MCQs in Oral Surgery: A comprehensive review

By Akeel Mosea

This comprehensive multiple choice questions style book covers most aspects of oral surgery. It uses real clinical scenarios with extensive answers based on textbooks and current literature. The reader will gain a broad understanding and confidence in different flap designs with their clinical indications, dentoalveolar surgery, correct use of exodontia instruments, soft tissue surgery, orthodontic surgery and surgical endodontics. The book also delves into dental infections and their management, medication related osteonecrosis of the jaw, osteoradionecrosis, trauma, surgical aspects of dental implants, oroantral communication. It also covers basic sciences, bleeding tendency and anticoagulants, local anaesthesia and sedation, different odontogenic and non-odontogenic lesions of the jaw.

The target audience for this book would be oral and maxillofacial surgeons, dental surgeons and any clinician with an interest in oral surgery. The book will be of particular interest to candidates sitting their exit examinations. 

About the Author 

Mr. Akeel Mosea  

Jordanian Board (OMFS), FFDRCSI(OSOM), MFDRCSI, Dip Imp Den RCS (Eng), BDS.  

Specialist in Oral and maxillofacial surgery (Jordan Medical Council). 

Specialist in oral surgery (UK General Dental Council). 

Specialty doctor in oral and maxillofacial surgery. The Princess Alexandra Hospital. United Kingdom.

Specialist oral surgeon. Colchester Dental specialist Centre (Part of BUPA).

• Language: English
• Publisher: Lulu.com
• Release date: Jul 17, 2021
• ISBN: 9781105336263

Book preview

Copyright © 2021 Akeel Mosea

All rights reserved, including the right to reproduce this book, or portions thereof in any form. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse engineered, or stored, in any form or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical without the express written permission of the author.

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Preface 

There are numerous oral surgery textbooks on the shelf. However, we found a shortage of review books in the specialty with multiple choice style and in-depth explanatory answers. 

The MCQs in oral surgery is a comprehensive book that covers most aspects of oral surgery. It provides clinical scenarios with answers based on literature review, textbooks and clinical experience. It has the potential to move the reader to a higher level of understanding and integration of knowledge with elimination of any misconceptions. This book will be particularly useful for candidates sitting exams. 

The author has written two accompanying books in implant dentistry and one in plastic facial skin reconstruction. We are delighted to have received excellent feedback. The MCQs in oral surgery should follow the same spirit of our previous publications.  

Finally, I would like to thank you for your time in reading this book and hope you find it valuable and enjoyable. 

Best wishes 

Akeel Mosea 

Questions and Answers

1. Which one of the following flaps is correctly designed?

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1. Answer: c

As a general rule in mucoperiosteal flap design, a release incision should start at 90˚ from the junction of the apical and middle thirds of the interdental papilla, before it swerves vertically in the interdental space parallel to the roots, this can help better approximation of the wound edges. Please refer to the diagram below:

PapillaReleaseIncision.jpg

Correct papilla release incision design.

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Incorrect release incision will lead to difficulty in repositioning of the flap, necrosis of its pointed end and gingival recession.

Wounds heal best over concave or flat surfaces. Extending an incision over a root eminence convexity will increase risk of wound dehiscence, especially if there is missing bone (root has dehiscence or there is pathological/surgical bony defect, which means there is no base blood supply to the flap).

Failure to respect the above rules may lead to difficulty in restoring the dental papilla, delayed healing, with resultant gingival recession.

2. The following pictures show two patients on your oral surgery day list:

ThickandThinBiotypes.jpg

You are intending to perform a gingival sulcus incision involving a number of upper front teeth with a releasing arm. Assuming all patients and surgery related factors were similar. Which one of the following statements is correct?

a. Patient A can be at a higher risk of gingival recession post operatively than patient B.

b. Compared to patient A, there is more risk of dehiscence in the release incision of the flap in patient B, should the incision extend over the root eminence.

c. You may expect a more optimum healing in patient B than patient A.

d. A gingival sulcus incision is contraindicated in both patients if they have a high smile line.

e. A release incision is contraindicated in both patients if they have a high smile line.

2. Answer: b

The gingival biotype is normally clinically evaluated, based on the general appearance of the gingiva around the teeth.

Thick biotype has dense and thick gingiva. The teeth are squarer in shape, and the interdental papillae are short.

