Kuwait Dental Board Oral & Maxillofacial Surgery cheat sheet

Mandible blood supply: inferior alveolar artery (branch of maxillary) is the main supply; the lingual and facial arteries contribute; periosteal supply dominates in the body, so stripping both periosteum and medullary supply risks necrosis.

Lingual nerve lies medial to the mandibular third molar, usually 0-3 mm buccal to the lingual cortex at the crest; the nerve is at risk with lingual flap retraction and lingual split techniques.

Facial nerve exits the stylomastoid foramen; the marginal mandibular branch runs below the inferior border of the mandible in the subplatysmal plane anterior to the facial vessels, so submandibular incisions should stay 1-2 cm below the border.

Warfarin: monitor INR; dental extraction is generally safe with INR <= 3.5-4.0; do not stop the drug, use local hemostatic measures. Direct oral anticoagulants (dabigatran, rivaroxaban, apixaban) are usually continued for minor oral surgery with local measures.

Lidocaine 2% with 1:100,000 epinephrine: maximum dose 4.4 mg/kg (7 mg/kg with epinephrine, absolute max ~500 mg); articaine 4% max 7 mg/kg; mepivacaine 3% max 6.6 mg/kg; prilocaine max 8 mg/kg (risk of methemoglobinemia).

Antibiotic prophylaxis for infective endocarditis (NICE/ACC/AHA context): high-risk cardiac conditions only (prosthetic valve, previous IE, certain congenital heart disease); amoxicillin 2 g orally 30-60 min pre-procedure, or clindamycin in penicillin allergy per local guidance.

Bisphosphonate-related osteonecrosis of the jaw: risk rises with IV potency and duration; avoid elective extractions; if extraction is unavoidable, minimize trauma, primary closure, and consider drug holiday only after oncology consultation.

Epinephrine in local anesthetic: vasoconstriction, reduced bleeding, prolonged anesthesia; caution in uncontrolled hyperthyroidism, pheochromocytoma, and severe cardiovascular disease; limit to ~0.04 mg (2 cartridges of 1:100,000) in cardiac patients.

Healing of extraction socket: clot forms within hours; granulation tissue by day 7; epithelialization by 2-4 weeks; bone fill by 6-10 weeks; remodeling continues for months.

Panoramic radiograph: useful screening for impacted teeth, cysts, and gross pathology; magnification ~20-30%; not reliable for subtle bone loss or early caries; cone-beam CT (CBCT) for 3D assessment of impaction, implant site, and fractures.

Radiographic signs of malignancy: ill-defined borders, ragged margins, 'moth-eaten' bone destruction, periosteal reaction (sunburst), widening of PDL, floating teeth.

Cone-beam CT effective dose is much lower than medical CT but higher than panoramic; use ALARA and justify each scan; field of view should be limited to the region of interest.

Differential diagnosis of radiolucency: cyst, tumor, infection, metabolic, vascular; use 'SCALP' or similar systematic approach: Site, Size, Shape, Borders, Internal structure, Effect on adjacent structures.

Impacted third molar assessment: Winter's classification (mesioangular, distoangular, horizontal, vertical), Pell-Gregory (depth and ramus relationship); note root morphology and proximity to inferior alveolar canal.

Biopsy principles: incisional for large/uncertain lesions, excisional for small lesions; avoid incisional biopsy of suspected malignancy if excisional is feasible; send in formalin (not for frozen section or microbiology).

Fine-needle aspiration (FNA) for salivary gland and neck masses; ultrasound-guided FNA improves yield; core biopsy for lymphoma or when FNA is nondiagnostic.

Preoperative assessment includes medical history, bleeding risk, airway, and imaging; consent should document risks including nerve injury, bleeding, infection, and dry socket.

Odontogenic keratocyst (OKC): often multilocular, grows along bone with minimal expansion, high recurrence; consider Gorlin syndrome (nevoid basal cell carcinoma) if multiple or in young patients.

Inferior alveolar nerve block: target the lingual nerve just above the lingual cortex, 1 mL over 1 minute; failure often due to accessory innervation or variation in anatomy; consider Gow-Gates or Vazirani-Akinosi alternatives.

