity. Eds. Proffit WR, White RP,
Sarver DM. Mosby 2003. Page 491.

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Question:
A patient arrives at the emergency department 2 weeks following a LeFort I osteotomy with advancement
and impaction of the maxilla by another surgeon. The parents describe and uneventful course to date until
profuse epistaxis lead them to call 911. On your arrival, the patient is stable with the exception of
borderline hypotension and the bleeding has stopped without intervention. Which of the following would
be the most prudent next step?

A. Place bilateral anterior nasal packs for 24 hours.

B. Return to the operating room for exploration of the surgical site.
C. Fluid resuscitation and referral back to the operating surgeon.
D. Arrange interventional angiography.

Answer: D

Rationale:
Bleeding during Le Fort I osteotomy and downfracture is usually the result of injury to the terminal
branches of the internal maxillary artery including the descending palatine and sphenopalatine arteries.
Even after the Le Fort I downfracture, intraoperative injury to the descending palatine vessels may occur
as a result of significant maxillary advancement or impaction. Postoperative hemorrhage following
maxillary surgery typically presents as epistaxis with bleeding into the anterior and/or posterior nasal
cavity. This may occur at any point during the first month after the surgical procedure and may be the
result of breakdown of previous clot or necrosis of arterial vessels which were stretched by the surgical
movement. An initial “sentinel” episode of brisk bleeding may stop spontaneously giving the false
impression that the problem has resolved. Angiography and interventional radiology techniques provide
detailed visualization and localization of the source of bleeding. The bleeding vessel may be stopped by
embolization without the need to reopen the wound, remove rigid fixation devices, and dismantle skeletal
segments. Angiography also allows detailed visualization of the arterial system and detection and
management of pseudoaneurysm involving the internal maxillary artery or its terminal branches.

Reference:
Preoperative, intraoperative and postoperative care in Fonseca Oral and Maxillofacial Surgery, Saunders
2000. Page 187.

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Question:
Which of the following is the most common source of venous bleeding during maxillary osteotomy at the
LeFort I level?

A. Facial vein
B. Pterygoid venous plexus
C. Laceration of the pterygoid musculature
D. Descending palatine veins

Answer: B

Rationale:
The pterygoid plexus of veins is located directly posterior and medial to the maxilla. Its location makes it
vulnerable to injury during creation of the osteotomy and use of an osteotome for pterygomaxillary
disjunction. It is the most common source of intraoperative venous hemorrhage in patients undergoing
LeFort I osteotomy. Management of venous hemorrhage from the pterygoid plexus requires packing and
application of topical hemostatic agents.

Reference:
Lanigan DT: Vascular Complications Associated with Orthognathic Surgery. Oral and Maxillofacial
Surgery Clinics of North America. Volume 9, Number 2, May 1997. pp. 232.

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Question:
Aside from serial cephalometric radiographs, which of the following is considered the next most reliable
method of estimating the facial skeletal maturity?

A. Evaluation of the C-spine

B. Hand-wrist films
C. Panoramic evaluation of dental development
D. Tanner’s developmental stages

Answer: A

Rationale:
Radiographic assessment of the hand-wrist anatomy has been utilized to estimate a patient's skeletal age
when early orthodontic or surgical treatment is contemplated. The theoretical basis is that the chronology
of ossification in the bones of the hand and wrist can be related to the rest of the skeleton. The
relationship between the bony development of the hand-wrist complex and the facial skeleton is not well
correlated. Recently, the radiographic assessment of the cervical spine vertebrae for estimating skeletal
development has been proposes. Although not perfect, the use of cervical spine development as an
indicator of skeletal age is better correlated with the facial skeleton and the adolescent growth spurt. This
technique has the additional advantage that no additional radiographs are required since the cervical
vertebrae are visible on a cephalometric radiograph.

Reference:
Franchi L., Baccetti T, McNamara JA Jr. Mandibular growth as related to cervical vertebral maturation.
Am J Orthod Dentofac Orthop 118: 335-340. 2000.

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Question:
The most unstable skeletal movement in orthognathic surgery procedures is:

A. genioplasty – any direction.

B. maxillary inferior repositioning.
C. mandibular setback.
D. segmental maxillary expansion.

Answer: D

Rationale:
Segmental surgery for transverse maxillary expansion is associated with the highest rate of relapse
following orthognathic surgery. Palatal soft tissue resistance and dental compensations often add to this
instability.

Reference:
Proffit WR, Turvey TA, Phillips C: Orthognathic Surgery A Hierarchy of Stability. Intl J Adult Orthod
Orthognath Surg. 11:191-204, 1996.

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Question:
A 16-year-old patient with a skeletal Class III malocclusion is beginning orthodontic treatment in
preparation for eventual LeFort I osteotomy and bilateral sagittal split osteotomies. The patient has
significant crowding in both maxillary and mandibular arches and dental compensations are present. If
extraction of maxillary and mandibular premolars is indicated, which of the following combinations is
most appropriate given the patient’s clinical findings and eventual surgical plan?

A. Extraction of maxillary first and mandibular second premolars

B. Extraction of maxillary second and mandibular first premolars
C. Extraction of maxillary and mandibular first premolars
D. Extraction of maxillary and mandibular second premolars

Answer: A

Rationale:
Extraction of maxillary first premolars in this clinical situation allows for adequate space for alignment of
crowded maxillary incisors. The space created allows for correction of inclination for teeth that have
drifted forward during development of dental compensations. As the maxillary first premolar spaces are
closed, the anterior teeth are retracted maximizing the degree of maxillary skeletal advancement.

In Class III patients undergoing presurgical orthodontic treatment, extraction of mandibular first
premolars is rarely indicated. This is because closure of the extraction spaces will require retraction of
the anterior teeth resulting in less favorable tooth-lip balance. Extraction of the second mandibular
premolars provides the necessary space for alleviation of crowding while avoiding retraction of the
incisors.

Reference:
Bailey L.J., Sarver D.M., Turvey T.A., and Proffit W.R. Class III Problems. In: Contemporary Treatment
of Dentofacial Deformity. Eds. Proffit WR, White RP, Sarver DM. Mosby 2003.

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Question:
Which of the following statements regarding Passavant’s Ridge is correct?

A. It is observed only as part of the cleft palate malformation.

B. It does not facilitate velopharyngeal closure.
C. It forms along the palatopharyngeus muscle.
D. It forms along the superior constrictor muscle.

Answer: D

Rationale:
Passavant's ridge is a soft tissue prominence which extends into the pharynx. The structure is usually
described in association with cleft palate, but has been described in many normal subjects. The soft tissue
structure also frequently contributes positively to velopharyngeal closure. The ridge usually forms along
the superior border of the superior pharyngeal constrictor muscle, but its exact position on the posterior
pharyngeal wall may vary.

Reference:
The Nature of the Velopharyngeal Mechanism. In: McWilliams B.J., Morris H.L., and Shelton R.L.
(Eds), Cleft Palate Speech. B.C. Decker, Philadelphia, Pp. 197-235, 1990.

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Question:
When performing Le Fort I osteotomy in an ungrafted bilateral cleft lip and palate patient, which of the
following surgical techniques should be avoided?

A. Autogenous bone grafting and rigid fixation

B. Osteotome separation of the pre-maxilla from the nasal septum and vomer
C. Advancement of lateral segments for closure of cleft-dental gap
D. Circumvestibular incision and maxillary downfracture

Answer: D

Rationale:
Preservation of an anterior buccal mucosal pedicle is critical to preserving blood circulation to the
premaxilla in patients that have not undergone previous bone graft reconstruction of bilateral cleft defects.
A circumvestibular incision in the ungrafted bilateral cleft lip and palate patient would lead to aspectic
necrosis of the premaxillary segment. Maxillary advancement in these patients is carried out through
separate right and left vestibular incisions with limited tunneling anteriorly. A small vertical incision
within the midline may be utilized for separation of the nasal septum and mobilization of the premaxillary
segment.

Reference:
Turvey TA, Vig K, Fonseca RJ. Maxillary Advancement and Contouring in The Prescence of Cleft Lip
and Palate. In Turvey et al Facial Cleft and Craniosynostosis, 1996 WB Saunders. pp. 460.

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Question:
A child born with an isolated cleft palate presents with severe myopia early in life. The most likely
diagnosis is which of the following syndromes?

A. Pierre Robin Sequence

B. Stickler Syndrome
C. Van der Woude Syndrome
D. Velocardiofacial Syndrome

Answer: B

Rationale:
Isolated cleft palate is associated with an underlying syndrome more frequently (as much as 50%) than
cleft lip and palate. Stickler syndrome has been identified as the most common diagnosis causing both
cleft palate and Robin sequence. Patients with Stickler syndrome demonstrate a collagen metabolism
disorder. Relevant clinical findings include early myopia and an increased risk of retinal detachment
which may go un-noticed early in life. It is recommended that infants with an isolated cleft of the
secondary palate undergo formal ophthalmologic evaluation at some point during their first year of life.

van der Woude syndrome can be caused by deletions in chromosome band 1q32, and linkage analysis has
confirmed this chromosomal locus as the disease gene site. van der Woude syndrome is an autosomal
dominant syndrome typically consisting of a cleft lip or cleft palate and distinctive pits of the lower lips.
The degree to which individuals carrying the gene are affected is widely variable, even within families.
These variable manifestations include lip pits alone, absent teeth, or isolated cleft lip and palate of varying
degrees of severity. Other associated anomalies have also been described. About 1-2% of patients with
cleft lip or palate have van der Woude syndrome.

Velocardiofacial syndrome (VCFS) is a genetic condition characterized by structural or functional palatal

abnormalities, cardiac defects, unique facial characteristics, hypernasal speech, hypotonia, developmental
delay, and learning disabilities. As many as 15-20% of patients have Robin sequence.

Reference:
Wyszynski, DF, Cleft Lip and Palate in Origin to Treatment. Oxford University Press, 2002.

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Question:
Which of the following surgical techniques for cleft palate repair retains an anterior soft tissue pedicle for
improved flap perfusion?

A. von Langenbeck technique

B. Furlow Z-plasty technique
C. Bardach (2-flap) technique
D. Pushback procedure

Answer: A

Rationale:
The von Langenbeck palate repair technique involves the creation of two full thickness mucoperiosteal
flaps with care taken to preserve anterior soft tissue pedicles. The theoretical advantage of the anterior
soft tissue attachments is additional blood supply for the elevated flaps. During the Bardach (2-flap) and
pushback procedures, similar soft tissue flaps are elevated, but no anterior pedicle is maintained. The
Furlow procedure involves the use of double opposing Z-plasties with the musculature elevated with the
posteriorly based flaps on the nasal and oral sides.

Reference:
Posnick JC: The Staging of Cleft Lip and Palate Reconstruction Infancy Through Adolescence. In
Posnick JC Craniofacial and Maxillofacial Surgery in Children and Young Adults. pp. 804.

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Question:
In the unrepaired cleft palate, the levator veli palatini muscle inserts abnormally into:

A. the medial pterygoid plate.

B. the lateral pterygoid plate.
C. the posterior hard palate.
D. Passavant’s ridge.

Answer: C

Rationale:
The goals of cleft palate repair are twofold; first, water tight closure of the oral-nasal communication, and
second, the creation of a dynamic soft palate for normal speech production. The most important muscular
component of the soft palate is the levator veli palatini muscle which functions to elevate the velum and
allow for appropriate speech production. In patients with an unrepaired cleft palate, the levator
musculature is clefted and has abnormal insertions along the posterior edge of the hard palate.

Reference:
Cutting, CB, Rosenbaum J, Rovati L: The technique of muscle repair in the cleft soft palate. Operative
Techniques in Plastic and Reconstructive Surgery, Vol 2, No 4(November), 1995: pp 215-222

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Question:
In an infant born with a unilateral complete cleft lip and palate, primary repair of the cleft lip should be
carried out when the child is:

A. 1 week of age and weighs 5 lbs (2.2kg).

B. 10 weeks of age and weighs 10 lbs (4.5 kg).
C. 10 months of age and weighs 10 lbs (4.5 kg).
D. 10 months of age and weighs 20 lbs (9.1 kg).

Answer B

Rationale:
Generally, cleft lip repair is carried out when the child is 10 to 12 weeks of age. General guidelines were
developed for reduction of anesthetic risk and suggested that the surgery be undertaken when the child is
approximately 10 weeks of age, weighs at least 10 lbs, and has a serum hemoglobin of at least 10 mg/dl.
This has often been referred to as the “rule of 10's” for the timing of cleft lip repair.

Reference:
Posnick JC: The Staging of Cleft Lip and Palate Reconstruction Infancy Through Adolescence. In
Posnick JC Craniofacial and Maxillofacial Surgery in Children and Young Adults. pp. 798.

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Question:
During primary repair of the cleft palate, utilizing Bardach’s (two-flap) technique, the palatal
mucoperiosteal flaps are based upon which artery?

A. Ascending pharyngeal artery

B. Facial artery
C. Greater palatine artery
D. Sphenopalatine artery

Answer: C

Rationale:
Two-flap palatoplasty techniques involve the elevation of full-thickness mucoperiosteal flaps on each side
of the cleft defect for oral side closure. After the nasal mucosa is closed, these soft tissue flaps are
sutured together in the midline for closure of the cleft defect. During the initial dissection and elevation
of the flaps, the greater palatine neurovascular bundles are identified and protected. The result is that the
axial soft tissue flaps are raised based upon the blood supply of the greater palatine arteries bilaterally. If
the greater palatine artery is injured or cauterized, then the axial pattern soft tissue flap becomes a random
pattern flap (i.e. not based on one specific arterial supply) with perfusion from the palatal soft tissue
attachments.

Reference:
Bardach J: Two-flap palatoplasty: Bardach's technique. Operative Techniques in Plastic and
Reconstructive Surgery, Vol 2. No 4(November), 1995: pp 211-214.

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Question:
Secondary bone graft reconstruction of the cleft maxilla and alveolus is undertaken:

A. at the time of the palate repair during infancy.

B. when the maxillary central incisor is 2/3rds formed.
C. when the maxillary canine is ¼ to 2/3 developed.
D. after partial eruption of the maxillary canine.

Answer: C

Rationale:
By definition, secondary bone graft reconstruction is carried out after the initial closure of the hard and
soft palate. Generally, bone grafting is performed between 6 and 10 years of age, but the specific timing
is based upon the child's dental development instead of chronological age. Bone graft reconstruction of
the cleft maxilla is undertaken based on the development of the permanent maxillary canine tooth. If
partial eruption of the canine is allowed prior to bone graft placement, unfavorable periodontal outcome
results.

