American Board of Oral and Maxillofacial Surgery

OMSSAT 2004 Assessment Tool

2003-2004 Oral and Maxillofacial Surgery Self Assessment
Tool (OMSSAT) Committee
Patrick J. Louis, DDS, MD, chair

Dentoalveolar Surgery Cosmetic Surgery

Vasiliki Karlis, section editor David Cottrell, section editor

John Fidler Jonathan Bailey

Godfrey Funari Hussam Batal
Raymond Fonseca Scott Bolding
Robert Glickman Carmine Colarusso
Louis Rafetto Mike Hunter
Eric Rippert David Lustbader
Andrea Schreiber Pushkar Mehra
James Sikes Joe Niamtu
Dennis Smiler David Stanton
Mary Stavropoulos James Wu
Theodore Tanabe
Deborah Zeitler Trauma

Medical Assessment and Management Richard Haug, section editor

of the Surgical Patient
Nabil Abaza
Patrick Vezeau, section editor Remy Blanchaert Jr
Jon Bradrick
Shawn Bailey Vito Cardo
Jeffrey Bennett Pushkar Mehra
Lionel Candelaria Karel deLeeuw
Kirk Engel Robert Diecidue
James Heit Michael Ellis
Anthony Kramer Godfrey Funari
Teresa Morgan Edwin Granite
Bruce Rotter Steven Kaltman
Noah Sandler Stewart Lazow
Daniel Sarasin Vincent Perciaccante
Vernon Sanders Louis Rafetto
William Synan Eric Rippert
Lawrence Weeda Gary Schween
K. Jeff Westlund Sterling Schow
William [Link] Vernon Sellers
David Shafer
Robert Strauss
Joseph Van Sickels
Dennis-Duke Yamshita
Organizational Representatives

AAOMS Raymond Fonseca

ABOMS Kirk Fridrich
OMS Faculty Section Peter Larsen

The oversight, deliberation and recommended answers for this assessment represent the
combined opinions of the authors and reviewers. They are not endorsed by nor do they
represent a standard of practice of the American Board of Oral and Maxillofacial
Surgeons.

Copyright© 2004 by the American Board of Oral and Maxillofacial Surgery. All rights
reserved. Printed in the United States of America.
1. The clinical sign differentiating superior orbital fissure syndrome from orbital apex syndrome is:

A. absence of superior palpebral fold

B. proptosis
C. dilated and fixed pupil
D. decreased visual acuity

ANSWER: D

RATIONALE:
Symptoms of superior orbital fissure syndrome include:
1. Pupillary dilation via alteration in cranial nerve III function in it's innervation of the
pupillary constrictors.
2. Paresis of cranial nerves III, IV, and IV causing ophthalmoplegia.
3. Cranial nerve III involvement causes paresis of the levator palpebrae superiorus muscle,
leading to ptosis and loss of the superior palpebral fold.
4. Neurosensory disturbance to the first division of cranial nerve V with hypesthesia of the
supraorbital and supratrochlear nerves and loss of the corneal reflex.
5. Proptosis from engorgement of the ophthalmic vein and lymphatics.

The orbital apex syndrome includes all of the above plus optic nerve involvement, leading to
changes in visual acuity.

REFERENCE:
Zacharides et al, The superior orbital fissure syndrome. J Maxillofac Surg 13: 125-8, 1985
Zacharides et al, Orbital apex syndrome. Int J Oral Maxillofac Surg 16:352-4, 1987

2
2. Post auricular ecchymosis in cases of high velocity trauma is usually indicative of:

A. fracture of the vertex of the skull

B. mandibular fracture
C. basilar skull fracture
D. LeFort III fracture

ANSWER: C

RATIONALE:
A fracture of the skull base results in the extrusion of blood subperiosteally. This hematoma or
ecchymosis may be exhibited at the thin skinned mastoid region (post- auricular), as
hemotympanum, as bilateral periorbital ecchymosis, or as a posterior pharyngeal ecchymosis or
hematoma.

REFERENCE:
Wong, M.E.K., and Johnson, J.V.; in Fonseca, R.J.: Oral and Maxillfacial Surgery. W.B.
Saunders, Co. 2000: 254, 255
Stedman's Medical Dictionary; 27th Ed. 2000 Lippincott Williams & Wilkins, Philadelphia, PA

3
3. Alignment of which of the following is the most reliable for proper reduction of the
zygomaticomaxillary complex fracture?

A. Frontozygomatic suture
B. Sphenozygomatic suture
C. Infraorbital rim
D. Medial orbital rim

ANSWER: B

RATIONALE:
The sphenozygomatic suture area has been previously analyzed and shown to be an area for
confirmation of alignment of the zygomatic arch and the zygomatic complex (ZMC). This has
also been shown to key point for fixation thru biomechanical studies.

The sphenozygomatic suture is a broad area along the greater wing of the sphenoid and can be
approached along the internal aspect of the lateral orbit. Even in severe midface fractures the
greater wing of the sphenoid is intact thus acting as a key landmark for proper reduction of the
ZMC fracture.

Reduction of the frontozygomatic suture or the infraorbital rim alone can result in errors due to
the small surface area. The medial orbit is generally not involved in a ZMC fracture.

REFERENCE:
Rohner D, Tay A, Meny CS, Hutmacker DW, Hammer B.: The sphenozygomatic suture as a
key site for osteosynthesis of the orbitozygomatic complex in panfacial fractures: A
biomechanical study in human cadavers based on clinical practice. Plast Reconstr Surg 110:
1463, 2002.

Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the
importance of sagittal buttresses, soft tissue reductions and sequencing treatments of segmental
fractures. Plast Reconstr Surg 103: 1287, 1999.

4
4. Which of the following is the least cosmetic surgical approach for an adolescent with an orbital
floor fracture?

A. Subciliary incision
B. Post septal transconjunctival incision
C. Infraorbital incision
D. Preseptal transconjunctival incision.

ANSWER: C

RATIONALE:
Although the infraorbital incision provides direct and excellent exposure of the orbital rim and
floor with a low incidence of complications, it frequently produces a noticeable scar. In
younger people, this scar increases in size with growth. The subciliary incision is more
cosmetic. Whether pre- or post-septal, the transconjunctival incisions do not involve the skin
and are cosmetically hidden.

REFERENCE:
Fonseca, R.J. and Walker, R.V.: Oral & Maxillofacial Trauma. Philadelphia, PA: W.B.
Saunders, Co; 1991: 463, 1184.
Haug, R.H. and Buchbinder, D.: Incisions for access to Craniomaxillofacial Fractures. Atlas of
Oral & Maxillofacial Clinics of North America. 1993; 1:1-29.

5
5. The first step in the general order of treatment of panfacial fractures is:

A. Establish soft and hard tissue reduction

B. Expose all fracture sites
C. Alleviate soft tissue entrapments
D. Apply internal fixation

ANSWER: B

RATIONALE:
The first issue in the order of treatment of panfacial fractures is to ascertain the sites and
conditions of the disrupted anatomical structures. This can only be accomplished by exposure
of the entire injured facial skeleton. Soft tissue entrapments are next alleviated, the osseous
fractures are then reduced, and rigid fixation is applied followed by soft tissue approximation.

REFERENCE:
Assael, Leon A.: Atlas of Facial Fractures. Oral & Maxillofacial Surgery Clinics of North
America. Vol. 11, No. 2, May 1999, 320-321

6
6. Acute dacryocystitis following trauma is treated by all of the following except:

A. warm compresses
B. intubation of the canaliculi and injection of dye
C. systemic or topical nasal decongestants
D. incision and drainage

ANSWER: B

RATIONALE:
Dilation, intubation and dye injection are diagnostic, not therapeutic measures. Moreover,
these maneuvers should not be attempted in the face of an acute dacryocystitis. Incision and
drainage of the lacrimal sac, administration of medicaments (systemic or topical
decongestants,) or palliative care(warm compresses) are acceptable treatment modalities..

REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic
Clinics of North America 1991; 24: 59-78

7
7. Epiphora can be caused by all of the following except:

A. Telecanthus with rounding of the medial canthus

B. Entropion of the lower lid
C. Ectropion of the lower lid
D. A soft tissue laceration of the lateral aspect of the upper eyelid

ANSWER: D

RATIONALE:
Ectropion and entropion can affect the contact of the inferior lacrimal punctum with the tear
fluid decreasing lacrimal fluid flow through the punctum and leadin to epiphora. Traumatic
telecanthus can also lead to alterations in tear flow and drainage in the medial aspect of the
inferior palpebral area and decrease lacrimal drainage through the inferior canilculus. The
codnition affect lacrimal fluid drainage but not lacrimal fluid delivery to the palpebral fissure.
Although a laceration through the laterial aspect of the upper eyelid can disrupt tear flow from
the lacrimal gland, such a decrease in tear production would not lead to epiphora.

REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic
Clinics of North America 1991; 24: 59-78

8
8. Disruption of the nasolacrimal apparatus with subsequent epiphora occurs most commonly after
which facial fracture:

A. Nasal
B. LeFort III
C. Nasoethmoidal
D. Zygomaticomaxillary

ANSWER: C

RATIONALE:
The incidence of nasolacrimal disruption is 0.2% following nasal fracture, 3-4% following
midface fractures, 17-21 % following naso-ethmoidal fractures, almost non existent following
zygomatic-maxillary fractures. The location of the zygoma is so far removed from the lacrimal
apparatus so as to make it a concomitant injury.

REFERENCE:
Osguthorpe JD, Hoang G: Nasolacrimal injuries, evaluation and management. Otolaryngologic
Clinics of North America 1991; 24: 59-78

9
9. Confirmation of a CSF leak following a fontal sinus fracture is best done with which of the
following imaging studies?

A. A high resolution computed tomography cisternogram after administration of

intrathecal fluorescein
B. A facial series of radiographs to include a Caldwell and lateral view
C. A non contrast computed tomography study of the brain
D. Magnetic resonance imaging of the base of the skull

ANSWER: A

RATIONALE:
Plane radiography is incapable of confirming a CSF leak. While magnetic resonance is helpful
with soft tissues, without dye, this diagnostic aid is useless. A similar rationale exists for non-
contrast CT. An intrathecal injection of dye, and confirmation of the dye at distant sites is
diagnostic.

REFERENCE:
Manolidis, S.: Management of frontal sinus trauma. Seminars in Plastic
Surgery 2002; 16:261-271

10
10. The most likely diagnosis in a patient with painful proptosis, progressive visual loss, restricted
extraocular movement, and increased intraocular pressure following surgery to reduce a
zygomatic fracture is:

A. Horner’s syndrome
B. Movement of an alloplastic implant
C. Injury to the infraorbital nerve
D. Retrobulbar hematoma

ANSWER: D

RATIONALE:
Movement of an alloplastic implant is generally asymptomatic. Injury to the infraorbital nerve
produces anesthesia or paresthesia over it's cutaneous distribution (the lower eyelid area).
Horner's syndrome, caused by a disruption in the sympathetic innervation to the upsilateral
maxillofacial region, is characterized by: a constricted pupil (by unopposed parasympathetic
constriction), ptosis (by loss of smpathetic inneration to Mueller's muscle), and anhidrosis (by
interruption of sympathetic innervation to cutaneous sweat glands). The symptoms described
are most consistent with retrobulbar hematoma, and require prompt diagnosis and intervention.

REFERENCE:
Korinth MC, Ince A, Banghard W, Huffmann BC, Gilsbach JM: Pterional orbita decompression
in orbital hemorrhage and trauma. Trauma 2002; 53:73-
78

11
11. Suspension wires utilized to stabilize a LeFort I fracture resists forces in which direction?

A. Superior
B. Inferior
C. Anterior
D. Posterior

ANSWER: B

RATIONALE:
The recent development and improvements in miniaturized bone plate systems has greatly
enhanced treatment of midface fractures and diminished but not obviated the need for wire
suspension with direct wiring techniques. While wires may provide minor resistance to
deformation in an anterior and posterior direction, they offer no resistance superiorly. The best
answer is that the resist deformation in an inferior direction and thereby resist facial
elongation.

REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

12
12. When evaluating visual acuity in the orbital trauma patient:

A. The pupils should be dilated.

B. Eyeglasses should not be worn by the patient, even if available.
C. Viewing through a pinhole can compensate for some refractory errors.
D. Topical tetracaine can aid acuity evaluation.

ANSWER: C

RATIONALE:
Dilation may mask signs and symptoms of neurologic injury. Pupillary dilation does not aid in
a visual acuity examination but is utilized to fully visualize the retina, vessels and the optic
disc. Pre-existing visual acuity defecits (such as myopia and presbyopia) can mimic traumatic
visual acuity loss; and therefore the use of prescription eyeglasses can facilitate the distinction
of pretaumatic from traumatic visual defecits. Topical tetracaine is a local anesthetic and is of
no value in the evaluation of visual acuity. If pretraumatic myopia is prsent, acuity evaluation
while looking through a pinhole can substitute somewhat for corrective lenses if such lenses
are not available.

REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p
TRA6. Classification D - Trauma - Soft tissue

13
13. Which of the following is true when treating eyelid lacerations:

A. Eyelid and ocular mobility should be evaluated before injecting local anesthetic.
B. Fat herniation is not an indication of orbital septum violation.
C. Fat herniation is not an indication of possible globe penetrating injury.
D. Iridocyclitis describes an irregularly shaped pupil which “points” away from the area of
globe injury.

ANSWER: A

RATIONALE:
Iridocyclitis is a traumatic anisocoria and many times points towards the injury. Fat herniation
occurs with aging and of itself is not necessarily indicative of traumatic septum violation.
Herniated fat without lid laceration is therefore of no consequence; however, fat herniation
through a lid laceration indicates septum violation and mandates the need for careful
evaluation for penetrating globe injury. Penetrating globe injury is diagnosed by visualization
of the globe surface. The lid should be examined prior to the administration of local anesthesia
because edema and local anesthesia may limit motility.

REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA
7-8. Classification D - Trauma - Soft tissue

14
14. Which of the following is true when treating injuries of the external ear:

A. Cartilage should never be sutured, thereby avoiding necrosis.

B. Loose or macerated skin should be extensively débrided.
C. Cartilage lacerations should be sutured with conventional, interrupted chronic gut sutures
to encourage overlapping.
D. Cartilage should be sutured with slowly resorbable figure-of-eight sutures.

ANSWER: D

RATIONALE:
Cartilagenous lacerations should be approximated to reconstruct anatomy and prevent chronic
chondritic inflammation. Interrupted sutures may promote cartilage margin overlap; the use of
figure of eight sutures prevents overlap of lacerated cartilage margins. Cartilage has a limited
vascurlar supply, originating from overlying soft tissue; therfore extensive debridement of
overlying soft tissue should be discourage.

REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA
18-19. Classification D - Trauma - Soft tissue

15
15. When the medial canthal ligament is attached to a bony segment in naso-orbito-ethmoidal(NOE)
fracture repair the transcanthal wire is best placed:

A. after all soft tissue injuries have been addressed.

B. anterior to the original insertion of the canthal ligament.
C. posterior and inferior to the original insertion.
D. posterior and superior to the original insertion.

ANSWER: D

RATIONALE:
The purpose of the trans-canthal wire is to secure the canthal ligament and boney segment in
the pretraumatic position. Pull of the soft tissues displaces the bone and canthal ligament in an
anterior and inferior direction. Therefore a wire placed posterior and superior to the original
insertion provides a vector whose resistance to displacement is most ideal and provides the
best alignment.

REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p TRA
75-76. Classification D - Trauma - Soft tissue Oral and Maxillofacial Surgery In-Training
Examination (OMSITE) questions for the Trauma Section.

16
16. An 18-year-old man is stabbed to the left upper chest. You record a blood pressure of 75/60. He is
gasping for air, breath sounds are diminished on the left, and his trachea is deviated to the right.
The initial treatment should be:

A. Perform tracheal intubation.

B. Obtain a chest x-ray to verify the pneumothorax.
C. Place a chest tube between the anterior and midaxillary line in the fifth intercostal space.
D. Perform needle decompression of the left chest.

ANSWER: D

RATIONALE:
This is a classic tension pneumothorax and treatment is a clinical diagnosis with immediate
needle decompression of the second intercostal space, midclavicular line The time involved in
waiting for a chest x-ray might prove lethal. Insertion of a chest tube in a controlled fashion to
facillitate lung re-expansion normally follows needle deompression of the tension
pneumothroax. Endotracheal intumbation with positive pressure ventilation often worsen a
tension pneumothrorax, but may be indicated for other types of chest injuries.

REFERENCE:
1997 ATLS for Doctors, Sixth Edition.

17
17. A 21-year-old female is an unrestrained driver involved in a MVA. She suffers a scalp laceration
and is noted to have lost 1000mL of blood at the scene. You would expect her vital signs to be
consistent with:

A. Pulse rate >100, normal systolic blood pressure, decreased pulse pressure, respiratory rate
of 20-30, urinary output of 20-30mL/hr.
B. Pulse rate <100, normal systolic blood pressure, normal or increased pulse pressure,
respiratory rate of 14-20, urinary output of >30mL/hr.
C. Pulse rate >120, decreased systolic blood pressure, decreased pulse pressure, respiratory
rate of 30-40, urinary output of 5-15mL/hr.
D. Pulse rate >140, decreased systolic blood pressure, decreased pulse pressure, respiratory
rate of >35, urinary output that’s negligible.

ANSWER: A

RATIONALE:
These findings are consistent with a Class II hemorrhage, 750-1500ml, The vitals signs or such a
blood loss are consistent with those in response A. Response D reflects the vital signs of a Type
IV blood loss, Response C a Type III and Response B a Type I.

REFERENCE:
1997 ATLS for Doctors, Sixth Edition.

18
18. A 65-year-old man fell down the stairs. Upon examination of him, you notice that he opens his
eyes to speech, localizes pain, and mutters inappropriate words. You assess his Glasgow coma
scale (GCS) to be:

A. 13
B. 11
C. 9
D. 7

ANSWER: B

RATIONALE:
According to the Glascow Coma Scale, the patient can open his eyes in response to commands
speech, (3 out of 4); localizes pain, (5 out of 5); yet produces inappropriate words, (3 out of 6);
for a Glascow coma score of 11.

REFERENCE:
1997 ATLS for Doctors, Sixth Edition

19
19. The most frequent location of internal orbital injury in children seven years old and under is the?

A. floor
B. medial wall
C. lateral wall
D. roof

ANSWER: D

RATIONALE:
Fronto-orbital injuries are the most frequent in this age group. Because the antrum, sphenoid,
ethmoid and frontal sinuses are not yet pneumatized in this age group, fronto-basilar (or roof)
injuries most commonly occur. Wall or floor injuries occur in young children.

REFERENCE:
Koltai PJ, Amjad I, Meyer D, et al. Orbital fractures in children. Arch Otol Head Neck Surg
121:1375, 1995

20
20. After nasal injuries in children, growth disturbance are most associated with premature
ossification of which suture?

A. Nasofrontal
B. Septovomerine
C. Nasomaxillary
D. Nasoethmoidal

ANSWER: B

RATIONALE:
The septovomerine suture determines growth in this area. If this suture is involved in trauma
growth consequences are a concern since neither of the other sutures, if involved, provides as
deforming a growth consequence.

REFERENCE:
Precious DS, Delaire J, Hoffman CD. The effects of nasomaxillary injury on future growth. Oral
Surg, Oral Med, Oral Pathol, 66:525, 1983.

21
21. When reconstructing an orbital floor injury, the safe distance for dissection from the infraorbital
rim to the anulus of Zinn is up to how many millimeters?

A. 20
B. 25
C. 35
D. 40

ANSWER: D

RATIONALE:
According to a recent cadaveric study involving specimens with intact soft tissue, the mean
distance from the inferior orbital rims to the annulus of Zinn is 39.4 mm +/- 2/9 mm.
Previously cited studies on dry skulls, using bony landmarks only with no soft tissue
references at the orbital apex provide clinically less useful information.

REFERENCE:
Danko I, Haug RH. An Experimental investigation of the safe distance for internal orbital
dissection. J Oral Maxillofac Surg 56:749, 1998.

22
22. The most common chronic problem associated with the surgical treatment of frontal sinus
fractures is?

A. The development of mucoceles

B. Chronic pain
C. Osteomyelitis
D. Contour deficits and irregularities

ANSWER: B

RATIONALE:
With the advent of rigid internal fixation, contour deficits and irregularities are infrequent.
Using modern aseptic protocols, osteomyelitis is very uncommon. While mucoceles do occur
in rare instances when sinus membrane regenerates, pain remains the most frequent of chronic
problems.

REFERENCE:
Haug RH, Cunningham LL Management of Fractures of the Frontal Bone and Frontal Sinus.
Selected Readings in Oral and Maxillofacial Surgery. 10:6, 1-32, 2002.

23
23. Patients who survive facial fractures are most likely to have suffered what forms of facial injury?

A. Upper only
B. Mid only
C. Lower only
D. Combinations of lower, mid and upper

ANSWER: C

RATIONALE:
Mandibular injury is associated with c-spine injury, but mid- and upper are associated with
death. Mid- and upper-facial third injuries initially act as shock absorbers until a particular
magnitude of impact, after which they transmit force to the neurocranium. The more
commonly results in fatality than does trauma to the lower 1/3 of the facial skeleton.

REFERENCE:
Plaiser BR, Punjabi AP, Super DM, et al: The relationship between facial fractures and death
from neurologic injury. J Oral Maxillofac Surg 58:708, 2000

24
24. The intercanthal distance in the uninjured adult patient is approximately:

A. 25-30 mm
B. 31-35 mm
C. 36-40 mm
D. 41-45 mm

ANSWER: B

RATIONALE:
The inter-canthal distance in adult Caucasians is 33 + mm. This varies minimally with gender
and race. The other answers are outside of this range.

