2009 Oral and Maxillofacial Surgery

Self Assessment Tool (OMSSAT)

Administration Dates: April 11, 2009 - April 25, 2009

2008 – 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT) Committee

Chair - Patrick J. Vezeau

Anesthesia Pathology/Reconstruction
Section Editor – Jeffery D. Bennett Section Editor – Jon D Holmes

Patrick J. Vezeau Brian Schmidt

Trevor Treasure Brent Ward
David Todd Dale Baur
Thomas Rollar Rui Fernandes
Julie Ann Smith Sam E. Farish
John Pruitt Eric Carlson
Vincent Perciaccante Luis Vega
Frank Paletta Robert M. Laughlin
Harry Papadopoulos Somsak Sittitavornwong
Karen Keith Rajesh Gutta
Daniel Sarasin Nasser Said
Brian Bell

TMD/Pain
Section Editor – Vincent Perciaccante
Orthognathic/Cleft/Craniofacial

Section Editor – BJ Costello

John H. Campbell
Louis Mercuri
Sean Edwards
Leslie Heffez
John Caccamese
Harry Papadopoulos
Paul S. Tiwana
Steve Kraus
Patrick Ricalde
Sidney L. Bourgeois, Jr.
Tinerfe J. Tejera
Brian Farrell
Paul S. Tiwana
Greg Ness
Gregory Casey
Patrick Louis
Jonathan Bailey
Jeff Schultz
Ramon Ruiz
Gary Bouloux
Roger Throndson
Jason Baker
Louis Mercuri
John Allen
Edward J. Miller, Jr.
Kamal F. Busaidy
David P. Timmis
 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following patients would best allow safe induction of an intubation general
anesthetic according to current American Society of Anesthesiologists guidelines?

A. 6 month old male having taken 30 ml of formula 5 hours ago

B. 15 year-old male having taken 500 ml cola 2.5 hours ago

C. 46 year-old female having taken 40 ml of fresh squeezed orange juice 3.5 hours ago

D. 65 year-old having eaten peanut butter on toast 6 hours ago.

Answer: B

Rationale:
Perioperative fasting guidelines were revised by the ASA to reflect length of time and
nature of ingested foods correlated to gastric emptying time, and hence risk of
aspiration. Studies suggest that clear liquids (water, soda pop, coffee without creamer,
fruit juice without pulp), regardless of volume ingested, essentially clear the stomach after
two hours in healthy individuals who have no conditions which might delay gastric
emptying, and that clear fluid starvation over 2 hours may be counterproductive with
respect to dehydration and post-anesthetic recovery. Conditions which may delay gastric
emptying may include: gastroparetic conditions (diabetic neuropathy), proliferative
connective tissue disorders, obesity, extreme pain or fear, and opioid use. Non-clear
liquids such as non-human milk products and formula delay gastric empyting similar to
solids. Human milk has an intermediate gastric emptying period, for which a four hour
fast has been recommended. A six hour fast from all “light”solids (i.e., non-meat and
non-fat) and non-clear liquids (except breast milk) has been recommended for otherwise
healthy individuals who have no gastric emptying delaying factors. Fat and meats should
be avoided for at least 8 hours prior to induction of general anesthesia, since these
significantly delay gastric emptying.

The 15 year-old male falls within these ASA guidelines. The 6 month old has taken
formula, not breast milk and must fast 6 hours. The 46 year-old female has fresh
squeezed and hence pulp-laden fruit juice, and also requires a 6 hours fast. The 65
year-old male has had peanut butter, a highly fatty food and must fast for at least 8
hours.

Reference:
American Society of Anesthesiology Taskforce on Preoperative Fasting: Practical
Guidelines
for Preoperative Fasting. Anesthesology, 90:896-905 1999

McGlinch BP: Issues in Ambulatory Anesthesia. In: Faust RJ et al: Anesthesiology

Review
rd
(3 . Ed.) Churchill Livingstone, Philadelphia, 2002 pp477-479

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following decreases the incidence or severity of perioperative pulmonary

aspiration?

A. Post-aspiration left lateral Trendelenberg position

B. Age appropriate for uncuffed endotracheal tube

C. Post-aspiration tracheal lavage

D. Exploratory bronchoscopy

Answer: B

Rationale:
Post-anesthetic pulmonary aspiration occurs in 1:3000-10,000 general anesthetics
administered. Most aspirations are sub-clinical with minor symptoms that resolve
spontaneously. The amount of tracheal and bronchial mucosal damage brought about by
aspiration of gastric contents increases with the amount of aspirate, its acidity, and the
amount of particulate matter present. Certain disorders are associated with a higher risk
of aspiration, including: extreme age, gastrointestinal or upper abdominal procedures,
pregnancy, obesity, GERD, gastric mobility disorders, and recent meal.

While not uncommon in the pediatric population, aspiration in this population is generally
not as serious as in the adult population and has a much lower morbidity and mortality.
Uncuffed endotracheal tubes are generally used in pediatric patients 8 years of age or
younger; so a patient age appropriate for use of an uncuffed tube has a decreased
aspiration risk. Post-aspiration positioning should be in the right lateral Trendelenberg
position, since the left mainstem bronchus leaves the trachea at a more acute angle than
the right and therefore viscous aspirated material is more likely to flow into the left
mainstem in a left decubitus position than would flow in the right mainstem in a right
decubitus. Since tracheobronchial mucosal chemical damage occurs within seconds and
relative neutralization of aspirant occurs within minutes, routine tracheobronchial lavage
for most pulmonary aspiration cases is not indicated. Similarly, exploratory
bronchoscopy is not routinely indicated unless large amounts of particulate matter are
aspirated.

Reference:
Warner MA: Perioperative Pulmonary Aspiration. In: Faust RJ et al: Anesthesiology
Review. Churchill Livingstone, Philadelphia, 2002. pp 564-568

th
Office Anesthesia Evaluation Manual, 6 ed. American Association of Oral and
Maxillofacial
Surgeons, 2002. pp 32-33

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

You plan office extractions for a 65 year-old female with a history of compensated congestive
heart failure and Parkinson’s disease. Pre-anesthetic vital signs include BP = 135/85, pulse is
100, respirations = 15. She has taken her routine medications including selegiline (selective
irreversible MAO-B inhibitor), digoxin (cardiac glycoside), enalapril (ACE inhibitor), and
potassium. After initiating conscious sedation using nitrous oxide/oxygen, fentanyl and
midazolam, you note the following vital sign changes prior to local anesthetic administration: BP
= 70/40, pulse = 85, respirations = 18. The pulse oximetry reading has dropped to 90. You
note no change after administering 100% oxygen, flumazenil (Romazicon), and naloxone
(Narcan). Which next step would be the most appropriate?

A. Trendelenberg position

B. 750 ml intravenous saline fluid bolus

C. Ephedrine 2.5 mg IV

D. Phenylephrine (neosynephrine) 0.1 mg IV

Answer: D

Rationale:
Intraoperative hypotension can present treatment challenges in the medically
compromised patient. This patient presents with a history of compensated ischemic
congestive heart failure and is on a digitalis glycoside (digitoxin), and an angiotensin
converting enzyme inhibitor (enalapril). Her history of congestive heart failure would
mitigate against any maneuver that might lead to increased central venous pressures,
which may precipitate a new episode of congestion. Therefore, Trendelenberg
positioning and a relatively large isotonic intravenous fluid challenge might not be
desired early therapies.

Selegiline is a relatively selective monoamine oxidase-B inhibitor, which preferentially

decreases the central metabolism of dopamine. It is used in the treatment of
Parkinson's disease; either to replace carbidopa/levodopa early in the disease course or
to decrease the latter's dosage and minimize dopaminergic side effects. Older
nonselective MAOI's depressed the central metabolism of a number of monoamine
neurotransmitters including serotonin, epinephrine, norepinephrine, and dopamine; and
have been used for refractory depression. Relatively MAOI-A selective drugs decrease
the metabolism of the first 3 listed neurotransmitters; so that side effects can include
hypertensive crises and. In low to moderate doses, selegeline activity is approximately
80% MAOI-B and 20% MAOI-A. Selegeline has a fairly frequent incidence of orthostatic
hypotension, which can be exaggerated with the concomitant use of vasodilators such
as nitrous oxide, benzodiazepines, and opioids. The first step in treating intraoperative
hypotension in this case is to terminate the procedure and cautiously reverse the agents
used. Cautious use of low dosages of an alpha selective peripheral vasoconstrictor
would be indicated next to increase blood pressure without increasing cardiac
chronotropy. Low-dose phenylephrine would be a good choice in this situation.
Ephedrine is an indirect alpha- and beta-stimulating agent that should be avoided, since
some MAOI-A inhibition occurs with selegiline. The interaction between indirect acting
sympathomimetic drugs and MAOI occurs because an MAOI increases the amount of
presynaptic transmitter that is available to be released. The central release of

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

monoamine neurotransmitters in the case of MAOI-I inhibition could lead to a

hypertensive crisis. Also, the beta adrenergic effects of ephedrine would potentially
worsen the tachycardia in this patient with a history of ischemic heart disease. Direct
acting sympathathomimetic agents are not contraindicated in combination with MAOIs.

Reference:
Baranov D et al: Neurologic Diseases. In: Fleisher L: Anesthesia and Uncommon
Diseases. WB Saunders, Philadelphia, 2006 pp 261-4

Jedd M: Monoamine Oxidase Inhibitors and Anesthesia. In: Faust R et al:

Anesthesiology Review Churchill Livingstone, Philadelphia 2002 pp 163-4

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following muscle relaxants is the best choice for intubation in the atopic patient
with severe gastroesophageal reflux disease?

A. Succinylcholine

B. Mivacurium

C. Atracurium

D. Rocuronium

Answer: D

Rationale:
Succinylcholine is a depolarizing muscle relaxant. Due to initial depolarization of skeletal
muscles, a variety of side effects can occur. These include: increased intraocular
pressures, myalgias, increased intracranial pressures, and intragastric pressure
increases. The latter effect is brought about by skeletal abdominal muscle contracture.
The increase in intragastric pressure secondary to succinylcholine can be blocked by
precurarization. Additionally, succinylcholine causes an even greater increase in lower
esophageal pressure, such that the increase in gastric pressure does not routinely result
in aspiration of gastric contents. However, in the patient prone to incompetence of the
gastroesophageal sphincter, increases in intragastric pressures can lead to regurgitation
and aspiration of stomach contents.

Non-depolarizing muscle relaxants avoid these pressure increases. However, the

benzylisoquinolone derivatives (mivacurium, atracurium, cisatracurium, metocurine, and
d-tubocurarine) can cause histamine release, especially in large doses or when injected
quickly. In the atopic patient, who presumably has significant environmental allergy
symptoms, the effects of additional sudden histamine release mediated by atracurium or
mivacurium (with bronchospasm, hypotension, and tachycardia) would best be avoided.

Steroidal non-depolarizing muscle relaxants include rapacuronium, vecuronium,

rocuronium, pancuronium, and pipercuronium. These lack histamine releasing properties
and may be indicated in the atopic patient. Rocuronium has an intermediate onset of
action and duration of effect, and would be a good choice for this patient.
Rapacuronium, having an onset and duration of effect approaching that of
succinylcholine, was initially developed as a substitute for the depolarizing paralytic
agent, especially in the pediatric population who have a higher incidence of bradycardia
with succinylcholine. However, it has been found to have an unacceptably high rate of
severe bronchospastic toxicity, especially if a history of bronchospastic disease is
present; and it's bronchospastic activity appears to be dose-related. Rapacuronium has
recently been withdrawn from the US market.

Reference:
Christopherson T: Succinylcholine Side Effects. In: Fleisher L: Anesthesia and
Uncommon Diseases. WB Saunders, Philadelphia, 2006 pp 134-6

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

th
Stoelting R, Miller R: Basics of Anesthesia, 4 Ed. Churchill Livingstone, Philadelphia
2000 pp 89-106

Rajchert D et al: Rapacuronium and the risk of bronchospasm in pediatric patients.

Anesth Analg 94:483-4 2002

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following medications would not require significant dosing adjustments in the
elderly patient?

A. Cisatracurium

B. Alfentanil

C. Desflurane

D. Thiopental

Amswer: A

Rationale:
Physiologic changes in the aging process include decreases in perfusion, relative
increase in poorly perfused fatty tissues, slowed redistribution of medications, decreased
pulmonary and cardiac reserve, decreased hepatic and renal blood flow hence
decreased hepatic and renal drug elimination, reduced hepatic microsomal enzyme
activity, and increased central nervous system sensitivity to anesthetic agents.

Atracurium and its cojoiner cisatracurium are nondepolarizing muscle relaxants. Unlike
other benzylisoquinilone muscle relaxants, these two agents have little histamine release
tendency and thereby have no significant cardiovascular effects. Both undergo
spontaneous nonenzymatic degradation at body temperatures (Hoffman elimination) and
also undergo hydrolysis by nonspecific plasma esterases. Because of these factors, plus
the fact that the sensitivity of the neuromuscular junction does not change with age, no
dosage adjustment for cisatracurium is necessary in the aged patient.

The pharmacodynamics of opioids, inhalational anesthetics, and other intravenous

agents are markedly changed with advances in age, generally thought to be due to a
marked increase in CNS sensitivity to such agents, necessitating downward dosing
adjustments in initial administration in the elderly. Pharmacokinetics are less profoundly
altered, but maintenance dosing of intravenous anesthetics should be also adjusted
downward due to a slower redistribution. This slower redistribution is due to decreased
muscle mass (which is generally well perfused and classically is the “first compartment”
of redistribuion), and the increases in poorly perfused adipose tissue leading to delayed
final body drug clearance from the fat reservoir. Contributing to this slow clearance are
the geriatric cardiac, hepatic, and renal changes mentioned previously.

References:
Stoelting R, Miller R: Elderly Patients. In: Stoelting R, Miller R: Basics of Anesthesia
Churchill Livingstone, Philadelphia, 2000 pp 376-85

Sandler N, Swift J: Geriatric Considerations. In: Bennett J, Rosenberg M: Medical

Emergencies in Dentistry. WB Saunders, Philadelphia, 2002 pp 73-6

Keyword: assessment of patient for anesthesia, pharmacology of anesthetic agents,

geriatric patient, neuromuscular blocking agents, pharmacokinetics

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A patient with a T-4 spinal injury has a 4.5 hour general anesthetic. The patient has no foley
catheter because the intended surgery was to have taken 2 hours. The patient suddenly
becomes hypertensive and bradycardic. The ECG reflects sinus bradycardia in Lead II. Flushing
is evident in the face and mucous membranes. You notice the patient sweating and exhibiting
mydriasis of both pupils. The best explanation for this complex of symptoms is:

A. myocardial infarction.

B. autonomic hyperreflexia.

C. increased intracranial pressure.

D. massive pulmonary embolism.

Answer: B

Rationale:
Autonomic hyperreflexia is a syndrome of massive, disinhibited reflex sympathetic
discharge in response to cutaneous or visceral stimulation below the level of the spinal
cord lesion. Myocardial infarction may manifest under anesthesia as hypotension and by
changes on the ECG; lead V5 being the most sensitive in detecting ischemia. Lead II will
detect ischemia in the RCA distribution. New Q waves and ST segment changes are
suggestive of M.I. Elevated intracranial pressure may lead to the Cushing reflex which is
hypertension and bradycardia, but only when the ICP approaches systemic arterial
pressure. A massive pulmonary embolism will show tachycardia, hypotension,
hypoxemia and right axis deviation on ECG.

Reference:
Amzallag m: Autonomic hyperreflexia. Int Anesthesiol Clin 31: 87, 1993

Hambly PR, Martin B: Anesthesia for chronic spinal cod lesions. Anesthesia 53: 273,
1998

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following drugs should be avoided for induction of general anesthesia in the severe
coronary artery disease patient?

A. Propofol

B. Fentanyl

C. Sevoflurane

D. Ketamine

Answer: D

Rationale:
Ketamine is contraindicated in the CAD patient due to its resultant tachycardia and
hypertension. This will increase the demand for oxygen upon the heart muscle. Propofol
has minimal effects upon oxygen demand by the heart. It will produce a decrease in
arterial blood pressure and decrease in CO. Opiates will reduce both HR and BP. Most
opiates will reduce sympathetic tone and enhance parasympathetic tone. Inhalational
agents may show a beneficial effect against ischemia in humans.

Reference:
Warltier Dc, Pagel PS, Kersten JR: Approaches to the prevention of perioperative
myocardial ischemia. Anesthesiology 92: 253, 2000

Allen RB: Ischemic Heart Disease and Myocardial Infarction. Anesthesia Secrets, 2nd
Edition, Philadelphia, PA, Hanley & Belfus Inc 2000, pg 189-192.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

You are extracting teeth on a morbidly obese man who is a heavy smoker and has obstructive
sleep apnea. The patient receives 100 mcg of fentanyl and 5 mg of midazolam prior to local
anesthetic injection. After a few minutes you note that the patient’s ventilation has decreased
and he appears clinically cyanotic. However, the pulse oximeter reads 96% (SpO2). What is the
most likely explanation for this phenomenon?

A. Motion artifact due to patient movement

B. High levels of carboxyhemoglobin

C. Elevated hemoglobin and hematocrit

D. Supplemental oxygen by nasal cannula

Answer: B

Rationale:
Heavy smokers may have high levels of carboxyhemoglobin. Oxygenation is
overestimated in the presence of significant levels of carboxyhemoglobin. This occurs
because the pulse oximeter sees carboxyhemoglobin as oxyhemoglobin.

Contemporary pulse oximeters average signals over different periods of time. This
reduces the effect of noise (motion) upon the reading. An obese patient may have
elevated levels of hemoglobin and hematocrit associated with sleep apnea. This occurs
under periods of chronic hypoxemia. This would not elevate the SpO2.

Reference:
Barker SJ, Tremper KK: The effect of carbon monoxide inhalation on pulse oximetry and
transcutaneous PO2 . Anesthesiology 73:573, 1990

Buckley RG, Aks SE, Eshom JL, et al: The pulse oximetry gap in carbon monoxide
intoxication. Ann Emerg Med 24:252, 1994

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

An 18 year-old healthy male patient in your office was given 10 mg of midazolam, 50 mcg of
fentanyl and 30 mg of propofol during a long extraction case. The patient has prolonged
emergence from anesthesia and decreased ventilations. The pulse oximeter reads 89%
oxygenation on 4 L nasal cannula oxygen. The patient is administered flumazenil 0.2 mg and
naloxone 0.2 mg. His mental status and ventilations improve. Forty minutes later in your
recovery room he appears drowsy and is non-responsive to commands. The pulse oximeter
reads 91%. Shallow unobstructed respirations are approximately 12 per minute. How should
you proceed?

A. Administer flumazenil

B. Administer supplemental oxygen

C. Support the patient’s airway

D. Administer naloxone

Answer: A

Rationale:
Resedation is a potential problem given the short half-life of reversal agents. Flumazenil's
onset is 1 – 2 minutes, its peak effect is 2 – 10 minutes, and its duration of effect is 45 –
90 minutes. Naloxone's onset is 1 – 2 minutes, its peak effect is 5 – 15 minutes and its
duration of effect is 60 – 240 minutes. The patient was given a large dose of
benzodiazepine. In this situation, it is likely that the benzodiazepine was more likely
contributory to the initial depressed ventilations and prolonged emergence despite both
naloxone and flumazenil being administered by the practitioner. Another dose of
Flumazenil is the appropriate treatment. The maximum total dose is 3 mg. This patient is
able to maintain an unobstructed airway and has spontaneous ventilations. Supporting
the patient's airway is not necessary as he is not demonstrating obstruction.
Administering supplemental oxygen may increase the level of oxygen saturation,
however, will not correct the depressed level of consciousness.

Reference:
Weinbrum A, Geller E: The respiratory effects of reversing Midazolam sedation with
Flumazenil in the presence or absence of narcotics. Acta Anesthesiol Scand Suppl
92:65, discussion 78, 1990.

Klotz U, Kanto J: Pharmacokinetics and clinical use of Flumazenil. Clin Pharmacokinet

14:1, 1988

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The OMS team is treating an orbital floor blow-out fracture in a 47 year-old man who has a
history of hypertension and is a smoker. During elevation of the orbital contents the patient is
noted to become hypotensive (SBP = 65) and bradycardic (45). The most appropriate initial
pharmacologic treatment for this clinical situation is?

A. Ephedrine 20 mg IV

B. Transcutaneous pacing

C. Epinephrine 1.0 mg IV

D. Atropine 0.5 mg IV

Answer: D

Rationale:
It is evident that the patient has experienced an oculocardiac reflex. Atropine remains the
first-line drug for acute symptomatic bradycardia. The recommended dose is 0.5 mg
every 3-5 minutes to a maximum of 3 mg. Scopolamine is an anticholinergic agent.
However, it is not used in treating symptomatic bradycardia. Transcutaneous pacing is
indicated for the treatment of symptomatic bradycardia if the patient fails to respond to
atropine. Epinephrine is used to treat symptomatic bradycardia as a second-line drug in
an infusion of 2-10 mcg/min. Ephedrine is a sympathomimetic amine which may be used
to treat the hypotensive patient. However, considering the most likely etiology of the
hypoetension and bradycardia it would be an inappropriate agent.

Reference:
Advanced Cardiovascular Life Support – Provider Manual, Field JM editor, American
Heart Association, 2006

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and

Emergency Cardiovascular Care: Management of symptomatic bradycardia and
tachycardia. Circulation 2005;112:IV-67-IV-77.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The patient you are treating is a spinal cord injured dialysis patient with end stage renal disease
(ESRD). He exhibits a serum potassium of 5.1. Which of the following muscle relaxants is the
agent of choice with this patient?

A. Rocuronium

B. Vecuronium

C. Atracurium

D. Succinylcholine

Answer: C

Rationale:
The administration of succinylcholine in patients with renal failure or spinal cord lesions
can lead to an exaggerated hyperkalemia response. This may result in adverse cardiac
events. This phenomenon occurs from the proliferation of post-synaptic acetylcholine
receptors beyond the neuromuscular junction. This results in an increase in serum
potassium upon depolarization by succinylcholine administration.

Renal excretion of the nondepolarizing muscle relaxants, atracurium, rocuronium,

mivacurium is approximately 10%, vecuronium approximately 15% with the other
nondepolarizing muscle relaxants being more dependent on renal excretion. Of the
nondepolarizing agents atracurium is the preferred agent because it undergoes
spontaneous Hofmann degradation and ester hydrolysis. A larger initial dose of the water
soluble atracurium is required to produce rapid paralysis in patients with altered body
water composition. Less frequent and smaller doses will be required to maintain paralysis
in the patients with ESRD.

Reference:
Hunter JM, Jones RS, Utting JE: Use of the muscle relaxant atracurium in anephric
patients. J R Soc Med 75:336-340, 1982

Thapa S, Brull, SJ: Succinylcholine-Induced hyperkalemia in patients with Renal failure.

An old question revisited. Anesth Analg 91: 237-241, 2000

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following best supports the discontinuation of pyridostigmine (Mestinon -

cholinesterase inhibitor) during the anesthetic management of the patient with myasthenia
gravis?

A. Continuation would increase risk of cholinergic crisis

B. Continuation would increase risk of respiratory muscle weakness

C. Discontinuation decreases sensitivity to respiratory depression associated with opioids

D. Continuation results in resistance to succinylcholine and shortened duration

Answer: A

Rationale:
Myathenia gravis is an autoimmune disease of the motor endplate. These patients have
a 70 -80% reduction in the number of acetylcholine motor-endplate receptors.
Approximately 25% of these receptors are required for functional neuromuscular
transmission.

Anticholinesterase therapy is the primary pharmacologic treatment of patients with MG.

The goal of the administration of an anticholinesterase agent is to increase the amount of
acetylcholine. The increase in acetylcholine overcomes the reduction in acetylcholine
receptors with a resultant increase in neuromuscular function. The anticholinesterase
agents generally used in the management of MG are edrophonium, pyridostigmine,
neostigmine and ambedonium. These agents do not cross the blood brain barrier.
Pyridostigmine is the most commonly prescribed agent because of its 3 – 6 hour duration
and the fewer muscarinic side effects. Administration of excessive amounts of
anticholinesterase agents can result in cholinergic crisis. Cholinergic crisis is manifested
by bradycardia, hypotension, increased secretions, lacrimation, wheezing, muscle
weakness, nausea and vomiting, and constricted pupils.

There are several points to consider in the anesthetic management of a patient with MG.
(1) Respiratory function should be assessed preoperatively through pulmonary function
tests. Opioids must be used sparingly to avoid further compromising a patient with
diminished respiratory reserve. (2) There is differing opinions pertaining to the
continuation of the patient's anticholinesterase agent. If the patient continues their
anticholinesterase there is the potential for various drug interactions including
prolongation of the succinylcholine, and antagonism of the nondepolarizing
neuromuscular blocking agent. Continuation of the anticholinesterase has the potential
risk of resulting in cholinergic crisis. The benefit of stopping the anticholinesterase agent
is the avoidance of a cholinergic crisis post-operatively. Additionally, the withholding of
the anticholinesterase agent results in muscle weakness and a reduction or elimination of
the need for neuromuscular blockade. If neuromuscular blockade is required the MG
patient demonstrates a resistance to succinylcholine and a prolongation of its effects; and
an increased sensitivity to nondepolarazing agents. The latter is a result of the
diminished neuromuscular receptors in a patient with MG.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Reference:
Barak A: Anesthesia and myasthenia gravis. Can J Anaesth 39:476-486;1992

Abel M: Myasthenia gravis in Clinical Cases in Anesthesia. Ed Reed AP & Yudkowitz FS.
Elsevier 2005 pages 137 – 142

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following patterns is characteristic of a response to nerve stimulation produced by

a depolarizing neuromuscular agents?

A. A lack of fade in response to train of four (TOF)

B. Increase in post-tetanic stimulation

C. Tetanus is associated with fade in muscle response

D. Fourth twitch of TOF disappears with 60-70% receptor occupancy

Answer: A

Rationale:
A nerve stimulator delivers a set electrical impulse either as a single stimulus, a tetanic
stimulation, or a series of 4 impulses (TOF – train of four). Clinically the TOF and the
tetanic stimulation provide the greatest clinical information.

The train of four delivers 4 impulses at a set frequency. The practitioner assesses the
ratio of the amplitude of the fourth twitch to that of the first twitch. In a patient who has
received a non-depolarizing neuromuscular blocking agent the twitches disappear in
st nd
reverse order (1 twitch 90-95% receptor occupancy, 2 twitch 85-90% receptor
rd th
occupancy, 3 twitch 80-85% receptor occupancy, 4 twitch 75-80% receptor
occupancy). A lack of observable fade on a train of four is used clinically to assess for
recovery from a neuromuscular blockade. In a patient who has received a depolarizing
agent the TOF is uniformly decreased.

Tetanic stimulation is an impulse that is administered at a frequency of 50 Hz. A fade in

muscle response or “tetanic fade” occurs secondary to a non-depolarizing muscle
relaxant. A lack of tetanic fade occurs with a depolarizing agent. A tetanic fade or loss of
contraction associated with the tetanic stimulation indicates a phase 2 neuromuscular
blockade, which may be associated with prolonged exposure to succinylcholine. A
tetanic stimulation causes the release of acetylcholine. This can cause a post-tetanic
facilitation associated with non-depolarizing agents.

Reference:
Donati F, & Bevan DR: Neuormuscular blocking agents. In Clinical Anesthesia Editors
th
Barash PG, Cullen BF, Stoelting RK. 5 ed. Lippincott, Williams & Wilkins. Pg 440 – 444

Torda TA: Monitoring neuromuscular transmission. Anaesth Intensive Care 30:123;2002

rd
Duke J: Muscle relaxants and monitoring of relaxant activity. InAnesthesia Secrets 3 ed.
Mosby Elsevier. Page 88 - 96

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 37 year-old female presents for emergent surgery. She has been recently diagnosed with
Graves’ disease but has yet to start any treatment. She also has hypertension and arthritis. Her
only medication is Lasix (furosemide), which she takes sporadically. What would be the most
appropriate medication to administer pre-operatively to avoid anesthetic complications in this
emergent situation?

A. Propylthiouracil

B. Decadron

C. Iodide

D. Propranolol

Answer: D

Rationale:
Graves disease is a hyperthyroid state that typically occurs in females between the ages
of 20 – 40 years of age. The stress of surgery can cause a life threatening exacerbation
of this state called thyroid storm. Thyroid storm is a hypermetabolic condition that
presents with hypertension, dysrhythmias including tachycardia, myocardial ischemia,
and hyperthermia.

A patient who is hyperthyroid must be treated prior to being taken to surgery. For
elective cases this is frequently done with antithyroid medications such as
propylthiouracil or methimazole. Propylthiouracil inhibits iodination and coupling reactions
in the thyroid gland inhibiting the synthesis of thyroid hormones and inhibiting the
peripheral conversion of T4 to T3. It takes 6 – 8 weeks of treatment for a patient to
become euthyroid.

Iodide containing solutions, such as potassium iodide or Lugol's solution, may also be
administered. These agents inhibit T3 and T4 release for a period of time from days to
weeks. Iodide is usually administered with either antithyroid drugs or -adrenergic
antagonists and preoperative preparation can take ideally from 7 to 14 days.
-adrenergic antagonists are effective in attenuating sympathetic activity. Propranolol
does not inhibit hormone synthesis but does prevent the conversion of T4 to T3. The
administration of a -blocker does prevent sympathetic activity such as hypertension and
dysrhythmias. Corticosteroids, such as decadron, can also be used in the management
of thyrotoxicosis because they reduce thyroid hormone secretion and peripheral
conversion of T4 to T3

The administration of a -adrenergic antagonist is the preferred agent in the

management of an acute situation requiring emergent surgery.

Reference:
th
Miller, RD. Miller's Anesthesia, 6 edition. Elsevier, 2005, pg 1045-1047.

American Board of Oral and Maxillofacial Surgery 19

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pgs 807-808, 1016-1017.

American Board of Oral and Maxillofacial Surgery 20

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 22 year-old 50 kg female presents for the extraction of 4 wisdom teeth. Pre-operative vital
signs are BP 115/75 and HR 64 regular. Anesthetic induction was achieved with midazolam 3.5
mg, fentanyl 50 mcg, ketamine 50 mg and propofol 50 mg. Lidocaine 144 mg with epinephrine
0.072 mg was administered. The patient’s heart rate increases to 95 after the ketamine and
local anesthesia with epinephrine. Fifteen minutes after the conclusion of the procedure and a
total of 45 minutes from the time the patient received the last anesthetic agent, the patient is
slightly confused, complaining of palpitations, and feeling warm. The patient’s blood pressure is
150/60, heart rate is 145 and irregular, respiratory rate is 22 and end-tidal CO2 via nasal cannula
sampling is 43. What is the most appropriate diagnosis and treatment?

A. Increased heart rate most likely secondary to combination of ketamine and epinephrine.
In a healthy individual would observe for another 30 minutes.

B. Increased heart rate most likely secondary to combination of ketamine and epinephrine
and possible postoperative pain. The persistent elevation in heart rate warrants
pharmacologic intervention.

C. Tachycardia, and hypercapnea must alert the practitioner to consider a diagnosis of

malignant hyperthermia and initiate dantrolene therapy.

D. The clinical presentation is that of a hypermetabolic state. Would consider a diagnosis of

hyperthyroidism and initially manage with esmolol 20 – 30 mgs.

Answer: D

Rationale:
Signs of hyperthyroidism include (1) sinus tachycardia, (2) warm, moist skin, (3) systolic
hypertension with widened pulse (although with severe tachycardia and decompensation
can become hypotensive), (4) atrial fibrillation (10% incidence). Initial treatment includes
intravenous fluids to replace intravascular volume, acetaminophen for hyperthermia and
beta-adrenergic blockade.

The sympathomimetic effect of ketamine results in an increase in heart rate ( 20%) and
an increase in blood pressure. These effects are seen within minutes of the drugs
intravenous administration and persist for approximately 20 minutes. In this scenario the
increased heart rate and blood pressure should not have persisted for the duration
described. The pulse pressure is also widened more consistent with hyperthyroidism.

The most sensitive indicator of malignant hyperthermia is hypercapnea and one of the
early manifestations is tachycardia. Other early clinical manifestations of MH include
muscle rigidity and tachypnea. Later clinical findings include increased temperature, and
skin mottling. In the clinical scenario presented the patient was not administered an agent
associated with the induction of MH. MH can be considered in the differential, however,
should not be primary.

Reference:
nd
Van Tassel & Schulman. Malignant Hyperthermia in Complications in Anesthesiology. 2
edition ed Atlee pg 654-656

American Board of Oral and Maxillofacial Surgery 21

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

th
Gronert, Pessah, Muldoon et al. Malignant Hyperthermia Miller's Anesthesia 6 edition.
ed Miller RD Elsevier pg 1169-1186

Reves JG, Glass PSA, et al: Intravenous nonopioid anesthetics. In Miller RD (ed): Miller's
th
Anesthesia, 6 ed Churchill Livingston, 2005 pg 317-378

Prielipp RC, Roberts PR: Hyperthyrodism: Thyroid Storm. In Atlee JL (ed). Complications
nd
in Anesthesia. 2 edition Elsevier 2007 pg 454-456

American Board of Oral and Maxillofacial Surgery 22

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 27 year-old female with a previously unknown medical history arrives in the PACU after repair
of a facial laceration under general anesthesia. She has not had a significant blood loss.
Shortly after arrival, she is noted to have a heart rate of 150, a temperature of 39o C, a
respiratory rate of 30, oxygen saturation of 99 %, and a blood pressure of 92/65. A blood gas
reveals a pH of 7.4, PaO2 of 80, PaCO2 of 38, and a bicarbonate of 24. She is agitated and
confused. What is the most likely diagnosis?

A. Thyrotoxicosis

B. Malignant Hyperthermia

C. Pheochromocytoma

D. Postoperative pain

Answer: A

Rationale:
Thyrotoxicosis is associated with tachycardia, hyperpyrexia, altered sensorium, and
hypotension. Patients are normally not acidotic. Malignant hyperthermia is unlikely since
patient is not acidotic. MH would also be associated with muscle rigidity.
Pheochromocytoma is not likely as this patient is hypotensive, not hypertensive as would
be expected in pheochromocytoma. Although pain could cause tachycardia and
tachypnea, it should also cause hypertension. This patient has not had significant blood
loss so it is unlikely that her hypotension is due to hypovolemic shock.

Reference:

th
Miller, RD. Miller's Anesthesia, 6 edition. Elsevier, 2005, pg 1045-1047.

th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pgs 807-808, 1016-1017.

Keyword: Complications of anesthesia, Anesthetic technique, thyroid disease,

hypermetabolic state, thyrotoxicosis

American Board of Oral and Maxillofacial Surgery 23

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 26 year-old , 60 kg female has just opened her eyes after a 35 minute procedure. The patient
was initially sedated with midazolam 3.5 mg and fentanyl 100 mcg. The patient was then
administered atropine 0.4 mg, ketamine 30 mg, and propofol 60 mg. A continuous infusion of
propofol was maintained for the duration of the surgery at 6 mg/kg/hr. The total propofol dose
for the bolus and infusion was 375 mg. The patient maintained a patent airway with
spontaneous ventilations during the procedure. The patient’s vital signs during recovery were
BP 110/65 and HR 72 regular. Approximately 5 minutes after the procedure the patient had
what appeared to be a brief self limiting seizure. The patient had another seizure 5 minutes
later. An EEG was normal. Which of the following scenarios is most consistent with this event?

A. Myoclonic activity associated with opioid compounded by hypoxia

B. Emergence reaction associated with ketamine

C. Dysphoric reaction associated with atropine(tertiary amine)

D. Idiopathic reaction associated with propofol; etiology unknown

Answer: D

Rationale:
Most anesthetic medications have both pro- and anticonvulsant neuroexcitatory effects.
For example, propofol has greter anticonvulsant effect on ECT than other anesthetics.
However, propofol has neuroexcitatory effects that range from mild involuntary myoclonic
limb movements to grand mal seizure – like activity. These neuroexcitatory events may
occur with induction, emergence or during recovery from the anesthetic. They may occur
in patients with and without prior history of neurologic disease. EEG's done on patients
have not been consistent with seizures. This is the most likely differential for the
described scenario.

Myoclonus, sometimes resembling seizures, but without EEG evidence of seizure

activity, has been observed with high dose opioids. In clinical practice, opioid induced
muscle rigidity and myoclonus are most often observed on induction of anesthesia, but
have been observed postoperatively.

Tertiary amines cross the blood brain barrier and can cause central anticholinergic
syndrome. Central manifestations of anticholinergic overdose include disorientation,
agitation, hallucinations, ataxia and seizures. Peripheral manifestations of
anticholinergic overdose include tachycardia, mydriasis, facial flushing, hyperpyrexia,
urinary retention and decreased sweating. Treatment of central anticholinergic
syndrome is with physostigmine.

Reference:
Walder B, Tramer MR, Seeck: Seizure – like phenomenon of propofol: A systematic
review. Neurology 58:1327-1332;2002

American Board of Oral and Maxillofacial Surgery 24

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Dearlove JC, Dearlove OR: Cortical reflex myoclonus after propofol anaesthesia.
Anaesthesia 57:834-835;2002

nd
Wilkhu H, Chan KP, et al: Nonbarbiturate anesthetics. In Complications in Anesthesia 2
edition ed Atlee JL pgs 80 - 84

Keyword: pharmacology of anesthetic agents, complications of anesthesia, propofol,

seizure

American Board of Oral and Maxillofacial Surgery 25

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 56 year-old male was admitted at after sustaining a fractured mandible. The patient
undergoes general anesthesia for open reduction of a mandible fracture 15 hours later. He has
a history of hypertension, cigarette smoking, daily alcohol consumption, and cocaine use. He
last used cocaine two days ago. While awakening in the recovery room, he becomes
progressively more confused, tremulous, and agitated. The patient does not complain of pain.
Monitoring shows heart rate – 115; BP 180/98; RR – 22; oxygen saturation – 92%; ECG – sinus
tachycardia. Which medication would you administer initially to manage this situation?

A. Morphine sulfate

B. Labetalol (Trandate)

C. Haloperidol (Haldol)

D. Lorazepam (Ativan)

Answer: D

Rationale:
After surgery, possible causes of delirium include cerebral hypoperfusion, hypotension,
hypoxia, anemia, hyperthermia, fluid and electrolyte abnormalities, acid-base
disturbances, inadequate analgesia, anticholinergic syndrome, and benzodiazepine,
opioid or alcohol withdrawal. Alcohol withdrawal is certainly likely, especially if this
patient has been npo prior to surgery in addition to having limited alcohol intake because
of his injury.

Alcohol withdrawal presents as combativeness, tremors, disorientation, hallucinations

and convulsions. Onset of alcohol withdrawal is usually 10 – 30 hours after cessation of
alcohol consumption. The syndrome of alcohol withdrawal may occur under anesthesia.
Delirium tremens develops after prolonged abstinence.

If the patient is suspected to have alcohol withdrawal, then a benzodiazepine is most

effective. Lorazepam is probably the most popular choice because it is fast-acting, mildly
sedating, and has no active metabolites. Morphine sulfate would be a good choice if his
agitation was due to poor analgesia; however, he reported minimal pain. Haloperidol is a
butyrophenone with antipsychotic effects that are usually effective for control of
postoperative delirium.

The signs and symptoms of cocaine intoxication include: tachycardia, hypertension

hallucinations, convulsions, cerebrovascular accident, headache, and chest pain.
Treatment of cocaine intoxication includes the use of -adrenergic antagonists (e.g.
labetalol or esmolol), nitrates and calcium channel blockers. The half life of cocaine is
approximately ½ to 1 ½ hours. It is unlikely that this patient is manifesting signs of acute
cocaine intoxication. Signs and symptoms of cocaine withdrawal include agitation,
anxiety, myalgias and tremors.

Reference:

American Board of Oral and Maxillofacial Surgery 26

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Cavaliere F, D'Ambrosio F, Volpe C, Masieri S: Postoperative delirium. Current Drug

Targets 2005, 6, 807-814.

Meagher DJ: Delirium: Optimising management. BMJ 2001, 322, 144-149.

rd
Karre S, Duke J: Alcohol and substance abuse in Anesthesia Secrets ed. Duke J 3
edition Elsevier pages 317-322

Keyword: complications of anesthesia, assessment of patient for anesthesia, alcohol

intoxication, hypertension, tachycardia, cocaine intoxication, alcohol withdrawal

American Board of Oral and Maxillofacial Surgery 27

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A healthy 22 year-old female who is 5 foot 2 inches, 170 pounds presents for extraction of 1
tooth. Oxygen at 4 liters/minute is administered via nasal cannula. Five minutes after oxygen
administration is initiated the patient is induced with propofol 140 mgs. The patient becomes
apneic. Pulse oximeter reads 100%. The surgeon proceeds with extracting the tooth and does
not take immediate intervention to provide airway support and positive pressure ventilation.
Which of the following either justifies or counters the surgeon’s actions?

A. Preoxygenation with the 36% oxygen mixture for 5 minutes will maintain the oxygen
saturation at or above 90% for at least 3 minutes in this individual

B. The surgeon should initiate positive pressure ventilation as obese patients desaturate
approximately twice as rapidly as individuals with lean body mass.

C. Preoxygenation with an FiO2 of 0.36 will produce a PAO2 of 160 mm Hg which does not
provide ample reserve for the surgeon to complete a 30 second procedure

D. The administration of propofol will not result in prolonged apnea and continuous
insufflation of oxygen will sustain an oxyhemoglobin saturation > 90%.

Answer: B

Rationale:
Preoxygenation is the process of administering oxygen to a patient prior to inducing
anesthesia. The intent is to replace the volume of nitrogen in the lungs with oxygen
(denitrogenation). PAO2 is calculated using the formula PAO2 = FiO2 (PB-PH2O) –
PaCO2/RQ where PB = 760, and PaCO2/RQ = 40/0.8. Preoxygenation provides a
reservoir of oxygen occupying the functional residual capacity that can diffuse into the
alveolar capillaries and provide oxygen during periods of hypoventilation and apnea.
Preoxygenation with 100% oxygen for 5 minutes can provide up to 10 minutes of oxygen
reserve to a healthy individual during periods of apnea and normal oxygen utilization. In
one study comparing healthy individuals of ideal weight to obese individuals who were
preoxygenated with 100% oxygen, the obese individuals desaturated to an oxygen
saturation < 90% approximately twice as fast as the nonobese individuals (2.7 minutes
compared to 6 minutes). In another study a nonobese patient breathing room air will
desaturate to an oxygen saturation < 90% in about 2 minutes.

Achievement of a general anesthetic depth solely with propofol will be more predictable
in its recovery. However, the apneic patient, especially the obese patient, cannot rely on
recovery from the propofol bolus and resumption of ventilation to maintain oxygenation.
Apneic oxygenation is a technique that is dependent on pharyngeal insufflation of
oxygen. This technique is dependent on more oxygen diffusing out of the alveoli into the
capillaries than carbon dioxide diffusing into from the capillaries into the alveoli. This
decrease in intrathoracic pressure relative to atmospheric pressure facilitates oxygen
delivery. Carbon dioxide is not removed from the alveoli limiting the duration of this
oxygenation technique. Apneic oxygenation is dependent on a patent airway. It is most
likely that a bolus of propofol that produces apnea also compromises airway patency.

Reference:

American Board of Oral and Maxillofacial Surgery 28

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Rosenblatt WH. Airway management. In Clinical Anesthesia ed Barash P, Cullen BF,

th
Stoelting RK 5 ed. Lippincott, Williams, & Wilkins pages 599 – 600

Baraka AS, Taha SK, Aouad MT, et al: Preoxygenation: Comparison of maximal
breathing and tidal volume breathing techniques. Anesthesiology 91:612;1999

Keyword: airway management, apnea, preoxygenation, apneic oxygenation, obese

patient

American Board of Oral and Maxillofacial Surgery 29

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 68 year-old male with a history of emphysema is anesthetized for management of a panfacial

fracture. Intraoperative medications administered include sevoflurane, propofol, succinylcholine,
and morphine. The patient is orally intubated with difficulty. Two hours into the surgery the
anesthesiologist comments that the patient has been developing increased airway pressures.
Auscultation of the chest is difficult with distant sounds. Oxygen saturation is 90%. The patient
is also noted to be hypotensive despite fluid replacement for the blood loss. Which of the
following interventions should be considered?

A. Reposition the endotracheal tube

B. Needle decompression of the chest

C. Administer four puffs of albuterol

D. Administer phenylephrine

Answer: B

Rationale:
As a patient with emphysema subjected to positive pressure ventilation, he is at risk of
pulmonary bullae rupture resulting in a tension pneumothorax. A tension pneumonthorax
is suspected when peak airway pressures increase, accompanied by hypotension,
hypoxemia, decreased breath sounds, and decreased tidal volume on the side of the
pneumothorax. Needle decompression in the second intercostal space in the mid-
clavicular line will relieve the tension aspect of the pneumothorax and can be life saving.
Difficult intubation could also create a false passage and contribute to a pneuomothorax.
If the endotracheal tube had been placed too deep, this may account for decreased
breath sounds and hypoxemia, but hypotension would not be likely. Albuterol would be
helpful if bronchoconstriction was present, but this is a pneumothorax.

