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When things go wrong · Oral Surgery · INBDE Patient Cases

Surgical Complications INBDE Patient Cases

By Dr. Isaac Sun, DDS

7 ADA INBDE-format patient cases on surgical complications. 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.

7 patient cases35 linked questionsADA INBDE formatFull distractor explanations

Seven ADA INBDE-format patient cases on oral surgery complications: dry socket presenting as delayed severe pain in a smoker after a lower third molar and treated with irrigation and a medicated dressing (not antibiotics), an oroantral communication confirmed by the Valsalva test and managed by size with sinus precautions, an inferior alveolar nerve paresthesia that is documented and monitored, persistent post-extraction hemorrhage managed by local measures with a workup for an undisclosed bleeding disorder, a root displaced into the maxillary sinus requiring retrieval, Ludwig's angina as an airway-threatening spreading infection, and medication-related osteonecrosis of the jaw at a non-healing extraction site in an antiresorptive patient. Topics include dry socket, hemorrhage, nerve injury, oroantral communication and sinus perforation, displaced roots, infection, and MRONJ.

Case Coverage Map
What each case is testing
Severe pain four days after a wisdom tooth:
Dry socket recognition (delayed pain, lost clot, smoker), irrigation and a dressing (not antibiotics), and prevention.
Air passing to the nose after an upper molar:
Oroantral communication, the Valsalva test, size-based management, sinus precautions, and a displaced root into the sinus.
A numb lip after wisdom tooth removal:
Inferior alveolar nerve paresthesia, the sensory terminology, the usually transient course, and document-reassure-monitor with referral criteria.
A socket that keeps bleeding:
Local hemostasis first, reactionary bleeding, checking for an undisclosed bleeding disorder/anticoagulant, and escalation if it fails.
A root that disappeared toward the sinus:
Root displaced into the maxillary sinus, retrieval/referral, the over-aggressive-retrieval cause, sinus precautions, and prevention.
A swelling spreading under the jaw:
Ludwig's angina as an airway-threatening emergency, airway priority, urgent referral, and the contrast with localized infection.
A socket that won't heal in a bisphosphonate patient:
MRONJ at the extraction site, the antiresorptive cause, prevention living in patient evaluation, conservative management, and IV-dosing risk.
Patient case: Severe pain four days after a wisdom tooth
0 of 5 answered, 0 correct
Patient
Female, 26 years old
Chief Complaint
Throbbing pain that started a few days after a lower wisdom tooth extraction.
Background and/or Patient History
  • Lower third molar extracted 4 days ago; pain had improved, then worsened
  • Smoker; reports a foul taste
  • The socket looks empty
Allergies
NKDA
Medications
  • None
Current Findings
  • Severe throbbing pain with a foul odor and an empty socket with exposed bone
  • No swelling or systemic signs of spreading infection
  1. Question 1
    Moderate
    Severe pain starting a few days after extraction with an empty socket is most consistent with:
  2. Question 2
    Moderate
    This patient's risk factors include:
  3. Question 3
    Moderate
    The appropriate management is:
  4. Question 4
    Moderate
    Antibiotics are not the primary treatment because dry socket is:
  5. Question 5
    Easy
    To prevent dry socket in the future, the patient should be advised to:

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Patient case: Air passing to the nose after an upper molar
0 of 5 answered, 0 correct
Patient
Male, 49 years old
Chief Complaint
Feels air or liquid passing between the mouth and nose after an upper molar extraction.
Background and/or Patient History
  • Maxillary first molar just extracted; roots were close to the sinus on the radiograph
  • Notices air passing to the nose
  • A small communication is suspected at the socket
Allergies
NKDA
Medications
  • None
Current Findings
  • Suspected oroantral communication after maxillary molar extraction
  • Communication appears small
  1. Question 1
    Moderate
    The test to confirm an oroantral communication is the:
  2. Question 2
    Moderate
    Because the communication appears small (about 2 mm or less), management is often:
  3. Question 3
    Moderate
    The patient must be instructed NOT to:
  4. Question 4
    Moderate
    If a larger communication had been present, management would shift to:
  5. Question 5
    Moderate
    If a root had been pushed into the sinus during retrieval, the appropriate step would be to:

