Oral Surgery

MFD Part 2 Dublin, November, 2010

Station 1

OPG with impacted lower 8 & radiolucency at angle of the mandible.

1. Type of impaction?
1. According to angulation: Mesioangular (Winter’s Classification).
2. According to depth: Position C (Pell & Gregory Classification)
2. Differential Diagnosis of the lesion?
1. Dentigerous Cyst.
2. Odontogenic Keratocyst
3. Ameloblastoma.
3. Symptoms arise because of the presence of the lesion in this area?
1. Swelling.
2. Difficulty in opening or closing the mouth (Trismus).
3. Expansion of the bone in case of (in case of Ameloblastoma).
4. Treatment options for the lesion?
You should first biopsy the lesion to identify it.
1. Marsupilization.
2. Enucleation.
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MFD Part 2, November 2011, Dublin

Station 2

Picture 1
OPG, upper occlusal and 2 periapical views of the upper anterior teeth showing
impacted upper canines.
1. Name of this technique?
Parallex Technique.
NOTE:
There are two types of parallex technique :
1.Horizontal Parallex Technique.
This technique includes moving the tube head in a horizontal direction mesially or
distally as in the pictures using the SLOB Technique (Same Lingual Opposite
Buccal) as below:
2.Vertical Parallex Technique

This technique includes moving the tube head in a horizontal direction upward or
downward as in the pictures using the SLOB Technique (Same Lingual Opposite
Buccal) as below:
2. Describe how is upper occlusal radiograph is taken?

1. The patient is seated with the head supported and with the occlusal plane
horizontal and parallel to the floor and is asked to support a protective thyroid
shield.

2. The image receptor, suitably barrier wrapped, is placed flat into the mouth on
to the occlusal surfaces of the lower teeth. The patient is asked to bite together
gently. The image receptor is placed centrally in the mouth with its long axis
crossways in adults and anteroposteriorly in children.

3. The X-ray tube head is positioned above the patient in the midline, aiming
downwards through the bridge of the nose at an angle of 65–70° to the image
receptor.
NOTE

Illustrating Pictures for the upper occlusal technique:

A Diagram showing the position of the image receptor in relation to the lower
arch.
B Positioning from the front; note the use of the protective thyroid shield.
C Positioning from the side.
D Diagram showing the positioning from the side.
Example of the resulting upper occlusal radiograph.
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MFD Part 2 , May 2012, Dublin
Station 3

X-ray Radiograph showing lower posterior radiolucent lesion.

1. Name of the X-ray view?
Lateral Oblique View.
2. What are the two most likely differential Diagnosis?
1. Ameloblastoma.
2. Odontogenic Myxoma.
3. Describe the lesion?
This is a lateral oblique view of a radiolucent lesion in the left posterior area of
the mandible extending mesiodistally from the lower left second premolar to the
anterior border of the left ramus of the mandible. It has a multilocular
appearance and a well-defined margin.
NOTE : Regarding lesion description you can add any other information, such as,
the size of a lesion. For example, you can measure the size of a lesion with a ruler
and write its size is roughly (3cm*3cm), but you have to pay attention to the time
factor during the exam so as not to experience a lack of time for the other
questions.
4. Choose one lesion from what you wrote above and describe how does the
lesion occur?
1. Ameloblastoma: It may arise from epithelial lining of dentigerous cyst. The
earliest evidence of transformation is characterized by: polarization of basal cells,
superior displacement of nuclei, hyperchromatism and cytoplasmic vacuolization.
Slender tube –like rete ridges extends into the fibrous wall and the overlying
spinous layer resembles stellate reticulum. When the bulk of the tumor protrudes
luminally, the designation luminal ameloblastoma is used. When the majority of
the tumor cells invade the fibrous wall, the term mural ameloblastoma is used.
The term unicystic ameloblastoma applies to those lesions in which the
ameloblasts line the entire cyst lining.
2. Odontogenic Myxoma: It occurs in both hard and soft tissue. Those arising in
the jaws are tumors of odontogenic mesenchyme. This is a tumor of young adults
arising within bone and can invade the surrounding tissue extensively.
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MFD Part 2 Dublin November 2012

Station 4
1. Where is the canine impacted?
It is impacted palatally because when the x-ray tube moves distally the impacted
canine moves in the same direction and vice versa.
2. What technique is this?
Horizontal Parallex Technique.
SLOB Technique ( Same Lingual Opposite Buccal)
3. How do you take an upper occlusal view?
1. The patient is seated with the head supported and with the occlusal plane
horizontal and parallel to the floor and is asked to support a protective thyroid
shield.
2. The image receptor, suitably barrier wrapped, is placed flat into the mouth on
to the occlusal surfaces of the lower teeth. The patient is asked to bite together
gently. The image receptor is placed centrally in the mouth with its long axis
crossways in adults and anteroposteriorly in children.