Positive aspiration rates: inferior alveolar block ~10-15%; use aspiration before injection; intravascular injection of local anesthetic can cause seizures and cardiovascular collapse.

Maximum doses: lidocaine 4.4 mg/kg (7 mg/kg with epinephrine); articaine 7 mg/kg; bupivacaine 1.6 mg/kg (long-acting, cardiotoxic); calculate by cartridge volume (1.8 mL in most cartridges).

Signs of local anesthetic toxicity: perioral numbness, metallic taste, tinnitus, slurred speech, seizures, then CNS depression and cardiovascular collapse; manage with airway, oxygen, benzodiazepine for seizures, and lipid emulsion for bupivacaine.

Sedation: minimal sedation (anxiolysis) preserves airway reflexes; moderate sedation (conscious sedation) requires monitoring (pulse oximetry, capnography, blood pressure) and a provider trained in airway management.

Midazolam: short-acting benzodiazepine, amnesic, respiratory depressant; flumazenil is the reversal agent; caution in elderly and hepatic impairment.

Propofol: rapid onset, respiratory and cardiovascular depression; only for trained providers with airway equipment; no specific reversal.

Nitrous oxide/oxygen: rapid onset and offset; contraindicated in bowel obstruction, pneumothorax, recent middle ear surgery, and first trimester of pregnancy; monitor oxygen saturation.

Postoperative pain: NSAIDs (ibuprofen) are first-line for odontogenic pain; combine with paracetamol; avoid NSAIDs in renal impairment, peptic ulcer, and third trimester; opioids only when indicated.

Indications for extraction: nonrestorable caries, periodontal disease, fracture, impaction, orthodontic need, infection source, and pathology; consider alternatives and consent.

Surgical extraction principles: adequate access, bone removal, tooth sectioning, and elevation; avoid excessive force; protect adjacent teeth and bone.

Dry socket (alveolar osteitis): severe pain 2-4 days post-extraction, empty socket, exposed bone; risk factors smoking, oral contraceptives, traumatic extraction; treat with irrigation and medicated dressing.

Post-extraction bleeding: apply pressure with gauze, local hemostatic agents (oxidized cellulose, gelatin sponge, tranexamic acid mouthwash), suture; check for bleeding disorders and anticoagulants.

Third molar surgery risks: inferior alveolar nerve injury (temporary ~1-5%, permanent <1%), lingual nerve injury, dry socket, infection, root fracture, displacement into spaces.

Coronectomy: intentional retention of roots when close to inferior alveolar canal; reduces nerve injury risk; contraindicated if roots are infected or mobile.

Frenectomy: for ankyloglossia or persistent diastema; laser or scalpel; watch for lingual nerve and submandibular duct injury.

Apicoectomy: indicated for failed endodontic treatment with persistent periapical pathology; ensure adequate root canal filling and apical seal; avoid damage to adjacent structures.

Postoperative instructions: pressure, ice, soft diet, oral hygiene, avoid smoking and straws; review if pain, swelling, or fever persists.

Ludwig's angina: bilateral submandibular, sublingual, and submental space infection; board-like swelling, tongue elevation, airway compromise; treat with airway management, IV antibiotics, and surgical drainage.

Space infections: submandibular, sublingual, buccal, canine, infratemporal, pterygomandibular, parapharyngeal, retropharyngeal; spread depends on root apex location relative to muscle attachments.

Antibiotics for odontogenic infection: amoxicillin-clavulanate or penicillin plus metronidazole; clindamycin for penicillin allergy; IV for severe or spreading infection; always combine with source control.

Signs of severe infection: trismus, dysphagia, drooling, stridor, fever, elevated white count, and rapid spread; airway assessment is priority.

Mandibular fracture: parasymphysis most common; assess occlusion, step deformity, inferior alveolar nerve function, and condylar segments; panoramic and CT imaging.

Le Fort fractures: I (maxilla above apices), II (pyramidal, through infraorbital rim), III (craniofacial dysjunction); assess for midface mobility and airway.

Zygomatic complex fracture: malar prominence loss, subconjunctival hemorrhage, diplopia, infraorbital nerve numbness; assess with submentovertex or CT.

Orbital blowout fracture: restricted upward gaze (inferior rectus entrapment), enophthalmos, diplopia; CT coronal view; urgent ophthalmology referral if visual acuity changes.