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Patient case: A numb lip after wisdom tooth removal
0 of 5 answered, 0 correct
Patient
Male, 23 years old
Chief Complaint
Numb lower lip on one side after a lower wisdom tooth was removed.
Background and/or Patient History
  • Lower third molar (roots near the inferior alveolar canal) removed yesterday
  • Numbness and tingling of the lower lip and chin on that side
  • No pain; otherwise healing well
Allergies
NKDA
Medications
  • None
Current Findings
  • Altered sensation of the lower lip/chin consistent with inferior alveolar nerve involvement
  • No signs of a severed nerve identified
  1. Question 1
    Moderate
    Numbness of the lower lip and chin after lower third molar surgery indicates involvement of the:
  2. Question 2
    Moderate
    Altered (but present) sensation like this is termed:
  3. Question 3
    Moderate
    The expected course of most such injuries is:
  4. Question 4
    Moderate
    Appropriate management now is to:
  5. Question 5
    Moderate
    Referral for specialist evaluation is warranted if the deficit:

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Patient case: A socket that keeps bleeding
0 of 5 answered, 0 correct
Patient
Female, 64 years old
Chief Complaint
Bleeding from an extraction site that has not stopped at home.
Background and/or Patient History
  • Routine extraction earlier today; oozing has continued for hours
  • Did not mention any medications at the first visit
  • Returns with a blood-soaked gauze
Allergies
NKDA
Medications
  • Possibly undisclosed
Current Findings
  • Persistent post-extraction bleeding
  • Medication and bleeding history to be clarified
  1. Question 1
    Moderate
    The first step in managing this bleeding is:
  2. Question 2
    Hard
    Bleeding that continues for hours as the local anesthetic wears off is described as:
  3. Question 3
    Moderate
    Because local measures are not quickly controlling it, the clinician should:
  4. Question 4
    Easy
    This case underscores the importance of:
  5. Question 5
    Moderate
    If local measures and adjuncts still fail to control the bleeding, the next step is:

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Patient case: A root that disappeared toward the sinus
0 of 5 answered, 0 correct
Patient
Male, 52 years old
Chief Complaint
During an upper molar extraction, a root fragment was pushed superiorly.
Background and/or Patient History
  • Maxillary molar extraction; apical root fragment displaced during attempted retrieval
  • Fragment appears to have entered the maxillary sinus on imaging
  • Patient otherwise stable
Allergies
NKDA
Medications
  • None
Current Findings
  • Root fragment displaced into the maxillary sinus
  • Oroantral communication possible
  1. Question 1
    Moderate
    A root fragment displaced into the maxillary sinus should generally be:
  2. Question 2
    Moderate
    This complication often results from:
  3. Question 3
    Moderate
    A frequently associated finding is:
  4. Question 4
    Moderate
    The patient should be advised about sinus precautions, including to:
  5. Question 5
    Moderate
    The lesson this case reinforces from the exodontia module is to:

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Patient case: A swelling spreading under the jaw
0 of 5 answered, 0 correct
Patient
Male, 45 years old
Chief Complaint
Rapidly spreading swelling under the jaw and floor of the mouth, with difficulty swallowing.
Background and/or Patient History
  • Recent lower molar infection/extraction
  • Bilateral firm swelling of the submandibular and sublingual areas; elevated, displaced tongue
  • Difficulty swallowing and early breathing difficulty; febrile
Allergies
NKDA
Medications
  • None
Current Findings
  • Spreading floor-of-mouth infection with airway concern (Ludwig's angina pattern)
  • Systemic signs present
  1. Question 1
    Hard
    A rapidly spreading bilateral floor-of-mouth infection with a raised tongue and swallowing/breathing difficulty is:
  2. Question 2
    Moderate
    The most important immediate concern is:
  3. Question 3
    Moderate
    Appropriate action is to:
  4. Question 4
    Moderate
    This contrasts with most postoperative infections, which are:
  5. Question 5
    Easy
    Recognizing this links to which other module?

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Patient case: A socket that won't heal in a bisphosphonate patient
0 of 5 answered, 0 correct
Patient
Female, 68 years old
Chief Complaint
An extraction site that has not healed, with exposed bone, weeks later.
Background and/or Patient History
  • On antiresorptive therapy (bisphosphonate)
  • Extraction performed about 10 weeks ago; the site never closed
  • Exposed bone is visible and mildly tender
Allergies
NKDA
Medications
  • Bisphosphonate
Current Findings
  • Non-healing extraction site with exposed bone in an antiresorptive patient
  • Pattern consistent with MRONJ
  1. Question 1
    Moderate
    A non-healing extraction site with exposed bone for over 8 weeks in an antiresorptive patient is:
  2. Question 2
    Moderate
    The medication class responsible is:
  3. Question 3
    Easy
    The best way this complication could have been reduced is addressed in:
  4. Question 4
    Hard
    Management of established MRONJ generally favors:
  5. Question 5
    Moderate
    MRONJ risk is highest in patients on:

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Keep studying
Surgical Complications core recall

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

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