Reference:
th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pg 578.

th
Stoelting RK, Dierdorf SF. Anesthesia and Co-Existing Disease, 4 edition. Churchill
Livingstone, 2002, pg 179, 186.

Keyword: complications of anesthesia, emphysema, tension pneumothorax, traumatic

intubation

American Board of Oral and Maxillofacial Surgery 30

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

What action would you take in regards to the ventilation of an intubated anesthetized patient
who is in bronchospasm?

A. Increase expiratory time by decreasing ventilator rate

B. Decrease inspiratory flow rates to decrease inspiratory time

C. Apply PEEP (positive end expiratory pressure)

D. Increase minute volume

Answer: A

Rationale:
The objective in managing a patient who is having a bronchospastic episode is to
minimize lung hyperinflation. Lung hyperinflation occurs when there is diminished
expiratory flow which results in gas trapping in the alveoli and small airways. Lung
hyperinflation can be prevented by increasing the expiratory to inspiratory ratio.
A slow breathing rate should be used to allow for adequate ventilation and adequate time
for exhalation. This should be coupled with an increase in inspiratory flow rate which will
decrease inspiratory time. PEEP should not be used because it impairs exhalation and
increases the likelihood of distal air trapping. A decrease in minute ventilation (tidal
volumes less than 10 mg/kg) will allow controlled hypoventilation and should be used
also to allow for adequate ventilation and exhalation.

Reference:
th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pg 576.

th
Stoelting RK, Dierdorf SF. Anesthesia and Co-Existing Disease, 4 edition. Churchill
Livingstone, 2002, pg 203

rd
Packer M. reactive airway disease. In Anesthesia Secrets. Ed Duke J 3 edition,
Mosby/Elsevier pg 261

Keyword: airway management, complications of anesthesia, mechanical ventilation,

bronchospasm

American Board of Oral and Maxillofacial Surgery 31

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

An 18 year-old 65 kg male with sickle cell anemia is involved in a motor vehicle accident
sustaining a mandibular fracture. He is admitted to the hospital and goes to the operating room
10 hours after admission. On admission the patient is started on 0.9% NS with 20 mEq
potassium at 110 mL/hr. The patient’s HCT is 30% at the start of surgery. During surgery blood
loss is approximately 75 cc. The patient receives 500 cc of Lactated Ringer’s solution
intraoperatively. On arrival to the PACU the patient is shivering and complaining of feeling cold
with a body temperature of (96 F). Demerol (maperidine) 25 mg IV is administered for the
shivering. Shortly thereafter the patient complains of dyspnea and extremity pain. Respiratory
rate is 20. An ABG is taken and the results are pH 7.38, PaO2 of 80, PaCO2 of 42, and a
bicarbonate of 22. What factor could be contributory to the patient’s presentation?

A. Hypothermia

B. Dehydration

C. Anemia

D. Demerol

Answer: A

Rationale:
The clinical manifestations of sickle cell disease result from the deformation of the RBC's
(sickling) and the deformed RBC shape causing obstruction and stasis of blood flow. This
results in tissue ischemia and is manifested as pain. Any organ system can be affected
and the pain can present in the chest, back, abdomen and extremities. Other
manifestations include splenic sequestration and acute chest syndrome (clinical
manifestations: chest pain, dyspnea, fever and pulmonary hypertension). In order to
prevent a conditions that promote sickling the surgical team must ensure that the patient
is oxygenated and ventilated (avoid acidosis) adequately. Adequate oxygenation is
dependent on adequate oxygen carrying capacity. The patient's hematocrit should be
maintained around 30%. Vascular stasis must also be avoided. Adequate hydration is
critical to minimizing vascular stasis; and in this case the patient was administered
adequate fluids for maintenance and blood loss replacement. Normothermia is also
important in avoiding vascular stasis. Hypothermia may cause peripheral
vasoconstriction promoting vascular stasis and hyperthermia accelerates hemoglobin S
polymerization. Anesthetic drugs generally have no impact on promoting sickle cell crisis.

Reference:
Dierdorf SF, Walton JS: Anesthesia for patients with rare and coexisting diseases. In
th
Clinical Anesthesia. Eds Barash PG, Culen BF, Stoelting RK, 5 ed Lippincott, Williams,
& Wilkins pg 518 – 520

nd
Stoelting RK, Dierdorf SF: Handbook of Anesthesia and Co-Existing Disease 2 edition
Churchill Livingston 2002 pages 365-367

Keyword: assessment of patient for anesthesia, Sickle cell disease

American Board of Oral and Maxillofacial Surgery 32

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Levonordefrin in the local anesthetic agent causes a decrease in which of the following
cardiovascular affects?

A. Mean arterial pressure

B. Heart rate

C. Diastolic blood pressure

D. Systemic vascular resistance

Answer: B

Rationale:
Levonordefrin lacks significant beta-2 activity. The vasoconstricting activity associated
with alpha agonism raised the mean arterial pressure. A compensatory vagal reflex is
initiated by the baroreceptors in the aortic arch and carotid sinuses and the heart rate is
decreased. Epineprhine is the vasoconstrictor most appropriate for hypertensive patients
and levonordefrin is the vasoconstrictor most appropriate for patients with tachycardic
conditions.

Drug SBP DBP MAP HR

Epinephrine
Levonordefrin

Reference:
Jastak JT, Yagiela JA, Donaldson D: Local Anesthesia of the Oral Cavity,
Saunders1995 page 74

Robertson VJ, Taylor SE, and Gage TW: Quantitative and qualitative analysis of the
pressor effects of levonordefrin, J Cardiovasc. Pharamcol 6:929,1984

Key word: local anesthesia, levonordefrin

American Board of Oral and Maxillofacial Surgery 33

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which local anesthetic has the greatest risk of cardiotoxicity?

A. Articaine

B. Bupivicaine

C. Ropivicaine

D. Prilocaine

Answer: B

Rationale:
In general, larger doses of local anesthetics are required to produce cardiovascular
toxicity compared to CNS toxicity. The more potent and lipid-soluble drugs, such as
bupivicaine, ropivicaine, and etidocaine, are more cardiotoxic compared to the other local
anesthetics. For these drugs there is a smaller difference in dose of local anesthetic
agent that may cause cardiovascular collapse compared to dosage that may cause
respiratory collapse. When the more potent lipid soluble drugs are overdosed there is a
greater likelihood that the patient will develop ventricular dysrhythmias resulting in
cardiovascular collapse in contrast to hypotension, bradycardia and hypoxia that follows
an overdose of the other less potent local anesthetics, such as lidocaine, articaine,
mepivicaine, and prilocaine. There are several mechanisms by which the more potent
local anesthetics may cause cardiotoxicity:

1) Diminished activity of the nucleus tractus solitarii has been shown in animals. This
region of the medulla controls autonomic activity of the CV system
2) Potent inhibitory effect on sympathetic reflexes
3) Greater potential for direct cardiac electrophysiologic toxicity
4) High affinity for sodium channels in the cardiac myocyte
5) Potent local anesthetics dissociate from sodium channels so slowly that during
physiologic heart rates there is inadequate time for complete recovery and conduction
block accumulates.

The increase in cardiotoxicity is increased with hypoxia, acidosis, and pregnancy.

Ropivicaine is structurally similar to bupivicaine, which is a racemic solution. Ropivicaine
is approximately equipotent to bupivicaine; however, it is marketed as the less toxic S-
enatiomeric solution.

Reference:
Liu SS, Joseph Jr. RS: Local anesthetics. in Clinical Anesthesia. Eds Barash PG, Culen
th
BF, Stoelting RK, 5 ed Lippincott, Williams, & Wilkins pg 3-4666

th
Kumar S: Local anesthetics. In Anesthesia Secrets. ed Duke J. 5 edition,
Mosby/Elsevier pg 101

Keyword: local anesthesia, bupivicaine, cardiovascular toxicity

American Board of Oral and Maxillofacial Surgery 34

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following drugs decreases lower esophageal sphincter tone?

A. Neostigmine

B. Glycopyrrolate

C. Metoclopramide

D. Succinylcholine

Answer: B

Rationale:
The lower esophageal sphincter is a 2 to 3 cm segment of the gastrointestinal tract
located above and below the diaphragm that is under increased pressure. The likelihood
for reflux is related to the barrier pressure or the difference between the lower
esophageal sphincter pressure and gastric pressure. The lower esophageal sphincter is
innervated by vagal and sympathetic nerves. Certain drugs with anticholinergic effects,
including atropine, glycopyrrolate, and tricyclic antidepressants, have been shown to
relax the lower esophageal sphincter. This has not been shown to be of clinical
significance. Decreased lower esophageal sphincter tone is associated with pregnancy,
obesity, hiatal hernia, and gastroesophageal reflux disease (GERD). A number of
medications that increase acetylcholine activity, including succinylcholine,
prochlorperazine, metoclopramide, edrophonium, and neostigmine, also will increase
lower esophageal sphincter tone.

Reference:
th
Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia, 4 ed. Philadelphia, Lippincott
Williams & Wilkins, 2001, pp. 560, 1042, 1042t.

Morgan GE, Mikhail MS, Murray MJ, Clinical Anesthesiology, 3d ed. New York, McGraw-
Hill, 2002, pp. 186-187, 202-205, 209, 245.

Keywords: pharmacology of anesthetic agents, aspiration, esophageal sphincter tone,

anticholinergics

American Board of Oral and Maxillofacial Surgery 35

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In a patient homozygous for atypical pseudocholinesterase, which of the following best explains
the prolonged action of succinylcholine?

A. Increased proportion of drug at neuromuscular junction

B. Slowed diffusion away from the neuromuscular junction

C. Development of a “dual” or phase I block

D. Unopposed prejunctional activity

Answer: A

Rationale:
Most of the succinylcholine administered to a patient is metabolized by
pseudocholinesterase in the bloodstream to succinylmonocholine, a metabolite with
minimal neuromuscular blocking properties. Only five percent of the injected drug ever
reaches the neuromuscular junction. Neuromuscular blockade ends when
succinylcholine diffuses into the extracellular space. Prolonged blockade occurs in
individuals who are homozygous for atypical pseudocholinesterase, which has 1/100 the
affinity of the normal enzyme for succinylcholine. As a consequence, more
succinylcholine reaches the neuromuscular junction. In these individuals, urinary
excretion and protein binding contribute to the clearance of the drug.

Reference:
th
Barash PG, Cullen BF, Stoelting RK. Clinical Anesthesia 4 ed, Philadelphia, Lippincott
Williams & Wilkins, 2001, pp. 421-424, 538-540.

Stoelting RK: Pharmacology and Physiology in Anesthetic Practice, 2d ed. Philadelphia,

Lippincott, 1991, p. 178.

Keyword: pharmacology of anesthetic agent, neuromuscular blocking agents,

cholinesterase

American Board of Oral and Maxillofacial Surgery 36

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which drugs combination balances out the potential adverse hemodynamic properties of each
agent?

A. Propofol and remifentanil

B. Ketamine and propofol

C. Etomidate and midazolam

D. Midazolam and propofol

Answer: B

Rationale:
Hemodynamic changes occur after induction of anesthesia. Propofol will decrease heart
rate, decrease mean blood pressure, and decrease systemic vascular resistance.
Ketamine will increase heart rate, increase mean blood pressure, and increase systemic
vascular resistance. Midazolam maintains relatively stable hemodynamics however, can
cause a slight decrease in the mean blood pressure, decrease in heart rate and decrease
in systemic vascular resistance. Etomidate differs from most of the other rapid onset
induction agents in that its administration results in minimal changes in heart rate, mean
blood pressure and systemic vascular resistance. Remifentanil will decrease heart rate. It
will produce minimal to no decreases in preload or afterload.

The cardiostimulant effects of ketamine blunt the cardiodepressant effects of propofol.

Reference:
Reves JG, Glass PSA, et al: Intravenous nonopioid anesthetics. In Miller RD (ed): Miller's
th
Anesthesia, 6 ed Churchill Livingston, 2005 pg 317-378

Frizelle HP, Duranteau J, et al: A comparsion of propofol with a propofol-ketamine

combination for sedation during spinal anesthesia. Anesth Analg 84:1318-1322;1997

Keyword: pharmacology of anesthetic agent, propofol, ketamine

American Board of Oral and Maxillofacial Surgery 37

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 46 year-old male (BMI - 32) with controlled asthma presents for full mouth extraction,
alveoloplasty, mandibular tori reduction and placement of 12 implants. After administration of
midazolam, fentanyl and propofol the patient becomes apneic and you are unable to ventilate.
The patient is positioned from the 30 head up position to the supine position to facilitate airway
management and remains in this position for the duration of surgery. Multiple attempts at
intubation are unsuccessfully. A classic LMA (laryngeal mask airway) is inserted and the patient
is ventilated with positive pressure ventilation. After placement of the LMA the surgeon decides
to complete the surgery. Ventilation is initially controlled. Inspiratory pressure required is 30 cm
H20. The surgery lasts 2.5 hours. Which statement pertaining to this scenario is most accurate?

A. The use of a classic LMA for an obese, asthmatic patient was inappropriate

B. Surgery length exceeds manufacturers recommendation for classic LMA

C. The inspiratory pressure used in this case was higher than suggested

D. Supine position increases the risk of gastric insufflation and aspiration

Answer: C

Rationale:
The LMA is an airway device that is placed in the oropharynx and allows ventilation of the
patient by creating a seal with an inflatable cuff. The largest size LMA should be used.
The cuff should then be inflated. The sealing pressure for the LMA should ideally be less
than 20 cm H2O, although it should never exceed 60 cm H2O. When first introduced it
was recommended not to use positive pressure ventilation (PPV) with a LMA. However
since that time, it has been demonstrated that PPV is appropriate and in selected
situations possibly preferred with a LMA.

When using PPV, a patient with normal lung compliance should not require inspiratory
pressures more than 20 to 25 cm H2O. When using a LMA inspiratory pressure should
be less than 20 cm H2O which is the sealing pressure of the device under normal
circumstances. Additionally, it has been shown that with positive pressure ventilation with
inspiratory pressures < 17 cm H2O there has been no difference in gastric inflation
between an endotracheal tube and a LMA.

Since the introduction of the LMA there has been a wealth of literature that has
demonstrated its use in unconventional patients. The LMA is ideal for the asthmatic
patient in which the lower airway does not require manipulation. Morbid obesity,
significant GERD, and full stomach are contraindications to the use of the LMA. However,
this patient with mild obesity is not a contraindication. While the LMA does not provide a
seal between the esophagus and the trachea the risk of aspiration is not greater in low
risk patients. Even in patients with full stomachs or patients who present for emergency
surgery there is a low incidence of aspiration. When comparing mask to LMA ventilation
during CPR the risk of aspiration is 4 times greater with a mask. Trendelenberg
positioning may be a factor predisposing a patient to aspiration.

The manufacturer recommends that a LMA should not be used in cases lasting longer
than 3 hours.

American Board of Oral and Maxillofacial Surgery 38

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Reference:
Todd DW. A comparison of endotracheal intubation with the LMA for ambulatory oral
surgery. JOMS 60:2-4;2002

Rosenblatt WH. Airway management. In Clinical Anesthesia ed Barash P, Cullen BF,

th
Stoelting RK 5 ed. Lippincott, Williams, & Wilkins pages 602-605

Keyword: airway management, laryngeal mask airway

American Board of Oral and Maxillofacial Surgery 39

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The elimination and clearance of which anesthetic agent is least affected by the co-
administration of a potent inhalational agent?

A. Ketamine

B. Methohexital

C. Midazolam

D. Diazepam

Answer: D

Rationale:
All anesthetic medications are to some degree eliminated and cleared by the liver. There
are drugs that have low hepatic extraction ratios. These drugs are dependent on
enzymatic activity of the liver and are less dependent on liver blood flow. Other drugs
have high hepatic extraction ratios and most of the drug is removed from the blood as it
flows through the liver. This is referred to as perfusion-limited clearance and is largely
dependent on hepatic blood flow. Drugs with low hepatic extraction ratios include
thiopental, diazepam, and lorazepam. Drugs with intermediate hepatic extraction ratio
include methohexital and midazolam. Drugs with high hepatic extraction ratio include
propofol, ketamine and etomidate. Aging or decreased cardiac output results in higher
plasma levels of drugs that are dependent on perfusion limited clearance. Concomitant
administration of a potent inhalational agent can decrease liver blood flow and decrease
the clearance and elimination of drugs with a high hepatic ratio. Other factors that may
decrease hepatic blood flow include hypocapnia, congestive heart failure, intravascular
volume depletion and adrenergic blockade

Reference:
th
White PF, Romero G. Nonopioid intravenous anesthesia. In Clinical Anesthesia 5 ed,
Barash P, Cullen BF, Stoelting RK (ed). Lippincott, Williams, & Wilkins page 338

Reves JG, Glass PSA, et al: Intravenous nonopioid anesthetics. In Miller RD (ed): Miller's
th
Anesthesia, 6 ed Churchill Livingston, 2005 pg 317-378

Keyword: pharmacology of anesthetic agent, inhalational agents, nonopioid anesthetics,

pharmacokinetics

American Board of Oral and Maxillofacial Surgery 40

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which anesthetic agent can produce adverse cardiovascular effects when administered to a
patient taking tricyclic antidepressants?

A. Dexmedetomidine

B. Ketamine

C. Etomidate

D. Desflurane

Answer: B

Rationale:
Tricyclic antidepressants block catecholamine reuptake. Increasing concentrations of
circulating catecholamines can lead to tachycardia and hypertension. Ketamine has
sympathomimetic effects and can potentiate the cardiovascular effects of tricyclic
antidepressants. Of the inhalational agents halothane should be avoided as it may result
in ventricular arrhythmias. There is no drug interaction causing cardiovascular effects
with any of the other agents.

Reference:
Wise-Faberowski L, Black S: Antidepressants. Atlee JL (ed) in Complications in
nd
Anesthesia 2 ed 2007 Elsevier pg 106-107

White PE, Romero G: Nonopioid intravenous anesthesia. Barash PG, Cullen BF,
th
Stoelting RK (ed) in Clinical Anesthesia 5 edition 2006 Lippincott, Williams & Wilkins pg
344-346

Keyword: pharmacology of anesthetic agents, ketamine, tricylcic antidepressants

American Board of Oral and Maxillofacial Surgery 41

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following describes the effect of desflurane on the cardiovascular system?

A. Maintaining positive pressure ventilation with desflurane minimizes the potential for
cardiovascular collapse

B. Of the potent anesthetic agents, desflurane promotes an abnormal collateral blood flow
redistribution (coronary steal) that causes myocardial ischemia

C. Airway pungency associated with desflurane causes a reflex tachycardia not seen with
sevoflurane

D. The concomitant administration of fentanyl with desflurane potentiates the sympatholytic

effect of fentanyl resulting in a decrease in heart rate

Answer: C

Rationale:
All potent inhalational agents have dose dependent effects on the cardiovascular system.
The mechanism actions are slightly different. The two new agents, sevoflurane and
desflurane, cause dose dependent depression of myocardial function; however, they are
known to maintain cardiac output. The myocardial depressant effects of sevoflurane and
desflurane are less than halothane and enflurane. All inhalational agents cause a
decrease in blood pressure. Sevoflurane and desflurane cause a decrease in blood
pressure as a result of a decrease in systemic vascular resistance. This contrasts with
halothane which causes a depression in myocardial contractility contributing to its
decrease in blood pressure.

In regards to heart rate, desflurane is associated with an increase in heart rate. At

anesthetic levels greater than 1 MAC, desflurane is associated with increases in heart
rate that are comparable to that of isoflurane. Increases in inspired concentrations of
desflurane have caused increases in heart rate. These changes in heart rate are
approximately 10 – 15 beats per minute. The increase in heart rate may be associated
with the pungency of the anesthetic agent and its effect on airway receptors.
Concomitant administration of opioids or clonidine blunts the increase in heart rate, but
does not cause a decrease in heart rate. Sevoflurane provides a relatively stable heart
rate without change.

All potent volatile anesthetics relax vascular smooth muscle which leads to vasodilation.
This potentially can result in abnormal distribution of blood flow to the coronary blood
vessels in patients with coronary artery disease. Concentrations of sevoflurane and
desflurane at 1.5 MAC were not associated with coronary steal. In one study,
sevoflurane, demonstrated a favorable increase in collateral coronary blood flow.

Maintaining spontaneous ventilation is thought to be cardioprotective because the

concentration of the agent that produces cardiovascular collapse exceeds the
concentration of the agent that produces apnea.

Reference:

American Board of Oral and Maxillofacial Surgery 42

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Ebert TJ. Inhalation anesthesia. Barash P, Cullen BF, Stoelting RK (ed) In Clinical
th
Anesthesia 5 ed. Lippincott, Williams, & Wilkins pages 401-405

Preckel B, Bolten J: Pharmacology of modern volatile anesthetics. Best Practice and

Research. Clinical Anaesthesiology. 19:331;2005

Keyword: pharmacology of anesthetic agent, anesthetic agents, inhalational agents,

desflurane, cardiovascular disease

American Board of Oral and Maxillofacial Surgery 43

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

What actions can optimize a mask induction with sevoflurane in the patient with a difficult
airway?

A. Priming the system with 1 MAC sevoflurane

B. Pretreatment with an opioid

C. Pretreatment with a benzodiazepine

D. Pretreatment with an antisialogogue

Answer: C

Rationale:
Mask induction with a potent inhalational agent has several advantages in the adult
patient with a difficult airway. The primary safety benefit is the ability to maintain
spontaneous ventilation and for the patient through the spontaneous ventilations to
regulate their own anesthetic depth. Mask induction is achieved with sevoflurane which is
non-irritating to the airway. There are several different techniques in which to achieve a
mask induction with sevoflurane. The single breath technique requires that the anesthetic
circuit is primed with 8% sevoflurane. The patient takes a maximal exhalation and then
takes a maximal inspiration and holds their breath. Once anesthetic depth is achieved the
patient will resume spontaneous ventilation. Alternatively, the patient can breathe
incrementally increasing doses of sevoflurane until appropriate anesthetic depth is
achieved. With 8% sevoflurane induction is frequently achieved within 1 minute. Stage 2
anesthesia and its unwanted side effects are avoided with this agent and the need for an
antisialogogue is not indicated. Pretreatment with a benzodiazepine will potentiate the
anesthetic effects of the sevoflurane and may facilitate mask induction. The
benzodiazepine will not contribute to apnea, as is likely with the pretreatment with an
opioid, which can contribute to apnea and would negate the safety of this technique.

Reference:
Ebert TJ. Inhalation anesthesia. In Clinical Anesthesia ed Barash P, Cullen BF, Stoelting
th
RK 5 ed. Lippincott, Williams, & Wilkins pages 415-416

Ho KY. Chua WL. Lim SS. Ng AS. A comparison between single- and double-breath vital
capacity inhalation induction with 8% sevoflurane in children. Paediatric Anaesthesia.
14(6):457-61, 2004

Lerman J. Inhalation agents in pediatric anaesthesia - an update. Current Opinion in

Anaesthesiology. 20(3):221-6, 2007

Keyword: Anesthetic technique, , mask induction, sevoflurane

American Board of Oral and Maxillofacial Surgery 44

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Prior to administering general anesthesia to a 1 year-old born at 32 weeks, one should be

concerned with:

A. bronchopulmonary dysplasia.

B. intracranial hemorrhage.

C. oxygen-induced retinopathy.

D. Sudden Infant Death Syndrome.

Answer: A

Rationale:
BPD is a chronic pulmonary disorder that typically afflicts premature infants who required
increased concentrations of oxygen and mechanical ventilation at birth to treat respiratory
distress syndrome. This results in increased airway reactivity, decreased arterial
oxygenation due to ventilation-to-perfusion mismatch. Risk factors for retinopathy
include prematurity, need for mechanical ventilation and periods of oxygenation at partial
pressures greater than 80mm Hg, but the risk is negligible for supplemental oxygen
administration given after 44 weeks postconception. SIDS is the sudden death of an
infant under one year of age which remains unexplained after a thorough review and
investigation. Most cases occur within six months with the greatest number between 2-4
months. SIDS is unpredictable, occurs quickly, often associated with sleep and with no
signs of suffering. Risk of intracranial hemorrhage is increased in infants born less than
34 weeks usually occurs in the first week to ten days of life

Reference:
Stoelting & Miller Basics of Anesthesia Ch. 27, Pediatrics Text

Stasic AF. Perioperative implications of common respiratory problems. Seminars in

Pediatric Surgery. 13(3):174-80, 2004

Cote CJ. Zaslavsky A. Downes JJ. Kurth CD. Welborn LG. Warner LO. Malviya SV.
Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined
analysis. Anesthesiology. 82(4):809-22, 1995

Keyword: assessment of patient for anesthesia, pediatrics

American Board of Oral and Maxillofacial Surgery 45

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Administration of dry anesthetic gases and oxygen at room temperature via an anesthetic
breathing system that bypasses the nose may lead to:

A. Atelectasis

B. Alveolar-arterial shunting

C. Heat Loss

D. Hypertension

Answer: C

Rationale:
The most important reason to provide heated humidification during general anesthesia is
to decrease heat loss and associated decrease in body temperature. Normally, air
passing through the nose is warmed to body temperature and saturated with water vapor
before reaching the carina. Administration of dry anesthetic gases and oxygen at room
temperature via an anesthetic breathing system that bypasses the nose may lead to
cytologic damage of the respiratory epithelium, drying of secretions, and water and heat
loss from the patient. This is particularly important in infants and children who are
rendered poikilothermic with general anesthesia.

Reference:
Anesthesia Systems in Basics of Anesthesia 4th edition, (eds) Stoelting & Miller Churchill
Livingston, 2000 page 145

Dripps/Eckenhoff/Vandam. Introduction to Anesthesia Ch.5

Keyword: anesthetic technique, complications of anesthesia

American Board of Oral and Maxillofacial Surgery 46

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 63 year-old male with a past medical history of hypertension, coronary artery disease, and
gout has the following vital signs in the PACU. BP = 200/120, P = 84, RR = 18, T = 99.1, oxygen
saturation is 98%. What medication is most appropriate?

A. Labetalol 20 mg

B. Hydralazine 10 mg

C. Phentolamine 5 mg

D. Esmolol 30 mg

Answer: A

Rationale:
Several of the factors that could cause postoperative hypertensive urgency are unlikely in
this current situation, such as hypoxemia, pain, and bladder distension. Pre-existing
hypertension is the most likely etiology in this vignette, as it is present in more than 50%
of patients who develop hypertension in the PACU. In managing this individual both the
blood pressure and heart rate are elevated. The goal is to administer a medication that
will decrease both.

Labetalol is an alpha, and beta-1 blocker, and would be a good choice in terms reducing
blood pressure without untoward effects on the heart. It preferentially has greater
effects to effects by a ratio of approximately 4 to 1. Its onset occurs in 5 – 10 minutes.
Hydralazine causes direct arterial vasodilatation. Its onset is slow taking 10 – 20 minutes.
This slow onset may result in an excess administration of hydralazine. Hydralazine is an
appropriate agent when the goal is to decrease the blood pressure in an individual who is
hypertensive with a relative bradycardia. The decrease in blood pressure associated with
hydralazine may result in a compensatory increase in heart rate. Hydralazine, if
administered by itself is relatively contraindicated, except in younger patients, due to the
risk of creating myocardial ischemia.

Phentolamine antagonizes alpha-adrenergic receptors, which can cause reflex

tachycardia. This could adversely affect myocardial work and also lead to ischemia.
Esmolol is a -selective blocker. It has a short half life of approximately 9 minutes. The
drug is generally administered by infusion because of its short half life. When
administered in an oral surgery office as a bolus a rule of thumb is that an esmolol dose
of 10 – 20 mg pushed over 20 seconds will reduce the heart rate by 15 – 20 beats per
minute. However, in this patient, the hypertension is probably both cardiogenic (due to
tachycardia) and peripheral, so that the use of a 2 -1 selective blocker alone would not
be as appropriate as labetalol.

Reference:
Holm SW, Cunningham LL, Bensadoun E, Madsen MJ: Hyptertension: Classification,
pathophysiology, and management during outpatient sedation and local anesthesia. J
Oral Maxillofac Surg 2006, 64:111-121.
Stoelting RK, Miller RD: Basics of Anesthesia, Fourth Edition, 2000, Chapter 32 –
Postanesthesia Care Unit.

American Board of Oral and Maxillofacial Surgery 47

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Keyword: complications of anesthesia, cardiovascular disease, hypertension

American Board of Oral and Maxillofacial Surgery 48

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Dexmedetomidine (Precedex®) acts on which receptor?

A. -aminobutyric (GABA)

B. Mu-1

C. 2 adrenergic

D. 2 adrenergic

Answer: C

Rationale:
The sedative, analgesic, and antishivering properties of dexmedetomidine are produced
by stimulation of presynaptic 2 receptors, which decreases norepinephrine release from
presynaptic neurons. It also stimulates postsynaptic 2 receptors, which hyperpolarizes
neural membranes. The net effect is the attenuation of central nervous system
excitation, especially the area of the brain stem called the locus coeruleus.

GABA receptors are responsive to benzodiazepines and ethanol. Dexmedetomidine does

not bind to the Mu or any other opiod receptor.

Reference:
Bekker A, Sturaitis MK: Dexedetomidine for neurological surgery. Neurosurgery 2005
57:1-10

Gerlach AT, Dasta JF: Dexmedetomidine: An updated review. Ann Pharmacother 2007;
41, 245-252.

Stoelting RK, Miller RD: Basics of Anesthesia, Fourth Edition, 2000, Chapter 3 -
Autonomic Nervous System.

Keyword: pharmacology of anesthetic agents, Dexmedetomidine

American Board of Oral and Maxillofacial Surgery 49

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Question: Administration of which of the following drugs does not produce active metabolites?

A. Diazepam

B. Meperidine

C. Morphine

D. Lorazepam

Answer: D

Rationale:
Diazepam is metabolized into two pharmacologically active metabolites,
desmethyldiazepam and oxazepam; which leads to prolonged sedative effects.
Meperidine has an active metabolite, normeperidine which has half the potency of
meperidine and may have CNS side effects (CNS excitability – seizures). Normeperidine
is eliminated by the kidneys. It is more likely for active metabolites to accumulate when
the drug is administered orally. Morphine is metabolized by the kidney into two
metabolites. One is morphine-6-glucuronide, which is more potent than morphine itself.
Lorazepam (and oxazepam) undergoes extrahepatic conjugation and does not form
active metabolites.

Reference:
Fukami MC, Ganzberg SI. Pharmacology of Outpatient Anesthesia Medications. In:
Miloro M, Ghali GE, Larsen P, Waite P, editors. Peterson's Principles in Oral and
Maxillofacial Surgery. Hamilton: BC Decker Inc; 2004. p. 83-101.

Haas DA. Parenteral Sedation. In Fonseca RJ, Frost DE, Hersh EV, Levin LM. (eds):
Oral and Maxillofacial Surgery, Vol 1, 2000 WB Saunders, Philadelphia, p. 79-94.

Keyword: pharmacology of anesthetic agents, drug metabolism, benzodiazepine

American Board of Oral and Maxillofacial Surgery 50

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Your postoperative patient is in the recovery room and has been treated for nausea and
vomiting. Two hours after this treatment, the patient begins to experience torticollis and
blepahrospasm. Which of the following agents was most likely used to treat this patient’s
nausea and vomiting?

A. Prochlorperazine (Compazine)

B. Ondansetron (Zofran)

C. Dexamethasone (Decadron)

D. Scopolamine (Transderm – Scop)

Answer: A

Rationale:
Antiemetic agents are categorized according to their primary mechanism of action. The
drugs generally used for the management of nausea and vomiting are the antihistamines,
antimuscarinics, antidopaminergics, and the antitrytominergics.

Receptor blocking actions of commonly administered antimetic agents

Agent Dopamine Acetylcholine Histamine Serotonin
Antihistamine Diphenhydramine Promethazine Weak Weak Moderate Moderate
Strong Strong None None
Antimuscarinics Scopalamine Weak Strong Weak None
Antidopaminergics Prochlorperazine Metoclopramide Strong Moderate Weak None
Moderate Weak None Moderate
Antitryptaminergics Odansetron None None None Strong
Reference #1
Metoclopramide is also classified as a prokinetic agent and exerts peripheral cholinergic
activity that increases lower esophageal sphincter tone and hastens gastric emptying.

This patient is experiencing extrapyramidal symptoms as a result of an anti-emetic

medication. Of these medications, prochlorperazine, is the only one which can causes
the extrapyramidal effects, occurring due to its anti-dopaminergic effects. Treatment of
the extrapyramidal symptoms can be with either the antihistamine diphenhydramine
(Benadryl) or the anticholinergic benzatropine (Cogentin.)

Reference:
Yagiela JA: Review of antiemetic therapies. Oral and Maxillofacial Surgery Clinics
11:647-658;1999

th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pgs 1005-1008.

Fonseca RJ, Ed. Oral and Maxillofacial Surgery. WB Saunders, 2000, pg 90-92.

rd
Faust RJ. Anesthesiology review, 3 edition, Churchill Livingstone, 2002, pg 167-168.

American Board of Oral and Maxillofacial Surgery 51

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Keyword: complications of anesthesia, pharmacology of anesthetic agents, antiemetics

American Board of Oral and Maxillofacial Surgery 52

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In which of the following situations should the use of flumazenil be avoided?

A. Diazepam overdose

B. Pre-existing ischemic heart disease

C. Head injury

D. Concomitant opioid/benzodiazepine use

Answer: C

Rationale:
Flumazenil can increase intracranial pressure, and its use in head injury patients should
be avoided. Flumazenil is useful therapeutically as well as diagnostically in drug
overdose. If the overdose included benzodiazepines, flumazenil would at least reverse
the effects of the benzodiazepine. Flumazenil use does not result in significant
cardiovascular or hemodynamic effects in healthy patients or in those with ischemic heart
disease.

Use of opioids is not a contraindication to the use of flumazenil to reverse a

benzodiazepine. However, if sedation is primarily due to the opioid, flumazenil will not
reverse it.

Reference:

th
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology, 4 edition. Lange Medical
Books, 2006, pg 286.

th
Stoelting RK, Miller RD. Basics of Anesthesia, 4 edition. Churchill Livingstone, 2000,
pg 343.

Keyword: complications of anesthesia, flumazenil

American Board of Oral and Maxillofacial Surgery 53

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following antihypertensive medications should be held preoperatively?

A. Atenolol (β-1 selective blocker)

B. Clonidine (alpha-2 adrenergic agonist)

C. Lisinopril (ACE inhibitor)

D. Minoxidil (vasodilator)

Answer: C

Rationale:
While there is no universal agreement, many believe that ACE inhibitors and angiotensin
receptor antagonists should be held the day of surgery. Peri-induction hypotension can
result from the loss of sympathetic tone associated with anesthesia induction
superimposed upon renin-angiotensin system (RAS) blockade. The vasopressin system
is the only intact system left to maintain BP, and vasopressin release is not a fast-
response system compared to the sympathetic nervous system. The usual pressors
used intraoperatively (ephedrine and phenylephrine) might be insufficient with RAS
blockade as well as sympathetic tone loss associated with anesthesia induction. In
general, however, antihypertensives should be maintained until the time of surgery and
restarted as soon as possible postoperatively. Less intraoperative lability of blood
pressure occurs in a well controlled hypertensive patient. Acute withdrawal of
antihypertensives may precipitate rebound hypertension or myocardial ischemia. Beta
blockers and alpha 2 agonists are especially associated with rebound hypertension
(atenolol, clonidine). If depletion of intravascular volume is a concern, diuretics may be
withheld preoperatively.

Reference:
rd
Duke, James, ANESTHESIA SECRETS, 3 edition, 2006, pp 198, 201.

Behnia R. Molteni A. Igic R. Angiotensin-converting enzyme inhibitors: mechanisms of

action and implications in anesthesia practice. Current Pharmaceutical Design. 9(9):763-
76, 2003

Keyword: anesthetic technique, pharmacology of anesthetic agents, hypertension,

antihypertensive medications

American Board of Oral and Maxillofacial Surgery 54

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Why are pediatric patients more susceptible to airway compromise when they are supinely
positioned?

A. The rostrally positioned epiglottis will narrow the airway when patient supine.

B. Diaphragmatic breathing is compromised with supination.

C. Relatively vertical rib position decreases ventilatory efficiency.

D. Airway compliance increases in the supine position.

Answer: B

Rationale:
Positioning a patient supinely results in less effective thoracic expansion and a greater
dependence on diaphragmatic breathing. The pediatric patient is more dependent on
diaphragmatic breathing because of the relatively horizontally angled ribs and the less
developed accessory muscles. The tongue is positioned higher in the oral cavity
impinging on the soft palate secondary to the rostrally positioned larynx. Supine
positioning may compromise the airway secondary to tongue, and not epiglottal
obstruction. The pediatric airway is more compliant than the adult. Increased compliance
makes the airway susceptible to collapse secondary to increased negative inspiratory
pressure. This may occur when the child, in an attempt to compensate for the tongue
obstruction, increases respiratory effort. However, airway compliance itself does not vary
with position of the patient.

Reference:
Perioperative Considerations in the Management of Pediatric Surgical Patients. In
OMFS Clinics of North America, Vol 18, Number 1, February 2006, pp. 36-37

Bennett, Dembo, Butterfield: Pediatric Sedation. Miloro (ed) in Peterson's Principles of

nd
Oral and Maxillofacial Surgery 2 edition 2004 pg103-130

Keyword: airway management, assessment of patient for anesthesia, pediatric airway,

pediatric sedation

American Board of Oral and Maxillofacial Surgery 55

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is the least likely to unmask the negative inotropic effects of ketamine?

A. Uncompensated shock

B. Chronic -blocker therapy

C. Cocaine use

D. Excessive volume resuscitation

Answerr: D

Rationale:
Ketamine is a phencyclidine derivative used for anesthesia. It stimulates the sympathetic
nervous system centrally. This results in increased plasma levels of epinephrine and
norepinephrine. This results in an approximate 30% increase in blood pressure and heart
rate. The onset of these effects occurs within 3 to 5 minutes of the drugs intravenous
administration and persist for approximately 20 minutes. Prior administration of
benzodiazepines can blunt the cardiovascular stimulant effects associated with ketamine.

Ketamine has direct negative inotropic effects. These negative inotropic effects are
usually overshadowed by the sympathetic stimulation. The negative inotropic effects may
be unmasked with depletion of endogenous catecholamine stores (cocaine use, chronic
-blocker therapy) or when the sympathetic compensatory mechanism is overwhelmed
as occurs when patients are in shock or are critically ill.

Reference:
Stoelting RK: Nonbarbiturate induction drugs. Stoelting RK (ed). In Pharmacology and
Physiology in Anesthetic Practice. Lippincott-Raven 1999 pages 148-155

Reich DL, Silvay G: Ketamine: An update on the first 25 years of clinical experience. Can
J Anaesth 36:186-197;1989

nd
Thannikary L, Naik B: Ketamine. Atlee JL (ed) in Complications in Anesthesia 2 ed
2007 Elsevier pages 78-79

Keyword: pharmacology of anesthetic agent, ketamine

American Board of Oral and Maxillofacial Surgery 56

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In regards to beta-blocker therapy to prevent ischemic injury in a surgical patient with stable
coronary artery disease, which of the following statements is correct?

A. All of the beta blocker agents have similar ischemic risk reduction.

B. Dosage is adjusted to a resting rate of 50 to 60 beats per minute.

C. Effects on the heart rate and inflammatory response occur rapidly.

D. Common side effects include pulmonary edema and bronchospasm.

Answer: B

Rationale:
Patients undergoing major noncardiac surgery are at increased risk of perioperative
myocardial ischemia, nonfatal myocardial infarct, and cardiac mortality as a result of
underlying coronary artery disease. Various approaches for the prevention of
devastating cardiac complications are used including the restoration of the supply-
demand mismatch with drug therapy (beta-blockers and nitrates).

Beta-blockers exert their cardioprotective effects by multiple mechanisms including: 1.

Reduction in myocardial demand via reduction in heart rate and contractility,
Improvement in energy efficency and outcome, 3. Antiarrhythmic effect, 4. Anti-
inflammatory effect, 5. Antirenin and antiangiotensin properties.
The effects on heart rate, contractility and energy substrate shift from fatty acids to
glucose occur quickly. The anti-inflammatory response become evident only after weeks
of treatment.

There is no advantage in regards to cardiac risk reduction to any particular beta- blocker,
as long as it is a beta-1 selective agent. There is no optimal period to begin beta-
blockers preoperatively, although there may be benefit to begin therapy 30 days before
surgery to get all the pleiotropic effects. Dosage adjustments to gain a resting heart rate
of 50 to 60 beats per minute are important. The drug therapy should not be interrupted
during the perioperative period, in order to avoid rebound tachycardia and hypertension.
Side effects of beta-blocker therapy most commonly reported are dyspnea and
intermittent claudication. These problems are infrequently seen in patients using beta-1
selective agents. Pulmonary edema and bronchospasm are uncommon complications
with beta-1 blocker therapy.
Preoperative assessment using American College of Cardiology/American Heart
Association guidelines for the perioperative cardiovascular of patients scheduled for
noncardiac surgery is indicated in patients with suspected or documented coronary artery
disease who are scheduled to have intermediate or high risk surgery.

Reference:
Fleisher LA, Beckman JA, et al: ACC/AHA 2006 Guideline Update on Perioperatve
Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative
Beta Blocker Therapy. J Am. Coll. Cardiol. 47:2343-2355,2006

American Board of Oral and Maxillofacial Surgery 57

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Schouten O, Shaw LJ, et al. A meta-analysis of the effectiveness of beta-blocker use in

different types of noncardiac surgery. Coron Art Dis 2006

Keyword: pharmacology of anesthetic agent; anesthetic technique, beta blockers

American Board of Oral and Maxillofacial Surgery 58

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 50 year-old male presents for full mouth tooth extraction, and reduction of his mandibular tori.
The patient denies any medical problems and review of symptoms is unremarkable. Upon
physical examination, a loud, high pitch, blowing, pansystolic murmur best heard in the cardiac
apex region is detected. The sound radiates into the left axilla, which does not increase with
inspiration. In addition, the patient’s EKG shows atrial fibrillation and left ventricular
hypertrophy. Which of the following principles in perioperative management of this individual
should be followed?

A. Faster heart rate and increase preload

B. Faster heart rate and maintain preload

C. Slower heart rate and increase preload

D. Slower heart rate and maintain preload

Answer: B

Rationale:
Auscultation of the heart is important in the preoperative anesthesia workup. The
mitral valve sounds and murmurs are usually best heard around the cardiac apex.
Systolic murmurs occur between S1 and S2 heart sounds. A pansystolic murmur
starts with first heart sound and ends with the second heart sound. These murmurs
are seen with back flow across the atrioventricular valves. Blood flows from a high
pressure chamber to a low pressure chamber usually through a valve that should be
closed. The location of maximum intensity is where the murmur originates. The
radiation of the sound is determined by the blood flow and intensity of the murmur.
Murmurs that originate in the right side of the heart tend to change with respirations.
This patient has mitral regurgitation (MR). In patients with chronic MR there is a slow
onset. Patients appear normal or mildly dyspneic and have a wide pulse pressure.
EKG findings may include atrial fibrillation and left ventricular hypertrophy.

American Board of Oral and Maxillofacial Surgery 59

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In chronic MR, the left ventricle propels a portion of its volume into the left atrium
resulting in reduced ventricular size and stroke volume. The normal ejection fraction
is maintained through reduced afterload. Initial compensatory response is increased
contractility which increases ventricular emptying. Ventricular eccentric hypertrophy
and dilation occurs early. Ventricular compliance increases so there is little change in
end diastolic pressure. There is minimal change in the left arterial pressure, which
helps protect the pulmonary vascular bed. This is due to left atrial distension, which
allows accommodation of the regurgitant volume. As the severity of the MR
progresses, there is decreased ability to compensate for forward blood flow through
contraction and compliance. The amount of ventricular dysfunction may not be
apparent in optimal conditions (i.e. maximium preload and minimal afterload). Right
sided heart failure and pulmonary vascular congestion is seen when the left atrium is
unable to distend further. Congestive heart failure usually develops once the
regurgitant fraction exceeds 60%. In MR patients with atrial fibrillation secondary to
atrial dilation, there is a reduced left ventricular end diastolic volume and decrease in
forward blood flow. Atrial fibrillation may exacerbate pulmonary congestion. During
anesthesia for patients with chronic MR, maintenance of preload is important and is
already maximized. Increasing afterload causes increase in regurgitant flow. There is
no indication for vasodilation therapy in patients with asymptomatic MR regurgitation
and preserved left ventricular function. Increased heart rate is beneficial by
decreasing ventricular volume.