Condylar fracture: consider closed reduction with intermaxillary fixation or open reduction depending on displacement; monitor for airway and malocclusion.

Odontogenic cysts: radicular (periapical) most common, dentigerous (associated with crown of impacted tooth), and odontogenic keratocyst (OKC) with high recurrence; histology confirms diagnosis.

Ameloblastoma: benign but locally aggressive odontogenic tumor; usually mandibular posterior; multilocular 'soap bubble' appearance; treatment is resection with margins; recurrence common with curettage.

Odontoma: most common odontogenic tumor; compound (tooth-like) or complex; usually asymptomatic; conservative excision.

Salivary gland tumors: parotid most common site; pleomorphic adenoma most common benign; mucoepidermoid carcinoma most common malignant; FNA and imaging guide management.

Pleomorphic adenoma: benign mixed tumor; superficial parotidectomy with facial nerve preservation; enucleation risks recurrence.

Warthin tumor: benign, cystic, often in older males and smokers; usually parotid tail; conservative excision.

Mucoepidermoid carcinoma: graded low/intermediate/high; low-grade behaves indolently; high-grade requires wide resection and neck dissection consideration.

Adenoid cystic carcinoma: perineural invasion, late recurrence, and distant metastasis; long-term follow-up required.

Ranula: mucocele of sublingual gland; floor of mouth; treat with excision of sublingual gland or marsupialization; plunging ranula extends into neck.

Squamous cell carcinoma (SCC) of the oral cavity: most common oral malignancy; risk factors tobacco, alcohol, betel quid, HPV (oropharyngeal); biopsy for any nonhealing ulcer >2 weeks.

TNM staging: T describes tumor size and invasion, N regional nodes, M distant metastasis; staging guides treatment and prognosis.

Management of oral SCC: wide local excision with margins (usually 1-1.5 cm), neck dissection for clinically positive or high-risk necks, and adjuvant radiotherapy for adverse features.

Reconstruction: local flaps for small defects; free flaps (radial forearm, fibula, anterolateral thigh) for larger defects; consider bone reconstruction with fibula or iliac crest.

Radiotherapy effects: mucositis, xerostomia, osteoradionecrosis, trismus; avoid elective extractions in irradiated fields; hyperbaric oxygen controversial.

Neck dissection: levels I-V; selective neck dissection for clinically negative neck in high-risk oral SCC; radical neck dissection for extensive nodal disease.

Sentinel lymph node biopsy: emerging for early oral SCC with clinically negative neck; not universally standard.

Osteoradionecrosis: irradiated bone exposed >3 months without healing; management includes conservative care, antibiotics, and resection with reconstruction in advanced cases.

Chemotherapy and immunotherapy: cisplatin-based regimens; immunotherapy (PD-1 inhibitors) for recurrent/metastatic disease; multidisciplinary team approach.

TMD classification: myofascial pain, internal derangement (disc displacement with/without reduction), degenerative joint disease, and inflammatory disorders.

Disc displacement with reduction: clicking, normal opening; without reduction: limited opening, deviation to affected side, no click.

Imaging: panoramic for screening; MRI for disc position and joint effusion; CBCT for bony changes.

Conservative management first: patient education, soft diet, jaw exercises, NSAIDs, muscle relaxants, occlusal splint, and physical therapy.

Occlusal splint: stabilization appliance for bruxism and myofascial pain; not proven to permanently alter occlusion.

Arthrocentesis: joint lavage for closed lock and acute disc displacement; can be combined with steroid injection.

Surgery: arthroscopy, disc repair, or joint replacement for severe refractory cases; reserved for selected patients.

Red flags: unilateral swelling, unexplained weight loss, night pain, and neurological symptoms warrant further investigation for malignancy or systemic disease.

Orthognathic surgery: correct skeletal discrepancies; preoperative orthodontics, model surgery, and cephalometric planning; common procedures Le Fort I, bilateral sagittal split osteotomy (BSSO), and genioplasty.

BSSO risks: inferior alveolar nerve injury (common, often temporary), unfavorable split, bleeding, and relapse; fixation with plates or screws.