REFERENCE:
Murphy WK, Laskin DM: Intercanthal and interpupillary distance in the black population. Oral
Surg Oral Med Oral Pathol 69:676, 1990

25
25. Which of the following is true of the annulus of Zinn?

A. It is attached to the lacrimal, ethmoid and sphenoid bones.

B. It contains the ophthalmic artery and its branches.
C. It is the origin of the rectus and oblique muscles.
D. It contains the maxillary and ophthalmic divisions of the trigeminal nerve.

ANSWER: B

RATIONALE:
The annulus of Zinn contains the ophthalmic artery and its branches. The oblique muscles
originate outside of the annulus. The annulus is distant from the lacrimal bone, and does not
contain the maxillary division of the trigeminal nerve.

REFERENCE:
Dutton JJ: Atlas of clinical and surgical orbital anatomy. WB Saunders Co. Philadelphia PA,
1994 pgs 1-80.
Rowe NL. Fractures of the zygomatic complex and orbit. In:Rowe NL, Williams JL.
Maxillofacial Injuries. Churchill Livingstone. New York, New York, 1985 p 450.

26
26. Which of the following is the best definition in the Markowitz and Manson classification system
of a Type II nasoethmoidal injury?

A. a single large fragment, with the canthal ligament attached.

B. minor comminution, with the canthal ligament attached.
C. comminution beneath the canthal ligament.
D. comminution with the canthal ligament detached.

ANSWER: B

RATIONALE:
Below are figures adapted from the original article on nasoethoidmal fractures published by
Markowitz and Manson in 1991. Choice B is the correct answer. Choice A represents a Type I
fracture. Choice C doesn't fit into any classification scheme since it doesn't address the region of
the canthal ligaments. Choice D represents a Type III fracture.

This figure depicts the nasoethmoidal region. The region shaded is the central fragment. The inset
figure represents a Type I fracture, where the canthal ligament is attached to a large central
fragment and there is no comminution of the fractured nasoethmoidal region.

27
This figure represents a Type II fracture. There is some comminution of the nasoethmoidal region
but the canthal ligament is attached to a substantial fragment of bone.

This figure represents a Type III fracture. The canthal ligament is detached or there is severe
comminution with the canthal ligament attached to a small fragment of bone.

REFERENCE:
Markowitz BL, Manson PN, Sargent L, et al: Management of the medial canthal tendon in
nasoethmoid orbitae fractures: the importance of the central fragment in classification and
treatment. Plast Reconstr Surg 87: 843 1991.

28
27. When repairing cranial bone trauma utilizing a coronal approach, the temporal branches of the
facial nerve can best be preserved by:

A. avoid extending the incision into the preauricular areas

B. confining the surgical dissection between the superficial temporal fascia and the deep
temporal fascia
C. insuring the surgical dissection is deep to the superficial layer of the deep temporal fascia
D. avoid reflecting the periosteum of the zygomatic arch.

ANSWER: C

RATIONALE:
The temporal branches lie immediately beneath the superficial layer of the temporal fascia, just
above the superficial layer of the deep temoral (temporalis) fascial. Dissection below the
superficial temporal fascia this layer may injure the nerve. Dissection beneath the superficial
layer of the deep temporal fascia preserves the temporal facial nerve branches.

REFERENCE:
Abubaker AO, Sotereanos G, Patterson GT. Use of the coronal surgical incision for
reconstruction of severe craniomaxillofacial injuries. JOMS 48:579-586, 1990.

29
28. Which of the following surgical approaches for repair of orbital trauma has the highest incidence
of post operative scleral show?

A. Transconjunctival without lateral cantholysis

B. Infraorbital (orbital rim)
C. Upper eyelid blepharoplasty
D. Subciliary

ANSWER: D

RATIONALE:
Several studies have shown that the subciliary approach has the highest rate of post operative
scleral show. The scar contracture associated with the infraorbital approach does no affect the
orbicularis to the same degree as for other incisions. The transconjunctival incision is
associated with minimal scleral show. The design of the upper blepharoplasty incision is
associated with the least percentage of this complication.

REFERENCE:
Patel PC, Sobota BT, Patel NM, et al. Comparision of Transconjunctival versus subciliary
approaches for orbital fractures. J Cranio-maxillofacial trauma 4(1):17-21, 1998.

30
29. The most sensitive clinical laboratory indicator able to confirm cerebrospinal fluid leakage is:

A. Comparison of suspected fluid glucose to patient’s serum glucose

B. Dipstick test utilizing glucose oxidase
C. Beta 2 transferrin level of suspected fluid
D. Comparison of protein and potassium levels of suspected fluid to nasal secretions and
serum levels

ANSWER: C

RATIONALE:
Beta 2 transferrin is found only in the brain and eyes. The patient's CSF may be contaminated
with blood and therefore mimic serum. The dipstick test is colorimetric and if contaminated with
red blood, may alter the results. Again, CSF may be contaminated with nasal secretions or blood
and thus mimic those fluids rather than CSF.

REFERENCE:
Brandt MY, Jenkins WS, Fattahi TT, Haug RH. Cerebrospinal fluid: Implications in oral and
maxillofacial surgery. JOMS 60:1049-1056, 2002

31
30. The end metabolic degradation byproducts of bioresorbable osseous fixaton devices (plates and
screws) are:

A. glycolic acid
B. lactic acid
C. carbon dioxide and water
D. Acetic acid

ANSWER: C

RATIONALE:
Both homopolymer and copolymer products follow the same metabolic degradation pathway
culminating in the citric acid cycle, ultimately ending with the production of carbon dioxide
and water.

REFERENCE:
Peltoniemi H, Ashammakhi N, Kontio R, et al. The use of bioabsorbable osteofixation devices in
craniomaxillofacial surgery. Oral Surg Oral Med Oral Path, 94(1):5-14, 2002

32
31. An adult patient, with a normal dentition, has a closed right mandibular subcondylar fracture with
90 degree medial displacement of the condylar head. Secondary to this fracture, the patient
could be expected to demonstrate which of the following clinical findings?

A. Deviation of the mandible to the left with opening

B. Reduced right lateral excursion
C. Right posterior apertognathia
D. Reduced left lateral excursion

ANSWER: D

RATIONALE:
With a right subcondylar fracture, the action of the right lateral pterygoid muscle would be
reduced and the patient would deviate to the right upon opening, and would experience
diminished left lateral excursion. Lastly, decreased right ramus height would cause an occlusal
prematurity on the right side.

REFERENCE:
Hlawitschka M, Eckelt U. Assessment of patients treated for intracapsular fractures of the
mandibular condyle by closed techniques. JOMS 60:784-791, 2002

33
32. In the case of an isolated lesion of the right oculomotor nerve:

A. The right globe rotates upward and outward.

A. The left eye consensual light reflex is preserved.
B. Motor nerves alone are affected resulting in ptosis and miosis.
C. Light stimulation of the left eye results in a consensual reflex in the right eye.

ANSWER: B

RATIONALE:
Motor and sensory nerves are affected. Light stimulation in the left eye produces no
consensual reflex in the right eye, since the oculomotor nerve carries parasympathetic branches
that allow consensual pupillary constriction. The left eye consensual light reflex is preserved.
Only abduction (via cranial nerve VI) and adduction (via cranial nerve IV) of the right globe
are possible.

REFERENCE:
Rowe NL, Williams J Ll: Maxillofacial Injuries, London, Churchill Livingstone, 1985

34
33. Low velocity missile wounds are characterized by:

A. small entry wounds and larger exit wounds.

B. bullet speed over 2000 ft per second
C. minimal tissue avulsion
D. soft tissue cavitation injury

ANSWER: C

RATIONALE:
Low velocity wounds are characterized by a small and clean cut or ragged entrance wound but no
exit wound. When hard tissue is struck fracture, comminution and displacement occurs, but
external avulsion is rare. The soft tissue cavitation is minimal. Low velocity missiles travel at less
than 2000 ft/sec.

REFERENCE:
Shelton DW, Albright CR: Study in wound ballistics. J Oral Surg 1967; 25: 341

35
34. Which of the following best describes the most appropriate initial fluid bolus during the fluid
resuscitation of a pediatric patient.

A. 1 liter lactated Ringer’s solution

B. 500 cc normal saline
C. 20 cc/kg body weight crystalloid solution
D. 10 – 15 cc/kg body weight colloid solution

ANSWER: C

RATIONALE:
Initial resuscitation for pediatric patients is done with crystalloid solution, and the volume
administered is determined by body weight. Fluid resuscitation is not accomplished with set
amounts of fluid., nor is colloid an appropriate medium for initial intravascular resuscitation.

REFERENCE:
Advanced trauma life support for doctors student course manual. Sixth edition. Page 97

36
35. Along which wall of the orbit is there a normal bony prominence just behind the equator of the
globe?

A. Superior and lateral

B. Lateral and inferior
C. Inferior and superior
D. Inferior and medial

ANSWER: D

RATIONALE:
The bone anatomy of the orbital walls has been well defined. Often forgotten in
clinical practice, however is the elevation of the infero-medial orbital wall behind the equator
of the globe. In addition, significant alteration of the bony anatomy along the medial wall is
sometimes not appreciated because displacement can result in a straight medial wall that to the
uninitiated appears normal.

REFERENCE:
Manson PN, Clifford CM, Iliff NT, Morgan R: Mechanisms of global support and posttraumatic
enophthalmos: I. The anatomy of the ligament sling and its relation to intramuscular cone orbital
fat. Plast Reconstr Surg 77(2): 193-202, 1986.

37
36. In the setting of traumatic blindness, which of the following is an acceptable indication for
surgical decompression of the optic nerve?

A. failure to respond to high-dose steroid therapy

B. visual loss immediately following the trauma event
C. penetrating trauma
D. delayed visual loss following blunt trauma

ANSWER: D

RATIONALE:
Following blunt trauma visual recovery after decompression is not likely whenever there was
immediate blindness, penetrating ocular injury, or failure to respond to the initiation of high-dose
steroids.

REFERENCE:
Anderson RL, Panje WR, Gross CE: Optic nerve blindness following blunt forehead trauma.
Ophthalmology 89:445-455, 1982.

38
37. Failure to re-suspend the periosteum overlying the zygoma after fracture repair most commonly
results in which of the following deformities?

A. ectropion of the lower eyelid

B. sagging of the facial soft-tissues
C. thinning of the upper lip
D. inward rotation of the vermillion

ANSWER: B

RATIONALE:
Ectropion results from overzealous dissection, tissue injury or pexing of the periorbita.
Thinning of the lip and inward rotation of the vermillion should only be a consideration if the
periosteum was dissected from the anterior maxilla. Following coronal or hemicoronal flap
elevation and exposure of the zygomatic bone and malar eminence, posterio-superior
resuspension of the periosteum is indicated to prevent tissue sagging.

REFERENCE:
Yaremchuk MJ: Orbital deformity after craniofacial fracture repair: avoidance and treatment. J
Craniomaxillofac Trauma 5(2):7-16, 1999.

39
38. Which of the following is the appropriate amount of time for the arch bar fixation of a
dentoalveolar fracture:

A. 3-5 days
B. 7-10 days
C. 14-17 days
D. 21-25 days

ANSWER: D

RATIONALE:
Isolated tooth avulsion is treated by splinting for seven tot en days with isolation from occlusal
function and endodontic therapy on theeth with fully developed apices. In the case of a true
alveolar fracture, three to four weeks, or twenty one to twenty eight days is an appropriate
duration of arch bar fixation.

REFERENCE:
Peterson, L. DDS, MS, et. al. Oral and Maxillofacial Surgery, 3rd Ed., 1998, pp. 577 & 580.

40
39. When a primary tooth is traumatically intruded one should:

A. extract the tooth.

B. observe for 12 months and extract if it should not re-erupt.
C. splint the tooth 2-3 weeks.
D. observe for 4-8 weeks and extract if it should not re-erupt.

ANSWER: D

RATIONALE:
Immediate extraction does not give the tooth any chance for survival. If splinted in the intruded
position, the tooth is condemned to a malposition. If splinted in the proper position, the
expanded alveolus would not permit intimate root contact between the surrounding alveolus
and periodontal ligament remnants on the root and therefore preclude survival. Observation for
a year indicates that the tooth is ankylosed. Observation for 4-8 weeks and then extraction if no
re-eruption is observed is the most appropriate answer.

REFERENCE:
Fonseca, RJ. Oral & Maxillofacial Surgery 2000. p.69

41
40. The initial antibiotic coverage for a cat, dog, or human bite is:

A. penicillin
B. clindamycin
C. cephalexin
D. amoxicillin with clavulanate

ANSWER: D

RATIONALE:
Augmentin. This antibiotic is bacteriocidal for the range and spectrum of human and animal bite
pathogens including Staphylococcus species and Pasteurella multocida.

REFERENCE:
Fonseca, RJ. Oral & Maxillofacial Surgery 2000. p.385

42
41. A patient seen in the emergency department presents with: elevated venous pressure, muffled
heart sounds, and decreased arterial pressure. What is the most likely diagnosis?

A. Dissecting aortic aneurism

B. Cardiac tamponade
C. Acute myocardial infarction
D. Pneumothorax

ANSWER: B

RATIONALE:
The patient presents with the classic Beck's triad of increased venous pressure, decreased
arterial pressure, and muffled heart sounds indicating cardiac tamponade. dissecting aortic
aneurysm may cause a drop systolic pressure in Class III or IV shock, but would not exhibit
increased venous pressure or muffled hear sounds. Acute myocardial infarction can present
with a number of different blood pressure changes, but usually does not exhibit heart sounds.
Tension pneumothorax can cause decreases in pulse pressure and muffled heart sounds, but
also is accompanied by ipsilateral chest resonance and decreased breath sounds, and often with
tracheal shift to the contralateral side.

REFERENCE:
ATLS Student Course Manual, 1997 p99-100

43
42. Traumatic disruption of the adult nasolacrimal system is best handled acutely by:

A. Silicone nasolacrimal duct intubation x 3-4 months

B. Cannulation with Bowman probe of the inferior canaliculus
C. Cannulation with Bowman probe of the superior canaliculus
D. Dacryocystorhinostomy

ANSWER: A

RATIONALE:
Nasolacrimal duct intubation may bypass a disrupted nasolacrimal apparatus and avoid the
morbidity associated with a dacryocystorhinostomy. Dacryocystorhinostomy is reserved for a
chronic condition. Cannulation should be instituted for both inferior and superior canaliculi.

REFERENCE:
Fonseca and Walker. Oral and Maxillofacial Trauma, p.533-534.

44
43. A 22 year old male status post two gun shot wounds to the face and abdomen presents with a
blood pressure of 80/40 and a pulse of 160 after 2 liters of Ringers lactate. There is no significant
facial hemorrhage or expanding hematoma. Proper immediate management is:

A. four vessel angiography of the neck

B. CT scan of the abdomen
C. diagnostic peritoneal lavage
D. emergency celiotomy

ANSWER: D

RATIONALE:
This patient exhibits no symptoms of massive hemorrhage from the facial gunshot wounds,
and is hemodynamically unstable with a penetrating abdominal injury. This is a clssic
indication for an emergency celiotomy for intra-abdominal hemorrhage control. CT abdominal
scans or diagnostic peritoneal lavage may be indicated in blunt tauma with evidence of intra-
abdominal hemerrhage; but these procedures are time-consuming and are indicated if there is
greater hemodynamic control. From the clinical presentation, although eventual head and neck
angiography may be indicated, the more emergent problem is shock from abdominal blood loss
and must be addressed first by cleotomy.

REFERENCE:
ATLS Student Course Manual 1997, pp 165-6

45
44. The following demonstrates facial lacerations, which of the following most closely follows the
resting skin tension lines?

46
ANSWER: B

RATIONALE:
'The concept of resting skin tension lines (RSTLs) was introduced by Borges and Alexander in
1962. They based their definition of these RSTLs on how a wound tends to behave following
incision of the skin, i.e., whether the wound gapes widely or very little. It has been known for
decades (Dupuytren, 1834, Langer 1861) that skin incisions placed right angles to skin tension
lines produce widely gaping wound margins. If these lines are followed during the incisions or
excision of scars and neoplasms generally a far better result will be achieved than if the incisions
cross the tension lines. The course of the facial tension lines does not always coincide with
normal wrinkle lines due to aging.'
The answer is B. All of the other lacerations are at right angles to the RSTLs

REFERENCE:

47
Kastenbauer ER, Reconstructive surgery of the external nose. In: Head and Neck Surgery, 2nd ed.
Vol I. Tardy ME Jr, Kastenbauer ER. editor. Naumann HH, coordinating editor. Thieme Medical
Publishers Inc, New York. 1995, pp 303-304.

48
45. Which of the following signs and/or symptoms are associated with venous thrombosis?

A. Homans sign
B. Levine’s sign
C. Quinke’s sign
D. Psoas sign

ANSWER: A

RATIONALE:
Homan's sign: calf pain with forcible dorsiflexion of the foot, associated with lower extremity
deep venous thrombosis. Levine's sign: clenched fist over the chest while describing chest
pain: associated with angina and acute myocardial infarction. Quinke's sign: alternating
blushing and blanching of the fingernail following light compression: seen in aortic
regurgitation. Psoas sign (iliopsoas test): extension and elevation of the right leg produces pain
in cases of inflammation of the psoas muscle: indicative of appendicitis.

REFERENCE:
Stedman's Medical Dictionary 23rd ed., Williams & Wilkins, 1976 Bates B: A Guide To Physical
Examination, 2nd ed. Lippincott, 1979

49
46. In taking the blood pressure on an extremely obese patient, the standard size cuff would result in
a blood pressure reading that is:

A. accurate
B. higher than the actual blood pressure
C. lower than the actual blood pressure
D. unreliable, since it is not possible to obtain an accurate blood pressure on an extremely
obese patient.

ANSWER: B

RATIONALE:
When considering the correct size of cuff, two pertinent points should be recalled: 1.) The
inflatable bladder in the cuff should be able to completely encircle the arm with minimal overlap.
2.) The width of the bladder in the cuff should be approximately 20% greater than the diameter
of the extremity used for the blood pressure cuff. Applying a cuff that is too small for an obese
arm will produce a falsely elevated blood pressure reading; while applying too large a cuff on a
thin arm will cause a falsely decreased blood pressure reading. Additionally, applying the cuff
too loosely will produce a falsely elevated reading.

REFERENCE:
Malamed S: Sedation: A Guide To Patient Management. Mosby, 2003 p. 28

50
47. Which of the following statements concerning cardiac output and myocardial work is true?

A. Preload represents passive ventricular wall stress and is best measured during systole
B. The primary determinants of afterload are the total peripheral resistance the heart muscle
must pump against and changes in intrathoracic pressure
C. Increasing heart rate is an efficient means of increasing myocardial work
D. Contractility is a direct measurement of the ability of the heart muscle to withstand
passive stretching

ANSWER: B

RATIONALE:
Cardiac afterload is indirectly measured through blood pressure and mean arterial
pressure. Increasing afterload (for example, via increasing peripheral vascular resistance or
intrathoracic pressure) or increasing heart rate increases myocardial oxygen consumption and
work.

While preload does indeed represent passive ventricular wall stress, it is measured during
diastole when the heart muscle wall is in its passive state. Preload is generally a reflection of
the volume status of the patient. Increased heart rate is an inefficient means to increase cardiac
output. Elevated heart rate is also potentially harmful in that it decreases the time that oxygen
and nutrients can be delivered to the myocardial cells (diastolic perfusion time). Contractility
is defined as the ability of the heart muscle to shorten with appropriate stimulation. With
increased shortening of the muscle fibers during myocardial contraction, the heart can generate
additional cardiac output more efficiently (an inotropic response) than by increases in heart
rate (a chronotropic response).

REFERENCE:
Norton JM: Toward consistent definitions of preload and afterload. Adv Physiol Educ 25: 53-61,
2001.

51
48. Which of the following concerning AV node conduction is true?

A. Modulation is achieved through nicotinic and cholinergic mechanisms.

B. AV conduction on the ECG is represented by the Q-T interval.
C. Digoxin enhances conduction speed.
D. No intrinsic automaticity is present at this node.

ANSWER: A

RATIONALE:
The vagus nerve provides cholinergic stimulation to the heart at the AV node and mediates a
negative chronotropic effect. Catecholamines have the opposite effect and increase speed of
impulse conduction through the AV node via nicotinic receptors. Catecholamines also cause
an increase in myocardial inotropy.

In ECG tracings, the P-R interval represents the usual delay (0.20 secs) in conduction through
the AV node. While digoxin is a positive ionotrope, it is also a negative chronotrope,
decreasing the conduction velocity through the AV node. Although the automaticity of the
AV node is usually masked by the more rapid impulses generated by the sino-atrial node, in
the absence of atrial impulses the AV nodal junction often will generate depolarization at a rate
of 40 to 60 impulses per minute.

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

52
49. Which of the following concerning Wolff-Parkinson-White Syndrome is true?

A. Sigma waves may alter the P-R interval on ECG.

B. Conduction is via the bundles of His.
C. Rapid ventricular response may be controlled with digitalis.
D. Procainamide may decrease conduction through accessory pathways.

ANSWER: D

RATIONALE:
WPW is a syndrome of rapid ventricular response to atrial stimulation by conduction through the
accessory Bundle of Kent, bypassing the AV node and therefore the ability of the AV node to
control over-rapid atrial impulse conduction to the ventricles. A gradual upslope of the P-R
interval, the delta wave, is an ECG characteristic of this disorder. Emergent control of atrio-
ventricular tachycardic conduction is by synchronized cardioversion if the patient is unstable.
Medical management includes those drugs that can decrease impulse transmission through the
accessory pathway (procainamide, amiodarone.) Digitalis and verapamil increase AV node
refractoriness to conduction and can increase conduction through the aberrant pathway, which
can cause serious deterioration in cases of tachycardia of supraventricular origin. Definitive
treatment of the stable patient includes radiofrequency ablation of aberrant pathways.