3. The X-ray tube head is positioned above the patient in the midline, aiming
downwards through the bridge of the nose at an angle of 65–70° to the image
receptor.
4. What are the treatment options for the palatally impacted canine?
1. Interceptive treatment by extraction of the deciduous canine (SIGN Grade A)
2. Transplantation (SIGN Grade B)
3. Surgical exposure and orthodontic alignment (SIGN Grade C)
4. Surgical removal of the palatally ectopic permanent canine (SIGN Grade C)
5. No active treatment/leave and observe (SIGN Grade C)
NOTE : These treatment options are according to SIGN Guideline in the
management for the palatally ectopic maxillary canine.
LINK TO DOWNLOAD THE PAPER

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Station 5

X-ray with impacted lower 8

1. Describe what you see.
This is a panoramic view of a radiolucent lesion associated with impacted lower
right third molar in the right posterior area of the mandible extending
mesiodistally from the mesial root of lower right second molar to the right ramus
of the mandible. It has unilocular appearance and a well-defined margin.
2. What are the symptoms that the patient may complain of?
1. Swelling
2. Difiiculty in opening the mouth (Trismus)
3. What is the differential diagnosis?
1. Dentigerous Cyst
2. Odontogenic Keratocyst
3. Ameloblastoma
4. Give 3 treatment options.
You should first biopsy the lesion to identify it.
1. Marsupilization
2. Enucleation
3. Decompression
5. What is the long term complication?
1. Jaw fracture due to weakening of mandibular bone.
2. Displacement of other teeth.
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MFD Part 2 Examination Bahrain June 2013

Station 6
1. What is this?
You should first biopsy the lesion to identify it.
Most probable mucocele
2. Two Differential Diagnosis.
1. Hemangioma
2. Pyogenic granuloma.
3. What is the difference between the lesions you mentioned from the lesion in
the picture?
Hemangioma and pyogenic granuloma have a blood content while Mucocele
contains mucous.
4. Treatment.
You should first biopsy the lesion to identify it.
Surgical excision with the associated damaged gland and duct.
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Station 7

1. What are these types of x-ray?

Panoramic X-ray
2. Differential Diagnosis?
1. Ameloblastoma
2. Odontogenic Myxoma.
 3. Odontogenic Keratocyst

3. Spot Diagnosis.
According to US National Library of medicine :
Spot diagnosis means the initial pattern that may trigger the possible
diagnosis.
In case of ameloblastoma, It can cause expansion of the mandibular bone and
facial asymmetry.
NOTE:
In case of presence of histological picture

The diagnosis is Unicystic Ameloblastoma as it shows histopathologic features

consistent with unilocular ameloblastoma with desmoplastic, clear cell and
granular cell changes
4. Treatment.
You should first biopsy the lesion to identify it.
Surgical Excision
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MFD Part 2 Jordan December 2014
Station 8
 1. What is the X-ray type?
Axial CT X-ray.
2. Differential Diagnosis of the lesion?
1. Ameloblastoma.
2. Odontogenic Myxoma.
3. Odontogenic Keratocyst.
3. Most Probable Diagnosis?
The most probable diagnosis is Ameloblastoma due to the expansion seen in
the axial CT.
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Station 9
View 1

View 2

1. What are the types of these x-rays?

View 1: Periapical x-ray
View 2: Occlusal x-ray
2. How do we take the second x-ray?
1. The patient is seated with the head supported and with the occlusal plane
horizontal and parallel to the floor and is asked to support a protective thyroid
shield.

