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ORAL & MAXILLOFACIAL SURGERY - Complete Question Bank Answers

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SECTION 1: ANESTHESIA

1. Define Local Anesthesia. Theories & Mechanism of Action

Chemical Classification

• Esters: Procaine, chloroprocaine, cocaine, tetracaine - hydrolyzed by plasma pseudocholinesterase
• Amides: Lidocaine, mepivacaine, bupivacaine, prilocaine, articaine - metabolized in the liver

Physicochemical Properties

1. pKa - determines onset (lower pKa = faster onset; more uncharged form at tissue pH)
2. Lipid solubility - determines potency
3. Protein binding - determines duration of action

Mechanism of Action (Sodium Channel Blockade)

1. LA is injected as a salt (weak acid) in solution - exists in ionized (charged) and nonionized (uncharged) forms
2. The uncharged lipid-soluble form penetrates the nerve sheath and axonal membrane
3. Inside the axoplasm, it re-equilibrates - the charged (cationic) form enters the sodium channel from the axoplasmic side
4. It binds to a specific receptor within the sodium channel, blocking Na⁺ influx
5. With no Na⁺ influx → the firing threshold is not reached → no action potential → conduction block

Theories of Local Anesthesia

Composition of LA Solution

• Local anesthetic agent (e.g., lignocaine 2%)
• Vasoconstrictor (e.g., adrenaline 1:80,000) - prolongs action, reduces bleeding, lowers systemic toxicity
• Reducing agent (sodium metabisulphite) - antioxidant for vasoconstrictor
• Preservative (methylparaben)
• Vehicle (sterile water/saline)

Role of Vasoconstrictors

• Cause local vasoconstriction → slow absorption into bloodstream
• Increase depth and duration of anesthesia
• Reduce systemic toxicity (lower peak blood levels)
• Reduce bleeding in the operative field
• Adrenaline (epinephrine) 1:80,000-1:200,000 is most commonly used
• Contraindicated in: hyperthyroidism, severe cardiovascular disease, phaeochromocytoma, patients on non-selective beta-blockers, and end-arteries (digits, penis, nose tip)

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2. Inferior Alveolar Nerve Block (IANB)

Anatomy

• At the level of the occlusal plane of mandibular molars
• 1 cm above and behind the mandibular third molar region
• At the junction of pterygomandibular raphe

Landmarks

1. Coronoid notch - greatest concavity on anterior border of ramus (palpate with index finger)
2. Pterygomandibular raphe - vertical fibrous band visible when mouth opened wide; needle inserted just lateral to it
3. Occlusal plane of lower molars - determines the height of injection
4. The needle is placed at the intersection of: a horizontal line at the occlusal plane + a vertical line 1 cm medial to the anterior ramus border

Technique (Conventional/Direct Technique)

1. Patient opens mouth maximally
2. Operator palpates coronoid notch with index finger - thumb placed in the retromolar fossa
3. Barrel of syringe rests on the opposite lower premolars
4. Needle (long, 27G) inserted at the medial surface of ramus, just lateral to the pterygomandibular raphe, at the height of the coronoid notch
5. Advance 2-2.5 cm until bone is contacted (medial surface of ramus near mandibular foramen)
6. Withdraw 1 mm, aspirate, then deposit 1.5-1.8 mL slowly
7. Withdraw halfway, deposit 0.5 mL for lingual nerve (lies anterior & medial to IAN at this point)

Gow-Gates Technique (High Condylar Block)

• Targets V3 at the neck of condyle (higher than conventional IANB)
• Anesthetizes: IAN + lingual nerve + auriculotemporal nerve + mylohyoid nerve + buccal nerve (in 75%)
• Higher success rate; used when conventional IANB fails
• Landmarks: tragus-commissure line; needle directed to neck of condyle below the mesiolingual cusp of upper second molar

Signs of Successful IANB

• Tingling/numbness of lower lip and chin on the injected side (mental nerve territory)
• Numbness of the tongue on the same side (lingual nerve)
• Onset: 3-5 minutes

Complications of IANB

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3. Infraorbital Nerve Block

• Maxillary anterior teeth (canine to central incisor)
• Adjacent buccal gingiva and mucosa
• Lower eyelid, side of nose, upper lip (cheek area)

Landmarks

1. Infraorbital foramen - 4-7 mm below the infraorbital rim, in line with the pupil (supraorbital notch-pupil-infraorbital foramen lie in a vertical line)
2. Zygomaticomaxillary suture - lateral reference
3. Palpate the foramen - directed inferiorly and slightly lateral (nerve exits downward and medially)

Technique

1. Palpate and mark the infraorbital foramen
2. Insert needle through skin, 1-1.5 cm below the foramen, directing toward it
3. Do NOT enter the foramen (risk of nerve damage)
4. Aspirate; deposit 1-2 mL just at the foramen rim

1. Retract upper lip, insert needle at the mucobuccal fold between upper lateral incisor and canine
2. Direct needle parallel to the long axis of the upper second premolar, toward the infraorbital foramen
3. Advance until resistance felt at the rim of the foramen
4. Aspirate, deposit 1.5-2 mL slowly