Reference:
Ochs MW: Alveolar Cleft Bone Grafting(Part II): Secondary Bone Grafting, J Oral Maxillofac Surg 54:
83-88, 1996.

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Question:
The surgical technique for creation of a superiorly based pharyngeal flap requires elevation of which
muscle from the posterior pharyngeal wall?

A. Palatopharyngeus muscle
B. Palatoglossus muscle
C. Superior constrictor muscle
D. Levator Veli Palatini

Answer: C

Rationale:
A superiorly based pharyngeal flap is commonly used for the management of velopharyngeal
insufficiency related to cleft palate. A soft tissue flap is developed from the posterior pharyngeal wall.
This is done by elevating the posterior pharyngeal wall soft tissues including the superior constrictor
muscle off of the prevertebral fascia. This flap is then inset within the soft palate nasal side closure.

Reference:
Ilankovan V: Secondary cleft lip and palate repair. Operative Maxillofacial Surgery. Chapman and Hall
1998. pp215.

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Question:
In the United States, the incidence of cleft lip or cleft lip with cleft palate is:

A. equal among all races.

B. greatest among Caucasians.
C. greatest among African-Americans.
D. greatest among Asian-Americans.

Answer: D

Rationale:
Cleft lip with or without cleft palate is a common congenital malformation with an incidence of
approximately 1 in 700 live births, but significant variation is encountered when different ethnic/racial
populations are examined. African Americans have an incidence which is significantly lower than the
general population while Asians have the highest rate of birth prevalence. By contrast, isolated cleft
palate has a lower overall incidence of approximately 1 in 2,000 live births with similar distribution
among the different racial and ethnic populations.

Reference:
Costello BJ, Ruiz RL. Cleft Lip and Palate: Comprehensive Treatment Planning and Primary Repair. In:
Miloro M, Ghali GE, Larsen PE, and Waite PD (Editors): Peterson's Principles of Oral and Maxillofacial
Surgery, Second Edition. BC Decker. Hamilton. 2004. Pp: 839-858.

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Question:
The successful creation of velopharyngeal competence after superior pharyngeal flap surgery requires:

A. adequate lateral pharyngeal wall mobility.

B. palatal elongation at the time of surgery.
C. the presence of Passavant’s ridge.
D. glottic closure.

Answer: A

Rationale:
The superiorly based pharyngeal flap remains the standard approach for surgical management of patients
with velopharyngeal insufficiency after cleft palate repair. The procedure involves the creation of a soft
tissue flap from the posterior pharyngeal wall which is subsequently inset within the soft palate. The
result is that the size of the nasopharyngeal cavity is decreased. The larger nasopharyngeal opening
which could not be completely closed by the patient is instead converted into two (right and left) smaller
lateral pharyngeal ports. Closure of these ports is easier for the patient to accomplish as long as adequate
lateral pharyngeal wall motion is present.

Reference:
Argamaso R V: Pharyngeal Flap Surgery for Velopharyngeal Insufficiency, Operative Techniques in
Plastic and Reconstructive Surgery, Vol 2, No 4 (November), 1995: pp 233-238

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Question:
Dynamic sphincter pharyngoplasty is performed by elevating myomucosal flaps which include which
muscle?

A. Superior constrictor muscle

B. Palatopharyngeus muscle
C. Palatoglossus muscle
D. Tensor Veli Palatini

Answer: B

Rationale:
The dynamic sphincter pharyngoplasty procedure involves the use of two superiorly based myomucosal
flaps created within each posterior tonsillar pillar. Each flap is elevated with care taken to include as
much of the palatopharyngeous muscle as possible. The flaps are then attached to each other and inset
within a horizontal incision on the posterior pharyngeal wall. The goal of this procedure is to create a
single nasopharyngeal port that has a contractile ridge posteriorly in order to improve velopharyngeal
closure.

Reference:
Gray SD, Pinborough-Zimmerman J: Diagnosis and Treatment of Velopharyngeal Incompetence. Facial
Plastic Surgery Clinics of North America. 4:3 (August) 1996: pp. 405-413.

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Question:
Isolated cleft palate occurs most commonly:

A. in males.
B. on the right side.
C. in females.
D. on the left side.

Answer: C

Rationale:
In contrast to cleft lip and palate, there is a female predominance of cleft palate. The ratio is
approximately 3:2.

Reference:
Wyszynski, DF, Cleft Lip and Palate From Origin to Treatment. Oxford University Press, 2002.

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Question:
The age at which the initial repair of a cleft palate is performed is based primarily on:

A. the anticipated development of speech.

B. the child’s ability to eat.
C. concerns for airway patency.
D. the anticipated need for bone grafting.

Answer: A

Rationale:
Ideally, one balances the need for an intact palate for normal speech production with the least interference
of maxillary growth. Typically, children will begin to make purposeful speech at approximately 9 to 12
months of age. Most cleft palate centers recommend cleft palate repair between the ages of 9 and 18
months with the exact timing based upon the child's language development as opposed to chronologic
age. In a child who reaches an articulation age that requires an intact palate, failure to close the cleft
leaves them vulnerable to the development of maladaptive speech patterns which are then difficult to
break.

Reference:
Posnick JC: The Staging of Cleft Lip and Palate Reconstruction Infancy Through Adolescence. In
Posnick JC Craniofacial and Maxillofacial Surgery in Children and Young Adults. Pp 803-805.

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Question:
Which of the following is most appropriate in the feeding of an infant with an unrepaired cleft palate?

A. Using a squeezable bottle with a one-way valve

B. Using a reclined feeding position
C. Frequent burping of the infant
D. Fabrication of a custom feeding appliance or obturator

Answer: A

Rationale:
The presence of an unrepaired cleft palate causes difficulty with feeding due to the inability to form an
adequate seal between the tongue and palate. The cleft defect prevents the infant from creating negative
pressure needed to suck fluid from a bottle. Specialized feeding devices typically combine oversized
nipples with reservoir spaces and large openings, a squeezable bottle to push fluid into the nipple
assembly, and a one-way valve that allows the bolus of fluid to pass from the bottle to the nipple in order
to minimize the amount of work the child must perform to feed. Infants should be positioned upright
during feeding in order to facilitate management of the fluid bolus and secretions. Obturators for feeding
have been used as feeding aids, but their value is not established. Their use has no effect on the infant's
ability to generate suction. The parent still must provide assisted feeds, and in infants with retrognathia
and posteriorly positioned tongues, they create the risk of airway occlusion. Additionally, they must be
monitored and adjusted frequently, making them both expensive and time consuming.

Reference:
Costello BJ, Ruiz RL. Cleft Lip and Palate: Comprehensive Treatment Planning and Primary Repair. In:
Miloro M, Ghali GE, Larsen PE, and Waite PD (Editors): Peterson's Principles of Oral and Maxillofacial
Surgery, Second Edition. BC Decker. Hamilton. 2004. Pp: 839-858.

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Question:
In addition to the classically described maxillomandibular anomalies, the most consistent finding
associated with hemifacial microsomia is:

A. cataracts.
B. a tortuous internal carotid artery displaced toward the midline.
C. microtia.
D. a single central incisor.

Answer: C

Rationale:
Hemifacial microsomia is associated with several soft tissue anomalies in addition to the common skeletal
manifestations. These include, but are not limited to, microtia, facial nerve palsy, skin tags, soft tissue
and muscular hypoplasia, microphthalmos, and macrostomia.

Reference:
Turvey, TA, Vig, KWL, Fonseca RJ, Facial Clefts and Craniosynostosis Principles and Management. WB
Saunders, 1996.

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Question:
Which of the following statements is correct regarding distraction osteogenesis of the maxilla in patients
with clefts?

A. Long-term stability is greater when compared with traditional orthognathic surgery.

B. There is less likelihood of postoperative velopharyngeal insufficiency when compared with
traditional orthognathic techniques.
C. Less orthodontic finishing is required when compared with traditional orthognathic surgery.
D. Appliances are usually required to be retained for several months prior to removal.

Answer: D

Rationale:
Distraction osteogenesis has not been proven to provide significant advantages when one looks at post-
operative stability or velopharyngeal insufficiency. Similar results have been seen when compared with
studies done after traditional orthognathic surgery. There is no difference in orthodontic finishing
requirements, and additional compensation may be required when compared with traditional techniques.
During the consolidation phase, appliances (either internal or external) are kept in place for several
months.

Reference:
Turvey TA, Ruiz RL, and Costello BJ. Orthognathic surgery in the cleft patient. In: Oral and
Maxillofacial Surgery Clinics of North America: Secondary Cleft Surgery. Philadelphia: W.B. Saunders,
14: 491-507, 2002

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Question:
Which of the following statements best describes the most likely etiology of hemifacial microsomia?

A. X-linked condition
B. Autosomal recessive condition
C. Fibroblast growth factor receptor defect
D. Intrauterine vascular injury

Answer: D

Rationale:
The facial deformities associated with hemifacial microsomia are heterogeneous and demonstrate extreme
variability of expression. Previous work by Poswillo suggested that early vascular disruption of the
developing stapedial artery with expanding hematoma during intrauterine development resulted in
destruction of differentiating tissues within the first and second branchial arches.

Reference:
Poswillo D.E. The pathogenesis of the first and second branchial arch syndrome. Oral Surg 35:302, 1973.

Kaban LB. Congenital Abnormalities of the Temporomandibular Joint. In: Kaban LB, Troulis M. (Eds.):
Pediatric Oral and Maxillofacial Surgery, pp302-339. WB Saunders, Philadelphia, 2004.

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Question:
Which of the following skeletal findings is associated with a diagnosis of holoprosencephaly?

A. Orbital hypertelorism
B. Premaxillary hyperplasia
C. Mandibular deficiency
D. Absence of nasal bones

Answer: D

Rationale:
Orbital hypotelorism with trigonocephalic skull deformity and absence of the nasal cavity and nasal bones
are among the skeletal deformities frequently seen in infants with holoprocencephaly. Abnormal
development of the premaxillary segment is also encountered and may result in a midline cleft or the
characteristic single central incisor within a hypoplastic premaxilla. Mandibular morphology is normal.

Reference:
Schendel S.A., Tessier P., and Tulasne J.F. Facial Clefting Disorders and Craniofacial Synostosis:
Skeletal Considerations. In: Turvey T.A., Vig K.W.L., and Fonseca R.J. (Eds), Facial Clefts and
Craniosynostosis: Principles and Management. W.B. Saunders, Philadelphia, Pp. 95-128. 1996.

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Question:

The CT image above demonstrates which of the following conditions?

A. Metopic suture craniosynostosis

B. Coronal suture craniosynostosis
C. Sagittal suture craniosynostosis
D. Lambdoid suture craniosynostosis

Answer: B

Rationale:
The CT scan image shown above reveals right sided unilateral coronal suture craniosynostosis. The right
coronal suture is absent and there is a classic skeletal deformity characterized by anterior plagiocephaly,
orbital dystopia, and nasal bone asymmetry. This craniofacial deformity is the result of both arrested
development at the site of the affected suture and an abnormal compensatory overgrowth at the site of the
remaining open sutures. When the coronal suture is absent, the skeletal deformity also causes shortening
of the anterior skull base on the affected side.

Reference:
Turvey TA, Ruiz RL. Craniosynostosis and Craniofacial Dysostosis. In: Fonseca RJ, Baker SB, and
Wolford LM, (Editors): Oral and Maxillofacial Surgery: Volume 6, Philadelphia, WB Saunders, 2000,
Pp: 195-220.

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Question:
Premature fusion (craniosynostosis) of the metopic suture will result in which of the following cranial
vault deformities?

A. Brachycephaly
B. Scaphocephaly
C. Trigonocephaly
D. Posterior plagiocephaly

Answer: C

Rationale:
Metopic suture craniosynostosis results in a classic trigonocephalic skull dysmorphology. Because the
metopic suture is absent and growth perpendicular to this region is arrested, there is a characteristic
triangular shaped anterior skull. In addition, patients demonstrate horizontally retrusive lateral orbital
rims and hypotelorism.

Reference:
Ghali GE, Sinn DP. Nonsyndromic Craniosynostosis. In: Miloro M, Ghali GE, Larsen PE, and Waite PD
(Editors): Peterson's Principles of Oral and Maxillofacial Surgery, Second Edition. Hamilton, BC Decker,
2004. Pp: 887-900.

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Question:
A newborn child is noted to have multiple suture craniosynostosis associated with an underlying
diagnosis of Crouzon syndrome. Which of the following represents the most appropriate age at which
primary cranio-orbital surgery should be undertaken?

A. 4 to 12 months
B. 13 to 24 months
C. 3 to 5 years
D. 7 to 10 years

Answer: A

Rationale:
In untreated patients with more than one cranial vault suture affected, the likelihood of increased
intracranial pressure exceeds 40 %. Despite this increased risk, signs of increased ICP are rarely seen
prior to one year of age. Primary cranio-orbital decompression is typically undertaken at some point prior
to one year of age.

Reference:
Posnick JC, Ruiz RL, and Tiwana PS. Craniofacial Dysostosis Syndromes: Staging of Reconstruction.
In: Miloro M, Ghali GE, Larsen PE, and Waite PD (Editors): Peterson's Principles of Oral and
Maxillofacial Surgery, Second Edition. Hamilton, BC Decker, 2004. Pp: 901-929.

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Question:
The Facial Bipartition Osteotomy differs from the Monobloc Osteotomy in that it:

A. utilizes a bifrontal craniotomy for the intracranial approach.

B. allows for fronto-orbital contouring at the time of surgery.
C. allows for correction of orbital hypertelorism.
D. is more commonly used in the reconstruction of Crouzon Syndrome.

Answer: C

Rationale:
The monobloc operation allows the surgeon to simultaneously advance the midface and fronto-orbital
units through a transcranial approach for correction of the total midface deficiency characteristic of
Crouzon syndrome. The facial bipartition procedure consists of the same surgical steps as the monobloc
performed in combination with the removal of a section of bone from the midline. Because it allows
correction of orbital hypertelorism, bipartition is often the procedure of choice for correction of the orbital
and midfacial deformity associated with Apert syndrome.

Reference:
From Ruiz RL, Turvey TA, Tiwana PS: Monbloc and Facial Bipartition Osteotomies. Atlas of Oral and
Maxillofacial Surgery Clinics of North America. Number 10, March 2002. pp 131-148.

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Question:
In an individual with Treacher Collins Syndrome, what surgical phase of reconstruction is best carried out
at 8 to 10 years of age?

