What is considered insensible loss?

Sweating, Evaporation from lungs due to anesthesia dry vapors, wound

evaporation
How much insensible loss occurs in OMFS procedures?
-2-4cc/kg/hr?
How do you calculate volume status of an immediate postop patient?
1 !alculate "aintenance fluids utili#ing 4$2$1 %ule &4cc/kg/hr for the first
1'kg, then 2cc/kg/hr for the 2
nd
1'kg, then 1cc/kg/hr thereafter($ e.g., 70kg
pt =110cc/hour
2 !alculate total )outs*$
a +,- from midnight until surgery &unless in-house and getting
maintenance fluids( represents missed maintenance fluids$ e.g.,
NPO at midnight to 8am= -880cc
. "aintenance fluid during surgery$ e.g., 4hr surgery=-440cc
c Estimated .lood loss / 0 &./c .lood is colloid($ e.g., 0cc =
-1!0cc
d 1nsensi.le loss &0cc/kg/hr for -"2S($ e.g., 70kg pt in 4hr surgery=
-840cc
e 3rine output during case$ e.g., -"00cc
0 !alculate total )ins*$
a !rystalloid given during surgery$ e.g., 4000cc #$=%4000cc
. !olloid given during surgery &.lood/al.umin( / 0$ e.g., 1 unit
packed red &'ood ce''s ()*0cc+=%70cc
4 4dd num.ers to find status$ e.g., pt is PO,-.-/0 *00cc
What is ideal urine output for an adult? for a child?
1cc/hr/kg for child 4'kg pt 5 4'cc/hr
'6cc/hr/kg adult 7'kg pt 5 06cc/hr
If patient had Negative body balance of liter how much do you have to
change maintenance fluid if you want to do it slowly over !hours?
7'kg pt maintainence is 11'cc/hour &1'''cc/6hours 5 2''cc/hr( 8he patient
would have to have fluid rate of 01' per hour for 6 hrs
What ways can you chec" bloods loss?
Skin 8urgor, Specfic gravity of urine, -rthostatic vital signs, skin temp &if
hands are cold to the el.ow there is a 1'9 .lood loss(
unit #$% represents what change in H&'?
-09 is correct .ut :;< might state 69
What is considered orthostatic changes?
4fter waiting 2 min at new position =% increased >1' .pm or ;, dropped
>2'mm=g
What are the causes of vertical ma(illary e(cess?
3pper airway occlusion, ie enlarged tonsils
"outh .reathers their tongue is not against the palate shaping it
%eFort I with impaction patient is complaining to e(cessive tearing)
What is this called and what li"ely happened?
Epiphora
;lockage of the nasolacrimal duct with .one or edema or from over impaction
How far is the nasolacrimal duct from nasal floor?
1'-16mm
What are the causes of post op *
rd
molar infections with unerupted
teeth?
1 2racture of the mandi.le during e/traction
2 %etained foreign .ody ie sponge
0 =ematoma under the flap that secondarily gets infected
4 "etastatic lesion in the ?aw that secondarily infects
6 1mmunocompromised host =1@, cancer, steroid dependent pt
When you harvest ribs for 'M+ surgery you get called that the patient is
having difficult breathing what li"ely happened?
,neumothora/
On ,# how can you diagnose pneumothora(?
4usculation 5 decreased .reath sounds on the affected side
If you suspect pneumothora( what do you do ne(t?
,lace pt on '2, place pulse o/ on patient
!heck post op chest /ray
-rder S'-' new chest /ray
Name the sutures involved in .M& fracture?
Aygomaticoma/illary
Aygomaticotemporal
Aygomaticofrontal
Aygomaticosphenoidal
What are the /night and North classifications for .M& fractures?