REFERENCE:
Harrison's Principles of Internal Medicine 13th ed., McGraw-Hill, 1994. pp1028-9
Guidelines 2000 For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,
American Heart Association. P. 119
Dubin D: Rapid Interpretation of EKG's, 4th ed. Cover Publishing, 1989 p. 157

53
50. Non-pathological heart sounds, S1 and S2 can be characterized by:

A. left heart valve closure usually louder than right.

B. splitting of S1 during inspiration.
C. fixed splitting of S2 in the adolescent.
D. splitting of S2 on expiration.

ANSWER: A

RATIONALE:
Left (mitral) valve closure is louder due to the higher pressure in the aorta and left heart. S1
splitting, which represents a significant difference in the timing of closure of the mitral and
tricuspid valves, is usually due to a pathologic process such as pulmonic stenosis or right bundle
branch block. Non-pathologic split of S2 can occur on inspiration. Paradoxical S2 split occurs on
expiration, with the most common associated pathology being left bundle branch block. Fixed S2
split can be indicative of atrial septal defect or right ventricular failure.

REFERENCE:
Bates, Barbara, MD. “A Guide to Physical Examination and History Taking” 4th ed. J.B.
Lippincott Company pp 259-261
Stoelting RK, Miller RD. Basics of Anesthesia 4th ed. Churchill Livingstone pp 248-270

54
51. Ventricular dilation in congestive heart failure is the result of:

A. increased cardiac output.

B. increase in circulating catecholamines.
C. decrease in ventricular afterload.
D. increase in end-diastolic ventricular volume.

ANSWER: D

RATIONALE:
Congestive heart failure is defined as the inability of the heart to maintain a cardiac output that
meets the demands of peripheral organs. Catecholamine output is initially increased to attempt to
increase heart rate and contractive force in order to maintain cardiac output. However, this is also
accompanied by an increase in peripheral vascular resistance causing increased afterload.
Eventually the myocardium cannot compensate and the end-diastolic ventricular volume is
increased, due to decreased cardiac output and increased end-diastolic volume blood in left
ventricle prior to systole. Myocardial failure can be secondary to coronary artery disease, non-
ischemic cardiomyopathy, or longstanding valvular problems such as aortic incompetence.

REFERENCE:
Redding, S and Montgomery M. Dentistry in Systemic Disease. First edition JBK Publishing
1990 Pg 176-177.
Barash, Cullen, Stoelting : Clinical Anesthesia 2nd Edition J.B. Lippincott Company,
Philadelphia 1992 pg 989-1017.

55
52. Peripheral pedal edema and jugular venous distension are primarily characteristics of:

A. left heart failure

B. right heart failure
C. pulmonary edema
D. nephrotic syndrome

ANSWER: B

RATIONALE:
Right heart failure causes systemic venous congestion, resulting in jugular venous distension and
causing peripheral edema from lymphatic stasis.

Left sided heart failure causes pulmonary vascular congestion, leading to pulmonary edema,
dyspnea, orthopnea, and changes of pulmonary vasculature on chest radiographs. Nephrotic
syndrome is a glomerulonephropathy causing severe proteinuria precipitating a large decrease in
intravascular osmotic pressure and fluid loss to the interstitial tissue. While peripheral edema is a
prominent symptom, intravascular volume depletion occurs and jugular venous distension is
therefore not observed.

REFERENCE:
Redding, W., Montgomery M. : Dentistry in Systemic Disease, 1st ed. JBK Publishing 1990 pg
178-179
Barash, Cullen, Stoelting: Clinical Anesthesia 2nd Edition, J.B. Lippincott Company, Philadelphia
pg 989-1017.

56
53. Increased risk factors associated with patients diagnosed with congestive heart failure and
managed with digitalis include all of the following except:

A. ejection fraction < 40%.

B. left atrial pressure > 20 mm Hg.
C. hyperkalemia
D. calcium channel blokers

ANSWER: C

RATIONALE:
Digitalis toxicity can be enhanced in the hypokalemic state and precipitate serious cardiac
dysrhythmias.

Normal cardiac ejection fractions are 60-80%, and when < 50% constitute a risk of congestive
failure. Normal left atrial pressure is 4-12 mm Hg; when elevated it represents increased preload
and increases the work of a compromised myocardium, increasing risk. Calcium channel
antagonists and beta blockers can decrease already impaired myocardial performance.

REFERENCE:
Rozien M, Fleisher L: Essence of Anesthesia Practice. WB Saunders, 1997
Yao F: Anesthesiology Problem Oriented Patient Management 4th ed., Lippincott,
1998

57
54. When pre-operatively evaluating a patient that has an implanted permanent pacemaker, all of the
following are true except:

A. Epicardial pacemakers do not require antibiotic prophylaxis for bacteremia-producing

procedures.
B. A demand type pacemaker should be switched to a fixed rate mode to avoid interference
of the pace making activity from intraoperative radiofrequency emitting equipment
(example; electrocautery).
C. Dual chamber pacemakers can develop pacemaker-mediated tachycardia.
D. Patients with a pacemaker can not be defibrillated.

ANSWER: D

RATIONALE:
All current pacemakers allow defibrillation; however they should be checked for proper
function after defibrillation. Demand pacemakers can undergo interference from any strong
radiofrequency source, especially if it is grounded to the patient (such as electrocautery;) so
demand pacemakers should be set on a fixed rate to avoid inappropriate interference with the
demand function. Pacemaker-mediated tachycardia is a possible complication of dual-
chamber(atrial and ventricular) pacing when the atrial lead senses retrograde depolarizations
because of ventriculoatrial conduction. The resulting tachycardia often has a rate equal to the
upper rate limit of the pacemaker. Pacemaker-mediated tachycardia can be eliminated by
various reprogramming maneuvers, such as lengthening the post-ventriculoatrial refractory
period.

REFERENCE:
th
Yao F: Anesthesiology Problem Oriented Patient Management 4 Ed. Lippincott-Raven
1998.
st
Goldman, Bennett (eds.): Cecil's Textbook of Medicine 21 Edition.
Rozien M, Fleisher L: Essence of Anesthesia Practice, WB Saunders 1997.
Advanced Cardiac Life Support Guidelines 1997, American Heart Association

58
55. Which of the following statements regarding aortic stenosis is incorrect?

A. Aortic stenosis is typified by a midsystolic ejection murmur and a narrowed pulse

pressure.
B. The triad of angina, syncope and congestive heart failure represents progression of
symptoms associated with aortic stenosis.
C. The development of supraventricular arrhythmias including atrial fibrillation creates
hemodynamic problems for the patient with aortic stenosis.
D. Hypotensive anesthesia for the aortic stenosis patient is cardioprotective by decreasing
afterload and myocardial work.

ANSWER: D

RATIONALE:
Hypotension (reduced systemic vascular resistance ) does little to relieve the fixed afterload
arising from a stenotic aortic valve; however hypotension lowers the diastolic coronary profusion
gradient leading to myocardial ischemia. Therefore, induced hypotensive states are
contraindicated in the patient with a stenoticaortic valve.

Aortic stenosis is characterized by a crescendo-decrescendo systolic murmur (which may radiate

to the carotids) and narrowed pulse pressure. With left ventricular hypertrophy an apical thrust
may be seen. The triad of angina, syncope and congestive heart failure correlate directly with
mortality; the 50% survival data for these symptoms are 5,3, and 2 years respectively from the
onset of symptoms without surgical treatment. Patients with aortic stenosis need the left
ventricular filling obtained through a well timed atrial contraction. Supraventricular arrhythmias
decrease ventricular filling (especially in the less compliant myocardium of left ventricular
hypertrophy) and therefore decrease the amount of blood available for ejection past the stenotic
aortic valve.

REFERENCE:
Yao F: Anesthesiology Problem Oriented Patient Management 4th Ed., Lippincott-Raven, 1998.
Rozien M, Fleisher L: Essence of Anesthesia Practice, WB Sauders, 1997.
Advanced Cardiac Life Support Guidelines1997, American Heart Association

59
56. Which of the following produces a diastolic murmur?

A. Aortic stenosis
B. Mitral regurgitation
C. Mitral valve prolapse
D. Mitral stenosis

ANSWER: D

RATIONALE:
Mitral stenosis produces a diastolic rumbling murmur. By auscultation one can hear an
opening snap followed by a low-pitched diastolic rumble best heard at the apex. Diagnosis is
confirmed by Doppler echocardiography. The most common cause of mitral stenosis is
rheumatic fever. The first symptom of mitral stenosis is usually dyspnea on exertion as a
result of pulmonary venous congestion secondary to elevated left atrial pressure.

The most common causes of aortic stenosis are rheumatic fever and congenital anomaly.
Associated symptoms include syncope, dyspnea on exertion and angina. In the adult the
physical findings are consistent with a systolic ejection (crescendo-decresendo) murmur and
delayed pulse up-stroke. Diagnosis is confirmed with cardiac catheterization. Mitral
regurgitation often is detected by a holosystolic rumbling murmur, while mitral valve prolapse
yields a systolic click murmur.

REFERENCE:
Stoelting RK, Dierdorf ST: Valvular Heart Disease, in, Stoelting RK, Dierdorf ST(eds) Handbook
for Anesthesia and Co-Existing Disease, Churchill Livingstone 1993
Kopitsky RG, Genton RE: Myocardial and Valvular Heart Diseases, in, Dungan WC, Ridner
ML(eds) Manual of Medical Therapeutics 26 edition, Little Brown 1989
Campbell D: Aortic Stenosis, in, Abernathy CM, Harken AH (eds) Surgical Secrets, Mosby
Yearbook 1991
Campbell D: Mitral Stenosis, in, Abernathy CM, Harken AH (eds) Surgical Secrets, Mosby
Yearbook 1991

60
57. Which of the following statements regarding premature ventricular contractions PVC’s are true?

A. Unifocal PVC’s in patients without a previous cardiac history may indicate early signs of
myocardial infarction
B. Six or more PVC’s in a minute, especially if they are multifocal are considered
ventricular tachycardia.
C. They should always be treated promptly to avoid the risk of ventricular tachycardia or
fibrillation.
D. They rarely occur in a normal, healthy individual.

ANSWER: B

RATIONALE:
Six or more PVC's per minute are by definition ventricular tachycardia. Depending upon the
clinical situation, antiarrhythmic therapy may be justified, especially if these are multifocal.
Unifocal PVC's in an otherwise healthy individual warrant investigation for nonspecific cardiac
challenges such as hypoxemia, hypercarbia, acidemia, sympathetic surge, drug effects and
electrolyte disturbances. They are, however, not indicative of impending myocardial infarction.
Therefore an intelligent consideration of the clinical situation and a search for possible causes in
the otherwise healthy patient should be performed rather than a “knee jerk” response of
antiarrhythmic therapy.

REFERENCE:
Office anesthesia evaluation manual, AAOMS, 6th ed., p.31, 2000.
Elamana V: Anesthetic considerations in patients with cardiac arrhythmias, pacemakers and
AICDs. International Anes Clin 39(4): 21-42, 2001.

61
58. What is the maintenance fluid requirement of a healthy 70 kg adult who is restricted from oral
intake NPO while awaiting surgery?

A. 60 cc/hr
B. 80 cc/hr
C. 110 cc/hr
D. 140 cc/hr

ANSWER: C

RATIONALE:
The calculation for fluid replacement for a healthy individual is as follows:

HOURLY CALCULATION
40 ml/hr for the first 10 kg of body weight
20 ml/hr for the 2nd 10 kg of body weight
10 ml/hr for each additional 10 kg
Total = 110 cc/hr

DAILY CALCULATION
1st 10 kg x 100 ml = 1000 ml
2nd 10 kg x 50 ml = 500 ml
50 kg x 20 ml = 1000 ml
Total = 2500 ml/24 hr
= 104 ml/hr

REFERENCE:
Abubaker, A. and Benson, K.; Surgical Correction of Dentofacial Deformities, Vol. I, Bell, W.,
Proffit, W., White, R, 1980, pg. 223

62
59. Initiators of hepatic cirrhosis include all of the following except:

A. Chronic cholestasis
B. Halothane
C. Uncontrolled diabetes mellitus
D. Right heart failure

ANSWER: C

RATIONALE:
Chronic biliary obstruction can cause cirrhotic liver changes. Halothane, by an immune-
mediated reaction to metabolic byproducts, can cause a fulminant acute hepatic necrosis that
may lead to cirrhosis in susceptible individuals. Prolonged severe right heart failure can lead
to hepatic fibrosis and "cardiac cirrhosis." Although the microangiopathy of uncontrolled
diabetes mellitus can affect many organ systems, hepatic involvement is unusual.

REFERENCE:
OMS Knowledge Update Vol. I, Part 2 AAOMS 1995 p PEV 38
th
Harrison's Principles of Internal Medicine, 13 ed. McGraw-Hill, 1994 pp 1478-1489

63
60. A patient with a history of renal impairment and a measured glomerular filtration rate of 20
ml/min could be expected to manifest with which of the following?

A. Microcytic hypochromic anemia

B. Compensatory respiratory hypoventilation
C. Low anion gap
D. Hypertension tendency

ANSWER: D

RATIONALE:
Glomerular filtration of 20 ml/min would be considered to have moderate to severe renal
failure. Moderate to severe renal failure affects the rennin-angiotensin system causing
hypertension. Lack of renally-produced erythropoietin in renal failure yields a normochromic,
normocytic anemia by decreased red blood cell production. Renal failure also causes a high
anion-gap metabolic acidosis, which often is accompanied by a compensatory respiratory
hyperventilation.

REFERENCE:
Petersen L, Indresano A, Marciani R, Roser S: Principles of Oral and Maxillofacial Surgery
Volume I, Chapter 2 p. 31 1992

64
61. Which medication should be avoided in the thyrotoxic patient?

A. atropine
B. methimazole
C. potassium iodide
D. propranolol

ANSWER: A

RATIONALE:
Thyrotoxicosis is manifested by a hyperadrenergic state including hypertension and tachycardia.
Atropine would aggravate the cardiovascular effects of this disorder and should be avoided.
Antithyroid medications such as methimazole and propothiouricil decrease thyroid hormone
synthesis and decrease peripheral conversion of T4 to the more metabolically active T3. Initial
intravenous potassium iodide actually decreases the acute release of T3 and T4 from the thyroid,
although long-term it can increase iodine storage in the gland. Propranolol mitigates the
cardiovascular effects of hyperthyroid activity and is used in acute management of the disease.

REFERENCE:
Pronovost P, Paris K: Perioperative management of thyroid disease.
Postgrad Med 98:83-96, 1995
Gavin L: Thyroid crisis. Medical Clin N Amer 75:179-190, 1991

65
62. All of the following conditions are seen in patients with severe untreated hypothyroidism except:

A. Dementia
B. Cardiac failure
C. Hypolipidemia
D. Coma

ANSWER: C

RATIONALE:
Untreated severe hypothyroidism manifests with altered mental status up to and including
coma, heart failure, muscular weakness/lethargy, and hyperlipidemia especially low density
lipoproteins often with advanced athlerosclerosis.

REFERENCE:
Vezeau PJ: Thyroid disorders. In: Bennett J (ed.): Medical
Emergencies in Dentistry, WB Saunders, 2002. pp 374-5

66
63. All of the following may be observed in the patient with untreated adrenal insufficiency except:

A. decreased systemic vascular resistance

B. peaked T waves on ECG
C. hypernatremia
D. rales

ANSWER: C

RATIONALE:
Adrenal insufficiency can include both cortisol and aldosterone production. Lack of cortisol can
lead to decreased systemic vascular resistance and hypotension, especially under physiologic
stressors. In the face of this challenge in a cardiac-debilitated patient, high-output congestive
heart failure can lead to rales being auscultated. Physiologically, aldosterone release is under
control of the rennin-angiotensin system; and aldosterone promotes renal sodium and water
retention and potassium excretion. Conversely, hypoaldosteronism can lead to hyponatremia due
to sodium losses, and to hyperkalemia, which is manifested by peaked T waves on ECG.

REFERENCE:
McKenna S: Adrenal Sufficiency. In: Bennett J (ed.): Medical
Emergencies in Dentistry, WB Saunders, 2002. pp 379-387

67
64. Which of the following is the initial treatment for diabetic ketoacidosis?

A. Insulin
B. Isotonic saline
C. Potassium chloride
D. Sodium bicarbonate

ANSWER: B

RATIONALE:
Restoration of fluids and electrolytes is the first resuscitative priority due to dehydration and
sodium depletion. Initial hydration rapidly corrects plasma volume and increases the efficacy
of later insulin therapy. Intracellular potassium depletion may be masked by near normal or
slightly elevated serum potassium levels, especially in a volume-depleted patient. Therefore,
following initial rehydration, insulin administration is also accompanied by titrated intravenous
potassium with careful electrolyte measurements. Volume expansion and insulin
administration usually resolves the metabolic acidosis from ketoacid production, and
bicarbonate administration is not indicated in most cases.

REFERENCE:
Wall B: Diabetic ketoacidosis. Med Clin N Amer 79:9-37, 1995

68
65. A normal glycosylated hemoglobin (Hemoglobin A1c) level is:

A. 4-6 %
B. 10-12 %
C. 15-18%
D. 20-25%

ANSWER: A

RATIONALE:
The major form of glycohemoglobin, termed hemoglobin A1c normally comprises only 4-6%
of total hemoglobin. It would be higher in chronically hyperglycemic patients due to
condensation of glucose with free amino acids on the globin component of hemoglobin.
Therefore, 2, 3, and 4 are too high for a healthy individual.

REFERENCE:
Little, J., Falace, D., Miller, C., and Rhodus, N: Dental Management of the Medically
Compromised Patient, 5th edition, Elseiver Science,1997, pg. 397

69
66. Which of the following would be considered the drug of choice for treatment of severe
pseudomembranous colitis?

A. Vancomycin
B. Cefazolin
C. Clindamycin
D. Metronidazole

ANSWER: D

RATIONALE:
Metronidazole is an antibiotic which is effective against Clostridium difficile which causes
pseudomembranous colitis. Vancomycin, due to its cost and concerns of promoting
vancomycin microbiologic resistance (especially by Staphylococcus strains) has limited its oral
use to very severe, metronidazole-resistant C. difficile enterocolitis infections. Cefazolin and
clindamycin disturb the balance of intestinal flora and have been implicated as causative agents
in the development of this infection.

REFERENCE:
Little, J., Falace, D., Miller, C., and Rhodus, N: Dental Management of the Medically
th
Compromised Patient, 5 edition, Elseiver Science, 1997 p. 306
Moyenuddin M, Williamson J, Ohl C: Clostridium difficile-associated diarrhea: Current
strategies for diagnosis and therapy. Curr Gastrolenterol Rep 4(4):279-286, August 2002

70
67. What endocrine abnormality is often an associated sequela of chronic renal failure?

A. Secondary hyperparathyroidism
B. Primary adrenal insufficiency
C. Hypothyroidism
D. Primary hyperaldosteronism

ANSWER: A

RATIONALE:
With renal failure there is decreased glomerular filtration which results in an increased level of
serum phosphate. This tends to cause serum calcium to be deposited in bone leading to a decrease
serum calcium level. In response to low serum calcium the parathyroid glands are stimulated to
secrete parathormone (PTH) which results in secondary hyperparathyroidism. Primary adrenal
insufficiency usually is a result of an autoimmune disorder but may also result from cancer,
infection, or trauma. Hypothyroidism may result from any failure along the pituitary-thyroid axis
(hypothalamus failure to release thyroid releasing hormone, adenohypophyseal failure to release
thyroid stimulating hormone, or thyroid secretory failure.) Primary hyperaldosteronism results
from adrenal cortical hyperplasia (specifically of the zona glomerulosa) or an aldosterone-
secreting adenoma of the adrenal gland. None of the latter three states is a sequela of chronic
renal failure.

REFERENCE:
Harrison's Principles of Internal Medicine 13 ed., McGraw-Hill, 1994, pp. 2160-1

71
68. Increased anion gap may be found in :

A. Hyperkalemia
B. Multiple myeloma
C. Hypoalbuminemia
D. Ketoacidosis

ANSWER: D

RATIONALE:
Anion gap gives information concerning "unmeasured" serum anions. Diabetic ketoacidosis is
the most common cause of an increased anion gap. Hyperkalemia, increased proteinaceous
cation in multiple myeloma, and decreased proteinacious anion in hypoalbuminemia will all
cause a decreased anion gap.

REFERENCE:
Wallach J: Interpretation of Diagnostic Tests. Little, Brown, 1992.
p. 396

72
69. Which of the following concerning the management of the Parkinson’s disease patient is false?

A. Sialorrhea and cardiac sphincter dysfunction increase the incidence of pulmonary

aspiration.
B. Ephedrine should be avoided if the patient takes selegiline.
C. Levodopa should be discontinued 24 hours prior to neuromuscular blocking agents.
D. Levodopa therapy may lead to hypovolemia and dyskinesia.

ANSWER: C

RATIONALE:
Levodopa has a short half-life and withdrawal prior to surgery can precipitate muscle rigidity and
attendant difficulties in respiration and handling the patient. Sialorrhea, esophageal and laryngeal
dysfunction increase aspiration risk in Parkinson's patients. Selegiline is a monoamine oxidase-B
inhibitor that decreases dopamine catabolism, and mitigates Parkinsonism's decreases in
dopamine in the caudate nucleus and the putamen. Ephedrine can precipitate an adrenergic crisis
in MAO-B treated patients. Levodopa increases the activity of the rennin-angiotensin system,
potentiating hypovolemia.

REFERENCE:
Benumof JL, Anesthesia & Uncommon Diseases, WB Saunders 1998 pp. 6-7; Atlee JL,
Complications in Anesthesia WB Saunders 1999

73
70. You consult on a patient status post motor vehicle accident and see that a neurosurgery consult
has noted the presence of epidural hematoma with transtentorial herniation. Which of the
following would not be typical symptoms?