Complications

• Hematoma (infraorbital vessels)
• Damage to infraorbital nerve if needle enters foramen
• Swelling/bruising around eye
• Failure due to incorrect direction

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4. Contraindications of Local Anesthesia

• Allergy to LA agent or preservative (methylparaben)
• Infection at injection site (risk of spreading infection; may also fail due to low pH)
• Coagulopathy (uncontrolled) - risk of hematoma
• Vasoconstrictor-specific contraindications: thyrotoxicosis, pheochromocytoma, uncontrolled cardiac arrhythmia, MAO inhibitor therapy
• Absolute refusal by patient (medicolegal)

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5. Stages of General Anesthesia (Guedel's Classification)

1. Stage I - Analgesia: Conscious, cooperative, pain reduced
2. Stage II - Excitement/Delirium: Unconscious but excitable; breath-holding, vomiting risk - dangerous stage, pass through quickly
3. Stage III - Surgical Anesthesia (4 planes based on eye movement, respiration, muscle tone):
   • Plane 1: Regular breathing, eye movement stops
   • Plane 2: Corneal reflex lost
   • Plane 3: Intercostal paralysis begins, pupil dilates
   • Plane 4: Complete intercostal paralysis - danger zone
4. Stage IV - Medullary Depression: Respiratory and circulatory failure - death if not reversed

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6. Preanesthetic Medications

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SECTION 2: EXODONTIA

7. Indications & Contraindications for Dental Extraction

Indications

1. Severe dental caries beyond restoration
2. Advanced periodontal disease (Grade III mobility)
3. Failed root canal treatment
4. Impacted teeth causing recurrent pericoronitis, pathology, or orthodontic crowding
5. Fractured teeth (non-restorable)
6. Supernumerary teeth causing malocclusion
7. Pre-radiation extraction of teeth in the radiation field
8. Pre-cardiac surgery (removal of infected foci)
9. Orthodontic extractions for space creation
10. Malposed teeth causing trauma
11. Teeth associated with pathology (cysts, tumors)

Contraindications

• Severe cardiovascular disease (recent MI, uncontrolled hypertension)
• Coagulopathy / anticoagulant therapy
• Uncontrolled diabetes
• Active leukemia or lymphoma
• Pregnancy (1st and 3rd trimesters - relative CI)
• Bisphosphonate therapy (risk of MRONJ)
• Post-radiation to jaws (risk of osteoradionecrosis)
• Renal/hepatic failure

• Acute infection/cellulitis (abscess - relative; drain first or incise)
• Malignant disease in the area
• Inadequate mouth opening (trismus)

Principles of Extraction

1. Expansion of the socket - elevate and expand the periodontal space
2. Luxation - loosen the tooth from its socket
3. Delivery - remove tooth in the path of least resistance
4. Correct hand position and fulcrum
5. Use of appropriate instruments (forceps suited to anatomy)
6. Minimum trauma to surrounding structures
7. Primary closure when indicated

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8. Impacted Mandibular Third Molar

Classification

• Mesioangular (most common, ~43%)
• Horizontal
• Vertical
• Distoangular (most difficult)
• Transverse/Inverted/Buccoangular/Linguoangular

• Class A: Crown at same level as adjacent tooth (occlusal plane)
• Class B: Crown between occlusal plane and cervical line of second molar
• Class C: Crown below cervical line of second molar (fully embedded)

• Class I: Adequate space between ramus and second molar
• Class II: Partial space (anterior border of ramus covers part of crown)
• Class III: Tooth entirely within ramus

Winter's WAR Lines

1. W - White line: Follows the occlusal plane of molar teeth to the ascending ramus
2. A - Amber line: Connects the deepest points of bone on either side of the impacted tooth
3. R - Red line: Perpendicular from amber line to white line at the point where tooth must be delivered

Surgical Procedure - Horizontally Impacted Lower Third Molar

• Ward's incision: horizontal incision along the gingival margin of second molar, extending to retromolar region, with a releasing incision anteriorly (Szmyd or Ward envelope flap)
• Reflect a full-thickness mucoperiosteal flap

• Use a surgical handpiece (straight/contra-angle) with round bur
• Remove bone from the buccal and distal aspects to expose the crown
• Distobuccal bone removal most important for access

• For horizontal impaction: section the tooth at the cementoenamel junction with a fissure bur
• Remove the crown first, then the roots separately (or elevate the sectioned segments)

• Use a Coupland's elevator (No. 1, 2, 3) to loosen and deliver segments
• Apply elevator in the mesial aspect using the mesial root as a fulcrum

• Remove all debris, smooth any sharp bone edges
• Irrigate with normal saline

• Reposition flap, suture with 3-0 black silk or resorbable sutures
• Interrupted or mattress sutures

Indications for Removal of Impacted Third Molars

1. Recurrent pericoronitis
2. Dental caries (impacted tooth or adjacent second molar)
3. Dentigerous cyst formation
4. Periodontal disease
5. Resorption of adjacent roots
6. Orthodontic reasons
7. Preventing fracture of mandibular angle
8. Neuralgic pain