Group I: nondisplaced fractures
Group II: Arch fractures only with classic three fracture lines producing V-
shaped deformity
Group III: Unrotated body fx. - direct blow to zygomatic prominence. The
zygoma is drien posterior and medially. The infraorbital rim is
displaced inferior and medially at the buttress
Group IV: !edially rotated body fractures
Group V: "aterally rotated body fractures - superior displacement of inferior
orbital rim with lateral displacement at the frontozygomatic suture
Group VI: #omplex$comminuted fractures
1n 1BC1, <night and +orth proposed a new anatomically .ased classification system of #ygoma fractures &.ased on
DaterEs view radiograph(, which they hoped would help .etter determine the prognosis and treatment of such in?uries
Froup 1 encompassed fractures with no significant displacement as evidenced clinically and radiographically Dhile
fracture lines may .e seen, their recommendation was that this group reGuires no surgical intervention 4 soft diet and
careful avoidance of any further in?ury is prudent
Froup 11 fractures include only those of the arch caused .y a direct .low that .uckles the malar eminence inward 8his
fracture is often associated with trismus -ften, this type of fracture can .e treated satisfactorily .y a Fillies approach or
other standard techniGues
3nrotated .ody fractures, medially rotated .ody fractures, laterally rotated .ody fractures, and comple/ fractures &defined
as the presence of additional fracture lines across the main fragment( .elong to groups 111, 1@, @, and @1, respectively
<night and +orth defined these groups .y their sta.ility after reduction 8hey found that 1''9 of group 11 and group @
fractures were sta.le after a Fillies reduction, and no fi/ation was reGuired =owever, 1''9 of group 1@, 4'9 of group 111,
and 7'9 of group @1 were unsta.le after reduction and reGuired some form of fi/ation
Name the bones of the orbit? 0Name cloc"wise or countercloc"wise1
%oof$ 2rontal .one, :esser wing of sphenoid
"edial$ "a/illa, lacrimal, ethmoid, ;ody of sphenoid
2loor$ "a/illary, palatine, Aygoma
:ateral Aygoma, Freater wing of the sphenoid
What two dissection approaches can be ta"en in lingual nerve
e(plorations2repairs?
,ro/imaldistal
Histalpro/imal
Where do you e(pect to find the pro(imal segment of the lingual nerve?
;etween the medial pterygoid and the temporalis tendon
What is the OM#NS classification? What does it stand for? ffforor?for?
forfor?
What cancers are li"ely to metastasi3e to the 4aws?
;reast, :ung, <idney, ,rostate, 8hyroid &:;< answer(
Domen$ .reast followed .y the adrenal, colo-rectum, female genital organs and thyroid
"en$ lung, followed .y the prostate, kidney, .one and adrenal 8he most common location of the
metastatic tumors was the mandi.le, with the molar area the most freGuent site involved
%irshberg A& et al. !etastatic tumors to the 'awbones: analysis of ()* cases.
+ ,ral -athol !ed. .))/ 0ep12(345:((6-/.
When consenting for e(traction of *
rd
molars what is the ris" for lingual or
inferior alveolar nerve paresthesia vs anesthesia?
:ingual 1/16'' chance of paresthesia of these 1'9 will have permanent
anesthesia
14+$ 1/76' chance of paresthesia of these 09 will have permanent anesthesia
+um.ers vary .y study this is what :;< states
Why is I-N more li"ely to regain function after in4ury during e(traction?
;ony 14+ canal acts as a conduit for regeneration
What is a 'inels Sign?
Steadman5s Med 6ictionary7 8inelIs sign is elicited .y percussing the skin over
the median nerve ?ust pro/imal to the carpal tunnelJ when it is positive, the
patient will complain of an electric sensation radiating into the thum., inde/,
middle, or ring fingers
What is a 8'inel9li"e Sign:?
1t can used to descri.e lingual nerve patients when one percusses over the site
of lingual nerve in?ury and the patient gets a shock like sensation traveling down
the tongue 8his suggests that that nerve is regenerating 1f compared over time
the sensation will travel more distal on the tongue 8his is to .e distinguished
from dysesthesia which is pain on percussion at the site of in?ury 1t is .est to
.anish this )Sign* from your voca.ulary if youEre in :;<Es presenceK
What are the most stable to least stable s"eletal movements during
orthognathic surgery?
"a/illa up, "andi.le forward, !hin any direction, "a/illa forward, "a/illa
asymmetry, "a/illa up and mandi.le forward, "a/illa forward and mandi.le
.ack, "andi.le asymmetry, "andi.le .ack, "a/illa down, "a/illa wider
What are the least stable s"eletal movements during orthognathic surgery?
"a/illa widening or ma/illary disimpaction
Why does one leave a ;9*mm posterior open bite when performing bilateral
costochrondral rib grafts to the mandible ramus condyle unit?
1t allows for settling of the graft helping to avoid a relapse open .ite
What are the stages of fracture healing with closed reduction?
Secondary =ealing &Stages are 1nitial stage hematoma, !artilaginous callus,
;ony callus, remodeling(
What are the stages of fracture healing with open reduction with internal
fi(ation?
,rimary healing &reGuires e/cellent anatomic reduction, minimal mo.ility, good
vascular supply(
6escribe the process in which a non vasculari3ed bone graft is integrated
into the donor site?
What are the ways in which a mandible fracture can be reduced?
!losed, -pen wires &semi rigid fi/ation(, plates and screws &rigid fi/ation(,
e/ternal fi/ation
What constitutes rigid fi(ation for mandible fractures?
What are the %eFort I anatomic landmar"s during surgery?