2. The image receptor, suitably barrier wrapped, is placed flat into the mouth on
to the occlusal surfaces of the lower teeth. The patient is asked to bite together
gently. The image receptor is placed centrally in the mouth with its long axis
crossways in adults and anteroposteriorly in children.
3. The X-ray tube head is positioned above the patient in the midline, aiming
downwards through the bridge of the nose at an angle of 65–70° to the image
receptor.
3. What is the name of the technique used to localize the canine?
Horizontal Parallex Technique
4. Position of the canine in relation to other teeth?
It is palatally impacted
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MFD Part 2 UAE April 2015

Station 10

1. Diagnosis?
You should first biopsy the lesion to identify it.
Mucocele.
2. What are the two structures that I should care about during treatment?
1. Lingual Nerve.
2. Labial branch of mental nerve.
3. Type of content?
Mucus content
4. Other areas where you can find this lesion?
1. Floor of the mouth.
2. Buccal mucosa.
5. Affect which part of the gland?
The duct and acini of the gland
6. Lined with epithelium?
No. Not lined with epithelium.
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MFD Part 2 , Dublin , May 2015
Station 11

35 year old woman complaining of discolored lateral incisor with history of

previous trauma. X-ray shows apical radiolucency with resorption of the apex in
relation to the radiolucency
a. What is your diagnosis?
You should first biopsy the lesion to identify it.
Radicular Cyst
b. What treatment would you do?
RCT followed by apicectomy
c. Describe the steps for the treatment you mentioned above.
1. Pre-operative care.

2. Anaesthesia and haemostasis.

3. Soft-tissue management.

4. Hard-tissue management.
 5. Curettage of area.

6. Resection of root.

7. Retrograde cavity preparation.

8. Retrograde filling.

9. Replacement of flap and suturing.

10.Post-operative care.
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Bahrain June 2015
Station 12

View 1
View 2

1. Identify both views?

View 1 : Panoramic Radiograph
View 2 : Axial CT
2. Describe what you see in the first radiograph?
This is a panoramic view of a radiolucent lesion associated with impacted tooth
in the right posterior area of the mandible extending mesiodistally from the
premolar area to the right ramus of the mandible. It has a unilocular
appearance and a well-defined margin.
3. Differential diagnosis?
1. Ameloblastoma.
2. Dentigerous Cyst.
3. Odontogenic Myxoma.
4. Odontogenic Keratocyst.
NOTE : you can see in the panoramic x-ray that the radiolucent lesion is
associated with impacted tooth which may lead some to think that the lesion has
only one diagnosis possibility of being a dentigerous cyst, but you have to look
also at the CT x-ray to notice the presence of expansion which can also lead to the
diagnosis of ameloblastoma.
4. Management?
You should first biopsy the lesion to identify it.
Surgical Removal.

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Station 13
View 1

View 2

1. What are these views?

View 1 : Periapical radiograph
View 2 : Occlusal radiograph
2. How to take the second one?
 1. The patient is seated with the head supported and with the occlusal plane
horizontal and parallel to the floor and is asked to support a protective thyroid
shield.

2. The image receptor, suitably barrier wrapped, is placed flat into the mouth on
to the occlusal surfaces of the lower teeth. The patient is asked to bite together
gently. The image receptor is placed centrally in the mouth with its long axis
crossways in adults and anteroposteriorly in children.

3. The X-ray tube head is positioned above the patient in the midline, aiming
downwards through the bridge of the nose at an angle of 65–70° to the image
receptor.

3. Left canine location in relation to the teeth?

It is Buccally impacted.
4. Another indications for occlusal radiograph?
1. Periapical assessment of the upper anterior teeth, especially in children but
also in adults unable to tolerate periapical holders.

2. Detecting the presence of supernumeraries and odontomes.

3. Evaluation of the size and extent of lesions such as cysts or tumors in the
anterior maxilla.

4. Assessment of fractures of the anterior teeth and alveolar bone.

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Sudan jan 2016

Station 14
7-periapical of central incisors with radiolucency around the apex
1. Describe the lesion.
This a periapical radiograph of a maxillary right central incisor tooth associated
with a radiolucent lesion around the apex of the tooth. The lesion is unilocular
and has a well-defined margin.

2. What is the Diagnosis?

You should first biopsy the lesion to identify it.
Periapical Cyst (Radicular Cyst)
3. Treatment options ?
1. RCT and long-term follow-up (may be 1 year evaluation) to observe the lesion
healing.
2. In case of failure of RCT, persistent infection or the lesion doesn’t resolve,
surgical treatment is the treatment of choice as we need to remove the
lesion and do biopsy. So, we may consider Apicectomy.