Contraindications for Removal

1. Elderly patient with deeply embedded tooth causing no symptoms
2. Partially erupted with good access and no symptoms
3. Compromised systemic health
4. Adjacent vital structures at high risk (IAN proximity)
5. Post-radiation jaw

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9. Principles in Use of Elevators

1. Never use adjacent tooth as fulcrum (unless it is also to be extracted)
2. Wheel-and-axle principle - rotational force around the long axis
3. Inclined plane principle - wedge between tooth and bone
4. Lever principle - rotate elevator to expand socket
5. Apply force in a controlled manner, always with finger guards
6. Keep the elevator in contact with bone - not soft tissue

Uses of Elevators

• Luxate tooth prior to forceps application
• Remove roots or root fragments
• Remove unerupted teeth
• Hemisection and removal of root pieces

Complications of Elevators

• Displacement of root into maxillary sinus or inferior alveolar canal
• Fracture of adjacent alveolar bone
• Injury to adjacent tooth
• Dislocation of adjacent tooth
• Nerve injury (lingual, IAN)
• Fracture of elevator

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10. Post-Extraction Complications

Immediate

• Hemorrhage (primary)
• Syncope
• Injury to adjacent teeth/nerves

Early (within 24-48 hours)

• Reactionary hemorrhage (within 24h, as vasoconstrictor wears off)
• Pain, swelling, trismus
• Acute alveolar osteitis (Dry Socket)

Late

• Secondary hemorrhage (3-7 days, usually from infection)
• Dry socket (Alveolar osteitis): Most common delayed complication; loss of the blood clot, exposed bone, severe pain radiating to ear. Management: irrigation, alvogyl/obtundent dressing, analgesics

Dry Socket (Acute Alveolar Osteitis)

• Incidence: 2-5% of all extractions; up to 20-30% in mandibular third molars
• Predisposing factors: Smoking, oral contraceptive pill, poor oral hygiene, traumatic extraction, excessive irrigation of socket
• Pathogenesis: Fibrinolysis of blood clot - proposed by Birn's hypothesis (local fibrinolytic activity destroys the clot)
• Features: Severe throbbing pain 3-4 days post-extraction, radiating to ear; empty socket with exposed bone and food debris; foul odor
• Management: Gentle irrigation with warm saline/chlorhexidine, placement of obtundent dressing (Alvogyl - eugenol + bismuth + iodoform), analgesics, antibiotics if signs of infection

Management of Post-Extraction Hemorrhage

• Assessment: Distinguish primary (during/immediately after) vs. reactionary (within 24h) vs. secondary (infection, 5-7 days)
• Local measures: Pressure pack with gauze (20 min), suturing, bone wax for bone bleeders, oxidized cellulose (Surgicel), tranexamic acid packs, silver nitrate cautery, resorbable hemostatic agents (Gelfoam)
• Systemic: Identify coagulopathy; fresh frozen plasma, Vitamin K, platelet transfusion as needed

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11. Transalveolar Extraction

• Roots of abnormal shape/size
• Hypercementosis
• Ankylosis
• Very deep roots
• Previously root-filled teeth
• Proximity to vital structures

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SECTION 3: PRINCIPLES OF SURGERY

12. Hemorrhagic Disorders & Management of Hemophilia for Extraction

Classification of Hemorrhagic Disorders

• Hereditary telangiectasia (Osler-Weber-Rendu)
• Purpura (Henoch-Schönlein)
• Vitamin C deficiency (scurvy)

• Thrombocytopenia (ITP, TTP, drug-induced)
• Thrombocytopathia (Glanzmann's thrombasthenia, Bernard-Soulier)
• Von Willebrand disease (most common inherited bleeding disorder)

• Hemophilia A (Factor VIII deficiency, X-linked recessive)
• Hemophilia B / Christmas disease (Factor IX deficiency)
• Hemophilia C (Factor XI deficiency)
• Liver disease (reduced clotting factor synthesis)
• Vitamin K deficiency (II, VII, IX, X)
• DIC

Management of Hemophilia A Patient for Extraction

1. Liaise with hematologist
2. Check baseline APTT, Factor VIII level (target >50% for extraction)
3. Administer Factor VIII concentrate (recombinant) preoperatively to raise level to 50-100%
4. DDAVP (Desmopressin) - for mild hemophilia A: raises Factor VIII by releasing it from endothelial storage
5. Tranexamic acid (antifibrinolytic) given pre-op and continued for 5-7 days post-op
6. Use long-acting factor replacement (continue 7-10 days)

1. Use regional anesthesia cautiously (IANB can cause hematoma); consider infiltration or PDL injection
2. Minimize trauma - atraumatic technique
3. Pack socket with resorbable hemostatic agents (Gelfoam, oxidized cellulose)
4. Place tranexamic acid-soaked gauze
5. Suture the socket

