 11 Maxillofacial &Dental SBA

September 2021

The Royal College of

Emergency Medicine

MRCEM INTERMEDIATE SBA

SEPTEMBER 2021

11 Maxillofacial & Dental

SBA

Collected by Dr. Haitham Khalil September 2021

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Maxillofacial & Dental  QUESTION 1 >

A 27 year old man presents to the Emergency Department after being involved in an
altercation in a pub. He was punched to the face multiple times. A coronal section of his
CT is shown. What is the diagnosis?

Fracture of the lateral wall of the maxillary sinus 3%

✓ Fracture of the orbital floor 73%

x Fluid level in the ethmoid sinus 6%

Fracture of the frontal process of the zygomatic bone 3%

Fracture of the zygomaticomaxillary complex 16%

ANSWER
There is a fracture of the orbital floor with herniation of the inferior rectus muscle in the maxillary sinus.

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 Maxillofacial & Dental  QUESTION 2

A 43 year old woman presents to the Emergency Department with a 3 day history of facial pain and swelling
associated with pain in her tooth. She has no past medical history. Observations are normal. You diagnose a dental
abscess. How would you manage this patient?

Prescribe oral antibiotics and advise to attend emergency dentist 38%

Administer dental block for analgesia 2%

x Incision and drainage under local anaesthesia 11%

Admission under maxillofacial surgery 7%

✓ Prescribe analgesia and advise to attend emergency dentist 41%

ANSWER
Antibiotics are generally not indicated for otherwise healthy people at low risk of complications when there are no signs of spreading infection.

Advise that definitive treatment can only be given by a dentist and medication will not eliminate the source of infection, and that serious
complications may occur if the abscess is not treated correctly by the dentist.

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Maxillofacial & Dental  QUESTION 3 >

An 18 year old rugby player presents to the Emergency Department after getting
punched during a game. He was not wearing any dental protection at the time and his
central upper left incisor (UL1) is missing. His teammates found the missing tooth and
have brought it to the Emergency Department in milk. Which of the following
management steps is correct?

Scrub debris from the root of the avulsed tooth 10%

Do not re-implant teeth that have been avulsed for more than 30 minutes 17%

✓ Irrigate the socket to remove any blood clots 54%

Routine antibiotics are not required 10%

Soak the avulsed tooth in hydrogen peroxide prior to re-implantation 8%

ANSWER

The tooth should be held in a physiologically acceptable medium (saliva or milk) before re-implantation.
It is important to hold the tooth at the crown only (the part that is normally visible in the mouth) and to
avoid touching the root surface.
Saline should be used to briefly clean debris from the root of the tooth and also to irrigate the socket to
remove any blood clots that may be present here (allowing for revascularisation of the tooth).
The tooth should be gently placed back into the socket, and splinting carried out, ensuring that the tooth
is orientated correctly in the correct socket.
Antibiotics should be given and a tetanus booster considered.
Early and prompt referral to dental surgeon or maxillofacial surgeon is required.
It is worth noting that teeth that are outside of the mouth for more than 60 minutes are more likely to fail
and undergo root resorption (breakdown) or ankylosis (fusion of root to the bone) and ultimately fail.

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 Maxillofacial & Dental  QUESTION 4

A 54 year old man presents to the Emergency Department after being struck in the eye by a squash ball whilst
playing squash. He was not wearing eye protection. There is orbital swelling and diplopia on upward gaze and you
suspect a fracture. Which of the following muscles is most likely affected causing this symptom?

Superior rectus 8%

Superior oblique 6%

✓ Inferior rectus 71%

x Inferior oblique 13%

Medial rectus 2%

ANSWER
The patient most likely has an orbital floor fracture. Diplopia/ophthalmoplegia may occur, particularly on upward gaze, due to trapping of the
herniated inferior rectus muscle.
 Maxillofacial & Dental  QUESTION 5

You have been asked to give a teaching session to a group of medical

students. You are covering the practicalities of wound closure in the
Emergency Department, including indications and contraindications. Which of
the following facial wounds is suitable for closure in the Emergency
Department?

Lip laceration passing through vermillion border 22%

Laceration involving the nasal cartilage 7%

✓ Laceration to the anterior 1/3 of the tongue 51%

Eyelid laceration involving the eyelid margin 12%

Auricular laceration extending into the external auditory canal 8%

ANSWER
Consultation with a surgical subspecialist (e.g. plastic or maxillofacial surgeon, ophthalmologist),
if available, is suggested in the following situations:

Wounds to the zygoma (cheek) with associated injury to the facial nerve, facial artery, or
parotid gland or ducts
Lacerations that involve the nasal cartilage, ala, or columella
Eyelid or orbital lacerations that involve the eyelid margin or tarsal plate, have protruding
subcutaneous fat or involve the tear duct or lacrimal gland
Lip lacerations through the vermillion border
Complex auricular lacerations
Complex wounds that require extensive revision or that have significant skin loss that may
require grafting
Wounds with associated fractures (e.g. mandibular fracture, orbital fracture) that will
require surgical subspecialty care

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 Maxillofacial & Dental  QUESTION 6

A 19 year old man presents to the Emergency Department with a history of "jaw pain" and trismus after yawning. You
suspect an anterior temporomandibular joint (TMJ) dislocation. Which of the following is a risk factor for TMJ
dislocation?

Male gender 6%

Under 20s 3%

Ankylosing spondylitis 10%

Long term corticosteroid use 9%

✓ Marfan's syndrome 73%

ANSWER
Connective tissue disorders, such as Marfan's and Ehlers-Danlos syndrome, increase likelihood of TMJ dislocation.

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 Maxillofacial & Dental  QUESTION 7

A 32 year old man is brought to the Emergency Department after being assaulted with a baseball bat. He was hit in
the face several times. You suspect a Le Fort type injury. Which of the following structures MUST be fractured in all
types of Le Fort fracture?