A. Craniosynostosis release
B. Distraction osteogenesis for mandibular advancement
C. Orbito-zygomatic reconstruction
D. Orthognathic surgery

Answer: C

Rationale:
Patients with Treacher Collins Syndrome frequently require bone grafts for construction of missing and
hypoplastic orbital-zygomatic structures. Early surgery should be avoided since ongoing orbital growth
may make the surgical outcome less predictable. Orbital structures are almost their adult size by
approximately age 7. This makes late childhood the ideal time for construction of orbital and zygomatic
components. If surgical correction of the orbital-zygomatic deformity is undertaken during infancy or
early childhood, then subsequent growth may adversely effect the outcome.

Reference:
Waitzmann AA, Posnick JC, Armstrong D, et al. Craniofacial skeletal measurements based on computed
tomography: II. Normal values and growth trends. Cleft Palate Craniofacial Journal 29:118, 1992.

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Question:
In an infant undergoing craniofacial reconstructive surgery involving a transcranial approach, which of
the following clinical findings is an early indicator of cerebral air embolus?

A. Decreased end tidal CO2 levels

B. Increased end tidal CO2 levels
C. Oxygen desaturation
D. Hypertension

Answer: A

Rationale:
The pediatric cranial vault contains a number of diploic channels. As the cranium is exposed and
craniotomy is completed, it becomes possible for air to enter the venous circulation and travel to the
pulmonary vasculature. In children with a patent foramen ovale, air may also cross from the right to the
left side of the heart and eventually enter the systemic, including cerebral, circulation. Air emboli may
result in pulmonary hypertension, impaired coronary blood flow, and stroke. The earliest clinical sign of
air embolism during a transcranial procedure is a decrease in end tidal CO2. This is often followed by
hypotensive crisis.

Reference:
Krane EJ, Domino KB. Anesthesia for Neurosurgery. In: Motoyama EK, Davis PJ (Editors): Anesthesia
for Infants and Children. Philadelphia, Mosby, 1996, Page 552.

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Question:
In a patient with Kaban Type IIb Hemifacial Microsomia, which of the following describes the condyle-
ramus complex?

A. Unaffected
B. Minimally dysmorphic and hypoplastic
C. Severely dysmorphic and hypoplastic
D. Congenitally absent

Answer: C

Rationale:
The Kaban classification system is utilized to describe the mandibular skeletal defect associated with
hemifacial microsomia. The Type I skeletal deformity is characterized by a mandibular condyle-ramus
complex that is normal in morphology, but hypoplastic. Type IIa patients demonstrate an abnormally
shaped ramus with more pronounced hypoplasia of the condyle and temporomandibular joint structures.
In Type IIb, the deformity of the ramus is more severe and the condyle is severely hypoplastic and
malpositioned. The Type III deformity consists of complete absence of the TMJ and ramus.

Reference:
Kaban LB. Congenital Abnormalities of the Temporomandibular Joint. In: Kaban LB and Troulis M.
(Editors): Pediatric Oral and Maxillofacial Surgery. Philadelphia, WB Saunders, 2004, Page 302.

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Question:
Which of the following syndromes is associated with the finding of bilateral complex syndactyly of
fingers and toes?

A. Apert syndrome
B. Carpenter syndrome
C. Crouzon syndrome
D. Saethre-Choetzen

Answer: A

Rationale:
All infants born with Apert syndrome demonstrate facial findings consistent with the other craniofacial
dysostosis syndromes including craniosynostosis and total midfacial deficiency. In addition, patients with
Apert syndrome have a high incidence of other anomalies including cleft palate, deafness, developmental
delay, bilateral complex syndactyly of the fingers and toes, and other skeletal anomalies.

Reference:
Apert Syndrome: Evaluation and Staging of Reconstruction. In: Posnick JC. (Editor). Craniofacial and
Maxillofacial Surgery in Children and Young Adults. Philadelphia, WB Saunders, 2000, Page 308.

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Question:
A 16-year-old patient with a history of repaired cleft palate undergoes maxillary advancement and
develops velopharyngeal insufficiency with significant hypernasality after the orthognathic procedure.
What is the most appropriate next step?

A. Pharyngeal flap surgery 4 to 6 weeks postoperatively

B. Z-plasty for lengthening of the soft palate at 4 to 6 weeks postoperatively
C. Repeat Le Fort I level osteotomy for repositioning of the maxilla
D. Re-evaluation at 6 months postoperatively

Answer: D

Rationale:
Although most patients with repaired cleft palate who undergo maxillary advancement tolerate the change
in soft palate position, a minority of patients will demonstrate a deterioration of velopharyngeal function
and hypernasality. When it does occur, velopharyngeal insufficiency typically resolves with a return to
the patient's presurgical baseline by 6 months. It is prudent to delay subsequent surgery to reduce nasality
for at least 6 months following maxillary advancement as most patients will not require surgical
intervention.

Reference:
Turvey TA, Ruiz RL, Vig KWL, and Costello BJ. Orthognathic Surgery in the Patient with Cleft Palate.
In: Miloro M, Ghali GE, Larsen PE, and Waite PD (Editors): Peterson's Principles of Oral and
Maxillofacial Surgery, Second Edition. Hamilton, BC Decker, 2004. Page 1274.

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Question:
In the classic Millard (Rotation-Advancement) technique for cleft lip repair, the “C” flap may be utilized
for reconstruction of the nostril sill or:

A. for recreating the philtral column on the cleft side.

B. for lengthening the cleft side columella.
C. for performing a gingivoperiosteoplasty.
D. may be banked for use at a later date.

Answer: B

Rationale:
The “C” flap is a soft tissue flap developed along the non-cleft side that may be utilized for a number of
purposes depending on the anatomy of a particular cleft defect. Specific uses include nostril sill
construction or lengthening of the lip.

Reference:
Millard, DR Cleft Craft: The Evolution of Its Surgery, Volume I: The Unilateral Deformity, Little, Brown
, and Company, 1976.

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Question:
In the event that an alveolar cleft bone graft begins to extrude bone during the post-operative period, the
surgeon should do which of the following?

A. Manage it expectantly with local debridement and supportive measures.

B. Immediately return to the operating room to remove the failed graft.
C. Immediately augment the graft with additional bone from another donor site.
D. Place additional sutures in the mucosa at the site of bone extrusion to prevent further bone loss.

Answer: A

Rationale:
Bone graft reconstruction of the cleft maxilla and palate is typically accomplished with the use of fresh,
autogenous corticocancellous bone grafts harvested from the anterior iliac crest. Other bone harvest sites
include the cranial vault and tibia. Necrosis and loss of a small bone fragment is a relatively common
occurrence after bone graft repair of the cleft maxilla. In the absence of severe infection, management is
conservative consisting primarily of local wound care measures such as frequent irrigation and hygiene.
Many patients may loose several small bone fragments and still go on to heal an adequate amount of bone
to accomplish the goals of cleft repair.

Reference:
Padwa, B, Mulliken J OMS Clinics of North America Vol 15. Elsevier, 2003.

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Question:
Which of the following indications for bone graft reconstruction of the cleft maxilla and alveolus is
unique to patients with bilateral deformities?

A. Provision of bone support to dentition

B. Creation of alveolar ridge continuity
C. Closure of oronasal fistulas
D. Stabilization of the premaxilla

Answer: D

Rationale:
The goals of bone graft reconstruction in patients with cleft lip and palate include:
• Providing adequate bony matrix for the developing teeth (e.g. canine and lateral)
• Closure of any residual oronasal fistula(s)
• Create alveolar ridge continuity
• Improve bony support for the nasal base on the cleft side.

In patients with bilateral deformities, there is an additional goal of stabilizing the mobile premaxillary
segment. Reconstruction of the bilateral cleft defects consolidates the maxillary arch into a continuous
bony structure and enhances orthodontic stability.

Reference:
Larsen PE. Reconstruction of the Alveolar Cleft. In: In: Miloro M, Ghali GE, Larsen PE, and Waite PD
(Editors): Peterson's Principles of Oral and Maxillofacial Surgery, Second Edition. Hamilton, BC Decker,
2004. Page 859-860.

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Question:
Which of the following techniques may cause unfavorable lateral condylar displacement during
application of rigid internal fixation for a patient undergoing bilateral sagittal osteotomies for mandibular
advancement?

A. Lag screw placement

B. Use of a bone shim in between segments
C. Recontouring of the distal segment
D. Addition of a symphysis osteotomy

Answer: A

Rationale:
Changes in intercondylar width may occur as a result of sagittal split osteotomy. As the distal segment is
advanced, there is often the creation of a gap at the anterior-superior extent of the osteotomy site. If the
segments are compressed together at the time of rigid fixation placement, there is a fulcrum based on the
distal segment and lateral displacement of the condyle. Several techniques have been described in order
to avoid unfavorable condylar displacement. These include the use of bicortical position screws,
placement of bone shim between the proximal and distal segments, recontouring of the proximal/lingual
aspect of the distal segment, and addition of a midline/symphyseal osteotomy. Use of lag screw fixation
will compress the segments and actually cause lateral condylar displacement. Alternatively, lag screws
may be utilized only when at least one position screw is placed first in order to maintain the anterior
osteotomy gap.

Reference:
Tucker M.R., Frost D.E., and Terry B.C. Mandibular Surgery. In: Tucker M.R., Terry B.C., White R.P.,
and VanSickels J.E. (Eds), Rigid Fixation for Maxillofacial Surgery. J.B. Lippincott, New York, Pp. 251-
295, 1991.

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Question:
Which of the following clinical features is frequently encountered in patients with Treacher Collins
Syndrome?

A. Malar Hypoplasia
B. Craniosynostosis
C. Partial anodontia
D. Bifid nose

Answer: A

Rationale:
Treacher Collins Syndrome is an autosomal dominant disorder affecting the hard and soft tissues of the
st nd
1 and 2 branchial arches. It is commonly associated with a number of findings including malar
hypoplasia with clefting of the zygomatic arches, mandibular hypoplasia with condyle-ramus anomalies,
apertognathia, and hearing loss. Craniosynostosis, partial anodontia, and bifid nose are not associated
with this disorder.

Reference:
Posnick JC: Treacher Collins Syndrome Evaluation and Treatment. In Posnick JC Craniofacial and
Maxillofacial Surgery in Children and Young Adults. pp. 391

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Question:
In females, facial skeletal maturity typically occurs during which age range?

A. 11 to 13 years
B. 14 to 16 years
C. 16 to 18 years
D. after age 18

Answer B

Rationale:
Females approach facial skeletal maturity at approximately 14 to 16 years of age. This is sooner than
what is observed in males who reach completion of jaw growth at approximately 18 years of age.

Reference:
Proffit WR. Contemporary Treatment of Dentofacial Deformity. Philadelphia, Mosby, 2003.

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Question:
TMJ Disc position is unchanged in what percentage of cases two years following arthrotomy for disc
repositioning?

A. 15%
B. 25%
C. 55
D. 85%

Answer: D

Rationale:
The concept of arthrotomy for disc repair was championed by McCarty and Farrar with their 1979 report
of 327 disc repairs. In spite of reports describing successful outcomes, few reports have evaluated disc
position following “repair.” Montgomery, et al imaged 35 joints an average of 2 years after disc repair
and noted that disc position was unchanged in 86% of joints, worse in 6%, and improved in 8%.
Assuming that these discs were repositioned at the time of surgery, these data suggest that disc position is
prone to relapse at some point after disc repair. A smaller series of 23 joints showed persistent disc
displacement in 48% of joints after disc repair.

Reference:
Montgomery MT, Gordon SM, Van Sickels JE, et al. Changes in signs and symptoms following
temporomandibular joint disc repositioning surgery. J Oral Maxillofac Surg 50:320, 1992

McCarty WL, Farrar WB: Surgery for internal derangements of the TM joint. J Prosth Dent 42: 191, 1979

Westesson PL, Cohen JM, Tallents RH: Magnetic resonance imaging of TM joint after surgical treatment
of internal derangement. Oral Surg Oral Med Oral Pathol 71, 407, 1991

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Question:
A variety of neurotransmitters play a role in the generation of orofacial pain. The primary
neurotransmitter for pain is:

A. Substance-P
B. Serotonin
C. Glutamate
D. Prostaglandin I2

Answer: C

Rationale:
Glutamate is the primary neurotransmitter for pain. It is the first agent released following trauma.
Substance-P plays a major role in pain however it requires higher intensity stimulation for release
compared to glutamate. Inflammatory messengers such as PGI2 and serotonin act through the activation
of adenylate cyclase sensitive nocioceptive terminals.

Reference:
Merrill, RL; Neurophysiology of orofacial pain. Oral Maxillofac Clinic North Am. 12:169, 2000

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Question:
Modified condylotomy is principally indicated for which of the following conditions?

A. Anterior disc displacement without reduction and associated degenerative joint disease
B. Anterior disc displacement with reduction
C. Central disc perforation with osteoarthrosis
D. Superior joint space adhesions and chronic limited opening

Answer: B

Rationale:
Condylotomy has been shown to work most favorably in cases of anterior disc displacement, especially in
the setting of disc displacement with reduction. Modified condylotomy can effect disc reduction and alter
favorably the natural course of internal derangement in reducing disc displacement.

Reference:
Nickerson, JW: Condylotomy in surgery of the temporomandibular joint. Oral Maxillofac Clinic North
Am. 1:315-316 1989

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Question:
In performing TMJ arthrocentesis, the initial point of entry into the superior joint space is:

A. 10 mm anterior to the tragus, and 5mm inferior to the tragocanthal line.

B. 10mm anterior to the tragus, and 2mm inferior to the tragocanthal line.
C. 15mm anterior to the tragus, and 2mm inferior to the tragocanthal line.
D. 15mm anterior to the tragus, and 5mm inferior to the tragocanthal line.

Answer: B

Rationale:
Puncture landmarks for arthrocentesis are established with reference to a line connecting the tragus and
lateral canthus. The initial puncture should be 10 mm anterior to the tragus and 2 mm below the canthal-
tragal line.

Reference:
Israel HA: Kendell BD, Frost DE: Arthrocentesis. Atlas of Oral and Maxillofac Surg Clin North Am. 4:1,
1996.

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Question:
What subnucleus of the trigeminal brainstem nucleus complex is primarily involved in the receiving and
processing of facial pain?

A. Subnucleus interpolaris of cranial nerve V.

B. Subnucleus caudalis of cranial nerve IX.
C. Subnucleus caudalis of cranial nerve V.
D. Subnucleus oralis of cranial nerve V.

Answer: C

Rationale:
Trigeminal sensory nerves relay mechanical, thermal, chemical, and proprioceptive information from
craniofacial regions. The trigeminal spinal nucleus is divided into oralis, interpolaris, and caudalis
subdivisions. The subnucleus caudalis is the largest subdivision and is primarily responsible for facial
pain.