1. Continue factor replacement for 7-10 days
2. Tranexamic acid mouthwash 10 mL four times daily (swish and spit for 2 min) for 5-7 days
3. Soft diet, avoid aspirin/NSAIDs
4. Written instructions and 24-hour emergency contact

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13. Sterilization & Asepsis

Sterilization Methods

• Steam under pressure: 121°C at 15 psi for 15 min (or 134°C at 30 psi for 3 min)
• Destroys all microorganisms including spores
• Suitable for: metal instruments, surgical gowns, dressings, glassware
• Disadvantage: Cannot be used for heat-sensitive items

• Hot air oven: 160°C for 1 hour, or 170°C for 45 min, or 180°C for 30 min
• Less efficient than moist heat (requires higher temperature and longer exposure)
• Suitable for: glassware, oils, waxes, powder

• Glutaraldehyde 2% (Cidex): 20-30 min for disinfection; 10h for sterilization
• Used for heat-sensitive items: endoscopes, rubber/plastic equipment
• Ethylene oxide (ETO): Low temperature gas sterilization for delicate electronics, plastics

• Gamma irradiation: industrial sterilization of single-use items
• UV radiation: surface sterilization only (limited penetration)

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14. Suture Materials & Techniques

Classification

• Natural: Plain catgut (absorbed in 10-14 days), Chromic catgut (21-28 days) - absorbed by phagocytosis
• Synthetic: Polyglycolic acid (Dexon), Polyglactin 910 (Vicryl, 56-70 days), Poliglecaprone (Monocryl)

• Natural: Silk (braided), Linen
• Synthetic: Nylon (monofilament), Polypropylene (Prolene), Polyester (Dacron)

Suturing Techniques

1. Simple interrupted - most common in oral surgery; each stitch is independent
2. Horizontal mattress - everting; good for tension-free closure
3. Vertical mattress - good eversion and dead-space elimination
4. Continuous/Running - faster; poor if one knot fails
5. Figure of eight - hemostatic; used to close extraction socket

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15. Anaphylaxis Management

1. Stop the triggering agent
2. Call for help
3. Lay patient flat, elevate legs (if hypotensive)
4. Adrenaline (Epinephrine) 0.5 mg IM (1:1000) - FIRST-LINE; into anterolateral thigh; repeat every 5-15 min if no improvement
5. 100% O2, secure airway (may need intubation)
6. IV access - large bore cannula
7. IV fluids: 500-1000 mL rapid crystalloid infusion
8. Antihistamine: Chlorphenamine 10 mg IV/IM (second-line)
9. Steroid: Hydrocortisone 200 mg IV (second-line; helps prevent biphasic reaction)
10. Monitor vital signs, ECG, pulse oximetry
11. Transfer to hospital; observe for 24h (biphasic reaction risk)

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16. Syncope (Vasovagal Attack)

• Cause: Emotional stress, pain, anxiety - vagal stimulation → vasodilation → reduced cardiac output → cerebral hypoperfusion
• Signs: Pallor, sweating, bradycardia, nausea, loss of consciousness
• Management: Lay flat (Trendelenburg), loosen clothing, pass ammonia capsule near nose, O2, recovery usually spontaneous within minutes

Other Medical Emergencies Summary

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SECTION 4: INFECTIONS

17. Osteomyelitis of the Jaw

Classification

• Acute suppurative osteomyelitis (ASO)
• Chronic suppurative osteomyelitis (CSO) - primary or secondary

• Garre's osteomyelitis (chronic sclerosing with periostitis)
• Diffuse sclerosing osteomyelitis
• Focal sclerosing osteomyelitis (condensing osteitis)
• SAPHO syndrome

Acute Suppurative Osteomyelitis

• Bacteria invade medullary cavity → inflammatory exudate forms → increases intramedullary pressure → thrombosis of blood vessels → ischemia and necrosis → sequestrum (dead bone) forms → surrounded by involucrum (reactive new bone)

• Severe, deep-seated, boring pain in jaw
• Swelling - both intra- and extraoral
• Trismus
• Pus discharge (intraoral/extraoral sinuses)
• Loosening of teeth in the involved area
• Paresthesia of lower lip (inferior alveolar nerve involvement) - Vincent's sign
• Lymphadenopathy
• Pyrexia, malaise

• "Moth-eaten" appearance - irregular radiolucency
• Sequestrum (dense opaque dead bone surrounded by radiolucent zone)
• Involucrum (dense reactive periosteal new bone)

1. Antibiotic therapy - high-dose IV penicillin (first-line) or amoxicillin-clavulanate; clindamycin if penicillin-allergic
2. Surgical drainage - incision and drainage of pus
3. Sequestrectomy - removal of sequestrum once demarcated
4. Decortication - for chronic/diffuse cases: removal of outer cortex to expose medullary cavity and allow vascular ingrowth
5. Hyperbaric oxygen (HBO) - for chronic/refractory cases; increases tissue O2 tension, promotes healing