Inferior orbital floor 9%

Nasal septum 14%

x Zygomatic arch 17%

Nasofrontal suture 16%

✓ Pterygoid plate 44%

ANSWER
Fracture of the pterygoid plates is mandatory to diagnose Le Fort fractures, as these connect the midface to the sphenoid bone dorsally.

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Maxillofacial & Dental  QUESTION 8 >

A 23 year old man presents to the Emergency Department complaining of pain in his
jaw after being punched. Which of the following is NOT an indication to request a
mandibular x-ray?

Malocclusion of the teeth 7%

✓ Wound overlying the mandible 50%

Broken teeth 20%

Pain with the mouth closed 15%

Trismus 8%

ANSWER
A number of clinical findings have been identified to correlate with the presence of a mandibular fracture.

Manchester Mandibular Fracture Decision Rule

1. Do the patient's teeth meet abnormally (i.e. malocclusion)?
2. Is the patient unable to open his/her mouth normally (i.e. trismus)?
3. Does the patient have any broken teeth?
4. Does the patient report pain while their mouth is closed?
5. Is there a step deformity?

If yes to any of the above, then request mandibular x-ray

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 Maxillofacial & Dental  QUESTION 9

A 43 year old woman presents to the Emergency Department after being punched to the right side of her face. She is
complaining of trismus. X-rays have confirmed a zygomatic arch fracture. She has received intravenous morphine for
analgesia and ondansetron for associated nausea. What is the most likely cause of this patient's trismus?
 

Concomitant mandibular fracture 18%

Injury to masseteric nerve 15%

Cranial nerve VI injury 5%

✓ Impingement of the coronoid process 52%

Acute dystonic reaction secondary to antiemetic 11%

ANSWER
The temporalis muscle and coronoid process of the mandible lie beneath the arch and may become trapped in depressed fractures of the
zygomatic arch, leading to trismus.
 Maxillofacial & Dental  QUESTION 10

An 18 year old man presents to the Emergency Department after being involved in an altercation on a night out. He
was struck in the face with a broken bottle and has sustained a laceration to the face. On examination you note a 5
cm laceration to the right cheek, running parallel and 1cm inferior of the zygomatic arch. Which of the following is
most likely damaged by this type of injury?
 

✓ Parotid duct 50%

Superficial temporal artery 6%

x Maxillary nerve 29%

Auriculotemporal nerve 10%

Mental nerve 5%

ANSWER
Deep lacerations to the cheek and to areas anterior to the ear warrant careful evaluation for injury to the parotid gland, parotid duct and/or the
facial nerve. Refer for exploration in theatre if there is any clinical suspicion of involvement of any of these structures.
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Maxillofacial & Dental  QUESTION 11 >

A 72 year old woman presents to the Emergency Department with a 3 day history of
increasing facial swelling and pain. She has a past medical history of insulin dependant
diabetes. You see a periapical abscess on examination of her mouth. You decide
antibiotic therapy is indicated. Which of the following antibiotics is the most appropriate
first line choice?

Metronidazole 36%

x Ciprofloxacin 7%

Cefalexin 12%

✓ Penicillin V 41%

Azithromycin 3%

ANSWER
If an oral antibiotic is indicated prescribe a 5-day course of either amoxicillin or phenoxymethylpenicillin
(clarithromycin if penicillin allergic).

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 Maxillofacial & Dental  QUESTION 12

A 23 year old woman presents to the Emergency Department after being involved in an altercation in a nightclub.
She recalls being punched twice, once on the left side of her face and once directly to her nose. She did not lose
consciousness and has full recollection of the events. You arrange for facial x-rays. Which of the following findings on
facial x-ray is pathognomonic for an orbital blow-out fracture?

✓ Teardrop sign 80%

Fluid level in maxillary sinus 8%

x Disruption of McGrigor-Campbell lines 6%

Fluid level in frontal sinus 3%

Westermark sign 4%

ANSWER
The diagnosis of orbital blow-out fracture may be made on routine facial x rays (e.g. the pathognomonic "teardrop sign") but CT scan remains the
gold standard if this injury is suspected or identified.
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Maxillofacial & Dental  QUESTION 13 >

A 54 year old man is brought to the Emergency Department after getting hit in the
face by the wing mirror of a passing lorry. On examination he is maintaining his own
airway and you note bilateral periorbital ecchymosis (raccoon eyes) and clear
deformity of the midface. Facial CT shows a Le Fort type II fracture. Which of the
following structures MUST be fractured in a Le Fort type II injury?

Anterolateral margin of the nasal fossa 13%

Inferior wall of maxillary sinus 17%

x Alveolar ridge 6%

✓ Inferior orbital rim 50%

Zygomatic arch 14%

ANSWER
Le Fort fractures:

Anterolateral margin of the nasal fossa involvement:

If fractured, it is a type I fracture
If intact, it excludes a type I fracture
Inferior orbital rim involvement:
If fractured, it is a type II fracture
If intact, it excludes a type II fracture
Zygomatic arch involvement:
If fractured, it is a type III fracture
If intact, it excludes a type III fracture
If the nasofrontal suture is involved, then it is either a type II or III fracture

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 Maxillofacial & Dental  QUESTION 14

A 54 year old woman presents to the Emergency Department complaining of left sided facial and
ear pain. She has no past medical history and smokes 20 cigarettes a day. She had a dental
extraction 3 days ago. On examination you note no facial swelling and all observations are within
normal parameters. What is the most likely diagnosis?