A. Ipsilateral fixed, dilated pupil

B. Decerebration
C. Decorticate posturing
D. Coma

ANSWER: C

RATIONALE:
Epidural hematoma, usually caused by a middle meningeal arterial bleed, occurs between the
dura mater and the inner table of the calverium. The classic triad of trastentorial herniation
includes decerebrate posturing (extension of the arm at the elbows with internal arm rotation),
a fixed and dilated pupil on the side of the herniation, and coma. Decerebrate posturing
indicates neurologic damage at or below the midbrain. Decorticate posturing indicates severe
neurologic damage in the hemisphere above the midbrain; and is clinically typified by arm
flexion and fist clenching.

REFERENCE:
Fonseca and Walker, Oral and Maxillofacial Trauma, WB Saunders 1991 pp. 148-149

74
71. Which of the following statements regarding myasthenia gravis is incorrect?

A. Initial symptoms often include diplopia and ptosis.

B. The etiology involves decreased acetylcholine secretion at the neuromuscular junction.
C. Edrophonium is useful in diagnosis of this disorder.
D. Physiologic stress can exacerbate clinical symptoms, including respiratory muscle failure.

ANSWER: B

RATIONALE:
Myasthenia gravis is an autoimmune disease characterized by decreased acetylcholine
receptors at the neuromuscular junction which leads to muscle weakness even with normal
acetycholine secretion. . Ocular muscles are often the first affected, with diplopia and ptosis
especially after repetitive eye activities. Stressors such as infection or surgery can exacerbate
muscle weakness, including respiratory muscles. Edrophonium, an acetylcholinesterase
inhibitor, often brings rapid relief from muscle weakness; however false negative and positive
test results are not uncommon.

REFERENCE:
Goetz L, Textbook of Clinica Neurology 1st ed., WB Saunders, 1999 pp. 1024-1025
Cecil's Textbook of Medicine, 21st ed., WB Saunders, 2000 pp 2221-2

75
72. Which of the following statements concerning myotonic dystrophy is true?

A. ECG abnormalities are uncommon.

B. Inheritance is autosomal recessive.
C. Initial cardiac involvement most often is hypokinesis.
D. Extremity weakness progresses from distal to proximal.

ANSWER: D

RATIONALE:
Distal-to-proximal weakness is the most common progression pattern, although myotonia and
stiffness may occasionally predominate. The inheritance is autosomal dominant. Predominant
cardiac involvement is by fatty degeneration and fibrosis of specialized cardiac conductive tissue
(sino-atrial and atrio-ventricular nodes and His-Purkinje system.) This makes dysrhythmias the
most common cardiac pathology accompanying myotonic dystrophy.

REFERENCE:
Braunwald E, Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed. WB Sauanders,
2001 p. 2265
Cecil's Textbook of Medicine, 21st ed. WB Saunders, 2000 p. 2209
Miller, Anesthesia 5th ed. Churchill-Livingstone, 2000 p. 973

76
73. Wernicke’s encephalopathy :

A. may be precipitated in susceptible individuals by saline infusion.

B. is due to folic acid deficiency.
C. is characterized by ophthalmoplegia and ataxia.
D. is often anteceded by mental status changes.

ANSWER: C

RATIONALE:
Often the initial presenting signs of Wernicke's encephalopathy include abducens palsy,
horizontal diplopia, nystagmus, and strabismus; and ataxia may cause ambulation difficulties.
These neuromuscular signs often antecede mental changes. The disorder is caused by
deficiency of thiamine (vitamin B1); administration of which can quickly reverse ocular
symptoms but often has little effect on mental changes once they have occurred (such as
anterograde and retrograde amnesia, apathy, drowsiness, confusion.) Glucose infusion into a
thiamine-depleted individual (generally alcoholics) can precipitate Wernicke's syndrome and
all alcoholics receiving glucose infusions should have concomitant thiamine administration
(50-100 mg immediately and then daily.)

REFERENCE:
Textbook of Primary Care Medicine 3rd ed., Mosby, 2001 p 1479

77
74. Which of the following concerning posttraumatic diabetes insipidus is true?

A. A hypertonic polyuria ensues.

B. Extreme dehydration may accompany hyponatremia.
C. An adenohypophyseal hormone analog is an effective treatment.
D. The targets of treatment are renal collecting ducts.

ANSWER: D

RATIONALE:
Traumatic diabetes insipidus results from a decreased secretion of antidiuretic hormone from the
neurohypophysis (posterior pituitary.) The other neurohypophyseal hormone is oxytocin.
Adenohypophyseal (anterior pituitary) hormones include follicle stimulating hormone,
leuteinizing hormone, thyroid stimulating hormone, somatostatin, melanocyte stimulating
hormone, and adrenocortical stimulating hormone.

Lack of ADH causes a decrease in water resorption from the renal collecting ducts, resulting in a
voluminous hypotonic urine production, causing dehydration manifested by serum
hyperosmolarity and hypernatremia. Treatment usually includes administration of intravenous or
intranasal desmopressin, an analog of ADH that is almost devoid of vasopressor effects (unlike
vasopressin.)

REFERENCE:
Harrison's Principles of Internal Medicine, 13th ed., McGraw-Hill, 1994 pp1926-8
Guyton, AC: Textbook of Medical Physiology 6th ed, WB Saunders, 1981 pp. 429-430

78
75. Which of the following may be indicated in the treatment of acute intracranial injury?

A. Ventilation-induced serum pCO2 < 25mm Hg

B. Intravenous glucocorticoids
C. IV administration of 10% dextrose in 0.45% saline
D. Mannitol 1 mg/kg initial bolus

ANSWER: D

RATIONALE:
Osmotic diuresis with IV mannitol is commonly used to decrease intracranial pressure from
acute head injury. There are no studies confirming the benefit of glucocorticoid use in
reducing elevated intracranial pressure from acute head injury. Judicious and limited
hyperventilation may be used to temporarily bring pCO2 down to 30 mm Hg but prolonged
periods of pCO2 < 25mm may cause significant cerebral vasoconstriction, worsening
ischemia. Hypotonic fluids such as 0.45% normal saline may increase cerebral edema, and
dextrose- containing fluids can contribute to hyperglycemia-induced cerebral injury.

REFERENCE:
ATLS Student Course Manual, 1997 American College of Surgeons pp 202-4

79
76. The pathophysiology for Horner’s syndrome is:

A. interruption of preganglionic parasympathetic fibers.

B. Interruption of postganglionic sympathetic fibers.
C. aberrant conduction between motor branches of cranial nerve V and cranial nerve III.
D. traumatic or pathologic changes in the ciliary ganglion.

ANSWER: B

RATIONALE:
Horner's syndrome is the result of disruption of sympathetic innervation to the orbital region
characterized by miosis (unopposed parasympathetic-mediated papillary constriction;) upper lid
ptosis (by loss of sympathetic innervation to Mueller's muscle;) enophthalmos (either “apparent”
by ptosis, or more rarely by atrophy of orbital contents if the syndrome occurs in a young patient
or is longstanding;) and more inconsistently ipsilateral facial anhidrosis (lack of sweating.)
Aberrant conduction (usually via a congential anomaly) between the motor branches cranial nerve
V to the terminal branches of cranial nerve III produces Marcus Gunn syndrome (“jaw-winking”
syndrome,) characterized by resting lid ptosis and upward motion of the superior lid with
mandibular movement. Interruption of the parasympathetic fibers of the ciliary ganglion (where
parasympathetic fibers to the orbit synapse) would result in pupillary dilation (mydriasis.)

REFERENCE:
Hollingshead WH: Anatomy for Surgeons, Volume 1. The Head and Neck, 2nd ed. Hoeber
Medical, New York, 1968 pp 115, 172
Bullock JD: Marcus-Gun jaw- winking ptosis: Classification and surgical management. J
Ophthomol Strabismus 17:375-9, 1980

80
77. A patient with a left homonymous heminanopsia may indicate a lesion in the:

A. optic chiasm
B. right optic radiation
C. right optic nerve
D. left optic tract

ANSWER: B

RATIONALE:
Lesions of the optic radiation and of the optic tract produce a contralateral hemianopsia (loss of
the contralateral field of vision in both eyes; in this case, a right optic radiation lesion causing a
left homonymous hemianopsia.) Optic chiasm lesion produce a bitemporal hemianopsia (loss
of temporal, i.e. lateral, field of vision in both eyes.) Lesions of the optic nerve produce an
ipsilateral blind eye.

REFERENCE:
nd
Alper's and Mancalls' Essentials of Neurologic Examination 2 ed.
th
DeGowan & DeGowan: Diagnostic Examination 6 ed.
th
Bates: A Guide to Physical Examination, 7 ed., Lipponcott, 1980

81
78. Which medication is contraindicated for office-based anesthesia in a patient with partially
controlled tonic-clonic seizure activity?

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

ANSWER: D

RATIONALE:
Although many thiobarbiturates decrease cerebral metabolism and electrical activity and are
used as anticonvulsants, the oxybarbiturate methohexital has increased central nervous system
excitatory effects and may precipitate seizures in epileptics. Propofol, fentanyl, and ketamine
have no such pro-convulsant effects.

REFERENCE:
Weinberg G: Basic Science Review of Anesthesiology. McGraw-Hill, 1997 pp16-19

82
79. At which parasympathetic ganglion do ocular preganglionic fibers synapse with postganglionic
fibers?

A. Superior cervical
B. Pterygopalatine
C. Otic
D. Ciliary

ANSWER: D

RATIONALE:
Parasympathetic ganglia are present near the target organ, unlike sympathetic where the ganglia
are near the spinal cord. Parasympathetics to the globe arise from cranial nerve III and synapse at
the ciliary ganglion, just posterior to the globe. The otic ganglion synapses parasympathetic
nervous system fibers from cranial nerve IX and supplies the parotid gland. The pterygopalatine
ganglion receives presynaptic PSNS fibers from cranial nerve VII and supplies the secretory
glands of the palate and nasal cavity. The superior cervical ganglion is sympathetic.

REFERENCE:
Vander S, Luciano T Human Physiology: The Mechanisms of Body Function. McGraw-Hill
1998 pp. 213-216
Romanes GJ, “Cunningham's Manual of Practical Anatomy, Volume 3: Head & Neck. Oxford
Medical Publications, 1986

83
80. In comparing the characteristics of rheumatoid arthritis (RA) and osteoarthritis (OA), which of
the following is incorrect?

A. RA has a significant inflammatory component while OA does not.

B. RA usually presents with multiple symmetric joint involvement; OA usually involves
only one or two joints initially.
C. Both processes have associated systemic manifestations, including fatigue, weakness, and
malaise.
D. There are no laboratory tests that are pathognomonic or accurately diagnostic for either
process.

ANSWER: C

RATIONALE:
Signs and symptoms of RA include multiple symmetric joint involvement, a significant
inflammatory component, morning joint stiffness lasting more than one hour, symmetric
swelling of the proximal interphalangeal joints, systemic manifestations of fatigue, weakness,
and malaise. In comparison, OA is characterized by involvement of only one or two joints or
joint groups (at least initially) morning stiffness lasting less than 15 minutes, and the initial
hand lesions usually involve the distal interphalangeal joints. OA has no systemic
involvement. There are no laboratory tests that are specifically pathogonomic for either
process, although there area a number of serum markers that may accompany RA (such as
elevations of rheumatoid factor, erythrocyte sedimentation rate; and a normochromic,
microcytic anemia.)

REFERENCE:
Little and Falace: Dental Management of the Medically Compromised Patient6th ed.
Harrison's Principles of Internal Medicine, 15th ed., McGraw-Hill

84
81. In obstructive pulmonary disease, which of the following changes in the total lung capacity
(TLC) and residual volume (RV) occurs?

A. TLC is normal or decreased; RV is decreased

B. TLC is normal or decreased; RV is increased
C. TLC is normal or increased; RV is decreased
D. TLC is normal or increased; RV is increased

ANSWER: D

RATIONALE:
In obstructive pulmonary disease, total lung capacity may be normal or increased and residual
volume is increased; both by air entrapment and emphysematous changes. Vital capacity is often
decreased as the amount of nonventilated or poorly ventilated lung volume increases.

REFERENCE:
The ICU Book, 1991, p. 322

85
82. A 79 year old white male presents to your office for removal of carious teeth. Medical history
review reveals chronic obstructive pulmonary disease (COPD), hypertension, peptic ulcer
disease, athlerosclerosis with occasional angina, and osteoarthritis. Daily medications include
isosorbide dinitrate, furosemide, and acetaminophen. After conscious sedation with midazolam
and local anesthesia with prilocaine, you note that in recovery he has slowly become ashen
looking and the pulse oximetry reading has fallen to 85%. Which of the following measures is
most appropriate?

A. Intubation and hyperventilation with 100% oxygen

B. Titrated administration of 0.4 mg flumazenil IV
C. Methylene blue administration 1 mg/kg IV
D. Assisted ventilation by face mask with room air.

ANSWER: C

RATIONALE:
This situation may appear to be pulmonary in origin, but in fact represents acquired
methemoglobinemia. This condition can be precipitated by nitrates, (such as isosorbide
dinitrate) acetaminophen, prilocaine, articaine, and a number of other medications, especially
in genetically susceptible individuals. The oxidized (ferric) state of the methemoglobin
molecule cannot be reversed by increasing the FIO2, which also may decrease the respiratory
drive in COPD. Sedation reversal by flumazenil will have no effect on the condition.
Cautious administration of methylene blue will reduce methemoglobin back to a ferrous state,
normalizing the oxygen binding/delivering capacity of hemoglobin.

REFERENCE:
th
Benumof JL Anesthesia & Uncommon Diseases, 4 ed. WB Saunders, 1998 pp288-9

86
83. Which of the following medication is least indicated for acute control of asthma?

A. Cromolyn sodium
B. Metaproterenol
C. Dexamethasone
D. Diphenhydramine

ANSWER: A

RATIONALE:
Chromolyn sodium is a mast cell stabilizer preventing the release of histamine in the mucosa
of the tracheobronchial tree when used chronically, but acts too slowly to be useful on an
emergent basis. Metaproterenol is a beta agonist used to dilate the airway and reverse
bronchoconstriction. Dexamethasone may be used intravenously to control the mucosal
inflammatory component of acute asthma. Diphenhydramine, a histamine antagonist, may be
administered concomitantly with a beta agonist and a steroid to decrease histamine-mediated
bronchoconstriction and mucosal edema.

REFERENCE:
th
Harrison's Principles of Internal Medicine 13 ed., McGraw-Hill, 1994 pp 1170-2

87
84. Which of the following medications is the most appropriate agent when considering intubation
general anesthesia for the patient with chronic bronchitis and emphysema?

A. Desflurane
B. Methohexital
C. Vecuronium
D. Nitrous oxide

ANSWER: C

RATIONALE:
Vecuronium, a non-depolarizing muscle relaxant, is a steroidal medication and therefore lacks
histamine-releasing tendencies that occur with the benzoisoquinolone non- depolarizers.
Histamine release can increase tracheobronchial mucosal edema and cause
bronchoconstriction. Desflurane, although a potent bronchodilator, is also an airway irritant,
causing coughing and increasing sympathetic tone; and may not be desirable in the patient with
chronic bronchitis. Methohexital when used as an induction agent can precipitate
laryngospasm and bronchospasm in airways already irritated by chronic disease. Nitrous
oxide's extremely low blood solubility will cause it to come out of solution to expand areas of
hypoventilation in the lung, which may cause pneumothorax in patients with emphysematous
changes and pulmonary blebs.

REFERENCE:
Weinberg, G (ed.) Basic Science Review of Anesthesiology McGraw-Hill, 1997

88
85. Which statement regarding acute respiratory failure is correct?

A. It represents inadequate ventilation, caused by partial obstruction of the airway at the

level of the trachea
B. It involves the inability of the lungs to provide adequate exchange of O2 and CO2
C. Generally, diagnosis is made by clinical signs and chest radiography.
D. A PaO2 of <80mm Hg or PaCO2 >40 mmHg is consistent with a diagnosis of acute
respiratory failure.

ANSWER: B

RATIONALE:
Acute respiratory failure is the inability of the lungs to provide adequate arterial oxygenation
with or without acceptable elimination of carbon dioxide. It culminates in hypoventilation,
hypercarbia, and hypoxemia.

Partial obstruction of the airway at the level of the trachea represents stridor. Measurement of
arterial blood gases and pH are mandatory in the diagnosis and management of acute
respiratory failure. It is distinguished from chronic respiratory failure on the basis of the
relationship of the PaCO2 to pH (acute respiratory failure shows no partial compensation of
hypercarbia.) Respiratory failure is diagnosed with arterial hypoxemia (PaO2 <60mm Hg
despite supplemental O2), hypercarbia (PaCO2 >50mm Hg), and SaO2 <92%. On room air,
normal PaO2 is 90-100 mmHg, normal PaCO2 is 40 mm Hg, and oxygen saturation is 98-
100%. Functional residual capacity and lung compliance are also reduced in respiratory failure

REFERENCE:
Stoelting, RK and Dierdorf, SF. Handbook For Anesthesia and Co-Existing Disease. New
York. 1993. Churchill-Livingstone, Inc. pp. 129-133.
th
Hurford WE, [Link]. Clinical Anesthesia Procedures of the Massachusetts General Hospital. 5
Edition. 1998. Lippincott-Raven. pp. 618-621.

89
86. Which of the following is a form of restrictive lung disease?

A. Asthma
B. Bronchiectasis
C. Cystic fibrosis
D. Sarcoidosis

ANSWER: D

RATIONALE:
Sarcoidosis is restrictive because sarcoid lesions cause a decreased compliance of lung
parenchyma, restricting the amount of lung capacity. Asthma, bronchiectasis, and cystic fibrosis
increase airway ventilatory resistance (especially during exhalation) and air entrapment, and are
therefore obstructive diseases.

REFERENCE:
Harrison's Principles of Internal Medicine, 12th edition, p. 1036

90
87. When used in mandibular third molar extraction sockets, oxidized methylcellulose has been
associated with transient changes in mandibular nerve function due to:

A. mechanical irritation of the nerve

B. irritation caused by metabolic breakdown products
C. acidic pH in the extracellular fluid surrounding the nerve
D. direct giant cell nerve injury

ANSWER: C

RATIONALE:
When metabolized, oxidized methylcellulose imparts a surrounding fluid pH of 2.8. Although
direct mechanical trauma may always be a cause of neural dysfunction, the acid pH of the
oxidized methylcellulose breakdown environment may be the most likely factor of neural
dysfunction when used in the mandibular third molar extraction socket.

REFERENCE:
Conrad SM: Neurosensory disturbances as a result of chemical injury to the inferior alveolar
nerve. OMS Clin N Amer 13:256, 2001
Loescher AR, Robinson PP: The effect of surgical medicaments on peripheral nerve function.
Br J Oral Maxillofac Surg 36:330-2, 1998

91
88. The most likely explanation for the greater extent of edentulous bone resorption seen in the
mandible compared to the maxilla once teeth are lost is:

A. diminished blood flow through the inferior alveolar canal

B. greater muscle attachments to the mandible
C. increase mandibular osteoclastic activity
D. greater mandibular bone density

ANSWER: A

RATIONALE:
Though the pathogenesis of bone loss in the maxilla and mandible is obviously influenced by
metabolic, traumatic, and infectious processes; the mandible is more susceptible due to its
vascular supply. Bone density and osteoclastic activity are secondary issues and muscle
attachments alone are not implicated in bone loss.

REFERENCE:
Fonseca, RJ, Oral and Maxillofacial Surgery Vol 7, Reconstruction and Implant Surgery, WB
Saunders 2000

92
89. When performing a z-plasty to remove a prominent labial frenum the secondary incisions are
made at an angle approximately 60 degrees to allow the main limb to be rotated:

A. 33 degrees
B. 45 degrees
C. 60 degrees
D. 90 degrees

ANSWER: D

RATIONALE:
A z-plasty is designed to rotate the frenum or scar 90 degrees. Secondary incisions made at
other angles may not allow as great a rotation of the main limb (in this case, the main frenum
incision) as those made at 60 degrees tothe main limb.

REFERENCE:
Fonseca, RJ, Oral and Maxillofacial Surgery Vol 7, Reconstruction and Implant Surgery, WB
Saunders 2000

93
90. Which of the following is not an indication for the extraction of impacted third molars?

A. To prevent incisal crowding

B. To prevent caries and root resorption of the 2nd molar
C. To prevent a unanticipated split during orthognathic surgery
D. To allow distalization of teeth for orthodontic treatment

ANSWER: A

RATIONALE:
There are several indications for the extraction of impacted third molars, depending on the
nd
position and soft tissue envelope; Root resorption, caries, and demineralization of the 2
rd rd
molar are indications for 3 molar removal. The presence of impacted 3 molars during a
bilateral sagittal split osteotomy may increase the likelihood of an unfavorable split and
therefore may be removed six months prior to planned osteotomy. If uprighting or distalization
nd rd
of the 2 molar is required, the 3 molar should be removed to prevent caries and root
rd
resorption. No evidence exists that shows removal of impacted 3 molars will prevent incisor
crowding.

REFERENCE:
Fonseca, RJ, Oral and Maxillofacial Surgery Vol 7, Reconstruction and Implant Surgery, WB
Saunders 2000

94
91. The best technique for managemnt of an unerupted labially positioned maxillary canine lying
high in the alveolus in a normally developing 14 year-old female is:

A. an apically repositioned flap with bracketing and orthodontic tooth advancement

B. exposure via a full thickness mucosal incision at the level of the impaction
C. a full thickness flap, orthodontic bracketing, flap replacement and orthodontic tooth
advancement under flap
D. full thickness apically repositioned flap to allow passive eruption

ANSWER: C

RATIONALE:
A full thickness flap allows for maintenance of the attached gingiva. A mucosal incision at the
level of the impaction would prevent the attached gingiva from moving with the tooth and an
apically repositioned flap may not reliably expose the canine crown. In addition, an apically
repositioned flap may not allow adequate exposure to remove bone and bond an orthodontic
appliance.