Garre's Osteomyelitis

• Chronic, non-suppurative, sclerosing osteomyelitis with periosteal proliferative reaction
• Causes focal, hard, painless bony expansion of mandible (usually in children)
• "Onion peel" periosteal layering on X-ray
• Treatment: Remove causative tooth + antibiotics; bone usually remodels

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18. Ludwig's Angina

• Most commonly from mandibular molar (second/third molar) periapical abscess (70-90%)
• Also: compound mandibular fractures, floor of mouth lacerations, submandibular sialadenitis
• Microbiology: Mixed aerobic and anaerobic organisms (Streptococcus, Staphylococcus, Bacteroides)

• Bilateral submandibular swelling - brawny, woody induration (no fluctuation - cellulitis, not abscess)
• Elevation and posterior displacement of tongue
• Dysphagia, drooling
• Dysphonia - "hot potato" voice
• Trismus
• Dyspnea - risk of airway obstruction (most feared complication)
• Pyrexia, tachycardia, malaise

1. Airway first - the most critical step; awake fiberoptic intubation or surgical airway (tracheostomy) if airway compromised
2. High-dose IV antibiotics: Amoxicillin-clavulanate + Metronidazole, or Penicillin + Metronidazole; add Clindamycin if allergic
3. IV fluids, NG feeding, nutritional support
4. Surgical drainage - external bilateral submandibular and submental incisions; open floor of mouth; drain all involved spaces
5. Daily wound packing and irrigation
6. Monitor closely in ICU

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19. Spread of Odontogenic Infection & Fascial Spaces

• Canine space (from upper canine periapical abscess)
• Buccal space (molars, premolars)
• Infratemporal space (upper third molars)
• Masseteric space
• Pterygomandibular space (lower third molars)
• Sublingual space (anterior mandibular teeth)
• Submandibular space (lower molars - lingual plate perforation below mylohyoid)

• Temporal space
• Lateral pharyngeal space
• Retropharyngeal space
• Parapharyngeal space

• Buccally → Buccal space or Masseteric space
• Lingually above mylohyoid → Sublingual space → lingual cervical cellulitis
• Lingually below mylohyoid → Submandibular space → Ludwig's angina
• Posteriorly → Pterygomandibular space → Lateral pharyngeal space

Pterygomandibular Space

• Medial: Medial pterygoid muscle
• Lateral: Medial surface of mandibular ramus
• Superior: Lateral pterygoid muscle
• Inferior: Pterygopalatine raphe
• Anterior: Pterygomandibular raphe (buccopharyngeal)
• Posterior: Parotid gland

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20. Oroantral Fistula (OAF)

• Extraction of upper posterior teeth (premolars, molars) - most common
• Periapical infection involving antrum floor
• Trauma
• Cysts or tumors eroding antral floor
• After Caldwell-Luc operation

• Volume: ~15 mL; pyramidal shape
• Floor formed by the alveolar process (roots of upper molars and second premolars closely related)
• Lined by Schneiderian (pseudostratified ciliated columnar) membrane
• Drains via ostium into middle meatus

• Air/fluid regurgitation from nose on drinking
• Nasal voice
• Chronic maxillary sinusitis signs (pain, purulent discharge from nose)
• Positive nose-blowing test (bubbling through socket)
• Transillumination test positive
• OPG/CT: opacification of maxillary sinus

• Figure-of-eight suture over socket
• Blood clot formation and healing by secondary intention

1. Rehrmann's flap (buccal advancement flap): Most common; trapezoidal buccal mucoperiosteal flap advanced to cover the defect; requires periosteal scoring to allow advancement
2. Palatal rotation flap: Pedicled palatal mucoperiosteal flap rotated to cover; robust blood supply; donor site heals by secondary intention
3. Buccal fat pad (Bichat's fat pad): Useful for larger defects
4. Tongue flap: For very large defects
5. Caldwell-Luc operation: To clear infected sinus before closure

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SECTION 5: ORAL PATHOLOGY (CYSTS, TUMORS)

21. Odontogenic Keratocyst (OKC)

• Thin, uniform parakeratinized stratified squamous epithelial lining (6-8 cells thick)
• Prominent, palisaded, columnar basal cells
• High recurrence rate

• Most common in mandibular posterior body/ramus/angle region
• Peak: 2nd-3rd decade; slight male predilection
• Often asymptomatic until large; may cause expansion and displacement of teeth
• Associated with Gorlin-Goltz syndrome (nevoid basal cell carcinoma syndrome) - multiple OKCs, calcified falx cerebri, basal cell carcinomas, bifid ribs

• Well-defined unilocular (usually) or multilocular radiolucency
• Scalloped or smooth borders
• Rarely causes expansion (grows anteroposteriorly within medullary bone)
• May be pericoronal (associated with crown of unerupted tooth)

• Uniform parakeratinized stratified squamous epithelium (5-8 cell layers)
• Flat epithelial-connective tissue interface
• Palisaded columnar/cuboidal basal cells
• Keratinous material in lumen
• Satellite cysts/daughter cysts in the capsule = reason for high recurrence