Dental abscess 18%

Osteomyelitis 2%

x Osteonecrosis of the mandible 10%

✓ Alveolar osteitis 58%

Gingivitis 12%

ANSWER

Post-extraction alveolitis (dry socket) is pain emanating from bare bone where a blood clot fails to develop in the
tooth socket or if the blood clot becomes dislodged.
It is much more common among smokers.
Typically, the pain begins on the 2nd or 3rd postoperative day in the vicinity of the extraction site, is referred to the
ear, and lasts from a few days to many weeks.
 Maxillofacial & Dental  QUESTION 15

A 27 year old presents to the Emergency Department at 19:00. Three hours

earlier she had a molar tooth extracted by her dentist. She gives a history of
ongoing bleeding from the extraction site for the last hour - she has been
unable to contact her own dentist or any emergency dental services, she
has therefore presented to the Emergency Department. On examination you
note active bleeding from the empty socket, the patient is
haemodynamically stable at present. What is the first management step in
this patient?

Place saline soaked gauze in socket and ask patient to bite down firmly for 20 80%
✓
minutes

Suture the wound to stabilise socket edges 2%

x Apply haemostatic dressing to the socket 10%

Rinse mouth with chlorhexidine 4%

Inject local anaesthetic with adrenaline to cause vasoconstriction 4%

ANSWER
Management of post-extraction bleeding:

Gently rinse the mouth once with warm (not hot) water to wash out excess blood.
Advise the patient to place a rolled up piece of cotton or a gauze swab moistened with
saline or water over the socket and to bite firmly on it. Maintain the pressure for 20
minutes before checking whether the bleeding has stopped. If necessary, repeat.
If application of pressure does not work, find the source of the bleeding.
Consider:
Applying a haemostatic dressing to the socket (e.g. oxidised cellulose such as
Surgicel or hemocollagene sponge).
Suturing the wound to achieve good soft-tissue closure and/or to stabilise the
socket edges.
 Maxillofacial & Dental  QUESTION 16

A 54 year old patient presents to the Emergency Department with a history of facial pain and swelling following a
dental procedure 2 days ago. On examination you note a fever and tenderness over the neck and throat. You suspect
Ludwig's angina. What space is initially infected in this condition?

Retropharyngeal space 13%

Pterygomandibular space 5%

x Pretracheal space 5%

Parapharyngeal space 3%

✓ Submandibular space 74%

ANSWER
Ludwig's angina is a bilateral infection of the submandibular space that consists of two compartments in the floor of the mouth, the sublingual
space and the submental space.
 Maxillofacial & Dental  QUESTION 17

You have been asked to give a teaching session to a group of Foundation Year 2 doctors starting their Emergency
Medicine rotation. The topic is dental trauma. Which of the following statements regarding avulsed teeth is TRUE?

Do not irrigate the socket of an avulsed tooth 9%

✓ If a primary tooth has been avulsed then it should not be reimplanted 57%

x It is important to hold the avulsed tooth at the root and not the crown 9%

Water is an ideal medium for transporting avulsed teeth 6%

Teeth that are outside of the mouth for more than 30 minutes are more likely to fail 19%

ANSWER
If a primary tooth has been avulsed then IT SHOULD NOT BE REIMPLANTED. Doing this is likely to result in further damage to the underlying adult
tooth.

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 Maxillofacial & Dental  QUESTION 18

A 23 year old woman presents to the Emergency Department after falling through a glass door. She has sustained a
laceration to her face. On examination she is unable to frown and the right side of her mouth is droopy. Which of the
following structures is most likely injured?

Orbicularis oris muscle 6%

Buccinator muscle 6%

x Maxillary nerve 5%

✓ Facial nerve 78%

Mandibular nerve 5%

ANSWER
Deep lacerations to the cheek and to areas anterior to the ear warrant careful evaluation for injury to the parotid gland, parotid duct and/or the facial
nerve.

The facial nerve traverses the parotid gland to supply the muscles of facial expression. The function of the facial nerve and its branches should be
assessed: (1) temporal – contract the forehead and elevate the eyebrow; (2) zygomatic – open and shut eyes; (3) buccal – smile; (4) mandibular – frown; (5)
cervical – contract the platysma muscle. Unrepaired injury may result in permanent disfigurement.
 Maxillofacial & Dental  QUESTION 19

A 19 year old medical student presents to the Emergency Department with a 1 hour history of trismus and bilateral
temporomandibular joint (TMJ) pain after yawning. He is unable to swallow his saliva. He has had a similar episode in the
previous 12 months. You suspect a bilateral anterior temporomandibular joint (TMJ) dislocation. What is the first step in
the management of this patient?
 

Analgesia and patient applied traction 32%

✓ Intra-oral reduction without local anaesthesia 36%

x Intra-articular injection of local anaesthetic prior to intra-oral reduction 14%

Referral to maxillofacial surgeon for specialist reduction under general anaesthesia 12%

Extra-oral reduction 7%

ANSWER
The standard intraoral technique for reduction of the anteriorly dislocated TMJ is designed to push the mandible inferiorly and posteriorly back into the
mandibular fossa. This can be done from either an anterior or posterior approach. If the standard technique fails, other techniques have also been
described involving intra-articular injection of local anaesthetic, extraoral techniques and a wrist pivot method.
 Maxillofacial & Dental  QUESTION 20

A 23 year old martial art student presents to the Emergency Department following a
tournament match. He is complaining of pain and swelling to the face. What
abnormality can be seen on this x-ray?

Fracture of mandibular body 6%

✓ Fracture of zygomatic arch 66%

x Fracture of lateral orbital rim 6%

Fluid filled maxillary sinus 4%

Fracture of the zygomaticomaxillary complex 18%

ANSWER
There is a fracture of the left zygomatic arch.
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Maxillofacial & Dental  QUESTION 21 >

A 54 year old presents to the Emergency Department after being kicked in the face by
a horse. What x-ray view is shown?

Occipito-mental (OM30) 6%

Occipito-mental (OM15) 5%

✓ Orthopantomogram (OPG) 76%

Mandibular view 10%

Frontal view 4%

ANSWER
The orthopantomogram (OPG) is the most accurate technique and consequently the best initial film for
screening for mandibular fracture but should be followed by additional views if clinical suspicion remains.
 Maxillofacial & Dental  QUESTION 22

An 18 year old man presents to the Emergency Department after falling on some steps
leaving a nightclub. How would you classify this injury?