Le Fort I osteotomy: mobilizes maxilla; risks include bleeding (descending palatine artery), nerve injury, and relapse; fixation with miniplates.

Distraction osteogenesis: gradual lengthening of bone; used for mandibular hypoplasia and craniofacial syndromes; requires latency, distraction, and consolidation phases.

Rhinoplasty: functional and esthetic; assess airway, septum, and tip support; risks bleeding, infection, and revision.

Blepharoplasty and facelift: assess skin laxity, fat, and underlying structures; avoid excessive tension and nerve injury.

Orthognathic stability: relapse more common with large movements and condylar resorption; long-term follow-up.

Patient selection: realistic expectations, psychological assessment, and informed consent; document preoperative photographs and measurements.

Implant success criteria: stability, no peri-implant radiolucency, bone loss <0.2 mm/year after first year, no pain or mobility; survival vs success distinction.

Bone density: Lekholm and Zarb classification; CBCT for bone volume and vital structures; minimum bone width and height for standard implants.

Implant placement timing: immediate, early, or delayed; immediate placement after extraction in selected cases with intact socket walls.

Sinus lift: lateral window or crestal approach for posterior maxilla; assess sinus health and membrane thickness; risks membrane perforation and infection.

Guided bone regeneration: barrier membranes and bone grafts; principles of osteogenesis, osteoinduction, and osteoconduction.

Peri-implantitis: inflammation with bone loss; risk factors smoking, poor hygiene, and history of periodontitis; treat with debridement and possible surgery.

Pre-prosthetic surgery: alveoloplasty, tuberosity reduction, frenectomy, and vestibuloplasty; aim for adequate denture-bearing area.

Implant loading: immediate, early, or delayed; consider primary stability and occlusal load.

Medical considerations: uncontrolled diabetes, smoking, and head/neck radiation increase failure risk; assess and optimize before surgery.

Medical emergency kit: oxygen, suction, epinephrine, antihistamine, bronchodilator, glucose, aspirin, nitroglycerin, and defibrillator; check expiry dates regularly.

Syncope: most common emergency; supine position, legs elevated, oxygen, monitor; if no recovery, assess for other causes.

Anaphylaxis: epinephrine IM 0.3-0.5 mg (1:1000) in adults, repeat every 5-15 minutes; oxygen, IV fluids, and antihistamine as adjuncts.

Local anesthetic overdose: stop injection, airway, oxygen, benzodiazepine for seizures, lipid emulsion for bupivacaine; monitor vitals.

Infection control: standard precautions, hand hygiene, personal protective equipment, sterilization of instruments (autoclave), and safe sharps disposal.

Medically complex patients: consult with physician; consider antibiotic prophylaxis, anticoagulation management, and stress reduction; monitor blood glucose in diabetics.

Hypertension: avoid elective surgery if severely uncontrolled; monitor blood pressure; caution with epinephrine-containing local anesthetics.

Asthma: avoid triggers, have bronchodilator available; stress reduction and adequate anesthesia; avoid aspirin in aspirin-sensitive patients.

Pregnancy: avoid elective surgery in first trimester; use category B drugs; left lateral position to avoid supine hypotension; local anesthesia with epinephrine is acceptable.

Study designs: randomized controlled trial (highest for therapy), cohort, case-control, cross-sectional, case series; systematic reviews and meta-analyses synthesize evidence.

Levels of evidence: systematic reviews of RCTs > RCTs > cohort > case-control > case series > expert opinion; GRADE assesses quality.

Sensitivity: true positive rate; specificity: true negative rate; positive predictive value depends on prevalence.

Confidence interval: range of plausible values; narrower with larger sample size; p-value <0.05 commonly used but not a measure of effect size.

Bias: selection, information, confounding, and publication bias; randomization and blinding reduce bias.

Informed consent: capacity, disclosure of risks/benefits/alternatives, voluntariness, and documentation; emergency exception when immediate treatment is needed.

Confidentiality and data protection: patient information must be protected; share only on need-to-know basis; comply with local regulations.

Professional ethics: honesty, competence, patient autonomy, and conflict-of-interest disclosure; report impaired colleagues and adverse events.

Clinical audit and quality improvement: measure against standards, implement change, and re-audit; part of evidence-based practice.