Reference:
th
Okeson, J: Management of Temporomandibular Joint Disorders and Occlusion, 4 edition. Mosby,
1998, p34

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Question:
Muscle contraction type headache will most commonly result in which symptom?

A. Unilateral pulsating head pain

B. Prostration and nausea
C. Scotoma and/or photophobia
D. Sensation of a constricting band about the head

Answer: D

Rationale:
In contrast to vascular headache, muscle contraction type headache is usually not associated with visual
symptoms, prostration and nausea. Muscle contraction headache can be acute or chronic and is associated
with sustained contraction of skeletal muscles. The temporalis muscle is often involved in muscle
contraction headache. Symptoms are usually generalized with the sensation of a “constricting band”
about the head. The pain of muscle contraction headache is described as dull and throbbing in nature.
Unilateral, pulsating headache associated with prostration/nausea, and visual symptoms are features of
migraine headache.

Reference:
th
Okeson, J: Management of Temporomandibular Joint Disorders and Occlusion, 4 Edition. Mosby,
1998, p222-223.

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Question:
The use of contralateral coronoidectomy/coronoidotomy during the surgical management of bony TM
joint ankylosis is most appropriately established by:

A. Pre-operative CT imaging
B. Examination under anesthesia with pharmacologic muscle relaxation
C. Examination immediately after arthrotomy/excision of ankylosis
D. Pre-operative MR imaging

Answer: C

Rationale:
Contralateral coronoidectomy/coronoidotomy may be necessary due to temporalis shortening/fibrosis.
The requirement for contralateral coronoidectomy/coronoidotomy is established through examination of
mandibular mobility after arthrotomy/excision of ankylosis.

Reference:
Kaban L: A protocol for the management of TMJ ankylosis. J Oral Maxillofac Surg 48:1145-1152, 1990.

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Question:
A key technical element in the performance of modified condylotomy that differs from vertical ramus
osteotomy for mandibular setback is:

A. Short vertical osteotomy directed from the sigmoid notch posteriorly through the posterior border
of the ramus.
B. Deliberate anterior re-positioning of the proximal segment.
C. Long vertical osteotomy directed from sigmoid notch to the gonial angle.
D. Deliberate partial detachment of the medial pterygoid muscle from the inferior aspect of the
proximal segment.

Answer: D

Rationale:
A posteriorly directed osteotomy is more likely to be associated with excessive condylar sag, if not
condylar displacement by unopposed lateral pterygoid activity. Medial pterygoid muscle is deliberately
stripped from the inferior aspect of the proximal segment to produce condylar sag with modified
condylotomy. To minimize ir prevent condylar sag, lateral pterygoid stripping is minimized in vertical
ramus osteotomy for mandibular setback.

Reference:
Hall HD; Modified condylotomy for treatment of painful temporomandibular joint with a reducing disc. J
Oral Maxillofac Surg 51; 133-142, 1993.

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Question:
Which of the following findings may help differentiate TMJ osteoarthritis from rheumatoid arthritis?

A. Prolonged morning stiffness

B. Joint space narrowing
C. Crepitant joint sounds
D. Preauricular tenderness

Answer: A

Rationale:
Morning stiffness is typically found with rheumatoid arthritis but not osteoarthritis. Joint space
narrowing, crepitant joint noise and preauricular pain may be seen in both conditions.

Reference:
Silverstein K; Arthritis of the temporomandibular joint. In: Fonseca, RJ. Bays RA, Quinn PD (eds); Oral
and Maxillofacial Surgery. WB Saunders, 2000, p78-81.

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Question:
What percentage of adults have an asymptomatic TM joint internal derangement?

A. 0%
B. 15%
C. 30%
D. 45%

Answer: C

Rationale:
Katzberg, et al discovered that 25/76 (33%) asymptomatic volunteers (no joint noise, locking, or pain or
tenderness) had an internal derangement in one or both joints. 79/102 (79%) symptomatic patients had an
internal derangement in one or both joints. The symptomatic participants were more likely to have disc
displacement without reduction. Similar data is presented by Kircos, et al.

Reference:
Katzberg RW, Westesson PL, Tallents RH, et al: Anatomic disorders of the TM joint disc in
asymptomatic subjects. J Oral and Maxillofac Surg 54: 147, 1996

Kircos LT, Ortendahl DA, Mark AS: Magnetic resonance imaging of the disc in asymptomatic
volunteers. J Oral and Maxillofac Surg 45:852, 1987

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Question:
What percent of infants and children under 5 years of age have been found to have a displaced TM joint
disc?

A. 0%
B. 15%
C. 30%
D. 45%

Answer: A

Rationale:
In both adult and pediatric patients TMJ pain is associated with disc displacement in 77-94% of subjects.
The incidence of painful disc displacement peaks during puberty. The prevalence of asymptomatic disc
displacement is 6% in a population with a median age of 11 years (Hans, et al) and 34% in a population
with a median age of 16-19 years (Ribeiro, et al). The high prevalence of disc displacement in
asymptomatic joints suggests that internal derangement may be congenital. However, the finding by
Paesani, et al of normal disc position in 60 joint imaged in children aged 2-5 years supports an acquired
etiology for internal derangement.

Reference:
Hans MG, Liberman J, Goldberg J, et al: A comparison of of clinical examination, history, and magnetic
resonance imaging for identifying orthodontic patients with TM joint disorders. Am J Orthod Dentofac
Orthop 101: 54, 1992.

Ribeiro RF, Tallents RH, Katzberg RW, et al: The prevalence of disc displacement in symptomatic and
asymptomatic volunteers aged 6 to 25 years. J Orofac pain 11: 37, 1997.

Paesani D, Ezequiel S, Martinez A, et al: Prevalence of TM joint disk displacement in infants and young
children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:15,1999.

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Question:
Patients with TM joint pain most likely to seek initial help at what ages?

A. 0-20 years
B. 20-40 years
C. 40-60 years
D. 60-80 years

Answer: B

Rationale:
Patients in the 20-40 year age range are most likely age group to seek treatment for internal derangement.

Reference:
Nickerson JW, Boering, G: Natural course of osteoarthrosis as it relates to internal derangement of the
TM joint. Oral Maxillofac Surg Clin North Am 1: 27, 1989

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Question:
Which of the following factors predispose to post-modified condylotomy malocclusion?

A. Pre-operative class I occlusion

B. Bilateral surgery
C. Ligation of anterior teeth to arch bar
D. Absent molar occlusion on the side opposite the condylotomy

Answer: B

Rationale:
Bite disturbance is minimized with a brief (1 week –unilateral, 2-3 weeks-bilateral) period of
maxillomandibular fixation followed by a period (3-4 weeks-bilateral, 5 weeks-unlateral) of training
elastic use. Bite disturbance is more common in the setting of bilateral condylotomy, pre-existing
malocclusion, and missing molars on the operated side. Ligation of anterior teeth can allow for dental
compensation and minimize open bite malocclusion especially after bilateral condylotomy.

Reference:
Hall HD, Nickerson JW, McKenna SJ: Modified condylotomy for treatment of the painful
temporomandibular joint with a reducing disc. J Oral Maxillofac Surg 51:133-142, 1993.

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Question:
Which of the following complications associated with TM joint arthroscopy may be accounted for by the
foramen of Huschke and Huguire’s canal?

A. External auditory canal edema

B. Intracranial extravasation of joint irrigant
C. Perforation of the tympanic membrane
D. Injury to the temporal branch of the facial nerve

Answer: A

Rationale:
External auditory canal edema and possibly tympanic membrane edema may be explained by
extravasation joint irrigant through the foramen of Huschke, a residual defect in the tympanic plate.
Another potential explanation for this complication is extravasation of fluid along the ligaments within
Huguire's canal within petrotympanic fissure.

Reference:
Tsuyama M, Kondoh T, Seto K, et al: Complications of TM joint arthroscopy: A retrospective analysis of
301 lysis and lavage procedures performed using the triangulation technique. J Oral and Maxillofac Surg.
58: 500, 2000.

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Question:
Trigeminal neuralgia is characterized by:

A. proxysmal unilateral pain in the distribution of one or more divisions of the 5th cranial nerve.
B. predilection for males in the 4th decade of life.
C. chronic, continuous, unilateral pain in the distribution of one or more divisions of the 5th cranial
nerve.
D. predilection for females in the 3rd decade of life.

Answer: A

Rationale:
Trigeminal neuralgia is characterized by paroxysmal, lacinating pain in the distribution of one or more of
th th th
the divisions of the 5 nerve in a woman in the 6 or 7 decade of life. Pain of trigeminal neuralgia is
usually provoked by trivial stimulation of the involved dermatome. Traumatic trigeminal neuralgia occurs
in a younger population and is associated with tissue or nerve injury. Traumatic trigeminal neuralgia is
characterized by continuous burning pain.

Reference:
Graff-Radford SB: Trigeminal neuralgia. Oral Maxillofac Surg Clinic North Am. 12:237, 2000.

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Question:
The mechanism of action of the sumatriptan (Imitrex) in the management of migraine headache is:

A. ihibition of pre-synaptic serotonin receptors.

B. ihibition of cerebral vessel and dural pain fibers.
C. dwn regulation of pain fibers by inhibition of Substance-P re-uptake.
D. ihibition of the vasoconstrictor phase of migraine headache.

Answer: B

Rationale:
The mechanism of action of the sumatriptan and other “triptans” is by inhibition of cerebral vessel and
dural pain fibers. Additionally, the “triptans” are serotonin agonists are directly bind 5-HT pre-synaptic
receptors causing vasoconstriction. Thus, “triptans” modulate vascular headache pain by direct inhibition
of dural/cerebral vascular pain fibers and by antagonism of cerebral vasodilation.

Reference:
Dym H: Diagnosis and treatment of headache. Oral Maxillofac Surg Clin North Am. 12:248, 2000.

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Question:
Findings consistent with Wilkes stage IV TMJ internal derangement include:

A. recent progression to disc displacement without reduction.

B. maximum interincisal oral opening less than 25mm.
C. altered mandibular condyle morphology.
D. low condyle signal intensity on MR T2 images.

Answer: C

Rationale:
Wilkes stage IV (intermediate late stage) internal derangement is defined as complete disc displacement
with hard-tissue degenerative remodeling changes and clinical chronicity. Interincisal opening is usually
greater than 30mm in late-stage disease. Option A describes early Wilkes stage III (intermediate stage)
internal derangement. Option B suggests a component of muscle guarding/splinting that does not define a
particular Wilkes stage. Maximum opening usually exceeds 25 mm in stage IV internal derangement as a
result of progressive disc deformity. Option D describes the controversial concept of avascular necrosis
and is not associated with a particular Wilkes stage.

Reference:
Wilkes CH: Surgical treatment of internal derangement of the temporomandibular joint: A long-term
study. Arch Otolaryngol Head Neck Surg 117:64, 1991

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Question:
Wilkes stage III (intermediate stage) internal derangement is best described by which of the following
statements?

A. Chronic location of disc and condyle anterior to the articular eminence.

B. Major mechanical and inflammatory symptoms, moderate to marked disc deformity, partial or
complete forward disc displacement
C. Painless, early reciprocal clicking, no inflammatory symptoms, slight anterior disc displacement
D. Clinical chronicity, complete forward disc displacement, hard and soft tissue degenerative
remodeling

Answer: B

Rationale:
Option A describes chronic TMJ dislocation. Option C describes Wilkes stage I (early stage) internal
derangement. Option D describes Wilkes stage IV (intermediate late stage) internal derangement.

Reference:
Wilkes CH: Surgical treatment of internal derangement of the temporomandibular joint: A long-term
study. Arch Otolaryngol Head Neck Surg 117:64, 1991.

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Question:
When applied to Wilkes stage II and early stage III anterior disc displacement modified condylotomy has
been shown to effect MRI disc reduction in what percentage of joints?

A. 10%
B. 20%
C. 50%
D. 80%

Answer: D

Rationale:
Modified condylotomy is capable of effecting disc reduction in 80% of joints with anterior disc
displacement with reduction (Wilkes stage II) or with discs that have recently progressed to non-reducing
disc status (Wilkes early stage III).

Reference:
Werther JR, Hall HD, Gibbs SJ: Disk position before and after modified condylotomy in 80 symptomatic
joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79:668, 1995.

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Question:
Sleep bruxism is associated with which of the following features?

A. Periodic limb movement disorder

B. Cessation of caffeine consumption
C. Anxiety disorders
D. Nasal CPAP use

Answer: C

Rationale:
Sleep bruxism shares many features with untreated obstructive sleep apnea. In an evaluation of over
13,000 subjects sleep bruxism was associated with anxiety disorders, caffeine consumption but is was not
associated with periodic limb movement or nasal CPAP use.

Reference:
Ohayon MM, Li KK, Guilleminault C: Risk factors for sleep bruxism in the general population. Chest
119:53, 2001.

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Question:
What statement best describes TMJ involvement in rheumatoid arthritis?

A. TM joint involvement is present in greater than 80% with rheumatoid arthritis.

B. There is poor correlation between TMJ radiographic changes and the severity of rheumatoid
disease.
C. Progression of TM joint bone loss is associated with elevated plasma levels of C-reactive protein.
D. The most common CT radiographic finding is condylar osteophyte formation.

Answer: C

Rationale:
Elevated plasma C-reactive protein is associated with progression of TM joint bone loss. The next most
common laboratory evaluation for RA is rheumatoid factor (RF) which is positive in 70-80% of patients.
RF titers greater than 1:1280 are associated with severe and progressive disease. A positive anti-nuclear
antibody (ANA) titer will be detected in 15-20% with rheumatoid arthritis. Radiographic TM joint
involvement is seen in approximately 40% with rheumatoid arthritis. TM joint symptoms occur in
approximately 30% with rheumatoid arthritis. The most common CT radiographic finding is decreased
joint space.

Reference:
BayerN, Kara SA, Koc MC, et al: Temporomandibular joint involvement in rheumatoid arthritis: A
radiological and clinical study. Cranio 20:105, 2002.

Nordahl S, Alstergren P, Kopp S: Radiographic signs of bone destruction in the arthritic

temporomandibular joint with special Reference to markers of disease activity: A longitudinal study.
Rheumatol 40:691, 2001.

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Question:
The concept of minimizing stress on the TM joint following mandibular ramus osteotomies to correct a
Class II skeletal malocclusion is described by which statement?