Thin biotype has delicate, friable and almost translucent gingiva, with obvious scalloping over the root eminence, which may have fenestrations/dehiscence of the facial bone plate. The interdental papillae are triangular and longer. The crowns of the teeth are also more triangular shape and longer too.

The gingival biotype may vary from tooth to tooth in the same person. It may also differ with age, gender, medical condition, and dental arch location. Patient A has thick biotype, while patient B has thin-medium gingival biotype.

Implications of gingival biotypes in oral surgery:

Crown lengthening: relapse with gingival re grow can happen in thick biotypes. Extreme care should be exercised with thin biotypes not to overcorrect.

Flap design and handling: thin biotypes need extra attention when designing a flap type, and when performing incisions, flap reflection and in suturing. It is best to avoid sulcus incisions around teeth with sub gingival restorations i.e., porcelain bonded crown, or at least the patient should be warned about unaesthetic show of the restoration margins afterwards. Vertical release incisions should always be made between the teeth roots.

Careless flap handling may lead to tear of the friable gingival tissues. Sometimes the blade cutting edge can blunt quickly, and as a result, the tissues are not always cut down to bone. We recommend running the sharp round edge of Mitchel trimmer back and forward with pressure over the incision line to tear down any remaining intact periosteum, so a clean flap can be reflected atraumatically. A similar complementary stroke with the sharp end of a curved Warwick-James elevator can be used for the same purpose in case of sulcus incision.

A cutting needle is best be avoided in thin biotypes. Reverse cutting or non-cutting round needle with a fine suture thread should be considered instead.

Thick biotype produces more scarring in the gingiva compared to thin biotype. This can be significant if the patient has a high smile line. The scar looks pale in colour, and sometimes the suture marks can be obvious.

Teeth extraction: There is minimal alveolar bone wall labially over teeth with thin biotype. Excessive bucco-lingual forceps luxation is best avoided to preserve the bone. In general, more bone remodelling is expected here after tooth extraction, which may lead to volume loss. Therefore, socket preservation technique using bone substitutes/guided tissues regeneration should be considered for the fresh socket, especially if dental implants are planned in the future.

Dental implants: healing in thick biotype following implant placement can be more predictable. Immediate implant might not be ideal if there is a concern about socket wall integrity.

Ref:

Shah R, Sowmya NK, Thomas R, Mehta DS. Periodontal biotype: Basics and clinical considerations. J Interdiscip Dentistry 2016; 6:44-9

3. Which one of the following lower wisdom tooth flap designs is contraindicated?

ALlWisomToothFlaps.jpg

3. Answer: e

The triangular flaps (Ward and the smaller modified Ward flap) and the envelope flaps are the most used flaps in lower wisdom teeth surgery. Less common are the comma flap and the inverted L. Flap E is incorrectly designed envelope flap because the distal release incision extends into the lingual sulcus and can potentially damage the lingual nerve, especially if the nerve lies in unusual high up position.

The alveolar process holding the wisdom tooth overhangs the submandibular fossa medial to the ramus. The distal release incision should start behind the wisdom tooth and should deflect buccally over the bone towards the external oblique ridge.

UnusalLingualNevrveEnveleopeFlap.jpg

In some patients, the lingual nerve (yellow line) takes unusual superficial course near the wisdom tooth/retromolar pad, and this makes the nerve very vulnerable during wisdom tooth surgery. Therefore, the distal incision (black line) should always be angled laterally up to the external oblique ridge (easily palpable and more lateral than many junior surgeons may think!).

In a cadaveric study involving 669 lingual nerves, 94 cases (14.05%) had the nerve above the lingual crest, and in 1 case (0.15%), the nerve was in the retromolar pad region. In the remaining 574 cases (85.80%), the horizontal and vertical distances of the nerve to the lingual plate and the lingual crest was (0.00 to 3.20 mm) and (1.70 to 4.00 mm), respectively. In 149 cases (22.27%), the nerve was in direct contact with the lingual plate of the alveolar process.

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Posterior view of the mandible. Lingual nerve (L) position in relation to the lingual plate (P) and crest (C) can be variable; it can lie above or below the crest, in contact or away from the lingual plate. Notice the mylohyoid line (M) which represents the attachment of mylohyoid muscle. It separates the floor of the mouth from the submandibular fossa (below the line). Also, notice how the wisdom tooth alveolus overhangs the submandibular fossa

Ref:

Behnia, Hossein, et al. An Anatomic Study of the Lingual Nerve in the Third Molar Region. Journal of Oral and Maxillofacial Surgery, vol. 58, no. 6, 2000, pp. 649–651.