REFERENCE:
Fonseca, RJ, Oral and Maxillofacial Surgery Vol 7, Reconstruction and Implant Surgery, WB
Saunders 2000

95
92. A vertical releasing incision for surgical exposure is planned during dentoalveolar surgery. Which
of the following statements best describes the design of the anterior margin?

A. It should end at the mesiobuccal line angle of the tooth

B. It should cross the prominence of the canine tooth
C. The extension should divide the interproximal papilla
D. The incision should directly cross the facial aspect of the tooth

ANSWER: A

RATIONALE:
Releasing incisions aid in providing visualization and surgical exposure. A vertical releasing
incision should cross the free gingival margin at the line angle of the tooth and should not be
directly on the facial aspect of the tooth nor directly in the papilla. The incision is not a straight
vertical incision but rather oblique, to allow the base of the flap to be broader than the free
gingival margin. It should not cross bony prominences, such as the canine eminence. This would
increase the likelihood of tension in the suture line, thus, possible wound dehiscence. Incisions
that cross the free margin of the facial aspect of the tooth do not heal well because of tension and
can result in a periodontal defect of the attached gingiva. Incisions that cross the gingival papillae
damage the papillae and may result in localized periodontal problems.

REFERENCE:
Peterson, Ellis, Hupp, Tucker, Contemporary Oral and Maxillofacial Surgery, 4th Edition, Mosby
2003: 158-9

96
93. As compared to submucous vestibuloplasty, secondary epithelialization vestibuloplasty should be
performed when the patient:

A. does not have existing dentures

B. has an associated epulis fissuratum
C. has phenytoin hyperplasia
D. is young, with a better healing potential

ANSWER: B

RATIONALE:
Vestibuloplasty by submucous resection or secondary epithelialization may be indicated when
a maxillary denture is unstable due to high muscle attachments with good underlying bone
height and contour. both submucous vestibuloplasty and secondary epitheliazation require the
same extent of supraperiosteal soft tissue dissection. However, submucous vestibuloplasty
avoid the often painful healing associated with healing by secondary epithelialization. In some
instances, horizontal epithelial incision is necessary, such as to remove an epulis fissuratum or
when superior repositioning of the incision is necessary (when a shallow vestibular depth
would cause inward vermillion rolling with a submucous vestibuloplasty technique.)
Phenytoin hyperplasia, age, and existing dentures do not aid in the choice of vestibuloplasty
technique.

REFERENCE:
nd
Fonseca RJ, Davis WH. Reconstructive Preprosthetic Oral and Maxillofacial Surgery. 2
Edition, Philadelphia, PA: WB Saunders; 1995; 789

97
94. Which of the following is considered an advantage of mineral trioxide aggregate (MTA) over
amalgam in periradicular surgery:

A. more positive seal

B. promotes electrochemical reaction
C. no danger of contamination by moisture
D. less expensive than amalgam

ANSWER: A

RATIONALE:
When compared to amalgam, MTA as a root end filling material has demonstrated more
positive seal, desirable hydrophilic behavior, no electrochemical reaction, no corrosive
properties, and no tattooing. Moisture control continues to be a concern in all retrograde
materials and the cost of MTA is greater than that of conventional amalgam.

REFERENCE:
Fink, JB, “ Predicting the success and failure of surgical endodontic treatment” OMS Clinics,
May 2002, p.162

98
95. When treatment planning implants in children, it is recommended to place the implants after
growth cessation. This is best evaluated by:

A. serial cephalometric radiographs taken at 6 months

B. chronologic age
C. skeletal body height
D. hand-wrist films evaluating epipheseal fusion

ANSWER: A

RATIONALE:
Chronological age and skeletal body height are poor indicators of growth completion. Skeletal
age is better but, growth of facial bones lags slightly behind growth of long bones. Serial
cephalometric radiographs provide the most accurate determination of facial growth
completion. If no growth can be seen in 1 year it can be assumed that growth has ceased.
Hand wrist films are a good indicator when compared to standardized films.

REFERENCE:
Kearns G, Implants in Children, OMS Knowledge Update Vol 3, p.67-81

99
96. Which of the following is the most reliable radiologic predictor of possible inferior
alveolar nerve injury during third molar surgery?

A. Diversion of the inferior alveolar canal

B. Deflection of third molar roots
C. Narrowing of third molar roots
D. Bifurcation of the root apex

ANSWER: A

RATIONALE:
While a variety of radiologic signs have been suggested to be associated with an increase in the
risk of injury to the alveolar nerve during third molar removal, only three have been positively
associated with an increased incidence of neurosensory deficit. They include diversion of the
inferior alveolar canal, darkening of the root and interruption of the white line. None of the other
choices listed have been associated with an increased risk.

REFERENCE:
Rood and Shehab, British Journal of Oral and Maxillofacial Surgery, 1990, Vol. 28, pp 20-25.

100
97. Which of the following suture material is the slowest to be resorbed?

A. Polyglactin 9/10 (Vicryl)

B. Polyglycolic acid (Dexon)
C. Surgical gut – chromic
D. Polydioxanone (PDS II)

ANSWER: D

RATIONALE:
Vicryl and Dexon are both resorbed within 60 and 90 days by esterhydrolysis. While the rate
of resorption of chromic gut is patient dependent, it is uniformly resorbed more rapidly(via
enzymatic proteolysis) than the other materials listed. PDS II is only minimally absorbed until
th
the90 day with continued resorption by ester hydrolysis not complete until 18-30 months.

REFERENCE:
Jenkins, Brandt, and Dembo, “Suture Principles in Dentoalveolar Surgery”, Oral and
Maxillofacial Surgery Clinics of North America, Advanced Topics in Dentoalveolar Surgery,
May 2002, pp 213-229.

101
98. Which of the following cardiac conditions is not indicated for antibiotic prophylaxis
when removing a carious first molar?

A. Prosthetic cardiac valves

B. Hypertrophic cardiomyopathy
C. Mitral valve prolapse without regurgitation
D. A history of bacterial endocarditis

ANSWER: C

RATIONALE:
The American Heart Association recommends antibiotic premedication for patients with a
variety of cardiac conditions known to have moderate to high risk of endocarditis. Among
others, these include prosthetic cardiac valves, a history of bacterial endocarditis, and
hypertrophic cardiomyopathy. While mitral valve prolapse with regurgitation should also be
premedicated, MVP without regurgitation does not require pre-treatment with antibiotics.

REFERENCE:
Savage, M.G., “Antibiotic Prophylaxis and Dentoalveolar Surgery”, Oral and Maxillofacial
Surgery Clinics of North America, Vol. 14, No. 2, 2002, pp 231-240.

102
99. All of the following reasons support removal of at least 3 mm of root during endodontic
root surgery (apicoectomy) except:

A. removal of lateral canals

B. allows favorable placement of the soft tissue incision
C. allows access for removal of associated pathologic tissue
D. ease of placement of a retrofill restoration

ANSWER: B

RATIONALE:
The resection of 3 mm or more of the apex allows a larger surface for the retrograde preparation.
Because the greatest number of lateral canals is located near the apex, resection of 3 mm or more
also removes many of these difficult to seal canals, increasing the chance for success. Removal of
apical root structure allows access to excise periapical pathology. The location and design of the
soft tissue incision is determined by other factors.

REFERENCE:
Fink, J.B., “Predicting the Success and Failure of Surgical Endodontic Treatment”, Oral and
Maxillofacial Surgery Clinics of North America, Vol. 14, No. 2, 2002, pp153-165.

103
100. What diameter restorative table would require the most apical placement when inserting
an implant to support a single maxillary central incisor restoration?

A. 3.25 mm
B. 4.1 mm
C. 4.3 mm
D. 5.0 mm

ANSWER: A

RATIONALE:
Narrow diameter restorative tables require more interocclusal space to allow the emergence
profile necessary to develop proper physiologic contours in the final restoration. Therefore, the
narrower the diameter of the restorative table, the deeper the implant would have to be placed.

REFERENCE:
Rotter, B.E., “Emergence Profile Considerations for Implant Surgery”, Oral and Maxillofacial
Surgery Clinics of North America, Vol. 8, No. 3, August, 1996, pp 413-429

104
101. All the following are associated with a significant increase in complications after the
removal of asymptomatic impacted third molars except:

A. age of the patient

B. use of prophylactic antibiotics
C. experience of the surgeon
D. position of the tooth

ANSWER: B

RATIONALE:
Studies document an increase in the incidence and severity of complications associated with
increasing patient age, degree and position of the impaction, and the experience of the operating
surgeon. While recent studies suggest that in certain sub groups, prophylactic antibiotics may
improve quality of life related measures during recovery, there is no evidence they decrease the
rate of infection.

REFERENCE:
Chiapasco, deCicco, and Marrone, “Side Effects and Complications Associated with Third Molar
Surgery”, Oral Surgery, Oral Medicine, Oral Pathology, Vol. 76, No. 5, October, 1993, pp 412-
420.
Sisk, Hammer, Sheldon, Joy, “Complications Following the Removal of Impacted Third Molars”,
Oral and Maxillofacial Surgery Clinics of North America, Vol. 44, pp 855-859, 1986.
Sekhar, Narayanan, and Baig, “Role of Antimicrobials in Third Molar Surgery: A Prospective,
Double-Blind Randomized, Placebo Controlled Clinical Study”, British Journal of Oral and
Maxillofacial Surgery, Vol. 39, pp 134-137, 2001.
Zeitler, D., “Prophylactic Antibiotics for Third Molar Surgery: A Dissenting Opinion”, Journal of
Oral and Maxillofacial Surgery, Vol. 53, No. 60, pp 61-64, 1995,

105
102. Which statement is not an indication for a labial vestibuloplasty, with floor-of-mouth lowering
and split thickness skin graft?

A. High muscle attachment of floor-of-mouth such that the denture is displaced when
speaking
B. Inadequate vestibular depth, with high buccinator attachment
C. Lack of sufficient keratinized tissue covering the denture bearing areas of the mandibular
ridge
D. Atrophic mandible with less than 10 mm of mandibular bone height

ANSWER: D

RATIONALE:
The generally recognized minimum mandibular bone height for satisfactory denture bearing
after a labiobuccal vestibuloplasty, lowering of the floor of the mouth and periosteal coverage
by application of a split thickness skin graft is 15 mm. Proper contour of the alveolar ridge and
keratinized tissue surface over this ridge is desirable. The split thickness skin graft adheres to
denuded periosteum and provides a firm, resilient covering similar to keratinized gingiva.

REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

106
103. Which statement is not true regarding pericoronitis of a mandibular 3rd molar?

A. The condition results from debris and bacterial contamination around the crown of a
partially impacted tooth
B. The infection is caused by normal oral flora
C. Infection arises if host defenses become compromised and cannot maintain the delicate
balance with the bacterial flora
D. Antibiotics are indicated to decrease bacterial load

ANSWER: D

RATIONALE:
Antibiotics are a key aspect in localizing an infection and limiting its spread to adjacent tissue
organs, areas, and spaces. Pericoronal infections that are localized to the immediate enveloping
tissues and give no evidence of spread to adjacent tissue planes may require local debridement
and definitive treatment consisting of removal of the erupting tooth and/or pericoronal tissues.

REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

107
104. Which of the following statements describing alveolar osteitis is incorrect?
A. Generally develops 3-5 days after surgery
B. Is an inflammation of bone, not necessarily an infection
C. Is characterized by lysis of the socket blood clot
D. Requires vigorous bone scraping to stimulate new blood clot formation

ANSWER: D

RATIONALE:
Alveolar osteitis is essentially an inflammation of the bony socket from a recently extracted
tooth. Treatment consists of gentle debridement of the socket and placement of a suitable
obdundant until the area becomes asymptomatic. Usually no local anesthesia is required.

REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

108
105. Management of oral-antral communications may require all of the following for closure except:

A. tissue flap mobilization with water-tight closure

B. stripping of all the sinus mucosa
C. antibiotics and decongestants
D. Metallic foil, membrane, or bone grafts

ANSWER: B

RATIONALE:
An established oral-antral communication may require several surgical aspects to close the defect
successfully. Cardinal principles include (1) no active infection of the maxillary sinus and (2)
adequate drainage of secretions into the nasal cavity. Stripping of all of the sinus mucosa is
usually not indicated and can result in regeneration of a non-respiratory epithelium which may be
detrimental to long term sinus health. Only the diseased mucosa requires removal.

REFERENCE:
Peterson, LJ Contemporary Oral and Maxillofacial Surgery, 3rd Edition, Mosby, 1998

109
106. When performing a floor-of-the-mouth lowering procedure, it is necessary to:

A. perform a subperiosteal dissection

B. cover the denuded region with a soft tissue graft
C. avoid altering muscle attachments in patients diagnosed with retrolingual sleep apnea
D. detach all muscle attachments at the genial tubercle

ANSWER: C

RATIONALE:
Patients with suspected or diagnosed obstructive sleep apnea should not have muscle
attachments altered in floor-of -mouth lowering procedures because this may worsen or create
obstruction. Supraperiosteal dissections are performed and the incision margin is sutured to the
periosteum at the depth of the vestibule. It is not necessary to place a soft tissue graft over the
denuded periosteum as this may be allowed to secondarily epithelialize. The genioglossus
muscle attachments at the genial tubercle may be partially removed to increase the lingual
sulcus, but approximately ½ of the genioglossus attatchment should remain intact to ensure
proper tongue function.

REFERENCE:
Fonseca RJ Oral and Maxillofacial Surgery Vol. 7 p. 49WB Saunders2000

110
107. When performing maxillary sinus lifting and possible simultaneous implant placement which of
the following is the primary determinate of an acceptable recipient site for implant placement?

A. 2 mm of vertical bone height on panorex radiograph

B. 3 mm of vertical bone height on panorex radiograph
C. primary implant stability at the time of placement
D. elevation of the sinus membrane without perforation

ANSWER: C

RATIONALE:
Vertical bone height may be a consideration in the treatment planning phase of simultaneous
sinus lifting and implant placement. In general 4 mm of vertical bone height will provide a
situation that may allow for simultaneous placement however, the true determinate is primary
implant stability.

REFERENCE:
OMS Knowledge Update Volume 1 Part 1 IMP p. 47-53

111
108. When performing a vestibuloplasty with split thickness skin graft what is the ideal thickness of
the donor skin graft?

A. 0.012 to 0.015 inches

B. 0.012 to 0.015 mm
C. 0.030 to 0.035 inches
D. 0.030 to 0.35 mm

ANSWER: A

RATIONALE:
When harvesting a split thickness skin graft the ideal thickness should be 0.012 to 0.015
inches. This allows the graft to contain both epidermis and the superficial dermis. Allowing
early revascularization.

REFERENCE:
Fonseca, RJ, Davis WH, Reconstructive Preprosthetic Oral and Maxillofacial Surgery, WB
Saunders, Philadelphia, 1995, p.752

112
109. A patient radiographically exhibits mesioangular mandibular third molar impaction and a lack of
bone along the distal surface of the adjacent second molar. Up to which age would you expect
predictable bony regeneration along the distal second molar surface after third molar removal
without the use of adjunctive tissue regeneration techniques? ?

A. Up to 14 years
B. 18 years
C. 25 years
D. 30 years

ANSWER: C

RATIONALE:
The likelihood of persistence of a pre-existing preoperative periodontal defect posterior to the
second molar in the postoperative period increase with the age of the patient. Kugelberg found
that patients younger than 25 years had a zero to minimal increase in the depth of the periodontal
attachments. In patients that are 25 years of age or less one can predict bony regeneration of such
defects.

REFERENCE:
OMS Knowledge Update Vol 1, Part 2, DAV
Kugelberg, CF. Periodontal healing two and four years after impacted lower third molar surgery.
Int J Oral Maxillofac Surg. 1990; 19:341-345

113
110. Closure of a well established, oral-antral fistula greater than 5 mm in diameter may be
most predictably accomplished by:

A. Long term antibiotic and decongestant therapy

B. Periodic observation for at least six months
C. Rotation of a palatal island flap
D. Bone graft augmentation to the fistula.

ANSWER: C

RATIONALE:
Communication between the maxillary sinus and oral cavity is an uncommon complication and
occurs mostly on the sites of the maxillary first molar, followed by the second molar, third
molar, and second premolar. Although smaller defects of less than 5 mm in diameter may close
spontaneously, larger communications generally require surgical closure. Palatal flaps are
based on the greater palatine artery and can be mobilized and rotated to close oral-antral
fistulae. The most practical palatal flap design is a rotational flap that has a wedge removed
near its base to facilitate rotation. When mobilized, the palatal tissue serves as an excellent
source of tissue to close an oral-antral fistula, especially in an edentulous areas because there is
no vestibular distortion.

REFERENCE:
Principles of Oral & Maxillofacila Surgery, Larry Peterson, AT Indresano, R Marciani, S Roser;
1997, Vol 2, pages 1002-1004.
Lee JJ, Kok SH, Chang HH, Yang PJ, Hahn LJ, Kuo YS. Repair of oroantral communications in
the third molar regio by random palatal flap. International Journal of Oral and Maxillofacial
Surgery. 31 (6): 677-80, 2002 Dec.
Kraut RA, Smith RV. Team approach for closure of oroantral and oronasal fistulae. Atlas of the
Oral and Maxillofacial Surgery Clinics of North America 8 (1): 55-75, 2000 Mar.

114
111. Appropriate placement of an endosseous dental implant is determined by:

A. Placing the implant where available bone exists.

B. Where the patient expects the implant to be placed.
C. A surgical guide fabricated for the placement of the implant.
D. Placing the implant where adequate soft tissue exists to submerge the implant.

ANSWER: C

RATIONALE:
Implant placement should be guided by the prosthetic requirements, and may be best
accomplished by using a surgical guide. Contemporary tissue grafting and regenerative
techniques allow fixture placement in prosthetically appropriate positions.

REFERENCE:
Principles of Oral & Maxillofacial Surgery, Peterson,
Indresano, Marciani, Roser; 1997, Vol 2, page 1144

115
112. Regarding platelet rich plasma is use in bone grafting procedures, which statement is most
accurate?

A. It involves bank blood, concentrate added to a bone graft.

B. Autologous whole blood containing leukocytes and fibrinogen which promote clotting
within the graft
C. Primary use is in the donor site to prevent an osseous defect.
D. Efficacy stems from concentration of growth factors by sequestering and concentrating
autologous platelets.

ANSWER: D

RATIONALE:
Platelet-rich plasma is an autologous source of platelet-derived growth factor and transforming
growth factor beta that is obtained by sequestering and concentrating platelets by
centrifugation. This technique produces a concentration of human platelets containing growth
promoting substances (including platelet-derived growth factor and transforming growth factor
beta) within them. These growth factors increase the maturation rate 1.5 to 2 times compared
to grafts without platelet-rich plasma.

REFERENCE:
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE; Platelet-rich plasma;
Growth factor enhancement for bone grafts. Oral Surgery, Oral Medicine, Oral Pathology, Vol
85, No. 6, June 1998, page 638

116
113. What is the minimum radiographically safe minimal distance that an implant may be placed from
the superior lamina of the inferior alveolar canal when utilizing a panoramic radiograph?

A. 0.5 mm
B. 1.0 mm
C. 2.0 mm
D. 5.0 mm

ANSWER: C

RATIONALE:
When using a panoramic radiograph, variations in vertical magnification within the
radiographic image make a safety margin of 2.0mm between the end of the implant and the
inferior alveolar canal desirable. Because of its greater precision, computed tomography
enables the clinician to select an implant that will be 1.0mm above the canal. Implant burs vary
depending on the manufacturer and the surgeon must understand that the specified length (for
example, a 10mm marking) may not reflect an additional millimeter included for drilling
efficiency.

REFERENCE:
Kraut RA, Chalal O. Management of patients with trigeminal nerve injuries after mandibular
implant placement. JADA 133(10): 1351-4, 2002 Oct
Tarnow DP, Magner AW, Gletcher P. The effect of the distance from the contact point to the
crestal bone on the presence or absence of the interproximal dental papilla. Journal of
Periodontology 1992 Dec:63(12) 995-996.

117
114. The recommended solution for irrigation during implant site preparation is:

A. chilled normal saline

B. chilled sterile water
C. body temperature Dextrose 5% in sterile water
D. body temperature sterile water

ANSWER: A

RATIONALE:
Chilled solution is recommended for better cooling. Water, and other hypotonic solutions have
been shown to cause rapid death of bone cells.

REFERENCE:
Giglio, Laskin, “ Perioperative Errors Contributing to Implant Failure”, OMS Clinics of North
America, May 1998, p.200

118
115. Peri-implantitis can be categorized as:

A. an early failure
B. a late failure
C. a complication of overheating of the bone
D. a complication of rough –surface implants

ANSWER: B

RATIONALE:
Peri-implantitis is defined as radiographically detectable peri-implant bone loss occurring after
initial successful osseointegration combined with soft tissue inflammation lesion that
demonstrates suppuration and probing depths of 6mms or more. The process begins at the
coronal aspect of the implant, whereas the more apical portion remains clinically stable
(osseointegrated).

REFERENCE:
Truhlar, “Peri-implantitis”, OMS Clinics of North America, May 1998, p. 299-301

119
116. Using the buccal object rule, if the x-ray cone is moved away from the area in question, and the
crown of an impacted tooth (when compared to adjacent erupted tooth roots) appears to move in
the same direction as the cone, the crown is considered to have which position compared to the
erupted tooth roots?

A. buccal
B. gingival
C. palatal/lingual
D. distal

ANSWER: C

RATIONALE:
The SLOB rule states: "Same Lingual Opposite Buccal." In this situation, the cone was moved
away and the crown of the impacted tooth moved in the same direction (same), so the object is
palatal or lingual to the adjacent erupted tooth roots.