• Enucleation + curettage with peripheral ostectomy (Burs/Carnoy's solution applied to cavity walls)
• Marsupializiation as a first stage for large cysts (reduces size, then enucleation)
• Carnoy's solution (ethanol, chloroform, ferric chloride): chemical cauterization of cavity lining - reduces recurrence
• Peripheral ostectomy: removal of 1-2 mm of bone around cavity
• Resection for large, aggressive, or recurrent lesions
• Recurrence rate: 25-60% due to daughter cysts in capsule

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22. Ameloblastoma

1. Conventional (solid/multicystic) ameloblastoma - most common, most aggressive
2. Unicystic ameloblastoma - less aggressive; often pericoronal
3. Extraosseous/peripheral ameloblastoma - in soft tissue
4. Metastasizing ameloblastoma (malignant behavior despite benign histology)

• Most common odontogenic tumor
• Mandible > Maxilla (80:20); angle/ramus region predominant
• Slow-growing, painless expansion
• "Egg-shell crackling" on palpation (paper-thin cortex)
• May cause facial asymmetry, tooth displacement
• Maxillary ameloblastomas are more aggressive (expand into nasal cavity, orbit, skull base)

• "Soap bubble" or "honeycomb" multilocular radiolucency
• Well-defined, scalloped corticated borders
• Tooth displacement and root resorption
• Cortical expansion and thinning

• Resection with 1-1.5 cm margins of apparently normal bone (gold standard)
• Low-grade (unicystic): enucleation with curettage may suffice
• Continuity resection (hemimandibulectomy) for large lesions
• Reconstruction: iliac crest bone graft (within 6 weeks), fibula free flap for large defects
• Immediate reconstruction with reconstruction plate and bone graft

• Enucleation + curettage; close follow-up
• Marsupialization may reduce tumor size before enucleation

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23. Fibrous Dysplasia

• Monostotic (single bone, 70-80%): Most common; affects jaw
• Polyostotic (multiple bones): McCune-Albright syndrome (fibrous dysplasia + café-au-lait spots + precocious puberty in girls)
• Craniofacial fibrous dysplasia

• Slow, painless bony enlargement, typically in 1st-2nd decades
• Usually stops at puberty (hormone-dependent)
• Mandible and maxilla commonly involved
• Jaw expansion: buccal and palatal surfaces; can cause malocclusion, displacement of teeth
• Maxillary involvement may obliterate paranasal sinuses

• "Ground glass" appearance (diffuse, uniformly hazy, obliteration of normal trabeculae) - most characteristic
• Ill-defined borders that blend with normal bone
• "Orange peel" or "Chinese writing" pattern
• No sclerotic rim (unlike OKC)

• Conservative recontouring (surgical shaving/osteoplasty) for cosmetic deformity - only after puberty (when lesion stabilizes)
• Rarely requires radical resection
• Regular monitoring with serial radiographs
• Bisphosphonates (pamidronate) for active, painful, or rapidly progressive disease
• Biopsy to confirm diagnosis when in doubt

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24. Dentigerous Cyst (Follicular Cyst)

• Often asymptomatic; discovered on routine X-ray
• Slow expansion; can reach large size
• Tooth displacement/resorption of adjacent teeth

• Well-defined unilocular radiolucency associated with the crown of an unerupted tooth
• Pericoronal attachment at the CEJ
• Smooth, corticated border
• Root of associated tooth projects into the radiolucency

• Thin, non-keratinized stratified squamous epithelium (2-4 cells thick)
• Flat interface with fibrous connective tissue
• No rete pegs
• May undergo transformation to ameloblastoma or squamous cell carcinoma (rare)

• Enucleation with extraction of associated impacted tooth (small-medium cysts)
• Marsupialization for large cysts (decompress, then enucleate)

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SECTION 6: TRAUMA & FRACTURES

25. Classification of Mandibular Fractures

1. Dentoalveolar
2. Condylar (condylar head, subcondylar, condylar neck)
3. Coronoid
4. Ramus
5. Angle (most common fracture site)
6. Body (premolar region)
7. Symphysis/Parasymphysis
8. Multiple

• Class I: Fracture with teeth present
• Class II: Fracture in edentulous area
• Class III: Fracture in edentulous jaw

• Favorable: Muscle pull reduces the fracture
• Unfavorable: Muscle pull displaces the fracture

Angle of Mandible Fracture

• Pain and swelling over angle of mandible
• Trismus (masseter/pterygoid spasm)
• Gagging on the ipsilateral side (posterior open bite if unfavorable)
• Deviation of mandible on opening (toward the fracture side)
• Malocclusion
• Paresthesia of lower lip if IAN is involved
• Step deformity palpable extraorally and intraorally

• OPG (panoramic): best initial view for mandible
• PA mandible view
• CT scan (gold standard for condylar and comminuted fractures)

• Closed reduction + IMF (Intermaxillary Fixation): Using arch bars (Erich arch bars), wire ligatures (Ivy loops); jaw wired shut for 4-6 weeks
• Open reduction + rigid internal fixation (ORIF): Using miniplates and screws (Champy's principles)
• Champy's lines of osteosynthesis: Ideal placement of plates along lines of tension to provide adequate stabilization without compressive forces