4. The current evidence regarding triangular flaps used in wisdom tooth surgery suggests:

a. Is associated with less incidence of alveolar osteitis compared to envelope flap.

b. Is associated with lower risk of infection than envelope flap.

c. Is associated with higher chance of wound dehiscence than envelope flap.

d. a&b.

e. None of the above.

4. Answer: e

In the 2020 Cochrane review of surgical techniques used in mandibular wisdom teeth surgery, it was found that there was insufficient evidence to determine whether envelope or triangular flap design has led to more alveolar osteitis or wound infection. Therefore, the Cochrane reviewers in the 2020 version were unable to make firm recommendations to surgeons to inform their techniques for removal of mandibular third molars.

This is different to the 2014 Cochrane version where It was determined that triangular flaps were associated with a 71% reduction in alveolar osteitis at one week and reduction in pain at 24 hours compared with envelope flaps (moderate quality evidence). The older version also showed no difference in overall infection rates, in maximum mouth opening or in permanent sensation. However, there was some evidence that residual swelling after one week was slightly increased in the triangular flap groups compared to envelope flap types (low quality evidence).

Ref:

Coulthard P, Bailey E, Esposito M, Furness S, Renton TF, Worthington HV. Surgical techniques for the removal of mandibular wisdom teeth. Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD004345. DOI: 10.1002/14651858.CD004345.pub2.

Bailey E, Kashbour W, Shah N, Worthington HV, Renton TF, Coulthard P. Surgical techniques for the removal of mandibular wisdom teeth. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD004345. DOI: 10.1002/14651858.CD004345.pub3.

5. During lower wisdom tooth surgical flap incision, you overextended the disto buccal release arm long over the external oblique ridge. You may expect all the following except:

a. Buccal haematoma and swelling.

b. Limitation of mouth opening.

c. Paraesthesia of the buccal mucosa.

d. Paraesthesia of the buccal gingiva opposite the upper and lower molars.

e. Paraesthesia of the cheek.

5. Answer: d

The long buccal nerve originates from the mandibular branch of the trigeminal nerve. In the mandible, it passes downward and forward immediately deep to temporalis muscle (medial to the ramus of the mandible), and onto the lateral surface of the buccinator muscle. It supplies branches to the skin of the cheek before piercing buccinator to supply the mucous membrane of the cheek, buccal sulcus, and the lower alveolar process in the region of the molars/premolars. The upper molars buccal gum is supplied by the posterior superior alveolar nerve (not the long buccal nerve!).

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Long buccal nerve on both sides.

Long buccal nerve block can be achieved by injecting the local anaesthetic solution distal and buccal to the last molar tooth at the apex of the retromolar triangle formed by the internal and external oblique ridge.

In lower wisdom tooth surgery or in harvesting a ramus block bone graft, it is advisable not to extend the incision over the external oblique ridge/ramus higher than the level of the occlusal plane to minimise the possibility of cutting the long buccal nerve and artery, buccinator muscle, as well as exposing the buccal fat pad.

Ref:

Jonson DR, Moore WJ, Anatomy for dental students. Third edition. Oxford. 1997. Print.

6. Which one of the following flaps can be the least ideal for access purpose to the apical third of a long tooth root?

a. Gingival sulcus incision involving more than two teeth.

b. Trapezoid flap (three sides).

c. Ochsenbein- Luebke.

d. Vertical flap.

e. Velvart (papilla base flap).

6. Answer: a

Access to the root surface can be fulfilled by a number of flaps:

Gingival sulcus flap: involves two or more teeth adjacent to the offending tooth. Pros: easy to perform and reposition, no scarring (important if high smile line). Cons: limited stretch, so only useful for access to the coronal-mid part of the root depending on the root length. Also risk of gingival recession especially in thin biotypes (care with subgingival restorations i.e., porcelain bonded crowns). Difficult to maintain post op hygiene.

EndodonticSurgerySulcus.jpg

Gingival sulcus incision.

Triangular flap: composed of gingival sulcus incision with a release incision, often mesially placed. The