Reference:
Izrailtyan I, Mathew JP. Perioperative Management of Valvular Heart Disease,
Perioperative Medicine: Managing for Outcome, Newman MF, Fleisher LA, et al.
Sanders, 2008. pp 203-218

Garwood S, Lee DL,. Valvular Heart Disease.Foundations of Anesthesia: Basic and

Clinical Science, Hemmings HC, Hopkins PM. Mosby , 2000, pp 429-438

The Cardiovascular System in A Guide to Physical Evaluation and History Taking. Bates
B., J.B. Lippincott, Philadelphia

Keyword: assessment of patient for anesthesia, anesthetic technique, heart murmurs

American Board of Oral and Maxillofacial Surgery 60

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The following capnogram was obtained during controlled mechanical ventilation through a
closed anesthesia breathing circuit. It is suggestive of an:

A. airway leak.

B. incompetent expiratory valve.

C. incompetent inspiratory valve.

D. equipment obstruction.

Answer: D

Rationale:
Capnography is a standard monitor used during general anesthesia, which provides
graphic representation of exhaled CO2 over time. Delivery of CO2 to the lungs parallels
pulmonary capillary blood flow and cardiac output. The most sensitive method to detect
ventilation of the lungs following tracheal intubation is by detection of exhaled CO2 by
capnography. Many patient and mechanical problems can be detected early by
examination of the morphology of the capnogram. Systematic evaluation is essential.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The shape of the capnogram can vary depending on the breathing system, respiratory
pattern and frequency, and mode of ventilation. The normal capnogram, in the healthy
patient under general anesthesia mechanically ventilated in a closed system, is
rectangular. There are four phases of the capnogram: 1. Inspiratory baseline, 2.
Expiratory upslope, 3. Expiratory Plateau, 4. Inspiratory downslope. The CO2
concentration during inspiratory baseline is zero in a closed circle circuit. If the
inspiratory baseline CO2 is greater than zero, this indicates rebreathing of CO2. In
pediatric anesthesia increased inspired CO2 is a common artifact due small tidal volume,
short inspiratory time, and high respiratory rates that exceed the capnograph's ability to
track the values back to zero. An incompetent expiratory valve causes an elevated
inspiratory baseline. The expiratory upslope in normal conditions is nearly vertical. If
obstruction occurs in the patient's airway, endotracheal tube or sampling site, upslope is
slanted. Expiratory plateau is nearly horizontal. In cases of expiratory airway or
mechanical obstruction, a steeper slope is present. Inspiratory downslope produces a
steep decline in the CO2 concentration. Incompetent inspiratory valve causes a
prolonged downslope. Airway leakage causes hypoventilation of patient resulting in
elevated CO2 concentrations (i.e. hypercapnea).

Reference:
Lobato EB, Gravenstein N,. Monitoring of Anesthesia Gases, Capnography, and Pulse
Oximetry. Foundations of Anesthesia: Basic and Clinical Science, Hemmings HC,
Hopkins PM. Mosby, 2000, pp. 153-160

Good ML. Capnography: uses, interpretations, and pitfalls. Barash PG, Deutsch S, Tinker
JH, eds. ASA refresher courses in anesthesiology, Vol. 18. Lippincott, Philadelphia, PA
1991, pp. 179-190

Keyword: airway management, anesthetic technique, capnography

American Board of Oral and Maxillofacial Surgery 62

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which agent is associated with post-operative ataxia, limb paresthesia, and memory loss that
develops over a few weeks after an anesthetic in the elderly patient?

A. Etomidate

B. Desflurane

C. Nitrous oxide

D. Dexmedetomidine

Answer: C

Rationale:
Nitrous oxide irreversibly oxidizes the cobalt ion in reduced vitamin B12. This inactivates
vitamin B12, which is essential for the function of methionine synthetase. Methionine
synthetase is necessary for the transmethylation of homocysteine to methionine.
Methionine is an essential amino acid and thus its deficiency results in impaired DNA
synthesis. Methionine synthetase is also important for methylation of myelin. The result of
impaired methylation includes paresthesias and ataxia. Psychological symptoms may
also develop manifested as depression and memory loss.

Most healthy patients have sufficient stores of vitamin B12 and have no adverse effect
from an anesthetic with nitrous oxide. However, elderly patients may have vitamin B12
deficiencies. Eleven percent of men between the ages of 65 to 74 have been reported to
have a vitamin B12 deficiency and 24% of men older than 75 years of age have been
found to have a vitamin B12 deficiency. The incidence was reported to be lower in
females with 9% and 17% found to have a vitamin B12 deficiency in these age group,
respectively. Other patients who may have a deficiency in vitamin B12 include alcoholics,
vegetarians and patients with impaired B12 absorption (pernicious anemia.)

Reference:
Clarke R, Refsum H, et al: Screening for vitamin B12 and folate deficiency in older
persons. Am J Cli Nutr 77:1241;2003

Ilnicky S, Jelencsik, et al: MR findings in subacute combined degeneration of the spinal

cord caused by nitrous oxide anaesthesia – two cases. Eur J Neurol 9:101;2002

nd
Praetel C: Nitrous Oxide: Neurotoxicity. in Complications in Anesthesia, 2 ed; (ed) Altee
JL Saunders/Elsevier 2007 pg 69-71

Keyword: pharmacology of anesthetic agents; complications of anesthesia, nitrous oxide

American Board of Oral and Maxillofacial Surgery 63

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following pertaining to muscle rigidity secondary to opioid administration is correct?

A. Hoarseness is a manifestation of muscle rigidity in the sedated patient

B. Concomitant administration of N2O decreases incidence and severity

C. Muscle rigidity is secondary to direct action on the muscle fibers

D. Concomitant administration of midazolam increases incidence

Answer: A

Rationale:
Opioids can produce muscle rigidity. The mechanism in which muscle rigidity occurs
does not involve a direct effect on the muscle fiber but is thought to involve the nucleus
pontis raphae. The prevention of muscle rigidity secondary to the administration of
muscle relaxants supports the lack of direct action on the muscle fibers. Administration of
benzodiazepines has been shown to prevent or attenuate the muscle rigidity.
Concomitant administration of nitrous oxide increases the incidence of muscle rigidity.
The clinical manifestations of opioid rigidity typically involves trunchal rigidity resulting in
the inability to ventilate a patient causing hypoxia and hypercarbia. Vocal cord closure is
a significant contributing factor in the inability to provide positive pressure ventilation. Mild
manifestations of muscle rigidity in the conscious patient may include hoarseness.

Reference:
Mirenda J, Tabatabai M, et al: Delayed and prolonged rigidity greater than 24 h following
high-dose fentanyl anesthesia. Anesthesiology 69:624;1989

Benthuysen J, Smith N, et al: Physiology of alfentanil-induced rigidity. Anesthesiology

64:440;1986

Keyword: complications of anesthesia, opioids, muscle rigidity

American Board of Oral and Maxillofacial Surgery 64

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following opioids is preferred in the renal failure patient?

A. Alfentanil

B. Fentanyl

C. Meperidine

D. Morphine

Answer: B

Rationale:
Morphine is metabolized to morphine-3 and morphine-6 water soluble glucoronides. M6G
levels can significantly increase in the patient with renal failure resulting in respiratory
failure. Meperidine is metabolized to normeperidine. Normeperidine is renally eliminated
and an increase in normeperidine results in CNS excitatory effects. Fentanyl congeners
are not significantly altered by renal failure. However, a decrease in plasma protein
binding may potentially alter the free fraction of the fentanyl class of opioids. Because of
a decrease in initial volume of distribution and an increased free fraction of drug in renal
failure, alfentanil is thought to produce increased clinical effect.

Reference:
Davies G, Kingswood C, et al: Pharmacokinetics of opioids in renal dysfunction. Clin
Pharmacokinet 31:410;1996

Chauvin M, Lebrault C, et al:Pharmacokinetics of alfentanil in chronic renal failure.

Anesth Analg 66:53;1987

Keyword: pharmacology of anesthetic agents, renal disease, opioids

American Board of Oral and Maxillofacial Surgery 65

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following drug interactions involving vasoconstrictors in local anesthesia is of

greatest concern?

A. Epinephrine and monoamine oxidase inhibitors

B. Levonordefrin and tricyclic antidepressants

C. Epinephrine and tricyclic antidepressants

D. Levonordefrin and selective serotonin reuptake inhibitors

Answer: B

Rationale:
Tricyclic antidepressants have been used for the management of depression, although
recently replaced by the newer selective serotonin reuptake inhibitors (SSRIs.) These
drugs are still used for such conditions as neuropathic pain, amongst other conditions.
The tricyclic antidepressants block the reuptake of biogenic amine neurotransmitters by
nerve terminals potentiating the action of the neurotransmitter. Adrenergic
neurotransmitters can likewise be potentiated by this action. Epinephrine is potentiated
approximately threefold in a patient taking tricylcic antidepressants. Levonordefrin is
potentiated approximately six to eight fold in a patient taking tricyclic antidepressants.
Therefore of the two vasoconstrictors in local anesthetic preparations levonordefrin has
greater potential adrenergic side effects in a patient taking tricylcic antidepressants.

Historically it was taught that epinephrine could not be administered to a patient taking a
monoamine oxidase inhibitor agent. However, most of exogenously administered
epinephrine is inactivated by catechol-O-methyltransferase (COMT). Levonordefrin
cannot be metabolized by MAO and the only route of biotransformation is COMT.

Reference:
Jastak JT, Yagiela JA, Donaldson D: Local Anesthesia of the Oral Cavity,
Saunders1995 Chapter 3

Yagiela JA. Adverse drug interactions in dental practice: interactions associated with
vasoconstrictors. JADA 130:701;1999

Key word: local anesthesia, levonordefrin, tricyclic antidepressants

American Board of Oral and Maxillofacial Surgery 66

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

What is the effect of an anesthetic agent on bispectral index (BIS) monitoring?

A. Nitrous oxide with i.v. anesthetic agents may produce a paradoxical BIS response.

B. The combination of an opioid and propofol will result in hypnosis at lower BIS value.

C. Decrease in the range activity with ketamine causes paradoxical response.

D. Analgesic concentrations of opioids produce moderate reduction in BIS value.

Answer: A

Rationale:
Bispectral index displays a numerical value that ranges from 0 to 100. BIS values of 100
represent an awake individual, 70 – moderate sedation, 40 to 60 – adequate hypnotic
effect for general anesthesia. The BIS index corresponds to several anesthetic agents,
such as propofol, methohexital, benzodiazepines, and potent inhalational agents (e.g.
sevoflurane). It is of limited value with low doses of opioids, ketamine and nitrous oxide.
Nitrous oxide and ketamine may have paradoxical responses. The paradoxical response
to ketamine is secondary to an increase in the beta range activity accompanied by a
reduction in the delta power. Low concentrations of opioids do not change the BIS
response during propofol infusions.

Reference:
Coste C, Guignard B, et al: Nitrous oxide prevents movement during orotracheal
intubation without affecting BIS value. Anesth Analg 91:130;2000

Guignard B, Menigaux C, et al: The effect of remifentanil on the bispectral index change
and hemodynamic response after orotracheal intubation. Anesth Analg 90:161;2000

Barr G, Jackson JG, Owall A, et al: Nitrous oxide does not alter bispectral index: study
with nitrous oxide as sole agent and as an adjunct to i.v. anaesthetics. Br. J Anaesth
1999;82:827

Rampil IJ, Kim JS, Lenhardt R, et al: Bispectral EEG index during nitrous oxide
administration. Anesthesiology 89:671;1998

lysakowski C, Dumont I, Pelligrini M, et al: effects of fentanyl, alfentanil, remifentanil, and

sufentanil on los of consciousness and bispectral index during propofol induction of
anesthesia. Br J Anaesth 86:627;2001

Dahaba A: Different conditions that could result in the bispectral index indicating an
incorrect hypnotic state. Anesth Analg 101:765:2005

Keyword: anesthetic technique, BIS monitoring

American Board of Oral and Maxillofacial Surgery 67

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

When considering a one stage versus two stage cleft palate repair, two primary considerations
include:

A. swallowing and sucking.

B. speech and swallowing.

C. speech and growth.

D. growth and swallowing.

Answer: C

Rationale:
Proponents of the one stage repair cite speech as the major concern and undertake
repair at ages 9-14 months in most cases. The one stage repair addresses the tissues
posterior to the incisive foramen in one operation. Two stage palate repair advocates are
more concerned with optimizing maxillary growth, and will consider obturating the hard
palatal cleft or leaving it open initially after a relatively early soft palate repair. This allows
more maxillary growth to occur and perhaps provides a better growth outcome according
to some studies. This is a controversial area and there is considerable literature that is
conflicting. What is universal is the constant balance between speech development and
growth potential when one considers the timing of palate repair. Proponents of the one
stage repair purport that speech outcomes are improved—at least in the short term.
Proponents of the two-stage repair claim similar long-term speech results with relatively
minor early problems with speech. Those who utilize the two-stage repair also claim
improved growth outcomes over the long term.

Reference:
Friede H. Maxillary growth controversies after two-stage palatal repair with delayed hard
palate closure in unilateral cleft lip and palate patients: perspectives from literature and
personal experience. Cleft Palate Craniofac J. 2007 Mar;44(2):129-36.

Van Lierde KM, Monstrey S, Bonte K, Van Cauwenberge P, Vinck B. The long-term
speech outcome in Flemish young adults after two different types of palatoplasty. Int J
Pediatr Otorhinolaryngol. 2004 Jul;68(7):865-75.

American Board of Oral and Maxillofacial Surgery 68

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In patients with velopharyngeal dysfunction requiring secondary surgery for speech, prospective
studies have shown which of the following procedures can be performed effectively with
equivalent long term results?

A. Sphincter pharyngoplasty and superiorly based pharyngeal flap

B. Sphincter pharyngoplasty and pharyngeal wall implant

C. Superiorly based pharyngeal flap and inferiorly based pharyngeal flap

D. Sphincter pharyngoplasty and inferiorly based pharyngeal flap

Answer: A

Rationale:
In two relatively recent prospective randomized studies examining the efficacy of
sphincter pharyngoplasty and superiorly based pharyngeal flaps, the results were
equivalent after one year when each procedure was tailored to specific patient needs.
This may include utilizing the pharyngeal flap procedure for defects that are more central
when one looks at the pattern of closure of the velum versus those that have lateral gaps.
Patients with lateral gaps or port lateral wall motion may benefit more from
pharyngoplasty.

Reference:
Abyholm, F., et al., Pharyngeal flap and sphincterplasty for velopharyngeal insufficiency
have equaloutcome at 1 year postoperatively: results of a randomized trial. Cleft Palate
Craniofac J, 2005. 42(5): p. 501-11.

Ysunza, A., et al., Velopharyngeal surgery: a prospective randomized study of

pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg, 2002. 110(6): p.
1401-7.

American Board of Oral and Maxillofacial Surgery 69

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

For patients with clefts, which of the following is true regarding outcomes of maxillary distraction
osteogenesis versus traditional LeFort I osteotomy?

A. Velopharyngeal insufficiency is less common with distraction

B. Aesthetics are superior with conventional LeFort I osteotomy

C. Intra-operative complications increase with conventional LeFort I osteotomy

D. Stability is similar with conventional osteotomy or distraction

Answer: D

Rationale:
To date, there is little evidence that demonstrates the advantages of maxillary distraction
over LeFort I osteotomies for most patients. Decisions must be made based on
individual patient needs and desires as well as surgeon capabilities. This usually relates
to the maximal amount of advancement required. The normal “watershed” area of
stability is at about 10 millimeters of maxillary advancement. In some rare instances,
patients require much more than 10 millimeters of advancement and the distraction
technique may be better suited for these patients. Larger advancements are easier to
achieve in many instances utilizing the distraction technique. However, both speech and
stability are similar whether the surgeon utilizes traditional techniques or distraction
osteogenesis. In the majority of cases, patients can be managed without advancements
greater than 10 millimeters. Several recent studies have confirmed these concepts.

Reference:
Chanchareonsook N, Whitehill TL, Samman N. Speech outcome and velopharyngeal
function in cleft palate: comparison of Le Fort I maxillary osteotomy and distraction
osteogenesis--early results. Cleft Palate Craniofac J. 2007 Jan;44(1):23-32.

Cheung LK, Chua HD. A meta-analysis of cleft maxillary osteotomy and distraction
osteogenesis. Int J Oral Maxillofac Surg. 2006 Jan;35(1):14-24.

American Board of Oral and Maxillofacial Surgery 70

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following palate repair techniques aims to primarily lengthen the palate by the
transposition of random pattern musculo-mucosal flaps?

A. Wardill-Kilner pushback

B. von Langenbeck closure

C. Two-flap palatoplasty

D. Furlow palatoplasty

Answer: D

Rationale:
The Furlow palatoplasty is performed by transposing random pattern musculo-mucosal
flaps by means of a double opposing z-plasties. In theory, this technique “lengthens” the
palate. Practical data is lacking regarding the actual lengthening that occurs, but results
of this procedure are good. The other procedures listed are variations of a two-flap
palatoplasty in which a “straight-line” closure is performed with muscular reconstruction
of the velum.

Reference:
Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986
Dec;78(6):724-38.

Kirschner RE, Wang P, Jawad AF, Duran M, Cohen M, Solot C, Randall P, LaRossa D.
Cleft-palate repair by modified Furlow double-opposing Z-plasty: the Children's Hospital
of Philadelphia experience. Plast Reconstr Surg. 1999 Dec;104(7):1998-2010;
discussion 2011-4

American Board of Oral and Maxillofacial Surgery 71

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A mother in her third trimester who is found to be “large for dates” undergoes an ultrasound. A
large fetal cervical mass is noted along with significant polyhydramnios. In terms of a delivery
plan, your principle concern is:

A. airway management for the fetus at the time of delivery.

B. potential uterine metastasis from the lesion.

C. scheduling a cesarean delivery due to potential cephalopelvic disproportion.

D. rule out esophageal atresia as suggested by the polyhydramnios.

Answer: A

Rationale:
A large fetal cervical mass creates the potential for postnatal airway embarrassment.
Upper airway obstruction is further suggested by the polyhydramnios, which may be
caused by the inhibition of normal fetal swallowing of amniotic fluid due to pharyngeal
obstruction. This will be the most immediate concern for at the delivery of this child. The
most common cervical masses are teratomas and cystic hygromas neither of which
would metastasize. The perinatal team should plan develop a plan for airway
management of this child that may involve an ex utero intrapartum treatment (EXIT)
procedure. This multidisciplinary, highly coordinated intervention involves the planned
cesarean delivery of the fetus while the mother undergoes a deep general anesthetic with
the goal of maintaining uteroplacental bloodflow and thereby oxygenation of the fetus
while a definitive airway is established and secured. This may be accomplished with
direct laryngoscopy and endotracheal intubation or tracheostomy. If the mass is large
enough or situated in the lower anterior neck in such a manner so as to preclude an
orderly tracheotomy, then plans for a transition to extracorporeal membrane oxygenation
(ECMO) should be in place until a definitive airway can be established. The work up for
the polyhydramnios can take place postnatally though the cervical mass is the most likely
etiology. Other causes of polyhydraminos may include gastrointestinal obstruction or
lack of fetal swallowing due to CNS dysfunction

Reference:
Marwan A, Crumbleholme TM. The EXIT procedure: principles, pitfalls and progress.
Semin Pediatr Surg 2006. 15:107-115.

Ogamo M, Sugiyama T, Maeda Y, et al. The ex utero intrapartum treatment (EXIT)

procedure for giant fetal neck masses. Fetal Diagn Ther. 2005. 20:214-218.

American Board of Oral and Maxillofacial Surgery 72

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which muscle is the focus of intravelar veloplasty?

A. Salpingopharyngeus

B. Superior constrictor

C. Tensor veli palatini

D. Levator veli palatini

Answer: D

Rationale:
The levator veli palatini was the focus in Kriens intravelar veloplasty described in 1969.
This muscle is aberrantly oriented sagittally and inserted at the posterior edge of the hard
palate. During the operation, the muscle bundles are dissected free, re-oriented
transversely and sewn to each other. The tensor contributes little to palatal function and
instead exists as an aponeurosis in the soft palate proper. The salpingopharyngeus and
superior constrictor do not contribute any muscle fibers to the velum.

Reference:
Kriens OB. An anatomical approach to veloplasty. Plast Reconstr Surg 1969 43:29-41.
Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003 112(6):
1542-1548.

American Board of Oral and Maxillofacial Surgery 73

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Presurgical orthopedics in the initial management of an infant with a cleft lip and palate has
been shown to result in:

A. improved weight gain.

B. less growth restriction.

C. improved esthetic outcomes from lip and nose reconstruction.

D well approximated segments for surgical repair.

Answer: D

Rationale:
Presurgical orthopedics have long been used in the initial management of the cleft
deformity. Despite this history, evidence in support of their benefit remains lacking. The
Dutch cleft project has looked extensively at their role in comprehensive cleft care. They
have not been able to identify any benefit in terms of weight gain, nutritional status, and
facial appearance. Others have shown that active orthopedics combined with
gingivoperiosteoplasty may actually be deleterious in regards to midfacial growth and
development. In short, no convincing evidence warrants their use and some studies
have called for the abandonment of this procedure as it potentially wastes scare
healthcare resources and taxes the family unnecessarily.

Reference:
Berkowitz S, Mejia M, Bystrk A. A comparison of the effects of the Latham-Millard
procedure with those of a conservative treatment approach for dental occlusion and facial
esthetics in unilateral and bilateral complete cleft lip and palate: part I. Dental occlusion.
Plast Reconstr Surg 2004 113(1):1-18.

Prahl C, Prahl-Andersen B, van't Hof MA, Kuijpers-Jagtman AM. Infant orthopedics and
facial appearance: a randomized clinical trial (Dutcheft). Cleft Palate Craniofac J 2006
43(6): 659-664.

Prahl C, Kuijpers-Jagtman AM, Van't Hof MA, Prahl-Andersen B. Infant orthopedics in

UCLP: effect in feeding, weight, and length: a randomized clinical trial. Cleft Palate
Craniofac J 2005 42(2): 171-7.

American Board of Oral and Maxillofacial Surgery 74

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Velopharyngeal dysfunction characterized by an absolute tissue deficiency is best termed

velopharyngeal:

A. mislearning.

B. incompetence.

C. insufficiency.

D. hypoplasia.

Answer: C

Rationale:
The terminology describing velopharyngeal dysfunction has historically been imprecise
and inaccurate. A more precise definition of the varying etiologies has been described to
reflect the heterogeneity of etiologies that lead to the characteristic and stigmatizing
features of velopharyngeal dysfunction. Velopharyngeal insufficiency refers to a structural
defect that causes the velum to be too short to close against the posterior pharyngeal
wall. Incompetence describes a mechanism where the parts do not work properly such
that velopharyngeal movement is inadequate to achive closure independent of tissue
bulk. Mislearning refers to improper activation and coordination of the tissue of the
velopharynx to achieve closure. Hypoplasia is not a descriptor used in the differential
diagnosis of someone with velopharyngeal dysfunction.

Reference:
rd
Peterson-Falzone S, Hardin-Jones M, Karnell M. Cleft palate Speech. 3 ed. St Louis:
Mosby, 2000. 371pp.

Kummer AW. Cleft Palate and Craniofacial Anomalies. Effects on speech and resonance.
nd
2 ed. Clifton Park, NY: Thomson Delmar Learning. 2008. 678pp.

American Board of Oral and Maxillofacial Surgery 75

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A submucous cleft palate is classically defined by:

A. chronic otitis media with effusion.

B. bifid uvula.

C. embryologic primary palatal defect

D. hard palate fistula.

Answer: B

Rationale:
The submucus cleft was first described by Calnan in 1954 as a triad of a bifid uvula,
palatal muscle diastasis and a notched hard palate. The palatal muscle diastasis can be
visualized as a zona pellucida where the thin tissues at the midline of the velum appear
more translucent than the adjacent tissue. The palatal muscle cleft may result in middle
ear dysfunction but is not a requirement for diagnosis.

Reference:
Calnan J. Submucous cleft palate. Br J Plast Surg 1954; 6:264-282.
Edwards SP and Costello BJ. Submucous Cleft Palate. In Decision Making in Oral and
Maxillofacial Surgery. D Laskin and O Abubaker eds, Quintessance: Chicago 2007.
pp142-143.

American Board of Oral and Maxillofacial Surgery 76

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The primary rationale of staging a primary palatoplasty where the soft palate is repaired first and
the hard palate at a later date is to:

A. improve speech outcomes.

B. improve growth outcomes.

C. restore normal Eustachian tube function.

D. permit a primary gingivoperiosteoplasty.

Answer: B

Rationale:
Fiede H. Maxillary growth controversies after two-stage palatal repair with delayed hard
palate closure in unilateral cleft lip and palate patients:perspectives from the literature
and personal experience.

Reference:
Cleft Palate Craniofac J 2007 Mar; 44(2): 129-136.
Bardach J, Morris HL, Olin WH. Late results of primary veloplasty: the Marburg Project.

Plast Reconstr Surg 1984. 73(2): 207-218.

American Board of Oral and Maxillofacial Surgery 77

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The head of a child afflicted with a positional plagiocephaly assumes the following shape when
viewed from above:

A. trapezoid.

B. octagon.

C. parallelogram.

D. ovoid.

Answer: C

Rationale:
The underlying etiology of an aberrant head shape can usually be determined from
clinical exam though it should be confirmed radiographically. The head shape deformity
associated with a craniosynostosis is the result of a diseased suture. The dysmorphology
can be predicted from Virchow's law where compensatory head growth will occur parallel
to the diseased suture. Growth restriction will occur perpendicular to that suture.
Furthermore, the diseased suture will be ridged and palpable. The positional head
deformity results from external molding forces on a malleable head with normal, patent
sutures. These will not be ridged. As such, the head of an infant with a lambdoid
synostosis will be trapezoidal in shape with occipital flattening on the affected side with
the ipsilateral ear drawn back toward the diseased suture. The ipsilateral brow may also
be drawn posteriorly. The regional growth restriction results in a trapezoidal shape when
the infants head is viewed from above with the base on the non-affected side. The
postitional plagiocephaly by contrast will take the form of a parallelogram. Here, when the
infant's head is viewed from above, the side of the head with occipital flattening will have
the ipsilateal ear anteriorly displaced along with the brow.

Reference:
Posnick JC. Posterior Plagiocephgaly: Unilateral Lambdoid Synsostosis and Skull
Molding. In Craniofacial and Maxillofaical Surgery in Children and Young Adults. Ed.
Posnick JC. 2000. Philadelphia: Saunders. Pp.231-248.

Huang MH, Mouradian WE, Cohen SR and Gruss JS. The differential diagnosis of head
shapes: separating craniosynostosis from positional deformities and normal variants.
Cleft Palate Craniofac J. 1998, 35:204-11.

American Board of Oral and Maxillofacial Surgery 78

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

If a child with severe obstructive sleep apnea has velopharyngeal dysfunction and is not a
current candidate for surgical treatment of apnea, the best option for management of the
velopharyngeal dysfunction is a:

A. Furlow conversion palatoplasty.

B. superiorly based pharyngeal flap.

C. prosthetic obturator or lift appliance.

D. pharyngeal wall implant.

Answer: C

Rationale:
Patients with unstable airways are not good candidates for augmentative surgery for the
correction of VPD which carries a risk of exacerbating airway obstruction. Each of the
listed procedures carries the risk of exacerbating any existing airway obstruction except
the prosthetic approach which may be removed at night. Pharyngeal wall implants tend
to migrate and are not particularly effective over the long-term.

Reference:
Edwards SP and Costello BJ. Velopharyngeal Insufficiency. In Decision Making in Oral
and Maxillofacial Surgery. D Laskin and O Abubaker eds, Quintessance: Chicago 2007.
Pp 146-148.

Marsh JL. The evaluation and management of velopharyngeal dysfunction. Clin Plast
Surg 2004, 31:261-269.

American Board of Oral and Maxillofacial Surgery 79

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is a typical feature of cleidocranial dysplasia?

A. Sagittal craniosynostosis.

B. Absent zygoma.

C. Agenesis or hypoplastic mandibular condyles.

D. Multiple unerupted permanent teeth.

Answer: D

Rationale:
Cleidocranial dysplasia is a rare, autosomal dominant disorder associated with mutations
of the RUNX2 gene. Its features include disturbance of development of the cranial vault,
face, the clavicles and the pelvis. They typically have a short stature. Craniofacial
features include frontal, parietal and occipital bossing, delayed or incomplete ossification
of the metopic suture anterior fontanelle, hypertelorism, flat nasal bridge and midfacial
hypoplasia. Dental problems are the focus of much of their treatment. They present with
multiple retained primary teeth, delayed or failed eruption of permanent teeth and the
presence of multiple supernumary teeth the magnitude of which can be striking. The
clavicles are often absent or hypoplastic and may permit approximation of the shoulders
anteriorly.

Reference:
th
Syndromes of the Head and Neck. Gorlin RJ, Cohen MM Jr, and Hennekam CM. 4 ed.
New York: Oxford University Press. 2001. 1283pp.

Cleidocranial Dysplasia: 2 Generations of Management. J Can Dent Assoc 2006, 72:337-

342.

American Board of Oral and Maxillofacial Surgery 80

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is more commonly associated with a syndromic condition?

A. Unilateral cleft of the lip and alveolus

B. Isolated cleft palate

C. Unilateral cleft of the lip and palate

D. Bilateral cleft of the lip and palate

Answer: B

Rationale:
Isolated cleft palate is etiopathogenically different from cleft lip with or without cleft palate.
As many as 50% of infants born with an isolated cleft palate will have a syndromal
association whereas only 15% of those with clefts of the lip with or without a palate will
share such an association.

Reference:
th
Syndromes of the Head and Neck. Gorlin RJ, Cohen MM Jr, and Hennekam CM. 4 ed.
New York: Oxford University Press. 2001. 1283pp.

Carter CO, Evans K, Coffey R, et al. A family study of isolated cleft palate. J Med Genet
1982, 19:329-331.

American Board of Oral and Maxillofacial Surgery 81

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Parents of a 7 year-old male with an isolated cleft palate report that he is having difficulty in
school because he can not see the chalkboard. His ophthalmologic complaints should trigger
your concern for:

A. velocardiofacial syndrome.

B. Stickler syndrome.

C. Aarskog syndrome.

D. Van der Woude syndrome.

Answer: B

Rationale:
Isolated cleft palate is etiopathogenically different from cleft lip with or without cleft palate.
As many as 50% of infants born with an isolated cleft palate will have a syndromal
association. Stickler syndrome is one of the most common syndrome diagnoses in this
population and the most common diagnosis in the syndromic Robin sequence
populations. It is primarily an autosomal dominant disorder characterized by multiple
systemic anomalies, principally including articular, ophthalmologic and facial findings.
The ophthalmologic findings are varied but most commonly consist of congential high
grade hyopia and retinal detachment. The facies are characterized by a depressed nasal
bridge, midfacial hypoplasia, micrognathia and a cleft palate. Any child with a cleft palate
with visual complaints should be investigated for Stickler's syndrome. Velocardiofacial
syndrome (q22 deletion) typically presents with cleft palate, cardiac anomalies, and a
number of other features. Van der Woude syndrome classically exhibits clefting and
lower lip pits. Aarskog syndrome exhibits cleft lip and palate, short statue, hypertelorism,
widow's peak, and x-linked inheritance.

Reference:
th
Syndromes of the Head and Neck. Gorlin RJ, Cohen MM Jr, and Hennekam CM. 4 ed.
New York: Oxford University Press. 2001. 1283pp.

th
Smith's Recognizable Patterns of Human Malformation. Jones KL. 6 ed. Philadelphia:
Elsevier Saunders. 2006. 954pp.

American Board of Oral and Maxillofacial Surgery 82

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 4 month-old with facial asymmetry and leftward head tilt exhibits a left sternocleidomastoid
muscle mass, but normal vision and hearing. The patient is of normal height, weight, and
developmental milestones. The most likely diagnosis is:

A. cervical teratoma.

B. cystic hygroma.

C. congenital hemangioma.

D. congenital muscular torticollis.

Answer: D

Rationale:
This child is presenting with a left neck mass, ipsilateral head tilt and resultant facial
deformity. The condition is referred to as torticollis. Torticollis is etiologically diverse with
both muscular and nonmuscular causes. Nonmuscular torticollis etiologies can include
ocular abnormalities, cervical spine anomalies and a variety of neurologic conditions.
Muscular torticollis is divided into three groups. Type I congenital muscular torticollis, the
most common form, presents with a palpable, mobile mass within the substance of the
SCM. This mass, referred to as fibromatosis colli, generally regress during the first year
of life and can be diagnosed with an ultrasound. In Type II muscular torticollis, the
affected SCM is short and tight but no mass is present. Lastly, in type III or postural
torticollis, no mass nor tightness of the SCM is encountered. Nonmuscular causes are
less likely given that the child does not seem have any visual or auditory preferences, is
able track well in both directions and has no neurologic deficits. Teratomas,
hemangiomas and cystic hygromas, all neck masses seen in infants, would not typically
result in changes in head posture unless they were so large as to push the head away
from the lesion, as opposed to ipsilateral head tilt that is seen with CMT.

Reference:
Twee TD. Congenital muscular torticollis: current concepts and review of treatment. Curr
Opin in Pediatr 2006, 18:26-29.

Ballock RT and Song, KM. The prevalence of nonmuscular causes of torticollis in

children. J Pediatr Orthop 1996, 16:500-504.

American Board of Oral and Maxillofacial Surgery 83

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The most versatile orthognathic surgical procedure for positioning the mandible in a more
appropriate relationship to the maxilla is:

A. intra-oral vertical ramus osteotomy.

B. bilateral sagittal split osteotomy.

C. inverted “L” osteotomy.

D. anterior subapical mandibular osteotomy.

Answer: B

Rationale:
The bilateral sagittal split osteotomy is primary utilized to produce a three-dimensional
repositioning of the mandibular dental bearing segment such that a more appropriate
occlusion is achieved. While the other osteotomies listed can be utilized to perform some
movements effectively, none are as versatile as the sagittal split osteotomy; which can be
utilized in anterior, posterior, inferior, superior, and rotational movements.

Reference:
Epker BN. Modifications in the sagittal osteotomy of the mandible. J Oral Surg 35: 157-
159, 1977.

Bell WH, Proffit WR, White RP. Surgical correction of dentofacial deformities, vol 1,
Philadelphia, W.B. Saunders, 1980.

American Board of Oral and Maxillofacial Surgery 84

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is commonly utilized for treating obstructive sleep apnea in the normal
dentate adult?

A. Surgically assisted rapid palatal expansion with a LeFort I osteotomy

B. LeFort I osteotomy without mandibular advancement.

C. Vertical ramus osteotomy with rigid fixation

D. Mandibular symphysis osteotomy with genioglossus advancement

Answer: D

Rationale:
The mandibular symphysis osteotomy with genioglossus advancement is commonly
utilized to treat obstruction at the tongue base in patients with obstructive sleep apnea.
The procedure has been shown to be effective alone and in conjunction with
uvulopalatopharyngoplasty. Various methods have been described including box
osteotomies, modified genioplasties, and other geometric designs to achieve the same
basic advancement of the musculature associated with the genial tubercles; namely the
genioglossus muscle bellies. The SARPE does not improve airway dynamics and the
vertical ramus osteootomy with rigid fixation generally worsens them. The LeFort I
osteotomy is used in conjunction with the BSSO to improve airway dynamics and
maintain a stable occlusion, thus the LeFort I alone is not utilized.

Reference:
Miller FR, Watson D, Boseley M. The role of the Genial Bone Advancement Trephine
system in conjunction with uvulopalatopharyngoplasty in the multilevel management of
obstructive sleep apnea. Otolaryngol Head Neck Surg. 2004;130:73-79.

Hendler BH, Costello BJ, Silverstein K, Yen D, Goldberg A. A protocol for

uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibular advancement in
patients with obstructive sleep apnea: an analysis of 40 cases. J Oral Maxillofac Surg.
2001;59:892-899.

American Board of Oral and Maxillofacial Surgery 85

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The most effective surgical protocol for treating severe obstructive sleep apnea in the obese
patient is:

A. uvulopalatopharygnoplasty with tonsillectomy/adenoidectomy.

B. maxillomandibular advancement osteotomy.

C. segmental osteotomy of the anterior mandible with genioglossus advancement.

D. bilateral sagittal split osteotomies with distraction osteogenesis.

Answer: B

Rationale:
The most effective treatment in the published literature for treating obstructive sleep
apnea is maxillomandibular advancement(MMA) utilizing the Le Fort I osteotomy and
bilateral sagittal split osteotomies. Uvulopalatopharyngoplasty with or without
tonsillectomy/adenoidectomy has been shown to have an efficacy of only 5 to 50% in
patients with obstructive sleep apnea. MMA has been shown to be 80 to 99 % effective
in treating obstructive sleep apnea, even in populations that fail other therapies. MMA
has been postulated to increase the pharyngeal dimensions along multiple sites including
the retropalatal and retrolingual areas. Even small increases in pharyngeal diameter can,
in accordance with the Bernoulli principle, decrease airway resistance in direct relation to
the cube of the increased airway diameter. However, the success rates drop markedly
when the patient is obese. MMA has a greater chance of being effective in the obese
population when compared with other therapies such as UPPP/genioglossus
advancement which fail frequently in the morbidly obese patient.

Reference:
Riley RW, Powell NB, Li KK, Troell RJ, Guilleminault C. Surgery and obstructive sleep
apnea: long-term clinical outcomes. Otolaryngol Head Neck Surg 2000;122:415–21

Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the
upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19(2):156–77

American Board of Oral and Maxillofacial Surgery 86

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Segmental osteotomies of the maxilla at the Le Fort I level are commonly utilized to treat which
of the following discrepancies:

A. a V-shaped maxilla.

B. multiple teeth blocked out of the arch with transverse discrepancy.

C. multiple planes of occlusion of the maxilla with anterior open bite.

D. transverse discrepancy that is more severe in the anterior than posterior.

Answer: C

Rationale:
The segmental osteotomies of the maxilla are commonly utilized to address mild to
moderate posterior transverse discrepancies, multiple planes of occlusion with or without
open bites, or asymmetry of the arch. The surgically assisted rapid palatal expansion is
commonly utilized to treat a v-shaped maxilla, teeth blocked out of the arch, and
transverse discrepancies that are more severe in the anterior than posterior.

Reference:
Turvey TA. Maxillary expansion: a surgical technique based on surgical-orthodontic
treatment objectives and anatomic considerations. J Maxillofac Surg 13:51-58, 1985.

Bell WH. Turvey TA. Surgical correction of posterior crossbite. J Oral Surg 32: 811-822,
1974.

American Board of Oral and Maxillofacial Surgery 87

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following maxillary orthognathic procedures is the most stable over the long-term?

A. Inferior repositioning with bone grafting

B. Superior repositioning

C. Advancement

D. Widening in the transverse plane

Answer: B

Rationale:
Profitt et. al. studied the stability of orthognathic procedures in a number of patients over
many years in their classic studies at UNC-Chapel Hill. The hierarchy of stability that
became clear from this data set indicates that maxillary superior repositioning is the most
stable procedure of this group. The other procedures, which involve considerably more
soft tissue stretching, have significantly less stability over the long-term and have a
tendency to relapse in a greater percentage of patients.

Reference:
Proffitt WR, Turvey TA, Phillips C. Orthognathic surgery: a hierarchy of stability. Int J
Adult Orthod Orthogn Surg 11: 191-204, 1996.

Proffit Wr, Phillips C, turvey TA. Stability following superior repositioning of the maxilla
by Le Fort I osteotomy. Am J Orthod Dentofac Orthop 92: 151-161, 1987.

American Board of Oral and Maxillofacial Surgery 88

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Severe bleeding associated with the Le Fort I osteotomy is most commonly associated with
which of the following vessels?

A. Maxillary artery

B. Ascending palatine artery

C. Infra-orbtial artery

D. Retromandibular vein

Answer: A

Rationale:
The maxillary artery is in close proximity to the posterior osteotomy site of the Le Fort I,
II,and III osteotomies, and as such is in danger of injury during the procedure.
Procedures to address the bleeding include interventional radiology techniques for
embolization, surgical control at the local site, or proximal control at the external carotid
prior to the maxillary branching point. Significant collateralization may be present
necessitating a more distal surgical control of the bleeding.

Reference:
Turvey TA and Fonseca RJ. The anatomy of the internal maxillary artery in the
pterygopalatine fossa: its relationship to maxillary surgery. J Oral Surg 38: 92-95, 1980.

Lanigan DT, Hey JH, West RA. Major vascular complications of orthognathic surgery. J
Oral Maxillofac Surg 49: 571-577, 1991.

American Board of Oral and Maxillofacial Surgery 89

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is the most stable orthognathic mandibular procedure over the long-term
when rigid fixation is utilized?

A. Bilateral sagittal split osteotomies with advancement

B. Bilateral sagittal split osteotomies with closure of open bite

C. Bilateral sagittal split osteotomies with setback

D Intra-oral vertical ramus osteotomies with setback

Answer: A

Rationale:
The bilateral sagittal split osteotomy with advancement utilizing rigid internal fixation has
been shown to be superior in stability to other movements or to other methods of
repositioning the mandible. Advancement of the mandible is generally very stable up to
approximately 7 to 10 millimeters. Advancement beyond 10 millimeters is associated
with a higher chance of relapse—approximately 1 millimeter or more. Closure of an
anterior open bite is considered less stable and prone to relapse, but this has been
performed with success and reported in a case series fashion. While reported in the
literature, the published reports are short term studies with stability data that does not
approach the significance of the data collected by Profitt et al. The mandibular setback is
fairly stable as well, but has a higher relapse potential when compared with BSSO with
advancement. The same is true of the IVRO with setback.

Reference:
Proffitt WR, Turvey TA, Phillips C. Orthognathic surgery: a hierarchy of stability. Int J
Adult Orthod Orthogn Surg 11: 191-204, 1996.

Bacetti T et. Al. Skeletal effects of early treatment of Class III malocclusion. Am J
Orthod Dentofac orthop 113: 333-343, 1998.

American Board of Oral and Maxillofacial Surgery 90

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Of the following, which is the most stable form of fixation for bilateral sagittal split osteotomies
with advancement?

A. Three superior border bicortical titanium alloy screws

B. Three superior border bicortical resorbable screws

C. One superior border wire and two bicortical inferior border screws

D. Three inferior border bicortical titanium alloy screws

Answer: A

Rationale:
It has been shown in a number of studies on rigid internal fixation that three-superior
border screws placed in a bicortical fashion is superior to other forms of fixation. In
general, resorbable fixation has not been shown to be more stable when compared with
titanium screws. When possible it is suggested that surgeons spread the dimensions of
screw placement over greater distance when possible as this may increase stability.

Reference:
Retzik M, Schoorl W. Bone repair in the mandible: a histologic and biometric
comparison between rigid and semirigid fixation. J Oral Maxillofac Surg 41: 215-218.
1983

Timmis DP, Aragon SB, Van Sickles JE. Masticatory dysfunction with rigid and nonrigid
osteosynthesis of sagittal split osteotomies. OOO 62: 119-123. 1986

American Board of Oral and Maxillofacial Surgery 91

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following has been shown to exacerbate obstructive sleep apnea?

A. Rapid weight loss

B. Increased caffeine intake

C. Mandible advancement appliances

D. Prescription sleep aids

Answer: D

Rationale:
All of the treatments have been shown to be effective at treating obstructive sleep apnea
with the notable exception of sleep aid medications. These typically exacerbate sleep
apnea by relaxing the tone of the pharyngeal walls and worsening obstruction. This is
similar to the effect of alcohol on patients with OSA. Most OSA patients are encouraged
to stop all sleep aid medications, alcohol, or other substances that may alter the normal
sleep cycle.

Reference:
Dement WC. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep
th
Medicine. 4 ed. Philadelphia, Pa: Elsevier; 2005:1-12

Schwab RJ, Goldberg AN, Pack AI. Sleep apnea syndromes. In: Fishman AP,
rd
ed. Fishman's Pulmonary Diseases and Disorders. Vol 2. 3 ed. New York,
NY: McGraw-Hill; 1999:1617-37.

American Board of Oral and Maxillofacial Surgery 92

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In order to accurately reposition both the maxilla and mandible with bimaxillary surgery, which of
the following is required?

A. A vertical reference during surgery

B. Mandibular repositioning first

C. A computer simulation of the facial profile

D. Maxillary repositioning first

Answer: A

Rationale:
Double jaw surgery may begin with either mandibular repositioning or maxillary
repositioning if the model surgery is planned with this in mind. This is generally a
preference of the operating surgeon and much has been written about the benefits of
each version. In some instances when a repeatable mandibular position is not possible,
such as type III hemifacial microsomia, then mandibular surgery is performed first out of
necessity—there is no predictable condylar position on the affected side. An
intermediate splint is necessary to correlate the position of the first jaw movement with
the model surgery. The second jaw movement is performed by finalizing the occlusion.
A facebow transfer is utilized to transfer the relationship of the cranial base and the jaws
to the articulator for model surgery. A vertical reference is important to ensure proper
positioning of the maxilla and its relationship to the planned vertical position of the smile
and tooth to lip at rest although this may be internal or external. Recent literature has
shown that internal references are potentially much less accurate than external
references. Computer simulations of the outcome have limited value and are not
necessary to accurately position the segments. They can be helpful in judging final
aesthetics to some extent.