✓ Complicated crown fracture 35%

Enamel and dentine fracture 46%

x Enamel fracture 10%

Root fracture 6%

Alveolar bone fracture 4%

ANSWER
Complicated crown fracture: Fracture through the tooth extending into the dental pulp of a tooth. Also known
as an enamel-dentine-pulp fracture. Note the central pink pulp.
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Maxillofacial & Dental  QUESTION 23 >

A 54 year old man is brought to the Emergency Department after getting hit in the
face by the wing mirror of a passing lorry. On examination he is maintaining his own
airway and you note bilateral periorbital ecchymosis (raccoon eyes) and clear
deformity of the midface. Facial CT shows a Le Fort type III fracture. Which of the
following structures MUST be fractured in a Le Fort type III injury?

Anterolateral margin of the nasal fossa 6%

Inferior wall of maxillary sinus 10%

Alveolar ridge 7%

x Inferior orbital rim 20%

✓ Zygomatic arch 57%

ANSWER
Le Fort fractures:

Anterolateral margin of the nasal fossa involvement:

If fractured, it is a type I fracture
If intact, it excludes a type I fracture
Inferior orbital rim involvement:
If fractured, it is a type II fracture
If intact, it excludes a type II fracture
Zygomatic arch involvement:
If fractured, it is a type III fracture
If intact, it excludes a type III fracture
If the nasofrontal suture is involved, then it is either a type II or III fracture

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Maxillofacial & Dental  QUESTION 24 >

A 72 year old man is brought to the Emergency Department after falling down on the
local high street. Paramedics tell you his face hit a solid traffic bollard and they are
concerned about a facial fracture. On examination he is maintaining his own airway
and you note bilateral periorbital ecchymosis (raccoon eyes) and clear deformity of the
midface. Facial CT is arranged. Which of the following CT findings would classify this
injury as Le Fort type I?

Fracture of medial wall of the orbit and zygomatic arch. 5%

Fracture through the medial wall of the maxilla and the inferior orbital rim. No fracture of the 10%
zygomatic arch.

x Fracture line extending through nasofrontal suture. 20%

Fracture of the orbital floor and zygomatic arch. 7%

✓ Horizontal fracture through the maxilla. No orbital or zygomatic involvement. 59%

ANSWER
Le Fort type I (Floating Palate)

Horizontal fracture through maxilla above the roots of the teeth

May result from a force of injury directed low on the maxillary alveolar rim in a downward direction
Fracture extends through the alveolar ridge, lateral nose and inferior wall of the maxillary sinus; there
is separation of the body of the maxilla from the pterygoid plate and nasal septum

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 Maxillofacial & Dental  QUESTION 25

A 68 year old woman presents to the Emergency Department with a 2 day history of fever, dysphagia and mouth
pain. On examination she has a tender, symmetrical induration of the submandibular area. Her tongue is slightly
protruded. What is the most likely source of infection to explain this patient's condition?

✓ Dental infection 69%

Acute sinusitis 1%

x Bacterial tonsillitis 15%

Acute otitis media 3%

Glandular fever 13%

ANSWER
The patient has Ludwig's angina. Over two-thirds of patients with Ludwig’s angina have a dental source of infection, usually involving the second
or third mandibular molar teeth.
 Maxillofacial & Dental  QUESTION 26

An 18 year old rugby player is brought to the Emergency Department by his teammates. He was punched to the face during
a game. You are concerned about the risk of an orbital floor fracture. Which of the following is NOT a typical clinical feature
of an orbital floor fracture?

Enophthalmos 9%

Malar region numbness 7%

Diplopia 7%

x Subconjunctival haemorrhage 9%

✓ Persistent nasal discharge 69%

ANSWER

Enophthalmos (due to increased orbital volume)

Diplopia/ophthalmoplegia, particularly upward gaze (due to trapping of the herniated inferior rectus muscle)
Orbital emphysema (fracture into adjacent paranasal sinus, usually the maxillary)
Malar region numbness (injury to infraorbital nerve)
Subconjunctival haemorrhage – if a clear posterior border cannot be seen , it is likely blood has tracked round the eye from a fracture of the orbital
wall
 Maxillofacial & Dental  QUESTION 27

A 59 year old man presents to the Emergency Department with a 1 day history of facial
pain, fever and dysphagia. He has a history of insulin dependant diabetes. He had a molar
extraction due to infection two days before symptoms developed. What is the most likely
diagnosis?

Peritonsillar abscess 3%

✓ Ludwig's angina 86%

x Retropharyngeal abscess 10%

Acute epiglottitis 0%

Allergic angioedema 2%

ANSWER
Ludwig's angina is a bilateral infection of the submandibular space that consists of two compartments in the
floor of the mouth, the sublingual space and the submental space. Over two-thirds of patients with Ludwig’s
angina have a dental source of infection, usually involving the second or third mandibular molar teeth.
 Maxillofacial & Dental  QUESTION 28

A 23 year old man presents to the Emergency Department. He has sustained a deliberate self harm wound to the
forehead. You examine the injury and note a 7cm laceration to the forehead extending through the dermis. There is
no evidence of nerve or vessel injury. Apposition of the wound edges is easily achieved, however there is an increase
in tension with certain facial expressions. Which of the following is the best option for closure?

Tissue adhesive (Glue) 9%

Adhesive tape (Steristrips) 22%

x Wound staples 7%

✓ Suture 55%

Primary closure not indicated 7%

ANSWER

Suturing is indicated for any laceration through the dermis, especially wounds that require careful wound approximation.
Most facial wounds should be closed with simple interrupted suture placement.
 Maxillofacial & Dental  QUESTION 29

A 32 year old is brought to the Emergency Department after being found collapsed in the street.
Enroute to the Emergency Department his GCS improves to 15 and he tells you he has been
drinking heavily and thinks he fell. He has evidence of trauma to the face. Which of the following
best describes the findings on this x-ray?