A. Avoidance of mandibular counterclockwise rotation and ramus lengthening with mandibular

advancement
B. Application of rigid fixation and early mandibular mobilization
C. Simultaneous intracapsular TM joint surgery and ramus osteotomies for mandibular advancement
D. Application of semi-rigid fixation

Answer: A

Rationale:
The concept of minimizing TM joint stress refers to measures to avoid counterclockwise mandibular
rotation and ramus lengthening at the time of mandibular advancement. The type of fixation (rigid vs.
semi-rigid vs. non-rigid) has no proven impact on joint problems after orthognathic surgery.
Simultaneous arthrotomy and ramus osteotomies have not been demonstrated to control TM joint stress
after orthognathic surgery.

Reference:
Wolford LM, Reiche-Fischel O, Pushkar, M: Changes in temporomandibular joint dysfunction after
orthognathic surgery. J Oral Maxillofac Surg 61:655, 2003.

Cottrell DA: Discussion Re: Wolford LM, Reiche-Fischel O, Pushkar, M: Changes in temporomandibular
joint dysfunction after orthognathic surgery. J Oral Maxillofac Surg 61:661, 2003.

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Question:
The roof of the glenoid fossa is formed primarily by the:

A. ptrous part of temporal bone.

B. suamous part of temporal bone.
C. tmporal part of zygomatic bone.
D. tmpanic part of the temporal bone.

Answer: B

Rationale:
The roof of the fossa is formed primarily by the squamous portion of the temporal bone. It is separated
from the tympanic plate by the squamotympanic fissure. The medial 2/3rds the roof of the fossa is inferior
to the middle cranial fossa. The petrous portion of the temporal bone is pyramidal, wedged in at the base
of the skull between the sphenoid and occipital bones and does not form part of the fossa.

Reference:
Spagnoli DB: Anatomy of the temporomandibular joint. Oral Maxillofacial Surgery Knowledge Update.
American Association of Oral Maxillofacial Surgeons, Chicago, 1994 1:17.

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Question:
During surgical dissection of the TMJ the most posterior element of the temporal branch of the facial
nerve transverses the zygomatic arch how many cm anterior to the most anterior concavity of the external
auditory canal?

A. Range of 1.5-3.0 cm with a mean of 1.5 cm

B. Range of 1.5-3.0 cm with a mean of 2.0 cm
C. Range of 0.8-3.5 cm with a mean of 2.0 cm
D. Range of 0.8-3.5 cm with a mean of 1.5 cm

Answer: C

Rationale:
l-Kayat and Bramley performed 56 cadaveric dissections and measured the distance from the anterior
concavity of the external auditory canal to the point where the temporal branch of the facial nerve crosses
the zygomatic arch. The range was found to 0.8-3-5cm with a mean distance of 20 mm.

Reference:
Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar
arch. Br J Oral Surg 17:91-103, 1979.

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Question:
What is characteristic of the presentation of psoriatic arthritis involving the TMJ?

A. Polyarthritis in a man
B. Affects 50% of patients with cutaneous psoriasis
C. Serology positive for rheumatoid factor (RF) and antinuclear antibody (ANA)
D. Bilateral TMJ arthritis with restricted opening

Answer: A

Rationale:
Psoriatic arthritis affects men more that women. It often presents as a rheumatoid-like, erosive
polyarthritis affecting approximately 6% of the patients with psoriasis. Laboratory studies are usually
negative for RF and ANA, and there are no rheumatoid nodules. TMJ involvement is characterized by
episodic unilateral arthritis with restricted opening. Timing of exacerbation of TMJ and skin symptoms is
often coincident.

Reference:
Hoffman KD: Differential diagnosis and characteristics of TMJ disease and disorders. Oral Maxillofacial
Surgery Knowledge Update, American Association of Oral and Maxillofacial Surgeons, Chicago, 1994
1:51.

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Question:
Which of the following modalities have a clinical application in the prevention of heterotopic bone
formation after surgical treatment of bony ankylosis of the TM joint?

A. Systemic corticosteroids
B. Short-term bisphosphonate administration
C. External beam irradiation
D. Aggressive passive range of motion exercises

Answer: C

Rationale:
Various modalities have been employed to decrease heterotopic bone formation after surgical treatment of
TM joint ankylosis. Bisphosphonates must be taken over a prolonged period of time to limit heterotopic
bone formation. Low dose radiation therapy administered in the first few days following arthrotomy can
also limit heterotopic bone deposition. Systemic corticosteroids have no role in limiting heterotopic
ossification. Aggressive, passive range of motion exercises may actually stimulate heterotopic bone
formation from muscle trauma.

Reference:
Stanton DC, Stewart JCB: Tumors of the temporomandibular joint. In: Fonseca RJ, Bays RA, Quinn PD
(eds): Oral and Maxillofacial Surgery, Vol 7, WB Saunders, Philadelphia, 2000, p377.

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Question:
What statement most closely describes the Christiansen total TM joint prosthesis?

A. System depends on CAD-CAM technology for fabrication of the condylar element.

B. Fossa element is composed of pre-cured polymethylmethacrylate.
C. Fossa element is composed of cobalt-chromium alloy.
D. Fossa and universal condylar element are composed of cobalt-chromium alloy.

Answer: D

Rationale:
The Christiansen total TM joint prothesis fossa element is composed of cobalt-chromium alloy. Both pre-
cured polymethylmethacrylate and cobalt-chromium condylar elements have been used with this system
however the “universal” condylar prosthesis is composed of a polymethylmethacrylate head and cobalt-
chromium ramus element. Though a patient-specific prosthesis can be fabricated using CAD-CAM
technology, stock elements are available.

Reference:
Gerard DA, Hudson JW: The Christiansen TMJ prosthesis system. Oral and Maxillofac Clin North Am.
12: 61, 2000.

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Question:
Which facial feature is characteristic of skeletal deformity associated with advanced juvenile rheumatoid
arthritis of the temporomandibular joint?

A. Macrognathia and class I skeletal deformity

B. Macrognathia and class II skeletal deformity
C. Micrognathia and class I skeletal deformity
D. Micrognathia and class II skeletal deformity

Answer: D

Rationale:
The TM joint is most often involved in the polyarticular subtype of juvenile rheumatoid arthritis (JRA).
The clinical features of JRA of the TM joint include pain, joint tenderness, crepitant sounds,
stiffness/decreased range of motion. Radiographic changes consist of condylar erosion, ramus shortening
and an accentuated antegonial notch. The mandible appears micrognathic with clockwise rotation and the
development of a Class II open bite malocclusion.

Reference:
Barriga B, Lewis TM, Law DB: An investigation of the dental occlusion in children with Juvenile
Rheumatoid Arthritis. Angle Orthod 44: 329, 1967

Abubaker OA: Differential diagnosis of arthritis of the TM joint. Oral Maxillofac Clin North Am 7:1,
1995

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Question:
Botulinum toxin type-A, when used in the treatment of chronic facial pain of muscular origin produces its
effects by:

A. spastic paralysis of the muscle.

B. attenuation of muscle contraction through inhibition of acetylcholine release.
C. increased inhibitory neuron Substance P production.
D. acetylcholine re-uptake inhibition.

Answer: B

Rationale:
Botulinum toxins are a group of eight toxins elaborated by Clostridium botulinum, a gram positive
anaerobic organism. The primary effect of botulinum toxin is receptor-mediated endocytosis of the toxin
in the area of neuromuscular synapse with selective proteolysis of the vesicular protein SNAP (synaptonal
associated protein). This event prevents the release of acetylcholine into the neuromuscular junction.

Reference:
von Linden JJ, Neiderhagen B, Berge S: Type –A botulinum toxin in the tre.

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Question:
A patient undergoes left temporomandibular joint reconstruction via a preauricular approach. One week
later, he still is unable to raise his eyebrow or close his eye on the operated side. The most appropriate
next step at this time is:

D. observation for 3 weeks then perform EMG.

E. surgical exploration of the wound.
F. electromyography study.
D. electroneurography study.

Answer: D

Rationale:
Electrophysiologic testing (EPT) is the most reliable prognostic tool for the assessment of post-traumatic
nerve recovery. The utility of EPT is in its ability to differentiate injuries that will recover from injuries
possibly requiring surgical intervention. EPT has limited applicability in the first three days post-injury
because Wallerian degeneration is incomplete and false positive results are common. Proper timing of
EPT should also take into account the 2-3 weeks necessary for denervational muscle changes following
nerve injury.

Electroneurography and electromyography are the two EPT modalities used to study facial nerve
function. Electroneurography is the most accurate method of predicting of nerve recovery. When the
response to electroneurography is less than 10% of the normal side a poor outcome is expected.
Conversely, if the response to electroneurography remains greater than 10% of the response on the
unaffected side up to three weeks post-injury the prognosis for spontaneous recovery is favorable.
Electroneurography should first be performed after Wallerian degeneration is complete, approximately
three days post-injury.

Electromyography estimates the extent of muscle denervation and the timing and completion of
functional recovery. Therefore electromyography is delayed for 2-3 weeks until denervation changes
occur. Electromyography is most useful in the period 2-3 weeks post-injury to 15 weeks post-injury.

Early EPT is widely recommended to assess the magnitude of nerve injury and determine the role for
early nerve repair.

Reference:
Davis RE, Telischi FF: Traumatic Facial nerve injuries, J CranioMaxillofac Trauma 1:30, 1995.

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Question:
What statement most closely describes the Lorenz total temporomandibular joint prosthesis?

A. Cobalt-chromium ramus component with HA coating to enhance stability.

B. Titanium ramus component with plasm sprayed coating to enhance stability.
C. Ultra high molecular weight fossa component stabilized with screws.
D. Polymethylmethacrylate fossa stabilized with screw fixation and polymethylmethacrylate bone
cement.

Answer: C

Rationale:
The Lorenz total TM joint prosthesis is composed of cobalt-chromium ramus component. The host-bone
surface of the ramus component is roughened with a titanium plasma coating. The fossa element is made
of ultra-high molecular weight polyethylene that is stabilized with screws. Polymethylmethacrylate bone
cement may also be used to fill voids but the cement is not designed as a load bearing medium.

Reference:
Quinn PD: Lorenz prosthesis. Oral Maxillofac Clin North Am 12: 93, 2000.

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Question:
In the preauricular approach to the temporomandibular joint, the temporal branch of the facial nerve is
located:

A. superficial to the SMAS layer.

B. deep to temporalis fascia.
B. on the deep surface of the temporoparietal fascia.
D. at least 3 cm anterior to the tragus.

Answer: C

Rationale:
The temporal branch of the facial nerve is situated between the temporoparietal fascia and the temporalis
fascia on the deep surface of the temporoparietal fascia.

Reference:
Ellis E and Zide MF: Surgical Approaches to the Facial Skeleton. Williams and Wilkins, 1995, p167

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Question:
After TMJ arthrotomy utilizing a preauricular approach, a patient reports sensory alteration of the
preauricular skin. Damage to what nerve is responsible for this finding?

A. Great auricular
B. Auriculotemporal
C. Chorda tympani
D. Zygomaticotemporal

Answer: B

Rationale:
rd th
The auriculotemporal branch of the 3 division of the 5 cranial nerve provides sensation to the
preauricular skin.

Reference:
Holmlund AB: Arthroscopy. In: Fonseca RJ, Bays RA, Quinn PD (eds): Oral and Maxillofacial Surgery.
WB Saunders, 2000, p268

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Question:
Examination of a 61 year old woman with a one year history of intermittent right TMJ pain reveals
tenderness of the right mandibular condyle, crepitant joint sounds, and mandibular opening limited to
29mm. Both hands have firm, painless enlargements of the distal interphalangeal joints. A panoramic
radiograph reveals cortical disruption of the right condyle. The erythrocyte sedimentation rate is
12mm/hour, latex fixation and antinuclear antibody (ANA) serology are negative. The most likely
diagnosis is:

A. rheumatoid arthritis.
B. gouty arthritis.
C. osteoarthritis.
D. giant cell arteritis.

Answer: C

Rationale:
Osteoarthritis (OA) is a chronic non-inflammatory condition that effects the articular cartilage of synovial
joints. Unlike rheumatoid arthritis the synovium is only involve secondarily. Osteoarthritis is the most
common disease affecting the TM joint. In contrast to rheumatoid arthritis, when osteoarthritis involves
the hands the DIP joint is most often involved. Unlike rheumatoid arthritis (RA), morning stiffness is not
characteristic of OA but when present generally lasts less than 30 minutes. Radiographic changes in OA
consist of subchondral sclerosis, condylar flattening, lipping and erosion. Laboratory findings in OA are
unremarkable where as in RA the erythrocyte sedimentation rate is usually significantly elevated and the
latex agglutination test is positive.

Gouty arthritis of the TMJ is more likely to be seen in late stage disease. The initial joint most frequently
affected in gout is the MTP of the great toe. Giant call arteritis does not affect the TM joint and is
associated with an elevated sedimentation rate.

Reference:
Silverstein K: Arthritis of the temporomandibular joint. In: Fonseca RJ, Bays RA, Quinn PD (eds): Oral
and Maxillofacial Surgery. WB Saunders, 2000, p75-91.

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Question:
A TMJ arthrotomy has been performed. The patient returns post-operatively with the complaint of
flushing, warmth and perspiration in the temporal region on the operated side when eating. She is
suffering from:

A. hyperhydrosis syndrome.
B. Frey’s syndrome.
C. Froin’s Syndrome.
D. Meniere’s syndrome.

Answer: B

Rationale:
Frey syndrome, or “gustatory sweating” is a relatively common complication of parotidectomy but
uncommon following TM joint arthrotomy. It is believed to be caused by aberrant regeneration of post-
ganglionic parasympathetic parotid secretomotor fibers with severed post-ganglionic sympathetic fibers
innervating facial sweat glands.

Reference:
Dolwick MF, Armstrong JW: Complications of temporomandibular joint surgery. In: Kaban L, Perrott d,
Pogrel T (eds): Complications in Oral and Maxillofacial Surgery. WB Saunders, Philadelphia, 1997, p 93.

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Question:
A patient with a history of diurnal bruxism presents with bilateral TMJ pain and muscle tenderness
refractory to non-steroidal antiinflammatory medication. She has limited opening with absence of
clicking, crepitus and deviation. A recent TMJ MRI is negative for internal derangement. Reasonable
treatment at this point should include:

A. occlusal equilibration.
B. diagnostic arthroscopy for lysis and lavage.
C. splint therapy.
D. arthrocentesis with local anesthetic and intraarticular steroids.

Answer C

Rationale:
In the setting of normal TM joints, bruxism and muscular pain the most appropriate treatment should be
initially directed towards the control of bruxism. Of the options listed, only splint therapy has a
potentially beneficial role in the management of bruxism. In this clinical scenario there is no indication
for initia irreversible treatments such as occlusal equilibration, arthroscopy, etc.