Reference:
McCance, A. M., Moss, J. P. and James, D. R. (1992) Le Fort I maxillary osteotomy: Is it
possible to accurately produce planned pre-operative movements? British Journal of Oral
and Maxillofacial Surgery, 30, 369–376.

Cotterel, D. A. and Wolford, L. M. (1994) Altered orthognathic surgical sequencing and a

modified approach to model surgery, Journal of Oral and Maxillofacial Surgery, 52, 1010–
1020.

American Board of Oral and Maxillofacial Surgery 93

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

When a cleft is associated with a syndrome, the most common inheritance pattern is:

A. sex-linked.

B. autosomal dominant.

C. autosomal recessive.

D. trisomy.

Answer: B

Rationale:
The most common syndromes associated with clefting are Stickler syndrome,
velocardiofacial syndrome, and van der Woude syndrome. All of these are autosomal
dominant disorders in which the gene is transferred to the progeny 50% of the time.
Autosomal recessive disorders require that both parents have the gene for the disorder
and transfer it to the child. Probability dictates that this is a rare occurrence. Trisomy
does occur in patients with clefts, but occurs more rarely that those with autosomal
dominant disorders.

Reference:
Rollnick BR, Kaye CI. Mendelian inheritance of isolated nonsyndromic cleft palate. Am J
Med Genet. 1986 Jul;24(3):465–473.

Jenkins M, Stady C. Dominant inheritance of cleft of the soft palate. Hum Genet.
1980;53(3):341–342.

American Board of Oral and Maxillofacial Surgery 94

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The posterior-anterior cephalometric radiograph is helpful in determining the:

A. amount of anterior-posterior discrepancy between the maxilla and mandible.

B. amount of vertical hyperplasia present in the maxilla and mandible.

C. amount of transverse discrepancy between the maxilla and mandible.

D. ideal vertical position of the anterior maxilla.

Answer: C

Rationale:
The ideal vertical position of the maxilla is most often determined with clinical tooth to lip
measurements in conjunction with cephalometric values seen on the lateral
cephalometric analysis. The posterior-anterior (PA) cephalometric radiograph can be
utilized to analyize the position of the maxilla and/ or mandible as it relates to the cranial
base, orbits, and skeletal/dental midlines. The PA view can also offer an assessment of
occlusal cant. However, its main utility in this scenario is that PA cephalometric analyses
can be utilized to measure the relative difference of maxillary and mandibular width to
judge the degree of transverse discrepancy.

Reference:
Braun S, Bottrel JA, Lee KG, et al. The biomechanics of rapid maxillary sutural
expansion American Journal of Orthodontics and Dentofacial orthopedics 118: 257-261,
2000.

Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. Diagnosis and
treatment of transverse maxillary deficiency. Int J of Adult Orthod Orthognathic Surg
120: 75-96, 1995

American Board of Oral and Maxillofacial Surgery 95

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following cephalometric values would most likely be seen in a in a mature
Caucasian male with maxillary hypoplasia and a Class III malocclusion?

A. SNA = 82 degrees

B. SNB = 80 degrees

C. Nasion Perpendicular to A point = -6

D. Nasion perpendicular to A point = +6

Answer: C

Rationale:
A normal SNA value is 82 and indicates normal maxillary position. SNB is a measure of
mandibular position and is also normal at 80 degrees. Nasion perpendicular is another
measure of facial projection. Nasion perpendicular to A point is normal at -3 to -5 mm for
many patients, and over-projected at +6. When A point is 6 mm behind a line drawn from
nasion perpendicular and thru Frankfort horizontal indicates maxillary hypoplasia.

Reference:
Anthanasiou AE: Orthodontic cephalometry, Chicago, 1995, Mosby.

Proffit WR and Ackerman JL. Orthodontic diagnosis: the development of a problem list.
In Profitt WR: Contemporary orthodontics, ed 3, St. Louis, 2000, Mosby.

American Board of Oral and Maxillofacial Surgery 96

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The blood supply to the maxilla in a LeFort I osteotomy depends primarily upon which arteries?

A. Anterior and posterior ethmoidal

B. Descending palatine and nasopalatine

C. Ascending palatine and ascending pharyngeal

D. Infraorbital and maxillary

Answer: C

Rationale:
The blood supply for the Le Fort I osteotomy is derived primary from the ascending
pharyngeal vasculature, posterior palatal vasculature, and the lateral pedicles of soft
tissue that remain attached after the vestibular incision is made. Compromise of the
lateral segments of tissue may risk the vascular supply to the segment(s). Except the
maxillary artery, the arterial blood supplies listed in A, B, and D are often transected at
their distal supply points during the initial incision and osteotomy.

Reference:
Bell WH. Biologic basis for maxillary osteotomies. Am J Phys Anthropol 38: 279-289.
1973.

Bell WH et. al. Bone healing and revascularization after total maxillary osteotomy. J Oral
Surg 33: 253-260, 1975.

American Board of Oral and Maxillofacial Surgery 97

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The timing of orthognathic surgery in a severe class III teenager would best be determined
using:

A. chronologic or dental age.

B. cervical spine analysis on a cephalometric radiograph.

C. serial anthropomorphic measurements.

D. timing of first menses.

Answer: B

Rationale:
The peak velocity of growth for the maxillofacial structures in most individuals is fairly
standard at 14 to 16 years of age in females and 16 to 18 years of age in males.
However, disproportionate growers with dentofacial anomalies require a more detailed
analysis. This is particularly true of class III patients who are prone to grow for longer
periods of time based on their disproportionate mandibular growth. Both hand-wrist and
cervical spine measures can be used to judge skeletal maturation with equal predictive
value. Serial cephalometric evaluations can also be used to measure a slowdown of
growth velocity over time in an individual. Serial anthropomorphic measures rely on soft
tissue, and have not been shown to be effective at predicting maturation of the facial
skeleton for the purposes of treatment planning orthognathic surgery.

Reference:
Grave KC, Brown T: Skeletal ossification and the adolescent growth spurt. Am J
Orthodont 69: 611-619, 1976.

Franchi L, Baccetti T, McNamara JA. Mandiublar growth as related to cervical vertebral

maturation. Am J Orthod Dentofac orthop 118: 335-340, 2000.

American Board of Oral and Maxillofacial Surgery 98

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In a Le Fort I osteotomy the bone cut at which location is performed last?

A. Lateral nasal walls

B. Nasal septum

C. Pterygoid plates

D. Anterior maxillary walls

Answer: C

Rationale:
After the initial osteotomy is made across the anterior lateral maxillary surfaces, each of
the above areas is separated with osteotomies. A common Lefort I osteotomy sequence
is:
1. antero-lateral maxillary walls.
2. nasal septum.
3. lateral nasal walls to the anterior portion of the vertical palatine bone (stopping at the
palatine bone to avoid the descending palatine arteries).
4. pterygoid plates.
5. downfracture of the maxilla.

Some surgeons elect not to osteotomize the lateral pterygoid plates with an osteotome or
saw, but rather separate the plates during down fracture of the entire maxilla. Either way,
the pterygoid disjunction step is usually left until the end due to the proximity of the
maxillary artery and pterygoid plexus. If either vascular structure is injured and bleeding
ensue, the osteotomies are complete and expeditious maxillary downfracture to control
bleeding can be performed.

Reference:
Obwegeser H. Surgical correction of small or retrodisplaced maxillae. Plast Reconstr
Surg 44: 351-365, 1969.

Precious DS, Morrison A, Ricard A. Pterygomaxillary separation without the use of an

osteotome. J Maxillofac Surg 49: 98-99, 1991.

American Board of Oral and Maxillofacial Surgery 99

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In a child that is 5 years of age with obstructive sleep apnea, the most common choice for
surgical treatment is:

A. genioglossus advancement with anterior mandibular osteotomy.

B. bilateral sagittal split osteotomy.

C. tonsillectomy with or without adenoidectomy.

D. septoplasty.

Answer: C

Rationale:
Most children with significant obstructive sleep apnea can be treated with non-surgical
measures, but some may be considered for surgical care if their apnea-hypopnea index
is severe, other disease measures are significant, or particularly large tonsils and/or
adenoid tissues are present (as is frequently found in a child with severe obstructive
sleep apnea.) Osteotomies of the mandible are generally not preferred as an initial
surgical procedure, and often are technically difficult due to developing tooth structures.
Septal deviation contributes only a small amount to most patients with obstructive sleep
apnea, and significant growth potential may be caused by early septal surgery.

Reference:
Messner AH, Pelayo R. Pediatric sleep-related breathing disorders. Am J Otolaryngol
2000;21: 98-107.

Lim J, McKean M. Adenotonsillectomy for obstructive sleep apnea in children. Cochrane

Database Syst Rev 2003;(4):CD003136.

American Board of Oral and Maxillofacial Surgery 100

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Vascular compromise after a 3 piece segmental Le Fort I osteotomy is most likely to occur at
which site?

A. Adjacent to the interdental osteotomy sites

B. Central incisors

C. Posterior hard palate lateral to the palatine foramen

D. Posterior hard palate medial to the palatine foramen

Answer: A

Rationale:
While rare, vascular compromise is most likely to occur adjacent to the osteotomy sites,
often between the canine and the adjacent lateral incisor or premolar tooth. While the
posterior hard palate can be affected, the blood supply is usually robust enough to allow
for good blood supply via the lateral pedicles of soft tissue. The central incisors may also
be affected, but most often the areas of concern are adjacent to the osteotomy sites
where periosteal elevation or buckling/compression of the palatal soft tissue pedicle may
have lead to local vascular compromise.

Reference:
Turvey TA and White RP. Maxillary Surgery. In Proffit, White , and Sarver's
Contemporary Treatment of Dentofacial Deformity. Mosby, 2003. 288-311.

Nelson RL, et al. Quantification of blood flow after Le Fort I osteotomy. J Oral Surg 35:
1016, 1977.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is an unlikely complication following sagittal split osteotomy of the
mandible?

A. Excessive bleeding

B. Class II positioning of the teeth due to poor condylar positioning during fixation

C. Transection of the inferior alveolar neurovascular bundle

D. Poor splitting of the proximal segment causing an inappropriate fracture

Answer: A

Rationale:
Excessive bleeding is very rare during isolated sagittal split osteotomies. Transection of
the inferior alveolar nerve and “bad splits” occur in approximately 3% of cases in a recent
review. Class II positioning of the teeth can occur somewhat frequently if care is not
taken to position the condyles of the proximal segments in centric relation during fixation.
If proximal segment malposition occurs, it is most often recognized by a malocclusion
intraoperatively rather than postoperatively, and easily corrected.

Reference:
Turvey TA. Intraoperative complications of sagittal osteotomy of the mandibular ramus:
incidence and management. J Oral Maxillofac Surg 43: 504-509, 1985.

Tucker MR, Ochs MW. Use of rigid internal fixation for management of intraoperative
complications of mandiublar sagittal-split osteootomy. Int J Adult Othod Orthogn Surg 2:
71-80, 1988.

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Which of the following is a feature of velocardiofacial syndrome?

A. Deletion of 22q11.2

B. Ring 18 chromosome

C. Autosomal recessive inheritance

D. Retinal detachment

Answer: A

Rationale:
Velocardiofacial syndrome is an autosomal dominant disorder that is very commonly
seen in patients with isolated cleft palate. DNA analysis is often performed to look for the
common deletion of 22q11.2. Expression is variable although the features are fairly
consistent in many patients including cardiac defects in 85% of patients. Other features
include mental retardation, learning disabilities, internal carotid deviation, micrognathia,
narrow palpebral fissues, and microcephaly. Retinal detachment is seen in Stickler
syndrome. A ring chromosome anomaly is a unique entity and unrelated to VCF
syndrome.

Reference:
Shprintzen, R. J.; Goldberg, R. B.; Young, D.; Wolford, L. : The velo-cardio-facial
syndrome: a clinical and genetic analysis. Pediatrics 67: 167-172, 1981.

Shprintzen, R. J.; Wang, F.; Goldberg, R.; Marion, R. : The expanded velo-cardio-facial
syndrome (VCF): additional features of the most common clefting syndrome. (Abstract)
Am. J. Hum. Genet. 37: A77, 1985.

American Board of Oral and Maxillofacial Surgery 103

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The sagittal split osteotomy of the mandible procedure includes which of the following steps?

A. Subperiosteal dissection inferior and medial to the mandibular foramen

B. Preservation of the nerve within the proximal segment

C. Osteotomy lateral to the inferior alveolar canal

D. Propagation of the split in a posterior to anterior direction

Answer: C

Rationale:
Propagation of the split with osteotomes and/or spreaders is performed from anterior to
posterior to allow for the posterior and inferior borders to split as the anterior and superior
aspects of the osteotomy are widened. This usually allows the Hunsuck modification to
occur in the posterior aspect of the osteotomy such that the lingual depression of the
mandible is fractured rather than the extreme posterior ramus border.

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

Hunsuck EE: A modified intraoral sagittal splitting technique for correction of mandibular
prognathism. J Oral Surg 26: 249-252, 1968.

American Board of Oral and Maxillofacial Surgery 104

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is a phase unique to distraction osteogenesis?

A. Reparative

B. Inflammatory

C. Latency

D. Neovascular

Answer: C

Rationale:
The phases of distraction include an osteotomy, latency, distraction, and consolidation.
The osteotomy is performed first, followed by a brief latency phase (the length of which
may be variable based on age of the patient, location of the osteotomy, and healing
potential of the osteotomy site.) The distraction phase continues as long as the
lengthening is required, and this is followed by a consolidation phase which typically lasts
months. Neovascularization is a phase of healing, often associated with inflammation.

Reference:
Smith K, Harnish M. Pediatric sleep apnea treated with distraction osteogenesis. In
Samchucov, cope and Cherkashin Eds. Craniofacial Distraction Osteogenesis, St. Louis
Mosby, 2001, 2013-224

Ilizarov GA: The tension-stress effect on the genesis and growth of tissues. I. The
influence of stability of fixation and soft tissue preservation. Clin Orthop 238: 249-280,
1989.

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Which of the following provides maximum orthodontic anchorage to move the anterior segment
of the maxilla distally?

A. Trans-palatal arch

B. Maxillary low pull head gear

C. Skeletal anchors just anterior to first maxillary molars

D. A skeletal anchor at the anterior cortex between the central incisors

Answer: C

Rationale:
Maximum anchorage will be achieved when there are a greater number of teeth in an
anchorage segment. When using traditional orthodontic mechanics, if maxillary first
bicuspids are extracted, then the anterior incisors and canines will have more of a
tendency to retract when the orthodontist closes the extraction space. If the maxillary
second bicuspids are extracted, then the molars are more likely to move anteriorly to
close the space, rather than the anterior teeth moving distal. A transpalatal arch provides
very good anchorage via the molars on both sides of the arch. Skeletal anchorage in the
posterior maxilla provides absolute anchorage to move the anterior teeth toward the
distal. A skeletal anchor placed in the anterior maxilla provides little anchorage that is
useful when distalizing the maxillary teeth.

Reference:
Smith RJ, Burstone CJ. Mechanics of tooth movement. Am J Orthod 85: 294-307, 1984

Profitt WR. Mechanical Principles in Orthodontic Force Control. In Contemporary

nd
Orthodontics, 2 edition. Mosby, 1993, 289-315.

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Another term used to describe hemifacial microsomia is:

A. oculoauriculovertebral spectrum.

B. Smith-Lemil-Optiz syndrome.

C. Kabuki syndrome.

D. otomandibular dysostosis.

Answer: A

Rationale:
Hemifacial microsomia has many forms, expressions, and various names. Every form of
inheritance has been described including sporadic occurrence, dominant, recessive, and
x-linked. The term hemifacial microsomia is mostly descriptive regarding the
dysmorphology, although oculoauriculovertebral spectrum more accurately describes the
dysmorphology. Goldenhar syndrome is the term utilized for patients who have multiple
anomalies in other systems, and often have bilateral, but asymmetric expression of the
dysmorphology. Otomandibular dysostosis is a pseudonym for Treacher-Collins
Syndrome. Patients with Kabuki syndrome usually display microcephaly, large ears, cleft
palate, ptosis, cardiac anomalies, and other findings. Smith-Lemil-Opitz syndrome
typically exhibits a cleft palate, micrognathia, low-set ears, epicanthal folds, cardiac
defects, genitourinary anomalies and other findings.

Reference:
Gorlin, R. J. : Branchial arch and oro-acral disorders.In: Gorlin, J. J.; Cohen, M. M., Jr.;
Levin, L. S. (eds.) : Syndromes of the Head and Neck. 3rd ed. London: Oxford Univ.
Press 1990. Pp. 641-649

Kelberman, D.; Tyson, J.; Chandler, D. C.; McInerney, A. M.; Slee, J.; Albert, D.; Aymat,
A.; Botma, M.; Calvert, M.; Goldblatt, J.; Haan, E. A.; Laing, N. G.; Lim, J.; Malcolm, S.;
Singer, S. L.; Winter, R. M.; Bitner-Glindzicz, M. : Hemifacial microsomia: progress in
understanding the genetic basis of a complex malformation syndrome. Hum. Genet. 109:
638-645, 2001.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following female patients is most likely to outgrow Orthognathic mandibular
repositioning?

A. A class II female who received phase I growth modification in the mixed dentition prior to
receiving bilateral sagittal split osteotomies at age 16

B. A class II female who had bilateral sagittal split osteotomies at age 14, but no phase I
growth modification

C. A class III female who had bilateral sagittal split osteotomies at age 13

D. A class III female who had bilateral sagittal split osteotomies at age 16

Answer: C

Rationale:
Most females have finished the vast majority of their skeletal growth velocity by age 16.
However, skeletal Class III patients have a more significant chance for relapse or
overgrowth of their corrections if surgery is performed at an early age (prior to skeletal
maturity), since late mandibular growth is more commonly seen in patients with
mandibular hyperplasia. In contrast, skeletal Class II patients are less likely to outgrow
their corrections independent of growth modification because of disproportionately
hypoplastic mandibular growth and poor growth potential. Timing of class III patients is,
therefore typically delayed compared with those that are class II. Patients with class II
deformities may have “earlier” orthognathic procedures with an expectation for a
definitive result, whereas Class III patients who undergo early procedures have a
tendency to require additional therapy. Bone scans, hand-wrist radiographs, cervical
spine analysis, or serial cephalometric exams may indicate ongoing growth. Growth
modification has no effect on long-term outcome of the sagittal position of the surgerized
mandible.

Reference:
Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth.
Part 1. Mandibular deformities. Am J Orthod Dentofac Orthop 119: 95, 2001.

Snow MD, Turvey TA, Walker D, Profitt WR. Surgical mandibular advancement in
adolescents post surgical growth related to stability. Int J Adult Orthod Orthop 6: 143,
1991.

American Board of Oral and Maxillofacial Surgery 108

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The two-piece Le Fort I osteotomy is most commonly utilized to treat which of the following
discrepancies?

A. Posterior maxillary transverse discrepancy

B. Anterior maxillary transverse discrepancy

C. A Bolton discrepancy

D. A multi-plane occlusion

Answer: A

Rationale:
With the hinge point usually between the central incisors, a two-piece LeFort I osteotomy
allows expansion posteriorly and little change in the anterior region. As such a Bolton
discrepancy is not addressed with this technique, and multiplane occlusion is best
addressed with either additional segments or orthodontic compensation. The surgically
assisted rapid palatal expansion procedure is designed to provide transverse (anterior >
posterior) expansion that is significantly more than what a 2-piece LeFort I osteotomy can
achieve. In the SARPE a large diastema in conjunction with the anterior expansion is
created between the central incisors to facilitate treatment of anterior crowding, a v-
shaped arch, and an arch length discrepancy.

Reference:
Bell WH, Turvey TA. Surgical correction of posterior crossbite. J Oral Surg 32: 811-822,
1974

Turvey TA. Maxillary expansion: a surgical technique based on surgical-orthodontic

treatment objectives and anatomic considerations. J Maxillofac Surg 13: 51-58, 1985.

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A submentovertex radiograph obtained during presurgical evaluation reveals a “V” shaped

mandible with divergent rami. In which direction will mandibular setback via bilateral sagittal
split osteotomies with lag screw fixation displace the condyles?

A. Medially

B. Laterally

C. Anteriorally

D. Posteriorally

Answer: A

Rationale:
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.
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, and is demonstrated in a submentovertex plane film. 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 the BSSO is
used in this patient population, a positional (non-lag) screw technique should be used,
with th possible placement of a bone shim posterior to the screws to help minimize
medial condylar torquing.

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.

Tucker M, Terry B, White R, et al. Rigid Fixation for Maxillofacial Surgery. W.B.
Saunders, 1991

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following techniques is most likely to produce unfavorable condylar displacement
during fixation of bilateral mandibular sagittal ramus osteotomies?

A. Lag screw placement

B. Bicortical position screw placement

C. Monocortical bone plates

D. Single bicortical position screw first followed by lag screw placement

Answer: A

Rationale:
Changes in intercondylar width may occur as a result of sagittal split osteotomy. 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 condylar displacement. Alternatively, lag
screws may be utilized only when at least one position screw is placed first in order to
maintain the 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.

Tucker M, Terry B, White R, et al. Rigid Fixation for Maxillofacial Surgery. W.B.
Saunders, 1991

American Board of Oral and Maxillofacial Surgery 111

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Vascular disruption of the developing middle stapedial artery with hematoma formation is
suspected as an etiology for which of the following?

A. Cleft lip and palate

B. Treacher-Collins syndrome

C. Hemifacial microsomia

D. Craniofacial dysostosis syndromes

Aswer : C

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. Since this initial hypothesis, additional hypotheses
have been put forward for some of the other instances of hemifacial microsomia that
occur. One theory involves failure of migration of the neural crest cells of the first and
second branchial arches. Other possibilities have been cited such as disruption of the
fetal tissues during the prenatal period. Treacher-Collins syndrome may have a similar
etiology with respect to the neural crest cell migration, but not the vascular disruption as it
occurs bilaterally and is remarkably symmetric. The craniofacial dysostosis syndromes
such as Apert syndrome, involve the early fusion of cranial vault and cranial base sutures
in the fetus causing growth restriction is the midface and orbits. Cleft lip and palate
etiology is multifactorial and does not involve vascular disruption.

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

Gorlin, R. J. : Branchial arch and oro-acral disorders.In: Gorlin, J. J.; Cohen, M. M., Jr.;
Levin, L. S. (eds.) : Syndromes of the Head and Neck. 3rd ed. London: Oxford Univ.
Press 1990. Pp. 641-649

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Craniosynostosis of both coronal sutures will result in which of the following?

A. Brachycephaly

B. Scaphocephaly

C. Trigonocephaly

D. Posterior plagiocephaly

Answer: A

Rationale:
Unilateral coronal suture craniosynostosis results in a classic deformity characterized by
flattening of the forehead (anterior plagiocephaly) and orbital dystopia associated with the
arrested development of the anterior cranial base and orbit on the affected side. When
both coronal sutures are affected, there is foreshortening of the entire anterior cranial
base and flattening of the forehead producing the characteristic brachycephalic skull
deformity. In addition, patients demonstrate a symmetric orbital deformity associated
with growth restriction along the coronal sutures and sphenoethmoidal sutures.
Scaphocephaly is caused by sagittal synostosis. Trigonocephaly is caused by metopic
synostosis. Posterior plagiocephaly is typically a descriptor of unilateral “flatness” found
most often in repetitive sleep positioning. Rarely this can be caused by labdoid
synostosis.

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.

Huang MH, Mouradian WE, Cohen SR and Gruss JS. The differential diagnosis of head
shapes: separating craniosynostosis from positional deformities and normal variants.
Cleft Palate Craniofac J. 1998, 35:204-11.

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A child with a diagnosis of hemifacial microsomia presents with moderate unilateral hypoplasia
of the ascending ramus, condyle, and glenoid fossa. The condyle is malpositioned anterior and
medial when compared to the contralateral (unaffected) side. Mandibular range of motion is
affected, but remains satisfactory. This mandibular-TMJ deformity is consistent with which
skeletal type hemifacial microsomia?

A. Type I

B. Type IIa

C. Type IIb

D. Type III

Answer: B

Rationale:
Patients with Hemifacial Microsomia will present with varying degrees of mandibular and
temporomandibular joint hypoplasia as a primary finding in the condition. Kaban has
refined a classification system useful in defining the degree of mandibular deformity in
these patients. The specific type of mandibular/TMJ deformity present is a critical factor
in deciding upon the specific reconstructive techniques that will be employed. The
following is a brief synopsis of each Kaban type:
Type I: All skeletal components (glenoid fossa, condyle, ascending ramus) are present
with a mild degree of hypoplasia. Normal function is present.
Type IIa: All of the skeletal components demonstrate a moderate degree of hypoplasia.
While present, the condyle may appear to be malpositioned so that it is anterior and
medial to the contralateral (normal) side. Function is affected, but remains satisfactory.
Type IIb: There is moderate to severe hypoplasia of the glenoid fossa and the condyle-
ramus complex. Despite an abnormal and severely hypoplastic condyle, many patients
will still have a working joint and an actual “stop” where the condylar segment seats
against the skull base. Most patients will demonstrate function that is limited to simple
rotation of the condyle without any translational movements.
Type III: This is the most severe form of mandibular hypoplasia with complete absence of
the condyle-ramus complex and the glenoid fossa. The affected side of the mandible has
no working articulation against the skull base.

Reference:
Kaban LB, Moses MH, Mulliken JB. Correction of hemifacial microsomia in the growing
child: A follow-up study. Cleft Palate J 23 (Suppl 1) 50, 1986.

Kaban LB. Congenital Abnormalities of the Temporomandibular Joint. In: Kaban LB and
Troulis MJ (Eds). Pediatric Oral and Maxillofacial Surgery. Pp. 302-339. Elsevier,
Philadelphia, 2004.

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A patient with velocardiofacial syndrome is scheduled to undergo a superiorly based, posterior

pharyngeal flap procedure. During presurgical nasopharyngoscopy, prominent pharyngeal wall
pulsations are noted. Which of the following arteries is most likely the source of these clinical
findings?

A. Vertebral

B. Internal carotid

C. Ascending pharyngeal

D. Maxillary

Answer: B

Rationale:
The superiorly based pharyngeal flap recruits tissue from the posterior wall of the
pharynx and inserts it within the nasals side of the soft palate. The procedure involves
the elevation of a superiorly based myomucosal flap (includes mucosa and superior
pharyngeal constrictor muscle) off of the underlying pre-vertebral fascia.

Patients with velocardiofacial syndrome often have anomalous internal carotid arteries as
a feature of the condition. This poses a potential risk of hemorrhage during surgical
procedures for velopharyngeal insufficiency. Presurgical diagnostic procedures in these
patients include nasopharyngoscopy which may demonstrate arterial pulsations within
the pharyngeal walls, magnetic resonance imaging, and angiography of the cervical
region.

Reference:
Costello BJ, Ruiz RL, Turvey TA. Velopharyngeal insufficiency in patients with cleft
palate. Oral Maxillofacial Surg Clin N Am 14 (2002) 539-551.

Kummer AW. Cleft Palate and Craniofacial Anomalies. Effects on speech and resonance.
nd
2 ed. Clifton Park, NY: Thomson Delmar Learning. 2008. .

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Which statement regarding surgically assisted rapid palatal expansion is correct?

A. Complete downfracture of the maxilla is required in order to realize adequate maxillary

mobility

B. The procedure creates more expansion within the posterior maxilla than the anterior
maxilla

C. The procedure is indicated when the amount of expansion necessary is less than 6 mm
total

D. Adequate mobilization of the posterior maxilla requires an osteotomy of the the lateral
buttress region.

Answer: D

Rationale:
During surgically assisted rapid palatal expansion (SARPE), there is greater widening
within the anterior maxilla than there is posteriorly. By contrast, a segmental osteotomy
will produce more expansion posteriorly than anteriorly. This is the result of each
procedure having a distinctive “hinge” pattern during the actual maxillary widening.

The SARPE procedure is reserved for cases in which greater than 8 to 10 mm of

widening is necessary. If segmental osteotomy is undertaken for widening of greater
than 10 mm, the likelihood of soft tissue dehiscence, periodontal defects, and poor long
term stability increases.

The surgical approach for SARPE requires that osteotomies be created at all of the
points where potential resistance to lateral expansion will be encountered. These include
the palatal suture, lateral buttresses, and pterygomaxillary junction. Complete maxillary
downfracture is not required.

Reference:
Bailey LJ. Segmental Le Fort I osteotomy to effect palatal expansion. J Oral Maxillofac
Surg 55:728-731, 1997.

Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. Diagnosis and
treatment of transverse maxillary deficiency. Int J of Adult Orthod Orthognathic Surg
120: 75-96, 1995

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When performing a double opposing z-plasty (Furlow) cleft palate repair, which of the following
describes the correct elevation of the levator musculature?

A. Muscle is elevated with the anteriorly based mucosal flaps

B. Muscle is elevated with the posteriorly based mucosal flaps

C. Muscle is elevated with both oral side mucosal flaps

D. Muscle is elevated with both nasal side mucosal flaps

Answer: B

Rationale:
During the Furlow procedure, two sets of Z-plasty flaps are elevated; one on the oral side
and another on the nasal side. In each case, the anteriorly based flap is elevated as oral
mucosa only and the posteriorly based flap is developed as a myomucosal flap that
includes the levator musculature. The result is one mucosal flap (anteriorly based) and
one myomucosal flap (posteriorly based) on the oral side and the same (but mirror
image) on the nasal side. When the flaps are transposed, there is alignment of the
muscle sling and lengthening of the soft palate.

Reference:
Furlow LT Jr. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986
Dec;78(6):724-38.

Kirschner RE, Wang P, Jawad AF, Duran M, Cohen M, Solot C, Randall P, LaRossa D.
Cleft-palate repair by modified Furlow double-opposing Z-plasty: the Children's Hospital
of Philadelphia experience. Plast Reconstr Surg. 1999 Dec;104(7):1998-2010;
discussion 2011-4.

American Board of Oral and Maxillofacial Surgery 117

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A ratio of bizygomatic with to facial height of 0.86, in a female, suggests which of the
following?

A. Lower facial asymmetry

B. Vertical maxillary excess

C. Lower facial elongation

D. Normal facial proportions

Answer: D

Rationale:
Presurgical data collection for patients undergoing orthognathic procedures includes a
careful evaluation of facial proportions and esthetics. Anthropometric measurements are
a useful part of this process and may be compared with standard measurements and
cross-sectional data. In the above example, the relationship between bizygomatic width
and lower facial height is useful in evaluating the patient's facial form. Knowing this
presurgically helps the surgeon decide what to do with the vertical position of the
maxillomandibular complex during surgery. In a normally-proportioned face, the ration of
bizygomatic width to lower face height is 0.88 in males and 0.86 in females. The
measurements described would suggest a normal facial proportion in a female patient.

Reference:
Farkas LG, Munro JR. Anthropometric facial proportions in medicine. Springfield, Ill,
1987, CC Thomas Publishers.

Proffit WR. The Search for Truth: Diagnosis. In Proffit WR, White RP (Eds). Surgical
Orthodontic Treatment. Mosby. 1991. Pp: 93-141.

Turvey TA and White RP. Maxillary Surgery. In Proffit, White , and Sarver's
Contemporary Treatment of Dentofacial Deformity. Mosby, 2003.

American Board of Oral and Maxillofacial Surgery 118

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Assuming a six millimeter movement, which of the following has the greatest relapse potential?

A. Bilateral sagittal split osteotomies for advancement

B. Intraoral vertical ramus osteotomies for setback

C. Bilateral sagittal split osteotomies for setback

D. Lengthening of the mandibular ramus by distraction

Answer: D

Rationale:
The mandible may be moved forward or back with relatively good stability. Lengthening
of the mandibular ramus so that the gonial angle region is inferiorly positioned may be
done surgically, but is associated with a strong tendency for relapse. This is associated
with extensive remodeling of the inferior border of the ramus in the area of the
pterygomandibular muscle sling. Fortunately, the vertical position of the gonial angle is
not usually a significant problem in patients undergoing dentofacial correction. In
patients who undergo ramus lengthening for conditions such as hemifacial microsomia,
occlusal correction is maintained even when there is extensive relapse at the ramus.

Reference:
Proffit WR. The Search for Truth: Diagnosis. In Proffit WR, White RP (Eds). Surgical
Orthodontic Treatment. Mosby. 1991. Pp: 149-152.

Proffit WR and Ackerman JL. Orthodontic diagnosis: the development of a problem list.
In Profitt WR: Contemporary orthodontics, ed 3, St. Louis, 2000, Mosby

American Board of Oral and Maxillofacial Surgery 119

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

During advancement genioplasty via inferior border osteotomy of the mandible, what is the ratio
of soft tissue to hard tissue change?

A. 20%

B. 60%

C. 80%

D. 100%

Answer: C

Rationale:
The degree of soft tissue movement associated with hard tissue changes in genioplasty
is predictable. In most patients, the soft tissues move forward approximately 80% as
much as the bone. This ratio is lower with reduction genioplasty and greater when
vertical movements are undertaken.

Reference:
McDonnell JD, McNeill RW, West RA. Advancement genioplasty: a retrospective
cephalometric analysis of osseous and soft tissue changes. J Oral Maxillofac Surg
35:640-647. 1987.

Holdaway RA. A soft tissue cephalometric analysis and its use in orthodontic treatment
planning. Am J Orthod 1983; 84: 1-28.

American Board of Oral and Maxillofacial Surgery 120

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 40 year-old female presents with a painless 1.5 cm, sessile mass of the tongue dorsum,
which has been present for an unknown period of time (Figure A). The lesion is excised and
submitted for histopathology (Figures B and C). Which of the following is the most likely
diagnosis?

A. Squamous cell carcinoma

B. Granular cell tumor

C. Schwannoma

D. Leiomyoma

Answer: B

Rationale:
Based on the available information, granular cell tumor is the most likely diagnosis.
Granular cell tumors are benign tumors felt to be of neural origin composed of round or
spindle cells with pink cytoplasm secondary to abundant lysosomes. Also demonstrated
above is their lack of capsule, and they are not well-circumscribed (as are the
Schwannoma and leiomyoma.) The tongue is the most common location with a peak
incidence in the 40 -60 year age range. Female to male ratio is 2:1. Treatment is
excision with clear margins. Interestingly, recurrence is rare even following incomplete
removal.

Squamous cell carcinomas are not typically associated with intact mucosa.
Schwannomas are benign neural tumors arising in association with nerves. While a
similar clinical picture is possible, Schwannomas are more common in patients in the 20-
30 year age range. They are associated with Antoni A areas and Verocay bodies and
hypocellular myxoid Antoni B areas. Often a capsule is identified on light microscopy .
Local excision is treatment. Leiomyomas are rare tumors of smooth muscle origin.
Histologically, a well-circumscribed lesion is noted with smooth muscle spindle cells.

Reference:
nd
Neville BW, Damm DD, Allen CM and Bouquot JE: Oral and maxillofacial pathology 2
ed. Philadelphia, PA, W.B. Saunders, 2002, p.465-466.

American Board of Oral and Maxillofacial Surgery 121

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Collins BM, Jones AC. Multiple granular cell tumors of the oral cavity: report of a case
and review of the literature. J Oral Maxillofac Surg 53: 707-711, 1995.

American Board of Oral and Maxillofacial Surgery 122

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 72 year-old female presents with an asymptomatic, firm gingival lesion measuring 1.5 cm in
diameter (Figure A). Excision and histopathology were performed (Figures B and C). Which of
the following is the most likely diagnosis?

A. Peripheral odontogenic fibroma

B. Giant cell fibroma

C. Peripheral ameloblastoma

D. Peripheral ossifying fibroma

Answer: C

Rationale:
Clinical appearance and histology make peripheral ameloblastoma the most likely
diagnosis. Peripheral (extraosseous) ameloblastomas are rare, accounting for less than
1% of ameloblastomas. They arise from odontogenic epithelial rests, and usually occur
on the alveolus. They share histopathologic features of intraosseous variety: islands of
ameloblastic epithelium lying beneath the surface mucosa. Treatment is local excision,
and the clinical course is typically more innocuous than the intraosseous counterpart.

Peripheral odontogenic fibromas can be confused with the extraosseous ameloblastoma.

Differentiating factors include dentin or cementum elements and lack of reverse
polarization in the odontogenic fibromas. Giant cell fibromas are more common than
peripheral ameloblastomas. They may be sessile or pedunculated and are usually less
than 1cm. Mandibular gingival is more commonly involved. Histologically, there is a
mass of connective tissue, which does not contain epithelial components. The peripheral
ossifying fibroma also presents on the alveolus, and is relatively common. It is
associated with teens and young adults. It may be ulcerated. Histologically, it contains
mineralized elements.

Reference:
nd
Neville BW, Damm DD, Allen CM and Bouquot JE: Oral and maxillofacial pathology 2
ed. Philadelphia, PA, W.B. Saunders, 2002, p.619.

American Board of Oral and Maxillofacial Surgery 123

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

El-Mofty SK, Gerard NO, Farish SE, Rodu B. Peripheral ameloblastoma: A clinical and
histologic study of 11 cases. J Oral Maxillofac Surg 49:970-974, 1991.

American Board of Oral and Maxillofacial Surgery 124

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A 73 year-old female presents with a painless 2 cm, nodular mass involving the left upper lip. A
smaller mass involves the upper right lip. A biopsy is performed. Which of the following is most
likely?

A. Canalicular adenoma

B. Mucocele

C. Pleomorphic adenoma

D. Oncocytoma

Answer: A

Rationale:
The demographic, clinical and histologic information provided make cancalicular
adenoma the most likely answer. Canalicular adenomas are rare tumors arising from
minor salivary glands with a predilection for the upper lip (75%). The vast majority occur
th
in the older adult with the 7 decade being the most common. In addition, occurrence of
a second lesion suggests canalicular adenoma. Histologically, duct like structures with
uniform columnar cells are present. Treatment is excision, and recurrence uncommon.
Mucoceles are rare in the upper lip, and are typically more translucent. Histologically,
extravasated mucous is seen surrounded by inflamed tissue. Pleomorphic adenomas of
the minor glands account for around 40% of minor salivary gland tumors. More common
in young adults (age 30-50). Histologically, a mixed cellular pattern is seen surrounded
by a capsule which may be incomplete. Usually will not be multi-focal unless previous
surgery has resulted in seeding to surrounding area. Oncocytomas (oxyphilic adnomas)
a benign salivary gland tumors made up of large epithelial cells. Peak incidence is the
th
8 decade. Histologically, one sees a well-circumscribed tumor made up of polyhedral
cells.

Reference:
nd
Neville BW, Damm DD, Allen CM and Bouquot JE: Oral and maxillofacial pathology 2
ed. Philadelphia, PA, W.B. Saunders, 2002, p.417.

American Board of Oral and Maxillofacial Surgery 125

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, p 538.

American Board of Oral and Maxillofacial Surgery 126

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

A painless, doughy mass of the superficial lobe of the parotid gland which demonstrates
increased uptake of technicium pertechnetate 99 most likely represents which of the following?

A. Pleomorphic adenoma

B. Warthin tumor (Papillary cystadenoma lymphomatosum)

C. Oncocytoma

D. Basal cell adenoma

Answer: B

Rationale:
While pleomorphic adenoma is the most common tumor of the parotid gland, Warthin
tumor contains lymphoid elements, which are demonstrated by the technicium scan.
While not commonly used in parotid mass work up, recent review demonstrated utility of
Te99 scan. Warhtin tumor is a benign neoplasm, and while much less common than
pleomorphic adenomas, they represent the second most common parotid tumor (5.3% of
parotid tumors. Clinical presentation is similar: a slow growing mass. There is a
tendency for Warthin tumors to occur bilaterally in 5-14%. Treatment is excision. Some
authors have suggested observation in elderly patients of the contralateral tumor (if
present) once diagnosis is confirmed.

Pleomorphic adenomas have mixed cellularity, but lack lymphoid elements.

Oncocytomas are rare and contain polyhedral cells (oncocytes), but lack lymphoid
elements that would be identified on the technetium scan. Basal cell adenomas is rare
(<1% of salivary tumors), but 75% occur in the parotid gland. It is encapsulated and well-
circumscribed. It is made up of cords of basaloid cells arranged in a trabecular pattern.
It does not contain lymphoid elements.

Reference:
Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, p 536.

Nakahara T, Suzuki T, Hashimoto J et al. Role of salivary gland scintigraphy with Te-99
pertechnetate in determining treatment of solitary parotid gland tumors : a retrospective
study. Clin Nucl Med 32; 363-366, 2007.

American Board of Oral and Maxillofacial Surgery 127

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In the first 3 days following autogenous corticocancellous bone grafting, growth factors driving
wound healing and osteoid formation are derived primarily from which source?

A. Platelet degranulation

B. Transferred stem cells

C. Circulating macrophages

D. Transferred ostoblasts

Answer: A

Rationale:
Wound healing can basically be divided into 3 phases: inflammatory, proliferative, and
remodeling. The initial wound healing phase (inflammatory phase), which lasts 3-5 days,
is characterized by a dependence on platelet degranulation to provide the necessary
wound factors that drive the early wound healing phase. Following wounding platelets
aggregate to the site (clot) and release a variety of factors including, transforming growth
factor beta, which promote connective tissue differentiation, and platelet derived growth
factors (PDGFaa, PDGFab, PDGFbb0, which induce cellular proliferation and
angiogenesis). Platelets also secrete vascular endothelial growth factor (VEGF) and
epithelial growth factor (EGF). These factors drive the wound healing process until the
second phase at which time activated monocytes (macrophages) take over as the
primary stimulus for wound healing in the later inflammatory phase (5-7 days post injury).
Transferred stem cells do not provide growth factors, but are acted upon by them. As
above, macrophages act in the later part of the inflammatory response to amplify the
earlier effects of the platelets. Transferred osteoblasts will form osteoid in the healing
process under the influence of the above factors initially supported by plasmatic
circulation until angiogenesis occurs.

Reference:
Marx RE, Garg AK: Bone structure, metabolism and physiology: its impact on dental
implantology. Implant Dentistry 7: 267-275.

Marx RE, Ehler WJ, Peleg M: Mandibular and facial reconstruction: rehabilitation of the
head and neck cancer patient. Bone 19(1 suppl): 59s-82s, 1996.

American Board of Oral and Maxillofacial Surgery 128

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

During the period 5-7 days following autogenous corticocancellous bone grafting, growth factors
derived from which of the following sources drive wound healing and osteoid production?

A. Circulating macrophages

B. Fibroblasts

C. Osteoclast activity

D. Neutrophils

Answer: A

Rationale:
At 5-7 days post transplant, the influence of platelet derived growth factors begins to
wane, and growth factors secreted by macrophages, including, PDGDs and various TGF-
betas, drive the late inflammatory phase of wound healing and early proliferative phase.
Macrophages are primarily attracted and influenced by the hypoxic environment and as
the hypoxia improves through the establishment of circulation via angiogenesis,
fibroblasts begin to establish themselves as the modulator of wound healing.
Osteoclasts resorb transplanted bone and release growth factors, including, bone
morphogenic protein (BMP) which influences bone formation in the later phases of bone
graft healing. Neutrophils are most active in the earliest phase of healing (within minutes
of wounding) where they function to eliminate bacteria and other contaminants. Their
influence ceases after a few days unless a wound is infected.

Reference:
Marx RE, Garg AK: Bone structure, metabolism and physiology: its impact on dental
implantology. Implant Dentistry 7: 267-275.

Marx RE, Ehler WJ, Peleg M: Mandibular and facial reconstruction: rehabilitation of the
head and neck cancer patient. Bone 19(1 suppl): 59s-82s, 1996.

Search Terms: = Intraoral bone graft harvesting including complications

American Board of Oral and Maxillofacial Surgery 129

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Angiogenesis within the maturing corticocancellous graft is down-regulated by which of the

following?

A. Cessation of platelet degranulation

B. Osteoclastic activity initiation

C. Flattening of the steep oxygen gradient

D. Osteoblastic maturation

Answer: C

Rationale:
Hypoxia drives angiogenesis. Macrophages are stimulated by hypoxia to secrete growth
factors (epithelial growth factor) that stimulate development of microcirculation within the
graft. Initially transplanted cells are supported by plasmatic circulation (diffusion from
surrounding tissue). Down-regulation of angiogenesis is necessary to prevent
granulation tissue formation. Once oxygen tension increases in the bed, equilibration of
tissue oxygen tension with that of the surrounding tissue leads to inactivation of
angiogenesis by decrease in the difference in oxygen levels in the healing tissue bed and
the surrounding tissue (i.e, decrease of the initially steep oxygen tension gradient.)
Osteoclasts and osteoblast function does not influence angiogenesis. Platelet
degranulation is important in the early phase of wound healing but angiogenesis is not
complete by the time platelet influence is slowing. Macrophages are down-regulated by
the improvement in oxygen tension at the wound site, and their influence gives way to the
mesenchymal cells.

Reference:
Marx RE, Garg AK: Bone structure, metabolism and physiology: its impact on dental
implantology. Implant Dentistry 7: 267-275.

Marx RE, Ehler WJ, Peleg M: Mandibular and facial reconstruction: rehabilitation of the
head and neck cancer patient. Bone 19(1 suppl): 59s-82s, 1996.