Fracture of the right zygomatic arch 14%

✓ Fracture of the zygomaticomaxillary complex 43%

x Orbital blow-out fracture 25%

Le Fort type I fracture 12%

Fracture of the right medial maxillary sinus wall 6%

ANSWER
In zygomaticomaxillary complex fractures, the following fracture components are usually identified:

Fracture of the zygomatic arch and/or diastasis of the zygomaticotemporal suture

Fracture of the lateral orbital rim and/or diastasis of the frontozygomatic suture
Fractures of the inferior orbital rim and maxillary sinus wall and/or diastasis of the zygomaticomaxillary suture
 Maxillofacial & Dental  QUESTION 30

A 32 year old boxer presents to the Emergency Department following a match. He sustained multiple blows to the
right side of the face and you note swelling and bruising around the right orbit. On examination you note vertical
diplopia. What is the most likely cause for this finding?

Loss of innervation of the superior oblique muscle 3%

Oculomotor nerve palsy 6%

x Trochlear nerve palsy 10%

✓ Entrapment of the inferior rectus muscle 70%

Entrapment of the superior oblique muscle 10%

ANSWER
The patient most likely has an orbital floor fracture. Diplopia/ophthalmoplegia may occur, particularly on upward gaze, due to trapping of the
herniated inferior rectus muscle.
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Maxillofacial & Dental  QUESTION 31 >

A 68 year old woman presents to the Emergency Department after a syncopal

episode. She recalls walking up a flight of concrete steps before feeling "lightheaded".
She is complaining of pain in her jaw. What is the diagnosis?

Fracture of the angle of the mandible 5%

Fracture of the mandibular ramus 13%

x Fracture of the mandibular condyle 5%

✓ Fracture of the mandibular body 71%

Fracture through the mandibular symphysis 6%

ANSWER
There is a fracture of the body of the mandible.
 Maxillofacial & Dental  QUESTION 32

A 45 year old man presents to the Emergency Department complaining of dental pain referred to the ear. He had a
molar extraction 2 days previously. You suspect alveolar osteitis (dry socket). Which of the following is a risk factor for
developing this condition post-extraction?

✓ Smoking 73%

Obesity 2%

High caffeine intake 7%

x Drinking above recommended amounts of alcohol 10%

History of aphthous ulcers 7%

ANSWER
It is much more common among smokers and oral contraceptive users and occurs mainly after removal of mandibular molars, usually wisdom
teeth.
 Maxillofacial & Dental  QUESTION 33

An 18 year old rugby player is brought to the Emergency Department by his teammates. He was punched to the face
during a game. On examination you note orbital emphysema and paraesthesia in the malar region. Which nerve is
most likely injured?

Inferior alveolar nerve 12%

Supraorbital nerve 5%

x Mental nerve 6%

Infratrochlear nerve 6%

✓ Infraorbital nerve 72%

ANSWER
The infraorbital nerve can be injured in an orbital floor fracture and cause numbness to the malar region.

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 Maxillofacial & Dental  QUESTION 34

A 32 year old man presents to the Emergency Department with a 2 day history of a
painful mouth and swollen face. He has a history of intravenous drug use and chronic
alcohol misuse. On examination you note extensive dental caries and the above finding.
What is the diagnosis?

Periodontal abscess 52%

Gingivitis 3%

✓ Periapical abscess 35%

Aphthous ulcer 7%

Squamous cell carcinoma 4%

ANSWER
Bacteria associated with dental infection include oral streptococci and anaerobes (including Prevotella,
Bacteroides, and Fusobacterium species). Dental abscess is usually polymicrobial.

There are two main types of dental abscess:

Periapical abscess — caused by infection of the root canal of the tooth usually secondary to dental caries
(can also occur as a result of trauma)
Periodontal abscess - originates in deep periodontal pockets between the tooth and the gum and occurs
when there is occlusion of drainage of the periodontal pocket (as in chronic periodontitis)

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Which one of the following statements is correct regarding the management of dental emergencies in
the UK?

One-fifth of health authorities have no formal arrangements for emergency dental care at
weekends

A patient with an emergency dental problem will be treated in a similar fashion, no matter
where they are located in the UK

There are comprehensive out-of-hours arrangements for the care of patients with dental
problems in the UK

Non-traumatic dental problems account for approximately 1:5000 patients attending

emergency departments (EDs) in the UK

Studies have shown that junior doctors in the ED have an excellent knowledge of both dental
anatomy and the management of dental abscess

1 point(s)
2. Question

You are the working in the minors area of the ED and you examine the mouth of a 6-year-old boy.
Which one of the following combinations of deciduous and permanent teeth are you most likely to
see?

Deciduous incisors, canines and permanent molars

Permanent incisors, deciduous canines and permanent molars

Permanent incisors, permanent canines and permanent molars

Deciduous incisors, canines and molars

Deciduous incisors, permanent canines and molars

1 point(s)
3. Question

Which one of the following statements is correct regarding the anatomy and pathophysiology of a
dental abscess?

The most common pathogens in dental abscess are mixed anaerobic and aerobic species

The neurovascular components of the tooth are contained within the periodontal ligament

Occasionally infection may spread through the deep fascial planes and cause Vincent's
angina

The gingiva is the most common site of entry of infection ultimately forming an abscess
 Prevotella is an uncommon anaerobic cause of dental abscess

1 point(s)
4. Question

A 64-year-old male smoker presents with ongoing mandibular pain which became worse when he went
outside for a morning walk. On examination his observations are within normal limits, he has a BMI of
36 and generalised poor oral hygiene though no obvious abscess. Select the most appropriate
investigation that should be performed on initial assessment of this patient.