How many millimeters can you safely place an e(ternal fi(ation mar"er in
the nasal bone for %e Fort I osteotomies?
10mm
What is the incidence of I-N anesthesia2paresthesia after $SSO?
What radiographic signs are associated with inferior alveolar nerve in4ury
during third molar removal?
Hiversion of the inferior alveolar canal
Harkening of the third molar root
1nterruption of the cortical white line of the canal
How do you calculate respiratory distress inde(?
L4penas M =ypopneas M %E%4s/ 8otal sleep timeN
How do you calculate apnea hypopnea inde(?
7Apenas 8 %ypopneas$ Total sleep time9
What is an apneic vs an hypopneic event?
4pnena 5 no .reathing 4ctually 2'9 .asal airflow for 1' seconds
=ypopnea 5 O'9 or lower .asal airflow with a 4 9 drop in -2 sat
%espiratory effort related arousal &%E%4( 5 no change in -2 sat due to
increased respiratory effort &often noticed as a .ig snort or gasp(
What respiratory distress inde( is clinically significant?
%H1 > 6 is a.normal, %H1>2' is clinically significant for -S4
What are normal cephalometric measurements for OS- wor"ups7
"andi.ular ,lane P =yoid distance +ormal is 164 M/- 0mm
Soft ,alate length ,+S P 8ip of soft palate +l is 07M/- 0mm
,osterior 4irway space ,oint ; through Fonion +l is 11M/-mm
What is the ma(imum dose of local anesthetic that can be used?
What < of &lass III bites are due to ma(illary hypoplasia?
Q7'9
What < of vascular malformations will have deformities of the underlying
bone? 0Whether directly involved or not=1
Q069 &4s a corollary to this Guestion, it does not appear to make a difference
what type of vascular malformation it is &ie$ its not a )pressure* or )flow* thing(
since high flow malformations donEt necessarily have more change in the
underlying .one and in fact, lymphatic malformations often have the most
profound effects on the mandi.le, leading to hemihypertrophy of the involved
side 8his is hypothesi#ed to .e due to some sort of upregulating signal from the
vascular malformation(
What is the advantage of the endoscopic approach to submandibular gland
stone removal?
8he duct is dilated and navigated through multiple su.divisions and irrigated
4lso one can find additional stones 6'9 of patients have 2-4 additional stones
missed on traditional imaging &!8, Sialogram, 8echnician salivary flow studies(
Strictures can also .e identified to .e dialated or marsupuli#ed if e/tremely
narrow
How long is the stent left in place after sialodochoplasty?
2-4 weeks
What are the post op instructions for a salivary stone retrieval patient?
Hrinks e/tra fluids, gland massage, use sialogogues &ie lemon drops(
How much does the chin move forward with mandibular closure of an open
bite?
8he .ony chin point moves forward 2mm with every 1mm of open .ite closed
What defines the following anatomic spaces?
!anine- ;etween levator anguli oris and levator la.ii superioris
;uccal ;etween .uccinator and overlying skin .etween #ygomatic arch and
.order of mandi.le
1nfratemporal- ,osterior to the ma/illaJ medially .y the lateral pterygoid plate,
superiorly .y .ase of skull, inferiorly .y lateral pterygoid, laterally .y
temporalis muscle and continues with deep temporalis space
Su.mental- ;etween 2 anterior .ellies of the digastric and mylohyoid and skin
Su.lingual- ;etween oral mucosa and mylohyoid
Su.mandi.ular- ;etween mylohyoid and overlying skin, anterior digastric
anteriorly, ,osterior Higastric posteriorly
"assenteric- ;etween medial aspect of medial pterygoid and lateral aspect of
masseter
,terygomandi.ular- "edial to mandi.le and lateral to medial pterygoid
8emporal- 8emporal line superiorly, arch inferiorly, medially the muscleJ deep
temporal is deep to the muscle and continuous with the infratemporal
space
:ateral ,terygoid- ;etween medial pterygoid laterally, superior constrictor
medially, from skull .ase to hyoid .oneJ anterior is the raphe, posteriorly is
the retropharyngeal spaceJ slyoid process and associated muscles divide
it into anterior and posterior compartments
%etropharygeal- ;etween superior constrictor and alar portion of preverte.ral
fasciaJ from skull .ase to !7-81 where alar and .uccopharyngeal fascia
fuse can e/tend into posterosuperior mediastinum
,reverte.ral- ;etween alar fascia and preverte.ral fasciaJ from pharyngeal
tu.ercle of skull .ase to diaphragmJ can e/tend into entire mediastinum
When completing %eFort I cut of lateral nasal wall which structure must you be aware of?
