Dental MCQ
Local anesthesia and nerve pathways · Head & Neck · INBDE Patient Cases

Bones & Foramina INBDE Patient Cases

By Dr. Isaac Sun, DDS

11 ADA INBDE-format patient cases on bones & foramina. Each case is a shared patient box (chief complaint, history, medications, allergies, exam) followed by linked multiple-choice questions with full distractor explanations. Practice the way the real exam is structured.

11 patient cases55 linked questionsADA INBDE formatFull distractor explanations

Eleven ADA INBDE-format patient cases on skull foramina and the structures that pass through them: the foramen ovale and mandibular foramen (inferior alveolar nerve and the Gow-Gates block), the cribriform plate (CSF rhinorrhea and anosmia), the infraorbital foramen and greater palatine canal (anesthetic diffusion into the orbit), the incisive foramen (nasopalatine duct cyst), the mental foramen (periapical mimic and nerve injury after apical surgery), the foramen spinosum (middle meningeal artery and epidural hematoma), the stylomastoid foramen (Bell's palsy versus stroke), the jugular foramen (jugular foramen syndrome with hoarseness and a weak shoulder shrug), and the styloid process (Eagle syndrome).

Case Coverage Map
What each case is testing
Persistent pain after multiple IAN blocks:
V3 through foramen ovale, why pulpal anesthesia fails, and the Gow-Gates rescue.
Lip numbness after a third molar extraction:
Inferior alveolar nerve in the mandibular canal, Seddon injury grades, and the referral window.
Clear nasal drip after midface trauma:
Cribriform plate fracture, CSF rhinorrhea and anosmia (CN I), and meningitis precautions.
Double vision after an infraorbital injection:
Anesthetic tracking through the infraorbital foramen into the orbit (CN VI).
Orbital signs after a maxillary nerve block:
V2 via the greater palatine canal to the pterygopalatine fossa, and diffusion into the orbit.
Heart-shaped radiolucency between the upper incisors:
Incisive foramen, nasopalatine duct cyst versus periapical disease, and the painful nasopalatine block.
Dark spot at a premolar apex with a tingling lip:
Mental foramen mimicking periapical pathology, and mental nerve injury after apical surgery.
Lucid interval after a blow to the temple:
Middle meningeal artery at the foramen spinosum, the lens-shaped epidural bleed, and emergency transfer.
One-sided facial droop at a cleaning:
Stylomastoid foramen and CN VII, Bell's palsy versus stroke, and eye protection.
Hoarse voice and a weak shoulder on a cancer screen:
Jugular foramen (CN IX, X, XI), uvula deviation, and the malignancy red flag.
Throat and ear pain on swallowing:
Elongated styloid process, glossopharyngeal irritation, and the panoramic incidental finding.
Patient case: Persistent pain after multiple IAN blocks
0 of 5 answered, 0 correct
Patient
Male, 36 years old
Chief Complaint
"You've numbed me three times and I can still feel the tooth."
Background and/or Patient History
  • Healthy, no systemic disease
  • Presenting for endodontic treatment on tooth #30 with symptomatic irreversible pulpitis
  • Two standard IAN blocks plus a long buccal infiltration with 2% lidocaine and 1:100,000 epinephrine already delivered
Allergies
NKDA
Medications
  • None
Dental History
  • Prior IAN blocks have always worked
  • No prior endodontic treatment
Current Findings
  • Profound soft-tissue anesthesia of the right lower lip, chin, and anterior two-thirds of the tongue
  • Tooth #30 still responsive to cold testing
  • Tooth #30 responsive to instrumentation in pulp chamber
  • No swelling, no trismus
  1. Question 1
    Easy
    The lip and tongue are numb but tooth #30 is not. What does this localize the failure to?
  2. Question 2
    Easy
    Through which foramen does the nerve targeted by an IAN block exit the skull base?
  3. Question 3
    Moderate
    Which factor most commonly explains pulpal anesthesia failure in irreversible pulpitis?
  4. Question 4
    Moderate
    Which supplemental technique is most appropriate next?
  5. Question 5
    Hard
    A Gow-Gates block deposits anesthetic closer to the neck of the condyle, near the V3 trunk before it branches. Why does this approach often succeed when standard IAN blocks fail?