A throat swab

A soft tissue view of the neck

An orthopantomogram (OPG) x-ray

Blood tests including FBC, U+E, ESR

An ECG

1 point(s)
5. Question

A 26-year-old man presents to the ED complaining of one day of unilateral posterior mandible pain. He
states that the pain is similar to when he had an impacted wisdom tooth on the other side one year
ago. He denies any trauma and is normally fit and well and doesn’t take any medication. His
observations are all normal and examination of the oral cavity reveals no erythema, swelling or any
other signs of intraoral pathology. Which one of the following options represents your best course of
action in this case?

Refer the patient to the maxillofacial team for surgical exploration

Advise him to take paracetamol and ibuprofen for the pain and instruct him to return to the
ED if his pain worsens over the next few days

Advise him to take paracetamol and ibuprofen for the pain and refer him back to his own
dentist

Prescribe amoxicillin and ibuprofen and refer him back to his own dentist

Organise an orthopantomogram (OPG) and ask the maxillofacial specialist to see him in the
ED

1 point(s)
6. Question

You are working in the ED on a night shift when the triage nurse informs you that a man who presented
earlier with toothache and a fever, now looks unwell. He is sitting in the waiting room, appears
tachypnoeic and is complaining that he is unable to swallow. Which one of the following statements
represents the optimal course of action you should take?
 Move the patient to the resuscitation room and ask a junior ED colleague to see him

Ask the triage nurse to complete a set of observations in the triage room and report back to
you

Move the patient to the resuscitation room, assess him yourself and consider contacting a
senior anaesthetist and otolaryngologist urgently

Move the patient to an assessment area and contact the maxillofacial specialist

Ensure the patient is next in the queue to be seen

1 point(s)
7. Question

A 36-year-old woman with rheumatoid arthritis and currently on maintenance prednisolone presents
with right sided lower mandible pain and swelling. She has been taking ibuprofen and amoxicillin,
prescribed by her GP, for the last two days. On examination her observations are; pulse 120/minute,
blood pressure 115/72, respiratory rate 20/minute, temperature 38.2°C. There is an obvious swelling at
the base of her right second molar.

Which one of the following statements is the optimal disposal plan for this patient?

Refer her for admission under the care of a maxillofacial surgeon

Arrange for her to be admitted under the care of a rheumatologist for administration of
intravenous antibiotics

Prescribe metronidazole and paracetamol and arrange for her to return to a maxillofacial
clinic the next day

Advise the patient to go and see her dentist for removal of the tooth

Prescribe metronidazole and paracetamol and advise her to see her dentist for review

1 point(s)
8. Question

A previously well 38-year-old woman, presents to the ED one evening with a 7-day history of a dental
abscess. She is still complaining of pain and there is obvious swelling to the lower left cheek over the
first molar which has not changed appreciably in the last week. She has just finished a five day course
of amoxicillin 500mg TDS from her dentist. A set of observations are done which are all normal except
for a temperature 37.9°C. Which one of the following treatments is most appropriate in this patient?

Arrange admission under the care of the maxillofacial surgeon

Prescribe metronidazole 400 mg TDS and refer the patient back to her dentist

Prescribe ibuprofen 400 mg TDS and advise her to see her dentist ASAP
 Prescribe amoxicillin 500 mg TDS for a further week

Prescribe co-amoxiclav 625mg TDS and refer her back to her dentist

1 point(s)
9. Question

A 39-year-old man is brought to the ED by ambulance at 05:00h with severe pain in his mouth and
obvious bilateral submandibular erythema and swelling. The paramedic advises you that the patient
has a temperature of 38.8°C and is struggling to breathe as his tongue is protruding from his mouth.
You make a rapid diagnosis of Ludwig’s angina. Which one of these statements is true regarding this
diagnosis?

The presence of neck swelling rules out this diagnosis

A soft tissue x-ray of the neck should be ordered urgently as this will guide treatment of this
patient

It likely that the infection originated in his tonsils and spread to the sublingual space

Apart from airway management, oral antibiotic therapy is the only other treatment needed
for this patient

A surgical airway may be required in this patient

1 point(s)
10. Question

The next patient you see is a 48-year-old alcoholic man complaining of a worsening sore mouth for the
past two weeks. He hasn’t seen his GP and is not registered with a dentist. On examination his
observations are normal apart from a temperature of 37.7°C. You find generalised erythema and
swelling of the gingiva with a grey membrane covering the upper part of the gum. You make a
diagnosis of acute necrotising ulcerative gingivitis. Which one of the following statements is correct
regarding this diagnosis.

A 3-day course of either amoxicillin or metronidazole is appropriate for this problem

This problem is most commonly caused by fungal infection of the gingiva

This diagnosis is also known as trench mouth or Ludwig’s angina

The fact that the patient is an alcoholic has made no difference to the development of this
problem

The patient requires admission for urgent maxillofacial treatment

Finish Exam
 1 point(s)
1. Question

Considering the incidence and type of mandibular fractures presenting to the emergency department (ED),
which one of the following statements is true?

Injuries sustained in road traffic accidents are the most common cause of mandibular fracture

Approximately one-third of mandibular fractures occur to the body of the mandible

Other facial fractures are rarely found in association with mandibular fracture

Mandibular fracture is an uncommon facial fracture; zygomatic, nasal and maxillary fractures are
more frequent

In majority of mandibular fractures there are multiple fracture sites

1 point(s)
2. Question

A patient attends the ED with an apparent dislocated temporomandibular joint (TMJ). Which of the following
statements correctly describes the presentation of TMJ dislocation to the ED?

The TMJ contains a cartilage which stabilises and reduces the range of movement of the joint

Anterior TMJ dislocation is commonly accompanied by fracture of the mandible

The TMJ can dislocate in an anterior, posterior, medial and lateral direction

Dislocation of the TMJ is a frequent presentation to the ED

Most TMJ dislocations are unilateral

1 point(s)
3. Question

When taking a history from a patient who has sustained a traumatic mandibular problem, which one of the
following statements is correct?