Hescending palatine artery
What is bone strength at different times of healing?
Cwks 50'9
0mo57'9
Cmo5B'9
1yr5B69
How much does the lingual nerve regenerate each day
1mm
How many patients after lingual nerve repair have functional sensory return after year?
OO69
What is the success rate for return of taste after lingual nerve in4ury?
069
What constitutes functional sensory return?
2pt sensation R2'mm, no pain, .rush stroke and light touch intact
What pt is li"ely to get >>< return of function after lingual nerve in4ury?
Sharp knife in?ury in a child with immediate repair
What contributes to failure of lingual nerve repair7?
Daiting more than 0 months to repair the nerve in ptEs with anesthesia or if there is a large si#e
discrepancy .etween the pro/imal and distal nerves
What defines neuropra(ia?
:oss of nerve function for 0-C weeks
When patient is under general anesthesia what can the anesthiologist follow to ensure
ade?uate cardiac output? 3rine output
When pt is undergoing hypotensive anesthesia why do they receive so much fluid?
8o ensure adeGuate end organ perfusion
What if the @N calls stating
;, is elevated =% is elevated 5 pain
5 =ypo/ia
What is a se?uence to death in patient in MMF?
-vermedication, upper airway o.struction, hypo/ia, fatigue, respiratory arrest, cardiac arrest
Aital sign indicators7
;, low, =% =igh
=ypovolemia check urine color, check fluid .alance, check skin turgor,
;, elevated and =% decreased
!oncern for increased intracranial pressure
;, and =% low
-vermedication
Iliac crest harvest7
4nterior iliac spine is landmark for lateral femoral cutaneous nerve &nerve usually sits
1'mm anterior/inferior to 41S(
E/pected .lood loss of appro/imately 1 unit per harvest
* possible approaches7
o lateral to crest
,referred <a.an method
8issue drifts laterally away from crest &hidden in .ikini line for good
esthetics(
2arthest from nerve
o medial to crest P good esthetics
o on crest P highest incidence of wound .reakdown
Bse of drains7
o 4dvantages$
%educe rate of infection
Speed up recovery
Hecrease chance of wound .reakdown due to minimi#ed hematoma
4llow staff to keep track of .lood loss
o Hisadvantages$
!ollapse dead space and decrease amount of su.seGuent .one fill P
therefore less .one is availa.le for re-harvest if necessary
'he clinical sign differentiating superior orbital fissure syndrome from orbital ape(
syndrome is7
1. a&sence o2 superior pa'pe&ra' 2o'd
3. proptosis
4. di'ated and 2i5ed pupi'
6. decreased 7isua' acuity

ANSWER: D
RATIONALE:
Symptoms of superior orbital fissure syndrome include:
1. Pupillary dilation via alteration in cranial nerve III function in it! innervation of
t"e pupillary con!trictor!.
#. Pare!i! of cranial nerve! III$ I%$ and I% cau!in& op"t"al'ople&ia.
(. )ranial nerve III involve'ent cau!e! pare!i! of t"e levator palpe*rae
!uperioru! 'u!cle$ leadin& to pto!i! and lo!! of t"e !uperior palpe*ral fold.
+. Neuro!en!ory di!tur*ance to t"e fir!t divi!ion of cranial nerve % ,it"
"ype!t"e!ia of t"e !upraor*ital and !upratroc"lear nerve! and lo!! of t"e corneal
refle-.
.. Propto!i! fro' en&or&e'ent of t"e op"t"al'ic vein and ly'p"atic!.
T"e or*ital ape- !yndro'e include! all of t"e a*ove plu! optic nerve involve'ent$
leadin& to c"an&e! in vi!ual acuity.
When closing oronasal fistulae where should the suture "nots be buried?
.he knots shou'd &e p'aced so that they are on the nasa' sur2ace.
What are the goals of alveolar cleft closure?
8he rationale for its closure includes 1( sta.ili#ing the ma/illary arch, 2( permitting support for
tooth eruption, 0( eliminating oronasal fistulae, and 4( providing improved esthetic results
What is Osteoconductive Stimulation?
S-steoS means S.oneS -steoconduction refers to the a.ility of some materials to serve as a
scaffold on which .one cells can attach, migrate &meaning move or ScrawlS(, and grow and divide
1n this way, the .one healing response is SconductedS through the graft site, ?ust as we say that
electricity is conducted through a wire -steogenic cells generally work much .etter when they
have a matri/ or scaffold to attach to
What is Osteoinductive Stimulation?
1nduction of .one formation refers to the capacity of many cytokines or peptides in the .ody to
stimulate primitive Sstem cellsS or immature .one cells to grow and mature, forming healthy .one
tissue
How many films are needed to ade?uately image the mandible?