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Patient case: Persistent lip numbness after #32 extraction
0 of 5 answered, 0 correct
Patient
Female, 24 years old
Chief Complaint
"My lip and chin on the right are still numb four weeks after my wisdom tooth."
Background and/or Patient History
  • Healthy, no systemic disease
  • Surgical extraction of impacted tooth #32 four weeks ago
  • Pre-op pano showed inferior alveolar canal in close apposition to root apices with darkening of the roots where they crossed the canal
  • Persistent right lower lip and chin numbness with tingling on skin tap
  • No tongue involvement
Allergies
NKDA
Medications
  • Oral contraceptive
Dental History
  • Routine
  • No prior surgical complications
Current Findings
  • Healed extraction socket at #32 with no infection
  • Decreased light-touch and pinprick sensation over the right lower lip and chin
  • Two-point discrimination reduced on the right lower lip and chin
  • Tongue sensation normal, taste normal
  1. Question 1
    Easy
    Numbness of the lip and chin without tongue involvement localizes the injury to which nerve?
  2. Question 2
    Easy
    The IAN travels in which bony canal between which two foramina?
  3. Question 3
    Moderate
    Which Seddon classification best describes a nerve injury with axonal disruption but intact endoneurial tubes, often expected to recover over months?
  4. Question 4
    Hard
    What is the most appropriate next step at this four-week visit?
  5. Question 5
    Moderate
    Which pre-op CBCT finding most strongly predicts IAN injury risk during third molar removal?

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Patient case: Clear nasal drip after midface trauma
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Patient
Male, 28 years old
Chief Complaint
"My nose keeps dripping clear fluid and everything tastes salty since the accident."
Background and/or Patient History
  • Healthy, no systemic disease
  • Motor vehicle collision two days ago, face struck steering wheel (seatbelted)
  • Presenting for evaluation of fractured tooth #9 and upper lip laceration
  • Continuous clear watery drainage from right nostril, worse on leaning forward
  • Salty taste in posterior pharynx and complete loss of smell
Allergies
NKDA
Medications
  • Ibuprofen for pain
Dental History
  • Routine
Current Findings
  • Bilateral periorbital bruising (raccoon eyes)
  • Tooth #9 complicated crown fracture with pulp exposure
  • Healing upper lip laceration
  • Clear drainage from the right naris
  • Drop on gauze shows central blood spot with clear halo
  • Bilateral anosmia confirmed on alcohol-pad screening
  1. Question 1
    Easy
    Anosmia after midface trauma localizes the injury to which structure?
  2. Question 2
    Moderate
    The halo sign on gauze (central blood with a clear ring) and the salty taste suggest which fluid?
  3. Question 3
    Moderate
    Which cranial nerve is responsible for smell, and what is its embryologic origin relative to the other cranial nerves?
  4. Question 4
    Hard
    What is the appropriate immediate management from the dental office?
  5. Question 5
    Moderate
    Why must the dental team avoid using a Valsalva maneuver, high-volume air-water syringe, or positive-pressure devices on this patient?

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Patient case: Double vision after an infraorbital injection
0 of 5 answered, 0 correct
Patient
Female, 31 years old, thin habitus
Chief Complaint
"Right after the shot for my front tooth, I started seeing double."
Background and/or Patient History
  • Healthy, no systemic disease
  • Presenting for restoration of tooth #8
  • Infraorbital nerve block delivered with 1.5 mL of 2% lidocaine with epinephrine while palpating the foramen extraorally
  • Double vision on left gaze and heavy right eyelid within five minutes
  • Upper lip and #8 profoundly numb
Allergies
NKDA
Medications
  • Oral contraceptive
Dental History
  • First infraorbital block
  • Prior maxillary infiltrations uneventful
Current Findings
  • Vitals stable
  • Profound anesthesia of right upper lip, ala of nose, and lower eyelid
  • Right upper eyelid mildly ptotic
  • Right eye does not fully abduct, producing diplopia on left gaze
  • Pupils equal and reactive, vision intact
  1. Question 1
    Easy
    The needle for an infraorbital block is aimed at which foramen, and which nerve is the intended target?
  2. Question 2
    Moderate
    Why does an infraorbital injection placed too high or too deep risk affecting eye movement?
  3. Question 3
    Moderate
    The patient cannot abduct the right eye fully. Which cranial nerve has most likely been affected?
  4. Question 4
    Moderate
    What is the appropriate management?
  5. Question 5
    Hard
    Which technique change most directly reduces the risk of recurrence at the next visit?