American Board of Oral and Maxillofacial Surgery 130

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is true regarding the desmoplastic fibroma of the jaws?

A. These tumors are most commonly diagnosed in adults older than 40 years of age

B. Males are more commonly affected than females

C. Recurrence with conservative treatment such as enucleation and curettage is

uncommon

D. The tumor may present as a multilocular or unilocular radiolucency

Answer: D

Rationale:
The desmoplastic fibroma is an aggressive benign tumor of the jaws that occurs in
patients younger than 30 years of age with a mean of 14 years. It has an equal gender
predilection, and occurs more commonly in the mandible than maxilla. Histologically, the
tumor is made up of small, elongated fibroblasts without atypia. Radiographically, the
tumor may appear as a multilocular radiolucency or a unilocular radiolucency. Extension
into surrounding soft tissue is not uncommon. Recurrence is common with conservative
surgical intervention (curettage results in 30% -90% recurrence) such that resection is
recommended for cure. Resection should involve 1-1.5 cm bone margins and one
anatomical barrier i.e. supraperiosteal dissection beyond tumor.

Reference:
Stewart JCB: Benign nonodontogenic tumors. In: Regezi JA, Sciubba JJ, Jordan RCK
th
(eds): Oral Pathology – Clinical Pathologic Correlations. 5 edition, chapter 12, St.
Louis, WB Saunders Co., pp 283-301, 2007.

Pogrel MA: Benign nonodontogenic lesions of the jaws. In: Ghali GE, Larsen PE, Waite
PD (eds): Oral and Maxillofacial Surgery. Second edition. Chapter 31. Ontario, BC
Decker. Pp602-603, 2004.

American Board of Oral and Maxillofacial Surgery 131

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

When considering the reconstruction of a 7 cm segmental defect of the mandible, which of the
following donor sites will most adequately provide sufficient cancellous bone?

A. Anterior ilium

B. Bilateral tibial plateau

C. Posterior ilium

D. Calvarium

Answer: C

Rationale:
The reconstruction of a 7 cm segmental defect of the mandible will require 70 cc's of
cancellous bone for effective reconstruction of mandibular height and breadth so as to
permit future prosthetic rehabilitation. In general terms, 1 cc of cancellous bone is
required for each mm of segmental defect that is reconstructed. The anterior ilium will
predictably supply 40 cc's of cancellous bone, and no more than 50 cc's of cancellous
bone. The tibial plateau will supply about 10-15 cc's of cancellous bone such that a
bilateral harvest will supply approximately 30 cc's of bone. The available diploe in the
calvarium will not predictably supply sufficient bone for reconstruction of a 7 cm
segmental defect of the mandible. The posterior ilium will provide approximately 100 cc's
of cancellous bone, making this donor site optimal in such a reconstruction.

Reference:
Haug RH, Carlson ER: Reconstruction of Avulsive Defects of the Maxillofacial Complex.
In: Fonseca RJ, Walker RV, Betts NJ, Barber HD, Powers MP (eds): Oral and
rd
Maxillofacial Trauma, 3 edition, chapter 36, St. Louis, WB Saunders Co., pp 1035-
1069, 2005.

Wilk RM: Bony reconstruction of the jaws. In: Ghali GE, Larsen PE, Waite PD (eds): Oral
and Maxillofacial Surgery. Second edition. Chapter 39. Ontario, BC Decker. Pp789-791,
2004.

Search Terms: = Mandibular Reconstruction, Intra oral bone graft harvesting including
complications

American Board of Oral and Maxillofacial Surgery 132

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The history of a previous placement of a subclavian venous port for the administration of
chemotherapy could be considered a relative contra-indication for the use of which of the
following myocutaneous pedicled flaps on the ipsilateral side?

A. Deltopectoral

B. Posteriorly based platysma

C. Pectoralis major

D. Superiorly based sternocleidomastoid

Answer: C

Rationale:
Patients undergoing chemoradiation protocols for carcinoma of the head and neck, as
well as other malignant neoplasms, often undergoes the placement of a subclavian
venous port for the administration of chemotherapy. While rare, the thoracoacromial
arterial axis, which provides the dominant vascular supply to the elevated flap, could
potentially be injured under such circumstances during the subclavian puncture. While
the lateral thoracic artery provides secondary blood supply, it is often divided to improve
the arc of rotation of the pectoralis flap. An arteriogram can be obtained to verify the
quality of the vascular pedicle. The deltopectoral flap receives its blood supply from
perforators of the internal mammary artery. The posteriorly based platysma flap and the
superiorly based sternocleidomastoid flap is perfused by the occipital artery.

Reference:
Carlson ER. Pectoralis major myocutaneous flap. Oral Maxillofacial Surg Clin N Am
2003; 15(4): 565-575

Urken ML, et al. Atlas of Regional & Free Flaps for Head and Neck Reconstruction, 1995
Raven Press, pages 85-96

Baur DA. The platysma myocutaneous flap. Oral Maxillofacial Surg Clin N Am 2003;
15(4): 559-564

American Board of Oral and Maxillofacial Surgery 133

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In harvesting bone from the anterior ilium, the sensory nerve most at risk near the posterior
extent of the access incision is the:

A. lateral femoral cutaneous nerve.

B. lateral cutaneous branch of the subcostal nerve.

C. lateral cutaneous branch of the iliohypogastric nerve.

D. ilio-Inguinal nerve.

Answer: C

Rationale:
During the harvest of autogenous bone from the anterior ilium, two sensory nerves are
most at risk for damage, the Lateral cutaneous branch of the iliohypogastric nerve and
the lateral cutaneous branch of the subcostal nerve. The lateral cutaneous branch of the
subcostal nerve crosses closer to the anterior spine of the ilium, while the lateral
cutaneous branch of the iliohypogastric nerve crosses the crest more posterior in the
area of the tubercle making it more in harms way at the posterior extent of the incision.
The other two nerves are normally well removed from the incision site.

Reference:
Marx RE, Morales MJ. Morbidity from bone harvest in major jaw reconstruction. J Oral
Maxillofacial Surg 1988;48:196-203

Peterson's principles of oral and maxillofacial surgery. BC Decker Inc. second ed. 2004
Chapter 39: 783-801. Wilk RM

American Board of Oral and Maxillofacial Surgery 134

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following condition is characterized by Coast of Maine hyperpigmentation,

precocious menarche, hyperthyroidism, and expansion affecting multiple bones that
radiographically appear as a ground glass opacity?

A. Gardner syndrome

B. Cherubism

C. Albright syndrome

D. Central giant cell granuloma

Answer: C

Rationale:
The signs listed classically describe Albright Syndrome: Hyperpigmentation, endocrine
disturbances, and polyostotic fibrous dysplasia. Albright syndrome (Albright hereditary
osteodystrophy, pseudohypoparathyroidism): two types described, both of which result
from adequate parathyroid hormone (PTH), but dysfunctional biochemical pathway
responsible for activation of the target cells. So, patients appear to have
hypoparathyroidism. Diagnosis is typically made after recognition of accelerated
maturation. Other clinical findings that may be present include: mild mental retardation,
obesity, round face, and short stature. Measurement of elevated PTH and associated
hypocalcemia, hyperphosphatemia, and normal renal function confirms the diagnosis.
Management includes administration of vitamin D and calcium, and prognosis is good
with careful follow-up and adjustment of medications as necessary.

Reference:
Peterson's principles of oral and maxillofacial surgery. BC Decker Inc. second ed. 2004
Chapter 31: 597-616.

Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, p 749.

Neville BW, Damm DD, Allen CM and Bouquot JE: Oral and maxillofacial pathology 1st
ed. Philadelphia, PA, W.B. Saunders, 1995, pp 611-612.

Search Terms: = Pathology diagnosis and work up

American Board of Oral and Maxillofacial Surgery 135

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In a free soft tissue graft, cellular components survive for the first two days primarily through the
process of:

A. capillary ingrowth.

B. plasmatic imbibition.

C. circulation provided by anastomosis.

D. inosculation.

Answer: B

Rationale:
For the first three days, diffusion by plasmatic circulation is the source of nutrients for the
grafted cells. Capillary ingrowth penetrates the grafts around day 2-3. Some feel that
growth factors derived from platelets may accelerate healing, but these growth factors
don't provide nutrients to the cells. A free soft tissue graft is not a vascularized free soft
tissue flap, which is supported by circulation provided by anastomosis between donor
and recipient vessels. Inosculation refers to connections that form directly between host
and recipient vessels that occurs in free grafts.

Reference:
Peterson's principles of oral and maxillofacial surgery. BC Decker Inc. second ed. 2004,
p 8.

Glogau RG, Haas AF: Skin grafts. Baker et al. Local Flaps in Facial Reconstruction.
Mosby 1994. pp.247-248, 254.

Search Terms: = Soft tissue reconstruction/regional flaps

American Board of Oral and Maxillofacial Surgery 136

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which sub-type of basal cell carcinoma is characterized histologically by finger-like extensions

of tumor cells into the surrounding dermis that make treatment by standard surgical excision
prone to recurrence?

A. Superficial

B. Nodulo-ulcerative

C. Sclerosing or Morpheaform

D. Basosquamous

Answer: C

Rationale:
Basal cell carcinomas can be subdivided into four types listed here in decreasing
incidence: nodular (or noduloulcerative), sclerosing (or morphea), basosquamous, and
multicentric (superficial) type. The nodular type, being the most common, typically
presents as the classic “rodent ulcer” recognized by most clinicians as a basal cell
carcinoma. It usually present as firm, translucent (pearly) papules with telengiectatic
blood vessels. Pigmentation can be present, and lead to a concern for melanoma, which
should be taken into consideration when planning a biopsy. Late stages are
accompanied by crusting and a central ulcerated depression as the central portion
becomes necrotic from lack of blood supply. Histologically, the lesions contain nests and
strands extending perpendicular to the basement membrane. Squamous differentiation
can occur within the lesion leading to the basosquamous variety, which behaves in a
more aggressive fashion more akin to a squamous cell cancer with an increased
incidence of recurrence and metastases (9.7% in one study). The sclerosing variant may
appear as a scar or fibrotic skin and lack elevation. It is made up of nests and cords of
tumor cells within a dense fibrosis. Its borders are often indistinct, and microscopic
extension into the surrounding dermis can lead to positive margins and an increased
chance of recurrence following excision. As they enlarge, the sclerosing type can
develop central depressions giving them the appearance of a scar. Finally, the
superficial or multicentric form typically presents as a red scaling lesion, and although it
occurs on the skin of the head and neck, it is more common on the trunk and extremities.
As they enlarge, it can take on the appearance of a nonspecific dermatitis.

American Board of Oral and Maxillofacial Surgery 137

 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Fingerlike extensions of tumor cells into the surrounding dermis are a characteristic of the
Sclerosing or Morpheaform Basal Cell Carcinoma. Due to the potential to recurrence
these tumors are best treated with Moh's surgery. The current technique of Moh's
micrographic surgery evolved from Dr. Frederic E. Mohs' chemosurgery technique, which
he developed while working with Professor M.F. Guyer in the Department of Zoology at
the University of Wisconsin. Dr. Mohs was evaluating the effects of zinc chloride on
cancerous tissue, when he discovered that in addition to tissue necrosis, it resulted in
excellent fixation of the tissue, which provided an excellent specimen for histologic
examination. A paste was ultimately developed, which contained a binder, Sanquinara
canadensis; a matrix, Stibnite (Hummel chemical company, South Plainfield, NJ); and
zinc chloride 45% by weight. In 1941, He presented his technique of chemosurgery.
This technique involved application of the fixative for a prescribed period of time
(maximum tissue penetration occurs at 18 hours following application), followed by
removal and microscopic examination of the fixed tissue. Depth of penetration is
controlled by altering the thickness and surface area on which the paste is applied.
Successive layers are removed until tumor clearance was accomplished. Although
infrequently used today, Mohs fixed tissue technique is still promoted by some for
treatment of melanoma and extensive skin cancers that are highly vascular. An
important part of the procedure was the specific way in which Dr. Mohs oriented his
specimen, which in theory allowed examination of 100% of the margin. Others would
argue that the most important component of the technique is that the surgeon performing
the excision is also evaluating the margins. This decreases the potential communication
error, especially regarding specimen orientation, that may occur between surgeon and
pathologist since in this case they are one and the same. At the time of his original work,
frozen section analysis of margins was not available, and although labor intensive, the
fixed tissue technique allowed for significantly improved cure rates compared to
traditional surgical excision. Several modifications of the technique occurred including
elimination of the fixative in most cases and in 1953, Dr. Mohs presented his technique
modified for use with fresh tissue and frozen analysis of margins. Careful orientation of
the specimen was the same, and the entire margin was still evaluated, which offered
advantages over traditional surgical excision and margin analysis.

Reference:
Brooks NA. Mohs surgery fixed-tissue technique: current approach and indications.
Facial Plas Clin NA. 6:267-274, 1998.

Friedrich RE, Giese M, Li L, et al: Diagnosis, treatment and follow-up control in 124
patients treated with basal cell carcinoma of the maxillofacial region treated from 1992 to
1997. Anticancer Res 25: 1693-1697, 2005.

Search Terms: = Pathology diagnosis / work up

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A superficial spreading melanoma that has tumor cells extending into the papillary dermis is
classified as Clark level:

A. I.

B. II.

C. III.

D. IV.

Answer: B

Rationale:
Superficial spreading melanoma is most common among those 40-60 years of age. It is
frequently located on the mid-upper back in both sexes and the legs of females. In the
facial region, it is usually located on the infraorbital skin and forehead. Treatment and
prognosis is guided by depth of invasion indicated by Clark's levels of invasion or
Breslow's measurement of tumor thickness (in mm). Clark's level is assigned based on
the architectural location of the tumor cells within the skin, dermis and soft tissue. Level I
is tumor limited to epidermis. Level II has tumor extending into the papillary dermis,
Level III has tumor cells filling the papillary and extending to the reticular dermis. In level
IV tumor cells extend into the reticular dermis. And, Level V is extension into the
subcutis. While Clark's levels and Breslow thickness are used, most surgeons use
thickness to guide margins of excision (1 cm if <2mm, 2 cm margins if 2-3 mm, 3 cm if
greater than 3mm thick ) and need for sentinel node biopsy (usually indicated in depths
>1mm).

Reference:
Miloro, M. et al, Peterson's Principles of Oral and Maxillofacial Surgery, Second Edition,
BC Decker 2004, pp 683-684.

Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, pp.725-733 .

Search Terms: = Pathology diagnosis / work-up

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Which of the following is an interpolated flap?

A. Palatal

B. Bilobed

C. Rhomboic

D. Nasolabial

Answer: D

Rationale:
An interpolated flap is transferred by pivotal movement and has a linear configuration; its
base is not contiguous with the defect. Thus the pedicle must pass over or under
intervening tissue. The nasolabial flap is an example of an interpolated flap. If the
interpolated flap is passed over the intervening tissue it requires a second stage to divide
the pedicle and inset the flap. The palatal flap is a pedicled, rotational flap and the
bilobed and rhomboic flaps are transposition flaps.

Reference:
Swanson NA. Classification, definitions and concepts in flap surgery in Baker, S.
Swanson NA (eds) Local Flaps in Facial Reconstruction. First edition. Elsevier. 1995,
pp70-74.

Miloro, M. et al, Peterson's Principles of Oral and Maxillofacial Surgery, Second Edition,
BC Decker 2004, pp. 774-776.

Search Terms: = Soft tissue reconstruction/regional flaps

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Which of the following has the lowest risk of developing into squamous cell carcinoma?

A. Non-homogenous leukoplakia

B. Erythroplakia

C. Homogeneous leukoplakia

D. Proliferative verrucous leukoplakia

Answer: C

Rationale:
Non-homogenous leukoplakia (1) and erythroplakia (2) and proliferative Verrucous
Leukoplakia (3) are all high risk lesions. Homogeneous leukoplakia has a 3% risk of
transformation over 7 years (1). While, excision or ablation of leukoplakia does not lower
ones risk of subsequent development of invasive squamous cell carcinoma, concern for
microinvasion or carcinoma in situ (CIS) increases with development of non-homogenous
areas or erythroplasia (red speckling) within the area of leukoplakia. Up to 20-25% of
speckled leukoplakia may harbor invasive cancer or CIS, or subsequently transform.
Excision of these areas may be indicated while best treatment for homogenous areas is
structured follow-up and selective biopsy as indicated by clinical changes. Proliferative
verrucous leukoplakia (PVL) is a specific sub-type that warrants special attention. It is an
insidious and progressive expression of field cancerization phenomenen whereby
mucosa progresses through stages of leukoplakia, verrucous carcinoma and finally
squamous cell carcinoma. It is indicated for aggressive surgical intervention, and
possibly medical therapy (anti-fungals) in an attempt to control it. Long-term prognosis is
poor.

Reference:
Holmstrup P, Vedtofte P, Reibel J, Stoltze K. Long-term treatment outcome of oral
premalignant lesions. Oral Oncology 2006;42:461-474

Silverman S Jr, Gorsky M, Lozada F. Oral leukoplakia and malignant transformation. A

follow-up study of 257 patients. Cancer. 1984 Feb 1;53(3):563-8.

Bagán J, Jimenez Y, Sanchis J, Roveda R, Milian M, Murillo J, Scully C. Proliferative

verrucous leukoplakia: high incidence of gingival squamous cell carcinoma. J Oral Path
Med.2003 32(7), 379-382.

Search Terms: = Pathology diagnosis /work-up

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Proliferative verrucous leukoplakia (PVL) has:

A. male predilection.

B. strong association with tobacco.

C. gingiva as a common site of occurrence.

D. causation from human papilloma virus.

Answer: C

Rationale:
Proliferative verrucous leukoplakia (PVL) is a specific sub-type of leukoplakia that
warrants special attention. It is an insidious and progressive expression of field
cancerization phenomenon whereby mucosa progresses through stages of leukoplakia,
verrucous carcinoma and finally squamous cell carcinoma. Gingiva is the most common
site. PVL has a 4:1 female predilection and its association with tobacco is weak. Peak
incidence is around age 65 and it is rare before the age of 45. Candida is associated
with the vast majority of cases. Its role in the instigation or promotion has not been
defined. Diagnosis is made by biopsy, which must be deep enough (into submucosa or
to level of periosteum) to make diagnosis and to enable detection of any invasive
component. It is indicated for aggressive surgical intervention with excision to the level of
the periosteum or submucosa, and possibly medical therapy (anti-fungals) in an attempt
to control it. Attempts at margins clear of clinical evidence of leukoplakia are not
necessary as alteration of the adjacent mucosa at the molecular level is almost certain.
Elimination of obvious disease is the goal. Recurrence rate is high and patients should
be maintained in close (2 mos.) follow-up. Long-term prognosis is poor as patients
typically progress at some point to invasive carcinoma.

Reference:
Hansen LS, Olson JA, Silverman S Jr. Proliferative verrucous leukoplakia. A long-term
study of thirty patients. Oral Surg Oral Med Oral Pathol. 1985 Sep;60(3)285-98.

Silverman S, Gorsky M. Proliferative verrucous leukoplakia: A follow-up study of 54

cases Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;84:154-7

Bagán J, Jimenez Y, Sanchis J, Roveda R, Milian M, Murillo J, Scully C. Proliferative

verrucous leukoplakia: high incidence of gingival squamous cell carcinoma. J Oral Path
Med.2003 32(7), 379-382.

Bagán J, Murillo J, Poveda R, Gavaldá et al. Proliferative verrucous leukoplakia: unusual

locations of oral squamous cell carcinomas, and field cancerization as shown by the
appearance of multiple OSCCs. Oral Oncology 2004;40:440-43

Bagán JV, Jimenez Y, MurilloJ, Gavalda, et al. Lack of Association Between Proliferative
Verrucous Leukoplakia and Human Papillomavirus Infection. J Oral Maxillofac Surg
2007;65:46-49

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Immediately following inset of a nasolabial flap, note is made of excessive ecchymosis and
increased turgor. Which of the following maneuvers is indicated?

A. Release of sutures

B. Doppler pedicle to ascertain integrity of arterial inflow

C. Intravenous heparin bolus followed by maintenance level of heparin

D. Application of vacuum assisted closure device (VAC)

Answer: A

Rationale:
Increased turgor and ecchymosis indicate venous congestion, which may be secondary
to pressure on the pedicle or heamtoma formation under the flap. Release of sutures
allows outflow to resume, and alteration of the flap inset or tunnel can be performed.
Arterial inflow is intact leading to the congestion. Doppler is not necessary. Heparin
boluses should be avoided intra-op. The VAC device is excellent for split thickness
grafts, or management of open wounds, but has no role in early flap salvage.

Reference:
Herford AS, Ghali GE: Local and regional flaps. In: Ghali GE, Larsen PE, Waite PD (eds):
Oral and Maxillofacial Surgery. Second edition. Chapter 38. Ontario, BC Decker. pp. 780-
781, 2004.

Schuster R, Moradzadeh A, Waxman K. The use of vacuum-assisted closure therapy for

the treatment of a large infected facial wound. Am Surg 72: 129-131, 2006.

Search Terms: = Soft tissue reconstruction/regional flaps

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Which of the following represents the most reliable method of reconstruction of this
ameloblastoma?

A. Tooth extraction and decompression of the tumor, followed approximately six months
prior by ablative surgery via subperiosteal dissection and immediate bone grafting

B. Resection of the tumor with placement of a reconstruction bone plate and immediate
corticocancellous bone grafting

C. Segmental resection with maxillomandibular fixation for 6 weeks followed by

corticocancellous grafting

D. Segmental mandibulectomy and immediate reconstruction with a free fibular

microvascular flap

Answer: D

Rationale:
Answer (A): Decompression should not be advantageous in perforating solid
ameloblastoma and may seed tumor cells into surrounding uninvolved tissue. Supra-
periosteal, not subperiosteal, dissection should be performed for tumor perforation;
adhering to the principle of having an uninvolved anatomical layer over any potential
tumor extension.

Answer (B) and (C): Immediate reconstruction in cases such as the one illustrated leads
to an unacceptable risk of graft loss because of unavoidable intraoral bacterial
contamination of a large free non-vascularized osseous graft. Prolonged
maxillomandibular fixation compromises oral hygiene, limits nutritional intake, and does
not completely stabilize the proximal mandibular segments, especially from rotational
forces brought about by muscle pull and scar contractions. The contemporary use of
rigid reconstruction plates in many cases makes prolonged MMF unnecessary.

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Answer (D): Soft tissue and bone loss in the anterior mandible in this case makes
immediate reconstruction using a vascualrized osteocutaneous flap the best option in this
case. However, controversy exists regarding the place of free fibular grafts in immediate
mandibular reconstruction, since the osseous bulk and form are often inferior to that
obtained by appropriately placed particulate grafts from the ileum. This may be less of a
concern in the modern era of implant rehabilitation.

Reference:
Oral and Maxillofacial Surgery Knowledge Update. 2006 Vol 4, PTH/166.

Futran N., Farwell D., Smith R., Johnson P., Funk G. Definitive management of severe
facial trauma utilizing free tissue transfer. Otolaryngology - Head and Neck Surgery
132(1): 75-85

Marx RE, Stevens MR. Reconstruction of avulsive maxillofacial injuries. In: Fonseca RJ
and Walker RV, eds. Oral and Maxillofacial Trauma, Vol. 2. Philadelphia, W.B. Saunder,
1991: 1023-1104.

Carlson ER, Marx RE. Mandibular reconstruction with particulate bone cancellous
marrow grafts – Factors resulting in predictable reconstruction of the mandible. In:
Worthington P and Evans J, eds. Controversies in Oral and Maxillofacial Surgery.
Philadelphia: W.B. Saunders, 1993: 288-300.

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Which of the following would be distinctive features in the histologic structure of calcifying
epithelial odontogenic tumor (Pindborg tumor)?

A. Duct-liked structure

B. Concentric Liesegang ring calcifications

C. Hyalinized material

D. Stellate cells

Answer: B

Rationale:
Answer (A): Duct-liked structure is found in adenomatoid odontogenic tumor
Answer (B): Concentric Liesegang ring calcifications is a distinctive feature in histologic
structure of calcifying epithelial odontogenic tumor (Pindborg tumor).
CEOT is an uncommon tumor with a peak incidence around 40 years. It typically
presents as a mixed radilolucent-radiopaque lesion although it may be completely
radiolucent early. It arises from odontogenic epithelium but the exact cell of origin
remains controversial. Histologically they are unencapsulated with sheets of polygonal
cells. Liesegang rings are represented by calcifications within amorphous amyloid.
Enucleation results in recurrence rates of 15-30 % making resection with 1.0-1.5 cm of
bone and one uninvolved anatomical barrier the method of choice for curative surgery.
Answer (C): Hyalinized material could be found in calcifying epithelial odontogenic tumor
but it is not a distinctive feature.
Answer (D): Stellate cells are found in histological feature of ameloblastoma.

Reference:
Oral and Maxillofacial Surgery Knowledge Update, 2006 Vol 4, PTH/115-133.

Weber AL, Kaneda T, Scrivani SJ, Aziz S. Jaw: cysts, tumors, and nontumorous lesions.
In: Som PM, Curtin HD, eds. Head and Neck Imaging. St Louis, Mo: Mosby, Inc; 2003:
930-994.

Search Terms: = Pathology diagnosis / work-up

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Which of the following rankings of imaging studies is correct with regard to the sensitivity and
specificity for the detection of lymph node metastasis in head and neck cancer? (FDG PET = F-
fluorodeoxyglucose positron emission tomography, CT = computed tomography, MRI =
magnetic resonance imaging, and US = ultrasonography)

A. MRI > CT > FDG PET > US

B. CT > MRI > FDG PET > US

C. FDG PET > CT > MRI > US

D. US > FDG PET > CT > MRI

Answer: C

Rationale:
While a contrasted computed tomography scan from skull base to clavicles along with a
chest radiograph and comprehensive metabolic profile remain the standard work-up for
patients with oral squamous cancer, positron emission tomography imaging is becoming
increasingly common. FDG-PET relies on the fact that rapidly growing tumor cells
uptake radioactive labeled glucose molecule faster and in greater quantities than
surrounding cells. PET can be combined with CT to gain a better delineation of the
tumor. False positives can results from healing wounds (biopsies) and infection. A
recent study prospectively compared FDG PET with conventional imaging modalities
(CT, MRI, ultrasonography) in lymph node staging of head and neck cancer and found
that PET had a sensitivity and specificity of 90% and 94%, respectively, compared with
82% and 85% for CT, 80% and 79% for MRI, and 72% and 70% for ultrasonography.

While showing promise, PET is NOT part of the standard workup for SCC of the oral
cavity.

Reference:
Oral and Maxillofacial Surgery Knowledge Update. 2006 Vol 4, PTH/33.

Chisin R, Macapinlac HA. The indications of FDG-PET in neck oncology. Radiol Clin
North Am. 2000; 38: 999-1012.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following are most commonly associated with lichen planus?

A. Subepithelial bullae formation and lace-like striations (Wichham’s striae)

B. Crusting of lips and a band-like infiltrate of lymphocytes

C. Wickham’s striae and “saw-tooth” rete pegs

D. Intraepithelial lesions and deposits of IgM, IgG, IgA, C3 and fibrinogen

Answer: C

Rationale:
Lichen planus is a T cell mediated autoimmune disease. The immune system is
activated against antigens in the basal cell layer resulting in inflammatory infiltrate at the
basal layer with liquefaction necrosis and separation. It is most common in patients older
than 40 years, and affects men and women equally. It occurs in threee forms: reticular,
plaque and erosive. Biopsies are submitted in Michel's medium to allow
immunofluorescence to assist in ruling out other immune modulated disorders, such as,
pemphigoid and pemphigus vulgaris. Classically, reticular form of lichen planus
presents as irregularly shaped white plaques that are associated with lace-like striations
(Wickham's striae). Biopsies of lichen planus show epithelial changes that consist of
parakeratosis and orthokeratosis, varying thickness of the spinous cell layer, “saw-tooth”
rete peg formation (hydropic degeneration) of the basal cell layer. Treatment consists of
topical and occasionally systemic steroids for erosive forms. While uncommon (1-3%)
malignat transformation is a known risk of erosive lichen planus. Follow-up is required.
The lesions of pemphigus are intraepithelial. Pemphigoid is characterized by
subepithelial bullae formation that affects mucous membranes, including the oral cavity.

Immunohistological studies have not identified specific features that are diagnostic for
oral lichen planus.

Reference:
Oral and Maxillofacial Surgery Clinics of North America, Cutaneous & Mucous
Membrane Lesions of the Head and Neck; Diagnosis and Management. 1998: Feb 10(1):
95-129.

Williams DM. Vesiculo-bullous mucocutaneous disease: benign mucous membrane and

bullous pemphigoid. J Oral Pathol Med. 1990 Jan 19(1):16-23. Review.

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Which of the following is the standard treatment for mandibular osteosarcoma?

A. Chemotherapy and radiation only

B. Surgical resection with a wide (2-3 cm) margin and consideration for preoperative and
postoperative chemotherapy

C. Surgical resection with a wide (2-3 cm) margin and planned post-operative radiation
therapy

D. Surgical resection with a wide (2-3 cm) margin following neo-adjuvant chemotherapy and
radiation therapy

Answer: B

Rationale:
Osteosarcomas or osteogenic sarcomas present on average at a later age than those of
long bones (37 vs. 25). Typical presentation involves an expansile lesion of the mandible
or as a incidental finding on a radiograph. Biopsy is performed and workup includes chest
radiograph or CT and CT of the head and neck. Management of osteosarcoma of the
head and neck involves wide surgical resection. Induction chemotherapy is considered if
the sarcoma is felt to be “nonresectable” (if the surgeon feels that the odds of getting
clear margins with resection are low). More recently, induction chemotherapy is
becoming more common in all but the smallest tumors in an attempt to eliminate distant
micrometastasis. The resection specimen can then be evaluated for responsiveness and
post-operative chemotharpy can be modified as needed based on the responsiveness
judged by tumor necrosis. Postoperative chemotherapy is typically given in cases of
mandibular osteosarcoma. Although radiation therapy may be considered post-
operatively in rare cases (typically palliation), there is no accepted role for planned post
or pre-resection radiation therapy in the management of osteosarcoma. Overall survival
is around 50% at 5 years.

Reference:
Smeele LE, Kostense PJ, van der Waal I, Snow GB. Effect of chemotherapy on survival
of craniofacial osteosarcoma: a systematic review of 201 patients. J Clin Oncol. Jan
1997;15(1):363-367.

Carlson ER, Panella T, Holmes JD. Sarcoma of mandible. J Oral Maxillofac Surg. Jan
2004;62(1):81-87.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following is true regarding neurogenic tumors of the mandible?

A. Schwannoma cannot be resected with preservation of the nerve

B. Neurofibromas always occur as part of an autosomal dominant syndrome

C. Involvement of the inferior alveolar nerve is more likely to be seen in patients with
neurofibromatosis type 1 rather than in patients with neurofibromatosis type 2

D. Neurofibromas are characterized histologically as an encapsulated spindle cell tumor

with variable amounts of tissue known as Antoni A and Antoni B

Answer: C

Rationale:
Neurogenic tumors are usually subdivided into Schwannomas and Neurofibromas.
Schwannomas typically arise on a “stalk” allowing resection with preservation of the
nerve from which it is arising. Histologically they are encapsulated tumors with excision
resulting in near 100% cure. Conversely, neurofibromas are unencapsulated and
infiltrating tumors arising from perineural fibroblasts. The parent nerve is completely
enveloped and entangled with the tumor requiring resection of the nerve trunk.
Neurofibromas typically occur with neurofibromatosis type 1. Type II neurofibromatosis
involves central tumors commonly affecting cranial nerve VIII and not neurofibromas.
Schwannoma can typically be resected with preservation of the nerve. Antoni A and B
tissue are observed with Schwannomas.

Reference:
Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, pp. 408-419.

De Lange J, Van den Akker HP. Clinical and radiological features of central giant-cell
lesions of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Apr
2005;99(4):464-470.

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A 17 year-old female presents with a two month history of a maxillary anterior swelling. She has
no other associated symptoms. A biopsy is performed and the histomicrograph is presented
below. What is the most likely diagnosis?

A. Adenocarcinoma

B. Ameloblastic fibroma

C. Ameloblastoma

D. Adenomatoid odontogenic tumor

Answer: D

Rationale:
The adenomatoid odontogenic tumor, referred to as adenomatoid odontogenic cyst by
some, is a cystic hamartoma arising from odontogenic epithelium frequently associated
with an impacted canine tooth. Approximately 2/3 arise in the anterior maxilla most
commonly affecting the anterior maxilla of young women. Treatment involves
enucleation of the tumor. Preservation of the affected canine tooth if present is usually
not possible because the tooth is enveloped by the tumor. The clinical presentation of an
anterior maxillary swelling in a woman is clinically consistent with an adenomatoid
odontogenic tumor. The histology demonstrating duct-like structures of columnar
epithelial cells and calcification are consistent with adenomatoid odontogenic tumor.

Reference:
Buchner A, Merrell PW, Carpenter WM. Relative frequency of central odontogenic
tumors: a study of 1,088 cases from Northern California and comparison to studies from

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other parts of the world. J Oral Maxillofac Surg. Sep 2006;64(9):1343-1352.

Philipsen HP, Reichart PA. Adenomatoid odontogenic tumour: facts and figures. Oral
Oncol. Mar 1999;35(2):125-131.

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When harvesting an anterolateral thigh flap, dissection of the septocutaneous perforators is

carried out between which two muscles?

A. Rectus femoris and sartorius

B. Sartorius and vastus intermedius

C. Vastus lateralis and rectus femoris

D. Vastus intermedius and vastus lateralis

Answer: C

Rationale:
The anterior lateral thigh flap provides an excellent amount of soft tissue for
reconstruction of ablative wounds of the head and neck. Its main advantage is that the
donor site can almost always be closed primarily with an inconspicuous scar on the thigh.
Body habitus is the main determinant of usefulness. Excess fat on the lateral thigh may
lead to excessive bulk in some defects requiring alternative flap choices. The ALT has
subplanted some of the alternative flaps such as the rectus abdominus and radial
forearm flap. The muscles which are first encountered when raising the anterior lateral
thigh flap are: the vastus lateralis (laterally) and the rectus femoris medially. Deep to the
vastus lateralis is the vastus intermedius and traveling from superior lateral to inferior
medial is the Sartorius muscle. The Sartorius is not encountered in the routine dissection
of the ALT flap

Reference:
Fernandes R, Lee J: Use of the lateral circumflex femoral artery perforator flap in the
reconstruction of gunshot wounds to the face. JOMS 2007 65: 1990-1997.

Fernandes R: Anterolateral thigh flap in mandibular reconstruction. Atlas Oral Maxillofac

Surg Clin North Am. 2006 Sep;14(2):185-9

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The arterial supply to the latissimus flap is the:

A. angular.

B. thoracodorsal.

C. circumflex scapular.

D. thoracoacromial.

Answer: B

Rationale:
The latissimus dorsi flap remains an excellent choice for reconstructing defects requiring
bulk or large areas of skin coverage, which is its primary advantage. Other advantages
include ease of harvest and ability to close most donor sites primarily. It can be
transferred as a pedicled flap or free vascularized flap. The primary disadvantage is the
frequent need to adjust the patient's position to harvest which does not allow
simultaneous harvest. The dominant blood supply to the latissimus free flap is the
thoracodorsal artery which originates from the subscapular artery. Secondary segmental
pedicles come from perforating arterial branches of the posterior intercostals artery
(lateral) and from lumbar artery (medial).

Reference:
Mathis S, Nahai F: Reconstructive Surgery, principles, anatomy and technique. Volume
1 page: 567; Quality Medical Publishing 1997

Herford AS, Ghali GE: Local and Regional Flaps. In: Ghali GE, Larsen PE, Waite PD
(eds): Oral and Maxillofacial Surgery. Second edition. Chapter 38. Ontario, BC Decker. p
780, 2004.

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When harvesting an osseocutaneous scapular free flap, which of the following is the dominant
artery to the flap?

A. Circumflex scapular

B. Thoracodorsal

C. Angular

D. Thoracoacromial

Answer: A

Rationale:
The scapula flap is a versatile osteocutaneous flap whose main advantage is the mobility
of the skin paddle(s) in relationship to the bone. An extensive amount of skin is
available, and several paddles can be created. The pedicel is long and of good caliber,
and there is minimal donor site morbidity. The primary disadvantage is the need to
reposition the patient, which precludes a two-team, simultaneous approach. The flap is
one of several flaps based on the important subscapular system, including the lat dorsi
flap, which is based on the thoracodorsal vessels. The dominant pedicle to the scapular
osseocutaneous flap is the circumflex scapular artery. The angular artery (a branch of the
thoracodorsal artery) supplies the inferior aspect of the scapula an should be included if
the tip of the scapula is required in the reconstruction, but it is not the dominant pedicle to
the flap. The thoracoacromial pedicel is of course the dominant blood supply to the
pectoralis flap.

Reference:
Mathis S, Nahai F: Reconstructive Surgery, principles, anatomy and technique. Volume
1 page: 619; Quality Medical Publishing 1997.

Dolan RW: Microvascular surgery. In: Lore JM, Medina JE (eds): An Atlas of Head and
Neck Surgery. Fourth Edition. Chapter 24. Philadelphia, PA. Elsevier. p 1428, 2005.

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Which of the following can safely be preserved when resecting the solid mandibular
ameloblastoma represented by the 3- dimensional computed tomogram and clinical
photograph?

A. The inferior alveolar nerve

B. The marginal branch of the cranial nerve VII

C. The inferior border of the mandible

D. The oral mucosa overlying the biopsy site.

Answer: B

Rationale:
Although the preservation of the inferior alveolar nerve is advocated by some, long term
evidence of the safety of this practice has not been shown. Although the solid or
multicystic ameloblastomas have been shown to infiltrate the connective tissues
surrounding the nerves, they do not invade the nerves themselves. Cells adherent to the
connective tissue surrounding the nerve may remain and attempts at preserving the
nerve may lead to recurrence of the tumor or to incomplete removal. In other words,
while not neurotropic they (amelobalsotmas) are neuroadherent, resulting in a possibility
of tumors cells being left behind. In addition, if one were to agree that one tumor free
anatomic barrier should be removed when resecting ameloblastomas, then the
epineurium of the nerve would need to be removed since the tumor abuts (but not
invades) this layer. There is no data to support preservation of the inferior alveolar
nerve.

OBJECTIVE: Growth characteristics of ameloblastomas involving the inferior alveolar

nerve were examined to determine the most appropriate surgical management of the
nerve at the time of the surgical procedure. STUDY DESIGN: Clinical and histopathologic
examinations were performed on 22 resected mandibles in which the inferior alveolar
nerve was lying adjacent to, or contained within, the tumor. RESULTS: Patterns of tumor
involvement of the nerve bundle were evaluated with respect to the presence of bone (11

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patients) or connective tissue wall (7 patients) between the tumor and the nerve bundle,
and tumor infiltration of perineural connective tissue (4 patients). Neither invasion into the
nerve sheath nor invasion into the nerve itself by the ameloblastoma was detected.
Tumor infiltration of the tissue surrounding the nerve was identified for the multicystic and
solid types but not for the unicystic type. Presence of bone or connective tissue wall
between the tumor and the nerve bundle was dominant in the unicystic and plexiform
ameloblastomas, whereas tumor infiltration of the perineural tissue was frequently
observed in ameloblastomas with the follicular pattern. CONCLUSION: The preservation
of the inferior alveolar nerve may be possible in the management of the unicystic type of
ameloblastoma. However, a more radical approach is necessary for treatment of
multicystic or solid tumors, especially those exhibiting a follicular pattern.

Reference:
Norifumi Nakamura et.al. Growth characteristics of ameloblastoma involving the inferior
alveolar nerve: a clinical and histopathologic study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2001;91:557-62

Carlson ER, Marx RE. The ameloblastoma: Primary, curative surgical management.
JOMS 64; 484-494, 2006.

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Which of the following malignant salivary gland tumors is most common?

A. Warthin’s tumor

B. Carcinoma ex Pleomorphic adenoma

C. Mucoepidermoid carcinoma

D. Adenoid cystic carcinoma

Answer: C

Rationale:
Mucoepidermoid carcinoma is the most common malignant salivary gland tumor. It is the
most common parotid gland malignancy accounting for almost 90% of primary parotid
salivary gland cancers, and is the most common salivary malignancy affecting children.
Treatment is predicated on grade with higher grades tending to behave more like
squamous cell carcinoma with earlier metastasis and requiring more aggressive
treatment. While pleomorphic adenoma is the most common salivary gland tumor,
carcinoma ex pleomorphic adenoma is rare. Warthin's tumor is benign. Adenoid cystic
carcinoma is the second most common salivary malignancy.

Reference:
Bell RB, et al. J Oral Maxillofac Surg 63:917, 2005.

Ord RA, Pazoki AE: Salivary gland disease and tumors. In: Ghali GE, Larsen PE, Waite
PD (eds): Oral and Maxillofacial Surgery. Second edition. Chapter 35. Ontario, BC
Decker. p 672, 2004.

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Which of the following salivary gland tumors is most often associated with perineural invasion?

A. Pleomorphic adenoma

B. Mucoepidermoid carcinoma

C. Polymorphous low grade adenocarcinoma

D. Acinic cell carcinoma

Answer: C

Rationale:
Polymorphous low grade adenocarcinoma (PMLGA) arises from terminal duct cells and
is associated with perineural invasion but has a much different prognosis than adenoid
cystic carcinoma, which is also associated with perineural invasion. Investigators are
unsure why this is the case, but some suggest that it lacks much metastatic ability unlike
the Adenoid cystic ca. PMLGA most commonly affects the minor salivary glands and is
second only to mucoepidermoid cancer in this site. In the past it was frequently mis-
diagnosed, but more recently has been recognized as being more common than
previously thought.10 year survival is over 80%.

Reference:
Neville, Damm. Oral and Maxillofacial Pathology. WB Saunders 1995. P 357.

Ord RA, Pazoki AE: Salivary gland disease and tumors. In: Ghali GE, Larsen PE, Waite
PD (eds): Oral and Maxillofacial Surgery. Second edition. Chapter 35. Ontario, BC
Decker. p 672, 2004.

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In which salivary gland does pleomorphic adenoma most commonly occur?

A. Parotid

B. Submandibular

C. Sublingual

D. Palatal (minor salivary glands)

Answer: A

Rationale:
Pleomorphic adenoma is the most common tumor of the parotid gland and the parotid
gland is the most common site for pleomorphic adenoma. Pleomorphic adenoma is the
most common benign salivary gland tumor affecting both the major and minor glands.
The most common presentation is a painless, mobile mass (except in the palate were it is
usually fixed by the dense overlying mucosa). Treatment consists of excision with a cuff
of normal tissue to ensure removal. Involvement of the sublingual and submandibular
glands is usually treated with excision of the affected gland. Involvement of a minor
gland of the palate requires excision with 0.5-1.0 cm margins to avoid tumor spillage.
Recent studies have suggested extracapsular excision of parotid pleomorphic adenomas
is adequate, but tumor spillage is associated with a high risk of recurrence and must be
avoided. Most authors suggest a margin of normal parotid parenchyma with the
resection, and avoidance or extracapsular dissection except in areas of contact with the
facial nerve. Complete superficial parotidectomy, however, is not required.

Reference:
Marx RE, Stern D: Oral and Maxillofacial Pathology . Chicago, Il. Quintessence
Publishing, 2003, p 528-532.

Salivary Gland Diseases. In Regezi JA, Sciubba JJ, Jordan RCK (eds): Oral Pathology:
Clinical Pathologic Correlations. Chapter 8. St. Louis, Missouri, Elsevier, pp. 195-196,
2008.

Witt RL: The significance of the margin in parotid surgery for pleomorphic adenoma.
Laryngoscope. 2002 Dec;112(12):2141-54.

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Histologic grade is the most important prognostic indicator for which malignant salivary gland
neoplasm?

A. Acinic cell carcinoma

B. Mucoepidermoid carcinoma

C. Polymorphous low-grade adenocarcinoma

D. Pleomorphic adenoma

Answer: B

Rationale:
Histologic grade is the most important prognostic indicator in mucoepidermoid
carcinoma. Grading primarily depends on the relative mix of mucous secreting cells,
epidermoid cells, intermediate cells and clear cells, although growth pattern and atypis
also are taken into account. Lower grades tend to have a preponderance of mucous
producing cells and can form large cysts. Higher grades have more epidermoid
components, and increased atypia. Knowledge of grade guides treatment. High grade
mucoepidermoid cancers tend to behave more like squamous cell cancers of the oral
cavity with more frequent involvement of surgical margins and a greater propensity for
lymph node metastasis. Low grade mucoepidermoid cancers rarely recur. Multi-modality
therapy is frequently used in the treatment of higher grade. Elective neck dissection
should be considered in high grade and some intermediate grade mucoepidermoid
cancers.

Reference:
Rapidis AD, Givalos N, Gakiopoulou H, Stavrianos SD, Faratzis G, Lagogiannis GA,
Katsilieris I, Patsouris E.Mucoepidermoid carcinoma of the salivary glands. Review of the
literature and clinicopathological analysis of 18 patients.