4;-"S ;oard answer is that you need 2 views at right angles to each other
What films are in a mandible series and what can they image?
; "andi.lular o.liGues 5 angles to premolar region
8ownes view &4, skull film(5 ,osterior #ygomatic archs, !ondyles &since closer to the film(
,4 skull film, :ateral skull film, Su.mentoverte/
When harvesting iliac crest what nerves can be damaged?
:ateral femoral cutaneous 5 ,aresthesia to the lateral thigh
Sciatic +erve from the .ump roll placed under the gluteus muscle
,eroneal from the patients safety strap .eing placed lower on the leg resulting in foot drop
How many degrees does the ma(illa have to cant to be clinically obvious?
2our degrees or more
What reference point is used to correct a ma(illary cant?
8he amount to of tooth show at the canines, the degrees of cant are eGual to mm of needed
movement to correct ie 4 degrees eGual .ringing down the canine 4mm to level the plain plus
and additional 2mm if you want to show the canines
When performing a $SSO what unfavorable fractures can result?
=ori#ontal fracture of the ramus, ;uccal plate fracture, :ingual plate fracture, Su.condylar,
Sigmoid notch fracture
,t sustained blow to face and can5t open their mouthC what li"ely happened?
8rismus is likely from a depressed #ygomatic arch fracture or A"! that is impinging on the
coronoid
What mandibular fractures should one worry about with a blow to chin?
,arasymphsis and/or su.condylar,
What are the in4uries that can be sustained with a blow to the chin?
Skin laceration, su.condylar fracture&s(, cervical spine in?ury
What < of patients undergoing orthognathic surgery re?uire removal of hardware
postoperatively? What are the most common reasons?
Q269 of patients usually have hardware removed due to$
1 ,alpa.le hardware
2 8emperature sensitivity
What are the normal 'M+ ranges of motion?
"1- is Q06-66 with a mean of 40mm +ormal e/cursive movements are C-12mm
What percentage of a child5s body weight is from blood volume?
7-O9
What are the steps in the 'M+ an"ylosis release?
1 4ggressive resection of the ankylotic segment
2 1psilateral coronoidectomy
0 !ontralateral coronoidectomy
4 :ining the ?oint space with temporalis fascia or cartilage
6 %econstruction of the ramus with a costochrondral graft
C %igid fi/ation of the graft
7 Early mo.ili#ation and aggressive ,8
O 1f patient loses "1- then should have manipulation under anesthesia
What artery supplies the temporalis muscle flap used in 'M+ surgery?
Heep temporal artery
What are the causes of 'M+ an"ylosis?
8rauma 02-BO9 cases ,ossi.ly from intra-articular hematoma with scarring
:ocal or systemic infection 1'-4B9 cases -titis media or mastoiditis hemotogenous spread
Why does the cornoid have to be ressected in 'M+ an"ylosis surgery?
4nkylosis prevents movement of the mandi.le at the 8"T 8he suprahyoid muscles pull on the
mandi.le and the temporalis muscle pull which resists movement causes .ony hyperplasia of the
coronoid
How do you decide if the contralateral coronoid has to be removed in 'M+ an"ylosis
release?
-nce the affected side is released and the ipsilateral coronoid is resected you enter the mouth
and see if the mandi.le can easily .e dislocated on the contraleral side with minimal force 12 it
canEt then you must also ressect the contralateral coronoid
6iagram the modifications to the sagittal split osteomtomies
Obwegeser D 'rauner techni?ue 0E!F1 -riginal description of sagittal split osteotomy
Hunsuc" modification 0EGH1
-Allow the horizontal osteotomy to propagate posteriorly without
completing a complete corticotomy
DalPont modification (1961)
-Bringing vertical corticotomy anteriorly on buccal surface of the mandible
to area of first molar (allowing increased length of movement).
What is the position of the premaxilla in patients with bilateral cleft palates
The premaxilla starts off being protrusie and long in the ertical plane. :t fre;uently
returns to a <normal= position by the time patients are teenagers.
What are the ! modification for "enioplast#
Tessier > ,steotomy proximal to the mental foramina to ensure smooth transition
between mandible and new chin position
?aban > @issection the mental neres freeing them so that they are mobile and not
sacrificed
-errot > Adapting <x= plate so that the screw holes are oriented ertical instead of
perpendicular to the buccal surface of the adanced chin this preents the patient
from being able to feel the plate
Troulis > 0he recommended a microplate at the lateral wings instead of wire stablization
What is the $G% abx protocol for post ortho"nathic sur"er#
. dose preop& . dose intraop& . dose in recoery room1 unless: -t has bonegraft& medpore
implant& then should hae full course of Abx. :f a drain is placed& pt should be on Abx
for /4 hrs post remoal of drain.