Reference:
Laskin DM: Diagnosis and etiology of myofascial pain and dysfunction in medical management of
temporomandibular disorders. Oral Maxillofac Surg Clin North Am. 7:77, 1995.

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Question:
Frey’s syndrome after TMJ reconstruction results from:

A. transection of the auriculotemporal nerve.

B. aberrant regeneration of sympathetic and parasympathetic fibers.
C. damage to otic ganglion preganglionic parasympathetic fibers.
D. aberrant regeneration of postganglionic adrenergic fibers.

Answer: B

Rationale:
Sympathetic innervation controls sweating and vascular smooth muscle tone. Postganglionic
parasympathetic fibers from the otic ganglion are severed in this condition. Misdirected regeneration of
parasympathetic fibers to sweat gland sympathetic fibers and receptors accounts for this condition.

Reference:
Marx RE, Stern D: Oral & Maxillofacial Pathology: A Rationale for Diagnosis and Treatment.
Quintessence Publishing Co, Inc, Chicago, 2003, pp. 28-29.

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Question:
What statement is true regarding the action of the superior head of the lateral pterygoid muscle?

A. Superior head is the principle cause of anterior disc displacement.

B. Has the same origin as the inferior head of the lateral pterygoid muscle.
C. Heterogeneous muscle with increased activity in closing, opening, protrusion, and contralateral jaw
movement.
D. Increased activity in closing, opening, retrusion and ipsilateral movements.

Answer: C

Rationale:
The action of the superior head of the lateral pterygoid muscle (SHLP) is controversial. However,
sophisticated analysis of motor unit activity has demonstrated muscle unit heterogeneity in the SHLP.
Therefore depending on the medial-lateral location of muscle units increased SHLP may occur with
closing, opening, protrusion, and contralateral jaw movements.

Reference:
Planachet I, Whittle T, Wanigaratne K, et al: Functional heterogeneity in the superior head of the human
lateral pterygoid. J Dent Res 82: 106, 2003

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Question:
What is the least common variety of MRI diagnosed disc displacement in symptomatic TM joints?

A. Medial
B. Lateral
C. Anterior
D. Anterolateral

Answer: B

Rationale:
As many as seven types of disc displacement have been described in MR imaging of symptomatic TM
joints. Werther, et al demonstrated that 74% of disc displacements fall into the two most common groups,
anterior (45%) and medial rotary ((29%). Of the options listed lateral disc displacement is the least
common, occurring in 2.5% of symptomatic joints. Similarly, Simmons found no case of lateral disc
displacement in 58 symptomatic joints imaged with MRI.

Reference:
Simmons HC, Gibbs SJ: Initial TMJ disk recapture with anterior repositioning appliances and relation to
dental history. J Craniomandib Prac 15:28, 1997.

Werther JR, Hall HD, Gibbs SJ: Disk position before and after modified condylotomy in 80 symptomatic
TM joints. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 79: 668, 1995.

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Question:
The arthrokinetic reflex is an orthopedic principle which describes:

A. muscle spasms causing arthritides.

B. muscles causing referred pain to an adjacent joint.
C. internal derangement of joints causing spasms in adjacent muscles.
D. internal derangements are secondary to muscle spasm.

Answer C

Rationale:
The arthrokinetic reflex is an orthopedic concept that states that internal derangement can cause muscle
spasm in the muscles supporting that joint and that when the internal derangement is resolved the muscles
cease to spasm. For example, in the setting of disc displacement with reduction, increased EMG activity
of the temporalis and masseter muscles occurs when the condyle slides over the posterior band of the disc
during closure. Muscle activity decreases when the disc position is normalized with mouth opening.

Reference:
Isberg A, Widmalm SE, Ivarsson R: Clinical, radiographic and electromyographic study of patients with
internal derangements of the temporomandibular joint. Am J Orthodont 88:453, 1985.

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Question:
What is most diagnostic to verify a temporomandibular joint source of facial pain?

A. Magnetic resonance imaging

B. Doppler auscultation of TMJ
C. Detailed patient history
D. Auriculotemporal nerve anesthetic block

Answer: D

Rationale:
Though MR imaging and doppler may depict an internal derangement and suggest a source for pain,
internal derangement may occur coincidentally in the setting of complex facial pain not originating in the
TM joint. Although a detailed history can often suggest the source of pain, diagnostic nerve blocks can be
used to systematically localize a source of pain. Diagnostic anesthetic block of the auriculotemporal nerve
largely eliminates the temporomandibular joint from a complex facial pain presentation and can facilitate
localization of a pain source.

Reference:
Pertes RA, Gross SG. Clinical Management of Temporomandibular Disorders and Orofacial Pain.
Quintessence Publishing Co., Inc. 1995, p156.

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Question:
Non-arthroscopic lysis and lavage of the temporomandibular joint is an effective adjunct in the
management of:

A. myofascial pain dysfunction.

B. recent onset disc displacement without reduction.
C. synovitis.
D. temporal tendonitis.

Answer: B

Rationale:
Temporomandibular joint arthrocentesis includes lavage of the upper joint space, hydraulic distension,
manipulation, and instillation of a corticosteroid. Arthrocentesis is indicated for acute or chronic
limitation of motion due to anterior disc displacement without reduction and hypomobility due to
restriction of condylar translation in the superior joint space.

Reference:
Murakami KI, Matsuki M, Iizuka T, OnoT: Recapturing the persistent anteriorly displaced disk by
mandibular manipulation after pumping and hydraulic pressure to the upper joint cavity of the
temporomandibular joint. J Craniomandib Prac. 5:17, 1987.

Frost DE, Kendell BD: The use of arthrocentesis for treatment of TM joint disorders. J Oral Maxillofac
Surg 57: 583, 1999.

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Question:
During surgery for bony ankylosis of the TM joint brisk skull base bleeding medial and anterior to the
glenoid fossa is most likely from what vascular structure?

A. Internal jugular vein

B. Middle meningeal artery
C. Internal carotid artery
D. Ascending pharyngeal artery

Answer: B

Rationale:
The important vascular structure medial and anterior to the glenoid fossa is the middle meningeal artery
(MMA). The mean anterior-posterior distance of the MMA from a line tangent to the maximum height of
the glenoid fossa is 2.4mm. The distance of the internal carotid artery and internal jugular vein from the
same landmark is 6.5 and 8.7mm respectively. Though injury to the MMA is uncommon, catastrophic
bleeding may occur if this structure is violated during surgery medial to the TM joint.

Reference:
Talebzadeh N, Rosenstein TP, Pogrel MA: Anatomy of the structures medial to the TM joint. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 88: 674, 1999.

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Question:
Which of the following statements regarding melanoma is true?

A. The incidence in the white population has decreased significantly over the past 2 decades.
B. Melanoma commonly occurs in patients who demonstrate pale skin, red hair, freckles, and the
tendency to burn while in the sun.
C. Nodular melanoma is more common than the superficial spreading variety.
D. The acral lentiginous melanoma is most common in the oral cavity.

Answer: B

Rationale:
The incidence of melanoma continues to grow in the white population with the highest rate being in
northern Australia. Of this population, melanoma is seen most commonly in people with red or blond
hair, fair skin, large numbers of freckles, and the potential to burn easily when in the sun. The superficial
spreading melanoma is the most common variety being seen almost twice as often as the nodular type.
The acral lentiginous melanoma as the name denotes is a tumor of the palmar, plantar, and subbing skin.

Reference:
Regal, DS, Friedman, RJ, Kip, AW. The incidence of malignant melanoma in the United States as we
approach the 21st century. J Am Acad Dermatol 1996; 34:839-847.

Clark, WH, Elder, DE, van Horn, M. The biologic forms of malignant melanoma. Hum Pathol 1986;
17:443-450.

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Question:
Which of the following is not a sun-induced skin lesion?

A. Actinic Keratosis
B. Bowen’s Disease of Skin
C. Erythroplasia of Queyrat
D. Morpheaform variant of basal cell carcinoma

Answer C

Rationale:
Even though histologically very similar to Bowen's Disease, Erythroplasia of Queyrat is a dysplastic
lesion of the penis in uncircumcised males. It usually arises on the inner surface of the prepuce. Actinic
keratosis, Bowen's disease of skin (carcinoma in situ) and the morpheaform (sclerosing) variant of basal
cell carcinoma are all well accepted examples of sun induced skin disease.

Reference:
Hodge, SJ, Turner, JE. Histopathologic concepts of intraepithelial epithelioma. Int J Dermatol 1986;
25:372-375.

Graham, JH, Helwig, EB. Erythroplasia of Queyrat. A clinicopathologic and histochemical study.
Cancer 1972; 32:1396-1414.

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Question:
Which of the following statements regarding the basal cell carcinoma (BCC) is true?

A. The BCC is the least common malignant skin tumor.

B. The majority of BCC’s are found in the trunk.
C. The BCC is often associated with Xeroderma Pigmentosum.
D. The multifocal superficial variant is the most common type of BCC.

Answer: C

Rationale:
80% of BCC's are in the head and neck region. The BCC as well as the squamous cell carcinoma are both
seen in cases of Xeroderma Pigmentosum. The most common variant of the BCC is the solid type, which
represents approximately 70% of all cases.

Reference:
Miller, DL, Weinstock, MA. Nonmelanoma skin cancer in the United States Incidence. J Am Acad
Dermatol 1994; 30:774-778.

Miller, SJ. Biology of the basal cell carcinoma. J Am Acad Dermatol 1991, 24:1-13.

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Question:
Which of the following is true regarding Nevoid Basal Cell Carcinoma Syndrome (Gorlin-Goltz
Syndrome)?

A. Inheritance is Autosomal Dominant with a variable and complete penetrance.

B. The basal cell carcinoma is only seen on non sun-exposed skin.
C. The basal cell carcinomas in this syndrome appear at a much later age than the more typical basal
cell carcinoma.
D. Rib abnormalities are seen in approximately 90% of the patients.

Answer: A

Rationale:
Inheritance is autosomal dominant with complete penetrance and variable expressability. The basal cell
carcinomas seen in Basal Cell Nevus Syndrome are typically seen on sun-exposed and non sun-exposed
skin, they occur at an earlier age than the classic basal cell carcinoma, and rib abnormalities (bifid rib) are
seen in about 60% of patients with this syndrome.

Reference:
Gorlin RJ, Goltz RW. Multiple nevoid basal-cell epithelioma, jaw cysts and bifid rib syndromes. N Engl
J Med 1960; 262:908-912

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Question:
Which of the following is true regarding the keratoacanthoma (KA)?

A. It is a quickly growing lesion of the skin.

B. It is often multiple when seen in the head and neck region.
C. It is a skin tumor of older females.
D. It is just as common on non-exposed skin as on skin exposed to the sun.

Answer: A

Rationale:
The classic presentation of a KA is a solitary lesion of the facial sun-exposed skin in an older male. It is
typically a fast growing lesion, reaching its maximal size within approximately 6 weeks. This is a feature
that helps to distinguish it from squamous cell carcinoma of the skin.

Reference:
Schartz RA. Keratoacanthoma. J Am Acad Dermatol 1994; 30:1-19.

Ahmed, AR. Multiple keratoacanthoma. Int J Dermatol 1980; 19:96-499.

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Question:
The primary identifying histologic feature of the odontogenic keratocyst (OKC) is:

A. orthokeratin.
B. daughter cysts.
C. parakeratin.
D. rete peg formation.

Answer: C

Rationale:
Parakeratin is the defining histologic feature of the OKC. Orthokeratin is found in other odontogenic
cysts particularly the dentigerous cyst. Daughter cysts are not an exclusive feature of OKC's either
although their presence contributes to the high recurrence rate potential. Rete peg formation is not a
histological feature of the OKC due to such a thin epithelial lining of 6 – 10 cells.

Reference:
Oral Maxillofacial Surg Clin N Am 15 (2003) 325-333.

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Question:
Which of the following represents the unique differentiating histologic pattern of the calcifying
odontogenic cyst (COC)?

A. Cuboidal to columnar epithelial pattern

B. Multinucleated giant cells near the basal cell layer
C. Daughter cyst
D. Anuclear cell keratinization

Answer: D

Rationale:
The most prominent and unique characteristic of the Gorlin cyst (COC) is “ghost cell” keratinization.
These cells are anuclear and retain the cell outline. There is a dystrophic mineralization process that
occurs here. Cuboidal to columnar epithelial pattern does exist here but is not the unique differentiating
histologic feature. Daughter cysts are more prominent in OKC

Reference:
rd
Regezi, JA, Sciubba, JJ Oral Pathology Clinical Pathologic Correlation 3 Ed. W.B. Saunders Co.
1999 pp.304-305.

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Question:
Which of the following represents the major differentiating characteristic of an anterior maxillary
dentigerous cyst versus adenomatoid odontogenic tumor (AOT)?

A. AOT is always a mixed radio-opaque radiolucent lesion.

B. Age and sex distribution pattern.
C. Attachment of the dentigerous cyst to the cemento-enamel junction of the involved tooth.
D. AOT is confined to the anterior maxilla.

Answer: C

Rationale:
The AOT can be either a mixed radio-opaque/ radiolucent or a radiolucent lesion. The radiographic
characteristic of the AOT vs. dentigerous cyst is the complete encompassing of the involved tooth by the
cyst lining in the AOT vs. CEJ attachment in the dentigerous cyst. Age and sex distribution patterns are
not defining characteristics in differentiating the two. AOT is not confined to the anterior maxilla.

Reference:
Regezi, JA Sciubba, JJ, Oral Pathology Clinical and Pathologic Correlations 3rd Ed. W.B. Saunders Co.
1999; 291-295, 339.

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Question:
Which of the following represents the major distinguishing characteristic accounting for the high
recurrence rate of odontogenic keratocysts in the basal cell nevus (Gorlin-Goltz) syndrome patient?

A. The fragile lining of the cyst

B. The presence of daughter cysts
C. Benign neoplastic biologic behavior
D. Incomplete removal of the original cyst lining

Answer: C

Rationale:
Although all of the above are plausible sswers, in the basal cell nevus syndrome the biologic behavior of
the OKC more closely resembles a benign neoplasm. According to Toller, the aggressive nature of the
OKC in this syndrome relates to remnants of the dental lamina as precursors to new cyst formation. This
characteristically resembles odontogenic tumors.

Reference:
Shear, M. Oral Maxillofacial Surg Clin N Am 15 (2003) 335-345.

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Question:
Osteosarcoma occurs in which of the following patterns?

A. Less frequently in the mandible than maxilla

B. More frequently in the mandible than maxilla
C. With about the same frequency in the maxilla and mandible
D. With increasing frequency according to age

Answer: B

Rationale:
"Mandibular osteosarcomas are more frequent than those in the maxilla (60% vs 40%)." In general terms,
osteosarcoma of the facial skeleton occurs in a younger age group, with declining frequency in older
patients.