A downward blow to a partially open mouth is a typical traumatic cause of anterior TMJ dislocation

A fall onto the point of the chin typically fractures the body of the mandible

Loss of consciousness rarely occurs in mandibular fracture

Patients with a connective tissue disorder are less likely to dislocate their TMJ, due to a greater range
and freedom of joint movement
 A lateral blow, usually as a result of interpersonal violence, typically causes fracture of the
mandibular condyle

1 point(s)
4. Question

Upon examining the patient and inspecting the face and mandible, which one of the following statements is
true?

A closed mouth, which the patient is unable to open, is found in a dislocated TMJ

Bleeding from the ear is only due to a basal skull fracture or ruptured tympanic membrane

A tilted or asymmetrical appearance of the mouth is pathognomonic of displaced mandibular fracture

Haematoma in the sublingual space is indicative of mandibular fracture

Lacerations to the gum mucosa are common and do not correlate with the presence of a fracture

1 point(s)
5. Question

Following your examination, you move on to feel and move the mandible. One of these statements regarding
further examination is true – which one is it?

The commonest cause of a patient complaining that their teeth don’t fit 'correctly' is a tooth fracture
or avulsion

The tongue blade test is clinically useless in practice

Zygomatic arch fracture may limit movement of the mandible

Insertion of a gloved finger in the external auditory meatus enables palpation of the coronoid process
of the mandible

Checking sensation over the upper lip and cheek is important as the mental nerve may be damaged in
mandibular injury

1 point(s)
6. Question

Having examined your patient with mandibular trauma, your next decision is whether an x-ray is necessary.
Which one of the following statements is true regarding this decision?

Malocclusion is not a useful discriminator in deciding whether an x-ray is needed

Use of a decision rule is limited by its ability to reduce the number of x-rays taken by 5 %

The presence of blood in the mouth is a useful indicator in the decision to x-ray
 A 100 % sensitive decision rule has been developed for mandibular injury

It has been demonstrated that clinicians have greater diagnostic accuracy than a decision rule

1 point(s)
7. Question

You make a decision to order an x-ray on your patient. Which one of the following statements regarding x-ray
ordering is correct?

An orthopantomogram (OPG) and standard mandibular series are equally accurate in detecting a
mandibular fracture

A chest x-ray should be ordered on all patients who have lost a tooth which cannot be accounted for

Temporomandibular joint views are best for identifying a TMJ dislocation

In an unconscious patient with a head injury, CT scan of the mandible is inaccurate and standard x-
rays must be taken to exclude a fracture

The addition of an AP mandible view to an OPG increases the accuracy of fracture detection

1 point(s)
8. Question

You diagnose a mandibular fracture in a 35 year old man who has attended the ED following an alleged assault.
Which one of the following statements is true regarding his management?

A bilateral mandibular body fracture is a potential airway problem as anterior tongue support may be
lost

Most patients with mandibular fracture can be discharged with follow up arranged in the
maxillofacial outpatients clinic two weeks later

Antibiotics are not indicated in patients with fractures of the mandible

All patients with a flail fracture of the mandible must have the fracture reduced immediately by
pulling it forwards

The location of the fracture is immaterial in the decision how to manage it, as all mandibular
fractures are internally fixed

1 point(s)
9. Question

A 65-year-old woman presents to the ED with a clinically bilaterally dislocated TMJ. Which one of the following
statements is correct regarding her presentation and management?

The dislocation must be reduced by placing the operator’s fingers in the mouth
 The operator must protect themselves against a human bite when reducing the dislocation

The most likely cause for the dislocation is that she has fallen onto her chin

Reduction of the dislocation is made difficult by spasm of the digastric muscles

A medial dislocation can be reduced in the ED by a modification of the anterior dislocation technique

1 point(s)
10. Question

You successfully reduced your patient’s TMJ dislocation. Which one of the following statements is true
regarding the post reduction management of your patient?

Advice to the patient should include supporting the mandible with the hand when yawning and
laughing

Having been given appropriate advice, the patient can be discharged to their GP with no need for
follow up

A Barton bandage is an important adjunct in stabilising the TMJ after reduction and should be applied
to all patients

Post reduction x-rays are unnecessary

The patient can be allowed to eat a normal diet as long as they don’t open their mouth wide

Finish Exam

Andrew Smith
June 19, 2019 at 1:02 pm
(https://www.rcemlearning.co.uk/modules/mandibular-and-temporomandibular-
injury/exams/mandibular-and-temporomandibular-injury/#comment-7267)

Very informative module

Reply
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1. Question

A 14 year old patient attends following being hit in the face with a hockey ball whilst not wearing a mouthguard.
He has lost 2 adult teeth. What is the name for this type of injury?

Luxation

Subluxation

Concussion

Avulsion

Extraction

2. Question

Where should the patient and clinician hold the tooth from?

Crown

Root

Anywhere on the tooth is fine

The tooth shouldn’t be touched at all

 3. Question

Assuming the teeth are still viable, which is the most appropriate treatment?

Send the patient away, advising them to report to a dentist

Splint the teeth back into place and advise a dental follow up

Inform the patient that nothing can be done to save the teeth

4. Question

Which of the following is not a potential longer term complications of tooth reimplantation?

Resorption

Anklyosis

Devitalisation

Discolouration

Tooth crown fracture

Finish Exam

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December 23, 2018 at 12:35 am (https://www.rcemlearning.co.uk/modules/dental-emergencies-2/lessons/more-

 1 point(s)
1. Question

A 75 year old patient on warfarin attends following an extraction done at his local dentist. He is
complaining of bleeding which has not stopped with simple pressure alone. Which of the following
would be incorrect in the management of this patient?