What is &ec'with(Wiedemann s#ndrome
:t is generally accepted that the diagnosis can be established if at least three diagnostic
findings are present. macrosomia 3pre-natal and$or post-natal gigantism5& macroglossia
and abdominal wall defect 3omphalocele& umbilical hernia& diastasis recti5
hemihyperplasia& embryonal tumors& adrenocortical cytomegaly& ear anomalies 3anterior
linear earlobe creases& posterior helical pits5& isceromegaly& renal abnormalities&
neonatal hypoglycemia& cleft palate& and a positie family history.
What must a patient with &ec'with(Wiedemann s#ndrome be monitored for
#hildren with AB0 hae an increased risC for embryonal tumor deelopment&
primarily within the first D-4 years of age. The most common tumors include BilmsE
tumor and hepatoblastoma& but others including rhabdomyosarcoma& adrenocortical
carcinoma& and neuroblastoma hae been reported.
What 'eeps a )#"omatic arch reduced followin" a Gilles approach
The arch is held in place by the deep temporal fascia from aboe and the origin of the
masseter from below.
What are the most common causati*e or"anism leadin" to sialadenitis
Alpha-hemolytic 0trep and anaerobes.
What is the most common causati*e or"anism leadin" to acute+ supporati*e
parotitis What a"e "roup(s) is this most commonl# seen in
0taph. The ery young and the elderly. Fecent illness and dehydration are both risC
factors.
&one "raft facts,
.. Aone morphogenic proteins 3A!-s5 are found in greater concentrations in cortical
s cancellous grafts.
2. A!-s are released as the bone graft is resorbed
(. #ortical bone graft strength decreases steadily following grafting& reaching its
nadir at ( months.
/. #ancellous bone graft strength increases steadily following grafting.
&ancellous graft &ortical graft
;etter survival of osteogenic cells .ecause the
structure allows diffusion and early microvascular
anastomoses
Hense .one is a .arrier to diffusion
:arge endosteal surface supplies
osteoprogenitor cells
Small endosteal surface
4.undant red marrow supplies many
osteoprogenitor cells
2ewer osteopregenitor cells
=ealing .y creeping su.stitutionJ new .one is
deposited on dead tra.eculae followed .y
%emoval of necrotic matri/ from around the
central canals of osteons occurs first followed .y
removal of necrotic matri/ new .one formation
%elatively weak
%elatively strong
%ow is osteom#elitis dia"nosed
%istory is most important& followed by radiographic imaging.
What is a three phase bone scan
Tc labeled phosphorus shows increased uptaCe in area of high osteoblast actiity
The images obtained are immediate 3flow5& .D minute 3blood pooling5& and four hour 3bone imaging5. The
scan findings are different in cellulitis and osteomyelitis. #ellulitis results in increased actiity in the first
two phases and normal or diffusely increased actiity in the third phase. :n comparison& osteomyelitis
results in intense uptaCe in all three phases. Galse positie findings can occur with posttraumatic in'ury&
following surgery& diabetic feet& septic arthritis& noninfectious inflammatory bone disease& cancer& healed
osteomyelitis& and -agetEs disease.
What is an indium bone scan %ow does it wor'
:ndium labeled leuCocyte scanning uses white blood cells labeled with radioactie indium as the tracer. :t
accumulates at sites of inflammation or infection and in the bone marrow. :t is not specific for bone. 0ince
it accumulates in marrow& it is less sensitie for imaging those areas with red marrow 3eg& the axial
sCeleton5
The indium scan can also be used for the diagnosis of osteomyelitis at sites of fracture nonunion. Two
prospectie studies found a sensitiity and specificity of ). and )6 percent& respectiely& in this setting
What dia"nostic ima"in" is utili)ed in dia"nosin" osteom#elitis
-lain film-panorex
#T
!F:-earliest indicator is inflamed marrow
Aone 0can-Technetium-non-specific
-:ndium tagged BA#s 3most specific in acute osteomyelitis5
What are the most common e*ents leadin" to mandibular osteom#elitis
Tooth extraction 3usually third molar5
Under-treated or untreated fracture
%ematogenous spread 3Third Borld5
Is there a critical timeframe within which a mandibular fracture must be treated
-rior to the adent of rigid fixation& untreated fractures older than 2/-/4hrs were
considered infected and were at increased risC for osteomyelitis.
What is the -llis protocol for treatment of an infected fracture
Hien recent eidence& the best treatment is to start :V abx until any purulence discharge
ceases& then taCe to the ,F& dIbride and complete rigid fixation.