Oral Oncol. 2007 Feb;43(2):130-6. Epub 2006 Jul 20. Review.

Aro K, Leivo I, Makitie AA: Management and outcome of patients with mucoepidermoid
carcinoma of major salivary gland origin: a single institution's 30 year experience.
Laryngoscope 118(2):258-262, 2008.

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Which of the following has been shown to be associated with a decreased risk of development
of osteoradionecrosis?

A. Radiation dose of >70Gy

B. Removal of questionable teeth 16 days prior to commencement of radiation therapy.

C. Long term edentulism

D. Once daily fractionation

Answer: C

Rationale:
While previously thought to decrease the risk of ORN, removal of teeth prior to initiation
of XRT has recently been shown to increase the risk of future ORN if preformed within 3
weeks of initiation of XRT. Long-term edentulism, however, offered a protective benefit.
Once daily fractionation and dose >70Gy were both associated with increased risk as
well.

Reference:
Chang DT, Sandow PR, et al. Do pre-iradiation dental extractions reduce the risk of
osteoradionecrosis of the mandible ? Head Neck 29 (6)528-536, 2007.

Goldwaser BR, Chuang SK, et al. Risk factor assessment for the development of
osteoradionecrosis. J Oral Maxillofac Surg 2007:65: 2311-2316.

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Which of the following is the single most important factor to consider when deciding whether or
not to perform an elective neck dissection in a patient with a squamous cell carcinoma of the
tongue?

A. Tumor diameter

B. Depth of invasion

C. Tumor differentiation

D. Presence of lymphovascular invasion

Answer: B

Rationale:
Depth of invasion is the most critical factor when trying to decide whether or not to
perform an elective neck dissection. Depth of invasion >2-4 mm has been shown to be
significant risk factor for occult metastasis. The other factors listed, while important
considerations, have not been shown to be as predictive.

Reference:
Pillsbury HC, Clark M. A rationale for therapy of the N 0 neck: Joseph H. Ogura
Lecture. Laryngoscope 1997; 107: 1294-1315.

Spiro JD, Spiro RH, Shah JP, et al. Critical assessment of supraomohyoid neck
dissection. Am J Surg 1988; 156: 286-289.

Holmes J, Dierks, E. Oral Cancer in Peterson's principles of oral and maxillofacial

surgery. BC Decker Inc. second ed. 2004

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Which of the following is true regarding bisphosphonate induced osteonecrosis of the jaw?

A. Halting intraveonous forms of the medication has been shown to be beneficial in the
management of these patients

B. Removal of any remaining teeth should be performed prior to starting intravenous

bisphosphonate therapy

C. The mandible and maxilla are at equal risk

D. Osteopetrosis is a naturally occurring analogue to bisphosphonate induced osteonecrosis

Answer: D

Rationale:
Halting IV bisphosphonates has not been shown to be of benefit in the management of
BONJ. All teeth need not be removed prior to starting IV bisphosphonates, but any
questionable teeth should be extracted prior to starting therapy. The maxilla and
mandible seem to be equally at risk. Osteopetrosis (Marble bone disease) shares many
of the clinical features with BONJ.

Reference:
Advisory task force on bisphosphonate-related osteonecrosis of the jaws. American
Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related
osteonecrosis of the jaws.

J Oral Maxillofac Surg. 2007 Mar;65(3):369-76.

Marx, RE. Oral and Intravenous bisphosphonate induced osteonecrosis of the jaw:
history, etiology, prevention and treatment. Chicago, Il Quintessence. 2006

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Which of the following is true regarding full thickness skin grafts?

A. They are more prone to primary contraction than split thickness skin grafts

B. They are more prone to secondary contraction than split thickness skin grafts

C. Leaving more dermis at the donor site will promote faster healing

D. Thickness is typically 0.3-0.45 mm

Answer: A

Rationale:
Full or split thickness skin grafting allows repair of large wounds that are not amenable to
healing by secondary intention and in which flap repair is not indicated or necessary.
Unlike flaps, grafts are dependant on nutrition from the recipient bed (plasmatic
circulation or imbibition) for 48 to 72 hours until capillary in growth occurs. During the
early wound healing phase, absolute stability of the graft provides the best opportunity to
prevent shearing and graft loss. Full-thickness grafts include the epidermis and dermis
and usually provide a more esthetic result with less late wound contracture if there is
satisfactory take of the graft. The supraclavicular and post-auricular areas provide good
quality skin for full thickness grafting with good color match for most facial sites. Skin
harvested from the upper eyelids provides an excellent thin full thickness graft.
Disadvantages of full thickness grafting include need for closure of the donor site, and
increased risk for either partial of complete graft failure. Split thickness grafts include
epidermis and a portion of the dermis. Healing of the donor site depends on epithelial
migration from skin appendages and lateral edges. Split thickness grafts are less
esthetic in most cases, and are susceptible to more contracture. Advantages include the
ability to cover larger areas, and higher successes with graft take.

Primary contracture refers to the immediate shrinkage that occurs when a soft tissue
graft is harvested, and full thickness grafts are more susceptible to primary contracture
than STSG. FTSG, however, are more resistant to late contracture than STSG, and
provide a more esthetic result. By definition, FTSG include the entire dermis. STSG are
typically 0.3-0.45 mm thick, and are more prone to late contraction. Full thickness skin
grafts are indicated in areas in which the esthetics of a split thickness graft are
unacceptable (i.e. most areas of the face), and the area is small enough to allow full
thickness grafting. Full thickness grafts are more resistant to trauma.

Reference:
Zide MF, Trokel Y. Head and Neck skin cancer. In: Ghali GE, Larsen PE, Waite PD
(eds): Oral and Maxillofacial Surgery. Second edition. Chapter 37. Ontario, BC Decker. p.
718, 2004.

Baker SR, Swanson NA. Local flaps in facial reconstruction. St. Louis, MO. Mosby. 1995.

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Which of the following is the most appropriate elective neck dissection for a squamous cell
carcinoma involving the anterior-lateral oral tongue measuring 2.1 x 2.0 cm and 3 mm deep?

A. Selective neck dissection with removal levels I-III

B. Modified radical neck dissection with removal of levels I-V

C. Radical neck dissection with removal of levels I-V

D. Sentinal node biopsy

Answer: A

Rationale:
Classification of Neck Dissections
Neck dissections can be broadly classified as comprehensive or selective.
Comprehensive neck dissections include all of the lymph node levels removed in a
standard radical neck dissection (Levels I-V), and include radical neck dissection and
modified radical neck dissection. A dissection which leaves in place one or more of
these levels is considered a selective neck dissection. Likewise, any dissection that
removes additional lymph node levels or non-lymphatic structure is termed an extended
neck dissection. Specific definitions are outlined below:

Radical neck dissection (RND):

Refers to the removal of all ipsilateral cervical lymph node groups extending from the
inferior border of the mandible to the clavicle, from the lateral border of the sternohyoid
muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to
the anterior border of the trapezius. Included are levels I through V. This entails the
removal of three important, non-lymphatic structures: the internal jugular vein, the
sternocleidomastoid muscle and the spinal accessory nerve. (Figure 2)

Modified Radical Neck Dissection (MRND):

Refers to removal of the same lymph node levels (I through V) as the radical neck
dissection, but with preservation of the spinal accessory nerve, the internal jugular vein or
the sternocleidomastoid muscle. The structures preserved should be named. While
some authors propose subdividing the modified neck dissection into three types: Type I
preserves the spinal accessory nerve, Type II preserves the spinal accessory nerve and
the sternocleidomastoid muscle, and Type III preserves the spinal accessory nerve, the
sternocleidomastoid muscle and the internal jugular vein, the standard is to name the
preserved structure following the MRND abbreviation instead of using subtypes.

Selective Neck Dissection (SND)

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Refers to the preservation of one or more lymph node groups normally removed in a
radical neck dissection. In the 1991 classification scheme there were several “named”
selective neck dissections. For example, the supraomohyoid neck dissection removed
the lymph nodes from levels I-III. The subsequent proposed modification in 2001 sought
to eliminate these “named” dissections. The committee proposed that selective neck
dissections be named for the cancer that the surgeon was treating and to name the node
groups removed. For example, a selective neck dissection for most oral cavity cancers
would encompass those node groups most at risk (levels I-III) and be referred to as a
SND (I-III). (Figure 3)

Extended neck dissection

The term extended neck dissection refers to the removal of one or more additional lymph
node groups, non-lymphatic structures or both, not encompassed by a radical neck
dissection. For example, mediastinal nodes or non-lymphatic structures, such as, the
carotid artery, hypoglossal nerve, etc. (Figure 4)

Selective neck dissection with removal of levels I-III (previously referred to as a

supraomohyoid neck dissection) is the most appropriate answer. While promising,
sentinel node biopsy is still considered experimental in the oral cancer setting. Both
modified and radical neck dissections are better reserved for therapeutic neck
dissections.

Reference:
Carlson ER, Miller I. Surgical management of the neck in oral cancer. Oral Maxillofac
Surg Clin N Am 2006; 18: 533-546.

Pitman KT, Ferlito A, Devaney KO, et al. Sentinal lymph node biopsy in head and neck
cancer. Oral Oncology 2003; 39:343-349.

Holmes JH. Neck Dissection: Nomenclature, Classification and Technique. Oral

maxillofac Surg Clin N Am 2008; 20: 459-475.

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The most common cutaneous malignancy affecting Caucasians is:

A. squamous cell carcinoma.

B. basal cell carcinoma.

C. malignant melanoma.

D. Merkel cell carcinoma.

Answer: B

Rationale:
Basal cell carcinomas are 4x more common than squamous cell carcinoma in
caucasians. Squamous cell carcinomas are the most common cutaneous malignancy
affecting African-Americans. Although less common, skin cancers affect dark and
intermediate-skinned ethnic groups. The incidence is around 3.4 per 100,000 in Blacks.
In ethnic groups with dark-skin, squamous cell cancer is most common in contrast to
basal cell cancer in Caucasians. In addition, ultraviolet radiation plays less of a role in
the development of squamous cell cancers in these groups, and squamous cell cancers
tend to occur in non-solar exposed areas in these groups, and may arise in areas of
chronic irritation, such as hidradenitis. Basal cell cancers do, however, show an
association with sun exposure in blacks with an increased risk in sun-exposed areas.

Reference:
Collins GL, Nickoonahand N, Morgan MB: Changing demographics and pathology of
nonmelanoma skin cancer in the last 30 years. Semin Cutan Med Surg 1: 80-83, 2004.

Carcinoma of the skin. In Greene FL, Page DL, Fleming ID, Fritz AG, Balch CM, Haller
th
DG, Morrow M, editors. AJCC Cancer Staging Manual. 6 ed. New York: Springer-
Verlag; 2002. p 201-220.

Gloster HM, Neal K: Skin cancer in skin of color. J Am Acad Dermatol 55: 741-760,
2006.

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For which of the following cutaneous malignancies is adjuvant radiation therapy standard in
most cases?

A. Merkel cell carcinoma

B. Squamous cell carcinoma

C. Malignant melanoma

D. Basal cell carcinomas

Answer: A

Rationale:
Originally thought to be of indolent behavior, it is now recognized that Merkel cell cancers
are aggressive tumors with a high incidence of local recurrence, regional and distant
metastases. Local and regional failure rates of 33% and 75% respectively have been
reported. Regional metastases rates of 66%, and distant metastases of 36% have been
reported.

The rarity of Merkel cell cancer (MCC) precludes large trials to develop and compare
treatment regimens, and therefore, non-standardized therapy is the norm. Aggressive
therapy, including consideration of treating the at risk lymph node basins is
recommended by most authors. Radiation therapy to the primary site, as well as at risk
nodal basins, has become standard in Merkel cell cancer. Multi-modality therapy
combining surgery and irradiation is indicated in most cases of this potentially lethal
cancer. MCC is radiosensitive and radiation should be considered to the primary site, as
well as, to the at risk nodal basins as an adjunct in most cases to improve local and
regional control. Interestingly, Merkel cell carcinoma is one of the few cutaneous
malignancies in which chemotherapy can play a significant role. MCC is
chemosensative, and chemotherapy has been used with some success in palliating
patients with non-surgical disease. Median overall survival prior to the routine use of
adjuvant therapy was 24 months, and 65% of patients died of distant disease. Survival at
one year and five years is 88% and 30-64% respectively.

Radiation therapy has little role to play in the others in most cases.

Reference:
Agelli M, Clegg LX. Epidemiology of primary Merkel cell carcinoma in the United States.
J Am Acad Dermatol 49: 832-841, 2003. [Erratum appeared in: J Am Acad Dermatol 50:
733, 2004].

Medina-Franco H, Urist MM, Fiveash J, et al. Multimodality treatment of Merkel cell

carcinoma: case series and literature review of 1024 cases. Ann Surg Onc 8:204-208,
2001.

Allen PJ, Zhang ZF, Coit DG. Surgical management of Merkel cell carcinoma. Ann Surg
229: 97-105, 1999.

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Which of the following is true regarding Moh’s micrographic surgery?

A. It uses a chemofixative (zinc chloride) for in situ tissue fixation

B. It results in lower 5 year recurrence rates when compared traditional surgical excision for
lip squamous cell cancers

C. It uses a vertical specimen sectioning technique to allow examination of 100% of the

tumor margin

D. It utilizes delayed repair of defects

Answer: B

Rationale:
Mohs chemosurgery depends on in situ fixation techniques. The current Mohs
micrographic technique does not. It uses horizontal and oblique sectioning to allow
examination of 100 % of the margin resulting in lower recurrence rates. It has nothing to
do with repair techniques chosen. Current Moh’s micrographic surgical technique does
not involve an in situ fixative as the Moh’s chemosurgical technique does. The current
technique of Moh’s micrographic surgery evolved from Dr. Frederic E. Mohs’
chemosurgery technique, which he developed while working with Professor M.F. Guyer in
the Department of Zoology at the University of Wisconsin. Dr. Mohs was evaluating the
effects of zinc chloride on cancerous tissue, when he discovered that in addition to tissue
necrosis, it resulted in excellent fixation of the tissue, which provided an excellent
specimen for histologic examination. A paste was ultimately developed, which contained
a binder, Sanquinara canadensis; a matrix, Stibnite (Hummel chemical company, South
Plainfield, NJ); and zinc chloride 45% by weight. In 1941, He presented his technique of
chemosurgery. This technique involved application of the fixative for a prescribed period
of time (maximum tissue penetration occurs at 18 hours following application), followed
by removal and microscopic examination of the fixed tissue. Depth of penetration is
controlled by altering the thickness and surface area on which the paste is applied.
Successive layers are removed until tumor clearance was accomplished. Although
infrequently used today, Mohs fixed tissue technique is still promoted by some for
treatment of melanoma and extensive skin cancers that are highly vascular. An important
part of the procedure was the specific way in which Dr. Mohs oriented his specimen,
which in theory allowed examination of 100% of the margin. Others would argue that the
most important component of the technique is that the surgeon performing the excision is
also evaluating the margins. This decreases the potential communication error,
especially regarding specimen orientation, that may occur between surgeon and
pathologist since in this case they are one and the same. At the time of his original work,
frozen section analysis of margins was not available, and although labor intensive, the
fixed tissue technique allowed for significantly improved cure rates compared to
traditional surgical excision. Several modifications of the technique occurred including
elimination of the fixative in most cases and in 1953, Dr. Mohs presented his technique
modified for use with fresh tissue and frozen analysis of margins. Careful orientation of
the specimen was the same, and the entire margin was still evaluated, which offered
advantages over traditional surgical excision and margin analysis.

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Traditional Surgical Excision vs. Mohs micrographic surgery. There is ongoing debate
regarding the choice of surgical technique for cutaneous malignancies of the head and
neck. Five year recurrence rates following traditional surgical excision have been
reported to be as high as 10.1 % in BCC, and between 10.9% (lip) and 18.7% (ear) in
SCC located in high risk areas. In contrast, Mohs’ excision is associated with a 5 year
recurrence rate of 1% for BCC and between 3.1% for lip and 5.3% for ear squamous cell
cancers. Despite the advantages of Mohs’ surgery discussed previously, there are well-
known disadvantages, including the labor and time intensiveness of the technique, which
can drive up costs of excision. Cost comparisons between Mohs’ micrographic surgery
and traditional surgical excision (TSE) have been difficult, and results contradictory. Bialy
and colleagues performed an interesting study comparing TSE and Mohs excision, and
found that the costs were comparable when Moh’s was compared to TSE with frozen
section control of margins or when compared to cases that included further treatment for
inadequate margins. They cautioned, however, that choice of repair technique often
influenced costs more than the method of excision. Dermatologic surgeons experienced
in Moh’s technique often allow certain wounds to heal by secondary intention instead of
performing coverage by local flap or grafting. Also, their excisions took place in an
outpatient clinic. Patients may not tolerate excision of larger tumors, which often require
multiple layers and lengthy procedures, under local anesthetic. Mohs surgery can be
performed under general anesthetic, but costs are increased significantly. Given the
sheer number of cutaneous malignancies, some have argued that Mohs surgery should
be reserved for specific indications (see table 3), and that traditional surgical excision is
faster and allows for an acceptable cure rate. Finally, the decision to perform Mohs’
excision technique versus traditional surgical excision may be determined by availability.
Patients in many areas simply do not have access to a surgeon or dermatologist with
training and competence in Mohs’ surgical technique. Properly performed traditional
surgical excision with or without frozen section control, remains an option for most lesions
in the head and neck. Lymph node involvement in cutaneous malignancy

Reference:
Rowe DE, Carroll RJ, Day CL. Long term recurrence rates in previously untreated
(primary) basal cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol
15: 315-328, 1989.

Cook J, Zitelli J. Mohs micrographic surgery: a cost analysis. J Am Acad Dermatol 39:
698-703, 1998

Mohs FE: Chemosurgery: Microscopically controlled surgery for skin cancer. Springfield,
IL, Charles C. Thomas, 1978

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Which of the following locations is associated with less aggressive behavior in cutaneous
malignancies?

A. Periauricular skin

B. Nasolabial folds

C. Canthi

D. Labiomental fold

Answer: D

Rationale:
Cutaneous malignancies arising in the so-called H-zone behave more aggressively for
some incompletely understood reason. Tumors in these locations seem to grow in a
more vertical fashion. Topographically, certain locations are associated with a more
aggressive clinical course. This is described as the so-called “H-zone” which includes
the eyelids, canthi, nose, nasolabial folds, upper lip, periauricular skin, including the
preauricular skin of the cheek, and frontozygomatic region of the forehead. For reasons
incompletely understood, tumors arising in these locations tend to have a more vertical
as opposed to horizontal growth pattern and therefore tend to invade more deeply. In
addition, some authors have suggested that surgeons may treat cancers in these
important esthetic subsites less aggressively leading to residual tumor and recurrences.
Additional factors suggested as contributing to the more aggressive behavior seen with
tumors arising in these areas include embryonic fusion planes, density of nerve endings,
and proximity to muscles of facial expression, cartilage and bone.

Reference:
Granstrom G, Aldenborg F, Jeppsson PH. Influence of embryonic fusion lines for
recurrence of basal cell carcinomas in the head and neck. Otolaryngol Head Neck Surg
95: 76-82 , 1986.

Wentzell JM, Robinson JK, Embryologic fusion planes and spread of cutaneous
carcinoma: a review and reassessment. J Dermatol Surg Oncol 16: 1000-1006, 1990.

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A 35 year-old white male presented with the following radiograph and a biopsy was performed.
Which of the following is the most likely diagnosis?

A. Calcifying odontogenic cyst

B. Keratocystic odontogenic tumor (odontogenic keratocyst)

C. Ameloblastoma

D. Intraosseous mucoepiermoid carcinoma

Answer: C

Rationale:
Ameloblastoma is relatively rare odontogenic tumor, first recognized by Falkson in 1879,
and represents approximately 1% of all oral tumors yet it is by far considered as the most
common odontogenic tumor. . It involves patients with a wide age range and there is no
recognized sex predilection. Approximately 85% of ameloblastomas arise in the mandible
with marked predilection for the posterior area and the balance is seen in the posterior
area of the maxilla and sinonasal involvement is also well-documented.

The neoplasm arises from odontogenic epithelial rests of Malessez that remain behind
after cessation of odontogenesis. Histologically the origin of this tumor may be from

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odontogenic cystic epithelial lining, the basal cells of the mucosal epithelium; enamel
organ ; or heterotopic epithelium from extra-oral sites such as the pituitary gland. The
tumor is divided into three distinct categories; solid/multicystic (conventional); unicystic;
and peripheral (extraooseous). 86% +of all cases belong to the solid type followed by the
unicystic type, which comprise 6% + of reported cases.

The distinction between these variants of ameloblastoma is important since it carries

diagnostic, therapeutic and prognostic implications. While the solid variant of tumor
show an infiltrative pattern and follows an aggressive course characterized by bone
destruction and post treatment recurrence, ,the unicystic variant is more or less confined
to a cystic lining and carries a much better prognosis and lower post conservative total
enucleation recurrence rate. One exception is when unicystic ameloblastoma infiltrates
deeply into the cystic wall (as seen in this case) and would be equivalent to and treated in
a similar manner tot the solid variant. Because of this variation of biological behavior of
cystic ameloblastoma, some have advocated abandoning the term “unicystic” and instead
suggest the following terms to describe cystic ameloblastomas: intraluminal
(ameloblastoma cells projecting into the lumen with no invasion of the surrounding
connective tissue wall); mural (ameloblastoma cells found within the connective tissue but
not to the connective tissue periphery); and transmural (tumor cells found through the
entire thickness of the connective tissue wall.)
Histologically, all ameloblastomas display features that more or less recapitulate the
process of odontogenesis prior to the epithelial mesenchymal interaction which ultimately
lead to hard tissue production. Columnar type epithelial cells showing reverse polarity
with vacuolization at the peripheral aspects are seen, arranged in follicles, long stands or
islands. The cells enclose a more loose type of cells that mimics the stellate reticulum
type tissue identified in tooth germ during odontogenesis.

Reference:
Nastri AL, Wiesenfeld D, Radden BG, et al: Maxillary ameloblastoma: A retrospective
study of 13 cases. Br J Oral Maxillofac Surg 1995; 33: 28-32.

Williams T. The ameloblastoma: A review of the literature. Selected Readings in Oral and
Maxillofac Surg 1992; 2: 1-17.

Neville B W, Damm D D, Allen C M, Bouquot J E. Oral and Maxillofacial Pathology.

Philadelphia: Saunders, 512-522. 1995

Biol. 2005; 563:148-64.

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A 40 year-old black male presented with this slowly enlarging submucosal, asymptomatic mass
on the upper lip. Histology of the biopsy is shown. What is your most likely diagnosis?

A. Fibroma

B. Granular cell tumor

C. Monomorphic adenoma

D. Schwannoma (neurilemmoma)

Answer: D

Rationale:

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Schwannoma (neurilemmoma) is benign neoplasms derived from Schwann cells. It has

a predilection for the head and neck, with approximately 25-40% occurring in that region
and flexor surfaces of the upper and lower extremities. It usually presents as an
asymptomatic slow growing submucosal nodule but occasionally may case pain.
rd th
Neurilemmomas tend to occur during the 3 to 4 decades of life. There is a prevalence
for tongue involvement but they may be seen virtually anywhere within the oral cavity.
The histomorphological features of schwannomas are pathognomonic, showing an
encapsulated tumor composed of Schwann cells arranged in a classic pattern: cellular
pallisaded areas (called Verocay bodies); areas of haphazard cell arrangement (Antoni
A); and other loose, hypocellular areas (Antoni B.)

Simple surgical excision is the treatment of choice,7 radiation therapy is contraindicated

since the tumor is radioresistant and incident radiation may induce sarcomatous
transformation. Post surgical local recurrence of Schwannoma is uncommon.

Reference:
6Elahi MM, Audet N, Rochon L, Black MJ. Intraparotid facial nerve schwannoma. J
Otolaryngol. 1995;24:364–367.

21Chauvin PJ, Wysocki GP, Daley TD, Pringle GA. Palisaded encapsulated neuroma of
oral mucosa. Oral Surg Oral Med Oral Pathol. 1992;73:71–74.

Giuliano A, Luis O, Fernando G. Asymptomatic submandibular mass Oral Surgery, Oral

Medicine, Oral Pathology, Oral Radiology and Endodontics 2003; 95: 529-532)

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A 35 year-old female presents with a feeling of pressure in the area of tooth #30 which
otherwise tested vital. A radiograph and biopsy were performed. Which is the most likely
diagnosis?

A. Cementoblastoma

B. Osteoblastoma

C. Condensing osteitis

D. Focal idiopathic osteosclerosis

Answer: A

Rationale:
The cementoblastom (true cementoma) is a relatively rare neoplasm of odontogenic
ectomesenchyme, comprising between 1% and 6.2% of all odontogenic tumors. This
tumor is laid down by cementoblasts and commonly presents as a large mass that is
characteristically fused to the tooth roots. The latter feature differentiates the tumor from
osteoblastoma which otherwise shares close to identical histological features with
cementoblastoma. Histologically, the tumor reveals relatively acellular and irregular broad
sheets and trabeculae of cementum with marked cementoblastic rimming identified
within. Prominent reversal lines are commonly observed within the dense mass and
cementooclasts are usually seen in the peripheral portion of the lesion. (Fig 3)

In addition to the resorption identified between the mass and the roots, the periodontal
ligament also characteristically encircles the mass circumferentially. The lesion is limited
to the jaws with marked prevalence for the mandible. Cementoblastoma is a true
neoplasm that should be completely excised with extraction of the associated tooth, even
though the pulp is vital.

Reference:
Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial pathology. In:
St Louis: Mosby; 1997;p. 144–145.

9Slootweg PJ. Cementoblastoma and osteoblastoma: a comparison of histologic

features. J Oral Pathol Med. 1992; 21:385–389.

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Said-Al-Naief N. Odontogenic tumors for general pathologists. Adv Exp Med

Biol. 2005; 563:148-64.

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A 42 year-old male presents with an asymptomatic mass of the dorsal tongue. A biopsy is
performed. Which of the following is the most likely diagnosis?

A. Squamous cell carcinoma

B. Granular cell tumor

C. Ectopic thyroid tissue

D. Neurofibroma

Answer: B

Rationale:
The granular cell tumor is a benign soft tissue neoplasm of Schwann cell origin that most
commonly involve the dorsal tongue aspect but may be also seen on the ventral surface
as well. The tumor characteristically appears as an asymptomatic; dome shaped non
ulcerated submucosal nodule covered with normal appearing surface. It primarily
involves adult females.

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Microscopically, in up to 50% of cases, the tumor is characteristically associated with

downward epithelial proliferation toward the connective tissue (pseudoepitheliomatous
hyperplasia) which could be mistaken for invasive carcinoma. The tumor cells are large
polygonal or oval cells that exhibit fine or coarsely granular eosinophilic cytoplasm and
small eccentric nuclei. The cells grow as trabeculae, thick cords or ribbons that typically
infiltrate the surrounding connective tissue and muscle. Immunohistochemical stain can
further confirm the neural origin of granular cell tumor by showing positive reactivity for S-
100 protein and special stain for PAS clearly delineated the lysosomal content of the
granular cytoplasm. Granular cell tumor is best treated by conservative surgical excision.
Recurrences are rare and usually reported with incompletely excised lesion although
reports of lack of recurrence despite incomplete excision of the tumor also exist.
Examples of malignant granular cell tumors are also documented.

Reference:
Williams H.K. and Williams D.M. Oral granular cell tumours: a histological and
immunocytochemical study, J Oral Pathol Med 1997;26:164–169.

Junquera L.M., de Vicent J.C., Veg J.A., Losa J.L , Albertos J.M. and Lopez-Arranz J.S.
Granular-cell tumours: an immunohistochemical study, Br J Oral Maxillofac Surg
1997;35:180–184.

Buley D, Gatter KC, Kelly P.M., Heryet A and Millard P.R. Granular cell tumours revisited
An immunohistological and ultrastructural study, Histopathology 1988; 12:263–274.

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A 17 year-old male presented with a pericoronal radiolucency associated with impacted tooth
#5. What is your diagnosis?

A. Dentigerous Cyst

B. Unicystic Ameloblastoma

C. Adenomatoid Odontogenic Tumor

D. Calcifying Odontogenic Cyst

Answer: C

Rationale:
Adenomatoid odontogenic tumor (AOT) is a relatively uncommon distinct odontogenic
tumor that typically presents as an asymptomatic swelling that most commonly presents
as a pericoronal radiolucency associated with the crown of an impacted canine (or other)
tooth of teenagers and young adults more than the posterior region of the jaw.

With the absence of radiographic evidence of calcification, it cannot be distinguished

from other pericoronal radiolucencies. It can occur in central or peripheral locations and
frequently causes expansion and displacement of adjacent neighboring teeth. The tumor
shows characteristic histomorphological pattern; duct like structures and solid areas of
epithelium with variable degrees of inductive changes. Amorphous amyloid -like
eosinophilic material may be also seen.

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AOT should be treated with conservative enucleation with excellent prognosis and
recurrence is unexpected when the tumor is completely removed.

Reference:
Philipsen HP, Reichart PA: Adenomatoid odontogenic tumour: facts and figures. Oral
Oncol 1998, 35:125-131.

Toida M, Hyodo I, Okuda T, Tatematsu N: Adenomatoid odontogenic tumor: report of two

cases and survey of 126 cases in Japan. J Oral Maxillofac Surg 1990, 48:404-408.

Philipsen HP, Reichart PA: The adenomatoid odontogenic tumour: ultrastructure of

tumour cells and non-calcified amorphous masses. J Oral Pathol Med 1996, 25:491-496.

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A 15 year-old female presented with radiographic evidence of bone resorption around the
anterior mandibular teeth. No other bony lesions or soft tissue lesions were detected. What is
your most likely diagnosis?

A. Langerhans cell histiocytosis

B. Hodgkins lymphoma

C. Intrabony fungal infection

D. Periodontal disease

Answer: A

Rationale:
Langerhans cell histiocytosis is a non neoplastic condition of bone, histologically
characterized by the presence of an admixture of histiocytes and eosinophils, commonly
showing zonal distribution. The histiocytes also show grooved nuclei and distinctly co-
express positive reaction with S-100 protein and CD1a antibodies by
immunohistochemistry staining. They also display characteristic tennis racket-shaped
granules; Birbeck granules by electron microscopic examination. The disease may be
localized and generalized. The localized disease; eosinophilic granuloma can occur in
polyostotic or monostotic forms.

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The jaws are affected in approximately 10% to 20% of all EG cases with prevalence for
the posterior mandible and is typically associated with the radiographic pattern depicted
in this case showing the phenomenon of “teeth hanging in air”. The disseminated form
may involve infants and is commonly associated with acute systemic involvement,
including hepatomegaly, splenomegaly, anemia, lymphadenopathy and cutaneous rash
in addition to the generalized bone involvement and is referred to as Letterer-Siwe
disease Alternatively, can occur in older children with the characteristic triad of
exophthalmia, diabetes and dessiminated bony involvement where it became known as
Hand-Schuller-Christian disease.

EG is best managed by thorough curettage and debridement of bone. Extraosseous soft

extension may be managed with a low dose of radiation (1200 rads). Patients have to
followed and a skeletal bone survey is beneficial to investigate for any other lesions
elsewhere.

Reference:
2Risdall RJ, Dahner LP, Duray T, Kobrinsky N, Robinson L, Nesbit ME. Histiocytosis-X
(Langerhans cell histiocytosis): prognostic role of histopathology. Arch Pathol Lab Med.
1983;107:59–63.

16Hartman KS. Histiocytosis X: a review of 114 cases with oral involvement. Oral Surg
Oral Med Oral Pathol. 1980;49:38–54.

17Dagenais M, Pharoah MJ, Sikorski PA. The radiographic characteristics of

histiocytosis X: a study of 29 cases that involve the jaws. Oral Surg Oral Med Oral
Pathol. 1992;74:230–236.

18Pringle GA, Daley TD, Veinot LA, Wyosocki GP. Langerhans cell histiocytosis in
association with periapical granulomas and cysts. Oral Surg Oral Med Oral Pathol.
1992;74:186–192.

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Relative indications for elective neck dissection in the treatment of squamous cell cancer of the
lower lip include:

A. depth of invasion > 4-6 mm.

B. intense inflammatory response at the host-tumor interface.

D. lack of perineural invasion on pathology.

C. surface dimension > 1 cm.

Answer: B

Rationale:
Lack of an intense inflammatory response at the host-tumor interface is a predictor of
recurrence and metastasis. Presence of perineural invasion is not an indicator for neck
dissection. Surface dimension of greater than 2 cm (rather than 1cm) is a relative
indication as well as depth of invasion > 4-6 mm.

Reference:
de Visscher JG, van den Elsaker K, Grond AJ, et al. Surgical treatment of squamous cell
carcinoma of the lower lip: evaluation of long-term results and prognostic factors--a
retrospective analysis of 184 patients. J Oral Maxillofac Surg. Jul;56:814-20, 1998.
discussion 820-1. JOMS 1998

Vartanian JG, Carvalho AL, de Araujo Filho MJ, et al. Predictive factors and distribution
of lymph node metastasis in lip cancer patients and their implications on the treatment of
the neck. Oral Oncol 40: 223-227, 2004.

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Which of the following is true regarding appropriate initial margins in the excision of cutaneous
malignancies?

A. 4 mm will clear 98% of sclerosing (morpheaform) basal cell carcinomas

B. 3-4 cm is recommended for dermatofibrosarcoma protuberans (DFSP)

C. 8-10 mm are recommended for nodular basal cell carcinoma

D. Initial margins in Moh’s micrographic surgery are 3 mm from clinical extent of tumor

Answer: B

Rationale:
An initial peripheral margin of 4 mm will clear 98% of nodular basal cell cancers, whereas
a 2 mm margin will clear only 75%. More generous margins, of 8-10 mm have been
suggested for more aggressive BCC, such as the morpheaform subtype. For smaller
BCC (5 mm or less) initial margins of 2-3 mm may be acceptable. Initial margins of 4-6
mm, which will clear the tumor in 95% of cases, are suggested for small to medium
squamous cell cancers. Advanced lesions require margins of 10-20 mm. The depth of
excision should include the subcutaneous tissue immediately subjacent to the tumor in
most cases of squamous and basal cell cancers. Currettage is used initially to remove
tumor in Moh's micrographic technique. Dermatofibrosarcoma protuberans is a relatively
uncommon soft tissue neoplasm with intermediate-to-low grade malignancy but locally
agreessive with a high recurrence rate. Due to its infiltrating growth pattern DFSP
commonly extends far beyond the clinical margins requiring wide excision of 3 cm or
greater down to and including fascia.

Reference:
Brodland DG, Zitelli JA: Surgical margins for excision of primary cutaneous squamous
cell carcinoma. J Am Acad Dermatol 27: 241-248, 1992.

Dzubow LM, Rigel DS, Robins P: Risk factors for local recurrence of primary squamous
cell carcinoma. Arch Dermatol 118: 900-902, 1982.

Wolf DJ, Zitelli JA: Surgical margins for basal cell carcinoma. Arch Dermatol 123: 340-
344, 1987.

Koplin L, Zarem HA: Recurrent basal cell carcinoma: A review concerning the incidence,
behavior, and management of recurrent basal cell carcinoma, with an emphasis on the
incompletely excised lesion. Plas Recon Surg 65: 656-664, 1980.

Barnes L, Coleman JA, Johnson JT. Dermatofibrosarcoma protuberans of the head and
neck. Arch Otolaryngol 110: 398-404, 1984.

Roses DF, Valensi Q, LaTrenta G, et al. Surgical treatment of dermatofibrosarcoma

protuberans. Surg Gynecol Obstet 162: 449-452, 1986.

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Rutgers EJ, Kroon, BR, Albus-Lutter CE, et al. Dermatofibrosarcoma protuberans:

treatment and prognsosis. Eur J Surg Oncol 18: 241-248, 1992.

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Which of following describes the mechanism of action of topical imiquinod (Aldara) on actinic
keratosis?

A. Stimulates T-cell response leading to upregulation of anti-tumor effects

B. Vitamin A analogue that functions to inhibit the growth of abnormal cell lines and induce
normal maturation into dysregulated growth

C. Anti-metabolite that inhibits thymidylate synthetase

D. Potent cyclo-oxygenase-2 (COX-2) inhibitor which has been shown to be up-regulated in

certain malignancies

Answer: A

Rationale:
Topical medications play an important role in the management of actinic keratosis.
Aldara is an immunomodulator that upregulates T cells and stimulates an intense
immune response. Retinoids are Vitamin A analogues. Effudex (5FU) is an anti-
metabolite. Solaraze gel 3% is a topical COX 2 inhibitor.

Reference:
Prstojevich SJ, Nierzwicki BL. Treatment options for premalignant and malignant
cutaneous tumors. Oral Maxillofac Surg Clin N Am. 17:147-160, 2005.

Burns CA, Brown MD: Imiquimoid for the treatment of skin cancer. Dermatol Clin 151-
164, 2005.

Stockfleth E, Meyer T, Benninghoff B, et al: A randomized, double blind, vehicle

controlled study to assess 5% imiquimoid cream for the treatment of multiple actinic
keratosis. Arch Dermatol 138: 1498-1502, 2002.

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A 52 year-old male presents with an exophytic lesion involving the gingiva overlying the right
mandible. Biospy reveals squamous cell cancer. Assuming a surface dimension of 2.5 cm in
greatest dimension and considering the radiograph, the appropriate clinical T classification
would be:

A. 1

B. 2

C. 4a

D. 4b

Answer: B

Rationale:
Superficial involvement of the alveolar bone of the mandible along a tooth root is not
does not upstage a patient to T4 status. Based on surface dimension of 2.5cm, the
tumor is appropriately staged T2.

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Reference:
Holmes J, Dierks, E. Oral Cancer in Peterson's principles of oral and maxillofacial
surgery. (ed 2). Hamilton, Ontario, BC Decker Inc. 2004

AJCC staging manual (ed 6). New York, NY, Springer 2002 pp23-32.

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Assigning of a clinical stage to a patient with a squamous cell cancer is based on:

A. findings of the clinical examination of the patient.

B. all information available prior to initiation of definitive therapy.

C. histopathologic grading of the biopsy.

D. radiographic findings.

Answer: B

Rationale:
Assigning of the appropriate clinical stage is important to compare results and treatment
outcomes. Clinical stage is based on all data, clinical exam and radiographic studies,
prior to initiation of definitive treatment. It is not based solely on clinical examination of
the patient. Staging is based on the TNM classification system as outlined by the
American Joint Committee on Cancer.

Reference:
Holmes J, Dierks, E. Oral Cancer in Peterson's principles of oral and maxillofacial
surgery. (ed 2). Hamilton, Ontario, BC Decker Inc. 2004

AJCC staging manual (ed 6). New York, NY, Springer 2002

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Which of the following is included in a minimum appropriate workup for a patient with a
squamous cell cancer of the oral cavity?

A. Chest radiograph

B. Panoramic radiograph

C. Chest CT

D. Positron emission tomography (PET) scan

Answer: A

Rationale:
In the standard workup for a patient with squamous cell cancer of the oral cavity, contrast
enhanced computed tomography from the skull base to clavicles, blood chemistry
including liver function tests, and chest radiographs are considered the minimum data
needed for appropriate staging. PET scan and panorex radiographs are useful but not
currently considered standard. Chest CT may be useful if signs of metastasis are found
on chest plane radiographs.

Reference:
Ghali GE, Connor MS. Oral Cancer: Classification, Staging, and diagnosis in Peterson's
principles of oral and maxillofacial surgery. (ed 2). Hamilton, Ontario, BC Decker Inc.
2004 pp 617-630.

AJCC staging manual (ed 6). New York, NY, Springer 2002 pp.23-32.

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A 45-year-old female presented with a history of continued pain of several months duration of
the left mandible with associated expansion. Her symptoms failed to resolve following extraction
of the first molar. What is the most likely diagnosis?

A. Residual cyst

B. Osteosarcoma

C. Dry socket (alveolar osteitis)

D. Traumatic neuroma

Answer: B

Rationale:
The presence of unremitting pain coupled with the radiographic features (irregular
widening of the periodontal ligament space, widening and inferior displacement of the
inferior alveolar canal) should raise the possibility of a malignant neoplasm. The
presence of irregular opacification, the location in the posterior mandible and the patient's
age are all consistent with a diagnosis of osteosarcoma. The other options can be ruled
out based on the radiographic presentation.

Reference:
Fernandes R, Nikitakis NG, Pazoki A, Ord RA. Osteogenic sarcoma of the jaw: a 10-year
experience. J Oral Maxillofac Surg 2007;65(7):1286-92.

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Dodson TB, Caruso PA, Nielsen GP. Case records of the Massachusetts General
Hospital. Weekly clinicopathological exercises. Case 2-2004. A 32-year-old man with
pain and swelling of the jaw. N Engl J Med. 2004;350(3)

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A 50-year-old male developed a lesion at the site of an extraction socket. The tooth had been
removed 7 days earlier. Histologic examination of the tissue would most likely reveal:

A. a nodule of dense fibrovascular connective tissue surfaced by stratified squamous

epithelium.

B. a mass of granulation tissue containing proliferative endothelial cells and small blood
vessels with occasional spicules of necrotic bone.

C. a pool of extravasated mucus surrounded by a rim of compressed granulation tissue and

minor salivary gland lobules.

D. islands of markedly atypical squamous epithelium with numerous atypical mitotic figures
invading the basement membrane.

Answer: B

Rationale:
This is an example of an epulis granulomatosa (pyogenic granuloma in an extraction
socket). Although the possibility of a metastatic lesion to the extraction socket must be
ruled out by biopsy, this is an uncommon occurrence. Option A describes a fibroma,
Option B describes a mucocele (extravasation type), Option C describes a pyogenic
granuloma (the correct response) and Option D describes an invasive squamous cell
carcinoma

Reference:
nd
Neville BW, Damm DD, Allen CM, Buoquot JE. Oral and Maxillofacial Pathology 2
edition. WB Saunders Co. Philadelphia PA 2002.pp 447-8.

Nathanson NR. Recurrent epulis granulomatosa; report of a case. Oral Surg Oral Med
Oral Pathol 1951;4(7):854-7.

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The most appropriate diagnosis for the lesion in the mandible (45 year-old male) is:

A. primary intraosseous squamous cell carcinoma.

B. periapical cyst.

C. ameloblastoma.

D. odontogenic keratocyst. (keratocystic odontogenic tumor)

Answer: C

Rationale:
The radiograph reveals a destructive, multilocular radiolucency involving the body of the
mandible. Of the options listed, only ameloblastoma and odontogenic keratocyst typically
present as multilocular radiolucencies. The biopsy demonstrates classic features of a
follicular ameloblastoma (islands of odontogenic epithelium bordered by columnar and
palisaded ameloblastic cells with polarized hyperchromatic nuclei surrounding a stellate
reticulum-like central component).

Reference:
Vickers RA, Gorlin RJ. Ameloblastoma: Delineation of early histopathologic features of
neoplasia. Cancer 1970;26(3):699-710.

Reichart PA, Philipsen HP, Sonner S. Ameloblastoma: biological profile of 3677 cases.
Eur J Cancer B Oral Oncol 1995;31B(2):86-99.

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A 55-year-old female was referred for biopsy of an asymptomatic radiolucent area incidentally
noted following routine radiographic examination. The biopsy report states that “the specimen
consists of normal hematopoietic bone and spicules of viable bone.” The most appropriate
diagnosis is:

A. osteosarcoma.

B. traumatic bone cyst.

C. focal osteoporotic marrow defect.

D. stafne (static) bone cyst.

Answer: C

Rationale:
The radiographic presentation of a well-circumscribed radiolucent area in the edentulous
area of the posterior mandible in a post-menopausal woman are all compatible with “focal
osteoporotic (bone) marrow defect”. The histologic diagnosis confirms the clinical
impression.

Reference:
Schneider LC, Mesa ML, Fraenkel D. Osteoporotic bone marrow defect: radiographic
features and pathogenic factors. Oral Surg Oral Med Oral Pathol 1988;65(1):127-9.

Barker BF, Jensen JL, Howell FV. Focal osteoporotic bone marrow defects of the jaws.
An analysis of 197 new cases. Oral Surg Oral Med Oral Pathol 1974;38(3):404-13.

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The most appropriate diagnosis for the long-standing soft tissue lesion in this 47-year-old male
is:

A. peripheral odontogenic fibroma.

B. peripheral ossifying fibroma.

C. osteosarcoma.

D. pyogenic granuloma.

Answer: B

Rationale:
The clinical photo reveals a light pink “bump on the gums” of long standing duration in a
patient with abundant subgingival calculus. This is suggestive of a reactive gingival
lesion. From the list presented, the only reactive lesions are pyogenic granuloma and
peripheral ossifying fibroma. The histology reveals islands of bone in a background of a
moderately dense cellular fibrous stroma, consistent with peripheral ossifying fibroma.

Reference:
Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma.
Oral Surg Oral Med Oral Pathol 1987;63(4):452-61

nd
Neville BW, Damm DD, Allen CM, Buoquot JE. Oral and Maxillofacial Pathology 2
edition. WB Saunders Co. Philadelphia PA 2002.pp 451-2.