Reference:
Marx RA, Stern D. Oral and Maxillofacial Pathology A Rationale for Diagnosis and Treatment;
Quintessence, Chicago 2003, 799.

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Question:
Which of the following represents the best treatment strategy for osteosarcoma of the jaws?

A. Chemotherapy followed by resective surgery followed by more chemotherapy

B. Chemotherapy followed by resective surgery with neck dissection
C. Radiotherapy to shrink followed by resective surgery
D. Ablative surgery alone

Answer: A

Rationale:
Osteosarcomas of the jaws are ideally treated with initial (neoadjuvant) chemotherapy of about five
cycles, followed by surgery, which is followed by two or three additional doses of chemotherapy
(adjuvant). Radical neck dissection has no role to play in the management of osteosarcoma, as lymphatic
dissemination is almost non-existent, while hematogenous dissemination is the rule. Some osteosarcomas
of the facial skeleton may be treated by ablative surgery alone, however, this is not considered the best
treatment.

Reference:
Curran AE, Damm, D, Drummond, JF Pathologically Significant Pericoronal Lesions in Adults
Histopathologic evaluation. J Oral Maxillofac. Surg 60 6l3-617, 2002.

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Question:
Rhabdomyosarcoma is best treated by which of the following treatment protocols?

A. Surgery
B. Surgery and radiation
C. Surgery and chemotherapy
D. Surgery, radiation and chemotherapy

Answer: D

Rationale:
For rhabdomyosarcoma, chemotherapy added to surgery and radiation therapy has been reported to
improve 5-year survival compared with that seen with surgery and/or radiation therapy alone.

Reference:
Kramer AM, The role of chemotherapy in head and neck malignancy" in Malignant Tumors of the
Maxillofacial Region, Pogrel MA ed. OMFS Clin NA Vol 5, No. 2, May 93, 313.

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Question:
Low-grade mucoepidermoid carcinoma of the posterior mandible with no perforation of the bone and no
adenopathy is best treated by which of the following protocols?

A. Resective surgery and post-surgical radiation

B. Resective surgery and post-surgical chemotherapy
C. Resective surgery alone
D. Radiation followed by chemotherapy

Answer: C

Rationale:
Treatment (of LG mucoepidermoid CA) is normally mandibular resection; postoperative radiation therapy
is often not required, particularly for low-grade tumors, making mandibular reconstruction a simpler
proposition.

Reference:
Pogrel MA, The diagnosis and management of salivary gland tumors" in Malignant Tumors of the
Maxillofacial Region, Pogrel MA ed. OMFS Clin NA Vol 5, No. 2, May 93, 325

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Question:
Osteoradionecrosis can be characterized as which of the following?

A. An osteomyelitic process
B. Impaired wound healing
C. Vitalized irradiated bone exposure
D. Peripheral vasculitis

Answer: B

Rationale:
Osteoradionecrosis can be characterized as impaired wound healing due to the nature of radiation induced
vasculitis and subsequent radiation fibrosis which severely compromises or even eliminates the
microvasculature of the periosteum as well as endosteal tissue vascular channels while challenging and
disabling the overlying integumental vascular plexus as well. There is a certain amount of intranuclear
destruction that does occur in all cells present in the radiated field rendering some cell death through
DNA disruption; however, the majority of injury occurs to the endothelial vascular lining via superoxide
radicals.

Reference:
Schwartz HC, Kagan AR Osteoradionecrosis of the Mandible. Am J Clin Oncol 25(2) 168-171, 2002.

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Question:
Calcified and soft tissue radiation injury is generally caused by which of the following?

A. Direct DNA injury

B. Superoxide radical generation
C. Endothelial fibrosis
D. Mucositis and xerostomia

Answer: B

Rationale:
Calcified and soft tissue radiation injury in general is caused by superoxide radical generation as the
enzymatic protective pathways against superoxides are by and large severely compromised by the
sustained radiation exposure. This directly affects the calcified tissue by severely limiting its vascular
metabolic support.

Reference:
Heimbach RD Radiation effect on tissue. In Davis JC, Hunt TD (eds) Problem Wounds The Role of
Oxygen. New York, Elsevier Science 1988, p 53.

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Question:
Tooth removal induced osteoradionecrosis is more likely to occur in which of the following scenarios?

A. Immediately after radiation therapy

B. 6-12 months post treatment
C. With the presence of a coexisting metabolic disorder
D. Following salivary gland atrophy

Answer: B

Rationale:
Tooth removal induced radiation necrosis is more likely to occur six to twelve months post treatment as
radiation vasculitis and fibrosis are a progressive entity from radiation therapy induction to the
completion and progressing factor in a compounding fashion. Initially, there is hyperemia of the insulted
tissues with the vascularity remaining intact to the greater degree but with slow progression towards cell
death and fibrosis over time which enhances the opportunity for other tissue necrosis such as bone.

Reference:
Hudson JW Osteomyelitis and Osteoradionecrosis. In Fonseca RJ (ed) Oral and Maxillofacial Surgery
Surgical Pathology. Philadelphia, WB Saunders Company, 2000, pg 484-495.

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Question:
Brodie’s abscess is commonly associated with infection of which of the following?

A. Bone
B. Teeth
C. Tonsils
D. Sutures

Answer: A

Rationale:
Brodie's abscess is commonly associated with infection of a bone. It was identified anatomically and
classically many years ago in orthopedic literature relative to axial or long bone osteomyelitis where there
appeared to be a very well organized infectious process that walled itself off from the host immune
response and any other therapeutic modalities save for surgical intervention. This same phenomenon has
been appreciated in the mandible as it is commonly seen with the inflammatory response of the
periosteum and the walling effect that can occur in terms of limiting the wound from a vascular
penetrance.

Reference:
Hudson JW Osteomyelitis of the jaws A 50-year perspective. J Oral Maxillofac Surg 1993; 51:1294.

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Question:
The presence of purulence in an osteomyelitic wound specifically characterizes the infection as which of
the following?

A. Acute
B. Chronic
C. Immunologically responsive
D. Vascularly compromisedal

Answer: C

Rationale:
The presence of gross purulence in an osteomyelitic wound characterizes as infection as immunologically
responsive due to the actual composition of the purulence being made up by white blood cells or
granulocytes, phagocytizing foreign body under the chemotactic influence of an inflammatory/immune
cascade. The presence of pus in an osteomyelitic wound will not permit the distinction between acute and
chronic osteomyelitis.

Reference:
Cierny G, Mader TJ, Pennick JJ A clinical staging system for osteomyelitis. Contemp Orthop 1985;
10:17.

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Question:
A 7.5 cm segmental defect of the mandible would be expected to require the harvest of what volume of
corticocancellous bone for reconstructive surgery?

A. 35-45 cc’s
B. 75-85 cc’s
C. 105-115 cc’s
D. >115 cc’s

Answer: B

Rationale:
It is generally recommended that a segmental defect of the mandible be reconstructed with 1 cc of
corticocancellous bone per every 1 mm of defect. Adding 10% to this harvested volume will ensure the
procurement of sufficient bone. As such, a 7.5 cm defect, or 75 mm, would be expected to require 75-85
cc's of bone.

Reference:
Marx RE, Morales MJ Morbidity from bone harvest in major jaw reconstruction A randomized trial
comparing the lateral anterior and posterior approaches to the ilium. J Oral Maxillofac Surg 48 196-203,
1988.

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Question:
The best donor site for harvest of bone for reconstruction of a 7.5 cm segmental defect of the mandible
would be which of the following?

A. Clavicle
B. Posterior ilium
C. Anterior ilium
D. Tibia

Answer: B

Rationale:
The harvest of 75-85 cc's is predictably possible only from the posterior ilium. The clavicle is not
generally described as a donor site for mandibular reconstruction. The anterior ilium is expected to yield
approximately 30 – 40 ml of cancellous bone, while the tibia would be expected to yield approximately
15 – 20 ml. Therefore, a 7.5 cm defect of the mandible can only be predictably reconstructed with a
harvest of bone from the posterior ilium.

Reference:
Stevens MR Bone harvesting techniques. Oral and Maxillofacial Surgery Knowledge Update 1 RCN 19-
34, 1994.

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Question:
The administration of hyperbaric oxygen is planned for a patient scheduled for reconstruction of a
segmental defect of the mandible with corticocancellous bone where the lower third of the face was in the
direct field of radiation therapy. How many treatments would be recommended?

A. 10 preoperatively, none postoperatively

B. 20 preoperatively, 10 postoperatively
C. 20 preoperatively, 20 postoperatively
D. 30 preoperatively, 10 postoperatively

Answer: B

Rationale:
The time honored protocol for the administration of HBO to an irradiated patient in preparation for
mandibular reconstruction is 20 preoperative treatments followed by surgery and 10 postoperative
treatments. This protocol assumes that a diagnosis of osteoradionecrosis of the mandible has not been
met. When such a diagnosis is met, the patient receives 30 treatments of HBO initially followed by re-
evaluation.

Reference:
Quereshy FA, Powers MP Reconstruction of the maxillofacial cancer patient. In Fonseca RJ (ed) Oral and
Maxillofacial Surgery, Volume 7, Reconstructive and Implant Surgery, Chapter 15, Philadelphia, WB
Saunders Co., 361-444, 2000.

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Question:
Which of the following media is best for corticocancellous bone storage following the harvest of the
bone?

A. D5W
B. Hypertonic saline
C. Sterile water
D. Normal saline

Answer: D

Rationale:
An isotonic solution is crucial to avoid rupture of bone cells. The only isotonic solution among the
answers is normal saline. D5W and sterile water are hypotonic, while hypertonic saline is hypertonic.
Hypotonic and hypertonic solutions do not support the physiology of harvested bone.

Reference:
Marx RE, Snyder RM, Kline SN Cellular survival of human marrow during placement of marrow-
cancellous bone grafts. J Oral Surg 37 712-718, 1979.

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Question:
What length of time is permitted between harvest to placement to ensure the survival of a majority of
harvested cells in a corticocancellous bone graft?

A. 1 hour
B. 2 hours
C. 3 hours
D. 4 hours

Answer: D

Rationale:
Harvested bone cells show about a 95% viability up to four hours at OR temperatures.

Reference:
Marx RE, Snyder RM, Kline SN Cellular survival of human marrow during placement of marrow-
cancellous bone grafts. J Oral Surg 37 712-718, 1979.

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Question:
Which of the following is true regarding reconstruction of the maxilla following extirpative tumor
surgery?

A. Maxillofacial prostheses are rarely indicated, as they are essentially non-functional.

B. Restoration of facial contour is of little importance, regardless of the type of procedure and/or
prosthesis, since restoration of function is the key to success.
C. Separation of the oral mucosa from the nasal-antral mucosa is a significant consideration for any
surgical restorative procedure.
D. Bony reconstruction should be accomplished as soon as possible after initial malignant tumor
surgery, to prevent scar contracture and provide for the best result.

Answer C

Rationale:
Separation of the oral mucosa from the nasal-antral mucosa is very important. Saliva is kept out of the
nasal cavity. Speech and function are usually improved by this separation. The quality of the mucosa is
different as well, with an obturator better adapted to the oral mucosa.

Reference:
nd
Fonseca and Davis, Reconstructive Preprosthetic Oral and Maxillofacial Surgery, 2 Ed. pp. 1116-
1118

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Question:
The primary limiting factor for the length of bone that can be harvested in a vascularized transfer of fibula
is which of the following?

A. Stability of the ankle and knee joint

B. Length of the peroneal artery
C. Length of the venae comitantes
D. There is no limit, the entire fibula can be transferred

Answer: A

Rationale:
The primary role of the fibula is stabilization of the knee and ankle joint. Five to six centimeters of fibula
should be left proximally and distally for this reason to prevent instability of these joints. The peroneal
nerve also limits the proximal dissection, but that is not a choice. The take-off of the peroneal artery from
the posterior tibial artery limits the pedicle length, but not the bone length. Likewise, the venae
comitantes can be harvested along the length of the arterial pedicle, but does not limit the bone stock.
Although controversial, some surgeons do feel the entire proximal fibula can be harvested, including the
portion that contributes to the knee, however, the distal portion must always be preserved for ankle
stability. Therefore, A is the best choice.

Reference:
Urken ML, et al. Atlas of regional and free flaps for head and neck reconstruction. Raven Press 1995.

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Question:
Which of the following nerves is most commonly harvested with the radial forearm fasciocutaneous flap
and reconstructed when attempting to provide a sensate flap reconstruction?

A. Ulnar nerve
B. Lateral antebrachial cutaneous nerve
C. Medial antebrachial cutaneous nerve
D. Radial Nerve

Answer: B

Rationale:
The lateral antebrachial cutaneous nerve provides sensation to the territory harvested most commonly
with the RFFF. It can be reconstructed to the lingual nerve in attempt to provide a sensate flap. Harvest
of the ulnar nerve would lead to excessive morbidity as it is a motor and sensory nerve. It would affect
the ability to flex and abduct the wrist and movement of the thumb. Fine movements of the fingers would
also be affected. The radial nerve is specifically protected in the harvest of the radial forearm flap, and
indeed the subfascial plane of dissection must be broken to preserve this nerve. Finally, the medial
cutaneous antebrachial nerve can be harvested, but it does not supply the territory typically harvested.

Reference:
Schustermann MA. Microsurgical reconstruction of the cancer patient. Lippincott-Raven 1997.

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Question:
Anastamosis of which pair of vessels provides for in-flow and out-flow for a vascularized fibula flap?

A. Posterior tibial artery and vein

B. Anterior tibial artery and vein
C. Popliteal artery and popliteal vein
D. Peroneal artery and venae commitans

Answer: D

Rationale:
The peroneal artery and its associated venae commitans make up the vascular pedicle to the vascularized
fibula flap. The popliteal artery divides into the anterior tibial and posterior tibial arteries. The posterior
tibial then gives off the peroneal artery, which supplies the vascular territory of the fibula flap. Harvest of
the popliteal artery would leave the lower leg without a blood supply. The posterior tibial artery is
preserved to maintain vascular blood supply to the lower leg.

Reference:
Urken ML, et al. Atlas of regional and free flaps for head and neck reconstruction. Raven Press 1995.

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Question:
Transfer of a vascularized radial forearm flap without confirming intact communication between the
superficial and deep palmer arches through an Allen’s test will result in vascular compromise to which of
the following?