To continue the use of pressure with damp gauze

To take INR, FBC and clotting bloods and consider the use of a reversal agent.

The use of topical tranexamic mouthrinse to help stop bleeding

To place local haemostatic measures, such as haemocollagen and resorbable sutures

To encourage the patient to use regular saline mouthrinses to clean out the blood from his
mouth

1 point(s)
2. Question

A 6 year old boy attends to A&E after falling from a bicycle. He is otherwise fit and well, but is
complaining of a missing tooth. When the patient smiles you see the following:

(https://www.rcemlearning.co.uk/wp-

content/uploads/dental_image_post_quiz_1.jpg)

In the image above, how many adult teeth are visible?

(taken from http://www.oralanswers.com/the-differences-between-baby-teeth-and-permanent-teeth/

(http://www.oralanswers.com/the-differences-between-baby-teeth-and-permanent-teeth/))

2
 1

1 point(s)
3. Question

Following on from the previous question, what would your immediate treatment plan be for this patient?
Assume that an OPT x-ray has been taken and shows that the tooth has not been intruded and is indeed
missing.

Ask patient if he has tooth with him. If so, immediately wash tooth root with saline, and
reimplant into socket, and splint into place. Advise follow up with dentist

Reassure patient that the tooth lost was a deciduous tooth, advise follow up with dentist and
warn of risk of damage to underlying adult teeth

Check to make sure that there are no respiratory symptoms. Take a history to determine if
the missing tooth’s location is known. Consider the use of chest x-ray

1 point(s)
4. Question

A medically fit and well patient attends with a dental abscess on the right side of his face as shown in
the image below. He has good mouth opening, no reported difficulty swallowing, but complains of a
very severe pain and has been unable to eat food for several hours. Which of the following is the best
management strategy?

(https://www.rcemlearning.co.uk/wp-

content/uploads/dental_post_image_2.jpg)

Image taken from http://yxzl.baiduyy.com/chm11/jzyxtp/ch.6.htm

Lance abscess extraorally with a needle to allow drainage, and take a swab for culturing and
sensitivity testing. OPT radiograph to identify cause and consider extraction.

Prescription of strong analgesics and advise patient to see a dentist

 Taking of swabs from the skin and intraorally to determine whether the infection source
started intraorally or extraorally

Admit for 48 hours of IV antibiotics, consider cardiac review for possible infective endocarditis

Orthopantomogram to identify the causative tooth, incision and drainage intraorally taking a
pus swab for culturing and sensitivity testing. Consider tooth extraction

1 point(s)
5. Question

A 34 year patient presents with severe pain 3 days after a recent dental extraction, with an associated
bad taste. On examination, you see the following intraorally. Medically he smokes 30/day and drinks 20
u/week of alcohol, and is otherwise fit and well. What is the correct management?

(https://www.rcemlearning.co.uk/wp-

content/uploads/dental_post_image_3.jpg)

Taken from http://imgarcade.com/1/what-does-dry-socket-look-like-after-tooth-extraction

Urgent open surgical exploration of the area with surgical osteotomy to prevent further bony
necrosis

Admit for IV antibiotics and IV fluids

Prescription of oral antibiotics and oral analgesics

Irrigation of the area with a chlorhexidine gluconate based mouthrinse and application of
alveogyl

Irrigation of the area with saline irrigation and application of alveogyl

Finish Exam

baboul
September 12, 2017 at 2:57 pm
(https://www.rcemlearning.co.uk/modules/dental-emergencies-
2/exams/more-dental-emergencies-post-test/#comment-4682)

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Name that Broken Bone

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Author: Jemina Loganathan / Editor: Adrian Boyle / Reviewer: Tadgh Moriarty / Codes:  C3AP1d,
CAP18 / Published: 13/11/2020

This 18-year-old patient was allegedly punched by a stranger during a night out. He presented with
marked facial swelling and numbness over his right cheek.

(https://www.rcemlearning.co.uk/wp-

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Question 1 of 1
1. Question

Which fracture is visible on this facial bones x-ray?

nasal septum

frontal bone

infraorbital margin

zygomatic arch

mandible

There is a depressed fracture of the right zygoma which is part of the infraorbital margin. The
zygoma is connected to three other bones producing the zygomatic complex; the frontal bone,
the maxilla and the sphenoid bone. Disruption of the zygomatic complex often results in eye
abnormalities and this patient had horizontal diplopia on right lateral gaze. He also had marked
paraesthesia over the right cheek. The paraesthesia is secondary to neuropraxia of the
infraorbital nerve, a branch of the maxillary division of the trigeminal nerve. This leaves the
skull via the infraorbital foramen in the maxilla. Neuropraxia such as this can occur after blunt
trauma and it usually resolves in 6-8 weeks. This patient was referred to the maxillofacial
surgeons and the zygomatic fracture was treated with open reduction and internal fixation
using several metal plates.

When assessing apparently isolated facial bone injury – be sure to assess for the concomitant
head injury that was sustained, and do not miss a spinal injury. For this zygomatico-orbital
injury it is important to perform an ophthalmological assessment noting globe integrity,
presence/absence of a hyphema, proptosis or endopthalmos and eye movements to assess for
any evidence of intraocular muscle entrapment.

Up to 50% of these injuries will be managed conservatively. It is important on discharge to

remind patients to try avoid blowing their nose or pinching their nose when sneezing. This has
the potential to cause orbital emphysema.

The prescribing of antibiotics in these cases remains controversial. A best bets review in 2003
was inconclusive due to lack of studies. A review article in 2015 stated that the frequent use of
antibiotics was nor supported by literature recommendations but instead with low level
evidence. In essence, local practice guidelines or advice from local maxilla-facial service should
be followed.

References

1. McMinn’s Color Atlas of Human Anatomy (McMinn’s Clinical Atlas of Human Anatomy)
Peter H. Abrahams MBBS FRCS(Ed) FRCR DO(Hon)