Question 1:

This man received a blow to the left side of his face whilst playing rugby.

What is your provisional diagnosis?

State two important clinical signs which would support this diagnosis.

Name the radiograph which will best demonstrate your diagnosis.

Question 1: Answer
Displacement of zygomatic arch.

Clinical signs

Facial deformity

Restricted mandibular movements.

Submentovertex radiograph and optional 10 occipito-mental radiograph

Question 2:
This is an orthopantomogram of a young boy who fell on to the ground from the first floor of a
building.

What is the approximate age of the patient?

What is your diagnosis?

Question 2: Answer
9 years.

Bilateral (intracapsular) fracture of the condyles.

Possible complications

Ankylosis of the temporo-mandibular joint.

Retardation of growth of the mandible.

Question 3:

This slide shows the mouth of a man who received a direct blow to his left lower jaw.
Give three clinical signs that would support a diagnosis of fracture of the mandible.

Question 3: Answer
Clinical signs of a fractured mandible

Mucosal tear

Step deformity of the occlusion.

Sublingual haematoma

Question 4:

Slide A shows an upper left central incisor which was avulsed and replanted 10 minutes later.
Slide B shows the tooth one year later.

What has happened?

What could have gone wrong?

Question 4: Answer
The apex has closed, suggesting continued vitality.

The tooth may have lost vitality, in which case endodontic treatment would be indicated. The
periodontal ligament appears to be intact. There is no evidence of external resorption. If the extra oral
period had been greater than 30 minutes, there would be a strong likelihood of external resorption.
Question 5:

This slide depicts injury sustained by a 2-year-old who has just fallen and suffered
trauma to the upper teeth.

What has happened to these teeth?

How would you manage the problem?

What are the clinical consequences of this condition?

Question 5: Answer
The upper right central and lateral primary incisors have been intruded.

Take a radiograph to establish a baseline picture of the area involved. Reassure the parent and allow
the teeth to reerupt, which normally takes up to 6 months.

Clinical consequences

Ankylosis, which is rare, and necessitates extraction.

When the teeth re-erupt, they may:

be vital and normal in appearance;

become non-vital, when extraction is advised as infection can damage the permanent
successor;

darken, assuming a yellow hue, due to calcific obliteration of the pulp cavity. No treatment is
necessary following this post-traumatic sequel.

Question 6:
This panoramic radiograph shows two fractures of the mandible following a traumatic incident.

Do the lower third molars contribute to the injury?

What is the treatment?

Question 6: Answer
The lower third molars cause a weakness in the angle of the mandible, and fracture in this region is
more likely than if they were absent.

Remove the lower third molars, apply rigid internal fixation with or without intermaxillary fixation as
necessary.

Question 7:

This woman complained of inability to bring her front teeth together following a traumatic incident.

Name two fractures which could cause this symptom.

State two other causes for anterior open bite.

Question 7: Answer
Condylar fracture (bilateral).
Maxillary fracture (Le Fort 1, 11 and 111).

Developmental vertical maxillary excess.

Persistent thumbsucking.

Question 8:

This 3-year-old girl suffered a blow to the face when she fell from her bicycle. She suffered only the
dentoalveolar injury shown.

What is the correct management of this injury?

What are the possible complications?

Question 8: Answer
These teeth should be removed. The labial plate is comminuted and any free bone particles must be
meticulously removed. Any bone still attached to the periosteum may be retained. Reduce any
further alveolar fracture then suture the gingiva with 4/0 Vicryl or Dexon sutures. Tetanus
immunisation should be checked and in this case it would be appropriate to give antibiotics.

Possible complications

Pulp necrosis and abscess formation of the injured teeth (blue-gray crown discolouration).

Alveolar bone and/or root resorption with loss of injured teeth.

 Slow calcification of coronal pulp chambers and root canals of injured teeth.

Enamel defects of crowns of developing permanent incisors.

Question 9:

What kind of radiographic projection was used for this slide?

List the structures you can identify.

Describe any fractures you can see.

Question 9: Answer
Coronal CT scans (coronal reconstruction of axial scan) at the level of the external auditory meatus.

Structures identified

Cavernous sinus

Middle cranial fossa

Petrous temporal bone

Ascending rami of mandible

Lower left third molar.

Fractured right coronoid process. Fractured left angle of mandible.

Question 10:

This slide shows the central incisor of a 10-year-old who suffered a complicated crown fracture with a
large exposure. Part (a) shows the tooth at the time of injury and Part (b) shows the tooth 12 months
later.

What treatment was carried out to achieve this result?

Question 10: Answer

The process is called apexogenesis.

A Cvek pulpotomy was undertaken using calcium hydroxide. The tooth remained vital as root
development continued indicating no damage to the epithelial root sheath. Some hard tissue
formation is evident in the root canal at the level of amputation.