What if the infection is chronic+ or there is a defect
:f debridement of the 3chronic5 infection leads to a defect& then a bone plate is necessary.
A young patient will often bridge the defect whereas an older patient will re;uire a bone
graft once the site is healed.
What are . causes of posterior *ertical maxillar# excess (V$-) leadin" to anterior
open bite
.. -urely sCeletal-demonstrated on lateral ceph with longer than normal 0ella--J0
2. -urely dentoaleolar-demonstrated on lateral ceph with normal 0ella--J0 but
increased distance from -J0 to occlusal surface of molar
(. #ombined dentoaleolar$sCeletal-combination of the aboe
What are the two main t#pes of *ascular malformations
/umors and malformations
:nfantile hemangioma is a true tumor 3neoplasm5& is not present at birth&
undergoes a proliferatie phase and then inolutes& sometimes leaing a fibro-
fatty residual. %emangiomas are Hlut .8.
Vascular malformations can be categorized as high flow or slow flow
malformations. %igh flow malformations are usually AV!s. 0low flow can be
capillary& enous& lymphatic or combination of the aboe malformations.
Venous malformations are present at birth& do not inolute& and can increase in
size later on in life and may increase in size during puberty.(D K of AV!s
inole the bone.
What is the infection rate with primar# bone "raft reconstruction at the time of
tumor resection
.*-D*K that is why some adocate that you do not reconstruct at the same time
Bhat reason would you want a free ascularized graft at the time of reconstructionL
:f you were concerned that you might need radiation treatment. This preents the
delay in needing to go bacC to the ,F for the free flap.
What is the maximal distance one can "raft with a non*asculari)ed "raft
Dcm.
When treatin" /$0 an'#losis patients what is considered a functionall#
acceptable result
2*-2Dmm at one year
%ow much mouth openin" do #ou need to be able to do the followin" acti*ities
spea'in"+ chewin"+ posterior dental wor'
0peaCing D-.*mm
#hewing 2*-2Dmm
-osterior @ental BorC (*mm
:f treatment planning for a "eGort :: or ::: instead of "efort :& what must you taCe into
considerationL
The position of the globes relatie to the orbit.
If there appears to be a smaller ad*ancement on #our model sur"er# what
happened %ow could #ou pic' this up prior to "oin" to the 12
The models were not mounted correctly in #F
#hecC the lateral ceph and ensure that the moement on the models agrees with the
lateral ceph.
What is Goldenhar 3#ndrome
3!ulliCen states old term as it is hemifacial microsomia with extracranial
manifestations& and term should not be used5 -er "A? extended spectrum hemifacial
microsomia with epibulbar dermoid cysts
What extracranial abnormalities can accompan# hemifacial microsomia
0Celetal 3 bifid ribs& Vertebral axoatlantal instability& 0colosis& pectum excaatum&
#J0 %ydrocephalus& #ardioacular: V0@& Tetrology of Gallot& !V-& Anomalous
pulomary return& Fenal: Agenesis& Vescorueteric reflux& H:: @iaphragmatic hernia&
HMF@& :ntestinal malrotation& Annular pancreas& -ulmonary: Tracheoesophageal
fistula.
Bhat ,!MJ0 score is associated with extracranial findingsL
0ee for answer
'itle7 -"E+S-,lus$ analysis of craniofacial and e/tracraniofacial anomalies in hemifacial
microsomia
Source7 8he !left palate-craniofacial ?ournal L1'66-CC6CN =organ yr$1BB6 vol$02 iss$6 pg$4'6 -12
Bhat is the difference between Treacher #ollins and A %emifacial microsomiaL
Farely bilateral hemifacial microsomia is symmetric treacher collins
#hecC genetics on pt Tcof1/Treacle gene present in many cases of Treacher #ollins
Treacher #ollins is Autosomal @ominant
%emifacial !icrosomia
Treacher #ollins will also hae lower-eyelid colobomas and medial third eyelash
deficiency& palpebral fissure anomaly with antimongoloid slant
%ow man# anterior open bites are due to posterior *ertical maxillar# excess
NO*K
What are the theoretical limits of amount of posterior impaction durin" 4e5ort
Anatomic
-osterior #hoane- :atrogenic posterior nasal obstruction
:nferior Turbinate
Jasolacrimal duct
Msthetics
,ccusal plane steepening up .2 degrees once exceeded pt appears retrognathic as the
mandible is not completely closed.