REFERENCE:
Felsenfeld and Aghaloo, “ Surgical exposure of impacted teeth”, OMS Clinics of North America,
May 2002, p.188

120
117. Which of the following fuided tissue membrane material is non-resorbable?

A. polylactic acid
B. glycolide and trimethylene carbamate copolymer
C. expanded polytetrafluoroethylene
D. freeze-dried xenographic lamellar bone

ANSWER: C

RATIONALE:
Exanded polytetraflurothylene is the most studied and widely used non-resorbable material
used for guided tissue regeneration. The other listed materials are resorbed and avoid the
necessity of a procedure to harvest a non-resorbable material.

REFERENCE:
Garg, " Bone induction with/without membranes and using platelet-rich plasma", OMS Clinics
of North America, August 2001, p. 438

121
118. Which syndrome is not associated with multiple impacted teeth?

A. Cleidocranial dysplasia
B. Down syndrome
C. Gardner syndrome
D. Peutz-Jaeger syndrome

ANSWER: D

RATIONALE:
Peutz-Jaeger syndrome exhibits autosomal dominant inheritence, peroral ephilides, and
nonmalignant intestinal polyposis. There are no supernumerary or impacted teeth associated
with this syndrome. Cleidocranial dyspalsia is inherited autosomal dominant and the patients
usually have short stature, long necks with drooping shoulders due to absent or hypoplastic
clavicles. These patients may exhibit maxillary hypoplaisa with possible submucous clefting
and supernumerary teeth. Down syndrome (also known as trisomy 21) is usually caused by
mititoc chromosomal nondisjunction, resulting in an extra chromosome. Variable mental
retardation, congenital heart disease, T cell and B cell dysfunction, increased incidence of
acute lymphocytic leukemia, predilection for Alzheimer disease, fissured tongue,
macroglossia, oral cefting, and multiple impacted teeth are all features of Down syndrome.
Gardner syndrome is also autosomal dominant with premalignant intestinal polyposis, multiple
osteomas, fibromas of the skin, epidermal trichilemmal cysts, and supernumerary impacted
teeth.

REFERENCE:
Zeitler, D. Management of Impacted Teeth Other Than Third Molars. OMFS Clinics of NA
5:95-103, 1993.

122
119. Surgical uprighting of a mesioangular impacted mandibular second molar will usually also
require:

A. removal of buccal bone

B. bonding of a bracket
C. removal of the adjacent impacted third molar
D. intentional root fracture

ANSWER: C

RATIONALE:
Removal of buccal bone is not advised as the second molar may not be stable when uprighted.
A bracket is usually unnecessary. Intentional root fracture will doom the procedure. Removal
of the impacted third molar is often necessary to create space, since the uprighting cause
distalization of the second molar crown.

REFERENCE:
Zeitler D. Management of Impacted Teeth Other Than Third Molars. OMFS Clinics of NA 5:95-
103, 1993.

123
120. The lingual nerve lies above the mandibular 3rd molar alveolar crest which percentage of the
time?

A. 14
B. 32
C. 68
D. 86

ANSWER: A

RATIONALE:
The lingual nerve has been found to be superior to the lingual alveolar crest in the third molar
region 14.07% of the time.

REFERENCE:
Belinia, H. et al. “An Anatomic Study of the Lingual Nerve in the Third Molar Region” JOMS
58 (2000) pp 649-651

124
121. Upon extraction of a tooth, the healing process begins. The major source of angioblastic and
fibroblastic proliferation in the post extraction socket is derived from the:

A. open marrow space surrounding the socket.

B. cortical walls of the socket.
C. remnants of the periodontal ligament.
D. surrounding gingival tissue.

ANSWER: C

RATIONALE:
The cortical bone between the coagulum and the cancellous bone would act a barrier to the
healing of the dental alveolus except for the presence of the periodontal ligament. The
periodontal ligament is a major source for angioblastic and fibroblastic proliferation into the
blood coagulum.

REFERENCE:
Alling, C.C., Alling, R.D. “Biology and Prevention of Alveolar Osteitis”
SORM Vol. 4, Number 1

125
122. Bacteria commonly recovered from cases of pericoronitis include:

A. Fusobacterium, Streptococcus milleri, Peptostreptococcus.

B. Streptococcus pyogenes, Prevotella capillosis, Kingella kingal
C. Staphylococcus Xylosis, Prevotella bivia.
D. Streptococcus Pyogenes, Staphylococcus aureus, Bacteroides fragilis.

ANSWER: A

RATIONALE:
Most samples recover 10-15 different isolates. The predominant facultative anaerobic bacteria
include Streptococcus milleri. Predominate obligatory anaerobes include spirochetes and
fusobacterium. Pathogens well known for causing supprative infections such as
Staphylococcus aureus and Streptococcus pyogenes were only rarely found.

REFERENCE:
Peltroche-Llacsahuanga, et al “Investigation of Infectious Organisms Causing Pericoronitis of
the Mandibular Third Molar” JOMS 58:611-616 2000

126
123. The bacteria surrounding a failing implant differs from the microbiology associated with the
healthy implant. Which of the following best describes the bacterial population around a failing
implant?

A. Aerobic gram-positive cocci.

B. Anaerobic gram-positive cocci.
C. Aerobic gram-negative rods.
D. Anaerobic gram-negative rods.

ANSWER: D

RATIONALE:
Large numbers of gram-negative anaerobic rods (A. actinomycetemcomitans, P. gingivalis, P.
intermedia) tend to be found around the failing implant. The endotoxins produced by gram-
negative bacteria have the capability to adhere to the implant surface and cause inflammation,
which results in bone loss. Momsell in 2000 identified bacteria as the primary etiologic agent in
peri-implantitis. Healthy implants were found to be colonized with gram positive cocci.

REFERENCE:
Triplett, R.G. et al “Management of Peri-implantitis” Oral and Maxillofacial Surgery Clinics of
North America 15 (2003) 129-138

127
124. Bone augmentation at the site of osseointegrated implants protected by an expanded
polytetraflouroethylene (e-PTFE) membrane does not require:

A. immobility of the membrane.

B. trimming of the membrane away from adjacent teeth.
C. close adaptation of the membrane to the exposed implant.
D. extension of the membrane at least 3 mm beyond the defect margins.

ANSWER: C

RATIONALE:
Initial stabilization of the membrane is important for wound healing. Normally, material
stability can be achieved by placing the edge of the membrane subperiosteally. In order for any
defect to be treated successfully, it is essential to create and maintain a space under the
material into which cells with osteogenic capacity can migrate, so creation of a space between
the membrane and the implant is desirable to allow osteogenesis between the implant and
membrane. To cover the defect adequately, the membrane should extend at least 3 mms
beyond the margin of the defect. This extension should prevent soft tissue in-growth as well as
stabilizing the thrombus beneath the membrane.

REFERENCE:
Dahlin C, Sennerby L. Bone Augmentation os Osseointegrated Implants Induced by a
Membrane Technique. OMFS Clinics of N. Am. Vol. 3, No. 4, Nov. 1991, p. 941

128
125. Which of the following statements about the risk of bleeding in a patient who is to under go an
extraction is false?

A. Cancer chemotherapeutics may cause thrombocytopenia.

B. Alcohol abuse may cause changes in prothrombin time and partial thromboplastin time.
C. Broad-spectrum antibiotic therapy may affect factors II, VII, IX, and X as well as
prothrombin time.
D. Partial thromboplastin time is the most appropriate test for acquired coagulopathies.

ANSWER: D

RATIONALE:
The best screening test for aquired coagulopathies is the prothrombin time (PT) or the
International Normalized Ratio (INR). To have a reasonably good chance of achieving
hemostasis by local measures, the patient's PT should be within 1.5 times the control time and the
INR below 2.0. Myelosuppression, as manifested by leukopenia, thrombocytopenia, and anemia,
are common sequelae of cancer chemotherapy. Within 2 weeks of the beginning chemotherapy,
the white blood cell count falls to an extremely low level. Thrombocytopenia can be marked, and
spontaneous oral cavity bleeding may occur. Recovery from myelosuppression is usually
complete 3 weeks from cessation of chemotherapy. Alcohol abuse may cause liver cirrhosis and
thus decrease production of the liver dependent coagulation factors, thus obtaining a PT and PTT
may be prudent in this patient population. Broad spectrum antibiotics may cause a change in the
intestinal flora, which may decrease vitamin K production. Vitamin K is necessary for the liver to
produce adequate quantities of coagulation factors II, VII, IX, and X. If the patient has a history
of prolonged broad spectrum antibiotic therapy, the surgeon should be suspicious of decreased
hemostasis.

REFERENCE:
Peterson et al. Contemporary Oral and Maxillofacial Surgery. Pp. 278-82, 1988.

129
126. The minimum distance that should be maintained between endosseous dental implants is how
many millimeters?

A. 1
B. 3
C. 5
D. 7

ANSWER: B

RATIONALE:
To maximize the chance for success, there must be adequate bone width to allow1 mm of bone on
the lingual aspect and 0.5mm on the facial aspect of the implant. There should also be adequate
space between the implants. The minimal distance between implants varies slightly among
implant systems, but is generally accepted as 3mms. This minimal space is necessary to ensure
bone viability between implants and to allow adequate oral hygiene once the restorative dentistry
is complete.

REFERENCE:
Contemporary Oral and Maxillofacial Surgery. Peterson, Ellis, Hupp and Tucker. P. 390

130
127. Which of the following complications most commonly occurs after tooth autotransplantation?

A. Failure to develop periodontal anchorage

B. Acute periapical abscess
C. Alveolar bone resorption
D. Root resorption

ANSWER: D

RATIONALE:
In the cited reference, 114 out of 416 cases of tooth autotransplantation failed. Seventy of these
cases failed, and were lacking a tooth at initial follow-up. Of the remaining teeth, 58 failed
secondary to internal and external root resorption, 8 failed to achieve adequate bony stability, and
the final 4 developed periapical abscesses.

REFERENCE:
Pogrel MA: Evaluation of over 400 autogenous tooth transplants. J oral maxiollofac Surg 45:205,
1987.

131
128. The most commonly impacted supernumerary tooth is the:

A. mandibular premolar.
B. maxillary fourth molar.
C. maxillary canine.
D. mesiodens.

ANSWER: D

RATIONALE:
The most common impacted supernumerary tooth is the mesiodens. In descending order this is
followed by the supernumerary maxillary incisor, fourth molar, and mandibular premolar.

REFERENCE:
Kaban LB: Pediatric oral and maxiollofacial surgery, chapter 7, p. 105; Saunders1990.

132
129. Following one year of function, a healthy endosseous implant is expected to incur subsequent
bone loss of how many millimeters per year?

A. 0.1
B. 0.4
C. 0.8
D. 1.0

ANSWER: A

RATIONALE:
As described in the reference, in the first year of implant function, a loss of 0.8mm to 1.0 mm
of bone can be expected without any subsequent clinical complications.

REFERENCE:
nd
Misch C., Contemporary Implant Dentistry, 2 Edition, p.24, Mosby 1999.

133
130. Which of the following has the greatest modulus of elasticity?

A. Bone
B. Titanium
C. Hydroxyapatite
D. Gold Alloy

ANSWER: A

RATIONALE:
The modulus of elasticity is the ability of a material to flex or bend under stress. In the
mandible the muscles of mastication cause bone to flex on opening and closing. An implant
system should have the ability to flex also when the mandible is functioning. Hydroxyapatite is
brittle and has a low modulus of elasticity. Titanium flexes but is still relatively rigid. The gold
alloy used in the transmandibular implant (TMI) is the most flexible of these three choices but
none have as great an ability to bend under applied stress as does the mandible.

REFERENCE:
Fonseca, RJ and Davis, WH. Reconstructive Preprosthetic Oral and Maxillofacial Surgery 2nd
edition, WB Saunders 1995

134
131. A 60 year old women presents one week after a transmandibular implant to the lower jaw. A
postoperative panoramic radiograph reveals a non-displaced fracture between the right lateral and
medial post. The appropriate treatment would be to:

A. Remove the transmandibular implant

B. Place distal transmandibular extension plates to stabilize the fracture
C. Remove the baseplate
D. Recommend a soft diet and weekly observation

ANSWER: D

RATIONALE:
The transmandibular implant provides a rigid box frame in the anterior aspect of the mandible.
Any nondisplaced fracture that occurs within the box frame will be stabilized by the implant. In
this case the fracture occurred between the lateral and medial post, which is within the box frame.
There would be no reason to remove the implant and this option would require additional
stabilization. Removing the base plate would disrupt the box frame and could cause the fracture
to displace. If the fracture occurred proximal to the lateral post then a distal extension plate would
be indicated. The correct choice would be to observe the patient weekly and place them on a soft
diet.

REFERENCE:
Fonseca, RJ and Davis, WH. Reconstructive Preprosthetic Oral and Maxillofacial Surgery 2nd
edition, WB Saunders 1995

135
132. Which of the following statements concerning glucagon is correct?

A. Storage is in pancreatic beta islets

B. Clinical use is for acute hyperglycemia.
C. Primary target is myelocytes.
D. Secretion is under sympathetic control.

ANSWER: D

RATIONALE:
Pancreatic sympathetic innervation stimulates adrenergic mediated glucagon release.
Glucagon is released from alpha pancreatic islets; insulin is released by beta pancreatic islets.
Glucagon primarily targets hepatocytes to cause glycogenolysis and fatty gluconeogenesis.
Glucagon secretion is in response to hypoglycemia and to increased demand for glucose (such
as times of physiologic stress.)

REFERENCE:
Weinberg G: Basic Science Review of Anesthesiology, McGraw-Hill, 1997, p. 130

136
133. Which of the following is not a treatment common to traumatic limb crush injury, severe
electrocution, and malignant hyperpyrexia?

A. calcium chloride
B. sodium bicarbonate
C. mannitol
D. spironolactone

ANSWER: D

RATIONALE:
All three of theses musculoskeletal injuries are typified by rhabdomyolysis and electrolyte
disturbances including hyperkalemia and metabolic acidosis. Complications include renal
failure from myoglobin precipitation in nephrons, metabolic derangements from acidosis, and
hyperkalemia. Treatment includes minimization of myoglobin-induced renal impairment by
fluid expansion and osmotic diuresis by mannitol to minimize myoglobin deposition, sodium
bicarbonate to treat metabolic acidosis and to alkalinize the urine to promote myoglobin
solubility/excretion. Cardiac sequelae of hyperkalemia may be emergently opposed by
intravenous calcium administration. Spironolactone, a potassium-sparing diuretic, would not
be included in such treatment, although a loop diuretic such as furosemide may be useful.

REFERENCE:
ATLS Student Course Manual, 1997 American College of Surgeons pp 252-3
th
Harrison's Principles of Internal Medicine, 13 ed., McGraw-Hill, 1994 pp. 252-3

137
134. Bleeding time is an important evaluation of hemostasis in alcoholic chronic liver disease because
of all of the following except:

A. hepatic platelet sequestration

B. qualitative thrombocyte dysfunction
C. decreased coagulation factor production
D. hypersplenism

ANSWER: C

RATIONALE:
Bleeding time is the best single screening test for qualitative or quantitative platelet disorders.
Chronic alcoholic liver disease may be characterized by hepatic or hypersplenic platelet
sequestration (quantitative); while cirrhotic changes in the liver decrease platelet function
(qualitative). Although severe hepatic dysfunction can cause decreases in coagulation factor
production, this is measured by other tests such as prothrombin time and activated partial
thromboplastin time.

REFERENCE:
Wallach J: Interpretation of Diagnostic Tests Little, Brown, 1992. pp 358-364
OMS Knowledge Update Vol. I, Part 2, AAOMS, 1995 pp. PEV40-1

138
135. Which of the following statements concerning vasopressor use in ventricular fibrillation is
correct?

A. Escalating repeat epinephrine dosing may increase survival compared to non-escalating

dosing.
B. Vasopressin stimulates peripheral α-1 receptors more effectively than does epinephrine.
C. Antidiuretic hormone lacks cardiac inotropic effects.
D. Vasopressin may be given by the endotracheal route.

ANSWER: C

RATIONALE:
Vasopressin, the endogenous antidiuretic hormone, has marked vasoconstrictive properties
when given in doses much greater than found in vivo. Its vasoconstrictive activity is by
binding to the V1 receptor, with no activity at adrenergic alpha or beta receptors. Since it has
no beta-adrenergic affinity, it has no effect on cardiac inotropy or chronotropy. No consistent
evidence shows that escalating epinephrine dosing increases survival-to-discharge odds from
ventricular fibrillation, so that escalating dosing is considered acceptable but not recommended
by the American Heart Association. Vasopressin is not recommended for endotracheal
administration; common ACLS medications that can be given by this route are : lidocaine,
atropine, and epinephrine. Naloxone can also be give via the endotracheal tube.

REFERENCE:
Guidelines 2000 For Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,
American Heart Association.

139
136. When considering a general anesthetic for an 18 year old with Duschenne’s muscular dystrophy,
which statement is true?

A. Restrictive lung disease from muscle atrophy-mediated kyphoscoliosis is often present.

B. Steroidal depolarizing muscle relaxants are contraindicated.
C. Volatile anesthetics are general anesthetic agents of choice.
D. There is a female preponderance

ANSWER: A

RATIONALE:
The progressive muscle atrophy seen in Duschenne's muscular dystrophy causes vertebral and
rib contractures, resulting in kyphoscoliosis and a restrictive ventilatory defect. Although
depolarizing muscle relaxants are contra-indicated due to the possible induction of
hyperkalemia, steroidal muscle relaxants are non-depolarizing. Duschenne's muscular
dystrophy patients have a relatively high incidence of malignant hyperthermia, which may be
triggered by depolarizing muscle relaxants and volatile anesthetics; therefore both are contra-
indicated in this patient group. Duschenne's muscular dystrophy is an X-linked recessive
disorder and therefore more common in males.

REFERENCE:
th
Harrison's Principles of Internal Medicine 13 ed., McGraw-Hill, 1994 pp 2283-4

140
137. When repairing eyelid lacerations or avulsive injuries:

A. The eyelid skin should be aggressively débrided.

B. The lid margin is initially approximated with a suture at the “gray line”.
C. Repair must be completed within 24 hours.
D. Split thickness skin grafts are best for replacing avulsed eyelid skin.

ANSWER: B

RATIONALE:
The best answer is to re-approximate landmarks by suturing the lid at the gray line. A lid may
be repaired by a number of techniques, each of which has a specific time limitation, therefore
24 hours may vary. Aggressive debridement should be avoided. Split thickness skin grafts are
not the most desirable modality as they may have texture and color differences.

REFERENCE:
OMS Knowledge Update, Volume three, Section 6. Abubaker AO and Strauss RA, eds. p
TRA 9-10. Classification D – Trauma - Soft tissue

141
138. Which of the following is not seen in cases of fracture of the larynx with acute airway
obstruction.

A. Hoarseness
B. Palpable fracture
C. Dysphasia
D. Dyspnea

ANSWER: C

RATIONALE:
Dysphagia, pain on swallowing, is not part of the classic triad described by the other answers:
a palpable fracture, . hoarseness (if the vocal chords are compromised); and comprised
breathing.

REFERENCE:
1997 ATLS for Doctors, Sixth Edition

142
139. Which of the following is a common finding in patients with bilateral displaced fractures of the
condylar processes treated by closed reduction that is not commonly seen following proper open
reduction?

A. Temporomandibular joint ankylosis

B. Loss of posterior facial height
C. Temporomandibular disc displacement
D. Facial muscle weakness

ANSWER: B

RATIONALE:
Disc displacement may occur from the injury or the treatment, but has not been shown to be
significantly different for the two different types of treatment. Likewise, the incidence of
ankylosis has not been shown to be statistically different with either treatment. Facial
weakness via cranial nerve V damage is only possible in the setting of open reduction.

REFERENCE:
Ellis E, Throckmorton G: Facial symmetry after closed aand open treatment of fractures of the
mandibular condylar process. J Oral Maxilofac Surg 58:719-728, 2000.

143
140. A mandibular angle fracture with comminution, infection, or loss of bone buttressing is best
treated with which type of fixation:

A. miniplate
B. dynamic compression plate (DCP)
C. reconstruction plate
D. wire osteosynthesis

ANSWER: C

RATIONALE:
The need for absolute stability for these types of fractures negates wire or miniplate fixation.
DCP causes interfragmentary compression with possible bone devitalization and necrosis. The
reconstruction plate is specifically indicated in these instances.

REFERENCE:
Ellis- Treatment of mandible angle fractures using AO reconstruction [Link]-
1993;51(3):250-254.

144
141. When considering instituting total parenteral nutrition, which of
the following statements is true?

A. Peripheral venous access is appropriate if a large bore vein is present.

B. Bolus administration can precipitate a hypo-osmotic state.
C. Intrinsic protein stores are exhausted prior to carbohydrate and fat.
D. Acute pancreatitis is an indication for this therapy.

ANSWER: D

RATIONALE:
Total parenteral nutrition is indicated for many conditions which may cause malabsorption of
nutrients from the gastrointestinal tract such as acute pancreatitis. Central venous access is
necessary, as peripheral access cannot accommodate the volumes of concentrated fluid
necessary for total parenteral support of nutrition. Injudicious bolus administration of TPN
fluid (which often has a concentration greater than 1000 mosm/L) can cause a hyperosmotic
state. When calculating a particular TPN prescription, one must consider that intrinsic
carbohydrate stores are exhausted in less than 24 hours, while
the body's protein and fat stores may be available for weeks.

REFERENCE:
th
Condon R, Nyhus L: Manual of Surgical Therapeutics 9 ed., Little Brown, 1996. pp. 203-7

145
142. Which of the following medications may trigger asthmatic symptoms?