Question 11:
This is a radiograph of a patient who was punched in the face.

What is your diagnosis?

How would you treat this condition?

Question 11: Answer

Displaced fracture right body of mandible through socket 46.

Due to displacement and unfavourable muscle pull and lack of occlusal contact at fracture site,
maximum reduction and stability requires rigid internal fixation and inter-maxillary fixation as
necessary.

Question 12:

As a consequence of trauma, this maxillary lateral incisor has been fractured with the fracture line
extending below the alveolar crest on the palatal aspect.

Which of the following would be the preferred management of the periodontal tissues prior to
obtaining an impression to construct a crown for this tooth?

a. Gingivoplasty to expose fracture margin.

b. Use of electrosurgery to expose fracture margin.

c. Reflection of full thickness mucoperiosteal flap with possible bone resection to expose the
fracture margin.

Question 12: Answer

(c) Reflection of full thickness mucoperiosteal flap with possible bone reduction to expose fracture
margin.

Question 13:

This patient has received immediate treatment for a Le Fort III fracture which she sustained in a road
traffic accident.

Name three immediate measures which have been taken to treat this patient.

What is the most likely cause of the continuous blood-stained discharge through the right
nostril?
Question 13: Answer
Immediate measures

Endotracheal intubation with a cuffed tube to maintain the airway.

Orogastric tube to aspirate stomach contents.

Packing of left nasal cavity to control nasal bleeding.

Primary closure of lacerations.

Cerebrospinal fluid leak due to fracture of the anterior cranial base in the region of the cribriform plate
(CSF Rhinorrhoea).

Question 14:

This 8-year-old child presented with this gradually increasing lesion on his lower lip of three months'
duration.

What is your clinical diagnosis?

How would you treat this lesion?

Mention two dental abnormalities you see on this slide.

Question 14: Answer

Mucocoele (mucous extravasation cyst).

Treatment - Surgical excision.

Dental abnormailites

Missing lower central incisors.

Atypical lateral incisors.

uestion 15:

This slide shows two CT scans of a patient complaining of double vision, who received a direct hit on
the right eye with a squash ball.

What is your diagnosis?

What is the name given to this radiological sign?

Question 15: Answer

"Blow-out" fracture of the right orbital floor.

Tear drop sign.

Question 16:
This composite slide is of an I l-year-old boy who received a blow on the right central incisor. The
crown was very mobile and a middle third fracture of the root was evident.

How long should this splint remain in position, and why was it used?

What type of repair would you expect?

Question 16: Answer

Splints for root fractures should remain for about three months. In this middle third fracture with
mobility there has been displacement. Splinting minimises movement between the root fragments.
(b) The healing should take place with calcific tissue.

uestion 17:
This slide shows the reduction and fixation of a mandibular fracture with a compression plate.

Under what medical conditions would this method of fixation be advantageous?

State two disadvantages of this surgical approach.

Advantages -

Where intermaxillary fixation would compromise the patient, e.g. Epilepsy; Chronic airway
disease; Head injury.

Disadvantages -

Possible damage to the mandibular branch of the facial nerve.

External scar.

Question 18:
This radiograph is of a 4 and a half -year-old who suffered an injury to the upper right central incisor
at 7 months of age.

What has happened to the permanent successor?

What type of injury occurred to the primary incisor?

Question 18: Answer

What can be seen of the permanent incisor would suggest disturbance of crown formation which is
most probably dilaceration.

The primary central incisor was intruded in a palatal direction and rotated. The intruded primary
incisor re-erupted but the root failed to develop because of damage to the Hertwig's epithelial root
sheath. Its pulp chamber appears to have been obliterated by calcification.

Question 19:
This patient received injury to his lower lip and upper incisors following a fall from his bicycle.

What radiographs would you take to assess this injury?

Name three drugs you would use in the management of this case.

Question 19: Answer

Radiographs -

Periapical radiographs.

Upper standard occlusal radiograph.

Soft tissue lateral radiograph to check for a foreign body in the lower lip.

Drugs used in management -

Antimicrobial (Penicillin, Amoxycillin or Erythromycin).

Tetanus prophylaxis.

Analgesics (non-steroidal anti-inflammatory).

Question 20:
This patient sustained a motor vehicle accident and was sent home carrying perhaps the most
commonly overlooked jaw injury.

Diagnose the injury.

What would be the clinical signs of such an injury?

What treatment is indicated?

Question 20: Answer

Clinical signs -

Trismus

Pain

Deviation of mandible to affected side. Open bite on the opposite side

Treatment -

Condyle must be relocated either by manipulation or by direct reduction.

Short period of intermaxillary fixation (2 weeks) with up to 6 weeks of Class II elastic

traction on the side of the fracture

Early function following fixation.

Soft diet.