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26. Condylar Fractures

• By level: Intracapsular (head) / Condylar neck / Subcondylar
• By displacement: Non-displaced / Displaced / Dislocated (condyle displaced out of fossa)
• Bilateral vs. unilateral

• Unilateral condylar fracture: Deviation of mandible toward fracture side on opening; anterior open bite; premature contact on ipsilateral side
• Bilateral condylar fracture: Anterior open bite; inability to protrude mandible; bilateral preauricular pain; limited mouth opening

• Conservative (Closed): IMF for 1-2 weeks followed by physiotherapy - for undisplaced, in children, and elderly
• Open Reduction Indications:
  1. Condyle displaced into middle cranial fossa
  2. Inability to achieve satisfactory occlusion by closed means
  3. Lateral extracapsular displacement
  4. Bilateral condylar fractures with midface fractures
  5. Condylar fracture with associated mandibular fracture requiring ORIF
  6. Foreign body in joint

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27. Middle Third Facial Fractures (Le Fort)

Le Fort I Features

• Mobility of the tooth-bearing maxilla (held and moved independently of the midface)
• Lengthened or flattened face
• Guérin's sign: Bruising in the soft palate region
• Epistaxis
• Class III bite (anterior open bite)

Le Fort III Features

• Extensive periorbital edema, bilateral circumorbital ecchymosis ("raccoon eyes")
• Lengthening/flattening of the face ("dish face" deformity)
• Complete mobility of the midface
• Telecanthus (widening of intercanthal distance)
• Subconjunctival hemorrhage
• CSF rhinorrhea (cribriform plate involvement)
• Battle's sign (mastoid ecchymosis if base of skull fracture)

Management of Zygomatic Complex Fracture

• Incision in temporal region, elevator (Rowe's malar elevator) passed under temporalis fascia to reach the zygomatic arch
• Malar complex elevated back into position

• Infraorbital approach (for orbital floor)
• Upper buccal sulcus incision (for ZM buttress)
• Lateral orbital rim approach

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28. Orthognathic Surgery

Bilateral Sagittal Split Osteotomy (BSSO)

• Mandibular setback (for Class III) or advancement (for Class II)
• Splits the ramus sagittally; medial and lateral cortices separated
• Proximal segment contains condyle; distal segment carries teeth
• Fixed with miniplates or bicortical screws

Anterior Maxillary Osteotomy (Wassmund)

• Repositioning of anterior maxillary segment (upper incisor region)
• Used for correction of bimaxillary protrusion

Distraction Osteogenesis

• Gradual stretching of regenerating bone between cut ends
• Activation phase: 1 mm/day in 0.25 mm increments (4 times/day)
• Latency period: 5-7 days before activation
• Consolidation: 6-12 weeks
• Advantages: simultaneous soft tissue expansion, reduced relapse

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SECTION 7: TMJ & FACIAL PAIN

29. TMJ Ankylosis

• True ankylosis: Intra-articular, bony or fibrous
  • Bony: Complete bony fusion of condyle to glenoid fossa
  • Fibrous: Dense scar tissue within joint space
• False ankylosis (extra-articular): Coronoid impingement, fibrosis of muscles, zygomatic arch fracture causing coronoid impaction

1. Trauma (most common in children) - condylar fracture with inadequate treatment
2. Infection (otitis media, mastoiditis spreading to joint) - most common in developing countries
3. Rheumatoid arthritis
4. Radiation
5. Ankylosing spondylitis

• Restricted mouth opening (hallmark) - may be completely absent
• Facial asymmetry
• Deviation of chin toward affected side
• Retrognathia (bird-face deformity) if bilateral and during growth
• Dental crowding and malocclusion
• Sleep apnea (severe cases)

• Loss of joint space
• Bony continuity between condyle and fossa (bony ankylosis)
• "Mushroom-shaped" flattened condyle

1. Aggressive resection of ankylotic mass
2. Ipsilateral coronoidectomy
3. Contralateral coronoidectomy if opening < 35 mm
4. Lining of fossa with temporal fascia or cartilage
5. Reconstruction with costochondral rib graft (in growing children) or total joint prosthesis (adults)
6. Rigid fixation
7. Early mobilization and aggressive physiotherapy (mouth-opening exercises from day 1 post-op)

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30. Trigeminal Neuralgia (Tic Douloureux)

• Unilateral, sudden, electric shock-like, severe pain
• Lasts seconds to 2 minutes
• Triggered by light touch: eating, speaking, shaving, brushing teeth, cold wind
• Trigger zones: Corner of mouth, nasal ala, upper lip
• Between attacks: completely pain-free
• V2 (maxillary) and V3 (mandibular) divisions most commonly affected; V1 rare
• Female > male; onset after 40 years (90% of cases)
• Bell's sign: Deviation of the jaw toward the affected side on mouth opening (if motor branch involved)