A. Atropine
B. Ipatropium
C. Valdecoxib
D. Isoetharine

ANSWER: C

RATIONALE:
Valdecoxib (Bextra) is a cyclo-oxygenase-2 inhibitor. Any inhibitor of prostaglandin synthesis
(such as nonsteroidal anti-inflammatory drugs) can cause an increase in leukotrienes which
cause bronchoconstriction.

Atropine, being an anticholinergic, was formerly used to decrease bronchoconstriction in

asthma but is no longer used because of its systemic side effects. Ipatropium
bromide(Atrovent) is an inhaled anticholinergic used in chronic refractory asthma and in
chronic obstructive pulmonary disease. Isoetharine (Bronkosol) is an inhaled B2 agonist used
for bronchodilation as a nebulized solution.

REFERENCE:
th
Washington Manual of Medical Therapeutics 28 ed., Little Brown, 1995 pp. 238-242

146
143. The superior tarsal crease is important in upper lid blepharoplasty as it usually coincides with the:

A. Inferior aspect of the blepharoplasty skin incision

B. Superior aspect of the blepharoplasty skin incision
C. Fusion of tarsus to the skin
D. Fusion of the orbital septum to the skin

ANSWER: A

RATIONALE:
The inferior aspect of the blepharoplasty incision is placed at the superior eyelid crease. This
eyelid crease is formed due to the fusion of the levator superioris with the orbicularis oculi and
skin. Although, usually seen to be within 8-12 mm of the lid margin in Caucasians, the
position varies with age and racial characteristics. The superior aspect of the skin incision is
dictated by the amount of skin removal needed. The "pinch test" gives a good idea for
placement of the superior incision. The orbicularis oculi is a sphincter-like muscle beneath the
skin and it extends throughout the upper eyelid. Its position does not directly correlate with the
upper eyelid skin fold/crease. The orbital septum lies beneath the orbicularis oculi and is an
extension of the periosteum of the orbit. It fuses to the levator muscle and not directly to the
skin.

REFERENCE:
Karesh JW: Blepharoplasty. An overview. In: James Hupp, ed. Esthetic surgery of the aging face,
Atlas of the Oral and Maxillofacial Surgery Clinics of North America. September 1998

147
144. When planning blepharoplasty procedures, the surgeon must realize that the inferior oblique
muscle lies between:

A. lacrimal gland and middle fat pad

B. middle and lateral fat pads
C. nasal and middle fat pads
D. nasal fat pad and medial canthus

ANSWER: C

RATIONALE:
The Lacrimal gland is found in the upper eyelid and not in the lower eyelid. The middle and
lateral fat pads are close to each other and are not separated by a muscle. The inferior oblique
muscle lies in between the nasal and middle fat pads and must be protected during fat excision in
this area. It is especially prone to damage in transconjuctival lower eyelid blepharoplasty
procedures. The inferior oblique muscle lies lateral to the middle fat pad and not medial to it.

REFERENCE:
Karesh JW: Blepharoplasty. Esthetic surgery of the aging face, Atlas of the Oral and
Maxillofacial Surgery Clinics of North America. September 1998
Loeb R: Esthetic surgery of the eyelids. Springer-Verlag, New York. 1989

148
145. The “nasal tripod” concept in rhinoplasty procedures refers to:

A. Upper lateral and lower lateral cartilages and nasal septum

B. Fusion of the upper lateral and lower lateral cartilages
C. Medial and lateral crura of the lower lateral cartilages
D. Nasal septum and medial crura of the lower lateral cartilages

ANSWER: C

RATIONALE:
The two upper lateral cartilages fuse with the nasal septum to form the
Internal nasal valve area. The lower lateral cartilages and septum provide support for the nasal
tip. The upper and lower lateral cartilages do not directly fuse with each other. The close
relationship through a fibrous attachment contributes to tip support and an intercartilagenous
incision will interrupt this attachment. The medial crura are taken together to form one leg of the
tripod and the lateral crurae form one leg each of the tripod. Changes in tip rotation and position
may be visualized in terms of modification of this tripod during rhinoplasty. The nasal septum
and medial crura are closely associated to form a primary tip support mechanism. Full transfixion
incisions interrupt this attachment and may cause tip drooping.

REFERENCE:
Kennedy BD, Kinnebrew MC: Indications and Techniques for Rhinoplasty. In Peterson LJ (ed).
Principles of Oral and Maxillofacial Surgery, JB Lippincott, Philadelphia

149
146. Which of the following surgical incisions are made during external rhinoplasty procedures?

A. Marginal and transcollumellar incisions

B. Ttranscollumellar and intercartilagenous incisions
C. Intercartilagenous and transfixion incisions
D. Hemi-transfixion and marginal incisions

ANSWER: A

RATIONALE:
The marginal rim incision is made along the caudal margin of the lower lateral cartilage. The
transcollumellar incision is a skin incision across the mid-columella. Bilateral marginal and the
transcollumellar incisions help complete external skeletonization of the nasal skeleton. The
intercartilagenous incision is used in endonasal rhinoplasty techniques. The blade passes deep
to the lateral crura and superficial to the upper lateral cartilage. The transfixion incision is
generally used in endonasal rhinoplasty procedures for exposure of caudal septum. A complete
transfixion incision transects the attachment of both medical crura to the septum, and thus
some loss of tip support results. The hemitransfixion incision is also used in endonasal
rhinoplasty procedures for exposure of caudal septum. As it is only made on one side and
usually stops short of the anterior nasal spine, it preserves some tip support as compared to a
complete transfixion incision.

REFERENCE:
Zide MF: Applied surgical anatomy of the nose. In: Cosmetic Oral and Maxillofacial Surgery.
Oral and Maxillofacial Surgery Clinic of North America, vol 2 (2), 1990
Kennedy BD, Kinnebrew MC: Indications and Techniques for Rhinoplasty. In Peterson LJ
(ed). Principles of Oral and Maxillofacial Surgery, JB Lippincott, Philadelphia

150
147. A medium depth chemical peel using 35 to 40% Tricholoracetic acid (TCA) is expected to
penetrate:

A. epidermis and papillary dermis

B. epidermis, papillary dermis and upper reticular dermis
C. epidermis, papillary dermis, upper and mid-reticular dermis
D. epidermis, papillary dermis, upper, mid and lower reticular dermis

ANSWER: B

RATIONALE:
Chemical peels are classified according their depth of penetration into superficial, medium, and
deep depth peels. Superficial peels penetrate into the epidermis and papillary dermis. Examples
of superficial peel agents include TCA (up to 30%), Jessner's solution, and Glycolic acid (10-30
%). Medium depth peels penetrate into epidermis, papillary dermis and upper reticular dermis.
Examples of medium peel agents include TCA (35-50 %), phenol (88%), and Jessner's solution
plus TCA (35%). Deep depth peels penetrate into epidermis, papillary dermis, upper and mid
reticular dermis. Examples of deep peel agents include Bakers phenol and Litton's phenol.
Extension of chemical peeling agents into the lower reticular dermis produces scarring and is not
indicated.

REFERENCE:
Demas PN, Braun TW: Chemical skin resurfacing. In: James Hupp (ed). Esthetic surgery of the
aging face, Atlas of the Oral and Maxillofacial Surgery Clinics of North America. 1998

151
148. A 40 year-old female requesting cosmetic facial laser resurfacing is classified as a Fitzpatrick
skin type II patient. She is likely to have which of the following characteristics:

A. Red hair, light skin, blue-green eyes, never tans

B. Black hair, dark skin, black eyes, easily tans
C. Brown-black hair, medium-dark skin, brown-black eyes, easily tans
D. Blond hair, light skin, blue eyes, tans with difficulty

ANSWER: D

RATIONALE:
Fitzpatrick type 1 patients give a history of always having a skin burn with sun exposure.
Fitzpatrick type V patients give a history of very rarely burning on sun exposure. Fitzpatrick type
IV patients rarely if ever, burn on sun exposure. Fitzpatrick type II patients give a history of
usually burning on sun exposure. Fitzpatrick divided skin types into six categories based on the
skin color and their reactivity to the sun exposure

Skin type skin color tanning response

I white always burns never tans
II white usually burns, tans with difficulty
III white sometimes mild burn, tan very easily.
IV brown rarely burn, tan with ease
V dark brown very rarely burn, tan very easily
VI black no burn, tan very easily

REFERENCE:
Guttenberg SA, emery RW: Aesthetic cutaneous laser surgery and chemical peels. In: Fonseca R,
Baker S, Wolfor LM (eds). Oral and Maxillofacial Surgery, Vol 6, WB Saunders, Philadelphia,
2000
Brian Harsha: preoperative considerations for laser resurfacing, cosmetic facial surgery oral and
maxillofacial surgery clinics of north America Nov 2000

152
149. A 65 year old female with cervicofacial rhytidosis has completed a cervicofacial rhytidectomy
within the past 15 hours. Her facial bandage is in place and she is having extreme pressure and
pain under the bandage on the right side. The most likely cause of this pain is?

A. Cervical Nerve injury

B. Infection
C. Muscle Injury
D. Hematoma

ANSWER: D

RATIONALE:
A hematoma is the most common and significant cause of pain after a cervicofacial
rhytidectomy. Most hematomas occur within 1 to 15 hours after surgery, but can occur up to
48 hours after the procedure. The incidence has been reported to be 10 to 15 % of all patients
undergoing this procedure. Prevention with good surgical technique and hemostasis is
important. Some surgeons place drains to assist with prevention of a hematoma. Infections
following cervicofacial rhytidectomies are rare, and are usually occur 3 to 4 days out if they
occur at all. Muscle injury while quite rare could cause pain in the neck region, however it is
usually not associated with pressure sensations. Cervical nerves are less likely to be injured ,
but the great auricular nerve is the most commonly injured of the cervical chain with an
incidence reported from 0.53% to 2.6%. Most nerve injuries during this procedure do not
cause pain, but anesthesia.

REFERENCE:
Rees, TD, Aston, SJ, Thorne, CH. Postoperative Considerations and Complications. In Aesthetic
Plastic Surgery. Rees TD and Latrenta, GS. Second Edition Vol II. W. B Saunders Company
1994.

153
150. Botulinum Toxin A prevents wrinkles of the skin by what neuroactivity at the neuromuscular
junction?

A. Blocks the release of acetylcholine

B. Blocks the release of norepinephrine
C. Prevents binding of acetylcholine
D. Prevents binding of norepinephrine

ANSWER: A

RATIONALE:
Botulinum Toxin A is being used frequently in cosmetic surgical practices to inhibit the
function of the muscles of facial expression. Botulinum Toxin is an endotoxin produced by the
bacterium Clostridium botulinum. Botulism (caused by consumption of C. botulinum-
contaminated food) is not an infection per se but is a side affect caused by the ingestion of the
endotoxins that are produced by this bacteria. This toxin can be lethal when consumed in
excess dosages. The FDA has approved the use of a preparation of botulinum toxin Type A
(Botox) for muscular disorders, but not for cosmetic use. The mechanism of action is that the
Botox molecule binds to the neuromuscular endplate and blocks the release of acetylcholine.
Botulinum toxin does not effect the binding of acetylcholine, and has no effect on
norepinephrine release or binding.

REFERENCE:
Niamtu, J. The use of Botulinum Toxin in Cosmetic Facial Surgery. Oral and Maxillofacial
Surgery Clinics of North America. Vol 12, No 4, 2000.

154
151. What is the normal nasolabial angle in Caucasian females?

A. 60-74
B. 75-90
C. 95 to 110
D. 115-130

ANSWER: C

RATIONALE:
The nasolabial angle is the defining element of nasal tip elevation as the nose relates to the
upper lip. The average Caucasian female nasolabial angle is 95-110.

REFERENCE:
Larrabee WF. Facial analysis for rhinoplasty. Otolaryngol Clin North Am 20:653-674, 1987.
Willet JM: How to assess the nose for rhinoplasty. J Otolaryngol 25: 23-25, 1996.

155
152. Four weeks following a malar augmentation utilizing a Silastic prosthesis the patient complains
of severe pain and paresthesia in the infraorbital region on the right side only. What clinical
decision protocol would be advised?

A. Place patient on narcotics for 4 weeks until the pain is controlled

B. Ignore the problem, this is common and should improve with time
C. Surgically explore the region and check the position of the implant
D. Place the patient on a muscle relaxant to relieve the pain

ANSWER: C

RATIONALE:
Malar augmentation with an alloplastic implant is generally a mildly painful procedure. The
infraorbital nerve is in close proximity of the malar implant position, and could cause pressure on
the nerve if malpositioned. Ignoring the problem long term could cause permanent paraesthesia.
During surgical placement is important to place the implant in a pocket that is free from
interference with the infraorbital nerve. Placing a patient on narcotics will assist with pain
management, but will not eliminate the source of the problem. Ignoring ongoing pain for a
prolonged period may create a chronic pain state, and the source of the pain may not improve.
Early impingement management is important to avoid permanent nerve damage. Muscle relaxants
will not improve nerve damage pain.

REFERENCE:
LaTrenta, GS. Facial Contouring. Ch 32 in Aesthetic Facial Surgery. Rees RD, and Latrenta,
GS. Second Edition vol. II, WB Saunders Company, 1994.

156
153. Following upper lid blepharoplasty, the most common cause of post-operative
lagophthalmus of the upper eye lid is due to:

A. wound dehiscence.
B. debulking of orbicularis muscle.
C. excessive amount of skin removal.
D. pre-op ptosis condition.

ANSWER: C

RATIONALE:
Excess skin removal can lead to lagopthalmus. Assessment of visual status, including acuity
and EOM, lacrimation, and pain is necessary. Management is directed by degree of
lagopthalmus. Mild conditions may be managed by massage, time and proper ocular
lubricants while the tightness may relax avoiding further surgery. If the corneal surface is
compromised, a skin graft may be necessary. The posterior auricular area is usually best match
for color and skin thickness. Ptosis is a frequent complication with this repair. Wound
dehiscence usually leads to aesthetic compromise. Debulking of the orbicularis is to excessive
skin removal, and minimizes the occurences of lagopthalmus. Pre-op ptosis would be
addressed in your surgical treatment plan, and combine a Muller- conjuctival resection or
levator aponeurosis procedure combined with blepharoplasty.

REFERENCE:
Putterman: Cosmetic Oculoplastic Surgery, 3rd edition,

157
154. A peri-operative open roof deformity created during a rhinoplasty to remove a bony or
cartilaginous hump is most commonly corrected with?

A. Onlay bone graft.

B. Septoplasty.
C. Suturing of the upper lateral cartilage.
D. Lateral nasal osteotomies.

ANSWER: D

RATIONALE:
Lateral nasal osteotomies are necessary events in rhinoplasty surgery to symmetrically narrow
the lateral nasal sidewalls medially and create a more natural appearance. Onlay cartilage and
bone grafts can be a treatment option during revision rhinoplasty to correct an open roof
deformity, with soft tissue prolapse. Lateral osteotomies are performed after the dorsal
reduction to give a stable bony platform to safely remove a nasal hump. Performing the lateral
nasal osteotomies last in the surgical sequence, immediately preceeding the application of
pressure splints, diminishes inta-operative swelling, oozing, post-operative swelling and
ecchymosis.

REFERENCE:
Tardy: Rhinoplasty The Art and the Science, Volume 1

158
155. Defects in the upper and lower lip that are greater than 1/3 but less than 2/3 of the length
of the lip are best treated by which flap?

A. Gillies FAN Flap.

B. Abbe’ Flap.
C. V-Y Advancement Flap.
D. Nasolabial flap.

ANSWER: B

RATIONALE:
The Abbe' flap is an excellent choice. This is a well vascularized flap based on the labial vessels.
It allows reconstruction of the defect with lip tissue from the opposing lip. Disadvantages of this
flap are that it is 2-stage repair and may cause relative microstomia. The flap does not provide a
sensate reconstruction. The Gillies FAN flap is designed for defects greater than 75% of the upper
or lower lip. Sensate reconstruction is achieved. The Abbe flap is not indicated in defects greater
than 2/3 of the upper and lower lip. V-Y advancement flap is used to bring oral cavity mucosa to
the vermillion. Close proximity of the donor site to the recipient site is needed. The nasolabial
flap is indicated for the upper lip only.

REFERENCE:
Facial Plastic Surgery Clinics of North America, Nov 1996

159
156. In performing facial scar revisions or new facial incisions, knowledge of resting skin tension lines
(RSTLs) is relevant in aesthetic scar outcomes because?

A. Facial nerves run parallel to RSTLs.

B. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision parallels RSTLs.
C. The likelihood of developing a thickened or hypertrophic scar is inversely related to the
degree to which the injury or incision runs perpendicular to RSTLs.
D. RSTLs have minimal effects on scar developments.

ANSWER: B

RATIONALE:
The facial nerve and its brances run both parallel and perpendicular to RSTLs.
Scar revisions or planned scars should be oriented with respect to RSTLs. These well
documented, natural tissue planes display the least amount of tension and are ideal for scar
placement. RSTLs very often correspond to nature's wrinkles, running perpendicular to
underlying muscle movement.

REFERENCE:
Scar Revison,Dermatologic Clinics,vol.16, January 1998

160
157. The neurosensory innervation and vascular supply to the nose are derived from?

A. maxillary division of trigeminal nerve, internal and external carotid system

B. opthalmic division of trigeminal nerve, internal and external carotid system
C. maxillary and opthalmic division of trigeminal nerve, internal and external carotid system
D. maxillary and opthalmic division of trigeminal nerve, internal carotid only.

ANSWER: C

RATIONALE:
Virtually all of the sensory innervation to the nasal area is derived from either the opthalmic
(V1) or maxillary (V2) division of the trigeminal nerve. The nose is highly vascular, possesing
arterial contributions from both the internal and external carotid system. The outer nose and
anterior septum are supplied from the external carotid system via the facial artery and its
branches. The superior septum and orbital area are supplied through the internal carotid system
via the ethmoidal branches of the opthalmic artery.

REFERENCE:
Rhinoplasty: The Art and the Science, Volume 1, Tardy

161
158. When considering blepharoplasty, brow lift, or botox injections, the major muscles of the
forehead and eyebrow which must be considered include:

A. procerus, corrugator supercillii, occipitofrontalis and orbicularis oculi

B. temporalis, occipitofrontalis, and corrugator supercillii
C. procerus, corrugator supercillii, and temporalis.
D. temporalis, corrugator supercillii, occipitofrontalis and orbicularis oculi

ANSWER: A

RATIONALE:
The occipitofrontalis allows the scalp to move anteriorly and posteriorly, elevating the eyebrows.
The orbicularis oculi close the eyelid, in doing so it also pulls down the skin of the forehead,
temple and cheek. The corrugator lowers and moves the brows medially, producing vertical
wrinkles of the forehead. The procerus lowers the medial brow and produces horizontal wrinkles
over the nose. In the forehead region, all muscles are innervated by the temporal branch of the
facial nerve, except for the procerus, which is innervated by the buccal branch of the facial nerve.

REFERENCE:
Pre-operative evaluation of the blepharoplasty patient, Clinic. Plast. Surgery 1993

162
159. Botulinum toxin A, when used for cosmetic purposes, can be expected to last:

A. permanently
B. 1-2 months
C. 4-6 months
D. 8-10 months

ANSWER: C

RATIONALE:
The effects of botulinum toxin are temporary, typically lasting for four to six months depending
on the muscle injected and the amount of toxin used. Studies submitted to the FDA by the
manufacturer report an average of four months therapeutic effect for cosmetic indications

REFERENCE:
Package Insert, Botox Cosmetic. Allergan, Inc. 2001
Coffield, JA, et al. The site and mechanism of action of botulinum neurotoxin. In: Jankovic, J,
ed. Therapy With Botulinum Toxin. New York, NY: Marcel Decker; 1994:3-15.

163
160. The generally accepted initial total dose for treatment of glabellar lines with botulinum
type A toxin is:

A. 4 units
B. 20 units
C. 50 units
D. 100 units

ANSWER: B

RATIONALE:
For initial treatment of glabellar lines, the starting dose is recommended to be 20 units divided
into five injection sites of 4 units each: two sites in each corrugator muscle and one site in the
procerus muscle

REFERENCE:
FDA Study for the Approval of Botox Cosmetic (botulinum toxin type A) for the Treatment of
Glabellar Lines. Allergan, Inc. 2000.
Niamtu, Joseph III. The Use of Botulinum Toxin in Cosmetic Facial Surgery. In: Oral and
Maxillofacial Surgery Clinics of North America. November, 2000. Vol. 12 No. 4 pp 595-612.

164
161. The most common complication that occurs when injecting botulinum toxin type A in the
periocular region is:

A. blepharoptosis
B. ophthalmoplegia
C. Horner’s syndrome
D. loss of lateral gaze

ANSWER: A

RATIONALE:
The most common complication of injecting botulinum toxin type in the periocular region is
blepharoptosis, due to diffusion of the toxin into the levator palpebrae superioris muscle. This
can be minimized by injecting at least one cm above the bony supraorbital rim.

REFERENCE:
Package Insert, Complications/Untoward Events, Botox Cosmetic, Allergan, Inc. 2001.
Niamtu, Joseph III. The Use of Botulinum Toxin in Cosmetic Facial Surgery. In: Oral and
Maxillofacial Surgery Clinics of North America. November, 2000. Vol. 12 No. 4 pp 595-612.

165
162. Common medications prescribed preoperatively for facial skin resurfacing include all of
the following except:
A. oral steroid
B. anti-viral agent
C. tretinoin cream
D. oral antibiotic

ANSWER: A

RATIONALE:
The use of antibiotics and antiviral agents pre and post-operatively has been well established as
protocol in skin resurfacing to prevent bacterial infection and post surgical herpetic outbreaks.
Tretinoin cream allows for removal of superficial cells to enhance the penetration of the CO2
laser. Steroids are contraindicated.