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Patient case: Orbital signs after a maxillary nerve block
0 of 5 answered, 0 correct
Patient
Female, 44 years old
Chief Complaint
"My eye felt strange and I saw double right after the deep palate injection."
Background and/or Patient History
  • Presenting for surgical extraction of teeth #2, #3, and #4 with alveoloplasty
  • Maxillary (V2) nerve block attempted through the greater palatine canal to anesthetize the whole quadrant
  • Needle advanced about 30 mm up the canal before deposition
  • Double vision and a heavy upper eyelid on the right within minutes
Allergies
NKDA
Medications
  • Lisinopril for hypertension
Dental History
  • Several prior uneventful infiltrations
  • First high V2 block
Current Findings
  • Profound anesthesia of the right maxillary teeth, palate, and midface
  • Right partial ptosis and limited eye movements
  • Pupil equal and reactive, vision preserved
  • Vitals stable, no respiratory distress
  1. Question 1
    Easy
    The V2 block via the greater palatine canal is intended to reach which space?
  2. Question 2
    Easy
    Through which foramen does V2 enter the pterygopalatine fossa from the middle cranial fossa?
  3. Question 3
    Moderate
    How did the block produce double vision and ptosis?
  4. Question 4
    Moderate
    Which feature reassures you this is anesthetic diffusion and not a stroke or hematoma?
  5. Question 5
    Hard
    What is the appropriate management?

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Patient case: Heart-shaped radiolucency between the upper incisors
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Patient
Male, 47 years old
Chief Complaint
"My dentist saw a dark spot on the x-ray between my two front teeth."
Background and/or Patient History
  • Routine recall exam, no pain
  • Periapical and CBCT show a well-defined radiolucency at the maxillary midline behind teeth #8 and #9
  • Both central incisors test vital to cold and electric pulp testing
  • Small firm swelling of the anterior palate just behind the incisive papilla
Allergies
Penicillin
Medications
  • None
Dental History
  • Regular recalls
  • No trauma history
Current Findings
  • Well-corticated heart-shaped midline radiolucency, roughly 9 mm
  • Lesion centered over the incisive canal, not on a single tooth apex
  • Teeth #8 and #9 respond normally to vitality testing
  • No tooth mobility or sinus tract
  1. Question 1
    Easy
    The radiolucency overlies the incisive foramen. Which nerve normally passes through it?
  2. Question 2
    Easy
    The vital teeth and midline location favor which diagnosis?
  3. Question 3
    Moderate
    Why is the heart shape often seen on the radiograph?
  4. Question 4
    Moderate
    What is the appropriate next step?
  5. Question 5
    Hard
    A nasopalatine (incisive foramen) injection is used clinically for what, and what is its main drawback?

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Patient case: Dark spot at a premolar apex with a tingling lip
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Patient
Female, 58 years old
Chief Complaint
"There's a dark circle near my lower back tooth and my lip tingles since the gum surgery."
Background and/or Patient History
  • Apicoectomy of tooth #20 (mandibular second premolar) performed two weeks ago
  • Pre-op periapical showed a round radiolucency near the #20 apex that had been queried as a periapical lesion
  • Tooth #20 had tested vital before surgery
  • New tingling and reduced sensation of the lower lip and chin on that side since the procedure
Allergies
NKDA
Medications
  • Atorvastatin
Dental History
  • Crown on #20
  • No prior endodontic treatment on #20
Current Findings
  • Round corticated radiolucency near the #20 apex, continuous with the mandibular canal
  • Reduced light touch over the lower lip and chin on the affected side
  • Tongue sensation and taste normal
  • Healing surgical site, no infection
  1. Question 1
    Easy
    The lip-and-chin numbness sparing the tongue localizes to which nerve?
  2. Question 2
    Easy
    The pre-op radiolucency that mimicked a periapical lesion was most likely what?
  3. Question 3
    Moderate
    Which finding would have best distinguished the mental foramen from a periapical lesion before surgery?
  4. Question 4
    Moderate
    How did the apicoectomy most likely injure the mental nerve?
  5. Question 5
    Hard
    What is the appropriate management at two weeks?