• Dental pain (constant, not triggered)
• Postherpetic neuralgia (history of zoster rash, burning quality)
• MPDS (muscular, dull aching)
• Atypical facial pain
• Cluster headache
• Multiple sclerosis (if young patient)

• Carbamazepine 600-1200 mg/day - drug of choice; sodium channel blocker; highest response rate; monitor CBC, LFTs, sodium
• Oxcarbazepine - better tolerated; watch for hyponatremia

• Gabapentin, pregabalin, phenytoin, baclofen, lamotrigine

1. Microvascular decompression (MVD) - gold standard surgical procedure; separates offending vessel from trigeminal root; highest long-term success with lowest recurrence
2. Percutaneous procedures on gasserian ganglion:
   • Radiofrequency thermocoagulation
   • Balloon microcompression
   • Glycerol rhizolysis
3. Gamma Knife (Stereotactic radiosurgery)
4. Peripheral nerve block/avulsion - alcohol block of mental, infraorbital, or supraorbital nerve

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31. TMJ Dislocation

• Inability to close mouth (open lock)
• Pain, muscle spasm
• Drooling, inability to speak clearly
• Condyle palpable anterior to articular eminence
• Bilateral: chin displaced forward, hollow preauricular fossae

• Manual reduction (Hippocratic method): Thumbs on lower molars, fingers below chin; push mandible down and back while tilting chin up
• Pre-medication with muscle relaxant (diazepam 5-10 mg IV) or local anesthesia to reduce spasm
• After reduction: bandage (Barton's bandage) for 2-4 weeks; soft diet

• Eminectomy (removal of articular eminence) - allows free condylar movement, preventing re-dislocation
• Eminoplasty (augmentation of eminence with bone graft) - increases eminence height to block excessive condylar movement
• Dautrey's procedure (condylar shave)
• Injection of sclerosing agent into joint

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SECTION 8: PRE-PROSTHETIC & IMPLANT SURGERY

32. Alveoloplasty

• Simple alveoloplasty: smoothing of sharp bony spicules after extraction
• Dean's alveoloplasty: Complete re-shaping including removal of facial cortex; for multiple extraction cases
• Interseptal alveoloplasty: Removal of interdental septa, collapse of buccal plate

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33. Osseointegration (Dental Implants)

• Biocompatible implant material (titanium)
• Implant design (surface texture - roughened/acid-etched/sandblasted)
• Surgical technique (no overheating of bone; <47°C)
• Status of host bone (adequate bone volume and density)
• Loading conditions (no immediate overloading)

1. Blood clot formation around implant
2. Primary bone formation (woven bone)
3. Remodeling to lamellar bone (haversian remodeling)
4. Direct bone-implant contact (3-6 months)

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QUICK-REFERENCE SUMMARY TABLE

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What's Covered

• Definition, theories & mechanism of LA (specific receptor, membrane expansion, surface charge)
• Inferior alveolar nerve block - landmarks, technique, Gow-Gates, complications
• Infraorbital nerve block - landmarks, intraoral technique
• Vasoconstrictors, composition of LA, stages of GA, preanesthetic medications

• Indications/contraindications and principles of extraction
• Winter's WAR lines, Pell & Gregory classification of impacted third molars
• Surgical procedure for horizontally impacted lower third molar
• Post-extraction complications including dry socket (Birn's hypothesis), hemorrhage management
• Elevator principles and complications

• Hemophilia management with factor VIII protocol, DDAVP, tranexamic acid
• Sterilization (autoclave, dry heat, cold/chemical, ETO)
• Suture materials (absorbable vs. non-absorbable) and techniques
• Anaphylaxis management, syncope, and medical emergencies summary table

• Osteomyelitis classification, pathology, Vincent's sign, moth-eaten X-ray, sequestrectomy
• Garre's osteomyelitis (onion peel periosteum)
• Ludwig's angina - bilateral, brawny, airway emergency, drainage
• Fascial space spread of infection, pterygomandibular space boundaries
• Oroantral fistula - anatomy, Rehrmann's flap, palatal rotation flap

• OKC - parakeratinized, daughter cysts, Gorlin syndrome, Carnoy's solution
• Ameloblastoma - soap bubble X-ray, histological types, resection with 1 cm margin, Kaban protocol
• Fibrous dysplasia - GNAS1 mutation, ground glass appearance, recontouring after puberty
• Dentigerous cyst - pericoronal, enucleation vs. marsupialization

• Mandibular fracture classification, angle fracture management, Champy's lines
• Condylar fractures - indications for open vs. closed reduction
• Le Fort I, II, III - Guérin's sign, dish face, CSF rhinorrhea
• Zygomatic complex fracture - Gillies temporal approach
• Orthognathic surgery - BSSO, distraction osteogenesis

• TMJ ankylosis - Kaban protocol, costochondral graft in children
• Trigeminal neuralgia - carbamazepine first-line, MVD surgical gold standard
• TMJ dislocation - Hippocratic reduction, eminectomy

• Alveoloplasty, Dean's alveoloplasty, osseointegration