REFERENCE:
Harsha, BC. Preoperative Considerations for Laser Skin Resurfacing. Oral and Maxillofacial
Surgical Clinics of North America. Vol. 12 No. 4. November 2000. pp. 555-565.

166
163. The percentage of soft tissue to bony advancement associated with an anterior horizontal sliding
osteotomy (genioplasty) of the mandible typically is:

A. 20-30
B. 40-50
C. 60-70
D. 80-90

ANSWER: D

RATIONALE:
While results of soft tissue advancement can vary depending on technique, a true horizontal
genioplasy with a broad based soft tissue pedicle (standard technique) will result in an 80-90%
soft tissue advancement.

REFERENCE:
Betts, Norman J and Fonseca, Raymond J. Soft Tissue Changes Associated with Orthognathic
Surgery. In: Modern Practice in Orthognathic and Reconstructive Surgery. Ed. William H.
Bell. W.B. Saunders Company. Philadelphia, PA. 1992. pp.2171-2209.

167
164. Which of the following describes the effects of intrinsic aging of the skin that are noted
histologically?
A. dermal collagen production increases
B. the epidermis thickens
C. dermal elastin production decreases
D. rete pegs are promoted and enhanced

ANSWER: C

RATIONALE:
Dermal elastin production decreases with age. Generalized age-related dermal atrophy
incledues decreased rete peg, epidermal thinning, and decreased dermal collagen production.

REFERENCE:
Obagi, S, Bridenstine, J: Lifetime Skin Care. Oral & Maxillofacial Surgery Clinics of North
America Vol 12, No 4. Nov 2000, p 533.

168
165. The normal distance in Caucasians from the upper eyelid margin to the superior tarsal
crease is usually:

A. 3 millimeters
B. 5 millimeters
C. 10 millimeters
D. 15 millimeters

ANSWER: C

RATIONALE:
The supratarsal crease is generally 9-10 millimeters above the lash line of the upper eyelid in
Caucasians. The crease represents an area where fibers from the levator aponeurosis attach to
the posterior surface of the skin.

REFERENCE:
Karesh, JW: Blepharoplasty. Atlas of Oral & Maxillofacial Surgery Clinics of North America
Vol 6, No 2. Sept 1998, pp 88 & 95.

169
166. During closed rhinoplasty, delivery of the lower lateral cartilages requires the surgeon to
perform a marginal incision and which other incision?

A. intercartilaginous
B. transfixion
C. Killian
D. transcolumellar

ANSWER: A

RATIONALE:
During closed rhinoplasty, delivery of the lower lateral cartilages requires the use of a marginal
incision and an intercartilaginous incision. The transfixion incision connects the right and left
nares through the columnella and is near the caudal edge of the cartilaginous septum, not the
lower lateral cartilage. The Killian incision is used to approach the septum. The
transcolumnellar incision is used in open rhinoplasty.

REFERENCE:
Kennedy, BD, Cosmetic Rhinoplasty, in Oral And Maxillofacial Surgery Vol 6 , Fonseca, RJ
editor WB Saunders Co, 2000. p 326.

170
167. In cosmetic facial surgery, dilute solution of local anesthesia and epinephrine is used to
facilitate anesthesia, hemostasis and fat removal. This anesthetic technique is called:

A. hypotensive anesthesia
B. tumescent anesthesia
C. disassociative anesthesia
D. neuroleptic anesthesia

ANSWER: B

RATIONALE:
Tumescent anesthesia most commonly involves Lidocaine 0.1% and epinephrine 1: 1 million.
This solution is injected into the tissues under pressure to cause a tumescent effect, hence the
name. This mixture provides local anesthesia, hemostasis and facilitates fat removal.

REFERENCE:
Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, DeMarco M,
Feldman SR, Fleischer AB.
<[Link]
0288&dopt=Abstract> The safety of liposuction: results of a national survey.
Dermatol Surg. 2002 Nov;28(11):971-8.

171
168. Hair follicles and sebaceous glands are in which skin layer?

A. Superficial epidermis
B. Deep epidermis
C. Superficial dermis
D. Deep dermis

ANSWER: D

RATIONALE:
The hair follicles and sebaceous glands reside in the deep dermis and this area is never
intentionally invaded in cosmetic resurfacing as a full thickness burn would ensue with serious
scarring.

REFERENCE:
Trelles MA, Garcia L, Rigau J, Allones I, Velez M.
<[Link]
1973&dopt=Abstract> Pulsed and scanned carbon dioxide laser resurfacing 2 years after
treatment: comparison by means of scanning electron microscopy. Plast Reconstr Surg. 2003 May
1;111(6):2069-78.

172
169. In cosmetic blepharoplasty of the upper eyelid, the following tissue layer is not routinely
incised, reduced or recontoured:

A. Eyelid skin
B. Orbicularis oculi muscle
C. Orbital septum
D. Mueller’s Muscle

ANSWER: D

RATIONALE:
In routine cosmetic upper eyelid blepharoplasty, excess skin, muscle and fat are removed. The
fat is retroseptal, lying immediately beneath the orbital septum. The levator aponeurosis is the
next visible layer and deep to that lies Mueller's muscle which is assists with upper eyelid
elevation. This muscle is not incised or recountoured in routine bepharoplasty of the upper
eyelid.

REFERENCE:
E. Niamtu, J Cosmetic Facial Surgery
Oral and Maxillofacial Surgery Clinics of North America Volume 12, number 4, November, 2000
W.B. Saunders, Philadelphia Pages 673-76

173
170. In submental liposuction, problems with skin dimpling, waviness, and depressions can be
prevented with the following:

A. leaving an adequate layer of subcutaneous fat

B. allowing the skin to adhere to platysma
C. removing all subcutaneous fat
D. keeping the plane of fat removal deep to the platysma layer

ANSWER: A

RATIONALE:
A layer of subcutaneous fat is necessary to prevent adherence of the skin to the mylohyoid and
the platysma muscles. Waviness and dimpling can occur if fat removal is uneven or when areas of
skin are devoid of subcutaneous fat. Keeping the fat removal deep to the platysma layer will lead
to minimal esthetic improvement and the possibility of facial nerve injury.

REFERENCE:
Kennedy,B. Suction Lipectomy of the Youthful Neck. Cosmetic Oral and Maxillofacial Surgery.
Oral and maxillofacial Surgery Clinics of North America - Vol 2, No. 2, May 1990.

174
171. A 40 year old woman consults with you regarding her microgenia. Her occlusion was
corrected years ago with orthodontics, and she suffers from mild obstructive sleep apnea. Her
condition would best be corrected with:

A. an alloplastic chin augmentation

B. an autogenous bone graft to the chin
C. a mandibular sagittal split osteotomy
D. an advancement genioplasty

ANSWER: D

RATIONALE:
Advancement of the genial tubercles and genioglossus muscle will help this patients cosmesis,
and positively influence her obstructive sleep apnea. A sagittal split osteotomy alone will
create a malocclusion. Neither a chin implant nor an onlay bone graft to the chin will advance
her genial tubercles or suprahyoid musculature.

REFERENCE:
Lee, NR. Genioplasty Techniques. Cosmetic Facial Surgery. Oral and Maxillofacial Surgery
Clinics of North America. Volume 12, Number 4, November,2000.

175
172. Which agent is best used to treat hyperpigmentation following skin resurfacing?

A. Glycolic acid
B. Phenol
C. Hydroquinone
D. Isotretinoin

ANSWER: C

RATIONALE:
Hydroquinone inhibits melanin formation and increases melanocyte degradation. This causes a
reversible hypopigmentation and melanocyte inhibition. Glycolic acid, phenol, and
isotretinoin are all skin resurfacing agents and are not used for the treatment of
hyperpigmentation.

REFERENCE:
Demas, Bridenstine, and Braun. Pharmacology of Agents Used in the Management of Patients
Having Skin Resurfacing. J Oral Maxillofac Surg. 55:1255-1258, 1997.

176
173. The most common complication following otoplasty is:

A. infection
B. perichondritis
C. hematoma formation
D. hypertrophic scar formation

ANSWER: C

RATIONALE:
Hematoma formation is generally seen in the retroauricular space. It is treated by evacuation
and pressure dressings, while antibiotics should be considered.

REFERENCE:
DUDLEY, WH, et al. Otoplasty for Correction of the Prominent Ear. J Oral Maxillofac Surg.
53:1386-1391, 1995.

177
174. Which of the following statements regarding esthetic evaluation of the midface is true?:

A. The zygomatic prominence should be located 2 cm inferior and 1.5 to 2 cm lateral to the
lateral canthus of the eye.
B. The infraorbital rim should be 0 to 2 mm behind the cornea
C. Greater than 3-4 mm of sclera should be exposed inferiorly between the limbus and the
lower eyelid.
D. The zygomatic prominence should be located several mm superior to the Frankfort
horizontal plane.

ANSWER: A

RATIONALE:
The midface region is best evaluated in four basic views - frontal in repose and smiling,
profile, three-quarter oblique, and basal. The zygomatic prominence is located 2 cm inferior
and 1.5-2 cm lateral to the lateral canthus, and below the Frankfort Horizontal plane. The
infraorbital rim should be 0-2 mm anterior to the cornea. Normal scleral show is less than 4
mm.

REFERENCE:
Zide and Epker. Systematic Aesthetic Evaluation of the the Cheeks for Cosmetic Surgery.
Cosmetic Oral and Maxillofacial Surgery, Oral and Maxillofacial Surg

178
175. When narrowing the nose at the end of a rhinoplasty procedure, the lateral nasal bone osteotomies
are made superiorly to which soft tissue landmark?
A. Nasion
B. Radix
C. Medial canthus
D. Superior septal angle

ANSWER: C

RATIONALE:
The glabella and radix of the nose are incorrect and will result in carrying the osteotomy too
far superiorly into thick bone, preventing infracturing and causing a surperior hinging. The
correct answer is to carry the lateral ostetomies superiorally to the level of the medial canthus
which corresponds to thinner bone allowing for backfracture of the nasal bones. The superior
septal angle is a nonsensical distractor in this question.

REFERENCE:
Oral and Maxillofacial Surgery Updates, Vol 1(Part II) pp25-45, 1995.

179
176. When performing lower lid blepharoplasty, how many fat pads are normally excised or reduced?
A. one
B. two
C. three
D. four

ANSWER: C

RATIONALE:
Lower lid blepharoplasty normally involves removal of fat from all three fat compartments. In
the upper lid, there are two fat compartments and the lacrimal gland is located superior and
lateral. Failure to identify and remove fat from all three fat pads in lower lid surgery can result in
insufficient fat removal and/or asymmetry. Of course, exceptions exist and fat removal should be
guided by clinical judgement. Care must be taken to identify and avoid injury to the inferior
oblique muscle.

REFERENCE:
Langdon J D, Patel M F. Operative Maxillofacial Surgery. Chapman and Hall 1998: pp. 493-
498.

180
177. When performing carbon dioxide laser skin resurfacing, the deep landmark of the ablation is the:

A. basement membrane
B. epidermis
C. papillary dermis
D. reticular dermis

ANSWER: D

RATIONALE:
Each patient is unique and requires tailoring of technique to adapt to individual skin
morphology. However, the anatomic depth of laser resurfacing is the reticular dermis. If this
anatomic plane is not known or recognized, significant complications may result. This is
determined by a chamois (light tan) color occuring in the resurfaced area during the second
pass with the carbon dioxide laser.

REFERENCE:
Oral and Maxillofacial Surgery, Vol VI. Fonseca. pp 408-455.2000.

181
178. Which of the following periorbital tissues represent an extension of the periosteum?

A. Tarsal plate
B. Whitnall’s Tubercle
C. Orbital septum
D. Lockwoods ligament

ANSWER: C

RATIONALE:
The orbital septum is a direct extension from the periosteum of the orbit and separates the
preseptal and postseptal orbital components. Whitnall's tubercle is a slightly raised prominence
in the lateral orbital rim on the zygoma which serves as an attachment for the lateral canthal
ligament. The tarsal plates are comprised of dense connective tissue and are located in both the
upper and lower eyelids. The tarsal plates help form and support the shape of the eyelids.
Lockwood's ligament is a fascial suspensory ligament which helps maintain the vertical position
of the globe within the orbit.

REFERENCE:
Cook BE, Lemke BN: Cosmetic Blepharoplasty. Oral and Maxillofacial Surgery Clinics of
North America. pp. 673-684, November, 2000

182
179. In a standard facelift operation, which of the deeper tissues is commonly altered?

A. Parotidomasseteric fascia
B. Dermis
C. Erb’s point
D. Superficial musculoaponeurotic system

ANSWER: D

RATIONALE:
The SMAS is the anatomic plane for a standard facelift procedure and lies superficial to the
major nerves and blood vessels, but deep to the subdermal plexus. It is normally imbricated or
excised and repositioned during a face-lift surgery. Incisions are normally made through the
dermis but the dermal layer itself is not altered during surgery. The parotidomasseteric fascisa
covers the lateral masseter muscle and splits to envelop the parotid gland, but is not altered in a
th
standard facelift operation. Erb's point in located on the side of the neck in the area of the 5
th
and 6 cervical nerves.

REFERENCE:
Facelift: Facial Plastic Surgery Clinics of North America. William H. Beeson, ed., Nov., 1993.

183
180. Retrobulbar hematoma occurring after cosmetic blepharoplasty is best treated by:

A. warm compresses
B. atropine drops
C. emergent evacuation
D. intravenous antihypertensive medication

ANSWER: C

RATIONALE:
Retrobulbar hematoma is reported to occur in 0.04% of all blepharoplasty procedures. Blindness
can result from a retrobulbar hematoma and immediate evacuation for decompression is the
treatment of choice.

REFERENCE:
Cook BE, Lemke BN: Cosmetic blepharoplasty. Oral and Maxillofacial Surgery Clinics of
North America, pp 684-686, Nov. 2000.

184
181. Intradomal sutures are placed during rhinoplasty to:

A. narrow the alar bases

B. maintain the position of the upper lateral cartilages
C. narrow and/or elevate the nasal tip
D. close an open-roof deformity

ANSWER: C

RATIONALE:
The nasal tip or intradomal region is located at the junction of the medial and lateral crura.
Intradomal sutures can control and position the nasal tip. The nasal cinch suture or alar reduction
can narrow the alar base width. Lateral osteotomies are used to close an open-roof deformity.
Suturing can be used to maintain upper lateral cartilage position in some cases.

REFERENCE:
Johnson CM, Toriumi DM: Open structure Rhinoplasty. WB Saunders, Philadelphia, 1990.
Abubaker AO, Benson KJ: Oral and Maxillofacial Surgery Secrets. Hanley&Belphus, Inc.,
Philadelphia, 2001.

185
182. The internal nasal valve is formed by the junction of which structures:

A. junction of the lower and the upper lateral cartilage

B. junction of the nasal bones with the nasal septum
C. junction of the upper lateral cartilage and nasal septum
D. junction of the lower lateral cartilage with the medial crura

ANSWER: C

RATIONALE:
The medial part of the upper lateral cartilage joins the quadrangular cartilage. The angle formed
by the attachment should be around 10-15 degrees. The nasal valve angle should be accessed
preoperatively and angle less than 10 should be corrected intraoperatively. The junction of the
upper and the lower lateral cartilages is called the scroll area and is the site of the
intracartilaginous incision. The junction of the lower lateral cartilage and the medial crura
provides the tip support (tripod theory).

REFERENCE:
Mitchell Collins rhinoplasty page 1-14 Atlas of oral and maxillofacial surgery sept 95

186
183. All of the following are primary nasal tip support mechanism except:

A. Shape, angulation, size, and springiness of the lower lateral cartilage

B. Attachment of the medial crura to the inferior cartilage septum
C. Attachment of the lower aspect of the upper lateral cartilage to the superior part of the
lower lateral cartilage
D. Junction of the upper lateral cartilage with the nasal septum

ANSWER: D

RATIONALE:
The nasal tip support mechanisms are divided into primary and secondary mechanisms which
are choices A, B, C The six secondary tip support mechanisms include: 1- interdomal
ligament. 2-strut effect of nasal cartilaginous septum. 3-prominence of the anterior nasal spine.
4-thickness of the skin. 5-membranous nasal septum. 6-fibrous and cartilaginous elements
attaching lower lateral cartilage to the pyriform rim.

REFERENCE:
Robert Alexander 15-25 Atlas of oral and maxillofacial surgery Sept 95.

187
184. All of the following solutions are used for superficial chemical peel except:

A. 10-30% trichloracetic acid TCA.

B. Baker’s phenol solution.
C. glycolic acid 10-30%.
D. Jessner solution.

ANSWER: B

RATIONALE:
Chemical peels are classified as superficial, medium depth and deep depth peels depending on the
degree of penetration into the epidermis. The superficial peel penetrates into the stratum basale or
papillary dermis and the solutions used are TCA 10-30%, Jessner solution and alpha-hydroxy
acid. Medium depth peels penetrates into the upper reticular dermis and the solutions used are
TCA 35-50% and Jessner plus TCA 35%, or phenol 88%. The deep depth peel penetrates into the
mid reticular dermis and the solutions used are the Baker's phenol and the Litton's formulation.

REFERENCE:
Chemical skin resurfacing, Peter N Demas, and Thomas W Braun1-25 atlas of oral and
maxillofacial surgery Sept 98

188
185. To identify the probability of ectropion following lower lid blepharoplasty which of the following
test is performed?

A. Schrimer’s
B. snap
C. Cottle
D. confrontation

ANSWER: B

RATIONALE:
Schrimer's test is used to determine the risk of the patient to develop a dry eye problems
following blephroplasty by measuring tear production. The snap test is used to evaluate lower
eyelid laxity. The lower eyelid is grasped and pulled gently forward and then quickly released
the normal eyelid should snap immediately backward. If there is a delay of few seconds or the lid
remains off the globe, then the risk of ectropin is high and a lid shortening procedure should be
considered. Cottle's test is used to evaluate the internal nasal valve function. Confrontation is a
clinical method to evaluate visual fields.

REFERENCE:
James W karesh: blephroplasty. Atlas of oral and maxillofacial surgery clinics Sept 98 81-109
Mitchell Collins rhinoplasty page 1-14 Atlas of oral and maxillofacial surgery sept 95

189
186. Which of the following materials will provide the most permanent result for lip and soft tissue
augmentation:

A. Alloderm
B. Collagen
C. Autologous fat
D. Expanded poly tetra flouraline (PTFE)

ANSWER: D

RATIONALE:
Both fat and alloderm will give an intermediate-term result for 6-18 months. Collagen will
give a short-term result of 6 months. PTFE, being non-resorbable, will give a more permanent
result.

REFERENCE:
Ramirez A, et al current concepts in soft tissue augmentation. Facial plastics clinics of north
America may 2000. page 235-251

190
187. A patient with actinic keratoses and wrinkling present at rest is a Glogau’s classification:

A. Class I.
B. Class II.
C. Class III.
D. Class IV.

ANSWER: C

RATIONALE:

Photoaging groups- Glogau's classification is divided into four groups:

Group I- mild (usually age 28-35)
No keratoses, little wrinkling, no scarring, little or no makeup
Group II- moderate ( usually age 35-50)
Early actinic keratoses, early wrinkling, mild scarring, little makeup
Group III- advanced (usually age 50-65)
Actinic keratoses, wrinkling present at rest, moderate acne scarring, wears makeup
always
Group IV- severe ( usually 65-75)
Actinic keratoses and skin cancer has occurred, wrinkling severe, severe acne
scarring, wears makeup that does not cover but cakes on

REFERENCE:
Glogau RG: Chemical peel symposium American academy of dermatology
European Journal of Dermatology. Vol. 11, Issue 2, March - April 2001: 168-9, Meeting report

191
188. The use of a spreader graft in rhinoplasty :

A. increases alar base width

B. has no effect on the internal nasal valve
C. increases the internal nasal valve patency
D. decreases the internal nasal valve patency

ANSWER: C

RATIONALE:
The use of the spreader graft allows an increase in patency of the internal nasal valves, thereby
improving breathing. It also improves nasal esthetics in many cases.

REFERENCE:
Rohrich R, et al. use of spreader grafts in external approach to rhinoplasty. Clinics In plastic
surgery 1996. page 255-262

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189. During facelifting surgery, Erbs point is located:

A. 4 cm inferior to the ear lobule and along the anterior sternomastoid border
B. 4 cm inferior to the ear lobule and along the posterior sternomastoid border
C. 6 cm inferior to the ear lobule and along the posterior sternomastoid border
D. 6 cm inferior to the ear lobule and along the anterior sternomastoid border

ANSWER: C

RATIONALE:
The greater auricular nerve and accessory nerves must be protected during rhytidectomy.
Extra caution should be exercised when performing dissection in Erb's point area. Remaining
superficial to the fascia over the sternomastoid at Erb's point ensures that injury to the greater
auricular and accessory nerve is avoided

REFERENCE:
Bernstein G: Surface landmarks for the identification of key anatomic structures of the face and
neck J Dermatol Surg Oncol 1986: 12, 722.

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190. Narrowing of the nasal tip during rhinoplasty is best achieved by:

A. Removal of a strip from the nasal septum

B. Osteotomies of the nasal bones and removal of a bony strip
C. Interdomal suturing
D. Removal of a strip from the upper lateral cartilages

ANSWER: C

RATIONALE:
Narrowing of the nasal tip can be achieved by removal of a cephalic 2-5 mm strip from the lower
lateral cartilages and/or with interdomal suturing. The procedures often result in upward rotation
of the tip. A shield graft can be placed from any removed septum to further define the tip.
Narrowing of the nasal septum, excisiong upper lateral cartilage and nasal bone osteotomies will
have no significant affect on the nasal tip width.

REFERENCE:
Kennedy BD: Cosmetic rhinoplasty. In, Oral and Maxillofacial Surgery, Volume 6. Fonseca R,
Baker, Wolford LM (eds). WB Saunders, Philadelphia. 2000. pp 303-349

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