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A 50 year-old male presents with an asymptomatic lesion of the palate. An incisional biopsy was
performed. What is the most appropriate diagnosis?

A. Lymphoma

B. Candidiasis

C. Erythroplakia

D. Squamous cell carcinoma

Answer: D

Rationale:
The clinical picture is highly suggestive of a squamous cell carcinoma of the soft palate.
Although erythroplakia is a reasonable clinical diagnosis based on the clinical photograph
alone, this is strictly a clinical term. The submitted photomicrograph clearly demonstrates
islands of epithelium demonstrating keratinization and numerous enlarged, atypical
appearing nuclei that are invading connective tissue. Hence the diagnosis should be
squamous cell carcinoma.

Reference:
Reichart PA, Philipsen HP. Oral erythroplakia--a review. Oral Oncol 2005;41(6):551-61.

Stambuk HE, Karimi S, Lee N, Patel SG. Oral cavity and oropharynx tumors. Radiol Clin
North Am 2007;45(1):1-2

Search Terms= Pathology diagnosis / work-up, Soft tissue histopathology

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A 62 year-old male with poorly controlled diabetes presents with maxillary, orbital, and facial
cellulitis with necrotic tissue; plus orbital abnormalities including epiphora, blurred vision, ptosis,
ophthalmoplegia and periorbital paresthesias.. The most likely diagnosis is:

A. superior orbital fissure syndrome.

B. cavernous sinus thrombosis.

C. mucormycosis.

D. obital myositis.

Answer: C

Rationale:
Mucormycosis is an infection that is typically seen in diabetics (poorly controlled) and is
often associated with the signs and symptoms above.

Superior orbital fissure syndrome includes diplopia, opthalmoplegia, exopthalmos, ptosis,

and visual changes when associated with orbital apex syndrome.

Cavernous sinus thrombosis findings include lateral gaze palsy, periorbital edema,
exopthalmous, mydriasis, opthalmoplegia, ptosis, hypo- or hyperesthesia in V1 and V2
with late meningeal signs and systemic sepsis.

Reference:
Tierney MR, Baker AS. Infections of the head and neck in diabetes mellitus. Infect Dis
Clin North Am. 1995 Mar;9(1):195-216.

Marx RE, Stern D. Oral and Maxillofacial Pathology: A rationale for diagnosis and
treatment. Quintessance, 2003, P54

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The most common bacterial isolates from early odontogenic infections are:

A. alpha – hemolytic streptococci.

B. Eikenella corrodens.

C. beta – hemolytic streptococci.

D. Staphalococcus aureus.

Answer: A

Rationale:
Alpha hemolytic strep predominate cultures in early odontogenic infections.

Reference:
Rega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic sensitivities of head and neck
space infections of odontogenic origin. J Oral Maxillofac Surg. 2006 Sep;64(9):1377-80.

Storoe W, Haug RH, Lillich TT. The changing face of odontogenic infections. J Oral
Maxillofac Surg. 2001 Jul;59(7):739-48.

Labriola JD, Mascaro J, Alpert B. The microbiologic flora of orofacial abscesses. J Oral
Maxillofac Surg. 1983 Nov;41(11):711-4.

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When evaluating airway infections using a lateral plane radiograph, which of the following is true
regarding maximum normal prevertebral soft tissue landmark thickness measurements at C2
and C6?

A. C2 ≤ 20mm and C6≤ 6mm

B. C2 ≤ 6mm and C6 ≤ 20 mm

C. C2 ≤ 6mm and C6 ≤ 2 mm

D. C2 ≤ 2mm and C6 ≤ 6 mm

Answer: B

Rationale:
Normal soft tissue thickness at known landmarks can assist in the diagnosis of
impending airway obstruction. A standard often quoted is reflected in answer B.

Reference:
Flynn TR. Anesthetic and airway considerations in oral and maxillofacial infections. In
Topazian RG, Goldberg MH (eds): Oral and maxillofacial infections, ed 3. Philadelphia;
WB Saunders. 1993, P503.

Flynn TR. Emergency medicine clinics of North America, vol 18, number 3, August 2000.

American Board of Oral and Maxillofacial Surgery 205

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Kartagener’s triad is a syndrome involving sinusitis,:

A. asthma, nasal polyps.

B. situs inversus, bronchiectasis.

C. lung disease, infertility.

D. bronchiectasis, nasal polyps.

Answer: B

Rationale:
Kartagener's syndrome is associated with increased risk of sinus and pulmonary
infections. It results from cilia dyskinesia. Recognition of the association is important in
the management of the patient with multiple sinus infections. Situs inversus (mirroring of
the major visceral organs), bronchiectaiss (abnormal and permanent distortion of one or
more of the conducting bronchi and sinusitis make up the triad of Kartagener's syndrome.

Reference:
Chandra RK, Kennedy DW. Sinus infections. In Miloro M, Ghali GE, Larsen PE and
Waite PD (eds). Peterson's Principles of Oral and Maxillofacial Surgery, 2004, vol 1,
p302.

Teknos TN, Metson R, Chasse T: New developments in the diagnosis of Kartagener's

syndrome. Otolaryngol Head Neck Surg 1997 Jan; 116(1): 68-74

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Hand-foot-and-Mouth Disease is caused by:

A. coxsackievirus.

B. Ebstein-Barr virus.

C. paramyxovirus.

D. Togaviridae.

Answer: A

Rationale:
Coxsackievirus belongs to the Picornaviridae family with group A causing hand-foot-and
mouth disease with classic vesicular lesions on the tongue or buccal mucosa as well as
the hands and feet (including palms and soles) and uncommonly the buttocks and
genitalia.

EBV is associated diseases include mononucleosis, Burkitt's lymphoma, and

nasopharyngeal carcinoma. Paramyxovirus infections include Newcastle disease,
measles, and mumps. Togaviridae infections include western equine encephalitis and
rubella.

Reference:
Buchner A. Hand, foot, and mouth disease. Oral Surg Oral Med Oral Pathol. 1976
Mar;41(3):333-7.

Laskaris G. Oral manifestations of infectious diseases. Dent Clin North Am. 1996
Apr;40(2):395-423.

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Which of the following groups of medications is a known cause of temporomandibular joint

dislocation?

A. Benzodiazepines

B. Tricyclic antidepressants

C. Monoamine oxidase inhibitors

D. Phenothiazines

Answer: D

Rationale:
Phenothiazines have been used in the treatment of schizophrenia, but are now used
less frequently than in the past. In oral and maxillofacial surgery they have been used for
their anti-emetic properties in the management of postoperative nausea. With the
availability of newer drugs, and are now used less frequently. Because these drugs block
brain dopamine receptors (especially D2 receptors), they may cause extrapyramidal side
effects which include a Parkinson-like syndrome with bradykinesia, rigidity, and tremor,
as well as akathisia and dystonias. These are usually reversible and respond to
treatment with diphenhydramine or muscarinic blocking agents. Tardive dyskinesia,
which includes choreoathetoid movements of the muscles of the lips and buccal cavity,
may take months to develop and may be irreversible. Several cases have been reported
in the literature of phenothiazine induced temporomandibular joint dislocation in
association with these extrapyramidal side effects.

Reference:
August M, Troulis MJ, Kaban LB. Hypomobility and Hypermobility Disorders of the
Temporomandibular Joint. In: Miloro M, Ghali GE, Larsen P, Waite P, editors. Peterson's
Principles in Oral and Maxillofacial Surgery. Hamilton: BC Decker Inc; 2004. p. 1044-45.

Ryan M, LaDow C. Subluxation of the temporomandibular joint after administration of

prochlorperazine: report of two cases. J Oral Surg 26(10):646-8, 1968.

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A patient complains of a sudden onset of limited jaw movement. Physical examination of

mandibular movement identifies the patient to have 21mm of mouth opening with deflection to
the right and limited protrusion with deflection to the right and limited left lateral mandibular
movement. The diagnosis mostly likely is:

A. disc displacement with reduction - right TMJ.

B. disc displacement without reduction - right TMJ.

C. disc displacement with reduction - left TMJ.

D. disc displacement without reduction - left TMJ.

Answer: B

Rationale:
Patients with disc displacement with reduction do not have limited jaw dynamics and are
diagnosed with the palpable reciprocal click. This patient had limited mouth opening and
no complaints of joint noises which excludes A and C. An acute disc displacement
without reduction is associated with limited condylar translation. This patient reports
having a sudden onset of limited jaw movement. The history plus the physical findings of
the direction of mandibular deflection and limited lateral movement is describing a classic
presentation of a disc displacement without reduction of the right TMJ.

Reference:

Okeson JP. Joint intracapsular disorders: Diagnostic and nonsurgical management

considerations. In: Gremillion H, editor. Dental clinics of North America: Elsevier
Saunders; 2007; 51(1): 85-103

Differential diagnosis and management considerations of temporomandibular disorders.

In: Okeson JP, editor. Orofacial pain; guidelines for assessment, diagnosis, and
management. Carol Stream (IL): Quintessence Publisher Co., Inc.: 1996. p 113-184

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To facilitate mouth opening, the head and neck can be placed into which of the following
positions?

A. Extension

B. Flexion

C. Rotation

D. Side bend

Answer: A

Rationale:
Combined movement and electromyographic recordings showed concomitant neck
muscle activity during head-neck movements, indicative of an active repositioning of the
head. Opening was always accompanied by head-neck extension and jaw closing by
head-neck flexion. Various studies give further support to the concept of a functional
trigemino-cervical coupling during jaw activities in man.

Reference:
Eriksson PO, Zafar H, Nordh H. Concomitant mandibular and head-neck movements
during jaw opening – closing in man. J Oral Rehab 1998; 25:859-70

Haggman-Henrikson, B and Eriksson, PO. Head Movements during Chewing: Relation

to Size and Texture of Bolus. J. Dent. Res., November 1, 2004; 83(11): 864 - 868.

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Which of the following is a reported method of preventing heterotopic bone formation following
temporomandibular joint reconstruction?

A. Corticosteroids

B. Low dose radiation therapy (10 – 20 Gy)

C. Doxycycline

D. Ciprofloxacin

Answer: B

Rationale:
Low dose radiation therapy, indomethacin and autologous fat grafts around the joint
prosthesis are all reported methods to prevent heterotopic bone formation. Risk factors
for heterotopic bone formation are previous heterotopic bone formation after surgery,
surgery or trauma, hypertrophic arthritis, and diseases with an ossifying diathesis. The
pathophysiology and activating factors of heterotopic bone formation remain unknown. It
is believed that hetertopic bone formation is a result of the inappropriate differentiation of
pluripotential mesenchymal cells into osteoblastic stem cells (1). In reviewing the
orthopedic literature for the prevention of heterotopic bone formation the total dose range
for low dose radiation therapy to prevent heterotopic bone formation was 5 – 16 Gy.
Indomethacin and low dose radiation therapy offer significantly better function compared
with no therapy. Low dose radiation therapy has advantages over indomethacin in
regards to compliance and acute toxicity (2). Radiation may prevent pluripotential
mesenchymal stem cells from proliferating and differentiating into osteoblasts or
chondroblasts by altering the transcription of DNA. Radiation induced malignancies are a
concern as is the potential for increased risk of gastrointestinal disturbances with
indomethacin use (3).

Reference:
Lo TCM. Radiation therapy for heterotopic ossification. Sem Radiat Oncol, 9(2):163-
170, April 1999.

Kienapfel H, Koller M, Wust A, Sprey C et al. Prevention of heterotopic bone formation

after total hip arthroplasty: a prospective randomised study comparing postoperative
radiation therapy with indomethacin medication. Arch Orthop Trauma Surg, 199:296-
302, 1999.

Seegenschmiedt MH, Makoski HB, Micke O. Radiation prophylaxis for heterotopic

ossification about the hip joint - a multicenter study. Int J Radiat Oncol Biol Phys,
51(3):756-765, 2001.

Milam SB. Management of the Patient with End-Stage Temporomandibular Joint

Disease. In Miloro, M (ed). Peterson's Principles of Oral and Maxillofacial Surgery, 2nd
ed. 2004, BC Decker, Hamilton, p. .

Quinn PD, Giannakopoulos H, Carrasco L. Management of surgical failures. Oral

Maxillofac Surg Clin NA, 2006; 18(3):411-417.

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Wolford L, Karras SC. Autologous fat transplantation around temporomandibular joint

total joint prosthesis: preliminary treatment outcomes. J Oral Maxillofac Surg, 1997;
55(3):245-251.

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What condition would be responsible for moderate limitation of range of motion without pain for
a previously asymptomatic patient following release of intermaxillary fixation for bilateral vertical
ramus osteotomies with a large mandibular setback?

A. Mechanical interference by the coronoid process

B. Anterior disk displacement without reduction

C. Bony intra- articular ankylosis

D. Anterior disk displacement with reduction

Answer: A

Rationale:
Setting the mandible backward using the vertical ramus osteotomy (VRO) alters the
position of the coronoid process and its relation to the medial aspect of the zygomatic
arch. The coronoid process has a lateral flare. When the osteotomy heals, the coronoid
process is 'permanently' held in closer proximity to the arch. When the mandible rotates
and translates open, it translates the coronoid process forward bumping into the medial
aspect of the zygomatic arch.

Reference:
Kursoqlu P, Capa N: Elongated mandibular coronoid process as a cause of mandibular
hypomobility. Cranio 2006 24(3), 213-16.

Lai SS, Tseng YC, Huang IY, Yang YH, Shen YS, Chen CM. Skeletal changes after
modified vertical ramus osteotomy for correction of mandibular prognathism. Journal of
Plastic, Reconstructive And Aesthetic Surgery, 2007, 60(2): 139-145.

Gross M, Gavish A, Calderon S, Gazit E. The coronoid process as a cause of mandibular

hypomobility--case reports. J Oral Rehabil. 1997, 24(10): 776-81.

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A 30 year-old female presents with constant pain in her temporomandibular joints. Her pain
does not worsen as the day goes on and mastication is painful. She is currently taking ibuprofen
for her knees and proximal interphalangeal joints. She has a temperature of 100.5. Maximal
interincisal opening is 30 mm with crepitus bilaterally with a skeletal anterior open bite. Panorex
shows bilateral degenerative changes to the anterior superior slopes of the condyles and
posterior slopes of the eminences. What is the appropriate initial management?

A. Antibiotics and pain management

B. Splint therapy and medical management

C. Arthroscopic arthroplasty

D. Bilateral total joint replacement with correction of open bite

Answer: B

Rationale:
This patient has a number of indicators for rheumatoid arthritis and initial treatment
should be directed toward pain management, occlusal stabilization, and control of
rheumatoid arthritis. Rheumatoid arthritis patients will often have a low grade
temperature during exacerbations and antibiotics are not indicated. Arthroscopic
arthroplasty is not indicated for initial treatment; however, if the etiology of the limited
range of motion is due to an anteriorly displaced disc this may be helpful after the
disease is under control. Total joint replacement would be a viable option for closure of
open bite after disease is controlled.

Traditionally, pharmacologic treatment of rheumatoid arthritis has consisted of initial use

of non-steroidal anti-inflammatory drugs. If the patient
demonstrated radiographic damage, the more toxic, disease-modifying anti-rheumatic
drugs (DMARDs) would be employed. It is now standard practice to introduce these
drugs at the time of diagnosis. Methotrexate, leflunomide, sulphasalazine,
corticosteroids, cyclosporine, parenteral gold, and auranofin have been shown to reduce
radiographic progression.

Reference:
Abubaker AO and Laskin DM: Nonsurgical Management of Arthritis of the
Temporomandibular Joint. Oral and Maxillofacial Surgery Clinics of North America, Feb
1995, 4-7.

Hoffman, K. Differential and Diagnosis and Characteristics of TMJ Disease and

Disorders,Knowledge Updates Vol. 1 1994 TMJ section

Keen HI. Emery P. How should we manage early rheumatoid arthritis? From imaging to
intervention. Current Opinion in Rheumatology. 17(3):280-5, 2005 May.

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A 50 year-old patient who complains of morning limitation of jaw movement that improves with
increased function and a progressive class II malocclusion and apertognathia should be
suspected of having:

A. idiopathic condylar resorption.

B. osteoarthritis.

C. rheumatoid arthritis.

D. severe bruxism.

Answer: C

Rationale:
Rheumatoid arthritic TM joint involvement occurs late in the disease. Distinguishing
features of rheumatoid arthritis is morning stiffness that improves during the day or with
function. The patient eventually suffers a change in profile and occlusal relationships.
Patients with idiopathic condylar resorption may present with a progressive class II
malocclusion and open bite as well, but range of motion is usually not restricted. Patients
with osteoarthritis of the TMJ do not develop a significant occlusal change. Severe
bruxism will present as tooth wear and muscle pain, but similarly will not experience
development of a progressive open bite or class II occlusion.

Reference:
Silverstein K: Arthritis of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn
PD (eds):Oral and Maxillofacial Surgery Vol 4. 2000, WB Saunders, Philadelphia, p. 79-
82.

Delantoni A, Spyropoulou E, Chatzigiannis J, Papaemitriou P. Sole radiographic

expression of rheumatoid arthritis in the temporomandibular joints : a case report. Oral
Surg, Oral Med, Oral Path, Oral Radiol, Endodont, 102(4):e37-40, Oct 2006.

Broussard JS Jr. Derangement, osteoarthritis, and rheumatoid arthritis of the

temporomandibular joint: implications, diagnosis, and management. Dental Clinics of
North America, 49(2):327-342, April 2005.

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Which of the following primarily affects males between the ages of 15 and 40?

A. Juvenile rheumatoid arthritis

B. Ankylosing spondylitis

C. Psoriatic arthritis

D. Pseudogout

Answer: B

Rationale:
Ankylosing spondylitis (Marie-Strumpell disease, rheumatoid spondylitis) primarily affects
the articulation of the spine and adjacent soft tissue. It primarily affects males between
ages 15 – 40 and only rarely affects people over 50. TMJ involvement occurs in 4% -
50% of patients late in the course of the disease. The most common complaints are
pain, stiffness, decreased range of motion, and eventually ankylosis. Thirty percent of
patients have radiographically evident ankylosing spondylitis on plain films of the TM
joints.

Reference:
Silverstein K: Arthritis of the Temporomandibular Joint. In Fonseca RJ, Bays RA, Quinn
PD (eds):Oral and Maxillofacial Surgery Vol 4. 2000, WB Saunders, Philadelphia, p. 84-
85.

Sanders B. Temporomandibular joint ankylosis secondary to Marie-Strumpell disease. J

Oral Surg, 33(10):784-786, Oct 1975.

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An 11-year-old male sustained a blow to the chin and laceration of his forearm in a skateboard
accident eight days ago. He now complains of limited mandibular opening and point tenderness
over the left temporomandibular joint. Radiographs rule out jaw fracture, but a joint aspirate is
significant for thick purulent material. Which of the following organisms is most likely to be
associated with this infection?

A. Neisseria sp.

B. Streptococcus sp.

C. Prevotella sp.

D. Staphylococcus sp.

Answer: D

Rationale:
Septic or infectious arthritis is the least common of arthritides affecting the TMJ; and is
especially rare in children. However, it can result in the most severe destruction and
degeneration of the TMJ complex. Organisms can reach the joint through hematogenous
spread through the bloodstream, joint instrumentation, laceration, direct extension
through soft tissues, or by blunt trauma which predisposes the TMJ to infection.

Organisms most commonly associated with the condition are Staphylococcus, Neisseria,
and Streptococcus. In the scenario presented here, the most likely culprit is
Staphylococcus, whose portal of entry can be accounted for by the arm wound.

Sexually transmitted septic arthritis (Neisseria sp.) is unlikely in this individual, and
Streptococcal arthritis would also be unusual without history of an odontogenic infection.
Prevotella (formerly Bacteroides) and Escherichia infections would be very unlikely in
TMJ septic arthritis.

Reference:
Bounds, CA, Hopkins, R, Sugar, A. Septic arthritis of the temporo-mandibular joint – a
problematic diagnosis. Br J Oral Maxillofac Surg 25:61-7, 1987

Leighty, SM, Spack, DH, Myall, RWT, Burns, JL. Septic arthritis of the
temporomandibular joint: review of the literature and report of two cases in children. Int J
Oral Maxillofac Surg 22:292-7, 1993

th
Topazian R.G., Goldberg M.H., Hupp J.R., Oral & Maxillofacial Infections, 4 Edition,
W.B. Saunders Co., 2000, p 436

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Which of the following cytokines may predict successful treatment by arthrocentesis when found
in TMJ synovial fluid from joints with chronic closed lock?

A. Tumor necrosis factor alpha (TNF-α)

B. Interleukin 1 (IL-1)

C. Interleukin 6 (IL-6)

D. Interleukin 10 (IL-10)

Answer: D

Rationale:
TNF-α, IL-1, and IL-6 are pro-inflammatory cytokines produced primarily by activated
macrophages. All have been implicated in cartilage degeneration in conditions including
rheumatoid arthritis and osteoarthritis, and all have been detected in synovial washings
from symptomatic TMJs. IL-10, however, is a powerful inhibitor of macrophage activation
and reduces production of TNF-α, IL-1, IL-6, and other mediators of inflammation. It has
been suggested that IL-10 may be useful in reducing intracapsular inflammation
associated with rheumatoid arthritis. This cytokine has been found in higher
concentrations in TMJs subsequently treated successfully by lavage than in joints which
were not successfully improved by lavage.

References:
Hamada Y, Kondoh T, Holmlund AB, Yamamoto M, Horie A, Saito T, Ito K, Seto K,
Sekiya H. Inflammatory cytokines correlated with clinical outcome of temporomandibular
joint irrigation in patients with chronic closed lock. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2006;102:596-601.

van de Loo FAJ, Joosten LAB, van Lent PLEM, Arntz OJ, van den Berg WB. Role of
interleukin-1, tumor necrosis factor a, and interleukin-6 in cartilage proteoglycan
metabolism and destruction. Arthritis Rheum 1995;38:164-72.

van Roon JAG, van Roy JLAM, Gmelig-Meyling FHJ, Lafeber FPJG, Bijlsma JWJ.
Prevention and reversal of cartilage degradation in rheumatoid arthritis by interleukin-10
and interleukin-4. Arthritis Rheum 1996;39:829-35.

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Mechanical stress in the TMJ may lead to synovitis, osteoarthritis and adhesion formation
through formation of:

A. free radicals.

B. glycosaminoglycans.

C. hyaluronate.

D. superoxide dismutase.

Answer: A

Rationale:
Oxidative stress, mediated by reactive oxygen species or free radicals, has been
postulated to serve an intermediary role between mechanical stress, hypoxia-reperfusion
cycling, synovial microbleeding, or several other potential intracapsular pathologic events
and synovitis, osteoarthritic degenerative changes, and adhesion formation. These
changes have been shown to be reduced, not enhanced, by hyaluronate or superoxide
dismutase. Glycosaminoglyans are molecules found in healthy collagen and are not
directly implicated in adhesion formation or synovitis.

Reference:
Cai HX, Luo JM, Long X, et al. Free-radical oxidation and superoxide dismutase activity
in synovial fluid of patients with temporomandibular disorders. J Orofacial Pain 2006;20
(1):53-58.

Demirbag S, Cetinkursun S, Tasdemir U, et al. Comparison of

hyaluronate/carboxymethylcellulose membrane and melatonin for prevention of adhesion
formation in a rat model. Human Reproduction 2005;20(7):2021-2024.

Dijkgraaf LC, Zardeneta G, Cordewener FW, et al. Crosslinking of fibrinogen and

fibronectin by free radicals: A possible initial step in adhesion formation in osteoarthritis
of the temporomandibular joint. J Oral Maxillofac Surg 2003;61(1):101-111.
Oxidative stress and degenerative temporomandibular joint disease: A proposed
hypothesis. Milam SB, Zardeneta G, Schmitz JP. J Oral Maxillofac Surg 1998;56(2):214-
223.

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What GABA-like medication listed below is considered a valuable adjunct to carbamazepine or

phenytoin due to its synergism, less undesirable side effects, and analgesic properties in
treatment of refractory trigeminal neuralgia?

A. Amitryptiline (Elavil)

B. Baclofen (Lioresal)

C. Clonazapam (Klonopin)

D. Lamotrigine (Lamictal)

Answer: B

Rationale:
Anticonvulsants remain the mainstay of treatment of trigeminal neuralgia. Baclofen
(Beta-4-chlorophenyl-gamma-aminobutyric acid) is the only GABA similar compound
listed. It has shown analgesic properties in rates and resembles carbamazepine and
phenytoin in its effects on the spinal trigeminal nucleus. It has been shown to exhibit less
undesirable side effects than the above listed medications.

Amitryptiline, a 5-HT reuptake blocking agent, functions as an antidepressant that is

particularly effective for atypical forms of TGN. Clomapramine is the most potent of the
5-HT reuptake blocking medications and is felt to be a more suitable candidate for
treatment of TGN than amitryptiline.

Lamotrigine is an anti-seizure medication with side effects of life threatening rashes and
the potential for liver disease.

Klonopin is a benzodiazepine anti-anxiety medication that is frequently used in

conjunction with anticonvulsant therapy with good results.

Reference:
Chole R, Rannjitkkumar P, Degwekar S, Bhowate R: Drug Treatment of Trigeminal
Neuralgia: A Systematic Review of the Literature. J Oral Maxillofac Surg 65: 40-45,
2007.

Bagheri S, Farhidvash F, Perciaccante V: Diagnosis and Treatment of Patients with

Trigeminal Neuralgia. J Am Dent Assoc Vol 135, No 12, 17113-1717, 2004.

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A 38 year-old female is referred to you for her complaint of severe, right mandible and cheek
pain. Her dental exam was benign and she had not undergone any recent dental procedure.
She characterized the pain as “pulsing” that was accompanied by symptoms of nausea and
vomiting. It would last from “a few hours” to two and one-half days and would be interrupted by
frequent periods of remission. The diagnosis most consistent with the above history would be:

A. cluster headache.

B. trigeminal neuralgia.

C. atypical odontalgia.

D. facial migraine.

Answer: D

Rationale:
The International Headache Society classifies a headache as migraine when it lasts from
4-72 hours and is associated with at least one of the following symptoms:
1. nausea.
2. vomiting.
3. photophobia.
4. phonophobia.

As well as two of the following:

1. unilateral.
2. moderate to severe.
3. throbbing.
4. aggravated by movement.

Cluster headaches occur in males more than females and although also usually
ipsilateral, tend to be associated with unilateral nose congestion and lacrimation.
Trigeminal neuralgia is usually a transient pain without autonomic signs or symptoms.
Atypical odontalgia is a severe pain originating in usually a maxillary molar or adjacent
tooth that spreads to contiguous areas of the face.

Facial migraines are a variant of the common migraine with identical pharmocologic
treatment recommended.

Reference:

Penarrocha M, Bandres A, Penarrocha M, Bagan JV: Lower-Half Facial Migraine: A

Report of 11 Cases. J Oral Maxillofac Surg 62: 1453-1456, 2004.

Headache Classification Committee of the International Headache Society: Classification

and diagnostic criteria for headache disorders, cranial neuralgias and facial pain.
Cephalalgia 8:46, 1988 (suppl 7).

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A 68 year-old female presents with poorly localized, non-anatomical, continuous left sided facial
pain of 4 years duration. Her medical history is remarkable for generalized anxiety disorder.
There is no evidence of temporomandibular joint dysfunction, myofascial pain,
lymphadenopathy or dental causes. Soft tissue exam is unremarkable. The diagnosis of atypical
facial pain (AFP) can be made after which diagnostic or therapeutic modalities?

A. Magnetic resonance imaging of the brain

B. Computerized tomography (CT) scan of the head

C. A trial of amitryptyline medication

D. Exclusion of other probable diagnoses

Answer: D

Rationale:
The evaluation of a patient with facial pain is often difficult. A thorough history and
detailed clinical exam are imperative. Examination should be systematic and include the
teeth, lymphoreticular system, salivary glands, nasopharynx, oropharynx,
temporomandibular joints, myofascial tissues, cervical spine and the cranial nerves.
Magnetic resonance imaging is useful in evaluating for many organic causes of pain
including tumors, vascular compression and multiple sclerosis. Computed tomography is
not routinely used in the evaluation of facial pain due to its poor soft tissue delineation.
Amitryptiline is a tricyclic antidepressant that has some efficacy in the treatment of certain
pain syndromes including atypical odontalgia and atypical facial pain. The diagnosis of
AFP requires that all other potential sources of pain been eliminated through a thorough
history, clinical examination and imaging modalities. The diagnosis of AFP is therefore a
diagnosis of exclusion.

Reference:

Agostoni E, Frigerio R and Santoro P. Atypical facial pain: clinical considerations and
differential diagnosis. Neurological Sciences. 2005: 26; suppl 2, 71-742.

Burchiel K. A new classification for facial pain. Neurosurgery. 2003: 53; 1164-6

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A 34 year-old white female presents with moderate intermittent sharp right sided facial pain of 6
months duration. The pain is lancinating with episodes lasting several minutes. Clinical
examination reveals no myofascial pain, no temporomandibular joint tenderness or clicks and a
full range of mandibular motion. Cranial nerve evaluation reveals diplopia on left lateral gaze as
well as hypoesthesia of the right maxillary division of the trigeminal nerve. The diagnosis in this
patient would be made most accurately with which of the following?

A. Patient history

B. Clinical examination

C. CT scan

D. MRI scan

Answer: D

Rationale:
The diagnosis in any patient will always depend on a thorough history and complete
physical examination. Although the patient described above has pain typical of trigeminal
neuralgia, the development of this condition in a young female combined with other
cranial nerve abnormalities is concerning. The differential diagnosis should include
multiple sclerosis or a mass lesion. An MRI is the most sensitive modality to evaluate a
patient for multiple sclerosis and a mass lesion. A CT scan is better suited to evaluation
of hard tissues and would not facilitate the diagnosis of multiple sclerosis.

Reference:
Yang et al. Magnetic Resonance imaging used to assess patients with trigeminal
neuralgia. Oral Surg Oral Med Oral Path Oral Rad and Endo. 1996: 81: 343-50

Zakrewska J. Diagnosis and differential diagnosis of trigeminal neuralgia. Clinical Journal

of Pain. 2002: 18; 14-21

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A 34 year-old female patient presents with a 3 month history of facial pain. Her medical history
is unremarkable. She reports no allergies. Clinical examination reveals the presence of mild
bilateral masseter and temporalis muscle tenderness and bilateral temporomandibular joint
reciprocal clicks with moderate pain. The maximum incisal opening is 38 millimeters. MRI
illustrates bilateral anterior disc displacement with reduction. No joint effusion is seen. The most
appropriate initial treatment modality for this patient would be:

A. arthrocentesis.

B. occlusal equilibration.

C. a non-steroidal anti-inflammatory drug.

D. narcotic pain medication.

Answer: C

Rationale:
Conservative management of temporomandibular joint dysfunction may include a number
of modalities. These may include a soft diet, vocal rest, heat application, cold application,
non-steroidal anti-inflammatory drugs, muscle relaxants, occlusal splint therapy, physical
therapy and psychological counseling. Surgical treatments may include arthrocentesis,
arthroscopy, arthroplasty, condylotomy and autogenous or alloplastic joint reconstruction.
Narcotic analgesic medication is well suited to the management of acute post-surgical
pain and pain secondary to malignancy, however, it should only be used in
temporomandibular joint dysfunction when non-steroidal anti inflammatory drugs have
not been effective or cannot be tolerated. Opioid pain medication has the potential for
patient tolerance, dependence and abuse. Accordingly it has a limited role in the long-
term management of temporomandibular joint dysfunction. Occlusal equilibration has not
been shown to result in significant pain reduction of TMJ origin. Arthrocentesis may play
a role in the management of pain of TMJ origin, but only after conservative modalities
have been implemented and proven unsuccessful.

Reference:
Dionne RA. Pharmacological treatments for temporomandibular disorders. Oral Surg Oral
Med Oral Path Oral Rad Endo. 1997: 83; 134-142

Bergman S. Management of musculoskeletal pain. Best Practice and Research Clinical

Rheumatology. 2007: 21; 153-166

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Syncope associated with glossopharyngeal neuralgia is thought to result from which of the
following?

A. Severe paroxysmal pain

B. Bradycardia or asystole

C. Reflex tachycardia

D. Styloid process nerve impingement

Answer: B

Rationale:
Syncope is associated with glossopharyngeal neuralgia in up to 2% of individuals with
the condition. Although not definitively proven, this is thought to result from sudden
bradycardia, and in some cases asystole.

Severe paroxysmal pain may occur with other facial pain syndromes, but has not been
associated with syncope. Reflex tachycardia, styloid process impingement on the
glossopharyngeal nerve, and carotid sinus hypersensitivity have not been associated
with glossopharyngeal neuralgia

Reference:
Rushton, JG, Stevens, JC, Miller, RH. Glossopharyngeal (Vagoglossopharyngeal)
neuralgia: a study of 217 cases. Arch Neurol 38:201-5, 1981.

Rosen, TD. Trigeminal neuralgia. Neurol Clin N Am 22:185-206, 2004.

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Clonidine, as a topical agent in the management of neuropathic pain, is characterized as an

analgesic with which of the following properties?

A. Promoting analgesia through a peripheral pathway.

B. Exerting its effect much like morphine.

C. Easily reversed by naloxone.

D. Having cross-tolerance with opioids.

Answer: B

Rationale:
Clonidine has been implicated in promoting analgesia through a central pathway at both
the supraspinal and spinal levels. Both clonidine and morphine exert their effect along a
common central neuronal pathway. The analgesia induced by clonidine, however, differs
in that it is not reversed by naloxone and exerts no cross-tolerance with opioids. Side
effects of clonidine include sleepiness, thirst, and xerophthalmia. An erythematous rash
can also occur. There is no significant alteration of blood pressure or heart rate reported
with topical use.

Reference:

Nakamura M, Feireira SH: Peripheral analgesia action of clonidine: Mediation by

release of endogenous enkephalin-like substances. Eur J Pharmocol 146: 223-28,
1988.

Corazza M, Mantovani L, Virgil A, et al. Allergic contact dermatitis from a clonidine

transdermal delivery system. Contact Dermatitis 32: 246, 1995.

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Increased bruxism may be seen in which of the following classes of drugs?

A. Tricyclic antidepressants

B. Benzodiazepines

C. Selective serotonin reuptake inhibitors

D. Monoamine oxidase inhibitors

Answer: C

Rationale:
The muscle relaxant properties of benzodiazepines may decrease the effects of bruxism.
Tricyclic antidepressants produce significant analgesia, and thus play an important role in
the management of TMD patients. They may also treat nocturnal bruxism and any sleep
disturnbances. MAO inhibitors are generally not used in the management of head and
neck pain because of their numerous side effects. SSRI's (like paroxetine) and
heterocyclic antidepressants (like bupropion) can cause focal dystonias which may lead
to increased bruxism.

Reference:
Karlis V, Glickman R. Nonsurgical Management of Temporomandibular Disorders. In:
Miloro M, Ghali GE, Larsen P, Waite P, editors. Peterson's Principles in Oral and
Maxillofacial Surgery. Hamilton: BC Decker Inc; 2004. p. 952-53.

Milam S. Management of the Patient with End Stage Temporomandibular Joint Disease.
In: Miloro M, Ghali GE, Larsen P, Waite P, editors. Peterson's Principles in Oral and
Maxillofacial Surgery. Hamilton: BC Decker Inc; 2004. p. 1022-23.

Bostwick JM, Jaffee MS. Buspirone as an antidote to SSRI-induced bruxism in 4 cases.

Journal of Clinical Psychiatry 60 (12): 857-860, 1999.

Romanelli F, Adler DA, Bungay KM. Possible paroxetine-induced bruxism. Annals of

Pharmacotherapy; 30 (11):1246-8, 1996.

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Which of the following groups of afferent neurons are responsible for transmitting noxious
stimuli from the orofacial region to the CNS?

A. A-delta fibers, C-polymodal nociceptors, silent nociceptors

B. A-delta fibers, A-beta fibers, silent nociceptors

C. A-delta fibers, A-beta fibers, C-polymodal nociceptors

D. A-beta fibers, C-polymodal nociceptors, silent nociceptors

Answer: A

Rationale:
The trigeminal nerve is composed of a functional unit with differing fiber types that
transmit a variety of information. The A alpha fibers are the largest myelinated fibers with
the fastest conduction velocity; they mediate position and fine touch through muscle
spindle afferents and skeletal muscle efferents. The A beta fibers mediate proprioception.
A-beta fibers respond to non-noxious mechanical stimuli. The smallest myelinated fibers
are the A delta fibers that carry pain (“first” or “fast” pain) and temperature information.
The smaller diameter and slower-conducting unmyelinated C fibers mediate “second” or
“slow” pain and temperature sensations. In addition, the joint nerves contain silent
nociceptors, which are mechanoinsensitive when the joint is normal. These units are
neither activated by local mechanical stimulation of the joint nor by innocuous and
noxious joint movements. However, they show some chemosensitivity.

A-delta fibers, C-polymodal nociceptors, silent nociceptors are all afferent neurons that
respond to noxious stimuli and are thus called nociceptors. They are the nociceptors for
the trigeminal nerve. During development of inflammation in the joint, articular afferents
show increased mechanosensitivity. While low-threshold fibers show stronger responses
to innocuous and noxious stimuli, high-threshold fibers show a reduction of their
mechanical threshold and are then activated by normally innocuous stimuli. In addition,
numerous silent nociceptors become mechanosensitive. At this stage, a receptive field
can be localized in the joint, and formerly silent nociceptors begin to respond to joint
movements. Present evidence suggests that the induction of mechanosensitivity results
from the action of inflammatory mediators on these neurons. The recruitment of these
fibers for sensory processing under inflammatory conditions is thought to be an important
mechanism for the induction of inflammation-evoked hyperexcitability.

Reference:
Merrill RL. Neurophysiology of Orofacial Pain. Oral and Maxillofacial Clinics of North
America 12(2):165-179, 2000.

Ogle O, Hertz MB. Myofascial Pain. Oral and Maxillofacial Clinics of North America
12(2):217-231, 2000.

Türp JC, Sommer C, Hugger A (eds): The Puzzle of Orofacial Pain. Integrating Research
into Clinical Management. Pain Headache. Basel, Karger, 15:18-27, 2007.

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Migraine headaches, cluster headaches and paroxysmal hemicrania are examples of which
type of pain?

A. Intracranial

B. Extracranial

C. Central neuropathic

D. Neurovascular

Answer: D

Rationale:
Migraine and cluster headaches, as well as paroxsymal hemicrania are classified as
neurovascular headaches. Neurovascular pain occurs from nerve – vessel contact. For
example, the mechanism of migraine headaches begins with vasoconstriction of cranial
arteries. This constriction may produce prodromal symptoms. The subsequent
vasodilatation is what causes the pain associated with migraine headaches.

Cluster headaches are distinctive recurrent, severe headaches occurring on one side of
the head in the orbitotemporal region associated with ipsilateral photophobia, lacrimation,
and nasal congestion. They occur more commonly in men.

Paroxysmal hemicrania presents in a similar fashion to cluster headaches, but differs in

that the attacks are of shorter duration and more severe. It occurs more commonly in
females.

Reference:
Laskin DM, Greene CS, Hylander WL. TMDs An Evidence Based Approach to Diagnosis
and Treatment, Chicago: Quintessence Publishing Company, Inc, 2006: 302-305

Dorlands Medical Dictionary, ed28, Philadelphia. W.B. Saunders Company, 1994: 735,
1042

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Occipital neuralgia originates from which cervical nerve root?

A. C1

B. C2

C. C3

D. C4

Answer: B

Rationale:
According to all anatomy and dissection studies, the only correct response is C2.
Occipital neuralgia indicating suspected Involvement of the greater occipital nerve (GON)
should be considered in a patient who complains of significant muscle tension in his/her
upper cervical spine with pain radiating from the back of the head / neck to the occipital
area, top of the skull, TMJ area and in or around the ear.

Reference:
Bogduk N. The clinical anatomy of the cervical dorsal rami. Spine 1982; 7(4): 319-29

Bogduk N. The anatomy of occipital neuralgia. Clin Exp Neural 1980; 17:167-84

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The interaction between cervical and trigeminal afferents occurs in what portion of the trigeminal
nucleus that is located in the circle of the diagram below?

A. Pars oralis

B. Pars interpolaris

C. Pars caudalis

D. Pars medius

Answer: C

Rationale:
The trigeminal nucleus has three divisions from caudal to distal; Pars oralis, Pars
interpolaris, and Pars caudalis. Pars medius does not exist. Animal and human studies
clearly show the convergence of cervical and trigeminal afferents in the nucleus caudalis
of the trigeminal nerve. Shoulder and neck myofascial pain has been shown to cause
referred pain to the head and jaw as well as influencing jaw motor function. The
explanation for this clinical observation is the convergence and central excitation of
cervical and trigeminal afferents in one of the three divisions of the trigeminal nucleus.

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Reference:
Piovesan EJ, Kowacs PA, Oshinsky MI. Convergence of cervical and trigeminal sensory
afferents. Curr Pain Headache Rep 2003; 7:377-382

Svennsson P, Arendt-Nielsen L. Muscle pain modulates mastication: an experimental

study in humans. J Orofac Pain 1998: 12:7-16

Bogduk N. The neck and headaches. Neuro Clin 2004; 22:151-171

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A headache diagnosis that accounts for 15% - 35% of all chronic and reoccurring headaches,
and that is often misdiagnosed because of the considerable overlap in symptoms with other
causes of headache is:

A. migraine.

B. cervicogenic.

C. cluster.

D. tension-type.

Answer: B

Rationale:
Cervicogenic headaches are referred pain perceived in any region of the head caused by
a primary nociceptive source in the musculoskeletal tissues innervated by the cervical
nerves. Cervicogenic headache is one of the three large headache groups; the other two
are tension-type headache and common migraine without aura. Cervicogenic headache
accounts for 15% to 35% of all chronic and recurrent headaches.

Migraine and tension-type headaches are the more common headaches.

Migraine headaches are periodic vascular headaches that are usually temporal and
unilateral often found with irritability, nausea, vomiting and photophobia. Prodromal
sensory symptoms (aura) usually occur.

Tension type headaches are a headache associated with nervous tension anxiety and
stress often related to chronic contraction of the strap muscles.
Cluster headaches are distinctive recurrent, severe headaches occurring on one side of
the head in the orbito-temporal region associated with ipsilateral photophobia,
lacrimation, and nasal congestion. Cluster headache is not as prevalent as are migraine,
tension-type and cervicogenic headache.

Reference:
Nilson AN. The prevalence of cervicogenic headache in a random population sample of
20-59 year olds. Spine 1995; 20: 1884-8

Pfaffenrath V, Kaube H. Diagnostics of cervical spine headache. Funct Neurol 1990; 5:

157-64

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The following describes what type of headache?

The pain is usually unilateral but when severe can be felt on the opposite side. The main
manifestation of the headache is in the temporal, frontal, and ocular areas. It has fluctuating
long-term course with remissions and exacerbations; some patients have a continuous basal
headache, others do not. During the headache attack, there may be the following accompanying
phenomena; ipsilateral blurring and reduced vision, a “migraine like” phenomena like nausea
and loss of appetite; there may even be vomiting. Phonophobia and photophobia occur
frequently. Some patients complain of dizziness and of difficulty swallowing during symptomatic
periods. Even between attacks patients may feel stiffness and reduced mobility of the neck.

A. Rebound

B. Cervicogenic

C. Ciliary neuralgia

D. Hormone

Answer: B

Rationale:
The answer is determined by knowing the description of the other headaches (see
below). The primary differential diagnosis is what is mentioned in the last sentence about
the stiffness and reduced mobility in the neck. Stiffness and reduced mobility of the neck
has not been used to describe the other three headaches.
Rebound headaches: Rebound headaches are also called medication overuse
headaches. They tend to occur every day, sometimes waking you in the early morning
and continuing throughout the day. The pain may be most severe at first, when the
medication begins to wear off.
Sometimes, a rebound headache causes dull, achy pain. In other cases, the pain may be
throbbing or pounding.

You may notice other signs and symptoms as well, including:

Nausea
Anxiety
Restlessness, irritability and difficulty concentrating
Memory problems
Depression
ƒ Trouble sleeping

Ciliary neuralgia: Ciliary neuralgia is better known today as cluster headache. There are
two main clinical patterns of cluster headache -- the episodic and the chronic:
Episodic: This is the most common pattern of cluster headache. It is characterized by 1-3
short attacks of pain around the eyes per day, with these attacks clustered over a stretch
of 1-2 months followed by a pain-free remission, a breathing spell. The average length of
remission is a year.

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Chronic: Characterized by the absence of sustained periods of remission, chronic cluster

headache may start with no past history of cluster headaches, or it may emerge several
years after the patient has experienced an episodic pattern of cluster headaches.

Hormone headaches: Hormone headaches are closely related to a woman's

reproductive cycle and sexual hormones. The hormone headaches may be caused by
premenstrual syndrome, menopause, and during a woman's menstrual cycle. They can
also be caused by oral contraceptives, pregnancy, and postpartum.