Bhat muscles control M,!L -rimary and secondaryL
Bhat are the inerations to the extraocular musclesL
What are the issues in describin" subcond#lar fractures
a. :ntracapsular s Mxtracapsular 3%igh s "ow5
b. @isplacment 3:n Gossa s out of Gosssa5
c. ,erride and ,erlap 3%ow much on medial or lateral5
What muscle pull contributes to de*iation of the chin with a subcond#lar fracture
Unopposed contralateral lateral pterygoid muscle pull
%ow much blood loss is expected with a bicortical anterior iliac crest bone "raft
2D*-(D*cc intraoperatie then additional 2D*cc in the first 2/hours post op especially if
there is a drain in place 3A patient can lose up to one unit of blood5
%ow much marrow can #ou har*est from each of the follow sites
.. Anterior iliac P 2*-(*cc uncompressed marrow
2. -osterior iliac P 2*-/*cc uncompressed marrow
(. Anterior tibial plateau P 2* cc uncompressed 3depends on how you approach tibia5
What mo*ements are most stable if #ou treatin" a patient with idiopathic cond#lar
resorption use con*entional ortho"nathic sur"er# without a rib "raft
"ess than Dmm of sagittal moement& treating the deformity in one 'aw alone& if the
posterior ramus height is greater than (Dmm
When placin" a 66 rib "raft what pre*ents o*er"rowth in the "rowin" patient
%aresting only .mm of cartilage on the rib
What leads to o*er"rowth of the 66 rib "raft in the "rowin" patient
!icromotion at the osteochrondral 'unction if the there is a large piece of cartilage this
leads to tumor liCe oergrowth of the cartilage ery much liCe a osteochrondroma This
is from stimulation of the chrondrocytes
"inear growth also in the young patient if too much cartilage is present at the growth
center . This leads to prognthism and class ::: malocclusion.
7fter a fracture or osteotom# what is the bone stren"th When is it at full
stren"th
O weeCs (*K strength
(months 6*K strength
. year normal strength
Who is Gilles
0ir %arold Hilles -lastic surgeon from Jew Qealand who deeloped many region flaps
for facial reconstruction. Also described at the approach to Qygmomatic fractures and
Q!#Rs. Also he described the use of the submentoetex film.
Bhat are the anatomic Aarriers for a Hilles approach to the Qygomatic archL
"aterally the masseter muscle& medially the temporalis fascia
Bhat can you use instead of Hilles forcep to reduce a Qygomatic archL
Goley inflated under the arch& pacCing pacCed extraorally and remoed D days later
intraorally.
What are the indication to open a mandible fracture
.. -t cannot tolerate !!G ie not reliable 3drunC& homeless& seizure disorder
handicapped5
2. Gracture is proximal to the tooth bearing segment ie a displaced angle fracture.
:f there is a parasymphyseal fracture what can you use to stabilize the fractureL
A lingual splint much liCe a retainer with an arch bar also on the teeth.
What are the . most common clinical si"ns of /$0 prosthesis failure re8uirin"
sur"ical inter*ention
-!alocclusion
-@ecreased F,!
--ain
What are the films included in a $andibular 3eries
--A 0Cull
-"ateral 0Cull
-Fight "ateral ,bli;ue
-"eft "ateral ,bli;ue
-TowneRs View
%ow lon" should #ou lea*e Prolene sutures on the face
-D days
Wh# 9 da#s+ not more+ not less
-The sCin seals in /4h& but the tracts will epithelialize if more than O days& leaing
<railroad tracCs=
Wh# should #ou do dermal la#er
-To preent the spread of the wound. The dermal layer has collagen and is the strength
layer.
To preent dead space and hematoma formation.
%ow lon" does *icr#l last
- ( weeCs 32. days5
Wh# especiall# that time
-:t taCes 2. days 3( weeCs5 to hae enough collagen to bridge the edges of the dermal
layer in a sufficient ;uantity to reach O*K of the tensile strength of the wound.
%ow can #ou a*oid unfa*orable fractures in 4e 5ort I osteotom#
- -terygoid osteotome should be placed <downhill= along occlusal plane and not <uphill.=
:mproper uphill positioning can cause unfaorable fracture. This can result in retrobulbar
hematoma and cause damage to the optic nere.
If #ou ha*e bilateral parotid swellin" and ima"in" shows (6/) c#stic lesions in
parotid+ what mali"nanc# is in #our differential
BarthinRs tumor
What:s a treatment protocol for a subcond#lar fracture (neither hi"h nor low)
Tight !!G for ( weeCs& elastics for ( weeCs& elastics only at night for ( more weeCs.
The condyle will not heal in the right place& therefore the occlusion will depend on
muscle memory. There will always be a #F$#, discrepancy on the affected site after
fracture heals.
What is the sensor# inner*ation of the /$ ;oint
Hreater auricular& auriculotemporal and deep temporal neres all contribute.