4. Steps of the procedure.

Steps of Apicectomy procedure:
1. Pre-operative care.
 2. Anaesthesia and haemostasis.

3. Soft-tissue management.

4. Hard-tissue management.

5. Curettage of area.

6. Resection of root.

7. Retrograde cavity preparation.

8. Retrograde filling.

9. Replacement of flap and suturing.

10.Post-operative care.
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Bahrain 2016

Station 15

View 1
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View 2

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View 3

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View 4

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View 5

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View 6
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1. Mention the impacted lower 8 angulation in each x-ray.

View 1 : Horizontal/Transverse (Buccally Oblique) Impaction
View 2 : Horizontal/Transverse (Lingually Oblique) Impaction
View 3 : Vertical Impaction of lower 8
View 4 : Mesioangular Impaction of lower 8
View 5 : Horizontal/Transverse Impaction of lower 8
View 6 : Distoangular Impaction of lower 8
2. Which one is the most difficult type of impaction and which one is the
easiest according to the x-ray radiographs?
The most difficult type : Distoangular
The easiest one : Mesioangular
3. Which one is the closest to the inferior alveolar canal?
Mesioangular type of impaction is the closest one.
According to US National Library of Medicine
4. What is the other way of treatment other than the conventional Surgical
Removal?

1. Impacted third molar tooth can be moved coronally by orthodontic

extrusion after removal of overlying bone and it can be then safely
extracted.
 This way of treatment can used if the impacted third molar apex is
located in or in close proximity to the inferior alveolar canal to
reduce the risk of inferior alveolar nerve injury.
2. Coronectomy : which means removal of the impacted tooth crown
and tooth root is left undisturbed. This way of treatment is
recommended to be done in teeth with no infection or mobility.
Also, teeth with horizontal impaction should be excluded from this
kind of treatment because tooth sectioning can endanger the inferior
alveolar nerve.
3. Novel Surgical Technique : This approach consisted of the surgical
removal of the mesial portion of the anatomic crown to create
adequate space for mesial third molar migration. After the migration
of the third molar had taken place, the extraction could then be
accomplished in a second surgical session minimizing neurological
risks.

5. What are the radiographic and clinical signs of third molar proximity to
the inferior alveolar canal?
The Radiographic signs :
1. Darkening of the roots.
2. Deflected tooth roots.
3. Interruption of the one or two white lines of the inferior alveolar
canal.
The Clinical Sign :
Third molar proximity to the inferior alveolar nerve can lead to inferior
alveolar nerve damage which can cause post-operative sensory
disturbances.
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MFD Part 2 UAE April 2017

Station 16
1. Name of the radiograph?
Cone Beam Computed Tomography (CBCT)
2. What are the uses of this type of radiograph? Mention 4.
1. Surgical Planning for impacted teeth.
2. Accurate placement of dental implants.
3. Determining bone structure and tooth orientation.
 4. Bilateral TMJ Assessment.
3. What is the possible cause of impaction?
Over retained deciduous teeth and arch Length tooth size
discrepancy.
4. How will you treat it?
1. Extraction of over retained deciduous teeth.
2. Exposure to the impacted canine.
3. Orthodontic alignment of the impacted
maxillary canines.
5. What is the complication of doing surgery in this area?
Sectioning of the palatine artery due to 90 degree incision of the
palate to the gingival crevice.
NOTE : To avoid this complication use always an envelope flap.
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Station 17

Picture 1

Periapical view of a palatal canine. The deciduous canine has a distal

restoration, is non-vital, and can be seen to exhibit periapical pathology
(arrow).

1. Differential Diagnosis
1. Periapical Granuloma
2. Periapical Cyst (Radicular Cyst).
2. Treatment.
You should first biopsy the lesion to identify it.
1. Extraction of the deciduous canine and removal of the periapical
pathology.
2. Alignment of the impacted canine in its proper position.

Picture 2

1. What is the age of the patient?

Almost 12.5 years.
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Station 18
1. Differential Diagnosis
1. Dentigerous Cyst.
2. Odontogenic Keratocyst.
3. Ameloblastoma.
2. Risk Factors
1. Swelling.
2. Difficulty in opening the mouth (Trismus)

MFD Part 2 Ireland April 2014

hematoma and dry socket
3. Which is more common occurs after extraction?
Dry Socket.