Hormone headaches are often mistaken for migraine headaches, simply because the
symptoms are very similar. However, pain is usually only felt on one side of the woman's
head. As with migraines, intense throbbing, nausea, vomiting, and sensitivity to light,
sound, and smells may be experienced. A hormone headache may last anywhere from a
few hours to a few days, just as migraine headaches do. In many women, hormone
headaches are so severe that they can become debilitating, just as migraine headaches
are.
Because oral contraceptives change the levels of hormones that are produced in the
body, they often cause hormone headaches. However, at the same time, oral
contraceptives are also commonly used to prevent hormone headaches - again, by
changing the hormone levels. What works well for one woman probably won't work for
the next in terms of use of oral contraceptives and hormone headaches.

Reference:
Nilson AN. The prevalence of cervicogenic headache in a random population sample of
20-59 year olds. Spine 1995; 20: 1884-8

Pfaffenrath V, Kaube H. Diagnostics of cervical spine headache. Funct

Neurol 1990; 5: 157-64

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A Type 2 insulin dependent patient with poor glucose control and peripheral neuropathy
presents with the above CT and MR imaging and a biopsy report of chondroma from an ENT
surgeon. Her chief complaint is left TMJ pain, limited opening and difficulty eating. Which of the
following will have the most predicatable result?

A. Left condylectomy, wide local excision of soft tissue, temporary alloplast to maintain
occlusion and reconstruction with autogenous costochondral graft

B. Left mandibulectomy, left neck dissection, temporary alloplast to maintain occlusion and
autogenous costochondral reconstruction in the future.

C. Left condylectomy and immediate reconstruction with an autogenous vascularized fibula

graft

D. Left condylectomy and immediate alloplastic total left TMJ reconstruction.

Answer: D

Rationale:
Both wide local excision of soft tissue and a neck dissection are unnecessary because
the lesion is not an aggressive local or malignant tumor. An autogenous costochondral
graft in a 76 year old patient would be ill-advised not only medically but biologically as the
rib of a 76 year-old is typically only cortical bone. A vascularized graft in a 76 year old,
poorly controlled diabetic likely carries a high incidence of failure due to vascular
compromise. Treatment of an osteochondroma only requires condylectomy and
likelihood of functional and aesthetic success for this patient with an alloplastic
reconstruction is excellent.

Reference:
Mercuri, L. G.; Edibam, N. R. and Giobbie-Hurder, A.: 14-Year Follow-Up of a Patient
Fitted Total Temporomandibular Joint Reconstruction System. J Oral Maxillofac Surg
65:1140-1148, 2007

Herrera AF, Mercuri LG, Petruzzelli G., and Rajan P.: Simultaneous Occurrence of 2
Different Low-Grade Malignancies Mimicking Temporomandibular Joint Dysfunction. J
Oral Maxillofac Surg 65:1353-1358, 2007.

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When performing a costrochondral graft for the reconstruction of the temporomandibular joint,
typically how thick is the cartilage component of the graft?

A. 0-1mm

B. 2-5mm

C. 6-8mm

D. 11-13mm

Answer: B

Rationale:
2-5 mm of cartilage is the recommended amount of cartilage left at the TMJ (proximal)
end of a costrochondral graft. A minimal amount of cartilage is recommended to
decrease the lever arm action and risk of separation of the cartilage and osseous
components.

The functional similarities between mandibular condyle and rib cartilage have been
demonstrated, therefore maintaining a cartilage cap allows a costochondral graft to
replace the condylar head.

Some authors feel that limiting the cartilage cap reduces the risk of overgrowth, but this
has proven to be unpredictable.

Reference:
Marx RE, Stevens MR. Oral and Maxillofacial Surgery Knowledge Update, Vol I, USA:.
American Association of Oral and Maxillofacial Surgeons, 1994. RCN29-RCN31

Abubaker AO, Benson KJ. Oral and Maxillofacial Surgery Secrets, Philadelphia: Hanley
and Belfus, Inc, 2001. 291

Fernandes R, Fattahi T, Steinberg B: Costochondral Rib Grafts in Mandibular

Reconstruction. Atlas Oral Maxillofac Surg Clin North Am - 01-SEP-2006; 14(2): 179-83

Caccamese JF Jr, Ruiz RL, Costello BJ - Costochondral Rib Grafting. Atlas Oral
Maxillofac Surg Clin North Am - 01-SEP-2005; 13(2): 139-49

Poswillo D. Experimental reconstruction of the mandibular joint. Int J Oral Surg

1974;3:400

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Which of the following is true of autogenous costrochondral bone graft harvesting?

A. In a child under 12 years of age, the subsequent growth of the graft is predictable

B. A post-operative chest x-ray should only be ordered if a pleural tear was visualized
intraoperatively

C. A chest tube should be placed for 24-48 hours anytime a pleural tear is visualized
intraoperatively

D. The latissimus dorsi muscle limits the amount of length of rib harvested

Answer: D

Rationale:
Both overgrowth and undergrowth of costochondral grafts can be seen in children.

A postoperative chest x-ray should be ordered for every patient. Many times a
pneumothorax will not be visualized intraoperatively, but will be evident on a chest x-ray.
For small pleural tears, a chest tube is not required. A small red rubber catheter attached
to low volume suction can be placed in the pleural cavity through the tear. A purse-string
suture is then placed around the catheter. The anesthesiologist provides positive
pressure, and the suture is tied as the catheter is removed. If unsuccessful, then a chest
tube is placed. The latissimus dorsi limits the amount a lateral dissection of the rib being
harvested.

Reference:
Kaban, LB, Pogrel MA, Perrott DH. Complications in Oral and Maxillofacial Surgery,
Philadelphia: W.B. Saunders Company, 1997. 108-109
Fonseca RJ. Oral and Maxillofacial Surgery, Vol 4, Philadelphia: W.B. Saunders
Company, 2000. 305

Mulliken JB, Ferraro NF, Vento AR. A retrospective analysis of growth of the constructed
condyle-ramus in children with hemifacial microsomia. Cleft Palate J. 1989;26:312–317

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When using a modified vertical ramus osteotomy and distraction osteogenesis in TMJ
reconstruction:

A. a bidirectional distractor is typically used.

B. bicortical screws are required.

C. a reverse “L” osteotomy is used to create the transport segment.

D. the distractor should be closed completely before placement.

Answer: C

Rationale:

When performing distraction osteogenesis using a modified VRO, a reverse “L” osteotomy is
used. After condylectomy, a vertical osteotomy is made from the sigmoid notch inferiorly to
correspond with the distraction device. A horizontal osteotomy is the created through the
posterior border of the mandible to create the transport segment with a reverse “L” shaped cut.
Typically, monocortical 1.5mm screws are used in a unidirectional distractor. It is helpful to
open the distractor 2-3mm to facilitate making the posteriorly directed osteotomy.

From Spagnoli DB, Gollehon SG. Distraction Osteogenesis in Reconstruction of the Mandible
and Temporomandibular Joint. Oral and Maxillofacial Surg Clin N Am 18 (2006) 383-398

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Reference:
Spagnoli DB, Gollehon SG. Distraction Osteogenesis in Reconstruction of the Mandible
and Temporomandibular Joint. Oral and Maxillofacial Surg Clin N Am 18 (2006) 383-398

Zhu S, Hu J, Li J, Ying B. Reconstruction of Mandibular Condyle by Transport

Distraction Osteogenesis: Experimental Study in Rhesus Monkey. JOMS 64:1487-1492,
2006

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When using a second metatarsal free vascularized graft to reconstruct the temporomandibular
joint, what artery is transferred with the flap and used for anastomosis?

A. Dorsalis pedis

B. Lateral plantar

C. Medial plantar

D. Medial calcaneal

Answer: A

Rationale:
nd
When performing the 2 metatarsal vascularized free flap, the vessels transferred are
the dorsalis pedis artery and its venous comitantes. Two venous comitantes are often
transferred. Anastomosis usually consists of the arterial supply to the facial artery and
one vein to the posterior facial vein and one to the external jugular vein. In traditional
non-vascularized grafts, such as costochondral grafts, the major disadvantage is the
greater potential for resorption and degenerative changes. The vascularized tissue
transfer has the advantage of long term maintenance of vertical height.

References :
Landa LE, Gordon C, Dabar N, Sotereanos GC. Evaluation of Long-Term Stability in
Second Metatarsal Reconstruction of the Temporomandibular Joint. JOMS 61:65-71,
2003

Netter FH. Atlas of Human Anatomy, ed2, Canada: Friesens Corporation, 1997. 491-500

Dierks EJ, Buehler MJ. Complete Replacement of the Temporomandibular Joint with a
Microvascular Transfer of the Second Metatarsal-Phalangeal Joint. Oral and
Maxillofacial Surg Clin N Am 12 (2000), 139-147

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Regarding total TMJ prosthesis placement, which of the following contributes to achieving a
successful outcome?

A. The prosthetic condylar head should be able to extend beyond the edge of the fossa
prosthesis

B. The fossa prosthesis must be fitted with tripod stability

C. Bone fixation screws are inserted into the temporal bone through the glenoid fossa to
secure the fossa prosthesis

D. Polymethacrylate cement should be used as a medium to custom fit the fossa prosthesis

Answer: B

Rationale:
Throughout the evolution of total TMJ prostheses, certain guidelines have been identified
regarding design and placement that greatly contribute to the overall success of the
prostheses. These guidelines are currently utilized by the manufacturers the total TMJ
prostheses available today. The fossa prosthesis must provide extended coverage over
the articular eminence to allow unobstructed full range of motion of the condyle. If the
prosthetic condylar head is permitted to contact the edge of the fossa prosthesis, this will
create a mechanical obstruction during its movement.

The fossa prosthesis must demonstrate tripod stability so that there is no rocking motion.
Instability of the fossa will ultimately lead to failure of the joint, and possible irreversible
damage to the middle cranial fossa. The use of polymethacrylate cement is advocated
as a filler to eliminate dead space, but should not be used as a medium to custom fit the
fossa prosthesis. Over time, the polymethacrylate will resorb if loaded and should not be
used to support the fosssa prosthesis. Bone fixation screws are used to secure the fossa
prosthesis to the temporal bone, but not through the glenoid fossa. The thickness of the
temporal bone comprising the glenoid fossa is insufficient to provide stable support of the
prosthesis.

Reference:
Quinn P.D. Alloplastic Reconstruction of the Temporomandibular Joint
In: Fonseca's Oral & Maxillofacial Surgery, Vol. 4, Temporomandibular Disorders,
Editors: Bays R.A., Quinn P.D., W.B. Saunders Co., 2000, p. 323-9

Wolford L.M., Dingworth D.J., Talwar R.M., Pitta M.C.

Comparison of Two Temporomandibular Joint Total Joint Prosthesis Systems
Journal of Oral & Maxillofacial Surgery, June 2003, Vol 61, Issue 6, p. 685-90

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A 48 year-old essentially healthy female presents with an MIO of 5 mm and this CT. She states
she has had 6 prior TMJ surgeries in the past 10 years, including the placement and removal of
both Silicone rubber and Teflon-Proplast disc replacement devices. Which treatment, in addition
to bilateral gap arthroplasty, is most appropriate?

A. Silicone rubber block implants.

B. Autogenous costochondral grafts.

C. Autogenous vascularized fibula grafts

D. Total alloplastic reconstructions

Answer: D

Rationale:
Silicone rubber is not recommended for implantation in situations where it will be
functionally loaded. Higher failure rates have been demonstrated in autogenous grafts
after failed silicone rubber and Proplast-Teflon implants.

Good long term functional results have been shown in total alloplastic reconstruction of
TM joints after silicone rubber and Proplast-Teflon implants have been removed.

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Reference:
Henry, C.H. and Wolford, L.M.: Treatment Outcomes for TMJ Reconstruction after
Proplast-Teflon Implant Failure. J Oral Maxillofac Surg 51:352-358, 1993.

Mercuri, L.G. and Giobbe-Hurder, A: Long Term Outcomes After Total Alloplastic TMJ
Reconstruction Following Exposure to Failed Materials. J Oral Maxillofac Surg 62:1088-
1096, 2004.

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Efficient movements during rhythmic jaw opening-closing require well coordinated and
simultaneous movements between muscles of the jaw and:

A. tongue.

B. lips.

C. neck.

D. throat.

Answer: C

Rationale:
Recent findings of simultaneous and well coordinated head-neck movements during
single as well as rhythmic jaw opening-closing tasks has led to the conclusion that
'functional jaw movements' are the result of activation of jaw as well as neck muscles,
leading to simultaneous movements in the temporomandibular, atlanto-occipital and
cervical spine joints. It can therefore be assumed that disease or injury to any of these
joint systems would disturb natural jaw function. Notably, head fixation led to reduced
mandibular movements and shorter duration of jaw-opening/-closing cycles. The findings
suggest recruitment of neck muscles in jaw activities, and that head fixation can impair
jaw function. The results underline the jaw and neck neuromuscular relationship in jaw
function.

No studies were found to suggest that tongue, lip and throat muscles assist or interfere in
opening and closing movements of the mandible

Reference:
Eriksson, Per-Olof. Zafar, Hamayun. Haggman-Henrikson, Birgitta. Deranged jaw-neck
motor control in whiplash-associated disorders. European Journal of Oral Sciences.
112(1):25-32, 2004 Feb.

Haggman-Henrikson, B. Nordh, E. Zafar, H. Eriksson, P-O. Head immobilization can

impair jaw function. Journal of Dental Research. 85(11):1001-5, 2006 Nov

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Forceful contraction of cervical spine muscles has been shown to intensify which of the
following subjective complaints?

A. Jaw popping

B. Ear ringing

C. Nasal congestion

D. Double vision

Answer: B

Rationale:
Objective tinnitus represents only 1% of cases with tinnitus. Subjective tinnitus
represents the remaining 99% of ear ringing. Subjective tinnitus is an otologic
phenomenon of phantom sounds. The sensory upper cervical dorsal roots and the
sensory components of cranial nerves (V, VII, IX, X) converge on a region of the brain
stem that is known as the medullary somatosensory nucleus. Subjective tinnitus is a
neural threshold phenomenon and cervical muscle contraction alters the neural activity
that is responsible for tinnitus. One hundred and fifty patients with subjective tinnitus
were tested with a series of head and neck maneuvers to assess whether any of the
maneuvers changed their tinnitus. Eight percent of patients had increased tinnitus during
the test. (ref #1).

No studies have been identified that show cervical spine muscle contraction intensifies
jaw popping, nasal congestion and double vision.

Reference:
Levine RA Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis.
Am J Otolaryngol 1999; 20:351-62

Abel MD, Levine RA. Muscle contractions and auditory perception in tinnitus patients and
nonclinical patients. J Craniomandibular Pract 2004; 22(3): 181-91.

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Botulinium toxin A (BTX-A):

A. is a pre-synaptic neurotoxin which causes dose-dependent weakness in skeletal muscle.

B. has its primary effect on gamma motor neurons in the muscle spindles.

C. blocks sodium-mediated release of acetylcholine from motor nerve endings.

D. causes paralysis by neural sprouting with re-innervation of the muscle.

Answer: A

Rationale:
The treatment of TMD's often involves the use of BTX-A. BTX A has its primary effect
on alpha motor neurons in the muscle spindles,
Receptor-mediated endocytosis of the botulinum toxin in the area of the synapses
causes subsequent selective proteolysis of the vesicular protein SNAP (synaptomal-
associated protein). This prevents calcium-mediated release of acetylcholine from motor
nerve endings into the neuromuscular synaptic gap resulting in paralysis by functional
denervation of the affected portions of the muscle.

Reference:
Freund B, Schwartz M, Symington JM. Botulinum toxin: new treatment for
temporomandibular disorders. Br J of OMS; 2000, 38, 466-471.

Melling J, Hambleton P, Shone CC. Clostridium botulinum toxins: nature and preparation
for clinical use, Eye; 1988: 216-223.

von Linden JJ, Neiderhagen B, Berge S: Type A botulinum toxin in the treatment of
chronic facial pain associate with masticatory hyperactivity.
J Oral Maxfac Surg 61:774, 2003

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Which statement is correct regarding mechanisms of inflammation in myofascial pain?

A. Trigger point activity is unrelated to excessive release of acetylcholine (ACh) at the

endplate

B. Release of ACh in a dysfunctional endplate causes a muscle contraction and an eventual

increase in the local supply of oxygen

C. ACh release increases when adenosine triphosphate (ATP) decreases due to muscle
contraction

D. Increased ATP in contracted muscles causes release of local chemicals resulting in pain
and inflammation

Answer: C

Rationale:
The treatment of TMD's involves a thorough understanding of trigger points. Myofascial
pain is related to trigger points. The trigger points result from excessive release of ACh
at the endplate. This eventually causes a decrease of oxygen supply in the muscle. A
decrease in ATP causes release of local chemicals resulting in pain and inflammation.

Reference:
Laskin D.M., et. al. TMDs An Evidence-Based Approach to Diagnosis and Treatment.
Quintessence, 2006, p.487.

Mense S, Simons DG. Muscle Pain: Understanding its Nature, Diagnosis, and Treatment.
Philadelphia: Lippincott Williams & Wilkins, 2001.

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Chronic myogenous pain in the masseter muscles may be appropriately treated by which of the
following modalities?

A. Cyclobenzaprine (10 mg qhs)

B. Arthrocentesis

C. Amitriptylline (150 mg every night)

D. Active daily jaw mobilization exercises

Answer: D

Rationale:
Cyclobenzaprine, a muscle relaxant, has been shown to be efficacious for acute pain of
myogenous origin, but the same is not true of chronic pain. Additionally, muscle
relaxants are prone to abuse. Use of cyclobenzaprine is recommended for short periods,
for management of acute myogenous pain, in conjunction with other conservative
approaches such as a bite stabilization splint. Arthrocentesis is not a procedure
indicated for myogenous pain. Low dose amitriptylline (30 mg per day) can be
efficacious in treating myogenous pain, but higher (antidepressant) doses are not
appropriate for this condition. Jaw mobilization excercises have shown a therapeutic
efficacy comparable to the use of an interocclusal appliance in the management of pain
of myogenous origin.

Reference:
Laskin, D., Greene, C., Hlander, W. TMD's, Evidence Based Approach to Diagnosis and
Treatment. Quintessence Publishing 2006, pp 353-357 and pp 496-497

Magnusson, T. Syren, M. Therapeutic jaw exercises and interocclusal

appliance therapy. A comparison between two common treatments of
temporomandibular disorders. Swedish Dental Journal. 23(1):27-37, 1999.

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A healthy 30 year-old female presents with a 3 month history of diffuse right sided jaw pain that
is worse in the morning. The pain is worse with opening wide and attempting to chew. Exam
reveals tenderness over the right masseter, right temporalis and right temporomandibular joint.
She has no swelling and a class I occlusion.
Which of the following treatments would be most efficacious?

A. Arthrocentesis

B. Arthroscopy

C. Splint therapy

D. Narcotic analgesics

Answer: C

Rationale:
The most likely diagnosis for this patient is myofascial pain secondary to nocturnal
bruxism. There is ample literature to suggest that nonsurgical treatment modalities may
account for as much as a 74 to 85% favorable response rate in patients with TMD.

Narcotics should not be used because opioid analgesics should be prescribed only for
moderate to severe pain of limited duration, due to the high potential for addiction. This is
usually a chronic problem. Arthroscopy and arthrocentesis are best utilized for the
management of internal derangement not myofascial pain.

Reference:
Green CS, Laskin DM. Long term evaluation of treatment for myofascial pain dysfunction
syndrome: a comparative analysis. J Am Dent Assoc 1983; 7:235–8.

Okeson JP, Hayes DK. Long term results of treatment for temporomandibular disorder:
an evaluation by patients. J Am Dent Assoc 1986;12:473–8.

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Which of the following findings is most often associated with fibromyalgia?

A. Dull, deep and diffuse pain of muscles

B. Peak age occurrence of 18-25 years of age

C. Muscle ache and stiffness late in the day

D. Limited jaw range of motion with spasms

Answer: A

Rationale:
Fibromyalgia's muscular symptoms include generalized muscle ache and soreness,
morning muscle stiffness, and fatigue. When diagnosed, the symptoms are present for
more than 6 months and are associated with stress, weather changes, G.I. problems
and, in the face, pain in the muscles of mastication. Diagnostic criteria for pain in the
muscles of the face associated with fibromyalgia include a dull, deep and diffuse pain, a
female to male ratio of 9:1 with a peak age of 45-55 years. The mandibular range of
motion is usually normal without a muscle spasm component.

Reference:
Wolfe F, Smythe H, Yunus M, et al: The American College of Rheumatology 1990
criteria for the classification of fibromyalgia: Report of the multicenter criteria committee.
Arthritis Rheum 33: 160,1990.

Plesch O, Wolf E, Lona N: The relationship between fibromyalgia and

temporomandibular disorders: Prevalence and symptom severity. J Rheumatol 23:
1948-52, 1996.

Balasubramaniam R. Laudenbach JM. Stoopler ET. Fibromyalgia: an update for oral

health care providers. [Review] [191 refs] [Journal Article. Review] Oral Surgery Oral
Medicine Oral Pathology Oral Radiology & Endodontics. 104(5):589-602, 2007 Nov.

Balasubramaniam R. de Leeuw R. Zhu H. Nickerson RB. Okeson JP. Carlson CR.

Prevalence of temporomandibular disorders in fibromyalgia and failed back syndrome
patients: a blinded prospective comparison study. [Comparative Study. Journal Article]
Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 104(2):204-
16, 2007 Aug

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Which statement best describes the relationship between myofascial pain disorder (MPD) and
fibromyalgia (FM)?

A. MPD is a mild form of FM

B. MPD is rare in FM patients

C. MPD shares features of FM

D. MPD and FM are unrelated conditions

Answer: C

Rationale:
FM is a systemic condition characterized by widespread muscle and joint pain and
fatigue. It is not a diagnosis of exclusion, but is determined by a set of clinical criteria
established by the American College of Rheumatology in 1990. The criteria specify that
painful points must be bilateral and both above and below the waist, thus MPD alone is
not FM. MPD does occur more commonly in FM patients than the overall population, and
both conditions share the features of stiff, sore muscles, subjective swelling, aggravation
by poor sleep or stress, and others. Many hypotheses regarding a common etiology of
FM, MPD, chronic fatigue syndrome, irritable bowel syndrome, and other potentially
related disorders are presently receiving serious attention in the TMD, rheumatologic,
physical medicine, and internal medicine literature.

Reference:
Balasubramaniam R, de Leeuw R, Zhu H, Nickerson RB, Okeson JP, Carlson CR.
Prevalence of temporomandibular disorders in fibromyalgia and failed back syndrome
patients: a blinded prospective comparison study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2007 Aug;104(2):204-16.

Chakrabarty S, Zoorob R. Fibromyalgia. Am Fam Physician. 2007 Jul 15;76(2):247-54.

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An anxious-appearing 38 year-old female complains of a stiff, sore jaw. She is tender to

palpation over her temples and zygomatic arches bilaterally. Her interincisal opening is 36mm,
but stretches to 40mm with light finger pressure. This increases her bilateral cheek pain. Her
lateral and protrusive movements are of normal range and non-painful. Further testing for this
patient may include:

A. erythrocyte sedimentation rate (ESR).

B. cutaneous thermography.

C. diagnostic local anesthetic injection.

D. electromyography.

Answer: C

Rationale:
The history and clinical examination findings in this patient are most consistent with
myofascial pain disorder (MPD). MPD is often associated with anxiety, and presents as
muscle tenderness and stiffness, which are worsened by function. Inter-incisal opening
of 36mm with a “soft end feel” and normal lateral excursive and protrusive movement
without pain are not consistent with intracapsular disorders and make MRI imaging of the
TMJ's inappropriate. Cutaneous thermography and electromyography are techniques
which may be useful in clinical research, but have no proven use in clinical diagnosis.
However, local anesthetic injection or even dry needling of a trigger point in myofascial
pain may have both diagnostic and therapeutic utility.

Reference:
Cifala J. Myofascial (trigger point pain) injection: theory and treatment. Osteopath. Med.
1979;April:31-36.

Lewit K. The needle effect in the relief of myofascial pain. Pain 1979;6(1):83-90.

Fricton JR, Kroening R, Haley D, Siegert R. Myofascial pain syndrome of the head and
neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol
1985;60:615-23.

Alvarez DJ, Rockwell PG. Trigger Points: Diagnosis and Management. Am Fam
Physician 2002;65:653-60

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The below open mouth view MRI images of the left temporomandibular joint demonstrate:

A. an anterior displaced disc with reduction, avascular necrosis of the condyle and condylar
hypomobility.

B. an anterior displaced disc without reduction and condylar hypomobility.

C. an anterior displaced disc with reduction and normal condylar mobility.

D. an anterior displaced disc without reduction, avascular necrosis of the condyle and
condylar hypomobility.

Answer: B

Rationale:
The MRI reveals an anteriorly displaced disc without evidence of reduction upon opening
and condylar hypomobility, as the condyle never reaches the tip of the articular
eminence. In cases of internal derangement, the lateral condyle pole loses bone stock
either as the result of lateral disc attachment loss or is the cause of lateral disc
attachment loss.

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Reference:
Laskin, DM: Internal Derangement. In, TMDs, An Evidence-Based approach to Diagnosis
and Treatment. Laskin, DM; Greene, CS; Hylander, WL (eds).Quintessence Publishing,
Hanover Park, IL 2006, pp.252-253.

Larheim, TA and Westesson, PL: TMJ Imaging. In, TMDs, An Evidence-Based approach
to Diagnosis and Treatment. Laskin, DM; Greene, CS; Hylander, WL (eds).Quintessence
Publishing, Hanover Park, IL 2006, pp. 149-179.

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A 16 year-old female presents to your office with a chief complaint of acute right TMJ pain and
limited mouth opening ever since she yawned yesterday and heard a “pop” come from her right
jaw joint. She denies any prior symptoms, although admits to chronic gum chewing and painless
right TMJ clicking. Her MIO is < 20 mm, deviates to the right, and has no joint noise. She has a
tender right masseter and temporalis tendon and when asked to point to the area with the most
pain she points directly to the right TMJ. She has a slight right buccal segment open bite. What
is your diagnosis?

A. An acute posterior displaced disc, reflex masticatory muscle spasm/pain and right TMJ
intra-capsular edema

B. A chronic right disc displacement without reduction, reflex masticatory muscle

spasm/pain and right TMJ intra-capsular edema

C. An acute right disc displacement without reduction, reflex masticatory muscle spasm/pain
and right TMJ intra-capsular edema

D. A possible right TMJ intra-capsular fracture with reflex masticatory muscle spam/pain and
intra-capsular edema

Answer: C

Rationale:
The patient’s history and clinical exam support the diagnosis of an acute right TMJ disc
displacement without reduction, reflex masticatory muscle spasm/ pain, and right TMJ
intra-capsular edema. The onset of her symptoms was acute and the pain is localized to
the right TMJ area. The decreased MIO is new and onset was not gradual. Examination
of her right masseter and temporalis reveals tenderness consistent with muscle spasm.
The slight ipsilateral occlusal change is consistent with intra-capsular edema from the
event. The presence of a previous right TMJ click which abruptly stops with an associated
limitation in mouth opening is further evidence of progression from a reducing disc to a
non reducing disc. Posterior disc displacement is extremely rare, if it even exists at all.

The patient gives no history of trauma and with a fracture she would likely have a contra
lateral open bite rather than one on the ipsilateral side.

Reference:
Laskin, DM: Internal Derangement. In, TMDs, An Evidence-Based approach to Diagnosis
and Treatment. Laskin, DM; Greene, CS; Hylander, WL (eds).Quintessence Publishing,
Hanover Park, IL 2006, pp.252-253.

Stegenga, B and de Bont, LGM: Internal Disc Derangements. In, TMDs, An Evidence-
Based approach to Diagnosis and Treatment. Laskin, DM; Greene, CS; Hylander, WL
(eds).Quintessence Publishing, Hanover Park, IL 2006, pp. 125-136.

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Injury to branches of the facial nerve (C.N. VII) during the preauricular approach to the
temporomandibular joint most commonly involves the:

A. zygomatic which lie a mean 2 cm anterior to the preauricular crease.

B. temporal which lie a mean 2 cm anterior to the preauricular crease.

C. zygomatic which lie a mean 2 cm anterior to the bony external auditory canal.

D. temporal which lie a mean 2 cm anterior to the bony external auditory canal.

Answer: D

Rationale:
The most posterior temporal branches lie anterior to the post-glenoid tubercle. Their
location was measured as 0.8 – 3.5 cm (mean 2.0 cm) and more recently measured at
2.12 cm ± 0.21 cm (range, 1.68 to 2.49 cm); from the anterior margin of the bony external
auditory canal. The zygomatic branches are inferior and anterior to the surgical field and
much less likely to be injured in the approach to the TMJ.

Illustration of Al-Kayat and Bramley’s cadaveric study of the facial nerve, with
comparisons to the present study. Adapted from Quinn PD: Color Atlas of
Temporomandibular Joint Surgery, Mosby, St Louis, MO, 1998.

Miloro et al. Temporal Branch of the Facial Nerve. J Oral Maxillofac Surg 2007.

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Reference:
Al – Kayat A. , Bramley P. , A modified preauricular approach to the TMJ and malar
arch Brit J Oral Surgery 1979-80; 17:91

Michael Miloro, Scott Redlinger, Diane M. Pennington, Tommy Kolodge; In Situ Location
of the Temporal Branch of the Facial Nerve, JOMS December 2007 (Vol. 65, Issue 12,
Pages 2466-2469)

Surgery for Internal Derangement of the Temporomandibular Joint by Leslie B. Heffez in

Principles of Oral & Maxillofacial Surgery, ed: Peterson, Larry J., Indresano, A. Thomas;
Marciani, Robert D. and Roser, Steven M. Vol. 3, 1992, pg. 1937

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Which of the following surgical procedures is most likely to be associated with the development
of crepitus and degenerative changes of the mandibular condyle over time when managing a
TMJ with a Wilkes’ stage IV internal derangement?

A. Arthroscopy

B. Arthroplasty with disc plication

C. Discectomy without replacement

D. Total alloplastic joint replacement

Answer: C

Rationale:
The surgical management of temporomandibular joint internal derangement may involve
a multitude of surgical procedures. Arthroscopy, arthroplasty with disc plication,
discectomy with replacement, discectomy without replacement and total alloplastic joint
replacement, have all shown some degree of efficacy in the management of
temporomandibular joint dysfunction. Radiographic changes after discectomy are
stabilized in 6 months with long term pain relief of 80 – 90%. Despite the potential for
alleviating pain and increasing range of motion, discectomy without replacement is likely
to result in joint crepitus and degenerative changes over time. This is a result of the
mandibular condyle functioning against the articular surface of the glenoid fossa without
an interposed cartilage disc.

Wilkes Classifications for Internal Derangement1

Class I: Painless clicking. No restricted motion. Slight forward displacement of disk.
Class II: Occasional painful clicking, intermittent locking, headaches. Slight
forward displacement of disk, beginning deformity and slight thickening of posterior edge.
Class III: Frequent pain, joint tenderness, headaches, locking, restricted motion,
and painful chewing. Anterior disk displacement with significant deformity/prolapse of
disk.
Class IV: Chronic pain, headaches, and restricted motion. Increase in severity from
III with early to moderate degenerative changes, flattening of eminence, deformed
condylar head, sclerosis.
Class V: Variable pain, joint crepitus, and painful function. Disk perforation, filling
defects, gross anatomic deformity of disk and hard tissues with degenerative arthritic
changes.
1
Quinn, P. ”Color Atlas of Temporomandibular Joint Surgery” ; Chapter 4:Surgery
for Internal Derangements, Table 4.1,p56. Mosby 1998.

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Reference:
Holmlund A. Arthroscopy. In Oral and Maxillofacial Surgery: Temporomandibular Joint
Disorders. Eds: Bays R and Quinn P. WB Saunders. 2000, 255-274

Bays R. Surgery for internal derangement. In Oral and Maxillofacial Surgery:

Temporomandibular Joint Disorders. Eds: Bays R and Quinn P. WB Saunders. 2000,
275-300

Hall, HD. The role of discectomy in treating derangements of the temperomandibular

joint. Oral and Maxilofacial Surg Clin N Am. 1994; 6:287-94.

Quinn P. Alloplastic reconstruction of the temporomandibular joint. In Oral and

Maxillofacial Surgery: Temporomandibular Joint Disorders. Eds: Bays R and Quinn P.
WB Saunders. 2000, 316-332

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The increased presence of proteoglycan monomers in chronic closed lock or painful clicking is
due to:

A. increased mRNA expression coding for proteoglycan precursors.

B. decreased mRNA expression coding for proteoglycan synthesis.

C. increased degradation of proteoglycans.

D. incomplete synthesis of proteoglycans.

Answer: C

Rationale:
In cartilage, the tensile strength depends upon collagen fibers, while the presence of
proteoglycans with their glycosaminoglycan side chains gives the tissue an osmotic
swelling pressure – essential for the capacity for taking up and distributing point load.
Even though fibrocartilage such as the TMJ disc and the meniscus of the knee contain
larger proportions of collagen and smaller amounts of proteoglycans and
glycomaminoglycan side chains – their presence is important for the biomechanical
properties of the tissue. Temporomandibular joints with chronic closed lock have shown a
substantial loss of proteoglycans from the affected disc and an increase in their
degradation as reflected by the presence of proteoglycan monomers. The increase in
proteoglycans monomers noted in painful clicking and chronic closed lock is due to
increased degradation of the articular disk, not to increased expression of genes coding
for their production.

Reference:
Paegle DI, Holmlund A, Hjerpe A. Expression of proteoglycan mRNA in patients with
painful clicking and chronic closed lock of the temporomandibular joint. Int J Oral
Maxillofac Surg, 2005, 34:656-658.

Paegle DI, Holmlund A, Hjerpe A. Matrix glycosaminoglycans in the temporomandibular

joint disc in patients with painful clicking and closed lock. Int J oral Maxillofac Surg 2003,
32:397-400.

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Temporomandibular joint effusion seen on magnetic resonance imaging indicates which of the
following conditions?

A. Anterior disc displacement

B. Disc perforation

C. Osteoarthritis

D. Synovitis

Answer: D

Rationale:
The amount of joint effusion is known to correlate with the severity of synovitis detected
at arthroscopic surgery in patients with internal derangement. Biochemical analysis of
effusion fluid in both internal derangement and osteoarthrosis contains higher
concentrations of total protein and proinflammatory cytokines IL-6 and IL-8 than does
synovial fluid from joints without effusion, strongly suggesting that effusion fluid is
released from inflamed synovial tissue.

Disc position, perforation, or osteoarthritic conditions have not been shown to correlate
with the presence or magnitude of joint effusion.

Effusion can be found at bilaminar zone (white arrow).

Reference:
Segami, N, Nishimura, M, Kaneyama, K, et al. Does joint effusion onT2 magnetic
resonance images reflect synovitis? Comparison of arthroscopic findings in internal
derangements of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 92:341-5, 2001

Segami, N, Miyamaru, M, Nishimura, M, et al. Does joint effusion on T2 magnetic

resonance images reflect synovitis? Part 2. Comparison of concentration levels of
proinflammatory cytokines and total protein in synovial fluid of the temporomandibular
joint with internal derangements and osteoarthrosis. Oral Surg Oral Med Oral PatholOral
Radiol Endod 94:515-21, 2002

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Which MR pulse sequence would best demonstrate a joint effusion?

A. Fast spin echo imaging

B. T1 weighted

C. T2 weighted

D. Fat suppression imaging

Answer: C

Rationale:
The spin echo pulse sequence is the most commonly used pulse sequence in MRI. The
two variables of interest in spin echo sequences are the repetition time (TR) and the echo
time (TE). The pulse sequence timing can be adjusted to give T1 weighted, proton
density, or T2 weighted images. A short TR and a short TE will give a T1 weighted image.
A long TR and a short TE will give a proton density image, and a long TR and a long TE
will give a T2 weighted image.
T2 weighted images are most sensitive to fluid and vascular changes which can occur
interstitially or within virtual spaces such as the superior joint space. These areas appear
as high signal intensities to contrast with the lower signal intensities of non-inflamed
areas.

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Marked anterior disc displacement. The T2 sagittal sequence shows a superior

compartment effusion and condylar erosion (white arrows).

From: Whyte AM. McNamara D. Rosenberg I. Whyte AW. Magnetic resonance imaging in
the evaluation of temporomandibular joint disc displacement--a review of 144 cases.
International Journal of Oral & Maxillofacial Surgery. 35(8):696-703, 2006 Aug.

Reference:
Comparison of altered signal intensity, position, and morphology of the TMJ disk
in MR images corrected for variations in surface coil sensitivity. Oral Surgery, Oral
Medicine, Oral Pathology, and Endodontology, vol 101, issue 4, pages 515-522, 2005

Taylor DB, Babyn P, Blaser S, Smith S, Shore A, Silverman ED, Chuang S, Laxer RM.
MR evaluation of the temporomandibular joint in juvenile rheumatoid arthritis. J Comput
Assist Tomogr May-June 17(3):449-54, 1993

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In the lubrication system of the temporomandibular joint, which of the following forms a fluid film
that prevents friction on the articular surface?

A. Phospholipase A2

B. Hyaluronic acid

C. Metalloproteinase-1

D. Calpain

Answer: B

Rationale:
The lubrication system of the TMJ allows the disc to slide along the slope of the
eminence. Two major constituents are responsible for free joint movement: surface-
active phospholipids and hyaluronic acid. Hyaluronic acid is a high molecular weight
muccopolysaccharide that forms a full fluid film that keeps the articular surfaces
separated and prevents friction. In vitro, the adherence of hyaluronic acid to
phospholipids membranes (liposomes) protects them from hydrolysis by phospholipase
A2.

Reference:
Hills BA. Synovial surfactant and the hydropholic articular surface. J. Rheumatol 1996;
23(8): 1323-5.

Nitzan DW, Nitzan U, Dan P, et al. The role of hyaluronic acid in protecting surface-
active phospholipids from lysis by exogenous phospholipase A2. Rheumatology (Oxford)
2001; 40(3): 336-40.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

In patients with internal derangements evaluated by MRI, the second most common type of
disc displacement following anterior displacement is:

A. antero-medial.

B. lateral.

C. medial.

D. antero-lateral.

Answer: D

Rationale:
In a recent study utilizing MRI to evaluate temporomandibular joint disc displacement by
Whyte et al, the percentage of patients with a displaced TMJ disc presenting with anterior
displacement was 44%, medial displacement 1%, lateral displacement 3%, antero-medial
displacement 6%, and antero-lateral displacement was 29%.

Antero-lateral displacement is more frequent than the other choices with the likely cause
due to weakness of the lateral capsular attachment. The medial capsular attachment is
much stronger and is reinforced by the insertion of the lateral pterygoid muscle. Pure
lateral disc displacement is uncommon.

One hundred and forty four patients underwent magnetic resonance imaging (MRI) for
evaluation of suspected internal derangement (ID) of the temporomandibular joint (TMJ).
All scans were performed on a state-of-the-art scanner by highly experienced
technologists and evaluated by a single Head and Neck/Maxillofacial radiologist.
Seventy-nine percent of patients were female and 21% male. Age distribution of the
cases was bi-modal with first peak at 20-30 years of age and second peak at 50-60 years
of age. Of the 82.5% of cases with disc displacement, 59.5% demonstrated reduction
with opening and 40.5% did not reduce. Anterior disc displacement is common (44%) and
sideways displacement rare (4%). Antero-lateral displacement was the second
commonest type of displacement (29%) probably related to the weakness of the lateral
disc attachment.

Reference:
Whyte AM, McNamara D, Rosenberg I, Whyte AW. Magnetic resonance
imaging in the evaluation of temporomandibular joint disc displacement-a review of 144
cases. Int J. Oral Maxillofac. Surg., 2006, 35:696-703.

Foucart J-M, Caprentier P, Pajoni D, Marguelles-Bonnet R, Pharaboz C. MR of 732

TMJ's: anterior, rotational, partial and sideways disc displacements. Eur J Radiol 1998:
28: 86-94.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

The fact that post-operative pain levels are dramatically decreased as early as one month
following discectomy, disc repositioning, laser assisted arthroscopy or condylotomy in patients
treated for internal derangements can best be attributed to:

A. placebo effect resulting from surgery.

B. the natural course of internal derangements.

C. reduced pain levels corresponding directly to early improvements in range of motion.

D. it is the surgery itself.

Answer: D

Rationale:
Hall, Indresano, Kirk and Dietrich in a controlled, prospective study of four surgical
procedures for treatment of TMJ internal derangements found marked improvement in
pain levels and diet that were not statistically different between the four procedures.
Ranges of motion at one month were either the same or decreased so that there was no
correlation between this variable and pain levels. Placebo affects usually around 35% of
the sample size, whereas in this study, 90% of the patients showed pain improvement at
one month. The natural course of internal derangements usually results in 50% of the
patients reporting improvement in pain levels at one year that is slow and gradual. The
authors feel that it is surgery itself that accounts for this early and sustained pain relief.

Reference:
Hall HD, Indresano AT, Kirk W, Dietrich M: Prospective Multicenter Comparison of 4
Temporomandibular Joint Operations. J Oral Maxillofac Surg 63: 1174-79, 2005.

Dolwick MF: The role of temporomandibular joint surgery in the treatment of patients
with internal derangements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83: 150,
1997.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

After performing a right TMJ arthroscopy under general anesthesia the patient is extubated and
complains of difficulty breathing and swallowing which was not present pre-operatively. She
denies any pain. Attached below are clinical photographs of intraoral findings. What is the most
likely cause of this problem?

A. Perforation of the external auditory canal

B. Perforation of the medial capsule

C. Acute cellulitis

D. Air emphysema

Answer: B

Rationale:
The most likely cause of this lateral pharyngeal swelling is perforation of the medial drape
and forcing fluids into the infratemporal fossa. This is not likely to occur if an adequate
outflow port has been established. Whether or not a mechanical pump or hand-operated
syringe is used, extravasation is a continual risk for arthroscopic procedures.
Complications of such medial fluid extravastion include pharyngeal embarrassment of
airway requiring overnight hospitalization, periorbital and temporal edema, and transient
cranial nerve V and VII effects.

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Hemorrhagic complications of arthroscopy involves inadvertent puncture or laceration of

the overlying vessels on entry. These may include, but are not limited to, superficial
temporal artery/vein (A/V), transverse facial A/V, or even the masseteric artery. Bleeding
and hematoma formation is usually due to injury to the superficial temporal artery.
Accumulation of blood is usually superficial and visible externally along the puncture site
not intra-orally. Perforation of the external auditory canal (EAC) can result in trauma to
the external and middle ear but the fluids will usually egress thru the EAC. Infection from
arthroscopy is rare due to the large amount of fluid utilized during the procedure and the
constant lavage. Infections also will take time to develop making this unlikely. Air
insufflation is not used in TMJ arthroscopy and therefore there is no mechanism for air
emphysema.

Reference:
Carter JB, Schwaber MK. Temporomandibular joint arthroscopy: complications and their
management. Oral Maxillofac Surg Clin North Am 1989;1(1): 185–99.

White RD. Retrospective analysis of 100 consecutive surgical arthroscopies of the

temporomandibular joint. J Oral Maxillofac Surg 1989;47:1014–21.

Tsuyama M, Kondoh T, Seto K, Fukuda J. Complications of temporomandibular joint

arthroscopy: a retrospective analysis of 301 lysis and lavage procedures performed using
the triangulation technique. J Oral Maxillofac Surg 2000;58(5):500–5.

Small NC. Complications in arthroscopic surgery performed by experienced

arthroscopists. J Arthrosc Rel Surg 1988;4:215–21.

Preisler SA, Koorbusch GF, Olson RAJ. An acquired arteriovenous fistula secondary to
temporomandibular joint arthroscopy: report of a case. J Oral Maxillofac Surg
1991;49:187–90.

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 2009 Oral and Maxillofacial Surgery Self Assessment Tool (OMSSAT)

Which of the following procedures can result in radiographic evidence of regeneration of the
articular portion of the mandibular condyle?

A. Modified condylotomy

B. Surgical arthroscopy

C. Arthrocentesis

D. Open arthroplasty with muscle flap

Answer: A

Rationale:
After modified condylotomy, Hall and Nickerson have demonstrated repair of
degenerative condylar lesions, as well as progressive bone remodeling of the condyle.
The growth of bone, primarily on the posterior and superior surfaces of the condyle, has
previously been noted to occur in some joints after modified condylotomy. In one study,
this type of bone growth was present in 32% of the condyles 1 year after the operation.
This has not been demonstrated with any other procedure.

Reference:
Nickerson JW, Veaco NS: Condylotomy in surgery of the
temporomandibular joint. Oral Maxillofac Surg Clin North Am
1:303, 1989

Hall HD, Nickerson JW Jr, McKenna SJ: Modified condylotomy

for treatment of the painful temporomandibular joint with a
reducing disk. J Oral Maxillofac Surg 51:133, 1993

Hall HD, Navarro EZ, Gibbs SJ. One- and three-year prospective outcome study of
modified condylotomy for treatment of reducing disc displacement.
J Oral Maxillofac Surg. 58:7-17; 2000.

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