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Patient case: Lucid interval after a blow to the temple
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Patient
Male, 22 years old
Chief Complaint
"I got hit in the side of the head and broke a tooth; now I have a bad headache."
Background and/or Patient History
  • Struck on the right temple by a baseball two hours ago, with a brief loss of consciousness then recovery
  • Presented to the dental clinic for a fractured tooth #7 and lip laceration
  • Initially alert and conversant, now becoming drowsy with worsening headache
  • One episode of vomiting in the waiting room
Allergies
NKDA
Medications
  • None
Dental History
  • Routine
Current Findings
  • Right temporal bruising and tenderness over the pterion
  • Right pupil now larger and sluggish
  • Fractured crown #7, lip laceration
  • Declining level of consciousness during the visit (lucid interval followed by deterioration)
  1. Question 1
    Easy
    The blow at the pterion most likely tore which vessel?
  2. Question 2
    Easy
    The middle meningeal artery enters the skull through which foramen?
  3. Question 3
    Moderate
    The lucid interval followed by deterioration is most characteristic of which bleed?
  4. Question 4
    Moderate
    The blown right pupil signals what?
  5. Question 5
    Hard
    What does the dental team do now?

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Patient case: One-sided facial droop at a cleaning
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Patient
Male, 39 years old
Chief Complaint
"Half my face drooped overnight and I can't close my right eye."
Background and/or Patient History
  • Woke with right-sided facial weakness, no dental anesthesia that day
  • Presented for a scheduled hygiene visit
  • Mild ache behind the right ear for a day before onset
  • No limb weakness, no slurred speech, no headache
Allergies
NKDA
Medications
  • None
Dental History
  • Routine recalls
Current Findings
  • Cannot raise the right eyebrow or wrinkle the right forehead
  • Incomplete right eye closure with Bell's phenomenon
  • Right nasolabial fold flattened, drooping corner of mouth
  • Limbs and speech normal; taste reduced on the right anterior tongue
  1. Question 1
    Easy
    Involvement of the forehead points to which type of lesion?
  2. Question 2
    Easy
    The facial nerve exits the skull to reach the face through which foramen?
  3. Question 3
    Moderate
    How is this distinguished from facial weakness after an IAN block?
  4. Question 4
    Moderate
    What is the appropriate management for Bell's palsy?
  5. Question 5
    Hard
    Which feature would push you away from Bell's palsy toward an urgent stroke workup?

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Patient case: Hoarse voice and a weak shoulder on a cancer screen
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Patient
Male, 63 years old
Chief Complaint
"My voice has gone hoarse and I keep choking on water."
Background and/or Patient History
  • Presented for an oral cancer screening and denture adjustment
  • Progressive hoarseness and difficulty swallowing over three months
  • Right shoulder feels weak when lifting
  • 30-pack-year smoking history
Allergies
NKDA
Medications
  • None
Dental History
  • Full upper denture
  • Irregular attender
Current Findings
  • Absent gag on the right with reduced palatal elevation; uvula pulls to the left
  • Hoarse, breathy voice
  • Weak right trapezius and sternocleidomastoid on testing
  • Tongue protrudes midline; firm right upper-neck mass palpable
  1. Question 1
    Easy
    Absent gag, hoarseness, and weak shoulder shrug together point to lesions of which nerves?
  2. Question 2
    Easy
    These three nerves leave the skull together through which foramen?
  3. Question 3
    Moderate
    The uvula deviates to the left. What does this indicate?
  4. Question 4
    Moderate
    The tongue protrudes midline. Why does this matter for localizing the lesion?
  5. Question 5
    Hard
    What is the appropriate action by the dental team?

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Patient case: Throat and ear pain on swallowing
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Patient
Female, 50 years old
Chief Complaint
"I get a sharp pain in my throat and ear when I swallow or turn my head."
Background and/or Patient History
  • Presented for a panoramic radiograph before implant planning
  • Recurrent unilateral throat pain radiating to the ear, worse on swallowing and head rotation
  • Foreign-body sensation in the throat
  • Tonsillectomy in childhood
Allergies
NKDA
Medications
  • None
Dental History
  • Partially edentulous lower arch
Current Findings
  • Pano shows a markedly elongated, partly calcified right styloid process
  • Firm structure palpable in the right tonsillar fossa, reproducing the pain on palpation
  • Cranial nerve exam otherwise normal
  • No mucosal lesion
  1. Question 1
    Easy
    The elongated bony spike on the pano arises from which process?
  2. Question 2
    Easy
    The styloid process lies just lateral to which neurovascular structures near nearby foramina?
  3. Question 3
    Moderate
    Which nerve, irritated by the styloid, best explains throat-and-ear pain triggered by swallowing?
  4. Question 4
    Moderate
    What helps distinguish Eagle syndrome from trigeminal neuralgia?
  5. Question 5
    Hard
    What is the appropriate management pathway?

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Bones & Foramina core recall

Refresh the anatomy facts these cases depend on: nerve numbers, foramina, functions, and lesion findings.

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