A. Palm
B. Thumb
C. Middle finger
D. 5th digit

Answer: B

Rationale:
Sacrifice of the radial artery relies on an intact communication between the superficial and deep palmer
arches. This is typically confirmed pre-operatively by an Allen's test. The technique is as follows:

1. Elevate the patient's hands above heart

2. Occlude radial and ulnar arteries
3. Have the patient open and close fist several times
4. Lower the hand below heart
5. Release ulnar artery and time blood flow return to hand
6. Repeat with radial artery

If there is no communication between the superficial and deep palmar arches, sacrifice of the radial artery
th
will result in vascular compromise to the thumb. The palm, middle finger and 5 digit are supplied by
the ulnar artery.

Reference:
Urken ML, et al. Atlas of regional and free flaps for head and neck reconstruction. Raven Press 1995.

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Question:
Salivary gland involvement in conjunction with xerostomia or xerophthalmia are required clinical
findings to establish the diagnosis of which of the following?

A. Sjogren’s syndrome
B. Sialosis
C. Sarcoidosis
D. Lymphoma

Answer: A

Rationale:
Sjogren's syndrome is an autoimmune disease that causes a lymphocyte-mediated destruction of exocrine
glands. This results in a decrease in glandular secretion of the salivary glands (xerostomia) and the
lacrimal glands (xerophthalmia).

Reference:
Marx RE Incisional parotid biopsy for diagnosis of systemic disease. Oral and Maxillofac Surg Clin
North Am 7:505-517, 1995

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Question:
Which of the following entities is characterized by diffuse bilateral parotid enlargement secondary to
nutritional changes?

A. Sjogren’s syndrome
B. Sarcoidosis
C. Lymphoepithelial lesions
D. Sialosis

Answer: D

Rationale:
Sialosis is a generalized hypertrophy of the individual acinar cells that results in bilateral enlargement of
the parotid gland. It is not associated with an immune disorder or neoplastic process. The parotid
enlargement is usually secondary to nutritional changes brought about by alcoholism or bulimia. An
incisional parotid biopsy is indicated to rule out Sjogren's disease, sarcoidosis and lymphoma.

Reference:
Parret J, Cros P, Dumas P, et al Sialosis hypertrophiques. Rev Stomatol Chir Maxillofac 80:329-333,
1979.

Marx RE Incisional parotid biopsy for diagnosis of systemic disease. Oral and Maxillofac Surg Clin
North Am 7:505-517, 1995.

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Question:
A black female patient presents with history of easy fatigability, anorexia, and hilar adenopathy with
parotid and lacrimal gland enlargement. The most likely diagnosis is:

A. sarcoidosis.
B. lymphoma.
C. Sjogren’s syndrome.
D. anorexia.

Answer: A

Rationale:
Sarcoidosis is a systemic disease characterized by infiltration of tissues with sarcoid granulomas. In
Heerfordt's syndrome, clinical enlargement of the parotid and lacrimal gland (sarcoid infiltrate) is seen
together with retinal damage. Chronic sarcoidosis has a 6:1 black to white patient ratio and a slight female
predilection. Anorexia, lethargy and pulmonary involvement with hilar adenopathy are a common clinical
finding.

Reference:
Thomas PD, Hunninghake GW Current concepts of the pathogenesis of sarcoidosis. Am Rev Respir Dis
135:747-754, 1987.

Marx RE Incisional parotid biopsy for diagnosis of systemic disease. Oral and Maxillofac Surg Clin
North Am 7:505-517, 1995

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Question:
Which of the following statements regarding benign lymphoepithelial parotid lesions is true?

A. It is a pre-malignant condition with a high likelihood of malignant transformation.

B. Total parotidectomy is often indicated.
C. May present as an isolated salivary gland abnormality or a manifestation of Sjogren’s disease.
D. It is often associated with a viral infection.

Answer: C

Rationale:
Benign lymphoepithelial lesions typically present as a unilateral or bilateral parotid gland swelling
resulting from a diffuse benign infiltration of lymphoid cells. It is believed that these lesions develop as a
result of an immunologic abnormality. These lesions can also be seen in association with Sjogren's
syndrome. There is no specific treatment for these lesions other than follow-up and observation given the
small potential for malignant transformation and its relationship with Sjogren's syndrome.

Reference:
Regezi JA, Sciubba JJ. Salivary gland diseases. In Oral Pathology: Clinical Pathologic Correlations.
Philadelphia, W.B. Saunders, 1989, pp 243-245.

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Question:
Karapandzic type flaps might be chosen for lip reconstruction under which of the following situations?

A. Only for the upper lip

B. For defects less than one third of the lower lip
C. For closure of lower lip defects up to 60% of the lower lip
D. Are best avoided for lower lip reconstruction as nerves and primary vessels are cut

Answer: C

Rationale:
Karapandzic flaps are excellent single stage closures of moderately sized defects of the lower lips,
especially in homebound patients and patients with a natural dentition. This flap transfers vascularized
tissue to close lower lip defects up to 60% of its length. The result will be upper and lower lips unequal
in size, and with a slightly retruded lower lip relative to the upper lip.

Reference:
Lip Reconstruction by M. Zide and J. Dean in Maxillofacial Surgery by Booth, Schendel and Hausamen,
Churchill-Livingstone, Edinburgh 1999, ch 45.

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Question:
Current therapy for melanoma suggests that sentinel lymph node biopsy is which of the following?

A. Only useful for nodular melanoma.

B. Is possibly useful for intermediate depth melanomas.
C. May, by itself, save the patients life by stopping the flow of melanoma cells.
D. Is only useful for melanomas deeper than 4 mm and in patients older than 60 years of age.

Answer: B

Rationale:
Sentinel lymph node biopsy is indicated in the assessment of cervical node involvement in intermediate
depth melanomas.

Reference:
Wagner J, Gordon MS, Chuang T, and Coleman JJ. Current therapy of cutaneous melanoma. PRS April
2000, p1774.

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Question:
Which of the following best describes the use of an Abbe flap for lip reconstruction?

A. Should be limited to defects over 25% of upper lip loss

B. Is a random pattern flap
C. Should be restrained with intermaxillary fixation to prevent dislodgement
D. Should be cut down (divided and inset) no sooner than 5 weeks

Answer: A

Rationale:
An Abbe flap is a local pedicled axial pattern flap for upper and lower lip reconstruction. It is ideally
used for defects greater than 25% of upper lip loss and approximately 33% of lower lip loss. The pedicle
is divided at about 2-3 weeks.

Reference:
Zide MF and Fuselier C The partial thickness cross-lip flap for correction of post-oncologic surgical
defects. JOMS 59 1147, 2001.

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Question:
Which of the following best describes the use of a rhomboid flap in facial reconstruction?

A. Places all final scars in resting skin tension lines

B. Is dependent on having the pivot point move in the lines of maximum extensibility (opposite the
RSTL)
C. Does not distort any adjacent tissues
D. Is perfect for most forehead defects

Answer: B

Rationale:
The rhomboid flap is a transpositional flap. As such, the pivot point, where the greatest degree of tension
exists, must move in extensible lines. This flap will not place all scars in resting skin tension lines, and
distortion of adjacent tissues will occur.

Reference:
Calhoun KH, Seikaly H, Quinn FB. Teaching paradigm for decision making in facial skin defect
reconstructions Arch Otol Vol 124, Jan 1998.

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Question:
The attached immunofluorescence photomicrograph shows deposition of immunoglobulin in mucosa.
The pattern of deposition is diagnostic of which of the following?

A. Pemphigus Vulgaris
B. Bullous pemphigoid
C. Dermatitis herpetiformis
D. Lupus erythematosis

Answer: A

Rationale:
Direct immunofluorescence is a useful diagnostic tool to confirm the histologic features of these mucous
membrane and dermal diseases. In pemphigus vulgaris, deposition of immunoglobulin is along the
plasma membranes of epidermal keratinocytes in a fish-net-like pattern (as the enclosed slide shows).
Whereas in bullous pemphigoid the immunoglobulin and complement deposits are linear at the basement
membrane (by EM at the level of lamina lucida). In dermatitis herpetiformis (Duhring Disease) the
immunoglobin deposits are the IgA subtype and are selectively localized in the tips of dermal papillae.
Lupus erythematosus is not a bullous disease but is a localized cutaneous form of systemic lupus
erythematosis. Direct immunochemistry is characteristic of granular deposits of immunoglobulin and
complement at the dermoepidermal junction.

Reference:
Murphy, C and Mihm, M. The skin. Chapter 27. In Cotran, R., et al (eds.) Robbins Pathologic Bases of
th
Disease, 6 ed., Figure 27-35, W. B. Saunders, Philadelphia, 1999, pp. 1170-1213.

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Question:
A 55 year old woman presents to your office for evaluation of an oral blister. Your examination reveals
an 8 mm lesion of the right maxillary gingiva. The surrounding area is erythematous. You perform an
incisional biopsy of the region. Your diagnosis is which of the following?

A. Pemphigus vulgaris
B. Pemphigoid
C. Squamous cell carcinoma
D. Lichen planus

Answer: B

Rationale:
A sub-basilar split is noted, thereby supporting the diagnosis of pemphigoid. Pemphigus would be
expected to have a suprabasilar split, and squamous cell carcinoma and lichen planus do not typically
exhibit a sub-basilar split.

Reference:
nd
Neville BW, Damm DD, Allen CM, Bouquot JE (eds) Oral and Maxillofacial Pathology, 2 Edition,
Chapter 16, Dermatologic Diseases, Philadelphia, WB Saunders Co., 672, 2002.

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Question:
The pathology laboratory performs a special study on the tissue that you supply. Which of the following
best describes this test?

A. Indirect immunofluorescence
B. Direct immunofluorescence
C. In situ hybridization
D. Polymerase chain reaction with Western Blot

Answer: B

Rationale:
The pathologic section clearly demonstrates an immunofluorscent pattern. The basement membrane
lights up, supporting a diagnosis of pemphigoid. Since the patient's tissue is submitted, the test is direct
immunofluorescence by definition. Indirect immunofluorescence involves submitting the patient's blood
for antibody assay. In situ hybridization and polymerase chain reaction with Western Blot have no role in
the diagnosis of vesciculobullous disease of the oral cavity.

Reference:
th
Regezi JA, Scuibba JJ, Jordan RCK (eds) Oral Pathology: Clinical Pathologic Correlations, 4 Edition,
Chapter 1, Vesiculobullous Diseases, St. Louis, Elsevier Science, 14, 2003.

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Question:
An 8 year old boy is evaluated with swelling of the anterior mandible and a multilocular radiolucency of
the symphysis, crossing the midline. You perform an incisional biopsy, the results of which are noted in
the figure. Which of the following is the diagnosis?

A. Central giant cell lesion

B. Peripheral giant cell lesion
C. Osteosarcoma
D. Ameloblastoma

Answer: A

Rationale:
The classic findings of giant cell lesion are noted in the histomicrograph. These include dilated
capillaries, the presence of giant cells, and hemosiderin pigment. The scenario describes a central
process, hence, this is not a peripheral giant cell lesion. Malignant osteoid is not noted in the section, nor
is odontogenic epithelium. As such, osteosarcoma and ameloblastoma do not represent accurate
diagnoses.

Reference:
th
Regezi JA, Scuibba JJ, Jordan RCK (eds) Oral Pathology: Clinical Pathologic Correlations, 4 Edition
, Chapter 12, Benign Nonodontogenic Tumors, St. Louis, Elsevier Science, 300, 2003.

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Question:
A 12 year old boy presents with left facial swelling and a multilocular radiolucency on panoramic
radiograph. An incisional biopsy is performed, the result of which is noted in the figure. Which of the
following represents the accurate diagnosis?

A. Ameloblastoma
B. Ameloblastic fibroma
C. Ameloblastic fibro-odontoma
D. Odontogenic keratocyst

Answer: B

Rationale:
The histomicrograph clearly shows odontogenic epithelium in the background of a rich fibroblastic
stroma. These findings support the diagnosis of ameloblastic fibroma. The histopathologic features do
not support a diagnosis of ameloblastoma, ameloblastic fibro-odontoma or odontogenic keratocyst.

Reference:
nd
Neville BW, Damm DD, Allen CM, Bouquot JE (eds) Oral and Maxillofacial Pathology, 2 edition,
Chapter 15, Odontogenic Cysts and Tumors, St. Louis, WB Saunders Co., 627, 2002.

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Question:
Which of the following best describes the advantages of a full thickness skin graft in facial reconstruction
compared to a split thickness skin graft?

A. More contracture of a full thickness skin graft compared to a split thickness skin graft
D. More predictable healing of a full thickness skin graft compared to a split thickness skin graft
E. Less postoperative care for the donor site of a full thickness skin graft compared to a split
thickness skin graft
D. Fewer donor site infections of a full thickness skin graft compared to a split thickness skin graft

Answer: C

Rationale:
The main advantages of a full thickness skin graft over a split thickness skin graft for facial reconstructive
surgery include less contracture of the healing graft, and less labor regarding the donor site's
postoperative management. This is owing to the ability to primarily close the donor site of a full
thickness skin graft, while the donor site of a split thickness skin graft must heal by tertiary intention.
During this time, the split thickness skin graft donor site must be dressed with an occlusive dressing such
as Opsite or Tegaderm. With this in mind, the potential for postoperative infection is such that the closed
wound may develop infection, while the defect pertaining to the split thickness skin graft is open, and
therefore less likely to become infected postoperatively.

Reference:
Zide MF and Fuselier C The partial thickness cross-lip flap for correction of post-oncologic
surgical defects. JOMS 59 1147, 2001.

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Question:
Prior to general anesthesia you recommend that a patient stop smoking to improve lung function. How
long would it take for mucous hypersecretion to decrease to a normal level?

D. 2 months
E. 6 months
F. 10 months
G. 14 months

Answer: B

Rationale:
Cessation of smoking should allow for gradual improvement in lung function. Nicotine with a half-life of
approximately 30-60 minutes would fall precipitously with cessation of smoking for four hours prior to
administration of the anesthesia. Although of some benefit, the stimulation of the sympathoadrenal
system would take longer to normalize. Carboxyhemoglobin levels should approach that of a non-smoker
after a smoke free period of approximately 48 hours. This should allow for increased availability of
hemoglobin for oxygen transport. The hypersecretion of mucous requires a period of approximately six
weeks to decline to normal levels after cessation of smoking. Alveolar macrophage, antimicrobial
function has been shown to take six months or more to improve to that of a non-smoker. Narrowing of the
bronchial airways and air trapping is another problem seen with smoking. Improvement in pulmonary
function test generally requires a minimum period of six weeks of abstinence.

Reference:
Pearce AC, Jones RM. Smoking and Anesthesia: Preoperative abstinence and perioperative morbidity.
Anesthesiology 1984; 61:576.

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